1. JORDAN TROUT MENIERE’S DISEASE

2. DIAGNOSIS Triad of vertigo, hearing loss, and tinnitus Definite diagnosis from AAO-HNS: Two spontaneous episodes of vertigo lasting at least 20 minutes Sensorineural hearing loss confirmed by audiometry Tinnitus and/or perception of aural fullness H81.01-Meniere’s disease, right ear H81.02-Meniere’s disease, left ear H81.03-Meniere’s disease, bilateral H81.09-Meniere’s disease, unspecified ear

3. NIH Medical Arts (Photo]. (2010, July). In National Institute on Deafness and Other Communication Disorders [NIDCD] (Author), Meniere’s disease. Retrieved from http://www.nidcd.nih.gov/health/balance/pages/meniere.aspx#5

4. Komaroff, A. (2015, July 8). What is Meniere’s disease, and what can be done to treat it [Photo]. Retrieved from http://www.askdoctork.com/what-is- menieres-disease-and-what-can-be-done-to-treat-it-201507088067 Endolymphatic hydrops Caused by the buildup of fluid in inner ear Causes: Idiopathic Immune mechanism, genetic, viral, vascular, trauma PATHOGENESIS

5. CLINICAL MANIFESTATIONS Presentation: Ages 20-40 Characterized by acute attacks lasting 20 minutes to 24 hours with associated nausea, vomiting, and nystagmus Interval between attacks can be weeks to months Fullness or pressure in the affected ear Fluctuating sensorineural hearing loss of low frequencies HISTORY

6. CLINICAL MANIFESTATIONS ROS and Health History: Allergies and Autoimmune Disorders Viral Infection Recent URI Middle ear surgery Head trauma Previous neurologic disorders Cardiovascular disease Anxiety or mental illness Use of alcohol, tobacco, caffeine, recreational drugs Medications Family History of Meniere’s Disease, TIA, CVA, migraines HISTORY

7. CLINICAL MANIFESTATIONS Vital Signs (including orthostatic blood pressure) Otoscopic Exam Complete Neurological Exam: Cranial Nerve VIII: Whisper Test, Rinne and Weber Tests Cerebellar Function with Romberg and Tandem walking Consistent Nystagmus: Horizontal or Rotary PHYSICAL EXAM

8. Pruitt, A.A. ( 2014) Evaluation of dizziness. In Goroll, A. H., & Mulley, A. G. (Eds.), Primary care medicine: Office evaluation and management of the adult patient (7th ed.). (p. 1203). Philadelphia: Wolters Kluwer Health. Central Vertigo: Immediate nystagmus and vertigo Failure to resolve in 30 seconds No fatiguing with repeated testing Peripheral Vertigo: Latency period of 3-40 seconds before onset of nystagmus and vertigo Symptoms resolve in 30 seconds Fatiguing of symptoms with repeated testing DIX-HALLPIKE MANEUVER

9. DIAGNOSTIC TESTS Audiometry Vestibular Testing (ENG) ECoG and VEMP Laboratory work CBC, CMP, TSH, ESR, Lyme, lipid profile, RPR CT or MRI

10. DIFFERENTIAL DIAGNOSIS Differentials Benign paroxysmal positional vertigo (BPPV) Cogan’s syndrome Migraine Perilymph Fistula Labyrinthitis Vertigo secondary to medications Diabetes or Thyroid disease Red Flags Brainstem/Cerebellar Dysfunction MS TIA Acoustic Neuroma Syphilis: Secondary or early tertiary

11. TREATMENT Lifestyle: Salt Restriction (1-2g Na/day) Avoid stress, nicotine, alcohol, and caffeine Acute Episodes: Antiemetics (ondansetron 8 mg q12h; prochlorperazine 5-10 mg q6h) Vestibular Suppressants Antihistamines: Meclizine 25-50 mg q6h or dimenhydrinate 50 mg q4-6h Benzodiazepines: Lorazepam 1-2 mg q8h Anticholinergics: Scopolamine patch Symptomatic Relief

12. TREATMENT Drug Therapy: Mild Diuretics (250mg acetazolamide BID or 50 mg hydrochlorothiazide BID) PRN Vestibular suppressants/antiemetics Alternative medicine Rehabilitation Interventional Treatment by ENT: Intratympanic injection Surgery Positive pressure pulse generator (Meniett)

13. OUTCOMES Majority of patients are able to maintain normal daily activities Decrease in frequency after multiple attacks that can return months or years later Progression to hearing loss of higher frequencies and may become permanent Consider psychological impact

14. REFERENCES American Academy of Otolaryngology-Head and Neck Surgery (2015). Meniere’s disease: Patient health information. Retrieved from http://www.entnet.org/content/menieres-disease. Bickley, L. S., & Szilagyi, P. G. (2013). Bates' guide to physical examination and history taking (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Committee on Hearing and Equilibrium and American Academy of Otolaryngology-Head and Neck Foundation (1995). Committee on hearing and equilibrium guidelines for the diagnosis and evaluation of therapy in Menière's disease. Otolaryngol Head Neck Surg, 113(3), 181-185. Retrieved from http://oto.sagepub.com Dains, J., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Mosby. Dinces, E. A. (2015, November 23). UpToDate. Meniere disease. Retrieved from http://www.uptodate.com/contents/meniere-disease?source=search_result&search =meniere&selectedTitle=1%7E29#H1 Furukawa, M., Kitahara, T., Horii, A., Uno, A., Imai, T., Ohta, Y., &... Sakagami, M. (2013). Psychological condition in patients with intractable Meniere's disease. Acta Oto-Laryngologica, 133(6), 584-589. doi:10.3109/00016489.2012.759274 Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). Philadelphia: Wolters Kluwer Health. Komaroff, A. (2015, July 8). What is Meniere’s disease, and what can be done to treat it [Photo]. Retrieved from http://www.askdoctork.com/what-is-menieres-disease-and-what-can-be-done-to-treat-it-201507088067 McCance, K. L., & Huether, S. E. (2014). Pathophysiology: the biologic basis for disease in adults and children (7 th ed.). St. Louis, Missouri: Elsevier Mosby. National Institute on Deafness and Other Communication Disorders [NIDCD] (2010, July). Meniere’s disease. Retrieved from http://www.nidcd.nih.gov/health/balance/pages/meniere.aspx#5 NIH Medical Arts [Photo]. (2010, July). In National Institute on Deafness and Other Communication Disorders [NIDCD] (Author), Meniere’s disease. Retrieved from http://www.nidcd.nih.gov/health/balance/pages/meniere.aspx#5 Pruitt, A.A. ( 2014) Evaluation of dizziness. In Goroll, A. H., & Mulley, A. G. (Eds.), Primary care medicine: Office evaluation and management of the adult patient (7th ed.). (p. 1203). Philadelphia: Wolters Kluwer Health. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program (2014, May). Evaluation of vertigo in the adult patient. Retrieved from http://www.guideline.gov/content.aspx?id=48220

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