|Year : 2017 | Volume
| Issue : 1 | Page : 13-16
Meniere's disease: A mystery! Our way to diagnose
Haris Manzoor Qadri1, Arun Dehadaray2, Maitri Kaushik2, Danish Zamir Andrabi1
1 Department of ENT, Smt. Kashibai Navale Medical College and Hospital, Pune, Maharashtra, India
2 Department of ENT, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
|Date of Web Publication||6-Feb-2017|
Haris Manzoor Qadri
Smt. Kashibai Navale Medical College and Hospital, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Meniere's disease (MD) has long posed a diagnostic challenge. Characterized by recurrent vertigo, tinnitus, and fluctuant sensorineural hearing loss (SNHL), its presentation may limit initially to merely one or two of the above symptoms. Inability to obtain a fresh inner ear tissue leaves us to rely on hypothetical choices. Materials and Methods: Two adjuvants, glycerol test, and intratympanic gentamycin, were analyzed in our study, for their efficacy in diagnosing MD. Patients with symptoms of vertigo, tinnitus, and SNHL were evaluated. Those with presbycusis, conductive hearing loss (on pure tone audiogram [PTA]), benign paroxysmal positional vertigo (diagnosed by Dix Hallpike), retrocochlear pathology (short increment sensitivity index score below 70%), and central cause (magnetic resonance imaging angiography and neurology opinion) were excluded. Rest were subjected to glycerol test and subsequently intratympanic gentamicin. After a 6 month follow up, evaluation was performed for tinnitus and vertigo through a visual analog scale. Repeat PTA was done to look for any hearing deterioration due to gentamicin. Results: It was found that not only did glycerol positive patients get completely relieved of vertigo but also those who tested negative got completely or partially relieved of it. This shows a higher efficacy of intratympanic gentamycin as well as its significant association with glycerol test. Conclusion: This study lead us to form a strong diagnostic criterion which has already proven to be therapeutic in the management of MD.
Keywords: Glycerol test, intratympanic gentamycin, short increment sensitivity index
|How to cite this article:|
Qadri HM, Dehadaray A, Kaushik M, Andrabi DZ. Meniere's disease: A mystery! Our way to diagnose. Indian J Otol 2017;23:13-6
| Introduction|| |
Meniere's disease (MD) is one of the most difficult labyrinthine pathologies to diagnose. Recurrent rotatory vertigo, tinnitus, and fluctuant sensorineural hearing loss (SNHL) are characteristic symptoms of MD. However, MD can present initially only with tinnitus and hearing loss. Even in the presence of good clinical data, it is difficult to diagnose MD due to challenges in obtaining fresh inner ear tissue that can be fixed and processed for morphological analysis. Due to this, the mechanisms underlying many vestibular disorders have been described in a hypothetical manner.
Glycerol test has been used as adjuvant test to diagnose MD. Because of varied reliability, use of this test is limited, and there is a paucity in Indian literature regarding its significance. Intratympanic gentamicin is known to provide symptomatic relief; however, its role in diagnosis has not been studied so far.
| Materials and Methods|| |
A total of 36 patients with age group between 18 and 50 years with complaints of continuous or episodic vertigo, tinnitus, and SNHL coming to ear, nose, and throat (ENT) department of tertiary hospital were included in this prospective study. Patient who had presbycusis and conductive hearing loss were excluded from the study.
All the cases with labyrinthine symptoms were evaluated with detailed history and ENT examination. Magnetic resonance imaging angiography and neurologist's opinion was used to rule out central cause of vertigo. Patients with Dix-Hallpike positive were diagnosed as benign paroxysmal positional vertigo, treated by Epley's maneuver and excluded. Pure tone audiogram (PTA) with short increment sensitivity index (SISI) was done followed by glycerol test. Patients with SISI score <70% were also excluded from this study. All patients who were glycerol positive or negative were given intratympanic gentamicin (dose - 40 mg). Patients who did not get relieved after doing Epley's maneuver were sent for PTA, glycerol test, and later treated with intratympanic gentamicin. Six months follow-up was done. Postgentamicin improvement in vertigo and tinnitus was evaluated monthly using visual analog scale. Score between 8 and 10 was considered complete improvement, score 6–7 as partial improvement and <6 as no improvement. Repeat PTA was performed after 6 months to note any deterioration in hearing.
| Results|| |
Data were analyzed and evaluated statistically. Of 36 patients 24 patients were having vertigo with tinnitus with SNHL. Ten patients had only vertigo with SNHL, and two patients had only tinnitus with SNHL. [Figure 1] shows gender distribution of patients. 65% of the patients had episodes of vertigo lasting more than 20 minutes [Figure 2].
On PTA 69.44% of patients had low-frequency SNHL and 30.56% were found with high-frequency SNHL. Nearly 70% of patients were having SISI score more than 90% and 30% of patients having score between 70% to 90%. Glycerol test was done in all the patients, out of total, only 12 were positive. Only one patient with Dix-Hallpike positive in this study did not improve on Epley's maneuver but was also glycerol positive. After giving intratympanic gentamicin to 34 patients with vertigo, 21 patients (61.76%) were completely improved and only 12 (35.39%) showed partial improvement in vertigo, whereas only 1 (3%) showed no improvement [Figure 3].
Only one patient out of 26 got completely improved from tinnitus. On analyzing the glycerol test results for effect of intratympanic gentamicin on vertigo, 12 patients with glycerol positive, 10 got completely improved from vertigo and out of 22 glycerol negative cases, 11 got completely improved and 11 got partially improved from vertigo. After doing repeat PTA after 6 months, only 2.77%, that is, only one patient out of 36 had deterioration in hearing postintratympanic gentamicin.
| Discussion|| |
MD is one of the most difficult labyrinthine pathologies to diagnose. Due to the lack of knowledge on exact etiology, MD is mostly treated symptomatically. In the absence of universally approved tests, criteria given by the American Association of Otolaryngology - Head and Neck Surgery (AAO - HNS) are used for diagnosis. In our study, also we found 55.56% of males and 44.44% of females affected which depicted not much difference in the occurrence of MD with respect to gender. These results are in line with those of da Costa et al. We had 69.44% of patients who had low tone SNHL and the rest had high tone SNHL. Low tone SNHL is very peculiar of MD, but high tone SNHL can also be seen in few cases of MD.
Glycerol test is one of the most reliable and noninvasive tests for MD. However, its role in MD has not been studied much in the recent past. In our study, out of 36 patients, 33.33% of patients were having positive glycerol test and just 66.67% had glycerol negative test. There are various vestibular tests to diagnose recruiting ear such as SISI, alternate binaural loudness balance, stapedial reflex, etc. All these tests have their own limitations. SISI is one of the reliable tests to know recruitment. Nearly 70% of patients had SISI score more than 90%, strongly suggesting cochlear pathology. Intratympanic gentamicin is regularly tried for unilateral MD. Various studies have been performed to know the efficacy of this treatment on labyrinth symptoms and its effect on hearing level. In our study, postintratympanic gentamicin 61.76% of patients got completely improved from vertigo, 35.29% got partially improved and only 2.9% of patients did not improve at all. Lange et al. reported elimination of vertigo attacks in 53% of patients after a single dose and while application of the second dose in 8–15 days proved effective in 95% of the patients. While Lange et al. Also noted that hearing function was maintained in most patients. Eklund et al. indicated a significant reduction in tinnitus during the course of treatment and that average frequency of deafness was 10% which was dose dependent. In our study, only one patient got relieved of tinnitus, suggesting that single dose intratympanic gentamicin is not effective for tinnitus. Out of 36 cases, we found deterioration of hearing with single dose (40 mg) intratympanic gentamicin only in one case.
It is a known fact that intratympanic gentamicin is an effective treatment in MD. This means in our study out of 36 patients who were given intratympanic gentamicin, those improved or those who got partially improved are suspected case of MD. Till date, MD is diagnosed on the basis of criteria given by AAO - HNS in 1995, and this is purely based on clinical picture of the patient. MD is characterized by clinical trial of recurrent vertigo, fluctuant hearing loss and tinnitus. However, MD can also present alone with vertigo or with tinnitus and SNHL. However, clinician may not always encounter full blown picture on MD from the outset. Various forms of the MD may be encountered in early stage, with symptoms either arising from the vestibular or cochlear system. Till date, clinical symptoms and audiometric tests are basis of diagnosis. Differential diagnosis may be extremely difficult since most of findings are subjective and nonspecific. Misdiagnosis is, therefore possible, thus highlighting the great need for objective and reliable testing. The glycerol test is one of the reliable tests done for MD. Lu et al. suggested PTA and vestibular evoked myogenic potential after administration of glycerol provide potential status of MD. In our study, 10 out of 12 glycerol positive cases got completely improved from vertigo after intratympanic gentamicin. Out of 22 glycerol negative cases, 11 got complete improvement, and 11 cases were partially improved from vertigo. One case who was glycerol positive did not improve at all. Hence, we suggest that intratympanic gentamicin has higher efficacy in glycerol positive cases but has a definite role in glycerol negative cases too. There is a significant association of glycerol test and intratympanic gentamicin.
In the present study, MD was diagnosed on the basis of 6 criteria:
- Patients having episodic vertigo
- Patients having tinnitus
- Patients having high tone or low tone SNHL
- Patient SISI score more than 70%
- Patient glycerol positive or negative
- Patient improved of vertigo or tinnitus after giving intratympanic gentamicin.
- Definite MD: All six criteria should be present with particularly low-frequency SNHL
- Apparent MD: Any five criteria are present
- Likely MD: Vertigo and/or tinnitus with any three criteria out of above no 3. To no. 6 are present.
Partially improved patients from vertigo with gentamicin were not taken as positive criteria. Low tone SNHL was considered essential in patients who were diagnosed as certain MD.
Nearly 83.33% of glycerol positive cases improved of vertigo after intratympanic gentamicin. Thus by above findings, we suggest the utility of intratympanic gentamicin in glycerol positive cases is highly effective than glycerol negative cases. However, there were 11 out of 22 glycerol negative cases who also got improved and another 11 who got partially improved after intratympanic gentamicin, probably these are the patients who are glycerol negative but suffering from MD too.
After analyzing above findings, there were 10 cases who fulfilled all 6 criteria. They were diagnosed as definite MD. 10 patients who fulfilled 4 out of 6 criteria's were diagnosed as apparent MD. 17 patients had 3 out of 6 criteria and were diagnosed as likely MD. We also observed that all cases who were diagnosed as definite MD got completely relieved of vertigo postintratympanic gentamicin. In apparent MD all patients except one got benefited after intratympanic gentamicin and these are the patients we suggest to be considered subsequently as definite cases of MD.
There are no specific tests available to diagnose MD so we suggest that a small dose of intratympanic gentamicin can be used an adjuvant to glycerol test to diagnose MD as it has no effect on hearing.
| Conclusion|| |
Glycerol test has a significant role in diagnosing definite MD. A single dose of intratympanic gentamicin is more useful in diagnosing MD than glycerol test. Intratympanic gentamicin is therapeutically more beneficial in glycerol positive cases of MD. Intratympanic gentamicin does not cause significant deterioration of hearing.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Luxon LM. Balance disorders. Scott Brown's Otorhinolaryngology, Head and Neck Surgery. Vol. 3, 240. London: Hodder Arnold; 2008. p. 3673-4.
Vassiliou A, Vlastarakos PV, Maragoudakis P, Candiloros D, Nikolopoulos TP. Meniere's disease: Still a mystery disease with difficult differential diagnosis. Ann Indian Acad Neurol 2011;14:12-8.
Monsell EM, Balkany TA, Gates GA, Goldenberg RA, Meyerhoff WL, House JW, et al
. Committee on hearing and equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere's disease. American Academy of Otolaryngology Head and Neck Foundation, Inc. Otolaryngol Head Neck Surg 1995;113:181-5.
da Costa SS, de Sousa LC, Piza MR. Meniere's disease: Overview, epidemiology, and natural history. Otolaryngol Clin North Am 2002;35:455-95.
Seabra JC, Diamantino H, Faria E Almeida J. Neurootological evaluation of tinnitus. Int Tinnitus J 1995;1:93-97.
Lange G, Maurer J, Mann W. Long-term results after interval therapy with intratympanic gentamicin for Menière's disease. Laryngoscope 2004;114:102-5.
Eklund S, Pyykkö I, Aalto H, Ishizaki H, Vasama JP. Effect of intratympanic gentamicin on hearing and tinnitus in Meniere's disease. Am J Otol 1999;20:350-6.
Lu JZ, Zhang JG, Lai H. The relationship between ECochG and glycerol test in vertigo patients (report of 112 cases). Lin Chuang Er Bi Yan Hou Ke Za Zhi 2000;14:510-1.
[Figure 1], [Figure 2], [Figure 3]