W. Steven Pray, PhD, DPh

Disclosures

US Pharmacist. 2005;30(7) 

In This Article

Symptoms

Meniere's disease is actually a syndrome that involves several well-defined symptoms. One third to 45% of patients report an aura preceding the attack by a few minutes.[9,10] The aura consists of tinnitus, hearing loss, and a feeling of fullness in the ear. Most patients exhibit symptoms only in one ear initially; the number of patients who experience simultaneous de novo attacks of Meniere's disease in both ears is low.[11] Within a short period, the full-blown attack of Meniere's commences.

The Meniere's attack is characterized by paroxysms of vertigo. The vertigo is a rotational type, with a perceived spinning of the environment that lasts for 20 minutes or more in its most acute form.[10,12] Due to the perception of motion during the attack, the patient experiences the classical neural mismatch or sensory conflict that also produces motion sickness, making the nausea and vomiting that accompany Meniere's vertigo similar in theoretical origin. The attack may persist for as long as two to eight hours.[4,10,13] The sensation of vertigo worsens with any sudden movement.[4] The patient may notice that vertiginous disequilibrium persists for several days. If there was no aura preceding the attack, the onset of vertigo carries with it hearing loss (fluctuating and low frequency), tinnitus, and the feeling of aural fullness.[7] The tinnitus is roaring and usually on one side only.[8] It is low-pitched and continuous, but the intensity may vary (usually increasing) prior to an upcoming vertiginous attack and slowly easing as the attack subsides.[14] The feeling of fullness is in the same ear as the tinnitus. Attacks often include nausea and vomiting.[9] Furthermore, the patient will exhibit sweating and nystagmus, either in the horizontal or horizontorotary forms.[4,10]

In 3% of patients, tinnitus is the first sign that an attack of Meniere's is imminent.[10] In 42%, hearing loss is the first sign. In 11%, vertigo is the initial symptom, and in the remaining 44%, vertigo and hearing loss occur simultaneously. These estimates are critical in their import and implications, as the Meniere's patient may be driving a vehicle at the onset of an attack. If the attack includes vertigo at the outset, the patient may be unable to steer or control the vehicle. As attacks cannot be predicted or prevented with certainty, the afflicted individual should consider cessation of driving. However, should the individual have a variant of Meniere's in which the aura invariably precedes the attack, he or she may be able to continue driving, as long as it is carried out in locations where a vehicle may be stopped at a moment's notice. Also, those with Meniere's are cautioned not to drive, climb, operate heavy machinery, or engage in other potentially dangerous activities (e.g., hang gliding, surfing, swimming, piloting a plane) until one week has passed since the attack.

One of the most frightening symptoms of Meniere's is the "drop attack," also known as the otolithic crisis of Tumarkin.[5] According to the theory, excessive fluid accumulation deforms the otolith apparatus of the inner ear (the utricle and saccule), with a resultant overpowering feeling of tilting or falling. Patients attempt to reconcile this feeling with external reality and fall to the ground uncontrollably and suddenly. They may strike their head on a hard surface, causing severe injury, as there is no warning of the attack in most cases. The possible lack of warning that the feeling is imminent could cause a patient who is driving in heavy traffic to be unable to control the vehicle or apply the brakes.

After the acute attack subsides, a patient may notice that the hearing loss persists to the point that hearing in the affected ear is partially blocked.[10] Furthermore, the patient often feels an overwhelming sense of exhaustion after an attack, necessitating several hours of sleep.[5]

Meniere proposed an association between the disease and migraine headache.[15] Recent research has confirmed that the link is present for some patients, although others have suggested that the apparent association is actually due to a migraine variant called "migrainous vertigo," rather than classical Meniere's disease.

Some patients suffer from clusters of Meniere's attacks. For others, a single attack is followed by years of freedom from the most disabling symptoms; however, residual mild tinnitus and/or mild imbalance may arise.[5] As time passes, Meniere's begins to affect the other ear. After 30 years with Meniere's, one half of those affected have symptoms in both ears.[5]

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