Clinical profile of MéniÈre’s disease

INTRODUCTION Endolymphatic hydrops, defined as hydropic distension of the membranous cochlea, can be observed secondary to various pathologies. It has been reported that endolymphatic hydrops occurs with various diseases such as labyrinthitis, physical trauma, Mondini dysplasia, syphilis and autoimmune diseases(9). Apart from this, the idiopathic and symptomatic form of endolymphatic hydrops is defined as Ménière’s disease, the etiology of which no pathology can be held responsible can be determined. Ménière’s disease characteristically presents with fluctuating hearing loss, vertigo, and tinnitus. The diagnosis of the disease is traditionally based on complaints of hearing and balance, which appear as attacks. However, without long follow-up, Ménière has been diagnosed solely on the basis of clinical findings.

Dokuz Eylul Faculty of Medicine ENT Department İnciraltı – İzmir (**) Manchester University Faculty of Medicine ENT Professor, In case of diagnosis of English thalass, problems are likely to be encountered. Although there are various audiological tests developed, the importance of subjective complaints in the diagnosis of Ménière’s disease in the form of attacks still continues. In this publication, the clinical picture of a group of Ménière’s patients will be summarized and the value of symptomatology in definitive diagnosis will be discussed. METHODS and MATERIALS This study was carried out in the ENT and Audiology Departments of Manchester University Medical School Hospital, England. Formal approval was obtained from the Manchester Health Authority, Clinical Research Ethics Committee before initiating the study. Patients participating in the study were selected from a large group of patients. The criteria listed below were taken into account in order for the patients to be included in the study. The first three of these criteria are the diagnostic criteria accepted by the Hearing and Balance Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 1985. 51 Journal of ENT and Head and Neck Surgery, 1998; 6 (2): 51-54 M. Bülent ŞERBETÇİOĞLU et al. Inclusion criteria 1. Presence of symptom complex consistent with Ménière’s Disease: fluctuating cochlear symptoms (hearing loss, tinnitus, and ear fullness occurring simultaneously and/or exacerbated during seizures in the same ear) and actual occurring during seizures and ending in hours. rotational vertigo, 2. Fluctuating sensorineural or mixed-type hearing loss determined by pure tone audiometry, 3. Lack of central nervous system pathology, vestibular schwannoma or any other cochleovestibular disease based on complaints, history, physical examination and audiological tests, 4. Clinical follow-up findings consistent with Ménière’s disease in the tested ear. 5. No signs of conductive hearing loss in the tested ear, 6. The 0.5/1/2 kHz airway threshold average in the tested ear does not exceed 66 dB HL, 7. The patient has not undergone any inner ear surgery, 8. The patient’s age is presbycusis not exceeding the age of 66, which is considered the age limit for Nineteen patients who met the criteria listed above were selected from the patient files. The patients had a minimum follow-up of three years. Ménière’s disease was bilateral in two patients. As a result of testing both ears of these two patients, a total of 21 ears were tested. Twelve of the twenty-one ears belonged to female patients and nine belonged to male patients. Of the tested ears, 58% belonged to women and 42% to men. The ages of the patients ranged from 34 to 66 years, with a mean age of 52 years. As a result of detailed questioning, two patients with pathology other than Ménière’s disease were excluded from the study. Test protocol: The procedures and tests applied to Ménière patients are listed below: a. Bilateral otoscopy b. Pure tone audiometry c. Tympanometric examination and determination of acoustic reflex thresholds d. Questionnaire form: An inquiry form specially prepared for Ménière patients was sent to the patients to be answered. In this form, it was investigated whether each patient met the criteria of the study and the necessary information in the differential diagnosis of Ménière’s Disease was obtained. RESULTS The main complaint and the duration since the onset of the complaint. As of the period of the interrogation, the complaint that bothered the patients was grouped into three classes. The most prominent complaints were vertigo and imbalance (62%). The complaints are summarized in table 1. Table l The main complaints and percentages of the patients The nature of the main complaint Percent Vertigo 62% Hearing Loss 28% Tinnitus 10% Episodic vertigo and accompanying complaints. Episodic and peripheral vertigo was definitely present in all patients at some stage of the disease. The duration of episodic vertigo in patients is summarized in table 2. It was stated that vertigo lasted for a maximum of 4-5 hours in almost all patients. In addition, findings accompanying episodic vertigo were investigated. Nausea and vomiting were accompanying autonomic complaints secondary to vertigo in all 19 patients. Fifteen patients also had cold sweating. The patients were asked whether chest tightness or loss of consciousness accompanied episodic vertigo, and it was understood that none of the patients had these complaints. The absence of these complaints in episodic vertigo yellow did not suggest an extra-peripheral disease in the etiology of the balance disorder. Table 2 Duration and percentages of episodic vertigo attack in patients Duration of vertigo attack Percent 3 minutes -1 hour 21% 1 -3 hours 63% 3 – 24 hours 16% Complaints at times other than episodic vertigo. Fourteen patients had continuous tinnitus, except for episodes (74%). Twelve patients52 Journal of ENT and Head and Neck Surgery, 1988; 6 (2): 51-54 M. Bülent ŞERBETÇİOĞLU et al. His complaint of imbalance was also present outside of the episodes. In 13 patients (68%), the sensation of fullness in the ear was present at times other than episodes. Conditions that increase the severity of episodic vertigo and relaxation methods applied during vertigo. It was determined that moving the head increased vertigo in eight patients (50%). Stress, fatigue, hunger, alcohol, cheese and ice cream were listed as factors that triggered or exacerbated episodic vertigo in a small number of patients. When vertigo started, six patients stated that sleep was beneficial (32%), three patients reported prochloroperazine suppositories (16%), and one patient used betahistidine hydrochloride 16 mg tablets. Medical treatment of Ménière’s disease. Sixteen patients (84%) were regularly using betahistidine hydrochloride 16 mg tablets three times a day to cope with the balance problem. Five of the 16 patients were also using cinnarizine tablets when they experienced an attack of vertigo. Familial transmission of Ménière’s disease. Only five (26%) of 19 patients stated that Ménière’s disease was also encountered in another member of their family. Migraine accompanying Ménière’s disease. Migraine was associated with Ménière’s disease in four of the 11 female patients (36%) and in one of the eight male patients (13%). In all Ménière patients, this rate was found to be 26%). Having a family history of migraine disease. Five (45%) of the 11 female patients and three (38%) of the eight male patients had a family history of migraine. Although none of these three male patients had migraine-related complaints, it was understood that their mother or sister had this complaint. Migraine family history rate in all Ménière patients was determined as 42%. DISCUSSION AND CONCLUSIONS The diagnosis of patients included in this study is based on long-term medical follow-up, with a minimum of 3 years and most of them more than 5 years. As a result of the examination of the files and the filling of the inquiry form, those who doubted the diagnosis of Ménière’s disease were excluded from the study. In addition to the symptoms and findings of the patients, audiological diagnostic tools were also used to confirm the diagnosis of those included in this conflict. The duration of episodic vertigo in patients was also analyzed. Among them, Pfaltz and Matefi (1978)(17), in their series of 100 cases, the rate of episodic vertigo lasted between 3 minutes and 1 hour was 25%, the rate of those lasting between 1 and 3 hours was 65%, and those between 3 and 24 hours! also found 10%. In this study, the rate between 3 minutes and 1 hour was 21%, the rate between 1 and 3 hours was 63%, and the rate between 3 and 24 hours was 16%. In summary, the ratio of the duration of episodic vertigo in all cases is consistent with the figures in the published publication. Relationship between Ménière’s Disease and migraine Migraine is a disease with an episodic course and recurrences like de Ménière’s disease. Migraine is associated with abnormal vascular dynamics of the internal and external carotid and basilar artery systems. Cerebral blood flow is sensitive to the local level of carbon dioxide, oxygen, and metabolites, independent of systemic blood pressure, and this autoregulation is impaired during a migraine attack. It has been noted that labyrinth blood flow originating from the vertebrobasilar artery system is regulated by autoregulation like the cerebrum (Parker, 1995)(5). In both diseases, the severity, duration and frequency of the complaints vary from patient to patient. The appearance of the primary complaints in these two diseases in the form of attacks, the negative effect of stress, genetic predisposition, regulation of the circulation of the labyrinth and cerebrum under similar conditions, and the frequent occurrence of these two diseases in the same people led to the conclusion that these diseases are common features and are related to each other. Although the realization of the existence of this relationship is not new (Ménière, 1861)(2), it cannot be said that a consensus has yet been reached about the reason for the relationship. Table of Ménière’s Disease and etiology Based on the questionnaire, Paparella et al. detected a positive family history in 20% of a total of 500 Ménière patients (4). The familial transmission rate was found to be 26% in this study. Based on genealogical studies, a small number of cases of Ménière’s disease with autosomal dominant inheritance have been found (Oliveria and Braga, 1992)(3). While endolymphatic hydrops may occur secondary to a labyrinth pathology, there are also idiopathic cases in which no other additional labyrinth pathology can be detected. According to a generally accepted view, idiopathic and symptomatic53 Journal of ENT and Head and Neck Surgery, 1998; 6 (2): 51-54 M. Bülent ŞERBETÇİOĞLU et al. It is possible to attribute tic cases to multifactorial etiology. According to this view, despite the presence of a common pathological anatomical picture, it is thought that various factors, especially immunological, vascular and genetic factors, may be responsible for the etiology. However, it is very difficult to prove that the etiological factors predicted for each case are responsible for the main event (Angelborg, 1981)(1). In almost all of the patients included in this study, no patients who could be classified as cochlear and vestibular Ménière’s disease were found. This result was not found in any patient that could be classified as Ménière’s disease. This result is in line with the principles adopted by the Hearing and Balance Committee of the American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) in 1985, and similar publications investigating the complaints and findings in Ménière patients (Rassekh and Lee, 1992; Pfaltz and Matefi, 1978). (Pearson and Brackmann, 1985) are compatible.(6,7,8) When the timing of episodic vertigo and neurovegetative symptoms in patients are mentioned, episodic vertigo in the form of rotation of the environment for less than four hours, nausea and vomiting, which are observed in almost all patients, are typical findings of Ménière’s disease. Complaints and findings that have a very important place in the diagnosis. In this way, the diagnosis of Ménière’s disease based on episodic complaints and findings is consistent with the literature. In summary, in Ménière’s disease, unlike other vestibular diseases, the simultaneous exacerbation of unilateral hearing and balance complaints during seizures is essential. In the definitive diagnosis of Ménière’s disease-despite the presence of advanced audiological tests-long-term follow-up of the patient’s clinical picture remains important. Correspondence Address Dr. Bülent ŞERBETÇİOĞLU Dokuz Eylül Medical Faculty ENT USA 35340 İnciraltı – İZMİR

REFERENCES 1- ANGELBORG, C. Role of hyperosmolar solutions in induced threshold shift. Ménière’s Disease. Pathogenesis, Diagnosis and Treatment, International Symposium, Düsseldorf, 159-163, 1981. 2- MÉNIÈRE, P. Memoire sur des lesions de l’oreille Interne donnant lieu a des symptoms de congestion cerebrale apoplectiforme. Gazette Medical Paris, 1861, 597-601. Limited portion of the publication in English: Parker, W. Meniere’s Disease, Etiological considerations. Archives of Otolaryngoiogy, Head and Neck Surgery, Vol 121, No 4, 377-382, April 1995. 3- OLIVEIRA, CA and BRAGA AM Ménière Syndrome inherited as an autosomal dominant trait. Annals of Otology, Rhinology and Laryngology, 101, 590-594,192. 4- PAPARELLA, MM, SAJJADI, H., DA COSTA, SS, YOON, TH AND LE CT Significance of the lateral sinus and Trautmann’s triangle in Ménière’s disease. Ménière’s Disease, Pathogenesis, Pathophysiology, Diagnosis and Treatment. Proceedings of the Second International Symposium on Ménière’s Disease, 1989. 5- PARKER, W. Ménière’s disease. Etiological considerations. Archives of Otolaryngology, Head and Neck Surgery, Vol. 121, No: 4, 377-382, April 1995. 6- PEARSON, BW, BRACKMANN, DE, Committee on Hearing and Equilibrium guidelines for reporting treatment results in Ménière’s disease: Torok revisited. Otolaryngology Head and Neck Surgery, 93, 579-581,1985. 7- PFALTZ, CR AND MATEFI, L. Ménière’s Disease – or Syndrome? A critical review of diagnose criteria. Meniere’s Disease. Pathogenesis, Diagnosis and Treatment, International Symposium, Düsseldorf, 1-10,1981. 8- RASSEKH, CRISTOPHER, H. and HARKER, LEE, A. The prevalence of migraine in Ménière’s disease. laryngoscopy. Vol. 102, No: 2, 1992. 9- RAUCH, SD, MERCHANT, SN AND THEDINGER, BA Meniere’s Syndrome and endolymphatic hydrops. Double blind temporal bone study. Annals of Otology, Rhinology and Laryngology, 98, 873-883, 1989.

Related Posts

Leave a Reply

Your email address will not be published.