Transcript Trout, Jordan-Acute Condition Presentation

MENIERE’S DISEASE
JORDAN TROUT
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
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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
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
PATHOGENESIS
• Endolymphatic hydrops
• Caused by the buildup of
fluid in inner ear
• Causes:
• Idiopathic
• Immune mechanism,
genetic, viral, vascular,
trauma
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-ismenieres-disease-and-what-can-be-done-to-treat-it-201507088067
CLINICAL MANIFESTATIONS
HISTORY
• 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
CLINICAL MANIFESTATIONS
HISTORY
• ROS and Health History:
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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
CLINICAL MANIFESTATIONS
PHYSICAL EXAM
• 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
DIX-HALLPIKE
MANEUVER
• 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
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.
DIAGNOSTIC TESTS
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Audiometry
Vestibular Testing (ENG)
ECoG and VEMP
Laboratory work
• CBC, CMP, TSH, ESR, Lyme, lipid profile, RPR
• CT or MRI
DIFFERENTIAL DIAGNOSIS
Differentials
Red Flags
• Benign paroxysmal
positional vertigo (BPPV)
• Cogan’s syndrome
• Migraine
• Perilymph Fistula
• Labyrinthitis
• Vertigo secondary to
medications
• Diabetes or Thyroid
disease
• Brainstem/Cerebellar
Dysfunction
• MS
• TIA
• Acoustic Neuroma
• Syphilis: Secondary or
early tertiary
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
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)
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
REFERENCES
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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 (7th 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
QUESTIONS?