Given the symptoms of episodic dropsin hearing, rotatory vertigo, aural fullness, tinnitus in the right ear, thesuspected diagnosis would be Meniere’s disease. But a description of feeling ofimbalance when turning in bed to the right side and looking up indicates anassociated Benign Paroxysmal Positional Vertigo (BPPV).Inorder to confirm the diagnosis of Meniere’s disease, the following tests would be performed:1. Full- hearing evaluation:- Otoscope-tympanometry- otoacoustic emissions- pure tone audiometry PTA- Speech discrimination test2. Vestibular system evaluation- eye-movement examinations- Caloric test- vestibular evoked myogenic potentials VEMP will be beneficial in diagnosingMeniere’s disease, because the increased pressure of endolymph will potentiallylead to degeneration of hair cells in saccule.
3. Electrocochleography EcochG. is a test used to recordthe auditory-evoked responses of short latency from both cochleae and auditorynerves.
The EcochG parameters tested are: SummatingPotential(SP), whole nerve Action Potential (AP) and SP/AP ratio are used inthe assessment of endolymphatic hydrops. If the patient truly has Meniere’s disease, theresults of the previous tests would be:1. Otoscope will show intact external canal and tympanicmembrane.2. Tympanometry will show type A in both sides3.
Otoacoustic emissions will show slightly loweredresponses in frequencies ranging from 800 – 1100 Hz.4. Pure tone audiometry will show rising audiogram,because Meniere’s disease is suspected to be in its mid phase.
– if Audiogram showed an air- bone gap in lower frequencies, this would not bea result of a conductive factor but due to pressure exerted on the stapediusfootplate from endolymphatic hydrops. But this will be in the early stages of meniere’sdisease, and as the disease progresses, the gap will be diminished, and PTAthreshold will increase gradually resulting in a flat audiogram.5. No reduced speech discrimination will be present incontrast to what would be expected from the audiogram.6. Eye movement examination such as saccades and smoothpursuit will only be used to rule out any central involvement.7. Caloric test will show a negative canal paresis above20% indicating unilateral weakness in the right ear.
– If BPPV was in the horizontal semi-circular canal, the abnormal Caloric testresults would not necessarily be due to Meniere’s disease.8. VEMPs will show abnormal response in both ears. Theunaffected ear will show elevated thresholds, prolonged latencies in p13 andn23 will be seen in both affected and unaffected ears, but to a lesser degreein the unaffected ear.
The affected ear may show no response at all.In a study, patients with Meniere’s diseasewere divided into 4 stages according to their hearing loss. Based on theinformation given in the case history concerning the patient’s hearing loss,she would be in stage 2 or stage 3, which had either no VEMPs response orprolonged p13 and n23 latencies.
(citation)9. Electrocochleography will show enhancement insummating potential SP due to displacement of stereocilia as a result ofincreased pressure of endolymph, which leads to a widened SP/AP waveform. In order to confirm the diagnosis of BPPV, the following testswould be performed:1. Ordinarilywe would use Dix-Hall pike maneuver to confirm BPPV in posterior semi-circularcanal, but because of the patient’s neck problems, we will use side-lying test.Posterior SCC will be tested first because it’s the most common site of BPPV.2. VEMPscan be beneficial for the diagnosis of BPPV because the degeneration of theotolith organ that is usually found in the utricle, can involve the saccule. If the patient truly has BPPV in the posterior SCC, previous tests will havethe following results:1.
Sidelying test will show torsional up-beating nystagmus to the right side. If thisis not the case, roll then rose test will be used to test horizontal andanterior SCCs, respectively.2.
AbnormalVEMP characterized by prolonged latencies and reduced amplitudes will beobserved regardless of the SCC involved.if BPPC was cupuloithitis, VEMP will show normal results.*RegardingVEMP, more depressed and diminished responses are seen in Meniere’s diseasethan BPPV, because the macula in the saccule do not degenerate sufficiently toshow no response at all at VEMP. Management:Management of BPPV Liberatory maneuver (Semont) will be due tothe contraindication of neck pain. In this maneuver, the patient will be ina sitting position, she will tilt her head away from the right affected side,and then she will lie down on her right side with her head turned up.After five minutes she is moved quickly to the opposite side with her headlooking down, she will be in this position for 5-10 minutes, then she returnsto sitting position. Management of MD:Researches proving the efficiency ofvarious therapeutic interventions for Meniere’s are very limited due to Meniere’s unsteady natural, Therefore there isno agreed upon therapy strategy for Meniere’s.” Absence of robust prospective,randomized, placebo-controlled studies has led to a variety of medical andsurgical therapeutic interventions of uncertain value”.
(citation)There are two types of managementsto be provided depending on the purpose of intervention, acute and chronic. Acutemanagement is provided during the first 48 hours after an attack happened again, and chronic management is intended to improve the overall quality of life,since the symptoms of Meniere’s may become severe enough to cause a handicap.Acute Management:This type focuses on suppression ofsymptoms and reducing frequency and severity of attacks:It may involve drugs, mainlyvestibular suppressors (eg. Benzodiazepines) and antiemetic (eg meclizine).Also hydration and rest are very important specially for eliminating vertigo. Chronic management:this includes life-styleadjustments, Pharmacologic Therapy, Complementary and Alternative Medicines,multiple devices, rehabilitation therapy and surgical intervention. Audiologists play a major role inthe rehabilitation therapy which focuses in eliminating tinnitus , hearing andvestibular symptoms.
1) Inmany cases, simple directive counseling can be helpfull in managing tinnitus. (citation)Feenstra2) Hearingaids can also be used for eliminating tinnitus and hearing symptoms. However, due to the fluctuating nature of the Minere’s hearing loss, careshould be taken in the fitting process. 3) Foreliminating vestibular symptoms , Vestibular rehabilitation therapy can be used.This kind of rehabilitation rely mainly on neural plasticity and compensationof the vestibular dysfunction achieved training the central nerves system.A study testing the efficiency ofvestibular rehabilitation to eliminate symptoms of Meinere’s disease, patientsshowed significiant improvement in balance function on both objective andself-report tests (citation.)4) Life-styleadjustments aiming to avoid the triggers of attacks such as: caffiane, alcohol,anxiety and salt.
– Anxiety can be managed by behavior therapy and proper counseling for the patient.- salt reduction can be achieved by changing the diet of the patient and usingherbs and spices instead of salt in food.Many studies reported on reductionof salt in managing Meniere’s symptoms, no study support that sodiumrestriction alone is efficient in managing MD, but a study by Claes and Van deHeyning, suggests that patients should maintain a no more than 1gram of saltper day. (citation) 5) PharmacologicTherapy such as giving Diuretics, Steroidsand Amino glycoside Ablation.
– Intratympanic gentamicin (ITG) is one of the most used AminoglycosideAblation. “The large number of publishedreports on the efficacy of ITG has led to near abandonment of surgicalintervention.” (citation in text )- Patient’swith unilateral MD, such as our case would be recommended to follow the low-dose method described by (Harner. et al) 6) Devicessuch as:- The Meniett which is a low-intensitypressure generator that is worn in the external auditory canal, can be used toreduce vertigo’s severity and frequency specially on the short-term. – p-100 is also used as a less-expensive replacement for the Meniett.
However,studies that proves it’s efficiency are rare. 7) Surgicalinterventions (eg. Vestibular nerve section and endolymphatic sac surgery) areused to eliminate the symptoms of MD, but such surgeries result in noimprovement in hearing.In a study, no difference was foundin the overall improvement between patients treated conservatively, medicallyor surgically.For this patient, we will refer herto an ENT for any medical/ surgical interventions.
As audiologists, we can provide her with hearing aids and vestibularrehabilitation exercises, such as: Cawthorne-Cooksey Exercises, these exercises