Author:



Author: Teresa S. Wu, MD Reviewer: Thomas Payton, MD

Case Title: “I think I’m having a stroke!”

Target Audience: medical students, physicians’ assistants, nurse practitioners, residents

Primary Learning Objectives: key learning objectives of the scenario

1. The participant will obtain a detailed history and perform a comprehensive neurological exam.

2. The participant will formulate a broad & comprehensive differential diagnosis for patients presenting with vertigo.

3. The participant will avoid anchoring into a diagnosis and will carefully consider the data presented in the case.

4. The participant will explain the pathophysiology of Meniere’s Disease and offer options for symptomatic control and surgical treatment.

Secondary Learning Objectives:

1. The participant will actively manage and reassess the patient’s symptoms (IV antiemetics, benzodiazepines, IVF’s, etc.)

2. The participant will order the correct tests to rule-out an acute cerebral event

3. The participant will order the correct blood work to rule-out co-existing metabolic, hormonal, or endocrinological disturbances.

4. The participant will demonstrate compassion and empathy during the evaluation and management of the patient

Critical actions checklist:

1. Places patient on a cardiac monitor with pulse oximetry

2. Obtains a bedside ECG

3. Places the patient on supplemental oxygen

4. Checks a bedside point-of-care glucose

5. Performs a full neurological exam

6. Performs a hearing test

7. Orders a CT scan to rule out acute intracranial pathology

8. Places a peripheral IV

9. Draws labs to evaluate for metabolic disturbances, infections, and endocrine or hormonal abnormalities contributing to the symptomatology.

10. Elicits a history of vertigo, tinnitus, and hearing loss from the patient and makes the diagnosis of Meniere’s Syndrome.

11. Obtains a neurological consult to aid in the patient’s disposition

Environment

1. Room Set Up – Emergency Department Resuscitation Bay

a. Mannequin: SimMan 3G with a female wig

b. Equipment:

1. Cardiac Monitor

2. Blood pressure cuff (manual and automatic)

3. Peripheral IVs (18 gauge, 16 gauge)

4. Gauze

5. Tape

6. Tourniquet

7. Tegaderm

8. IV caps or heplocks

9. Oxygen Source/Tree

10. Non-rebreather

11. IV fluids (NS and LR)

12. Blood collection tubes (rainbow)

13. Urine specimen

14. Lab reports (CBC, CMP, coagulation panel, UA, cardiac enzymes)

15. Meclizine

16. Ativan

17. Antiemetics (zofran, phenergan, compazine, etc.)

18. Aspirin

19. Normal EKG

20. Normal head CT

21. Phone call to consults

Actors (optional)

1. Nurse

2. Paramedics to give report about the patient

3. Patient’s husband

4. Neurologist

5. Radiology technician

For Examiner Only

Author: Teresa S. Wu, MD

Case Title: “I think I’m having a stroke!”

CASE SUMMARY

CORE CONTENT AREA

Otolaryngology

SYNOPSIS OF HISTORY/ Scenario Background

A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. She was outside working on the garden when she started to feel dizzy. She went inside to “cool off” and started developing a “headache”. Her husband called 911 because he thought she was having a stroke.

When asked, the patient will note that her headache feels like “fullness” that came on gradually. Now she feels like the room is spinning. She’s had no visual changes, but she feels like there is a “buzzing in her ear”. She denies any chest pain, shortness of breath, paresthesias, weakness, nausea, or vomiting. This is the first time she has experienced these symptoms. She cannot recall any inciting event.

Past Medical History: HTN

Medications: Lisinopril

Allergies: PCN

Family History: HTN, CAD

Social History: Married. Retired. Denies EtOH, tobacco, or illicit drugs.

SYNOPSIS OF PHYSICAL

Patient is sitting upright in the gurney, diaphoretic, complaining of dizziness.

Her neurological exam is significant for decreased hearing on the left, nystagmus, and a positive Romberg.

HR 90 BP 167/52 RR 18 O2 Sat 99% Temp 37.6

For Examiner Only

CRITICAL ACTIONS

Scenario branch points/ PLAY OF CASE GUIDELINES

1. Critical Action

The participant should order a head CT or MRI to rule out an acute cerebral event.

Cueing Guideline: The patient and her husband should continue to ask the participant if she is having a stroke.

2. Critical Action

The participant should perform a thorough neurological exam and note that the patient’s exam is only notable for fatigable nystagmus and a positive Romberg test.

Cueing Guideline: The patient continues to complain that she feels “really, really dizzy”.

3. Critical Action

The participant should inquire more about the “roaring sound” and ask about associated tinnitus.

Cueing Guideline: The patient starts to complain that there is a “roaring sound” in her ears and that the sound is making her headache worse.

4. Critical Action

The participant should assess the patient’s hearing either through a gross assessment with finger rubs or via a tuning fork (Rinne and Weber’s tests).

The patient continues to ask the participant to repeat each question asked because she is “having a hard time hearing” him/her.

5. Critical Action

The participant should send the following blood tests to rule-out other certain metabolic disturbances, infections, and endocrine or hormonal abnormalities contributing to the symptomatology:

• TSH, Free T4 and T3

• CBC

• BMP

• ESR

• CRP

• UA

• FTA-ABS

Cueing Guideline: The nurse asks the participant what lab tests he/she would like to send.

Maximum Points for Critical Actions: 10 points

SCORING GUIDELINES

(Critical Action No.)

1. 2 points awarded if the CT or MRI is obtained.

2. 2 points awarded if a full neurological exam is performed. 1 point awarded if a partial neurological exam is performed.

3. 2 points awarded if the participant elicits more history and details concerning the “roaring sound” the patient is endorsing. 1 point awarded if the participant simply acknowledges the complaint.

4. 2 points awarded if the participant assesses the patient’s hearing by performing both Rinne and Weber’s tests. 1 point awarded if the participant performs only one of the above mentioned tests or simply evaluates for gross hearing loss through finger rub.

5. 2 points awarded if the participant orders all of the blood tests listed above. 1 point awarded if partial blood work is ordered.

For Examiner Only

HISTORY

Onset of Symptoms: The symptoms began gradually about an hour prior to arrival to the ED.

Background Info: A 60 y.o. female is brought in by EMS with a chief complaint of dizziness.

Chief Complaint: The patient was outside working on the garden when she started to feel dizzy. She went inside to “cool off” and started developing a “headache”. Her husband called 911 because he thought she was having a stroke. She has never had symptoms like this before and she feels like her dizziness is getting worse. She feels diaphoretic and nauseated.

Past Medical Hx: HTN

Past Surgical Hx: None.

Habits: Denies smoking, ETOH, or illicit drugs.

Family Medical Hx: HTN, CAD

Social Hx: Marital Status: married

Children: one, healthy

Education: BS

Employment: retired

ROS:

Positive for dizziness/vertigo, “roaring in her ears”, an occipital headache, decreased hearing, nausea, diaphoresis, and “feeling faint”

Negative for any chest pain, palpitations, shortness of breath, visual changes, weakness, paresthesias, abdominal pain, extremity swelling, or pain

For Examiner Only

PHYSICAL EXAM

Patient Name: Margaret Davenport Age & Sex: 60 y.o. female

General Appearance: Well-developed, well-nourished female in moderate distress. She is sitting upright in the gurney, diaphoretic, and moaning.

Vital Signs: HR 90 BP 167/52 RR 18 O2 Sat 99% Temp 37.6

Head: Normocephalic. Atraumatic.

Eyes: PERRLA bilaterally. Horizontal, fatigable nystagmus to the left. EOMI. No scleral icterus.

Ears: Normal TM’s bilaterally. Decreased hearing on the left. Weber test lateralizes to the right. Rinne test indicates that air conduction is better than bone conduction on the right.

Mouth: Clear. Moist. No asymmetry.

Neck: Supple. No masses. No JVD. No thyroid enlargement. No midline TTP.

Skin: Warm and dry. No rashes, cyanosis, or edema. 2+ capillary refill bilaterally.

Chest: No crepitus. No signs of trauma.

Lungs: CTA bilaterally. No rales, rhonchi or wheezes. Good air movement bilaterally.

Heart: RRR. No murmurs, rubs, or gallops. Normal S1 and S2.

Back: No spinal TTP. No CVAT.

Abdomen: Soft, NT/ND. +BS. No HSM.

Extremities: No cyanosis, clubbing, or edema. Normal range of motion bilaterally.

Rectal: Normal tone. Guaiac negative.

Pelvic: No discharge or bleeding. No CMT. No adnexal fullness or TTP. Normal uterine size.

Neurological: A&O x 4. CN II is diminished grossly bilaterally. CNIII-XII grossly intact. 4+ strength bilaterally throughout. No pronator drift. +Romberg. 2+ DTR’s bilaterally throughout. Normal heel to shin. Normal finger-to-nose. No dysdiadochokinesia.

Mental Status: Alert, coherent, with good insight.

For Examiner Only

STIMULUS INVENTORY

#1 Emergency Admitting Form

#2 BMP

#3 LFTs

#4 Magnesium

#5 Urine Drug Screen

#6 CBC

#7 Coagulation panel

#8 TSH

#9 EKG

#10 Head CT

For Examiner Only

LAB DATA & IMAGING RESULTS

Stimulus #2

Basic Metabolic Profile (BMP)

GLUCOSE 121 Latest Range: 60-99 MG/DL

SODIUM 140 Latest Range: 133-145 MEQ/L

POTASSIUM 4.9 Latest Range: 3.5-5.3 MEQ/L

CHLORIDE 106 Latest Range: 98-108 MEQ/L

CO2 23 Latest Range: 23-32 MEQ/L

BUN 7 Latest Range: 7-23 MG/DL

CREATININE 0.8 Latest Range: 0.6-1.3 MG/DL

CALCIUM 9.3 Latest Range: 8.5-10.3 MG/DL

Stimulus #3

Liver Function Tests (LFTs)

TOTAL PROTEIN 7.3 Latest Range: 6.1-7.9 GM/DL

ALBUMIN 4.0 Latest Range: 3.5-5.5 GM/DL

BILIRUBIN TOTAL 0.8 Latest Range: 0.1-1.4 MG/DL

BILIRUBIN DIRECT 0.2 Latest Range: 0.0-0.4 MG/DL

PHOSPHORUS 2.7 Latest Range: 2.4-4.7 MG/DL

ALK PHOSPHATASE 78 Latest Range: 0-135 IU/L

SGOT 41 Latest Range: 0-41 IU/L

SGPT 40 Latest Range: 0-63 IU/L

Stimulus #4

MAGNESIUM 2.0 Latest Range: 1.7-2.8 MG/DL

Stimulus #5

Urine Drug Screen

MARIJUANA SCREEN NEGATIVE No range found

COCAINE MET SCREEN NEGATIVE No range found

AMPHETAMINE SCREEN NEGATIVE No range found

METHAMPHETAMINE SCRN, UR NEGATIVE No range found

BARBITURATE SCREEN NEGATIVE No range found

OPIATES SCREEN NEGATIVE No range found

PHENCYCLIDINE SCREEN NEGATIVE No range found

METHADONE SCREEN NEGATIVE No range found

BENZODIAZEP SCRN NEGATIVE No range found

TRICYCL ANTIDEPRESS SCRN, UR NEGATIVE No range found

Stimulus #6

Complete Blood Count (CBC)

WBC 10.0 Latest Range: 4.0-10.0 THOU/CU MM

RBC 4.9 Latest Range: 4.30-5.90 M/UL

HEMOGLOBIN 13.0 Latest Range: 13.0-17.0 GM/DL

HCT 39.0 Latest Range: 39.0-51.0 %

MCV 92.7 Latest Range: 81.0-99.0 CU MICRONS

MCH 31.0 Latest Range: 27.0-33.0 UUG

MCHC 33.5 Latest Range: 32.5-36.5 %

RDW 11.7 Latest Range: 11.6-14.8 %

PLATELET COUNT 380 Latest Range: 150-400 THOU/CU MM

Differential

NEUT% 74 Latest Range: 40.0-74.0 %

LYMPH% 26 Latest Range: 12.0-40.0 %

MONO% 9.7 Latest Range: 4.0-12.0 %

EOSIN% 0.0 Latest Range: 0.0-8.0 %

BASO% 0.3 Latest Range: 0.0-2.0 %

Stimulus #7

Coags

PT 15 Latest Range: 12–15 seconds

INR 1.0 Latest Range: 0.8-1.2

Stimulus #8

TSH 2.0 Latest Range: 0.4-5 (IU/mL

Free T4 1.0 Latest Range: 0.7-1.5 ng/dL

Stimulus #9

EKG: normal

Stimulus #10

CT head: normal

Learner Stimulus #1

ABEM General Hospital

Emergency Admitting Form

Name: Margaret Davenport

Age: 60 year old

Sex: Female

Method of Transportation: EMS

Person giving information: Patient and her husband

Presenting complaint: Dizziness

Background: A 60 y.o. female is brought in by EMS with a chief complaint of dizziness. Her husband is present in the room.

Triage or Initial Vital Signs

HR 90 BP 167/52 RR 18 O2 Sat 99% Temp 37.6(C

Learner Stimulus #2

Basic Metabolic Profile (BMP)

GLUCOSE 121 Latest Range: 60-99 MG/DL

SODIUM 140 Latest Range: 133-145 MEQ/L

POTASSIUM 4.9 Latest Range: 3.5-5.3 MEQ/L

CHLORIDE 106 Latest Range: 98-108 MEQ/L

CO2 23 Latest Range: 23-32 MEQ/L

BUN 7 Latest Range: 7-23 MG/DL

CREATININE 0.8 Latest Range: 0.6-1.3 MG/DL

CALCIUM 9.3 Latest Range: 8.5-10.3 MG/DL

Learner Stimulus #3

Liver Function Tests (LFTs)

TOTAL PROTEIN 7.3 Latest Range: 6.1-7.9 GM/DL

ALBUMIN 4.0 Latest Range: 3.5-5.5 GM/DL

BILIRUBIN TOTAL 0.8 Latest Range: 0.1-1.4 MG/DL

BILIRUBIN DIRECT 0.2 Latest Range: 0.0-0.4 MG/DL

PHOSPHORUS 2.7 Latest Range: 2.4-4.7 MG/DL

ALK PHOSPHATASE 78 Latest Range: 0-135 IU/L

SGOT 41 Latest Range: 0-41 IU/L

SGPT 40 Latest Range: 0-63 IU/L

Learner Stimulus #4

MAGNESIUM 2.0 Latest Range: 1.7-2.8 MG/DL

Learner Stimulus #5

Urine Drug Screen

MARIJUANA SCREEN NEGATIVE No range found

COCAINE MET SCREEN NEGATIVE No range found

AMPHETAMINE SCREEN NEGATIVE No range found

METHAMPHETAMINE SCRN, UR NEGATIVE No range found

BARBITURATE SCREEN NEGATIVE No range found

OPIATES SCREEN NEGATIVE No range found

PHENCYCLIDINE SCREEN NEGATIVE No range found

METHADONE SCREEN NEGATIVE No range found

BENZODIAZEP SCRN NEGATIVE No range found

TRICYCL ANTIDEPRESS SCRN, UR NEGATIVE No range found

Learner Stimulus #6

Complete Blood Count (CBC)

WBC 10.0 Latest Range: 4.0-10.0 THOU/CU MM

RBC 4.9 Latest Range: 4.30-5.90 M/UL

HEMOGLOBIN 13.0 Latest Range: 13.0-17.0 GM/DL

HCT 39.0 Latest Range: 39.0-51.0 %

MCV 92.7 Latest Range: 81.0-99.0 CU MICRONS

MCH 31.0 Latest Range: 27.0-33.0 UUG

MCHC 33.5 Latest Range: 32.5-36.5 %

RDW 11.7 Latest Range: 11.6-14.8 %

PLATELET COUNT 380 Latest Range: 150-400 THOU/CU MM

Differential

NEUT% 74 Latest Range: 40.0-74.0 %

LYMPH% 26 Latest Range: 12.0-40.0 %

MONO% 9.7 Latest Range: 4.0-12.0 %

EOSIN% 0.0 Latest Range: 0.0-8.0 %

BASO% 0.3 Latest Range: 0.0-2.0 %

Learner Stimulus #7

Coags

PT 15 Latest Range: 12–15 seconds

INR 1.0 Latest Range: 0.8-1.2

Learner Stimulus #8

TSH 2.0 Latest Range: 0.4-5 (IU/mL

Free T4 1.0 Latest Range: 0.7-1.5 ng/dL

Learner Stimulus #9

EKG: Normal EKG demonstrating sinus tachycardia at 90-100 bpm

Learner Stimulus #10

CT Head: normal

For Examiner

Date: Examiner: Examinee(s):

Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)

The learner should be scored (based on level of training) for each item above with one of the following:

NI = Needs Improvement

ME = Meets Expectations

AE = Above Expectations

NA= Not Assessed

|Critical Actions |NI |ME |AE |NA |Category |

|Places patient on a cardiac monitor with pulse oximetry | | | | |PC, MK, PBL |

|Obtains a bedside ECG | | | | |PC, MK, PBL |

|Places the patient on supplemental oxygen | | | | |PC, MK, PBL |

|Performs a full neurological exam | | | | |PC, MK, PBL |

|Performs a hearing test | | | | |PC, MK, PBL |

|Orders a CT scan to rule out acute intracranial pathology | | | | |PC, MK, PBL, SBP |

|Places a peripheral IV | | | | |PC, MK, PBL |

|Draws labs to evaluate for metabolic disturbances, | | | | |PC, MK, PBL, SBP |

|infections, and endocrine or hormonal abnormalities | | | | | |

|contributing to the symptomatology. | | | | | |

|Elicits a history of vertigo, tinnitus, and hearing loss | | | | |PC, MK, ICS, SBP |

|from the patient and makes the diagnosis of Meniere’s | | | | | |

|Syndrome. | | | | | |

|Obtains a neurological consult to aid in patient | | | | |PC, MK, ICS, SBP |

|disposition. | | | | | |

Category: One or more of the ACGME Core Competencies as defined in the SDOT

PC= Patient Care

Compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

MK= Medical Knowledge

Residents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making

PBL= Practice Based Learning & Improvement

Involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

ICS= Interpersonal Communication Skills

Results in effective information exchange and teaming with patients, their families, and other health professionals

P= Professionalism

Manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

SBP= Systems Based Practice

Manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

References:

1. Minor LB, Schessel DA, Carey JP. Ménière's disease. Curr Opin Neurol. Feb 2004;17(1):9-16. 

2. Sajjadi H, Paparella MM. Meniere's disease. Lancet. Aug 2 2008;372(9636):406-14. 

3. Paparella MM. Pathogenesis and pathophysiology of Meniére's disease. Acta Otolaryngol Suppl. 1991;485:26-35. 

4. Paparella MM, Djalilian HR. Etiology, pathophysiology of symptoms, and pathogenesis of Meniere's disease. Otolaryngol Clin North Am. Jun 2002;35(3):529-45, vi. 

5. Merchant SN, Adams JC, Nadol JB Jr. Pathophysiology of Meniere's syndrome: are symptoms caused by endolymphatic hydrops?. Otol Neurotol. Jan 2005;26(1):74-81.

6. Kitahara M. Bilateral aspects of Meniére's disease. Meniére's disease with bilateral fluctuant hearing loss. Acta Otolaryngol Suppl. 1991;485:74-7. 

7. Morrison AW, Johnson KJ. Genetics (molecular biology) and Meniere's disease. Otolaryngol Clin North Am. Jun 2002;35(3):497-516. 

8. Mancini F, Catalani M, Carru M, Monti B. History of Meniere's disease and its clinical presentation. Otolaryngol Clin North Am. Jun 2002;35(3):565-80. 

9. Monsell EM. New and revised reporting guidelines from the Committee on Hearing and Equilibrium. American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg. Sep 1995;113(3):176-8.

10. Kentala E, Havia M, Pyykko I. Short-lasting drop attacks in Meniere's disease. Otolaryngol Head Neck Surg. May 2001;124(5):526-30. 

11. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Nov 2008;139(5 Suppl 4):S47-81. 

12. White J. Benign paroxysmal positional vertigo: how to diagnose and quickly treat it. Cleve Clin J Med. Sep 2004;71(9):722-8. 

13. Fattori B, Nacci A, Dardano A, Dallan I, Grosso M, Traino C. Possible association between thyroid autoimmunity and Menière's disease. Clin Exp Immunol. Apr 2008;152(1):28-32. 

14. Lorenzi MC, Bento RF, Daniel MM, Leite CC. Magnetic resonance imaging of the temporal bone in patients with Ménière's disease. Acta Otolaryngol. Aug 2000;120(5):615-9. 

15. de Sousa LC, Piza MR, da Costa SS. Diagnosis of Meniere's disease: routine and extended tests. Otolaryngol Clin North Am. Jun 2002;35(3):547-64. 

16. Wetmore SJ. Endolymphatic sac surgery for Ménière's disease: long-term results after primary and revision surgery. Arch Otolaryngol Head Neck Surg. Nov 2008;134(11):1144-8. 

17. Pullens B, Giard JL, Verschuur HP, van Benthem PP. Surgery for Ménière's disease. Cochrane Database Syst Rev. Jan 20 2010;CD005395. 

18. Sajjadi H. Medical management of Meniere's disease. Otolaryngol Clin North Am. Jun 2002;35(3):581-9, vii. 

19. Coelho DH, Lalwani AK. Medical management of Ménière's disease. Laryngoscope. Jun 2008;118(6):1099-108. 

20. Cope D, Bova R. Steroids in otolaryngology. Laryngoscope. Sep 2008;118(9):1556-60. 

21. Odkvist LM, Arlinger S, Billermark E, Densert B, Lindholm S, Wallqvist J. Effects of middle ear pressure changes on clinical symptoms in patients with Ménière's disease--a clinical multicentre placebo-controlled study. Acta Otolaryngol Suppl. 2000;543:99-101. 

22. Havia M, Kentala E. Progression of symptoms of dizziness in Ménière's disease. Arch Otolaryngol Head Neck Surg. Apr 2004;130(4):431-5. 

Keywords for future searching functions:

vertigo, tinnitus, hearing loss, Meniere’s Disease

Has this work been published? No

Debriefing Information:

← Meniere’s Disease is also known as idiopathic endolymphatic hydrops.

← It is a disorder of the inner ear resulting in the clinical triad of: vertigo, tinnitus, and hearing loss:

o Vertigo

▪ Vertigo is a subjective sensation of motion while motionless.

▪ At least 2 definitive episodes of vertigo of at least 20 minutes duration must have occurred to make the diagnosis.

▪ Duration is usually several hours long.

▪ Horizontal or rotatory nystagmus is always present during attacks of vertigo.

▪ Symptoms are often accompanied with nausea, vomiting, and anxiety.

▪ Acute attacks may be accompanied with sudden falls without loss of consciousness. These are termed crises of Tumarkin or drop attacks. Most studies find the incidence of drop attacks to be less than 10%. In one case series, self-reporting of drop attacks was 72% among patients with diagnosis of Ménière's disease.

▪ It is important to distinguish if the patient’s vertigo is suggestive of central vs. peripheral causes (Table 1)

Table 1: Characteristics of Peripheral Vs. Central Causes of Vertigo

|Sign of Symptom |Peripheral Vertigo |Central Vertigo |

|Nystagmus |-Horizontal or torsional |-Vertical, horizontal, or torsional |

| |-Inhibited by fixating eyes onto an object |-Not inhibited by fixating eyes onto an object |

| |-Diminishes with time; fatigueable |-May last weeks to months; not immediately |

| |-Does not change direction with alteration of |fatigueable |

| |gaze from side to side |-Fast phase of nystagmus may change with gaze |

| | |alteration from side to side |

|Imbalance |Mild to moderate; patient is usually able to |Severe; patient is typically unable to walk or |

| |walk |stand |

|Nausea and vomiting |May be severe in nature |Varies |

|Hearing loss or tinnitus |Commonly associated |Rarely associated |

|Non-auditory neurologic symptoms |Rarely associated |Commonly associated |

|Latency following provocative diagnostic |Long (up to 20 seconds) |Short (up to 5 seconds) |

|maneuver | | |

o Hearing loss

▪ Sensorineural hearing loss must be documented audiometrically in the affected ear at least once during the course of the disease.

▪ There may be fluctuation in the degree of hearing loss superimposed on a gradual decrement in function.

▪ Hearing loss affects low frequencies primarily.

o Tinnitus and aural fullness

▪ Tinnitus is often nonpulsatile and may be described as whistling or roaring.

▪ It may be continuous or intermittent.

← The etiology of Meniere’s Disease is still rather controversial.

← The underlying mechanism is believed to be distortion of the membranous labyrinth due to over-accumulation of endolymph secondary to obstruction or decreased drainage.

← Obstruction or decreased drainage is felt to be from infection, trauma, allergens, or idiopathic.

← The main morbidity associated with Meniere’s Disease is the debilitating nature of the symptoms, potential for drop attacks and subsequent trauma, and permanent hearing loss.

← If Meniere’s Disease is suspected, the examiner should perform the following tests:

o A full neurological exam including the Romberg test

o Dix-Hallpike Maneuver

o Gross hearing evaluation via finger rub

o Rinne test with a 256 MHz tuning fork

o Weber test with a 256 MHz tuning fork

← The differential diagnoses for Meniere’s Disease is quite broad and includes, but is not limited to:

o Benign positional vertigo

o Ischemic or hemorrhagic stroke

o Migraine headache

o Hypothyroidism or Myxedema coma

o Temporal lobe epilepsy

o Labyrinthitis

o Toxicities (e.g. Salicylate)

o Multiple sclerosis

o TIA

o Otitis media

o Vestibular neuronitis

o Meningitis

o Brainstem tumor

o Foreign body or cerumen in the ear canal

o Acoustic neuromas

o Perilymphatic fistulas

o Labyrinth trauma

o Herpetic encephalitis

o CNS syphyllis

o Wernicke’s encephalopathy

← Evaluation of the patient’s symptomatology should be directed towards ruling-out life threatening or emergent etiologies listed on this differential. Obtaining a neurology consult can aid in the patient’s final disposition.

← Treatment is symptomatic and can include:

o Antihistamines such as Meclizine or Dimenhydranate

o Anticholinergics such as Scopolamine

o Antiemetics such as Compazine, Zofran, or Phenergan

o Benzodiazepines such as ativan or valium

o Corticosteroids such as prednisone

← Refer patients to ENT for full audiometric testing.

← All patients should be educated about the chance for spontaneous remission (approximately 50%) vs. the need for further evaluation and surgical intervention.

← Patients should be warned about the risks of potential drop attacks and side effects of long term symptomatic management with medications.

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