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Diagnostic criteria for Meniere's

Timothy C. Hain, MD Page last modified: June 7, 2015

Comments on committee criteria (these are in reverse chronological order in the text)

Meniere's disease (or syndrome -- we will use either term here) is a "committee" disorder -- the diagnosis is based on whatever a committee of experts think. This differs from disorders diagnosed on objective physical measurements, and resembles the unfortunate situation with psychiatric disorders. Another way to put this is to say that "committee" disorders are "wastebasket" syndromes -- you remove all diagnoses that have more secure and verifiable sources, and with the left-overs, you assign them based on what a group of experts think. Another way to look at it is that is that a patient seeking to obtain disability can meet the criteria for most committee disorders by doing a little internet research and answering the questions posed by doctors correctly. This is a bad situation, and of course, it is best to make the criteria harder to fake.

Of course, committees can meet more than once, and they almost always come to different opinions each time. This is the clearly the situation with Meniere's, as we have now at least 4 different committee opinions (AAO 1992, AAO 1995, Japanese society from 1974, and the latest 2015 "International" criteria). Unlike the situation with some "practice standards", there was no formal invitation for review of these new "international" criteria. Usually this is done by emailing the proposed standard out to potential commentators well before they are published.

Clinicians can "vote with their feet" and ignore committee criteria. This may be the evolving situation with the criteria for vestibular migraine, which are just too cumbersome.

Here we will review in a critical way three sets of criteria for Meniere's disease -- the Japan criteria, the current standard 1995 AAO criteria, and the newly proposed "International Classification" from 2015. Our general thought is that the AAO 1995 criteria are actually very good. They might be best improved by just having a single criterion for "definite Menieres disease", relabelled as "Menieres' syndrome". In other words, leave out all of probable and possible categories. This is not much of a change. More thoughts about a better definition of Meniere's, that is a subset of the AAO 1995 criteria, are at the bottom of this document -- they are the opinions of the author, who is a very experienced vestibular clinician -- a committee of one so to speak. We do welcome comments.

"International Classification of Vestibular Disorders" (Lopez-Escamez et al, 2015).

This document was produced by a committee with members drawn from several clinical societies, who evidently volunteered to rewrite the criteria. It was not "voted on" -- this would be a very cumbersome process -- and in fact, we do not know even of a review process. It seems instead that this new document simply reflects the opinions of the individuals referenced as authors, with the implication that their opinions are reflective of a larger body of individuals who make up the societies. The authors were generally academic physicians who are editors of journals that publish papers concerning ear problems, or physicians who have published previous opinion papers about Meniere's.

Here are the "International" criteria:

Definite Meniere's disease:

  1. Two or more spontaneous episodes of vertigo 20 minutes and 12 hours
  2. low to medium frequency sensorineural hearing loss. Thresholds must be at least 30 dB HL worse in the affected ear at two contiguous frequencies below 2000 Hz.
  3. fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ears. Must occur within 24 hours of the vertigo episode.
  4. Not better accounted for by another vestibular diagnosis.

Comment: These criteria are a tighter version of the AAO-1995. They are tighter as they set an upper limit on duration, they require a specific type of hearing loss, and they require some change in reported symptoms within 12 hours. Strangely, this document provides A,B,C,E but leaves out criterion D -- one wonders about the editing of this document.

Probable Meniere's:

  1. episodic vestibular symptoms (vertigo or dizziness) 20 minutes to 24 hours associated with
  2. fluctuating aural symptoms (hearing, tinnitus or fullness)
  3. Not better accounted for by another vestibular diagnosis

 

This document also seems somewhat loosely edited --it provides A,B,D and leaves out C; 3 again is a wastebasket criterion. In addition to leaving out letters in their lists, there are also typos elsewhere (e.g. "cat" on page 14 -- perhaps this is meant to be "ear" as it has 3 letters)

AAO criteria, 1995

Certain Menieres disease

(it would seem nearly impossible to ever have definite Meniere's, while the patient is still alive, as it requires either an autopsy or surgically removed tissue).

Definite Meniere's disease

Comment: this is a very reasonable definition that is not quite as tight as the newly proposed "International" criteria. In particular, vertigo can last for more than 12 hours, and the hearing loss need not be low frequency. In the internet age, tighter criteria are preferable.

Probable Meniere's disease

Comment: This criterion is very loose as it could easily include any "one off" events such as ear infections -- we think a symptom collection diagnosis would be better -- i.e. vertigo, hearing loss, tinnitus.

Possible Meniere's disease

Comment: This criterion is way too loose -- doesn't belong under "Meniere's at all -- should be just a symptom diagnosis.

Japan criteria -- Meniere's disease research committee of Japan, 1974

    1. Repeated spells of whirling vertigo
    2. Fluctuating cochlear symptoms
    3. Exhaustion of CNS involvement, VIIIth nerve tumor, or other diseases.

They furthermore defined "definite Meniere disease" as including 1-3, and "Suspicious or uncertain Meniere's disease" as 1-3 or 2-3.

Commentary on the Japanese criteria for Meniere's disease:

Oddly, there is no true reference to the Japan criteria for Meniere's. It is alluded to in papers written about Meniere's from Japan, but evidently it went unpublished. See Shojaku et al (2009) for a typical description.

The Japanese criteria are too loose. Every subsequent criterian for Meniere's is narrower. They are not identical to the the AAO 1995 criteria, because there is no requirement for a somewhat objective finding (i.e. hearing loss -- hearing loss can still be "faked"). The "mushiness" to the Japanese criteria means Japanese studies are possibly reporting a different symptom collection than the AAO studies. The "fluctuating symptoms"is much broader than the requirement for a static hearing loss of the AAO criteria, because anyone could claim to have tinnitus or fullness -- these are not verifiable. If they had chosen to say "fluctuating hearing loss on audiometry", they would have been tighter, but this was not done. Because the term "cochlear symptoms" is used rather than splitting out hearing from tinnitus and fullness, there is less specificity. Item 3 is the wastebasket criterion We think that hearing loss should be required, and we agree that either tinnitus or fullness should be required as in the AAO, 1995 and later criteria

Regarding the definite/uncertain distinction, we would not use the term "disease" at all, and we like the "uncertain" term, although we would not even dignify it as "Meniere's" at all.

Dr. Hain's suggested criteria for Meniere's (2015). These are a narrowed version of the AAO-1995 criteria.

Hain criteria for Meniere's syndrome

When patients miss one or more criteria, the appropriate term would be "undiagnosed inner ear disorder", "uncertain", or "possible Meniere's disease". This is similar to the Japan criteria. We are not attempting to deal with bilateral Meniere's here, as this would be more complicated lacking a contralateral normal ear.

Everyone who fits the Hain criteria, also fit the AAO-1995 criteria, as the Dr. Hain criteria define a narrower subset of the AAO-1995 criteria.

Comment: The author of this page, Dr. Hain, has had a huge experience with diagnosing and treating Meniere's over the last 30 years.

Given the flaws of all criteria for Meniere's, including the most recent attempt in 2015, we think there is room to propose others. This definition above is a small adjustment to the 1995 AAO criteria, attempting to include the improvements of the "International" criteria, and adjust out the problematic changes that they introduced. Of course, a "group effort" will generally always have more problems attaining agreement than a single individual. While we have some anxiety about pointing this out, but "International" committees made up largely of individuals where English is not their first language, might not be the best at developing English documents where every word counts.

In the definition above, this is the rationale for preserving/changing items of the "International" proposal.

This definition might be improved by attempting to exclude the most common migraine variants, by excluding headache or sensory phenomena such as photophobia, but it is presently not clear if this is a useful process. The author of this page would be happy to entertain suggestions regarding any of these criteria.

REFERENCES

 

Copyright August 3, 2016 , Timothy C. Hain, M.D. All rights reserved. Last saved on August 3, 2016