Meniere's attack

Timothy C. Hain, MD • Page last modified: February 13, 2022

Most of the time, patients with Meniere's disease are not dizzy "on the spot", but occasionally a patient visit coincides with an attack. During an attack, dogma states that due to a rupture in the membrane between the endolymphatic and perilymphatic compartment, there is a "storm" including vertigo, nystagmus, tinnitus, fullness and an acute drop in hearing.

Case 1: Paretic nystagmus

This patient was in the office for a low-dose gentamicin treatment, and happened to have an attack while sitting in the examination chair.

The video link shows the nystagmus during this attack. It is not especially strong, and it is primarily torsional, beating clockwise. As this patients sick ear is clearly the right side, we are seeing an inhibitory nystagmus, primarily affecting the vertical canals.

The two audiogram results below show hearing testing during the same Meniere's attack (with nystagmus and nausea).

What is interesting here is that thresholds show relatively little change - -the ear is not "shut down" during this attack. The extremes are a little more pronounced.

 

Case 2: Irritative nystagmus during Meniere's attack.

Sometimes patients with Meniere's have nystagmus that goes in the "wrong direction" during their attack.

In the second case below, this man was examined at the bedside and had very little nystagmus. A few hours later, he had a rotatory chair test with the following nystagmus:

 

As his hearing loss is on the left side, this is an "irritative nystagmus" such as described by Hirai et al (2017).

This patient also had a profound "asymmetry" on the rotatory chair (shown above), and had torsional nystagmus after sitting on each side, after the Dix Hallpike tests.

 

References:

Hirai, C., et al. (2017). "Nystagmus at the Onset of Vertiginous Attack in Meniere's Disease." Otol Neurotol 38(1): 110-113.