Timothy C. Hain, MD • Page last modified: November 21, 2021
Whats new: VHIT plus caloric testing is a recent addition to the diagnostic repertoire. Serial audiometry is still the best method.
Patients sometimes ask why they need to have inner ear testing with Meniere's disease.
In our clinical otoneurology practice in Chicago, we usually see at least one new patient with Meniere's disease every week. As of 2016, we had more than 500 patients in our clinical database.
A patient who fits clinical criteria for Meniere's, but who is without any previous testing, is usually asked to undergo the following procedures
- Hearing testing (audiometry), with tympanometry and OAE. (hearing should be down). A time series of audiograms, if available, should show fluctuation and low-tone.
- ECOG (electrocochleography) -- presure may be normal or increased. It should be increased in Meniere's. ECOGs are technically difficult.
- VENG, rotatory chair (or VHIT) and VEMP testing (to document amount of damage and rule out SCD).
- Posturography -- rarely productive.
- Blood tests -- (should be normal): these are not always done.
- MRI of brain and IAC (consider 3T fiesta 4 hours after contrast). -- this is far less useful and far more expensive than a time series of audiograms however.
Some practices (not ours) also do "dehydration tests" using the glycerol, isorbide or furosemide to rule in Meniere's with a variety of outcome variables. (Lee et al, 2016)
Seo et al (2017) reported using the "furosemide loading test" with VEMP, and reported "Normalized amplitude of VEMP, using a tone burst sound at 250, 500, 700, 1000, 1500 and 2000 Hz, was measured before and after furosemide administration in the two groups. Improvement ratio (IR) of amplitude was calculated at each frequency." This to us seems like a large # of VEMP tests 6 per ear, before and after a strong diuretic (which might have consequences as well).
They sometimes say -- I am already dizzy - -why should I have tests done that could make me dizzier (briefly of course). Patients are also often concerned about expense of the tests, and of course, don't want to waste their time either.
MRI testing is very low yield in patients with "definate or probable" Meniere's disease (Robinette et al, 2018). It would seem to us that if someone starts with a "classic" low-tone hearing loss, it would be extremely unlikely to find an acoustic. The author of this page did, however, once find an acoustic on the opposite side of the Meniere's ear. This was probably just serendipity.
There are good reasons for this process, and in this page I attempt to explain the logic. In brief, the reasons are: 1). Confirm the diagnosis 2). Rule out common alternatives 3). Follow progress of the disorder. Here is the detail:
Many have recently pointed out that there is a pattern in Meniere's where the VHIT is normal and caloric is reduced. McGarvie et al (2015) discussed that calorics are more sensitive than VHITs to Meniere's. In particular, they said "There was a clear dissociation: patients with MD had a small or absent response to caloric stimulation of their affected ear, whilst their response to vHIT was in the normal range. " Choi et al (2017) also pointed out the discrepency. Fukushima et al (2018) compared VHIT to caloric tests in patients with MRI documented endolymphatic hydrops (EH). They reported "The difference in the vestibular EH between the presence and absence of CP was not significant if assessed using the vHIT (P = .5591), but it was statistically different if assessed using the caloric test (P = .0467)." Or in other words, calorics were sensitive to endolymphatic hydrops, but VHIT was not. Limviriyakul et al (2019) reported similar findings in patients with definite Meniere's disease. Similar findings are reported in EVA, another hydropic inner ear disease. One would think that this technique might also work for perilymph fistula, but no reports are available, and lacking a gold standard for diagnosis of PLF, they seem to be likely to continue to be unavailable
In aggregate, these data are convincing. This suggests that the pattern of a normal VHIT and abnormal caloric, in a patient with hearing symptoms typical of Meniere's, raises the odds substantially of this diagnosis. This may be better than doing an ECOG.
One would think that this relationship would also hold for Rotatory chair testing and VHIT testing, as the main difference between caloric and VHIT testing is the frequency spectrum tested, and the rotatory chair covers both ends-- but this has not been examined.
The diagnosis of Meniere's is a serious one, which has long term implications for deterioration in hearing and balance. Why confirm it (or rule it out ?)
The differential diagnosis of Menieres is broad and includes perilymph fistula, recurrent labyrinthitis, migraine, congenital ear malformations of many kinds, syphilis, Lyme disease, tumors such as acoustic neuroma, multiple sclerosis, posterior fossa arachnoid cysts, and other rare entities. Symptoms similar to Meniere's (fluctuating hearing, tinnitus, vertigo) can also be caused by impending strokes in the distribution of the anterior inferior cerebellar artery (Lee and Cho, 2003). Bilaterality of hearing fluctuation suggests a vascular cause such as migraine.
In Meniere's disease, hearing and balance generally progressively worsen over decades. This may lead to disability from hearing loss or imbalance or both. Monitoring hearing loss guides the intensity of treatment. Monitoring balance is less helpful, but may also be useful in situations where persons are working in dangerous environments where good balance is required.