Diagnosis precedes treatment. It's a simple concept, yet diagnostic uncertainty is a major frustration in treating Meniere's patients. A complete diagnosis includes estimates of the severity of symptoms, medical and nonmedical influences, and assessment of previous therapy. Each of these can affect treatment decisions. The literature about Meniere's disease is not very helpful either. Although Meniere's disease is uncommon— some even say it is rare—there are many single-author reports in the literature with huge numbers of patients. How is this possible? Clearly there is doubt about the diagnosis. Great results occur if the disease is absent.

The diagnosis is made on the basis of the history. The official definition of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) seems reasonable.1 A good, classic history with the criteria as outlined is adequate proof of Meniere's disease, even if another disorder is found. The following symptoms must be present for a confident diagnosis of Meniere's disease:

1. The principal symptom must be vertigo at some point in the disease. Vertigo is a spinning sensation. Overdiagnosers include any sensation of movement (swaying, weaving, veering) under the term vertigo, but these symptoms alone do not suggest an otologic cause. Acute vertigo often becomes less severe over time, so that dizziness symptoms like veering and swaying result. This description identifies how "dizziness" and "vertigo" are used in this chapter.

2. Sensorineural hearing, and aural fullness or tinnitus, particularly of a low tone type, must be present. Hearing may fluctuate.

3. Spells must be recurrent. A single spell of vertigo does not constitute Meniere's disease.

4. The spells must last 20 min or more, at least sometime in the disease. Actually it is unlikely that the pathophysiologic events2,3 that are attributed to Meniere's disease could occur within 20 min. A minimum time of 1 h seems stronger, but the official AAO-HNS definition suggests 20 min.

Some further diagnostic points to consider are that the physical examination is usually normal, and tests are optional. Many tests are interesting for research purposes, but no test proves or disproves the diagnosis of Meniere's disease. Vestibular testing for clinical purposes is poor. An audiogram should be done; an electronystagmogram (ENG) is usually perfomed as well, to confirm the presence of function in the other ear.

Destroying the only functioning ear would result in disaster. The summating potentials from electrocochleography and other tests are interesting but should not alter clinical treatment decisions. Figure 46-1 presents a flowchart for a treatment plan for Meniere's disease.

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