According to the information in the
case history, this patient will be given the diagnosis of Meniere’s disease (stage
3) associated with posterior canal Benign Paroxysmal Positional Vertigo
(BPPV)in the right ear. We gave her this diagnosis for the following reasons:
Meniere’s diagnosis: During the last
24 months she reports four episodes of drop in hearing on the right side,
associated right sided tinnitus, and aural fullness. She also reports rotatory
vertigo, lasting from 2-6 hours. Also, we estimated that she has stage 3 of
Meniere’s disease because she reported that is since
the last attack 3 months ago, her hearing loss has persisted and not feel stable
in the dark, which are hall marks in the stage 3.
BPPV diagnosis: In the last 6 weeks
she reports a new symptom of short lived rotatory vertigo on turning to her
right side in bed, and looking up. This occurs most times she makes these
v Tests and results:
ü For Meniere’s disease diagnosis we can perform the following tests:
Ø Audiologic tests
§ Pure tone audiometry: Due to her diagnosis of stage 3 the results
will show flattening sensorineural hearing loss in the right ear.
§ Speech audiometry: The result will revel reduced
or possibly worsening speech discrimination.
§ Otoacoustic emissions(OAE): The result will
revel lowered main frequencies, the frequency of emission may provide
§ Brainstem-evoked auditory responses(BEAR): The result will revel
normal, shorter or delayed wave 5 latency in the right ear.
§ Traveling-wave velocity(TWV): The result will revel faster
traveling waves (masked wave 5 latency difference b0.6 ms).
§ Low-frequency masking(LFM): The result will revel absent phase
dependence of masking, reduced modulation depth of audiometric threshold (b28
dB) and impaired masking of BEAR.
§ Immittance tests: The result will revel increased conductance
width, decreased resonance frequency and lowered threshold of the cochleostapedial
§ Electrocochleography (ECoG): The test measures the electrical
potentials produced in the inner ear in response to sound. It will record a
large waveform, which results from providing sound stimulation to the inner
ear. This waveform contains two components, the summating potential (SP) and
the action potential (AP). The summating potentials reflect the cochlear
bioelectric activity, while the action potentials reflect the activity of
distal afferent fibers of the 8th nerve. ECoG results for MD will show enhanced
negative SP, enlarged SP/AP ratio (N0.34), increased AP/N1 latency difference
to clicks of opposing polarity (N0.38 ms), increased SP/AP area curve ratio
(N1.34), and increased SP/AP width (N1.89).
(N1 means first
negative peak of the ECoG recording).
Ø Vestibular tests
§ Instrumental-aided study of nystagmus (e.g., by electronystagmography
and rotatory chair protocols): Often spontaneous nystagmus toward the
unaffected ear and canal paresis of the affected ear, occasionally vestibular
hyperactivity of the affected ear.
§ Vestibular-evoked myogenic potentials (VEMP): Measures the
sternocleidomastoid muscle contraction in response to loud sound. It also
measuring the otolith (saccule and utricle) function and both branches of the
vestibular nerve and the vestibulospinal tract. VEMP results for MD will show decreased
or absent amplitude in the infected ear.
§ Computed tomography(CT): The result will revel narrower, shorter,
or nonvisualized vestibular aqueduct, smaller external aperture, and abnormally
decreased periaqueductal pneumatization.
§ Magnetic resonance(MR): The result will revel narrowed
endolymphatic duct, obstructed endolymphatic sac, direct visualization of the
ü For the diagnosis of posterior BPPV we can perform the Side Lying
manoeuvre not the Dix– Side lying test
will show that in first 2-3 seconds there is no nystagmus. Then up-ward
vertical nystagmus (with torsional component towards the downward ear). Then
reversal of nystagmus upon sitting.
Also, the Videonystagmograghy (VNG) can use to diagnose the
posterior BPPV and the estimate results will be as the same as the positive
Side Lying test. However, the Electronystagmography (ENG) and the Caloric test
can’t be used in the diagnosis of the posterior BPPV because they can’t
diagnose the torsional nystagmus that result from this disease. In addition,
VEMP test can be used in the diagnosis of BPPV and the result will show reduced
or absent amplitude at the infected side and delayed peak latency (P13 or N1).
Treatment for each of MD and BPPV
should be considered independently.
Treatments of Meniere’s disease may
Motion sickness medications: such as
meclizine or diazepam (Valium) to reduce vertigo and help control nausea and vomiting.
Anti-nausea medication: such
as promethazine to control nausea and
vomiting during vertigo.
Diuretics: such as
triamterene to reduce the amount of fluid pressure in the inner ear, high Na?²
which helps to prevent attacks, should be used with caution because of
Middle ear injections:
Medications injected into the middle ear and is absorbed into the inner ear,
can help improve vertigo symptoms such as Gentamicin Steroids.
Vestibular rehabilitation exercises: can
be taught by a physical therapist and occupational therapist. It is performed
by repetitive balance exercises. Those exercises
help patients to habituate to their vestibular
loss helping them compensate for the effects of the inner ear disorder. VRE can
help in teaching patients to cope with vertigo and imbalance. Those exercises
are habituation exercise, gaze stabilization and balance exercise.
Hearing aids or cochlear implant
should be used with this patient because she has severe unilateral hearing
Meniett device: used when it is hard
to treat vertigo. It applies pulses of pressure to the ear canal through a
ventilation tube to improve fluid exchange. Using this device will show improvement in symptoms of vertigo, tinnitus and aural
§ Dietary agents(triggers) to avoid
the attacks, such as salt, caffeine, chocolate and alcohol.
§ Lifestyle adjustments to avoid or
reduce the occurrence of attacks symptoms (e.g. Sit
or lie down when she feels dizzy).
§ Surgery: is used when a patient has
severe attacks and has not had success with other treatment options. Procedures
Endolymphatic Shunt procedure to decrease fluid
production or increase fluid absorption which may alleviate vertigo.
Vestibular neurectomy to reduce vertigo while
preserving hearing in the affected ear.
Labyrinthectomy is done when there are hearing
and balance problems to control vertigo attack.
Treatment of BPPV
In order to treat BPPV, the patient
at first should wait for it to resolve. As the symptoms may resolve by
themselves within six months. The same medications of MD can be helpful during
this period to control the severe symptoms.
As she has neck pain, the Semont maneuver will
be used to move the calcium particles out of the
semicircular canals of the inner ear to a place where they will not cause
vertigo. It is done by seating her on the bench and turning her head to the
left side, then lowers her quickly to the right side for 30 seconds. Then
rapidly move her to the opposite side, maintaining alignment of neck and head
and wait for 30 seconds. Then return her to a seated position slowly.
After Semont maneuver, she is instructed to wait for 10 minutes after the
maneuver before going home. After the following two days, she should sleep with
the head between flat and upright at an angle of 45 degrees.
exercise is performed at home when the Semont maneuver fails. She is instructed
by the clinician to do the following: during sitting, turn her head a 45 degree
to the left and lie on the opposite side for 30 seconds. Then she gets up to
the sitting position for 30 seconds. Then turn her head a 45 degree to the right,
and lie on the opposite side for 30 seconds. Then return to the sitting
the symptoms persist for a year and more, it means that the maneuver or
exercise do not help in controlling the symptoms of BPPV. In this case,
surgical treatment may be recommended. The most common surgery is posterior
semicircular canal plugging or occlusion. In this surgery, the surgeon occludes
most of the posterior canal’s function but without affecting the other canals
or parts of the affected ear.
is another surgery called singular neurectomy. This is done by a section of the
ampullary nerve. This nerve job is to send impulses from the posterior
semicircular canal to the balance part in the brain. It has been replaced by
the posterior semicircular canal occlusion as it is simpler as it demands less