Portuguese Version

Year:  2003  Vol. 69   Ed. 1 - (12º)

Artigo Original

Pages: 69 to 72

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Ménière's disease and positional vertigo

Author(s): Mirella Boaglio,
Letícia Clemente Alvim Soares,
Carmem Silvia Marsiglia Natal Ibrahim,
Fernando Freitas Ganança,
Oswaldo Laércio Mendonça Cruz

Keywords: vertigo, dizziness, glucose, hyperlipoprotein, cholesterol, thyreoid.

Abstract:
Objective: Several authors have described the association between Ménière's disease and positional vertigo. The goal of this research was to evaluate the presence of the nystagmus of position and the dizziness sensation positional in patients with Menière's disease. Method: 44 patients with definite Menière's disease diagnosis according to the clinic and audiologic evaluation (filling the diagnosis criteria of the American Academy of Otolaryngology) and the confirmation of the endolymphatic hydrops by electrocochleography (SP/AP>30%). The research of the nystagmus of position was elicited through Brandt-Daroff's maneuver. This examination was considered positive by presence of the nystagmus and/or dizziness. Results: During the research of the nystagmus of position, 7 patients (16%) presented nystagmus and dizziness, 23 patients (52,2%) presented dizziness without nystagmus, the total number of disturbance was 68,1% (30 patients) in this sample. Conclusion: The association between Menière's disease and vertigo positional is relevant and its real occurrence will depend on criteria used in order to define this association. In this work, as much the appearance of the nystagmus as the dizzy sensation to Brandt-Daroff's maneuver was considered positive to the establishment of this association. The presence of vertigo positional with this methodology in patients with Menière's disease was 68%.

Introduction

The symptomatic triad of tinnitus, hearing loss and vertigo in paroxysmal episodes was described by Prosper Ménière in 1861, at the Imperial Academy of Medicine in Paris (Memoire sur des de l'oreille interne donnant lieu a des symptomes de congestion cerebrale apoplectiforme), based on a group of patients diagnosed as having "apoplectiform cerebral congestion"1. For the first time, it was suggested that the auditory system was repeatedly affected with onset of tinnitus and decrease in hearing, and since the inner ear was the affected site by onset of vertigo, dizziness and imbalance, followed by nausea, vomiting and seizures, it could be explained without the involvement of the central nervous system.

In 1874, Charcot2 named this entity Meniere's disease. After the histopathologic descriptions by Hallpike and Cairns in 19383, Meniere's disease has become known as the clinical expression of an idiopathic syndrome of endolymphatic hydrops.

The definite confirmation of the pathophysiologic alteration that characterizes the disease can only be attained by clinical pathology analysis of the temporal bone (post mortem), and therefore, the diagnosis is based on well-defined clinical criteria. According to the Committee on Hearing and Balance of the American Academy of Otorhinolaryngology4, in 1995, the presence of endolymphatic hydrops can be inferred based on the occurrence of spontaneous and recurrent episodes of vertigo, lasting at least 20 minutes, followed by nausea, vomiting, no loss of conscious, with horizontal rotation nystagmus always present, associated with hearing loss , aural fullness and tinnitus on the affected side.

Benign paroxysmal positional vertigo (BPPV) is characterized by paroxysmal episodes of sudden and quick vertigo that are experienced when the head of the patient is placed in a specific position. It is a condition whose onset may be isolated or associated with other labyrinthic affections, normally triggered and/or exacerbated by vertigo episodes5. The diagnosis of BPPV is based on clinical history and physical examination, since vertigo and nystagmus can be reproduced in the office by moving the patient's head to Hallpike's position. The nystagmus is always present after a latency period of 5 seconds, normally rotational or horizontal-rotational, fatigable and reverting direction when the patient resumes orthostatic position, if the posterior semicircular canals are affected; if it is horizontal, the lateral semicircular canals are affected, and if vertical and inferior, the superior semicircular canals are affected.

The association between positional vertigo and Meniere's disease has been described in the literature for some time2,5,6,7,8,9. Paparella10, in 1984, already believed that hydrops in the anterior portion of the labyrinth, that is, in the cochlear duct and sacculus, was the most important physiological finding in Meniere's disease. According to the author, most cases had a rupture of Reissner's membrane and the sacculus could distend up to the limits of the semicircular canals. The distended sacculus would serve as an endolymph reservoir, and the distension, in turn, would generate vertigo, including positional vertigo. Another possibility would be the occurrence of endolymph composition abnormalities, especially by contamination of endolymph and perilymph, favoring the formation of endolymphatic sediment that determined the onset of positional vertigo9, 11, 12.

In addition, the hydrops per se could cause a lesion of the utriculus macula, leading to displacement of otoconia.

Objective

To assess the presence of positional vertigo in patients with Meniere's disease using the positional vertigo study.

Methodology

We assessed 44 patients being 35 female (ages between 21 and 72 years, mean age of 46.7 years) and 9 male subjects (ages between 27 and 61 years, mean age of 45.2 years), with general mean age of 46.4 years. The definite diagnosis of Meniere's disease was given in the inter-critical period, according to the clinical and audiometric criteria defined by the 1995 Consensus of the American Academy of Otorhinolaryngology4: two or more episodes of vertigo lasting 20 minutes or more, hearing loss audiometrically documented in at least one occasion, tinnitus or pressure sensation on the affected ear.

All patients were assessed in the Ambulatory of Otoneurology, UNIFESP-EPM, and underwent anamnesis, otoscopy, pure tone and vocal audiometry, immittanciometry and computer vestibular exam15 (VEC-WIN/Neurograff). In addition to the clinical diagnosis and disease staging, the presence of endolymphatic hypertension was confirmed by electrocochleography (Echog) whose inclusion criterion was to have SP/AP ratio greater than 30%. The study of positional nystagmus was conducted by the maneuver of Brandt-Daroff using Frenzel lenses -13 diopter. The test was considered abnormal in the presence of nystagmus and/or positional vertigo.

Results

Out of 44 studied patients, 14 (31.8%) did not present abnormalities in the positional nystagmus search and 30 (68.2%) presented abnormalities, being 23 (52.2%) only vertigo and 7 (16%) vertigo and nystagmus. Of those patients with abnormal results, 6 (20%) were male and 24 (80%) were female subjects. No differences were observed concerning incidence of vertigo and vertigo + nystagmus and gender (Table 1).

Table 1. Prevalence of findings of positional nystagmus in patients with Meniere's disease by gender.

Discussion

Many authors have described the concomitance or association of benign paroxysmal positional vertigo and Meniere's disease. Hughes, Proctor11 assessed 781 patients with complaints of positional vertigo. Out of the total, 151 (19.3%) had positional vertigo and were diagnosed as having BPPV. The presence of coexisting or associated diseases with BPPV was observed in 99 patients (65.6%) being that 45 (45.4%) had association with Meniere's disease. They observed that the onset of Meniere's disease preceded the BPPV in most times. The peripheral origin of both diseases and the possible release of otoconia by utriculus' lesions caused by hydrops and endolymphatic hypertension could be the possible explanations for this fact.

Gross et al.9 evaluated 9 patients with diagnosis of concomitant Meniere's disease and BPPV. The symptoms of Meniere's disease were anterior to the onset of BPPV in all patients. One patient presented bilateral BPPV and unilateral Meniere's disease. The patients who had untreatable BPPV were submitted to otolyte replacement with Epley maneuver, with dissatisfactory results. Based on data analysis, the authors came up with the hypothesis that water balance abnormalities would induce the utricular and saccular macula and partial obstruction of membranous labyrinth could be the mechanisms involved in the coexistence of these two diseases.

Karlberg et al.12 assessed by means of a retrospective study, 2,847 patients with BPPV. Out of them, 0.6% (n=16) suffered from Meniere's disease, 0.8% (n=24) had unilateral acute peripheral vestibulopathy, 0.7% (n=21) had bilateral chronic peripheral vestibulopathy, 0.4% (n=12) had unilateral chronic peripheral vestibulopathy, 0.3% (n=8) had sensorineural loss, and the remaining 97.2% (n=2,766) had only BPPV. In the case of Meniere's disease, they wondered whether the endolymphatic hydrops could affect the utriculus, resulting in loss of otoconia and onset of secondary BPPV.

The high prevalence of abnormalities found in the positional nystagmus study in our sample (prevalence of 68.1% of vertigo and/or positional nystagmus) is in accordance with the findings reported by Paparella10, Cruz, Cruz Filho7, Wexler et al.14, Haid et al.7, Mizukoshi et al.15 and Gross et al.9. We point out that we have valued not only the percentage of 16% of the patients with isolated nystagmus, but also the occurrence of vertigo without nystagmus, observed in 52.2% of the patients, considered also as an abnormality in the study of positional nystagmus.

Conclusion

 The occurrence of abnormal results in positional nystagmus in patients with Meniere's disease is relevant.
 There were no significant differences in prevalence of positional nystagmus abnormalities by gender.

References

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14. Wexler DB, Harker LA, Voots RJ, McCabe BF. Monothermal differential caloric testing in patients with Ménière's disease. Laryngoscope 1991;101:50-5.
15. Mizukoshi K, Watanabe Y, Shojaku H, Matsunaga T, Tokumasu K. Preliminary guidelines for reporting treatment results in Ménière's disease conducted by the Committee of the Japanese Society for Equilibrium Research 1993. Acta Otolaryngol (Stockh) 1995;519 Suppl:211-15.

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1 Master, Speech Therapist and Audiologist, Discipline of Otorhinolaryngology, UNIFESP-EPM.
2 Otorhinolaryngologist, Master studies under course, Discipline of Otorhinolaryngology and Head and Neck Surgery, UNIFESP-EPM.
3 Speech Therapist and Audiologist, Master studies under course, Discipline of Otorhinolaryngology, UNIFESP-EPM.
4 Professor, Discipline of Otoneurology, UNIFESP-EPM.
5 Guest Professor, Discipline of Pediatric Otorhinolaryngology, UNIFESP-EPM.

Address correspondence to: Letícia Clemente A. Soares - Av. 11 de junho 1006/63 - Vila Clementino 04041-003 São Paulo SP. - E-mail: leticiaclemente@ig.com.br7

Article submitted on October 23, 2002. Article accepted on January 17, 2002.

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