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Jeni is here to help and advise. Her column in this edition focusses on Meniere's Disease

Please email her at Jeni@anAurora.co.uk

Symptoms and Incidence of Ménière's disease

Symptoms:
Ménière's disease is usually characterised by four symptoms.
1) Periodic episodes of rotatory vertigo or dizziness.
2) Fluctuating, progressive, low-frequency hearing loss
3) Tinnitus
4) A sensation of "fullness" or pressure in the ear.
Detailed description of symptoms

1) Periodic episodes of rotatory vertigo or dizziness.
Periodic attacks of vertigo (the so-called Ménière's "attack") is the most disruptive of the symptoms to the patient. It is usually the vertigo attack which causes the patient to seek medical treatment. Typically, vertigo occurs in the form of a series of attacks over a period of weeks or months, interspersed by periods of remission of variable duration. The attack consists of a period of dizziness or vertigo (dizziness may include a feeling of unsteadiness; the term vertigo is normally reserved for the perception of spinning).

The sensation of spinning may produce nystagmus (a beating of the eyes from side to side), nausea, vomiting, sweating and all the symptoms normally associated with extreme motion sickness. The onset of vertigo may be preceded by a sensation of fullness or pressure in the ear, increased hearing loss and tinnitus, as described below. The onset is frequently sudden, reaching peak intensity within minutes and lasting for an hour or more before subsiding. Unsteadiness may persist for the following hours or days.

Vertigo must be one of the worst chronic afflictions to affect the body. The vertigo patient perceives either that the world is spinning around them or that they themselves are spinning. With many other disabilities, some portion of a normal life can be continued. Vertigo disrupts virtually every aspect of life, since the patient loses the ability to do anything normally, especially when movement is involved.

In addition to the obvious hazard of falling, moving around is hampered by the fact that even small head movements often make the spinning sensation worse.

The resulting nausea, sweating and vomiting combine to make the patient subjectively very "ill". Vertigo can totally incapacitate the individual, so they cannot function. Often the patient will confine themselves to bed until the symptoms subside.

Most normal individuals probably cannot appreciate the devastating impact of this condition. Most of us are familiar with mild forms of vertigo or dizziness (from fair rides, excessive alcohol consumption, etc.). If you haven't recently experienced vertigo, try the following experiment (in a large open space, on a soft surface such as grass). Take hold of a heavy object at arms length (my son recommends a school backpack full of books) and spin around, leaning slightly backwards to balance the bag. Spin around 10-20 times at a rate of about 2 revolutions /second.

Alternatively, if you don't want to injure yourself by falling over, sit in an "executive" swivel chair and have someone spin you around as fast as they can without the chair becoming unstable, for 20-30 seconds. In both these cases, you will experience rotatory vertigo for a few seconds when you stop rotating. You will have the sensation you are still spinning, your eyes will exhibit nystagmus (a beating from side to side) and if you continue, you may experience nausea.

Based on this experience, you now partially understand the problem. There are additional factors which the patient must deal with. One is that their vertigo may last from hours to days, compared with the few seconds you experienced. With the brief episode you experienced, the vertigo declined quickly with time. For a patient, the vertigo may be sustained or even increase in intensity over a few hours.

Another difficulty the patient may have is that the vertigo can be made worse by "external" stimuli, such as head movements or loud sounds. Even TVs and radios may have to be avoided. It should also be considered that in this exercise, you had control over your situation and you knew you could stop when you wanted. You also knew that you would be fine tomorrow.

The Meniere's patient has to deal with a lack of control of their situation, except for the limited control provided by taking anti-vertiginous drugs. Even when the symptoms have passed, they must face the stress and uncertainty of when the next episode will occur, and whether it will be more or less severe than previous ones. It is generally true that most people underestimate how disruptive episodic rotatory vertigo can be to an individual's life.

2) Fluctuating, progressive, low-frequency hearing loss
the hearing loss usually affects one ear, which typically loses sensitivity to low-frequency (bass) sounds the most. As well as being harder to hear, sounds may appear "tinny" or distorted. Loud sounds may cause more discomfort than normal (loudness intolerance). The hearing loss fluctuates over time. Sometimes the hearing may recover to some extent, but then on other days hearing may be difficult.

In addition, the degree of hearing loss may get progressively worse with time, eventually affecting all sound frequencies and hearing may be completely lost in the affected ear.

3) Tinnitus
Tinnitus is sustained, loud "ringing" in the ears. Many normal individuals experience brief episodes of tinnitus, such as a loud "ping" which declines over a period of seconds to minutes. The tinnitus experienced by Ménière's patients is continual and does not abate with time, although its intensity may vary. The tinnitus is generally nonpulsatile. In addition, it may be heard more as a load roaring or buzzing sensation, rather than a whistling.
4) Aural fullness
T he feeling of "fullness" in the ear is similar to that experienced by barometric pressure changes (such as when riding up or down a hill, or ascending or descending in an airplane). However, this fullness cannot cleared by swallowing, as in the case of pressure changes.

Incidence and Prevalence of Ménière's Disease
Incidence and prevalence are sometimes confused. Incidence is defined as the number of new cases in a population over a period of time; Prevalence is the number of existing cases in a population at a given point in time.

The incidence of Ménière's disease has been estimated to range from 0.5 to 7.5 per 1000, although this figure depends upon a number of factors, such as the diagnostic criteria used to define the disease. It also varies by ethnic background, showing relatively high incidence in Britain and Sweden. However, it affects not only the white race but also black and oriental races.

Ménière's disease most commonly affects people in their 40's and 50's, although individuals from 20 onwards may be affected, as in the picture below. It is rarely, though occasionally, reported in children. Males and females appear to show a similar incidence of Ménière's.

Natural Time Course of Ménière's Disease
The time course of the disease has been documented in patients who were suitable candidates for surgery, but who declined surgical treatment of their vertigo (Silverstein et al. 1989). Initially, the frequency of vertigo attacks in these patients varied from less than 3 to more than 10 per month. After two years, more than half the patients were vertigo-free and most of the remainder showed less than 3 attacks per month. After 8 years, the vast majority were vertigo-free, although a small number showed less than 3 attacks per month. This decline of symptoms with time was generally comparable to the group of patients who elected to undergo surgery, although the severity of the vertigo was not compared during the two year period following surgery.

Also, although vertigo attacks may become less frequent over a number of years, the hearing loss tends to progress and tinnitus often remains a problem. Thus, it should not be concluded that spontaneous "recovery" from the disease occurs. There are also many patients in whom the symptoms do not abate, even after many years. There is tremendous variability in the long-term evolution of the disease.

Descriptions of symptoms by patients
For persons unfamiliar with Ménière's disease, these descriptions of symptoms make you realize how disruptive the disease can be.

If you have a question that you would like to ask, then email: jeni@anAurora.co.uk

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