A 33-year-old woman comes to the office due to intermittent dizziness. The patient describes a sensation of severe spinning accompanied by intense nausea that lasts 1-2 hours. She feels unsteady during these episodes and has to lie down with her eyes closed for relief. The patient has had several similar episodes during the past 2 years but has not noted any factors that precipitate the symptoms. She also hears a "mechanical humming" sound in her right ear during these episodes. The patient has no associated headaches, ear pain, or ear discharge. Temperature is 36.6 C (98 F), blood pressure is 130/84 mm Hg, and pulse is 86/min. On examination, air conduction is greater than bone conduction in both ears. When the base of a tuning fork is placed against her forehead, the sound is heard more prominently in the left ear. Which of the following is the most likely cause of this patient's condition?

Question

A 33-year-old woman comes to the office due to intermittent dizziness.  The patient describes a sensation of severe spinning accompanied by intense nausea that lasts 1-2 hours.  She feels unsteady during these episodes and has to lie down with her eyes closed for relief.  The patient has had several similar episodes during the past 2 years but has not noted any factors that precipitate the symptoms.  She also hears a "mechanical humming" sound in her right ear during these episodes.  The patient has no associated headaches, ear pain, or ear discharge.  Temperature is 36.6 C (98 F), blood pressure is 130/84 mm Hg, and pulse is 86/min.  On examination, air conduction is greater than bone conduction in both ears.  When the base of a tuning fork is placed against her forehead, the sound is heard more prominently in the left ear.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d54c_7fc2_bc81_0d1487c38f03_MD0003_00 This patient with episodic vertigo, tinnitus, and sensorineural hearing loss (based on Weber and Rinne tuning fork tests) has Ménière disease, a disorder of the inner ear characterized by increased volume and/or pressure of endolymph (endolymphatic hydrops). The resulting distension of the endolymphatic system causes damage to both the vestibular and cochlear components of the inner ear. Ménière disease is characterized by the following triad: Weber and Rinne Episodic vertigo (20 min to 24 hr), commonly associated with nausea and vomiting Sensorineural hearing loss, fluctuating and varying in severity and usually worsening over time (primarily affecting low frequencies at first and progressing to permanent loss over all frequencies) Low-frequency tinnitus in the affected ear, often accompanied by a feeling of fullness The diagnosis of Ménière disease is based primarily on clinical findings; however, audiometry should be performed to fully characterize the hearing loss and follow its course over time, and MRI should be obtained to rule out central nervous system lesions. Initial management includes restriction of sodium, caffeine, nicotine, and alcohol. Benzodiazepines, antihistamines, and antiemetics can relieve acute symptoms. Diuretics can be considered. A minority of patients may require interventional techniques (eg, endolymphatic shunt placement) for severe, intractable vertigo. (Choice A) Vestibular schwannomas can cause unilateral sensorineural hearing loss, sometimes with imbalance and tinnitus. However, symptoms are usually persistent and progressive rather than episodic, and true vertigo is not typical. (Choice B) Multiple sclerosis can cause episodic vertigo and sensorineural hearing loss. However, most patients have manifestations in multiple systems (eg, paresthesias, weakness, visual disturbances, urinary incontinence). (Choice D) Like Ménière disease, labyrinthitis can cause vertigo, hearing loss, and tinnitus. However, symptoms typically last a few days to several weeks. (Choice E) Benign paroxysmal positional vertigo is thought to be caused by calcium debris within the semicircular canals that alter normal fluid flow. It causes brief (<1 min), often intense episodes of vertigo triggered by changes in head position. Patients can have headaches or a feeling of ear fullness, but tinnitus and hearing loss are not typical. Educational objective: Ménière disease is a disorder of the inner ear characterized by increased volume and/or pressure of endolymph (endolymphatic hydrops). Clinical features include episodic vertigo, sensorineural hearing loss, and tinnitus or aural fullness. References: Meniere's Disease (http://www.ncbi.nlm.nih.gov/pubmed/30947172)

A 33-Year-Old Woman Comes to the Office Due to Intermittent