Electronystagmography in a woman with symptoms of clinical Meniere's syndrome. (Vestibulology Clinic).

A 51-year-old woman came to the office with a 9-month history of aural fullness and hearing loss in the left ear that appeared to be secondary to a healed perforation. Her condition had improved 2 weeks after the onset of these symptoms, but 1 month later she awoke in the middle of the night with palpitations and a cold sweat; these symptoms were soon followed by nausea and a sensation that "the room was moving." The moving sensation lasted approximately 2 hours. One week later, she experienced a similar spell and stayed home for several days. During that time she felt lightheaded and nauseous. Another week later, she woke up again feeling lightheaded; as the day went on, she began to feel worse and she eventually experienced nausea and vomiting on her way home from work.

The patient was treated with meclizine, but 8 days later she experienced another midnight episode of nausea and vomiting that lasted 5 hours. Computed tomography (CT) detected no evidence of an abnormality. She was prescribed triamterene/hydrochlorothiazide, and for the next 5 months she experienced no significant spells (although she did report intermittent lightheadedness and queasiness). However, she subsequently experienced a spell of lightheadedness and nausea while at work, and this was followed 1 week later by another spell at work that lasted 5 hours. Magnetic resonance imaging results on two occasions were negative.

She experienced another major spell 1 week prior to her initial office visit. She reported that her hearing loss on the left was fluctuating and that her aural fullness on the left comes and goes with the hearing loss." She reported no tinnitus. Her family history was significant for dizziness in three siblings.

Examination of the ears revealed anterior tympano-sclerosis on the left. Audiology reflected a slight drop of 6 and 8 kHz on the left. Acoustic immittance revealed shallow tympanometry. Electronystagmography detected a slight right-beating nystagmus in the supine and left-lateral positions. The alternate binaural bithermal caloric test demonstrated a less intense (but not clearly hypoactive) response from the warm stimulus on the left. The reduced vestibular response (RVR) was 13% left, and the directional preponderance was 18% right-beating. Simultaneous binaural bithermal testing revealed a type 2 response with an RVR left. Ultrathin CT (pixel size: 0.07 mm) of the temporal bones detected signs consistent with otosclerosis. A 5-hour glucose tolerance test found an exaggerated blood sugar response and hyperinsulinemia. She also had an elevated triglyceride level, which was consistent with her hyperglycemia and was reflective of a diet too high in carbohydrates. She was prescribed a bisphosphonate, a calcium supplement, fluoride, and diet therapy to address her metabolic factors. She has been free of dizziness ever since.

This patient apparently had symptoms of hydrops in the left ear. The simultaneous binaural bithermal stimulus induced responses that were consistent with a vestibular abnormality in the left ear and that were not evident on alternate binaural bithermal stimulus. The immittance Findings were consistent with tympanosclerosis and otosclerosis. Her family history hinted at a genetic tendency toward dizziness, which might also be indicative of otosclerosis. Finally, her metabolic status might have had an impact on the function of her inner ear.

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From Neurotologic Associates, P.C., New York City.