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ent.meniere-disease.core.v1

Ménière's disease (recurrent audiovestibular hydrops)

general_internal_medicineacutesubacutechronicadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame the encounter as a TWO-CHANNEL problem: (A) positively diagnose definite-vs-probable Ménière against the Bárány/AAO-HNS criteria, anchored on the AUDIOGRAM, and run the stepped management ladder incl. the Tumarkin drop-attack safety issue; (B) robustly distinguish vestibular migraine (commonest mimic, often comorbid), BPPV, vestibular neuritis, posterior-circulation TIA/stroke, SSNHL, and autoimmune inner-ear disease. Definitive stroke/BPPV/neuritis/migraine/SSNHL/falls management is routed OUT by engine_id, not re-authored.

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two-channel scope confirmed; out-of-scope definitive management flagged for engine_id routing

Patient inputs (16)

MD vertigo is SPONTANEOUS (not obligately position-triggered); an obligate head-position trigger with <1-min spells points to BPPV — route to ent.bppv.core.v1 (Lopez-Escamez 2015; AAO-HNS BPPV CPG)

Fluctuating LOW/MID-frequency SNHL in the affected ear is the cochlear pivot; purely high-frequency, non-fluctuating, or absent cochlear involvement argues against MD and toward presbycusis / vestibular migraine / neuritis (Lopez-Escamez 2015; Basura OHNS 2020)

Unilateral tinnitus + aural fullness completing the tetrad; bilateral or absent aural symptoms lowers the MD prior and raises migraine / systemic / autoimmune mimics (Lopez-Escamez 2015)

Migraine history / headache / photophobia-phonophobia with episodic vertigo points to vestibular migraine — the commonest MD mimic AND frequently comorbid; alters route and treatment (Lopez-Escamez 2015 — VM is the principal differential; Webster Cochrane 2023 VM prophylaxis)

Age, HTN, DM, AF, smoking, hyperlipidaemia, prior stroke/TIA raise the pre-test posterior-circulation-TIA prior for recurrent vertigo+hearing spells and lower the imaging/route-out threshold (clinical; ABCD2 context)

The single most discriminating history item — MD spells are 20 min-12 h spontaneous; BPPV is seconds, vestibular neuritis a single sustained AVS over days, vestibular migraine minutes-days; duration reroutes the entire differential (Lopez-Escamez J Vestib Res 2015 Bárány criteria)

Definite MD REQUIRES audiometrically documented low/mid SNHL in the affected ear on at least one occasion — the objective anchor that separates definite from probable MD and from purely-history mimics (Lopez-Escamez J Vestib Res 2015; AAO-HNS CPG Basura 2020)

The 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe truncal/gait ataxia, or other focal signs — episodic posterior-circulation TIA / AICA infarct can mimic recurrent audiovestibular spells; route OUT to neuro.posterior-circulation-stroke.core.v1 (AAO-HNS CPG 2020; clinical)

A SUDDEN (≤72 h) severe SNHL component — especially a first event — is SSNHL until proven otherwise (time-critical, steroid-window) → route to ent.sudden-sensorineural-hearing-loss.core.v1; can also be delayed endolymphatic hydrops post-SSNHL (Basura OHNS 2020; clinical)

Sudden unprovoked falls without LOC (otolithic crisis) carry a high injury/fracture risk and mandate accelerated ablative/surgical escalation + a falls-safety pathway (Véleine J Neurosurg 2022; Huppert Acta Otolaryngol 2010; AAO-HNS CPG 2020)

Bilateral involvement (rises to ~35% at 10 y / ~47% at 20 y) mandates a HEARING-PRESERVATION strategy and contraindicates bilateral ablation — a pivotal management modifier (Huppert/Strupp/Brandt Acta Otolaryngol 2010; AAO-HNS CPG 2020)

Serviceable hearing in the affected ear (and the only-hearing-ear question) sets the ABLATION GUARDRAIL — IT gentamicin / labyrinthectomy are hearing-destructive and are contraindicated where hearing must be preserved (Patel Lancet 2016; AAO-HNS CPG 2020)

A prior treated SSNHL episode followed later by recurrent vertigo defines DELAYED endolymphatic hydrops — a recognised MD-spectrum variant managed on the same ladder (Basura OHNS 2020; clinical)

Bilateral, rapidly progressive, steroid-responsive audiovestibular loss ± systemic autoimmune disease suggests autoimmune inner-ear disease (AIED) rather than idiopathic MD — different work-up/therapy (Basura OHNS 2020 — exclude alternative causes)

Unpredictable vertigo / drop attacks create driving and occupational (heights, machinery) hazard — mandatory safety counselling and, in many jurisdictions, fitness-to-drive reporting (AAO-HNS CPG 2020 — patient education/counselling)

Pregnancy gates the regimen — avoid routine diuretics/acetazolamide (volume/electrolyte, teratogenicity concerns) and limit antiemetic/vestibular-suppressant choice; favour low-salt + non-pharm + IT steroid if needed (AAO-HNS CPG 2020 safety; clinical)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningcentral_mimic_red_flag_route_out
    The 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe truncal/gait ataxia, focal neuro signs, or recurrent audiovestibular spells with high vascular risk — posterior-circulation TIA / AICA-territory stroke (AAO-HNS CPG Basura 2020; clinical)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretumarkin_drop_attack_safety
    Sudden unprovoked fall / “pushed to the ground” without loss of consciousness (Tumarkin otolithic crisis) in known/suspected Ménière — high injury/fracture risk (Véleine J Neurosurg 2022; Huppert Acta Otolaryngol 2010; AAO-HNS CPG Basura 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresudden_component_route_SSNHL
    A SUDDEN (≤72 h) severe sensorineural hearing-loss component, especially a first event or a step-change in hearing — SSNHL until proven otherwise (Basura OHNS 2020; clinical)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebilateral_progressive_SNHL
    Bilateral involvement or documented contralateral progression of audiovestibular loss (bilaterality rises to ~35% at 10 y / ~47% at 20 y) (Huppert/Strupp/Brandt Acta Otolaryngol 2010; AAO-HNS CPG 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateintractable_disease_surgical_escalation
    Disabling MD with recurrent attacks despite an adequate trial of the medical ladder (lifestyle/diuretic/betahistine + intratympanic corticosteroid) (AAO-HNS CPG Basura 2020; Patel Lancet 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprofound_hearing_loss_rehabilitation
    Progression to profound/non-serviceable SNHL in the affected ear (and the bilateral/only-hearing-ear question) (Huppert Acta Otolaryngol 2010 — ~50-60 dB loss in first 5-10 y; AAO-HNS CPG 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateintractable_vomiting_dehydration
    Severe persistent vomiting / inability to tolerate oral intake / clinical dehydration during a disabling MD attack (AAO-HNS CPG 2020; clinical)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateautoimmune_inner_ear_disease_alternative_dx
    Bilateral, rapidly progressive, fluctuating, steroid-responsive audiovestibular loss ± systemic autoimmune disease — autoimmune inner-ear disease rather than idiopathic Ménière (Basura OHNS 2020 — exclude alternative causes)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Ménière's disease — acute-attack symptomatic relief + stepped maintenance ladder (medical → intratympanic → surgical)
axis: meniere_stepped_care_and_acute_attackstep 0 - Step 0 — Acute attack: short-course symptomatic suppressant/antiemetic (bridge ONLY)
Selected step "Step 0 — Acute attack: short-course symptomatic suppressant/antiemetic (bridge ONLY)" — Active disabling vertigo spell with nausea/vomiting — strictly short-term symptomatic relief during the 20 min-12 h attack; NOT maintenance therapy (suppressants impair central compensation if continued)
  • prochlorperazine
    rescue
    antidopaminergic_antiemetic
    5-10 mg • PO/IM/buccal/IV • q6-8h PRN, short course (max: max 40 mg/day; short course only)
    triggers: acute_attack, severe_nausea_vomiting
    AAO-HNS CPG Basura 2020 — symptomatic acute-attack control; antiemetic/vestibular suppressant for the spell only. Counsel extrapyramidal/akathisia risk; avoid chronic dosing (impairs vestibular compensation; falls/EPS in elderly).
    rxcui 8704
  • dimenhydrinate
    rescue
    antihistamine_antiemetic
    50 mg • PO/IM/IV • q4-6h PRN, short course (max: max 400 mg/day; short course only)
    triggers: acute_attack, nausea
    Short-term antiemetic/vestibular-suppressant bridge for the acute spell (AAO-HNS CPG 2020 symptomatic care); limit to the attack — chronic use delays compensation.
    rxcui 3444
  • meclizine
    rescue
    antihistamine_vestibular_suppressant
    25 mg • PO • q6-8h PRN, short course (max: max 100 mg/day; short course only)
    triggers: acute_attack, motion_intolerance
    Vestibular suppressant for symptomatic acute-attack relief only; not disease-modifying — STOP once the spell resolves (AAO-HNS CPG 2020).
    rxcui 6676
  • ondansetron
    rescue
    5HT3_antagonist_antiemetic
    4-8 mg • PO/ODT/IV • q8h PRN, short course (max: max 24 mg/day PO; QT caution)
    triggers: intractable_vomiting, antidopaminergic_contraindicated
    Antiemetic for intractable vomiting where antidopaminergics are contraindicated (Parkinsonism/EPS risk); monitor QT; symptomatic only.
    rxcui 26225
  • diazepam
    rescue
    benzodiazepine_vestibular_suppressant
    2-5 mg • PO/IV • single / very short course only (max: single low dose; avoid repeat)
    triggers: severe_refractory_vertiginous_distress
    A single low dose for extreme refractory attack distress only; benzodiazepines markedly impair vestibular compensation and increase falls (esp. elderly) — explicitly avoid ongoing/maintenance use (AAO-HNS CPG 2020).
    rxcui 3322

outpatient playbook — drug actions (2)

  1. 1. low-salt diet ± thiazide diuretic (tier 1 maintenance)
    rxcui 5487
    25 mg HCTZ • PO • once daily
    trigger: Definite/probable MD, recurrent attacks, no pregnancy/contraindication (AAO-HNS CPG 2020 — low-quality evidence, low-harm first tier)
    Conventional first maintenance tier; monitor electrolytes; betahistine region-dependent + BEMED-negative (Adrion/Strupp BMJ 2016)
  2. 2. short-course prochlorperazine for an acute attack (symptomatic only)
    rxcui 8704
    5-10 mg • PO/buccal • PRN during the spell, short course
    trigger: Disabling acute attack with nausea/vomiting (AAO-HNS CPG 2020 — symptomatic only)
    Acute-attack bridge; STOP after the spell — no chronic maintenance suppressant

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Recurrent SPONTANEOUS episodic vertigo, each spell lasting 20 min to 12 h, with nausea/imbalance, recovering between attacks — the defining Ménière vertigo window (Bárány/AAO-HNS criteria, Lopez-Escamez J Vestib Res 2015; AAO-HNS CPG Basura 2020); Fluctuating unilateral hearing loss + tinnitus + aural fullness (especially worse around vertigo spells) — the cochlear arm of the Ménière tetrad (Lopez-Escamez 2015; Basura OHNS 2020); Audiogram showing low-to-mid-frequency sensorineural hearing loss in one ear (documented before/during/after a vertigo episode) — the OBJECTIVE diagnostic anchor that defines definite MD (Lopez-Escamez J Vestib Res 2015 — audiometric documentation required).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Ménière's disease (recurrent audiovestibular hydrops)** (ent.meniere-disease.core.v1).
Phenotype framing: Terminal vestibular differential with named pivots: Ménière (spontaneous 20 min-12 h spells + DOCUMENTED fluctuating low/mid SNHL + tinnitus/fullness — audiogram pivot) vs vestibular migraine (migraine features, often NO documented SNHL, frequently comorbid — migraine-criteria pivot, route to neuro.vestibular-migraine.core.v1) vs BPPV (seconds, obligate positional trigger, no cochlear symptoms — Dix-Hallpike pivot, route to ent.bppv.core.v1) vs vestibular neuritis (single sustained AVS days, no cochlear symptoms — monophasic-course pivot, route to ent.vestibular-neuritis.core.v1) vs posterior-circulation TIA/stroke (vascular risk + central signs — HINTS/4Ds pivot, route to neuro.posterior-circulation-stroke.core.v1) vs SSNHL (sudden severe SNHL ± vertigo — time-course pivot, route to ent.sudden-sensorineural-hearing-loss.core.v1) vs autoimmune inner-ear disease (bilateral rapidly progressive steroid-responsive — bilaterality+steroid-response pivot).
Scope: Frame the encounter as a TWO-CHANNEL problem: (A) positively diagnose definite-vs-probable Ménière against the Bárány/AAO-HNS criteria, anchored on the AUDIOGRAM, and run the stepped management ladder incl. the Tumarkin drop-attack safety issue; (B) robustly distinguish vestibular migraine (commonest mimic, often comorbid), BPPV, vestibular neuritis, posterior-circulation TIA/stroke, SSNHL, and autoimmune inner-ear disease. Definitive stroke/BPPV/neuritis/migraine/SSNHL/falls management is routed OUT by engine_id, not re-authored.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Ménière's disease — acute-attack symptomatic relief + stepped maintenance ladder (medical → intratympanic → surgical)** — step "Step 0 — Acute attack: short-course symptomatic suppressant/antiemetic (bridge ONLY)".
1. prochlorperazine 5-10 mg PO/IM/buccal/IV q6-8h PRN, short course (antidopaminergic_antiemetic, rescue) — AAO-HNS CPG Basura 2020 — symptomatic acute-attack control; antiemetic/vestibular suppressant for the spell only. Counsel extrapyramidal/akathisia risk; avoid chronic dosing (impairs vestibular compensation; falls/EPS in elderly).
2. dimenhydrinate 50 mg PO/IM/IV q4-6h PRN, short course (antihistamine_antiemetic, rescue) — Short-term antiemetic/vestibular-suppressant bridge for the acute spell (AAO-HNS CPG 2020 symptomatic care); limit to the attack — chronic use delays compensation.
3. meclizine 25 mg PO q6-8h PRN, short course (antihistamine_vestibular_suppressant, rescue) — Vestibular suppressant for symptomatic acute-attack relief only; not disease-modifying — STOP once the spell resolves (AAO-HNS CPG 2020).
4. ondansetron 4-8 mg PO/ODT/IV q8h PRN, short course (5HT3_antagonist_antiemetic, rescue) — Antiemetic for intractable vomiting where antidopaminergics are contraindicated (Parkinsonism/EPS risk); monitor QT; symptomatic only.
5. diazepam 2-5 mg PO/IV single / very short course only (benzodiazepine_vestibular_suppressant, rescue) — A single low dose for extreme refractory attack distress only; benzodiazepines markedly impair vestibular compensation and increase falls (esp. elderly) — explicitly avoid ongoing/maintenance use (AAO-HNS CPG 2020).

Setting playbook (outpatient) — Positively diagnose definite-vs-probable Ménière against the Bárány/AAO-HNS criteria anchored on the audiogram, exclude vestibular-migraine / retrocochlear / autoimmune mimics, start the stepped ladder at the lowest effective tier, and set up longitudinal neurotology + audiology follow-up with safety counselling (Lopez-Escamez J Vestib Res 2015; AAO-HNS CPG Basura 2020)
6. low-salt diet ± thiazide diuretic (tier 1 maintenance) 25 mg HCTZ PO once daily — Definite/probable MD, recurrent attacks, no pregnancy/contraindication (AAO-HNS CPG 2020 — low-quality evidence, low-harm first tier) (Conventional first maintenance tier; monitor electrolytes; betahistine region-dependent + BEMED-negative (Adrion/Strupp BMJ 2016))
7. short-course prochlorperazine for an acute attack (symptomatic only) 5-10 mg PO/buccal PRN during the spell, short course — Disabling acute attack with nausea/vomiting (AAO-HNS CPG 2020 — symptomatic only) (Acute-attack bridge; STOP after the spell — no chronic maintenance suppressant)

Non-pharmacologic actions:
- Dietary sodium restriction + caffeine/alcohol/tobacco reduction + trigger/stress management (AAO-HNS CPG Basura 2020)
- Intratympanic corticosteroid referral if attacks persist despite tier 1 and hearing preservation is desired (Patel Lancet 2016)
- Vestibular rehabilitation for chronic imbalance / fall risk (AAO-HNS CPG 2020)
- Hearing aid / hearing rehabilitation as SNHL progresses; psychological support (high anxiety/depression burden)
- Driving + occupational safety counselling (unpredictable vertigo / Tumarkin — fitness-to-drive reporting per jurisdiction) (AAO-HNS CPG 2020)

AVOID / contraindication checks:
- Intratympanic gentamicin hearing risk guardrail (AAO HNS CPG Basura 2020 — gentamicin is vestibulotoxic + cochleotoxic; CONTRAINDICATED if serviceable hearing must be preserved, in an only hearing ear, or in bilateral disease — prefer IT steroid / hearing preserving surgery)
- Avoid bilateral vestibular ablation (bilateral chemical/surgical ablation risks oscillopsia + permanent imbalance — Huppert Acta Otolaryngol 2010 bilaterality ~35 47% mandates a hearing and balance preservation strategy)
- No chronic vestibular suppressant maintenance (AAO HNS CPG 2020 — antihistamine/benzodiazepine/antidopaminergic suppressants are acute attack only; chronic use impairs central compensation and increases falls, esp. elderly)
- Diuretic acetazolamide avoid in pregnancy monitor electrolytes (use low salt + non pharm ± IT steroid in pregnancy; thiazide/acetazolamide need electrolyte/renal monitoring)
- Prochlorperazine extrapyramidal akathisia counsel (avoid repeated dosing; caution Parkinsonism/elderly)
- Betahistine no stable US rxcui and BEMED negative (region dependent; not US FDA approved; BEMED Adrion/Strupp BMJ 2016 negative — manage patient expectations; rxcui omitted not fabricated)
- Do not treat undiagnosed central or SSNHL as meniere (sudden severe SNHL → route to ent.sudden sensorineural hearing loss.core.v1; central signs → neuro.posterior circulation stroke.core.v1 — do NOT delay on the MD ladder)

Monitoring

Regimen monitoring:
- serial pure tone audiometry to track low mid SNHL fluctuation and progression (Lopez-Escamez 2015; Huppert Acta Otolaryngol 2010 — ~50-60 dB loss in first 5-10 y)
- vertigo attack diary drives ladder step up or step down (AAO-HNS CPG Basura 2020)
- post IT gentamicin close hearing and balance monitoring (ablation hearing-loss risk — Patel Lancet 2016; Webster Cochrane 2023 CD015246)
- diuretic electrolyte and renal monitoring (thiazide/acetazolamide)
- surveillance for contralateral progression to bilateral disease (Huppert 2010 — ~35% at 10 y / ~47% at 20 y; changes the hearing-preservation strategy)
- counsel attack frequency tends to burn out over years while hearing may decline (Huppert Acta Otolaryngol 2010)

Setting (outpatient) monitoring:
- Serial audiometry + vertigo-attack diary at each review to drive ladder step-up/step-down (AAO-HNS CPG 2020)
- Bilaterality surveillance — contralateral hearing/vestibular progression (Huppert Acta Otolaryngol 2010)
- Return precautions: new diplopia/dysarthria/dysphagia/dysmetria, severe headache, sudden severe hearing loss, recurrent injurious drop attacks → urgent re-eval / route OUT (AAO-HNS CPG 2020)

Follow-up plan: CHRONIC longitudinal arc (the core differentiator): structured neurotology + audiology follow-up with the stepped ladder revisited at each interval; vestibular rehabilitation for residual imbalance; hearing rehabilitation (hearing aid; cochlear implant if profound and the contralateral ear is also affected); psychological support (MD has high anxiety/depression burden); DRIVING and OCCUPATIONAL safety counselling (unpredictable vertigo / Tumarkin — fitness-to-drive reporting per jurisdiction); bilaterality surveillance and hearing-preservation planning; route elderly recurrent drop-attack patients to geriatrics.falls.core.v1 for the multifactorial falls programme.
- Close-out criterion: longitudinal stepped-care + vestibular/hearing rehab + safety-counselling + bilaterality-surveillance plan documented; falls referral made if criteria met

Monitoring phase: CHRONIC stepped-care monitoring: SERIAL AUDIOMETRY (track low/mid SNHL fluctuation and stepwise progression — hearing loss accrues mainly in the first 5-10 y, ~50-60 dB; Huppert 2010); vertigo-attack diary (frequency/severity drives ladder step-up/step-down); after IT GENTAMICIN, monitor hearing closely (ablation hearing-loss risk) and balance compensation; after IT steroid, reassess attack control to decide repeat vs escalate; diuretic course → electrolytes/renal monitoring; surveil for CONTRALATERAL progression to bilateral disease (changes the whole hearing-preservation strategy). Counsel that attack frequency tends to burn out over years even though hearing may decline.

Disposition

Current setting: outpatient — Positively diagnose definite-vs-probable Ménière against the Bárány/AAO-HNS criteria anchored on the audiogram, exclude vestibular-migraine / retrocochlear / autoimmune mimics, start the stepped ladder at the lowest effective tier, and set up longitudinal neurotology + audiology follow-up with safety counselling (Lopez-Escamez J Vestib Res 2015; AAO-HNS CPG Basura 2020)

Disposition criteria:
- Stable definite/probable MD on tier-appropriate therapy → continued outpatient neurotology + audiology follow-up (AAO-HNS CPG 2020)
- Intractable / Tumarkin / mimic → escalate to neurotology or route OUT by engine_id

Escalation triggers (move to higher acuity):
- Intractable attacks despite the medical ladder → neurotology referral for IT steroid → IT gentamicin → surgery decision (AAO-HNS CPG 2020)
- Recurrent injurious Tumarkin drop attacks → accelerated ablative/surgical pathway + falls programme (Véleine J Neurosurg 2022)
- Central signs / sudden severe SNHL → route to neuro.posterior-circulation-stroke.core.v1 / ent.sudden-sensorineural-hearing-loss.core.v1 (time-critical)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] The 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe truncal/gait ataxia, focal neuro signs, or recurrent audiovestibular spells with high vascular risk — posterior-circulation TIA / AICA-territory stroke (AAO-HNS CPG Basura 2020; clinical)
- [SEVERE] Sudden unprovoked fall / “pushed to the ground” without loss of consciousness (Tumarkin otolithic crisis) in known/suspected Ménière — high injury/fracture risk (Véleine J Neurosurg 2022; Huppert Acta Otolaryngol 2010; AAO-HNS CPG Basura 2020)
- [SEVERE] A SUDDEN (≤72 h) severe sensorineural hearing-loss component, especially a first event or a step-change in hearing — SSNHL until proven otherwise (Basura OHNS 2020; clinical)

Citations

- AAO-HNS Clinical Practice Guideline: Ménière's Disease — Basura et al, Otolaryngol Head Neck Surg 2020 (PMID 32267799; Executive Summary PMID 32267820) + Bárány Society Ménière diagnostic criteria — Lopez-Escamez et al, J Vestib Res 2015 (PMID 25882471) + BEMED betahistine RCT (Adrion/Strupp, BMJ 2016, PMID 26797774) + intratympanic methylprednisolone vs gentamicin (Patel et al, Lancet 2016, PMID 27865535) + Cochrane 2023 (Webster et al — IT gentamicin PMID 36847592, IT corticosteroids PMID 36847608, systemic pharmacology incl. betahistine/diuretics PMID 36827524) + vestibular neurotomy for disabling MD/Tumarkin (Véleine et al, J Neurosurg 2022, PMID 34996039) + natural history (Huppert/Strupp/Brandt, Acta Otolaryngol 2010, PMID 20001444). Reconciled 2026-05-17 — PubMed-verified; the 2020 AAO-HNS CPG + 2015 Bárány criteria are the current operational standard, no superseding guideline 2021-2026. [PMID:32267799](https://pubmed.ncbi.nlm.nih.gov/32267799/)
- Cited evidence (PMID 32267820) [PMID:32267820](https://pubmed.ncbi.nlm.nih.gov/32267820/)
- Cited evidence (PMID 25882471) [PMID:25882471](https://pubmed.ncbi.nlm.nih.gov/25882471/)
- Cited evidence (PMID 26797774) [PMID:26797774](https://pubmed.ncbi.nlm.nih.gov/26797774/)
- Cited evidence (PMID 27865535) [PMID:27865535](https://pubmed.ncbi.nlm.nih.gov/27865535/)

Last reconciled with current guidelines: 2026-05-17.
References
  • AAO-HNS Clinical Practice Guideline: Ménière's Disease — Basura et al, Otolaryngol Head Neck Surg 2020 (PMID 32267799; Executive Summary PMID 32267820) + Bárány Society Ménière diagnostic criteria — Lopez-Escamez et al, J Vestib Res 2015 (PMID 25882471) + BEMED betahistine RCT (Adrion/Strupp, BMJ 2016, PMID 26797774) + intratympanic methylprednisolone vs gentamicin (Patel et al, Lancet 2016, PMID 27865535) + Cochrane 2023 (Webster et al — IT gentamicin PMID 36847592, IT corticosteroids PMID 36847608, systemic pharmacology incl. betahistine/diuretics PMID 36827524) + vestibular neurotomy for disabling MD/Tumarkin (Véleine et al, J Neurosurg 2022, PMID 34996039) + natural history (Huppert/Strupp/Brandt, Acta Otolaryngol 2010, PMID 20001444). Reconciled 2026-05-17 — PubMed-verified; the 2020 AAO-HNS CPG + 2015 Bárány criteria are the current operational standard, no superseding guideline 2021-2026. — PMID:32267799
  • Cited evidence (PMID 32267820) — PMID:32267820
  • Cited evidence (PMID 25882471) — PMID:25882471
  • Cited evidence (PMID 26797774) — PMID:26797774
  • Cited evidence (PMID 27865535) — PMID:27865535