AUTHOR INFORMATION

Section 1 of 11

Authored by Nicholas Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants

Nicholas Lorenzo, MD, is a member of the following medical societies: Alpha Omega Alpha, and American Academy of Neurology

Edited by Mark S Slabinski, MD, Director, Emergency Services, Southeastern Ohio Regional Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; J Stephen Huff, MD, Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health System; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

Author's Email:	Nicholas Lorenzo, MD
Editor's Email:	Mark S Slabinski, MD

eMedicine Journal, July 12 2006, VOLUME 7, Number 7

INTRODUCTION

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Background: Ménière syndrome, also known as endolymphatic hydrops, is an inner ear (labyrinthine) disorder in which there is an increase in volume and pressure of the endolymph of the inner ear. It typically presents with waxing and waning hearing loss and tinnitus associated with vertigo. Patients may report an abnormal sensation of pressure or fullness in the ears. Multiple episodes may occur over a span of years, with remissions in between each acute episode. Hearing loss typically occurs.

Pathophysiology: Autopsy studies involving patients with Ménière syndrome have shown an increase in the volume of endolymph with distension of the entire endolymphatic system. This distension and increased fluid results in permanent damage to both the vestibular and cochlear apparatuses.

Frequency:

• In the US: As many as 50% of patients with Ménière syndrome have a positive family history of it, suggesting a genetic predisposition. The estimated prevalence is 150 cases per 100,000 population.

Mortality/Morbidity:

• Multiple episodes of vertigo and hearing loss eventually result in permanent damage to the vestibular and cochlear apparatuses. Thus, permanent hearing loss is the primary morbidity associated with this syndrome.

• Falls and accidents may be associated with this syndrome secondary to severe vertigo.

Sex: Generally, men and women are affected equally.

Age: Onset typically occurs in early- to mid-adulthood.

CLINICAL

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History:

• Prodrome of a fullness or blocked sensation in one ear

• Tinnitus followed by a decrease in hearing

• Vertigo is experienced concurrently with or follows shortly after the hearing symptoms. The vertigo typically lasts minutes to hours but may last as long as several days.

• Nausea, vomiting, diarrhea, pallor, and sweating commonly are associated with an acute attack.

• Following an acute episode, hearing may return to normal. After multiple episodes, hearing usually is decreased.

• Headache and gait unsteadiness may persist for several days after an acute attack.

• Recurrences are the rule; however, the frequency of these recurrences is unpredictable.

• Rarely, patients may experience such severe vertigo that they will collapse to the ground. These Ménière-related drop attacks are known as Tumarkin crises. Bilateral Ménière disease occurs in as many as one third of these patients.

Physical: A complete neurological examination is necessary to discover other conditions. Particular attention should be given to the cranial nerve examination; any abnormalities in the neurological examination that are not attributable to the vestibular system point toward another diagnosis.

• Vestibular maneuvers may be helpful in diagnosing this syndrome. Interpretation of either of the following maneuvers is identical.

• Nylen-Bárány maneuver: The patient sits at the end of the examining table and is laid back quickly, while the head is supported and the neck is carefully hyperextended. The head is first turned toward one shoulder; then, the maneuver is repeated with the head turned toward the other shoulder.

• Hallpike maneuver: The patient sits in the middle of the examination table. With the head and neck carefully supported, the patient quickly is laid to one side; then, the maneuver is repeated to the other side.

• In the interpretation of these maneuvers, the reproducibility of the vestibular symptoms, including vertigo, nausea, and malaise, should be noted. Typically, these symptoms are worse with the head in a particular position; that position should be noted.

• The maneuvers should be repeated several times over a 5-10 minute period, as tolerated by the patient. Fatigue and extinction of the vestibular symptoms (ie, whether or not the severity of the symptoms decreases with successive repetition of the maneuvers) should be noted.

• Nystagmus in primary gaze or gaze-invoked nystagmus should be noted. Most commonly, nystagmus is horizontal or rotatory. The fatigability and extinction of nystagmus with repetition of the maneuvers should be noted.

• In addition, the onset of nystagmus (ie, whether or not there is a latent period between the completion of the maneuver and the onset of nystagmus) should be noted. The length of the latent period (in seconds) should be noted.

• Peripheral vestibular dysfunction, as seen in Ménière syndrome, is associated with the following:
  • A short latency between the change in position and the vertigo, nausea, and malaise symptoms

  • A latency of several seconds after the change in position and before the onset of nystagmus

  • Fatigue and habituation of nystagmus and the vertigo, nausea, and malaise symptoms with repeated maneuvers

• Central lesions (ie, cranial nerve VIII, brainstem) are associated with the immediate onset (no latency) of nystagmus and the vertigo, nausea, and malaise symptoms. These phenomena do not fatigue or habituate with repetitive vestibular maneuvers.

• Evaluation of hearing is important in these patients. Gross testing of each ear can be achieved by gently rubbing the fingers and estimating the farthest distance from the ear that this sound can be heard. This distance should be recorded. Audiological testing is much more sensitive for hearing loss.

• Rinne test

• This test is best performed with a 256 Hz tuning fork. The vibrating tuning fork is placed against the mastoid bone, and the patient is asked to indicate when it can no longer be heard. At that moment, the opposite end of the tuning fork is placed over the pinna, and the patient is asked to indicate when the tuning fork can longer be heard.

• The test is normal when the tuning fork is heard through the ear for approximately twice as long as it is heard through bone conduction from the mastoid. (Normally, air conduction is greater than bone conduction.)

• Weber test

• This test can be performed with a 256 Hz tuning fork.

• The activated tuning fork is placed on the vertex of the skull, and the patient is asked if the sound of the tuning fork is equal in both ears.

• A normal result occurs when the patient reports that the tuning fork is heard equally in both ears.

• If there is middle ear disease or blocking of the external auditory canal, the sound is heard better on the affected side. If there is cochlear nerve dysfunction, the sound is diminished on the affected side.

• Evaluation of the vestibular tests is problematic in the ED. The patient may have symptoms that are exacerbated by movement, limiting these maneuvers. The alert patient will have visual fixation that suppresses nystagmus.

Causes:

• A variety of disease processes can affect the vestibular and cochlear systems.

• The exact cause of Ménière syndrome is unknown. The current theory is that it is the response of the inner ear to injury.

DIFFERENTIALS

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Headache, Migraine
Hypothyroidism and Myxedema Coma
Labyrinthitis
Multiple Sclerosis
Otitis Media
Stroke, Ischemic
Subarachnoid Hemorrhage
Toxicity, Salicylate
Transient Ischemic Attack
Vestibular Neuronitis

Other Problems to be Considered:

Aminoglycoside toxicity
Barre-Lieou syndrome (In addition to vertigo and unsteadiness, this syndrome is associated with cervical spondylosis. It presents with neck pain and a burning sensation in the face, tinnitus, dysphagia, and arm pain.)
Basilar meningitis
Brainstem tumors
Labyrinthine concussion
Labyrinthine otosclerosis
Neoplasms (especially those associated with cranial nerve VIII, eg, acoustic neuroma)
Posttraumatic (especially if associated with a skull fracture)
Quinine toxicity
Toxic or pharmaceutical injury to the vestibular apparatus (eg, alcohol, streptomycin, quinine, barbiturate, phenytoin, antihistamines)
Various infections (especially herpes zoster and CNS syphilis)
Vascular infarction of the labyrinth (usually associated with unilateral hearing loss)
Vasculitis (Cogan syndrome)
Wernicke encephalopathy

WORKUP

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Lab Studies:

• No lab studies are specific for Ménière disease.

• A CBC, urinalysis, chemistry panel, and alcohol and drug screening may be helpful if other causes are considered.

• If an infectious cause is suspected, consider blood cultures, urine culture, and a cerebral spinal fluid (CSF) examination.

Imaging Studies:

• In most cases, no imaging studies are required in patients with a typical history of Ménière syndrome.

• If an infectious cause is suspected, consider chest x-ray.

• If there is clinical suspicion for a central vestibular lesion, an MRI of the head, with and without gadolinium, should be considered. In most cases, it does not need to be performed on an emergent basis.

Other Tests:

• More extensive testing of these patients typically is not performed in the ED. This testing is performed under the direction of a neurologist or an ear, nose, and throat (ENT) specialist and may include the following:

• Brainstem auditory evoked potentials

• Electronystagmography

• Audiogram

• Otoscopy

• Caloric testing/electronystagmogram (ENG)

Procedures:

• Procedures that may be considered after extensive workup by an ENT specialist include systemic administration of streptomycin (an ototoxic drug with a high affinity for vestibular hair cells), labyrinthectomy, and vestibular nerve section.

TREATMENT

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Emergency Department Care:

• The severity of an acute attack can be determined after obtaining a thorough initial history and performing a physical examination.

• Supportive measures, such as IV rehydration if vomiting has been severe, should be initiated, as indicated.

• Medications for symptomatic relief of vertigo and nausea should be given, since this is a clinical diagnosis requiring only symptomatic care.

Consultations:

• In most cases, patients can be stabilized and discharged from the ED.

• In severe cases, those that are unremitting, or cases in which a secondary cause may be suspected, an ENT specialist or a neurologist may be consulted.

MEDICATION

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Medication use in the treatment of Ménière disease is primarily for symptomatic relief. Several medications (eg, meclizine, scopolamine, ephedrine, dimenhydrinate, diazepam) have antivertiginous properties, and other medications (eg, promethazine, prochlorperazine) are useful as antiemetics. The majority of acute episodes are short-lived and self-limited. A short tapering course of oral steroids occasionally may be helpful in treating an acute attack of Ménière disease. Diuretics, such as acetazolamide or hydrochlorothiazide, also may be helpful in specific patients when administered on a continuing basis. Innovar has been used successfully to treat patients failing first-line therapies, but its use should probably be considered only in consultation with the patient's primary care physician.

Drug Category: Antihistamines -- These agents are extremely useful in treating vertigo symptoms.

Drug Name	Meclizine (Antivert) -- Decreases the excitability of the middle ear labyrinth and blocks conduction in the middle ear vestibular-cerebellar pathways. These effects are associated with its therapeutic effects in vertigo.
Adult Dose	25 mg PO q4-6h
Pediatric Dose	Children: Not established Adolescents: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	May increase toxicity of CNS depressants, neuroleptics, and anticholinergics
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in angle-closure glaucoma, prostatic hypertrophy, pyloric or duodenal obstruction, and bladder neck obstruction

Drug Name	Dimenhydrinate (Dramamine) -- Used for the treatment and prophylaxis of vestibular disorders that may cause nausea and vomiting. Through its central anticholinergic activity, it diminishes vestibular stimulation and depresses labyrinthine function.
Adult Dose	50 mg PO/IM q4-6h or a 100 mg suppository q8h
Pediatric Dose	Neonates: Do not administer 2-6 years: 12.5-25 mg q6-8h; not to exceed 75 mg/d 6-12 years: 25-50 mg PO q6-8h; not to exceed 150 mg/d
Contraindications	Documented hypersensitivity
Interactions	Alcohol or other CNS depressants may have additive effect on dimenhydrinate; caution when administering concurrently with antibiotics that may cause ototoxicity; may mask ototoxic symptoms, caused by certain antibiotics and irreversible damage may result
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	IV products may contain benzyl alcohol, which has been associated with fatal gasping syndrome in premature infants and low birth weight infants; do not treat severe emesis with antiemetic drugs alone; may contain either sulfites or tartrazine, which may cause allergic-type reactions in susceptible persons; may impede diagnosis of conditions such as brain tumors, intestinal obstruction, and appendicitis; may obscure signs of toxicity from overdosage of other drugs

Drug Category: Anticholinergics -- These agents are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways.

Drug Name	Scopolamine (Isopto) -- Blocks action of acetylcholine at parasympathetic sites and antagonizes histamine and serotonin action. Transdermal scopolamine may be the most effective agent for motion sickness. Use in the treatment of vestibular neuronitis is limited by its slow onset of action.
Adult Dose	0.3-0.65 mg IM/SC/IV q4-6h Transdermal patch: Apply 2.5 cm2 patch to hairless area behind the ear q3d
Pediatric Dose	6 mcg/kg/dose IV/IM/SC to a maximum of 0.3 mg/dose, or 0.2 mg/m2 q6-8h
Contraindications	Documented hypersensitivity; primary glaucoma (including initial stages), pyloric obstruction, toxic megacolon, hepatic disease, paralytic ileus, severe ulcerative colitis, renal disease, obstructive uropathy, and myasthenia gravis
Interactions	Antipsychotic effectiveness of phenothiazines may be decreased by coadministration with scopolamine; anticholinergic side effects may be increased by concurrent therapy and phenothiazine dosages should be adjusted prn; coadministration with tricyclic antidepressants may increase anticholinergic side effects (eg, dry mouth, constipation, urinary retention) due to additive effect (tricyclic antidepressants with less anticholinergic activity may be beneficial)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in the elderly because of increased incidence of glaucoma; large doses may suppress intestinal motility and precipitate or aggravate toxic megacolon; anticholinergics may aggravate hiatal hernia associated with reflux esophagitis; patients with prostatism can have dysuria and may require catheterization; use cautiously in patients with asthma or allergies; a reduction in bronchial secretions can lead to inspissation and formation of bronchial plugs

Drug Category: Benzodiazepines -- By binding to specific receptor sites, these agents appear to potentiate the effects of gamma-aminobutyric acid (GABA) and to facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. These effects may offer benefits in the treatment of vertigo and emesis.

Drug Name	Diazepam (Valium) -- Depresses all levels of the CNS, including limbic and reticular formation, possibly by increasing GABA activity, which is a major inhibitory neurotransmitter.
Adult Dose	5-10 mg PO/IV/IM q4-6h
Pediatric Dose	<6 months: Do not administer 0.05-0.3 mg/kg/dose IV/IM over 2-3 min; repeat in 2-4 h, prn 0.12-0.8 mg/kg/d PO divided q6-8h; not to exceed 10 mg/dose
Contraindications	Documented hypersensitivity; narrow-angle glaucoma
Interactions	Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)

Drug Category: Phenothiazines -- These agents are useful in treating emesis.

Drug Name	Promethazine (Phenergan) -- Antidopaminergic agent effective in the treatment of emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system.
Adult Dose	25-50 mg PO/IM/PR q4-6h
Pediatric Dose	<2 years: Contraindicated >2 years: 0.5 mg/kg q4-6h
Contraindications	Documented hypersensitivity; children younger than 2 y (incidences of death due to respiratory depression)
Interactions	May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Can be associated with CNS depression, dry mouth, extrapyramidal symptoms, hypertension, hypotension, and skin rash; caution in patients with cardiovascular or hepatic disease May accentuate CNS depression when administered with other medications (that cause CNS depression), to include alcohol, narcotics, sedatives, and hypnotics

Drug Name	Prochlorperazine (Compazine) -- Antidopaminergic drug that blocks the postsynaptic mesolimbic dopaminergic receptors. Has an anticholinergic effect and can depress the reticular activating system. IV administration is not recommended for children.
Adult Dose	5–10 mg PO/IM q6h or 25 mg PR q12h
Pediatric Dose	2.5 mg PO/PR q8h, or 5 mg q12h prn 0.1-0.15 mg/kg/dose IM; change to PO as soon as possible Total daily dosage is not to exceed 7.5 mg in children <30 lb, 10 mg in children <40 lb, and 15 mg in children <85 lb
Contraindications	Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease
Interactions	Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine may cause hypotension
Pregnancy	D - Unsafe in pregnancy
Precautions	Drug-induced Parkinson syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most common extrapyramidal reaction in elderly; lowers seizure threshold; caution with history of seizures

Drug Category: Adrenergic agonists -- These agents are useful in treating vertigo, but their mechanism of action is unclear.

Drug Name	Ephedrine (Pretz-D, Kondon's Nasal) -- Stimulates the release of epinephrine stores producing alpha- and beta-adrenergic effects.
Adult Dose	25 mg PO q4-6h
Pediatric Dose	<2 years: Not recommended 2-5 years: 3 mg q6-8h >5 years: 6.25 mg q6-8h
Contraindications	Documented hypersensitivity; angle-closure glaucoma; cardiac arrhythmias
Interactions	Theophylline, atropine, or MAOIs may increase toxicity; alpha- and beta-blockers decrease vasopressor effects of ephedrine; cardiac glycosides and general anesthetics increase cardiac stimulation of ephedrine
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in the elderly, diabetes mellitus, hyperthyroidism, hypertension, cardiovascular disease, prostatic hypertrophy, or cerebrovascular insufficiency

Drug Category: Corticosteroids -- These agents have anti-inflammatory properties and cause profound and varied metabolic effects.

Drug Name	Prednisone (Deltasone) -- Useful in the treatment of inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, it may decrease inflammation.
Adult Dose	A short (3-5 d) course of oral prednisone can be utilized; a starting dose of 40-60 mg PO qd should be considered
Pediatric Dose	A short course (3-5 d) can be used in children, with a starting dose of 5-10 mg PO
Contraindications	Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Interactions	Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

FOLLOW-UP

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Further Inpatient Care:

• Inpatient care rarely is required and would include additional medications for symptom relief and consultation with a neurologist or an ENT specialist.

Further Outpatient Care:

• If symptoms persist or recur, the patient should be instructed to follow up with a primary care physician in 5-7 days. These episodes usually are self-limited.

• If the symptoms worsen (in either frequency or severity) and if they become associated with other neurological symptoms, such as diplopia, slurred speech, gait unsteadiness, or localized weakness or numbness, prompt re-evaluation is required.

• A low-salt and low-sugar diet is effective in reducing symptoms in some patients.

• Avoidance of particular foods (eg, chocolate, coffee, alcohol) is also helpful in some patients.

In/Out Patient Meds:

• Medications used for symptom relief in the ED should be considered for continued outpatient treatments.

Deterrence/Prevention:

• Deterrence is problematic because it is often ineffective. Though clear evidence to support their effectiveness is lacking, frequently given recommendations for prevention include the following:

• Reduce salt intake

• Stop smoking

• Avoid significant noise exposure

• Reduce stress

Complications:

• Injury because of a fall during an attack

• Hearing loss that may be progressive and permanent

Prognosis:

• Alternating attacks and remissions are normal.

• Balance problems tend to resolve with time, while hearing tends to worsen.

• Most symptoms can be managed with medications.

• Approximately 5-10% of patients require surgery for incapacitating vertigo.

Patient Education:

• Patients should be educated regarding the fluctuating nature of this disease. They should be forewarned that recurrences are common and expected.

• Patients should be cautioned about avoiding certain activities during which a vertigo spell would put them at risk for resultant traumatic injury.

• Patients should be cautioned about the potential sedative effects of many of the medicines used in treatment of this disease.

• For excellent patient education resources, visit eMedicine’s Brain and Nervous System Center and Ear, Nose, and Throat Center. Also, see eMedicine’s patient education articles Ménière Disease and Tinnitus.

MISCELLANEOUS

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Medical/Legal Pitfalls:

• Any misdiagnosed underlying condition, such as vertebrobasilar ischemia, a brainstem tumor, or CNS infection, that results in further neurological injury

• Failure to warn patients about increased risk of injury from a sudden vertigo spell during certain activities

• Complications from medications, such as an acute dystonic reaction to an antiemetic, sedative effects, and drug interactions

• At times, Ménière disease is diagnosed erroneously and is a "wastebasket diagnosis" for patients with chronic complaints of dizziness. Alternate diagnoses must be considered and excluded by a careful history, an examination, and appropriate tests, if needed.

TEST QUESTIONS

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CME Question 1: Which of the following is not associated with Ménière syndrome?

A: Hearing loss
B: Vertigo
C: Diplopia
D: Endolymphatic hydrops
E: C and D

The correct answer is C: Diplopia, or any other neurological sign or symptom that is not directly attributable to the vestibulocochlear system, is worrisome for a more grave diagnosis (eg, a brainstem tumor), emphasizing the importance of a complete neurological history and examination in these patients.

CME Question 2: Which of the following is not associated with Ménière syndrome?

A: Congenital inner ear deformities
B: Labyrinthitis
C: Physical trauma to the head and ear
D: Penicillin family of antibiotics
E: Syphilis

The correct answer is D: Ménière syndrome can be associated with the aminoglycoside family (not the penicillin family) of antibiotics. Aminoglycosides are toxic to the vestibular and cochlear systems.

Pearl Question 1 (T/F): Surgery is almost never indicated for severe cases of Ménière syndrome.

The correct answer is False: Several surgical procedures including labyrinthectomy and vestibular nerve section can be considered in severe cases of Ménière syndrome.

Pearl Question 2 (T/F): Streptomycin can be used as an ablative therapy in the treatment of Ménière syndrome.

The correct answer is True: Daily injections of streptomycin are a reasonable therapeutic option.

Pearl Question 3 (T/F): The membranous labyrinth plays an important role in the pathophysiology of Ménière syndrome.

The correct answer is True: The membranous labyrinth progressively dilates until permanent damage is done to the vestibular and cochlear systems.

Pearl Question 4 (T/F): A high fiber diet can be helpful in some patients with Ménière syndrome.

The correct answer is False: Dietary fiber content has no known association with Ménière syndrome. However, a low-salt diet can be helpful. In addition, avoidance of foods with high sugar and such specific foods as alcohol, coffee, or chocolate also can also be helpful.

BIBLIOGRAPHY

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• Baloh R W, Jacobson K, Honrubia V: Idiopathic bilateral vestibulopathy. Neurology 1989; 39: 272[Medline].
• Brandt T, Daroff RB: The multisensory physiological and pathological vertigo syndromes. Ann Neurol 1980 Mar; 7(3): 195-203[Medline].
• Brandt TH: Episodic vertigo. In Rake RE, ed. Conn's Current Therapy. 1985; 741.
• Committee on Hearing and Equilibrium: Report of Subcommittee on Equilibrium and its Measurement. Meniere's disease: criteria for diagnosis and evaluation of therapy for reporting. Trans Am Acad Ophthalmol Otolaryngol 1972 Nov-Dec; 76(6): 1462-4[Medline].
• Daroff RB: Evaluation of Dizziness and Vertigo. In: Glaser JS, ed. Neuroophthalmology Symposium 1977; 9: 39-54.
• Dix MR, Hallpike CS: The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952 Dec; 61(4): 987-1016[Medline].
• Drachman DA, Hart CW: An approach to the dizzy patient. Neurology 1972 Apr; 22(4): 323-34[Medline].
• Gates GA: Innovar treatment for Meniere's disease. Acta Otolaryngol 1999 Mar; 119(2): 189-93[Medline].
• Hamann K, Arnold W: Meniere's disease. Adv Otorhinolaryngol 1999; 55: 137-68[Medline].
• Jackson CG, Glasscock ME, Davis WE, et al: Medical management of Meniere's disease. Ann Otol Rhinol Laryngol 1981 Mar-Apr; 90(2 Pt 1): 142-7[Medline].
• James A, Thorp M: Meniere's disease. Clin Evid 2004 Jun; 664-72[Medline].
• Nadol JB Jr, Weiss AD, Parker SW: Vertigo of delayed onset after sudden deafness. Ann Otol Rhinol Laryngol 1975 Nov-Dec; 84(6): 841-6[Medline].
• Pulec J L: Meniere's disease: Etiology, natural history, and results of treatment. Otolaryngol. Clin. North Am 1973; 6: 25[Medline].
• Pulec JL: Meniere's disease: results of a two and one-half-year study of etiology, natural history and results of treatment. Laryngoscope 1972 Sep; 82(9): 1703-15[Medline].
• Ruckenstein MJ: Immunologic aspects of Meniere's disease. Am J Otolaryngol 1999 May-Jun; 20(3): 161-5[Medline].
• Schuknecht HF: Cupulolithiasis. Arch Otolaryngol 1969 Dec; 90(6): 765-78[Medline].
• Shoushtarian M, Lithgow B: A vestibular diagnostic response. Australas Phys Eng Sci Med 2004 Dec; 27(4): 189-98[Medline].
• Troost BT: Dizziness and vertigo in vertebrobasilar disease. Part II. Central causes and vertebrobasilar disease. Stroke 1980 Jul-Aug; 11(4): 413-5[Medline].
• Van de Heyning PH, Wuyts F, Boudewyns A: Surgical treatment of Meniere's disease. Curr Opin Neurol 2005 Feb; 18(1): 23-8[Medline].
• Wladislavosky-Waserman P, Facer GW, Mokri B, Kurland LT: Meniere's disease: a 30-year epidemiologic and clinical study in Rochester, Mn, 1951-1980. Laryngoscope 1984 Aug; 94(8): 1098-102[Medline].

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