Vertigo "Frequent Visitors": Progress and Significance of Classification and Diagnosis of Meniere's Disease

As a common clinical symptom, vertigo is a "frequent visitor" in otolaryngology, neurology, psychiatry, orthopedics and ophthalmology, and the causes are more complex, and the causes are different for patients of different
ages.
This article focuses on Meniere's Disease (MD),
a peripheral vertigo that often occurs in young adults.
The basic life
of the people in difficulty.

There are subtypes of MD, with large differences in clinical manifestations between individuals, different underlying etiology and pathogenesis, and different responses to treatment, resulting in a lack of etiological treatment and individualized treatment plan, large differences between the groups studied, increased heterogeneity, lack of comparability, and difficulties
in evaluating the efficacy of treatment and exploring the etiology.

In recent years, more and more attention has been paid to the diagnosis and treatment of MD heterogeneity[1], and scholars at home and abroad have explored from multiple angles to improve the classification ideas
of MD.
Let's
work with you to understand the latest classification progress and significance of MD.

Before that, let's review the diagnostic criteria
for MD.

Diagnostic criteria are the cornerstone of MD diagnosis

According to the MD Guidelines for Diagnosis and Treatment (Diagnostic criteria for Ménière's disease, 2015, Barany Society; MD Diagnosis and Treatment Guidelines, 2017, Chinese Medical Association Otolaryngology, Head and Neck Surgery Branch) [1-2], the diagnosis of MD can be divided into two parts
: clinical diagnosis and suspected diagnosis.

(1) Clinical diagnosis

1.
Diagnostic criteria

(1) 2 or more episodes of vertigo, each lasting 20min to 12h
.

(2) At least one audiology examination during the course of the disease confirmed that the affected ear had low to medium frequency sensorineural hearing loss
.

(3) The affected ear has fluctuating hearing loss, tinnitus and/or ear fullness
.

(4) Exclude vertigo caused by other diseases, such as vestibular migraine, sudden deafness, benign paroxysmal positional vertigo, labyrinthitis, vestibular neuritis, vestibular paroxysmal, drug toxic vertigo, posterior circulation ischemia, intracranial mass lesions, etc.
; In addition, secondary labyrinthography needs to be excluded
.

2.
Clinical staging[3]

The patient was staged
according to the mean hearing threshold of 0.
5, 1.
0 and 2.
0 kHz pure tones at the worst hearing in the intermittent hearing period in the last 6 months.
The clinical stage of MD is related
to the choice of treatment and prognosis.
For bilateral MD, the clinical stage
of both sides needs to be determined.

(2) Suspected diagnosis

The diagnostic criteria are as follows:

(1) 2 or more episodes of vertigo, each lasting 20min to 24h
.

(2) The affected ear has fluctuating hearing loss, tinnitus and/or ear fullness
.

(3) Exclude vertigo caused by other diseases, such as vestibular migraine, sudden deafness, benign paroxysmal positional vertigo, labyrinthitis, vestibular neuritis, vestibular paroxysmal, drug toxic vertigo, posterior circulation ischemia, intracranial mass lesions, etc.
; In addition, secondary labyrinthography needs to be excluded
.

New advances in the diagnosis of MD typing

The clinical research on MD typing gradually deepened from the external type to the intrinsic type, and early scholars mainly typed by observing the clinical manifestations (main symptoms, lateral classification, comorbidities, migraine, autoimmune diseases), and with the development of gene and cytokine levels, the importance of identifying the intrinsic type for MD typing is increasing
.

At present, there are seven main types of MD classification methods [4], and the editor lists
these classification ideas for you one by one.

➤The first type of method is to classify according to the main symptoms of the disease, and the vestibular type (only episodic vertigo) and cochlear type MD (only manifested as hearing loss, tinnitus or ear tightness, but no vertigo) proposed by the 1972 MD diagnosis and treatment standards were abandoned
in 1985.
In recent years, due to the development of imaging, endolymphatic hydrops can be visualized, and attention has been paid to the classification of symptoms again
.
This classification was reintroduced
in 2021 by Japanese standards.

➤The second type of method is divided into unilateral and bilateral MD
according to the side of the disease.
Patients with bilateral MD have a younger age of onset, a family history of migraine, and a
history of migraine.
Unilateral MD can progress to bilateral MD with the course of the disease, and how to prevent or stop this process is an important goal
of current clinical work.

➤ The third type of method is according to the classification of comorbidities, such as migraine, cardiovascular risk factors, autoimmune diseases, MD can be divided into simple MD, MD with a certain disease, generally speaking, simple MD vertigo attacks, hearing loss is mild, MD patients with migraine, migraine preventive treatment, such as choosing a healthy lifestyle, diet, etc.
, the use of migraine preventive drug nortriptyline, etc.
, is conducive to the control of MD vertigo symptoms and protects patients' hearing
.

Patients with MD with cardiovascular risk factors have greater hearing loss, lower speech recognition rates, and more frequent
seizures.
The role of cardiovascular factors in Meniere's disease deserves further study, and correction of cardiovascular risk factors may be beneficial to the control
of Meniere's disease.

➤The fourth type method is to comprehensively use cluster analysis, classify according to clinical manifestations, migraine, autoimmune diseases, and can divide unilateral and bilateral MD into 5 types (see table below), which updates our understanding of the gap between unilateral and bilateral MD and supports the role of
migraine, autoimmune diseases and genetic factors in MD.

Table 1 Bilateral MD typing

Table 2 One-sided MD typing

Note: BMD: bilateral Meniere's disease; HL: Hearing grade; VM: vestibular migraine; SMD: unilateral Meniere's disease; FMD: familial Meniere's disease
.

➤The fifth type of method is to classify the pathogenesis of MD, divided into familial and sporadic MD, all with gene mutations, Rxqucna T and Frejo L in-depth study of related genes to obtain, familial MD inheritance mode is more, mainly seen in autosomal dominant inheritance; Sporadic MD can also be caused
by rare mutations.
Studying the genes of MD patients is conducive to analyzing their etiology and improving the efficiency of
clinical screening.

➤ The sixth type method is to classify
according to the cytokine recombinant human interleukin-1β (IL-1β) level.
In 2018, Frejo classified MD as high/low IL-1β levels of MD, suggesting that MD is related to autoinflammatory responses, and clinicians can determine the characteristics
of MD patients by measuring cytokine levels in the future.

➤The seventh type of method is classified according to the pathological manifestations of endolymphatic sac, in 2018, Eckhard et al.
first reported that there are characteristic pathological changes in the endolymphatic sac of idiopathic endolymphatic hydrops-degeneration and dysplasia, and proposed two intrinsic types of MD: endolymphatic sac degeneration and dysplasia, revealing the relationship between endolymphatic sac pathological changes and MD, so that clinicians can explore the mechanism of MD to a higher level
.

The classification method of MD is helpful to explore the causes and genes of MD, provide patients with high homogeneity for clinical research, and provide higher quality evidence
for clinical diagnosis and treatment.
Typing can also extend MD treatment modalities, such as immunomodulators, migraine preventive treatment, improved blood rheology therapy, anti-allergy therapy, etc
.

brief summary

MD classification is a new direction of future MD diagnosis and treatment, the current MD classification method is still in the exploration stage, clinicians in the face of MD patients, should first clarify its classification, and for different types of MD to choose personalized treatment plan, on the basis of controlling their own underlying diseases on the basis of MD treatment, expand the treatment mode and dimension of MD, improve the treatment effect
.