This week, we are sharing another USMLE® Step 1-style practice question to test your knowledge of medical topics. Today’s case focuses on a 37-year-old woman who has had multiple episodes of dizziness lasting between 20 minutes to several hours. These episodes are associated with ringing in the left ear. Can you figure it out?
A 37-year-old woman comes to her primary care physician for evaluation of dizziness and hearing loss. The patient has had multiple episodes of dizziness lasting between 20 minutes to several hours. These episodes are associated with ringing in the left ear. The patient states, “These episodes are so debilitating I have to lie in bed until they are over. Sometimes the spinning sensation is so intense that I vomit.” Past medical history is noncontributory. She has not had any recent bacterial or viral infections. Vital signs are within normal limits, and physical examination reveals no significant findings. Audiometric testing demonstrates low-mid frequency hearing loss in the left ear. Hearing in the right ear is normal. Which of the following is the most likely diagnosis?
A. Benign paroxysmal positional vertigo
B. Otosclerosis
C. Meniere disease
D. Labrynthitis
E. Presbycusis

The correct answer to today’s USMLE® Step 1 Question is…
C. Meniere disease
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
A. Benign paroxysmal positional vertigo
Incorrect: Benign paroxysmal positional vertigo arises from calcium crystals, known as otoconia or otoliths, that become dislodged from their usual position within the utricle. Over time, the otoliths migrate into the semicircular canals and can cause vertigo triggered by changes in position. However, the condition would not lead to hearing loss.
B. Otosclerosis
Incorrect: Otosclerosis is characterized by bony remodeling and overgrowth of the middle ear ossicles. The footplate of the stapes is most commonly affected. The condition presents with low-frequency conductive hearing loss. Otosclerosis would not typically present with the vertigo experienced by this patient.
D. Labrynthitis
Incorrect: Labrynthitis, also known as vestibular neuritis, is caused by inflammation of the inner ear structures. The condition manifests with intermittent vertigo, hearing loss, and loss of coordination. However, labrynthitis typically occurs in the setting of an active or recent upper respiratory tract infection.
E. Presbycusis
Incorrect: Presbycusis is an age-related condition characterized by bilateral, high-frequency sensorineural hearing loss. However, presbycusis would not account for the episodes of vertigo experienced by this patient.
Main Explanation
This patient presents with episodes of vertigo, tinnitus, and low-mid frequency hearing loss. These findings are most consistent with Meniere disease.
Meniere disease is an inner ear disorder characterized by episodic attacks of vertigo, tinnitus, ear fullness, and hearing loss. Individual episodes can last anywhere from twenty minutes to 24 hours. The disease typically occurs in adults between the ages of 30 and 60. Meniere disease arises due to impaired reabsorption of endolymph fluid. Overtime, the fluid accumulates and causes distention of the semicircular canals; this phenomenon is termed endolymphatic hydrops.
Ultimately, these changes impair proper signaling through the labyrinthine system, causing disequilibrium, vertigo, sensorineural hearing loss, tinnitus, as well as a sensation of ear fullness. Meniere disease is primarily a clinical diagnosis. Patients should also undergo audiometric testing to evaluate for low-mid frequency sensorineural hearing loss.
Treatment of Meniere disease aims to decrease the volume of the endolymphatic fluid. This can be done by limiting the intake of salt, caffeine, alcohol, and nicotine. If symptoms persist, diuretics (e.g., hydrochlorothiazide, acetazolamide) can be used. In severe, disabling cases, surgical options (e.g., labyrinthectomy, vestibular neurectomy) can be considered.
Major Takeaway
Meniere disease is due to impaired reabsorption of endolymph fluid. The condition can manifest with vertigo, sensorineural hearing loss, and tinnitus. Treatment options include dietary modifications, diuretics, and in severe cases, surgery.
References
Espinosa-Sanchez, J.M., Lopez-Escamez, J.A. (2016) Meniere’s disease. Handbook of Clinical Neurology. 137, 257-277. Doi: 10.1016/B978-0-444-63437-5.00019-4.
Sajjadi, H., Paparella, M.M. (2008) Meniere’s disease. Lancet. 372(9636), 406-414. Doi: 10.1016/S0140-6736(08)61161-7.
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