Meniere's disease tends to present in episodes which can either be frequent or have long periods of remission. Between attacks, patients experience no symptoms [7]. The major clinical features are:

• Vertigo: This is the most disturbing clinical feature of this condition. Patients experience a feeling that they or their surroundings are moving or spinning. Apart from a spinning sensation, they may also feel dizzy, uneasy and have an imbalance sensation. Nausea and vomiting may be present. Each episode lasts for about 20 minutes to a couple of hours. Drop attacks may occur. Attacks tend to disrupt the entire schedule and each episode ends in the patient feeling sleepy. A sensation of being disoriented maybe present for a few days after an attack.

• Tinnitus: This is more prominent when the patient is exhausted or the surroundings are very quiet. They may hear noises and sounds coming from inside the body like buzzing, humming and hissing.

• Hearing loss: In the early stages hearing loss is not noticeable, but with progression of disease, hearing loss for all frequencies becomes prominent and permanent. Initially, deafness maybe there only for low frequencies.

Ear fullness is perceived prior to an attack of vertigo and it feels as if the ear has been plugged and is full of pressure. Thus, a typical attack consists of vertigo, tinnitus and loss of hearing. Towards the later stages vertigo reduces while tinnitus and deafness remain permanent. The presentation may vary from individual to individual.

The diagnosis is variable as there is no specific diagnostic test. It is based on history and clinical examination [8]. An important feature to note in Meniere's disease which helps differentiate it from other clinical conditions is the intermittent nature of its clinical course.

A complete history as regards to the frequency, intensity, duration and type of attacks should be noted. Degree of hearing loss and tinnitus should also be assessed. An audiometry test should be done to conclude the type of hearing loss. Speech discrimination should be tested for especially in the affected ear. An electronystagmogram is conducted to check for balance and function. Eye movements in a dark room should also be checked as they work in coordination [9]. CT or MRI scans of the skull can be done to rule out any other lesions.

Meniere's disease is not curable but various treatments are available to alleviate symptoms and reduce frequency of attacks. After understanding the cause and pattern of the individual case, the physician can very well judge the best treatment option for the patient. Initial line of treatment consists of:

• Low salt diet with a diuretic to reduce fluid content [10].
• Medication for vertigo, nausea and vomiting such as antiemetics.

These two therapies alone can help a majority of cases. If symptoms are not controlled with the above methods, there are two non destructive methods which are invasive but do not hamper the anatomy of the ear.

• Intratympanic injections of either gentamicin or dexamethsone. A temporary opening is made in the ear drum and the drug is injected into the middle ear space once or several times [11].
• Air pressure pulse generator, in this pressure is transmitted through the ear drum to alter the pressure in the inner ear.

Surgery is the last resort when attacks of vertigo cannot be controlled by above methods.

• Endolymphatic sac shunt or decompression which actually helps to improve the function of the ear actively by reducing fluid production and improving fluid drainage.
• Destructive surgeries such as vestibular nerve section help reducing vertigo.
• Labyrinthecotomy is a surgery where the entire inner ear is removed thus eliminating the function of hearing and balance in the ear [12].

Vestibular rehabilitation can improve the attacks. These exercises also help to maintain the sense of balance. Hearing aids can be used for hearing loss.

There is no permanent cure for this condition though various treatment strategies can improve the outlook. The intensity and severity can vary from individual to individual, thus it is very unpredictable. Some cases have long periods of remission which can last for months to years.

With progress of time, permanent sensorineural deafness and tinnitus sets in. Initially, it begins in one ear but over a period of time, both ears are involved. The approximate number of patients who end up with bilateral Meniere's disease is about 17 to 75%.

Sometimes the condition might be so severe that it can disable a person completely but this is rare. Most of the cases do well with or without any major medical help. The outlook is as unpredictable as the disease [6]. In the later stages when hearing loss is permanent, hearing aids and cochlear implants are used.

Although histologically Meniere's disease has been well characterized by endolymphatic hydrops, the exact etiology still remains unclear. Recent research shows a possible role of autoimmune processes, endocrine function, infection, allergy and genetic factors.

The inner ear has a membranous labyrinth which contains endolymph, if there is some problem with the drainage of this fluid it leads to the membranes becoming distended like a balloon due to pressure. This is the hallmark of hydrops. The reason for drainage being affected can be anything from a swelling of endolymphatic sac or other parts of the vestibular system. In some cases, an excess of fluid is secreted or there is presence of an obstruction in the outlet of the endolymphatic duct. This was the traditional thinking regarding the etiology.

Nowadays, it is hypothesized that an immunologic component seems to play in role in the causation. Individuals with autoimmune disorders seem to have Meniere's disease. Immunosuppressive therapy seems to improve hearing loss. Viral infections also maybe involved in the etiopathogenesis, especially the herpes simplex virus.
Strong genetic predisposition exists with a strong familial tendency. Other factors such as middle ear infection, head injury, or acoustic trauma have been postulated as etiological factors.

As there is no specific diagnostic test for Meniere's disease, the incidence and prevalence of this condition vary. The typical onset is seen between 20 to 50 years of age. Recent studies document that it affects women slightly more than men. Hardly 3% belong to pediatric group [3].

In the United States of America, it affects about 0.2% of the population. In Great Britain, it affects about 157 individuals out of 100,000. It tends to occur with increasing age and is common as a balance related disorder in the elderly [4]. Racial predisposition is still not clearly known. There is no correlation between age of the individual and bilateral involvement, both ears are affected equally.

Endolymphatic hydrops is the single most distinctive feature histologically and there is no general accepted theory regarding the pathophysiology. In Meniere's disease, how the hydrops forms is still unknown with no clear understanding of the etiopathogenesis.

The most widely accepted theory is the reabsorption of endolymph which leads to collection of fluid and distension of the membranes like a balloon. Electron microscopy shows perisacular degeneration and fibrosis while epithelial cells are replaced by mesenchymal cells [5]. With increase in fluid, a rupture of the membranous labyrinth mainly the Reissner's membrane takes place, as it is the thinnest. This leads to mixing of perilymph and endolymph which changes the electrochemical properties of the two fluids. This produces vertigo and nystagmus due to potassium rich endolymph.

Due to rupture of the membrane, open fistula spaces form between perilymph and endolymphatic spaces. Neural damage especially sensorineural deafness for low frequencies, tinnitus and aural fullness occur. Healing of ruptured membranes accompanied by release of pressure follows. Repeated episodes lead to deafness for all frequencies and ultimately, irreversible pathological changes.

There is no known preventive measure for Meniere's disease, but certain steps can be followed to reduce attacks.

• Ear infections should be promptly treated
• Low salt diet
• Avoid sudden jerky movements
• Reduce food triggers such as chocolate, caffeine, tea and alcohol

Recurrent spontaneous attacks of vertigo, hearing loss, tinnitus and a sense of aural fullness are the symptoms commonly experienced by an individual suffering from a condition called Meniere's disease. This disorder is also known as endolymphatic hydrops. It is a condition related to the inner ear wherein there is irregularity in the flow of the fluid in the inner ear. Initially it affects only one ear, but with time it tends to become bilateral [1].

The exact etiopathogenesis is not known and most of the cases remain idiopathic. Symptoms fluctuate and typically each attack lasts for 20 minutes to about 4 hours or more. Vertigo is rotational. Hearing loss which ultimately leads to deafness also occurs. Diagnosis is mainly based on history and examination. Acute attacks require bed rest and assurance. Surgery or pharmacological ablation of vestibular organ is considered in very severe disease [2].

Meniere's disease is a condition of the inner ear, which leads to episodes of vertigo, hearing loss and noises in the ear (tinnitus). Each episode may vary and there can be long periods of no symptoms at all. The reason for this condition is not known. A combination of genetic and autoimmune factors seem to play a role. This condition is more common in advanced age groups. As the disease progresses hearing loss becomes permanently impaired and by that time, both ears are affected.

Diagnosis is made by a medical physician based on clinical history and certain tests such hearing tests and scans. There is no cure and the goal of treatment is to reduce frequency of attacks and relieve symptoms. During an attack patient is advised to lie down and take complete rest without focusing on moving objects. Sleep will improve the condition of the patient. Driving is not advised unless symptoms are controlled. Medications and low salt diet can help to obtain a good control over this disease but if still no improvement then surgery can be resorted to as a last option.

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