Meniere's disease is a chronic inner ear disorder that primarily affects the ears’ membranous labyrinth. When one has Meniere’s disease, there is an excess amount of fluid present in the inner ear, this affects the ears hearing and balance mechanisms. Although research on Meniere’s disease is still under way, that endolymphatic hydrops (increased pressure in the ear) is the main cause of the symptoms, which are experienced. Furthermore the endolymphatic hydrops causes an imbalance in the fluid management of the ear, thus leading to an increase in accumulation of the endolymph as well as an increase in pressure, this is followed by the rupturing of membranes which line the emdolymphatic space. Because of this imbalance, the endolymph and perilymph fluids, which are ionically different, mix together thus intoxicating both the neural and sensory structures in the inner ear (Seikel,King & Drumwright, 2005).
The physical imbalance caused by the increase of endolymph, leads to mechanical disturbances of the otolithic and auditory organs. The saccule may experience dilation which will later make it adherent to the footplate of the stapes. Furthermore the periodic shrinkage and dilation of the utricle, also offers plays a role. The disruption of these so called normal ear functions can cause the attacks, as well as a sense of unsteadiness even during remission periods. The distention also causes a mechanical disturbance in the organ of corti. The repetitive attacks causes the death of hair cells in the inner ear, this, along with the contortion of the basilar membrane is known to cause tinnitus and hearing loss. The hydrops tend to affect the lower frequencies, because of the apex of the cochlear being more susceptible to pressure changes than the base, because the apex is more tightly wound (Seikel,King & Drumwright, 2005).
People with Meniere’s disease will experience vertigo episodes which will make them feel as though they are spinning. They will also experience varying degrees of tinnitus and hearing loss, which usually worsens during vertigo episodes. Meniere’s disease causes a progressive sensorineural hearing loss which in the early stages will return to normal after an attack, however as the attacks progress the hearing loss will worsen, an eventually become permanent.. The vertigo attacks are unpredictable and occur anywhere form twice a year to almost daily, it can also be unpredictable in the amount of time it will last, this ranges from minutes to hours. The vertigo episodes occur without warning signs and the severity of the attacks cannot be predicted (Stephens et al., 2010).
Meniere’s disease, according to Monsell et al. (2007) starts between the ages of 30 and 60 and it tend to affect more females than males. It is said to affect 2 out of every 1000 people. Furthermore, although Meniere’s is mostly unilaterally, approximately 20-40% of Meniere’s patients will eventually be bilaterally affected. It should also notice that in approximately 20% of cases, the patient is known to have some sort of family history of the Meniere’s disease.
Three stages (Stephens et al., 2010)
The Meniere's disease typically occurs in three stages of symptoms. The onset may however differ for each patient.
Stage 1
At this stage vertigo is the main symptom. The patient experiences vertigo attacks, where their surroundings seem to spin, this is sometimes accompanied by nausea and severe vomiting. Attacks occur in clusters and balance, hearing and tinnitus occurs during attacks, however they usually return to normal thereafter known as the remission period.
Stage 2
Consists of classical Meniere’s symptoms, making it easier to diagnose during this stage. There is a continuation of vertigo, tinnitus and fullness in the ear become even worse during attacks, and may not immediately return to normal thereafter. Hearing levels no longer return to normal after attacks.
Stage 3
Referred to as “Burnt out Meniere's”. At this stage hearing loss is severe across all frequencies. It might even be hard to recognize speech. Hair cells of the inner ear are destroyed, thus there will no longer be fluctuations of in hearing loss. Some may even experience “drop attacks”, which is the loss of balance for a few seconds, resulting in the patient falling to the floor. This can occur with no warning and little vertigo.

Risk Factors include: Head injuries | anxiety | Age (30-60) | headaches | Certain medication (ototoxic) | Weak immune systems | Infections of the ear | Allergies and viral infections | Family history (20% of cases) | The use of alcohol and smoking | Improper drainage of fluid (due to blockage or anatomical deformity) | |

B) Signs and Symptoms of Meniere’s disease Main symptoms | Other symptoms | Symptoms of sensorineural hearing loss | * Fluctuation in the loss of hearing | * Diarrhea | * Loss of hearing in the low frequency range | * A feeling of fullness or clogging in the ear | * headaches | * Ears feel clogged or full | * Episodes of vertigo which can last from 20 minutes to a couple of hours | * Pain in the abdomen area | * Progressive hearing loss (improves between attacks, but ultimately worsens over time) | * Tinnitus, (usually worsens during episodes of vertigo) | * Vomiting and nausea | * Dizziness | | * Uncontrollable eye movements | * Vertigo | | * Unsteady balance | * Social withdrawal | (Monsell et al., 2007) | (Paparella, 2008). | * Difficulty hearing speech |
(Komaroff, 2015)
Image1: difference between normal inner ear, and ear with Meniere’s disease

C) Description of hearing loss
Usually unilateral, but can occur bilaterally in some cases
Severity of the hearing loss: Mild-severe
Typically, the audiogram of someone with Meniere’s disease slopes from right to left – thus being lower in the low frequency range and improving in the higher frequencies. (Image 3)
Tympanogram (image 2): type A. The tympanogram tends to look for middle ear damage, Meniere’s on the other hand is a sensorineural hearing loss, thus the damage would be in the inner ear, as a result the tympanogram would not pick up the damage and it will return a type A, which means that the middle ear function is normal. 2) Meniere’s tympanogram (Kotb, 2011). 3) Meniere’s Audiogram (Wordpress, 2010).

D) After reviewing your test results, and taking into account the various symptoms you have mentioned such as the fluctuating loss of hearing and the ringing noise in your left ear, as well as the episodes of vertigo, which worsens your hearing and increases the sound of the ringing noise I have come to the conclusion that you may suffer from Meniere’s disease.
Meniere’s occurs because of a build of liquid in your inner ear, this liquid causes an increase in pressure which causes the membranous labyrinth that separates the different fluids in your ear, to break. These liquids then mix, and forms a toxic mixture that poisons and damages your auditory organs are hair cells As a result of these damages organs and receptors, you experience attacks of vertigo where it seems as though your surroundings are spinning. These attacks cause further damage to your hair cells in your inner ear, and thus they are unable to function properly, which causes your hearing to deteriorate and worsen over time. It is because of this buildup of fluid and the damage that it causes to your ear that you experience the ringing in your ears, vertigo, fluctuations of hearing and even the nausea and vomiting (Paparella, 2008).
The problem with Meniere’s disease is that we are not fully sure of its causes, thus there is no current cure for this disease. There are however a number of management systems that may allow you alleviate some of the symptoms as well as surgical options that may better your condition. Management options include the use of medications that may reduce the prominence of some symptoms such as the nausea, other options include a change in lifestyle to adapt to a low salt diet, and by cutting out products such as salt, caffeine, alcohol and chocolate. This is known to reduce the attacks of vertigo that you experience. It might be best to speak to a doctor and dietician regarding medication and a possible eating plan (Li & Lorenzo, 2012).
Hearing aids can be used to improve your quality of hearing, by amplifying sounds so that you are able to hear better in a variety of situations. You could also undergo vestibular therapy to help restore your balance and steadiness after attacks. If however you are looking for a more drastic option which aims to prevent the over accumulation of endolymph in the ear, thus also reducing the attacks and symptoms you may be referred and ENT who could perform either a labyrinthectomy, vestibular nerve section or endolymphatic sac decompression surgery (Li & Lorenzo, 2012).
I recommend that you take some time to think about your options, however it would be wise to speak to a dietician in the meantime so that you can reduce the risk of another attack, or at least alleviate the symptoms. If you decide to select the hearing aid option, I will assist you with the selection of the hearing aid as well as inform you on how the hearing aid functions, furthermore I could offer you information about difficulties that you might face should you select this option. If you decide that you would prefer a surgery, I could also refer you to an ENT who will be able to assist you with information about possible surgeries (Modern Medicine network, 2015).
Management
e) Although there is no cure for Meniere’s, there are a vast list of management options available to improve the quality of life of those with Meniere’s disease. These options include general management as well as specific management which is based on the symptoms experienced by the patient (Li & Lorenzo, 2012).
Referrals:
If the patient goes to see a doctor and complains about a possible loss of hearing during the episodes, or after the episodes, the doctor would have to refer the patient to an Audiologist, so that the Audiologist can conduct the necessary hearing tests (audiograms and tympanograms) in order to determine whether or not the patient does have a hearing loss. The Audiologist will then make the diagnoses with regards to the type, severity and cause of the hearing loss
The audiologist will be a part of a multi-disciplinary team, which consists of a doctor and in some cases an ENT and speech language therapist in order to maximise communication management. The Audiologist might refer the patient back to the doctor in order to discuss medications that may alleviate some symptoms such as the nausea, vomiting or headaches.
Should the patient opt for surgery instead of hearing aids, the Audiologist will refer the patient to a doctor specialising in the ears, nose and throat. The ENT would assist the patient with information regarding surgical options that could improve his/her hearing and balance (Modern Medicine network, 2015).
General management: * Regular check up’s with an Audiologist so that the deterioration of hearing can be monitored. Patients need to be active in the management of their own hearing. * The patient will have to look after and clean their own hearing aids, after they are taught how to do so by an Audiologist. * Patients who feel that they are unable to handle the symptoms of Meniere’s disease such as the vertigo episodes, should enrol in support and self-help groups which will provide the patient with the necessary support and knowledge that is needed in order to minimize the effects brought about by Meniere’s disease, such as the random vertigo episodes.

Specific treatment: * The patient can make use of an amplification device (hearing aids) in order to better his/her hearing. * Patients should make use of Vestibular rehabilitation therapy to deal with the vertigo episodes and regain their steadiness. * The patient should undergo Aural rehabilitation therapy * Communication strategies: in order to help the patient to effectively communicate with others * Patients can be referred to ENT, to undergo labyrinthectomy, a vestibular nerve section or endolymphatic sac decompression surgery.
(Li & Lorenzo, 2012)
Duty to care: * As an Audiologist, you would advise the patient to refrain from exposure to noise, by not making use of headphones, etc. * Make use of hearing protection, when you are in an area with high noise exposure * The Audiologist should make use of communication strategies in order to minimalize the effects of the loss of hearing and to improve the communication barrier * The patient should undergo Aural rehabilitation therapy to help him/her make cope with their loss of hearing and use it to the best of their ability * The Audiologist should advise the patient to join self-help or support groups, in order to help him/her to cope with Meniere’s disease and its symptoms such as vertigo. * The patient should attend regular check-up’s with an audiologist in order to monitor his/her hearing ability * Avoid going out alone, this might pose a threat because of the random episodes of vertigo

(Modern Medicine network, 2015).

Reference list.
Kotb, M. (2011). Type A tympanogram [Online image].Retrieved November 08, 2015 from http://www.drmkotb.com/EN/index.php?page=students&case=&A=1&B=6&C=0
Li, J., Lorenzo, N. (2012). Meniere Disease Clinical Presentation. Available: http://emedicine.medscape.com/article/1159069-clinical [2015, November 07]
Komaroff, A. (2015). What is Meniere’s disease [Online image].Retrieved November 09, 2015 from http://adkblog.s3.amazonaws.com/content/uploads/2015/07/AZ_d0310- 1.jpg
Modern Medicine network. 2015. When your patient is hearing impaired. Available: http://www.modernmedicine.com/modern-medicine/content/when-your- patient-hearing-impaired?page=full [2015, November 07]

Monsell, E. M., Teixido, M. T., Slattery, E. l., Wilson, M. D., Kung, B., &Hughes, G. B (2007). Nonhereditary hearing loss. In G. B. Hughes & M. L. Pensack (Eds.), (3rd edn.), Clinical otology (pp. 300-320). New York: Thieme.
Paparella M. (2008). Benign paroxysmal positional vertigo and other vestibular symptoms in Ménière disease. Ear Nose Throat Journal. 87(10), 561-562. Retrieved from https://www.nlm.nih.gov/bsd/pmresources.html

Seikel, J. A., King, D. W., & Drumwright, D. G., (2005). Anatomy and physiology for speech , language and hearing (3rd edn.), New York: Thomson Delmar Learning.

Stephens D, Pyykko I, Varpa K, Levo H, Poe D, Kentala E. (2010). Self-reported effects of Ménière's disease on the individual's life: a qualitative analysis. Otol Neurotol, 31(2), 335-338. Retrieved from https://www.nlm.nih.gov/bsd/pmresources.html

Wordpress. (2010). Meniere’s audiogram before treatment [Online image]. Retrieved November, 09, 2015 from https://healingmenieres.wordpress.com/audiogram-results/