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378                                          THE EAR

and periodic increases in the deafness with slight nausea only. Fullness in
the ear and suboccipital headaches are not uncommon features. Diarrhoea
has been noted during the first attack and it may recur on each occasion.

CLINICAL FEATURES. During the attack the patient is completely dis-
orientiated, unable to stand or to do anything for himself. Nystagmus is
present, and spontaneous past-pointing and falling may be elicited. There
is a diminished hearing response in the affected ear, and this is always
a sensorineural deafness, while distortion of sound (diplacusis) is not

DIAGNOSIS. Diagnosis must be made from many other conditions affecting
the labyrinth and cerebellum, and, in particular, an acoustic neuroma must
be considered. Some conditions causing vertiginous symptoms are men-
tioned later in this chapter. Full clinical examination must be carried out,
and any source of sepsis noted and corrected. All cochlear tests, Rinne,
Weber, audiometry, etc. and vestibular testing by caloric studies and electro-
nystagmography are performed. In the early case, between attacks, no
abnormality may be found, but, when present, the most common abnor-
mality is canal paresis on the affected side on caloric testing. The audiogram
may be normal, but usually a slight deterioration may be found in one ear,
and when the disease has progressed there is an increasing sensorineural
loss of the flat or low tone type, as compared with the steep upper tone fall
of traumatic or senile nerve deafness. Recruitment is present, and must
always be tested for, and speech discrimination is notably reduced. When
nystagmus is seen it is markedly rotatory and is to the unaffected side.

In advanced Meniere's disease the acute symptoms frequently disappear,
leaving an imbalance which may be constant or may recur at intervals
without nausea. In some instances there is a pjrpjgressiye loss_ofj?al.arice
over days or weeks with increasingjieafoLess and headache which terminates
with a paroxysm of vertigo, to be followed by immediate improvement in
the hearing and other symptoms (Lermoyez syndrome). The occurrence of
associated migraine is not unknown, while an anxiety state is understandably
and quite frequently a feature of considerable significance.

PROGNOSIS. This depends upon the response to the various forms of treat-
ment. If treatment does not control the attacks the outlook for the affected
ear is bad. At the same time, remission occurs so frequently that it is difficult
to be precise in prognosis after one attack. The disease may be bilateral in
as many as 20 per cent of cases, and under such circumstances the outlook
is unpleasant if treatment does not succeed, for prolonged invalidism may
lead to profound deafness.

TREATMENT, Many cases can be controlled by antihistamine labyrinthine
sedatives such as prochlorperazine maleate (Stemetil), cinnarizine (Stugeron)
or promethazine theoclate (Avomine), while betahistine hydrochloride (Sere)
or Lipoflavonoid, a compound containing choline bitartrate and other
drugs, have their advocates. Because many of these patients are anxious
they may be helped by sedatives or tranquillizers. Alternatively, an attempt
may be made to improve the blood supply to the inner ear. Nicotinic acid
has been widely used, but thymoxamine (Opilon) appears to be as effective,
particularly in those cases where hearing is fluctuating. A combination of
these treatments will control the symptoms in the majority of cases. Attempts
to reduce the labyrinthine hydrops by fluid and salt restriction have been