xRead - Episodic Vertigo (January 2026)

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Basura et al

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Intentional vagueness: None. Also, the presence of a documented/audiometrically objectified hearing loss may not be present at the time of testing. Role of patient preferences: Small. Some patients may elect not to get an audiogram for various reasons. Exclusions: None Policy level: Strong recommendation Differences of opinion: There was a minority of the group who felt that patients with probable MD can be treated without an audiogram, but the majority felt that the audiogram is key to confirming the diagnosis and all subsequent management. One committee member noted that there are no studies in MD that assess outcomes in those receiving an audiogram as compared with those who do not. The audiogram is required to move from a diagnosis of possible MD to definite MD. Some patients and providers may elect to proceed with noninvasive management without an audiogram. Supporting Text The purpose of this statement is to highlight the importance of obtaining audiometric data on all patients with a sus pected clinical diagnosis of MD. Hearing loss was part of the original description of this disease and remains a neces sary criterion based on the current international concen sus. 76,89-91 Audiometry is necessary to differentiate probable versus definite MD. Audiometry should include pure tone air conduction thresholds (pure tone average [PTA]) bilater ally, ruling out or quantifying any conductive component of the hearing loss (bone conduction thresholds, tympanome try, acoustic reflex measures, and/or otoscopy), and includ ing a measure of speech recognition (ie, word recognition/ discrimination score [WRS]) in each ear. If audiometric testing is not available for the initial otolaryngology evalua tion, tuning fork evaluation can be used to identify asymme trical hearing loss and whether there is a conductive component to the loss, 92 although a recent SR assessing tuning fork accuracy ‘‘does not support the individual reli ance on tuning fork tests for clinical screening and surgical candidacy assessment.’’ 93 Certainly, if this shows any con cerns for asymmetric hearing loss, a dedicated booth audio gram with speech testing must be conducted to validate concerns about asymmetric hearing loss. Rarely patients may resist audiometric assessment, and in these instances the patient must take an active shared decision-making role in deciding whether to undergo formal audiometry. Diagnostic criteria for MD require episodic vertigo, fluctuating hearing loss (sensorineural in the low to midfrequencies), tinnitus, and a perception of fullness in the involved ear. 79,94-96 While not excluding other frequencies of fluctuating hearing loss that may apply to MD, for the purposes of this document, ‘‘low- to midfrequency hearing loss’’ refers to audiometric frequencies 2000 Hz. 96 As MD typically (initially) presents unilaterally,

Based on the high prevalence of migraine in general, it is not uncommon for a patient to have both MD and VM. In both population-based studies and outpatient clinics using the Barany diagnostic criteria or the International Classification of Headache Disorders definition of VM, the prevalence of VM is high (2.7% in population studies and 10% in outpati ent clinics). 85-87 A recent retrospective cohort study from a dizziness specialty clinic in South Korea found that 35% (88 of 251) of MD patients also met criteria for definite or probable VM. 88 Therefore, the epidemiology of VM should be respected in the decision-making process. When there is uncertainty about VM or MD, treatment decisions can be difficult but should proceed through noninvasive therapeutic trials prior to any surgical or inner ear ablative interven tions. Destructive interventions should be reserved for those with severe progressive hearing loss/lack of usable hearing. Adequate clinical trials of abortive or prophylactic medi cines in VM are not available. Therefore, VM is not ‘‘ruled out’’ by a lack of response to typical migraine medicines. STATEMENT 3. AUDIOMETRIC TESTING: Clinicians should obtain an audiogram when assessing a patient for the diagnosis of Me´nie`re’s disease. Strong recommendation based on SRs of cross-sectional studies with consistently applied reference standard and blinding for diagnostic test ing with a preponderance of benefit over harms. Quality improvement opportunity: Determining both pure tone thresholds and measures of speech recognition will lead to more accurate diagnosis and appropriate and timely referrals for aural rehabili tation, hearing aids, and/or cochlear implants and may have significant implications for treatment options. National Quality Strategy domain: Effective Communication and Care Coordination Aggregate evidence quality: Grade A, based on SRs of cross-sectional studies with consistently applied reference standard and blinding for diagnostic testing Level of confidence in evidence: High Benefits: Improving diagnostic accuracy, identify ing deficits in contralateral ear (question of bilateral disease), improving treatment planning, establishing baseline of hearing prior to treatment, directing treatment options based on degree of residual hear ing (ablative vs nonablative), and identifying oppor tunities for aural rehabilitation Risk, harm, cost: Cost of testing, time of testing, patient distress at unrecognized hearing loss, dis crimination based on hearing impairment (vocation, access to disability benefits) Benefit-harm assessment: Preponderance of benefit over harm Value judgments: An audiogram is essential to make the diagnosis of definite MD. Action Statement Profile: 3