Ménière’s disease is an inner-ear disorder of episodic vertigo, fluctuating hearing loss, tinnitus and aural fullness, attributed to a disturbance of the inner-ear fluids. Its audiogram has a distinctive early signature — and a habit of changing between visits.

The audiometric signature

The classic early Ménière’s audiogram shows a unilateral, low-frequency, rising sensorineural loss: thresholds are worst at 250–1000 Hz and improve toward the higher frequencies, with no air–bone gap. The diagnostic criteria require audiometric documentation of low- to medium-frequency sensorineural loss in the affected ear on at least one occasion.¹³

Normal hearing

Ménière's disease

O Right ear, air
X Left ear, air
< Right ear, bone
> Left ear, bone

Signature: Unilateral low-frequency rising sensorineural loss; the other ear is normal.

Figure 1. Ménière's disease versus normal hearing. The affected ear shows a low-frequency rising sensorineural loss; the other ear is normal. There is no air–bone gap.

Fluctuation: the defining behaviour

What sets Ménière’s apart from most other audiograms is that it fluctuates. Early in the disease, hearing may return to normal between attacks, so a single normal audiogram does not exclude the diagnosis. This is why the criteria speak of documenting the loss “on at least one occasion” — and why serial audiograms, not one snapshot, are the right investigation.

TraineeAs the disease advances the picture changes. The loss tends to become flatter and to involve all frequencies, and the fluctuation lessens as a permanent loss settles in. The audiometric stage of definite Ménière’s is graded from the average threshold of the affected ear, and the loss seldom exceeds a profound degree. ¹⁵ Most cases are unilateral at presentation, though the proportion that become bilateral rises with disease duration.

Recruitment and the special tests

Ménière’s is a cochlear disorder, and a prominent one for recruitment — patients classically describe sounds becoming uncomfortably loud once they cross threshold. The SISI is therefore typically positive in the affected ear, consistent with a cochlear site of lesion, and tone decay is not a feature. The special tests here confirm the cochlear nature of a loss the history and audiogram have already made likely.

ClinicianA subtle pitfall: some Ménière’s ears show a small low-frequency air–bone gapin the absence of any middle-ear disease. The gap is thought to reflect the altered inner-ear mechanics of endolymphatic hydrops rather than a true conductive lesion, and it can be mistaken for one. Normal otoscopy and tympanometry, and the rest of the clinical picture, keep the interpretation on track. Ménière’s also remains fundamentally a clinical diagnosis of exclusion — the audiogram supports it but cannot establish it alone.