Deepak came to my clinic with a strange complaint that his previous doctor had dismissed as psychological. He would have severe vertigo attacks, but strangely, his hearing improved during these attacks instead of getting worse. His doctor said this was impossible-hearing loss in vertigo always worsens, right? Actually, no. Deepak had Lermoyez syndrome, a rare variant of Meniere’s disease.
Table of Contents: Lermoyez Syndrome Menieres Variant
In another case, Anita reported sudden falls without warning-she would just drop to the ground. No loss of consciousness, no confusion, no prior spinning sensation. Her family thought she was having seizures. Brain imaging was normal. Actually, she had Tumarkin’s otolithic crisis, another Meniere’s variant.
These unusual presentations are rare but important to recognize. Today I want to explain these variants.
Lermoyez Syndrome: “Reverse” Meniere’s
What is it?
Lermoyez syndrome is a variant of Meniere’s disease where the patient experiences the typical vertigo attacks, tinnitus, and aural fullness-but with a paradoxical twist: hearing improves during or just after the attack instead of worsening.
In typical Meniere’s, hearing gets worse during attacks and partially recovers afterward. In Lermoyez, it’s the opposite-hearing improves during attacks and worsens between them.
How common is it?
Lermoyez syndrome is rare-perhaps 5-10% of Meniere’s patients have this pattern. It’s probably underdiagnosed because doctors expect hearing to worsen during attacks.
Why does hearing improve with vertigo?
The exact mechanism isn’t fully understood. Some theories suggest that sudden changes in inner ear pressure might temporarily improve function in certain cases. Another theory suggests that endolymphatic pressure changes affect different areas of the cochlea differently-some become worse, others paradoxically improve. The clinical reality is that it happens, and we see this in our audiograms.
Clinical presentation:
Patients describe typical Meniere’s symptoms: sudden severe vertigo, tinnitus, aural fullness. But when they do hearing tests right after an attack, their hearing is actually better than it was before the attack. This improvement is usually temporary-hearing returns to baseline or worse between attacks.
Why is this important?
If a patient has Lermoyez syndrome and you’re not expecting it, you might mistakenly diagnose them with something else. Serial audiograms showing improving hearing during vertigo events are the clue.
👉 Also read: Why Does BPPV Keep Coming Back? Understanding Recurrence
Treatment:
Lermoyez syndrome is treated the same as typical Meniere’s disease-low-sodium diet, diuretics, and if needed, intratympanic steroids or an ototoxic antibiotic. The treatment response is similar.
Prognosis:
Like typical Meniere’s, Lermoyez can be episodic with remission periods. Some patients eventually have permanent hearing loss despite the initial improvement during attacks. The long-term course is similar to classical Meniere’s disease.
Tumarkin’s Otolithic Crisis: Drop Attacks
What is it?
Tumarkin’s otolithic crisis (also called “drop attacks”) is a sudden fall without warning, loss of balance, or loss of consciousness. The patient simply drops to the ground, fully aware and conscious, then recovers within seconds or minutes.
Mechanism:
We believe Tumarkin’s crisis results from sudden activation of the utricle (one of the balance organs in the inner ear). The utricular nerve sends a sudden signal to the brain causing loss of postural tone and sudden fall. It’s believed to be related to a sudden shift in endolymphatic pressure in Meniere’s disease.
Importantly, there’s no spinning sensation. The patient doesn’t feel dizzy. They just fall. Then they get up and continue about their day, though shaken.
How common is it?
About 25% of Meniere’s patients experience drop attacks at some point. Some experience just one or two in their lifetime. Others have recurrent episodes.
Why is this dangerous?
The main risk is injury from falling unexpectedly. Patients have fallen down stairs, been hit by cars, or sustained serious injuries. In elderly patients, hip fractures from falls can be life-threatening. This makes Tumarkin’s crisis a serious manifestation of Meniere’s disease.
👉 Also read: Posterior Canal BPPV, Complete Treatment Guide
Misdiagnosis risk:
Tumarkin’s crisis is often misdiagnosed as:
– Epileptic seizure (but patient has no loss of consciousness, no confusion, no post-ictal period)
– Cardiac syncope/fainting (but there are no cardiac symptoms, just sudden drop)
– Psychological problem (but it’s a real physical phenomenon)
The key distinguishing feature: the patient remains fully conscious and aware during the fall.
Clinical presentation:
A patient with Meniere’s disease suddenly falls without warning during walking or standing. They might be talking normally and then just collapse. They’re fully awake the whole time. They get up immediately, sometimes dazed but quickly oriented. There’s no spinning sensation, no palpitations, no seizure activity.
👉 Also read: Recurrent BPPV: Why It Keeps Coming Back
Prevention and management:
– Control the underlying Meniere’s disease with diet and medications
– Consider intratympanic an ototoxic antibiotic if drop attacks are frequent and disabling (an ototoxic antibiotic is particularly effective for vestibular symptoms including drop attacks)
– Home modifications to reduce fall risk (remove obstacles, use handrails, adequate lighting)
– Patients should avoid standing on heights (ladders, roofs) or working near traffic
– Medical alert bracelet in case of injury
Treatment:
First, make sure the Meniere’s disease itself is well-controlled. Low-sodium diet and diuretics should be optimized. If drop attacks persist despite these measures, intratympanic steroid injections are worth trying. If still unsuccessful, intratympanic an ototoxic antibiotic is highly effective for drop attacks-the destruction of vestibular function prevents these sudden attacks.
Other Meniere’s Variants
Delayed Endolymphatic Hydrops (DEH) or “Cochlear Meniere’s”
Some patients develop endolymphatic hydrops years after a sudden hearing loss event. This can occur after:
– Sudden sensorineural hearing loss from unknown cause
– Hearing loss from mumps or other viral infection
– Head trauma
– Chronic ear disease
Months or years later, they develop vertigo and other Meniere’s symptoms in the same ear that lost hearing. The audiogram shows pre-existing low-frequency hearing loss, then later vertigo develops. This is considered a variant of Meniere’s.
Bilateral Meniere’s Disease
As discussed before, about 30% of Meniere’s patients eventually develop disease in both ears. Bilateral Meniere’s is much more disabling and harder to treat because the patient can’t rely on one healthy ear for balance.
Vestibular Meniere’s
Some patients have Meniere’s disease with severe vestibular symptoms (vertigo, balance loss) but minimal hearing loss. The inner ear pressure primarily affects the balance system. These patients have frequent severe vertigo but relatively preserved hearing.
👉 Also read: Cervicogenic Vs Bppv Difference
Diagnostic Approach to Meniere’s Variants
When I evaluate a patient with suspected Meniere’s disease, I specifically ask about:
- Hearing changes during attacks (worse vs. same vs. improved)
- Sudden falls or drop episodes
- Recent trauma or viral infections before symptom onset
- Prior hearing loss in the affected ear
- Family history of Meniere’s or hearing loss
- Symptoms in one ear vs both ears
Serial audiograms are important. In Lermoyez, hearing shows improvement during attacks. In vestibular Meniere’s, hearing is relatively stable. In typical Meniere’s, hearing fluctuates with greater loss during attacks.
Imaging (MRI with delayed gadolinium) can demonstrate endolymphatic hydrops in all variants.
Case Example: Anita’s Tumarkin’s Crisis
Anita had been having classic Meniere’s symptoms for 18 months-episodic vertigo, hearing loss, tinnitus, aural fullness. Then one day while walking to her kitchen, she dropped suddenly. She was fully conscious and got up immediately. Her family thought she’d fainted, but her blood pressure was normal and she felt fine.
A week later, it happened again. Her neurologist ordered EEG (normal) and brain MRI (normal), which was good-it ruled out seizure. She came to my clinic terrified. I explained that this was Tumarkin’s otolithic crisis, a variant of her Meniere’s disease.
We optimized her medical management with lower sodium and higher diuretic dose. She had 3 intratympanic steroid injections. For several months, no more falls. But then they returned-one every 2-3 weeks.
I explained intratympanic an ototoxic antibiotic. She was hesitant because of hearing loss risk, but her hearing in that ear was already moderately impaired from years of Meniere’s, and the falls were becoming dangerous. After thorough discussion, she agreed.
I did the an ototoxic antibiotic injection series. For the past 18 months, she’s had zero drop attacks. She’s gained confidence in walking and no longer avoids standing. The slight additional hearing loss from an ototoxic antibiotic was worth it to her because her safety improved dramatically.
FAQ: Meniere’s Variants
Author Bio
Dr. Prateek Porwal, MBBS, DNB ENT, CAMVD | ENT & Vertigo Specialist has extensive experience recognizing and managing unusual variants of Meniere’s disease at Prime ENT Center, Hardoi, UP. He believes that awareness of these variants is important so patients receive correct diagnosis and avoid unnecessary testing for other conditions like epilepsy or cardiac disease.
If you’re experiencing unusual vertigo symptoms or sudden falls, proper evaluation is essential. Don’t settle for being told “it’s all in your head”-get assessed by a vestibular specialist.
Call 7393062200 or WhatsApp https://wa.me/917393062200
Prime ENT Center, Hardoi, UP
Website: drprateekporwal.com
Medical Disclaimer: This article is for educational purposes only and does not constitute medical advice, diagnosis or prescribing guidance. All medications must be taken under direct supervision of a qualified physician. Consult Dr. Prateek Porwal at Prime ENT Center, Hardoi for personalised treatment.
References
- Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere’s disease. Otolaryngology–Head and Neck Surgery. 1995;113(3):181–185.