Editorial: Menière's Disease: From Diagnosis to Treatment

Sebastiaan Hammer^1*Bert De Foer²Athanasia Korda³

• ¹Department of Radiology, Haga Hospital, The Hague, Netherlands
• ²Department of Radiology, Algemeen ziekenhuis ZAS Augustinus, Wilrijk, Belgium
• ³Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland

Menière's disease (MD) is a clinical condition characterized by attacks of vertigo, tinnitus, aural fullness and low frequency sensorineural hearing loss (1). The etiology of MD remains poorly understood. Although endolymphatic hydrops (EH) is not specific for MD, it is considered a pathological hallmark, as described by Cairns and Hallpike as well as Yamakawa on temporal bone specimens (2,3). MD is currently diagnosed using clinical criteria and audiometric testing (4). EH detection, as is now possible using innovative MRI techniques, has proven to be of additional value in selected patients (5,6). Moreover, vestibular tests may be useful. However, diagnosing MD remains challenging, especially as not all patients present with typical symptoms. Furthermore, there is an overlap with other differential diagnoses, such as vestibular migraine (VM).This research Topic aims to address research which focusses on developing diagnostic criteria and markers for MD as well as treatment strategies and includes 14 articles. 2 papers discuss the methodological needs for studying MD, and define outcome criteria in MD trials. Furthermore 10 articles encompass the broad spectrum of diagnosing MD, using EH and vestibular testing, and differentiate MD from other clinical entities. In addition, 2 papers focus on treatment strategies. This editorial synthesizes recent studies to highlight the evolving landscape of MD research and care. Pyykkö and colleagues demonstrated that vertigo attacks generally decline in frequency and severity over time, with spontaneous remission in approximately a third of patients. They report on 365 patients; ~34% spontaneous remission of episodic vertigo; 65.5% persistent balance problems; 34% VDAs; 10% severe falls; bilateral hearing loss 34.5%. Yet this apparent improvement masks a continuing burden: vestibular drop attacks (VDAs), chronic imbalance, cognitive issues, and emotional distress persist or worsen, particularly in patients with bilateral hearing loss or younger onset. Their work highlights the necessity of comprehensive management that goes beyond controlling vertigo to encompass fall prevention, hearing support, and psychological care In a long-term study, Gerritsen and co-authors found that even patients with socalled "intractable" MD frequently improved. A total of 35 patients were considered for surgery; of 33 with complete vertigo data 21/33 (64%) were free of vertigo after median 5.3 years; 71% eventually declined surgery. This finding emphasizes that intractability is often temporary, and suggests that overly aggressive ablative treatments should be reconsidered, especially given their irreversible risks. Mavrodiev and collaborators provided strong evidence that the dissociation between a reduced caloric response and a normal video head impulse test (vHIT) is a highly specific marker for MD, distinguishing it from vestibular migraine and other vestibular disorders. The total cohort consisted of 2,101 patients (including 627 definite MD and 473 VM): caloric-vHIT dissociation sensitivity ≈58.9%, specificity ≈83.5%; among MD, caloric test was abnormal in 71%. Similarly, Cheon and colleagues worked to define diagnostic thresholds for this dissociation, further standardizing its use in clinical practice. They report dissociation rates of ~56% in 51 MD patients. Together, these studies elevate caloric-vHIT dissociation as a cornerstone diagnostic biomarker. Several groups advanced understanding of endolymphatic hydrops, the pathological hallmark of MD. Lin (H.) and colleagues used wideband acoustic immittance and otoacoustic emissions in animal models to show how hydrops alters cochlear mechanics. Lorente-Piera and co-authors identified predictors of hydrops in early MD, supporting earlier diagnosis. Venkatasamy provided a review of secondary hydrops, underscoring that hydrops may result from trauma, infection, or surgery, and not only idiopathic MD.In human diagnostics, Huang proposed optimizing MD staging by integrating electrocochleography with audiometry, while Bernaerts demonstrated the power of hydrops MRI in differentiating MD from vestibular migraine. Together, these advances refine both staging and differential diagnosis. Chari and colleagues proposed a modern conceptual framework that integrates pathophysiology, symptom evolution, and patient-centered outcomes into a unified research model. This approach encourages a more personalized understanding of MD trajectories and treatment responses.In parallel, Boreel led the COSMED study, a scoping review that highlights the variability of outcomes used in MD clinical trials. By advocating for a core outcome set, Boreel and team aim to standardize trial measures, improving comparability and accelerating treatment advances. The role of endolymphatic sac surgery remains debated. Gibson reviewed its history, noting reports of short-and long-term vertigo control but also emphasizing the low quality of evidence and risks of complications. Given the natural resolution tendencies described by Gerritsen and the variability of outcomes, Gibson's analysis suggests that surgical interventions should be reserved for select cases, ideally within structured clinical trials. Lin (J.) and colleagues compared early-versus late-onset MD, revealing distinctive clinical features that influence disease progression and management needs. Earlyonset (n = 35) and late-onset (n = 37) reported differences in caloric abnormality rates (20% early vs 43.2% late) and hydrops severity by age-group. Early-onset cases often show more aggressive progression and psychosocial burden, while late-onset MD may follow a milder but persistent course. Age of onset therefore serves as a valuable stratifier in prognosis and therapeutic planning. Accurate distinction between MD and vestibular migraine remains a central challenge. Beyond the caloric-vHIT dissociation described by Mavrodiev and Cheon, Vosbeek emphasized the value of a battery of vestibular function tests to improve diagnostic precision. These insights, together with the hydrops MRI evidence from Bernaerts, sharpen clinicians' tools for resolving diagnostic ambiguity. While vertigo remains the most dramatic symptom of MD, multiple studies-Pyykkö on symptom evolution, Lin (J.) on age-related features, and Lorente-Piera on early predictors-stress that MD is a multidimensional disease. The persistence of imbalance, cognitive decline, and mental health issues demand a holistic approach to care. Clinicians must support not only symptom suppression but also quality of life across hearing, mobility, and psychological well-being. Collectively, these studies reshape the MD landscape: Menière's disease is no longer viewed as a simple vestibular disorder characterized by episodic vertigo. Instead, research led by Pyykkö, Gerritsen, Mavrodiev, Lin (H.), Cheon, Gibson, Chari, Huang, Bernaerts, Lin (J.), Vosbeek, Lorente-Piera, Venkatasamy, and Boreel paints a picture of MD as a complex, evolving condition requiring multidimensional diagnosis, personalized management, and rigorous research frameworks.