Tae Hoon Kong; Young Joon Seo

doi:10.21790/rvs.2025.014

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Review Article
Multimodal diagnostic evaluation in Ménière disease: a narrative review of vestibular function tests and gadoliniumenhanced magnetic resonance imaging for endolymphatic hydrops: Tae Hoon Kong^1,2, Young Joon Seo^1,2; Research in Vestibular Science 2025;24(4):205-214.
DOI: https://doi.org/10.21790/rvs.2025.014
Published online: December 15, 2025

¹Research Institute of Hearing Enhancement, Yonsei University Wonju College of Medicine, Wonju, Korea

²Department of Otorhinolaryngology – Head and Neck Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea

Corresponding author: Young Joon Seo Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea. E-mail: okas2000@yonsei.ac.kr

• Received: May 25, 2025 • Revised: September 12, 2025 • Accepted: September 26, 2025

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
FUNCTIONAL ASSESSMENT USING VESTIBULAR FUNCTION TESTS
IMAGING: HYDROPS VISUALIZATION
INTEGRATED DIAGNOSTIC FRAMEWORK
FUTURE DIRECTIONS
CONCLUSION
ARTICLE INFORMATION
REFERENCES

Abstract

Objectives
Ménière disease (MD) is a complex inner ear disorder marked by episodic vertigo, fluctuating hearing loss, and tinnitus. Despite established clinical diagnostic criteria, definitive diagnosis remains challenging due to symptom overlap and lack of objective biomarkers. This review examines the diagnostic utility of advanced vestibular function tests (VFTs)—caloric testing, video head impulse test (vHIT), vestibular evoked myogenic potentials (VEMPs), and rotatory chair testing—alongside three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging (MRI) imaging of endolymphatic hydrops (EHs). We propose an integrated diagnostic model that improves sensitivity, specificity, and clinical decision-making.
Methods
Evidence from recent cohort studies, meta-analyses, and high-resolution MRI protocols is synthesized. Sensitivity, specificity, and functional target profiles are compared across modalities. Test concordance and discordance patterns are reviewed, and a stratified risk algorithm is presented.
Results
Triple test concordance (caloric+vHIT+cervical VEMP [cVEMP]) provides 78% sensitivity and 92% specificity for definite MD. Gadolinium-enhanced 3D-FLAIR MRI detects cochlear EHs with sensitivities reported up to 95% and specificities commonly ranging from 85% to 90%, while vestibular hydrops detection shows comparatively lower sensitivity across studies. In our synthesis, combined strategies—operationalized as triple vestibular testing (caloric+vHIT+cVEMP) with selective MRI when indicated—improve overall diagnostic performance relative to single-modality testing (65% with a single test to 88% to 90% when ≥2 VFTs are abnormal, and MRI corroborates hydrops).
Conclusions
Multimodal assessment may serve as an objective adjunct to clinical criteria. In practice, we use MRI selectively—for atypical or refractory cases, or when VFTs are inconclusive—to complement the stepwise diagnostic pathway.
Keywords: Meniere disease; Endolymphatic hydrops; Vestibular function tests; Magnetic resonance imaging

INTRODUCTION

Ménière disease (MD) is a chronic disorder of the inner ear defined by the Bárány Society as a clinical syndrome characterized by spontaneous episodes of vertigo lasting 20 minutes to 12 hours, fluctuating low- to mid-frequency sensorineural hearing loss (SNHL), tinnitus, and/or aural fullness in the affected ear [1]. The diagnosis of definite MD requires at least two spontaneous episodes of vertigo, audiometrically documented hearing loss, and the presence of aural symptoms, in the absence of alternative vestibular diagnoses [1]. Despite these internationally recognized criteria, the diagnosis of MD remains difficult in clinical practice due to the subjective nature and episodic presentation of its symptoms.

Traditional diagnostic approaches are largely symptom-based, relying heavily on patient-reported history and standard audiometric evaluation [1,2]. However, these subjective methods are vulnerable to recall bias, symptom fluctuation, and overlap with other vestibular disorders such as vestibular migraine (VM) and benign paroxysmal positional vertigo (BPPV) [3]. Consequently, an overreliance on clinical history alone can lead to underdiagnosis or misdiagnosis, particularly in the early or interictal phases of MD [4].

Objective diagnostic methods, including vestibular function tests (VFTs) and radiologic imaging, have been increasingly employed to improve diagnostic accuracy. Each has distinct strengths and limitations. Functional tests such as the caloric test, video head impulse test (vHIT), vestibular-evoked myogenic potentials (VEMPs), and rotatory chair test assess the physiological integrity of the vestibular system at varying frequency ranges [5]. These modalities offer direct insights into end-organ dysfunction and are repeatable over time, but results may be influenced by compensatory mechanisms and interindividual variability [6].

On the other hand, magnetic resonance imaging (MRI)-based imaging, particularly using three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequences following intratympanic (IT) or intravenous (IV) gadolinium (Gd) administration, enables direct visualization of endolymphatic hydrops (EH), the pathological hallmark of MD [7,8]. These imaging techniques provide structural confirmation of disease but may yield false negatives in early-stage MD and require specialized imaging protocols and post-processing tools [9].

Neither functional testing nor imaging alone is sufficient to establish a comprehensive diagnostic picture. Functional tests evaluate the performance and dynamic response of the vestibular apparatus, whereas imaging elucidates the structural alterations associated with the disease. Importantly, studies have shown that the presence of EH on MRI does not always correlate with symptom severity, and conversely, some patients with definite clinical MD may lack radiologic evidence of hydrops [10]. This discordance underscores the necessity of combining both approaches for a reliable and robust diagnostic algorithm.

In this review, we examine the diagnostic value of current VFTs and MRI-based imaging in patients with MD. By comparing their sensitivity, specificity, and clinical applicability, we propose an integrated diagnostic framework that emphasizes the complementary strengths of physiologic and morphologic assessment tools.

FUNCTIONAL ASSESSMENT USING VESTIBULAR FUNCTION TESTS

Characteristics of Individual Test Modalities

Table 1 summarizes the clinical characteristics, target organs, and key findings of the main functional tests used in MD diagnosis, which will be discussed in detail below [11,12].

Caloric test: standard for low-frequency evaluation

The caloric test remains one of the most widely used tools for evaluating the function of the horizontal semicircular canal (SCC) at very low frequencies (~0.003 Hz). This test uses bithermal irrigation of the external auditory canal to stimulate endolymphatic flow, thereby assessing the integrity of the horizontal SCC’s vestibulo-ocular reflex (VOR) pathway [11]. In patients with definite MD, unilateral hypofunction has been reported in 56% to 67% of cases [1], a value that makes it moderately sensitive for diagnosing MD. Oliveira et al. [13] found caloric hyporeflexia in 56.4% of symptomatic ears and 36% of asymptomatic ears, both significantly more frequent than in control subjects (7.5%, p<0.001). Despite its strengths in detecting low-frequency dysfunctions, the caloric test has limitations. The test duration is relatively long (20–30 minutes), and many patients find the procedure uncomfortable due to dizziness or nausea. Additionally, it only assesses one canal and does not reflect high-frequency vestibular responsiveness, which limits its diagnostic comprehensiveness [9,12]. In cases of bilateral MD or fluctuating disease states, caloric responses may vary considerably, and central compensation may mask true dysfunction. As a result, interpretation often requires correlation with other test modalities and clinical symptoms. Nevertheless, caloric testing remains a useful tool for detecting peripheral vestibular asymmetry and tracking disease progression over time [9,14].

Video head impulse test: real-time high-frequency semicircular canal evaluation

The vHIT is a modern VFT that evaluates the high-frequency (approximately 2–5 Hz) performance of all six SCCs via measurement of the angular VOR (aVOR) during abrupt, passive head rotations [15,16]. By tracking eye movements with high-speed video-oculography, it allows for quantification of VOR gain and detection of corrective saccades. In MD, vHIT offers mixed diagnostic utility. Studies have shown that covert saccades—small compensatory eye movements not seen with the naked eye—are detectable in approximately 48% of MD patients, especially during progressive stages or after recurrent attacks [3]. However, the false-negative rate remains significant; normal vHIT results were observed in 37% of early-stage MD, potentially reflecting frequency-specific sparing of high-frequency afferents in the early disease course [4,17]. This phenomenon—referred to as caloric–vHIT dissociation—is now recognized as a hallmark of MD and arises because caloric stimulation evaluates different frequency bands than vHIT. Lee et al. [6] showed that 18% of MD patients demonstrated caloric hypofunction with normal vHIT, suggesting preferential damage to low-frequency vestibular fibers. While vHIT lacks the sensitivity of caloric testing in early or subtle lesions, it provides high specificity, allows for rapid bedside assessment, and evaluates all canals. It is particularly useful in acute vertigo evaluation and helps differentiate between central and peripheral etiologies based on gain symmetry and saccadic correction patterns [18].

Vestibular-evoked myogenic potentials: otolith function testing

VEMP testing provides an objective evaluation of otolith organ function, specifically the saccule via cervical VEMP (cVEMP) and the utricle via ocular VEMP (oVEMP). These reflexes are mediated by sound or vibration stimulation, which elicits short-latency myogenic potentials recorded from the sternocleidomastoid muscle for cVEMP and the inferior oblique muscle for oVEMP [19]. In MD, cVEMP amplitude is reduced in approximately 52% of patients, suggesting saccular dysfunction due to EH [5]. Similarly, oVEMP abnormalities—particularly altered frequency tuning and asymmetry ratios—are found in 44% of MD cases, reflecting utricular impairment [6]. Of particular diagnostic interest, cVEMP threshold elevation (>85 dB nHL) has been correlated with more severe cochlear damage. A recent prospective study reported that cVEMP thresholds above this cutoff had a strong predictive value for profound hearing loss, with an area under the receiver operating characteristic curve of 0.82 [7]. This suggests a potential role for VEMP in disease staging and prognostication. However, VEMP responses are age-dependent and often absent in elderly patients or those with weak neck musculature, limiting their reliability in these populations [20]. Moreover, interlaboratory variability in stimulus parameters (e.g., tone burst vs. clicks) and recording techniques can affect reproducibility. Despite these limitations, VEMP testing uniquely contributes information about the otolithic system, complementing canal-based tests like caloric and vHIT. When combined, these tests can identify the number of vestibular end organs involved, which has been correlated with symptom severity and vertigo frequency in MD [21].

Rotatory chair testing: mid-frequency, bilateral evaluation

Rotatory chair testing evaluates the VOR in response to controlled sinusoidal angular acceleration, typically at mid-frequencies (approximately 0.01–1 Hz). Unlike caloric or vHIT tests, which evaluate unilateral or canal-specific responses, rotatory chair testing provides bilateral, global vestibular system evaluation, particularly helpful in patients with bilateral or fluctuating MD [21,22]. A classic finding in MD is increased phase lead at low frequencies (e.g., 0.01 Hz), which reflects central compensation for peripheral vestibular loss. In a seminal study, phase lead >50% at 0.01 Hz was observed in 61% of MD patients [8]. This may be interpreted as a sign of reduced peripheral input and/or central overcorrection. Rotatory testing also offers better symmetry evaluation compared to caloric testing, which is highly sensitive to anatomical variance and unilaterality. Thus, in bilateral MD, rotatory testing has been shown to be superior to caloric irrigation in detecting functional deficits and quantifying residual vestibular function [22]. Limitations include the need for specialized equipment and less specificity to individual canals. Nevertheless, the test is well-tolerated, repeatable, and useful for longitudinal follow-up in patients undergoing treatment or evaluation for surgical intervention [22-24].

Test Concordance and Discordance

Due to the frequency-dependent nature of vestibular testing, a common and clinically significant finding in MD is the discordance between caloric and vHIT results. This is reflective of the disease’s preferential impact on low-frequency vestibular afferents, particularly within the horizontal SCC. In a large clinical study, 18% of patients with definite MD exhibited caloric hypofunction (abnormal) with preserved vHIT (normal gain) [9]. This pattern supports the hypothesis that early or interictal MD may affect low-frequency canal sensitivity while sparing high-frequency function. This “caloric–vHIT dissociation” has therefore become a recognized feature of peripheral vestibulopathy associated with MD. Conversely, 7% of patients demonstrated the opposite pattern—normal caloric responses but abnormal vHIT, which may indicate central pathology or a misclassification due to test variability [9]. Such discordant patterns necessitate careful correlation with clinical presentation and other test results to avoid diagnostic errors. This principle also applies to VEMP interpretation. Otolithic organs (saccule and utricle) may be variably affected in MD, and concordance between abnormal cVEMP, oVEMP, and caloric/vHIT findings supports more widespread labyrinthine involvement. These patterns emphasize the importance of test integration. Isolated interpretation of a single test, especially in fluctuating or early-stage MD, may yield misleading conclusions. Hydropic expansion of the membranous labyrinth may impair thermal convection, yielding caloric hyporesponsiveness despite preserved high-frequency aVOR on vHIT—one plausible mechanism for the characteristic dissociation observed in MD. Concordant findings across multiple modalities significantly enhance diagnostic confidence and may also correlate with disease severity and prognosis.

In terms of test timing matters, during interictal phases, vHIT may remain normal in early MD, whereas low-frequency measures (e.g., caloric) more often reveal hypofunction; during or shortly after attacks, transient asymmetries and otolithic threshold shifts can be exaggerated. We therefore recommend interpreting VFTs with explicit timing documentation and, when needed, repeat testing.

Multi-test Strategies: Functional Integration

To overcome the limitations of isolated vestibular tests, several groups have proposed multimodal diagnostic frameworks combining caloric, vHIT, and VEMP assessments. This triple-test approach provides a comprehensive evaluation of the SCCs (across frequency ranges) and otolithic organs. Table 2 presents a comprehensive overview of the sensitivity, specificity, and target organs of various vestibular tests in MD [10,23]. A recent study by Lee et al. [6] evaluated the diagnostic utility of the triple combination—caloric+vHIT+cVEMP—in patients with definite MD. In the triple-test paradigm (caloric+vHIT+cVEMP), a sensitivity of 100% and a specificity of 50% have been reported for definite MD, outperforming any single test alone; individually, the tests showed: caloric test sensitivity of 87.5% (specificity 93.8%), vHIT sensitivity of 50% (specificity 68.8%), and cVEMP sensitivity of 81.3% (specificity 68.8%)."reflecting complementary frequency and end-organ coverage [25]. Beyond diagnostic classification, the number of involved vestibular end organs—as detected by combined testing—has been shown to correlate with the Dizziness Handicap Inventory (DHI) scores and the frequency of vertigo attacks [23]. This suggests that multi-test strategies may also help stage disease burden and predict quality of life impact. Additionally, multivariate models incorporating these test results have shown promise in distinguishing MD from mimicking disorders such as VM. Such approaches could be further enhanced with artificial intelligence (AI)-based classifiers in future research.

Summary: Combine Functional Vestibular Tests in Ménière Disease

Tests vary by frequency sensitivity (e.g., caloric vs. vHIT) and end-organ specificity (e.g., VEMP): discordance patterns are disease-specific (e.g., caloric–vHIT dissociation); concordance strengthens diagnostic confidence; combined abnormality count correlates with vertigo severity and functional impairment; and triple-test models provide better sensitivity/specificity than individual modalities.

IMAGING: HYDROPS VISUALIZATION

Magnetic Resonance Imaging Techniques

MRI has emerged as a powerful tool for the in vivo visualization of EH, the pathological hallmark of MD. Using delayed Gd-enhanced 3D-FLAIR sequences, clinicians can distinguish between the endolymphatic and perilymphatic spaces based on differential signal enhancement.

Intratympanic gadolinium enhancement

IT-Gd injection involves direct delivery of contrast medium into the middle ear, which diffuses through the round window into the perilymph. Imaging is typically performed 4 hours postinjection using high-resolution 3D-FLAIR MRI. This technique has demonstrated excellent sensitivity for detecting cochlear hydrops, with one study reporting 95% sensitivity for radiologic hydrops in definite MD [26]. It allows clear separation of EH from perilymph and has the advantage of a high signal-to-noise ratio for inner ear structures. However, IT-Gd is an invasive and unilateral procedure, and visualization may be suboptimal if round window permeability is reduced.

Intravenous gadolinium enhancement

To overcome limitations of IT-Gd, IV-Gd injection has become a preferred noninvasive alternative. The recommended protocol includes double-dose contrast (0.2 mmol/kg) followed by a 24-hour delay before 3D-FLAIR acquisition to ensure perilymphatic diffusion. Recent studies suggest that IV-Gd can identify bilateral EH in 18% of patients with clinically unilateral MD, suggesting subclinical contralateral involvement [27]. While the spatial resolution is slightly inferior to IT-Gd, the ability to evaluate both ears simultaneously makes it suitable for routine clinical use and longitudinal monitoring.

Clinical Correlations

MRI-based grading of EH correlates strongly with audiovestibular symptoms. A significant association (ρ=0.62) has been reported between cochlear EH and low-frequency hearing loss thresholds [28,29]. Similarly, vestibular EH correlates with vertigo attack frequency (p=0.03), suggesting that MRI-detected hydrops reflects disease activity. A standardized hydrops grading system has been proposed by Nakashima et al. [28], which classifies EH as none, mild, or significant based on the endolymph-to-total lymph ratio. In a retrospective series, patients with Grade III (severe) hydrops had 4.2-fold increased odds of experiencing intractable vertigo compared to those with mild or no hydrops. Moreover, EH findings on MRI can assist in differential diagnosis. In contrast to MD, VM rarely shows positive EH on MRI, aiding in their distinction when symptomatology overlaps.

Limitations and Unmet Needs

Despite its promise, MRI evaluation of EH is limited by several factors.

• Timing sensitivity: Optimal visualization requires precise timing (4–24 hours post-Gd), which is logistically demanding.

• Quantitative inconsistency: There is no universally accepted threshold for defining “significant” EH.

• Inter-rater variability: Interpretation of hydrops grading is subjective, although recent AI-based segmentation models have improved agreement (κ=0.89 vs. 0.61 pre-AI) [29].

Future improvements include automated volumetric analysis, AI-assisted image classification, and integration with functional testing results to enhance diagnostic algorithms.

INTEGRATED DIAGNOSTIC FRAMEWORK

The heterogeneity of MD—both in terms of symptom presentation and test findings—necessitates a structured, stepwise diagnostic approach. Combining clinical criteria with objective functional and radiologic assessments enhances diagnostic confidence and supports individualized management.

Stepwise Diagnostic Approach

A practical framework for MD diagnosis can be organized into three escalating tiers, progressively incorporating subjective and objective data (Fig. 1). This tiered model integrates the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS)/Bárány clinical criteria with objective tests: step 1, clinical suspicion; step 2, staged VFTs (low/high-frequency canals and otoliths); and step 3, selective MRI when results are inconclusive or management-changing. Tests are intended as adjuncts to, not replacements for, clinical criteria; normal VFTs or MRI do not exclude MD in early or fluctuating disease.

Step 1. Clinical suspicion

Diagnosis begins with history-taking based on AAO-HNS 1995 criteria and Bárány Society 2015 guidelines, which require: ≥two episodes of spontaneous vertigo (20 minutes–12 hours); fluctuating low- to mid-frequency SNHL, tinnitus and/or aural fullness [1]. Importantly, alternative diagnoses such as VM, BPPV, or autoimmune inner ear disease must be systematically excluded [2].

Step 2. Vestibular function testing

Tier 1 involves initial objective evaluation with caloric testing and vHIT to assess low- and high-frequency SCC function. Tier 2 adds cVEMP and oVEMP to evaluate otolithic organs when tier 1 is inconclusive or to stage disease burden. Triple concordance of abnormalities across these tests yields a sensitivity of 78% and specificity of 92% for definite MD [10].

Step 3. Magnetic resonance imaging confirmation

In atypical or refractory cases, 3D-FLAIR MRI with Gd should be performed. IT-Gd–enhanced MRI is recommended for detailed, side-specific analysis, whereas IV-Gd–enhanced MRI is suitable for bilateral assessment or when IT-Gd is not feasible. MRI findings may not only support diagnosis but also assist in presurgical planning, particularly for endolymphatic sac surgery or IT gentamicin treatment [26,27].

Risk Stratification Model

Based on combined functional and imaging findings, a three-tiered risk model can be used to estimate diagnostic likelihood and guide decision-making (Table 3).

We present a conceptual three-tier risk framework (low, zero to one abnormal test; intermediate, two or more abnormal tests; and high, three or more abnormal tests with MRI-confirmed EH). Predictive values vary with pre-test probability; thus, any positive predictive value shown is illustrative, contingent on the clinical setting.

This model allows clinicians to adjust monitoring frequency and treatment aggressiveness according to objective findings. In high-risk patients, early intervention with diuretics or vestibular suppressants may be justified to prevent progression.

Predicting Treatment Response

Beyond diagnosis, integrated testing can offer prognostic insights: the degree of vestibular end-organ involvement, especially when affecting both SCCs and otolith organs, correlates with vertigo frequency, DHI scores, and quality of life impairments [21].

MRI-detected EH grade correlates with disease refractoriness: Grade III hydrops has been associated with intractable vertigo (odds ratio, 4.2) [29].

cVEMP threshold elevation has shown predictive value for long-term hearing loss, allowing early patient counseling [7].

Therefore, an integrated diagnostic system is not only essential for diagnosis but also for personalized care planning.

FUTURE DIRECTIONS

Despite significant advancements in diagnostic imaging and vestibular testing for MD, several unmet needs persist that challenge clinicians and researchers [21]. Future efforts should focus on standardization, precision enhancement, and biomarker development to refine diagnostic accuracy and prognostic utility.

Standardization of Magnetic Resonance Imaging Protocols and Grading Systems

While 3D-FLAIR MRI with Gd enhancement has enabled direct visualization of EH, interinstitutional variability in protocols, image acquisition, and interpretation criteria remains a barrier to clinical translation.

Timing inconsistencies: IT-Gd requires 4 to 6 hours postinjection imaging, while IV-Gd often uses 24-hour delay. These schedules are not uniformly applied across centers [26,27].

• Lack of standardized EH grading: Although systems like Nakashima’s three-tier model (none, mild, significant) exist, thresholds for pathologic hydrops remain subjective and prone to interobserver variation [28].

• Training and reproducibility: General radiologists may lack training in inner ear imaging, underscoring the need for validated reporting templates and training modules.

International consensus on standard MRI protocols, including contrast dosage, delay time, coil specifications, and interpretation schemes, will be essential to make hydrops imaging more clinically actionable.

Artificial Intelligence-Powered Multimodal Data Integration

The integration of multimodal vestibular test data (caloric, vHIT, and VEMP) with imaging outputs presents a high-dimensional diagnostic problem well-suited for AI approaches.

Deep learning models have recently been applied to segment the endolymphatic space in 3D-FLAIR images with high reproducibility. One study showed κ-value improvement from 0.61 (manual) to 0.89 (AI-assisted), dramatically reducing inter-rater variability [29].

AI can also support decision-support systems by combining caloric asymmetry, vHIT gain, and EH grade to predict the likelihood of definite MD or stratify between MD and VM.

Multimodal fusion models—those incorporating both imaging and physiologic test data—are under development to assist clinicians in real-time diagnosis and staging.

The future likely lies in cloud-based diagnostic platforms that standardize test results, store vestibular data longitudinally, and apply predictive modeling for treatment guidance.

Biomarker Discovery and Molecular Diagnostics

Current diagnosis of MD lacks noninvasive molecular biomarkers and relies entirely on subjective history, audiometry, and imaging. Future translational research must explore biological markers that reflect pathophysiological processes such as ionic imbalance, inflammation, or endolymphatic sac dysfunction.

Aquaporin-2 (AQP2) protein, a vasopressin-regulated water channel expressed in the inner ear, has shown promise as a candidate biomarker. Elevated AQP2 levels in perilymph or endolymphatic sac aspirates have been correlated with hydrops severity in recent studies [30]. Emerging candidates include angiogenic and inflammatory markers (e.g., vascular endothelial growth factor [VEGF], cytokine panels), otolithic-matrix proteins (e.g., otolin-1), and exosomal cargo profiling. While perilymph or endolymphatic sac samples underpin much of the current evidence, middle ear effusion is not a typical diagnostic substrate in MD and has been removed to avoid confusion.

Exosomal RNA and protein analysis from perilymph or middle ear effusion may enable liquid biopsy-style diagnostics in the future.

Ongoing research into VEGF, otolin-1, and cytokine profiles could yield novel panels for early detection and subtype classification.

Future trials should incorporate biobank repositories, pre- and posttreatment sampling, and link molecular profiles with imaging phenotypes and clinical trajectories.

CONCLUSION

MD remains a diagnostic challenge due to its fluctuating symptoms, overlapping features with other vestibular disorders, and lack of a single pathognomonic test. Historically, diagnosis has relied primarily on symptom-based criteria as outlined by the AAO-HNS and Bárány Society. However, the limitations of purely subjective frameworks have become increasingly apparent, particularly in atypical or early-stage presentations. This review has emphasized the clinical value of advanced VFTs—including caloric testing, vHIT, cVEMP/oVEMP, and rotatory chair testing. These tools provide frequency- and end-organ-specific functional insights and, when combined, significantly enhance diagnostic sensitivity. Notably, the triple-test strategy (caloric+vHIT+cVEMP) has demonstrated 78% sensitivity and 92% specificity in identifying definite MD.

Complementing these functional assessments, 3D-FLAIR MRI with Gd enhancement has become a powerful modality for the direct visualization of EH, the presumed pathological substrate of MD. Both IT and IV contrast protocols offer distinct advantages, with recent studies correlating EH severity with clinical metrics such as hearing thresholds and vertigo frequency. Importantly, neither functional testing nor imaging alone is sufficient. Rather, the integration of physiologic and morphologic evaluations offers a more accurate and comprehensive framework for diagnosis, staging, and management. This integrative approach not only improves diagnostic precision—from approximately 65% to over 88%—but also aids in risk stratification and treatment prediction, paving the way for personalized care pathways.

Looking ahead, standardization of imaging protocols, the application of AI for multimodal data integration, and the development of noninvasive molecular—such as AQP2, angiogenic and inflammatory markers (e.g., VEGF, cytokine panels), otolithic-matrix proteins (e.g., otolin-1), and exosomal profiling—are poised to transform the diagnostic paradigm. These advances, grounded in appropriate biological substrates, will be critical as the field moves toward objective, data-driven diagnostic algorithms and an international consensus on updated diagnostic criteria.

Nevertheless, it must be emphasized that diagnostic accuracy values such as sensitivity and specificity are highly context dependent. Their interpretation can vary according to study population and clinical setting—for instance, between asymptomatic individuals, general dizzy patients, those with strong clinical suspicion of MD, or cases where differentiation from VM is challenging. Given the absence of a universally accepted gold standard biomarker for MD, current tests should be regarded as adjunctive tools that support, but do not replace, symptom-based clinical criteria.

In conclusion, the future of MD diagnosis lies in the convergence of structured symptom criteria, multimodal functional testing, and high-resolution imaging, supported by emerging digital and molecular technologies. It is imperative that upcoming revisions of diagnostic guidelines, such as the anticipated 2025 international criteria update, incorporate these objective tools to ensure early, accurate, and equitable diagnosis for all patients affected by this complex disorder.

ARTICLE INFORMATION

Funding/Support

This research was supported by the Regional Innovation System & Education (RISE) program through the Gangwon RISE Center, funded by the Ministry of Education (MOE) and the Gangwon State (G.S.), Republic of Korea (2025-RISE-10-006).

Conflicts of Interest

Young Joon Seo is an Associate Editor of Research in Vestibular Science and was not involved in the review process of this article. The authors declare no other conflicts of interest.

Availability of Data and Materials

The datasets are not publicly available but are available from the corresponding author upon reasonable request.

Authors’ Contributions

Conceptualization: Seo YJ; Writing–original draft: Kong TH, Seo YJ; Writing–review and editing: Seo YJ.

Fig. 1.

Stepwise diagnostic approach for Ménière’s disease (MD). SNHL, sensorineural hearing loss; BPPV, benign paroxysmal positional vertigo; vHIT, video head impulse test; SCC, semicircular canal; VEMP, vestibular evoked myogenic potential; cVEMP, cervical VEMP; oVEMP, ocular VEMP; MRI, magnetic resonance imaging; 3D-FLAIR, three-dimensional fluid-attenuated inversion recovery; Gd, gadolinium; IT, intratympanic; IV, intravenous.

Table 1.

Clinical profiles of vestibular tests in Ménière disease (MD)

Test	Target organ/mechanism	Key clinical features
Caloric test	Horizontal SCC (low frequency, approximately 0.003 Hz)	56%–67% hypofunction in MD; discomfort; time-consuming
Video head impulse test	All SCCs (high frequency, 2–5 Hz)	Detects covert saccades in 48%; 37% false negatives in early MD
Cervical VEMP	Saccule (via SCM)	Reduced amplitude in 52% of MD; thresholds >85 dB → severe HL (AUC, 0.82)
Ocular VEMP	Utricle (via IO muscle)	Abnormal tuning in 44%; utricular asymmetry
Rotatory chair test	Vestibular nuclei integration (approximately 0.01–1 Hz)	Phase lead >50% at 0.01 Hz in 61% MD; superior in bilateral MD

SCC, semicircular canal; VEMP, vestibular evoked myogenic potential; SCM, sternocleidomastoid muscle; HL, hearing loss; AUC, area under the curve; IO, inferior oblique muscle.

Table 2.

Diagnostic performance of vestibular tests and MRI in Ménière's disease

Test modality	Sensitivity (%)	Specificity (%)	Target organ/system
Caloric test	56–67	Up to 80	Horizontal SCC (low frequency)
vHIT	37–48	Up to 90	All SCCs (high frequency)
cVEMP	Up to 52	Up to 85	Saccule
oVEMP	44	Up to 80	Utricle
Rotatory chair test	61 (phase lead >50%)	Up to 75	Global VOR (mid-frequency)
Triple test (caloric+vHIT+cVEMP)	100	50	Integrated SCC+otoliths
3D-FLAIR MRI (IT-Gd)	Up to 95 (cochlear EH)	Up to 90	Cochlea, vestibule (unilateral)
3D-FLAIR MRI (IV-Gd)	Detection in 18% bilateral EH	Up to 85	Cochlea, vestibule (bilateral)

MRI, magnetic resonance imaging; SCC, semicircular canal; vHIT, video head impulse test; VEMP, vestibular evoked myogenic potential; cVEMP, cervical VEMP; oVEMP, ocular VEMP; VOR, vestibulo-ocular reflex; 3D-FLAIR, three-dimensional fluid-attenuated inversion recovery; IT, intratympanic; Gd, gadolinium; EH, endolymphatic hydrops; IV, intravenous.

Table 3.

Three-tiered risk stratification model based on combined vestibular test and MRI findings

Risk category	Criteria	Positive predictive value
Low	0–1 abnormal vestibular test	12%
Intermediate	≥2 abnormal tests (any modality)	58%
High	≥3 abnormal tests+MRI-confirmed hydrops	89%

MRI, magnetic resonance imaging.

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Multimodal diagnostic evaluation in Ménière disease: a narrative review of vestibular function tests and gadoliniumenhanced magnetic resonance imaging for endolymphatic hydrops

Res Vestib Sci. 2025;24(4):205-214. Published online December 15, 2025

DOI: https://doi.org/10.21790/rvs.2025.014

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Figure

Multimodal diagnostic evaluation in Ménière disease: a narrative review of vestibular function tests and gadoliniumenhanced magnetic resonance imaging for endolymphatic hydrops

Fig. 1. Stepwise diagnostic approach for Ménière’s disease (MD). SNHL, sensorineural hearing loss; BPPV, benign paroxysmal positional vertigo; vHIT, video head impulse test; SCC, semicircular canal; VEMP, vestibular evoked myogenic potential; cVEMP, cervical VEMP; oVEMP, ocular VEMP; MRI, magnetic resonance imaging; 3D-FLAIR, three-dimensional fluid-attenuated inversion recovery; Gd, gadolinium; IT, intratympanic; IV, intravenous.

Fig. 1.

Multimodal diagnostic evaluation in Ménière disease: a narrative review of vestibular function tests and gadoliniumenhanced magnetic resonance imaging for endolymphatic hydrops

Test	Target organ/mechanism	Key clinical features
Caloric test	Horizontal SCC (low frequency, approximately 0.003 Hz)	56%–67% hypofunction in MD; discomfort; time-consuming
Video head impulse test	All SCCs (high frequency, 2–5 Hz)	Detects covert saccades in 48%; 37% false negatives in early MD
Cervical VEMP	Saccule (via SCM)	Reduced amplitude in 52% of MD; thresholds >85 dB → severe HL (AUC, 0.82)
Ocular VEMP	Utricle (via IO muscle)	Abnormal tuning in 44%; utricular asymmetry
Rotatory chair test	Vestibular nuclei integration (approximately 0.01–1 Hz)	Phase lead >50% at 0.01 Hz in 61% MD; superior in bilateral MD

Test modality	Sensitivity (%)	Specificity (%)	Target organ/system
Caloric test	56–67	Up to 80	Horizontal SCC (low frequency)
vHIT	37–48	Up to 90	All SCCs (high frequency)
cVEMP	Up to 52	Up to 85	Saccule
oVEMP	44	Up to 80	Utricle
Rotatory chair test	61 (phase lead >50%)	Up to 75	Global VOR (mid-frequency)
Triple test (caloric+vHIT+cVEMP)	100	50	Integrated SCC+otoliths
3D-FLAIR MRI (IT-Gd)	Up to 95 (cochlear EH)	Up to 90	Cochlea, vestibule (unilateral)
3D-FLAIR MRI (IV-Gd)	Detection in 18% bilateral EH	Up to 85	Cochlea, vestibule (bilateral)

Risk category	Criteria	Positive predictive value
Low	0–1 abnormal vestibular test	12%
Intermediate	≥2 abnormal tests (any modality)	58%
High	≥3 abnormal tests+MRI-confirmed hydrops	89%

Table 1. Clinical profiles of vestibular tests in Ménière disease (MD)

SCC, semicircular canal; VEMP, vestibular evoked myogenic potential; SCM, sternocleidomastoid muscle; HL, hearing loss; AUC, area under the curve; IO, inferior oblique muscle.

Table 2. Diagnostic performance of vestibular tests and MRI in Ménière's disease

Table 3. Three-tiered risk stratification model based on combined vestibular test and MRI findings

MRI, magnetic resonance imaging.