AM ER IC AN JOURNAL OF OT OLARYNGOLOGYH E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 3 933 9 8

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Menieres disease: importance of socioeconomic

and environmental factors

Hermann Simo, BS a , Shiayin Yang, M.D. a , Weikai Qu, M.D., Ph.D. b , Michal Preis, M.D. c ,
Munier Nazzal, M.D. b , Reginald Baugh, M.D. d,
a
College of Medicine & Life Sciences, The University of Toledo, 3000 Arlington Avenue, Toledo, OH
b
Department of Surgery, Division of Vascular Surgery, The University of Toledo Medical Center, 3000 Arlington Avenue MS #1095,
Toledo, OH
c
Department of Otolaryngology, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY
d
Department of Surgery, Division of Otolaryngology, The University of Toledo Medical Center, 3000 Arlington Avenue MS #1095, Toledo, OH

ARTI CLE I NFO A BS TRACT

Article history: Study objectives:

Received 2 September 2014 1. Describe the prevalence of Menieres disease in the United States.
2. Recognize important patient and environmental factors in Menieres disease.
Methods:
Discharge data from the Nationwide Inpatient Sample, the largest US all-payer inpatient
care database was analyzed for Menieres disease between 2008 and 2010 in
patients >10 years old. Patient characteristics including prevalence, age, sex, race,
household income, and geographic location were studied to determine any correlation
with disease prevalence.
T-test, Chi-square and logistic regression testing was used to compare the differences
between groups for continuous and categorical data.
Results:
The lower limit of Menieres prevalence in the United States population was 73 per
100,000, females 84 per 100,000 compared to 56 per 100,000 among males (OR = 1.51, 95% CI
1.481.54, P < 0.01).
Prevalence was highest in Caucasians 91 per 100,000, and was significantly higher than
other ethnic groups (P < 0.05).
Prevalence increased as age with the highest prevalence found in 8190 year age group.
Midwest prevalence (94 per 100,000) was significantly higher than other regions (P < 0.001).
Menieres is more common in less populated locations and the prevalence decreased as
population increased.
Menieres prevalence increased with household income. The highest prevalence was
found among the 76th100th quartile with rates of 86 per 100,000 for MD.
Conclusions: Environmental factors, race and ethnicity, gender and age appear to be
important factors in the prevalence of Menieres disease.
2015 Elsevier Inc. All rights reserved.

Corresponding author at: Department of Surgery, Division of Otolaryngology, 3000 Arlington Avenue MS #1095, Toledo, OH 43614. Tel.: + 1
419 383 6834; fax: +1 419 383 6636.
E-mail address: reginald.baugh@utoledo.edu (R. Baugh).

http://dx.doi.org/10.1016/j.amjoto.2015.01.009
0196-0709/ 2015 Elsevier Inc. All rights reserved.

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394 AM ER IC AN JOURNAL OF OT OLA RYNGOLOGYH E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 3 93 3 9 8
1. Introduction
Dr. Menieres [13] description of an otologic balance disorder
in 1861 identified two important factors associated with the
condition: its greater prevalence in women and association
with migraines. Despite this important start, the role of other
socioeconomic, environmental, and patient factors in the
prevalence of Menieres disease has not been well elucidated
in the subsequent 150 years. One limited area of study of
Menieres disease is the role of socioeconomic, environmen-
tal, and patient factors in the prevalence of Menieres disease.
The interplay of these factors is unclear due to the limited
populations previously studied. Using a national database,
the role of these factors in Menieres disease is explored [4].
2. Materials and methods
Discharge data from the Nationwide Inpatient Sample (NIS)
which is part of the Healthcare Cost and Utilization Project
(HCUP) sponsored by the Agency for Healthcare Research and
Quality (AHRQ) were analyzed to study all patients with a
diagnosis of Menieres disease. The NIS is the largest all-payer
inpatient care database in the United States that provides
information regarding the index hospital admission, which
includes patient demographic data, primary and secondary
diagnoses, primary and secondary procedures, hospital char-
acteristics, and inpatient and discharge mortality rates. The
International Classification of Disease, 9th Revision (ICD-9)
codes was used to identify all patients with a diagnosis of
Menieres disease between the years of 2008 through 2010.
Patients with a diagnosis of Menieres disease were analyzed
by specific demographic characteristics to determine if there
was any correlation between these factors and disease
prevalence. Demographic characteristics studied included
age, gender, race, household income, and geographic location.
IBM SPSS statistics ver.19 (SPSS Inc., an IBM Company,
Chicago, IL) and SAS 9.3 (SAS Institute, Cary NC) were used
to conduct all the statistical analyses. Rank-sum test and Chi-
square test were used to compare the differences between
groups for continuous and categorical data respectively. The
absence of clinical data precludes us from distinguishing
possible, probable, or definite Menieres disease. The adjust-
ment for possible confounding factors, such as age, gender,
race, median household income (MHI) of the patients as well
as the size, ownership, location, region and teaching status of
the hospital, was done by logistic regression analysis.
3. Results
From 2008 to 2010, there were 73,753 cases of Menieres disease
reported in the NIS inpatients discharge database. Among these
hospitalized patients older than 10 years of age, the prevalence of
Menieres disease was 73 per 100,000. The prevalence was higher
in 2009 compared to 2008 but there were no significant differences
in prevalence between 2008 and 2010. The prevalence in 2009 and
2010 was slightly higher than that in 2008 (P < 0.01). There was no
significant difference in prevalence between 2009 and 2010 (P =
0.568) (Table 1).
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Table 1 Annual prevalence table. The prevalence of
Menieres disease in 2009 and 2010 was slightly higher
than that in 2008 (P < 0.01). There was no significant
difference in prevalence between 2009 and 2010 (P = 0.568).
Annual prevalence (N/per 100,000)
in patients > 10 years old
2008 2009 2010 Overall
Meniere 24,151/71 24,970/74 24,632/73 73,753/73
All hospital 34,231,302 33,825,698 33,543,832 101,600,832
admissions
In comparison of disease prevalence by sex, Menieres disease
was found to be higher among females with a rate of 84 per
100,000 compared to a rate of 56 per 100,000 among males (OR =
1.51, 95% CI 1.481.54, P < 0.01). The incidence of rate of Menieres
disease among females was significantly high than that of males
in all the age groups that were older than 41 years old and in the
age 1120 group (p < 0.05 in all cases). No significant difference
was found in the incidence rate between males and females in
age 2130 and 3140 groups (p > 0.05). The median age of patients
was 70 years with a minimum age of 13 years and a maximum
age of 107 years. The prevalence increased as age increased
with the highest prevalence found among the 8190 year age
group (Fig. 1). Among different racial groups, disease prevalence
was highest in Caucasians with rates of 91 per 100,000, and was
significantly higher than any other ethnic group (P < 0.05) (Fig. 2).
Regressions demonstrated that both race and socioeconomic
status to do independently affect the rate of Meniere disease
(P < 0.001).
The prevalence of Menieres disease was studied in relation to
geographic region, location, and household income. In the Midwest
the prevalence was highest (94 per 100,000), with the other 3 regions
significantly lower (67, 65 and 66 per 100,000 in Northeast, South
and West, respectively; P < 0.001). There was no significant
difference in the prevalence among Northeast, South and West
regions. Menieres disease is more common in less populated
locations. The highest prevalence was found in micropolitan or
non-metro, non-micropolitan counties (82 per 100,000) and the
prevalence decreased when the population increased. Increasing
income was associated with an increased prevalence and was
independent of race (Fig. 3). The highest prevalence was found
among the 76th100th quartile with the rates of 86 per 100,000
roughly equivalent to racial differences (Fig. 4).
4. Discussion
4.1. Limitations
Ideal comprehensive statistics on the prevalence are lacking
for Menieres disease. A number of prevalence numbers have
been published from different countries by different authors.
The discussion about the prevalence and incidence is
hampered by the lack of understanding of the difference
between prevalence and incidence reflected in the literature.
Prevalence, the frequency at which a condition is found
within a population at a particular time, is its commonness.
As such it is a reflection of the burden of the condition
without a specific reference to time. Incidence reflects the risk
of developing a condition within a specific time frame.
Methodologically, Menieres disease studies often suffer
from a lack of a well-defined population. Other limitations
 AM ER IC AN JOURNAL OF OT OLARYNGOLOGYH E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 3 933 9 8 395

Fig. 1 Prevalence of Menieres disease at different decade age in inpatients population.

include changes in the population at risk over time, lack of
adequate diagnostic criteria, and a failure to make a distinc-
tion between relative frequencies, prevalence ratio, and the
incidence rate of the disease. Further limitations of adminis-
trative database studies are well known (Table 2). Using data
from billing sources has its limitations and tends to underes-
timate the true prevalence because of the absence of
ambulatory data. Despite these limitations significant in-
sights can be identified using these data sets.
4.2. Prevalence
European investigators have found the prevalence of
Menieres disease to range from 120 in Germany [5], 205 in
Italy [6] to 513 in Finland [7]. Havia et al.s study [7] has been
criticized based upon its methodology [5] and its rate 513 is
thought to be an overestimate. In the United States, Harris
and Alexanders [8] rate of 190 is the more recent prevalence
published and groups in the middle of the range of most

Fig. 2 Incidence rate of Menieres disease by gender according to age groups.

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396 AM ER IC AN JOURNAL OF OT OLA RYNGOLOGYH E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 3 93 3 9 8

Fig. 3 Prevalence of Menieres disease by region and locations.

European estimates. The Life Link Database that Harris and
Alexander [8] used is composed of paid claims from medical/
pharmaceutical interactions from inpatient and outpatient
sources from health plans. Despite requirements for contin-
uous enrollment, complete data availability, participation in
designated health plans, and proprietary adjustments in the
data to make it more representative, the databases validity
rests on billing codes. The database itself is no better than the
coding upon which it was based and is subject to the same
limitations of all billing databases. Whether the proprietary
adjustments made to the database alter the observed preva-
lence is unknown. Wladislavosky-Waserman et al.s [9]
30 year old study of Rochester MN inhabitants from 1950 to
1980 is probably the most often cited study of Menieres
prevalence, 218 per 100,000. Its limitations are many. Its racial
makeup is not reflective of the current US population, over
60 years has passed since some of the subjects covered in the
study were enrolled, and as has been previously identified,
about a third of the patients included in the study probably
did not meet the criteria for Menieres [6].
4.3. Populations
The frequency of male/female prevalence in Menieres
disease has been noted to generally be about equal with
perhaps some slight female preponderance. However the

Fig. 4 Prevalence of Menieres disease by household income.

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 AM ER IC AN JOURNAL OF OT OLARYNGOLOGYH E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 3 933 9 8
Table 2 Key limitations of administrative data.
Administrative data reflect the care received not the care needed.
The reliability of a given condition recorded is proportional to its
impact on reimbursement.
Diagnoses or conditions poorly or not reimbursed will be omitted
or classified using alternative means.
The cross walk between procedural codes and diagnoses codes
and inpatient and outpatient codes is impressive.
Identification of the reason for a procedure or condition is
imprecise at best.
Coding generally reflects the highest form of reimbursement for
that setting.
most comprehensive study suggested that the number of
women affected may be in decline [9]. Our study clearly
provides evidence that currently a clear female preponder-
ance is present. Our findings of a female predominance is
1.51, but not unlike other reported rates of gender differences
and similar to a more recent Menieres report [10].
The increased prevalence of Menieres in older populations
has been noted previously [7,8,10,11]. Declines in prevalence
after age 70 were noted in one European population [7]. Our
findings demonstrate a continued increase in prevalence for
another two decades before a decrease is seen.
Current conceptualizations of Menieres disease describe a
condition that is the result of degenerative dysfunction within
endolymphatic homeostatic mechanisms resulting in dysregu-
lation of ionic composition [12,13]. It is likely that a variety of
cumulative factors results in the final outcome known as
Menieres disease. Our finding of a progressive increase in the
prevalence of Menieres disease from age 20 to 90 is supportive
of the degenerative dysregulation hypothesis. Whether or not
this reflects a true change in environmental factors, a change in
the population due to greater mobility, or some other factor is
unknown and warrants further investigation.
4.4. Race and ethnicity
Japanese estimates of Menieres disease in the past 35 years
have varied widely from 3.5 per 100,000 to 73 per 100,000
when survey methodology was used to obtain the prevalence
rate [14]. Later rates based upon inpatient sources were lower
than ones that also included ambulatory information. Despite
methodological differences and populations surveyed, later
estimates cluster between 20 and 35 [11,15,16]. Compared to
reported European and US prevalence, Japanese prevalence
rates tend to be significantly lower.
The frequency of Menieres disease in African Americans
has been reported as either lower [17] or the same as
Caucasians in the US [18]. A lower frequency of disease has
also been reported in other ethnic groups in the US including
Hispanics, Asians, and Native Americans [10,18,19]. Our
findings established the prevalence of Menieres disease
among African Americans as lower and extend those findings
to demonstrate significant differences between the preva-
lence of self-designated race and ethnicity in other US sub-
populations (Fig. 2). The occurrence of Menieres disease in
sub-Saharan Africa is unclear as it has been reported to be
either higher [20] or lower [21] than comparable European
or American populations. Significant differences in rigor,
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397
methodology, and definitions used to characterize the popula-
tions make rigid comparisons of studies problematic; however
the differences between African American populations and
African populations should preclude generalization between
the two groups. Recent genetic investigations will likely provide
key insights into racial and ethnic differences [10].
4.5. Occupational and environmental factors
When first suggested that environmental factors may be
important in Menieres disease [22] - the hypothesis was
largely viewed as a curiosity. A later study from Nigeria
suggested greater access to facilities as an important factor
regarding prevalence. The applicability of the findings to US
and European populations remained unanswered as social,
environmental, societal and racial differences made reconcil-
iation of the findings difficult [20]. A comprehensive study
published later the same year suggested that the findings were
not applicable to US populations [9]. Later studies reported a
higher occurrence of Menieres disease among doctors,
nurses, and hospital employees [6]. Our study demonstrates a
greater prevalence of Menieres disease among higher income
populations. This confirms the association of Menieres disease
with income to US populations (Fig. 4). Further, we demonstrate
that effects of socioeconomic status are independent of race.
When subjects home location was examined, the prevailing
prevalence was greater in rural areas compared to cities and
towns. As the population increased, the prevalence of Menieres
decreased. A greater awareness of health, access to healthcare,
ease of patient communication with healthcare providers, and
unknown dietary/environmental factors may be responsible for
the higher reported occurrence of Menieres disease with
income. Many of these factors would seem to work against the
greater prevalence associated with location. Further research is
warranted to fully elucidate these findings.
5. Conclusion
The key characteristics of any population surveyed for the
prevalence of Menieres are age, race, gender. The older the
patient population, the greater the frequency of women, the
inclusion of ambulatory and inpatient data, and more
Caucasians, the greater the prevalence of Menieres that will
be found in the population. These factors are relevant to
future research and need to be considered to gain a greater
understanding of Menieres disease.
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