Differentials
Acoustic neuroma
SIGNS / SYMPTOMS
Small acoustic tumours typically present as unilateral high-frequency hearing loss with difficulty hearing on the telephone on affected ear.
Acoustic neuroma should be ruled out in any unilateral sensorineural hearing and therefore in patients with meniere's disease.[39]
INVESTIGATIONS
There is reduced word recognition score to an inordinate degree when compared with pure-tone air and bone conduction testing (phonemic regression), roll-over phenomenon, absent or elevated acoustic reflexes, abnormal findings on stapedial reflex decay, and abnormal auditory brainstem response.
Hearing tests may be within normal limits in patients with small acoustic neuromas.
MRI with gadolinium contrast will show a tumour involving the acoustic nerve.
Vestibular migraine (also called migraine-associated dizziness and migraine-associated vertigo)
SIGNS / SYMPTOMS
Incidence of migraine is significantly greater in populations of meniere's disease (MD) patients, and incidence of complaints of dizziness and MD is greater in migraine populations, than the incidence of either in the general unselected population.[40]
Symptoms and clinical test findings produced by both disorders overlap, and both conditions can co-exist in the same patient.
A very short (<15 minutes) or prolonged (>24 hours) duration of vertigo suggests migraine, and visual auras are more likely. Hearing loss is usually mild and stable over time.
INVESTIGATIONS
Investigations are variable and non-specific. Diagnosis is made on clinical history.[40]
Vestibular neuronitis
SIGNS / SYMPTOMS
Neural degeneration or viral infection of the eighth nerve can produce acute or chronic vertigo, nausea, and vomiting. There is no hearing loss, tinnitus, or aural fullness.
Occurs in epidemics and is most common in people between 40 and 50 years of age. Frequently, patients have had a recent viral infection.
Attacks are of precipitous onset, often occurring at night. Severe rotational vertigo lasts 12 to 36 hours with decreasing disequilibrium for the next 4 to 5 days.
INVESTIGATIONS
Electronystagmography (particularly using bi-thermal caloric testing) often shows unilateral weakness on the affected side, but may be normal.
Viral labyrinthitis
SIGNS / SYMPTOMS
Similar presentation to vestibular neuronitis but accompanied by hearing loss and tinnitus.[41]
INVESTIGATIONS
Patients show various degrees of hearing loss on complete audiological evaluation.
Benign paroxysmal positional vertigo (BPPV)
SIGNS / SYMPTOMS
Patients typically present with episodic vertigo lasting in the range of a few seconds to a minute elicited by certain head movements. These movements include lying flat with the neck extended and turned towards the affected ear, neck extension, and bending over. Unlike attacks caused by meniere's disease (MD), the vertigo spells are not associated with hearing loss, tinnitus, or aural fullness. The vertigo could recur over a period of weeks to months and may resolve spontaneously. Patients usually report a history of trauma or vestibular neuritis. It is important to note that BPPV and MD have been reported to co-exist in the same patient.[42]
INVESTIGATIONS
Hallpike's test will show rotatory nystagmus on the affected side. This is performed by starting in the sitting position then bringing to a supine position with the head turned 45° towards one side with 20° neck extension. Patients with BPPV usually demonstrate a short-lasting torsional nystagmus in this position.[43]
Vertebrobasilar insufficiency
SIGNS / SYMPTOMS
Cerebrovascular disease is more common in older people. The vertigo might be secondary to ischaemia of the labyrinth, brain stem, or both, because they are all supplied by the vertebrobasilar circulation.[44]
Vertigo spells usually last for several minutes, and are accompanied by nausea, vomiting, and severe imbalance. Associated symptoms may include visual blurring or black-outs, diplopia, drop attacks, weakness and numbness of the extremities, and headache.[44]
INVESTIGATIONS
Carotid duplex ultrasound may show changes of atherosclerosis, which implies changes in the cerebral circulation.
CT head may show evidence of previous cerebral infarction.
Magnetic resonance angiography of vessels of neck, base of skull, and circle of Willis may be abnormal.
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