Differentials
Vestibular neuritis
SIGNS / SYMPTOMS
Similar presentation to labyrinthitis but no hearing loss.
Vertigo is exacerbated by change in head position with respect to gravity.
INVESTIGATIONS
Normal audiogram.
Benign paroxysmal positional vertigo
SIGNS / SYMPTOMS
Similar presentation to labyrinthitis but no hearing loss.
INVESTIGATIONS
Normal audiogram.
A positive Dix-Hallpike's test (rotatory nystagmus and reproduction of symptoms).
Meniere's disease
SIGNS / SYMPTOMS
Fluctuating hearing loss, low-pitch tinnitus, low-frequency hearing loss, repeated episodes of vertigo.
INVESTIGATIONS
Complete audiological evaluation.
Includes pure-tone air and bone conduction, speech audiometry, tympanometry, and otoacoustic emissions.
Typically reveals sensorineural hearing loss mainly in the low frequencies, although other configurations of hearing losses may be present.
Vestibular schwannoma (acoustic neuroma)
SIGNS / SYMPTOMS
Small acoustic tumours typically present as unilateral high-frequency hearing loss with difficulty hearing on the telephone in the affected ear. Word discrimination score is greatly reduced when compared with pure-tone air and bone conduction testing (phonemic regression); rollover phenomenon, absent or elevated acoustic reflexes, abnormal findings on stapedial reflex decay, and abnormal auditory brainstem response.
Hearing tests may be normal in patients with small vestibular schwannomas.
INVESTIGATIONS
MRI with gadolinium contrast will show a tumour involving the vestibulocochlear nerve or eighth cranial nerve.
Posterior fossa cerebrovascular accident
SIGNS / SYMPTOMS
Ataxia, negative Romberg's test, dysarthria, dysphagia, hoarseness, facial paralysis, facial numbness, contralateral lower extremity weakness.
INVESTIGATIONS
Audiogram reveals sensorineural hearing loss.
CT scan of head.
Temporal bone fracture
SIGNS / SYMPTOMS
Recent head trauma.
INVESTIGATIONS
CT scan of head delineates extent of fracture.
Inner ear malformations
SIGNS / SYMPTOMS
Progressive hearing loss.
INVESTIGATIONS
MRI or CT scan of head reveals the malformation. Possible findings include atresia or malformation of ossicular chain, abnormal incus, or missing cura of the stapes.
Multiple sclerosis
SIGNS / SYMPTOMS
Symptoms are often asymmetric and involve only one side of the body or one limb.
Mild dragging of the foot and spasticity are often present.
INVESTIGATIONS
MRI head reveals demyelinating lesions. Sagittal fluid-attenuated inversion recovery images distinguish demyelinating lesions from non-specific white matter changes.
Labyrinthine haemorrhage
SIGNS / SYMPTOMS
Similar presentation to labyrinthitis.
INVESTIGATIONS
MRI T1-weighted images without contrast will show intra-labyrinthine hyper-intensity.
Temporal bone neoplasm
SIGNS / SYMPTOMS
Retro-tympanic mass, facial nerve paresis, lower cranial nerve deficits.
INVESTIGATIONS
MRI or CT scan of head will show tumour.
Vestibular migraine
SIGNS / SYMPTOMS
Associated headache, photophobia, phonophobia, aura.
INVESTIGATIONS
Imaging is normal.
Calorics on electronystagmography may be elevated.
Cholesteatoma
SIGNS / SYMPTOMS
May present with hearing loss, otorrhoea, otalgia.
INVESTIGATIONS
Otomicroscopy typically shows crust or keratin in the attic, pars flaccida, or pars tensa; temporal bone CT will show opacification of the middle ear or mastoid, with or without erosion; audiogram may show a conductive hearing loss.
Superior semi-circular canal dehiscence
SIGNS / SYMPTOMS
Sound or pressure induced dizziness. Autophony (hearing own voice and respiratory sounds in the ear), pulsatile tinnitus.
INVESTIGATIONS
Tullio (dizziness and nystagmus on loud noise) and Hennebert test (dizziness and nystagmus with altered middle-ear pressure) positive; audiogram shows conductive hyperacusis; vestibular evoked myogenic potentials (VEMPs) may have reduced thresholds (or larger VEMPs) may occur; CT temporal bones views in Poschl and Stenvers planes show semi-circular canal dehiscence.
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