What are the causes of ear fullness and vertigo?

Causes of Aural Fullness and Vertigo

The combination of aural fullness and vertigo most commonly indicates Ménière's disease, benign paroxysmal positional vertigo (BPPV), or vestibular migraine, with the specific diagnosis determined by attack duration, hearing symptoms, and triggers. 1

Primary Diagnostic Considerations

Ménière's Disease

Ménière's disease is the classic cause when aural fullness occurs together with vertigo, characterized by:

• Vertigo attacks lasting 20 minutes to 24 hours 1
• Fluctuating sensorineural hearing loss in the affected ear 1
• Tinnitus (ringing, buzzing, or other ear noises) 1
• Ear fullness or plugged sensation 1
• Believed to result from excess fluid (endolymphatic hydrops) within the inner ear 1

The diagnosis requires ≥2 episodes meeting these criteria, and symptoms occur spontaneously rather than being triggered by position changes 1.

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV causes vertigo but typically WITHOUT aural fullness, hearing loss, or tinnitus, making it distinguishable from Ménière's disease 1, 2:

• Brief vertigo episodes lasting seconds to <1 minute 1
• Triggered specifically by head position changes (rolling over in bed, looking up) 2
• No associated hearing symptoms 1
• Caused by dislodged otoconia (calcium crystals) in the semicircular canals 2

Vestibular Migraine

Vestibular migraine can present with aural fullness and vertigo, though less consistently than Ménière's disease 3:

• Vertigo attacks lasting minutes to days (more variable than Ménière's) 1, 2
• Hearing loss reported in 5.9-46.7% of patients 3
• Tinnitus in 17.8-69% of cases 3
• Ear fullness in 10.9-51% of cases 3
• Associated with migraine history, photophobia, or phonophobia 2
• Symptoms may occur without concurrent headache 2

Critical distinction: Vestibular migraine hearing loss tends to be mild, symmetrical, and at high frequencies, whereas Ménière's produces fluctuating unilateral hearing loss 3.

Other Important Causes

Superior Canal Dehiscence (SCD)

• Vertigo and oscillopsia triggered by loud sounds or pressure changes (Valsalva, coughing, sneezing) 2, 4
• May include aural fullness 2
• Distinguished by pressure/sound triggers rather than spontaneous attacks 2

Vestibular Neuritis/Labyrinthitis

• Single prolonged vertigo episode lasting >24 hours (not episodic) 1
• Vestibular neuritis: no hearing loss or aural fullness 1
• Labyrinthitis: sudden profound hearing loss with prolonged vertigo 1
• Not fluctuating or recurrent like Ménière's 1

Perilymphatic Fistula

• Vertigo triggered by pressure changes 2
• May follow ear surgery or occur spontaneously 2
• Can include fluctuating hearing loss 2

Otosyphilis

• Sudden unilateral or bilateral fluctuating hearing loss with vertigo 1
• Vertigo attacks not typically associated with aural symptoms immediately before/after 1

Diagnostic Algorithm

When evaluating aural fullness with vertigo, determine:

1. Attack duration:

   • Seconds: BPPV
   • 20 minutes-24 hours: Ménière's disease
   • Minutes to days: Vestibular migraine

   • 24 hours continuous: Vestibular neuritis/labyrinthitis or stroke

2. Triggers:

   • Position changes: BPPV
   • Spontaneous: Ménière's disease or vestibular migraine
   • Pressure/sound: Superior canal dehiscence

3. Hearing symptoms:

   • Fluctuating unilateral hearing loss: Ménière's disease
   • No hearing loss: BPPV, vestibular neuritis
   • Mild bilateral high-frequency loss: Vestibular migraine
   • Permanent profound loss: Labyrinthitis

4. Associated symptoms:

   • Migraine features (photophobia, headache): Vestibular migraine
   • Tinnitus + aural fullness + hearing loss: Ménière's disease

Critical Pitfalls

Do not assume all aural fullness with vertigo is Ménière's disease—vestibular migraine commonly presents with cochlear symptoms 3, 5. The key differentiator is the pattern of hearing loss (fluctuating unilateral in Ménière's vs. mild bilateral in vestibular migraine) and attack duration 1, 3.

Red flags requiring urgent neurologic evaluation include 1, 2:

• Downbeating nystagmus without torsional component
• Direction-changing nystagmus without head position changes
• Associated neurologic symptoms (dysphasia, dysphonia, visual changes)
• Failure to respond to appropriate peripheral vestibular treatment

Aural fullness can also occur from non-vestibular causes including external/middle ear disease, temporomandibular joint dysfunction, and autonomic dysfunction 6, but these typically lack true vertigo (spinning sensation).