What is the diagnosis and treatment for sensorineural hearing loss and vertigo?

Diagnosis and Treatment of Sensorineural Hearing Loss with Vertigo

MRI with dedicated internal auditory canal (IAC) protocol is the first-line imaging modality for diagnosing the cause of sensorineural hearing loss with vertigo, followed by appropriate treatment based on the identified etiology. 1, 2

Diagnostic Approach

Clinical Evaluation

• Assess hearing loss characteristics:
  • Sudden vs. gradual onset
  • Unilateral vs. bilateral
  • Fluctuating vs. stable
  • Associated symptoms (tinnitus, aural fullness)
• Evaluate vertigo features:
  • Episodic vs. continuous
  • Positional triggers
  • Duration of episodes
  • Presence of nystagmus

Differential Diagnosis

1. Menière's disease: Fluctuating hearing loss, episodic vertigo, tinnitus, aural fullness 1
2. Labyrinthitis/Labyrinthine infarction: Sudden hearing loss with acute vertigo 3
3. Vestibular schwannoma: Progressive unilateral hearing loss with imbalance 1
4. Autoimmune inner ear disease: Bilateral fluctuating hearing loss 1
5. Endolymphatic hydrops: Altered ratio of endolymph to perilymph 2
6. AICA infarction: Sudden hearing loss with vertigo and neurological symptoms 3

Diagnostic Testing

Imaging

1. MRI Head and Internal Auditory Canal (first-line):

   • Use dedicated IAC protocol with thin sections
   • High-resolution 3D T2-weighted sequences
   • With and without contrast to detect inflammatory changes and neoplasms
   • Superior for visualizing cochlear contents, vestibulocochlear nerve, and auditory pathways 1, 2

2. CT Temporal Bone (complementary):

   • For bony abnormalities (superior semicircular canal dehiscence, temporal bone fractures)
   • Submillimeter slices with bone window settings
   • Helpful for detecting otospongiosis and labyrinthine ossification 1, 2

Audiological Testing

• Pure tone audiometry to characterize hearing loss pattern
• Speech discrimination testing
• Tympanometry to rule out middle ear pathology

Vestibular Testing

• Electronystagmography (ENG) - prognostic value for recurrence and progression to Menière's disease 4
• Video head impulse test (vHIT) - assess semicircular canal function 3
• Vestibular evoked myogenic potentials (VEMPs) - evaluate otolith function 3

Treatment Approach

Medical Management

1. Corticosteroids:

   • First-line treatment for sudden sensorineural hearing loss
   • Short course of high-dose oral steroids (e.g., prednisone)
   • Consider intratympanic steroid injections for refractory cases 5

2. Symptomatic Management of Vertigo:

   • Meclizine: 25-100 mg daily in divided doses for acute vertigo
     • Caution: May cause drowsiness, dry mouth, and blurred vision
     • Contraindicated in patients with hypersensitivity to meclizine
     • Use with caution in patients with asthma, glaucoma, or prostate enlargement 6
   • Other vestibular suppressants: diazepam, promethazine as needed

3. Disease-Specific Treatments:

   • Menière's disease: Low-salt diet, diuretics, intratympanic gentamicin for refractory cases
   • Autoimmune inner ear disease: Immunosuppressive therapy
   • Labyrinthitis: Antibiotics if bacterial etiology is suspected

Surgical Management

• Reserved for cases refractory to medical management or specific pathologies:
  • Vestibular schwannoma resection
  • Endolymphatic sac decompression for Menière's disease
  • Ablative procedures (labyrinthectomy, vestibular neurectomy) for disabling vertigo 7

Prognostic Factors

• Presence of spontaneous nystagmus on initial ENG indicates higher risk of recurrent hearing loss (51.2% vs. 27.9%) and progression to Menière's disease (14%) 4
• Posterior semicircular canal dysfunction is common (74%) in patients with vertigo and sudden hearing loss 3
• Approximately 50% of patients with sudden sensorineural hearing loss recover completely within 2 weeks 5
• Bilateral sudden hearing loss has worse prognosis and requires thorough evaluation for systemic causes 1

Common Pitfalls to Avoid

1. Relying on standard head CT instead of dedicated temporal bone imaging or MRI
2. Failing to recognize that vertigo with SSNHL may represent a vascular emergency (AICA infarction)
3. Missing the diagnosis of vestibular schwannoma by not obtaining appropriate imaging
4. Overlooking the prognostic value of vestibular testing in predicting recurrence and progression
5. Delaying treatment of sudden sensorineural hearing loss, which can reduce recovery potential