Can tinnitus or hearing loss cause vertigo?

The Relationship Between Tinnitus, Hearing Loss, and Vertigo

Tinnitus and hearing loss are not direct causes of vertigo, but all three symptoms commonly co-occur in specific inner ear disorders, particularly Ménière's disease, where they represent different manifestations of the same underlying pathology rather than a causal relationship.

Understanding the Relationship Between These Symptoms

Tinnitus and Hearing Loss

• Tinnitus is the perception of sound when no external sound is present, often described as ringing, buzzing, or clicking sensations 1
• Tinnitus can be classified as:
  • Primary (idiopathic) or secondary to another condition
  • Subjective (heard only by the patient) or objective (audible to the examiner)
  • Pulsatile or nonpulsatile 1
• Tinnitus frequently co-occurs with hearing loss but does not cause vertigo independently 1

Vertigo and Its Causes

• Vertigo is defined as a false sensation of self-motion or a false sensation that the visual surroundings are spinning or flowing 1
• Vertigo has distinct causes separate from tinnitus, though they may share underlying pathologies 1

Common Conditions Where These Symptoms Co-occur

Ménière's Disease

• Characterized by a clinical tetrad of:
  • Episodic vertigo attacks
  • Fluctuating hearing loss
  • Tinnitus
  • Aural fullness 2
• The underlying pathophysiology involves endolymphatic hydrops (excessive endolymph accumulation in the inner ear) 2
• In Ménière's disease, these symptoms represent different manifestations of the same underlying disorder rather than one causing the other 2

Sudden Sensorineural Hearing Loss

• Often presents with unilateral hearing loss that may be accompanied by tinnitus and vertigo 3
• The triad of symptoms results from a common pathology affecting the inner ear, not from tinnitus causing vertigo 1, 3

Spontaneous Intracranial Hypotension

• Can present with Ménière-like symptoms including hearing loss, tinnitus, and vertigo 4
• Venous engorgement in the internal acoustic canal may be related to all these symptoms occurring simultaneously 4

Diagnostic Considerations

When to Consider Imaging

• The American Academy of Otolaryngology and Head and Neck Surgery Foundation recommends:
  • Targeted history and clinical examination as initial evaluation
  • Comprehensive audiological examination for patients with hearing problems or unilateral persistent tinnitus 1
• Imaging is not routinely indicated for all cases of tinnitus but may be necessary when:
  • Tinnitus is pulsatile
  • Tinnitus is unilateral with asymmetric hearing loss
  • Tinnitus is accompanied by focal neurological abnormalities 1

Differential Diagnosis of Vertigo

• Benign paroxysmal positional vertigo: Short-duration vertigo (seconds) without associated hearing loss or tinnitus 1
• Vestibular neuritis: Acute prolonged vertigo without hearing loss or tinnitus 1
• Vestibular migraine: Attacks of variable duration, less likely to have hearing loss 1
• Vestibular schwannoma: More likely to present with chronic imbalance than episodic vertigo 1

Clinical Implications

When Evaluating Patients with These Symptoms

• The co-occurrence of tinnitus, hearing loss, and vertigo should prompt consideration of inner ear disorders, particularly Ménière's disease 1, 2
• Low-frequency fluctuating hearing loss with tinnitus but without vertigo is not necessarily a prodromal sign of Ménière's disease - only a small percentage of such patients develop full Ménière's disease 5
• Patients with recurrent low-frequency hearing loss without vertigo may develop anxiety and psychogenic dizziness due to fear of developing Ménière's disease 5

Treatment Considerations

• Management should target the underlying condition rather than treating tinnitus as a cause of vertigo 1
• For Ménière's disease, treatment aims at relieving acute attacks of vertigo and preventing recurrent attacks 2
• For sudden sensorineural hearing loss with associated tinnitus and vertigo, prompt treatment with corticosteroids is often recommended 3

Common Pitfalls

• Mistaking the co-occurrence of symptoms for a causal relationship between tinnitus and vertigo 1
• Failing to recognize that positional changes can affect hearing symptoms in conditions like spontaneous intracranial hypotension 4
• Overlooking the psychological impact of these symptoms, which can lead to anxiety and secondary psychogenic dizziness 5