How does the differential diagnosis (DDX) change in a patient with vertigo and associated tinnitus?

How Tinnitus Changes the Differential Diagnosis in Vertigo

When tinnitus accompanies vertigo, the differential diagnosis shifts decisively toward otologic (inner ear) pathology rather than isolated vestibular disorders, with Ménière's disease becoming the primary consideration for episodic presentations. 1

Key Diagnostic Shift: Presence of Tinnitus Indicates Cochlear Involvement

The presence of tinnitus fundamentally narrows your differential because it signals involvement of the auditory system in addition to the vestibular system. This combination points to disorders affecting both the cochlear and vestibular portions of the inner ear. 1

Primary Diagnoses to Consider with Vertigo + Tinnitus:

Ménière's Disease (Most Common)

• Ménière's disease is the most common cause of chronic recurrent vertigo when associated with hearing loss or tinnitus. 1
• The classic triad includes: episodic vertigo attacks (lasting minutes to hours), fluctuating hearing loss, aural fullness, and tinnitus in the affected ear 1
• Episodes are spontaneous (not position-triggered) and fit the "spontaneous episodic vestibular syndrome" category 1
• Unlike BPPV, episodes last significantly longer (minutes to hours rather than seconds) 1

Labyrinthitis

• Characterized by sudden severe vertigo with profound hearing loss and prolonged vertigo lasting >24 hours 2
• Unlike vestibular neuritis (which causes vertigo without hearing symptoms), labyrinthitis affects both vestibular and cochlear portions, resulting in both vertigo and auditory symptoms including tinnitus 2
• The vertigo is typically accompanied by nausea and hearing loss, and is not episodic or fluctuating like Ménière's disease 2

Posttraumatic Vertigo

• Can present with vertigo, disequilibrium, tinnitus, and headache 1
• Symptoms arise from damage to peripheral or central structures 1
• History of head trauma is the key distinguishing feature 1

Perilymph Fistula

• Episodes of vertigo triggered by pressure changes (Valsalva, straining) rather than position 1
• May be accompanied by fluctuating hearing loss 1
• Can occur after middle ear or mastoid surgery, or spontaneously 1

Superior Canal Dehiscence (SCD)

• Vertigo induced by pressure changes, not position changes 1
• May present with conductive hearing loss and tinnitus 1
• Diagnosed via CT of temporal bones or vestibular evoked myogenic potential testing 1

What Becomes LESS Likely with Tinnitus:

BPPV (Benign Paroxysmal Positional Vertigo)

• BPPV is characterized by brief positional vertigo WITHOUT associated hearing loss or tinnitus 1
• The presence of tinnitus should prompt reconsideration of BPPV as the primary diagnosis 1

Vestibular Neuritis

• Affects only the vestibular portion of the inner ear, causing vertigo without hearing symptoms 2
• Tinnitus is not a feature of isolated vestibular neuritis 2

Vestibular Migraine

• While tinnitus can occasionally occur with vestibular migraine, it is not a defining feature and is considered an "emerging" rather than established criterion 3
• Primary symptoms include headache, photophobia, phonophobia, and visual aura 1

Critical Clinical Pitfalls:

Don't Miss Central Causes

• Rare vascular malformations like dural arteriovenous fistulas (DAVF) can present with pulsatile tinnitus and vertigo 4
• Pulsatile tinnitus that is heartbeat-synchronous is a red flag for vascular pathology 4, 5
• Vestibular paroxysmia from neurovascular cross-compression can present with paroxysmal vertigo and pulsatile tinnitus 5

Assess for Red Flags Requiring Urgent Evaluation

• Vertigo with speech difficulties, dysphagia, visual disturbances, or motor/sensory deficits requires urgent evaluation for central causes 2
• Severe imbalance disproportionate to vertigo or symptoms lasting >24 hours without improvement 2
• New-onset severe headache, particularly occipital headache with vertigo 2

Practical Diagnostic Algorithm:

1. Characterize the temporal pattern (acute vs episodic vs chronic) and triggers (position vs spontaneous vs pressure) 1

2. If episodic + tinnitus + hearing loss/aural fullness: Think Ménière's disease first 1

3. If acute prolonged (>24 hours) + tinnitus + profound hearing loss: Think labyrinthitis 2

4. If pressure-triggered + tinnitus: Consider perilymph fistula or superior canal dehiscence 1

5. If pulsatile tinnitus: Investigate for vascular causes (DAVF, neurovascular compression) 4, 5

6. If post-trauma + tinnitus: Consider posttraumatic vertigo with cochlear involvement 1