Upside-Down V Pattern on Audiometry
What This Pattern Indicates
An upside-down V pattern on audiometry (also called a "peak" or "cookie-bite" audiometric configuration) most commonly indicates early-stage Ménière's disease, though it can also be seen in other cochlear pathologies. This pattern shows preserved hearing at low and high frequencies with a dip in the mid-frequencies, creating an inverted V shape on the audiogram 1, 2.
Key Diagnostic Considerations
Ménière's disease is the classic association: In early stages, this disease characteristically produces low-to-mid frequency sensorineural hearing loss with fluctuation, which can manifest as a peak-type audiometric curve 1, 2.
The pattern evolves over time: In Ménière's disease, the peak pattern at onset (seen in 50% of cases initially) typically transforms into a flat audiometric curve over 5-10 years as high frequencies become progressively involved 2.
Fluctuation is a critical diagnostic feature: At disease onset, 68% of patients with the peak pattern demonstrate threshold fluctuation, which helps distinguish Ménière's disease from other causes 2.
Differential Diagnosis
While the upside-down V pattern strongly suggests Ménière's disease, you must exclude:
Vestibular schwannoma: Although all audiometric patterns can occur with acoustic neuromas, low-frequency patterns are less commonly associated with tumors 3. However, no audiometric pattern can reliably exclude retrocochlear pathology 3.
Other cochlear pathologies: Various cochlear disorders can produce mid-frequency hearing loss, though the peak pattern with fluctuation is most characteristic of Ménière's disease 2.
Essential Diagnostic Workup
Required Audiometric Testing
Obtain comprehensive audiometry including 1:
- Pure tone thresholds at 250-8000 Hz (including 3000 and 6000 Hz)
- Speech recognition threshold (SRT)
- Word recognition scores (WRS) in each ear
- Bone conduction testing to confirm sensorineural nature
Assess for Asymmetry
Calculate interaural asymmetry 1:
- Asymmetric hearing loss is defined as ≥15 dB difference in pure tone average (PTA at 500,1000,2000 Hz) between ears OR ≥15% difference in WRS between ears
- If asymmetry is present, imaging is mandatory to exclude vestibular schwannoma
Imaging Decisions
Order MRI with gadolinium of the internal auditory canals and posterior fossa if 1:
- Asymmetric sensorineural hearing loss is documented (≥15 dB PTA difference or ≥15% WRS difference)
- WRS is worse than expected for the PTA (suggests possible retrocochlear pathology)
- Progressive hearing loss occurs (>10 dB at 2+ frequencies or >10% drop in WRS)
MRI has 7-13.75% yield for pathogenic abnormalities in sudden/asymmetric hearing loss and is the highest-yield diagnostic test 1.
Management Approach
If Ménière's Disease is Suspected
Confirm the diagnosis requires 1:
- Documented low-to-mid frequency sensorineural hearing loss (≤2000 Hz)
- History of episodic vertigo (lasting 20 minutes to 12 hours)
- Tinnitus and aural fullness in the affected ear
- Audiometric confirmation of fluctuating hearing loss
Initial Treatment Strategy
Begin with conservative management: Dietary sodium restriction and lifestyle modifications are first-line 1.
Reserve vestibular suppressants for acute episodes only: Do not use medications like prochlorperazine routinely, as they interfere with central compensation and increase fall risk 4.
Establish baseline and monitor: Repeat audiometry at 6-month intervals initially to document fluctuation and progression 1, 2.
Follow-Up Protocol
Serial audiometry is essential 1, 2:
- Repeat testing at 6 months initially
- If hearing remains stable and no asymmetry develops, continue annual monitoring
- Trigger MRI evaluation if progressive loss >10 dB at 2+ frequencies or WRS drops >10% 1
Critical Pitfalls to Avoid
Do not assume the pattern is benign without imaging if asymmetry exists: No clinical features reliably distinguish tumor-related hearing loss from other causes 3.
Do not rely on tuning fork testing: Recent evidence does not support individual reliance on tuning forks for clinical screening 1.
Do not miss ear canal collapse during testing: This technical error can create spurious high-frequency hearing loss that mimics retrocochlear pathology 5. Ensure proper headphone placement and consider insert earphones if canal collapse is suspected.
Do not overlook the need for speech audiometry: WRS disproportionately poor for the PTA is a red flag for retrocochlear pathology requiring immediate imaging 1.
Recognize that hearing recovery does not exclude tumor: Patients with vestibular schwannoma can experience fluctuating or recovering hearing loss, mimicking Ménière's disease 3.