Audiological Testing for Vertigo and Tinnitus
A comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing should be obtained promptly (within 4 weeks) for any patient presenting with vertigo and tinnitus. 1
Essential Audiological Tests
Core Audiometric Battery
Pure tone audiometry is mandatory to measure hearing thresholds from low to high frequencies, as fluctuating or fixed sensorineural hearing loss is a key diagnostic feature distinguishing conditions like Ménière's disease from other causes of vertigo 1, 2
Speech audiometry should be performed as part of the comprehensive audiologic examination to assess speech recognition and discrimination abilities 2, 3
Acoustic reflex testing completes the standard audiologic battery and helps characterize the nature of any hearing loss (conductive, sensorineural, or mixed) 2
Tympanometry/immittance testing should be included to evaluate middle ear function and rule out conductive pathology 1
Additional Specialized Testing Based on Clinical Findings
Electrocochleography (ECoG) may be considered when Ménière's disease is suspected, as it measures electrical responses of the cochlea and auditory nerve, though it may cause ear discomfort 1
Video- or electronystagmography (VNG/ENG) evaluates vestibular function by recording eye movements during caloric stimulation, though this carries risks of vertigo, nausea, and takes approximately 1 hour to complete 1
Loudness discomfort level testing should be performed if the patient reports sound tolerance problems (hyperacusis) alongside their tinnitus 2
Critical Diagnostic Considerations
Timing and Urgency
The American Academy of Otolaryngology-Head and Neck Surgery emphasizes obtaining audiologic testing promptly (preferably within 4 weeks) rather than waiting, as this helps prioritize otolaryngologic evaluation, identify unsuspected hearing loss, and initiate workup for serious diseases causing unilateral symptoms 1
Key Audiometric Patterns to Identify
Low-to-mid frequency sensorineural hearing loss that fluctuates is characteristic of definite Ménière's disease (requires documentation on at least one occasion before, during, or after vertigo episodes) 1
Asymmetric or unilateral hearing loss mandates imaging studies (MRI with contrast) to rule out vestibular schwannoma or other retrocochlear pathology 1, 4
Bilateral hearing loss may suggest autoimmune causes, otosyphilis, or vestibular migraine rather than classic Ménière's disease 1
Imaging Considerations
Do not obtain imaging studies unless one or more red flags are present: unilateral/asymmetric hearing loss, pulsatile tinnitus, focal neurological abnormalities, or tinnitus localizing to one ear 1, 2
MRI with contrast is indicated when asymmetric hearing loss or unilateral tinnitus is documented on audiometry to exclude vestibular schwannoma 1, 4
CT temporal bone may be appropriate if bony abnormalities, middle ear pathology, or vascular anomalies are suspected based on examination or pulsatile tinnitus 5, 4
Common Pitfalls to Avoid
Do not delay audiologic testing waiting for symptoms to persist 6 months—the guideline allows immediate testing for unilateral symptoms or when clinically appropriate 1
Do not assume normal hearing based on patient report alone, as hearing loss may be unsuspected or fluctuating, and patients may not perceive mild losses that still benefit from intervention 1, 2
Do not order routine imaging for bilateral, non-pulsatile tinnitus with vertigo in the absence of asymmetric hearing loss or neurological findings, as this represents low-yield testing 1
Do not overlook the vestibular examination, as distinguishing true vertigo (rotational sensation) from vague dizziness is essential for accurate diagnosis—BPPV causes brief positional vertigo without hearing loss, while Ménière's disease requires episodes lasting 20 minutes to 12 hours with concurrent auditory symptoms 1