What are the differences between Meniere's disease, acoustic neuroma, and Benign Paroxysmal Positional Vertigo (BPPV)?

Distinguishing Meniere's Disease, Acoustic Neuroma, and BPPV

These three conditions differ fundamentally in their symptom duration, associated features, and natural history: BPPV causes brief (seconds to minutes) positional vertigo without hearing loss, Meniere's disease produces spontaneous vertigo attacks lasting 20 minutes to 12 hours with fluctuating hearing loss and aural fullness, and acoustic neuroma (vestibular schwannoma) typically presents with chronic imbalance and progressive asymmetric hearing loss rather than episodic vertigo.

Benign Paroxysmal Positional Vertigo (BPPV)

Key Distinguishing Features

• Duration: Vertigo episodes last seconds to less than one minute, triggered by specific head position changes 1
• Trigger: Symptoms are strictly positional and gravity-dependent (rolling over in bed, looking up, bending over) 1
• Hearing: No associated hearing loss, tinnitus, or aural fullness 1
• Natural history: Episodes tend to become less severe over time; the first episode is typically the worst 1

Diagnostic Approach

• Diagnosis is made by clinical history and positive Dix-Hallpike test without need for imaging or vestibular testing 1
• The posterior semicircular canal is most commonly involved 2, 3

Meniere's Disease

Key Distinguishing Features

• Duration: Vertigo attacks last 20 minutes to 12 hours (can extend to 24 hours in probable MD) 1
• Spontaneous onset: Attacks occur without positional triggers and are unprovoked 1
• Hearing: Fluctuating low- to mid-frequency sensorineural hearing loss documented on audiometry 1
• Associated symptoms: Fluctuating aural fullness and tinnitus in the affected ear 1
• Pattern: Symptoms fluctuate over time rather than remaining constant 1

Diagnostic Criteria

• Definite MD requires: ≥2 spontaneous vertigo attacks (20 minutes to 12 hours), documented low-to-mid frequency SNHL, fluctuating aural symptoms, and exclusion of other causes 1
• Probable MD allows for broader symptom duration (20 minutes to 24 hours) and includes dizziness in addition to vertigo 1

Acoustic Neuroma (Vestibular Schwannoma)

Key Distinguishing Features

• Presentation: Chronic imbalance rather than episodic profound vertigo 1
• Hearing: Progressive, asymmetric hearing loss that does not fluctuate 1
• Tinnitus: Present but associated with non-fluctuating hearing loss 1
• Natural history: Symptoms are permanent and progressive, not episodic 1

When to Suspect

• Patients presenting with additional neurologic symptoms beyond typical vestibular complaints 1
• Unilateral hearing loss with chronic imbalance rather than episodic vertigo 1
• Imaging is reserved for atypical presentations, not routine diagnosis of common vestibular disorders 1

Critical Differential Points

Symptom Duration Algorithm

• Seconds: Think BPPV 1
• 20 minutes to 12 hours: Think Meniere's disease 1
• Days with gradual improvement: Think vestibular neuritis or labyrinthitis 1
• Chronic/progressive: Think acoustic neuroma or other structural lesion 1

Hearing Loss Pattern

• No hearing loss: BPPV 1
• Fluctuating hearing loss: Meniere's disease 1
• Progressive, non-fluctuating hearing loss: Acoustic neuroma 1

Positional Component

• Strictly positional, brief: BPPV 1
• Not positional, spontaneous: Meniere's disease 1
• Neither positional nor episodic: Acoustic neuroma 1

Important Clinical Pitfalls

Coexistence of BPPV and Meniere's Disease

• BPPV occurs more commonly in patients with Meniere's disease than in the general population 1, 2
• When both conditions coexist, treatment success rates are lower and recurrence rates are higher for BPPV 4, 2, 5, 6
• BPPV associated with MD typically occurs in the same ear as the MD (71.9% of cases) 5
• These patients require more aggressive follow-up and repeated canalith repositioning procedures 4, 2, 6
• The mechanism may involve endolymphatic hydrops causing otoconia to dislodge 3

When Imaging Is Indicated

• Do not obtain routine imaging for typical BPPV 1
• Consider imaging only when additional neurologic symptoms are present (abnormal cranial nerve findings, visual disturbances, severe headache, gait disturbance) 1
• CNS disorders masquerading as BPPV are rare (3% of treatment failures) but include neurovascular compression, cerebellar disorders, and Arnold-Chiari malformation 1

Red Flags Requiring Further Evaluation

• Vertigo lasting >24 hours continuously: Consider stroke, vestibular neuritis, or labyrinthitis 1
• Neurologic symptoms (dysphonia, dysphagia, visual changes, drop attacks): Consider stroke/ischemia 1
• Severe otalgia with fever: Consider infectious causes 1
• Bilateral progressive hearing loss: Consider autoimmune causes 1