What is the management approach for a patient presenting with new onset vertigo and unilateral hearing loss?

Management of New Onset Vertigo with Unilateral Hearing Loss

This presentation demands urgent evaluation for sudden sensorineural hearing loss (SSNHL) with immediate initiation of systemic corticosteroids while simultaneously obtaining MRI brain with internal auditory canal sequences to exclude vestibular schwannoma and posterior circulation stroke. 1, 2

Immediate Clinical Assessment

Perform tuning fork testing immediately to confirm sensorineural rather than conductive hearing loss: 3

• Weber test: Place vibrating 256 or 512 Hz tuning fork at midline—if sound lateralizes to the unaffected ear, this confirms sensorineural loss on the affected side 3
• Rinne test: Air conduction should be better than bone conduction; if bone conduction is better, suspect conductive loss 3
• Examine for cerumen impaction, tympanic membrane perforation, or middle ear fluid to exclude conductive causes 3

Complete neurologic examination is mandatory to identify red flags requiring immediate stroke workup: 4, 2, 3

• Focal weakness, dysarthria, hemiataxia, or encephalopathy 4, 3
• Diplopia or visual disturbances 3
• Downbeating or gaze-evoked nystagmus (indicates central pathology) 4, 2
• Severe imbalance with inability to walk 2
• Facial weakness or other cranial nerve palsies 3

Critical Differential Diagnosis

The combination of unilateral hearing loss and vertigo has three primary considerations:

Vestibular schwannoma is the most common cerebellopontine angle tumor (>80% of cases) and presents with unilateral sensorineural hearing loss in 94% and unsteadiness in 17-75% of cases. 1 This is why MRI is mandatory.

Posterior circulation stroke (particularly AICA territory) can present with acute audiovestibular loss and must be excluded urgently. 4, 2, 5 Stroke rarely presents as isolated SSNHL but peripheral vestibular involvement is usually present with lateral pontomedullary infarction. 4

Idiopathic SSNHL with concurrent vestibular involvement carries significantly worse prognosis for hearing recovery compared to hearing loss alone. 2, 6

Urgent Diagnostic Workup

Audiometry must be obtained within 14 days to confirm SSNHL (≥30 dB decrease across 3 consecutive frequencies). 3

MRI brain with internal auditory canal sequences using gadolinium contrast is mandatory rather than CT: 1, 2

• Excludes vestibular schwannoma (the classic presentation of unilateral hearing loss with unsteadiness) 1
• Rules out AICA territory stroke or vestibulocochlear nerve infarction 2, 5
• Screens for demyelinating disease 2
• May demonstrate labyrinthine enhancement indicating labyrinthine disease 7

CT head should NOT be routinely ordered as it has low diagnostic yield (2.2% for acute dizziness) and cannot adequately evaluate retrocochlear pathology. 4

Immediate Treatment Protocol

Initiate oral corticosteroids immediately without waiting for MRI results, as treatment must begin within 2 weeks of symptom onset (ideally within 3 days for optimal outcomes): 2, 3

• Prednisone 1 mg/kg/day (maximum 60 mg daily) for 7-14 days with or without taper 2
• This is the only treatment with evidence-based support for SSNHL 2

Intratympanic dexamethasone can be offered: 1, 2

• As initial therapy if oral steroids are contraindicated 1, 2
• As salvage treatment if hearing recovery is incomplete after 2-4 weeks of initial corticosteroid therapy 1, 2

Short-term vestibular suppressants for acute symptom management only (first 2-3 days): 2, 8

• Meclizine 25 mg three times daily 2, 8
• Dimenhydrinate 50 mg every 6 hours 2
• Ondansetron 4-8 mg every 8 hours for nausea/vomiting 2

Red Flags Requiring Immediate Neuroimaging

Any of the following indicate non-idiopathic causes and demand urgent MRI: 4, 2, 3

• Bilateral hearing loss (rare in idiopathic SSNHL; consider meningitis, autoimmune disease, ototoxicity, syphilis, Lyme disease) 4, 3
• Prior fluctuating hearing loss (suggests Ménière's disease, autoimmune inner ear disease, Cogan's syndrome) 4, 3
• Severe vertigo lasting >24 hours with hearing loss 2
• Any focal neurologic symptoms or signs 4, 2, 3
• Recent head trauma or barotrauma 4, 3

Prognostic Considerations

The presence of vertigo at onset significantly worsens prognosis: 1, 2, 6

• Approximately one-third to two-thirds of SSNHL patients recover some hearing within 2 weeks 2
• Those with vertigo have substantially lower complete recovery rates 1, 2
• Vestibular involvement, particularly BPPV or unilateral hypofunction, predicts worse hearing outcomes especially in high frequencies 6

Common Pitfalls to Avoid

Do not delay corticosteroid initiation while awaiting imaging or audiometry—treatment efficacy decreases significantly after 2 weeks. 2, 3

Do not assume benign peripheral vertigo without excluding vestibular schwannoma via MRI, as this exact symptom constellation is the classic presentation. 1

Do not use vestibular suppressants beyond 2-3 days as they delay central compensation and prolong recovery. 2

Do not order CT instead of MRI—CT cannot adequately evaluate for retrocochlear pathology or small posterior fossa strokes. 4, 2