What is the initial management approach for a patient presenting with vertigo and tinnitus?

Initial Management of Vertigo with Tinnitus

Obtain a comprehensive audiologic examination within 4 weeks and perform a targeted history and physical examination to distinguish between peripheral vestibular disorders (Ménière's disease, BPPV) and central causes requiring urgent imaging. 1, 2, 3

Step 1: Immediate Clinical Assessment

Classify by Timing and Triggers

• Determine episode duration to narrow the differential diagnosis: episodes lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, or aural fullness suggest Ménière's disease, while brief episodes (<1 minute) triggered by head position changes indicate BPPV 1, 2

• Identify red flags for central causes including severe postural instability, cranial nerve deficits, age >50 with vascular risk factors, or focal neurological abnormalities—these mandate urgent MRI brain without and with IV contrast 2

• Distinguish true vertigo (rotational spinning sensation) from vague dizziness or lightheadedness, as only true vertigo indicates vestibular system dysfunction 1, 2

Perform Targeted Physical Examination

• Execute the Dix-Hallpike maneuver to test for posterior canal BPPV (85-95% of BPPV cases), and if negative with compatible history, perform the Supine Roll Test for lateral canal BPPV 2

• Conduct HINTS examination (Head Impulse, Nystagmus, Test of Skew) if acute vestibular syndrome is present, as it has 92.9% sensitivity and 83.4% specificity for central causes when performed by trained clinicians 2

• Avoid the common pitfall of assuming normal neurologic examination excludes stroke, as 75-80% of posterior circulation strokes causing vertigo may lack focal neurologic deficits initially 2

Step 2: Obtain Prompt Audiologic Testing

Essential Audiometry

• Order comprehensive audiologic examination within 4 weeks including pure tone audiometry, speech audiometry, acoustic reflex testing, and tympanometry for any patient with vertigo and tinnitus 1, 3

• Document hearing loss pattern as low-to-mid frequency sensorineural hearing loss (fluctuating or fixed) is mandatory for diagnosing Ménière's disease, while asymmetric or unilateral hearing loss mandates MRI with contrast to exclude vestibular schwannoma 1, 3

• Do not delay audiologic testing waiting for symptoms to persist 6 months—immediate testing is appropriate for unilateral symptoms or when clinically indicated 1, 3

Step 3: Determine Imaging Necessity

Selective Imaging Strategy

• Obtain urgent MRI brain without and with IV contrast only if one or more red flags are present: unilateral/asymmetric hearing loss, pulsatile tinnitus, focal neurological abnormalities, tinnitus localizing to one ear, positive Romberg test, or central warning signs on HINTS examination 1, 2, 3

• Avoid routine imaging in patients with typical peripheral vestibular symptoms (episodic vertigo with bilateral auditory symptoms, normal neurologic exam, negative Romberg) as CT head without contrast is inadequate and misses posterior fossa strokes 2

Step 4: Initiate Appropriate Treatment

For Probable Ménière's Disease (≥2 episodes of vertigo 20 minutes to 12 hours with fluctuating auditory symptoms)

• Educate patients about the natural history, symptom control measures, treatment options, and outcomes as a strong recommendation 1

• Offer a limited course of vestibular suppressants such as meclizine 25-100 mg daily in divided doses for acute symptom control, though patients should be warned about drowsiness and avoid driving or operating machinery 1, 4

• Do not prescribe positive pressure therapy as it is not recommended for Ménière's disease 1

For Persistent Bothersome Tinnitus

• Distinguish bothersome from non-bothersome tinnitus and identify whether symptoms are recent onset or persistent (≥6 months) to prioritize intervention 1

• Recommend hearing aid evaluation if hearing loss is documented on audiometry, as this addresses both the hearing loss and may reduce tinnitus perception 1

• Recommend cognitive-behavioral therapy for patients with persistent, bothersome tinnitus as a strong recommendation 1

• Do not routinely prescribe antidepressants, anticonvulsants, anxiolytics, intratympanic medications, Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating tinnitus 1

Critical Pitfalls to Avoid

• Do not misdiagnose central causes as BPPV, as CNS disorders masquerading as BPPV are found in 3% of treatment failures—if BPPV treatment fails, reconsider the diagnosis and obtain imaging 2

• Do not rely on patient's description of "spinning" alone—focus on timing, triggers, and associated symptoms which are more diagnostically useful 2

• Do not assume normal hearing based on patient report, as hearing loss may be unsuspected or fluctuating, and patients may not perceive mild losses 3

• Do not perform Dix-Hallpike when Romberg is positive, as this indicates central pathology requiring imaging first 2