What are the causes of vertigo and tinnitus in older adults?

Causes of Vertigo and Tinnitus in Older Adults

Peripheral Vestibular Causes (Most Common)

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults, affecting 9% of elderly patients referred to geriatric clinics, with three-fourths having fallen within the preceding 3 months. 1, 2

BPPV Characteristics

• Brief episodes lasting less than 1 minute triggered by specific head position changes 3, 2
• No associated hearing loss or tinnitus 2
• Caused by calcium carbonate crystals ("otoconia") becoming dislodged from their normal location in the inner ear 3
• Most cases are idiopathic, though can be associated with trauma, migraine, diabetes, osteoporosis, or prolonged bed rest 3
• Diagnosed by Dix-Hallpike or supine roll testing, not by imaging 3

Ménière's Disease

• Episodes last 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness 1, 2, 4
• Accounts for approximately 10% of vertigo cases in general practice 2
• Characterized by endolymphatic hydrops (excessive endolymph accumulation) causing damage to ganglion cells 4
• Bilateral involvement occurs in 25-40% of cases 5
• Tinnitus pitch is significantly lower in Ménière's disease (mean 2250 Hz) compared to isolated tinnitus with hyperacusis (mean 4538 Hz) 6

Vestibular Neuritis

• Sudden, unilateral vestibular loss causing acute persistent vertigo 2, 7
• No hearing loss or tinnitus (distinguishes from Ménière's disease) 7

Other Peripheral Causes

• Superior canal dehiscence syndrome: pressure-related triggers (Valsalva maneuver) differentiate it from BPPV 2
• Perilymph fistula: can occur post-surgery or spontaneously with pressure-triggered episodes and fluctuating hearing loss 2
• Posttraumatic vertigo: presents with vertigo, disequilibrium, tinnitus, and headache; hyperacusis and vertigo are likely comorbidities after head trauma 2, 6

Central (Neurologic) Causes—Critical to Exclude

Brainstem and cerebellar strokes are life-threatening causes that can mimic peripheral vertigo, with 75-80% of stroke-related acute vestibular syndrome patients having no focal neurologic deficits. 2

Stroke/Vertebrobasilar Insufficiency

• 10% of cerebellar strokes present similar to peripheral vestibular processes 2
• Physical examination may reveal dysarthria, dysmetria, dysphagia, sensory or motor loss, or Horner's syndrome 2
• Particularly important to consider in older adults with vascular risk factors 2

Vestibular Migraine

• Very common with lifetime prevalence of 3.2%, accounting for up to 14% of vertigo cases 2
• Episodes last 5 minutes to 72 hours with migraine features (photophobia, phonophobia, visual aura) 1, 2
• Requires ≥5 episodes of vestibular symptoms with current or history of migraine 2

Red Flags for Central Causes

• Downbeating nystagmus on Dix-Hallpike without torsional component 2
• Direction-changing nystagmus without head position changes (periodic alternating nystagmus) 2
• Direction-switching nystagmus (beats right with right gaze, left with left gaze) 2
• Baseline nystagmus without provocative maneuvers 2
• Failure to respond to conservative management (canalith repositioning or vestibular rehabilitation) 2

Other Central Causes

• Multiple sclerosis and demyelinating diseases 2
• Intracranial tumors 2

Tinnitus-Specific Causes

Pulsatile Tinnitus

• Vascular masses, aberrant arterial or venous anatomy, vascular malformations, and intracranial hypertension are primary considerations 3
• Objective tinnitus (audible to examiner) attributed to turbulent flow from atherosclerotic carotid disease, jugular bulb abnormalities, or abnormal emissary veins 3
• Requires dedicated temporal bone CT as first-line imaging 3

Nonpulsatile Tinnitus

• Most common variant, almost always subjective (heard only by patient) 3
• Associated with presbycusis, medication toxicities, environmental noise exposure 3
• Occurs in approximately 10% of US adult population 3
• May be caused by otologic, neurologic, and metabolic disorders, most often with sensorineural hearing loss 3
• Imaging is NOT recommended for subjective, nonpulsatile tinnitus that does not localize to one ear and is not associated with focal neurologic abnormality or asymmetric hearing loss 3

Tinnitus with Vestibular Lesions

• Tinnitus sufferers with low tinnitus pitch should undergo vestibular system evaluation, as mean tinnitus pitch is lower in patients with peripheral labyrinthine lesions 6
• Mean canal paresis is significantly higher in patients with Ménière's disease (23.7%) and vertigo with hyperacusis (25.9%) compared to hyperacusis alone (6.3%) 6

Other Causes in Older Adults

Non-Vestibular Medical Causes

• Postural hypotension: triggered episodes, particularly in older adults on multiple medications 2
• Medication side effects: common in polypharmacy situations 2
• Nearly half of emergency department patients with dizziness have medical (non-vestibular, non-neurologic) diagnoses 2

Psychiatric and Other

• Anxiety or panic disorder: can present as chronic vestibular syndrome 2
• Cervicogenic vertigo: variable presentation 2

Critical Clinical Pitfalls

Elderly menopausal patients may describe "vague dizziness" rather than true spinning vertigo, even with significant inner ear pathology like Ménière's disease, making careful questioning essential to avoid missed diagnoses. 1

• Specific questions about spinning sensation, duration, and associated symptoms (hearing loss, tinnitus) are essential to distinguish between conditions 1
• Timing (acute vs episodic vs chronic) and triggers are more diagnostically useful than the specific descriptor patients use 2
• As many as 50% of patients with tinnitus do not exhibit associated hearing loss; in these patients, the cause is rarely identified 8