What is the appropriate evaluation and management for an adult presenting with combined vertigo and tinnitus, likely due to a peripheral vestibular disorder such as Ménière’s disease?

Management of Vertigo with Tinnitus

For an adult presenting with combined vertigo and tinnitus, immediately perform a Dix-Hallpike maneuver to rule out BPPV, obtain comprehensive audiometry to document hearing patterns, and assess for Ménière's disease versus vestibular migraine based on whether hearing loss is fluctuating or stable. 1, 2

Initial Diagnostic Approach

Classify the presentation by timing and triggers rather than relying on the patient's subjective description of "dizziness" 2:

• Brief episodes (seconds to <1 minute) triggered by head position changes suggest BPPV 2
• Episodes lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness indicate Ménière's disease 1, 3
• Episodes lasting minutes to hours with stable or absent hearing loss, plus photophobia/phonophobia, suggest vestibular migraine 1, 4
• Continuous vertigo lasting days to weeks points to vestibular neuritis or posterior circulation stroke 2

Critical Physical Examination

Perform the Dix-Hallpike maneuver bilaterally to diagnose or exclude BPPV 2, 5:

• Positive findings: torsional upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, resolves within 60 seconds 2, 5
• If negative, perform supine roll test for lateral canal BPPV 2

Assess nystagmus characteristics to differentiate peripheral from central causes 5:

• Peripheral pattern: horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable 5
• Central pattern (RED FLAG): pure vertical without torsional component, direction-changing, not suppressed by fixation, non-fatigable 5

Perform Weber test and complete neurologic examination 4:

• Unilateral tinnitus with Weber lateralization mandates urgent neuroimaging 4
• Any focal neurologic deficits (dysarthria, limb weakness, diplopia, Horner's syndrome) require immediate MRI 2, 5

Essential Diagnostic Testing

Obtain comprehensive audiometry immediately to document 1, 2:

• Fluctuating low-to-mid frequency sensorineural hearing loss = Ménière's disease 1, 3, 6
• Stable or absent hearing loss = vestibular migraine 1, 4
• Asymmetric hearing loss = requires urgent MRI to exclude vestibular schwannoma or stroke 2, 4

Order MRI brain without contrast urgently if any red flags present 2, 4:

• Age >50 with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke) 2
• Unilateral or pulsatile tinnitus 2, 4
• Sudden unilateral hearing loss 2
• New severe headache with vertigo 2, 4
• Severe postural instability with falling 2, 5
• Pure vertical or direction-changing nystagmus 2, 5
• Any focal neurologic deficits 2, 5
• Failure to respond to appropriate peripheral vertigo treatments 2, 5

Do NOT order imaging if 2:

• Positive Dix-Hallpike test consistent with BPPV, no red flags, normal neurologic exam 2
• CT has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts 2

Management by Diagnosis

If BPPV Confirmed (Positive Dix-Hallpike)

Perform Epley canalith repositioning maneuver immediately 2:

• 80% success rate after 1-3 treatments 2
• 90-98% success with repeat maneuvers if initial treatment fails 2
• Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) as they prevent central compensation 2, 5
• Reassess within 1 month to document resolution 2

If Ménière's Disease Diagnosed (Fluctuating Hearing Loss + Tinnitus + Aural Fullness)

First-line management 1, 7, 3, 6:

• Dietary sodium restriction (<1500-2000 mg/day) 3, 6
• Diuretics for persistent symptoms (though evidence is limited) 7, 3
• Betahistine (commonly used in Europe; high-dose long-term prophylaxis is effective) 7, 8, 3
• Oral corticosteroids for acute attacks 7, 3
• Avoid caffeine, alcohol, and nicotine 6

For refractory cases 3:

• Intratympanic gentamicin when medical therapy fails 3
• Endolymphatic sac decompression surgery for non-responders 7, 3

Acute vertigo attack management 7:

• Vestibular suppressants (antiemetics, benzodiazepines) for acute symptom relief only 7
• Limit use to brief periods during severe distress 7

If Vestibular Migraine Suspected (Stable Hearing + Migraine Features)

Assess for diagnostic criteria 1, 4:

• At least 5 episodes of vestibular symptoms lasting 5 minutes to 72 hours 1
• Current or prior migraine history 1
• Migraine features (headache, photophobia, phonophobia, visual aura) during at least 50% of vertigo episodes 1, 4
• Motion intolerance and light sensitivity as triggers 1

Management 1, 4:

• Migraine prophylaxis (specific agents not detailed in guidelines but standard migraine prophylaxis applies) 1, 4
• Lifestyle modifications and trigger avoidance 1, 4
• Address hormonal triggers if applicable 4

If Vestibular Neuritis (Acute Persistent Vertigo Without Hearing Loss)

Management 8:

• Corticosteroids may improve recovery (though more evidence needed) 8
• Vestibular suppressants limited to acute phase only 8
• Early vestibular rehabilitation therapy to promote central compensation 8

Common Diagnostic Pitfalls to Avoid

Do NOT assume normal neurologic exam excludes stroke 2, 4:

• 75-80% of posterior circulation stroke patients with acute vestibular syndrome have no focal neurologic deficits 2
• 11-25% of high vascular risk patients with normal exam have posterior circulation stroke 2

Do NOT rely on patient's description of "spinning" versus "lightheadedness" 2, 4:

• Focus on timing, triggers, and associated symptoms instead 2, 4

Do NOT overlook vestibular migraine 1, 4:

• Accounts for 14% of all vertigo cases but is markedly under-recognized 1, 4
• 35% of Ménière's patients also meet criteria for vestibular migraine 1

Do NOT order CT instead of MRI when stroke suspected 2:

• CT sensitivity for posterior circulation infarcts is only 10-20% 2
• MRI has 4% diagnostic yield versus <1% for CT 2, 4

Do NOT continue betahistine if vestibular migraine confirmed 4:

• Betahistine is ineffective for migraine-related vertigo 4

Medication Review

Systematically review all medications as medication side effects are the most common reversible cause of chronic vestibular symptoms 2:

• Antihypertensives 2
• Sedatives 2
• Anticonvulsants (Mysoline, carbamazepine, phenytoin) 2, 5
• Psychotropic agents 2
• Ototoxic medications (aminoglycosides) 5

Follow-Up Strategy

Reassess within 1 month after initial treatment 2, 4:

• Document resolution or persistence of symptoms 2
• Repeat Dix-Hallpike if BPPV symptoms persist 2
• Counsel about recurrence risk (BPPV recurs in significant proportion) 2
• Address fall risk (dizziness increases fall risk 12-fold) 2, 4

Consider vestibular rehabilitation therapy 2, 4:

• For persistent dizziness after failed initial treatment 2, 4
• Significantly improves gait stability compared to medication alone 2
• Particularly beneficial for elderly patients or those with heightened fall risk 2

Screen for psychiatric comorbidities 2:

• Anxiety, panic disorder, and depression are common causes of chronic dizziness 2
• Panic disorder can generate both lightheadedness and true vestibular dysfunction 2