Vertigo and Hearing Loss

F.J. Wippold; P.A. Turski

Dizziness and Vertigo

Dizziness and vertigo (Table 1) are common clinical complaints. Vertigo is caused by a disturbed vestibular system and is subdivided into peripheral vertigo (due to failure of the end organs) or central vertigo (due to failure of the vestibular nerves or central connections to the brainstem and cerebellum).^1–5

View this table:

Rating of Techniques: Clinical condition—vertigo and hearing loss^*

Benign Positional Vertigo, Ménière Disease, and Peripheral Vestibular Disorders

Patients with benign positional vertigo rarely demonstrate imaging findings.^2,4 Ménière disease manifests as paroxysmal attacks of whirling vertigo due to failure of regulation of endolymph. CT or MR imaging, or both, may be used to evaluate the vestibular aqueduct, endolymphatic duct, and sac and to rule out associated infectious or neoplastic disease.^4–12

Vestibular neuritis and labyrinthitis may also cause vertigo. Labyrinthitis is usually viral in origin with few sequelae; however, bacterial labyrinthitis may progress to partial or complete occlusion of the lumen of the affected labyrinth, detectable on MR imaging as loss of the signal intensity of the fluid contents.^3,4 Progressive labyrinthitis obliterans may be diagnosed on high-resolution CT.¹³ Gadolinium enhancement of the labyrinthine structures or vestibular nerves may also occur and should not be mistaken for hemorrhage.^14–16

Superior semicircular canal dehiscence, another cause of vertigo, can be diagnosed by high-resolution coronal CT imaging of the temporal bones.^17–19 Diseases of the internal auditory canal and cerebellopontine angle, such as tumors, are readily evaluated with CT and MR imaging techniques.

Central Vestibular Disorders

Central lesions of the brainstem or cerebellum that result in central vertigo can be readily diagnosed by MR imaging. Posterior fossa vascular disorders may be evaluated with MR angiography or conventional angiography of the posterior fossa vasculature.^3,20,21 Cervical spondylosis, which causes vertigo by compressive osteophyte formation, may be evaluated with CT.^3,20,21

Sensorineural Hearing Loss

Sensorineural hearing loss (SNHL) results from the pathologic changes of inner ear structures such as the cochlea or the auditory nerve¹ and is best evaluated with gadolinium-enhanced MR imaging.^22–25

Patients with fluctuating SNHL may have congenitally enlarged vestibular aqueducts (apertures greater than 4 mm) detected by either CT or MR imaging.^26–29

The imaging findings must be correlated with audiometry.^27,28

Initial evaluation of symmetric or unilateral SNHL requires determination of whether the site of the lesion is cochlear³⁰ or retrocochlear.³¹ Following preliminary audiometric or auditory brain response testing, patients with retrocochlear localization should have a complete MR imaging study of the head to include the internal auditory canal, temporal bones, central nuclei in the brainstem, and the auditory pathways extending upward into the cerebral hemispheres.^{22,23,32–34} Gadolinium contrast enhancement may be used. CT is sometimes diagnostic in lesions 1.5 cm or greater in diameter when dedicated techniques are used, but it does not readily detect small brainstem lesions such as infarctions or demyelination.^33–40

In general, most cochlear disorders such as otosclerosis are evaluated by high-resolution CT imaging. Similarly, preoperative assessment for cochlear implants is usually best accomplished by using thin-section CT with reformatted multiplanar images. In patients with congenital etiologies for hearing loss, recent reports suggest that high-resolution MR imaging is more useful for surgical planning.^41,42

Conductive Hearing Loss

Conductive hearing loss results from pathologic changes of either the external or middle ear structures and is best evaluated with CT. Indications include suspected complications of acute and chronic otomastoiditis, such as cholesteatoma, and the assessment of congenital or vascular anomalies. Fistulization through the tegmen tympani of the temporal bone is usually detected by CT, though the actual involvement of the meninges and veins is better assessed by MR imaging. MR imaging is also indicated when complicated inflammatory lesions are suspected to extend into the inner ear or toward the sigmoid sinus or jugular vein. Neoplasms arising from or extending into the middle ear require the use of both techniques, as their combined data provide essential information. Vascular imaging should be performed when there is suspicion of a paraganglioma extending into the middle ear.⁴³

Trauma

CT is used extensively to delineate fractures, ossicular dislocations, fistulous communications, and facial nerve injury and to evaluate post-traumatic hearing loss.⁴⁴

Congenital and Childhood Hearing Loss

The ideal imaging method for children with unilateral or asymmetric sensory neural hearing loss is still controversial. Most reports suggest that children with unilateral or asymmetric sensory neural hearing loss should have a high-resolution temporal bone CT scan and that brain and temporal bone MR imaging be obtained in select cases. In general high-resolution CT has been shown to be efficacious for the preoperative work-up for congenital hearing loss due to aural dysplasia, congenital ossicular anomalies, large vestibular aqueduct syndrome, congenital absence of cochlear nerve, and labyrinthitis ossificans.^45–54

Review Information

This guideline was originally developed in 1996. The last review and update was completed in 2008.

Appendix

Expert Panel on Neurologic Imaging: Franz J. Wippold II, MD, Co-Author and Panel Chair; Patrick A. Turski, MD, Co-Author; Rebecca S. Cornelius, MD; James A. Brunberg, MD; Patricia C. Davis, MD; Robert L. De La Paz, MD; Pr. Didier Dormont; Linda Gray, MD; John E. Jordan, MD; Suresh Kumar Mukherji, MD; David J. Seidenwurm, MD; Robert D. Zimmerman, MD; Brian Nussenbaum, MD, American Academy of Otolaryngology; Michael A. Sloan, MD, MS, American Academy of Neurology.

Footnotes

This article is a summary of the complete version of this topic, which is available on the ACR Website at www.acr.org/ac. Practitioners are encouraged to refer to the complete version.
Reprinted with permission of the American College of Radiology.

References

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. Radiology of vertigo. In: Phelps PD, Lloyd GA, eds. Radiology of the Ear. St. Louis: Blackwell Scientific Publications; 1983: 137– 41
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2. Graham SS
. Evaluation of the dizzy patient. Ear Hear 1986; 7: 133– 37
PubMed
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. Vertigo: clinical assessment and diagnosis. Br J Hosp Med (Lond) 2008; 69: 330– 34
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. 3DFT-magnetic resonance imaging of the inner ear in Meniere's disease. Acta Otolaryngol 1994; 114: 595– 600
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. Tomography of the vestibular aqueduct in ear disease. Arch Otolaryngol 1979; 105: 91– 98
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1. Mateijsen DJ,
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3. Minor LB,
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PubMed
↵
1. Curtin HD
. Superior semicircular canal dehiscence syndrome and multi-detector row CT. Radiology 2003; 226: 312– 14
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1. Mong A,
2. Loevner LA,
3. Solomon D,
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. Sound- and pressure-induced vertigo associated with dehiscence of the roof of the superior semicircular canal. AJNR Am J Neuroradiol 1999; 20: 1973– 75
Abstract/FREE Full Text
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. Significance of auditory brain stem response and gadolinium-enhanced magnetic resonance imaging for idiopathic sudden sensorineural hearing loss. Otolaryngol Head Neck Surg 1995; 113: 271– 75
Abstract/FREE Full Text
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1. Hendrix RA,
2. DeDio RM,
3. Sclafani AP
. The use of diagnostic testing in asymmetric sensorineural hearing loss. Otolaryngol Head Neck Surg 1990; 103: 593– 98
PubMed
↵
1. Kano K,
2. Tono T,
3. Ushisako Y,
4. et al
. Magnetic resonance imaging in patients with sudden deafness. Acta Otolaryngol Suppl 1994; 514: 32– 36
PubMed
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1. Weber PC,
2. Zbar RI,
3. Gantz BJ
. Appropriateness of magnetic resonance imaging in sudden sensorineural hearing loss. Otolaryngol Head Neck Surg 1997; 116: 153– 56
Abstract/FREE Full Text
↵
1. Davidson HC,
2. Harnsberger HR,
3. Lemmerling MM,
4. et al
. MR evaluation of vestibulocochlear anomalies associated with large endolymphatic duct and sac. AJNR Am J Neuroradiol 1999; 20: 1435– 41
Abstract/FREE Full Text
↵
1. Mafee MF,
2. Charletta D,
3. Kumar A,
4. et al
. Large vestibular aqueduct and congenital sensorineural hearing loss. AJNR Am J Neuroradiol 1992; 13: 805– 19
FREE Full Text
↵
1. Okumura T,
2. Takahashi H,
3. Honjo I,
4. et al
. Sensorineural hearing loss in patients with large vestibular aqueduct. Laryngoscope 1995; 105: 289– 93, discussion 93–44
CrossRef PubMed
↵
1. Valvassori GE,
2. Clemis JD
. The large vestibular aqueduct syndrome. Laryngoscope 1978; 88: 723– 28
PubMed
↵
1. Hegarty JL,
2. Patel S,
3. Fischbein N,
4. et al
. The value of enhanced magnetic resonance imaging in the evaluation of endocochlear disease. Laryngoscope 2002; 112: 8– 17
CrossRef PubMed
↵
1. Davidson HC
. Imaging evaluation of sensorineural hearing loss. Semin Ultrasound CT MR 2001; 22: 229– 49
CrossRef PubMed
↵
1. Cueva RA
. Auditory brainstem response versus magnetic resonance imaging for the evaluation of asymmetric sensorineural hearing loss. Laryngoscope 2004; 114: 1686– 92
CrossRef PubMed
↵
1. Selesnick SH,
2. Jackler RK,
3. Pitts LW
. The changing clinical presentation of acoustic tumors in the MRI era. Laryngoscope 1993; 103: 431– 36
PubMed
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1. Gebarski SS,
2. Tucci DL,
3. Telian SA
. The cochlear nuclear complex: MR location and abnormalities. AJNR Am J Neuroradiol 1993; 14: 1311– 18
Abstract/FREE Full Text
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2. Swallow C,
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[1] ↵
Bagai A,
Thavendiranathan P,
Detsky AS
. Does this patient have hearing impairment? JAMA 2006; 295: 416– 28
CrossRef PubMed

[2] Bagai A,

[3] Thavendiranathan P,

[4] Detsky AS

[5] ↵
McGee SR
. Dizzy patients: diagnosis and treatment. West J Med 1995; 162: 37– 42
PubMed

[6] McGee SR

[7] ↵
Phelps PD,
Lloyd GA
Phelps PD,
Lloyd GA
. Radiology of vertigo. In: Phelps PD, Lloyd GA, eds. Radiology of the Ear. St. Louis: Blackwell Scientific Publications; 1983: 137– 41

[8] Phelps PD,

[9] Lloyd GA

[10] Phelps PD,

[11] Lloyd GA

[12] ↵
Dickins JR,
Graham SS
. Evaluation of the dizzy patient. Ear Hear 1986; 7: 133– 37
PubMed

[13] Dickins JR,

[14] Graham SS

[15] ↵
Macleod D,
McAuley D
. Vertigo: clinical assessment and diagnosis. Br J Hosp Med (Lond) 2008; 69: 330– 34
PubMed

[16] Macleod D,

[17] McAuley D

[18] ↵
Albers FW,
Van Weissenbruch R,
Casselman JW
. 3DFT-magnetic resonance imaging of the inner ear in Meniere's disease. Acta Otolaryngol 1994; 114: 595– 600
CrossRef PubMed

[19] Albers FW,

[20] Van Weissenbruch R,

[21] Casselman JW

[22] ↵
Kraus EM,
Dubois PJ
. Tomography of the vestibular aqueduct in ear disease. Arch Otolaryngol 1979; 105: 91– 98
CrossRef PubMed

[23] Kraus EM,

[24] Dubois PJ

[25] ↵
Lorenzi MC,
Bento RF,
Daniel MM,
et al
. Magnetic resonance imaging of the temporal bone in patients with Meniere's disease. Acta Otolaryngol 2000; 120: 615– 59
CrossRef PubMed

[26] Lorenzi MC,

[27] Bento RF,

[28] Daniel MM,

[29] et al

[30] ↵
Mateijsen DJ,
Van Hengel PW,
Krikke AP,
et al
. Three-dimensional Fourier transformation constructive interference in steady state magnetic resonance imaging of the inner ear in patients with unilateral and bilateral Meniere's disease. Otol Neurotol 2002; 23: 208– 13
CrossRef PubMed

[31] Mateijsen DJ,

[32] Van Hengel PW,

[33] Krikke AP,

[34] et al

[35] ↵
Nakashima T,
Naganawa S,
Sugiura M,
et al
. Visualization of endolymphatic hydrops in patients with Meniere's disease. Laryngoscope 2007; 117: 415– 20
CrossRef PubMed

[36] Nakashima T,

[37] Naganawa S,

[38] Sugiura M,

[39] et al

[40] ↵
Sajjadi H,
Paparella MM
. Meniere's disease. Lancet 2008; 372: 406– 14
CrossRef PubMed

[41] Sajjadi H,

[42] Paparella MM

[43] ↵
Xenellis J,
Vlahos L,
Papadopoulos A,
et al
. Role of the new imaging modalities in the investigation of Meniere's disease. Otolaryngol Head Neck Surg 2000; 123: 114– 19
CrossRef PubMed

[44] Xenellis J,

[45] Vlahos L,

[46] Papadopoulos A,

[47] et al

[48] ↵
Hasso AN,
Ledington JA
. Imaging modalities for the study of the temporal bone. Otolaryngol Clin North Am 1988; 21: 219– 44
PubMed

[49] Hasso AN,

[50] Ledington JA

[51] ↵
Mark AS,
Seltzer S,
Nelson-Drake J,
et al
. Labyrinthine enhancement on gadolinium-enhanced magnetic resonance imaging in sudden deafness and vertigo: correlation with audiologic and electronystagmographic studies. Ann Otol Rhinol Laryngol 1992; 101: 459– 64
Abstract/FREE Full Text

[52] Mark AS,

[53] Seltzer S,

[54] Nelson-Drake J,

[55] et al

[56] ↵
Seltzer S,
Mark AS
. Contrast enhancement of the labyrinth on MR scans in patients with sudden hearing loss and vertigo: evidence of labyrinthine disease. AJNR Am J Neuroradiol 1991; 12: 13– 16
Abstract/FREE Full Text

[57] Seltzer S,

[58] Mark AS

[59] ↵
Weissman JL,
Curtin HD,
Hirsch BE,
et al
. High signal from the otic labyrinth on unenhanced magnetic resonance imaging. AJNR Am J Neuroradiol 1992; 13: 1183– 87
Abstract/FREE Full Text

[60] Weissman JL,

[61] Curtin HD,

[62] Hirsch BE,

[63] et al

[64] ↵
Belden CJ,
Weg N,
Minor LB,
et al
. CT evaluation of bone dehiscence of the superior semicircular canal as a cause of sound- and/or pressure-induced vertigo. Radiology 2003; 226: 337– 43
PubMed

[65] Belden CJ,

[66] Weg N,

[67] Minor LB,

[68] et al

[69] ↵
Curtin HD
. Superior semicircular canal dehiscence syndrome and multi-detector row CT. Radiology 2003; 226: 312– 14
CrossRef PubMed

[70] Curtin HD

[71] ↵
Mong A,
Loevner LA,
Solomon D,
et al
. Sound- and pressure-induced vertigo associated with dehiscence of the roof of the superior semicircular canal. AJNR Am J Neuroradiol 1999; 20: 1973– 75
Abstract/FREE Full Text

[72] Mong A,

[73] Loevner LA,

[74] Solomon D,

[75] et al

[76] ↵
Kikuchi S,
Kaga K,
Yamasoba T,
et al
. Slow blood flow of the vertebrobasilar system in patients with dizziness and vertigo. Acta Otolaryngol 1993; 113: 257– 60
CrossRef PubMed

[77] Kikuchi S,

[78] Kaga K,

[79] Yamasoba T,

[80] et al

[81] ↵
Norrving B,
Magnusson M,
Holtas S
. Isolated acute vertigo in the elderly: vestibular or vascular disease? Acta Neurol Scand 1995; 91: 43– 48
CrossRef PubMed

[82] Norrving B,

[83] Magnusson M,

[84] Holtas S

[85] ↵
Busaba NY,
Rauch SD
. Significance of auditory brain stem response and gadolinium-enhanced magnetic resonance imaging for idiopathic sudden sensorineural hearing loss. Otolaryngol Head Neck Surg 1995; 113: 271– 75
Abstract/FREE Full Text

[86] Busaba NY,

[87] Rauch SD

[88] ↵
Hendrix RA,
DeDio RM,
Sclafani AP
. The use of diagnostic testing in asymmetric sensorineural hearing loss. Otolaryngol Head Neck Surg 1990; 103: 593– 98
PubMed

[89] Hendrix RA,

[90] DeDio RM,

[91] Sclafani AP

[92] ↵
Kano K,
Tono T,
Ushisako Y,
et al
. Magnetic resonance imaging in patients with sudden deafness. Acta Otolaryngol Suppl 1994; 514: 32– 36
PubMed

[93] Kano K,

[94] Tono T,

[95] Ushisako Y,

[96] et al

[97] ↵
Weber PC,
Zbar RI,
Gantz BJ
. Appropriateness of magnetic resonance imaging in sudden sensorineural hearing loss. Otolaryngol Head Neck Surg 1997; 116: 153– 56
Abstract/FREE Full Text

[98] Weber PC,

[99] Zbar RI,

[100] Gantz BJ

[101] ↵
Davidson HC,
Harnsberger HR,
Lemmerling MM,
et al
. MR evaluation of vestibulocochlear anomalies associated with large endolymphatic duct and sac. AJNR Am J Neuroradiol 1999; 20: 1435– 41
Abstract/FREE Full Text

[102] Davidson HC,

[103] Harnsberger HR,

[104] Lemmerling MM,

[105] et al

[106] ↵
Mafee MF,
Charletta D,
Kumar A,
et al
. Large vestibular aqueduct and congenital sensorineural hearing loss. AJNR Am J Neuroradiol 1992; 13: 805– 19
FREE Full Text

[107] Mafee MF,

[108] Charletta D,

[109] Kumar A,

[110] et al

[111] ↵
Okumura T,
Takahashi H,
Honjo I,
et al
. Sensorineural hearing loss in patients with large vestibular aqueduct. Laryngoscope 1995; 105: 289– 93, discussion 93–44
CrossRef PubMed

[112] Okumura T,

[113] Takahashi H,

[114] Honjo I,

[115] et al

[116] ↵
Valvassori GE,
Clemis JD
. The large vestibular aqueduct syndrome. Laryngoscope 1978; 88: 723– 28
PubMed

[117] Valvassori GE,

[118] Clemis JD

[119] ↵
Hegarty JL,
Patel S,
Fischbein N,
et al
. The value of enhanced magnetic resonance imaging in the evaluation of endocochlear disease. Laryngoscope 2002; 112: 8– 17
CrossRef PubMed

[120] Hegarty JL,

[121] Patel S,

[122] Fischbein N,

[123] et al

[124] ↵
Davidson HC
. Imaging evaluation of sensorineural hearing loss. Semin Ultrasound CT MR 2001; 22: 229– 49
CrossRef PubMed

[125] Davidson HC

[126] ↵
Cueva RA
. Auditory brainstem response versus magnetic resonance imaging for the evaluation of asymmetric sensorineural hearing loss. Laryngoscope 2004; 114: 1686– 92
CrossRef PubMed

[127] Cueva RA

[128] ↵
Selesnick SH,
Jackler RK,
Pitts LW
. The changing clinical presentation of acoustic tumors in the MRI era. Laryngoscope 1993; 103: 431– 36
PubMed

[129] Selesnick SH,

[130] Jackler RK,

[131] Pitts LW

[132] ↵
Gebarski SS,
Tucci DL,
Telian SA
. The cochlear nuclear complex: MR location and abnormalities. AJNR Am J Neuroradiol 1993; 14: 1311– 18
Abstract/FREE Full Text

[133] Gebarski SS,

[134] Tucci DL,

[135] Telian SA

[136] ↵
Daniels RL,
Swallow C,
Shelton C,
et al
. Causes of unilateral sensorineural hearing loss screened by high-resolution fast spin echo magnetic resonance imaging: review of 1,070 consecutive cases. Am J Otol 2000; 21: 173– 80
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American Journal of Neuroradiology

Vertigo and Hearing Loss

Dizziness and Vertigo

Benign Positional Vertigo, Ménière Disease, and Peripheral Vestibular Disorders

Central Vestibular Disorders

Sensorineural Hearing Loss

Conductive Hearing Loss

Trauma

Congenital and Childhood Hearing Loss

Review Information

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Vertigo and Hearing Loss

Dizziness and Vertigo

Benign Positional Vertigo, Ménière Disease, and Peripheral Vestibular Disorders

Central Vestibular Disorders

Sensorineural Hearing Loss

Conductive Hearing Loss

Trauma

Congenital and Childhood Hearing Loss

Review Information

Appendix

Footnotes

References

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