Abstract
Objectives
The objectives of this study were to describe the clinical course and outcome of patients with sudden sensorineural hearing loss (SSNHL) in conjunction with benign paroxysmal positional vertigo (BPPV), and hypothesize the possible pathophysiology of this entity.
Study design
Retrospective study of all patients with evidence of SSNHL with any type of BPPV between 2008 and 2012.
Settings
Tertiary care university hospital.
Subjects and methods
Five patients aged 56 to 71 were diagnosed with unilateral profound SSNHL and BPPV. Neurotologic examination revealed an ipsilateral torsional, up-beating nystagmus on Dix–Hallpike exam. Severe or profound ipsilateral–sensorineural hearing loss was recognized on audiometry. The rest of the exam was normal; this was in keeping with the diagnosis of SSNHL with ipsilateral posterior semicircular canal BPPV.
Results
All patients were treated with a modified Epley maneuver; oral steroids were administered for two weeks. In all cases vertigo resolved and the Dix–Hallpike exam became normal within several weeks. However, the hearing loss remained unchanged in two patients. Magnetic resonance imaging of the head was normal and ENG caloric test demonstrated mild ipsilateral canal paresis in two patients.
Conclusions
1. Patients with SSNHL and BPPV can have a variable clinical course and outcome. This entity may be quite common, but the diagnosis of BPPV can be missed if a complete neurological physical examination is not performed. 2. Arterial occlusions or selective multiple vascular or neural involvement may explain the pathophysiology of SSNHL with BPPV of the posterior semicircular canal.
1
Introduction
The annual incidence of sudden sensorineural hearing loss (SSNHL) ranges from 5 to 20 cases per 100,000 persons . The causes of SSNHL are speculative and may be multifactorial. The most common definition of sudden sensorineural hearing loss is a loss of 30 dB or more across ≥ 3 continuous frequencies within 72 h .
Vertigo is seen in about 30%–40% of cases of SSNHL and is considered to be a poor prognostic factor for hearing recovery . In one study vertigo was not an unfavorable sign of hearing recovery . One explanation for this discrepancy is that vertigo is a symptom and not a specific entity, and the studies do not differentiate types of vertigo.
The most common type of vertigo, in general, is benign paroxysmal positional vertigo (BPPV). Several previous studies have observed and discussed BPPV and SSNHL occurring simultaneously . BPPV most commonly involves the posterior semicircular canal, which is characterized by typical findings on Dix–Hallpike exam—up-beating, rotional, geotropic nystagmus found on one side with a latency of 5 to 10 s, and fatiguing within 10–20 s. Other, less common types of BPPV include horizontal SCC, which is diagnosed with the roll test, and anterior SCC, which is also diagnosed by the Dix–Hallpike exam.
The objective of our study was to describe a group of patients with simultaneous SSNHL and BPPV, review the possible etiology, and present conclusions on the clinical implications.
2
Patients and methods
After approval of the hospital’s Ethic committee Files of all patients with confirmed or suspected SSNHL, who were admitted to the Department of Otolaryngology-Head & Neck Surgery were reviewed. SSNHL was defined as a hearing impairment of greater than 30 dB in three contiguous frequencies that occurred in less than 3 days in the absence of a skull fracture . A complete neurological exam was performed when there were symptoms of vertigo. All patients with evidence of any type of BPPV and SSNHL between 2008 and 2012 were followed and their clinical findings were documented in the clinic.
A modification of the Epley maneuver (mEM) was used for treatment of pBPPV; neither premedication nor oscillation was used during the maneuver. All patients were closely followed up in our out-patient clinic until hearing stabilized, the patients had no further symptoms of vertigo, and the medical investigation was completed.
2
Patients and methods
After approval of the hospital’s Ethic committee Files of all patients with confirmed or suspected SSNHL, who were admitted to the Department of Otolaryngology-Head & Neck Surgery were reviewed. SSNHL was defined as a hearing impairment of greater than 30 dB in three contiguous frequencies that occurred in less than 3 days in the absence of a skull fracture . A complete neurological exam was performed when there were symptoms of vertigo. All patients with evidence of any type of BPPV and SSNHL between 2008 and 2012 were followed and their clinical findings were documented in the clinic.
A modification of the Epley maneuver (mEM) was used for treatment of pBPPV; neither premedication nor oscillation was used during the maneuver. All patients were closely followed up in our out-patient clinic until hearing stabilized, the patients had no further symptoms of vertigo, and the medical investigation was completed.
3
Results
Five patients with unilateral SSNHL were identified with BPPV. All the patients presented with SSNHL and a few hours later experienced positional vertigo with nausea.
In all of these patients the Dix–Hallpike exam was positive for ipsilateral up-beating and torsional geotropic–symptomatic nystagmus. The roll test for diagnosis of lateral SCC BPPV was normal, there were no gait disturbances, head impulse tests on both sides were negative, and no post-headshake nystagmus was observed. This was in keeping with the diagnosis of posterior semicircular canal BPPV. The main clinical data of these patients are presented in Table 1 .
| Medical history | Hearing loss | Caloric Test | MRI | Treatment | Outcome | |
|---|---|---|---|---|---|---|
| F 71 | HTN | Severe | Normal | Normal | P.O. Prednisone mEM | Vertigo: resolved Hearing: no change |
| M 50 | DM + HTN | Profound | Mild canal paresis (27%) | Normal | P.O. Predisone mEM | Vertigo: resolved Hearing loss: resolved |
| F61 | DM | Severe | Normal | Normal | P.O. Prednisone mEM IT-MP | Vertigo: resolved Hearing loss: improved |
| F56 | Amaurosis fugax S/P mitral valve replacement | Profound | Mild canal paresis (27%) | Normal | P.O. Prednisone mEM IT-MP | Vertigo: resolved Hearing: no change |
| F56 | Profound | Normal | Normal | P.O. Prednisone mEM | Vertigo: resolved Hearing loss: resolved |
Audiometry revealed severe to profound hearing loss of the affected ear, with reduced speech discrimination (40%–60%), and normal hearing in the contra-lateral ear.
All patients were treated with a mEM, and oral steroids (1 mg/kg) were administered for one week, after which the dosage was gradually reduced for an additional week. Two patients (3 and 4) also received salvage intratympanic prednisolone (62.5 mg/ml) 3 times. In total, hearing remained unchanged in two patients and three patients had complete recovery of hearing (e.g., Figs. 1 and 2 ).
