Case history
Case history #1
A 56-year-old woman presents with a 3-week history of imbalance, right-sided hearing loss, and tinnitus. She reports having an upper respiratory tract infection 1 week before the onset of her symptoms. Her symptoms began with a severe episode of room-spinning vertigo with associated nausea and vomiting that lasted all day. The next day she noticed right, high-pitched tinnitus and was unable to use the telephone in her right ear. She now reports constant imbalance and slight vertigo with quick head turns to the right.
Case history #2
A 46-year-old man presents to the emergency room with a sudden onset of room-spinning vertigo lasting for hours. There was no preceding illness or injury, and he denies any associated hearing symptoms such as tinnitus or hearing loss. However, his vertigo is intense and severe, causing him to vomit and experience intractable nausea. He is treated with supportive care using a combination of an antiemetic, benzodiazepine, and a corticosteroid. After approximately 48 hours, his vertigo subsides and he is discharged home, but he continues to experience imbalance that slowly improves over a 6-week period following his illness.
Other presentations
Patients presenting in the acute setting may have significant difficulty walking. Spontaneous horizontal-rotary nystagmus (rapid involuntary movement of the eyes) with the fast phase beating toward the uninvolved ear is frequently present.[1][4] Vertigo is of rapidly progressive onset and develops over several hours; sustained vertigo may follow, which lasts from hours to days. The vertigo in patients with labyrinthitis and vestibular neuritis would typically be present at rest despite cessation of movement, unlike that in patients with benign paroxysmal positional vertigo where patients’ symptoms cease within minutes after cessation of movement. Nevertheless, it may be triggered by movements.[5]
Patients with bacterial meningitis are often critically ill and may present after resolution of the acute illness with profound hearing loss and imbalance, with or without a history of acute vertigo.[6] Patients with syphilitic labyrinthitis can present with progressive hearing loss and pressure- or sound-induced vertigo (Hennebert and Tullio signs).[3] Syphilitic labyrinthitis may follow tertiary neurosyphilis that occurs many years after the primary infection, and is not seen with acute primary or secondary syphilis. Known as “the great mimicker,” otosyphilis has a variable presentation and should be in consideration for any patient with unexplained inner ear symptoms of variable or fluctuating sensorineural hearing loss with or without vertigo.[3]
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