Musculoskeletal, Skin & HEENT · Topic 14 of 14

Acute Vertigo & Sudden Hearing Loss

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HEENT · vertigo and sudden hearing loss

Acute Vertigo & Sudden Hearing Loss

In continuous vertigo, HINTS sorts stroke from neuritis and CT cannot exclude stroke. Brief positional vertigo is BPPV; sudden hearing loss needs prompt audiometry.

01 · The trapBrain CT for stroke: sensitivity only about 10%

02 · Use HINTSOnly in continuous vertigo with nystagmus

03 · BPPVBrief positional spinning: Dix-Hallpike, Epley

First moves, in order

Screen for red flags: ataxia, focal deficit, head or neck pain

Continuous dizziness with nystagmus: HINTS, only if trained in it

Acute vestibular syndrome: no brain CT, MRI for central or equivocal HINTS

Why BPPV happens

Displaced otoconia stimulate hair cells in a canal

BPPV: displaced otoconial crystals in a semicircular canal

Thought to be canalithiasis, most often in the posterior canal. The crystals stimulate hair cells and create the illusion of motion. BPPV is usually self-limited; canalith repositioning maneuvers treat it.

What you'll see

Sort by timing: seconds, days, or hours in recurring attacks

BPPV: brief spinning, seconds to minutes, with head movement

BPPV: no hearing loss

Neuritis: single attack of severe vertigo with vomiting

Neuritis: unidirectional horizontal nystagmus toward the unaffected side

Neuritis: no hearing loss, tinnitus or neurologic signs

Neuritis subsides over days to weeks

Meniere: recurrent vertigo lasting 20 minutes to 12 hours

Meniere: fluctuating low-frequency hearing loss, tinnitus, aural fullness

Central: disturbed gait or balance, ear symptoms rare

Central: nystagmus not suppressed by visual fixation

Diagnosis & imaging

Brain CT cannot clear the acute vestibular syndrome: MRI for central or equivocal HINTS

Central HINTS: normal head impulse, direction-changing nystagmus or skew

With nystagmus, new hearing loss on finger rub raises stroke concern

First 48 h: diffusion MRI misses about 50% of small posterior fossa strokes

Negative MRI, suspicion still high: repeat MRI or vascular imaging

Spontaneous episodic vertigo, TIA concern: CT or MR angiography, not plain CT

Dix-Hallpike: vertigo and torsional nystagmus start after 5–10 s (up to 30)

Dix-Hallpike: BPPV nystagmus lasts 10–30 s and fatigues

BPPV criteria met: no imaging or vestibular testing

Horizontal or no nystagmus, compatible history: supine roll test

In an ongoing attack, check oximetry, glucose, a pregnancy test and usually an ECG. The 10% CT figure varies with stroke type and timing: one study of small-vessel posterior stroke at about 6 hours found CT 41.8% versus diffusion MRI 95%.

Sudden hearing loss

Sudden sensorineural loss develops within 72 hours

Weber and Rinne at presentation: sensorineural vs conductive

Audiometry as soon as possible, within 14 days

Consider corticosteroids within 2 weeks of onset

Retrocochlear pathology: evaluate with MRI or auditory brainstem response

No routine head CT or nontargeted labs do not order

Red flags

Head or neck pain, ataxia, loss of consciousness urgent evaluation

Focal neurologic deficit stroke workup

Severe continuous symptoms for over 1 hour urgent evaluation

Any central HINTS component emergent stroke workup

Positional nystagmus: no latency, sustained, vertical or direction-changing CNS lesion, MRI

Headache and neck pain with imbalance vertebral dissection

New hearing loss or tinnitus with vertigo is not neuritis labyrinthitis, Meniere, stroke

Plain brain CT to evaluate acute vestibular syndrome do not use

Routine vestibular suppressants in BPPV not routine

Hearing loss with vertigo: labyrinthitis, Meniere disease or, rarely, a brainstem stroke involving the cochlear artery.

Treatment

BPPVposterior canal

Epley maneuver; medications are not routinely indicated

Neuritisfirst few days only

Meclizine Promethazine Benzodiazepine Antiemetics

Suppressants plus antiemetics for the first few days; add vestibular rehabilitation

Longer use delays central compensation and raises fall risk. Short-term steroids within 3 days are optional

Central signsposterior circulation stroke

Pursue an emergent stroke workup

Reperfusion windows are on the acute ischemic stroke sheet

Meniereattacks, then maintenance

Diuretic

Treat attacks symptomatically; maintain with a low-salt diet and diuretic

Sudden hearing lossidiopathic, data equivocal

Prednisone 60 mg daily

Typical course: 7–14 days, then a 5-day taper

Intratympanic steroid is salvage at 2–6 weeks; hyperbaric oxygen only with steroids

Ototoxicity, recovery, BPPV follow-up, no nystagmus

Aspirin or diuretic ototoxic loss often resolves within 24 hours of stopping

Antibiotics and chemotherapy may cause permanent loss once safe doses are exceeded

Sudden hearing loss: no routine antivirals or thrombolyticsalso no routine vasodilators or vasoactive agents

Hearing returns spontaneously in about 32–65%repeat audiometry after treatment and within 6 months

No postural restrictions after canalith repositioningreassess within 1 month to document resolution or persistence

BPPV: displaced otoconia, most often in the posterior canalincreases with age and risks injurious falls; usually self-limited over weeks to months

Acute vestibular syndrome without nystagmus: HINTS does not applyseverity of gait unsteadiness helps separate central from peripheral causes

Peripheral or central vertigo?

In continuous vertigo with nystagmus, HINTS separates them

	Peripheral	Central
Head impulse	Abnormal, with corrective saccade	Normal
Nystagmus	Unidirectional, horizontal	Direction-changing, vertical or torsional
Skew deviation	Absent	Present
Ear symptoms	Usually point here	Rarely present

Pearl

In continuous vertigo with nystagmus, a normal head impulse is the worrying finding.

Sources · GRACE-3: Acute Dizziness and Vertigo in the Emergency Department (SAEM, 2023) · Merck Manual Professional: Dizziness and Vertigo · Merck Manual Professional: Vestibular Neuronitis · Merck Manual Professional: Benign Paroxysmal Positional Vertigo · Merck Manual Professional: Sudden Hearing Loss · AAO-HNSF Clinical Practice Guideline: Sudden Hearing Loss (Update), 2019 · AAO-HNSF Clinical Practice Guideline: BPPV (Update), 2017 · Merck Manual Professional: Meniere Disease · Machner et al: Risk of acute brain lesions in dizzy patients in the ER (J Neurol 2020) · Posterior Circulation Stroke in Patients With Dizziness (JACEP Open 2026) · SAEM GRACE-3 Recommendations Infographic (2023) · Follow your institution's protocols.