Meniere’s disease, Labyrinthitis, Vestibular Neuritis, and Acoustic Neuroma: How to Spot the Difference

Meniere's disease, Labyrinthitis, Vestibular Neuritis

Meniere’s disease, Labyrinthitis, Vestibular Neuritis, and Acoustic Neuroma: How to Spot the Difference

Ménière's disease, labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo (BPPV), and acoustic neuroma are all causes of vertigo and are included on the NCCPA PANCE/PANRE EENT blueprint and family medicine rotation exam blueprints.

It is important to be able to differentiate quickly between these five causes of vertigo. They are common exam questions with significant overlap that exam writers leverage while creating high-quality clinical vignettes.

Let's take a quick look at how patient presentations will differ among these conditions and identify the key differences so that you can quickly make the correct diagnosis.

How to Differentiate Between Meniere's Disease, Labyrinthitis, Vestibular Neuritis, and Acoustic Neuroma

  • Labyrinthitis (affects entire labyrinth and vestibulocochlear nerve) = hearing loss + continuous vertigo + URI
  • Vestibular neuritis (affects vestibular nerve) = NO hearing loss or tinnitus + vertigo + URI
  • Meniere's disease = hearing loss + episodic vertigo + NOT associated with URI
  • Benign paroxysmal positional vertigo = No hearing loss or tinnitus + episodic vertigo with position changes
  • Acoustic neuroma = Unilateral hearing loss, insidious onset vertigo, and ataxia +/- facial numbness
Labyrinthitis is associated with CONTINUOUS vertigo along with hearing loss +/- tinnitus and is usually associated with an upper respiratory infection. This differentiates it from Meniere’s syndrome, which is EPISODIC and not typically associated with a viral infection. The features of acute labyrinthitis are similar to those of vestibular neuronitis, except labyrinthitis includes significant sensorineural hearing loss, which is NOT present in vestibular neuronitis. Benign paroxysmal positional vertigo can be differentiated by its association with position changes. While acoustic neuroma will present with unilateral hearing loss, an insidious onset, ataxia, and +/-  facial numbness as the acoustic neuroma on the vestibulocochlear nerve puts pressure on the facial nerve.
Disease Cause Characteristics Symptoms Diagnostic Test Treatment
Benign positional vertigo Otoconia (calcium carbonate crystals) dislodged from otolith organs, moving into semicircular canals Changes with position Vertigo without hearing loss, tinnitus, or ataxia MRI of the internal auditory canal Diagnosis: Dix-Hallpike maneuver

Treatment: Epley maneuver

Meclizine

Vestibular neuritis Viral infection affecting the vestibular nerve but sparing the cochlear branch Vertigo without position changes Vertigo but no hearing loss or tinnitus (inflammation of vestibular portion of CN VIII) Meclizine
Labyrinthitis Often viral infection, sometimes bacterial

Labyrinthitis involves inflammation of the labyrinth. It affects both the vestibular nerve (balance) and the cochlear branch (which transmits hearing information). It can cause a feeling of spinning (vertigo) and hearing loss.

Acute, self-resolving episode Continuous Vertigo

Hearing loss

Tinnitus

Self-limited

Meclizine + steroids
Meniere's disease Unknown, but involves fluid buildup in the inner ear

Not associated with URI

Chronic remitting and relapsing episodes Episodic Vertigo

Hearing loss

Tinnitus and chronic remitting and relapsing manner

Diuretics

Salt restriction

Unilateral CN VIII ablation (severe cases)

Acoustic neuroma Benign tumor on the vestibulocochlear nerve (CN VIII) Ataxia

Neurofibromatosis type II

MRI findings

Facial numbness

Vertigo

Unilateral hearing loss

Tinnitus AND ataxia

Surgical intervention
Question 1
A 60-year-old woman presents with sudden, brief episodes of vertigo triggered by specific head movements, such as rolling over in bed or looking up. There is no associated hearing loss or tinnitus. The Dix-Hallpike maneuver elicits transient nystagmus. What is the most likely diagnosis?
A
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo, hearing loss, tinnitus, and aural fullness.
B
Vestibular neuritis
Hint:
Vestibular neuritis presents with prolonged vertigo but not triggered by head movements, and without hearing loss.
C
Labyrinthitis
Hint:
Labyrinthitis includes vertigo and hearing loss, not solely provoked by position changes.
D
Benign paroxysmal positional vertigo
E
Acoustic neuroma
Hint:
Acoustic neuroma typically presents with progressive unilateral hearing loss and tinnitus, not episodic positional vertigo.
Question 2
A 35-year-old man experiences sudden onset of intense, continuous vertigo lasting several days, accompanied by nausea and vomiting. He denies any hearing loss or tinnitus. The symptoms began without any preceding illness or injury. What is the most likely diagnosis?
A
Benign paroxysmal positional vertigo
Hint:
BPPV causes brief episodes of vertigo related to head position changes.
B
Vestibular neuritis
C
Labyrinthitis
Hint:
Labyrinthitis also presents with auditory symptoms like hearing loss.
D
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo, hearing loss, tinnitus, and aural fullness.
E
Acoustic neuroma
Hint:
Acoustic neuroma usually presents with unilateral hearing loss and tinnitus, not acute vertigo.
Question 2 Explanation: 
Vestibular neuritis is characterized by acute, prolonged vertigo without associated auditory symptoms, often following a viral infection, though it can start without any apparent cause.
Question 3
A 45-year-old man presents with a sudden onset of vertigo, unilateral hearing loss, and tinnitus following an upper respiratory infection. The vertigo is severe and continuous, lasting for several days. What is the most likely diagnosis?
A
Benign paroxysmal positional vertigo
Hint:
BPPV is characterized by brief, positionally triggered episodes of vertigo without hearing loss.
B
Vestibular neuritis
Hint:
Vestibular neuritis presents with vertigo but without hearing loss or tinnitus.
C
Labyrinthitis
D
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo, not continuous, along with fluctuating hearing loss.
E
Acoustic neuroma
Hint:
Acoustic neuroma presents with progressive hearing loss and tinnitus, typically without acute vertigo episodes.
Question 3 Explanation: 
Labyrinthitis involves inflammation of the inner ear or labyrinth, leading to vertigo, hearing loss, and tinnitus, often following a viral infection.
Question 4
A 50-year-old woman reports recurrent episodes of vertigo, each lasting several hours, accompanied by unilateral hearing loss, tinnitus, and a sensation of fullness in the affected ear. These symptoms have been occurring intermittently over the past year. What is the most likely diagnosis?
A
Benign paroxysmal positional vertigo
Hint:
BPPV involves short-lived vertigo episodes triggered by head movements, without auditory symptoms.
B
Vestibular neuritis
Hint:
Vestibular neuritis is marked by a single prolonged episode of vertigo without hearing loss.
C
Labyrinthitis
Hint:
Labyrinthitis presents with continuous vertigo and hearing loss, typically following an infection.
D
Meniere's disease
E
Acoustic neuroma
Hint:
Acoustic neuroma involves progressive unilateral hearing loss and tinnitus but not episodic vertigo.
Question 4 Explanation: 
Meniere's disease is characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness, typically affecting one ear.
Question 5
A 58-year-old woman presents with gradual onset of unilateral hearing loss and tinnitus over the past year. She also notes occasional mild imbalance. An MRI is ordered and reveals a mass arising from the internal auditory canal. Which of the following is the most likely diagnosis?
A
Acoustic neuroma
B
Benign paroxysmal positional vertigo (BPPV)
Hint:
BPPV causes episodic vertigo without hearing loss or tinnitus.
C
Labyrinthitis
Hint:
Labyrinthitis includes vertigo and hearing loss but is not associated with a mass on imaging.
D
Meniere's disease
Hint:
Meniere's disease involves episodic vertigo and hearing loss but not due to a cerebellopontine angle mass.
E
Vestibular neuritis
Hint:
Vestibular neuritis presents with acute vertigo but no hearing loss.
Question 5 Explanation: 
Acoustic neuromas (also called vestibular schwannomas) are benign tumors arising from the Schwann cells of the vestibulocochlear nerve. They characteristically present with progressive unilateral hearing loss, tinnitus, and sometimes vestibular symptoms. Imaging confirms the diagnosis.
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