Expert: Harriet B Jacobster, Au.D. - 12/12/2008

Question
I am a 44 yo male that is otherwise healthy. I smoke, drink alcohol on occasion, and have at most one cup of coffee/day. Over the past two years I have had recurring, spontaneous episodes of vertigo with associated nausea, and imbalance. Each period begins with a severe vertigo attack. The episodes last between 2-3 weeks each with intermittent vertigo during the 2-3 week period.  

I had one moderate blow to the base of the skull 7 or 8 years ago that knocked me out. Follow up tests concluded a mild concussion but nothing more. Don't know if this is related since vertigo symptoms began around 2 years ago, within 1 month following elective cosmetic surgery (liposuction from stomach and flanks).

All problems are focused on right ear. I get fullness in the right ear, particularly when speaking loud; I teach a class. The fullness does not last, but comes and goes. I have constant high pitch tinnitus that gets worse during episodes. Tinnitus and high tone hearing loss is a result of years of high sound exposure in the 80's as a Marine. Have lost almost all hearing in right ear, which is a progression from high tone hearing loss over the years. Majority of perceived hearing loss has happened this year.

I have had two MRI's w/wo contrast, both normal, over the last two years. The MRI's were specifically ordered to determine if an acoustic neuroma exists. Bilateral vestibulocochlear nerves intact and normal. Cochlea, vestibules, and semicircular canals are normal. No enlargement of the endolymphatic sac is demonstrated. No abnormal mass in the brain. No abnormal restricted diffusion is present. No hydrocephalus or abnormal extraaxial fluid collections are present. Flow voids in the larger intracranial vessels are normal. Left maxillary sinus is diffusely decreased in size but otherwise clear.

Had an ENG that said "Caloric testing reveals unilateral weakness for the right ear which is a peripheral finding. (RVR UW: right ear 53% weaker) (DP: Left beating 37% stronger). All other ENG categories were normal. The ENT did not feel the need to follow up with an audiological assessment.

I have a new appt with a new ENT Jan 5 for a second opinion. Given all the possibilities for vertigo and tinnutus and what I have shared with you thus far, can you point me in the right direction for questions to ask? Possible causes? What is your assessment given the information I've provided? Is this Mennieres?

Answer
Hi Barry,
It seems as if you've had a pretty thorough workup.  The only other tests that may have been ordered are Electrocochleography (ECoG) and maybe an Auditory Brainstem Response. The ECoG is the definitive test for Meniere's, although your symptoms are not typical of Meniere's.  At this point, the ENG points to a weakness in the right peripheral system, and that could very definitely be the reason for your symptoms. The actual cause of this weakness may never be determined.  Do you experience any numbness as well? If so, you may want to consult a neurologist as well. At this point, the best thing to ask your ENT is about vestibular rehabilitation.  Usually peripheral lesions respond very well. Here is the site for the Vestibular Disorders Association which would serve as a great resource: www.vestibular.org.
Hope this helps.
Harriet B. Jacobster, AuD
Board Certified in Audiology