STEPTRACKERSPECIAL SENSES + NERVOUS SYSTEM | PATHOLOGY + PHYSIOLOGY + PHARMACOLOGY | HIGH-YIELD REVIEW

Inner Ear, Hearing Loss & Vertigo

Separate conductive from sensorineural loss at the bedside, name the cause of inner-ear damage, and sort vertigo by its timing.

FOCUS ON
Weber lateralizes to the conductive-loss ear and away from a sensorineural-loss ear; Rinne: bone > air = conductive. Sensorineural causes: presbycusis (high frequencies), noise, ototoxic drugs (aminoglycosides, cisplatin, loop diuretics), vestibular schwannoma. Vertigo by duration: seconds = BPPV; hours = Ménière; days = vestibular neuritis/labyrinthitis.
DISORDER
MECHANISM · CAUSE
FEATURES
CLUE · TREATMENT
Presbycusis
most common hearing loss
Age-related loss of cochlear hair cells at the base
Bilateral symmetric high-frequency sensorineural loss; trouble hearing speech in noise
Hearing aids
Noise-induced hearing loss
Outer hair cell damage from chronic or blast noise
Sensorineural loss with a notch near 4 kHz; tinnitus
Prevent with ear protection
Ototoxic drugs
Hair cell injury
Aminoglycosides, cisplatin, loop diuretics (furosemide, ethacrynic acid), vancomycin, aspirin (reversible tinnitus)
Aminoglycoside + loop diuretic = additive
Congenital & genetic hearing loss
Infection or inherited defects
Congenital CMV (most common nongenetic), rubella, syphilis, toxoplasmosis; Alport, Usher, Pendred, Waardenburg
Newborn hearing screen
Sudden sensorineural hearing loss
Often idiopathic (viral, vascular)
Rapid unilateral loss over < 72 h, tinnitus, fullness
Urgent steroids · MRI for schwannoma
Vestibular schwannoma
Schwann cells of CN VIII at the cerebellopontine angle; bilateral = NF2
Unilateral sensorineural loss, tinnitus, imbalance; later CN VII and V signs
Asymmetric hearing loss → MRI
BPPV
most common vertigo
Otoconia (calcium carbonate) loose in a semicircular canal (posterior)
Brief vertigo (< 1 min) on head position change (rolling in bed); no hearing loss
Dix-Hallpike ⁺ · Epley maneuver
Ménière disease
Endolymphatic hydrops (↑ endolymph)
Episodes lasting hours: vertigo + fluctuating low-frequency sensorineural loss + tinnitus + aural fullness
Salt restriction, diuretics
Vestibular neuritis · labyrinthitis
Viral inflammation of the vestibular nerve · of the labyrinth
Days of continuous vertigo, nausea, nystagmus; neuritis: hearing normal · labyrinthitis: hearing loss
Supportive, short vestibular suppressants
Central vertigo
Brainstem or cerebellar stroke, MS, tumor
Vertical or direction-changing nystagmus, ataxia, other neuro signs; normal head-impulse test
Emergency MRI
Smell and taste loss
Olfactory: viral URI (incl. COVID-19), head trauma (cribriform plate), Kallmann, early Parkinson/Alzheimer · taste: CN VII (anterior ⅔), CN IX, zinc deficiency
Anosmia, dysgeusia
Anosmia + hypogonadism → Kallmann

Mechanism — Weber and Rinne

Conductive lossSound can't enter
→
Weber → affected earAmbient noise masked
Rinne: bone > air
Sensorineural lossCochlea/nerve can't sense
→
Weber → better ear
Rinne: air > bone (both ↓)

The cochlea is tonotopic: high frequencies at the stiff narrow base, low frequencies at the apex — the base is hit first by age, noise and drugs.

Vertigo by timing

CAUSE
DURATION
HEARING
TRIGGER
BPPV
Seconds
Normal
Head position
Ménière
Hours
Fluctuating loss, tinnitus
Spontaneous
Vestibular neuritis
Days
Normal
After a viral illness
Labyrinthitis
Days
Loss
After a viral illness
Vestibular migraine
Minutes–hours
Normal
Migraine history
Central (stroke)
Persistent
Usually normal
Vascular risk factors

How it's tested

COMMON CONFUSIONWeber lateralizes toward the bad ear in conductive loss but toward the good ear in sensorineural loss. Rinne decides which: bone > air means conductive.
THE TRAPVertigo with vertical nystagmus, inability to walk, or a normal head-impulse test is central (cerebellar/brainstem stroke) until imaging says otherwise.
YOUR APPROACHHearing: Weber + Rinne → conductive or sensorineural → age, drugs, noise, infection, asymmetry. Vertigo: duration + trigger + hearing + neuro signs → peripheral vs central.

If you see… think…

Weber louder in the left ear, left Rinne bone > air → left conductive loss
Weber louder in the right ear, left Rinne air > bone → left sensorineural loss
75-year-old struggling with high-pitched voices → presbycusis
Hearing loss after gentamicin plus furosemide → ototoxicity
Infant failing the newborn hearing screen with periventricular calcifications → congenital CMV
Unilateral sensorineural loss with tinnitus → vestibular schwannoma — MRI
Vertigo for seconds when rolling over in bed → BPPV — Epley maneuver
Hours-long vertigo + fluctuating hearing loss + ear fullness → Ménière disease
Days of vertigo after a cold, normal hearing → vestibular neuritis
Anosmia and delayed puberty → Kallmann syndrome