ACR APPROPRIATENESS CRITERIA Vertigo and Hearing Loss F.J. Wippold II P.A. Turski Dizziness and Vertigo ditory nerve1 and is best evaluated with gadolinium-enhanced Dizziness and vertigo (Table 1) are common clinical com- MR imaging.22-25 plaints. Vertigo is caused by a disturbed vestibular system and Patients with fluctuating SNHL may have congenitally en- is subdivided into peripheral vertigo (due to failure of the end larged vestibular aqueducts (apertures greater than 4 mm) de- organs) or central vertigo (due to failure of the vestibular tected by either CT or MR imaging.26-29 nerves or central connections to the brainstem and The imaging findings must be correlated with 1-5 cerebellum). audiometry.27,28 Initial evaluation of symmetric or unilateral SNHL re- Benign Positional Vertigo, Me´nie`re Disease, and quires determination of whether the site of the lesion is Peripheral Vestibular Disorders cochlear30 or retrocochlear.31 Following preliminary au- Patients with benign positional vertigo rarely demonstrate im- diometric or auditory brain response testing, patients with aging findings.2,4 Me´nie`re disease manifests as paroxysmal at- retrocochlear localization should have a complete MR im- tacks of whirling vertigo due to failure of regulation of en- aging study of the head to include the internal auditory dolymph. CT or MR imaging, or both, may be used to evaluate canal, temporal bones, central nuclei in the brainstem, and the vestibular aqueduct, endolymphatic duct, and sac and to 4-12 the auditory pathways extending upward into the cerebral rule out associated infectious or neoplastic disease. 22,23,32-34 Vestibular neuritis and labyrinthitis may also cause vertigo. hemispheres. Gadolinium contrast enhancement Labyrinthitis is usually viral in origin with few sequelae; how- may be used. CT is sometimes diagnostic in lesions 1.5 cm ever, bacterial labyrinthitis may progress to partial or com- or greater in diameter when dedicated techniques are used, but it does not readily detect small brainstem lesions such as plete occlusion of the lumen of the affected labyrinth, detect- ACR CRITERIA 33-40 able on MR imaging as loss of the signal intensity of the fluid infarctions or demyelination. contents.3,4 Progressive labyrinthitis obliterans may be diag- In general, most cochlear disorders such as otosclerosis are nosed on high-resolution CT.13 Gadolinium enhancement of evaluated by high-resolution CT imaging. Similarly, preoper- the labyrinthine structures or vestibular nerves may also occur ative assessment for cochlear implants is usually best accom- and should not be mistaken for hemorrhage.14-16 plished by using thin-section CT with reformatted multipla- Superior semicircular canal dehiscence, another cause of nar images. In patients with congenital etiologies for hearing vertigo, can be diagnosed by high-resolution coronal CT im- loss, recent reports suggest that high-resolution MR imaging is aging of the temporal bones.17-19 Diseases of the internal au- more useful for surgical planning.41,42 ditory canal and cerebellopontine angle, such as tumors, are readily evaluated with CT and MR imaging techniques. Conductive Hearing Loss Conductive hearing loss results from pathologic changes of Central Vestibular Disorders either the external or middle ear structures and is best eval- Central lesions of the brainstem or cerebellum that result in uated with CT. Indications include suspected complica- central vertigo can be readily diagnosed by MR imaging. Pos- tions of acute and chronic otomastoiditis, such as cho- terior fossa vascular disorders may be evaluated with MR an- lesteatoma, and the assessment of congenital or vascular giography or conventional angiography of the posterior fossa anomalies. Fistulization through the tegmen tympani of the vasculature.3,20,21 Cervical spondylosis, which causes vertigo temporal bone is usually detected by CT, though the actual by compressive osteophyte formation, may be evaluated with involvement of the meninges and veins is better assessed by CT.3,20,21 MR imaging. MR imaging is also indicated when compli- cated inflammatory lesions are suspected to extend into the Sensorineural Hearing Loss inner ear or toward the sigmoid sinus or jugular vein. Neo- Sensorineural hearing loss (SNHL) results from the pathologic plasms arising from or extending into the middle ear re- changes of inner ear structures such as the cochlea or the au- quire the use of both techniques, as their combined data provide essential information. Vascular imaging should be This article is a summary of the complete version of this topic, which is available on the performed when there is suspicion of a paraganglioma ex- ACR Website at www.acr.org/ac. Practitioners are encouraged to refer to the complete 43 version. tending into the middle ear. Reprinted with permission of the American College of Radiology. Please address correspondence to Franz J Wippold II, MD, FACR, Neuroradiology Section, Trauma Mallinckrodt Institute of Radiology, 510 S Kingshighway Blvd, St. Louis, MO 63110-1076; CT is used extensively to delineate fractures, ossicular disloca- e-mail: [email protected]; or Patrick A Turski, MD, FACR, Department of Radiology, University of Wisconsin Hospital, E1/398, 600 Highland Ave, Madison, WI 53792-0001; tions, fistulous communications, and facial nerve injury and 44 e-mail: [email protected] to evaluate post-traumatic hearing loss. AJNR Am J Neuroradiol 30:1623–25 ͉ Sep 2009 ͉ www.ajnr.org 1623 Rating of Techniques: Clinical condition—vertigo and hearing loss* MRI Head and Internal CT Head MRA Head MRI Head and Internal Auditory Canal CT Temporal without and with or Auditory Canal without without Bone without with without and with Contrast Contrast Contrast Contrast Contrast CTA Head Sensorineural hearing loss, acute and 8 7 6† 3 N/A N/A intermittent vertigo Sensorineural hearing loss, no vertigo 8 7 5 4 N/A N/A Conductive hearing loss, rule out 3 3‡ 8 3 N/A N/A petrous bone abnormality Total deafness, cochlear implant 5 5 9 3 N/A N/A candidate, surgical planning Fluctuating hearing loss, history of 7 7 8 4 N/A N/A meningitis or to rule out congenital anomaly Episodic vertigo, new onset (hours to 764565 days) Vertigo, no hearing loss, normal 8 7 5 4 N/A N/A findings on neurologic examination Note:—MRI indicates MR imaging; MRA, MR angiography; CTA, CT angiography; N/A, not rated. * Appropriateness criteria scale from 1 to 9: 1 indicates least appropriate; 9, most appropriate. † For possible cholesteatoma with labyrinthine fistula. ‡ MR imaging is superior to CT for the detection of dural invasion and extradural extension. Congenital and Childhood Hearing Loss 7. Kraus EM, Dubois PJ. Tomography of the vestibular aqueduct in ear disease. Arch Otolaryngol 1979;105:91–98 The ideal imaging method for children with unilateral or 8. Lorenzi MC, Bento RF, Daniel MM, et al. Magnetic resonance imaging of the asymmetric sensory neural hearing loss is still controversial. temporal bone in patients with Meniere’s disease. Acta Otolaryngol Most reports suggest that children with unilateral or asym- 2000;120:615–59 9. Mateijsen DJ, Van Hengel PW, Krikke AP, et al. Three-dimensional Fourier metric sensory neural hearing loss should have a high-resolu- transformation constructive interference in steady state magnetic resonance tion temporal bone CT scan and that brain and temporal bone imaging of the inner ear in patients with unilateral and bilateral Meniere’s MR imaging be obtained in select cases. In general high-reso- disease. Otol Neurotol 2002;23:208–13 10. Nakashima T, Naganawa S, Sugiura M, et al. Visualization of endolymphatic lution CT has been shown to be efficacious for the preopera- hydrops in patients with Meniere’s disease. Laryngoscope 2007;117:415–20 tive work-up for congenital hearing loss due to aural dysplasia, 11. Sajjadi H, Paparella MM. Meniere’s disease. Lancet 2008;372:406–14 congenital ossicular anomalies, large vestibular aqueduct syn- 12. Xenellis J, Vlahos L, Papadopoulos A, et al. Role of the new imaging modalities in the investigation of Meniere’s disease. Otolaryngol Head Neck Surg drome, congenital absence of cochlear nerve, and labyrinthitis 2000;123:114–19 45-54 ossificans. 13. Hasso AN, Ledington JA. Imaging modalities for the study of the temporal bone. Otolaryngol Clin North Am 1988;21:219–44 14. Mark AS, Seltzer S, Nelson-Drake J, et al. Labyrinthine enhancement on gado- Review Information linium-enhanced magnetic resonance imaging in sudden deafness and This guideline was originally developed in 1996. The last re- vertigo: correlation with audiologic and electronystagmographic studies. Ann view and update was completed in 2008. Otol Rhinol Laryngol 1992;101:459–64 15. Seltzer S, Mark AS. Contrast enhancement of the labyrinth on MR scans in patients with sudden hearing loss and vertigo: evidence of labyrinthine dis- Appendix ease. AJNR Am J Neuroradiol 1991;12:13–16 Expert Panel on Neurologic Imaging: Franz J. Wippold II, 16. Weissman JL, Curtin HD, Hirsch BE, et al. High signal from the otic labyrinth on unenhanced magnetic resonance imaging. AJNR Am J Neuroradiol MD, Co-Author and Panel Chair; Patrick A. Turski, MD, Co- 1992;13:1183–87 Author; Rebecca S. Cornelius, MD; James A. Brunberg, MD; 17. Belden CJ, Weg N, Minor LB, et al. CT evaluation of bone dehiscence of the Patricia C. Davis, MD; Robert L. De La Paz, MD; Pr. Didier superior semicircular canal as a cause of sound- and/or pressure-induced ver- tigo. Radiology 2003;226:337–43 Dormont; Linda Gray, MD; John E. Jordan, MD; Suresh Ku- 18. Curtin HD. Superior semicircular canal dehiscence syndrome and multi-de- mar Mukherji, MD; David J. Seidenwurm, MD; Robert D. tector row CT. Radiology 2003;226:312–14 19. Mong A, Loevner LA, Solomon D, et al. Sound- and pressure-induced vertigo Zimmerman, MD; Brian Nussenbaum, MD, American Acad- associated with dehiscence of the roof of the superior semicircular canal.