Vestibular findings in a patient presenting with tinnitus and dizziness.

A 47-year-old woman presented with a 7-year history of tinnitus and dizziness. She described the tinnitus as originating "in my head" and louder on the left. She said the sound resembled television static. She also described another sound, this one a "distant beeping" in her head that was equally loud in both ears. The nature of the tinnitus had been constant until 2 weeks earlier, when its usual level increased. Moreover, the noise generally became louder 1 week prior to menstruation and returned to baseline alter its onset.

The patient's dizziness began at approximately the same time as her tinnitus. It occurred approximately six times per year, and each episode would last 2 or 3 hours. She described the dizziness as an "off-balance" feeling, but it was not disabling. She reported no subjective hearing loss or aural fullness. She also had a history of stiff neck, for which she was seeing a chiropractor.

On physical examination, the patient exhibited difficulty performing the sharpened tandem Romberg's test, tenderness over the right nuchal area, and a click in the left temporomandibular joint.

Several weeks later, the patient returned to the office. In the interim, she reported that she had experienced a sudden hearing loss in the right ear that had been treated elsewhere with a corticosteroid. By the time she returned to the office, her hearing had returned to normal both subjectively and on audiometry. Tympanometry revealed a stiffness pattern, which is characteristic of otosclerosis.

Electronystagmography detected no spontaneous, positional, or neck torsion nystagmus. The alternate binaural bithermal (ABB) caloric test revealed a 25% reduced vestibular response (RVR) right and a 6% right directional preponderance (DP). These findings are within the normal threshold of 30% for both RVR and DP elicited by ABB testing. The simultaneous binaural bithermal (SBB) test elicited a type 2 response with an RVR left.

Ultrathin computed tomography (CT) of the temporal bones detected evidence ofotosclerosis in both ears, slightly greater on the left. The patient's history and findings--dizziness beginning with the onset oftinnitus capitis that was louder on the left and that became louder prior to menstruation, findings of a stiffness pattern on tympanometry, and evidence ofotosclerosis on CT--were consistent with a diagnosis of otosclerosis. The ABB findings obtained shortly after the onset of a transient hearing loss in the right ear suggested a right-sided lesion. On the other hand, the SBB findings showed an asynchrony of the information entering the brainstem, which indicated a lesion on the left side, the side on which the tinnitus was louder.

The evidence was consistent with abnormalities in both vestibular and auditory function. The CT evidence of otosclerosis explained the etiology.