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## Complete Summary

#### GUIDELINE TITLE

Vertigo and hearing loss.

#### BIBLIOGRAPHIC SOURCE(S)

Turski PA, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont
PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Wippold FJ II,
Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Vertigo and hearing loss. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2006. 8 p. \[53 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Hasso AN, Drayer BP, Anderson
RE, Braffman B, Davis PC, Deck MD, Johnson BA, Masaryk T, Pomeranz SJ,
Seidenwurm D, Tanenbaum L, Masdeu JC. Vertigo and hearing loss. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):471-8.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 23, 2007, Gadolinium-based Contrast
    Agents](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Gadolinium):
    The addition of a boxed warning and new warnings about the risk of
    nephrogenic systemic fibrosis (NSF) to the full prescribing
    information for all gadolinium-based contrast agents (GBCAs).

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Vertigo

-   Hearing loss

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology\
Otolaryngology\
Pediatrics\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with vertigo and hearing loss

#### TARGET POPULATION

Patients with vertigo and hearing loss

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Magnetic resonance imaging (MRI), head

    -   Without contrast

    -   Without and with contrast

2.  Computed tomography (CT), head

    -   Without contrast

    -   Without and with contrast

    -   Air/contrast cisternography

3.  MR angiography (MRA), head

4.  CT angiography (CTA), head

5.  X-ray

    -   Skull

    -   Skull, tomography

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of recent
peer-reviewed medical journals, and the major applicable articles were
identified and collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Vertigo and Hearing Loss**

**Variant 1: Sensorineural hearing loss, acute and intermittent
vertigo.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, head, without   8                    
  and with contrast                        

  MRI, head, without   7                   High resolution internal auditory
  contrast                                 canal imaging.

  CT, head, without    6                   For possible cholesteatoma with
  contrast                                 labyrinthine fistula. Consider
                                           thin section through temporal
                                           bone.

  CT, head, without    3                    
  and with contrast                        

  CT, cisternography,  1                    
  head, air/contrast                       

  X-ray, skull         1                    

  X-ray, skull,        1                    
  tomography                               

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Sensorineural hearing loss, no vertigo.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, head, without   8                    
  and with contrast                        

  MRI, head, without   7                   High resolution internal auditory
  contrast                                 canal imaging.

  CT, head without     5                   Consider thin section through
  contrast                                 temporal bone.

  CT, head, without    4                    
  and with contrast                        

  CT, cisternography,  1                    
  head, air/contrast                       

  X-ray, skull         1                    

  X-ray, skull,        1                    
  tomography                               

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Conductive hearing loss, rule out petrous bone
abnormality.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, head, without    8                   Consider thin section through
  contrast                                 temporal bone.

  CT, head, without    5                    
  and with contrast                        

  MRI, head, without   5                   MR may be helpful if dural
  contrast                                 extension is suspected.

  MRI, head, without   5                    
  and with contrast                        

  CT, cisternography,  1                    
  head, air/contrast                       

  X-ray, skull         1                    

  X-ray, skull,        1                    
  tomography                               

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Episodic vertigo, new onset (hours to days).**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, head, without   7                    
  and with contrast                        

  MRI, head, without   6                    
  contrast                                 

  MRA, head            6                    

  CT, head, without    5                    
  and with contrast                        

  CTA, head            5                    

  CT, head, without    4                   Consider thin section through
  contrast                                 temporal bone.

  CT, cisternography,  1                    
  head, air/contrast                       

  X-ray, skull         1                    

  X-ray, skull,        1                    
  tomography                               

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: Vertigo, no hearing loss, normal neurological exam.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, head, without   8                    
  and with contrast                        

  MRI, head, without   7                    
  contrast                                 

  CT, head, without    5                   Consider thin section through
  contrast                                 temporal bone.

  CT, head, without    4                    
  and with contrast                        

  CT, cisternography,  1                    
  head, air/contrast                       

  X-ray, skull         1                    

  X-ray, skull,        1                    
  tomography                               

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 6: Total deafness, cochlear implant candidate, surgical
planning.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, head, without    9                   Consider thin section through
  contrast                                 temporal bone.

  MRI, head, without   5                    
  contrast                                 

  MRI, head, without   5                    
  and with contrast                        

  CT, head, without    3                    
  and with contrast                        

  CT, cisternography,  1                    
  head, air/contrast                       

  X-ray, skull         1                    

  X-ray, skull,        1                    
  tomography                               

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 7: Fluctuating hearing loss, history of meningitis or to rule
out congenital anomaly.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, head, without    8                   Consider thin section through
  contrast                                 temporal bone.

  MRI, head, without   7                    
  contrast                                 

  MRI, head without    7                    
  and with contrast                        

  CT, head, without    4                    
  and with contrast                        

  CT, cisternography,  1                    
  head, air/contrast                       

  X-ray, skull         1                    

  X-ray, skull,        1                    
  tomography                               

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Dizziness and Vertigo**

Dizziness is a common clinical complaint that accounts for 1% of visits
to United States office-based physicians. Vertigo is a form of dizziness
in which there is an illusion of movement (rotation, tilt, or linear
translation). The mechanism for vertigo is an imbalance of tonic
vestibular signals. Thus, vertigo is a hallucination of movement and is
a symptom of a disturbed vestibular system.

The complete vestibular system comprises the end organs in the temporal
bone, the vestibular components of the VIIIth cranial nerve, and the
central connections in the brainstem. The end organs in the temporal
bones are the cristae of the three semicircular canals that respond to
movement of the head and the macula of the utricle, which records the
position of the head. The semicircular canals record dynamic actions and
the utricle records static function. Vertigo is subdivided into
peripheral vertigo (due to failure of the end organs) or central vertigo
(due to failure of the vestibular nerves or central connections to the
brainstem and cerebellum).

**Benign Positional Vertigo, Ménière\'s Disease, and Peripheral
Vestibular Disorders**

Patients with benign positional vertigo describe episodic vertigo
lasting less than a minute, brought on by movements of the head and
without other associated symptoms. There are no radiological findings in
patients with benign positional vertigo.

In Ménière\'s disease, paroxysmal attacks of whirling vertigo are
usually accompanied by nausea, and are transient, lasting a few hours
but not days. The severe episodic vertigo is accompanied by tinnitus,
fluctuating hearing loss, and a feeling of fullness in the affected ear
or ears. Typically, hearing decreases and tinnitus increases during the
attack. Hearing may improve between attacks in early stages of the
disease. Generally, the hearing loss begins unilaterally and affects the
lower frequencies primarily; mid and high frequencies are affected in
later stages of the disease.

Ménière\'s disease is most common in middle age and may become bilateral
in up to 50% of the affected patients. The etiology of Ménière\'s
disease is a failure of the mechanism regulating the production and
disposal of endolymph, resulting in recurrent attacks of endolymphatic
hydrops. Since the endolymphatic duct and sac are the sites of
resorption of endolymph, these structures play an important role in the
pathogenesis of endolymphatic hydrops. The success of various surgical
procedures in relieving Ménière\'s disease symptoms has led to great
interest in using computed tomography (CT) or magnetic resonance imaging
(MRI), or both, to evaluate the vestibular aqueduct, endolymphatic duct,
and sac.

Unfortunately, there is no unanimity on the value of imaging in cases of
Ménière\'s disease. Some investigators have used CT or MRI to predict
results of shunt surgery, based on showing patency of the vestibular
aqueduct. Other investigators, however, report that the size, shape, and
patency of the vestibular aqueduct are of no value in predicting
surgical results in shunt procedures or in predicting occurrence of
bilateral disease. MR imaging, with its ability to detect the
endolymphatic duct and sac separate from the bony vestibular aqueduct,
may offer more useful information than CT. The value of CT and MRI rests
in their ability to rule out associated infectious or neoplastic
disease.

Vestibular neuritis is a clinical diagnosis based on an aggregate of
symptoms. The disease is characterized by an acute onset of severe
vertigo, lasting several days, followed by gradual improvement over
several weeks. Hearing is typically unaffected. The history includes
onset of vertigo following an illness such as an upper respiratory
infection. Most patients become completely symptom free following
resolution of the primary disease. Vestibular labyrinthitis is similar,
because the disease presents with the acute symptoms of vertigo but is
always associated with hearing loss. Labyrinthitis is usually viral in
origin but may result from acute or chronic bacterial middle ear
infections. Unlike viral labyrinthitis, labyrinthitis associated with
suppurative ear disease may progress to partial or complete occlusion of
the lumen of the affected labyrinth. Early on, the obstructed lumen may
be detected on MRI because of loss of the signal intensity of the fluid
contents. Later on, more complete obliteration of all the labyrinthine
structures occurs, with an end result of labyrinthitis obliterans, which
is readily diagnosed on high resolution CT.

With MRI, there may be gadolinium enhancement of the labyrinthine
structures or vestibular nerves during the acute or subacute stages of
vestibular neuritis or labyrinthitis, or both. Such results must be
interpreted with care, because sudden labyrinthine dysfunction may be
caused by spontaneous hemorrhage or injury, which results in abnormal
signal intensities within the labyrinthine structures secondary to the
blood products.

Superior semicircular canal dehiscent syndrome is a pathologic condition
in which sound or pressure transmitted to the inner ear may
inappropriately activate the vestibular system. The diagnosis of
superior semicircular canal dehiscent syndrome can be made by high
resolution coronal CT imaging of the temporal bones.

Sound-induced vertigo or nystagmus has been reported in perilymphatic
fistulas, syphilis, Ménière\'s disease, congenital deafness, chronic
otitis, and Lyme disease.

Diseases of the internal auditory canal and cerebellopontine angle are
generally not characterized by severe attacks of vertigo, but rather
with intermittent dizziness or periods of exacerbated dizziness, or
both. A variety of benign or malignant tumors of the petrous temporal
bone, such as paragangliomas, carcinomas, or metastatic tumors, may
directly involve the labyrinthine structures, causing vertigo. Such
processes are readily evaluated with modern imaging techniques.

**Central Vestibular Disorders**

Lesions of the brainstem or cerebellum that result in central vertigo
can be readily diagnosed by MRI. Vascular insufficiency in the
vertebrobasilar circulation is a common cause of vertigo in patients
older than age 50. Thrombosis of the labyrinthine artery or infarction
of the lateral medulla from vertebral or posterior inferior cerebellar
artery (PICA) insufficiency may cause severe vertigo. Subclavian steal
syndrome can cause a variety of symptoms, including vertigo. Such
conditions can be carefully evaluated with MR angiography or
conventional angiography of the posterior fossa vasculature.

A variety of other central nervous diseases may produce vertigo or
dizziness. These include seizure disorders, multiple sclerosis, ataxic
diseases, head injuries, or any cause of increased intracranial
pressure. Vertigo may result as a sequela of stroke, and transient
ischemic attacks may present as episodic dizziness.

Various metabolic disorders may result in dizziness. These include
thyroid disorders, hyperlipidemia, diabetes, and hypoglycemia.
Autoimmune diseases or diseases that affect the proprioceptive system
may cause vertigo. In many cases, the possibility of functional neurotic
symptoms must be considered in patients in whom no disease can be found.
Finally, cervical spondylosis is thought to cause vertigo by disc
degeneration and narrowing of the disc space, which affects nearby
nerves, or by osteophyte formation, which compresses the blood vessels.
In such cases, CT may be helpful.

**Hearing Loss**

Hearing loss is typically classified as conductive, sensorineural, or
mixed. Conductive hearing loss results from pathologic changes of either
the external or middle ear structures preventing the sound waves from
reaching the endolymph of the inner ear. Sensorineural hearing loss
(SNHL) results from the pathologic changes of inner ear structures such
as the cochlea or the auditory nerve and prevents neural impulses from
being transmitted to the auditory cortex of the brain.

**Sensorineural Hearing Loss**

SNHL may be sudden, fluctuating, or progressive. Sudden SNHL is a
manifestation of viral infections, vascular occlusive diseases, or
inner-ear membrane ruptures. Vertigo may be associated with these
conditions, which can help define whether the lesion is peripheral or
central. To discriminate among idiopathic, viral infections, and other
causes of SNHL, auditory brainstem responses and gadolinium-enhanced MR
imaging are used. Patients with cochleitis or cochlear nerve neuritis
typically have abnormal auditory brainstem responses and may be helped
by a tapering course of oral corticosteroids. Whether or not gadolinium
enhanced MR imaging shows enhancement of the cochlear nerve or cochlea
does not reliably guide corticosteroid therapy. However, some authors
suggest that MRI positive sudden deafness is more difficult to cure with
steroid therapy than MRI negative sudden deafness.

Fluctuating SNHL is a difficult disease to evaluate. The audiometric
examination would indicate the level of dysfunction, but not the likely
cause. Patients who are noted to have large vestibular aqueducts
(apertures greater than 4 mm) may have a congenital cause for
fluctuating hearing loss. Such patients with large vestibular aqueducts
have high frequency loss more often than low frequency loss. Fluctuating
SNHL due to an enlarged vestibular aqueduct appears to be more common in
children and young adults, an important point in differentiating this
disease from Ménière\'s disease, in which most patients are middle aged
or older. Of interest is that the vestibular aqueduct of patients with
Ménière\'s disease may be small, rather than large.

There is speculation on the causes of a sudden drop in hearing in
patients with large vestibular aqueducts. Two possible causes are reflux
of hyperosmolar fluid from the endolymphatic sac to the inner ear and
rupture of the membranous labyrinth or a perilymphatic fistula due to
transmission of intracranial pressure to the inner ear through the
enlarged vestibular aqueduct. It is well recognized that patients
sustaining relatively minor head trauma or who are subjected to extreme
barotrauma (scuba diving) may aggravate their episodes of hearing loss.
In such cases, it may be worthwhile to image the temporal bones to
detect enlarged vestibular aqueducts and thus advise the patients or
their parents of the dangers of contact sports or activities that entail
extreme barometric pressure changes. The imaging findings must be
correlated with audiometry, because the fluctuating SNHL of patients
with large vestibular aqueducts does not resemble the low frequency
changes characteristic of Ménière\'s disease, which may also be
associated with fluctuating hearing loss. Patients with isolated large
vestibular aqueducts may have a different pathophysiologic basis than
patients whose large aqueducts are associated with other inner-ear
malformations. Cases with complex inner ear malformations may be subject
to recurrent episodes of meningitis or the \"gusher\" syndrome, or both,
resulting in a dead ear at the time of surgical intervention such as a
stapedectomy.

Asymmetric SNHL or gradually declining unilateral SNHL is a common
symptom that may be ascribed to many different pathologic processes.
Initial evaluation is geared to localizing the site of the lesion,
(i.e., cochlear or retrocochlear). Most retrocochlear lesions are
associated with an abnormal auditory brainstem response, which is often
obtained before an imaging study. Whether auditory brainstem response
testing should be eliminated, as a cost saving measure, is a subject of
considerable debate. It seems unlikely that clinicians will refer
patients directly to MRI without at least preliminary audiometric or
auditory brain response testing, or both.

Patients with retrocochlear localization should have a complete MRI
study of the head in addition to the studies of the internal auditory
canal and temporal bones. The MRI examination should include complete
evaluation of the central nuclei in the brainstem as well as the
auditory pathways extending upward into the cerebral hemispheres.
Whether gadolinium contrast enhancement is routinely used depends on
many factors, including coil size, field of view, field strength, and
pulse sequences. CT is sometimes diagnostic in lesions 1.5 cm or greater
in diameter when dedicated techniques are used, but it does not readily
detect small brainstem lesions such as infarctions of demyelination.

In general, most cochlear disorders such as otosclerosis are evaluated
by high resolution CT imaging. Similarly, preoperative assessment for
cochlear implants is usually best accomplished using thin section CT
with reformatted multiplanar images. In patients with congenital
etiologies for hearing loss, recent reports suggest that high resolution
MRI is more useful for surgical planning.

**Conductive Hearing Loss**

CT is an excellent technique for demonstrating even small abnormalities
of the bony structures of the middle ear. For this reason it is the
modality of choice in the study of conductive hearing loss. However, not
every patient complaining of conductive hearing loss requires a CT
study. Established indications encompass conditions such as the
complications of acute and chronic otomastoiditis, the postoperative ear
following surgery for chronic otomastoiditis, the postoperative
localization of prosthetic devices, and the assessment of congenital or
vascular anomalies. Particularly, the precise extent of bone erosion
associated with cholesteatoma is correctly demonstrated by high
resolution CT. Conversely, although fistulization through the tegmen
tympani of the temporal bone is usually detected by CT, the actual
involvement of the meninges and veins is better assessed by MRI. MRI is
also indicated when complicated inflammatory lesions are suspected to
extend into the inner ear or towards the sigmoid sinus or jugular vein.
Neoplasms arising from or extending into the middle ear require the use
of both techniques, as their combined data provide essential
information. The most important data for surgical planning concern the
destruction of thin bony structures and the relationships of the lesion
to the dura and surrounding vessels. Vascular imaging should be
performed when there is suspicion of a paraganglioma extending into the
middle ear.

**Trauma**

Temporal bone trauma has numerous manifestations, many of which are
detected by current high resolution CT scanning techniques. CT is used
extensively to identify fractures, ossicular dislocations, fistulous
communications, hearing loss, and facial nerve injury.

**Congenital and Childhood Hearing Loss**

The ideal imaging method for children with unilateral or asymmetric
sensory neural hearing loss is still controversial. Several authors
suggest that all children with unilateral or asymmetric sensory neural
hearing loss should have a high-resolution temporal bone CT scan and
that brain and temporal bone MRI be obtained in select cases. In
general, high resolution CT has been shown to be efficacious for the
preoperative workup for congenital hearing loss due to aural dysplasia,
congenital ossicular anomalies, large vestibular aqueduct syndrome,
congenital absence of cochlear nerve, and labyrinthitis ossificans.

**Abbreviations**

-   CT, computed tomography

-   CTA, computed tomography angiography

-   MRA, magnetic resonance angiography

-   MRI, magnetic resonance imaging

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with vertigo and hearing loss

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Turski PA, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont
PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Wippold FJ II,
Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Vertigo and hearing loss. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2006. 8 p. \[53 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Neurologic
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Patrick A. Turski, MD; David J. Seidenwurm, MD;
Patricia C. Davis, MD; James A. Brunberg, MD; Robert Louis De La Paz,
MD; Pr. Didier Dormont; David B. Hackney, MD; John E. Jordan, MD; John
P. Karis, MD; Suresh Kumar Mukherji, MD; Franz J. Wippold II, MD; Robert
D. Zimmerman, MD; Michael W. McDermott, MD; Michael A. Sloan, MD, MS

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Hasso AN, Drayer BP, Anderson
RE, Braffman B, Davis PC, Deck MD, Johnson BA, Masaryk T, Pomeranz SJ,
Seidenwurm D, Tanenbaum L, Masdeu JC. Vertigo and hearing loss. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):471-8.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/VertigoandHearingLossDoc14.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on July 31, 2001. The information was
verified by the guideline developer as of August 24, 2001. This summary
was updated by ECRI on August 17, 2006. This summary was updated by ECRI
Institute on May 17, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Gadolinium-based contrast agents. This
summary was updated by ECRI Institute on June 20, 2007 following the
U.S. Food and Drug Administration (FDA) advisory on gadolinium-based
contrast agents.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008