Which signs suggest a vestibular schwannoma causing vertigo?

• A. Acute vertigo with bilateral hearing loss
• B. Progressive unilateral hearing loss, tinnitus, disequilibrium; may have decreased speech discrimination; sometimes ipsilateral nystagmus
• C. Direction-changing nystagmus with gaze
• D. Transient vertigo without hearing changes

Answer: (B)

The main idea is recognizing the audiovestibular pattern typical of a vestibular schwannoma. This tumor arises on the vestibulocochlear nerve and commonly presents with a gradual, unilateral sensorineural hearing loss accompanied by tinnitus and a sense of disequilibrium. A hallmark on exam or testing is that speech discrimination often declines disproportionately to what pure-tone thresholds would predict, reflecting cochlear nerve involvement from the tumor. Because the same side’s vestibular input is affected, patients may have vertigo or disequilibrium and, on examination, an ipsilateral nystagmus can be seen as the brain tries to compensate for the asymmetry in vestibular signaling.

This constellation—progressive unilateral hearing loss with tinnitus, disequilibrium, decreased speech discrimination, and sometimes ipsilateral nystagmus—fits vestibular schwannoma causing vertigo.

In contrast, acute vertigo with bilateral hearing loss points away from a unilateral tumor and toward a more symmetric or systemic/viral process. Direction-changing nystagmus with gaze suggests a central process or a different type of vestibular pathology, not the typical presentation of a schwannoma. Transient vertigo without hearing changes is more characteristic of brief peripheral vertigo episodes (like BPPV) or migrainous vertigo, not a slowly growing tumor.