Acoustic neuroma differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2], Arash Azhideh,

Overview

Acoustic neuroma must be differentiated from meningioma, intracranial epidermoid cyst, facial nerve schwannoma, trigeminal schwannoma, ependymoma, leiomyoma, intranodal palisaded myofibroblastoma, malignant peripheral nerve sheath tumour (MPNST), gastrointestinal stromal tumor, neurofibroma, Meniere's disease, and Bell's palsy.

Differential Diagnosis

Acoustic neuroma must be differentiated from:[1]

Differentiating features of common differential diagnoses are:[3]

Differentiating features of common differential diagnosis
Disease/Condition Differentiating Signs/Symptoms Findings on CT or MRI
Meningioma
Intracranial epidermoid cyst
  • No enhancing component
  • Very high signal on DWI (Diffusion weighted imaging)
  • Does not widen the internal auditory canal
Facial nerve schwannoma
Trigeminal schwannoma

Differential diagnosis for SSNHL:

Since the most common outcome of acoustic aeuroma is hearing loss, the differential diagnoses for SSNHL (Sudden Sensorineural Hearing Loss ) are listed below.[4]

Identifiable Causes of Sudden Sensorineural Hearing Loss
Autoimmune Autoimmune inner ear disease Neurologic Migraine
Behcet’s disease Multiple sclerosis
Cogan syndrome Pontine ischemia
Systemic lupus erythematosis Otologic Fluctuating hearing loss
Infectious Bacterial Meningitis Meniere’s disease
Cryptococcal meningitis Otosclerosis
HIV AIDS Enlarged vestibular aqueduct
Lassa fever Toxic Aminoglycosides
Lyme disease Chemotherapeutic agents
Mumps Non-steroidal anti-inflammatory drugs
Mycoplasma infection Salicylates
Syphilis Traumatic Inner ear concussion
Toxoplasmosis Iatrogenic trauma/surgery
Vascular Cardiovascular bypass Perilymphatic fistula
Temporal bone fracture Cerebrovascular accident/stroke
Sickle cell disease Metabolic Diabetes mellitus
Neoplastic Acoustic neuroma Hypothyroidism
Cerebellopontine angle or petrous meningiomas Functional Conversion disorder
Cerebellopontine angle or petrous apex metastases Malingering
Cerebellopontine angle myeloma

Differentiating Acoustic Neuroma from Meningioma based on CT Findings

The most important differential diagnosis of acoustic neuroma is meningioma of the pontine angle. Below given diagram demonstrates the difference between acoustic neuroma and meningioma of the pontine angle based on CT scan findings:[5]

 
 
 
 
 
 
 
 
 
 
 
 
<13cm3
 
 
Volume
 
 
>35cm3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Increased attenuation
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Marked calcification
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Oval shape
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
Round shape
 
 
Mostly No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acoustic Neuroma
 
 
 
 
 
No
 
 
Tumor reaches dorsum sellae anteriorly
 
 
Yes
 
 
 
 
 
Meningioma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mostly No
 
 
Apparently broad attachment to bone
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Center of tumor anterior to porus
 
 
Sometimes Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Tumor reaches > 2 cm above dorsum
 
 
Mostly Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sometimes
 
 
Peripheral edema
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mostly Yes
 
 
Widening of porus or other bone changes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging
Acute onset Recurrency Nystagmus Hearing problems
Peripheral
BPPV
[6][7][8]
+ + +/−
Vestibular neuritis
[9]
+ +/− + /−

(unilateral)

  • + Head thrust test
HSV oticus
[10][11][12][13]
+ +/− +/− + VZV antibody titres
Meniere disease
[14][15]
+/− + +/− + (Progressive)
Labyrinthine concussion
[16][17]
+ +
Perilymphatic fistula
[18][19][20]
+/− + +
  • CT scan may show fluid around the round window recess
Semicircular canal

dehiscence syndrome
[21][22]

+/− + +

(air-bone gaps on audiometry)

Vestibular paroxysmia
[23][24][25]
+ + +/−

(Induced by hyperventilation)

Cogan syndrome
[26][27][28]
+ +/− + Increased ESR and cryoglobulins
  • In CT scan we may see calcification or soft tissue attenuation obliterating the intralabyrinthine fluid spaces
Vestibular schwannoma
[29][30]
+ +/− +
Otitis media
[31][32]
+ +/− Increased acute phase reactants
Aminoglycoside toxicity
[33]
+ +
Recurrent vestibulopathy
[34][35]
+
  • It may happen infrequently, every one to two years
  • It may be associated with nausea and vomiting
  • It may overlap with vestibular migraine
Central
Vestibular migrain
[36][37]
+ +/− +/−
  • ICHD-3 criteria
Epileptic vertigo
[38]
+ +/−
  • They response well to anti-seizure drugs
Multiple sclerosis
[39][40][41]
+ +/− Elevated concentration of CSF oligoclonal bands
  • MS is at least two times more common among women than men
  • The onset of symptoms is mostly between the age of fifteen to forty years, rarely before age fifteen or after age sixty
Brain tumors
[42]
+/− + + + Cerebral spinal fluid (CSF) may show cancerous cells
  • On CT scan most of the brain tumors appears as a hypodense mass lesions
  • On MRI most of the brain tumors appears as a hypointense or isointense on T1-weighted scans, or hyperintense on T2-weighted MRI.
Cerebellar infarction/hemorrhage + ++/−
  • Based on the time interval between stroke and imaging we may have different presentations
Brain stem ischemia + +/−
  • Based on the time interval between stroke and imaging we may have different presentations
  • For more information click here
Chiari malformation
[43][44]
+ +
  • Patient may experience ringing in the ears
Parkinson
[45][46][47]
+

ABBREVIATIONS

VZV= Varicella zoster virus, MRI= Magnetic resonance imaging, ESR= Erythrocyte sedimentation rate, EEG= Electroencephalogram, CSF= Cerebrospinal fluid, GPe= Globus pallidus externa, ICHD= International Classification of Headache Disorders

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