By Marcello Cherchi, MD PhD
For patients
Thyroid problems are very common. Occasionally a person with a thyroid problem will complain of disequilibrium, but it is unclear whether the thyroid problem causes the disequilibrium. If you have a thyroid problem and you also feel disequilibrium, then your doctor may check several balance tests to look for other causes of that symptom.
For clinicians
Overview
Thyroid disease is common. A small proportion of patients with thyroid disease report disequilibrium, but the relationship between that symptom and the endocrine abnormality is unclear, and studies reach different conclusions about whether any such relationship exists. Given this uncertainty, we do not find it practical to screen for thyroid disease in patients complaining of vestibular symptoms. If a patient is diagnosed with thyroid disease, that should be managed (usually by an internist or endocrinologist) irrespective of the presence of vestibular symptoms. If a patient with thyroid disease complains of disequilibrium, it is medically reasonable to undertake a screening otovestibular workup to check for common vestibular diseases.
Introduction
Thyroid hormone plays a crucial role in energy metabolism in every cell in the body, so it is unsurprising that thyroid disorders can manifest with a broad variety of symptoms. A relatively small proportion of patients with thyroid disease report disequilibrium, but the relationship between the endocrine abnormality and the vestibular symptom is unclear. The few studies that exist reach different conclusions about whether there is any such relationship.
Studies reporting an association between thyroid disease and vestibular disease
Choi and colleagues (Choi et al. 2021) studied 19,071 patients with benign paroxysmal positional vertigo and 76,284 controls and reported that goiter, hypothyroidism, thyroiditis and hyperthyroidism were associated with BPPV (each p<0.05).
Kim and colleagues (Kim et al. 2020) studied 8,183 patients with Ménière’s disease and 32,732 controls and reported that goiter, hypothyroidism and hyperthyroidism were associated with Ménière’s disease (p<0.05).
Modugno and colleagues (Modugno et al. 2000) studied 70 patient with benign paroxysmal positional vertigo and reported that, “In 34 cases (48.5%) autoimmune alterations were found: in 19 cases (27.1%) the level of anti-thyroid antibodies far exceeded the normal values with a significant incidence in comparison with a control group (P<0.01). No other ‘risk factors’ were present.”
Teggi and colleagues (Teggi et al. 2021) retrospectively analyzed thyroid autoantibodies in 3,042 patients with benign paroxysmal positional vertigo and reported that, “anti-thyroid autoantibodies may play a role in recurrences in subjects with initial manifestations [of BPPV] between 40 and 60 years.”
Papi and colleagues (Papi et al. 2009) conducted a multivariate analysis of several serum tests (thyroid stimulating hormone, thyroid peroxidase antibodies, thyroglobulin antibodies) in 134 benign paroxysmal positional vertigo patients against controls and reported that, “BPPV is strongly associated with both hypothyroidism (mainly, subclinical hypothyroidism) and thyroid autoimmunity.”
Studies reporting no association between thyroid disease and vestibular disease
Sari and colleagues (Sari et al. 2015) studied thyroid antibodies (thyroid peroxidase antibodies, thyroglobulin antibodies) in 50 patients with benign paroxysmal positional vertigo, 52 patients with non-BPPV disequilibrium, and 60 controls, and reported that that they “didn’t find any relation between BPPV and thyroid autoimmunity.”
Miskiewicz-Orczyk and colleagues (Miśkiewicz-Orczyk, Kos-Kudła, Lisowska 2022; Miśkiewicz-Orczyk et al. 2022) studied several otovestibular tests (audiometry, tympanometry, Dix-Hallpike maneuver, caloric testing, rotatory chair testing) in 28 women with Hashimoto’s thyroiditis “and coexisting chronic vertigo” (19 benign paroxysmal positional vertigo, 7 Ménière’s disease, 2 vestibular neuritis) and reported that, “No correlation was found between… the results of thyroid function tests or the assessment of the vestibular end organ.”
The data from different studies are difficult to reconcile
Studies reach different conclusions regarding the relationship between thyroid disease and vestibular disorders. We are particularly struck by the completely opposite conclusions reached by Papi and colleagues (Papi et al. 2009) and Sari and colleagues (Sari et al. 2015).
Pathophysiological mechanism of disease
The mechanism by which thyroid disease might affect vestibular function is unknown. Modugno and colleagues (Modugno et al. 2000) studied thyroid autoantibodies in patients with benign paroxysmal positional vertigo and stated, “It can be hypothesized that the diffusion of immune-complexes in the inner ear could change the composition of the endolymphatic fluid exerting a mechanical stimulation of the receptors and provoking the typical vertigo.”
Notes
Since thyroid function does not appear to influence the results of instrumented vestibular tests (Miśkiewicz-Orczyk, Kos-Kudła, Lisowska 2022), there are currently no grounds for conducting screening vestibular tests in patients with thyroid disease. However, if a patient with thyroid disease complains of disequilibrium, it is medically reasonable to undertake a screening otovestibular workup, not for the purpose of “verifying thyroid-related vestibular disease,” but rather to check for common vestibular disorders.
References
Choi HG, Song YS, Wee JH, Min C, Yoo DM, Kim SY (2021) Analyses of the Relation between BPPV and Thyroid Diseases: A Nested Case-Control Study. Diagnostics (Basel) 11. doi: 10.3390/diagnostics11020329
Kim SY, Song YS, Wee JH, Min C, Yoo DM, Choi HG (2020) Association between Ménière’s disease and thyroid diseases: a nested case-control study. Sci Rep 10: 18224. doi: 10.1038/s41598-020-75404-y
Miśkiewicz-Orczyk K, Kos-Kudła B, Lisowska G (2022) The function of the vestibular organ in Hashimoto’s thyroiditis. Endokrynol Pol 73: 935-941. doi: 10.5603/EP.a2022.0076
Miśkiewicz-Orczyk K, Vlaykov A, Lisowska G, Strzelczyk J, Kos-Kudła B (2022) Does Thyroid Hormone Metabolism Correlate with the Objective Assessment of the Vestibular Organ in Patients with Vertigo? J Clin Med 11. doi: 10.3390/jcm11226771
Modugno GC, Pirodda A, Ferri GG, Montana T, Rasciti L, Ceroni AR (2000) A relationship between autoimmune thyroiditis and benign paroxysmal positional vertigo? Med Hypotheses 54: 614-5. doi: 10.1054/mehy.1999.0905
Papi G, Corsello SM, Milite MT, Zanni M, Ciardullo AV, Donato CD, Pontecorvi A (2009) Association between benign paroxysmal positional vertigo and autoimmune chronic thyroiditis. Clin Endocrinol (Oxf) 70: 169-70. doi: 10.1111/j.1365-2265.2008.03311.x
Sari K, Yildirim T, Borekci H, Akin I, Aydin R, Ozkiris M (2015) The relationship between benign paroxysmal positional vertigo and thyroid autoimmunity. Acta Otolaryngol 135: 754-7. doi: 10.3109/00016489.2015.1021932
Teggi R, Guidetti R, Gatti O, Guidetti G (2021) Recurrence of benign paroxysmal positional vertigo: experience in 3042 patients. Acta Otorhinolaryngol Ital 41: 461-466. doi: 10.14639/0392-100x-n1233
