What should I do for a 55-year-old patient who, three weeks after COVID-19 infection, reports a sensation of water in the right ear?

Management of Post-COVID Ear Fullness

For a 55-year-old patient with a sensation of water in the ear three weeks after COVID-19, perform otoscopic examination to rule out middle ear effusion or external ear canal pathology, and if examination is normal with persistent symptoms, this likely represents post-COVID audiovestibular dysfunction that warrants audiometric evaluation and symptomatic management.

Initial Clinical Assessment

The sensation of ear fullness is a well-documented post-COVID symptom, with prevalence rates reaching 74.4% in patients presenting with audiological complaints after SARS-CoV-2 infection 1. Your immediate priorities are:

• Otoscopic examination to exclude:

  • Middle ear effusion (serous otitis media)
  • External ear canal obstruction or stenosis (rare but reported with COVID-related thrombosis) 2
  • Tympanic membrane abnormalities
  • Signs of acute otitis media or mastoiditis

• Assess for red flag symptoms requiring urgent intervention:

  • Purulent ear discharge with fever (mastoiditis/intracranial complications) 3
  • Acute facial nerve palsy
  • Severe headache or altered consciousness
  • Vertigo with inability to ambulate

Pathophysiology Context

Post-COVID audiovestibular dysfunction likely results from multiple mechanisms 4:

• Direct viral invasion of the inner ear causing inflammation
• Microthrombotic events affecting cochlear blood supply
• Disturbed vestibulocochlear nerve conduction
• Altered central auditory processing

The 3-week timeframe places this patient in the post-acute phase, where symptoms typically manifest between 3 weeks to 3 months post-infection.

Diagnostic Workup

If otoscopic examination is normal:

• Obtain pure tone audiometry within the next 2-4 weeks to document any hearing threshold changes 1
• Consider tympanometry to assess middle ear function if Eustachian tube dysfunction is suspected
• Document associated symptoms:
  • Tinnitus (present in 59.6% of post-COVID audiological cases) 1
  • Subjective hearing loss (51.1% prevalence) 1
  • Vertigo or imbalance

If otoscopic examination shows middle ear effusion:

• This represents Eustachian tube dysfunction, which can persist post-viral infection
• Initial management is conservative (see below)

Management Algorithm

For Normal Otoscopy with Persistent Ear Fullness:

1. Reassurance and education

   • Explain that post-COVID audiovestibular symptoms are common and often self-limiting
   • Symptoms typically improve over 2-3 months but can persist up to 12 months 5

2. Symptomatic treatment:

   • Nasal decongestants (short-term, <5 days): pseudoephedrine or oxymetazoline spray for Eustachian tube dysfunction
   • Intranasal corticosteroids: fluticasone or mometasone daily for 2-4 weeks to reduce inflammation
   • Autoinflation techniques: Valsalva maneuver or specialized devices (Otovent balloon) performed 3-4 times daily

3. Follow-up timing:

   • Reassess in 4-6 weeks
   • If symptoms persist beyond 8-12 weeks or worsen, refer to ENT for comprehensive audiovestibular evaluation

For Middle Ear Effusion on Examination:

1. Conservative management for 6-12 weeks:

   • Intranasal corticosteroids (fluticasone 2 sprays each nostril daily)
   • Autoinflation exercises
   • Avoid air travel if possible during acute phase

2. Refer to ENT if:

   • Effusion persists beyond 12 weeks
   • Hearing loss documented on audiometry
   • Unilateral effusion (requires nasopharyngoscopy to exclude mass)

Critical Pitfalls to Avoid

Do not dismiss unilateral symptoms without thorough evaluation - while bilateral symptoms are more common with post-COVID dysfunction, unilateral presentations require exclusion of structural pathology 1.

Do not prescribe oral antibiotics empirically - post-COVID ear fullness is not bacterial unless there are clear signs of acute infection (purulent discharge, fever, severe otalgia) 6.

Do not delay ENT referral if red flags present - acute mastoiditis with COVID can progress rapidly to intracranial complications including subdural empyema 3, 7.

Avoid prolonged use of topical decongestants beyond 5 days due to rebound congestion risk.

When to Escalate Care

Immediate ENT or emergency evaluation if:

• Acute facial nerve weakness develops
• Purulent otorrhea with fever >38.5°C
• Severe headache, neck stiffness, or altered mental status
• Progressive hearing loss over days
• Severe vertigo with vomiting

Routine ENT referral (2-4 weeks) if:

• Symptoms persist beyond 8-12 weeks despite conservative management
• Documented hearing loss on audiometry
• Unilateral symptoms without clear explanation
• Patient anxiety requiring specialist reassurance

The evidence suggests most post-COVID audiovestibular symptoms improve spontaneously, but systematic evaluation prevents missing treatable conditions while providing appropriate reassurance 4.