What is the best course of action for a patient experiencing dizziness upon standing and worsening tinnitus?

Management of Orthostatic Dizziness and Worsening Tinnitus

For a patient experiencing dizziness upon standing and worsening tinnitus, the most appropriate next step is to obtain a comprehensive audiogram and consider MRI of the internal auditory canal if the tinnitus is unilateral or associated with asymmetric hearing loss. 1, 2

Evaluation of Orthostatic Dizziness

Initial Assessment

• Determine if dizziness is true vertigo (spinning sensation) or lightheadedness upon standing
• Orthostatic dizziness suggests potential causes:
  • Orthostatic hypotension
  • Vestibular disorders
  • Medication side effects
  • Dehydration

Management of Orthostatic Symptoms

1. Vestibular suppressants:

   • Offer a limited course of vestibular suppressants (e.g., meclizine) for symptomatic relief 1, 3
   • Caution: These should be used short-term only as they can delay central compensation

2. Non-pharmacological measures:

   • Advise patient to rise slowly from sitting/lying positions
   • Ensure adequate hydration
   • Consider compression stockings if orthostatic hypotension is confirmed

Evaluation of Worsening Tinnitus

Audiologic Testing

• Comprehensive audiogram: Essential for all patients with tinnitus, especially when worsening 1, 2, 4
  • Pure tone audiometry to assess hearing sensitivity
  • Speech audiometry to evaluate speech recognition abilities
  • Tympanometry to evaluate middle ear function

Imaging Considerations

• MRI of internal auditory canal and posterior fossa should be considered if: 1, 2
  • Tinnitus is unilateral
  • Associated with asymmetric hearing loss
  • Accompanied by other neurological symptoms
  • Not better explained by another disorder

Diagnostic Algorithm

1. Obtain comprehensive audiogram first

   • Establishes baseline hearing status
   • Helps differentiate between conductive and sensorineural hearing loss
   • Identifies asymmetric hearing loss requiring further investigation

2. Based on audiogram results:

   • If normal or symmetric hearing loss: Focus on managing orthostatic symptoms
   • If asymmetric hearing loss or unilateral tinnitus: Proceed to MRI

3. Consider additional testing:

   • Vestibular function testing if vertigo is severe or persistent
   • Blood pressure measurements in lying, sitting, and standing positions if orthostatic hypotension is suspected

Treatment Approach

For Orthostatic Dizziness

• Short-term vestibular suppressants (meclizine) 1, 3
• Hydration and positional change strategies
• Consider referral to neurology if symptoms persist despite management

For Tinnitus

• Document characteristics (pitch, loudness, variability) 1, 2
• Consider sound therapy options (white noise machines, smartphone apps)
• Cognitive behavioral therapy for persistent, bothersome tinnitus 2
• Hearing aids if hearing loss is identified 2

Follow-up Recommendations

• Document resolution, improvement, or worsening of symptoms 1
• Schedule follow-up within 4-6 weeks to assess response to initial management 2
• Consider referral to specialized tinnitus clinic if symptoms persist beyond 6 months 2

Common Pitfalls to Avoid

• Failing to remove cerumen before audiometric assessment 2
• Not considering orthostatic tinnitus as a possible diagnosis 5
• Prolonged use of vestibular suppressants 1
• Overlooking non-otologic causes of dizziness and tinnitus 2
• Ordering unnecessary imaging for non-concerning tinnitus presentations 2

The combination of orthostatic dizziness and worsening tinnitus requires thorough evaluation to rule out serious underlying conditions while providing symptomatic relief. The audiogram is the essential first diagnostic step that will guide further management decisions.