What is the diagnosis and treatment for a 67-year-old female experiencing dizziness and right ear pressure?

Diagnosis and Management of Dizziness with Right Ear Pressure in a 67-Year-Old Female

The most critical first step is to determine whether this represents benign paroxysmal positional vertigo (BPPV), Ménière's disease, or a central nervous system disorder through focused history-taking about symptom duration, triggers, and associated auditory symptoms, followed by the Dix-Hallpike maneuver to confirm or exclude BPPV. 1

Initial Diagnostic Approach

Key Historical Features to Elicit

Duration of dizziness episodes is the single most discriminating feature:

• Seconds to minutes suggests BPPV 2
• 20 minutes to 24 hours suggests Ménière's disease 1
• Days of continuous symptoms suggests vestibular neuritis or central causes 2

Positional triggers must be assessed:

• Ask specifically if dizziness occurs with rolling over in bed, looking up, or lying down—these strongly suggest BPPV 1
• Spontaneous episodes without positional triggers favor Ménière's disease or other etiologies 1

Associated auditory symptoms are critical for differential diagnosis:

• Fluctuating hearing loss, tinnitus, or ear fullness occurring WITH the dizziness episodes strongly suggests Ménière's disease 1
• Ear pressure alone without hearing changes may represent eustachian tube dysfunction or cerumen impaction 2

Physical Examination

Perform the Dix-Hallpike maneuver as the gold standard test for posterior canal BPPV:

• The patient sits upright, then rapidly lies back with head extended 20 degrees and turned 45 degrees to the right 1
• Positive test shows characteristic mixed torsional-vertical nystagmus with 5-20 second latency, crescendo-decrescendo pattern, and resolution within 60 seconds 1
• Sensitivity is 82% and specificity 71% among specialty clinicians 1
• A negative test does not rule out BPPV and may need repeating at a separate visit 1

Assess for central nervous system warning signs:

• Downbeat nystagmus without torsional component indicates central pathology requiring urgent neuroimaging 3, 4
• Direction-changing nystagmus or baseline nystagmus present at rest suggests central cause 3
• Gait disturbance, severe headache, or neurological deficits mandate immediate evaluation for stroke 1, 5

Diagnostic Testing Algorithm

If BPPV is Confirmed (Positive Dix-Hallpike)

Proceed directly to canalith repositioning procedure (Epley maneuver) without additional testing 1, 5

• This is both diagnostic and therapeutic
• No imaging or laboratory studies are needed for typical BPPV 5

If Ménière's Disease is Suspected

Order the following diagnostic tests:

• Audiogram to document low-frequency sensorineural hearing loss 1
• Video- or electronystagmography to assess vestibular function 1
• Consider electrocochleography if diagnosis remains uncertain 1
• MRI brain with contrast to exclude acoustic neuroma or other structural lesions 1

The American Academy of Otolaryngology-Head and Neck Surgery requires 2 or more episodes of vertigo lasting 20 minutes to 24 hours, plus documented hearing loss, tinnitus, or aural fullness for definitive Ménière's diagnosis 1

If Central Cause is Suspected

Immediate MRI brain is mandatory for:

• Downbeat nystagmus 3, 4
• Continuous dizziness lasting days without improvement 2, 5
• Associated neurological symptoms (diplopia, dysarthria, ataxia, weakness) 1, 5
• Age over 50 with new-onset vertigo and vascular risk factors 5, 6

Treatment Based on Diagnosis

For BPPV

Perform the Epley maneuver (canalith repositioning procedure) immediately 1, 5

• This is the most effective treatment with immediate symptom resolution in most cases 1
• Vestibular rehabilitation therapy if symptoms persist 1
• Counsel about 10-18% recurrence rate at 1 year and up to 36% long-term 1

For Ménière's Disease

Initiate conservative management first:

• Low-sodium diet (1500-2300 mg daily) 1
• Limit caffeine and alcohol 1
• Diuretics for fluid management 1
• Antivertigo medications (meclizine, dimenhydrinate) for acute episodes 1

Escalate to invasive therapies only if conservative measures fail:

• Intratympanic steroid or gentamicin injections 1
• Surgical options (endolymphatic sac decompression, vestibular nerve section) reserved for refractory cases 1

Critical Pitfalls to Avoid

Do not assume all dizziness with ear pressure is benign—central causes can be life-threatening:

• Posterior circulation stroke can present with isolated vertigo and ear symptoms 1, 5, 6
• The HINTS examination (Head Impulse, Nystagmus, Test of Skew) helps distinguish central from peripheral causes in acute vestibular syndrome 5, 6

Do not confuse ear fullness with true vertigo:

• Ear fullness is an auditory symptom, not vestibular 2
• True vertigo is a false sensation of rotational movement 1, 2

Do not overlook fall risk in elderly patients:

• BPPV increases fall risk significantly, with 53% of elderly patients with vestibular disorders falling at least once yearly 1
• Counsel about home safety, activity restrictions, and supervision until symptoms resolve 1

Bilateral symptoms suggest alternative diagnoses:

• Vestibular migraine or central causes are more likely than unilateral peripheral disorders 2

Loss of consciousness is never a feature of Ménière's disease:

• If syncope occurs with dizziness, evaluate for cardiovascular or neurological causes 2