What is the evaluation and management for a patient with otalgia, hearing loss, and vertigo?

Evaluation and Management of Otalgia, Hearing Loss, and Vertigo

Immediate Clinical Assessment

Distinguish sensorineural from conductive hearing loss immediately using tuning fork tests (Weber and Rinne) or audiometry, as this fundamentally determines the diagnostic pathway and urgency of evaluation. 1

The triad of otalgia, hearing loss, and vertigo suggests either:

• Peripheral vestibular pathology (Ménière's disease, labyrinthitis, vestibular schwannoma)
• Central nervous system pathology (posterior circulation stroke, particularly AICA infarction)
• Infectious/inflammatory processes (otitis media with labyrinthitis, mastoiditis)

Critical Red Flags Requiring Urgent Imaging

Obtain urgent MRI brain without and with IV contrast if any of the following are present: 1, 2

• Focal neurological deficits (dysarthria, ataxia, cranial nerve abnormalities)
• Severe postural instability or inability to stand/walk
• Age >50 with vascular risk factors
• Unilateral or asymmetric hearing loss
• Pulsatile tinnitus
• Abnormal HINTS examination (see below)
• Downbeating or direction-changing nystagmus

Critical pitfall: Up to 75-80% of patients with posterior circulation stroke present with isolated vestibular symptoms without focal neurologic deficits. 3 AICA infarction can present initially with sudden hearing loss and tinnitus before other brainstem symptoms develop. 4

Step-by-Step Diagnostic Approach

1. Characterize the Vertigo Pattern

Episode duration is the single most diagnostically valuable feature: 2, 3

• Seconds (<1 minute): BPPV—perform Dix-Hallpike maneuver immediately 2, 3
• 20 minutes to 12 hours: Probable Ménière's disease, especially with fluctuating low-to-mid frequency hearing loss, tinnitus, or aural fullness 1
• Hours to days (constant): Vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 3
• Minutes (episodic): Vestibular migraine or TIA 3

2. Perform Targeted Physical Examination

For brief episodic vertigo: Perform Dix-Hallpike maneuver—the gold standard for BPPV diagnosis. Positive findings include 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds. 3

For acute persistent vertigo: Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew), which has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity). 3 Central causes are suggested by:

• Normal head impulse test (abnormal is reassuring for peripheral cause)
• Direction-changing or downbeating nystagmus
• Positive skew deviation

Otoscopic examination: Essential to identify middle ear pathology, cholesteatoma, or signs of infection causing otalgia. 5

3. Obtain Comprehensive Audiologic Testing

Order audiometry within 4 weeks for any patient with hearing loss and vertigo. 1, 2 This must include:

• Pure tone audiometry
• Speech audiometry
• Acoustic reflex testing
• Tympanometry

Document the hearing loss pattern: 1

• Low-to-mid frequency sensorineural hearing loss (fluctuating or fixed) supports Ménière's disease
• Asymmetric or unilateral sensorineural hearing loss mandates MRI with contrast to exclude vestibular schwannoma
• Conductive hearing loss with otalgia suggests middle ear pathology

4. Determine Imaging Necessity

MRI head and internal auditory canals with and without IV contrast is the imaging modality of choice for sensorineural hearing loss with vertigo. 1 Indications include:

• Any unilateral or asymmetric sensorineural hearing loss 1, 2
• Pulsatile tinnitus 2
• Any red flags listed above 2, 3
• Failure to respond to appropriate peripheral vestibular treatments 2

Do NOT order imaging for: 2, 3

• Typical BPPV with positive Dix-Hallpike and no additional concerning features
• Bilateral auditory symptoms with normal neurologic exam and peripheral HINTS findings

Critical pitfall: CT head without contrast has <1% diagnostic yield for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts. 3 Never rely on CT to exclude stroke in this presentation. 3, 6

Management Based on Diagnosis

Probable Ménière's Disease (episodic vertigo 20 min-12 hours + fluctuating hearing loss/tinnitus/fullness)

Educate patients about natural history, treatment options, and outcomes—this is a strong recommendation. 1 Initial management includes:

• Salt restriction and lifestyle modifications 1
• Meclizine 25-100 mg daily in divided doses for acute symptom control 2, 7
• Hearing aid evaluation if hearing loss documented 2
• Cognitive-behavioral therapy for persistent bothersome tinnitus 2

BPPV (brief positional vertigo <1 minute)

Perform canalith repositioning procedures (Epley maneuver) immediately—this is first-line treatment with 80% success after 1-3 treatments and 90-98% after repeat maneuvers. 3 No medications or imaging needed for typical cases. 2, 3

Vestibular Neuritis/Labyrinthitis (acute persistent vertigo days-weeks)

• Short course of vestibular suppressants (meclizine) for acute phase only 7
• Early vestibular rehabilitation therapy significantly improves outcomes 3
• MRI if any atypical features or failure to improve 3

Suspected Central Cause or Stroke

Urgent MRI brain without and with IV contrast and immediate neurology consultation. 2, 3 Do not delay imaging for typical stroke protocols if AICA syndrome suspected (sudden hearing loss + vertigo + brainstem signs). 4

Critical Pitfalls to Avoid

• Never assume normal neurologic exam excludes stroke—most posterior circulation stroke patients with acute vestibular syndrome have no focal deficits initially. 3
• Never misdiagnose central causes as BPPV—if BPPV treatment fails, reconsider diagnosis and obtain imaging. 2
• Never rely on patient's description of "spinning" alone—focus on timing, triggers, and associated symptoms. 2, 3
• Never perform Dix-Hallpike when Romberg is positive—this indicates central pathology requiring imaging first. 2
• Never use CT instead of MRI when stroke is suspected—CT frequently misses posterior circulation infarcts. 3, 6