What workup is recommended for a patient with headaches, blurred vision, dizziness, and loss of balance 3 months after earwax removal, presenting with a white patch on the tympanic membrane?

Recommended Workup for Post-Earwax Removal Complications with Neurological Symptoms

This patient requires urgent MRI with diffusion-weighted imaging (DWI) to rule out central nervous system pathology, as the constellation of headaches, blurred vision, dizziness, and loss of balance 3 months after an ear procedure represents red flags that cannot be explained by local ear complications alone. 1

Immediate Diagnostic Priorities

Neuroimaging is Essential

• MRI with DWI is the first-line imaging modality when patients present with focal neurological deficits, severe headache with dizziness, or atypical presentations that suggest central causes 1
• The combination of headaches, blurred vision (suggesting possible visual pathway involvement), and vestibular symptoms (dizziness, loss of balance) occurring together raises concern for intracranial pathology 1
• While the white patch on the tympanic membrane suggests local trauma (likely tympanic membrane perforation or scarring from the earwax removal), this alone does not explain the systemic neurological symptoms 2, 3

Otologic Assessment

• Complete otoscopic examination with documentation of the tympanic membrane status, including assessment for perforation, signs of infection, and canal skin integrity 2
• Audiometry testing should be performed, as the patient's symptoms may indicate inner ear involvement or complications affecting the vestibulocochlear nerve 4
• Pneumatic otoscopy to assess tympanic membrane mobility and middle ear status 4

Critical Differential Diagnoses to Exclude

Central Nervous System Pathology (Highest Priority)

The case report in the evidence describes a remarkably similar presentation: a 37-year-old with headaches, dizziness, nausea, and subjective hearing loss that revealed an enhancing lesion in the internal auditory canal on MRI 4. While this patient's symptoms followed earwax removal rather than appearing spontaneously, the symptom constellation warrants similar investigation.

• Cerebellopontine angle or internal auditory canal lesions can present with these exact symptoms 4
• Posterior fossa pathology must be excluded given the balance disturbance and headaches 1
• Stroke or ischemia in the vertebrobasilar territory can cause dizziness, visual disturbances, and balance problems 1

Vestibular System Complications

• Vestibular neuritis or labyrinthitis could explain dizziness and balance issues, though the visual symptoms and headaches suggest more than isolated vestibular pathology 1
• Perilymphatic fistula from trauma during earwax removal could cause vestibular symptoms, though typically presents more acutely 3
• Ototoxicity if any substances entered the middle ear through an unrecognized perforation during the procedure 3

Local Ear Complications

• Tympanic membrane perforation with secondary infection spreading to vestibular structures 3
• Otitis media that was masked by cerumen and now causing complications 2
• Cholesteatoma presenting as a white patch, though less likely given the acute timeline 4

Comprehensive Workup Algorithm

First-Line Studies (Urgent)

1. MRI brain and internal auditory canals with and without gadolinium contrast, including DWI sequences 1, 4

   • This is non-negotiable given the red flag symptoms
   • Dedicated IAC sequences should be included 4

2. Complete audiometric evaluation including pure-tone audiometry and speech discrimination 4

3. Formal otoscopic examination with photodocumentation if available 2

Second-Line Studies (Based on Initial Findings)

1. CT temporal bone if MRI shows temporal bone pathology or if there's concern for superior canal dehiscence or ossicular chain disruption 1

2. Vestibular function testing (caloric testing, video head impulse test) once tympanic membrane integrity is confirmed 4, 3

   • Critical caveat: Never perform caloric testing if perforation is present, as cold water entering the middle ear causes severe vertigo 3

3. Ophthalmologic examination to evaluate the blurred vision, including fundoscopy to assess for papilledema (suggesting increased intracranial pressure) 1

Laboratory Studies

1. Basic metabolic panel and complete blood count to exclude systemic causes 4

2. Inflammatory markers (ESR, CRP) if infection or inflammatory process is suspected 4

Critical Pitfalls to Avoid

• Do not assume all symptoms are related to the local ear trauma – the 3-month delay and systemic nature of symptoms (headaches, vision changes) mandate central evaluation 2
• Do not perform caloric vestibular testing before confirming tympanic membrane integrity – this can cause severe complications if a perforation exists 3
• Do not dismiss the white patch as simple scarring without proper evaluation – it could represent cholesteatoma, fungal infection, or other pathology 4
• Do not delay neuroimaging while pursuing only otologic workup – the red flag symptoms (severe headache with dizziness, visual changes, balance loss) require urgent central nervous system evaluation 1

Immediate Management Pending Workup

• Refer to otolaryngology urgently for comprehensive evaluation 2
• Neurology consultation should be obtained given the constellation of neurological symptoms 1
• Keep the ear dry if perforation is suspected – use petroleum jelly-coated cotton during showering 3
• Avoid ototoxic medications including aminoglycoside drops if perforation is present 3
• Document baseline neurological examination including cranial nerve testing, gait assessment, and Romberg testing 1

Follow-Up Strategy

• Reassessment within 48-72 hours or sooner if symptoms worsen 2
• Immediate return precautions for worsening headache, new neurological deficits, fever, or ear drainage 2, 3
• Once imaging is complete and central pathology excluded, vestibular rehabilitation may be considered for persistent balance symptoms 1

The key distinction here is recognizing that while the earwax removal may have been the inciting event, the current symptom complex extends far beyond what local ear trauma would explain, necessitating comprehensive neurological investigation.