What is the diagnosis and initial treatment for a patient with worsening dizziness (vertigo), mild earache (otalgia) bilaterally, fatigue, and lethargy after a recent viral exposure, with a positive head impulse test and negative Dix-Hallpike maneuver?

Diagnosis: Acute Vestibular Neuritis

This patient has acute vestibular neuritis, and treatment should begin immediately with a short course of corticosteroids (methylprednisolone 100 mg daily for 3 days or equivalent) combined with symptomatic management using vestibular suppressants like meclizine for the first 2-3 days only, followed by early vestibular rehabilitation exercises. 1

Clinical Reasoning for Diagnosis

The clinical presentation strongly indicates vestibular neuritis based on several key features:

• Acute onset of continuous vertigo lasting more than 24 hours (two days in this case) with worsening on movement but always present, which is the hallmark of acute vestibular syndrome 2, 1
• Positive head impulse test showing corrective saccades, indicating unilateral vestibular hypofunction on the affected side 1
• Negative Dix-Hallpike maneuver, ruling out benign paroxysmal positional vertigo (BPPV) 3
• Negative test of skew deviation, helping exclude central causes 4
• Recent viral exposure with prodromal symptoms (fatigue, lethargy), as 30% of vestibular neuritis patients report flu-like symptoms before onset 5, 1
• Bilateral mild earache likely represents referred pain or viral upper respiratory involvement rather than true otologic pathology 2

The absence of hearing loss, tinnitus, or focal neurological deficits further supports peripheral rather than central pathology 2, 1.

Treatment Protocol

Immediate Management (First 3 Days)

Corticosteroid therapy is the cornerstone of specific treatment:

• Corticosteroids improve peripheral vestibular function recovery to 62% within 12 months compared to natural history 1
• Start methylprednisolone 100 mg daily or prednisone 1 mg/kg daily for 3 days, then taper over 7-10 days 2, 1

Symptomatic management for acute phase only:

• Meclizine 25 mg every 6-8 hours as needed for vertigo 6
• Antiemetics (ondansetron or promethazine) for nausea/vomiting 2
• Critical caveat: Limit vestibular suppressants to 2-3 days maximum, as prolonged use delays central compensation 2, 1

Early Rehabilitation (Starting Day 3-5)

Vestibular rehabilitation exercises should begin as soon as acute symptoms allow (typically by day 3-5):

• Early mobilization and vestibular exercises significantly improve central compensation 1
• Include gaze stabilization exercises and balance training 2
• This is essential for long-term recovery and prevents chronic vestibular dysfunction 1

Critical Differential Diagnoses to Exclude

While the clinical picture strongly suggests vestibular neuritis, always consider these central causes that can mimic peripheral vestibular disorders:

• Cerebellar or brainstem stroke: 10% of cerebellar strokes present similarly to peripheral vestibular processes 4, 7
• Red flags requiring immediate MRI brain: dysarthria, dysmetria, dysphagia, limb weakness, truncal ataxia, direction-changing nystagmus without head position changes, or downbeating nystagmus 4, 7
• This patient's negative skew deviation test and absence of neurological signs make central pathology unlikely, but remain vigilant 4

Common Pitfalls to Avoid

1. Do not order routine vestibular function testing if the clinical diagnosis is clear with typical features, as it adds unnecessary cost and delays treatment 8
2. Do not continue vestibular suppressants beyond 2-3 days, as this impairs central compensation and prolongs recovery 7, 2
3. Do not obtain routine neuroimaging in the absence of red flags, as the diagnosis is clinical 8, 4
4. Do not delay corticosteroid initiation, as early treatment (within 3 days) provides the best chance for peripheral vestibular function recovery 1

Follow-Up Requirements

• Reassess within 1 week to document symptom improvement and ensure vestibular rehabilitation compliance 7
• Earlier evaluation warranted if: new neurological symptoms develop, hearing loss occurs, severe headache develops, or symptoms worsen despite treatment 7
• Most patients show significant improvement within 7-10 days, though complete recovery may take weeks to months 2, 1