What is the treatment for a patient with ear pain and dizziness?

Treatment of Ear Pain and Dizziness

The treatment depends critically on identifying the underlying cause through targeted history and physical examination, with the most common etiologies being cerumen impaction, acute otitis externa, Ménière's disease, and vestibular disorders—each requiring distinct management approaches.

Initial Diagnostic Approach

The key to appropriate treatment is distinguishing between causes based on timing and triggers of dizziness combined with characteristics of ear pain 1:

Critical History Elements to Obtain

• Duration of vertigo episodes: 20 minutes to 24 hours suggests Ménière's disease 2
• Presence of hearing loss: Fluctuating hearing loss with vertigo points to Ménière's disease 2
• Ear fullness or pressure: Common in Ménière's disease 2
• Tinnitus characteristics: Ringing, buzzing, or other noises accompanying vertigo 2
• Pain characteristics: Severe pain with canal tenderness suggests acute otitis externa 2, 3
• Triggers: Sound or pressure-induced vertigo suggests superior canal dehiscence 4

Essential Physical Examination

• Otoscopic examination: Visualize the ear canal and tympanic membrane to identify cerumen impaction, otitis externa, or perforation 2, 3
• Tragal tenderness: Positive in acute otitis externa 3
• Dix-Hallpike maneuver: Identifies benign paroxysmal positional vertigo 1

Treatment Based on Specific Diagnosis

For Cerumen Impaction (if causing symptoms)

Cerumen should only be treated if it causes symptoms (ear pain, fullness, dizziness) or prevents needed assessment 2:

• Cerumenolytic agents followed by irrigation or manual removal 2
• Symptoms include decreased hearing, fullness, tinnitus, and dizziness 2
• Never use ear candles—they cause serious harm including perforation and have no proven benefit 2, 3

For Acute Otitis Externa

Topical antimicrobial therapy is the definitive first-line treatment, NOT oral antibiotics 3:

Essential Pre-Treatment Steps

• Perform aural toilet (gentle suction, dry mopping, or irrigation) to remove debris before administering drops 3
• Place a wick if severe canal edema prevents drop entry 3

Topical Antibiotic Selection

• If tympanic membrane is intact: Any FDA-approved topical preparation (ofloxacin 0.3%, neomycin/polymyxin B/hydrocortisone, ciprofloxacin) 3
• If tympanic membrane perforation or uncertain integrity: Use ONLY non-ototoxic fluoroquinolones (ofloxacin 0.3% or ciprofloxacin) 3
• Avoid aminoglycoside-containing drops when membrane integrity is uncertain due to ototoxicity risk 3

Pain Management

• Assess pain severity and prescribe appropriate analgesics based on intensity 2, 3
• NSAIDs (ibuprofen, naproxen) or acetaminophen for mild-to-moderate pain 2, 3
• NSAIDs significantly reduce pain compared to placebo during acute phase 2
• Opioids (oxycodone, hydrocodone) may be needed for severe pain 2
• Avoid topical anesthetic drops (benzocaine)—not FDA-approved and may mask disease progression 2, 3
• Pain typically improves within 48-72 hours of starting treatment 3

When to Add Systemic Antibiotics

Reserve oral antibiotics for specific circumstances only 3:

• Extension of infection beyond the ear canal 3
• Diabetes mellitus or immunocompromised status 3
• Topical therapy cannot reach infected area 3
• Treatment failure after 48-72 hours 3
• Use fluoroquinolones (ciprofloxacin) for Pseudomonas and Staphylococcus coverage 3

Expected Course and Follow-Up

• Clinical resolution occurs in 65-90% within 7-10 days 3
• Reassess if no improvement within 48-72 hours 3
• Consider treatment failure causes: inadequate drug delivery, poor adherence, fungal co-infection, allergic contact dermatitis, or incorrect diagnosis 3

For Ménière's Disease

There is no cure, but symptoms can be managed through a stepwise approach from least to most aggressive 2:

First-Line: Dietary Modifications

• Low-sodium diet (1500-2300 mg daily) 2
• Limit alcohol consumption 2
• Limit caffeine intake 2

Second-Line: Medications

• Diuretics (remove excess body fluid) 2
• Antivertigo medications for acute vertigo symptoms 2
• Meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases 5
• Antihistamines to treat allergies 2
• Betahistine (histamine analogue to increase vasodilation to inner ear) 2

Third-Line: Non-Invasive Therapies

• Vestibular rehabilitation (physical therapy) 2, 6
• Hearing aids 2

Fourth-Line: Middle Ear Injections

• Steroids through the eardrum 2
• Gentamicin (ablative therapy) 2

Fifth-Line: Surgery

• Endolymphatic sac decompression (hearing-sparing) 2
• Vestibular nerve section (hearing-sparing) 2
• Labyrinthectomy (hearing-ablative) 2

Essential Diagnostic Testing

• Audiogram to document hearing loss 2
• Video- or electronystagmogram to evaluate vestibular function 2
• MRI of brain to exclude vestibular schwannoma 2

For Vestibular Migraine (Important Differential)

Clinicians must assess for vestibular migraine when evaluating for Ménière's disease, as it closely mimics MD 2:

• Vertigo episodes can be <15 minutes or >24 hours (unlike MD's 20 minutes to 24 hours) 2
• Visual auras, motion intolerance, and light sensitivity are more common 2
• Hearing loss is mild, absent, or stable (unlike MD's fluctuating hearing loss) 2
• Treatment focuses on migraine prophylaxis and acute migraine management 2

Critical Pitfalls to Avoid

• Do NOT prescribe oral antibiotics for uncomplicated otitis externa—20-40% of patients inappropriately receive them 3
• Do NOT use ototoxic drops (aminoglycosides) when tympanic membrane integrity is uncertain 3
• Do NOT insert cotton swabs or objects into the ear canal—this can cause trauma and worsen infection 2, 3
• Do NOT use ear candles—they cause serious harm with no proven benefit 2, 3
• Do NOT undertreat pain—it can be severe and requires adequate analgesia 2, 3
• Do NOT fail to remove ear canal debris before administering drops—medication cannot reach infected tissue 3
• Do NOT ignore treatment failure at 48-72 hours—reassess for fungal infection, contact dermatitis, or incorrect diagnosis 3

Special Populations Requiring Modified Management

Diabetic or Immunocompromised Patients

• Higher risk for necrotizing otitis externa and otomycosis 3
• Consider systemic antibiotics even for uncomplicated cases 3
• Use atraumatic suctioning instead of irrigation 3
• Monitor carefully for extension beyond ear canal 3

Patients with Tympanic Membrane Perforation or Tubes

• Use ONLY non-ototoxic fluoroquinolones (ofloxacin 0.3% or ciprofloxacin) 3
• Avoid all aminoglycoside-containing preparations 3