What is the best course of action for diagnosing and managing persistent symptoms of facial pressure, dizziness, tinnitus, and motion sensitivity, despite previous evaluations and current treatment?

Comprehensive Reevaluation for Persistent Vestibular and Facial Pressure Symptoms

You require urgent brain and posterior fossa MRI imaging to exclude central nervous system pathology, as your constellation of persistent symptoms—including pulsatile tinnitus, positional dizziness, motion sensitivity, and atypical pressure patterns—meets multiple criteria for mandatory neuroimaging despite previous negative workup. 1, 2, 3

Critical Red Flags Requiring Immediate Imaging

Your symptom pattern demonstrates several concerning features that mandate advanced neuroimaging:

• Pulsatile tinnitus in one ear is an absolute indication for imaging studies according to the American Academy of Otolaryngology-Head and Neck Surgery, as this can indicate vascular abnormalities or increased intracranial pressure 1

• Persistent symptoms for 2 years despite multiple evaluations represents treatment failure that requires reevaluation for underlying peripheral vestibular or central nervous system disorders 1, 2

• Atypical symptom constellation including constant facial pressure extending to teeth, positional worsening, and extreme motion sensitivity without clear BPPV pattern suggests possible central pathology 2, 4, 3

• Approximately 3% of vestibular "treatment failures" have missed CNS disorders, and 10% of cerebellar strokes initially present as peripheral vestibular processes 2, 3

Specific Diagnostic Algorithm

Immediate Steps (Within 1-2 Weeks)

• Obtain MRI of brain and posterior fossa with and without IV contrast, specifically including internal auditory canals to evaluate for vestibular schwannoma, vascular compression, or posterior circulation pathology 1, 2, 4, 3

• Repeat Dix-Hallpike maneuver and supine roll test by a vestibular specialist, as 8-50% of initial BPPV diagnoses have persistent disease after failed treatment 1, 2, 4

• Comprehensive audiologic examination is mandatory given your unilateral pulsatile tinnitus, bilateral regular tinnitus, and muffled hearing—these indicate potential asymmetric hearing loss requiring workup 1

Key Physical Examination Findings to Document

Your provider must specifically assess for:

• Direction-changing nystagmus without head position changes, downward nystagmus in Dix-Hallpike, or basal nystagmus without provocation—any of these indicate CNS pathology requiring urgent evaluation 2, 4

• Focal neurological abnormalities including cranial nerve deficits, cerebellar signs (finger-to-nose testing, heel-to-shin, tandem gait), or asymmetric reflexes 1, 2

• Cervical spine evaluation given your description of neck muscle tightness affecting symptoms, though this alone does not explain pulsatile tinnitus 1

Treatment Considerations During Workup

What to AVOID

• Do NOT continue vestibular suppressants (meclizine, antihistamines, benzodiazepines) without definitive diagnosis, as they do not treat underlying causes and impede vestibular compensation 4, 3

• Do NOT assume your current diagnosis is correct—the American Academy of Otolaryngology-Head and Neck Surgery explicitly warns that 3% of treatment failures have undiagnosed CNS disorders 2, 3

• Avoid CT head imaging—it has less than 1% diagnostic yield for isolated dizziness and only 20-40% sensitivity for causative pathology compared to MRI 4

Appropriate Interventions

• If repeat Dix-Hallpike is positive, additional canalith repositioning maneuvers achieve 90-98% success rates with repeated attempts 1, 2, 4

• For persistent bothersome tinnitus, cognitive-behavioral therapy is recommended by the American Academy of Otolaryngology-Head and Neck Surgery as effective treatment 1

• Sound therapy may be offered for your bilateral tinnitus and ear pressure symptoms 1

Differential Diagnosis to Exclude

Given your specific symptom pattern, imaging must evaluate for:

• Vestibular schwannoma or other cerebellopontine angle tumors (unilateral pulsatile tinnitus, hearing changes) 1, 2

• Posterior circulation stroke or TIA (persistent dizziness, motion sensitivity, positional symptoms) 2, 4

• Increased intracranial pressure syndromes (constant head pressure, pulsatile tinnitus, positional worsening) 2, 3

• Vestibular migraine (motion sensitivity, pressure symptoms, though typically episodic rather than constant) 4

• Superior semicircular canal dehiscence (pressure-induced symptoms, autophony, though less likely given symptom pattern) 2

Critical Next Steps Within 1 Month

• Mandatory reassessment in 1 month regardless of MRI results to document resolution or persistence, as the American Academy of Otolaryngology-Head and Neck Surgery emphasizes this timeline to avoid missing the window for intervention 2, 3

• If MRI is normal, referral to specialized vestibular clinic for comprehensive vestibular function testing including videonystagmography, rotary chair testing, and vestibular evoked myogenic potentials 1

• Education on fall risk is crucial given your balance issues and 2-year symptom duration—vestibular dysfunction significantly increases fall risk 1, 3

Common Pitfalls in Your Case

• Multiple provider evaluations without resolution suggests either missed diagnosis or inadequate imaging—your pulsatile tinnitus alone mandates imaging that may not have been obtained previously 1

• Conflicting diagnoses from neurologists (some saying nothing wrong, others diagnosing different conditions) indicates need for objective testing rather than clinical impression alone 2, 3

• Surgical consideration without definitive diagnosis is inappropriate—surgery should only follow confirmed diagnosis with failed conservative management 1

• Assuming cardiovascular medications cause symptoms when you're stable on therapy is a common error—other causes must be actively searched for first 4