What is the differential diagnosis (ddx) and management of nasal congestion, headache, vertigo, unilateral ear pain, and hearing loss?

Differential Diagnosis and Management of Nasal Congestion, Headache, Vertigo, Unilateral Ear Pain, and Hearing Loss

Most Likely Diagnosis

This constellation of symptoms—nasal congestion, headache, vertigo, unilateral ear pain, and hearing loss—most strongly suggests acute otitis media with complications (potentially cholesteatoma with intracranial extension) or autoimmune inner ear disease, and requires urgent MRI brain with internal auditory canal sequences to exclude life-threatening complications such as sigmoid sinus thrombosis or stroke. 1, 2

Critical Red Flags Requiring Immediate Action

• Focal neurologic symptoms (weakness, dysarthria, ataxia, facial numbness) accompanying these symptoms indicate central nervous system pathology, particularly brainstem involvement, and mandate immediate MRI. 3, 1
• Fever with unilateral ear pain, headache, and vertigo raises concern for otitis media with intracranial complications including meningitis or sigmoid sinus thrombosis. 2
• Bilateral hearing loss or rapidly progressive symptoms suggest autoimmune inner ear disease, ototoxicity, or bilateral stroke. 3, 4

Differential Diagnosis Framework

Primary Considerations (Most Likely)

Otitis Media with Complications:

• Cholesteatoma invading toward the sigmoid sinus can cause unilateral ear pain, headache, vertigo, hearing loss, and nasal congestion from eustachian tube dysfunction. 2
• Physical examination reveals purulent discharge, tympanic membrane abnormalities, and possible mastoid tenderness. 3
• CT temporal bone without contrast shows soft-tissue mass in tympanic cavity and mastoid air cells. 2

Autoimmune Inner Ear Disease:

• Progressive fluctuating bilateral hearing loss (though can start unilaterally) that is steroid-responsive, with vertigo in some cases. 4, 3
• May present with vision, skin, and joint problems if part of systemic autoimmune disease. 4
• Cogan syndrome specifically presents with nonsyphilitic interstitial keratitis, hearing loss, and vertigo—concurrent eye pain, redness, lacrimation, and photophobia mandate evaluation for this condition. 4, 3

Vestibular Schwannoma:

• Unilateral sensorineural hearing loss with unsteadiness is the classic presentation, occurring in 94% and 17-75% of cases respectively. 5
• Chronic imbalance more likely than profound episodic vertigo; hearing loss does not typically fluctuate. 3

Secondary Considerations

Ménière's Disease:

• Episodic vertigo lasting 20 minutes to 12 hours, fluctuating low-frequency hearing loss, tinnitus, and aural fullness. 3
• Vertigo attacks are associated with aural symptoms immediately before or after attacks, distinguishing it from other causes. 3
• Nasal congestion is not a typical feature, making this less likely with the full symptom complex. 3

Acute Bacterial Sinusitis:

• Persistent purulent rhinorrhea, postnasal drainage, facial-dental pain, headache, and cough beyond 10-14 days. 3
• Can cause referred ear pain but typically does not cause true hearing loss or vertigo unless complicated by intracranial extension. 3

Vestibular Neuritis/Labyrinthitis:

• Sudden severe vertigo lasting >24 hours with nausea and vomiting. 3, 6
• Vestibular neuritis has NO hearing loss; labyrinthitis has profound hearing loss with prolonged vertigo. 3
• Not episodic, not fluctuating—single prolonged event. 3

Posterior Circulation Stroke:

• Vertigo with dysarthria, facial weakness, ataxia, nystagmus, unilateral numbness. 3
• Stroke rarely presents as isolated sudden hearing loss but peripheral vestibular involvement is usually present with brainstem infarct. 3
• Insults are permanent and do not fluctuate; may have dysphagia or dysphonia. 3

Less Common but Important

Infectious Causes:

• Lyme disease: erythema chronicum migrans, abnormal CSF, fluctuating bilateral audiovestibular symptoms. 3
• Syphilis: abnormal FTA-abs test, bilateral fluctuating hearing loss, multiorgan involvement. 3
• Meningitis: headache, fever, abnormal CSF, possibly other cranial nerve palsies. 3

COVID-19:

• Otologic and vestibular symptoms (hearing loss, tinnitus, vertigo, ear pain) occur within a month of typical COVID symptoms in majority of cases. 7
• Most symptoms resolve within 2 weeks. 7

Diagnostic Workup Algorithm

Step 1: Immediate Clinical Assessment

Comprehensive neurologic examination:

• Look for focal deficits, cranial nerve palsies, ataxia, dysarthria, nystagmus, or abnormal vestibular ocular reflex. 1, 6
• Perform Weber and Rinne tuning fork tests to distinguish conductive from sensorineural hearing loss. 3
• Weber lateralizes to affected ear in conductive hearing loss OR to unaffected ear in sensorineural hearing loss. 3
• Rinne: sound heard better by bone conduction indicates conductive hearing loss in that ear. 3

Otoscopic examination:

• Assess for purulent discharge, tympanic membrane perforation, retrotympanic mass, cholesteatoma, or cerumen impaction. 3
• Look for pinna or ear canal vesicles suggesting herpes zoster oticus (Ramsay Hunt syndrome). 3

Vital signs and constitutional symptoms:

• Fever, weight loss, or constitutional symptoms suggest infectious, inflammatory, or neoplastic causes. 8

Step 2: Mandatory Audiometry

Pure tone audiometry must be performed to:

• Confirm sensorineural hearing loss (≥30 dB loss at 3 consecutive frequencies) versus conductive loss. 5
• Identify isolated low-frequency hearing trough suggesting Ménière's disease. 3
• Document bilateral versus unilateral involvement. 4

Step 3: Imaging Strategy

MRI brain with internal auditory canal sequences (with gadolinium contrast) is the first-line imaging:

• Mandatory to exclude vestibular schwannoma, stroke, autoimmune disease, or structural lesions. 5, 1
• Should be obtained urgently if any focal neurologic findings are present. 3, 1
• ACR rates MRI as "usually appropriate" for unilateral hearing loss with vertigo. 3

CT temporal bone without contrast:

• Indicated if chronic ear disease, cholesteatoma, or mastoiditis is suspected on otoscopy. 2
• Can diagnose cochlear nerve aperture stenosis and differentiate otitis media from cholesteatoma. 3
• Shows soft-tissue mass in tympanic cavity and mastoid air cells in cholesteatoma. 2

Do NOT order routine CT head:

• Routine head CT with thick cuts has no role in initial evaluation and rarely offers useful information for sudden hearing loss. 3

Step 4: Laboratory Testing

If autoimmune disease suspected:

• ESR, CRP, ANA, RF to evaluate for systemic autoimmune disease. 4
• FTA-abs for syphilis if bilateral fluctuating hearing loss. 3
• Serum angiotensin-converting enzyme level or Gallium scan if sarcoidosis suspected. 3, 4

If infectious etiology suspected:

• CBC with differential, blood cultures if febrile. 8
• Lyme serology if appropriate epidemiologic exposure. 3
• Consider lumbar puncture if meningitis suspected (headache, fever, meningeal signs). 3, 2

Management Algorithm

Immediate Management (While Awaiting Imaging)

If sudden hearing loss component:

• Initiate oral corticosteroids immediately (prednisone 1 mg/kg/day, maximum 60 mg/day for 10-14 days with taper). 5
• Intratympanic dexamethasone can be offered as initial therapy if oral steroids contraindicated or as salvage treatment if hearing recovery incomplete after 2-4 weeks. 5

Symptomatic management:

• Meclizine 25-50 mg every 6-8 hours for vertigo (FDA-approved for vertigo associated with vestibular system diseases). 9
• Ibuprofen 400-800 mg every 6-8 hours for headache and ear pain (monitor for GI side effects). 10
• Antiemetics (ondansetron 4-8 mg) for nausea if needed. 6

Etiology-Specific Management

For Otitis Media with Complications:

• Broad-spectrum IV antibiotics (ampicillin plus ceftriaxone) if intracranial complications suspected. 2
• Urgent ENT consultation for possible mastoidectomy and tympanoplasty. 2
• Anticoagulation consideration if sigmoid sinus thrombosis confirmed. 2

For Autoimmune Inner Ear Disease:

• High-dose corticosteroids (prednisone 1 mg/kg/day) as first-line therapy. 4
• Rheumatology consultation for consideration of steroid-sparing immunosuppressive agents if steroid-responsive. 4
• Ophthalmology evaluation if Cogan syndrome suspected (eye symptoms present). 4

For Vestibular Schwannoma:

• Neurosurgery and neuro-otology consultation for management options (observation, stereotactic radiosurgery, or microsurgical resection). 5
• Hearing rehabilitation strategies if hearing loss significant. 5

For Ménière's Disease:

• Low-sodium diet (<2000 mg/day) and diuretics (hydrochlorothiazide/triamterene). 3
• Intratympanic gentamicin or endolymphatic sac surgery for refractory cases. 3

For Acute Bacterial Sinusitis:

• Amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days if bacterial sinusitis confirmed. 3
• Nasal saline irrigation and intranasal corticosteroids as adjunctive therapy. 3

For Vestibular Neuritis/Labyrinthitis:

• Short course of corticosteroids (methylprednisolone 100 mg daily for 3 days, then taper) within 72 hours of onset. 6
• Vestibular physical therapy is the cornerstone of recovery—begin as soon as acute symptoms subside. 6
• Avoid prolonged vestibular suppressants (>3 days) as they delay central compensation. 6

For Stroke:

• Immediate neurology consultation and stroke protocol activation. 3
• Antiplatelet or anticoagulation therapy per stroke guidelines. 3

Common Pitfalls and How to Avoid Them

Pitfall 1: Attributing all symptoms to sinusitis and missing serious pathology:

• True vertigo (spinning sensation) is NOT a typical feature of uncomplicated sinusitis—its presence mandates vestibular or neurologic evaluation. 3
• Unilateral hearing loss is NOT explained by sinusitis alone—requires audiometry and imaging. 5

Pitfall 2: Delaying imaging in patients with "peripheral" findings:

• Both peripheral and central vestibular disorders can manifest overlapping signs including vertical skew, nystagmus, abnormal vestibular ocular reflex, hearing loss, and gait instability due to shared neurovascular supply. 6
• Stroke should be considered in every person with acute vestibular syndrome because it can act as a harbinger of impending cerebellar herniation. 6

Pitfall 3: Ordering routine head CT instead of appropriate imaging:

• Routine head CT has no role and provides no useful information for this presentation. 3
• MRI with IAC sequences is mandatory for unilateral hearing loss with neurologic symptoms. 5, 1

Pitfall 4: Missing autoimmune causes:

• Progressive fluctuating hearing loss, especially bilateral, strongly suggests autoimmune etiology and requires trial of corticosteroids. 4
• Absence of systemic symptoms does not exclude autoimmune disease—audiovestibular manifestations may precede other organ involvement. 4

Pitfall 5: Prolonged use of vestibular suppressants:

• Meclizine and other vestibular suppressants should be limited to 3 days maximum as they delay central vestibular compensation. 6
• Vestibular physical therapy is the evidence-based treatment for long-term recovery. 6

Prognostic Considerations

The presence of vertigo at onset significantly worsens prognosis for hearing recovery, with substantially lower complete recovery rates compared to sudden hearing loss without vestibular symptoms. 5