What are the next steps for a 32-year-old female patient with dizziness, vomiting, and headaches, who has a history of an abscess treated with an unspecified antibiotic, a recent lack of sleep due to night shift work, and a small, non-infected tympanic membrane perforation on the right eardrum?

Immediate Next Steps for 32-Year-Old Female with Dizziness, Vomiting, and Tympanic Membrane Perforation

This patient requires urgent neuroimaging with MRI brain and internal auditory canals with gadolinium contrast to exclude central pathology, as the constellation of temple headaches, persistent dizziness, vomiting, and a 3-month delay from ear trauma to symptom onset cannot be explained by the small tympanic membrane perforation alone. 1

Critical Diagnostic Priorities

The combination of headaches, dizziness, and vomiting raises concern for intracranial pathology that must be excluded before attributing symptoms solely to the ear perforation. 1 The American Academy of Otolaryngology-Head and Neck Surgery recommends MRI with diffusion-weighted imaging as first-line imaging for patients presenting with focal neurological deficits, severe headache with dizziness, or atypical presentations suggesting central causes. 1

Why Neuroimaging is Essential

• Local trauma such as tympanic membrane perforation does not explain systemic neurological symptoms like temple headaches and persistent vomiting 1, 2
• Cerebellopontine angle or internal auditory canal lesions can present with headaches, dizziness, and balance issues 1
• Posterior fossa pathology must be excluded given the symptom constellation 1
• Vertebrobasilar territory stroke or ischemia can cause dizziness, visual disturbances, and balance problems 1

Immediate Workup Algorithm

First-Line Studies (Urgent)

• MRI brain and internal auditory canals with and without gadolinium contrast, including diffusion-weighted imaging sequences 1
• Complete audiometric evaluation including pure-tone audiometry and speech discrimination 1
• Formal otoscopic examination with photodocumentation - the white patch at 1 o'clock position should not be dismissed as simple scarring without proper evaluation 1

Baseline Documentation

• Complete neurological examination including cranial nerve testing, gait assessment, and Romberg testing 1
• Document timing, frequency, and duration of dizziness episodes 3

Urgent Specialty Referrals

• Otolaryngology referral for comprehensive evaluation of the tympanic membrane perforation and vestibular symptoms 1
• Neurology consultation given the constellation of neurological symptoms including temple headaches, dizziness, and vomiting 1

Immediate Management Pending Workup

Ear Protection Measures

• Keep the ear dry using petroleum jelly-coated cotton during showering 1, 2, 4
• Avoid swimming until perforation is healed 2
• Never irrigate the ear - irrigation with known or suspected tympanic membrane perforation can cause middle ear infection, severe vertigo from caloric stimulation, or ototoxicity 2, 4

Medication Considerations

• Avoid ototoxic medications, particularly aminoglycoside drops, as these can cause permanent hearing loss through perforations 1, 2
• If topical antibiotics are needed for infection, use only fluoroquinolone drops (ofloxacin or ciprofloxacin-dexamethasone) 2
• Consider meclizine 25-100 mg daily in divided doses for symptomatic vertigo relief 5, though this addresses symptoms rather than underlying cause

Critical Safety Precautions

• Do not perform caloric vestibular testing before confirming tympanic membrane integrity 1
• Avoid pneumatic otoscopy given the known perforation 6

Critical Pitfalls to Avoid

• Do not assume all symptoms are related to local ear trauma - the 3-month delay between ear cleaning and symptom onset, combined with the systemic nature of symptoms (temple headaches, vomiting), suggests alternative or additional pathology 1
• Do not attribute persistent dizziness solely to the perforation - while tympanic membrane perforations can cause mild conductive hearing loss, aural fullness, and mild tinnitus 6, they do not typically cause persistent severe dizziness with vomiting and headaches
• Do not delay neuroimaging - severe vertigo, nausea, and vomiting with a history of ear trauma may signify disruption of the ossicular chain or inner ear nerve damage 6

Additional Differential Diagnoses to Consider

• Vestibular migraine presenting with both vestibular symptoms and headache 2
• Post-traumatic causes if headaches resulted from head trauma during the initial ear cleaning episode 2
• Secondary infection spreading to vestibular structures 2
• Sleep deprivation effects from night shift work (though this alone would not explain the tympanic membrane finding or symptom persistence)

Follow-Up Considerations

• If imaging is negative and symptoms persist after cerumen removal was performed, consider that the perforation itself may have been iatrogenic from the ear cleaning procedure 4
• Ear irrigation complications occur in approximately 1 in 1000 cases and can include tympanic membrane perforation, otitis externa, pain, dizziness, and syncope 3, 4
• Most small traumatic perforations heal spontaneously within one month; otolaryngologic referral is necessary for perforations that do not heal within this timeframe 6