What are the evaluation and treatment options for a patient with inner ear balance issues, including a history of possible ear infections, head trauma, or medication use?

Evaluation and Management of Inner Ear Balance Disorders

Initial Diagnostic Approach

Begin by determining the temporal pattern of symptoms—acute, episodic, or chronic—as this fundamentally directs diagnosis and treatment. 1, 2

Critical History Elements

Characterize the vertigo precisely:

• Confirm true rotational vertigo (spinning sensation) versus vague dizziness, lightheadedness, or imbalance 1
• Document attack duration: seconds suggests BPPV, minutes to hours suggests vestibular migraine, hours suggests Ménière's disease, days suggests vestibular neuritis 1, 2
• Identify triggers: positional changes (BPPV), spontaneous (Ménière's, vestibular neuritis), or stress/migraine-related 1

Document associated otologic symptoms:

• Hearing loss pattern: fluctuating low-to-mid frequency suggests Ménière's disease 1
• Tinnitus and aural fullness: when fluctuating with vertigo attacks, strongly suggests Ménière's disease 1
• Ear discharge or pain: suggests infection or chronic suppurative otitis media 3

Assess risk factors and exposures:

• Recent head trauma: may indicate temporal bone fracture or perilymphatic fistula 3
• Ototoxic medications: aminoglycosides, loop diuretics, chemotherapy agents 1, 3
• Recent ear infections or meningitis 1
• Diabetes, which can cause inner ear ischemia 4, 5

Physical Examination Priorities

Perform targeted bedside vestibular testing:

• Dix-Hallpike test for posterior canal BPPV: watch for characteristic upbeat-torsional nystagmus lasting <60 seconds 1
• Supine roll test for horizontal canal BPPV 1
• Head impulse test: abnormal suggests vestibular neuritis or bilateral vestibular loss 2
• Otoscopic examination: identify retrotympanic masses, perforation, or infection 1, 3

Identify neurologic red flags:

• Focal neurologic deficits (facial weakness, dysarthria, diplopia) suggest stroke or intracranial pathology 1, 3
• Loss of consciousness never occurs with Ménière's disease—indicates alternative diagnosis 1, 3
• Severe headache with vertigo may indicate posterior circulation stroke 2

Diagnostic Testing Algorithm

Obtain audiometry at initial presentation for any patient with vertigo plus hearing symptoms 1, 6

• Documents characteristic low-to-mid frequency sensorineural hearing loss in Ménière's disease 1, 6
• Excludes conductive hearing loss from middle ear pathology 7

Reserve imaging for specific indications:

• MRI brain/IAC for unilateral tinnitus, asymmetric hearing loss, or neurologic deficits to exclude vestibular schwannoma 1
• Temporal bone CT only if retrotympanic mass seen on otoscopy or trauma suspected 1
• Do NOT image patients with isolated BPPV, bilateral symmetric tinnitus, or typical Ménière's disease without red flags 1

Treatment by Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

Perform canalith repositioning maneuvers immediately—they have 80% success rates with 1-3 treatments 1

• Epley maneuver for posterior canal BPPV 1
• Barbecue roll for horizontal canal BPPV 1
• Avoid vestibular suppressant medications except for severe acute distress 1

Common pitfall: BPPV can be secondary to other inner ear diseases in 3% of cases, particularly Ménière's disease, vestibular neuritis, or head trauma 5. Consider audiometry and caloric testing if BPPV recurs frequently 5.

Ménière's Disease

Initiate stepwise treatment starting with least invasive approaches 1, 6:

1. Dietary modifications (first-line):

   • Sodium restriction to 1500-2300 mg daily 1, 6
   • Limit alcohol and caffeine 1, 6
   • Identify personal triggers through symptom diary 1, 6

2. Pharmacotherapy for maintenance:

   • Diuretics to reduce endolymphatic volume 1, 6
   • Do NOT routinely use betahistine—the BEMED trial showed no significant benefit over placebo 6
   • Vestibular suppressants (meclizine, dimenhydrinate) only during acute attacks, not for maintenance 1, 6

3. Intratympanic therapies for refractory disease:

   • Intratympanic steroids: 85-90% vertigo improvement versus 57-80% with conventional therapy 6
   • Intratympanic gentamicin: 73.6% complete vertigo control but risk of hearing loss 6

4. Surgical options for failed medical management:

   • Endolymphatic sac decompression (hearing-sparing) 1
   • Vestibular nerve section (hearing-sparing) 1
   • Labyrinthectomy only for non-usable hearing 1, 6

Critical warning: 10-25% of Ménière's disease becomes bilateral—never perform ablative procedures on the only hearing ear 6

Do NOT use positive pressure therapy (Meniett device)—systematic reviews show no benefit over placebo 1, 6

Vestibular Neuritis

Acute vestibular syndrome lasting days requires differentiation from stroke 2:

• Head impulse test abnormal in vestibular neuritis, normal in stroke 2
• Vestibular suppressants for acute symptom relief (3-5 days maximum) 4
• Early vestibular rehabilitation accelerates compensation 4, 2

Bilateral Vestibular Loss

Presents with oscillopsia and imbalance rather than vertigo 2:

• Causes include ototoxic medications, meningitis, bilateral Ménière's disease 4, 2
• Head impulse testing, dynamic visual acuity, and Romberg tests are abnormal 2
• Vestibular rehabilitation is primary treatment 4, 2

Vestibular Rehabilitation Indications

Offer vestibular rehabilitation for:

• Chronic imbalance between Ménière's attacks 6
• Post-vestibular neuritis compensation 4, 2
• Following ablative procedures 6
• Bilateral vestibular loss 2

Do NOT use vestibular rehabilitation for acute vertigo attacks—it worsens symptoms 6

Follow-Up and Monitoring

Document systematically at each visit:

• Vertigo frequency and severity changes 1, 6
• Hearing status with serial audiograms 1, 6
• Tinnitus and aural fullness progression 1, 6
• Quality of life impact using validated instruments 6

Adjust treatment based on symptom evolution—Ménière's disease has a naturally fluctuating course with up to 60% placebo response 6