What are the possible causes and treatment options for a patient experiencing pain around the left ear, pressure to the left ear with ringing (tinnitus), and episodes of dizziness after having the flu?

Post-Influenza Ear Symptoms: Likely Viral Labyrinthitis or Vestibular Neuritis

This patient most likely has viral labyrinthitis or vestibular neuritis following influenza, and should be evaluated urgently to rule out other serious causes before initiating symptomatic treatment with vestibular suppressants and considering corticosteroids if seen within the first few days of symptom onset. 1

Differential Diagnosis

The combination of unilateral ear pain, pressure, tinnitus, and dizziness following flu suggests several possibilities that must be systematically evaluated:

Most Likely: Viral Labyrinthitis or Vestibular Neuritis

• Labyrinthitis presents with sudden severe vertigo, profound hearing loss, and prolonged vertigo lasting more than 24 hours, with associated nausea and hearing loss that is not episodic or fluctuating 1
• Vestibular neuritis is a viral infection of the vestibular system leading to acute prolonged vertigo with nausea and vomiting, but without hearing loss, tinnitus, or aural fullness; severe rotational vertigo typically lasts 12 to 36 hours with decreasing disequilibrium over 4-5 days 1
• The post-influenza timing strongly supports a viral etiology for inner ear involvement 2

Other Important Considerations to Rule Out

Otitis Media with Effusion (OME):

• Middle ear effusion can cause ear pressure, hearing loss, and dizziness, but typically lacks severe pain and is more common in children 3, 4
• Examination would show dull, retracted tympanic membranes with exudates 3

Cerumen Impaction:

• Can cause ear fullness, tinnitus, and dizziness, but this is easily identified and excluded on otoscopic examination 1
• Must be removed before establishing any other diagnosis 1

Ménière's Disease (unlikely given presentation):

• Requires at least 2 episodes of vertigo lasting 20 minutes to 24 hours with fluctuating aural symptoms 1
• This patient's single episode post-flu makes Ménière's less likely 1

Critical Evaluation Steps

Immediate Assessment Required

Distinguish conductive from sensorineural hearing loss:

• Perform otoscopic examination to identify cerumen impaction, middle ear fluid, or tympanic membrane abnormalities 1
• Conduct Weber and Rinne tuning fork tests at bedside 1
• Patients with sensorineural hearing loss will have normal otoscopic examination, whereas conductive hearing loss shows abnormalities 1

Characterize the dizziness:

• Confirm true vertigo (spinning sensation) versus vague dizziness or lightheadedness 1
• Determine duration: seconds (BPPV), minutes to hours (Ménière's or migraine), or prolonged 12-36 hours (vestibular neuritis) 1
• Ask if symptoms are positional (suggests BPPV rather than labyrinthitis) 1

Red flags requiring urgent neurologic evaluation:

• Focal neurologic symptoms (dysphasia, dysphonia, visual changes, facial numbness) suggest stroke rather than inner ear pathology 1
• Severe imbalance with drop attacks without loss of consciousness 1
• Bilateral symptoms or recurrent episodes 1

Diagnostic Testing

Audiometry is essential:

• Obtain comprehensive audiologic examination for unilateral tinnitus and hearing difficulties 5
• Helps distinguish labyrinthitis (with hearing loss) from vestibular neuritis (without hearing loss) 1

Imaging is NOT routinely indicated:

• Do not obtain imaging for tinnitus that does not localize to one ear, is nonpulsatile, and lacks focal neurologic abnormalities or asymmetric hearing loss 5
• However, if red flags are present or diagnosis remains unclear after initial evaluation, MRI may be warranted 1

Treatment Approach

Acute Management (First 72 Hours)

Vestibular suppressants for symptom control:

• Meclizine, dimenhydrinate, or benzodiazepines can be used for acute severe vertigo 1
• These should be discontinued after 3 days to avoid delaying central compensation 1

Corticosteroids (if seen early):

• Consider systemic corticosteroids if patient presents within first few days of symptom onset for vestibular neuritis 1
• Evidence is stronger for sudden sensorineural hearing loss component 1

Adequate analgesia:

• Address ear pain appropriately with analgesics 4

Subacute Management (After Initial Days)

Vestibular rehabilitation:

• Encourage early mobilization and vestibular exercises once acute phase resolves 1
• Prolonged use of vestibular suppressants impairs compensation 1

Monitoring:

• Most patients with viral labyrinthitis or vestibular neuritis experience complete resolution within 2 weeks 2
• If symptoms persist beyond expected timeframe, reassess for alternative diagnoses 2

What NOT to Do

Avoid antibiotics:

• Antibiotics are not indicated for viral labyrinthitis, vestibular neuritis, or OME 3, 4
• Only use if bacterial otitis media or other bacterial infection is confirmed 4

Do not use antihistamines or decongestants routinely:

• These are not recommended for OME or viral inner ear disorders 3

Common Pitfalls

• Assuming all post-viral ear symptoms are benign: Always rule out stroke, especially in older patients with vascular risk factors 1
• Missing cerumen impaction: This simple, treatable cause must be excluded first 1
• Prolonged vestibular suppressant use: This delays central compensation and prolongs recovery 1
• Failing to obtain audiometry: This is essential to distinguish labyrinthitis from vestibular neuritis and guide prognosis 5
• Overlooking COVID-19: In the current era, consider SARS-CoV-2 testing as otologic and vestibular symptoms can be presenting features 2