What's the next step for a patient with persistent right ear fullness, dampened hearing, and tinnitus despite completing a 10-day course of Augmentin (amoxicillin/clavulanate) and seeking a flu vaccine?

Immediate Management of Persistent Aural Fullness and Tinnitus After Failed Antibiotic Therapy

This patient requires a comprehensive audiologic examination today to evaluate for sudden sensorineural hearing loss (SSNHL), as the 10-day symptom duration with unilateral aural fullness, dampened hearing, autophony, and tinnitus—despite completing antibiotics—suggests inner ear pathology rather than bacterial otitis media. 1

Critical Next Steps for Today's Visit

1. Obtain Urgent Audiologic Testing

• Pure tone audiometry with speech audiometry must be performed immediately to determine if this represents SSNHL, which is defined as hearing loss occurring over 72 hours and requires prompt intervention for optimal recovery outcomes 1
• The initial urgent care diagnosis of "erythema and edema" without documented cerumen impaction, combined with lack of response to Augmentin, strongly suggests the wrong diagnosis was made 1
• Aural fullness is the primary presenting symptom of sudden hearing loss, and both patients and physicians often fail to recognize its urgency, leading to delayed treatment 1

2. Perform Targeted Physical Examination Today

• Repeat otoscopic examination specifically looking for: tympanic membrane abnormalities, middle ear effusion, or retrotympanic masses 2
• Perform cranial nerve examination with focus on CN VIII (hearing/vestibular function) 2
• Auscultate neck, periauricular region, and temporal area for bruits (though pulsatile tinnitus is not described here) 2
• Assess for any focal neurological abnormalities 2

3. Detailed History to Differentiate Diagnoses

Key questions to distinguish between possible etiologies:

• For Ménière's disease: Ask about episodic vertigo attacks (spontaneous onset, duration of minutes to hours), fluctuating hearing, and whether symptoms occur together 1
• For vestibular migraine: Inquire about migraine history, light sensitivity, motion intolerance, visual auras, and whether "hearing loss" feels more like difficulty processing sound (often bilateral in migraine) 1
• For Eustachian tube dysfunction: The autophony and transient relief with ear manipulation suggest this possibility, but 10-day duration without improvement warrants ruling out more serious pathology 1

4. Imaging Considerations

• Do NOT obtain imaging today unless audiometry reveals asymmetric hearing loss or unilateral sensorineural hearing loss, which would then warrant MRI to exclude vestibular schwannoma 2, 3
• Bilateral non-pulsatile tinnitus without focal neurological findings does not require imaging 2

Treatment Algorithm Based on Audiometry Results

If Audiometry Shows SSNHL:

• Immediate corticosteroid therapy is indicated (systemic steroids are standard treatment, though specific protocols vary) 1
• Prognosis depends on time to treatment—you are already at 10 days, making urgent intervention critical 1
• Maximum spontaneous recovery occurs in only 32-65% of cases, and even this may be overestimated 1

If Audiometry Shows Normal Hearing or Mild Conductive Loss:

• Consider Eustachian tube dysfunction as primary diagnosis
• The autophony and sensation of hearing own voice resonating strongly suggests this diagnosis
• Conservative management with nasal decongestants, nasal corticosteroids, and observation may be appropriate
• Avoid further antibiotics as the lack of response to Augmentin indicates non-bacterial etiology 1

If Audiometry Shows Hearing Loss with Tinnitus:

• Recommend hearing aid evaluation even if hearing loss is mild or unilateral, as hearing aids provide significant relief for tinnitus associated with hearing loss 1, 4
• Provide education and counseling about tinnitus management strategies 1, 4
• Consider sound therapy (background noise, white noise) for symptomatic relief 1, 4

Regarding the Flu Vaccine Request

Administer the flu vaccine today unless audiometry reveals active SSNHL requiring urgent corticosteroid therapy, in which case coordinate timing with the treating otolaryngologist 1. There is no contraindication to flu vaccination in patients with tinnitus or ear fullness, though rare case reports exist of tinnitus following mRNA vaccines 5.

Common Pitfalls to Avoid

• Do not prescribe additional antibiotics—the lack of response to 10 days of Augmentin definitively rules out bacterial infection 1
• Do not dismiss this as "just ear fullness"—this symptom can represent serious inner ear pathology requiring urgent intervention 1
• Do not delay audiometry—waiting to "see if it improves" wastes the critical treatment window for SSNHL 1
• Do not recommend dietary supplements (Ginkgo biloba, zinc, melatonin) for tinnitus, as they lack evidence of benefit 1, 4, 3
• Do not prescribe antidepressants, anticonvulsants, or anxiolytics specifically for tinnitus treatment without addressing underlying causes first 1, 4

If SSNHL is Confirmed: Long-Term Considerations

• Some patients will have underlying causes identified only after long-term follow-up (up to one-third of cases) 1
• Patients with partial or no hearing recovery require ongoing management from otolaryngological, audiological, and psychological perspectives 1
• Cognitive behavioral therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus if symptoms continue beyond 6 months 1, 4, 6