What are the potential causes and recommended treatments for a patient experiencing a whooshing sound in the right ear accompanied by dizziness?

Whooshing Sound in Right Ear with Dizziness: Diagnostic Approach and Management

The combination of a whooshing sound (tinnitus) in one ear with dizziness most likely represents either Ménière's disease, sudden sensorineural hearing loss (SSNHL), or benign paroxysmal positional vertigo (BPPV), and requires urgent audiometric testing and targeted physical examination to differentiate these conditions and rule out serious causes like stroke. 1, 2

Critical Initial Assessment

Characterize the Dizziness Pattern

The timing and triggers of dizziness are essential for diagnosis 2:

• Seconds-long positional vertigo: Suggests BPPV—perform Dix-Hallpike maneuver immediately 1, 2
• 20 minutes to 12 hours of vertigo: Consider Ménière's disease, especially with fluctuating hearing loss, ear fullness, or tinnitus 1
• Sudden onset with persistent symptoms: Suspect SSNHL, which presents with dizziness in 30-60% of cases and indicates poorer prognosis 1, 3

Key History Questions to Ask

Obtain specific details about 1:

• Duration: How long does each episode last?
• Hearing changes: Is there fluctuating hearing loss? Does it worsen during dizzy spells?
• Ear fullness: Does the right ear feel plugged or full?
• Tinnitus character: Is the "whooshing" constant or does it fluctuate with symptoms?
• Triggers: Does head position change provoke symptoms?
• Associated symptoms: Headache, visual changes, neurologic symptoms, nausea/vomiting?

Differential Diagnosis Framework

Ménière's Disease (Probable)

Definite Ménière's disease requires 1:

• Two or more spontaneous vertigo attacks lasting 20 minutes to 12 hours
• Audiometrically documented low- to mid-frequency sensorineural hearing loss
• Fluctuating aural symptoms (hearing loss, tinnitus, ear fullness) in the affected ear
• Other causes excluded

Probable Ménière's disease 1:

• At least 2 episodes of vertigo/dizziness lasting 20 minutes to 24 hours
• Fluctuating aural symptoms in the affected ear
• Other causes excluded

Sudden Sensorineural Hearing Loss

SSNHL presents with 1, 4:

• Sudden unilateral hearing loss (typically within 72 hours)
• Dizziness in 30-60% of cases—presence indicates worse prognosis 1, 3
• Nearly universal tinnitus 1
• Requires urgent evaluation and treatment within days for optimal outcomes 4

Benign Paroxysmal Positional Vertigo

BPPV characteristics 1, 5:

• Brief episodes (seconds, not minutes) of vertigo with position changes
• Not associated with hearing loss, tinnitus, or ear fullness 1
• Diagnosed by Dix-Hallpike maneuver showing characteristic nystagmus 1

Red Flags Requiring Urgent Neuroimaging

Immediately consider stroke or central causes if 1, 2:

• Neurologic symptoms (dysphasia, dysphagia, visual changes, weakness)
• Severe imbalance without vertigo
• Vertical or direction-changing nystagmus
• Negative HINTS exam in acute vestibular syndrome
• Symptoms lasting >24 hours without improvement

Diagnostic Testing Algorithm

Immediate Testing Required

1. Audiometry 1, 3:

   • Essential for all patients with unilateral tinnitus and dizziness
   • Documents hearing loss pattern (low-to-mid frequency in Ménière's, any frequency in SSNHL)
   • Takes approximately 30 minutes 1

2. Dix-Hallpike Maneuver 1:

   • Perform if positional triggers are present
   • Rules out BPPV as primary cause
   • Positive test shows latency period (5-20 seconds), then crescendo-decrescendo nystagmus lasting <60 seconds 1

Additional Testing Based on Clinical Suspicion

For Ménière's disease 1:

• Video/electronystagmography (VNG/ENG): Evaluates vestibular function; takes ~1 hour; may cause temporary vertigo and nausea 1
• Electrocochleography: Measures cochlear electrical responses; may cause ear discomfort 1
• MRI brain with contrast: Essential to exclude vestibular schwannoma and other structural lesions 1

For SSNHL 1, 4:

• Urgent audiometry (within days)
• MRI if indicated to exclude retrocochlear pathology
• Consider laboratory testing for autoimmune, infectious causes in select cases 4

Treatment Approach

For Ménière's Disease

Initial management 1:

• Sodium-restricted diet (lifestyle modification)
• Vestibular suppressants during acute attacks: Meclizine is FDA-approved for vertigo associated with vestibular system diseases 6
• Patient education about disease course and triggers 1

Escalation if inadequate control 1:

• Intratympanic gentamicin for refractory vertigo
• Endolymphatic sac decompression surgery
• Vestibular nerve section or labyrinthectomy for severe cases with non-serviceable hearing 1

For SSNHL

Urgent treatment (within days) 1, 4:

• High-dose oral corticosteroids are recommended 4
• Consider intratympanic steroids as salvage therapy if oral steroids fail 1
• Audiometric reassessment to monitor recovery 1

For BPPV

Immediate bedside treatment 1, 5:

• Canalith repositioning maneuvers (Epley maneuver)
• Provides immediate and long-lasting relief in most cases 5

Follow-Up and Monitoring

For Ménière's disease 1:

• Frequent follow-up initially to assess vertigo control and hearing stability
• Serial audiometry to monitor hearing progression 1
• Quality of life assessments to guide treatment intensity 1
• Adjust treatment based on attack frequency and severity 1

For SSNHL 1:

• Repeated audiometric assessment with continued follow-up
• Rehabilitation with hearing aids or implantable devices if hearing does not recover 1
• Address persistent tinnitus and psychological burden 1

Critical Pitfalls to Avoid

• Do not delay audiometry: Hearing testing is essential and cannot be deferred 1, 3
• Do not miss SSNHL: Time-sensitive condition requiring treatment within days for optimal outcomes 4
• Do not assume BPPV without testing: Hearing loss, tinnitus, and ear fullness exclude isolated BPPV 1
• Do not ignore red flags: Central causes like stroke require immediate neuroimaging 1, 2
• Do not repeat Dix-Hallpike unnecessarily: Causes patient discomfort and is not required for diagnosis 1