How should I evaluate and manage a patient presenting with dizziness and ear pain?

Evaluation and Management of Dizziness with Ear Pain

Begin with the Dix-Hallpike maneuver bilaterally to diagnose benign paroxysmal positional vertigo (BPPV), and simultaneously examine the ear canal and tympanic membrane to identify primary ear pathology causing the otalgia. 1

Initial Clinical Assessment

Distinguish true vertigo from other forms of dizziness by asking whether the patient experiences a false sensation of self-motion or spinning of the visual surroundings, which indicates vestibular system dysfunction. 1 Many patients use "dizziness" vaguely to describe lightheadedness or presyncope, which are not vestibular disorders and may indicate cardiovascular causes. 1

Critical History Elements

• Duration of dizziness episodes helps narrow the differential: seconds suggest BPPV, minutes to hours suggest vestibular migraine or Ménière's disease, and days to weeks suggest vestibular neuritis or stroke. 1
• Triggers distinguish causes: head position changes point to BPPV, standing up suggests orthostatic hypotension, and spontaneous episodes suggest Ménière's or vestibular migraine. 1
• Associated auditory symptoms including hearing loss, tinnitus, or aural fullness suggest Ménière's disease, while their absence points to BPPV or vestibular neuritis. 1
• Vascular risk factors (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) dramatically increase the likelihood of posterior circulation stroke, which accounts for 25% of acute vestibular syndrome overall but rises to 75% in high-risk cohorts. 1

Ear Pain Evaluation

Examine the tympanic membrane and external auditory canal to determine if the otalgia is primary (originating from the ear) or secondary (referred pain with normal ear examination). 2, 3

• Primary otalgia most commonly results from acute otitis media (characterized by erythematous, bulging, cloudy tympanic membrane) or otitis externa (painful cellulitis of the external auditory canal with erythema, edema, and drainage). 2
• Secondary otalgia with normal ear examination suggests temporomandibular joint syndrome, pharyngitis, dental disease, or cervical spine arthritis. 3
• Cerumen impaction can cause both ear pain and dizziness and should be identified and removed. 2

Physical Examination

Vestibular Testing

Perform the Dix-Hallpike maneuver bilaterally as the gold standard for diagnosing posterior canal BPPV, looking for torsional upbeating nystagmus with 5-20 second latency that crescendos then resolves within 60 seconds. 1

If Dix-Hallpike is negative, conduct the supine roll test to assess for horizontal canal BPPV, which accounts for 10-15% of BPPV cases. 1

For acute persistent vertigo, perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if you are trained in this technique, as it has 100% sensitivity for detecting stroke when performed by experts—superior to early MRI at 46% sensitivity. 1 However, emergency physicians achieve inadequate sensitivity, so do not rely on HINTS alone in the emergency department; obtain urgent MRI for high-risk patients regardless of HINTS results. 1

Red Flags Requiring Urgent MRI

Order MRI brain without contrast immediately for any of the following: 1

• Focal neurological deficits (dysarthria, limb weakness, sensory loss, diplopia, Horner's syndrome)
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or purely vertical nystagmus without torsional component
• Direction-changing nystagmus
• New severe headache accompanying dizziness
• Age >50 with vascular risk factors, even if neurologic exam is normal (11-25% harbor posterior circulation stroke)
• Normal head-impulse test (suggests central cause)
• Skew deviation on alternate cover testing

Diagnostic Testing Strategy

When Imaging Is NOT Indicated

Do not order neuroimaging for: 1

• Typical BPPV with positive Dix-Hallpike test and no red flags (diagnostic yield <1%)
• Acute persistent vertigo in patients <50 years without vascular risk factors, normal neurologic exam, and peripheral HINTS pattern by trained examiner
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

When Imaging IS Indicated

MRI brain without contrast is the preferred modality when imaging is needed, as CT has diagnostic yield <1% for isolated dizziness and misses most posterior circulation infarcts with only 10-20% sensitivity. 1 MRI with diffusion-weighted imaging has 4% diagnostic yield compared to <1% for CT. 1

Order MRI of brain and internal auditory canal with and without contrast for chronic recurrent vertigo with unilateral hearing loss or tinnitus to exclude vestibular schwannoma and enable definitive diagnosis of Ménière's disease. 1

Audiometric Testing

Obtain comprehensive audiometry for patients with unilateral tinnitus, persistent symptoms, or associated hearing difficulties to document the characteristic low-to-mid frequency sensorineural hearing loss pattern of Ménière's disease. 1, 4

Management Based on Diagnosis

BPPV Treatment

Perform the Epley canalith repositioning maneuver immediately after positive Dix-Hallpike test, which achieves 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1 No imaging or medication is needed for typical BPPV cases. 1

Avoid prescribing vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV, as they do not correct the mechanical pathology and may delay central compensation. 1

Reassess within one month after initial treatment to document resolution or persistence, and counsel about recurrence risk and fall prevention. 1

Acute Otitis Media or Otitis Externa

For acute otitis media, treat according to standard protocols with observation or antibiotics based on severity and patient age. 2

For otitis externa, initial management includes cleaning and drying the ear and application of topical antibiotics. 2 Swimmers should avoid polluted waters and ear-canal cleaning with cotton-tip applicators. 5

Ménière's Disease

Initiate salt restriction and diuretics for persistent symptoms, though evidence is limited. 1 Oral corticosteroids are recommended for acute attacks. 1

Consider intratympanic gentamicin for refractory vertigo when medical therapy fails, or endolymphatic sac decompression surgery for patients who do not respond to conservative measures. 1

Vestibular Neuritis

Limit vestibular suppressants to the acute phase only, followed by early vestibular rehabilitation to promote central compensation. 1

Medication Review

Systematically review all medications as a leading reversible cause of chronic dizziness, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 1

Special Considerations

Elderly Patients

Recognize that dizziness increases fall risk 12-fold in elderly patients, and BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within the prior 3 months. 1

Document fall history including number of falls in the past year, circumstances, and injuries sustained. 1

Vestibular Rehabilitation

Refer for vestibular rehabilitation therapy when dizziness persists after initial treatment, as it significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients or those with heightened fall risk. 1

Common Pitfalls to Avoid

• Do not rely solely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing, triggers, and associated symptoms instead. 1
• Do not assume normal neurologic exam excludes stroke, as 75-80% of posterior circulation strokes presenting with acute vestibular syndrome lack focal deficits. 1
• Do not substitute CT for MRI when stroke is suspected, as CT misses most posterior circulation infarcts. 1
• Do not overlook vestibular migraine, which accounts for 14% of all vertigo cases but remains markedly under-recognized, especially in younger patients. 1
• Approximately 50% of BPPV patients describe symptoms as lightheadedness or vague "off-balance" sensations rather than classic rotational vertigo, so perform Dix-Hallpike even without typical spinning description. 1