Clinical conundrum - Mr M

Richard Bishop richard at ovation.wgtn.planet.co.nz
Fri Nov 24 03:42:55 EST 1995


The following are details on an active 80 year old man who is 
exhibiting very unusual symptoms.   I am at a loss to account 
for them and he has been able to obtain no satisfactory medical 
opinion either.   If you have any thoughts on the matter I 
would be very grateful for your input.

Thanks in advance:

	Mr M came to see me early in 1994 with regard to problems with his 
	binaural hearing aids which he had purchased while on holiday 
	in Hawaii.   These replaced his previous monaural hearing aid 
	which had been quite satisfactory until that time when he felt 
	that his hearing problems were increasing.   The replacement 
	aids were not very satisfactory and we have been trying since 
	then to find something more suitable for him, with little 
	success.   Because of his history of noise exposure both from 
	explosions and gunfire in WWII and from his trade as a builder 
	he successfully registered a claim with ACC ("wokers 
	compensation") for noise-induced hearing loss.

	He finds that listening to people talking makes him feel "blocked
	up".	This symptom is not relieved with hearing aids.   Wearing
	hearing aids makes him feel decidedly worse.   If he wears either
	hearing aid with it turned off he feels slightly off-balance.   
	Using the Right hearing	aid makes him feel slightly off-balance 
	and produces the blocked-up feeling.   Using the Left hearing aid
	causes the same result plus a reasonably prompt onset of acute 
	vertigo, nausea and vomiting, lasting for 2 hours.   These symptoms
	have become more severe since I first saw him.

	He was referred to a neurologist by his GP who noted some "minor
	?temporal lobe abnormality" but I have not been able to obtain a 
	copy of	his findings.  I believe investigation at that time 
	included CAT.

	Audiologically, he has a stable, reasonably bilaterally symmetrical
	sensorineural hearing loss of mild to moderate degree in the low
	frequencies, becoming profound above 2kHz.   The dynamic range is 
	about 20 - 30dB across the frequencies.   Middle ear function is 
	reasonably normal on tympanometry.   Acoustic reflexes are normal 
	ipsilaterally on both sides as is the Left crossed reflex.    The 
	Right crossed reflex is absent.   Speech audiometry shows very poor
	discrimination bilaterally with virtually no advantage from diotic 
	presentation.

	Upper limits of comfortable loudness are bilaterally symmetrical 
	and within normal limits in the low frequencies.

	Speech audiometry using AB Short Word Lists shows poor 
	discrimination ability bilaterally with no significant 
	diotic advantage:
                                	LEFT         RIGHT      BINAURAL
	Optimum discrimination score    ca29%         ca27%         ca32%
	Obtained at                      100dB SPL     100dB SPL      80dB SPL
	Half-peak level elevation       ca45dB        ca45dB        ca40dB
	Slope (Norm = 4.0%/dB)           n/a%/dB       n/a%/dB       n/a%/dB
	Rollover Index                  n.s.          n.s.
	Everyday ave (Norm = 100%)         0%            0%            0%

	Tympanometry was essentially normal bilaterally:
                                	LEFT             RIGHT
	Ear canal volume                1.1ml            1.4ml
	Middle ear pressure             -15 -> -10daPa   0daPa
	Compliance                      1.1ml            0.6ml
	Gradient                        0.7              0.6
	Type                            A                A
	ThetaY226                       70o              62o

	Resistance and reactance in the Right ear are slightly higher than 
	the Left, and the gradient is lower (less-peaked).   It is possible
	that this could be due to inner ear effects.

	Acoustic reflex activity was well-defined in 3 out of 4 stimulus 
	modes and there was no apparent reflex decay in the Left 
	ipsilateral mode.   Further reflex decay measures were not undertaken 
as the 		procedure was very uncomfortable to him.
are only present when he 
		uses the hearing aids.





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