Clinical conundrum - Mr M
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
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
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
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:
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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