Clinical conundrum - Mr M

susan moreland smorelan at magnus.acs.ohio-state.edu
Fri Nov 24 16:27:36 EST 1995


In article <3816pmn5f at ovation.wgtn.planet.co.nz> richard at ovation.wgtn.planet.co.nz (Richard Bishop) writes:

has he ever had any vestibular evaluation?  the stuffed up sensation and the 
vertigo are suggestive of meniere's disease, although the timing of the 
vertigo is odd.  does he have tinnitus as well?  

i guess i would consider performing an ENG on the patient to obtain more 
information.  there appears to be a vestibular component that has not been 
addressed.  

susan


>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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