R. NICKBRYANMDS. JAMESZINREICHMD
A 44-YEAR-OLD man presented with a 1-year history of progressive right-sided hearing loss that developed after a syncopal episode during which he suffered blunt trauma to his occiput. He was unconscious briefly and was taken to the emergency department for evaluation. On arrival, he noted complete deafness in the left ear and marked hearing loss in the right ear, with tinnitus bilaterally. At that time, he denied vertigo. The physical examination was significant for hemotympanum in the left ear, with scant blood in the external auditory canal, no cerebrospinal fluid leak, normal facial strength, and a wide-based gait. A computed tomographic (CT) scan showed intraparenchymal hemorrhages in the frontal and temporal lobes bilaterally with associated edema and a right temporal subdural hematoma. Audiologic testing demonstrated profound hearing loss in the left ear and moderately severe sensorineural hearing loss (SNHL) in the right ear, with a speech discrimination score of 96% and a threshold of 60 dB. The patient received a short course of prednisone for presumed right auditory nerve traction, with modest improvement in his hearing. One year after the injury, the patient was referred to our clinic for fluctuating right-sided hearing loss. The patient reported that his hearing loss remained profound in the left ear and was worsening in a stepwise pattern in the right ear. His tinnitus persisted (greater in the left ear than in the right), and anosmia and dysgeusia had developed soon after the fall. He also complained of disequilibrium, which had improved with vestibular rehabilitation exercises. He reported no other syncopal events or neurologic symptoms. He had no significant history of noise exposure. He denied recent use of ototoxic agents and was taking no prescribed medications. The findings of a review of systems were noncontributory, and the results of otoscopy were normal. Audiologic testing showed a sloping moderate to profound right-sided SNHL, with a speech discrimination score of 30% (speech reception threshold, 65 dB); tympanometry revealed no abnormalities. Vestibular testing showed signs of persistent left vestibular hypofunction. The CT scans of the left temporal bone that were obtained immediately after the injury occurred are shown in the Figure 1. The right side was noted to have an enlarged vestibular aqueduct that was consistent with a congenital variation, but was otherwise normal.
Schindler JS, Niparko JK. Imaging Quiz Case 1. Arch Otolaryngol Head Neck Surg. 1998;124(7):814-818. doi:10.1001/archotol.124.7.814