A 45-year-old man comes to the office due to difficulty hearing in the right ear. The patient first noticed that he could not hear in his right ear when he awoke this morning. He has had no ringing in the ear, earache, or drainage, and no recent upper respiratory illness. There is also no associated vertigo, tinnitus, or imbalance. He has a history of seasonal allergy but has had no recent symptoms. The patient takes no medications, drinks alcohol occasionally, and does not use tobacco or illicit drugs.
Vital signs are within normal limits. Otoscopic examination shows a normal external auditory canal, and the tympanic membrane is gray with a normal light reflex. The patient is unable to hear a whisper in the right ear. Sound from a tuning fork placed in the middle of the forehead lateralizes to the left ear. The tuning fork is heard better when held in front of either ear compared to when placed on the ipsilateral mastoid. No nystagmus is present. The remainder of the examination is within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Question

A 45-year-old man comes to the office due to difficulty hearing in the right ear.  The patient first noticed that he could not hear in his right ear when he awoke this morning.  He has had no ringing in the ear, earache, or drainage, and no recent upper respiratory illness.  There is also no associated vertigo, tinnitus, or imbalance.  He has a history of seasonal allergy but has had no recent symptoms.  The patient takes no medications, drinks alcohol occasionally, and does not use tobacco or illicit drugs.
Vital signs are within normal limits.  Otoscopic examination shows a normal external auditory canal, and the tympanic membrane is gray with a normal light reflex.  The patient is unable to hear a whisper in the right ear.  Sound from a tuning fork placed in the middle of the forehead lateralizes to the left ear.  The tuning fork is heard better when held in front of either ear compared to when placed on the ipsilateral mastoid.  No nystagmus is present.  The remainder of the examination is within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_979b_2ef4_853d_5d11676aaa60_MD0002_00 This patient has acute unilateral hearing loss. Weber test shows lateralization to the unaffected ear, and Rinne test shows air conduction better than bone conduction in both ears. This is consistent with sensorineural hearing loss (SNHL). In contrast, patients with conductive hearing loss show bone conduction better than air conduction on Rinne test, and sound lateralizes to the affected ear on Weber test because ambient noise dampens sensitivity on the unaffected side. Most patients with acute unilateral SNHL have a benign etiology (eg, viral cochleitis) and recover spontaneously within 3-4 months. However, it can be difficult to determine the cause based on clinical findings alone, and patients with sudden-onset SNHL should be evaluated with audiometry and MRI to exclude more significant disease (eg, vestibular schwannoma). If the evaluation is nondiagnostic, some experts advise empiric therapy with high-dose systemic glucocorticoids and antiviral drugs (eg, valacyclovir). (Choice B) Ménière disease is a common cause of SNHL and is initially managed with sodium restriction (with or without diuretics). However, this patient has no tinnitus or vertigo to suggest Ménière disease and warrants additional evaluation. (Choice C) CT scan has low sensitivity for disorders of the brainstem and cerebellopontine angle and is not recommended for evaluation of sudden SNHL. MRI is the preferred imaging test due to its ability to identify acoustic neuroma, perilymphatic fistula, and multiple sclerosis. (Choice D) Stapedectomy involves removal of the stapes and replacement with a prosthesis. It is primarily performed for otosclerosis and other causes of conductive hearing loss. (Choice E) Decongestants and antihistamines are useful in managing eustachian tube dysfunction due to allergic rhinitis or viral upper respiratory infection. Eustachian tube dysfunction leads to conductive hearing loss, often accompanied by pain, crackling or popping sounds, and middle ear effusion. Educational objective: Most patients with acute unilateral sensorineural hearing loss have a benign etiology and recover spontaneously within 3-4 months. However, it can be difficult to determine the cause based on clinical findings alone, and patients should be evaluated with audiometry and MRI to exclude more significant disease (eg, vestibular schwannoma). __________ References: Clinical practice guideline: sudden hearing loss. (http://www.ncbi.nlm.nih.gov/pubmed/22383545) Sudden sensorineural hearing loss: an evaluation of treatment and management approaches by referring physicians. (http://www.ncbi.nlm.nih.gov/pubmed/19130968)

A 45-Year-Old Man Comes to the Office Due to Difficulty