A 66-year-old man comes to a community clinic after undergoing a computed tomography scan of the head at a local emergency department. He fell while stepping out of the bathtub and struck his head but did not lose consciousness. The patient sustained a small head laceration that was closed with sutures, but no other injuries were identified in the emergency department. He reports a longstanding history of normal-pressure hydrocephalus with frequent falls, but he has not followed up with his neurologist for several years. The patient is now asymptomatic with no headaches, focal weakness, or dizziness. His head computed tomography scan with bone windows is shown in the image below. After the appropriate steps, the patient returns for follow-up one year later. He now complains of hearing loss in the left ear. What is the appropriate response to his complaint?

Question

A 66-year-old man comes to a community clinic after undergoing a computed tomography scan of the head at a local emergency department.  He fell while stepping out of the bathtub and struck his head but did not lose consciousness.  The patient sustained a small head laceration that was closed with sutures, but no other injuries were identified in the emergency department.  He reports a longstanding history of normal-pressure hydrocephalus with frequent falls, but he has not followed up with his neurologist for several years.  The patient is now asymptomatic with no headaches, focal weakness, or dizziness.  His head computed tomography scan with bone windows is shown in the image below.  After the appropriate steps, the patient returns for follow-up one year later.  He now complains of hearing loss in the left ear.  What is the appropriate response to his complaint?

Quizplus · Accepted Answer

Explanation: This patient's hearing loss is likely secondary to Paget disease of bone (PDB). Hearing loss is a common complication of PDB, affecting as many as 37% of patients in one survey. There are likely multiple pathologic mechanisms, including compression of the auditory nerve by bony overgrowth or involvement of the cochlea and/or cochlear capsule itself. Treatment of PDB with calcitonin or bisphosphonate therapy may slow the progression of hearing loss but does not appear to reverse the loss that has already occurred (Choice E). Other interventions that have been studied include external hearing aids and cochlear implants. (Choice B) Multiple mechanisms of post-traumatic hearing loss, especially following temporal bone injury, have been described. However, most cases result in immediate rather than delayed hearing loss. Rare cases of delayed post-traumatic hearing loss have been reported, but in such cases magnetic resonance imaging is a more informative test than computed tomography. (Choice C) Hearing loss is not a typical symptom of normal-pressure hydrocephalus. Placement of a ventriculoperitoneal shunt would not likely improve this patient's hearing loss. In fact, hearing loss is a recognized complication of ventriculoperitoneal shunt placement. (Choice D) Age-related hearing loss (presbycusis) is a common problem that is typically bilateral and often managed with external hearing aids. Educational objective: Hearing loss is a common complication in patients with Paget disease of bone and likely has several different pathologic mechanisms. Treatment with calcitonin or bisphosphonates can slow the progression of hearing loss but is unlikely to reverse hearing loss that has already occurred. References: The mechanism of hearing loss in Paget's disease of bone. (http://www.ncbi.nlm.nih.gov/pubmed/15064610)

A 66-Year-Old Man Comes to a Community Clinic After Undergoing