An 81-year-old woman is brought to the clinic with complaints of constant ringing in her ears over the last several months. She also is having difficulty hearing, especially at social gatherings and while watching television. She has had 2 episodes of near falls during the past year. The patient's other medical problems include hypertension, recurrent urinary tract infections, and osteoarthritis. Her medications include hydrochlorothiazide and acetaminophen. She takes trimethoprim-sulfamethoxazole for urinary tract infections several times a year.
Physical examination shows a normal external ear, no signs of cerumen impaction, and pearly gray tympanic membranes bilaterally with a normal light reflex. She is mildly unsteady in Romberg's position with her eyes closed. There are no carotid bruits. She has an abnormal whisper test in both ears.
Which of the following is the most likely diagnosis?

Question

An 81-year-old woman is brought to the clinic with complaints of constant ringing in her ears over the last several months.  She also is having difficulty hearing, especially at social gatherings and while watching television.  She has had 2 episodes of near falls during the past year.  The patient's other medical problems include hypertension, recurrent urinary tract infections, and osteoarthritis.  Her medications include hydrochlorothiazide and acetaminophen.  She takes trimethoprim-sulfamethoxazole for urinary tract infections several times a year.
Physical examination shows a normal external ear, no signs of cerumen impaction, and pearly gray tympanic membranes bilaterally with a normal light reflex.  She is mildly unsteady in Romberg's position with her eyes closed.  There are no carotid bruits.  She has an abnormal whisper test in both ears.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_979d_9ff8_853d_65ac453dfde2_MD0002_00 This patient's presentation suggests presbycusis or age-related hearing loss. Presbycusis is a common condition that affects >50% of adults by age 75. Factors affecting onset and severity of presbycusis include low socioeconomic status, exposure to noise and ototoxins, chronic disease (eg, hypertension, diabetes, vascular disease), and smoking. Presbycusis is a form of sensorineural hearing loss caused by inner ear disorders, processing centers in the brain, or the vestibulocochlear nerve. Patients usually present with progressive, symmetrical, high-frequency hearing loss (consonant sounds) over many years. This can be accompanied by bilateral tinnitus, vertigo, and disequilibrium leading to frequent falls. Patients have difficulty hearing in the presence of competing backgrounds (social gatherings, television sounds) but appear to do well on a one-to-one basis. Early detection and treatment are important as hearing loss due to presbycusis can cause isolation and depression. Evaluation includes physical examination to exclude other causes of hearing loss (eg, cerumen impaction or tumors) and the whispered voice test for safe and accurate testing of hearing impairment. The Weber and Rinne tests can help differentiate between conductive and sensorineural hearing loss. An audiogram is needed to confirm diagnosis and guide treatment. Hearing aids are effective in most patients, although some with refractory hearing loss require cochlear implants. whispered voice test Weber and Rinne tests (Choice A) Blood supply to the inner ear originates from the vertebrobasilar system. Vertebrobasilar ischemic stroke thus can present with hearing loss due to labyrinthine infarction. However, most patients will have other symptoms such as vertigo that are of sudden onset. This patient's mildly abnormal Romberg test is due to decreased touch and vibration sense seen in association with aging. (Choice B) Ototoxic drugs include aminoglycosides, platinum-containing chemotherapeutic agents, intravenous loop diuretics, and nonsteroidal anti-inflammatory drugs. Hydrochlorothiazide is a thiazide diuretic not typically associated with hearing loss or tinnitus. (Choice C) Meniere disease classically presents with recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss (usually unilateral). Patients also report experiencing ear fullness or pain in the affected ear. (Choice D) Otosclerosis is an inherited disorder caused by abnormal bony growth in the middle ear (footplate of the stapes). It usually results in unilateral conductive hearing loss. Educational objective: Presbycusis is the most common cause of progressive, bilateral, high-frequency hearing loss in elderly patients. Early recognition and treatment are essential to prevent social isolation, depression, and functional disability (falls). The whispered voice test and audiogram can be used for diagnosis. Treatment involves hearing aids and cochlear implants for refractory hearing loss. __________ References: Presbycusis. (http://www.ncbi.nlm.nih.gov/pubmed/16182900) Hearing deficits in the older patient: "I didn't notice anything". (http://www.ncbi.nlm.nih.gov/pubmed/22436959)

An 81-Year-Old Woman Is Brought to the Clinic with Complaints