A 30-year-old woman comes to the office due to hearing loss in her right ear. A week ago, the patient developed symptoms of nasal congestion, cough, and rhinorrhea. Three days ago, she traveled from New York to London. On her return flight yesterday, the patient developed hearing loss and severe pain in her right ear and noticed a drop of blood on her finger when she scratched her ear canal. All symptoms have resolved except for persistent hearing loss in the right ear. Which of the following is the most appropriate next step in management?

Question

A 30-year-old woman comes to the office due to hearing loss in her right ear.  A week ago, the patient developed symptoms of nasal congestion, cough, and rhinorrhea.  Three days ago, she traveled from New York to London.  On her return flight yesterday, the patient developed hearing loss and severe pain in her right ear and noticed a drop of blood on her finger when she scratched her ear canal.  All symptoms have resolved except for persistent hearing loss in the right ear.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient with severe ear pain during a flight who now has persistent hearing loss most likely sustained barotrauma of the ear complicated by rupture of the tympanic membrane (TM). Under normal conditions, the eustachian tube opens intermittently, typically during swallowing or yawning. Failure to open adequately (eg, functional obstruction due to upper respiratory infection [URI], as in this patient) leads to a pressure difference between the middle ear and the outside environment. This pressure difference is more pronounced when there are significant shifts in barometric pressure (eg, during a plane's ascent and descent), which can lead to stretching of the TM, causing ear pain and hearing loss. eustachian tube In severe cases, the TM can rupture, which rapidly equalizes the pressure difference and relieves the stretching; this relieves the pain but may also result in minor bleeding (eg, drop of blood on the finger). Patients can have persistent hearing loss because of the TM rupture, as seen in this patient. Barotraumatic TM injuries typically heal spontaneously within a few weeks, so reassurance and follow-up is appropriate initial management. (Choice A) Aural irrigation can be used to treat cerumen impaction, which can cause unilateral hearing loss. However, cerumen impaction is typically neither painful nor associated with flying or URI symptoms. (Choice B) MRI of the internal auditory canal can detect a vestibular schwannoma, which can cause unilateral hearing loss. In general, hearing loss due to a vestibular schwannoma is slowly progressive, but some patients have acute hearing loss. However, a vestibular schwannoma is not painful, would not bleed, and is not associated with flying. (Choice C) Oral glucocorticoids are often used in patients with idiopathic sudden sensorineural hearing loss (SSHL). The cause of SSHL is unknown, but it is not associated with flying, ear pain, or bleeding from the ear. (Choice D) Oxymetazoline used prior to air travel might reduce URI-induced obstruction of the eustachian tube and reduce the risk of barotrauma, but it is unlikely to improve a TM rupture after it has occurred. (Choice F) Tympanoplasty is used to repair persistent TM perforations. However, an acute barotraumatic TM rupture often heals in a few weeks without surgical intervention. Educational objective: Barotrauma to the ear occurs most commonly after flying and can result in injury (eg, ear pain, hearing loss) to the tympanic membrane (TM). Most barotraumatic TM injuries heal spontaneously within a few weeks. References: Upper respiratory infections and barotraumas in commercial pilots: a retrospective study. (http://www.ncbi.nlm.nih.gov/pubmed/18856186) Otic barotrauma from air travel. (http://www.ncbi.nlm.nih.gov/pubmed/15949100)

A 30-Year-Old Woman Comes to the Office Due to Hearing