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Case Presentation Conference-Memorial-
January 24, 2002Jason Hunt M.D.
Brian Kerr M.D.
Peter Rigby M.D.
Chief Complaint
• 65 y.o. female presents with complaint of decreased hearing in the left ear.
• Has worsened over several years
• now what?
• No hx of infection, trauma, previous ear surgery. No pain.
• No significant noise exposure (works as librarian)., no family hx of hearing loss.
• No hx of ototoxic drugs.
• Complains of mild dysequilibrium
• tinnitus only on left (non-pulsatile)
• Otolaryngology ROS– no wt loss– no dysphagia, no odynophagia– no hoarseness or change in voice– no globus sensation– no aspiration or sense of choking on food.
• Med Hx: Hypertension, tx with HCTZ
• Surg Hx: none
• Meds: HCTZ
• ROS: unremarkable,– good exercise tolerance
walks for 30 minutes every morning
Physical Exam
• Ears
• Nose
• Throat
• neuro
Physical Exam
• Vibrant, pleasant women
• Remarkable findings:– Ears: normal exam, – oral: symm palate, +gag, tongue mobile– no facial weakness, no facial parasthesia– TVC equally mobile, – decreased corneal reflex left eye– left + Hitzleberger sign.
• Other clinical testing?
Forks
• Weber lateralized to the right
• Rinne: right is +
• Rinne: left is +
Imp/Plan:
IMP/Plan ?
ABR vs. MRI
• Advantages/Disadvantages
• E - Eighth nerve (wave I)……….2.0 msec
• C - cochlear nucleus (wave II)….3.0 msec
• O - superior olive (wave III)……4.1 msec
• L - lateral lemniscus (wave IV)..5.3 msec
• I - inferior colliculus (wave V)..5.9 msec
What about calorics?
Treatment Options
Treatment Options
• Observation
• surgery (what approaches?)
• what about gamma knife?
Surgery
• Retrosigmoid or suboccipital• hearing conservation except lateral 1/3 of IAC
• need to retract on cerebellum/ post op H/A
• Translabyrinthine• most direct/ good exposure (including VII)
• does not conserve hearing
• Middle Fossa approach• hearing conservation, exposes lateral 1/3 IAC
Anatomy
• Cerebellar Pontine Angle– medially lateral surface of brainstem– roof cerebellum/middle cerebellar ped.– Post. Cerebellum/cerebellar tonsil– floor arachnoid assoc. with lower nn.