Case 17 - 75 yo M with hearing loss

Question 1

Physical examination

Answer 1

HEENT exam (tested hearing by speaking with back turned, inspected sinuses, nose, mouth and throat, funduscopic exam and otoscopy, assessed hearing with Rinne and Weber tests, and whisper test)
CV and pulmonary exams
Neurologic exam (CNS, sensation, motor, reflexes, cerebellar - finger to nose, heel to shin)

Question 2

Closure

Answer 2

Stop taking aspirin

Question 3

Closure

Answer 3

Confirm that there is some degree of hearing loss
Stop taking aspirin
Refer you to an audiometrist, who will assess you for a hearing aid
Do you have any questions for me?

Question 4

Differential diagnosis

Answer 4

Presbycusis (b/l progressive hearing loss, age, HTN, + Rinne test without lateralization on Weber test)
Cochlear nerve damage (prior exposure to loud noise, b/l hearing loss, + Rinne test without lateralization on Weber test)
Otosclerosis (b/l progressive hearing loss and age, lack of lateralization on Weber test)

Question 5

Diagnostic work-up

Answer 5

Audiometry
Tympanography
Brain stem auditory evoked potentials
CT - head
VDRL/RPR (to R/O syphilis associated with Meniere's disease)

Question 6

Rinne test

Answer 6

Place the vibrating tuning fork against the patient’s mastoid bone and ask the patient to tell you when the sound is no longer heard. Once they signal they can’t hear it, quickly position the still vibrating tuning fork near the auditory canal, and again ask the patient if they are able to hear the tuning fork.

If the patient cannot hear any sound when the still vibrating tuning fork is placed at the auditory canal, conductive hearing loss is suspected.

Question 7

Weber test

Answer 7

In the Weber test a vibrating tuning fork is placed on top of the head equi-distant from the patient’s ears on top of thin skin in contact with the bone. The patient is asked to report in which ear the sound is heard louder.

A normal Weber test has a patient reporting the sound heard equally in both sides.

In an affected patient, if the defective ear hears the Weber tuning fork louder, the finding indicates a conductive hearing loss in the defective ear.

Question 8

Meniere’s disease

Answer 8

Hearing loss, tinnitus and vertigo

Associated with syphilis