Intermittent ringing in the ear turns constant
Intermittent ringing in the ear turns constant
Ms. B, aged 52 years, presented to her primary-care provider with complaints of a "blocked" left ear. She explained that the problem developed about one week earlier and started with a ringing sound that initially had been intermittent but was now constant. Ms. B reported no ear pain or drainage, but wondered if wax may be causing her symptoms. She had noticed that she couldn't hear the telephone with her left ear as well as she could with her right ear. She reported no previous or recent head trauma.
There was no history of ear problems, recurrent infections, or surgery. Ms. B's last complete physical was approximately four months earlier and noted a history of hypertension, obesity, and environmental allergies. Previous procedures included tonsillectomy as a teen and right-knee arthroscopy. Current medications were hydrochlorothiazide 25 mg daily, fexofenadine (Allegra) 180 mg daily, calcium supplement, and a multivitamin. The patient was a nonsmoker, drank one to two alcoholic beverages a month, and worked as a customer service representative at a health insurance company.
2. PHYSICAL EXAMINATION
Ms. B was afebrile, BP 116/64 mm Hg, pulse 76 beats per minute, and respiration 18 breaths per minute.
Examination of the ears revealed no ear or mastoid tenderness or inflammation. Pinnae appeared healthy. Right canal was patent with normal tympanic membrane landmarks. Left canal and tympanic membrane appeared the same.
Nasal exam showed good nasal airway bilaterally with mild mucosal edema and slightly boggy turbinates. There was no drainage or inflammation.
The remainder of the physical exam was unremarkable, including normal neurologic exam with symmetric and strong movements of face and extremities.
3. OTHER DATA
Ms. B's electronic health record was accessed for previous laboratory results done in conjunction with her most recent annual exam. Complete blood count and comprehensive metabolic panel were both normal, as was her mammogram.
Tuning fork testing (512 Hz) revealed positive Rinne bilaterally (air conduction greater than bone conduction) and Weber lateralized to the right. Ms. B was referred urgently to an ENT clinic for formal audiologic evaluation.
4. FOLLOW-UP and diagnosis
Later the same day, a hearing test of the right ear was normal, with a moderate low- to mid-frequency sensorineural hearing loss identified on the left. Speech understanding was perfect at 100% on the right and diminished at 68% on the left.
MRI of the brain with and without contrast ruled out a benign inner-ear tumor. Ms. B was diagnosed with sudden sensorineural hearing loss (SSNHL) in the left ear.
SSNHL is a medical emergency.1 It is defined as at least 30 dB loss of hearing over at least three frequencies occurring within three days, necessitating urgent evaluation by ENT and audiology specialists.2 An inner-ear problem should be suspected with normal outer and middle ear (Figure 1). Unfortunately, assessment of the middle ear is subjective without formal audiology testing, and patients with sudden hearing loss may be misdiagnosed with Eustachian-tube dysfunction or middle-ear effusion. Treatment of these conditions with oral decongestants or antihistamines delays therapy for SSNHL.
Although the etiology of SSNHL is often idiopathic,3 the consensus regarding treatment is use of oral or injected steroids.4 A controllable prognostic indicator for hearing recovery is time from onset of symptoms to treatment, with best results identified when patients are treated within 14 days of hearing-loss onset.3 Use of steroids involves consideration of potential side effects and interactions, which also emphasizes the need for identification of the nerve loss to guide appropriate treatment.5
6. PATIENT OUTCOME
Ms. B was treated with a long tapering course of oral prednisone taken with food to avoid stomach upset. She monitored her BP at home, with no significant increases noted during use of the prednisone.
Subsequent audiologic testing revealed improvement of her hearing, which returned to symmetric levels following an additional tapering course of prednisone.
Patients with sudden hearing loss may describe a "blocked" or "plugged" ear, say they have "water in their ear," or have unilateral tinnitus as their only complaint. If examination of the outer and middle ear shows no abnormalities, urgent consultation with ENT and audiology is indicated for expert evaluation, appropriate treatment, and optimal chance for hearing recovery. The best opportunity to restore hearing is with correct therapy within 14 days of symptom onset but does not preclude evaluation for sudden hearing loss that has been present for weeks or even months.
Dr. Wirkus is a nurse practitioner with Prevea Ear, Nose, and Throat in Green Bay, Wisc.
4. Slattery WH, Fisher LM, Iqbal Z, Liu N. Oral steroid regimens for idiopathic sudden sensorineural hearing loss. Otolaryngol Head Neck Surg. 2005;132:5-10.
5. Herr BD, Marzo SJ. Intratympanic steroid perfusion for refractory sudden sensorineural hearing loss. Otolaryngol Head Neck Surg. 2005;132:527-531.
All electronic documents accessed February 15, 2011