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Acoustic Neuroma

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor working in the emergency department. Your next patient is a 45-year-old woman called Sarah Jones, presenting with hearing loss. Please take a history and perform an appropriate examination.



 

Patient History:


Sarah Jones, a 45-year-old woman, teacher


You are here today as you have been experiencing problems with hearing in the right ear. You don't hear very well when talking to someone, especially in a crowded place. This has been progressively getting worse in the last few months.


You also started to receive a constant ringing noise in the right ear, which is more noticeable at night. This is associated with a sense of fullness in the right ear.


You just feel something is not quite right. You sometimes can have issues with balancing while walking up the stairs.


You do feel numbness on the right side of your face. Your colleagues have commented that your facial expression looks slightly different than usual.


No headache. No vision changes. No swallowing difficulty. No speech problems. No limb weaknesses. No fever. No ear pain or discharge. No coryza. Not aware of any weight loss. No night sweats.


Ideas, Concerns, Expectations:

  • You think this is likely due to old age. You are concerned as you now struggle to hear people in the classroom as a teacher; you often have to ask people to repeat themselves. You would like to see if you can get a hearing aid to solve this issue.


Past Medical History:

  • Irritable Bowel Syndrome

  • GORD

  • Depression


Drug History:

  • Omeprazole 20mg OD, Buscopan 10mg PRN QDS, sertraline 50mg OD

  • Allergic to shellfish - reaction: widespread rash.


Family History:

  • Nil


Social History:

  • You work as a primary school teacher.

  • You live with your husband in a small house.

  • You have a dog called Poppy.

  • You do not smoke or drink.

  • You are generally independent at home with no carers.


 

Examination Findings:

  • Facial nerve palsy affecting the right side with forehead sparing.

  • Impaired facial sensation (right) e.g. to light touch

  • +/- Ataxic gait / Romberg's sign positive

  • Sensorineural hearing loss in the right ear. Rinnes test positive (normal) in both ears. Weber test localises hearing away from the right ear.

  • Otoscopy- normal

  • Upper and lower limb motor and sensory examinations are otherwise normal.


 

Differentials:

  1. Acoustic neuroma affecting vestibulochocholear, facial and trigerminal nerves.

  2. Meningioma

  3. Epidermoid

  4. Arachnoid cyst


 

Investigations:

  • Basic observations

  • Neurosurgery and neurology referral for further investigations and management

  • Consider baseline routine bloods

  • Audiometry to assess hearing loss (sensorineural pattern)

  • MRI (Gadolinium-enhanced)/ CT Head to establish the diagnosis


 

Management:

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