I saw a patient who was hit by a baseball on the left temple three months ago. Since the injury she has noticed difficulty hearing in background noise. There was no loss of consciousness at the time of the incident. Her doctor told her she just had superficial bruising and did not feel there was a concussion or skull fracture. No radiographic images were obtained. Pure tone, speech and immittance testing were all normal. OAEs were not as robust as I would have expected for the hearing (no threshold was worse than 10 dB) and emissions were 50% present in the right ear and 80% present in the left. Any suggestions for the cause of this and what further testing and management approaches to recommend?
Trauma to the head can cause a concussive injury to the labyrinth. Important questions to ask after such an injury probably should have included associated symptoms such as; tinnitus, fullness, pressure, fluctuations of hearing and dizziness. At this time, audiometric testing might include LDL's, HINT in noise, ABR and ECoG. These tests may reveal abnormalities which might help explain the current signs and symptoms the patient is experiencing.
It is quite likely this patient is experiencing a mild hydrops secondary to possible concussional injury and the patient might benefit from diuretic therapy.
Other key issues that should be addressed include the motivation of the patient. For example, as this was an injury, is she/he looking for compensation? It's unfortunately a good rule of thumb, to always be on the lookout for secondary gain when clinical signs, symptoms and history don't quite add up.
Brian Perry, MD
Ear Medical Group, San Antonio Texas.
Dr. Perry completed his residency in Otorhinolaryngology at Duke University, and a fellowship in Otology, Neurotology and Skull Base Surgery at The University of Iowa. He is currently in private practice in San Antonio, where he continues to publish on a variety of otologic topics.