Case Study – GW

Background Information

GW is a 74-year-old male seen in a hospital ENT clinic for an audiological evaluation and VNG study. Pertinent medical history included four heart attacks (most recent was two years ago), hip replacement surgery (ten years ago), prostate cancer with no chemotherapy or radiation treatment (diagnosed nine years ago), and diabetes mellitus type II which is controlled by medications. He reported difficulty hearing bilaterally, and specifically said that sounds seemed “distorted” and has history of occupational noise exposure (carpentry). He denied tinnitus, recent or recurrent ear infections, aural pressure, otalgia, and otorrhea.

GW endorsed constant unsteadiness (duration: about one year) accompanied by head pressure and headaches. He also has occasional episodic vertigo lasting seconds to minutes that is triggered by head movement and turning to the right side. Although he has not fallen, his dizziness is affecting his quality of life. GW mainly stays at home and does not drive often. He has intermittent blurred vision, but believes it is likely due to his diabetes. GW reported he had constant unsteadiness 35 years ago for about one year before it resolved. There are no known symptoms that stop, lessen, or exacerbate his vertigo. He denied nausea, vomiting, allergies, exposure to irritation fumes, loss of consciousness, head injuries, tobacco use, double vision, numbness of face or extremities, weakness or clumsiness in arms and legs, confusion, and difficulty with speech or swallowing. GW denied taking any medications for dizziness, anxiety, depression, or pain for 48 hours prior to testing.

Procedure

Otoscopy

• Tympanic membranes visualized bilaterally

Tympanometry

• Type A tympanograms consistent with normal TM mobility bilaterally  

Pure Tone Audiometry

• Right Ear: Hearing WNL sloping to a moderate sensorineural hearing loss (SNHL)
  • Right ear asymmetry is noted. Stenger was performed to rule out non-organic etiology of hearing loss. Negative pure tone Stenger at 1500 Hz.
• Left Ear: Hearing WNL sloping to moderately-severe rising to moderate SNHL

Speech Audiometry

• Right Ear:
  • SRT of 20 dBHL (good agreement with PTA)
  • WRS = 96% at 60 dBHL
• Left Ear:
  • SRT of 40 dBHL (good agreement with PTA)
  • WRS = 68% at 80 dB HL; 56% at 70 dB HL (negative for rollover)

VNG

• Data was obtained with goggles positioned correctly, patient seated less than four feet from light bar, and patient was at eye-level with light bar
• Sinusoidal Tracking was normal.
• Saccades were normal.
• OPKs were normal. It should be noted that testing was not performed in full visual field as OPK results were obtained on a lightbar.
• Gaze Nystagmus: none observed.
• Positional Nystagmus:
  • Clinically significant nystagmus was observed in the supine position without vision (8 deg/sec). Additionally, direction-changing in single position nystagmus was observed (suggestive of CNS pathology) and was clinically significant for the following positions:
    • Right side without vision (8 deg/sec right-beating and 15 deg/sec left-beating)
    • Left side w/o vision (12 deg/sec right-beating and 12 deg/sec left-beating).
  • Nystagmus was observed but not clinically significant in the head right w/o vision position (6 deg/sec) along with direction-changing nystagmus for the head left w/o vision position (3 deg/sec right-beating and 6 deg/sec left-beating).

• Dix-Hallpike was positive to the right for BPPV. Epley maneuver performed without incident.
• Caloric Irrigation was symmetrical with normal fixation suppression.

Results

VNG Assessment:

• Results are consistent with BPPV in the head right position and are also suggestive of central pathology.

Take home message:

1. If a VNG is ordered, don’t cease testing after the Dix-Hallpike if positive for BPPV. While GW did have BPPV, he also had direction changing nystagmus during the positional testing portion of the VNG which is suggestive of central pathology.
2. Taking a thorough case history is a vital step in the diagnostic process of working with patients who are experiencing dizziness. This can tell you more about the nature of the dizziness, its timing and duration, any episodic triggers, potential neurological symptoms, and other general health issues.
3. It is important to understand the severity of the handicap and how it is affecting your patient’s quality of life. Although GW had not yet fallen, his lifestyle was limited due to the fear of falling.
4. Pay attention to your tracings and try to analyze while you are testing, especially if you see something unexpected such as direction-changing nystagmus.

Recommendations for GW

• Repeat testing per otologic plan.
• Follow up with ENT.
• Patient should discuss referral for neurology with ENT.
• Ambulatory precautions were discussed and explained to GW. He was given a handout of repositioning exercises to complete at home.
• Patient should return for hearing aid consultation. Binaural hearing aids pending medical clearance.

Audrey Taylor is a fourth-year graduate student at the University of Texas at Dallas and is currently completing her audiology externship with UT Physicians at Memorial Hermann Hospital in the Texas Medical Center. Her audiological interests include pediatric diagnostics and aural rehabilitation, cochlear implants, and advocating for individuals with hearing loss.