Download Case Presentation Conference -Memorial

Case Presentation Conference
-MemorialJanuary 24, 2002
Jason Hunt M.D.
Brian Kerr M.D.
Peter Rigby M.D.
Chief Complaint
• 65 y.o. female presents with complaint of
decreased hearing in the left ear.
• Has worsened over several years
• now what?
• No hx of infection, trauma, previous ear
surgery. No pain.
• No significant noise exposure (works as
librarian)., no family hx of hearing loss.
• No hx of ototoxic drugs.
• Complains of mild dysequilibrium
• tinnitus only on left (non-pulsatile)
• Otolaryngology ROS
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no wt loss
no dysphagia, no odynophagia
no hoarseness or change in voice
no globus sensation
no aspiration or sense of choking on food.
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Med Hx: Hypertension, tx with HCTZ
Surg Hx: none
Meds: HCTZ
ROS: unremarkable,
– good exercise tolerance
walks for 30 minutes every morning
Physical Exam
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Ears
Nose
Throat
neuro
Physical Exam
• Vibrant, pleasant women
• Remarkable findings:
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Ears: normal exam,
oral: symm palate, +gag, tongue mobile
no facial weakness, no facial parasthesia
TVC equally mobile,
decreased corneal reflex left eye
left + Hitzleberger sign.
• Other clinical testing?
Forks
• Weber lateralized to the right
• Rinne: right is +
• Rinne: left is +
Imp/Plan:
IMP/Plan ?
ABR vs. MRI
• Advantages/Disadvantages
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E - Eighth nerve (wave I)……….2.0 msec
C - cochlear nucleus (wave II)….3.0 msec
O - superior olive (wave III)……4.1 msec
L - lateral lemniscus (wave IV)..5.3 msec
I - inferior colliculus (wave V)..5.9 msec
What about calorics?
Treatment Options
Treatment Options
• Observation
• surgery (what approaches?)
• what about gamma knife?
Surgery
• Retrosigmoid or suboccipital
• hearing conservation except lateral 1/3 of IAC
• need to retract on cerebellum/ post op H/A
• Translabyrinthine
• most direct/ good exposure (including VII)
• does not conserve hearing
• Middle Fossa approach
• hearing conservation, exposes lateral 1/3 IAC
Anatomy
• Cerebellar Pontine Angle
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medially
roof
Post.
floor
lateral surface of brainstem
cerebellum/middle cerebellar ped.
Cerebellum/cerebellar tonsil
arachnoid assoc. with lower nn.