14/12/2023
CASE STUDY: EAR INFECTION OR TUMOUR?
A 60 year old gentleman attended for earwax removal. He explained that he had visited Thailand 11 months ago and since then has had problems with his LEFT ear. He feels as though it is blocked and cannot hear anything from it. It has gradually worsened over time. The day before this appointment, he reports having felt very unsteady, was unable to walk straight and felt nauseous too. Then he started to see darkness creeping in from the top of his vision before his vision fully disappeared. He said that his vision returned to normal after approximately 5 minutes. He is also experiencing a constant high pitched hissing/ringing on his left side only. He reports no history of migraines.
Upon examination his RIGHT ear canal was lined with tiny white flakes - this could be a type of skin condition or some sort of infection and the patient was advised to see his GP, but as the patient wasn't having any symptoms at all on this side the focus of this case study will be on his LEFT ear. No abnormalities were seen on his left eardrum, the typical landmarks that we look for are present. There doesn't appear to be any fluid build up behind the drum. The drum doesn't appear bulging or retracted and he isn't experiencing any pain, which indicates no involvement of the middle ear. He said he was unable to cope any longer as he cannot concentrate on anything because of his symptoms.
It could be labyrinthitis, an inner ear infection. It is most commonly caused by a virus, but can also start off as an untreated bacterial middle ear infection. Labyrinthitis symptoms are consistent with what the patient is experiencing; balance problems and difficulty walking, nausea, inability to concentrate, hearing loss, ringing in the ears, ear 'fullness' and rarely visual disturbances. Treatment often includes corticosteroids to reduce nerve inflammation, antiviral medication (or antibiotics if there's a sign of bacterial infection) and sometimes anti-sickness medication if the patient is experiencing nausea due to vertigo. However, labyrinthitis lasts for only days to a few weeks and usually goes away by itself without treatment; this gentleman had been experiencing these issues for almost a year.
Another possible explanation is that he has developed an acoustic neuroma, also known as a vestibular schwannoma. This is a non-cancerous tumour that grows on the hearing nerve. It is usually not life-threatening unless left unchecked when it can begin to press on the brain stem which controls basic functions such as breathing. They are very very slow-growing and treatment isn't always required. Symptoms can include hearing loss, tinnitus, balance problems, a feeling of 'fullness' in the ear and sometimes facial tingling or numbness. If the tumour is particularly large, it can press on other surrounding nerves and could affect vision. More often than not, acoustic neuromas only develop on one side. 95% of acoustic neuromas occur without a specific cause. Along with a full hearing assessment, it would require a head scan to diagnose.
Treatment is case-dependent and can include targeted radiation to stop further growth, surgery to remove it (hearing often doesn't return and surgery can make hearing worse, but it can help with any balance issues and facial numbness). Sometimes the patient will just be monitored instead with regular scans.
Outcome: No wax removal was required. Instead, I wrote a letter to the patient's GP to suggest a referral to Ear, Nose and Throat for further investigation.
