A 20-year-old woman came to the office with a 6-year history of Meniere's syndrome. Her condition had come on suddenly; her symptoms had been preceded by the onset of tinnitus in both ears, which was followed by violent rotary vertigo with nausea and vomiting. During each recurrence, these spells would last from 20 minutes to 2 hours. She had undergone placement of a right endolymphatic mastoid shunt, but she noticed no change in her dizziness postoperatively.
At her visit to the author's office, the patient reported no significant dizziness. She was taking cortisone, a diuretic, and a nausea suppressant, which were controlling this symptom. She still experienced some hearing loss in both ears, more so on the right. Beginning 6 years earlier, her hearing had progressively deteriorated until she underwent the mastoid shunt surgery. Thereafter, the quality of her hearing fluctuated and had remained fluctuant until 3 months prior to her office visit. It had been stable since.
The patient's primary concern was the preservation of her hearing. Her tinnitus in the left ear had resolved, but it was still present in the right ear. It had been constant for the preceding 3 months. She reported aural fullness in both ears (more so on the right) upon the onset of dizziness.
On clinical examination, the patient experienced difficulty performing the sharpened tandem Romberg's test. Her family history was negative for hearing loss and dizziness. Electronystagmography in the absence of medications revealed no spontaneous, positional, or neck-torsion nystagmus. The alternate binaural bithermal test elicited a hypoactive (and sometimes absent) response to the cool stimulus on the right and no response to the warm stimulus in either ear (a reduced vestibular response of 66 to 100% right and a directional preponderance of 66 to 100% right). Ice-water calorics in the right ear elicited a normal response, which represented a form of vestibular recruitment and suggested that the source of the dizziness was the labyrinth. The simultaneous binaural bithermal test elicited a type 1 response--that is, no nystagmus was produced with either the warm or cool simultaneous stimulus.
Audiometry identified a bilateral sensorineural hearing loss. The loss was moderately fiat in the left ear. The right ear exhibited a moderate to severe loss of low-tone hearing and a moderate loss of middle-and high-tone hearing. Further testing revealed that the patient had a 50-dB speech reception threshold (SRT) and an 84% speech discrimination score (SDS) in the right ear, and a 30-dB SRT and a 92% SDS in the left ear.
The vestibular findings in this case are consistent with a bilateral peripheral vestibular disorder. However, these findings might also be explained by the fact that stimulation of the efferents from the right ear suppressed or inhibited the auditory and vestibular hair cell function in the apparently unaffected left inner ear.
From Neurotologic Associates, P.C., New York City.
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