Clinical findings in a patient with aural fullness.

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A 55-year-old man presented with a 6-month history of hearing loss. He reported fullness in both ears, more so on the right, in addition to nasal congestion. His pattern of symptoms included intermittent decreases in hearing in the right ear followed by tinnitus in that ear; his hearing would return to normal in 10 seconds. He reported no dizziness. Subjectively, he said that his hearing loss was not a significant problem. He did have a family history of hearing loss but not tinnitus or dizziness.

Findings on inspection of the ears were normal. The Weber test lateralized to the right, and the Rinne test was positive in both ears. On tuning-fork testing, the 0.512 kHz frequency was less loud in the right ear than in the left; the 2.048 and 4.096 kHz frequencies were heard equally. Audiometry revealed a bilateral hearing loss (figure 1, A). The right ear had a moderate low-tone loss with a conductive component only at 0.25 kHz; assessments of hearing from 1 to 8 kHz in the right ear and at all frequencies in the left ear revealed only a mild loss.

Speech testing revealed a mild to moderate speech reception threshold in the right ear and a mild threshold in the left ear; the results of speech testing in quiet and in simulated background noise were normal (figure 1, B). Tympanometry was normal. Acoustic stapedial reflexes when the probe was in the right ear were mostly absent.

Computed tomography (CT) of the temporal bones revealed evidence consistent with severe capsular otosclerosis. CT of the left ear detected a sclerotic process in the anterior footplate of the stapes and the basal turn of the cochlea (figure 2, A). The right ear exhibited impingement of the otospongiotic process upon the anterior footplate of the stapes (figure 2, B). This finding was consistent with the mostly absent acoustic stapedial reflexes when the probe was in the right ear.

This case lends itself to several observations:

* The patient's symptoms were clearly reflected in the audiometry results.

* The etiology of the otosclerosis was clearly identified on imaging. The CTs demonstrated the cavitation that is commonly associated with severe to profound sensorineural hearing loss associated with otosclerosis. (1)

* In this case, the only symptom was aural fullness.

While there was clearly some hearing loss, more so in the right ear, the patient did not feel that his hearing had declined to a level where it required some sort of intervention (e.g., amplification).

This case also raises some questions:

* Are there many patients with this type of clinical finding for whom active medical treatment of otosclerosis could prevent or slow the progression of hearing loss?

* Might other otologic conditions be attributable to otosclerosis, and might they be identifiable on CT of the temporal bones?

It seems the answer to these questions might be yes.

Two recent reports clearly showed that pure sensorineural hearing loss can occur in a patient whose temporal bone histopathology reveals otosclerosis (2) and that normal hearing can occur in the presence of histopathologic evidence of otosclerosis. (3) If the same histopathology can be present with both a severe sensorineural hearing loss and with normal hearing, it is possible that otosclerosis of the otic capsule may explain a number of otologic symptoms.

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References

(1.) Youssef O, Rosen A, Chandrasekhar S, Lee HJ. Cochlear otosclerosis: The current understanding. Ann Otol Rhinol Laryngol 1998;107(12):1076-9.

(2.) Hayashi H, Onerci O, Paparella MM. Cochlear otosclerosis. Otol Neurotol 2006;27(6):905-6.

(3.) D'Ascanio L, Linthicum FH Jr. Multiple otosclerotic foci without hearing loss. Otol Neurotol 2007;28(4):572-3.

Kenneth H. Brookler, MD, FRCSC

From Neurotologic Associates, PC, New York City