Balance

Damage to the inner ear can lead to permanent hearing loss, vertigo and other severe balance problems. Immediate attention from an otolaryngologist, along with the proper treatment and follow-up, can make the critical difference between life-long profound deafness and a return to normal hearing.

With a recent case of inner ear trauma at Cornerstone Ear, Nose & Throat, we were able to restore a patient’s normal hearing although he only returned for follow-up when his conditioned had worsened.

A Dramatic Case

This 35-year-old man suffered traumatic injury when a tree branch struck him on the side of the head, entered the ear canal, and caused traumatic tympanic membrane (ear drum) perforation. The emergency department at Gaston Memorial Hospital prescribed Floxin Otic drops and Vicodin for pain, and conducted a CT of the brain. He was then appropriately referred to CornerStone Ear, Nose & Throat for further evaluation and treatment of his hearing loss and vertigo.

Figure 1 - Audiogram demonstrated a profound hearing loss
Figure X: The blue symbols indicate responses for the patient’s left ear while the red symbols represent the right ear. Immediately following the trauma, the patient’s audiogram demonstrated a profound hearing loss through the majority of the frequency range in the left ear. After corrective surgery, hearing threshold levels were restored to near normal levels in the low frequencies. Remarkably, bone conduction thresholds, which indicate the sensorineural component of hearing, were restored to near normal levels.

At his initial examination by practice founder and physician William McClelland, M.D., F.A.C.S., the patient reported ear pain, bleeding, decreased hearing, vertigo, imbalance, nausea and vomiting. When viewed microscopically, a 20 percent central perforation of the tympanic membrane was observed and the ossicles were visible through the perforation. An audiogram and tympanogram performed by our audiologist also indicated that normal hearing had dropped to mild sensorineural hearing loss in the right ear and severe to moderately severe mixed hearing loss had occurred in the left ear (see Figure X). The patient’s original CT scan revealed no skull or temporal bone fracture or internal hemorrhage. The patient was treated with oral steroids, Cefzil and Floxin Otic drops, and was advised to return for after undergoing a high resolution CT of his temporal bones.

Figure - 2 Diagram of the inner ear
“Despite poor follow-up compliance, this patient’s surgical results were outstanding, bordering on miraculous”, said Dr. McClelland. “His dizziness and hearing loss resolved completely after aggressive surgical intervention.”

After numerous attempts to contact him, the patient returned two and a half weeks later when his symptoms, including severe stabbing ear pain, significant bloody ear drainage, diminished hearing and dizziness had gotten worse. He also continued to experience notable vertigo. The patient had profound sensorineural hearing loss in the left ear, which was strongly suggestive of a traumatic perilymph fistula, and was unable to hear normal conversation.

Surgical Intervention

The patient was immediately scheduled for surgery the next day for left ear exploration. He was advised that even with the surgical procedure, his hearing and balance might never return to normal. Dr. McClelland performed a tympanoplasty with ossicular chain reconstruction, stapedectomy and repair of oval window perilymph fistula. The patient did not come in for post-surgery care within the recommended 6-12 day period and returned with an aural polyp and swollen graft, severe ataxia and the inability to stand up straight with his eyes closed. He also reported gradual hearing improvements and decreased balance problems. Dr. McClelland again explained the importance of timely follow-up care, prescribed another course of antibiotics, oral steroids and recommended follow-up in one week.

A Remarkable Recovery

Two weeks later, the patient returned and reported continued improvement and the ability to hear on his left side. He had no ear pain or drainage and no loss of balance or tinnitus. An otoscopic exam revealed normal appearance of the tympanic membrane with no perforation, no fluid and a well-healed surgical site. The patient’s hearing to conversational voice was intact and an audiogram revealed normal hearing.

Despite poor follow-up compliance, this patient’s surgical results were outstanding, bordering on miraculous, said Dr. McClelland. His dizziness and hearing loss resolved completely after aggressive surgical intervention.

When ear trauma of the inner ear results in bleeding, especially if accompanied by complaint of hearing loss in the ear, the patient should be referred to an otolaryngologist for microscopic exam and hearing evaluation, ideally within 24-48 hours. If there is dizziness or vertigo along with suspected ear trauma, a same-day referral should be requested by the referring physician.