The patient, Deming Li, male, 68 years old, was admitted to the hospital with “multiple cerebral infarction” as an outpatient due to “sudden hearing loss in the left ear for 8 days”.
Case characteristics.
(1) Elderly male with acute stroke-like onset and rapid peak of symptoms and signs.
(2) Previous history of hypertension for 30 years, up to 180/120 mmHg, taking regular medication; history of coronary heart disease for 9 years, not taking regular medication; history of hearing loss in the right ear for 1 year; history of benign positional vertigo for 6 months. He has been addicted to alcohol and tobacco for 40 years, and has quit for 10 years.
(3) Characteristics of this attack: sudden hearing loss in the left ear with tinnitus, no dizziness, headache, no nausea, vomiting
(4) Physical examination: Bp 160/100mmHg, clear speech, uncooperative examination, both pupils equal in size, sensitive light response, adequate eye movements, no nystagmus, symmetrical facial and frontal lines, tongue extension in the center, strong soft palate elevation, central uvula, pharyngeal reflex, hearing loss in both ears, obvious in the left ear, binaural air conduction > bone conduction, weak binaural bone conduction, disappearance of Weber test, muscle strength of all four limbs grade 4. Myotonia and tendon reflexes were moderate and symmetrical, pathological reflexes were not elicited, respiratory sounds in both lungs were clear, dry and wet rales were not heard, heart rate was 68 beats/min, rhythm was regular, no edema in both lower limbs.
(5) Adjunctive examinations.
Head CT: Bilateral paraventricular density was slightly low, scattered patchy hypointense shadow was seen in the right basal ganglia and left paraventricular area with blurred borders, uneven density in the brainstem, symmetrical slight enlargement of the ventricular system and widening and deepening of the sulcus fissure.
Electrical audiometry: disappearance of bony conduction in both ears.
Localization.
A patient with sudden hearing loss in the left ear in the distribution area of the vertebrobasilar artery blood supply, examination: hearing loss in both ears, weak bone conduction, lesion involving the auditory conduction pathway, combined with a variety of risk factors, considered internal auditory artery thrombosis, the distribution area of the vertebrobasilar artery blood supply, so localization; combined with the imaging brainstem density is uneven, support the diagnosis.
Qualitative.
Sudden onset of hearing loss in the left ear in a patient with sudden deafness. On examination: hearing loss in both ears, obvious in the left ear, so qualitative.
Differential diagnosis.
(1) Auditory neuroma patient presented with hearing loss in the right ear 1 year ago, and now presents with hearing loss in the left ear with tinnitus, with a history of vertigo 6 months ago, the patient has hearing loss and tinnitus at the same time, imaging brainstem density is not uniform, so the possibility of auditory neuroma is not excluded, can be about MRI to further clarify the diagnosis.
(2) The patient with bilateral mastoid lesion had sudden hearing loss in the left ear without any obvious cause, and on examination: Weber test disappeared and bone conduction was weak, so the possibility of mastoid lesion cannot be ruled out, and relevant auxiliary examinations can be performed to further clarify the diagnosis.
Treatment plan.
(1) Improve the relevant auxiliary examinations, about magnetic resonance, evoked potentials, nystagmography, etc., to further clarify the diagnosis.
(2) Antiplatelet, anticoagulation, cerebral protection and symptomatic support treatment.
(3) Monitor blood pressure and actively prevent complications.
(4) Monitor cardiac function and request internal medicine consultation if necessary.
(5) Ask a higher-level physician to see the patient to guide clinical