1. Case Presentation Conference -Memorial- January 24, 2002 Jason Hunt M.D. Brian Kerr M.D. Peter Rigby M.D.

2. Chief Complaint 65 y.o. female presents with complaint of decreased hearing in the left ear. Has worsened over several years now what?

3. No hx of infection, trauma, previous ear surgery. No pain. No significant noise exposure (works as librarian)., no family hx of hearing loss. No hx of ototoxic drugs. Complains of mild dysequilibrium tinnitus only on left (non-pulsatile)

4. Otolaryngology ROS –no wt loss –no dysphagia, no odynophagia –no hoarseness or change in voice –no globus sensation –no aspiration or sense of choking on food.

5. Med Hx: Hypertension, tx with HCTZ Surg Hx: none Meds: HCTZ ROS: unremarkable, –good exercise tolerance walks for 30 minutes every morning

6. Physical Exam Ears Nose Throat neuro

7. Physical Exam Vibrant, pleasant women Remarkable findings: –Ears: normal exam, –oral: symm palate, +gag, tongue mobile –no facial weakness, no facial parasthesia –TVC equally mobile, –decreased corneal reflex left eye –left + Hitzleberger sign. Other clinical testing?

8. Forks Weber lateralized to the right Rinne: right is + Rinne: left is +

9. Imp/Plan:

12. IMP/Plan ?

13. ABR vs. MRI Advantages/Disadvantages E - Eighth nerve (wave I)………. 2.0 msec C - cochlear nucleus (wave II)…. 3.0 msec O - superior olive (wave III)…… 4.1 msec L - lateral lemniscus (wave IV).. 5.3 msec I - inferior colliculus (wave V).. 5.9 msec

14. What about calorics?

15. Treatment Options

16. Observation surgery (what approaches?) what about gamma knife?

17. Surgery Retrosigmoid or suboccipital hearing conservation except lateral 1/3 of IAC need to retract on cerebellum/ post op H/A Translabyrinthine most direct/ good exposure (including VII) does not conserve hearing Middle Fossa approach hearing conservation, exposes lateral 1/3 IAC

18. Anatomy Cerebellar Pontine Angle –mediallylateral surface of brainstem –roofcerebellum/middle cerebellar ped. –Post.Cerebellum/cerebellar tonsil –floorarachnoid assoc. with lower nn.