Nonadjacent mass compression dizziness and hearing loss: A case report

Nonadjacent Mass Compression Dizziness and Hearing Loss: A Case Report Brett D. Gerwin, * John M. Gerwin, MD, FACS, ~ L. Clark Simpson, MD, FACS, ~ and Kenneth S. Gerwin, MD, FACS ~

(Editorla] Comment: The authors report a case that seems to underscore the importance of pursuing comprehensive MRI when evaluating sudden hearing loss. They acknowledge the difficulty in contributing these symptoms directly to this mass.) Patients w i t h s y m p t o m s of d i s t u r b e d balance, hearing loss, a n d tinnitus are c o m m o n l y seen in an otolaryngology practice. E n d o l y m phatic h y d r o p s , acoustic n e u r o m a , or cerebell o p o n t i n e angle t u m o r s a n d other i n n e r ear disorders are t y p i c a l l y e n c o u n t e r e d . M u c h less frequently, these s y m p t o m s m a y result from the c o m p r e s s i v e effect of an intracranial mass not adjacent to the 8th n e r v e b u n d l e .

sis of meningioma. She was seen at intervals over the next 16 months. During that time, serial andiograms documented a progressive improvement in her speech discrimination score in the left ear from a preoperative score of 16% up to 84% at 16 months (Table 1). However, the pure tone hearing loss and symptom of tinnitus in the left ear remained unchanged. Medications given during this time included time-release niacin, intramuscular injections of steroid, diuretics, and multiple vitamin preparations. A repeat scan with contrast done 1 year postcraniotomy showed no recurrence and was otherwise normal. Her symptom of dysequilibrium (not true vertigo) has persisted, is better than preoperatively, and is worse at night. She has been able to return to work as a clerk. DISCUSSION

CASE REPORT A 56-year-old white woman presented with symptoms of dysequilibrium, fullness, and tinnitus in the left ear. She did not describe true vertigo. Her physical examination showed swollen nasal turbinates. Her initial audiogram showed a severe left unilateral sensorineural hearing loss across the frequency range with normal hearing in the right ear. Speech discrimination scores were 16% in the left ear and 100% in the right ear (Fig 1). A gadolinium-enhanced magnetic resonance imaging (MRI) scan of the brain and internal auditory canals showed a 3-cm extra-axial mass along the left parietal convexity adjacent to the midtine consistent with a meningioma. There was no evidence of acoustic neuroma on the scan (Fig 2). The patient was referred to a neurosurgeon and underwent a left parietal craniotomy with removal of the meningioma. The pathology report confirmed the diagno-

From the *Untversity of Alabama at Btrmingham School of Medicine, Btrmingham, AL; tENT Associates of Alabama, Btrmingham, AL, and *Mornstown Memorial Hospital, Momstown, NJ Presented at the Annual Meetmg of the American Academy of Otolaryngology--Head and Neck Surgery, San Antonto, TX, September 13-16, 1998. Address reprint requests to John M. Gerwin, MD, FACS, Suite 402, 833 St Vincent's Dr, Birmingham, AL 35205. Copyrtght© 2000 by W B. Saunders Company 0196-0709/00/2101-0007510.00/0

Our c o m p u t e r literature search did not s h o w any other reports of parietal c o n v e x i t y m e n i n giomas causing unilateral sensorineural hearing loss w i t h d e c r e a s e d s p e e c h d i s c r i m i n a t i o n score a n d dysequilibrium. However, w e did find some papers that p r e s e n t e d similarly. DeMonte et al 1 r e p o r t e d a pineal m e n i n g i o m a presenting w i t h abnormal s p e e c h discrimination. Missori et al 2 r e p o r t e d 3 cases of pineal region t u m o r s presenting w i t h tinnitus and hearing loss. T h e y also r e v i e w e d a series of 72 other pineal region t u m o r s treated in their d e p a r t m e n t and f o u n d that 13 (18%) of t h e m also h a d hearing loss and tinnitus. Pathology in these cases inc l u d e d m e n i n g i o m a , m e l a n o m a , and pinealcytoma. In m o s t of these cases, the s y m p t o m s i m p r o v e d after surgical r e m o v a l of the tumor. Yanaka et al 3 r e p o r t e d a f o r a m e n m a g n u m m e n i n g i o m a coinciding w i t h a lateral cerebell o m e d u l l a r y cistern a r a c h n o i d cyst that pres e n t e d w i t h dizziness. In this case, s y m p t o m s again i m p r o v e d after surgery. D u n n i w a y and Welling 4 r e p o r t e d 5 cases m i m i c k i n g benign positional vertigo. Four were c e r e b e l l o p o n t i n e angle tumors, b u t i was a n o n a d j a c e n t g]ioma. Unfortunately, this patient died. H a d l e y et al 5

Amencan Journal of Otolaryngology,Vo121, No 1 (January-February),2000. pp 43-45

43

44

GERWlN ET AL

125

250

500

1000

400(3

2000

80O0 KEY TO AUDIOGRAM

10

-10

®

y

R(red)

0

"-

20 10

(,

.,..,/

A/C Unmasked O A/C Contralateral Masking /~ B/C Unmasked < B/C Contralateral Masking ~ N/R = No Response ~,O LE DNT = D~d Not Test CNT = C c u l d Not Test HL = Hearing Level SL = Sensat~onalLevel A = Aided Soundfield SRT = Speech Reception Threshold SD = Speech Dlscnmlnatlon PTA = Pure Tone Average (500 = 2K Hz) MCL = Most Comfortable Level (speech) UCL = Uncomfortable Level (speech)

10

(t

)2o :3O 417

5O

9; =o

,o ,0

'3

r

r-

J\.r

J

70

~.{ .o

8o

P"

gO

_= ¢¢

loo

q: uJ

110

HO

120

~20 8O0O

-L 100

25O

125

• ~r~

tS~

500

bO

1000

I~O

2OOO

4000

~50

~O

DO

Ear RE

R

PTA

DISCRIM

i L(blue) I t ! ! [

X [] > "7 X~ 3~

MCL

UCL

,5 Ioo7, 4-0

IF Audiometer:

GS1 - 61

....

Beltone 114 J

MA 41 Reliability:

Good ~

SF

OB822 Word

Fa=r

Poor

~

Inserts

Recorded

Headphones:

Standard

Fig 1.

live Votes

Initialaudiogram.

reported 5 patients with posterior fossa arachnoid cysts. Four of these were nonadjacent and presented with dizziness or vertigo. All patients responded well to surgery. Q u i e t al 6 reported a patient presenting with unilateral hearing loss, tinnitus, and vertigo. This pa-

tient had a cerebellar tumor compressing the brainstem and involving the cerebellopontine angle. However, the patient's symptoms were attributed to brainstem compression and did improve after partial tumor resection. This tumor was a medulloblastoma. Pollice et al 7 reported a case presenting with unilateral hearing loss and intermittent vertigo. Their patient had a nonadjacent posterior fossa arachnoid cyst. Haberkamp et al 8 reported 3 cases of posterior fossa arachnoid cysts. One of these presented as Meniere's syndrome and was nonadjacent. DeMonte et al 1 proposed a mechanism by which compression from pineal region tumors could cause hearing impairment. After a neuroanatomic review, they concluded that the auditory pathways could be impaired TABLE1, Speech D~scnmmatlon Scores Initial 6 mo 7 mo 9 mo 10 mo 16 mo

Figure 2

16% 40% 60% 72% 80% 84%

MASS COMPRESSION DIZZINESS AND HEARING LOSS

at any level from the superior olivary nuclei to the auditory radiations. They suggested that their patient's impairment occurred at the level of the upper pons and lower midbrain. Missori et al 2 thought that tumors might impair hearing by displacing and pushing the quadrigeminal plate and the geniculate bodies downward. Habercamp et al 8 proposed increased cerebrospinal fluid pressure as the cause of the hearing loss in their series of posterior fossa arachnoid cysts. Dunniway and Welling 4 said that the glioma they reported may have caused hearing loss by exerting a mass effect directly on the vestibular nuclei, because the glioma was located just anterior to the midbrain. In our case, one may only hypothesize where in the auditory pathway this parietal convexity meningioma caused compression impairment. However, during the time we have been taking care of this patient, we have sometimes thought that her meningioma was coincidental to coexisting endolymphatic hydrops. At various times during her postoperative course she received medication for endolymphatic hydrops, including time-release niacin, steroids, diuretics, and a multiple-vitamin preparation, without improvement in her dysequilibrium and tinnitus. At no time has she had true episodic vertigo or fluctuating hearing loss. Her tinnitus has varied in intensity and loudness, and her symptom of dysequilibrium is also variable. Although there has been no i m p r o v e m e n t in her pure tone hearing, her speech discrimination scores have steadily and consistently improved, from 16% at presentation up to 84% in the left ear at her 16-month postoperative visit. Because she did not have the classic symptoms of Meniere's disease and did not respond to medical treatment for it, we concluded that she did not have Meniere's disease. Her complete enhanced scans showed no evidence of acoustic neuroma and her speech discrimination scores steadily improved, so we believed she did not have an acoustic neuroma. We think that her

45

symptoms are the result of compression from her meningioma.

CONCLUSION Our patient presented with the c o m m o n l y encountered symptoms of disordered balance, hearing loss, and tinnitus. An audiogram showed unilateral sensorineural hearing loss with poor speech discrimination. A magnetic r e s o n a n c e imaging scan with g a d o l i n i u m showed a left parietal convexity meningioma. The meningioma was distant from the internal auditory meatus, cerebellopontine angle, and 8th nerve complex. Although we believe this tumor caused symptoms by its mass compressive effect, only the speech discrimination score dramatically improved after tumor removal. The importance of audiometry and nonlimited magnetic resonance imaging scan with gadolinium are underscored. This unique and remarkable case stands alone. The improvement in speech discrimination postoperatively substantiates this lesion as a heretofore not described source of treatable hearing loss and dizziness.

REFERENCES 1 DeMonte F, Zelby AS, Ossama A: Hearing impairment resulting from a pineal region memngioma. Neurosurgery 32 665-668, 1993 2. MissoriP, Delfim R, Cantore G. Tinnitus and hearing loss in pineal region tumors. Acta Neurochir 135:154-158, 1995 3 Yanaka K, Hyodo A, Fulimori H, et al: Foramen magnum meningioma and arachnoid cyst coinciding in the lateral cerebellopontine cistern Neurol Med Chir 32:581-584, 1992 4. Dunniway HM, Welling DB. Intracranial tumors mimickingbemgn paroxysmalpomtionalvertigo.Otolaryngol Head Neck Surg 188:429-436, 1998 5. HadleyMN, GrahmTW, Daspit CP, et ah Otolaryngologic mamfestatlons of posterior fossa arachnoid cysts. Laryngoscope95:678-681, 1985 6 Qui WW, Stucker FJ, Nguyen HI-I, et ah Effects of brain stem lesions on cochlear function: Mechanism of hearing improvement after removal of a brain stern tumor. OtolaryngolHead Neck Surg 115:560-567, 1996 7. Pollice PA, Bhatti NI, Niparko )K: Imaging qmz case 1. Arch OtolaryngolHead Neck Surg 123'762-765, 1997 8. HabercampTJ, MonsellEM, HouseWF, et ah Diagnosis and treatment of aractmoid cysts of the posterior fossa, OtolaryngolHead Neck Surg 103:610-614, 1990