Cool case: quick one

[neurodoc]

---

Members do not see this ad.

Here is a real case from residency. A 2 1/2 yo girl from Cambodia is brought to the ER by her parents for convulsions. She is afebrile. An MRI was obtained and it showed a 2cm diameter enhancing lesion in the right frontal lobe, with edema of the surrounding white matter. This case was presented in Neuroradiology rounds by the Chief of Neuroradiology. His opinion was that this was a glioma, and the patient had been scheduled for biopsy. A junior neuro resident looked closely at the MRI images and suggested that biopsy was absolutely unecessary. When he pointed the critical feature out to those in attendance, they agreed. The child was spared surgery. What did the resident point out?

This is an easy one, but I like it because it's a real case and shows how important careful observation, rather than just jumping to conclusions, can help patients.

Nick

 

[Wheezy]

Hypointense rim (haemosiderin). cavernous haemangioma (cavernoma).

Just a wild guess! The wrong age group, but let's just throw it out there for the forums sake.😀

--------------------

As for our guy with the VI nerve palsy. Has he been bitten by a tick recently (Burgdorferi i.e. Lyme) I think someone already mentioned this in the labs.

 

[Wheezy]

Here is a real case from residency. A 2 1/2 yo girl from Cambodia is brought to the ER by her parents for convulsions.

Nick

I was gonna say Neurocysticercosis, but the girl's lesion enchances. I don't think this is easy... but I need to make a bigger dent in my neuroradiology book😀

Nice case.

 

[neglect]

Blood pressure for the clinic visit is 134/82, and temperature is normal. I'll also add that he hasn't had a fever or been sick recently, and there's no history of head trauma.

Other exam notes that I didn't specifically mention: no periorbital edema, and fundoscopic exam appeared normal.

I'd give CSF/lab/imaging results, but that'd end the case right there, so I'll wait just a little bit longer to see if anyone figures out the one piece of history I'm fishing for. 🙄

Old photos might help if they show the strabismus from long ago - but at this point, such considerations are exclusionary. He still needs an MRI to exclude a mass. If negative, then he needs a neuroradiologist to look at it. If still negative, he will need a 3 to 6 month follow up scan.

 

[neglect]

Here is a real case from residency. A 2 1/2 yo girl from Cambodia is brought to the ER by her parents for convulsions. She is afebrile. An MRI was obtained and it showed a 2cm diameter enhancing lesion in the right frontal lobe, with edema of the surrounding white matter. This case was presented in Neuroradiology rounds by the Chief of Neuroradiology. His opinion was that this was a glioma, and the patient had been scheduled for biopsy. A junior neuro resident looked closely at the MRI images and suggested that biopsy was absolutely unecessary. When he pointed the critical feature out to those in attendance, they agreed. The child was spared surgery. What did the resident point out?

This is an easy one, but I like it because it's a real case and shows how important careful observation, rather than just jumping to conclusions, can help patients.

Nick

Cystercercosis? Tuberculoma?

 

[Sir Elroy]

All right, here's the key. Since neurodoc has another case, I'll finish this one off.

As the guy's walking out the door (after you order all the studies), he pauses to say:

"Say, there is something else I always wanted to ask a doctor, but I always forget. Over the last couple years, I've had to change my glove size a couple times - it almost feels like my hands are getting bigger. Any idea what would cause something like that?"

So you all were right on track, just would've needed the studies to tell you what the problem was (a pituitary macroadenoma).

 

[Sir Elroy]

Here is a real case from residency. A 2 1/2 yo girl from Cambodia is brought to the ER by her parents for convulsions. She is afebrile. An MRI was obtained and it showed a 2cm diameter enhancing lesion in the right frontal lobe, with edema of the surrounding white matter. This case was presented in Neuroradiology rounds by the Chief of Neuroradiology. His opinion was that this was a glioma, and the patient had been scheduled for biopsy. A junior neuro resident looked closely at the MRI images and suggested that biopsy was absolutely unecessary. When he pointed the critical feature out to those in attendance, they agreed. The child was spared surgery. What did the resident point out?

Nick

My guess would also be cysticercosis - maybe the resident pointed out the scolex in the center?

I don't think the lesion is in a typical location for encephalitis (HSV, Japanese or otherwise), but that's kind of in the back of my mind, as always are toxoplasmosis and CNS lymphoma.

 

[Nerdoscience]

Oh, very interesting on the sixth nerve one. For a GH secreting pit macroadenoma to affect 6 but not 2 is weird. Usually smashes at least the inferior (superior vis field), medial (temproal vis field) part of the optic chiasm before compressing nerves that come through the cavernous sinus.

 

[Nerdoscience]

I would think cestodes, not necessarily cystercerca. BTW, that one sends larval cysts to the brain. Hmmmm...

 

[Wheezy]

Nice one.

I've seen tones of patients with GH secreting macroadenomas. haven't seen a VI with it yet though. loadz of guys/gals with II nerve damage.

I still wonder about excess sweating.... anyway, good case. thanks😀

 

[neurodoc]

Congratulations to Sir Elroy, neglect, wheezy, and nerdo! What I pointed out to the attendees was the scolex. It was pretty clear on a few of the images, but for some reason no one had noticed it. It was a nice thing to observe, since it proved the lesion was in fact a metazoan life form and not something else (like a cancer or a lower life form, such as toxo or a bacterial abscess). And here we have a case where knowing what to look for and being able to see it actually saved a patient. One of my med school professors (pathology) liked to quote Goethe, who said something like "Mann sieht wass mann wiess," meaning "One sees what one knows." Forgive me if I didn't get the German exactly correct. My German is rusty, but the idea is pertinent to medical diagnosis, or really anything else in life.🙂

Nick

 

[neurodoc]

Oh, very interesting on the sixth nerve one. For a GH secreting pit macroadenoma to affect 6 but not 2 is weird. Usually smashes at least the inferior (superior vis field), medial (temproal vis field) part of the optic chiasm before compressing nerves that come through the cavernous sinus.

I agree. I'd bet that this patient did have a visual field defect that was just missed on the physical exam. Was the patient subjected to automated perimetry? Confrontational bedside visual field testing tends to be very crude. When I was a resident, I tried to make the exam more sensitive by using a laser pointer to perform a kind of projective perimetry test. I'd sit the patient facing a wall, and applied a red dot "sticker" to serve as a fixation point. I'd have the patient look at the dot with both eyes open and with his right and left eye sequentially while standing behind him a flashing the laser at random points on the wall. Using this technique, I was able to locate significant visual field defects pretty accurately, including "pie in the sky" field cuts.

Nick

 

[Nerdoscience]

Yeah, I actually HAVE the beginnings of the classic bitemporal hemianopia (superior quadrants only so far, and almost none on the right. But I can tell you how many fingers there are in every quadrant. Really amazing, considering that on formal visual field testing, the defect is quite dense. The "how many fingers" or blink when the fingers are coming test are not very sensitive.

 

[Sir Elroy]

Yeah, I imagine you all are right about the visual deficit. I didn't see the patient myself, but I'm guessing he was tested confrontationally - "how many fingers am I holding up?" type thing. But that didn't seem to be enough to pick up any problems.

I'll have to ask if he was tested more sensitively for visual loss after the diagnosis was made.

 

[Docxter]

I agree. I'd bet that this patient did have a visual field defect that was just missed on the physical exam. Was the patient subjected to automated perimetry? Confrontational bedside visual field testing tends to be very crude. When I was a resident, I tried to make the exam more sensitive by using a laser pointer to perform a kind of projective perimetry test. I'd sit the patient facing a wall, and applied a red dot "sticker" to serve as a fixation point. I'd have the patient look at the dot with both eyes open and with his right and left eye sequentially while standing behind him a flashing the laser at random points on the wall. Using this technique, I was able to locate significant visual field defects pretty accurately, including "pie in the sky" field cuts.

Nick

Pituitary adenomas can have cavernous sinus invasion without suprasellar extension causing mass effect on the chiasm. Not common, but certainly happens and I have seen many of these cases.

 

[Cali2007]

A cool discussion group! I saw a patient last week whose diagnosis is still impending and I would like to present this case here. It does not seem like a neuro case but I am interested to hear some feedback from you guys.

A 55 yo caucasian male came in with c/o of left-side face swelling on and off for a month. The swelling was first noticed by his family. When I saw this patient, I noticed that left face looked rounder than right face but it's not dramatic. One significant medical history is that he had a stabbed wound injury 15 years ago on the left jaw. Any other information you like to know about this case?

Sorry, Neurodoc, I cut in before your case is finished. I am curious about the answer to yours though.

 

[neglect]

A cool discussion group! I saw a patient last week whose diagnosis is still impending and I would like to present this case here. It does not seem like a neuro case but I am interested to hear some feedback from you guys.

A 55 yo caucasian male came in with c/o of left-side face swelling on and off for a month. The swelling was first noticed by his family. When I saw this patient, I noticed that left face looked rounder than right face but it's not dramatic. One significant medical history is that he had a stabbed wound injury 15 years ago on the left jaw. Any other information you like to know about this case?

Sorry, Neurodoc, I cut in before your case is finished. I am curious about the answer to yours though.

Does he have a Horner's?

OK, I don't know what to do with this one - neurology is full of unexplained things and this is probably going to be one of them.

30 yo man with single 20 minute episode of painless horizontal diplopia, no further reliable history (does not recall if present with right gaze, left gaze, did not cover/uncover). Detailed exam of CN's is normal: no INO, ocular palsy, no fatigue. No history of preceeding neurologic problem, and no specific problem of some examples of demyelinating attacks. He is a good citizen and psychologically normal with no recent life changes/secondary gains or any other code words for crazy/conversion. His brain MRI is pristine per both rads and me. His ACh-AB's are pending. Once they come back normal...

What would you do? I'm going to send him on his way. I think the workup pretty much excludes all the bad things.

 

[Nerdoscience]

For the diplopia guy: Do you know about Drinking, headaches, migraine auras, vertigo, dizziness, somnolence?

For the puffy guy - could this be angioedema? Was he on an ACE-I? Was his face weak? Except for the half and half thing, sounds very not neuro (unless the puffyness is weakness).

 

[Nerdoscience]

Here's a "read my mind" kind of case, but anyone care to guess? I am purposefully leaving a bunch of holes a la some previous posts, but maybe someone can get it... Maybe some people prefer this way. Hmmm?

You get called on a consult in the ER. 50 y/o is on a plane going to his daughter's college soccer game. All of a sudden, on the plane, he finds it hard to speak -- his words sound slurred. Also, he is dizzy and sick to his stomach. When he gets up, he stumbles. In the ER, they got a head CT, which showed no acute bleed, but is blurry and full of motion artifact. You don't have any other history yet.

any guesses? What other history do you want?

 

[neurodoc]

Here's a "read my mind" kind of case, but anyone care to guess? I am purposefully leaving a bunch of holes a la some previous posts, but maybe someone can get it... Maybe some people prefer this way. Hmmm?

You get called on a consult in the ER. 50 y/o is on a plane going to his daughter's college soccer game. All of a sudden, on the plane, he finds it hard to speak -- his words sound slurred. Also, he is dizzy and sick to his stomach. When he gets up, he stumbles. In the ER, they got a head CT, which showed no acute bleed, but is blurry and full of motion artifact. You don't have any other history yet.

any guesses? What other history do you want?

No bleed on CT? OK. Maybe a lacunar stroke. Maybe an embolism. MRI with FLAIR imaging?

Nick

 

[Nerdoscience]

How about history first? Any questions?

 

[Bill59]

You get called on a consult in the ER. 50 y/o is on a plane going to his daughter's college soccer game. All of a sudden, on the plane, he finds it hard to speak -- his words sound slurred. Also, he is dizzy and sick to his stomach. When he gets up, he stumbles. In the ER, they got a head CT, which showed no acute bleed, but is blurry and full of motion artifact. You don't have any other history yet.

Did the airplane have a pressurized cabin? Is he a smoker or anything else that would increase susceptibility to hypoxia/decompression?

 

[Cali2007]

for the 50 yo guy, I'd like to know whether he has ASD (the primary one)?

For my facial puffy case, Nerdoscience, you seemed to have a similar thought as our team. First, I believe it was not a neuro problem given he did not have weakness, numbness or tingling. He did not have any sensation problems (I checked) on the face or hearing problems. He complained of his vision but it seemed more like presbyopia than vision loss. We tried to rule out angioedema first. We ordered the complement panel and are waiting for the result.

 

[Cali2007]

For the 50 yo guy, the reason why I asked about ASD is that sometimes DVT can pass through ASD and get to the brain (ischemic stroke).

 

[neglect]

For the diplopia guy: Do you know about Drinking, headaches, migraine auras, vertigo, dizziness, somnolence?

None of it.

You get called on a consult in the ER. 50 y/o is on a plane going to his daughter's college soccer game. All of a sudden, on the plane, he finds it hard to speak -- his words sound slurred. Also, he is dizzy and sick to his stomach. When he gets up, he stumbles. In the ER, they got a head CT, which showed no acute bleed, but is blurry and full of motion artifact. You don't have any other history yet.

Stroke-like onsets are usually stroke. This one sounds brainstem. Head trauma? Weird neck tilting with sleep? Head pain? I'd think vert dissection.

Smell his breath: is he drunk? Did he take some ambien to ease his fear of flights?

The exam will help sort things out.

 

[Nerdoscience]

No neck tilting or head pain. Not drunk. Cabin was pressurized. No h/o ASD of any type (including PFO).

 

[Wheezy]

You get called on a consult in the ER. 50 y/o is on a plane going to his daughter's college soccer game. All of a sudden, on the plane, he finds it hard to speak -- his words sound slurred. Also, he is dizzy and sick to his stomach. When he gets up, he stumbles. In the ER, they got a head CT, which showed no acute bleed, but is blurry and full of motion artifact. You don't have any other history yet.

Lets work with what we have & then I'll ask a few questions:

Presenting compliant: disturbed speech & unsteady gait.

3 Steps: What's the problem? Where is the lesion? What caused the lesion?

The problem:
Is the "slurred speech" truely slurred i.e. dysarthria, or is it an expressive dysphasia? Is comprehension intact?
Is the unsteady gait due to a motor deficit or ataxia (cerebellar vs. sensory)?
Dizzyness was mentioned; is this vertigo, presyncope, ataxia or a nonspecific use of the word?
From the info it sounds like dysarthria with ataxia & vertigo.

Localization:
A brainstem lesion is most likely (test this with more history & a clinical exam), if there is no motor tract signs or motor cranial nerve signs I would assume a more lateral syndrome than medial.

Pathogenesis:
Sudden onset suggest vascular aetiology. 50 y.o. & low O2 tension are consistent with this.
sounds like Posterior circulation stroke so far. Cardioembolic lesions are top of the list.

DDx.
Cardioembolic: Atrial fibrillation, valvular lesions, aortic arch atheroma, mural thrombos (post MI), ASD/PFO (discussed)
Others: HTN, subclavian steal, brainstem cavernoma (haemorrhagic), vertebral artery dissection (discussed), Giant cell arteritis.

Time for some more history & exam:
Are the deficits presisting, has he had them before? did he have a headache a few days before (vasospasm after sentile bleed of SAH, I'm pushing my luck aren't I!!!).
Other neuro symptoms?
Vascular risk factors (HTN, Smoking, Lipid levels, family history)
Any drugs
Past medical history & current meds? & diet of course

Exam: speech, cranial, limbs & Gait. Just the results, we'll interpret.😀

then: i'd do MRI FLAIR/diffusion, MRA, TOE with bubble, ESR, ECG & holter, Lipids & glucose.

---------
My next post will be shorter😎

 

[Nerdoscience]

The problems are completely new. No headache. Speech is soft, hoarse, and slurred, but language is completely normal.

Is TOE a TEE in America?

 

[Nerdoscience]

Exam Part one: MS NL, R eyelid with mild ptosis, anisocoria with R<L, but equally reactive. Loss of R face pinprick but intact LT. Otherwise, CN intact.

 

[neurodoc]

Exam Part one: MS NL, R eyelid with mild ptosis, anisocoria with R<L, but equally reactive. Loss of R face pinprick but intact LT. Otherwise, CN intact.

R Horner's plus R nV? That's interesting. I can't place a single lesion. Maybe the anisocoria is a red herring (it may have been there before and previously un-noticed).

Nick

 

[NR117]

Sounds like a lateral medullary lesion (?infarct) to me - Wallenberg syndrome...

 

[Nerdoscience]

Can you explain the motion artifact?

 

[neurodoc]

Sounds like a lateral medullary lesion (?infarct) to me - Wallenberg syndrome...

The R nV and R Horner's are consistent with Wallenberg, and so is the speech hoarseness and vertigo. But where is the contralateral spinothalamic deficit (hemihypoesthesia to pinprick) and ipsilateral limb ataxia (these might have been there, but they weren't mentioned. Of course this could be an "incomplete" lateral medullary syndrome, due to a small infarct in the lateral upper medulla. The descending nV tract/nucleus and descending sympathetic tracts are close together there. The vertebral, PICA, and lateral medullary artery branches supply this portion of the medulla. If this is a stroke (and it presents that way), it's probably a lacune that affects that spares the more lateral regions of the Wallenberg zone.😳

Nick

 

[NR117]

Can you explain the motion artifact?

He had hiccups! Is that it? I think that can be part of the syndrome as well, when respiratory centres in the medulla are involved.

 

[Nerdoscience]

You got it. I have now seen two cases: one on Neuro and one in Neurorads where CT and/or MRI had lots of motion, and on exam the pt had intractable hiccups from a lateral medullary lesion.

 

[Methyldopa]

You got it. I have now seen two cases: one on Neuro and one in Neurorads where CT and/or MRI had lots of motion, and on exam the pt had intractable hiccups from a lateral medullary lesion.

Interesting case!

 

[neglect]

Cool one on the hiccups. Usually the MRI scares them out.

Bit off the beaten track:

28 yo man who seen at the VA. Recent d/c from the army after serving two years in Iraq. He has a chronic daily headache. It is bilateral, frontal, constant, non-throbbing, pressure. Always present. He also gets unilateral headaches that meet all migrainous criteria, began as a teen with a monthly mild headache, and are now occuring two or three times per week.

Exam is normal.

Any further questions?

 

[neurodoc]

Cool one on the hiccups. Usually the MRI scares them out.

Bit off the beaten track:

28 yo man who seen at the VA. Recent d/c from the army after serving two years in Iraq. He has a chronic daily headache. It is bilateral, frontal, constant, non-throbbing, pressure. Always present. He also gets unilateral headaches that meet all migrainous criteria, began as a teen with a monthly mild headache, and are now occuring two or three times per week.

Exam is normal.

Any further questions?

Exam is completely normal? Forgive me for asking, but I've examined many patients who were referred with symptoms and supposedly normal exams, who turned out to have significant abnormalities when I examined them. These abnormalities included subtle facial palsies, pronator drift, reflex asymmetries, visual field defects, papilledema, frontal release signs, reflex assymetries, etc. Thus, when you say the "exam is normal," I assume you mean it is entirely normal.

That being said, we have a patient with headaches and an entirely normal neurologic exam.

I also assumed the rest of his physical exam was normal. He is not hypertensive. He does not have diabetes or cardiopulmonary disease. In other words, he is, so far as you can determine, entirely healthy except for his headache.

Well, at this point I need to ask about medication history. Has he been taking analgesics for his HA? Is there a family history of migraine? Has he been challenged with triptans to see if these abort his HA?

A common cause of chronic HA is analgesic overuse. This can result in a "transformed migraine," and " analgesic rebound HA." Does he have allergies? "Sinus HA" is in the differential. The treatment for analgesic HA (cephalgia medicamentosa) is withdrawal of analgesics and a trial of prophylactic therapy.

Given that your patient is a veteran, and is probably being cared for in the VA system, you might as well get an MRI. You might as well get c-spine X-rays or even a C-spine MRI. A very small number of patients with HA may have frontal lobe lesions, and even chronic subdurals, and these can be "silent" as regards neurological signs.

That's my thinking on this case.😉

Nick

 

[neglect]

Exam is completely normal? Forgive me for asking, but I've examined many patients who were referred with symptoms and supposedly normal exams, who turned out to have significant abnormalities when I examined them. These abnormalities included subtle facial palsies, pronator drift, reflex asymmetries, visual field defects, papilledema, frontal release signs, reflex assymetries, etc. Thus, when you say the "exam is normal," I assume you mean it is entirely normal.

Let's just assume that when a neurologist says the exam is normal, the exam is about as normal as it's going to get.

Your analysis is entirely correct. I thought he was hiding either otc or opioid or whatevers from me, but none. As far as I can tell, sinus HA is an invention of the makers of sudaphed.

Instead, I took a sleep history. Turns out he hasn't slept more than perhaps 20 minutes since getting home - except when he drinks himself into a stupor. He also feels a constant state of anxiety and affirms flashbacks. He has PTSD, undiagnosed and treated only with alcohol and, I feel, the source of his worsening migraines and 'tension' type chronic daily headaches.

I thought it was an interesting case for a few reasons. First of all, getting no sleep will really mess up your migraines. Second of all, neurology has to be on the watch for psych stuff because of the bidirectional causality they share. Third of all because I think a neurologist can nail these cases without further tests, which keeps us in business, but undervalued - grumble.

 

[neurodoc]

Let's just assume that when a neurologist says the exam is normal, the exam is about as normal as it's going to get.

OK...forgive me for being a Doubting Thomas re the "Neuro Exam WNL." This usually is not a problem when a fellow neuologist, such as yourself, describes a WNL neuro exam. But in my experience, well over half of the referrals with "Neuro Exam WNL" that I get from my non-neuro colleagues are WNL when I examine the patients. This is fortunate, because it usually lets me make an educated guess where (and what) the lesion is and order further tests to confirm my guess. I'm really astounded at how few non-neurologists are able to perform good neurologic exams. I consult for an ER department and get called to see patients with "acute strokes." This is important now because of the possibility of treating stroke with thrombolysis. It's amazing to me how many times I have been called to see patients with Bell's Palsy, radiculopathy, and even Carpal Tunnel Syndrome, whom the ER doc felt were victims of "stroke."

Well, to get back to your HA patient...has he been worked up for sleep apnea? SA is a real problem that in my opinion has been "overdiagnosed." However, it can also be a real exacerbator of HA. Fortunately, it is easy to evaluate with a fairly simple sleep study.

BTW, you're absolutely right about sleep disturbances. We often fail to identify sleep problems. Besides HA, sleep disturbance can also exacerbate epilepsy. I've had many patients whose epilepsy was difficult to control because of insomnia.

Nick

 

[neurodoc]

But in my experience, well over half of the referrals with "Neuro Exam WNL" that I get from my non-neuro colleagues are WNL when I examine the patients.
Nick

Sorry, I meant "are NOT WNL when I examine the patients."😳

 

[Wheezy]

BTW, you're absolutely right about sleep disturbances. We often fail to identify sleep problems. Besides HA, sleep disturbance can also exacerbate epilepsy. I've had many patients whose epilepsy was difficult to control because of insomnia.

Nick

Just to echo that thought. I've seen that, especially with patients with Juvenile myoclonic epilepsy.

Another nice case.... so was the hiccups one.🙂

 

[neurodoc]

You got it. I have now seen two cases: one on Neuro and one in Neurorads where CT and/or MRI had lots of motion, and on exam the pt had intractable hiccups from a lateral medullary lesion.

This is a bit off topic, Nerdo, but I noticed your Wartenberg pinprick wheel in yhour panoply of neuro instruments. I've got one, but I haven't used it due to concerns about spreading infections. It may be a good device, but I use safety pins (which I use once and discard). For my oral exams I eschewed my Wartenberg Wheel, and I think I would have been flunked had I used it...

Nick

 

[Nerdoscience]

Yeah, I use a broken off cotton swab, and then pull off a wisp of cotton for LT as well. In med school, I once saw this weird linear pattern of petechiae on one of my elderly diabetic patient's legs. I was thinking, does this fit any autoimmune disease that I know, or does this follow vein like some infectious etiology? It took me a while to figure out that was where my intern (a neuro intern) had used a safety pin to test PP sensation!

But just so you know, I don't actually own a ravioli maker/ pinprick wheel.

 

[danielmd06]

Still interested in hearing more cases my friends.

 

[Nerdoscience]

Ditto. Bring em on!

 

[Nerdoscience]

Well, I've got one. I'll give you the HPI, and then I'll give you what you ask for, but nothing more.

51 y/o male presents with 2 mo h/o increasing sound of his "heart whoosing in [his] ear", which is now nearly constant. He denies dizziness, hearing loss. Never had anything like this before.

 

[Sir Elroy]

Hmm...assuming it is constant, I'd especially ask if he'd had any headache, weakness/numbness of the face, vision changes, seizures, or any altered level of consciousness. I'd also want to know whether it was in both ears or just one. I'd check to see about a history of heart trouble, hypertension, high cholesterol, kidney trouble, and smoking or other drug use (especially things like cocaine).

I guess the dangerous thing I'd wonder about would be a possible aneurysm. I don't know if aortic insufficiency could do that in both ears, but I'd definitely do a heart exam to check.

Otherwise, exam-wise I'd pay special attention to the cranial nerves, and I'd see if I could actually hear the whooshing over the offending ear(s).

And then my resident or attending would clue me into all the things I didn't think about. 😳

 

[neurodoc]

Well, I've got one. I'll give you the HPI, and then I'll give you what you ask for, but nothing more.

51 y/o male presents with 2 mo h/o increasing sound of his "heart whoosing in [his] ear", which is now nearly constant. He denies dizziness, hearing loss. Never had anything like this before.

I'll take your history as literal, word for word. Since you use "ear" [singular], I assume the "whooshing" is heard unilaterally. "Whooshing" indicates vascular turbulence, usuaully due to some sort of A-V fistula, but it can also be due to turbulence in a non-fistulous artery by something that restricts flow. The restriction can be external [compression] or internal [occlusion, intimal dissection, etc.]. And since we are talking about the ear, there is also the possibility of acoustic nerve injury.

I'd order an MRI of the brain with gad to look at the posterior fossa and an MR Angiogram.

Nick

 

[Nerdoscience]

Occasional "tension Headaches" lifelong, but none out of the ordinary lately. No weakness or numbness, vision changes, or seizures. It's only in his right ear. No history of heart trouble, but has "borderline high blood pressure" according to his doc, controlled without meds. No kidney trouble. Cholesterol was mildly elevated, but he started taking fish oil, and now it's good. No drug use. Only meds are the fish oil and occasionally a few aspirin for HA.

No "whooshing" on exam. What specifically would you do to test the CNs?