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Sensorineural hearing loss, taking steroid treatment, done PTA test, have diabetes and hypertension, MRI showed demyelination and mastoditis. Can brain tumour be ruled out?

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ENT Specialist
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Hi, this is a follow up query with respect to my fathers condition of sudden sensorineural hearing loss (SSHL).
My father complained of sudden loss of hearing on 24th April , i.e roughly 3 weeks ago. After taking him to ENT doctors, who diagnosed the condition as SSHL, steroid treatment began from 26 th may. He has been on steroids for three weeks +. Detailed medication is described separately. We have bben regularly conducting PTA tests to check progress of improvement. Initially, the hearing tests revealed a loss to the tune of 115 db in the right ear and 31.6 db in left ear. Currently the test has revealed 75.3 db in the right ear, with the interpretation now changed to severe hearing loss as opposed to profound hearing loss in the right ear. However the last test was actually a slight deterioration with the right ear reporting an increase of about 3 db, i.e from 73 db in the previous PTA test, the latest report has now shown 75.3 db. This has been the first time that the PTA test (conducted every three days) has shown a negative progress, though marginal. But, symptomatically, my father has not experience any sig ificant improvement, just marginal. The ear blockage continues to persist, only the noise level seems to have reduced a bit. In addition to oral, steroids, he has also been taking intratympanic steroids every 4 days. We are worried, since the improvement has not been significant and doctors are saying that treatment time window is maximum of 3 to 4 weeks, which is drawing to a close. The dosage of steroids which began at 70 mg a day has now been tapered down to 20mg. An additional complication is my fathers diabetes and hypertension. To control high sugar due to steroids, he has been advices insulin injections, thrice a day. Through insulin, sugar control has been managed so far. Doctors are advising one more week of steroids and then the dosage would be stopped.

We have also done a plain brain MRI test to rule out the case ofanytumor, as suggested by our ENT doctor. The test has revealedthefollowingfindings :

1. Multiple discrete and confluent bilateral periventricular white matter hyper intensities are noted , suggestive of foci of ischemic demyelination.
2. Right sided mastoditis.

The interpretation of radiologist and neurologist have been that while the first finding is age related and due to diabetes and hypertension, the second finding could be the reason for SSHL. The neurologist has also mentioned that plain MRI cannot detect any tumor, and contrast MRI is the definitive test for the same. However our ENT doctor has advices that contrast MRI is not required and, based on the interpretation of CP angle findings in MRI report, she is almost certain that no Tumor is there. The doctor has also mentioned that mastoditis could have been due to intratympanic injections. She has not advices any specific or separate medication to treat mastoditis. The same steroid treatment is continued.

With this detailed case history, I have the following queries :

1. Can we rule out any kind of brain tumor , based on the report of plain MRI? There are no other symptoms , father is complaining of. Or, is it recommended to go for contrast MRI ?

2. Given that right sided mastoditis has been reported in MRI and mastoditis indicates infection, so could that require specific investigation or other treatment ,other than steroids? Current medication listed here are mostly steroids, vitamins and some oxygen enriching drugs which has been prescribed. I need a confirmation on whether the line of treatment is optimal , or any additional treatment is available.
3. The steroid treatment has now been going on for 18 days, in a tapering down of dosage pattern. As per the doctor, the dosage would be stopped in next one week . In terms of improvement, there has been slow and marginal improvement, as discussed above. In such a scenario, should treatment be continued beyond a week. I am asking this, since, though very marginal, but it does appear that through treatment, my father has reported some reduction in hearing discomfort. So, the questionis, how long the treatment should be continued , before taking a decision to withdraw.
4. In the eventuality of no further treatment, what are the options of hearing aids? How well they can relieve symptoms? And what is the optimal category of hearing aid?
5. My father has reported better comfort with the post intratympanic injection. He feels better slightly after each injection. Should the injections be continued for more time in
anticipation of further improvement?

Thanks for going through the detailed case. Would really look forward to your analysis and treatment advice.

Posted Tue, 5 Jun 2012 in Ear, Nose and Throat Problems
Answered by Dr. Sumit Bhatti 15 hours later

Thank you for your query.

1. You cannot rule out every kind of brain tumor, based on the report of plain MRI. Since there is a suspicion of mastoiditis, a contrast MRI plus HR (High resolution) CT Temporal bones is advised. If the fluid in the mastoid is the injected steroid solution, it can be differentiated from mastoiditis.

2. You may add an antibioitic if there is mastoid tenderness. Carbogen or Hyperbaric Oxygen Therapy (HBOT) should be added. I hope that you have read my previous answer in detail.

3. Since he is diabetic, you may withdraw the oral steroids as planned by your doctors.

4. Rehabilitation includes the option of no treatment.
a. Hearing aids are difficult to use in Single Sided Deafness (SSD) as one ear is near normal and the other has profound hearing loss (if the condition is permanent).
b. Bone anchored hearing aids (BAHA) is an option. Traditional BAHA devices use an external Titanium Abutment. These include Cochlear and Oticon.
c. Sophono (Otomag) alpha 1 M is a new type of BAHA without an abutment.

5. Transtympanic (intratympanic) steroids may be continued for a total of five to six weeks.

6. You may share your investigation and progress reports here for more specific treatment and rehabilitation options.

I hope I have answered your query. If you have any follow up queries, I will be available to answer them.

Above answer was peer-reviewed by
Follow-up: Sensorineural hearing loss, taking steroid treatment, done PTA test, have diabetes and hypertension, MRI showed demyelination and mastoditis. Can brain tumour be ruled out? 15 hours later

Thanks a lot for answering my queries.

I have some follow up queries. Request you to please help me with them.

1. Given your suggestion of going for a contrast MRI + High Resolution CT scan, should we wait till the 5-6 weeks period of intratympanic injections course is over? Or is it absolutely important to do the tests now itself?

The reason for asking this question is that the ENT doctor at Medicity medanta, whom we are consulting, is of the opinion that no contrast MRI is required. She has examined the films from the plain MRI and based on the findings of the CP angle, her conclusion is that there are no tumors and Mastoditis is only due to injection of steroids.

However if you suggest that brain tumor is still a possibility which needs investigation, then we would have to go for contrast MRI. But can we wait till the intratympanic course is over? Pls advice.

2. An additional finding I want to report is that we just conducted a routine KFT test which has revealed UREA - 36 and Creatinine - 1.2. Na, K are within normal ranges. In this case, can we go ahead with MRI contrast and CT scan; I have been advised by some doctors that contrast material used in MRI and CT scans have damaging effects on kidney; so just want to be sure whether we can safely go ahead with the scans.

3. Are both contrast MRI and CT scans essential ? Is contrast MRI alone not be sufficient to diagnose any brain related infection/tumor etc ? If both are required, then can both be managed with minimal kidney risk ? Finally can both tests be conducted in a single day ?

4. Also wanted to report that yesterday we conducted one more round of PTA tests after a gap of 6-7 days. The findings have reported an improvement in hearing of the right ear from a previous value of 75db to 65db. So in a span of 21 days from the beginning of the symptom (PTA : 115 db in right ear), the PTA value has come down to 65 db in the affected ear. So improvement has been there; but still significant hearing loss is there. But we are stopping oral steroids as per doctor from tomorrow. Doctor has advised to continue with intratympanic dosage for atleast 2 more doses - (total of 5 doses of 125mg/2ml concentration - methyl predinisole have been administered). The frequency has been one dose in every 3-4 days. Do you feel that the dosage and frequency are optimal, given the results of the PTA?

5. Finally on the Carbogen and HBOT therapy, this is something that currently our doctor has not prescribed at all. I need to understand whether these are medications/ or any procedure which needs to be done in an hospital. In either case, can these be self adminstered i.e. as an OPD procedure which can be done separately? After discussions with the current doctor, this procedure has still not been recommended; so in case I have to go for this, then would need to do it privately. Please advice on the dosage/frequency that I can discuss with the hospital for an OPD procedure.

Thanks again for your valuable inputs Doctor.

Hoping to hear back from you with answers on these queries.


Answered by Dr. Sumit Bhatti 8 hours later

Thank you for writing back.

1. Most scans will fortunately be normal. You may wait till the 5-6 weeks period of intratympanic injections course is over. Since you already have a plain MRI, and since he is improving, in this case you may wait.

2. Contrast material used in MRI and CT scans may cause renal toxicity. However, the risk has to be weighed against missing a lesion.

3. Bone and blood flowing in blood vessels is not seen on MRI. Bone is seen on CT Scans. Soft tissue is better seen on MRI Scans. Both tests be conducted in a single day.

4. As i have mentioned before, spontaneous recovery occurs in 65% cases within 20dB or greater than 50% of total loss. The dosage and frequency of the intratympanic steroids is fine.

5. Finally on the Carbogen and HBOT therapy, this may be initially done in an hospital. These cannot be self adminstered. However these can be done on an OPD basis separately. Carbogen is given for 8-10 sittings once or twice a day. HBOT requires 90 min sessions in a chamber.

Kindly refer to the latest detailed Clinical Practice Guidelines of the AAOHNS (American Society of Otolaryngology - Head and Neck Surgery) March 2012 at the following link: WWW.WWWW.WW
If you have any further questions, I will be available to answer them.

Above answer was peer-reviewed by
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