As shown, there is asymmetrical sensorineural loss.
| S.T. | WRS % | @ HL | |
| Right | Not reported | 40 | 85 |
| Left | Not reported | 96 | 75 |
□ What are the AAO-HNS guidelines about when an ENT should obtain an MRI to determine if there may be a neuroma? Is the asymmetry of concern to you? Is the word recognition asymmetry of concern or is that expected given the poorer hearing in the right ear?
The tympanograms are shown below. Note that the ipsilateral right 1k reflex is crossed off indicating that the audiologist did not agree with the automated machine’s interpretation.
□ Comment upon the immittance findings.
The otoacoustic emissions are shown. It appears that the thin lines without a symbol are the noise levels and the circles are the responses. The right ear does not have any OAEs; the left ear has a 2k OAE at -10 dB with a 6.6 dB signal to noise ratio.
□ Evaluate the OAE results and correlate them with the audiogram. Are they expected or unexpected?
Management: The ENT ordered an MRI to rule out vestibular schwannoma. The patient was placed on TMJ protocol. The patient was asked to return after the MRI.
MRI findings:
MRI of the IACs Prior to & Following Contrast/
MRI of the Brain Prior to & Following Contrast: “Abnormal intracanicular enhancement of the right is present, measuring approximately 3 mm in the AP dimension x 8 mm in the transverse dimension. The 8 x 3 mm right intracanicular VS extends from the porus acousticus to the fundus of the IAC. The CPA is free of disease and the tumor does not abut the brainstem. Abnormal signal intensity-enhancement in the right IAC most consistent with VS as described.”
□ Locate the porus acousticus and fundus of the IAC through internet resources. Describe why this is considered an intracanalicular tumor.
Plan: “The risks, benefits, alternatives and goals of close observation with annual MRI versus stereotactic radiosurgery versus surgical excision of the right VS were discussed with the patient. He was asked to bring the MRI films in for my review and was asked to get a second opinion. He says he will get this second opinion in his home town. He was given the name of a neurotologist. He will follow up with his MRI films later this week.”
□ What is stereotactic radiosurgery and how does it differ from conventional surgery?