Report of a case
A woman in her 50s presented to our clinic with compliance of purulent
in the right ear and vertigo.
Detailed
medical history was documented. After decades of ear suppuration, the
patient had endoscopic tympanoplasty and ossicular chain reconstruction
surgery on the right ear two years ago. Severe hearing loss and vertigo
hit her the first-day post-surgery. After a month of treatment, she was
discharged from the hospital with alleviative vertigo but a complete
hearing loss in the right ear. According to the patient, her vertigo
improved during the past 2 years, and only rapidly turning her head
caused paroxysmal feelings of loss in orientation or floating.
Thorough evaluations were performed before the patient admit into our
department. First of all, during the physical examinations, we observed
cholesteatoma in the narrowed external canal as well as the scarred
tympanic membrane (Fig 1A). Then, the pure-tone audiometry indicated the
total sensorineural hearing loss in the right ear (Fig 1B). Furthermore,
we evaluated the vestibular function of the patient. We performed the
Vestibular Activities and Participation questionnaire for her. From
“unable to do” with 4 points to “none” with 0 points, we accessed 12
different activities during her daily life. She scored sixteen points
that positional changes attributed more to her difficulties. In
laboratory tests, her vestibular performance was generally acceptable,
and the videonystagmography (VNG) and sensory organization test (SOT)
were relatively normal. A 100% decrease in the right ear in the caloric
test while assessing the lateral semicircular canal may be attributed to
the thickened and scarring tympanic membrane (Fig 1C). Besides, breaks
in sound conduction in this patient and worse corporation lead to a
minimal response in the VEMP test that aims to reflect the function of
otolith organs. Thus, we performed ocular-counter text (OCR) to evaluate
the reflex of VOR from utricular maculae (Fig 1C) and subjective visual
vertical test (SVV) to assess the cognitive and perception of vestibular
organs. Our results indicated normal or compensated otolithic results in
both tests. A high-resolution CT scan was applied to determine the
reason for vertigo and purulence. Stenosis with cholesteatoma was found
in the external ear canal (Fig 1D). However, looking into the
reconstructed ossicular chain, we found that the stapes with the
prosthesis on top were dislocated into the vestibule cavity (Fig 1E).
These may explain the patient’s paroxysmal vertigo and persistent
hearing loss after surgery. We further took an MRI scan, which indicated
the falling stapes didn’t cause fibrosis in the inner ear (Fig 1F).
We first removed the cholesteatoma and adhesion in the external canal
during the surgery. Then, we found and removed the free cartilage slice
(Fig 2B), and the prosthesis (Fig 2C) after elevating the tympanomeatal
flap to access the tympanic cavity. The capitulum stapedius was free
flow in the oral window (Fig 2D). Then we smoothly picked up the stapes
from the vestibule cavity (Fig 2E). We used fascia and sponges to reseal
the oral window (Fig 2F). On the first day post-surgery, the patient
felt “released”. At the same time, rotating heads no longer introduce
vertigo. 2 months post-surgery, the patient described her paroxysmal
vertigo improved significantly during her visit. We performed the
Vestibular Activities and Participation questionnaire again. Compared to
16 points pre-surgery, the patient scored 0 points by then.