VA AM Report 11.15: Hearing loss and TBI

Yesterday we learned about a case of unilateral SNHL in a patient w/ a h/o TBI.

Sensorineural vs conductive hearing loss:

-Most sensitive test is audiogram, but in the exam room don’t forget you Weber and Rinne, as Izzy helpfully reminded us the Weber makes a W on the middle of your forehead, using a 512hz tuning fork place it (neuro will say firmly) in the middle of the top part of the forehead, the goal is here to assess whether it is louder in one ear than the other.

-Rinne is air vs bone conduction, when testing bone conduction firmly place the tuning fork on the mastoid process, the sound should be heard better through air than bone, if better heard on the mastoid then suggests a problem of conduction via the ossicles/TM.

-If the hearing loss is sudden and sensorineural, reasonable to call ENT and also start systemic steroids (pred 40 is fine) as this can possibly help decrease time to recovery and mitigate permanent, if any, loss of hearing. Should also order an audiogram in any case of hearing loss to quantify degree of loss.

TBI diagnosis

Concussion is a form of mild TBI! The diagnosis is clinical, but can include such features as:

-vacant stares
-delayed verbal responses
-inability to focus attention, easily distractible
-Disorientation to time and place
-Word salad
-Gait instability (balance issues, tandem gait)
-Emotional lability
-memory deficits

Sounds like being a resident amirite? Kidding, but the point is it can be a hard diagnosis to pin down, and usually requires more in-depth neuropsychiatric evaluation. Occasionally focal sensory deficits can occur including cortical blindness, global amnesia, even auditory problems as in this case. Treatment for acute mild TBI (our patient hit his head on a windowsill), is literally “brain rest.” Kids need to take time off school, adults in college should not attend class or attempt coursework, etc. Imaging isn’t always indicated but you can follow the Canada head CT rules or New Orleans head CT rules as a starting point. See below.

http://www.mdcalc.com/canadian-ct-head-injury-trauma-rule/

http://www.mdcalc.com/new-orleans-charity-head-trauma-injury-rule/

Thanks!

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