Case Study Report

Patient M is a 35 year old mother of two. Her history reported that she had a
gradual decline of hearing, with no sudden changes. She has left sided
tinnitus, which concerns her at times, but no balance problems. She works
part time in a cafe, where her responsibilities are ordering stock for the shop.

It can be seen that important information is missing from the history. We do

not know whether this patients hearing fluctuates. no notes regarding family
history, any pain or discharge from the ears. No is there any notes on
medications or any ear surgeries in her past. There is also no mention of
whether Patient M has been exposed to loud noises in her past. There has
also been no menton of otoscopy, which is important as it may identify a
valuable finding.

What is mentioned in the history is not further elaborated to gauge the

patients feelings and concerns. In particular the mention about the patients
tinnitus. She mentioned it was in the left ear and a ringing sound, however,
no mention of its loudness, whether it impacted her life (social or emotional),
when and how often it occured and what part of her lifestyle it affected when
she mentioned that it concerned her at times, for example her sleep.

As well as what has been mentioned above, the patients social history is
missing. In audiology the aim is bettering the quality of life of patients.
However without the knowledge how the patient is struggling in specific
situations, with no expanation to how or with any details, the impact cannot
be assessed and therefore improved upon effectively. What needed to be
asked was how she manages talking to individuals one-to-one, talking in
groups and with background noise.

Another important factor missing is how Patient M is dealing with talking on

the phoen. This is because in the history that was taken it mentions that it is
she who deals with ordering the stock on the phone. Due to this fact she
needs to be able to hear well on the phone in order for her to know what is
being said and to order the correct items. What also needs to be known is
how she communicates in meetings at work and with other colleagues, as it is
from these people she will be communicating with to get stock check
updates. From this she may require a referral for the 'Access to Work'
scheme. This scheme could enable for her to get a hard-of-hearing telephone,
or even a loop system for where her departmental meetings take place at
work.

It would be helpful to know how much more she struggles in those situations,
as well as the types of problems she may encounter. Patient M should have
been asked all of this, as well as her hobbies and what she does socially
outside of work. This is because her needs need to be assessed to consider
what parts of the hearing aid need to be enabled, such as volume control or
different programmes.

However, one of the major and most important questions were forgotten to
be asked. As Patient M is a mother, she should have been asked the age of
her children and whether she has any difficulty in hearing her children,
especially if she has very young children. From this information she may
require a referral to the Sensory Loss team where her home will be assessed
and possibly equipped with a baby alarm. She may also require smoke alarms
or an alarm clock.

From what is known from the patients history and from the audiogram that
was performed a possible diagnosis of otosclerosis may be made.
Otosclerosis is a disorder of the otic capsule bone, which is commonly
diagnosed by a patient's symptoms of progressive hearing loss with tinnitus.
It is usually detected by the third or fourth decades of life, which is shown in
the patient history as she is 35 years old and she hears tinnitus in her left
ear. Otosclerosis can be either unilateral or bilateral, and there has been
eveidence to show there is a link of otosclerosis which develops after
pregnancy and Paitient M is a mother of two.

One of the most significant finding is that the pure tone audiogram shows a
carhart notch, exclusive with otosclerosis, where the BC value has fallen at
2kHz. Through otoscopy what could have been seen was an otosclerotic flow
of blood behind the tympanic memebrane, which nothing was recorded for.
Speech aidiometry is a good diagnostic tool as results for otosclerosis would
give 100%. A tympanogram should also be performed to evaluate function of
the middle ear, which should give a shallow graph with normal ear volume.
Acoustic reflexes should also be performed, as these are absent with
otosclerosis. Another test that could be done is the tuning fork test, which
would give a Rhine negative result with otosclerosis. However, the best test
to be performed would be a CT or MRI scan as otosclerosiswould show the
fixation of the stapes footplate by new bone.

However having ruled out presbyacusis or an infectious hearing loss, as

patient has a conductive loss. She also cannot have a NIHL because of no
drop at 4kHz, which is characteristic with a noise injury. It is not true with
Menieres disease as patient does not have vertigo or a low frequency hearin
gloss. Multiple Sclerosis has also been ruled out because patient does not
have vertigo and her hearing loss was gradual in its onset.

It is due to all of the reasons above that it seems otosclerosis is the most
clinically significant finding diagnostically, especially from the information
provided, or lack thereof. Management options with otosclerosis can be from
just observing the patient, particularly if the hearing problem is unilateral and
of a mild conductive element. Once symptoms have become more
handicapping, there is the option of amplification or even surgery, which may
be limited or complete stapedectomy.