J Chin Med Assoc June Vol No Elsevier Taiwan - PDF document

•June 2010Vol 73No 6© 2010 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.mon clinical disease in otolaryngology.the cause of sudden hearing loss cannot be determined,but known causes include the following: viral infectionof the inner ear, toxin, immunologic causes, abrupt dis-ruptionof blood flood to the cochlear, and cerebello-pontine angle (CPA) lesion (e.g. acoustic neuroma,meningioma or arachnoid cyst).stitute1% of The posterior fossa, especially the CPA, represents themost common site of arachnoid cysts.may present with symptoms such as dizziness, tinni-Presentation with sudden deafness is very rare.Herein,we describe a 67-year-old male with arachnoid cyst whomanifested with SSNHL, which is rarely reported in theliterature.Case ReportA 67-year-old man came to our clinic with the com-plaint of sudden hearing impairment in his left ear, a severe swaying sensation, and tinnitus. There was nei-and neurological examinations were normal. All hema-tological findings were within normal limits. Skull radi-ography (Stenver’s view) revealed normal diameter ofthe internal auditory canal. The patient had a 1-year his-tory of hypertension. Panendoscopy was normal. Puretone audiometry showed sensorineural hearing losswith an average of 110dB on the left side (total deaf-ness) (Figure 1A). The auditory brain stem reThe patient was diagnosed with sudden deafness andsubsequently treated with oral prednisolone (1mg/kg)and intravenous low molecular dextran (MW4000,10% 500mL/Bot) per day during his 1-week hospi-talization. His dizziness and tinnitus were relievedThe audiogram did not improve until 1 monthlater, when it showed marked recovery, with an aver-age of 38dB improvement (average dB of 0.5k, 1k,2k, 4k) (Figure 1B). However, the auditory brainstem response still showed an absence of waves on theleft side. Under the suspicion of retrocochlear lesioninvolving the cranial nerves or their nuclei, magneticresonance imaging (MRI) of the brain was performed.Hsuan-Ho Chen, Chin-Kuo Chen*Department of Otolaryngology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, R.O.C.Arachnoid cysts can occur at different intracranial sites,including the cerebellopontine angle (CPA). They often occur inchildhood,in the posterior fossa. They may present with symptoms such as dizziness,tinnitus and hearing loss,or theymay be asymptomatic. Presentation with sudden deafness is very rare. We report the unusual presentation of a 67-year-old male with CPA arachnoid cyst and the complaint of sudden-onset deafness. In this case,the cystic lesion at the CPAwas found by magnetic resonance imaging of the brain. Pathology after retromastoid suboccipital craniotomy confirmedan arachnoid cyst. The treatment of this patient is discussed and the possible causes of CPA arachnoid cyst are brieflyreviewed. [J Chin Med AssocKey Words:arachnoid cyst,cerebellopontine angle,sudden sensorineural hearing loss *Correspondence to: Dr Chin-Kuo Chen,Department of Otolaryngology,Chang Gung Memorial Hospitaland Chang Gung University,5,Fusing Street,Gueishan,Taoyuan 333,Taiwan,R.O.C.E-mail: dr.chenck@gmail.comReceived: October 26,2009Accepted: April 23,2010 June 2010Vol 73No 6 Surprisingly, MRI showed a fluid-containing cyst (mea-2.1cm) occupying the left CPA withcranial nerves (Figure 2).After retromastoid suboccipital craniotomy, pathologyconfirmed an arachnoid cyst.The audiogram was not significantly changed after1 year of follow-up. The patient, however, did feelmuch relief from his tinnitus and dizziness.Arachnoid cysts are developmental collections of cere-brospinalfluid contained within the arachnoidal mem-brane and suof reported patients are children.There are 2 path-ways to development: primary anomalies and secondaryacquired lesions due to trauma, hemorrhage or infec-tion.In our patient, the symptoms occurred at a lateage and without any history of head injury or braininfection. What precipitated the onset of his symptomsis not clear.CPA arachnoid cysts has been estimated to accountThe symptoms of CPA arachnoid cyst includeataxia, gait disturbance, headache, nausea, vomiting,character change, and memory disturbance. Some symp-marized 33 cases of CPA arachnoid cysts that werereported either as individual case reports or as a sub-group in a series of infratentorial arachnoid cysts of(37%) followed by headache (33%), and the most com-cranial nervecranial nerve dysfunction caused byarachnoid cysts results in the symptoms of hypoacusia,tinnitus, and vertigo.greater than 30dB over at least 3 continuous audio-metric frequencies, which develops in a period of lessSSNHL may result from causes affect-cranial nerve, or more centralauditory tracts.Arachnoid cysts rarely manifest withSSNHL. Alaani et al reported 5 cases of CPA arachnoidcyst and only 1 initially presented with SSNHL. 1252505001,0002,0004,0008,000 Intensity (dB)Frequency (Hz) B A Figure 1.the left ear (A) and marked recovery after medical treatment (B). Figure 2.T2-weighted magnetic resonance imaging shows a fluid-containing cyst (white arrows),measuring 3.92.1cm,occupying June 2010Vol 73No 6 SSNHL evaluation should include a history andcomplete audiometry.MRI study of the audiovesti-bular nervous pathway and of the whole brain helpsSSNHL evaluation because a previous study foundthat about 31 of 54 (57%) cases of SSNHL presentedwith MRI abnormalities.Corticosteroids are widely used because of theiranti-inflammatory effect.corticoid receptors, resulting in the suppression ofproinflammatory molecules and reducing the quantityof inflammatory cells.Corticosteroids can be used inthe treatment of SSNHL.Our patient was treated withcorticosteroids initially. Remarkable recovery (38dBimprovement) was demonstrated on the audiogram atthe 1-month follow-up. A possible mechanism respon-sible for the effect may be a decrease in the degree ofcranial nerve edema caused by compression by theCPA arachnoid cyst.However, the extent of recoverydepends on the degree and duration of the neural com-pression,and the medical treatment effect is thoughtto be only temporary.Not all arachnoid cysts require surgical intervention.Indications for surgical intervention include any lesionthat has demonstrated growth, hydrocephalus or refrac-tory symptoms such as deafness, tinnitus and dizzi-ness referable to a cyst in this location.The surgicalchoice may be craniotomy, such as drainage, total orpartial removal of the cyst, shunting or fistulization ofsive endoscopic surgery has become the first-line therapyOperative management improves vesti-bular symptoms, but auditory deficits are less likely torespond to surgery.Our patient demonstrated that CPA arachnoid cystsmay present with sudden onset of hearing impairment.The possibility of a CPA lesion should be consideredin patients with SSNHL who are responsive to medicaltreatment. 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