Cases · Schwannoma (trap) · clinician

Worsening imbalance and one-sided tinnitus

A 54-year-old administrator with progressive imbalance, neck pain, and unilateral tinnitus — the catch worth not missing.

Vignette

A 54-year-old administrator presents with 18 months of progressive imbalance, particularly noticeable in the dark and on uneven ground. She has long-standing mechanical neck pain (worked at a screen-heavy job for 25 years) and has been told by two previous practitioners that this is cervicogenic dizziness. She has also developed intermittent right-sided tinnitus over the same period, which she attributed to stress. She has been on a programme of cervical mobilisation and proprioceptive retraining for four months with no clear improvement.

Examination and workup

Cervical examination shows the expected degenerative findings — restricted multi-directional motion, paraspinal tenderness, mildly positive cervical torsion test. Audiometry shows 25 dB asymmetric high-frequency sensorineural hearing loss on the right. vHIT shows mildly reduced gain on the right (0.74) with corrective saccades. Calorics show 38% unilateral weakness on the right. No central oculomotor signs.

Question

What should be done now?

AContinue the cervical-directed treatment and intensify the sensorimotor component for another 12 weeks
BMRI brain with internal auditory canal protocol, contrast-enhanced, urgent
CTrial of betahistine for likely early Ménière's disease
DRefer to ENT for audiometry repeat in 6 months to see if the asymmetry is stable
ECervical MRI to exclude an upper cervical structural lesion

Select an option to reveal the answer.

Teaching point

**Any asymmetric audiovestibular feature mandates MRI brain with IAC protocol** — regardless of how convincing the cervical history is. Vestibular schwannoma is uncommon enough to be missed and treatable enough that missing it is consequential. The catch is cheap (an audiogram and a focused MRI) and the cost of missing it is large. Add audiometry to the workup of any chronically dizzy patient with neck pain, and image any asymmetry without delay.

References

²⁹ Halmagyi GM, Chen L, MacDougall HG, Weber KP, McGarvie LA, Curthoys IS (2017). The video head impulse test. Frontiers in Neurology, 8:258. link
³² Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ (2008). Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology, 70(24 Pt 2):2378–2385. link