A 46-year-old man with a history of left ear discharge presented with newly onset HL and vertigo. His medical history was otherwise silent besides head trauma (car accident) that occurred seven months prior to the admission with residual positional vertigo. He denied oscillopsia, pressure-induced vertigo, or other vestibular symptoms. The otoscopy revealed a left thickened tympanic membrane with EAC discharge. Audiometric testing showed down-sloping sensorineural HL on the right and left-sided mixed HL with predominant conductive loss for low frequencies (). Right-beating spontaneous nystagmus enhanced by mastoid vibrations consistent with left acute vestibular loss could be observed on video-Frenzel examination. Nystagmus reduced in backward head bending, while increased with downbeat components in forward head tilts. Left Dix-Hallpike maneuver elicited paroxysmal up-beating nystagmus with left torsional components consistent with benign paroxysmal positional vertigo (BPPV) involving left-sided PSC, so he received Epley's repositioning procedures (). At the following examination 2 days later, positioning tests were uneventful, whereas right-beating spontaneous nystagmus enhanced by head shakings could be still detectable. Left tragal compression induced right-torsional nystagmus, followed by stronger opposite eye movements on release of the pressure (), whereas both nasal and glottic Valsalva maneuvers were uneventful. The patient underwent vHIT measurements on the same day, showing left global hypofunction and slightly reduced VOR-gain for the right PSC (). Temporal bones CT scan revealed soft tissue consistent with cholesteatoma obliterating the right-sided tympano-mastoid cavity and eroding ossicular chain, all SCs, sigmoid sinus bony wall, and tegmen tympani (). Angio-MRI of the brain ruled out venous thrombosis and meningeal involvement (). He received CWD mastoidectomy that evidenced bony erosions of each SC and permitted achievement of cholesteatoma removal. A thin matrix layer was left upon each bony defect, whereas tegmen dehiscence was repaired with bone-pate. Additional procedures for hearing restoration and LF obliteration were postponed at a later stage. Postoperative care included bed rest, intravenous broad-spectrum antibiotics, and corticosteroids tapering for additional two weeks. The patient's conditions progressively recovered and hearing threshold remained unchanged at 30 days. Spontaneous nystagmus was progressively reduced whereas vHIT findings and PIN aligning in the same axis persisted over time.\nWritten informed consent was obtained from each patient for the publication of this case report, including all data and images.
A 73-year-old woman referred to our center for a follow-up evaluation of right-sided canal wall down (CWD) mastoidectomy due to a COM with cholesteatoma. The surgical procedure was conducted two years earlier without simultaneous functional stage. She experienced symptoms consistent with right-sided cochleo-vestibular loss following surgery. Pressure-induced unsteadiness and dizziness represented her prominent residual vestibular symptoms. Otoscopy highlighted dry right EAC and well-preserved postoperative conditions. Her audiogram showed right-sided mixed HL with widened air-bone gap at lower frequencies and contralateral age-related sensorineural HL (). Although spontaneous nystagmus could not be observed with video-Frenzel goggles, mastoid vibrations elicited left-beating nystagmus. Horizontal nystagmus directed toward the affected side was evoked applying positive pressure on her right EAC, reversing on removal of the pressure. Conversely, no nystagmus could be noticed with Valsalva maneuvers. Even though she denied positional vertigo, left-beating nystagmus could be observed on supine positioning and slightly persistent geotropic direction-changing nystagmus was elicited after head rolls, with stronger amplitude on right-sided positioning (). vHIT measurements were taken on the same day, showing VOR-gain reduction for all SCs of the right side and mildly impaired function for left PSC (). High-resolution CT scan detected postoperative LF involving right HSC without inflammatory recurrences (). Although we proposed revision surgery for LF closure and hearing restoration, she refused additional procedures as audio-vestibular symptoms did not prevent her from leading a normal life.