Instructions
You are a medical student on placement in general practice. Your next patient is Analyn Tolentino, 54, a dental nurse, back to go over the hearing test she had for ringing in her left ear.
Take a focused history
Interpret the audiogram and tympanometry provided
Outline to the examiner:
- Your findings
- Your most likely diagnosis and differentials
- Next steps in management, including relevant investigations
- You do not need to examine the patient
- You do not need to explain the results to the patient
GP's ear examination, 3 weeks ago
Both ear canals clear; both eardrums intact and normal. Tuning fork (512 Hz): Weber louder in the right ear; Rinne positive (air louder than bone) in both ears.
Audiology report, last week
Analyn Tolentino. Pure tone audiogram and tympanometry at the audiology clinic. Audiogram thresholds are in dB HL; the right ear was masked while bone conduction was tested on the left.
Audiogram: right ear (dB HL)
Normal is 0 to 20. Air conduction at 250, 500, 1000, 2000, 4000 and 8000 Hz: 10, 10, 10, 15, 20, 20. Bone conduction at 500, 1000, 2000 and 4000 Hz: 5, 10, 10, 15.
Audiogram: left ear (dB HL)
Normal is 0 to 20. Air conduction at 250, 500, 1000, 2000, 4000 and 8000 Hz: 40, 40, 45, 50, 60, 60. Bone conduction, masked, at 500, 1000, 2000 and 4000 Hz: 40, 40, 50, 55.
Averages and word recognition
Pure tone average 500 to 4000 Hz: right 14 dB HL, left 49 dB HL. Word recognition at 40 dB above threshold (normal 90 to 100%): right 100%, left 56%.
Tympanometry, both ears
Type A on both sides. Right: peak -10 daPa, compliance 0.7 mL, canal volume 1.2 mL. Left: peak -15 daPa, compliance 0.6 mL, canal volume 1.3 mL. Normal compliance 0.3 to 1.6 mL.
Pure tone audiogram (audiology clinic, last week)
| Item | Value | Reference range |
|---|---|---|
| Right ear, air conduction (250 / 500 / 1000 / 2000 / 4000 / 8000 Hz) | 10 / 10 / 10 / 15 / 20 / 20 dB HL | 0-20 dB HL |
| Right ear, bone conduction (500 / 1000 / 2000 / 4000 Hz) | 5 / 10 / 10 / 15 dB HL | 0-20 dB HL |
| Left ear, air conduction (250 / 500 / 1000 / 2000 / 4000 / 8000 Hz) | 40 / 40 / 45 / 50 / 60 / 60 dB HL | 0-20 dB HL |
| Left ear, bone conduction, masked (500 / 1000 / 2000 / 4000 Hz) | 40 / 40 / 50 / 55 dB HL | 0-20 dB HL |
| Right pure tone average (500 Hz to 4 kHz) | 14 dB HL | 0-20 dB HL |
| Left pure tone average (500 Hz to 4 kHz) | 49 dB HL | 0-20 dB HL |
| Right word recognition score (at 40 dB above threshold) | 100% | 90-100 % |
| Left word recognition score (at 40 dB above threshold) | 56% | 90-100 % |
Thresholds are the quietest sound heard at each pitch, in dB HL. The right ear was masked while bone conduction was tested on the left.
Tympanometry (audiology clinic, last week)
| Item | Value | Reference range |
|---|---|---|
| Right ear tympanogram | Type A: single sharp peak at -10 daPa | - |
| Right ear compliance | 0.7 mL | 0.3-1.6 mL |
| Right ear canal volume | 1.2 mL | 0.6-1.5 mL |
| Left ear tympanogram | Type A: single sharp peak at -15 daPa | - |
| Left ear compliance | 0.6 mL | 0.3-1.6 mL |
| Left ear canal volume | 1.3 mL | 0.6-1.5 mL |