Case 36-2010

A 50-year-old woman was seen in the emergency department at Massachusetts Eye and Ear Infirmary (MEEI), affiliated with this hospital, because of pain and decreased hearing in the left ear. The patient had been in her usual state of health until 6 weeks earlier, when she noted decreased hearing, discomfort, and a sensation of blockage in her left ear. She saw an otolaryngologist at another hospital. On examination, there was maceration, desquamation, and minute hemorrhages on the left tympanic membrane, without perforation. An audiogram reportedly showed conductive hearing loss in the left ear, with a speech-reception threshold of 20 dB. A tympanogram was flat (indicating decreased mobility of the ear drum, a feature that is consistent with the presence of fluid in the middle ear). The ear canal was irrigated, and a crust was removed from the eardrum. The patient was treated with oral azithromycin and an otic suspension consisting of neomycin, polymyxin B, and hydrocortisone. Symptoms improved briefly but then recurred, with worsening pain, and she came to the emergency department at MEEI. The patient did not have otorrhea, tinnitus, fever, weight loss, cough, nausea, vomiting, or abdominal pain. Tests for tuberculosis and the human immunodeficiency virus had been negative in the past. A diagnosis of essential thrombocythemia had been made 18 years earlier; treatment had included interferon alfa and hydroxyurea and had been complicated by anemia that required intermittent transfusions. She had hypertension, anxiety, chronic diarrhea, and mild renal insufficiency. Her medications included anagrelide hydrochloride, darbepoetin alfa, and sertraline. She was allergic to hydroxychloroquine sulfate. She was married, had worked in a health care facility, and currently worked in an office; she had traveled to Europe, the Mediterranean, and in the distant past, to China and the Caribbean. She did not drink alcohol, smoke, or use illicit drugs. Her mother had had diabetes mellitus, hepatic and renal disease, and breast cancer, and her father had had heart disease and hypertension; her siblings and her child were healthy. On examination, the blood pressure was 152/72 mm Hg and the other vital signs were normal. The left auricle was normal. The left ear canal and tympanic membrane were erythematous, and the canal contained white debris; there was a serous effusion in the middle ear. The right ear was normal. The Rinne test revealed Case 36-2010: A 50-Year-Old Woman with Pain and Loss of Hearing in the Left Ear