Hi everyone! My name is Brad Kesser and I'm a professor of Otolaryngology Head
and Neck Surgery at the University of Virginia specializing in otology and
neurology. Otology-Neurotology is the subspecialty within Otolaryngology that
deals with the ears. I see patients with hearing loss, balance disorders, dizziness,
ringing in the ears, and so I'd like to review a recent Chicago Med episode
season 1, episode number 3 where a young girl presents to the emergency room
having fallen and complaining of hearing loss. Can you smile for me Dylan? Right
now I'd like you to tilt your head to your left for me. I already
the Epley. Didn't seem to help. In the acute setting of
seeing a dizzy patient in the emergency department, the smile is important to
document one of the cranial nerves that runs with the hearing and balance nerve.
Now, I'm not really sure why the doctor had the patient tilt the head over
except maybe looking for what we call a doll's eye reflex to make sure that the
eyes can track opposite to the head. The Epley maneuver in this acute setting
probably would not be indicated. The Epley maneuver is a diagnostic maneuver
to identify Benign Positional Vertigo which is a disease characterized by
brief episodes lasting maybe 15 seconds of dizziness caused by a particle that
has become dislodged in the inner ear. So the initial physical exam I agree with
the cranial nerve exam as well as the basic eye movement exam, but I'm not sure
at this point the Epley maneuver is necessary.
Can you hear this? Yes. How about now?
Not as well as the other. I'm a musician
getting my masters at CCPA. The conservatory? In this scene, The doctor is
doing a tuning fork exam. It's a relatively crude assessment of hearing
however, in the office, the tuning fork exam can be very valuable in assessing
the type of hearing loss a patient has. So in a crude way, I have my tuning fork here.
We can just assess generally the hearing... Can you hear that, can you hear that, and
in the scene the patient clearly has a difference in hearing between the two
ears. Now in a more rigorous manner, we test the hearing by putting the tuning
fork on the nose or the bridge of the nose and asking the patient if you can
hear the sound better or more toward one side. Interestingly if a patient has a
type of hearing loss that we call conductive hearing loss which is a
problem with the ear canal or the ear drum or the middle ear, they'll hear the
tone louder in that ear. On the other hand, if the patient has a sensory neural
hearing loss, they will tell you that they hear it louder in the opposite ear.
So they didn't do that part of the tuning fork test which could have given
them valuable information as to the type of hearing loss the patient has.
Impressive! Follow my finger for me. All right. I don't mean to scare you but
becoming a doctor was actually my fallback plan. I wanted to be a musician
a violinist in fact. So as I mentioned earlier, eye tracking is an important
component of the exam of the dizzy patient. The inner ear is closely yoked
to eye movement so when we turn our head right and left like I'm doing now, I can
maintain perfect eye contact because as my head turns right, my eyes turn left
and as my head turns left, my eyes turn right. So being able to document eye
movement and the ability to track the finger is important. Now in just a second
they're going to talk about nystagmus which I'll address just after the
next scene. She's got a slight nystagmus on the right. I know and the hearing loss on
the left. I'm thinking it could be something syndromic. Well apparently you didn't need a
consult. Come on! I value your opinion.
How come you've never told me you wanted to be a musician? You want an opinion? Call a
neurosurgeon and send her for a stat head CT. The doctors mention the term
nystagmus. Nystagmus is a characteristic eye movement that goes back and forth.
There's often a slow component and then a fast component that can be generated
by diseases of the inner ear. In fact, if you want to watch nystagmus, have
somebody close their eyes, turn round and round, and then open their eyes and you'll see
the eyes going back and forth like that. Now the eyes work together in concert so
when he says there's nystagmus in the right eye, that doesn't really make a lot
of sense because the nystagmus is going to be in both eyes. One other mention is
that they wanted to get a stat head CT. Now in the setting of an acutely dizzy
patient in whom you think there may be a stroke or a bleeding on the brain, a head
CT is a very good screening tool to look for a stroke... to look for a hemorrhage in
the brain or a subdural or epidural hematoma which is bleeding around the
brain. However a head CT might miss the primary diagnosis that we're going to
discover in just a minute. Has anyone from neurosurgery seen these?
Yes! They're talking about scheduling surgery as soon as possible
Acoustic neuroma tumors essentially caused by a genetic condition called
neurofibromatosis. It disturbs nervous system cell growth.
So these neuromas are pressing against your inner ear and that's why you've
been experiencing the hearing loss and the dizziness. We need to remove them and
stop the internal bleeding. So as I mentioned, a head CT would not be your
diagnostic study of choice for acoustic neuroma. An MRI scan with and without
contrast is the study of choice or the gold standard for diagnosing acoustic
neuromas. Now a large acoustic neuroma would be identified on a head CT but a
small acoustic neuroma may not be identified or may be missed on a head CT.
An MRI is really the study of choice. Now he also mentions this condition
called neurofibromatosis and I want to differentiate that there is neurofibromatosis
type 1 and neurofibromatosis type 2. In the type 2 variety patients have
acoustic neuromas and other benign tumors of the central nervous system but
acoustic neuromas in both ears so that would have been diagnosed really with an
MRI scan. In addition, the doctor tells the woman that the hearing loss and the
balance issues are because the tumor is putting pressure on the inner ear. Well
in fact, the inner ear is surrounded by the densest bone in all of the body. If
you want to take the thickest bone, the densest bone in all the body, it's the
bone that protects the organs of hearing and balance.
So, in fact these acoustic neuromas are pressing on the hearing and balance
nerve and interfering with the ability of the inner ear and the ability of the
hearing nerve and the balance nerve to deliver the signal back to the brain.
Hence the patients have balanced dysfunction and they have hearing loss.
As soon as possible. What are the side effects? There's a good chance you'll
lose your hearing. My hearing? Yes.
Dylon, I know it seems like your world is coming apart right now but we got lucky
here today, okay? That fall you took might have just saved your life.
I'm a musician. This could have killed you
and you don't always get a warning sign.
I want to transfer your upstairs and admit you into the hospital proper. Is
that okay with you? No! I want to talk to the woman who is in here earlier,
the violinist. Dr. Manning? I am NOT going anywhere until I talk to
her. There are many many warning signs prior to death approaching if the
tumors get very large. They cause headaches. They cause numbness on one
side of the face. They can cause nausea. They can cause vomiting. So there are
many many signs that neurofibromatosis type 2 patients will exhibit or acoustic
neuroma patients will exhibit prior to the approach of death or prior to a
tumor such as this actually killing the patient. I'd like to stress acoustic
neuromas are benign slow growing tumors even in the setting of neurofibromatosis
type 2. These tumors tend to be slow growing and many times we'll just watch
them and enable patients to enjoy their hearing for as long as they can because
typically treating these acoustic neuromas will cause hearing loss. Now
there are procedures that we can sometimes do to save the hearing, but it's
important to know this is not a STAT surgery. The surgery does not have to be
done on an emergent basis. We do these acoustic neuroma surgeries on an
elective basis. Iimportantly to give patients time to process and understand
the information and to understand their treatment options going forward.
She's not gonna do the surgery at least not until she's given the recital.
You told her those tumors may kill her. First hearing and being heard it's how
Dillon interacts with the world. She can't imagine her life without that
ability. She needs more time to process all of this. She doesn't have more time. I
don't know what to tell you. It's not our decision to make. I don't believe this.
The woman doctor clearly is supporting patient autonomy here and I think that's
a really really valuable and really important point. This is not an emergency.
This does not have to be done immediately. The young woman
who has the neurofibromatosis type two can take time to process the information
to understand her treatment options. Even if the recital were next week, the
surgery could be put off and done on an elective basis to allow this young woman
to perform in her recital. I wholeheartedly applaud the woman doctor's
expression to support patient autonomy.
I have a couple of issues with the surgical scene. First of all, the
patient's face would be covered. We do not want her nose and any kind of
bacteria to potentially spoil the sterile field. Secondly if you
remember from the top of the show, the hearing loss was in the left ear, yet
they're operating on the right ear. Typically we would operate on the wors
hearing ear first. Now, it may be possible that the larger
tumor that's really causing brain stem compression is on the
contralateral side or the other side from where the better hearing is or
from where the hearing loss is, in which case, we would have to
operate on the larger tumor, but nevertheless in a young patient like
this we would want to preserve her hearing as best we could. Her right ear
was her better hearing year at the top of the show, and yet they're operating on
the right side. Next we operate under a microscope this is delicate micro
surgery and just to sit and take a little piece of tissue out and hand it
to the scrub tech is really not the way it goes. This is not cancer, so we don't
need to do an en bloc resection. In other words, we don't need to take the
tumor out as one big piece with margins of healthy brain around it. This is a
benign tumor so we can take it out piecemeal. There are technological
advances that have really enabled us to remove these tumors relatively quickly
and efficiently when in a piecemeal fashion so we would absolutely do that
under under the microscope. It's not that we take a tiny piece and we give it
to the scrub tech to send to pathology. How did it go?
They got everything. She's gonna be fine. And her hearing?
So they operated on the right ear, yet she did have some hearing in the left
ear prior to surgery. Again, we would only operate on one ear or one tumor at a
time, so her other ear, the other ear should be preserved so they
wouldn't necessarily have to write to her. In addition, her voice box and her
speaking mechanism and her brain communication centers are all fine. I'm
not sure why the the writers or the director felt they needed to have her
right back to the doctors. She should have been able to speak to the doctors
without any problem. Now very very large acoustic neuromas can put pressure on
the vocal cord and the speaking nerve and that can cause hoarseness after
surgery, but again, I don't see why she would have needed to write to the
doctors. She could have easily spoken to them. So this episode of Chicago Med
illustrates a young woman who's had a fall we think because of an episode of
dizziness.The show opens in the emergency department where the doctors
are evaluating the source why did a young woman fall and have dizziness. They
get a head CT scan to rule out a stroke or a bleed in the brain and
they find these tumors on her hearing and balance nerve that we call acoustic
neuromas. Now she has tumors on both of her hearing inbalance nerves so she has
a condition we call neurofibromatosis type 2 which is defined as these benign
acoustic neuromas on the hearing and balance nerve. Now the treatment of
acoustic neuromas is typically elective. I also want to reiterate that most
acoustic neuromas are solitary. Just one unilateral on one side where the other
ear is healthy and fine and the hearing is normal. This particular patient has
neurofibromatosis type 2 which is a rare condition that causes tumors on both
hearing and balance nerves so both of her hearing nerves are at risk. The
dramatic part is that they want to admit her and take her to surgery immediately.
Well in fact, I do agree admitting her for
observation with serial neurologic exams or a serial head
CT scan to make sure she doesn't have any additional bleeding in the brain
would be indicated but she does not need to be admitted for emergency surgery to
remove the acoustic neuroma. In the show the tumor is on the right side, yet
they're operating whereas her hearing loss is greater on the left. We would
typically recommend surgery to remove the tumor on the worse hearing first so
that patients can enjoy their hearing for as long as they can before the tumor
has to be either irradiated or removed because I will tell you, removing the
tumor may many times result in a total profound sensory neural hearing
loss. There are operations that we can do to try to save the hearing and remove
the tumor, but these are challenging and only in the very best of hands are the
very best results obtained and even still we can save the hearing in maybe
fifty to sixty seven and sixty five percent of patients. Finally, she should
be able to hear after surgery with the ear that was not operated on and her
expressive language her ability to form words with her mouth and with her vocal
cords should be intact. So I don't know why she was asked to write on a piece of
paper other than potentially for dramatic inflection. So in summary, a good
job overall by the directors. A few small points that I wanted to bring out that
are relatively inconsistent with the way we manage patients with acoustic
neuromas and neurofibromatosis type 2 and it's information that I think is
important for you to understand as you watch Chicago Med. So I thank you for your
attention and be well and stay safe!