A 68-year-old woman presented dizziness whenever she put her finger into the right ear and also complained of water-streaming tinnitus, which indicated she would have been suffering from perilymph fistula. An exploratory tympanotomy was conducted. Leakage of perilymph from the round window was suspected, although the cochlin-tomoprotein (CTP) results were negative. After the procedure, the patient's finger-induced dizziness, tinnitus, and vertigo spells disappeared completely. However, her dizzy symptom did not improve. The patient also complained of general fatigue, weight loss, and insomnia, which led us to suspect comorbid depression. Antidepressants and vestibular rehabilitation treatment resulted in a significant improvement in her dizziness. Although it is not apparent whether the patient had a perilymph fistula, this case demonstrates the importance of evaluating not only physical symptoms but also psychological comorbidity, especially when the physical symptoms are intractable despite treatment.
Somatic symptoms that cannot be explained by a physical examination are termed "medically unexplained symptoms" (MUS).
We previously reported that depression may be difficult to diagnose in otolaryngology patients with MUS.
A 68-year-old woman presented with frequent vertigo spells and long-standing dizziness accompanied by right-sided tinnitus after acute sensorineural hearing loss in the right ear several months before. When the patient was 24 years old, her left ear was surgically treated for chronic otitis media. Her pure tone audiometry (PTA) score as measured on her first visit revealed bilateral mixed hearing loss (
An exploratory tympanotomy was conducted under general anesthesia. During the procedure, the leakage of perilymph was suspected in the round window under the microscope. However, in fact, the leakage of perilymph fluid was not confirmed by an increase of intracranial pressure by postural change (head-down position) or an increase of chest pressure. The tympanic space was irrigated with 0.1 cc of saline. The irrigation solution was collected in order to measure the level of cochlin-tomoprotein (CTP)-a common perilymph marker.
After the procedure, the patient's tinnitus, finger-induced vertigo, and nystagmus resolved completely. This marked improvement of symptoms suggested that her complaints had stemmed from a perilymph fistula. However, a definitive diagnosis of perilymph fistula was not possible without positive CTP results.
Although the surgery seemed to relieve most of the patient's symptoms, she still experienced her constant dizziness, which prevented her full engagement in social activities. In addition, the patient did not regain any hearing in her right ear. She complained of general fatigue, weight loss, and insomnia, which led us to suspect comorbid depression. The clinical evaluation was conducted using self-administered questionnaires. The dizziness handicap inventory (DHI)
On the basis of the questionnaire results, the treatment for depressive mood was considered to be an important issue before introducing vestibular rehabilitation to resolve a vestibular symptom of this patient. The antidepressant (miltazapiene, 7.5 mg/day) treatment was prescribed. Unfortunately, the patient was forced to stop the treatment owing to an adverse reaction to the medication. Substitute antidepressants (sertraline, 25 mg and sulpiride, 50 mg/day) were prescribed. This course of treatment was free of side effects and effective in addressing the patient's symptoms. Two weeks after starting this regimen, the patient reported an improvement in her clinical symptoms. With the aid of this pharmacotherapy, a program of vestibular rehabilitation was initiated to accelerate the patient's recovery. Four weeks later, the patient achieved a DHI score of 24 (physical, 8; emotional, 8; functional, 8)and HADS scores of 5 and 6, respectively. Her static posturography results improved as well: length of body sway for 60 s, 108.59 cm with eyes open and 148.56 cm with eyes closed; and area of body sway for 60 s, 8.09 cm2 with eyes open and 8.14 cm2 with eyes closed.
Patients with unrecognized depression who suffer from various somatic symptoms often consult with their physicians instead of visiting a psychiatrist, which results in the increased consumption of health care resources.
It is truly difficult to treat somatic disorders that present in association with psychiatric problems such as depression. In this case, the suspected perilymph fistula and comorbid depression rendered an accurate assessment difficult.
The patient's previous clinical history suggested the possibility of a perilymph fistula,
The persistence of dizziness after the surgery suggested a comorbid condition. Weight loss, general fatigue, and insomnia are common symptoms of depression. The HADS results supported our clinical impression. Furthermore, the patient's mental health status prevented her from participating in vestibular rehabilitation.
In conclusion, we report that it is important to evaluate not only physical symptoms but also possible psychological comorbidity, especially when the physical symptoms do not resolve even after relevant intervention and treatment.
This study is in part supported by grant from Magnetic Health Science Foundation 2014.
Pure tone audiometry (PTA) upon first presentation to our hospital. The PTA revealed that the patient had bilateral mixed hearing loss. The patient had undergone a left tympanoplasty 42 years previously. She reported a 2-month history of acute sensorineural hearing loss in the right ear.