Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 50 year old male, who has come to see his PCP because of worsening balance. He has noticed his gait becoming worse over the past two months. His wife made him come when she noticed he was constantly leaning on the hallway walls and railings when walking around the house. He says his balance hasn’t been great for a year or so. He described his gait as veering or felt like he was tilting with some days being worse than others. He does not feel like the room is spinning and does not feel light headed. No history of fever/chills, no headache, no vomiting, no blurry vision/changes in vision, no muscle weakness, no parasthesias or neuropathic pain. He has a 3-year history of tinnitus and hearing loss, but he attributes this change to working as a concert roadie since his late-twenties. However, he is confused that his hearing loss only occurred on the right side and is getting worse even though he no longer listens to loud music.
Physical Exam: Watching the patient walk into the office, his gait is unsteady and he requires the assistance of the wall and his adult son to maintain his balance. Romberg positive with swaying to the right. Dix-Hallpike was negative. Weber test localizes to the left ear and Rinne test shows a gross hearing deficit in the right ear for bone and air conduction.
Tests:
-Hearing test reveals decreased detection of all frequencies in the right ear, left ear shows no abnormalities.
-MRI with gadolinium contrast shows an enhancing mass at the right internal auditory canal with some extension to the right cerebellopontine angle.
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