A Woman with Diabetes and Recurrent Vertigo

A 57-year-old female with a past medical history of diabetes mellitus type 2 presented with a chief complaint of dizziness, nausea, and vomiting. Her symptoms began 5 days prior to presentation and were gradual in onset. The symptoms were paroxysmal in nature, consisting of 2 to 3 daily episodes that would last for roughly 2 hours. 

The patient denied any aggravating or relieving factors. On the day of presentation, she had a severe episode—described as a feeling that “the room was spinning” and associated with nausea and vomiting—that lasted 4 hours and did not relent until the patient received meclizine. 

She denied any recent upper respiratory infections, tinnitus, decreased hearing, headache, chest pain, or palpitations. The patient had a similar episode 5 years prior that resolved with meclizine and no underlying etiology was determined at that time. 

Physical examination. A horizontal nystagmus was present. Tympanic membranes were normal and no hearing loss was appreciated. The patient had a negative Dix-Hallpike maneuver. Her strength and sensation were symmetric and within normal limits bilaterally. She performed the finger-nose-finger test without difficulty. The remainder of the physical examination including vital signs was normal. 

Laboratory testing. All tests were unremarkable. An MRI of the brain, with and without contrast, showed an enhancing mass lesion within the right cerebellar pontine angle extending into the right internal auditory canal consistent with an acoustic neuroma (Figure). 

Treatment. A multitude of options are available for the treatment of an acoustic neuroma, and the selection is frequently based on the patient’s symptom burden and tumor size. Treatments can range from surveillance with MRI to radiation therapy or surgery. Conservative treatment with symptom control and MRI is more suitable for patients with small to medium sized tumors, especially in the elderly. 

As some patients can present with hearing loss, hearing status is an important factor to help decide whether to observe or take more aggressive measures. If observation is selected, tumor growth that is measurable on MRI usually correlates well with future growth, encouraging more aggressive measures. It is recommended that a follow-up MRI should be conducted within a year from initial presentation to establish the rate of growth.¹ 

This was the treatment option that was selected for our patient. Her main symptoms were vertigo, nausea, and vomiting—all of which were well-controlled with meclizine. The patient exhibited no hearing loss and her tumor size was approximately 1 cm with no hydrocephalus or obstruction. 

Monitored patients should receive annual scans during the first 3 to 5 years after diagnosis, and thereafter can be followed every 2 years until 10 years after presentation. After this, it is recommended that scans be repeated every 5 years, although there is no documented standard of care. It is reported that approximately half of patients who are observed will have some form of hearing loss during this period of observation, and treatment should be chosen based on each patient’s clinical picture.¹

There are many sequelae of acoustic neuroma, some of which were not present in our patient. Sudden hearing loss can be present in up to 26% of patients. Tinnitus can be present in 53% to 70% of patients, and is most commonly ipsilateral. Vertigo has been found in up to 58% of patients, can occur early in the disease process, and has the possibility of spontaneous resolution. Other possible sequelae that have been documented are dysequilibum, trigeminal nerve dysfunction, headache, facial nerve dysfunction, hoarseness, dysphagia, and dysarthria.²

Outcome of the case. The patient’s symptoms responded well to meclizine. Neurosurgical consultation was obtained, and no acute intervention was pursued. Close clinical follow-up and repeat MRI brain were scheduled.

References:

1. Meyer S, Post K. Acoustic neuroma. In: Winn HR. Youmans Neurologic Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders Inc; 2011:1460-1475. 
2. Stucken E, Brown K, Selesnick S. Clinical and diagnostic evaluation of acoustic neuromas. Otolaryngol Clin North Am. 2012;
3. 45(2):269-284.