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Asymmetric sensorineural hearing loss — MSRA MCQ

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HardMRIAsymmetric sensorineural hearing lossMSRA

A 58-year-old woman is reviewed after community audiology assessment for 10 months of gradually progressive right-sided hearing difficulty. Otoscopy and tympanometry are normal. She has no vertigo, tinnitus, facial numbness, facial weakness, headache or other focal neurological symptoms. Pure-tone audiometry confirms right-sided sensorineural hearing loss: thresholds are 15 dB poorer than the left ear at 1 kHz and 2 kHz, and differ by 10 dB or less at 0.5, 4 and 8 kHz. She has no contraindication to MRI. What is the most appropriate next investigation?

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Correct answer: E — Arrange MRI of the internal auditory meati

Explanation lettering: B = shown as A · D = shown as B · A = shown as C · E = shown as D · C = shown as E

This is asymmetric sensorineural hearing loss with no localising neurological signs. The key discriminator is the audiogram: there is a 15 dB asymmetry at 1 kHz and 2 kHz, which are adjacent frequencies within the NICE-specified test range. NICE advises considering MRI of the internal auditory meati (IAM) in this situation to assess for vestibular schwannoma or another cerebellopontine-angle lesion. A CT temporal-bone study is more appropriate when an osseous or middle-ear abnormality is suspected, neither of which is suggested by normal otoscopy, tympanometry and sensorineural rather than conductive loss. B is inappropriate because the MRI criterion is already met; serial audiometry should not delay indicated investigation. D would be relevant if the presentation suggested an acute central neurological event, but there are no such features. E incorrectly treats cranial neuropathy as necessary: localising signs mandate MRI irrespective of threshold, but their absence does not exclude MRI when the specified audiometric asymmetry is present.

Reference: NICE NG98: Hearing loss in adults: assessment and management, section 1.3 Investigation using MRI (Last updated 2 October 2023) — https://www.nice.org.uk/guidance/ng98/chapter/recommendations