- 49-year-old man presented with gradually worsening left-sided hearing loss, imbalance, facial numbness, and recent headache. - Examination found left sensorineural hearing loss, cerebellar ataxia, reduced sensation in the left V1 and V2 dermatomes, and signs of increased intracranial pressure. - This suggests a likely diagnosis of a left cerebellopontine angle benign lesion such as a vestibular schwannoma involving the left cerebellum and trigeminal nerve.

1. • 49 years gentleman.
• Studied till HS.
• Shopkeeper by occupation.
• Resident of West Bengal.
• Right handed dominant.
• Informant- Self, reliable.

2. Chief complaints
• Decreased hearing in left ear since 3 years.
• History of ringing sensation in left ear 2 years back.
• Imbalance while walking since 2 years.
• Left facial numbness since 5 months.
• Headache since 2 weeks.

3. Decreased hearing
• Apparently alright 3 years back.
• He noticed decreased hearing in left ear which was insidious in onset
and gradually progressive.
• He noticed it when he had difficulty in understanding words while
using mobile for which he started preferring right ear for conversation
and listening songs.

4. • No history of better hearing in crowded places.
• No history of increased clarity on increasing TV volume or while
listening to songs.
• No history of fluctuations in hearing loss or ear fullness.
• No history of ear discharge, ear ache, trauma, fever, drug intake.
• It was not associated with giddiness, vomiting.
• No history of occupational or accidental noise exposure.
• No history of similar complaints in right ear.

5. Tinnitus
• History of tinnitus 2 years back.
• It was insidious in onset and gradually progressing.
• It was heard in left ear, ringing like sensation, intermittent in nature,
lasting for 1-2 minutes initially and became continuous by 3 months.
• There were no aggravating or relieving factors.
• Ringing sensation in left ear stopped after 3 months.

6. Imbalance
• History of imbalance while walking since 2 years.
• It was insidious in onset and gradually progressive.
• History of difficulty in negotiating footwear on left side which needs
support of family member.
• Now he uses shoes and strapped footwear while walking.
• History of difficulty while turning, walking through narrow corridors
at home, climbing stairs.

7. • History of difficulty in doing finer activities like buttoning shirt,
holding objects in left hand, picking up objects.
• There was slowness in movements noted by the family. But it was not
associated with tightness in upper and lower limbs.

8. • Since 2 months, the symptoms have worsened as he is not able to
maintain his posture while sitting,requires a back support.
• He sways towards left side while walking and walks with widened
legs.
• Symptoms slightly worsen when he closes his eyes while washing face
or enters dark rooms.
• No history of cotton wool like sensation while walking. No history of
numbness or paraesthesia in lower limbs.

9. Facial numbness
• History of left facial numbness in upper and middle part since 5
months.
• It was insidious in onset and gradually progressing.
• Patient has not noticed any differences in perception of cold and hot
water on face.
• History of recurrent redness in left eye after washing face or riding
bike.
• No history of foreign body sensation in eyes.
• No history of excessive tearing associated with it.

10. • History of pain in the left cheek since 5 months with no aggravating
and relieving factors for which he consulted a dentist and dental
problems were ruled out.
• No history of difficulty in chewing food.
• No history of numbness in the buccal cavity.
• No history of food stuck between teeth and cheek that needs clearing
by tongue/finger.

11. Headache:
• History of headache since 2 weeks.
• It was insidious in onset and gradually progressive.
• It was mild in nature with heaviness in bifrontal region with a VAS score of
2-3/10.
• It gradually progressed over next 1 week which was moderate to severe in
nature.
• Headache was holocranial, headache increases by evening times associated
with 2-3 episodes of projectile vomiting which relieved his headache.
• It was not associated with blurring of vision, double vision, altered
sensorium.

12. • Patient had mild headache after that episode and was managed with
analgesics.
• No history of further episodes of vomiting.
• No history of similar headache in the past
• Headache was not associated with photophobia, phonophobia,
congestion of eyes.
• No history of triggering factors like lack of sleep, food, stress, exercise.

13. • No history of disturbances in smell, blurring of vision, double vision,
drooling of saliva or food from angle of mouth, decreased taste
sensation, swallowing difficulty, change in voice, nasal regurgitation,
articulation of speech, neck tilt, drooping of shoulder, weakness in
right upper and lower limbs.
• No history of swelling or patches on the body.
• Past medical history:
• Diabetes, hypertension
• Personal history:
• Non smoker and non alcoholic. Mixed diet.

14. • Family history: No history of similar complaints in the family.
• Functional status:
• 49 years gentleman, with hearing loss in left ear, gait disturbances
who need assistance of family member to walk. Patient can do his
daily activities by himself with minimal support.

15. Summary
• 49 years gentleman, known case of diabetes and hypertension,
presented with gradually worsening hearing loss in left ear since 3
years associated with tinnitus in the initial period, imbalance while
walking since 2 years with progressive worsening since last 2 months,
facial numbness on left side since 5 months and recent onset
headache since 2 weeks associated with vomiting 1 week back.

16. Substrates involved
• Left cochlear nerve.
• Left cerebellar hemisphere and vermis.
• Left middle cerebellar peduncle.
• Left V nerve- V1, V2.
• Features of raised intracranial pressure.

17. Analysis
• Hearing loss- Left sensorineural hearing loss.
• Imbalance- Cerebellar ataxia.
• V nerve- Sensory component.
• ICP- probably due to hydrocephalus.

18. • Probable diagnosis:
• Left cerebellopontine angle benign lesion probably vestibular
schwannoma with features of raised intracranial pressure.
• Differential diagnosis:
• Cerebellopontine angle schwanomma
• Meningioma.
• Epidermoid.

19. General physical examination:
• Conscious and oriented to time, place and person.
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy.
• Vitals-
• BP- 140/80mmhg
• HR-80bpm
• RR-16cpm
• No neurocutaneous markers

20. CNS
• Higher mental functions-
• MMSE- 28/30
• Cranial nerves:
• Smell- normal perception and recognition of smell.
• Vision:
• Acuity- 6/6 in both eyes.
• Field- No deficits by confrontation perimetry
• Colour vision- Normal
• Fundus- Disc is pink in colour, round shape, margins of optic disc is clear.
Vessels are visualised normally.

21. • Pupils- 2mm reacting to light bilaterally- both direct and consensual
reflex.
• EOM- normal
• Bruns nystagmus present- Gaze evoked bilateral nystagmus with
coarse nystagmus seen on looking to left and fine nystagmus seen on
looking to right.

22. • V nerve:
• Left V1, V2 hypoesthesia by 40% as compared to right.
• Motor- Normal power of mastication muscles.
• Corneal reflex-
• When stimulated from left- Direct and consensual reflex- absent.
• When stimulated from right- Direct and consensual reflex present.
• Jaw jerk- absent

23. • VII nerve:
• Decreased blink rate on left side
• Mild flattening of left nasolabial fold.
• Frowning, closure of eyes, blowing of wind, smiling- normal
• Taste- normal.

24. • VIII nerve:
• Finger rub test- not audible in left ear.
• Ear examination:
• External ear- normal, tympanic membrane visualised normal.
• Tuning fork test:
Right Left
Rinne test Positive Positive (reduced)
Webers test Lateralised to right -
Schwabach’s test Normal Reduced

25. • IX and X nerves:
• Uvula and arch of palate- central in rest and phonation.
• Gag- present bilaterally.
• Sensation in the posterior 1/3rd of tongue- normal
• XI nerve:
• Trapezius and sternocleidomastoid muscle- normal power.
• XII nerve:
• Tongue is central, normal power, no fasciculation and atrophy seen.

26. • Motor system:
• Bulk- normal in all 4 limbs
• Tone- hypotonia in left upper and lower limbs.
• Power:
• Grade 5/5 power in all 4 limbs.
• Reflexes-
• DTR- hyporeflexia in left upper and lower limbs.
2+ in right upper and lower limbs
• Superficial- Abdominal reflex- present
Plantars- flexor on right side, mute on left side.

27. • Sensory system:
• Fine touch, crude touch, temperature, pain, joint position sense and
vibration- normal
• Cortical sensations:
• 2 point discrimination, graphesthesia, stereognosis, tactile
localisation- normal.

28. • Cerebellar sings:
• Past pointing- present on left side.
• Nose to finger and toe to finger test- fails to reach the target. Intentional
tremor present in left hand.
• Heel shin test- positive on left side.
• Dysdiadochokinesia- positive on left side.
• Rebound test- positive
• Normal on right side.

29. • Gait- Wide based gait.
• Romberg’s test- Negative- as patient has ataxia with eyes open and
closed.
• Unterberger- Fukuda stepping gait- not able to perform by patient
due to ataxia.
• Tandem gait- Could not be performed by patient.

30. Summary
• 49 years gentleman, presenting with gradual worsening of left hearing
loss suggestive of sensorineural hearing loss with involvement of left
trigeminal nerve- V1 V2 dermatome, subtle facial paresis on left side
with left cerebellar ataxia.

31. Diagnosis:
• Left cerebellopontine angle benign lesion probably vestibular
schwannoma with involvement of ipsilateral cerebellum and
trigeminal nerve with features of raised intracranial pressure.