“DOCTOR, WHY AM I SO TIRED AND DIZZY?

” CASE STUDY

INTRODUCTON

This case study presents a presentation and progression of an acoustic neuroma of Alexis,
an actual patient. Vestibular schwannoma or acoustic neuroma is a noncancerous and usually
slow-growing tumor that develops on the eighth cranial nerve. Dropping and drooling were the
first symptoms that appeared which the patient perceived as acts of clumsiness. Afterward, more
symptoms manifested within a month, and the condition of the patient gradually became worse.
In addition to the previous symptoms, the patient developed constant dizziness, extreme fatigue,
deteriorated handwriting, and more. The doctor first diagnosed the patient with benign
paroxysmal positional vertigo (BPPV). However, the Epley maneuver and vestibulo-ocular
reflex (VOR) displayed negative results. The doctor then ordered an MRI scan and it revealed a
vestibular schwannoma, which is spanning her right cranial nerves IV-XI, as well as an
arachnoid cyst. The tumor also extended to her right inner ear.

This report attempts to answer a series of questions related to this case.

WRITTEN RESPONSE TO CASE STUDY AND ANALYSIS

Q1: What parts of Alexis’ nervous system are most likely affected? Which region of
the brain coordinates muscular activity? What cranial nerves are most likely involved? Be
sure to link each part to one or more symptoms. There are a total of 12 symptoms listed
above, discuss at least 5 of them.

The part of the nervous system that is most likely affected is Alexis’ brain. The part of
the brain that coordinates muscular activity is the cerebrum; it is the largest part of the brain
which controls speech, intelligence, memory, emotion, and sensory processing as well. The
cranial nerves most likely involved are the following:

• The symptoms of dropping items and Alexis tripping involuntarily or

“Butterfingers and clumsiness” as they call it is probably because of an anomaly in her
cerebellum.
 • The cranial nerves involved in her involuntary drooling are the CN VII (facial);
CN IX (glossopharyngeal); CN X (vagus).

• The cranial nerve involved in extreme fatigue is the reticular activating system and
is most probably due to the tumor pressing on the brainstem.

• A malfunction in the inner ear or the CN VIII (vestibulocochlear) causes her

occasional nausea.

• The feeling that her eyes don’t work together is because of an anomaly in her CN
VIII (vestibulocochlear): sensory for hearing and equilibrium; CN III (oculomotor), CN IV
(trochlear), CN VI (abducens): eye movement.

To summarize:

Part of the Nervous System Involvement

Cerebellum “Butterfingers and clumsiness” or

dropping items and tripping
involuntarily

CN VII (facial); CN IX (glossopharyngeal); CN X (vagus) Drooling

Reticular activating system Extreme fatigue that is most

probably due to the tumor pressing
on the brainstem.

Inner ear / CN VIII (vestibulocochlear) Occasional nausea

CN VIII (vestibulocochlear): sensory for hearing and A feeling that her eyes don’t work
equilibrium; CN III (oculomotor), CN IV (trochlear), CN together
VI (abducens): eye movement
 Q2: Is there additional information you think would be useful before any type of
clinical testing is performed? If so, please indicate what else you would like to know about
Alexis and/or her history

• I would first like to ask her about her family history to know if her condition is
possibly related to genetics and;

• If she have had an experience with similar symptoms in the past.

• I would also ask for their medical history in case it has something to do with a
previous ailment that she might have had.

Q3: Describe the structure of the inner ear. Indicate which structure(s) would most
likely be involved with the symptoms described.

The structure of the inner ear consists of the cochlea, semicircular canals, utricle, and
saccule. Its two main structures are the cochlea which is involved in hearing and the vestibular
system that is composed of three semicircular canals, saccule and utricle, responsible for
maintaining balance. Thus, dizziness is most probably because of a problem with the
semicircular canals and/or the vestibulocochlear nerve (CN VIII) radiating from the cochlea and
vestibular apparatus (Jones, 2014).

Q4: Alexis received negative results for both tests. What does that tell you? What do
you think the next steps or tests would be?

The negative results leads to a conclusion that the problem is located centrally (in the
cerebellum or the brainstem) or with the primary afferents or the cranial nerves that connect the
sensory information to the Central Nervous System. The test that would probably follow is an
MRI scan to examine Alexis’ brain further.

Q5: What is the Epley maneuver and how does it work? Describe the procedure for
the test.

The Epley maneuver is used to help treat the symptoms of benign paroxysmal positional
vertigo (BPPV) caused by canaliths detached from the utricle which then travels to the
semicircular canals. Vertigo happens when the canaliths move inside the canals, sending
incorrect signals to your brain about your position. This can make you feel like the world is
spinning. The Epley maneuver named after Dr. John Epley who made it, is designed to dislodge
these crystals and return them back to the utricle (John Hopkins Medicine, n.d.).

Follow these steps if the problem is with your right ear:

• Start by sitting on a bed.

• Turn your head 45 degrees to the right.

• Quickly lie back, keeping your head turned. Your shoulders should now be on the
pillow, and your head should be reclined. Wait 30 seconds.

• Turn your head 90 degrees to the left, without raising it. Your head will now be
looking 45 degrees to the left. Wait another 30 seconds.

• Turn your head and body another 90 degrees to the left, into the bed. Wait another
30 seconds.

• Sit up on the left side.

Follow these steps if the problem is with your left ear:

• Start by sitting on a bed.

• Turn your head 45 degrees to the left.

• Quickly lie back, keeping your head turned. Your shoulders should now be on the
pillow, and your head should be reclined. Wait 30 seconds.

• Turn your head 90 degrees to the right, without raising it. Your head will now be
looking 45 degrees to the right. Wait another 30 seconds.

• Turn your head and body another 90 degrees to the right, into the bed. Wait
another 30 seconds.

• Sit up on the right side.

 Q6: What symptoms might occur from a tumor pressing on CN IV-XI?

The symptoms that might occur from a tumor that’s pressing on the CN IV-XI are as
follows:

• CN IV: The inability to move the eye properly

• CN V: Difficulty in chewing, facial pain or numbness, corneal drying

• CN VI: The inability of the eye to move properly

• CN VII: Facial paralysis, diminished production of tears and saliva, impaired taste

• CN VIII: Hearing loss and difficulty in balancing

• CN IX: Drooling, impaired taste, difficulty in swallowing

• CN X: difficulty in swallowing, coughing, drooling, deficits in digestive, excretory

and

• Urinary smooth muscle motility

• CN XI: difficulty in swallowing, and changes in moving the head and the
shoulders

Q7: What symptoms might occur from the aggravation of CN VII during surgery?

An aggravation of CN VII may bring about facial paralysis such as the case with Bell's
palsy, the lack of tearing in the eye, impaired taste on that side of tongue. Conceivable
powerlessness to close the eye, difficulty holding food in mouth, difficulty pronouncing some
words, congested or steadily runny nose, diminished salivation or a dry mouth.

Q8: Look up vestibular schwannomas. What causes them?

Vestibular schwannomas are slow-growing and benign tumors that grow inside the ear.
This is caused by an overproduction of the Schwann cells. Schwann cells are the cells that
usually wrap around nerve fibers like onion skin to help support and insulate nerves (National
Institute on Deafness and Other Communication Disorders, 2017).
 Q9: What are the typical symptoms patients present?

Typical symptoms include:

• Asymmetric hearing loss

• Tinnitus (ringing in the ear

• Dizziness

• Loss of balance

• Facial numbness

• Facial weakness or paralysis on the side of the tumor

Q10: Did Alexis have the typical symptoms?

Alexis, did exhibit typical symptoms in a way such as dizziness. However, she had
increased hearing sensitivity, and she did not have changes in her facial expressions and
sensitivity, hindering a correct diagnosis in an earlier stage.

Q16: Why the urgency in getting back to the hospital when Alexis experienced a
CSF leak from her nose?

Alexis was rushed into hospital after experiencing CSF leak from her nose due to the
reason that CSF leak is dangerous which can cause complications such as headaches, meningitis
and seizures.

Q17: Explain why Alexis’ thorough explanation for why she was in the hospital
(previous section) and the humor she exhibited with the eye patch is good signs (hint: think
lobes of the brain).

After the brain surgery most of the patients that received anesthesia will be confuse. The
nurse asked Alexis why she is in the hospital, surprisingly she explained how she had vestibular
schwannoma unlike the other patient would respond that they have brain tumor. Generally, it was
explained earlier that after receiving the anesthesia you will be confuse but as for Alexis, she was
not confused and was able to explain the reason why she is in the hospital. Thus, it shows that
her frontal lobe was in good shape and it was not affected, that's why the nurses knew that it is a
good sign.

Q18: What cranial nerve(s) are responsible for Alexis’ residual effects of brain
surgery?

The cranial nerves that are responsible for Alexis’ residual effects of brain surgery are the
Cranial Nerve VII (facial) and Cranial Nerve X (vagus) for the hoarseness of her voice
(Vasković, 2020).

Q19: What is synkinesis?

Synkinesis describes unwanted contractions of the muscles of the face during attempted
movement. Commonly, patients will notice forceful eye closure when they attempt to smile or
other muscle spasms during routine facial movements (Stanford Facial Nerve Center, n.d.).

Q20: For each assistive device: indicate whether or not it could be used in Alexis’
case and why.

Traditional hearing aids

The traditional hearing aid could not be used in Alexis case due to the reason Hearing
deficits are also related to cognitive disability, although hearing aids may not bring sweeping
improvements in cognition or behavior to the demented.

Cochlear implant

The cochlear implant could not be used due to the damage of the nerve.

Brainstem implant

While auditory Brainstem can be used for Alexis’ case since it has a capacity to improve
localization by restoring useful aspects of hearing in the impaired ear. It is a good alternative for
those who cannot use a hearing aid or cochlear implant.

Bone anchored hearing aid (now called a bone anchored hearing system)
 Bone-anchored hearing system could be used in Alexis’ case since it is a type of
surgically implanted device for hearing loss, the patient indications are different (Victory, 2020).

Q21: What do you think is the best option? Explain your choice.

The assistive device mentioned above has bad side effects and can be used for a person
who is experiencing hearing loss. According to Alexis, she is deaf in right ear. However, the best
option for Alexis’ case is the bone-anchored hearing system due to the reason that it works and
benefits for people who has a single-sided deafness.

WRITTEN RESPONSE TO SCENARIOS

Physiological Focus:

Scenario A:

Alexis does not have the balance she used to. She routinely leaves a night light on in the
bathroom and tries to avoid being in dark areas. Being in the dark causes her to lose her balance.
Recently, as she was walking across campus in the evening (after the sun went down), she took a
longer path to stay on sidewalks rather than cut across the grass. Before surgery, she would have
cut across the grass, but now she was worried she’d trip on some uneven ground.

Avoiding dark areas after loss of one’s balance is advisable. Alexis should have a small
flashlight or a flashlight from a phone with her at all times, in case when it becomes dark. Using
a cane should also help with her balance. Canes are often used to assist in balance, to widen the
base of support, or to decrease weight bearing and pressure through one of her legs.

Scenario B:

Alexis cannot cry with her right eye. She has discovered that she does not tear up for
emotional reasons (e.g., a sad story) or for physical reasons (e.g., onions). In fact, she still uses
lubricating eye drops in her right eye (typically at bedtime and in the morning when she wakes
up). She’s noticed that her right eye will tear occasionally. This tends to happen when she’s
exercising; not immediately, but after some time. She also still has vertical displacement of her
vision. Her glasses have 4 diopters of prism ground in (2 up and 2 down) so that images are on
the same horizontal level regardless of which eye looks at them.
 The inability to cry with her right eye is one of the effects of her one-sided facial
paralysis. Since the right side of her face is paralyzed, none of her senses will work on that side.
It could take some time to get used to; however, her condition should get better over time.

Psychological Focus

Scenario A:

Alexis started wearing a pin that tells people, who read it, that she’s deaf on the right
side. Now she has an obvious sign of a problem. Do you think people will treat her differently? If
so, how might their actions differ from interacting with a non-hearing impaired individual?

Yes, people will treat her differently since she has an obvious sign of disability. Most
people will most definitely try their best to accommodate the hearing impaired person; for
instance, using gestures and expression, repeating or rephrasing what they say, and more. In
conclusion, there should not be too much of a difference in interacting with a hearing impaired
individual and a non-hearing individual. It is important to treat someone with a hearing loss as
you yourself like to be treated.

Scenario B:

While at a hotel, approximately 4 months after surgery, Alexis asked the concierge to
find a number for a guest’s room. The concierge dialed the phone then handed her the receiver.
She took it with her dominant hand (right) and out of habit put the phone to her (now deaf) right
ear. Alexis asked the concierge, “Should I be hearing something? I don’t hear any ringing.” After
realizing she was using her deaf ear, she switched ears, had her conversation, then handed the
phone back to the concierge and simply said, “Sorry, newly deaf.” What type of reaction do you
think this social interchange would yield?

The concierge will most likely be understanding and considerate of Alexis’ situation.
Unless the concierge is insensitive and adds any additional unnecessary comments (which
hopefully should not be the case). Alexis’ apologized for her condition, which is not her fault,
and so the concierge should accept it. Therefore, their exchange should be completely polite.
 REFERENCES

John Hopkins Medicine (n.d.). Home Epley Maneuver. Retrieved from:

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/home-epley-
maneuver

Jones, Michael (2014, September 5). Ear anatomy. Retrieved from:

https://www.mydr.com.au/hearing-health/ear-anatomy#:~:text=The%20inner%20ear
%20(also%20called,is%20responsible%20for%20maintaining%20balance.

National Institute on Deafness and Other Communication Disorders (2017, March 6). Vestibular
Schwannoma (Acoustic Neuroma) and Neurofibromatosis. Retrieved from:

https://www.nidcd.nih.gov/health/vestibular-schwannoma-acoustic-neuroma-and-
neurofibromatosis#:~:text=A%20vestibular%20schwannoma%20(also%20known,nerves
%20supplying%20the%20inner%20ear.

Stanford Facial Nerve Center (n.d.). Synkinesis. Retrieved from:

https://med.stanford.edu/ohns/OHNS-healthcare/facialnervecenter/conditions-we-
treat/synkinesis.html

Vasković, Jana (2020, October 29). 12 cranial nerves. Retrieved from:

https://www.kenhub.com/en/library/anatomy/the-12-cranial-nerves

Victory, Joy (2020, April 7). Bone-anchored hearing systems. Retrieved from:

https://www.healthyhearing.com/help/hearing-aids/bone-anchored#:~:text=Unlike
%20hearing%20aids%2C%20bone%2Danchored,that%20enter%20the%20ear%20canal.