Hearing loss is a common problem that everyone faces at some point in their lives. There are three main types of hearing loss: conductive, sensorineural, and mixed. Conductive hearing loss occurs when external sound cannot reach the inner ear due to some type of obstruction, such as earwax in the ear canal and fluid in the middle ear. Sensorineural hearing loss (SNHL) is caused by damage to the inner ear, which affects the nerve conduction pathway from the inner ear to the brain. Mixed hearing loss is a combination of conductive and sensorineural hearing loss. Sensorineural hearing loss (SNHL) is one of the most common types of hearing loss. A kiss on an external ear canal can create negative pressure that can affect the bones of the inner ear, causing tinnitus and hearing loss. This case report will discuss sensorineural hearing loss (or sudden sensory neural hearing loss (SSNHL)) caused by an innocent kiss on the patient’s ear.
Sensorineural hearing loss (SNHL) is basically of two types: acquired and congenital. Congenital SNHL is usually genetic and patients are born with this hearing loss. In some cases, prematurity and infections during pregnancy can be passed from mother to child and lead to congenital hearing loss. An acquired SNHL is defined as hearing loss later in life. Common causes of acquired SNHL include aging, noise, trauma, tumors, and medications. Usually, an acquired SNHL occurs gradually and later in life. Yet, in some cases, patients develop Sudden Acquired SNHL or Sudden Sensory Neural Hearing Loss (SSNHL), which causes deafness in the one-sided ear, for example trauma or an innocent love kiss. [1,2].
Presentation of the case
The patient is a 50-year-old female with a medical history of hypertension only controlled by lisinopril 20 mg daily who presented to hospital with a chief complaint of severe tinnitus and hearing loss in the right ear . The patient said she and her husband were watching a movie at home when her husband suddenly kissed her on the right ear. She said that suddenly after the kiss she had almost complete hearing loss in her right ear along with severe tinnitus and nausea. The patient said it happened a few hours ago at home, and her tinnitus and hearing loss did not seem to improve, so she decided to come to the hospital. The patient, in general, is in good health apart from her hypertension, which is very well controlled by lisinopril 20 mg daily. She stated that she had normal hearing before this episode. The patient has never worn a hearing aid. She has never had significant ear infections in the past. She denied neurological symptoms such as headache, diplopia, dizziness, history of meningioma, cancer, autoimmune disease, vasculitis, history of Lyme disease, fever or any changes in recent medications. The patient denied diabetes, strokes, recent infection, or any recent travel outside of her state or outside of the United States. The patient is a software engineer and works from home. The patient underwent a blood test, which was normal, as can be seen in the table 1.
On physical examination, the patient had a normal tympanic membrane, as seen in Fig. 1with a normal-appearing external auditory canal in both ears.
There were no signs of trauma inside or outside the ear. A full physical examination and skin check was performed, and no signs of physical abuse were found either. Cranial nerves II to XII are all intact. The patient then had a CT scan of the temporal bone with the brainstem, and an MRI of the brain with contrast was also performed, but no significant abnormalities were found. In the emergency department, an otolaryngologist was consulted and the patient was admitted with severe nausea and tinnitus.
The patient received 4 mg of Zofran IV to relieve nausea. Weber and Rinne tests were performed by the hospital otolaryngologist, and the patient was found to have sensorineural hearing loss only. She was also started on 60mg of prednisone daily by the otolaryngologist. The patient was then discharged from the hospital with a prescription for a decreasing dose of prednisone over two weeks and a follow-up appointment with the otolaryngologist outpatient clinic the following day. The patient underwent an audiogram which showed a sensorineural hearing loss of 30 decibels (dB) at 500 and 1000 Hz. The otolaryngologist said she had decreased stapedius reflex in her right ear, but a normal reflex was present in the left ear.
The patient was followed a week later at the outpatient clinic. She said she felt much better. There has been a significant reduction in tinnitus since the incidents, but she can still hear it when she is alone. The patient was followed up again in ENT and underwent an audiological evaluation, which showed that she still had sensorineural hearing loss of 15-20 DB at 1000-2000 Hz. see you again in two months for a reassessment. The patient reported that she felt much better and could now work almost normally.
Sudden sensorineural hearing loss (SSNHL) usually presents as acute unilateral sensorineural hearing loss. Most cases of SSNHL are idiopathic, although they can also occur for several other reasons, such as infections, cancer, vascular, metabolic diseases, medications, and trauma.
A kiss on the patient’s external auditory canal creates a large vacuum or negative pressure, which causes outward pressure on the tympanic membrane. This pressure on the tympanic membrane also creates negative pressure on the small bones in the ear attached to the tympanic membrane, i.e. the stapes, incus, and malleus. This causes the stapes to dislodge in the inner ear and inner ear fluid (also called perilymph) leaks out and damages the hair cells, leading to tinnitus and hearing loss. .
Diagnostic criteria for SSNHL include diagnosis of hearing loss as sensorineural, hearing loss of at least 30 dB, and hearing loss within 72 hours. [3,4].
Patients who have experienced sudden hearing loss should be evaluated within days of onset of symptoms. The first step is the assessment of the hearing loss itself; this can be done using audiometric equipment such as a tone-emitting otoscope or a whisper test. The next step is to distinguish sensorineural hearing loss from conductive hearing loss, which can be achieved by a simple Weber and Rinne test. A focused clinical history and physical examination should be performed on the patient who presents with suspicion of sudden sensorineural hearing loss (SSNHL), as was the case in this case. Audiometric tests are necessary to establish the diagnosis of sensorineural hearing loss. In addition, an MRI of the brain should be performed with contrast to assess any cochlear pathology .
All patients who have SSNHL, including identifiable causes, should be treated with glucocorticoids. For example, patients who have identifiable causes of SSNHL such as meningitis should be treated with antibiotics as well as steroids . Steroid treatment is usually offered for 2-8 weeks. We assess the patient’s response to the initial treatment with an audiometric test repeated in 2 to 4 weeks. If the patient notices an improvement in their hearing of more than 10 dB, no further treatment is necessary. However, if there is less than 10 dB of improvement, additional treatment should be offered, which includes longer duration of systemic steroids as well as possible intratympanic glucocorticoids. [6,7].
A sudden innocent kiss on a person’s external ear canal can lead to sensorineural hearing loss, which can be devastating and upsetting for the patient. This is also known as Reiter’s kissing ear syndrome first described by Levi Reiter in 2008. Patients such as young children and infants have small and narrow ear canals and are therefore more at risk. risk of this hearing loss. Physicians, healthcare professionals, parents and partners should be made aware of the risk associated with this innocent kiss. We should be able to quickly identify and begin treatment as soon as possible once diagnosed to have a better chance of full recovery.