More Than Meets the Ear

A CLINICAL PROBLEM-SOLVING article by Spyridon Marinopoulos from Johns Hopkins University School of Medicine, Baltimore.
A 62-year-old man presented with a “clogged” sensation and a 6-week history of diminished hearing in his right ear. Audiometry confirmed a mixed, but principally conductive, hearing loss in the right ear. Serous otitis media was diagnosed and treated with intranasal corticosteroids. His symptoms recurred 5 months later, and a right myringotomy was performed. He continued to report slightly “muffled” hearing.
Otolaryngoscopy revealed no obstructing lesions. Six months later, in late May, the patient reported stiffness and pain in his right shoulder after he had been working outside in the yard.
The patient was advised to take nonsteroidal antiinflammatory drugs and noted improvement, but the following week he reported a sore left shoulder and a tender right knee. He also had lower back pain and bilateral heel sensitivity. Over the next 2 days, his ankles became swollen and painful, and he reported fatigue, a low-grade fever, night sweats, and a decreased appetite. On further questioning, the patient described his heel sensitivity as “numbness.”
It remains a challenge for clinicians confronting one specific problem or symptom to determine whether it is part of a more complex clinical entity. In this case, the diagnosis eluded the treating physicians until a set of musculoskeletal symptoms developed that at first seemed unrelated to the patient's initial presentation with hearing loss. [Original Article]