14 year old male presented to the pediatrician on 2/12/18 with complaints of sore throat for 2 days with nasal congestion that increased to cough and some abdominal pain. Flu screen came back negative but rapid strep came back positive and diagnosed with acute streptococcal pharyngitis and he was prescribed Amoxil 875 mg 2x daily for 10 days.
On 3/5/18 the patient returned complaining of fullness in his left ear some ringing and some dizziness of being off balance and noting he had vomited once. The chief complaint was consistent ringing in L ear, can’t hear from L ear, stomachache, dizziness. The pediatrician diagnosed him with acute otitis media, left and indicated that he believed this was early onset of otitis with just fluid at this point and was making him dizzy and decided to treat with Amoxil 875 mg 2 x daily for 10 days.
Patient returned on 3/13/18 and stated he was still having a hard time hearing out of his ear and everything seemed muffled. He was diagnosed with acute serious otitis media and the pediatrician indicated we will go ahead and refer to pediatric ENT for hearing loss in left ear.
On 3/22/18 patient sees pediatric ENT and underwent audiological evaluation and noted to have profound hearing loss sensorineural in nature. Impression Sensorineural Hearing Loss, Left. Concern for sudden SNHL/may be secondary to viral labyrinthitis. Still has tinnitus and some dizziness. Noted discussing extensively with family that this occurred weeks prior and may not get any hearing back with treatment. Started on high dose prednisone.
Patient returned 3/26/18 and underwent Transtympanic dexamethasone perfusion procedure. Also underwent same procedure on 4/02/18 and 4/10/18.
On the 4/10/18 visit noted slight improvement in audiogram now 20% word recognition.
However, by 5/21/18 notes indicate patient reports hearing is subjectively poorer since last hearing evaluation.
It has been recommended patient undergo cochlear implant
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Do you believe there might have been medical error?
The symptoms of hearing loss and tinnitus and dizziness are classic for an inner ear problem. The pediatrician made an incorrect diagnosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The symptoms of hearing loss, tinnitus and dizziness are classic for an inner ear problem and are an emergency requiring immediate specialty treatment.
What makes you a good expert for this case?
I am an academic otolaryngologist, treating patients, teaching and training medical students and residents at one of the highest ranked medical centers in the country. I am published in the medical literature on hearing loss and hearing testing
How often do you encounter cases similar to this one in your practice?
Very often. Unfortunately, primary care doctors mis- diagnose sudden hearing loss and give an in accurate diagnosis of “fluid in the ear”. They delay the immediately necessary treatment and many patients have permanent deafness, a severe disability, as a result of the mid diagnosis and delay in treatment.
Do you believe there might have been medical error?
When the patient presented with dizziness and hearing loss, likely a prompt referral to an audiologist and/or an ENT could have revealed a SSNHL and earlier intervention might have improved the patient outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unlikely that the delay in care actually caused the SSNHL, this was a natural progression of either the viral or bacterial ear disease. The PCP initially gave antibiotics for both infections which was appropriate.
What makes you a good expert for this case?
I am a pediatric otolaryngologist and see patients similar to this scenario. Unfortunately SSNHL does happen and I have myself given steroids and intratympanic steroids for SSNHL. I am in academic practice and see exclusively children.
How often do you encounter cases similar to this one in your practice?
I would say in the pediatric population luckily this is rare. We may seen 1-2 of these per year.
Do you believe there might have been medical error?
on 3/5/18, pt presented with dizziness, hearing loss and tinnitus. While otitis media and resultant conductive hearing loss can cause these symptoms and is the more common etiology, sensorineural hearing loss ideally should have been considered. If sudden sensorineural hearing loss was considered and discovered early, it might have prompted emergent referral to ENT and earlier treatment.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While systemic corticosteroids and intratympanic steroids are common treatments for sudden sensorineural hearing loss, there is no strong evidence to show that any treatment is superior to no treatment. Studies show a trend toward benefit with early treatment but all such studies have problems with selection bias and poor controls. Also, most studies show that differences between treatment and placebo began to disappear as followup time increases as spontaneous recovery takes place. So it is difficult to prove that lack of treatment or delay in treatment affects eventual outcomes in a disease process where up to 65% of patient have spontaneous recovery and the benefits of treatment are unclear. and preferred and optimal treatment is not known.
What makes you a good expert for this case?
15 year experience in ENT at an academic center. Also, had sudden sensorineural hearing loss myself.
How often do you encounter cases similar to this one in your practice?
I see cases of sudden sensorineural hearing loss about 6 times a year.
Do you believe there might have been medical error?
The diagnosis of acute strep pharyngitis is clinically sound given the symptoms at the time. There is no evidence of discussion of any hearing loss at that visit so treatment was appropriate. The visit of 3/5 where the patient complains of hearing issues should have had an evaluation of hearing as the patient's complaint was directed towards that. The fact that there was a serous otitis media and that needed treatment after antibiotics is unusual but not unheard of. The MD should have explained that this dizziness and hearing loss may be due to the ear infection but should have followed with a hearing test to ensure it was only that. The delay until 3/22 for a hearing test limited to efficacy of the treatment of steroids. It may have not changed the outcome but it possibly could have.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Once the hearing test was established, the treatment appears to be appropriate and best practice standard of care. The delay of the hearing test and diagnosis may have kept the hearing from improving (although it is also possible that it may not have improved). The causation of the injury is partly due to the injury (viral) of the hearing nerve but recovery was affected by the delay in diagnosis and treatment of the original MD.
What makes you a good expert for this case?
I am the division chief of pediatric otolaryngology and have a prolific academic career in otolaryngology and pediatric otolaryngology. I have provided several legal reviews for cases over the past 10 years and have expertise in this arena. I have clinically expertise in pediatric otolaryngology and can speak to the particulars in this case.
How often do you encounter cases similar to this one in your practice?
Sudden sensorineural hearing loss does happen often (1x/week) but the delay in diagnosis does not happen often -- as it did in this case due to the strep infection. The MD unfortunately missed the fact that there may be a hearing loss separate from the ongoing infection.
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