a 30-year - old female patient admitted to our hospital with sudden hearing loss and tinnitus in the right ear .
her medical history also included lumbar discopathy . she d been using beta interferon at a dose of 0.3 mg on alternate days for the treatment of ms for the last 3.5 years .
physical examination of the patient demonstrated intact bilateral tympanic membranes , weber test was lateralized to the left ear , rinne test was positive ( + /+ ) in the left , and false negative ( + /-
pure tone audiogram was performed on the patient with the initial diagnosis of sudden hearing loss ( figure 1 ) .
the final diagnosis was total hearing loss in the right ear ( air conduction / bone conduction : 113/67 db ) .
the hearing acuity of the left ear was determined to be in normal hearing range ( air conduction / bone conduction : 18/12 db ) .
after the patient was admitted to our clinic , routine laboratory tests were run . in the laboratory tests
; there were no abnormal findings except wbc ; 12.710/mm , triglycerides ; 34 mg / dl , ck - mb ; 25 u / l , uibc ; 366 ug / dl .
contrast - enhanced cranial magnetic resonance imaging ( mri ) and neurology consultation were ordered for the patient . as a result of the consultation
accordingly , a new ms attack was not anticipated . to investigate vascular , connective tissue pathologies or infectious etiologies ,
the results of new laboratory tests were as follows : rheumatoid factor < 20 , anti - nuclear antibody ; negative (  ) , anti - phospholipid ig g ; negative (  ) , anti - phospholipid igm ; negative (  ) .
levels of protein c , protein s , von willebrant factor antigen were in their normal ranges . in elisa tests , levels of anti - toxoplasma ig m , anti - cmv ig m , ebv vca ig m , anti - hsv-1 ig m , anti - hsv-2 ig m , vdrl - rpr , anti - ds dna were within their normal ranges . in the light of these findings , classical parenteral treatment protocol of sudden sensorineural hearing loss was prescribed as prednisolone kg/1 mg / day with tapering dose , ranitidine 50 mg / day , pentoxifylline 900 mg / day , low - molecular - weight heparin 0.6 ml / day , acyclovir 2 g / day .
also hyperbaric oxygen therapy was administrated to the patient for 10 days at doses of 2.5 ata / day .
pure tone audiogram was performed totally 3 times during hospitalization period . in spite of all our medical treatments
the patient was discharged with oral treatment and followed up in our outpatient clinic . at the end of our treatment , audiologic examinations were performed . in november ,
one month after the onset of the disease , there was not any hearing improvement as detected on her pure tone audiogram ( figure 2 ) .
three months later spontaneous recovery was observed on her pure tone audiogram air / bone conduction 13/7 db , 30/27 db were reported for the left , and the right ear , respectively ( figure 3 ) .
depending on these findings , the patient s sudden hearing loss of the right ear might be related to ms disease .
sudden hearing loss ( shl ) is a hearing loss of 30 db or more , over at least three contiguous audiometric frequencies , that develops over a period of a few hours to 3 days [ 4 , 5 , 6 , 7 , 8 , 9 ] .
the etiology of the disease is not certain , but autoimmune vascular malformations , thrombotic , and central nervous system diseases are among the main reasons [ 4 , 5 ] .
ms is a demyelinating disease of the central nervous system that involves the white substance .
rarely cerebellum , brain stem and spinal cord can be effected by ms . as a result of autoimmunity ,
intravascular t cells attack the myelin sheath , and nerve fibers , then it starts as an inflammatory process . on the other hand , neural
regeneration begins in order to stop the damage at a minimum level . in 4 - 10 % of ms patients ,
sensorineural hearing loss occurs during periods of relapse or remission [ 5 , 6 ] .
detection of brain lesions of ms in mri , can provide evidence concerning the dissemination of ms lesions in space and time .
therefore a diagnosis of ms should be guided by the defined criteria of mri for this abnormality .
hearing loss in ms disease may be due to plaques which are placed on brain stem , any area of entrance of cochlear nerve into the brain stem , and auditory cortex [ 6 , 7 ] .
in this situation , auditory brainstem response ( abr ) test is the most appropriate test for the diagnosis of sensorineural hearing loss in ms patients .
also , elongations in interpeak latencies of i - iii , iii - v waves or changes in the morphology and amplitudes of iii and v wave s may be observed [ 7 , 8 ] . in the right ear abr of our patient , we observed elongation in absolute latencies of waves iii and v , as well as iii - v waves interpeak latencies . if sudden hearing loss is related with ms , it usually recovers without sequellae . in a retrospective study of hellman and his colleagues , 253 ms patients with sensorineural hearing loss were scanned , and sudden hearing loss was diagnosed in 11 of them .
in our patient , sudden hearing loss recovered with a mild sensorineural hearing loss , and no recurrence was observed in one year follow - up . in conclusion , whenever sudden hearing loss is diagnosed in a patient , physicians should request cranial imaging to differentiate for cranial pathologies such as ms .
sudden hearing loss can be the first symptom of ms or may indicate relapse of the disease .
 multiple sclerosis ( ms ) is the most common demyelinating disease of the central nervous system . 
 ms involves different regions of the central nervous system in different periods , and causes demyelination . 
 ms is a neuromotor disorder which progresses with remissions and relapses . 
 symptoms of ms may regress completely or heal after the relapses leaving sequelae . 
 sudden sensorinerural hearing loss ( sshl ) is hearing loss of 30 db or more over at least three contiguous audiometric frequencies that develops over a period of a few hours to 3 days . in 4 - 10 % of the ms patients 
 , sensorineural hearing loss occurs between relapses or remissions . in this case , 
 audiotory brainstem response ( abr ) test is the most appropriate test for the diagnosis of sensorineural hearing loss in ms patients . in this article 
 , we will discuss a patient diagnosed as ms who presented with sudden sensorineural hearing loss during the remission of the disease . 
CASE REPORT
DISCUSSION