Age: 56.0
Sex: M
Vaccine: COVID19
Symptoms: Cerumen removal, Deafness neurosensory, Deafness unilateral, Middle ear effusion, Otoscopy normal
Clinical narrative: Allergies: NKA NO Medicaitons at the time of vaccination NO significant PMH at the time of vaccination Pt reported previous reaction at vaccination 1/5/22.  Chart review revealed below: 4/9/21 Pt seen un urgent care for hearing loss.  Prescribed amoxicillin. 4/10/21 Pt seen in Urgent Care 3 days post vaccination.  The encounter diagnosis was Sudden idiopathic hearing loss of right ear with restricted hearing of left ear.   HPI: Developed sudden hearing loss on right ear , Evaluated at urgent care , had otoscopy not much cerumen  Started on antibiotics , hasn't picked it yet  He denies constitutional symptoms of fatigue, weakness, weight loss or gain, fevers, night sweats. Occasional ringing  The patient denies changes in visual acuity, diplopia or amaurosis, no discharge, matting, redness, tearing or eye pain. He denies constitutional symptoms of fatigue, weakness, weight loss or gain, fevers, night sweats. Works as computer engineer  Assessment/Plan:    1. Sudden idiopathic hearing loss of right ear with restricted hearing of left ear  Etiology unclear  Symptoms onset < 24hours  Otoscopy at action urgent care non significant Start steroid .no contraindication  Need follow up with pcp for MRI in 3 months msg sent to MD   - predniSONE (DELTASONE) 20 MG tablet; Take 3 tablets by mouth daily.  Dispense: 30 tablet; Refill: 0 - Audiology; Future 4/12 pt seen again and prescribed valacyclovir.  At that point the pt had no improvement in symptoms. 4/21 pt seen by ENT who performed an intratympanic steroid injection (1cc total). MD also ordered an MRI.  4/22 2nd ENT visit On examination, patient appears to be well. He is sitting and breathing comfortably. Exam of the head and neck is normocephalic and atraumatic. Affect is appropriate.  Facial function and gait are normal today.   Cranial nerves 2-12 appear to be unremarkable today.   Examination of the pinnae are bilaterally normal.   Otomicroscopic examination (Binocular Microscopy) Binocular microscopy was performed to assess the ear canal, tympanic membrane, and middle ear spaces where possible. Cerumen was removed using curettage and right angle picks as needed for visualization of the deeper structures of the eardrum.  Right: Ear Canal: clear Tympanic Membrane: intact Middle ear: effusion noted (previously injected one day ago)  Left: Ear Canal: clear Tympanic Membrane: intact without retraction  Middle ear: aerated   The remainder of the otologic physical examination is unremarkable.  ASSESSMENT AND PLAN   Assessment: MD had a detailed discussion with patient about their symptoms and diagnosis. He is a 56 y.o. man with sudden sensorineural hearing loss after the first dose of the COVID vaccine. While causality cannot be proven the temporal relationship is compelling. He is now s/p one intratympanic steroid injection and currently on a prednisone taper. Discussed importance of protecting left ear and possible utility of cochlear implant on the right should his hearing not recover.   Plan: 1. Continue prednisone 60mg daily for an additional week, then taper 10mg each day for a 5-day taper; this will take place after his last dose of 60 mg that he currently has. 2. Follow up with ENT for repeat intratympanic steroid injections 3. MRI next Tuesday 4/27 4. Followup with ENT 4/29 Thursday for possible second injection; recommend audiogram for any improvement in hearing 5. HBO2 not recommended 6. Consider cochlear implantation on right vs. Possible future molecular options if no improvement noted. 7. Continue valacyclovir.  7/19/21 Pt seen by PCP-right hearing loss after Covid Pfizer vaccine. He reports that his hearing is coming back.  12/22/21 Pt seen by PCP.  NO mention of continued hearing impairment and no records to indicate repeat visit to ENT.