Intended for healthcare professionals

Endgames Picture Quiz

A 68 year old woman with deteriorating hearing

BMJ 2014; 348 doi: (Published 01 May 2014) Cite this as: BMJ 2014;348:g2984
  1. Natalie Ronan, ear, nose, and throat specialist trainee year 5,
  2. George Barrett, ear, nose, and throat specialist trainee year 4
  1. 1Ear, Nose, and Throat Department, Royal Cornwall Hospital, Truro TR1 3LJ, UK
  1. Correspondence to N Ronan natalieronan{at}

A 68 year old woman presented to the ear, nose, and throat (ENT) clinic with gradually worsening bilateral hearing loss over at least the past five years. This was associated with some non-intrusive tinnitus but no other otological symptoms, history of vertigo, or associated systemic problems. She found that she was increasing the TV volume to a level that her family found uncomfortable, and she had started to avoid social situations because she struggled to hear conversation among the background noise. Her medical history was unremarkable except for well controlled hypertension, for which she was taking amlodipine. She also had no history of excessive noise exposure, no previous otological problems, and no family history of note.

The results of an ENT examination were unremarkable, with normal ear canals and tympanic membranes bilaterally. Tympanometry was also normal in both ears.

A pure tone audiogram was obtained .

Pure tone audiogram showing air conduction thresholds (“x” for the left ear and “o” for the right ear). The unmasked bone conduction threshold is indicated by ∆


  • 1. What is the likely diagnosis?

  • 2. What type of hearing loss does the pure tone audiogram show?

  • 3. When are similar presenting symptoms suspicious of underlying disease that warrants further investigation?

  • 4. What treatment options are available?


1. What is the likely diagnosis?

Short answer

Given the patient’s age, the insidious …

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