Positional Vertigo and Unilateral Gradual Hearing Loss Following Sleeve Gastrectomy: A Case Report.

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment option in patients with morbid obesity, with rare long-term sideeffects. In this report, we present a 42-year-old woman who reported positional vertigo and unilateral gradual hearing loss plus continuous tinnitus after LSG. The patient had no signs or symptoms of mental health disorders and the results of the haematological and serum biochemical tests were normal. However, audiometric test revealed mild sensorineural hearing loss with magnitude in high-frequency tones. Also, acoustic reflex threshold showed neural pathway damage, particularly at high frequencies, with no reflex. Pure tone audiometry showed signs of nerve damage in the inner ear. One possible justification for these complications might be eustachian tube dysfunction due to muscle relaxation. Muscle relaxation itself may occur as a result of adipose tissue loss around the ear muscles. Further evidence, however, would be required to better determine whether these complications are attributable to LSG, and to illuminate exact underlying reasons for such complications.

Introduction

Obesity is a major health problem worldwide.1,2 Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for morbid obesity, with beneficial effects on body weight reported in both the short and long term.3,4 Although the procedure is generally known to be safe, it may cause a number of side effects, including anastomotic leaks, hemorrhage, postoperative abscess, and sleeve stricture.5 Hearing impairments, however, is rarely reported after LSG. In this case report, we describe a 42-year-old woman with a chief complaint of positional vertigo, unilateral gradual hearing loss, and continues tinnitus after LSG.

Case Report

A 42-year-old woman was admitted to the Ear, Nose and Throat ward of Shariati educational hospital (Tehran, Iran) complaining from positional vertigo, unilateral gradual hearing loss, and continues tinnitus. Except a history of recent LSG for her morbid obesity, the patient had no other medical or psychological condition, including depressive disorder, bulimia nervosa, excessive consumption of coffee or alcohol, and smoking. Before the LSG, patient’s weight, height, and body mass index (BMI) were 110 kg, 164 cm, and 40 kg/m2, respectively. In months three and twelve after surgery, the BMI decreased to 33 and 27 kg/m2, respectively.

In month three post-surgery, the patient reported vertigo and hearing. At the beginning, both symptoms were mild, but they aggravated gradually, leading to intolerable vertigo and complete unilateral hearing loss at month 12. In month 12, the patient also developed a number of minor complications, including menstrual irregularities, female androgenetic alopecia, and appetite alteration. She reported an increased desire to salty and sour tastes, and a decreased desire to sweet foods.

The patient’s positional vertigo was getting intensified in the natural head position, i.e., when the head was in an upright position, with eyes looking straight, and got alleviated when the patient tilted her head to the right/left side. The Dix-Hallpike maneuver did not illuminate possible causes of positional vertigo and the eye motion test was also normal.

Unilateral hearing loss aggravated over a nine-month period. No trigger/causes were detected that could alleviate/aggravate the progression of the problem. The patients reported no history of head trauma, headache, migraine, dizziness, nausea/vomiting, recent infection, recent loud noise exposure, ear pain/discharge, or numbness. The otoscopy result was normal. Rinne and Weber tests also showed normal bone conduction in the absence of air conduction. The tympanogram was classified as type A in both right and left ears, and was considered to be normal. Audiometric test showed mild sensorineural hearing loss with magnitude in high-frequency tones. Acoustic reflex threshold showed Eustachian tube dysfunction. At high frequencies, the neural pathways also showed no reflex. Outer and middle ear curtain was normal in pure-tone audiometry. The test, however, showed nerve damage in the inner ear (Figure 1). During a 14-month follow-up, the abovementioned symptoms alleviated by symptomatic therapy, without specific medical interventions.

Figure 1

Pure tone audiometry.

Notes: Right: SRT, 15 db; MCL, 50 db; In quiet lebel, 100. Left: SRT, 15 db; MCL, 50db; In quiet level, 100.

Abbreviations: RE, right ear; LE, left ear; dB, decibel; SRT, speech recognition threshold; MCL, most comfortable level; AC, air conduction; BC, bone conduction.

Discussion

Clinical complications rarely occur after sleeve gastrectomy. In this case report, we presented a woman who suffered from positional vertigo and unilateral gradual hearing loss plus continues tinnitus after LSG. These complications can occur after sleeve gastrectomy but sever forms that become intolerable or impact patients’ daily life have been rarely reported to date.6–8 One possible mechanism might involve the relaxation of ear muscles due to the loss of surrounding adipose tissues. In adult humans, the eustachian tube contains a 24–26 millimeters fibrocartilaginous part. Due to the elastic nature of the fibrocartilaginous part, it is closed most of the time. It only allows the air to pass through during activities such as sneezing, yawning, or swallowing.9–11 The exact process involved in the opening of the fibrocartilaginous part has yet to be defined. It is suggested that muscular structures such as tensor veli palatini, elevator veli palatine and salpingopharyngeus muscles play an important part in this regard.8,11 Besides the dysfunction of peritubalmuscles, loss of Ostmann’s fat surrounding the muscles of the eustachian tube is among the potential mechanisms implicated in the pathophysiology of hearing loss induced by eustachian tube dysfunction.7 Studies showed that rapid weight lost following sleeve surgery may be associated with loss of adipocyte tissue around the eustachian tube, resulting in hearing loss and tinnitus.7,12

We also did no measure micronutrient levels of the patient, either before or after LSG. Micronutrient deficiencies might play a role in the development of vertigo through mechanisms such as neural impairments and decreased blood flow to the brain.13,14

Further reports are required to determine whether these complications are etiologically linked to LSG. Positive associations would have certain implications for the clinical management of patients who undergo LSG.

Conclusion

The complications associated with sleeve gastrectomy are rare; however, hearing loss may occur due to the relaxation of ear muscles following the loss of surrounding adipose tissues. Further cases with similar complications would better illuminate possible linkages between sleeve gastrectomy and subsequent hearing complications, including hearing loss and vertigo. Confirmed associations would have important implications for the clinical management of patients after sleeve gastrectomy.