The diffuse nature of the headaches, which can wake Sandra from her sleep, are worse in the morning and may be causing her dizziness, and therefore require an examination of her cranial nerves.

The presence of multiple cranial nerve deficits raises the likelihood that the cause of the headache is due to a space occupying lesion (SOL) compressing nerves around the cerebellopontine angle. The combination of hearing loss, dizziness and depressed corneal reflex make the diagnosis of an acoustic neuroma most likely. The headache itself is most likely to be the result of raised intracranial pressure.

The investigation of choice would be magnetic resonance imaging (MRI) as this is the most accurate way of diagnosing acoustic neuromas. It provides multiplanar imaging and allows for assessment of the labyrinth without using ionising radiation.^[3]

Alternatively computed tomography (CT) scanning can be employed using an iodine-based contrast medium. The advantages of CT are that it is widely available, cheaper than MRI and clearly shows bone erosion of the internal auditory canal (IAC). The disadvantage of CT is that it has a poor sensitivity to the detection of small neuromas (<10mm) and that neuromas entirely confined to the IAC cannot be detected.^[3]

A high signal density within the internal auditory meatus which is also encroaching upon the pons in a patient with dizziness, hearing loss and signs of neurological deficits within cranial nerves 5, 8 and 9 suggest the presence of a cerebellopontine angle lesion, which in an adult, is most likely to be an acoustic neuroma.

No further investigations are necessary as MRI is the diagnostic test of choice for diagnosing acoustic neuroma. The patient will now have to consider surgical intervention or radiotherapy.

Papilloedema is related to cerebrospinal fluid (CSF) obstruction. As a SOL increases in size, there is less space for CSF flow to occur resulting in an increased pressure in the CSF. As the pressure increases in the optic nerve sheath, venous drainage and axoplasmic flow is impeded resulting in swelling of the optic disc.^[2]

Acoustic neuromas represent about 6% of all intracranial tumours. They are benign, slow-growing tumours, which are caused by an over-proliferation of Schwann cells associated with the myelin sheath of the vestibular cochlear nerve.^[3,4] Pathologically, acoustic neuromas are vestibular schwannomas, but the term acoustic neuroma is commonly used. The tumour develops from the vestibular portion of the nerve but auditory symptoms are often the earliest. Unrecognised and slowly progressive hearing loss then occurs, sometimes preceded by tinnitus.^[5]

Vertigo and facial nerve paralysis may occur later on in the growth of the tumour as will symptoms associated with brainstem and cerebellar compression such as ataxia of gait, mild spastic tetraparesis and ataxia in the upper limbs. Continued compression may lead to depression of the corneal reflex and compression of the cerebral aqueduct, obstructing the flow of cerebrospinal fluid and consequently an increase in intracranial pressure.^[5]

The vestibular cochlear nerve arises from the pontomedullary junction of the brain stem and passes through the internal auditory meatus together with the facial nerve and nervus intermedius. Its location in the cerebellopontine angle means that an acoustic neuroma will cause possible compression of the surrounding nerves. Superior growth of the tumour will compress the trigeminal nerve leading to depression of the corneal reflex, which is one of the earliest physical signs.^[5] It would be anticipated that compression of the facial nerve would cause facial paralysis, but this is an unusual and late feature of the condition and the presence of such symptoms suggest a cause other than acoustic neuroma. However, facial twitching may occur, called hemifacial spasm.^[5] Inferior growth of the tumour may begin to compress the glossopharyngeal and vagus nerves leading to palatal weakness, dysphagia and dysarthria.

Meningiomas, cholesteatomas, hemangioblastomas, ectasia of the basilar artery and metastatic deposits of carcinoma or lymphoma may all occur in the cerebellopontine angle, as may medulloblastomas and astrocytomas of the cerebellum.^[5] With all these tumours, the presence of severe brainstem signs, facial nerve palsy’s, ataxia, papilloedema, headache and vomiting may occur. The physical signs need to be carefully documented and compared to what would be expected from an acoustic neuroma. The presence of facial nerve palsy should alert you to a cause other than an acoustic neuroma, and it would appear that auditory signs and symptoms are more common in acoustic neuromas.^[5]

The information provided suggests that Gloria’s headaches may be stress related, particularly considering the site of the pain, her admission that she has had some recent concerns, and the presence of palpitations and dyspnoea.

However, there is insufficient information available at this stage to rule out more serious pathology. More questions need to be asked before formulating a differential diagnosis.

Her pallor (skin and conjunctiva), high pulse and respiratory rate are suggestive of anaemia. Her diminished hearing suggests a possible labyrinthine cause of her tinnitus, although normal Weber’s and Rinne’s tests make this less likely.