Presentation of the case
Mrs. D., aged 70, consults her general practitioner because of pain in her left ear and a persistent ringing for two weeks. His medical history is complex, including type 2 diabetes, high blood pressure treated with medication, cervical spondylosis operated on 10 years ago and chronic kidney failure.
First medical consultation
During the first consultation, the doctor examines the external ear and the eardrum without observing any apparent abnormality. He prescribes a local anti-inflammatory treatment to relieve the pain and asks the patient to return in a few days if the symptoms persist.
Monitoring of prescribed treatments
Despite the local treatment prescribed, Mrs. D. noted no significant improvement after several days. She therefore returned to her doctor who then decided to add oral treatment with corticosteroids for a week to intensify the anti-inflammatory action.
Appearance of new neurological symptoms
Over the following weeks, Mrs. D. noticed not only that her ENT problems persisted but also that she presented progressive neurological disorders: difficulty coordinating her movements, muscular weakness and numbness in the lower limbs. She returns to her general practitioner who decides to carry out a brain scan to look for a possible central cause.
Brain scan results
The brain scan does not show any specific abnormality that could explain Mrs. D.’s symptoms, other than non-specific signs of age-related cortical atrophy. The general practitioner is therefore faced with a diagnostic dilemma faced with the persistence of ENT symptoms and the progressive appearance of neurological disorders.
Urgent hospitalization decision
A few days later, Mrs. D. presented a sudden worsening of her symptoms with difficulty speaking and swallowing, as well as right facial paralysis. His general practitioner then decided to hospitalize him urgently for additional investigations and specialized treatment.
Investigations carried out during hospitalization
During her hospitalization, Mrs. D. underwent several additional examinations including an electromyogram (EMG) which revealed diffuse damage to the peripheral nerves compatible with acute inflammatory polyneuropathy (Guillain-Barré). Furthermore, cervical magnetic resonance imaging (MRI) shows spinal cord compression due to pre-existing cervical osteoarthritis.
Expert judgment on management and identification of diagnostic errors
Mrs. D.’s treatment was marked by several diagnostic difficulties linked to the complexity of her medical history and the gradual appearance of atypical symptoms. The ringing in the ears, initially attributed to local inflammation, was in reality a precursor to a more serious neurological attack (stroke or Guillain-Barré).
The diagnostic errors made in this case led to delays in appropriate treatment, causing serious after-effects for the patient who could have benefited from specific treatment earlier if the appropriate investigations had been carried out from the start.
This clinical case highlights the importance of rapid diagnosis in the face of atypical progressive symptoms in an elderly person with a busy medical history. It also highlights the need for general practitioners to remain vigilant when new symptoms appear and to quickly refer their patients to specialists when necessary.
