Stony Ears With No Visible Changes in the Appearance

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Stony Hard ears with no visible changes Source: NCBI

One-year history of stiff ears, gradually becoming stony hard.

A 53-year-old man presented to the outpatient department with complaints of diarrhea, tiredness, generalized weakness, intolerance to cold, and decreased mental function fro the past 6 months. The patient also complained of stiffness in his ears for the past 1 year, which he described as if his ears were “turning to stone.”

The patient had consulted many physicians for the unusual stiffness in his ears, but all efforts ended in smoke.

On examination, his skin was pale, periorbital puffiness was noticed, and pubic hair was absent with soft testes. Chovstek’s sign was negative and there was no carpopedal spasm. His ears were generally stiff.

Neurological examination revealed:

  • Absent ankle jerk
  • Extensor plantar response
  • Positive Rhomberg’s sign.

Serological investigations revealed

  • Sodium 128 mEq/L
  • Potassium 3.3 mEq/L
  • Calcium (corrected) 7.2 mEq/L
  • Phosphate 1.8 mEq/L
  • Magnesium 1.5 mEq/L
  • Cortisol 0.20 μg/dl (normal 5–23 μg/dl)
  • Free T3 1.67 pg/ml (normal 2.3–4.2 pg/ml),
  • Free T4 0.69 ng/dl (normal 0.7–1.51 ng/dl),
  • TSH 5.33 (normal 0.5–5 μU/ml),
  • Positive TPO (106.3 IU/ ml),
  • Prolactin 47 ng/ml (normal 4–30 ng/ml),
  • Testosterone 76 ng/dl (normal 241–827 ng/dl)

Vitamin D insufficiency was noticed with a 25-hydroxy vitamin D level of 26 ng/ml (30–74 ng/ml). iPTH level was 20 pg/ml (10– pg/ml).

Non-Contrast CT scan of the head showing auricular calcification
Source: NCBI

Imaging studies were done. A non-contrast CT scan of the head showed auricular calcification but no basal ganglia calcification. Contrast-enhanced magnetic resonance imaging of sella showed partially empty sella with normal stalk. Vitamin B12 levels were low–normal with a value of 311 pg/ml (normal 187–1059 pg/ml).

Empty Sella on MRI
Source: NCBI

The echocardiography revealed global hypokinesia, dilated cardiomyopathy, and an ejection fraction of 35–40%.

A diagnosis of idiopathic adult-onset pituitary insufficiency with associated auricular calcification.

Intravenous hydrocortisone and l-thyroxine were initiated. Testosterone replacement, vitamin B12 supplementation, ACE inhibitor, and beta-blocker were also added to his treatment regimen. Tha patient showed substantial recovery. His overall health improved, and the patient became asymptomatic except for the stiff ears, which remained unchanged.

References

Yashpal Gogate, P. G. (2012, sept-oct). “Petrified ears” with idiopathic adult-onset pituitary insufficiency. Retrieved from Indian J Endocrinol Metab: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475916/

Howlett TA, Levy MJ, Robertson IJ. How reliably can autoimmune hypophysitis be diagnosed without pituitary biopsy? Clin Endocrinol (Oxf) 2010;73:18–21

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Dr. Arsia Parekh
Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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