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"For whom this bell tolls… it tolls for thee ," OB Anesthesiologists. A tale of isolated, chronic tinnitus after neuraxial labor analgesia.
Abstract Number: F5D-7
Abstract Type: Case Report/Case Series
Just as Donne's poem says, "No man is an island, entire of itself ," no aspect of the neuraxial system is independent of any other part that is also in communication with cerebrospinal fluid (CSF). Thus, it is well known that numerous disparate symptoms such as headache, nausea, neck stiffness, diplopia, and tinnitus  can all result from accidental dural puncture (ADP) associated with neuraxial labor analgesia. The pathophysiology is thought to be attributable to leakage of CSF out of the intrathecal space. This resultant intracranial hypotension has been shown on MRI to be associated with sagging of intracranial structures, meningeal enhancement, and vasodilation of blood vessels . Although positional headache is the most common symptom of ADP, other symptoms of intracranial hypotension may be more prominent, or even present on their own. Herein we discuss a case of isolated, chronic tinnitus after occult ADP.
A 32-year-old female, G2P1, vaginally delivered a term baby girl. A combined spinal epidural (CSE) was placed at 3 cm cervical dilation. The CSE note reports an uncomplicated procedure, without mention of ADP, but noted that she moved during placement. In her postpartum anesthesia assessment, she fully regained neurologic function, but reported bilateral tinnitus immediately after CSE placement. An epidural blood patch (EBP) was offered, but declined. Two months later, she returned complaining of unabating tinnitus. An EBP was then performed. Initially a bilateral change in tinnitus pitch was noted, but it returned to baseline by the next day. An EBP was repeated a week later with minimal change in symptoms. Given her underwhelming response to EBP, she was referred to the Neurology and Ear, Nose, and Throat clinics. An audiogram and external auditory exam showed no pathological findings. After a consult with the hydrocephalus clinic, a balanced steady-state gradient echo sequence brain and spine MRI with 3D reconstruction was ordered in search of a CSF leak. While the patient still reports constant tinnitus, she is not sure if she wants to proceed with the MRI.
EBP has been shown to relieve chronic ADP symptoms even 12 months after onset . Although the EBPs did not cure her tinnitus, the temporal association of her symptoms with her CSE, and the pitch change with her first EBP suggest continuous CSF leak, which should be confirmed by MRI . Epidural plica mediana may prevent adequate EBP spread to CSF leak sites , and an image-guided EBP may be needed to definitively treat . The cure of ADP symptoms can be a protracted process and nerve damage can worsen with time. Thus, although the bells may only toll in the heads of our patients, they also toll for obstetric anesthesiologists as we take "upon us the misery of our neighbors ."
 Donne. Meditation 17, 1623.
 Kuczkowski. 2007
 Sachs. 2014
 Klepstad. 1999
 Ginosar. 2016
 Kranz. 2011