Differential Diagnosis for Hearing Loss in a 59-year-old Woman with Paget Disease

Single Most Likely Diagnosis

• Otosclerosis: This condition is characterized by abnormal bone growth in the middle ear, which can cause hearing loss. The patient's history of Paget disease, a condition that affects bone remodeling, increases the likelihood of otosclerosis. The minimal hearing loss on the right to whisper and dulled tympanic membranes without injection are also consistent with this diagnosis.

Other Likely Diagnoses

• Hyperostosis of the temporal bone: This condition involves excessive bone growth in the temporal bone, which can be associated with Paget disease. It could potentially cause hearing loss, although it is less directly linked to the symptoms described compared to otosclerosis.
• Presbycusis: Age-related hearing loss is a common condition that could contribute to the patient's symptoms, especially given her age. However, the asymmetry of her hearing loss (more significant on the right) and the presence of other specific findings (e.g., decreased cranial motion during the flexion phase) suggest that presbycusis might not be the primary cause.
• Serous otitis media: This condition involves fluid accumulation in the middle ear, which can cause hearing loss. The dulled tympanic membranes could be indicative of this condition, but the absence of other typical symptoms (e.g., ear fullness, pain) and the specific context of Paget disease make it less likely.

Do Not Miss Diagnoses

• Vestibular schwannoma: Although less likely given the patient's presentation, a vestibular schwannoma (a benign tumor on the nerve connecting the inner ear to the brain) is a critical diagnosis not to miss due to its potential for serious complications if left untreated. The patient's hearing loss is unilateral, which could be consistent with this diagnosis, but other symptoms such as vertigo or tinnitus are not mentioned.

Rare Diagnoses

• Other rare conditions that could potentially cause hearing loss in this context include otospongiosis (a condition similar to otosclerosis but with a different pathological process), cochlear otosclerosis (a variant of otosclerosis affecting the cochlea), or Paget disease directly involving the temporal bone, leading to hearing loss. These conditions are less common and would require specific diagnostic testing for confirmation.