Page 101 - Read Online

Page 2 of 4 Larionova et al. Mini-invasive Surg 2020;4:59 I http://dx.doi.org/10.20517/2574-1225.2020.49

The current literature reveals PET can be a complication of bariatric surgery such as Roux-en-Y-bypass
[3]
and symptoms onset after 20 kg weight loss . A prospective cohort study in Brazil also showed association
[4]
between gastric bypass (Fobi-Capella technique) and PET . A poster at the Sages 2017 annual meeting
described a case of PET after sleeve gastrectomy with subsequent loss of 27.2 kg (EWL 70%), with BMI
2[5]
37.9 kg/m . We present a case of PET after laparoscopic sleeve gastrectomy and symptoms onset after
2
subsequent weight loss of 35 kg (EWL 59.5%), with BMI 46.6 kg/m .

CASE REPORT
2
A 36-year-old Caucasian female with Class III morbid obesity (131 kg, BMI 46.6 kg/m ) presented to our
multidisciplinary accredited bariatric program in April 2018. She successfully underwent laparoscopic
sleeve gastrectomy surgery. At her postoperative follow-up appointment six months later, her weight
dropped to 96 kg. She had lost 35 kg, EWL 59.5%. She also complained of severe autophony and aural
fullness. She started to hear her own voice and different noises leading to anxiety and insomnia. She
could hear her breathing when exercising. It began in her right ear and then she started to experience
it bilaterally. There was no otalgia, otorrhea, or tenderness. She denied any history of ear infections, ear
surgery, or noise exposure. Autophony was temporarily relieved with lowering her head between her knees
or forward-bending. Her symptoms were rapidly progressing. She came to see her primary care provider
and was initially misdiagnosed with a sinus infection.

She was started on antibiotics and nasal decongestants, which provided no relief. Nevertheless, her
symptoms persisted, and she was subsequently seen by an otolaryngologist. At her otolaryngology visit, her
otoscopy revealed clear ear canals. Pure tone testing revealed normal hearing, bilaterally. Word Recognition
scores were excellent for each ear. Tympanometry revealed normal middle ear pressure and compliance,
bilaterally. PET testing was positive for the right ear; changes to the immittance were synchronous with
breathing and most pronounced in the occluded-nostril condition [Figure 1]. Normal hearing with
evidence of PET was noted for the right ear. She was officially diagnosed with PET. She was offered medical
treatment for PET and decided to monitor her symptoms before proceeding with any surgical intervention.
She was recommended nonsteroidal anti-inflammatory medications but wanted to avoid them given
history of sleeve gastrectomy. She was started on oxymetazoline for five days and advised to discontinue
Flonase. She found acupuncture to be helpful to alleviate some of her symptoms.

DISCUSSION
There is no association between what type of bariatric surgery causes PET. Patients can present to their
primary care providers with multiple vague symptoms, which can be challenging to diagnose; therefore, a
detailed past medical and surgical history is required. Symptoms can vary from autophony, aural fullness,
aerophony, foreign body sensation, and tinnitus to severe anxiety and insomnia . Symptoms can increase
[6]
in frequency and duration with time and can be exacerbated with exercise. Symptoms can be relieved
with posture (placing the head in a dependent position), upper respiratory infection, or ipsilateral internal
[7]
jugular vein compression .
Certain diseases such as multiple sclerosis, anorexia, or motor neuron disease can be associated with PET.
It is important to consider all the possible differentials including psychiatric illnesses. Stress and anxiety
were identified as novel risk factors and may heighten the awareness of internal auditory sounds. According
to the literature, auditory verbal hallucinations or hearing voices (multiple voices or sounds such as
[8]
whispering or murmuring) are the most common symptoms, particularly in schizophrenia .
Our patient was appropriately referred to otolaryngology and diagnosed with PET. Treatment options for
[2]
PET can be minimally invasive, medical, and surgical depending on the severity of symptoms . Medical