Author: Jami Montagnino
Senior Editor: Rahul Kapur, MD
Editor: Rachel Sachs, DO

Patient Presentation:
A 50-year-old woman presented with noise-induced dizziness after head trauma.

History:
A 50-year-old otherwise healthy female was mountain biking when she went over her handlebars and sustained a helmeted head strike almost 4 months prior to initial presentation to our tertiary referral center. Additional injuries included dental trauma and lip laceration that had been repaired. On presentation, she scored a 16/22 on a concussion symptom index with a total symptom severity score of 36 out of 132. Her most prominent symptom was sensitivity to noise, which would cause nausea, fatigue, and headaches. She worked as an elementary school music teacher and was unable to return to full time duties, as she found that noise during class and while driving would cause her to feel nauseated and off balance, though she denied a room-spinning sensation. She was able to jog long distance without worsening her symptoms. Prior to her accident, she does note some true vertigo that would arise spontaneously, but this was rare. Also notable in her history is one prior concussion nine years ago with only mild symptoms that completely resolved.

Physical Exam:
Cranial nerves II-XII were intact. Normal convergence distance and saccades without increase in symptoms. Neck ROM intact without pain or symptoms. Normal strength, sensation, and reflexes in upper and lower extremities. Normal gait and tandem gait, negative Romberg.
On modified SCAT testing she scored 15/15 for immediate recall, 4/5 for delayed recall, 4/5 for concentration. She had 5 balance errors.
Dix-Hallpike and head thrust maneuvers normal.

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