Intermittent muffled hearing as a precursor to Bow Hunter's syndrome: A diagnostic consideration for family physicians, ENT, and stroke specialists.

We report the case of a 34-year-old female who presented with headaches, visual disturbances, and unsteadiness, mostly triggered by head rotation. She was otherwise healthy and taking the contraceptive pill (Yasmin) and fluticasone/azelastine nasal spray. Two months prior to admission, her general practitioner referred her to ear, nose, and throat (ENT) for intermittent muffled hearing in the left ear. ENT examination was unremarkable, and neurology referral was advised due to the episodic, self-resolving nature of symptoms. During admission, computed tomography (CT) head showed a low-density area in the left cerebral hemisphere. Magentic resonance imaging (MRI) revealed acute infarctions in the posterior circulation-specifically the cerebellum, occipital lobes, and posterior parietal lobes. A repeat MRI 48 h later showed a new right occipital infarct. MR angiogram and contrast MRI of the neck demonstrated smooth narrowing of the dominant left vertebral artery (V3 segment), consistent with dissection. Workup for secondary causes was normal. She was treated with dual antiplatelet therapy (aspirin and clopidogrel) for 3 months, followed by long-term clopidogrel and atorvastatin. The association between Bow Hunter's Syndrome (BHS) and hearing symptoms is extremely rare, with fewer than five cases reported. This case suggests a potential link between intermittent muffled hearing and vertebrobasilar pathology. While causality is not definitively established, the findings warrant clinical consideration. Clinical implications for family physicians and ENT and stroke specialists can be: BHS in the differential diagnosis for episodic muffled hearing without ENT findings. Watch for associated symptoms (e.g., dizziness, neck pain, visual changes). Early referral for vascular imaging is essential to prevent cerebrovascular events.