Stretched out on her back at a Pennsylvania spa enjoying a Fourth of July massage with a friend, Catherine Nettles Cutter felt a sudden jolt of pain shoot down the side of her neck into her collarbone and heard the loud crack that changed her life.
As she climbed off the massage table Cutter, then 56, felt nothing out of the ordinary. But when she awoke at 7 the next morning, she was violently dizzy and nearly deaf in her right ear; the left was unaffected.
“The room was spinning, and the vertigo was so bad I couldn’t open my eyes,” Cutter recalled.
Experts in three states would spend well over a year trying to figure out what had gone so wrong. Many tests and several procedures later, Cutter is much improved.
Cutter's is "a very complicated and unusual case," said Omar A. Choudhri, a University of Pennsylvania neurosurgeon and one of the specialists who treated her.
It wasn’t the first time Cutter found herself scrambling for a solution to a rare problem involving her neck. In 2010, she underwent painful surgery to restore her voice after a body surfing accident, the culmination of a circuitous process that took more than two years and involved visits to nearly two-dozen doctors.
That ordeal, she said, taught her how important it is “to persevere and be my own advocate” and to seek out experts. “I was bound and determined not to wait that long.”
At first Cutter, a professor of food science at Penn State who has battled intermittent migraines much of her life, thought the intense pressure she felt in her deaf ear might be causing a migraine that had triggered the vertigo.
She took an over-the-counter decongestant, but that didn’t help. Inching along walls to get to the car, she was taken by her husband to a walk-in clinic that was open on weekends. A nurse practitioner thought she might have benign paroxysmal positional vertigo caused by an inner ear imbalance or labyrinthitis, an infection of the inner ear. She prescribed an antihistamine to treat the latter and advised Cutter to see an ear, nose and throat specialist. Cutter went home and slept for the rest of the day.
The next day, still too dizzy to eat, she felt worse. The vertigo, which she described as “horrendous,” was accompanied by dry heaves and an inability to focus her eyes. Her husband called the clinic; a nurse told him his wife might be having a stroke and should be taken to the emergency room immediately.
After a CT scan and blood tests, doctors ruled out a stroke and gave her medicine to lower her inexplicably sky-high blood pressure. They, too, suspected labyrinthitis and prescribed anti-nausea medication.
During the next few weeks the vertigo gradually subsided, but the deafness remained. Tests showed that Cutter had lost more than 90 percent of the hearing in her right ear. She saw a physical therapist who twice performed the Epley maneuver, a manipulation used to treat positional vertigo. After an MRI scan ruled out a benign tumor called an acoustic neuroma, Cutter began receiving steroid injections in her ear which, doctors hoped, would restore her hearing. She also started vestibular rehabilitation, an exercise-based therapy to reduce the effects of vertigo.
None of it helped much.
Her ENT tentatively diagnosed her with Ménière’s disease, an uncommon inner ear disorder that causes severe dizziness. He recommended a low salt diet to reduce her spiking blood pressure and told her she should see a neurotologist, an otolaryngologist with expertise in the brain and nervous system, at a major teaching hospital.
Cutter remembers feeling deeply worried. There was no way she could teach in her current condition. Some days she could barely leave her bedroom. The pressure in her ear was unrelenting, as was the constant tinnitus that sounded like white noise punctuated by odd gurgling.
Cutter felt less able to function than she had the first time in 2008, when she wrenched her neck after a wave slammed her to the ocean floor during a Myrtle Beach vacation. Soon afterward she felt as though a taco chip was stuck in her throat. Swallowing became painful and her strong alto voice dwindled to a raspy whisper. Although Cutter repeatedly told doctors she thought something was wrong with her neck and mentioned the surfing mishap, for months they regarded the accident as coincidental to her pain and damaged voice.
That changed when surgeons at Penn discovered she had Eagle syndrome, a rare disorder that occurs when a piece of pointy bone that extends from the skull into the ear becomes elongated in some people and presses on a nerve. In Cutter’s case, surgeons believe the surfing accident stimulated growth of the bone, resulting in pain and the loss of her voice. Surgery, which restored her voice, involved clipping the excess bone.
Cause or coincidence?
Six weeks after her fateful massage, Cutter took a medical leave and drove four hours to Philadelphia to see a neurotologist.
He recommended she continue vestibular rehab. Because of her severe hearing loss, he suggested she undergo an evaluation for an implantable hearing aid. In December 2019, Cutter received a bone anchored hearing aid, which is used to treat single-sided hearing loss.
As she continued to struggle with vertigo, Cutter noticed that the position of her neck made a difference. When she lay flat on her back or turned her head, the vertigo was triggered almost instantly. Lying on her left side seemed to quell it.
She was sure, again, that her neck was key to the problem and that the massage was somehow responsible for her symptoms. But medical experts disagreed about what was causing her sudden sensorineural hearing loss or why the vertigo improved when she changed position. Several told her they thought whatever had happened during the massage was unrelated to her deafness and vertigo.
A Baltimore specialist ruled out Ménière’s. Another expert suspected vestibular migraines. After a Pittsburgh doctor suggested that the vertigo might be related to a blood vessel problem, a possibility the Penn neurotologist had also suggested, Cutter got a referral to Choudhri, director of the Penn Center for Cerebral Revascularization.
Cutter saw him March 9, 2020, a few days before the pandemic all but shut down the country.
Choudhri said he reviewed Cutter’s extensive workups as well as her unusual history, including the Eagle syndrome diagnosis.
“She was very clear that her vertigo was very positional,” the neurosurgeon recalled.
Although the diagnosis would require confirmation from a dynamic cerebral angiogram, a procedure that tracks blood flow through the brain using dye and X-rays, Choudhri told Cutter he suspected she had a very rare condition called bow hunter’s syndrome, also known as rotational vertebral artery syndrome.
Its colloquial name, coined in 1978 by a Utah neurosurgeon, comes from the head and neck turning involved in aiming a bow and arrow.
A bone spur on a neck vertebrae, often the result of aging, can cause the artery to pinch shut when the neck is turned, as it did in Cutter’s case. That compression obstructs blood flow to the brain, resulting in nausea, fainting, vertigo, tinnitus and visual disturbances; hearing loss is not known to result. Chiropractic manipulation, surgical positioning and sports are among the activities linked to bow hunter’s, which can cause a stroke.
The problem is more common in men. Imaging may miss it if the neck is stationary, Choudhri said, while a dynamic angiogram in which the head and neck are turned can reveal it.
“It’s not an easy diagnosis to make, and it’s rare to begin with,” said Choudhri, who estimates he has seen 10 cases in about 15 years. “There has to be some trigger; Cathy tends to form bony overgrowth,” he noted, referring to her Eagle syndrome.
An angiogram confirmed the diagnosis.
“It was pretty impressive,” the neurosurgeon said. “Her artery was completely pinched off.”
Neck manipulation during the massage, he theorizes, appears to have placed the bone spur in contact with Cutter’s vertebral artery. Choudhri recommended that she undergo surgery to remove the bone spur and fuse two vertebrae in her neck.
Normally the operation would have been scheduled quickly. But the pandemic delayed it for three months. In the interim, Cutter was terrified she might have a stroke. “My husband and I had a contingency plan to airlift me to Penn,” she said.
The June 2020 surgery, which also involved shoring up the artery, was successful, but did not substantially reduce Cutter’s vertigo, for reasons that were unclear. The hearing in her affected ear remained poor and the tinnitus constant.
In October she traveled to Cleveland to see a neurotologist and a vertigo specialist who prescribed medication to treat her recurrent headaches.
In March 2021, Cutter’s hearing aid was removed and she received a cochlear implant, a small surgically implanted device that can help restore hearing in people who are deaf or have suffered profound hearing loss. The device is also effective in suppressing tinnitus. Cutter said her ability to hear improved dramatically and the tinnitus was greatly reduced.
Although it is impossible to know for sure what caused her sudden hearing loss, Cutter said she was told by an audiologist that the massage might have blocked blood flow to hair cells in the ear that are crucial to hearing. Cases of sudden hearing loss have been reported after neck manipulation.
In the nine months since she received the cochlear implant, Cutter’s vertigo has diminished to a level she calls “manageable.”
“I feel so much better,” she said. And while she has sworn off massages, Cutter is philosophical. “I could have cracked my neck in another scenario,” she said.