Script for the working and differential diagnosis:

Acoustic Neuroma

Rule in:
Acoustic neuromas account for approximately 80% of tumors found within
the cerebellopontine angle.
Unilateral hearing loss is overwhelmingly the most common symptom
present at the time of diagnosis and is generally the symptom that leads to
diagnosis. Assume that any unilateral sensorineural hearing loss is caused by
an acoustic neuroma until proven otherwise.
The presence of unilateral tinnitus alone is a sufficient reason to evaluate
an individual for acoustic tumor. Although tinnitus is most commonly a
manifestation of hearing loss, a few individuals with acoustic tumors (around
10%) seek treatment for unilateral tinnitus without associated subjective
hearing loss.
Headaches are present in 50-60% of patients at the time of diagnosis, but
fewer than 10% of patients have headache as their presenting symptom.
Headache appears to become more common as tumor size increases and is a
prominent feature in patients who develop obstructive hydrocephalus
associated with a very large tumor.
Large tumors that press against the brainstem may affect other cranial
nerves that result in less common symptoms like the loss of sensation in the
face and mouth or altered swallowing and gag reflex.
Facial numbness occurs in about 25% of patients and is more common at
the time of presentation than facial weakness. Objective hypoesthesia
involving the teeth, buccal mucosa, or skin of the face is associated with
larger tumors
On the other hand, Acoustic neuromas, according to a journal written
by Chitkara et al, are predominantly solid tumors but cystic
degeneration in these tumors has been reported. Small cystic changes
in acoustic neuroma have been seen in 9.6-20.5% of cases. And cysts in
these tumors are usually single but it may be multiple in 30% of the cases.
Rule out:
And with the information on hand, this diagnosis cannot be totally be ruled
out.

Meningioma

Rule in:
Meningiomas are the second most common tumor of the
cerebellopontine angle (CPA) accounting for 3.1 to 12% of all tumors
following acoustic neuroma, which represent 76 to 91.3% of the total.
Meningioma within the temporal bone invades widely and is more
extensive than it macroscopically seems. It can follow cranial nerves to end
organs, and spread widely throughout the perilabyrinthine marrow and air
cells. In spite of its tendency to invade the dura and bone, maningiomas are
considered benign and their symptoms are primarily caused by the
neighboring neural structures compression. This allows meningioma to grow
in large space areas, such as the CPA. However if in case this tumor grew
inside the Internal Auditory Canal (IAC), symptoms come earlier, since there
is limited available space and the labyrinthine bone is commonly invaded,
hence the facial nerve and inner ear dysfunction.
The symptoms, physical findings, and audio-vestibular test results
most commonly found are: headache, sensorial hearing loss, tinnitus,
unsteadiness, dizziness, vertigo, hemi facial paresis, and abnormal
response to pure-tone audiometry. Our patient exhibited all of the said
signs and symptoms hence the ruling in of meningioma.
Rule out:
We have a male patient and it is known that Meningiomas are more
common in women than in men (2:1 when found intracranially)
Cranial MRI of the patient does not show dural tail sign. Dural Tail is seen
in 60-72% of cases

Epidermoid cyst

Rule in:
Epidermoid tumors are congenital lesions which account for about 1% of all
intracranial tumors and approximately 7% of Cerebellar Pontine Angle (Posterior Cranial
Fossa and Skull Base) tumors. It results from inclusion of ectodermal elements
during neural tube closure. Although predominantly congenital, the onset of
symptoms occurs between the second and fifth decades of life.
Epidermoid tumors are well-delineated cystic lesions that have an
irregular lobulated outer surface and insinuate along CSF cisterns.
Clinically these tumors produce an insidious and protracted symptoms and
signs, with slow growth of the mass, which involves cranial nerves, cerebellar
and brainstem structures.
Common presentations include a long history of tinnitus and hearing
loss. Occasionally, symptoms of facial paresis, headache, and
hydrocephalus occur.
Rule Out:
Vestibular symptoms are seldom seen. There are cases where the eighth
nerve involvement determines a poor symptomatology because the slow
growth does not cause vertigo. It is due to the compensation capability of the
vestibular system.
And a Parasellar extended cysts tend to express supratentorial
symptom which is not found on our patient.