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ENT > 1: Hearing Loss > Flashcards

1: Hearing Loss Flashcards

1
Q

What are the three types of hearing loss

A
  1. Sensorineural
  2. Conductive
  3. Mixed
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2
Q

What causes sensorineural hearing loss

A

Defect in inner ear or vestibulocochlear nerve

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3
Q

What causes conductive hearing loss

A

Defect in middle or outer ear

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4
Q

When does conductive hearing loss tend to present more

A

Children

Young Adults

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5
Q

When does sensorineural hearing loss tend to present

A

Middle-age

Older age

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6
Q

Give 5 causes of conducting hearing loss

A
  1. Otosclerosis
  2. Otitis media
  3. Barotrauma
  4. Cerumen impaction
  5. External auditory meatus atresia
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7
Q

What is cerumen impaction

A

Build-up of wax in the external auditory canal

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8
Q

What are 6 causes of sensorineural hearing loss

A
  1. Ototoxicity
  2. Meniere’s Disease
  3. Acoustic neuroma
  4. Presbycusis
  5. Inner ear infection (Mumps, measles, meningitis)
  6. Noise-induced hearing loss
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9
Q

Otosclerosis

A

Overgrowth of the stapes causing it to fix to the oval window

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10
Q

What is otitis media

A

Bacterial or viral infection of the middle-ear

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11
Q

What is barotrauma

A

Failure to equalise atmospheric pressure with the middle ear

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12
Q

How will otosclerosis present

A

Progressive conducting hearing loss. 70% develop it in the second ear.

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13
Q

What symptom is specific to otosclerosis

A

Paracusis Willisi

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14
Q

What is paracusis willisi

A

Patient’s hear better in noisy compared to quiet environments

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15
Q

What sign is seen on the tympanic membrane in otosclerosis

A

Schwartz sign

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16
Q

What is the schwartze sign

A

Red-blue tinge to tympanic membrane

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17
Q

In what age does otitis media present

A

6-24m following URTI

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18
Q

How will barotrauma to the ear present

A

sudden-onset stabbing pain in the ear. Tinnitus and hearing loss. Bleeding from the canal indicates perforation of the ear drum.

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19
Q

How does presbycusis present

A

High-frequency hearing loss

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20
Q

How does noise-induced hearing loss present

A

Gradual high-frequency hearing loss. Often unable to hear in noisy environments

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21
Q

How does meniere’s disease present

A

Episodes lasting to minutes-hours of:

  • Vertigo (Horizontal Nystagmus)
  • Sensorineural hearing loss
  • Tinnitus
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22
Q

What nerves are affected initially in acoustic neuroma

A
  • vestibular

- cochlear

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23
Q

What nerves are affected late in acoustic neuroma

A
  • trigeminal

- facial

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24
Q

How will early symptoms of acoustic neuroma present

A

Vestibular - vertigo

Cochlear - unilateral tinnitus, hearing loss

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25
Q

How will late symptoms of acoustic neuroma present

A

Trigeminal - facial parasthesia

Facial - unilateral paralysis

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26
Q

Explain investigations in work-up of hearing loss

A
  1. Inspection
  2. Whispered hearing test
  3. Rinne’s
  4. Weber’s
  5. Otoscopy
  6. Pure tone audiometry
  7. Tympanometry
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27
Q

What is looked for when inspecting the ear in hearing loss

A

Otitis externa

Cerumen Impaction

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28
Q

What is the whispered voice test

A

Gross hearing assessment

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29
Q

Explain the whispered voice test

A
  • Stand 60cm behind someones ear. Rub tragus in the ear not being tested.
  • Whisper a number into the other ear.
  • Repeat this 3-times. If the patient can hear in 2/3 it indicates their hearing is >12dB
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30
Q

In the whispered voice test, if having to use a conversational voice how many decibels can they hear

A

48db

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31
Q

In the whispered voice test, if having to use a loud voice how many decibels can they hear

A

72db

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32
Q

Explain weber’s test

A

Place a 512Hz tuning fork in the middle of the patient’s head and ask them where they hear it loudest

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33
Q

What is a mnemonic to remember results of weber’s test

A

SICA

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34
Q

In sensorineural hearing loss, where will the sound localise to

A

It would localise to the intact ear

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35
Q

In conductive hearing loss, where will the sound localise to

A

It would localise to the affected ear

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36
Q

What is a rinne’s positive test

A

When air conduction is better than bone conduction

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37
Q

What can cause a rinne’s positive test

A
  • Normal

- Sensorineural hearing loss

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38
Q

What is a rinne’s negative test

A

Bone conduction > Air conduction

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39
Q

What causes a rinne’s negative test

A

Conductive hearing loss

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40
Q

Explain pure tone audiometry

A
  • Patient is placed in a sound-proof room
  • Head phones deliver sounds at increasing frequencies
  • It is played initially above hearing threshold and increase in 10db increments until a 50% response rate is obtained
  • Transducer can be used to obtain bone conduction
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41
Q

What goes on the X-axis in pure tone audiometry

A

Frequency (Hz)

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42
Q

What goes on the Y-axis in pure tone audiometry

A

Decibels

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43
Q

What is normal hearing range on audiometry

A

Anything above 20db

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44
Q

Explain conductive hearing loss on audiometry

A

Auditory threshold increased in air conduction, normal bone conduction

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45
Q

What does conductive hearing loss on audiometry indicate

A

Middle or external ear pathology

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46
Q

Explain presentation of otosclerosis on audiometry

A
  • Air conduction is reduced

- Bone conduction shows a characteristic notch at 2,000Hz called cahart notch

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47
Q

Explain how presbycusis will present on audiometry

A

Decrease in air and bone conduction at higher frequencies

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48
Q

Explain how noise-induced hearing loss presents on audiometry

A

Decrease in noise and air conduction at 4,000Hz

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49
Q

What is tympanometry also referred to as

A

Acoustic impedance audiometry

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50
Q

What is tympanometry

A

Method to measure pressure in the middle-ear

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51
Q

Explain the procedure of tympanometry

A
  • In a normal ear compliance of the ear drum (and hence amount of fluid in mL displaced for a particular sound) peaks when middle ear pressure equals canal pressure
  • A probe with an air tight seal is put into the meatus - the amount of acoustic signal reflected back at points is used to generate a graph of compliance
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52
Q

What is a normal ear type on tympanometry

A

type A

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53
Q

What is type A

A

There will be a peak which will then decrease. It indicates a normal ear where ossicles are intact and no fluid in the middle-ear

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54
Q

How will type AD present

A

Reduced peak amplitude compared to type A. But, the peak is still present

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55
Q

Explain type AD

A

There is disruption of the ossicles or flaccid portion of the tympanic membrane

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56
Q

How will type B tympanometry present

A

Completely flat (there will be no peak)

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57
Q

Explain type B tympanometry

A

There is reduced compliance of the tympanic membrane due to fluid in the middle ear - meaning all sound will be reflected back

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58
Q

If a type B tympanometry at normal pressure what is the underlying pathology

A

Otitis Media

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59
Q

If a type B tympanometry at high pressure what is the underlying pathology

A

Grommets

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60
Q

If a type B tympanometry at low pressure what is the underlying pathology

A

Ceremen Impaction

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61
Q

What is type C tympanometry

A

There is a shift in peak of negative middle-ear pressure

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62
Q

What causes type C tympanometry

A

Resolving otitis media

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63
Q

What are the indications for MRI in hearing loss

A
  1. Adult with sensorineural hearing loss and localising signs (facial paraesthesia)
  2. Adult with asymmetrical sensorineural hearing loss of >15dB difference
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64
Q

What is an MRI trying to exclude in hearing loss

A

Acoustic neuroma

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65
Q

In terms of anatomy, how can the ear be divided

A

External ear
Middle ear
Inner ear

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66
Q

What are the two parts of the external ear

A
  1. Auricle (Pinna)

2. External auditory meatus

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67
Q

What is the function of the auricle

A

Directs sound towards the external acoustic meatus

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68
Q

What is the helix

A

Round cartilaginous structure

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69
Q

What is the concha

A

Depression in the middle of the auricle

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70
Q

What does the concha lead to

A

The concha continues as the external acoustic meatus into the skull

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71
Q

What is the external acoustic meatus

A

Tube that connects the concha to the tympanic membrane

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72
Q

What is the tympanic membrane

A

Connective tissue that enables middle ear to be to be observed

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73
Q

What is the point where the malleus attaches to the tympanic membrane called

A

Umbo

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74
Q

Where is the middle ear

A

Tympanic membrane to inner ear

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75
Q

What is the function of the middle ear

A

Transmits vibrations from the tympanic membrane to the inner ear via ossicles

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76
Q

What are the two components of the middle ear

A

Tympanic cavity

Epitympanic recess

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77
Q

What is the tympanic cavity

A

Contains the ossicles: stapedius, malleus and incus

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78
Q

What is contained lateral to the epitympanic recess

A

Mastoid air cells

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79
Q

What Is the role of mastoid air cells

A

When pressure in middle ear is low - they can release air acting as a buffer

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80
Q

What is the acoustic reflex

A

In response to loud noise the stapedius and tensor tympanic will contract - inhibiting vibrations of auditory canal and transmission of sound

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81
Q

What is the Eustachian tube

A

Connects the nasopharynx to the middle ear

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82
Q

What is the role of the Eustachian tube

A

To equalise pressure of middle ear

83
Q

What is the problem with the Eustachian tube

A

Acts as source of infection pass to the middle ear

84
Q

What are the 2 functions of the inner ear

A
  • Convert mechanical signals into electric signals for hearing
  • Maintain balance
85
Q

What are the two components of the inner ear

A
  1. Bony Labyrinth

2. Membranous Labyrinth

86
Q

What is the bony labyrinth

A

Series of bone cavities in petrous part of temporal bone made of cochlea, vestibule and semi-circular canals filled with perilymph

87
Q

What is the membranous labyrinth

A

In body of bony labyrinth = made of cochlear duct, semi-circular ducts, utricle and saccule - filled with endolymph

88
Q

What are the two openings in the inner ear

A

Oval window

Round window

89
Q

What is the oval window

A

Connects vestibule and middle-ear

90
Q

What is the round window

A

Connects middle-ear and scala tympani

91
Q

What are the 3 parts of the bony labyrinth

A

Vestibule
Cochlear
Semi-circular canals

92
Q

What does the vestibule contain

A

Utricle
Saccule
= both part of membranous labyrinth

93
Q

What does the cochlea contain

A

Cochlea duct - used for hearing

94
Q

What are the 3 semi-circular canals and their role

A

Posterior
Anterior
Lateral
= role in balance

95
Q

What type of fluid is the bony labyrinth filled with

A

perilymph

96
Q

What type of fluid is the membranous labyrinth filled with

A

endolymph

97
Q

what is the membranous labyrinth made of

A
  • Utricle
  • Saccule
  • Semi-circular ducts
  • Cochlea duct
98
Q

what is the cochlea duct also known as

A

Organ of corti

99
Q

what is the role of the saccule

A

Detects acceleration-deceleration of the head in a vertical plane

100
Q

what is the role of the utricle

A

Detects acceleration-deceleration of the head in a horizontal plane

101
Q

explain semi-circular ducts

A

on moving the head, the flow of endolymph changes speed or direction. Sensory receptors in the ampulla detect this and send signals to the brain enabling processing of balancing.

102
Q

How is the cochlea organised

A

Tonotropic - meaning different frequencies are processed at different parts

103
Q

Where are high frequencies processed

A

Base

104
Q

Where are low frequencies processed

A

Apex

105
Q

What is a mnemonic to remember pathway of hearing

A

E.COLI

106
Q

Explain pathway of hearing

A
  • Eight nerve
  • Cochlear nucleus
  • superior Olive
  • Lateral lemniscus
  • Infeiror colliculus
107
Q

What causes conductive hearing loss

A

Defect in outer or middle ear

108
Q

What are the outer ear causes of conductive hearing loss

A
  • Barotrauma
  • Chronic OM resulting in rupture of TM
  • External auditory canal atresia
109
Q

What are the 2 middle ear causes of conductive hearing loss

A

Cerumen impaction
Otitis media
Otosclerosis

110
Q

What is otosclerosis

A

Overgrowth of bone of the stapes causing it to fix to the oval window

111
Q

Explain the aetiology of otosclerosis

A

Autosomal dominant condition with incomplete penetrance

112
Q

What type of patients get otosclerosis

A

Young female patients:

20-40

113
Q

How will otosclerosis present clinically

A
  • Progressive bilateral conductive hearing loss
  • Tinnitus (75%)
  • Mild vertigo (25%)
114
Q

What is a specific symptom of otosclerosis

A

Paracusis Willsi = patient’s hear better in noisy environments

115
Q

What investigations are ordered for otosclerosis

A
  1. Otoscopy
  2. Rinne and Weber’s
  3. Pure Tone audiometry
  4. Tympanometry
116
Q

What will 10% of people have on otoscopy in otosclerosis

A

Schwartz sign = hyperaemia behind tympanic membrane seen as red discolouration

117
Q

How will rinne and weber’s test present in otosclerosis

A
  • Rinne negative

- Weber’s = localises to affected ear

118
Q

What will be seen on pure tone audiometry in otosclerosis

A

Cahart notch = increase in bone conduction threshold (dip in curve) at 2,000Hz

119
Q

What is first-line management for otosclerosis

A

Bone Anchored Hearing Aids

120
Q

What is surgical management of otosclerosis

A

Stapedotomy

Stapedectomy

121
Q

What is stapedotomy

A

Partial remove stapes

122
Q

What is stapedectomy

A

Removal stapes and replacement with prosthesis

123
Q

Explain surgery in otosclerosis

A

Surgery is preferred, however it can only be performed in the worst hearing ear - as contralateral previous surgery is a contraindication.

124
Q

What is sensorineural hearing loss due to

A

damage to inner ear or vestibular-cochlear nerve

125
Q

What is the commonest cause of SNHL

A

presbycusis

126
Q

What is presbycusis

A

age-related bilateral high-frequency hearing loss

127
Q

In which age does presbcycusis occur

A

incidence increases with age

128
Q

When is hearing worse in presbycusis

A

noisy environments

129
Q

What causes presbycusis

A

progressive damage to the organ of corti

130
Q

What will be seen on pure tone audiometry in presbycusis

A

decrease in air and bone conduction

131
Q

How is presbycusis managed

A

hearing aids

132
Q

What is noise-induced hearing loss

A

Hearing loss due to exposure to loud noises

133
Q

What are the two causes of NIHL

A
  • Repeated exposure to sounds >85dB

- One-off exposure to sounds > 120-150dB

134
Q

How does NIHL present

A
  • Often with loss of high-frequency sounds first

- Difficultly hearing in loud enviroments

135
Q

Explain pathophysiology of NIHL

A
  • Repeated exposure damages sterocilia on the organ of corti.
  • One off exposure to loud noice can cause rupture of TM and conductive hearing loss
136
Q

What is used as prophylaxis for NIHL

A

Noise-cancelling headphones

137
Q

What is used to manage NIHL

A

Hearing aids

138
Q

What is menière’s disease

A

impaired re-absorption of endolymph in the membranous labyrinth leading to accumulation and dilation of the system = endolymphatic hydrops

139
Q

What age is meniere’s disease most common

A

40-60y

140
Q

How does meniere’s disease change with age

A

Episodes decrease with age

141
Q

Explain presentation of meniere’s disease

A

Acute, Attacks usually last 2-4h and present with triad of:

  • tinnitus
  • unilateral SNHL
  • peripheral vertigo

this is associated with

  • Horizontal nystagmus
  • aural fullness
  • positive rhomberg test
142
Q

How will meniere’s disease present on audiometry

A

Reduced bone and air conduction in the affected ear. Often, low-frequencies are affected first

143
Q

What are two other investigations may order for menière’s disease

A
  • Elecetrocohleography

- Posterior fossa MRI

144
Q

What is electrocochleaography

A
  • Looks at electrical impulses evoked from vestibulocochlear nerve in response to sound
145
Q

What is used to treat acute attacks of meniere’s disease

A

Buccal bethistine

146
Q

What is used as prophylaxis for meniere’s disease

A

Prochlorperazine

147
Q

If meniere’s disease persists what is indicated

A
  1. Insertion of gentamicin via a grommet
  2. Labryinthectomy
  3. Vestibular neurectomy
148
Q

What are the risks of surgical procedures for menieres disease

A

Can cause total deafness

149
Q

what else should be considered in management of meniere’s disease

A

Driving - individuals should inform DVLA and not drive until symptoms controlled

150
Q

over what time frame do symptoms resolve in majority of patients

A

5-10years

151
Q

what is an acoustic neuroma

A

benign tumour of schwann cells surrounding vestibular.N

152
Q

what is the median age of acoustic neuroma onset

A

50

153
Q

what % of CPA tumours are acoustic neuromas

A

90

154
Q

what does bilateral acoustic neuromas indicate

A

NF2

155
Q

what chromosome is mutated in neurofibromatosis 2

A

chromosome 22

156
Q

what are the 4 tumours common in NF2

A
  1. Meningiomas
  2. Ependymomas
  3. Bilateral vestibular
    schwannoma
  4. Multiple intracranial
    schwannoma
157
Q

are acoustic neuromas unilateral or bilateral

A

unilateral (90%). Bilateral acoustic neuromas are only associated with NF2

158
Q

what nerve is affected early in acoustic neuromas

A

vestibular-cochlear nerve

159
Q

what are the 3 early symptoms of acoustic neuroma

A
  • Unilateral tinnitus
  • Unilateral SNHL
  • Dizziness
160
Q

why do individuals with acoustic neuroma not get vertigo

A

Due to the slow-growing nature of the tumour - the body often compromises

161
Q

what are the late symptoms of acoustic neuromas caused by

A

Due to damage to trigeminal (CN5) and facial (CN7) nerves

162
Q

what 2 symptoms are caused by compression of CN5 in acoustic neuroma

A
  • Loss of corneal reflex

- Facial parasthesia

163
Q

what symptom is caused by compression of CN7 in acoustic neuroma

A

Facial paralysis

164
Q

will the forehead be affected in CN7 damage due to acoustic neuroma

A

The forehead will be affected as it is a LMN paralysis

165
Q

what is the risk of acoustic neuromas

A

can compress other posterior fossa structures including the cerebellum and 4th ventricle

166
Q

what will compression of cerebellum cause

A

Ataxia

167
Q

what will compression of the 4th ventricle

A

Hydrocephalus

168
Q

who should suspected acoustic neuromas be referred to

A

urgent referral to ENT

169
Q

how are acoustic neuromas investigated

A
  • Rinne and Weber’s
  • Pure tone audiometry
  • MRI of CPA
170
Q

how will acoustic neuromas present on rinne and weber’s test

A

SNHL:

  • +ve Rinne’s
  • Weber’s = intact ear
171
Q

how will acoustic neuromas present on pure-tone audiometry

A

Decrease in air and bone conduction

172
Q

what is main investigation of acoustic neuromas

A

MRI of CPA

173
Q

what are indications for MRI in CPA

A
  • Asymmetry in SNHL between ears >15dB

- SNHL and other features

174
Q

what is primary management for acoustic neuromas

A
  • Active surveillance = MRI 6-12m
175
Q

what is second-line management for acoustic neuromas

A

Stereotactic radiosurgery

176
Q

when is stereotactic radio surgery indicated

A
  1. Tumour growth

2. Significant SNHL

177
Q

What ototoxic effects do antimalarials and aspirin have

A

Temporary hearing loss

Tinnitus

178
Q

What ototoxic effects do loop diuretics and macrolides have

A

Temporary hearing loss

179
Q

What ototoxic effects do aminoglycosides have

A

Permanent hearing loss and vestibular effects

180
Q

What ototoxic effects do antineoplastics have

A

Permanent hearing loss

181
Q

what is the definition of sudden hearing loss

A

loss of more than 30db in 3 contagious frequencies that onsets in less than 3d

182
Q

how can aetiology of sudden onset hearing loss be divided

A

unilateral sudden hearing loss and bilateral

183
Q

what is the 1 cause of bilateral sudden-onset sensorineural HL

A

autoimmune

184
Q

what are 7 causes of sudden-onset hearing loss

A
  • Vascular
  • NIHL
  • Glue ear
  • Acoustic neuroma
  • Ototoxicity
  • Mumps
  • Ossicular discontinuity
185
Q

what is glue ear, what age does it present, how does it present

A
  1. Otitis media with effusion
  2. Peaks at 2-years
  3. Conductive hearing loss following URTI
186
Q

how will glue ear present on otoscopy

A

Effusion in middle ear

187
Q

what type of hearing loss does glue ear cause

A

Conductive

188
Q

what cause ossicular discontinuity

A

Disruption of ossicles following trauma

189
Q

what type of hearing loss is present in ossicular discontinuity

A

Conductive

190
Q

what type of tympanometry is present in ossicular discontinuity

A

Ad = flatter peak compared to type A

191
Q

what type of sudden hearing loss will vascular or autoimmune lead to

A

SNHL

192
Q

if no cause is found for sudden hearing loss what is it called

A

idiopathic sudden sensorineural hearing loss (ISSHL)

193
Q

Explain referral for sudden onset hearing loss

A
  1. Develops sudden hearing loss in <3d in the past 30d = refer to ENT in 24h
  2. Develops sudden hearing loss in <3d more than 30d ago = refer to ENT in 2W
  3. Worsening of pre-existing hearing loss = refer to ENT in 2W
194
Q

What is often given for sudden onset hearing loss

A

High-dose steroids = Prednisolone (80mg)

195
Q

If prednisolone is ineffective, what else may be offered

A

Short hyperbaric oxygen therapy

196
Q

What are 3 unilateral causes of progressive hearing loss

A
  • Otosclerosis
  • Nasopharyngeal carcinoma
  • Acoustic neuroma
197
Q

In which ethnicity are nasopharyngeal carcinomas more common

A

Chinese/Hong-Kong

198
Q

How do nasopharyngeal carcinoma present clinically

A
  • Unilateral nasal lump
  • Neck lumps
  • Epistaxis
  • Conductive hearing loss = middle ear effusion on otoscopy
199
Q

What are two bilateral cases of progressive hearing loss

A

NIHL

Presbycusis

200
Q

When are hearing aids offered

A

If hearing loss is impacting ability to communicate

201
Q

What is the mechanism of behind the ear hearing aid

A

Amplifies sound to assist with hearing

202
Q

What are bone anchored hearing aids

A

Sound is transmitted directly to the cochlea via bone conduction

203
Q

What are cochlear implants indicated for

A

SNHL who has not benefitedd to conventional hearing aids

204
Q

What are audio induction loops

A

sound system where hearing loop provides magnetic, wireless signal picked up by hearing aid when set to T. It has a microphone and amplified.

ENT (16 decks)

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