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4.5. Neurology and SS > 5. Ear > Flashcards

5. Ear Flashcards

1
Q

Describe a pinna haematoma (cauliflower ear)

A

Path = blunt trauma, blood between cartilage and perichondrium (subperichondrial plane) - deprives cartilage of blood supply and pressure necrosis of tissue

Mx = prompt drainage needed + packing = untreated leads to fibrosis and new asymmetrical cartilage devel

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2
Q

Outline TM perforation

A

Ae = acute otitis media, acoustic trauma, foreign objects, severe head trauma

S+S = conductive hearing loss, tinnitus, earache, vertigo (N+V), discharge of mucus

Ix = ear exam

Mx = some are self-resolving, paper patch to promote healing, tympanoplasty
- severe ruptures may need to wear an ear plug to prevent water contact with the ear drum

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3
Q

Describe haemotympanum

A

Presence of blood in the middle ear cavity

Ae = usually sec to trauma (basilar skull fracture), nasal packing sec to nasal bleeding can cause blood to back up to the middle ear, haemophilia, ITP, anti-coag meds, ear infection

S+S = pain, sense of fullness in the ear, hearing loss

Mx = skull fractures usually heal on their own, Abx + ear drops for infection, remove nasal packing

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4
Q

Outline the aetiology and pathophysiology of acute otitis media

A

Acute middle ear infection. More common in infants, children than in adults (eustachian tube shorter and more horizontal = easier passage for infection from nasopharynx, can block easily, increased risk of infection)

Bacterial = H. influenzae S. pneumoniae, S. pyogenes (All common upper resp track MO)

Viral (2/3) = Respiratory Syncitial Virus, Rhinovirus

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5
Q

What are the signs and symptoms of acute otitis media?

A

URTI

Otalgia (infants pull/tug at the ear)

Fever

Red +/- bulging TM and loss of normal landmarks

  • Injected
  • TM perforation with discharge

Malaise

Conductive hearing loss

Cervical lymphadenopathy

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6
Q

How should acute otitis media be investigated?

A

Exam:

  • CN exam (petrositis can result in Gradenigo’s syndrome (Rare) triad of:
    • 6th nerve Palsy
    • Retroorbital pain due to irritation of ophthalmic branch of V5
    • Otitis media
  • Sternocleidomastoid muscle: Bezold’s abscess
  • Occipitotemporal region of head: Citelli’s abscess
  • LN exam
  • Throat and oral cavity examination

FBC, CRP

Discharge = MC+S

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7
Q

What is the best management for acute otitis media?

A

Majority resolve within 1-3 days - watch and wait

Oral fluids, analgesia

ORAL Abx (commonly amoxicillin) = Systemically unwell children, congenital heart disease, immunosuppression, >4 days, discharge, <2y with bilateral

Comp = temp lobe abscess, sigmoid sinus thrombosis, acute mastoiditis (ear pushed forward, IV Abx, surgical drainage), cerebellar abscess, facial palsy, meningitis,

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8
Q

Outline the aetiology and pathophysiology of otitis media with effusion

A

Aetiology = chronic inflammatory changes, Eustachian tube dysfunction.

Not an actual infection, build-up of fluid, nitrogen absorbed by middle ear mucosa, -ve pressure in middle ear, inflam of mucosa (glue), due to Eustachian tube dysfunction: can predispose to infection, decreases mobility of TM and ossicles affecting hearing

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9
Q

List the signs and symptoms of otitis media with effusion

A

Conductive hearing loss

Sensation of pressure

TM will appear dull, red, amber, retracted, retracted pockets, fluid levels, air bubbles

TM light reflex will be lost

Speech delay

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10
Q

How should otitis media with effusion be Ix?

A

Pure tone audiogram = conductive hearing loss

Tympanometry = reduced membrane compliance, type B (flat)

Flexible nasoendoscopy

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11
Q

How should otitis media with effusion be Mx?

A

Conservative = balloon

Watchful waiting - most resolve spontaneously in 2-3 months.

Some may persist - require grommets (tympanostomy tube) to ventilate middle ear

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12
Q

Outline otitis externa (swimmers ear)

A

Ae = trauma, (fingernails from itchy conditions: eczema/psoriasis), high humidity, absence of wax (self-cleaning), narrow ear canal, hearing aids

  • pseudomonas
  • staph aureus

Path = inflam of the external ear canal

S+S = discharge, pain (seen on retraction of pinna, more than OM), itch, tragal tenderness (usually due to excessive moisture)

Ix = ear exam, swab MC+S

Mx

  • Mild = aural toilet, ear kept water free, hydrocortisone cream to the pinna, EarCalm (2% acetic acid, antifungal/bacterial)
  • Moderate = cleaning, TOPICAL Abx (cipro ear drops), steroid drops
  • Severe = (EAC occluded), thin ear wick inserted, few days meatus will open for microsuction/careful cleaning

*** be aware of recurrent in DM, immunosuppressed = risk of malignant/necrotising otitis externa

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13
Q

Outline chronic otitis media

A

Ear with a tympanic membrane perforation in the setting of recurrent or chronic infection

S+S = hearing loss, otorrhoea, fullness, otalgia

Benign COM - dry TM perforation without active infection

Chronic serous OM - continuous serous drainage

Chronic suppurative OM - persistent purulent drainage through perforated TM

Ix = pure tone audiometry, MC+S

Mx = topical/systemic Abx, aural cleaning, myringoplasty, mastoidectomy

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14
Q

What is otosclerosis?

A

New bone formation around the stapes footplate - which leads to its fixation and consequent conductive hearing loss

Ae = autosomal dominant mutation

S+S = can be accelerated by preg, conductive deafness, tinnitus, vertigo, Schwartze’s sign (pink tinge to TM)

Ix = audiometry with masked bone conduction shows dip at 2Hz

Mx = hearing aid, surgery: stapedectomy or stapedotomy, cochlear implant

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15
Q

What causes BPPV?

A

Idiopathic canalolithiasis-debris in the semi-circular canal

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16
Q

What is the pathophysiology of BPPV?

A

Otoconia (otoliths) debris disturbed by head movement moving fluid in the vestibular apparatus semi-circular canals causing vertigo

17
Q

What are the signs and symptoms of BPPV?

A

Intermittent rotational vertigo lasting <20secs provoked by head turning

NO hearing loss or tinnitis

Can follow ear infection or head injury

18
Q

How should BPPV be investigated?

A

Nystagmus (tortional, geotropic - fast phase beats towards floor) on performing the Dix Hallpike manoeuvre

Rapid movement of sitting to supine with head turned 45 degrees to the right, 30 secs look for nystagmus, return to sitting, look for nystagmus for 30 sec again (reversal - beating in opposite direction, habituation - less intense), repeat on L side

19
Q

How is BPPV best managed?

A

Epley manoeuvre to clear the debris from the semi-circular canal, watchful waiting, labyrinthectomy

Brandt-Darrof exercises

20
Q

Outline the pathophysiology of Meniere’s disease

A

Increased hydraulic pressure within the inner ear endolymphatic system, break in the membrane that separates the perilymph (K-poor fluid) from the endolymph (K-rich fluid), chemical mixture bathes vestibular N receptors, depolarization blockade and transient loss of function, vertigo

21
Q

What signs and symptoms are seen in Meniere’s disease?

A

fluctuating sensorineural hearing loss, affects low frequency sounds, rotational vertigo lasting >20mins, unilateral tinnitus, aural fullness, +/- D+V

22
Q

How is Meniere’s disease investigated?

A

Pure-tone air and bone conduction with masking

Speech audiometry

Tympanometry/immitance/stapedial reflex levels

Otoacoustic emissions (OAE)

23
Q

How is Meniere’s disease best managed?

A

Psycho = reassurance

Diet = reduce salt, caffeine, alcohol, Chinese food

Medical = betahistine (labyrinthine vasodilator), thiazide diuretic, prochlorperazine (vestibular sedative) for acute vertigo

Surgical = grommet, intratympanic dex or gentamicin, antihistamine, endolymphatic sac decompression, surgical labyrinthectomy

24
Q

Outline Vestibular neuronitis

A

Inflammation of your vestibular nerve + ganglion - characterised by acute, isolated, spontaneous, and prolonged vertigo of peripheral origin

Ae = viral infection (measles, mononucleosis, rubella, mumps, shingles, chicken pox) - usually preceded by viral URTI

S+S = severe vertigo continuous over 24h, nystagmus, D+V, anxiety, usually unilateral (NO HEARING LOSS)

Ix = head impulse test (sit, fixed eyes on examiner, rapidly turn head 10–20 degrees, normally eyes stay fixed, abnormal the eyes get dragged off and correct back (saccade) to first position) - implies moderate to severe loss of function of the horizontal semi-circular canal on the side to which the test is positive.

Mx = self-limiting, anti-emetics, stop driving and inform the DVLA, buccal/PO prochlorperazine (vertigo, nausea) or cyclizine (antihistamine)

25
Q

Outline the Rinne hearing test

A

Mastoid bone then AC – which one is louder?

-ve = BC > AC
o Conductive deafness
o Severe sensorineural hearing loss (SNHL) – the other cochlear picks up the sounds via BC

+ve = AC > BC
o Normal
o Severe sensorineural hearing loss (SNHL)

26
Q

Outline the Weber hearing test

A

Fork on forehead – which ear is the sound heard in?

Conductive hearing loss = lateralises to affected ear

Severe sensorineural hearing loss (SNHL) = lateralises to contralateral ear

Normal = midline

Bilateral sensorineural loss = midline

27
Q

What causes conductive hearing loss?

A 
Wax
Pus
Foreign body
Otosclerosis
Otitis media
Glue ear
Ear trauma
28
Q

Outline the pathophysiology of conductive hearing loss?

A

Prob conducting sound via outer ear, tympanic membrane, ossicles (malleolus, incus, stapes)

29
Q

How should conductive hearing loss be treated?

A

Remove wax with warm water/olive oil

Treat infection

30
Q

What are the possible causes of sensorineural hearing loss?

A
  • environmental noise toxicity
  • presbycusis (primarily high-pitched frequencies)
  • congenital (CMV, rubella, toxoplasmosis)
  • mumps
  • acoustic neuroma
  • MS
  • stoke
  • vasculitis
  • ototoxic drugs (streptomycin, vancomycin, chloroquine, hydroxychloroquine)
31
Q

Outline the pathophysiology of sensorineural hearing loss

A

Prob with inner ear or cochlea or vestibulocochlear N
- idiopathic, congenital, presbycusis, vial infection, tumours, trauma, drugs

Sudden = ENT help, examine EAC and TM, Webers/Rinnes, FBC, ESR/CRP, U+Es, LFTs, TSH, autoimmune profile, clotting, fast glucose, cholesterol, audiometry (+/- audiological brainstem responses)

32
Q

How is sensorineural hearing loss best managed?

A

Hearing aid, cochlear implant

ISSHL = high dose pred, hyperbaric O2 therapy, intratympanic dexamethasone has a salvage role in Tx failure

33
Q

What is cholesteatoma?

A

Keratinising squamous ep in the middle ear cleft

  • congenital
  • acquired: iatrogenic, perforation, retraction pocket

Grows eroding local structures (commonly bone)

Associated with chronic infection

S+S = hear loss (mixed, toxins cause SN), tinnitus, dizziness, otorrhea-thick-intermittently blood stained

Mx = surgical removal of cholesteatoma sac, microsuction, Abx drops, mastoidectomy

34
Q

Outline presbycusis

A

Def = progressive degeneration of hearing in the auditory system leading to hearing impairment

Path = peripheral (cochlea) and central (neural) degeneration

Ix = audiogram (high frequency loss)

Mx = hearing aids

35
Q

Outline vestibular migraine

A

Nervous system problem that causes repeated eps of vertigo in pts who have a Hx of migraine

S+S = imbalance, sometimes true rotational sensation, vomiting, sensitivity to light/sound, +/- headache after, no hearing loss, sometimes tinnitus, ep can last several hours to few weeks

Mx = triptans, vestibular suppressant, anti-emetic (promethazine)

36
Q

Give a DDx for peripheral vs central vertigo

A

PERIPHERAL = BPPV, acute otitis media, labrinthitis, meniers, vestibular neuronitis, trauma

CENTRAL = meningitis, encephalitis, cerebellar haemorrhage, temporal lobe epilepsy, tumour

4.5. Neurology and SS (17 decks)

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