Chapter 6: Diseases of the Middle Ear and Mastoid Flashcards
1
Q
Thickened TM is due to…
A
Inflammation
2
Q
TM that contain white thick patches/entirely white and thick
A
Deposition of hyalinized collagen in its middle layer as a result of previous inflammation (tympanosclerosis)
3
Q
TM that is thinner from loss of its middle layer (membrana propria)
A
Eustachian tube ventilation dysfunction
4
Q
Chronic otitis media with drainage…
A
…is always accompanied by a perforations of the TM
5
Q
Classification of TM perforation
A
- Tubal-safe
- Central-safe
- Marginal-more serious
- Pars flaccida-more serious
6
Q
Inflammation of the TM
A
Myringitis
7
Q
Most notable finding is bleb formation (bullae) on the TM and adjacent canal wall
A
Hemorrhagic or bullous myringitis
8
Q
Usually a self limited disease and is associated with infection caused by Mycoplasma pneumoniae
Can caused sensorineural hearing loss
A
Adult hemorrhagic myringitis
9
Q
Drug of choice for myringitis with systemic manifestation
A
Erythromycin
10
Q
Relief of pain the blebs or vesicles can be…
A
Disrupted by fine needle or myringotomy knife
11
Q
Infant eustachian tube
A
Short, wide and horizontal in location
12
Q
As a child grows, the eustachian tube…
A
Elongates, narrows and develops a downward course medially
13
Q
Normal ET
A
Closed and opens by active muscular contraction of the tensor veli palatini muscle during swallowing and yawning
14
Q
Functions of ET
A
- Ventilation
- Drainage
- Protection
15
Q
Provides equalization of atmospheric pressure on both sides of the TM
A
Ventilation
16
Q
ET opens by muscular activity when the pressure differential is..
A
20-40 mmHg
17
Q
Essential for the opening of ET
A
Intact tensor veli palatini muscle
18
Q
Assessment of ET ventilation
A
- Toynbee maneuver
2. Valsalva maneuver
19
Q
Listening through an auscultation tube while the patient squeezes the nostrils and swallows
A
Toynbee maneuver
20
Q
Listening through an auscultation tube while patient squeezes the nose and blows hard against the occluded nostrils with a closed mouth
A
Valsalva maneuver
21
Q
ET protects the middle ear from…
A
Contaminated nasopharyngeal secretions and pathogenic organisms
22
Q
Disorders affecting the ET
A
- Abnormally patent tube
- Palatal myoclonus
- Obstruction
- Cleft palate
23
Q
Open all the time so that air enters the middle ear with respirations
A
Abnormally patent tube
24
Q
Significant weight loss–>loss of adipose tissue around the ET
A
Abnormally patent tube
25
Women on birth control pills
| Men taking estrogens
Abnormally patent tube
26
Can produce autophony (hearing one's respiration)
Sensation of fullness
Plugged up feeling in the ear
Abnormally patent tube
27
Ear exam: abnormally patent tube
TM is atrophic and thin and will move in and out with respiration
28
Method to correct abnormally patent tube
Insert a ventilation tube through the tympanic membrane-->decrease the disturbing effects
29
Rare condition in which the palatal muscles undergo periodic rhythmic contractions-->clicking sound in the ear
Palatal myoclonus
30
Palatal myoclonus association
```
Vascular lesion
Multiple sclerosis
Aneurysm of the vertebral artery
Tumors
Lesions of the brain stem or cerebellum
```
31
Treatment of palatal myoclonus
None
| Rarely: incision of the tensor tympani muscle of the middle ear
32
Causes of ET obstruction
Nasopharyngitis
| Adenoiditis
33
Ear exam of ET obstruction caused by nasopharyngeal tumor
Fluid in the middle ear
34
Chronic unilateral serous otitis media
Nasopharyngeal carcinoma
35
Other causes of ET obstruction
1. Foreign body (posterior pack for nasal epistaxis)
2. Mechanical trauma (aggressive adenoidectomy-->scarring and closing of tube)
3. Operative procedures that interfere with the tensor veli palatini
36
Results in ET dysfunction due to lack of anchorage of the tensor palatini muscle
Cleft palate deformity
37
Prevents the muscle from exerting sufficient contraction on the ET orifice to open it during swallowing-->inadequate ventilation of middle ear-->inflammation
Unrepaired cleft palate
38
Avoided procedure in patient with cleft palate
Adenoidectomy
39
Adenoidectomy in patients with cleft palate or submucous palate may produce
1. Palatal dysfunction
2. Nasality of voice
3. Regurgitation of liquids into the nasopharynx
40
Damage to tissue caused by changes in barometric pressure which occur during diving or flying
Barotrauma
41
A decrease (expand) or increase (compress) in environmental pressure, a given enclosed volume of a gas
Boyle's law
42
Most common site of barotrauma because of the complexity of ET function
Middle ear
43
Pressure difference between the environment and the middle ear space becomes to great, the cartilaginous portion of the ET will firmly collapse
About 90-100 mmHg
44
Sequence of injury occurs as the vacuum develops within the middle ear
TM is retracted inward (stretches the eardrum-->rupture of small vessels to produce injected appearance and hemorrhagic blebs within the drum)
As the pressure builds, small vessels within the middle ear mucosa also dilate and rupture-->hemotympanum-->occ will rupture the TM
45
Symptoms of middle ear barotrauma
1. Pain
2. Feeling of fullness
3. Decreased hearing
46
Ear exam of middle ear barotrauma
Injected and may exhibit hemorrhagic blebs within the drum or blood behind the eardrum
47
Treatment of middle ear barotrauma
1. Decongestants
| 2. Cessation of diving or flying (until the patient can equilibrate middle ear pressure again)
48
Most cases of middle ear barotrauma resolves within...
2-3 days
49
Severe cases of middle ear barotrauma resolves...
4-6 weeks
50
Pain in middle ear barotrauma indicates...
ET collapse
51
Antibiotics are given in middle ear barotrauma if..
Presence of perforation
| Occurred in dirty water
52
Prevention of middle ear barotrauma
Avoiding flying or diving with colds
| Using proper clearing technique
53
Symptoms of inner ear damage
1. Persistent tinnitus
2. Vertigo
3. Sensorineural hearing loss
54
Brief episodes of vertigo that occur while ascending or descending...
Alternobaric vertigo
55
Congenital stenosis of the ear plus maxillofacial dysostoses
Treacher Collins syndrome
56
Common cause of conductive hearing loss in adults
Otosclerosis
57
Otosclerosis inheritance
Autosomal dominant
58
Disease of the bony labyrinth, area of otospongiosis (soft bone) forms, esp in front of and adjacent to the footplate-->fixation of the footplate
Otosclerosis
59
Patient usually complains of a hearing loss when a level of 40dB or greater is reached
Otosclerosis
60
Otosclerosis Rinne test
Negative
| Bone conduction is heard louder than air conduction
61
TM appearance in otosclerosis
Normal or
| Pink or orange discoloration due to vascular otospongiosis in the middle ear (positive Schwartze's sign)
62
Management of otosclerosis
Surgical procedures offer an excellent chance for restoring hearing depending mainly on cochlear function
Complication (postoperative): sensorineural hearing loss
63
Symptoms of middle ear trauma
1. Pain
2. Bloody drainage
3. Hearing impairment
64
Treated by protecting the ear from water and administering systemic antibiotics if there is pain and inflammtion
Clean, traumatic perforations
65
Heal spontaneously
Clean, uncomplicated perforations
66
Treated with antibiotic ear drops and systemic antibiotics
| No attempt at closure is made until the infection resolves
Contaminated perforations
67
Painful and difficult to close by usual means
| Heat cauterization of the adjacent tissues which occurs prevents spontaneous closure
Perforations caused by hot slag
68
Significant hearing loss (>25 dB) and vertigo
Injury to the ossicular chains
69
True otologic emergemcy
| Immediate exploration of the middle ear and ossicular chain
Vertigo and hearing loss (trauma)
70
Sterile
Middle ear
71
Basic causative factor in acute otitis media
Obstruction of ET
72
Most acute otitis media infections are caused by...
Pyogenic bacteria
73
Most frequently recovered bacteria in AOM
1. S. pneumoniae: all age group
2. H. influenzae: under 5 years old
3. Beta-hemolytic streptococci
74
Classic symptoms of acute purulent otitis media
1. Pain
2. Fever
3. Malaise
4. Headache
5. Anorexia
6. Nausea and vomiting
75
Ear exam in acute purulent otitis media
1. TM is red and bulging
2. Vessels over TM and malleus handle become injected and therefore more prominent
3. Abscess of the middle ear
76
All medications in acute purulent otitis media should be administered for at least...
10-14 days
77
In acute purulent otitis media, patient was seen 2 days after initiating treatment, no evidence of resolution...
Myringotomy should be performed
78
Otitis-prone child
1. Male
2. Under age 2
3. Native American, white
4. 1st episode usually under age 6 months
5. S. pneumoniae episode
79
Caused by transudation of plasma from the blood vessels
Serous otitis media
80
Results from active secretion from glands and cysts in the lining of the middle ear cleft
Mucoid otitis media
81
Major underlying factor in otitis media
ET dysfunction
82
Other causative factors in otitis media
1. Hypertrophy of the adenoids
2. Chronic adenoiditis
3. Cleft palate
4. Tumors in the nasopharynx
5. Barotrauma
6. Inflammation (sinusitis, rhinitis)
7. Radiation therapy
8. Immunologic or metabolic deficiencies
83
Most common cause of hearing loss in school-age children
Middle ear effusion
84
Ear exam in serous otitis media
Drumhead immobility
| Bubbles behind the TM
85
Amber or yellow drumhead
Serous otitis media
86
Duller and more opaque drumhead
Mucoid otitis media
87
Medical treatment for serous and mucoid otitis media
1. Antibiotics
2. Antihistamine
3. Decongestants
4. ET tube ventilation exercises
5. Allergic hyposensitization
88
Medical management for mild serous otitis media is continued for a period of...
3 months
89
Persistence of fluid is an indication for surgical correction
1. Myringotomy incision
2. Removal of fluid
3. Insertion of a pressure equalization tube (act as a vent to allow air to enter the middle ear
90
Indications to proceed myringotomy sooner
1. Thinning of TM
2. Deep retraction
3. Significant hearing impairment
4. Poor school performance
91
Unilateral serous otitis media in an adult requires investigation of the...
Nasopharynx for tumor
92
Ventilations tubes are left in place until spontaneously extruded usually within a period of...
6 months to 1 year
93
Disadvantage of long-lasting tubes
Perforation of a perforation after extrusion
94
Greatest disadvantage of ventilation tubes
Need to keep the middle ear dry
95
Was of particular value in evaluating acute mastoiditis
| Nearly direct lateral view
Law view
96
Determine the position of the mastoid tegmen, sigmoid sinus and the general overall size of the mastoid
Law view
97
Not only shows the structures seen in Law position
| Permits visualization of the attic or epitympanum
Schuller view
98
Angulation of the head 45 degrees
Demonstrates the region of antrum and the head of the malleus
Modification of the direction: demonstrates the incus and the area of epitympanum
Mayer view/position
99
Similar to the modification of the Mayer position
| Less angulation of the beam provides a better visualization of the ossicles and epitympanic recess
Owens view
100
Modification of oblique view
| Provides additional information about the structures in the middle ear
Chausse III projection
101
View the long axis of the petrous pyramid to demonstrate the internal auditory canal, labyrinth and the antrum
Stenvers position
102
Shows both petrous pyramids through the orbits, permitting direct comparison of the petrous pyramids and internal auditory canal on the same film
Towne view
103
Structures of the middle ear (view)
1. Standard Schuller
2. Modified Mayer
3. Chausse III view
104
Possibility of an acoustic neuroma or abnormality in the petrous region or internal auditory canal (view)
1. Towne
2. Stenvers
3. Transorbital views
105
Degree of mastoid cell development
1. Pneumatic
2. Diploic
3. Sclerotic
4. Undeveloped
106
Well developed mastoid air spaces
Pneumatic
107
Pneumatization of the mastoid is disturbed by some infectious process-->only a few groups of large cells present
Diploic
108
Dense bone in the region of the mastoid, results from osteoblastic activity stimulated by repeated or chronic infection
Sclerotic
109
Preferred method of diagnosing middle ear, mastoid and inner ear abnormalities
CT scan
110
Signs and symptoms of Acute mastoiditis
1. Fever
2. Pain
3. Hearing loss
4. Bulging TM
5. Sagging posterior canal walk
6. Postauricular swelling
7. Mastoid tenderness (posterior and slightly superior to the level of the external canal--Macewen's triangle)
8. Radiographic findings (opacification of the mastoid air cells by fluid and interruption of the normal trabeculations of the cells)
111
Initial treatment of Acute mastoiditis
1. Wide myringotomy
2. Culture
3. IV antibiotics
112
Xray of Acute mastoiditis shows loss of trabecular pattern (progression of disease)
Urgent and complete mastoidectomy
113
Complications of Acute mastoiditis
1. Petrositis
2. Labyrinthitis
3. Meningitis
4. Brain abscess
114
Chronic otitis media is accompanied by...
Chronic mastoiditis
115
Active chronic infection of the middle ear and mastoid refers...
Presence of infection with drainage from the ear or otorrhea resulting from underlying pathologic changes such as cholesteatoma (granulation tissue)
116
Inactive chronic infection of middle ear and mastoid refers to...
Sequelae from a previously active infection that has burnt out, otorrhea is absent
117
Inactive chronic otitis media changes
1. Tympanosclerosis
2. Loss of osicles
3. Fixation or disruption of ossicles from previous infection
118
Thin, watery discharge and a history of painless onset
TB
119
Thin, fetid discharge with blood
Malignancy
120
Uncommon symptom in chronic middle ear suppuration
Pain
121
Pain in chronic middle ear suppuration
Complication is impending due to blockage of secretion, exposure of dura or lateral sinus wall or imminent brain abscess formation
122
Vertigo in chronic middle ear suppuration
Presence of fistula (erosion of the bony labyrinth, most commonly the horizontal semicircular canal)
123
Requires application of both positive and negative pressure to the TM and thereby across the middle ear space
Fistula test
124
TM perforation in chronic middle ear suppuration may be..
Marginal or central
125
Perforation in marginal or in the attic
Cholesteatoma should be suspected
126
Multiple perforations in the TM
Possible TB infection of the middle ear
127
Bone erosion, esp in the area of the attic (scutum missing)
Cholesteatoma
128
Conservative treatment for COM
1Keep water out of the ear and cleansing with careful spot suctioning (alcohol or hydrogen peroxide)
129
Surgery is planned in COM
Systemic antibiotic treatment for several weeks prior to surgery may reduce or eliminate active drainage and enhance surgical results
130
First evident through perforation in the posterior superior quadrant of the TM
Cholesteatoma
131
Keratinizing squamous epithelium that becomes entrapped in the middle ear space and mastoid
Cholesteatoma
132
Occurs secondarily to invasion of epithelial cells from the adjacent EAC through the attic into the mastoid
Cholesteatoma
133
Can cause osseous destruction and severe changes throughout the middle ear and mastoid
Can appear in an immature (soft) and mature (fibrous) form
Granulation tissue
134
Develops as a blind epithelium-lined sac with a small bottleneck opening
Gradually expands eroding the surrounding bone
Cholesteatoma
135
Primary purpose of surgery: COM
Removal of disease and achieved proper healing result
136
Eradicate infected tissue, creating a safe, dry ear
Mastoidectomy
137
Preservation and restoration of hearing
Tympanoplasty
138
Type of hearing loss in COM
Conductive hearing loss
| TM is intact, middle ears contains air, disruption of ossicular chain
139
Type of hearing loss in AOM and COM
Sensorineural deafness
140
The nerve is affected by purulent material directly in contact with the nerve
Facial nerve paralysis (AOM)
141
Facial nerve paralysis treatment (AOM)
1. Immediate wide myringotomy
2. Obtain culture
3. IV antibiotics
142
Granulation tissue or cholesteatoma adjacent to the nerve releases toxic products causes pressure
Facial paralysis (COM)
143
May result in destruction of the vestibular labyrinth
COM esp with cholesteatoma
144
Creating a negative and then a positive pressure against the middle ear and examining the patient for the development of vertigo and associated nystagmus
Fistula test
145
Result from extension into a fistula, infection that has invaded the round window, or meningitis resulting from otitis media
Suppurative labyrinthitis
146
2 forms of labyrinthitis
1. Serous: chemical toxin cause dysfunction
| 2. Suppurative: actual pus invades the inner ear
147
Becomes evident when a weakness of the 6th CN occurs in a patient with OM
Petrositis
148
1. Retro-orbital pain
2. 6th nerve paralysis
3. Supportive otitis media
Gradenigo's syndrome
149
Pain in extradural complications of COM is due to
Irritation of 5th CN
150
Petrositis occurs in individuals with...
Pneumatized petrous apetic cells
151
Infectious invasion of the sigmoid sinus as it courses through the mastoid
Lateral sinus thrombophlebitis
152
First sign of lateral sinus thrombophlebitis
Fever
153
Pain is isolated to the area of the mastoid emissary vessels, which can become red and tender
Griesinger's sign
154
Treatment of Lateral sinus thrombophlebitis
1. Removing the focus of infection in the infected mastoid cells, necrotic lateral sinus plate or an infected and often necrotic lateral wall sinus
2. Ligation of the internal jugular vein to prevent escape of the infected emboli into the lung and to other part of the body
155
A collection of pus between the dura and the bone overlying either the mastoid cavity or the middle ear
Extradural abscess
156
Most frequently associated with chronic suppurative otitis media with granulation tissue or cholesteatoma with erosion of the tegmen
Extradural abscess
157
Symptoms of extradural abscess
1. Pulsatile, purulent discharge
2. Severe earache
3. Ipsilateral headache
4. Low grade fever
5. Develops during episode of acute otitis media
158
May develop as direct extension of an extradural abscess or by extension of thrombophlebitis through the venous channels
Subdural abscess
159
Symptoms of subdural abscess
1. Develops from COM
2. Headache
3. Fever, restlessness
4. Focal seizures
5. Difficulty speaking
6. Coma
7. CSF may be normal, no organism
160
Most common intracranial complication from suppurative otitis media
Meningitis
161
Two types of meningitis
1. Localized: reveal bacterial organism
| 2. Generalized: viable microorganisms cannot be recovered from the spinal fluid
162
Clinical features of Meningitis
1. Neck stiffness
2. Fever
3. Nausea and vomiting
4. Headache
163
Symptoms of cerebellar abscess
1. Ataxia
2. Dysdiadochokinesia
3. Intention tremor
4. Past pointing
164
Symptoms of temporal lobe abscess
1. Focal seizure or aphasia
2. Toxicity
3. Headache
4. Fever
5. Vomiting
6. Lethargic state
165
Consists of an increase in intracranial pressure with normal CSF findings except for a marked increase in pressure
Otitic hydrocephalus
166
Symptoms of Otitic hydrocephalus
1. Intense persistent headache
2. Diplopia
3. Blurring of vision
4. Nausea and vomiting
167
Incision of the TM, either to provide ventilation to the middle ear, to permit drainage of middle ear fluid or to obtain cultures
Myringotomy
168
Myringotomy are made in the...
Anterior inferior or posterior inferior quadrants (to avoid injury to the ossicular chain)
169
Current indications for myringotomy in AOM
1. Persistent pain after 48 hours of antibiotic treatment
2. Potential development of complications
3. Development of otitis media in an immunosuppressed patient
4. Development of otitis media while on a systemic antibiotic
170
One of the most common indications for myringotomy today
Persistent chronic serous otitis media that has failed medical management
171
Current indications for ventilation tube placement at the time of myringotomy
1. Recurrent episodes of AOM in spite of continuous prophylactic antibiotics
2. Persistent serous otitis media that has not responded to conservative management
3. Persistent negative middle ear pressure and resultant atelectasis of the TM, esp retraction into the posterior superior quadrant
4. Development of persistent negative middle ear pressure in patients undergoing hyperbaric oxygen treatment
172
Primary tumors
1. Glomus jugulare or glomus tympanicum
173
Originates from glomus bodies that relate to the jugular bulb in the floor of the middle ear, or they can originate from nerve distributions elsewhere in the middle ear
Glommus jugulare or glomus tympanicum tumor
174
Can cause hearing loss and a sense of fullness
| May extend to the base of the skull, causing CN and intracranial complications
Glomus jugulare
175
Highly vascular tumor and can often be seen as a bulging purplish mass in the floor of the middle ear
Glomus jugulare
176
Blanching that occurs by pressure from a pneumatic otoscope
Brown's sign
177
Diagnostic tests for glomus jugulare
1. CT scan with contrast
2. Angiography
3. Retrograde jugular venography
178
Preferred modality of treatment for glomus jugulare
Surgery
| If extensive: surgery + radiotherapy
179
Most common malignant tumors of the middle ear in adults are...
1. Adenoid cystic carcinoma
| 2. Adenocarcinoma
180
Most common malignancy to extend from the external canal to the middle ear
Squamous cell carcinoma
