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CM- Ear Disease Flashcards

1
Q

What evaluation technique is used for:

  1. detailed testing of hearing
  2. evaluation of balance function
  3. inner ear fluid imbalance testing
  4. facial nerve testing
A
  1. audiogram
  2. electronystagmogram [ENG]
  3. electrocochleography [ECOG]
  4. electroneurography [ENOG]
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2
Q

What are the 2 large categories of otalgia?

A
  1. Otogenic [50-60%] = true ear pain
    - acute otitis media
    - acute otitis externa [swimmer’s ear]
  2. Non-otogenic = referred pain
    - myofacial pain dysfunction [TMJ]
    - tonsillitis
    - throat cancer
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3
Q

Describe the features of myofacial pain dysfunction syndrome.
What will the patient have in their history?
What will their presenting complaints be?
What does audiometry show?

A

History:

  1. clenching/gritting teeth; nocturnal grinding [bruxism]
  2. malocclusion or history of facial trauma, prior dental work

Present with:

  1. inflammation of muscles of mastication
  2. pressure and fullness of the ear
  3. subjective hearing loss [audiometry shows no objective hearing loss]
  4. light headed and off-balance but not true vertigo
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4
Q

Is hearing loss with myofacial pain dysfunction subjective or objective?

A

Subjective- the patient feels like they have hearing loss but auditometry does NOT document objective hearing loss

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5
Q

How is the diagnosis of TMJ/myofacial pain dysfunction syndrome made?

What is treatment?

A
  1. normal external auditory canal
  2. normal tympanic membrane
  3. tenderness of ipsilateral muscles of mastication and over the TMJ

Treat with:

  • NSAIDS for 10 days to 2 wks
  • soft diet/liquids to rest the jaw
  • massage and warm compress
  • occlusal guard if it persists
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6
Q

A patient presents with normal exam of the external auditory canal and tympanic membrane and an abnormal examination of the tonsils and pharynx.
What is the cause of their ear pain and what is treatment?

A

Cause: tonsillitis or pharyngitis

Treat: antibiotic therapy if bacterial or supportive measures if viral

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7
Q

Masses [malignancies or ulcerative lesions from what areas can present as otalgia?
What is are these tumors usually a consequence of?
What age individuals do they present in?

A
  1. nasopharynx
  2. larynx
  3. lateral pharyngeal wall
  4. pyriform sinus

Tumors in these areas are usually a consequence of heavy drinking and smoking and present in individuals 50-70
[also recently, HPV in men]

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8
Q

What are the 4 things tested with audiogram?

A
  1. pure tone test [air and bone]
  2. speech reception threshold
  3. speech discrimination score [word understanding]
  4. typanometry [ear drum mobility]
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9
Q

What age distribution is most affected by external otitis?
What is the causative agent in 50% of cases?
What are the 2 main predisposing factors?

A

Swimmer’s ear affects adults and children equally.
Pseudomonas is the cause in 50% of cases

  1. swimming or other exposure to water
  2. Q-tip trauma
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10
Q

What is the pathophysiology of external otitis?

A

The normal pH of the external auditory canal is acidic which suppresses the growth of pseudomonas.
When water from other sources enter the ext. ear, it makes it alkaline –> psuedomonas

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11
Q

A patient has experienced the development of otalgia over several hours. It is very intense and throbbing. His ear is so tender that any manipulation is painful. He has experienced mild hearing loss due to the swollen canal impeding soundwave movement.
On examination, you note a mucopurulent exudate, and his auditory canal is swollen shut.

What is the Dx?
What caused this?

A

External otitis- most likely caused by Pseudomonas after swimming or Q-tip trauma

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12
Q

What can external otitis proceed to?

What can it proceed to in people with diabetes or immunocompromised states?

A

Normal people –> cellulitis of facial and retroauricular tissue

Diabetes/immunocomp –> malignant [necrotizing] otitis externa where the infection spreads to the temporal bone causing osteomyelitis

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13
Q

A child presents with rapid onset severe otalgia that is aching with a feeling of pressure and fullness. He claims that he can’t hear, but audiogram shows no objective loss of hearing.
He has a fever, malaise and is lethargic.

What is the Dx?
What is the natural course of the problem?

A

Acute otitis media

  1. 24-48 hours of pain, fever, subjective hearing loss, pressure
  2. tympanic membrane spontaneously ruptures
  3. mucupurulent drainage into external auditory canal
  4. perforation of TM causes decreased pain
  5. drum heals spontaneously in 90% of cases w/o antibiotics
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14
Q

What are complications of acute otitis media in untreated individuals?

A
  1. facial nerve paralysis
  2. meningitis
  3. epidural or brain abscess
  4. sigmoid sinus thrombosis
  5. acute labyrinthitis w/ violent rotational vertigo&complete hearing loss
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15
Q

How is the diagnosis of acute otitis media made?

A

History and physical exam

PE:

  1. bulging red tympanic membrane
  2. pinna/external auditory canal are NOT painful
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16
Q

Describe the pathophysiology of a middle ear effusion. What kind of hearing loss does it cause?

A
  1. Eustachian tube gets obstructed
  2. negative pressure in the middle ear space retracts the tympanic membrane
  3. retracted tympanic membrane has limited movement –> hearing loss
  4. negative pressure in middle ear causes it to fill with transudate from surrounding tissue–>middle ear effusion [serous otitis media]

Fluid in the middle ear space causes CONDUCTIVE hearing loss

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17
Q

A 4 year old is having difficulty acquiring speech and language acquisition. His parents are very concerned so they take him to the pediatrician. On physical exam, a retracted dusky tympanic membrane is noted.

Audiometric evaluation shows conductive hearing loss.
Tympanometry shows poor movement.

What is the likely problem?

A

Middle ear effusion/ serous otitis media

18
Q

What are the 2 broad categories of hearing loss?

What parts of the auditory system are affected in each type?

A
  1. Sensorineural
    - cochlea
    - CN8
    - brainstem
  2. Conductive
    - external auditory canal
    - tympanic membrane
    - middle ear space
    - ossicular chain

[Mixed hearing loss can also occur]

19
Q

How do you distinguish between neurosensory and conductive hearing loss on physical exam?

A

Tuning fork test [512Hz]

20
Q

What is the difference between bilateral symmetrical neurosensory losses and unilateral losses in terms of most likely causes?
Which should be evaluated by an otolaryngologist?

A

Bilateral [both ears have same degree of hearing loss w/in 5-10 decibels at EACH frequency]

  1. genetic/hereditary factors
  2. environmental conditions [noise]

Unilateral:

  1. acquired structural lesion
    * * evaluate by otolaryngologist b/c it should be presumed to be cerebellopontine angle tumor [acoustic neuroma] until proven otherwise
21
Q

All unilateral otologic symptoms [esp. hearing loss and tinnitis] should be considered to represent what until proven otherwise?

A

Cerebellopontine angle tumor [acoustic neuroma]

22
Q

A unilateral middle ear effusion that does not clear in 4-6 weeks in an adult may indicate what?
What should be done to further evaluate?

A

a tumor in the nasopharynx causing Eustachian tube dysfunction.

This should be evaluated by an otolaryngologist with:

  1. flexible fiberoptic exam of nasopharynx
  2. CT
23
Q

Describe the Weber test.

A
  1. place 512Hz tuning fork on the patients forehead.
  2. vibrations travel via bone directly to cochlea
  3. if there is conductive hearing loss, sound through the external auditory canal and middle ear will be diminished in the affected ear
  4. bone conduction tuning fork vibrations will be LOUDER in the ear WITH CONDUCTIVE LOSS
24
Q

Describe the Rinne test.

A
  1. place the tuning fork on the mastoid tip behind the auricle pressed to bone
  2. move it to an inch outside the auditory canal
  3. if bone conduction is louder than air conduction, the patient has conductive hearing loss in that ear.

[rinne negative = abnormal = BC>AC]

25
Q

What is tinnitus?

What are the 2 categories?

A

Sound heard in one or both ears that is internally generated and not produced by any stimulus outside the body.

  1. objective
  2. subjective
26
Q

What is objective tinnitus?
What are the 4 major causes?
How is it appreciated by the examiner?

A

It is tinnitus that can be appreciated by an objective observer.
The most common is vascular tinnitus [sound of blood rushing through blood vessels]

  1. AVM
  2. vascular tumor near inner ear/temporal bone
  3. carotid with significant obstruction
  4. palatal myoclonus

It is appreciated by placing stethoscope near or around the ear

27
Q

What is subjective tinnitus?

What is it most frequently associated with?

A

When the patient hears sound that is inaudible to the examiner [even with amplification]

It is frequently associated with hearing loss where the frequency of the tinnitus is the same frequency as the max hearing loss [thought to be cochlear or thalamic]

28
Q

What is vertigo?

A

The illusion of movement when none is actually occurring.

29
Q

Where does peripheral vertigo arise?

Where does central vertigo arise?

A

Peripheral:

  1. semicircular canals of inner ear
  2. CN8
  3. brainstem vestibular nuclei

Central:

  1. supranuclear pathways
  2. cerebellum
30
Q

A patient presents with vertigo that feels like rotational movement.
She has nausea, vomiting, pallor and diaphoresis.
She says the onset is usually intermittent and it lasts for a few hours.

Is this more likely to be peripheral or central vertigo?

A

Peripheral

31
Q

A patient presents with vertigo that lasts for weeks/months at a time but is not very severe.
She has blurred vision, diplopia, numbness in the extremities, focal motor weakness, headache and occasional syncope.
Is this likely to be peripheral or central vertigo?

A

Central as noted by the CNS dysfunction of CN nerves, and sensory/motor changes

32
Q

A patient presents with sporadic, severe vertigo with unremitting nausea and vomiting. It lasts 1 or 2 days with gradual return of equilibrium.
There is no tinnitus, hearing loss or aural fullness.
What is the likely cause?

A

Viral labrynthitis

33
Q

A patient presents with vertigo that lasts 20 min to 4 hours. The vertigo is accompanied by low-pitched tinnitus, aural fullness and pressure, and fluctuating neurosensory hearing loss.

What is the Dx? What causes this?

A

Meniere’s disease

  • inner ear fluid imbalance and rupture of membrane
34
Q

A patient experiences vertigo when the left ear is in a downward position. The vertigo lasts 1 minute but recurs.
What is the Dx and cause?

A 
Dx = benign paroxysmal positional vertigo
Cause= otoconia which is calcium carbonate crystals free floating in the balance canals
35
Q

What are the 2 phases of nystagmus?
What is the direction of the nystagmus named for?
When can nystagmus arising from an inner ear problem be seen?

A
  1. Slow phase- inner ear to attempt to maintain visual fixation despite head movement
  2. fast phase- brainstem returns the nystagmoid eye

Named for the fast phase

Viral labrynthitis and Meniere’s can cause this, but visual fixation suppresses nystagmus from the inner ear so it can only be noted when the eyes are closed [NOT OBSERVABLE ON PE, must be measured with ENG which detects eye movement when the eye is closed]

36
Q

What are the 4 causes of peripheral labrynthine vertigo [not true vertigo]?

A
  1. MEE
  2. AOM
  3. cholesteatoma [erodes semicircle canal]
  4. acoustic neuroma
37
Q

What are the 4 main causes of otorrhea?

What do they look like?

A
  1. External otitis -mucopurulent
  2. Middle ear effusion with perforated tympanic membrane -mucopurulent
  3. CSF otorrhea- clear and can be tested with beta2-transferrin-a
  4. Cholesteatoma- mucopurulent but prolonged and unremitting
38
Q

A patient presents with clear otorrhea that tests positive for beta2-transferrin A protein. The patient has hearing loss, balance disturbance and facial paralysis.
What is the Dx and what was the inciting factor?

A

CSF otorrhea caused by trauma or ear surgery

39
Q

What is cholesteatoma?

A

An epidermoid inclusion cyst growing within the temporal bone

40
Q

What are the 4 places a cholesteatoma can erode?

What will the associated symptoms be for each?

A
  1. semicircular canal - vertigo and deafness
  2. facial nerve- paralysis
  3. ossicles- conductive hearing loss
  4. subarachnoid space - brain abscess or epidural abcess
41
Q

An otorrhea is mucopurulent but resistant to oral and topical antibiotic therapy. What is the likely cause? How do you confirm diagnosis?

A

Cholesteatoma

You need to see squamous epithelium within the confines of the middle ear space through a tympanic membrane perforation

Nervous System (32 decks)

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