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MD2 ENT > Common Conditions of the Ear > Flashcards

Common Conditions of the Ear Flashcards

1
Q

Describe the basic auditory pathway

A

Outer ear > middle ear > cochlea > brainstem nuclei > temporal lobe

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2
Q

What does the “O” symbol mean on an audiogram?

A

Right ear air conduction

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3
Q

What does the “X” symbol mean on an audiogram?

A

Left ear air conduction

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4
Q

What does the “[” symbol mean on an audiogram?

A

Right ear bone conduction

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5
Q

What does the “]” symbol mean on an audiogram?

A

Left ear bone conduction

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6
Q

How is mild hearing loss defined and what sort of functional difficulties are encountered?

A

20-40 dB

Manage in quiet situations with clear voices, difficult to hear soft speech and conversation, difficult to hear with background noise

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7
Q

How is moderate hearing loss defined and what are the functional impacts?

A

41-60 dB

Will miss most of the conversation, pronunciation is not clear, difficulty with background noise, limited vocabulary

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8
Q

How is severe hearing loss defined and what are the functional impacts? What can be done to improve severe hearing loss?

A

61-90 dB

Will not hear most conversational speech, speech and language do not develop spontaneously, very limited vocabulary, pronunciation is not clear

Hearing aids will greatly assist the child to develop speech; visual cues usually assist in understanding speech

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9
Q

How is profound hearing loss defined and what are the functional impacts?

A

91 dB

Cannot hear speech sounds; speech will not develop without a hearing aid and cochlear implant, will need manual communication for language if no implant; plateau in reading ability at about the Grade 4 level

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10
Q

What are the characteristics of normal hearing?

A

Air and bone conduction are similar

Hearing threshold is 20 dB or better

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11
Q

What are the characteristics of sensorineural hearing loss?

A

Air and bone conduction similar

Hearing threshold worse than 20 dB

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12
Q

What are the characteristics of conductive hearing loss?

A

Air and bone conduction are different

Hearing threshold is 20 dB or better for bone conduction

Hearing threshold is worse than 20 dB for air conduction

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13
Q

What are the characteristics of mixed hearing loss?

A

Air and bone conduction are different

Hearing threshold is worse than 20 dB for bone conduction

Hearing threshold is worse than 20 dB for air conduction

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14
Q

Salini, 14 years old, presents with a painful blocked L ear; her R ear is also itchy

She swims in the river every day after school

Otoscopic view of the left external ear canal attached

Possible Dx?

Likely organism and features on otoscopy which are suggestive?

Mx?

A

Dx: otitis externa with possibility of underlying immune deficiency, but most likely a local infection

Likely organism: fungal otitis externa, probably Aspergillus niger (spores visible, “wet newspaper” appearance)

Mx: analgesia, ear toilet/cleaning (tissue spears to mop out discharge, ear toilet with suction or mopping under direct vision), topical Abx therapy (specifically against fungal infections, e.g. Clioquinol/flumethasone)

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15
Q
A
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16
Q

Eric, 18 months old, has a cold and last night woke and cried several times; this morning there is thick, purulent discharge on his pillow and matted in his hair

He is happy but rubs at his ear

Right ear otoscopic examination attached

Possible Dx?

Possible causative organisms?

Mx?

A

Dx: acute otitis media with perforation

Causative organisms: pneumococcus, haemophilus influenzae (non-typable), moraxella catarrhalis

Mx: analgesia, ear toilet/cleaning, Abx, arrange FU in 2-3/12 to check for fluid

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17
Q

Who should be treated for acute otitis media with oral Abx?

A

A child who is:

2 years old or less

Has a tympanic membrane perforation

Is Indigenous

Has a known immunodeficiency

Has a cochlear implant

Has the only hearing ear infection

Has a possible complication, e.g. mastoiditis, facial paralysis, intracranial infection or venous thrombosis

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18
Q

3 possible complications of acute otitis media

A

Mastoiditis

Facial paralysis

Intracranial infection or venous thrombosis

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19
Q

What Abx should be given for acute otitis media?

If adherence likely to be a problem?

If an allergy to penicillin?

If recurrent acute otitis media or no improvement in acute symptoms after 48 hours of amoxycillin, amoxycillin + clavulonic acid?

A

Amoxycillin: 15 mg/kg up to 500 mg orally, 8-hourly for 5 days

If adherence likely to be a problem, amoxycillin: 30 mg/kg up to 1 g orally, 12-hourly for 5 days

If an allergy to penicillin, cefuroxime: for children 3/12 - 2 years, give 10 mg/kg up to 125 mg, and for children 2 years or more, give 15 mg/kg up to 500 mg orally, 12-hourly for 5 days

If recurrent acute otitis media or no improvement in acute symptoms after 48 hours of amoxycillin, amoxycillin + clavulonic acid: 22.5 + 3.2 mg/kg up to 875 + 125 mg orally, 8-hourly for 5-7 days

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20
Q
A
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21
Q

When is topical Abx therapy indicated for the Mx of acute otitis media? What Abx should be used and what other guidelines for their use are there?

A

Only if there is tympanic membrane perforation

Use a non-ototoxic medication such as ciprofloxacin drops

Generally use oral Abx as well, because acute otitis media with perforation is from a more virulent organism and there is more likely to be closure of the TM with oral therapy

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22
Q

Eric, 23 months old, return visit because his mother is concerned that he is not speaking, although he seems to understand well; he occasionally rubs at his ears but has not had further acute otitis media

Otoscopic views of R and L ear attached

PHx: acute otitis media with TM perforation

Dx?

Mx?

Who should have middle ear ventilation tubes inserted?

A

Dx: chronic otitis media with effusion (“glue ear”)

Mx: audiogram to confirm the hearling loss and to determine if there is a sensorineural component, consider for insertion of middle ear ventilation tubes (Eric meets the criteria below)

Criteria for middle ear ventilation tube insertion: bilateral middle ear fluid (probably for 5/12 in Eric’s case), delayed speech, retraction of the TM (especially in his L ear)

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23
Q

Criteria for middle ear ventilation tube insertion

A

OME for 4 months at least, with hearing loss or other signs and symptoms

Recurrent or persistent OME in a child “at risk” regardless of the hearing

OME and structural damage to the TM

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24
Q
A
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25
Q

What Ix are important to perform post-operatively following the insertion of a middle ear ventilation tube?

A

Post-operative audiology

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26
Q

Recurrent or persistent OME in a child “at risk” regardless of the hearing

What is an “at risk” child?

A

An “at risk” child has an increased risk of developmental difficulties due to factors not related to the otitis media with effusion:

Physical, e.g. cleft palate

Sensory, e.g. visual impairment

Cognitive, e.g. developmental delay

Behavioural, e.g. autism spectrum

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27
Q

What is classified as “significant” hearing loss in otitis media with effusion (OME)?

A

No data on the criteria; likely that it is different for different children

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28
Q

What % of children with persistent OME have hearing thresholds at 20 dB?

A

50%

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29
Q

What % of children with persistent OME have hearing thresholds at >35 dB?

A

20%

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30
Q

How is otorrhoea or an infected granuloma through a middle ear ventilation tube treated?

A

Topical Abx drops, e.g. ciprofloxacin, rather than oral Abx

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31
Q
A

Granuloma through middle ear ventilation tube

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32
Q
A

Tube blocked with dry secretions

33
Q

Rob, 64 years old, has intermittent discharge from his L ear; wife complains about offensive smell, but he has noticed it himself

He thinks he does not hear well on this side, and recently has felt off-balance when he sneezes

Dx?

Likely complications?

Ix?

Mx?

A

Dx: chronic suppurative otitis media with cholesteatoma

Likely complications: hearing loss (conductive from erosion of ossicles, sensorineural from erosion into labyrinth, or mixed), imbalance/vertigo from erosion into labyrinth (lateral semicircular canal)

Ix: ENT examination, tuning fork examination, audiogram, CT scan of the temporal bones

Mx: likely he will need a mastoidectomy to remove active disease, prevent complications and improve hearing

34
Q

What is chronic suppurative otitis media (CSOM)?

A

“Deafness and discharge”: recurrent or persistent bacterial infection of the ear, resulting in destruction of the tympanic membrane and sometimes the ossicles

35
Q

Are the problems caused by CSOM reversible or irreversible?

A

Irreversible

36
Q

Symptoms of CSOM

A

Itchiness

Discharge

Conductive hearing loss

(Usually no pain)

37
Q

Types of “disease” in CSOM, and their complications

A

Tubotympanic disease: central perforation (“safe”)

Atticoantral disease: cholesteatoma (“unsafe”)

38
Q

What is cholesteatoma?

A

Presence of keratinising squamous epithelium in the middle ear

39
Q

Why is cholesteatoma potentially dangerous?

A

Damages underlying bone

40
Q

What are the possible complications of chronic ear infection?

A

Bone erosion

Hearing loss

Intracranial complications

41
Q
A
42
Q
A
43
Q

5 complications of cholesteatoma

A

CHL (conductive hearing loss), usually from ossicular erosion

SNHL (sensorineural hearing loss) from erosion into labyrinth

Vertigo from labyrinthine fistula

Facial paralysis (acute if superimposed infection, or gradual and subtle)

Intracranial (potentially life-threatening; requires neurosurgical Mx before/with ear surgery)

44
Q

How is Weber’s test performed?

A

512 Hz tuning fork placed in midline of patient’s forehead

“Where can you hear the buzzing noise?”

45
Q

When is Weber’s test particularly useful? What are the expected findings in conductive vs sensorineural hearing loss?

A

Especially useful if asymmetric hearing

CHL: sound heard in worse-hearing ear

SNHL: sound heard in better ear

46
Q

How is Rinne’s test performed?

A

With a 512 Hz tuning fork, press against the patient’s mastoid and then hold it 1cm away from the ear

“Which is louder, behind the ear or in front?”

47
Q

What is a normal Rinne’s test result? What does an abnormal Rinne’s test indicate?

A

Normal: air conduction is better than bone conduction (“Rinne +”)

CHL: bone conduction better than air (Rinne -)

48
Q

What does this CT scan of the temporal bones demonstrate?

A

Erosion of lateral semicircular canal

49
Q

List 5 causes of otorrhoea

A

Wax

Otitis externa

Foreign body in ear canal

Acute otitis media with perforation

Chronic suppurative otitis media +/- cholesteatoma

50
Q

Phyllis, 37 years old, presents with 3/52 Hx of severe ear pain for which she has been administered Abx without relief

O/E: normal TM

Possible locations/causes of ear pain?

A

External ear canal: otitis externa, trauma, foreign body, tumour (e.g. SCC)

Middle ear: acute otitis media, CSOM, middle ear tumour

Referred otalgia

51
Q

Spot diagnosis

A

Acute otitis media

52
Q

Spot diagnosis

A

CSOM

53
Q

Where can otalgia be referred from and along what nerve pathways? What pathologies may result in these kinds of referred pain?

A

Oropharynx (IXth nerve): post-tonsillectomy, carcinoma of tongue base

Laryngopharynx (Xth nerve): pyriform fossa

Upper molar teeth, temporomandibular joint, parotid gland (V2 nerve): impacted wisdom teeth

Cervical spine (C2, C3)

54
Q

Systematic approach to diagnose referred otalgia

A
55
Q

Luke, 9/12 old, has had a fever and is irritable; his mother has notied that his face looks “screwed up” on the L side

R ear otoscopic examination attached

Dx?

Mx?

A

Dx: acute otitis media complicated by facial nerve palsy

Mx: insertion of ventilation tube to relieve pressure on facial nerve, oral/systemic Abx, oral/systemic steroids

56
Q

Shane, 44 years old, has had severe R ear pain for 2/7; today he cannot close his eye, and he dribbles from the R side of his mouth

He is concerned about stroke

O/E: notice he has vesicles in his concha, as well as a LMN facial palsy

Dx?

Mx?

A

Dx: herpes zoster oticus (Ramsay Hunt syndrome) from reactivation of the virus in the geniculate (facial) ganglion

Mx: oral steroids, audiology, protect eye from exposure keratopathy with artificial tears and a pad, if within 3/7 of symptom onset use anti-viral e.g. acyclovir

57
Q

Symptoms of Ramsay-Hunt syndrome

A

May also be hearing loss and vertigo/imbalance if CN VIII also involved

58
Q

Why is the facial nerve at risk of damage in diseases and surgery of the ear?

A

Has a course through middle ear and mastoid

59
Q

Francis, 72 years old, has had several episodes of vertigo; they occur when he rolls over in bed and onto his R side, and usually pass in a minute

He is worried that he is having “mini strokes”

Likely Dx?

Ix?

Mx?

A

Dx: BPPV

Ix: Dix-Hallpike manoeuvre

Mx: Epley manoeuvre

60
Q

Pathophysiology of benign paroxysmal positional vertigo (BPPV)

A

Otoliths from the utricle become loose, and lodge in the posterior (usually) semicircular canal

61
Q

How is the Dix-Hallpike manoeuvre?

A

The patient lies down with the head down and turned to one side

Turning the head to the R tests for R BPPV

After a latency period of a few seconds, the BPPV patient will have vertigo and rotational nystagmus towards the floor (geotropic)

This lasts less than a minute

62
Q

How is the Epley manoeuvre performed?

A

The Dix-Hallpike manoeuvre is performed to confirm the Dx

The head is turned 90 degrees to move the otoliths, and then the patient rolls onto the opposite shoulder and faces the bed

This moves the particles away from the posterior semicircular canal

63
Q

Colin, 29 years old, was on his honeymoon 3/52 ago, and become acutely sick; he had severe rotational vertigo, and every time he rolled over he vomited

There was no tinnitus; he recovers after a week, but still feels off-balance when he walks in the dark

O/E: ENT examination are unremarkable, no nystagmus, on the Romberg test he tends to fall to the R side, no other neurological signs, on clinical and tuning fork tests he does not have a hearing loss, normal audiogram

He is worried he has a brain tumour

Possible Dx?

A

Dx: vestibular neuritis, vestibular migraine, brainstem tumour or stroke, multiple sclerosis

64
Q

What is vestibular neuritis?

A

Abrupt onset of vertigo, possibly from a viral inflammation of vestibular ganglion; there is NO hearing loss or tinnitus, and balance should improve spontaneously over a period of weeks

65
Q

In a case of suspected vestibular neuritis, how can other diagnoses (e.g. tumour, MS) be excluded?

A

MRI

66
Q

Susie, 26 years old, has had three episodes of severe vertigo in last 6/12, each lasting several hours with associated N + V, and tinnitus

She is not sure if there was hearing loss, but her L ear feels blocked for days after the attack

She is afraid to go out on her own in case she gets dizzy

Ix: normal audiogram, normal MRI

Likely Dx?

Mx?

A

Dx: Meniere’s disease (endolymphatic hydrops)

Mx: vestibular suppressants (e.g. prochlorperazine, diazepam), maintenance therapy includes lifestyle (managing reversible stresses), dietary advice (<120mg Na+ per 100mg) and medications if persistent problems (thiazide diuretics, betahistine), consider surgery if persistent disabling vertigo

67
Q

What are the features of Meniere’s disease?

A

Features at least 3 of:

Vertigo (lasts at least half an hour, but less than a day)

Fullness in the ear

Roaring tinnitus

Initially low-frequency SNHL that fluctuates and eventually becomes worse and permanent

68
Q

In what % of patients with Meniere’s disease does vertigo continue to be disabling after medical treatment?

A

20%

69
Q

What is the aim of surgery for Meniere’s disease?

A

Improve vertigo symptoms

Rarely improves hearing loss (hearing aids are useful for most people with hearing loss, although the loss may become profound)

70
Q

What treatment is indicated for Meniere’s disease that is refractory to medical therapy?

A

Intratympanic gentamicin

Other surgery

71
Q

Describe the step-wise treatment for Meniere’s disease

A

Reassurance

Salt-reduced diet

Diuretics

Middle ear ventilation tube

Treatment with local overpressure

Endolymphatic sac surgery

Gentamicin injections

Vestibular nerve section

Complete destruction of the inner ear

72
Q

What are the three most common causative conditions in patients with vertigo and what is the difference between these conditions in terms of time course?

A

Positional (BPPV; aka positioning): lasts for <1 min

Meniere’s disease (endolymphatic hydrops): lasts a few hours but <24 hours

Vestibular neuritis (aka neuronitis): lasts days to weeks

73
Q

What other symptom is it important to distinguish vertigo from?

A

Dizziness

74
Q

List 4 general medical and 2 neurological causes of dizziness

A

General medical: anaemia, dysrhythmias, hypoglycaemia, drugs (e.g. antihypertensives)

Neurological: multiple sclerosis, migraines

75
Q

Timmy, 2/12 old, had a “refer” result in each ear from his newborn hearing screen; his objective radiology confirms that he has severe SNHL in both ears

His mother had an uneventful pregnancy and Timmy was born at term; there were no concerns about him in the newborn period

Mx?

A

Referral for hearing aids at Australian Hearing (aim is to have hearing aid use established by 6/12)

Early intervention programme

Opthalmology referral

Paediatrician

Referral for genetic counselling (if parents wish)

Application for Centrelink benefits

76
Q

When should hearing aid use be established in an infant with SNHL for optimal outcome?

A

Aim is to have hearing aid use established by 6/12

77
Q

Craig, 47 years old, describes “walking along the street and going deaf in the L ear”

No vertigo but had tinnitus

General health is good

No Rx, non-smoker

Audiogram attached: what does it show? Dx? Mx?

A

Audiogram shows SNHL in L ear with a “noise notch” in his R ear (he is a builder)

Dx: sudden SNHL that occurs within 3/7, in at least 3 frequencies, and is at least 30 dB

Mx: oral prednisolone 50 mg per day for 5 days, then tapered off

78
Q

How is newborn hearing loss screened for in Australia? What is the aim of this screening?

A

Now universal newborn hearing screen in Australia

Aim is to identify children who need early intervention by 3/12, and to establish hearing aid use by 6/12

79
Q

Why should sudden hearing loss be treated as early as possible with steroids?

A

To optimise chance of hearing improvement

MD2 ENT (10 decks)

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