Conditions Of The Ear Flashcards
(120 cards)
1
Q
What conditions can affect the pinna?
A
- Perichondritis
- Ramsay Hunt Syndrome
- Cauliflower ear
- Pinna Haematoma
2
Q
Presentation of Ramsay Hunt Syndrome
A
auricular pain
Facial nerve palsy
Painful red ear with vesicles
3
Q
Management of ramsay hunt syndrome
A
oral aciclovir + prednisolone
4
Q
What is a pinna haematoma?
A
Accumulation of blood between cartilage and overlying perichondrium
5
Q
What is a pinna haematoma due to?
A
Blunt trauma
eg. Contact sport
6
Q
What happens to an untreated pinna haematoma?
A
- cartilage is deprived of blood + pressure necrosis
- fibrosis of cartilage > new asymmetrical cartilage development (cauliflower ear)
- hearing not impaired but cosmetic implications
7
Q
Treatment of pinna haematoma
A
- Drainage + aspirate
- Prevent re-accumulation using a dressing between the two layers
8
Q
What conditions affect the external auditory meatus?
A
- acute otitis externa
- necrotising/malignant otitis externa
9
Q
What is acute otitis externa?
A
Inflammation of external acoustic meatus usually due to infection (staph aureus or pseudomonas aeruginosa)
10
Q
What organism normally causes otitis externa?
A
staphylococcus aureus
pseudomonas aeruginosa
11
Q
Presentation of acute otitis externa
A
Otalgia
Custard like discharge
+/- hearing loss
12
Q
Risk factors of acute otitis externa
A
- injury to EAM e.g. scratch from itching
- swimming
- warm weather
- skin problems e.g. eczema
13
Q
Treatment of acute otitis externa
A
Ear drops
(Topical antibiotics +/- steroids)
14
Q
What is malignant/necrotising otitis externa?
A
- complication of otitis externa
- infection spreads deeper > osteomyelitis of temporal bone + skull base
15
Q
Presentation of necrotising/malignant otitis externa
A
- severe otalgia (may keep them up at night)
- purulent discharge
- non resolving acute otitis externa
- hearing loss
- CN involvement
16
Q
What is the main organism that causes necrotising otitis externa?
A
Pseudomonas aeruginosa
17
Q
Risk factors of necrotising otitis externa
A
- male
- diabetic
- immunocompromised
- > 65 years old
- HIV
18
Q
Treatment of necrotising otitis externa
A
- urgent referal to ENT
- IV ciprofloxacin
- Analgesia
- Discharged with oral antibiotics (+ topical drops)
19
Q
What is the best imagining if suspecting necrotising otitis externa?
A
CT of temporal bone
20
Q
Why are middle ear infections more common in children?
A
Shorter, more horizontal pharyngotympanic tube
21
Q
Conditions affecting the middle ear
A
Acute otitis media (+/- effusion)
Mastoiditis
Cholesteatoma
22
Q
What is acute otitis media?
A
Middle ear infection
23
Q
Presentation of acute otitis media
A
- infants
- otalgia (child pulling ear as can’t communicate)
- fever
- red +/- bulging tympanic membrane
24
Q
Appearance of acute otitis media on otoscopy
A
red, bulging tympanic membrnae
loss of light refex
25
What organisms cause acute oitis media
- staph auerus
- strep pneumoniae
- haemophilus influenza
26
Treatment of acute otitis media
- most will resolve in 3-7 days
- analgesia *e.g. calpol, paracetamol*
- back up antibiotic prescription if doesn’t self resolve - *amoxicillin* for 5-7 days
27
When are abx needed in acute otitis media?
- >4 days
- <2 years olf with bilateral presentation
- immunocompromised
- systemically unwell
- evidence of perforation
28
Complications of acute otitis media
- tympanic membrane perforation
- facial nerve involvement
- mastoiditis
- intracranial complications *e.g. meningitis, sigmoid sinus thrombosis, brain abscess*
29
Presentation of mastoiditis
- sharp angle behind hear lost (boggy oedema)
- pinna pushed down and forward
- unwell + fever
- signs + symptoms of acute otitis media
30
How can infection spread from the middle ear to the mastoid bone?
Middle ear > mastoid antrum > mastoid air cell (mastoid bone)
31
Treatment of mastoiditis
IV abx
32
Presentation of otitis media with effusion
Well child
Hearing loss (like turning up the tv)
33
What is otitis media with effusion due to?
- due to pharyngotympanic dysfunction
- negative pressure in middle ear + inflammatory fluid activation
- decreased mobility of TM + ossicles > affecting hearing
34
Appearance of otitis media with effusion on otoscopy
- retracted typmanic membrane
- straw coloured fluid
- bubbles
35
What is another name for otitis media with effusion?
Glue ear
36
What is a red flag in otitis media with effusion?
if unilateral in adults - possibly cancer
37
Treatment of otitis media with effusion
- most resolve in 2-3 months
- grommets to maintain equilibration of pressures
38
Function of grommets
Act to maintain equilibration of pressures
39
What is cholesteatoma?
- congenital or acquired
- retraction pocket in tympanic membrane > dead skin accumulates
- grows into middle ear and beyond
40
Presentation of cholesteatoma
- foul smelling discharge from ear
- +/- progressive hearing loss
41
Treatment of cholesteatoma
Surgical treatment
(Mastoidectomy)
42
Conditions that affect the inner ear
- age related hearing loss (presbycusis)
- Benign paroxysmal positional vertigo
- Meniere’ disease
- acute labyrinthitis + acute vestibular neuronitis
43
What is presbycusis?
Age related hearing loss
Bilateral + gradual
44
Presentation of Ménière’s disease
- 40-60 years
- Unilateral
- Vertigo (potentially associated with aural fullness, N+V)
- Tinnitus
- Hearing loss
- horizontal nystagmus
- between 20 mins to several hours
45
Triad of Ménière’s disease
Vertigo
Tinnitus
Hearing loss
46
Treatment of meniere's disease
**IM prochlorperazine** - for attacks
**betahistine** - prevention
47
Typical history of a patient with BPPV
- older
- episodes of short lived vertigo in response to change in position
48
Treatment of BPPV
How does it work?
- **Epley manoeuvre** : moves the otoliths back into the utricle + saccule
- betahistine
- vestibular rehabilitation - Brandt-Daroff exercises
49
Outline the epley manouvere
What advice should be given to the pt to follow over th next 48 hours?
- sit up on bed
- turn head 45 towards affected ear
- lie down quickly onto back, keeping head turned
- wait 60 secs, then turn head to opposite side
- wait again, then turn body + head to lie on side
- wait again, slowly sit up keeping head turned + chin tucked
- sit for 20 mins
.
- avoid sudden changes in head position
- sleep in 45-60 sitting up position / do not lie flat
50
How does BPPV happen?
- Otoliths are deposited in the semicircular canals
- in a neutral head position, the crystals are static
- in certain head movements they are displaced
- resulting stimulus is unbalanced to the opposite ear > vertigo + dizziness
51
Diagnosis of BPPV
**Dix-Hallpike manoeuvre**
.
**Di**x - **Di**agnosis
52
outline the dix hallpike manoeuvre
What needs to be ruled out before carrying out test?
- rapidly lowering pt to supine position with an extended neck
- positive test recreates BPPV symptoms
- rotatory nystagmus
.
- rule out MSK problems *e.g. back or neck pain*
53
What is rotary nystagmus?
type of nystagmus where the eyes make rotational movements (in a circle)
54
Where are otoliths normally located?
Utricle
Saccule
55
Causes of post illness vertigo
acute labyrinthitis
acute vestibular neuronitis
56
Describe acute labyrinthitis
- prior history of URTI
- involvement of all inner ear structures
- sensorineural hearing loss
- tinnitus
- vomiting
- vertigo
57
Presentation of acute labyrinthitis
Sensorinureal hearing loss
Tinnitus
Vomiting
Vertigo
horizontal nystasmus towards unaffected side
Prior history of URTI
58
Management of acute labyrinthitis
- mostly self limiting
- proclorperazine or betahistine for dizziness
59
Presentation of acute vestibular neuronitis
- only affected vestibular nerve
- Sudden onset vomiting
- Severe vertigo lasting days
.
- No hearing loss or tinnitus
- **V**estibular - **V**omiting - **V**ertigo
60
Management of acute vestibular neuronitis
- buccal or IM *proclorperazine*
- vestibular rehabilitation exercises for chronic symptoms
61
Compare the presentation of acute labyrinthitis + acute vascular neuronitis
- both present with vomiting + vertigo (more severe in AVN)
- plus hearing loss + tinnitus in AL
.
- **L**abrinythitis - hearing **L**oss
- **N**euronitis - **N**o hearing loss
62
What is needed if a patient presents with sudden onset unilateral hearing loss with no explanation?
- immediate referral to ENT
- need to rule out **sudden sensorineural hearing loss** + **acosutic neuroma/vestibular shwannoma**
63
Describe conductive hearing loss
Examples
Pathology involving the external or middle ear
*e.g. wax, acute otitis media, otitis media with effusion, otosclerosis*
64
Presentation of otosclerosis
Gradual hearing loss
Unilateral > bilateral overtime
Otherwise well
Tinnitus
Young female
65
What is otosclerosis?
Gradual hearing loss over years
Due to bony growth on stapes
66
Treatment of otosclerosis
Hearing aids
Surgical (replacing stapes with prosthesis)
67
Describe sensorineural hearing loss
Examples
Pathology involving inner ear structures or vestibulocochlear nerve
*e.g. age related hearing loss, noise related hearing loss, Meinere’s disease, ototoxic meds, acoustic neuroma, suddent sensorineural hearing loss*
68
What is an acoustic neuroma/vestibular schwannoma?
- Benign slow growing posterior cranial fossa tumour
- Involves Schwann cells of vestibular component of CN VIII
- affects facial, vestibulocochlear + trigmeinal nerves
69
Presentation of acoustic neuroma/vestibular schwannoma + what nerve is affected
- **Unilateral hearing loss + tinnitus + vertigo** : vestibulocochlear
- **Facial nerve palsy**: facial nerve
- **Absent corneal reflex**: trigeminal nerve
70
what can be done to distinguish between a vestibular schwannoma vs posterior stroke
**HINTS manoeuvre**
Head Impulse, Nystagmus, Test of Skew
71
What is needed to diagnose acoustic neuroma?
MRI of cerebellopontine angle
72
Treatment of acoustic neuroma
Observe if small
High dose prednisolone
ENT referral
Surgery
Radiotherapy
73
Parts of the surface anatomy of the external ear
Helix
Antihelix
Concha
Tragus
Antitragus
Lobule
74
Is air or bone conduction better normally?
Air conduction is better
75
In conductive hearing loss, is air or bone conduction better?
Bone conduction
76
In sensorineural hearing loss is air or bone conduction better?
Air conduction
77
Normal findings of a Weber’s test
Centre
(Equal in both ears)
78
Findings of a Weber’s test in conductive hearing loss
Sound lateralises **towards pathology**
79
Findings of Weber’s test in sensorineural hearing loss
Sound lateralises away from pathology
80
A patient come to the GP complaining of a foul smelling discharge coming from their ear, what is the most likely diagnosis?
Cholesteatoma
81
What organism causes Ramsay Hunt syndrome?
Varicella zoster
82
Tympanic membrane pathologies
- perforations (wet vs dry)
- cholesteatoma
- tympano sclerosis
83
causes of perforated tympanic membrane
- infection (most common)
- barotrauma - pressure
- direct trauma
84
Types of tympanic membrane perforation related to location
- **peripheral** - at the edge
- **central** - in pars tense
- **attic** - upper part of TM (pars flaccida) | associated with cholesteatoma
85
Describe what you would see during an otoscope exam in a child with otitis media with effusion?
- TM is retracted due to negative pressure
- loss of cone of light
- straw coloured fluid
86
Describe what you would see during an otoscope exam in a child with otitis media without perforation or effusion
Bulging, red + inflamed tympanic membrane
87
Describe what you would see during an otoscope exam in a child with otitis externa
Oedematous, inflamed EAM +/- discharge
88
What is vestibulopathy?
It includes many disorders of the inner ear:
- bilateral vestibulopathy
- central vestibulopathy
- post traumatic vestibulopathy
- peripheral vestibulopathy
- recurrent vestibulopathy
- visual vestibulopathy
- neurotoxic vestibulopathy
89
Causes of bilateral vestibulopathy
- inner ear damage *e.g. medications - macrolide abx, loop diuretics, chemo drugs*
- autoimmune disease that cause inflammation to inner ear over time
- Ménière’s disease
- acoustic neuroma
- meningitis
- genetic or Congential abnormalities
- idiopathic
90
Presentation of bilateral vestibulopathy
- reduced balance function
- unsteadiness/disorientation
- blurred/jumpy vision
- fatigue
- neck ache
- brain fog
- gait and balance problems are worse if dark or on uneven surfaces
91
What is oscilloscia?
A vision problem which causes still objects to jump, jiggle or vibrate due to misalignment of eyes or balance system issue
92
Examples of vestibular function tests
- video-nystagmography
- rotational chair test
- caloric test
93
Management of bilateral vestibulopathy
- avoid trigger situations
- vestibular rehabilitation
- treat underlying cause if possible
- walking aids if severe
- avoid/stop too toxic medications
- stop medications which can cause dizziness *e.g. antiemetics, benzodiazepines, CCBs*
94
What is vestibular rehabilitation?
type of exercise based therapy to help the brain re-learn how to balance + how to respond to signals rom the visual, vestibular and proprioceptive systems
95
What test can you use to assess balance?
**Romberg test**
Standing up with eyes closed
96
Presentation of vestibular migraine
Migraine in combination with vertigo, imbalance, nausea + vomiting
97
What can trigger vestibular migraines?
- stress
- bright lights
- strong smells
- certain foods
- menstruation
- abnormal sleep patterns
98
Central vs peripheral vertigo
- **central**: pathology related to the cerebellum or brainstem
- **peripheral**: pathology in the inner ear
99
Common pathology causing central vertigo
- posterior circulation infarction (stroke)
- tumour
- multiple sclerosis
- vestibular migrainene
100
Common causes of peripheral vertigo
- BPPV
- Meniere's disease
- Labyrinthitis
- Vestibular neuronitis
101
What examinations may you want to do on a person presenting with vertigo?
- cerebellar exam - DANISH
- romberg's test
- dix-hallpike manoeurve
102
Drug management of peripheral vertigo
- prochlorperazine
- antihistamines - Betahistine
103
What is audiometry?
- Testing a patient’s hearing by playing a variety of tones + volumes using headphones (air conduction) + a bone conduction device (oscillator)
- the quietest a person can hear different frequencies
104
Outline the lay out of audiogram chart
- frequency (Hz) on x axis: left lower pitch > right higher pitch
- volume (dB) on y axis: higher up quiet > lower down louder
- X left sided air conduction
- ] left sided bone condition
- O right sided air condition
- [ right sided bone conduction
105
How is air conduction measured?
Using headphones
106
How is bone condition measured?
A bone conduction device
(An oscillatory)
107
What is masking?
Presenting noise to the non-test ear to prevent it from participating in the hearing
108
Results of on audiogram in:
- normal hearing
- sensorineural hearing loss
- conductive hearing loss
- mixed hearing loss
- **normal hearing**: all readings will be 0-20dB
- **sensorineural hearing loss**: air + bone readings will be >20dB
- **conductive hearing loss**: bone readings normal 0-20dB | air conduction >20dB
- **mixed hearing loss**: air + bone >20dB but >15dB between the two | bone>air
109
Results of audiogram in normal hearing
All readings between 0-20dB
110
Results of audiogram in sensorineural hearing loss
Both bone + air readings will be >20dB
111
Results of audiogram in conductive hearing loss
Bone conduction normal 0-20dB
Air condition >20dB
.
Bone > air conduction
Louder volume needed to hear air
112
Results of audiogram in mixed hearing loss
Both air + bone >20dB
Difference of >15dB between the two
Bone > air (air needs louder sound)
113
What drugs can cause tinnitus?
- aspirin/NSAIDs
- aminoglycosides *e.g. gentamicin*
- loop diuretics *e..g furosemide, bumetanide*
- quinine
114
Findings of Cholesteatoma on otoscope
Attic crust
Seen in uppermost part of ear drum
115
Genetic cause of congenital deafness
- GJB2 mutation - sensorineural hearing loss
- OTOF mutation
- usher syndrome
- waardenburg syndrome
- alport syndrome
116
Non genetic causes of congential deafness
- TORCH infection
- ototoxic drug exposure *e.g. gentamicin*
- maternal diabetes
- maternal hypothyroisim
- fetal alcohol syndrome
- hypoxia
- prematurely
- neonatal meningitis/sepsis
117
What are the TORCH infections?
- **T**oxoplasma gondii
- **Other** *e.g. syphilis, listeria, varicella zoster*
- **R**ubella
- **C**ytomegalovirus
- **H**erpes simplex 2
118
Clinical features of congential deafness
- lack of startle response to loud noise
- failure to localised sound
- delayed/absent speech development
- poor speech clarity
- behavioural issues related to lack of communication
- delayed communication developmental milestones
119
Investigations of congential deafness
- newborn hearing screening
- audiometry
- genetic testing
- CT or MRI of inner ear
120
Management of congenital deafness
- **sensorineural**: hearing aids, cochlear implants
- **conductive**: reconstructive surgery of middle ear, bone conduction hearing devices
- abx for neonatal infection
- SALT
- sign language
- specialised education support
