Conditions Of The Ear Flashcards
What conditions can affect the pinna?
- Perichondritis
- Ramsay Hunt Syndrome
- Cauliflower ear
- Pinna Haematoma
Presentation of Ramsay Hunt Syndrome
Facial nerve palsy
Painful red ear with vesicles
What is a pinna haematoma?
Accumulation of blood between cartilage and overlying perichondrium
What is a pinna haematoma due to?
Blunt trauma
eg. Contact sport
What happens to an untreated pinna haematoma?
- cartilage is deprived of blood + pressure necrosis
- fibrosis of cartilage > new asymmetrical cartilage development (cauliflower ear)
- hearing not impaired but cosmetic implications
Treatment of pinna haematoma
- Drainage + aspirate
- Prevent re-accumulation using a dressing between the two layers
What conditions affect the external auditory meatus?
- acute otitis externa
- necrotising otitis externa
What is acute otitis externa?
Inflammation of external acoustic meatus usually due to infection (staph aureus or pseudomonas aeruginosa)
What organism normally causes otitis externa?
staphylococcus aureus
pseudomonas aeruginosa
Presentation of acute otitis externa
Otalgia
Custard like discharge
+/- hearing loss
Risk factors of acute otitis externa
- injury to EAM e.g. scratch from itching
- swimming
- warm weather
- skin problems e.g. eczema
Treatment of acute otitis externa
Ear drops
(Topical antibiotics +/- steroids)
Presentation of necrotising otitis externa
- severe otalgia (may keep them up at night)
- purulent discharge
- non resolving acute otitis externa
- hearing loss
- CN involvement
What is the main organism that causes necrotising otitis externa?
Pseudomonas aeruginosa
Risk factors of necrotising otitis externa
- male
- diabetic
- immunocompromised
- > 65 years old
What is necrotising otitis externa?
- complication of otitis externa
- infection spreads deeper > osteomyelitis of temporal bone + skull base
Treatment of necrotising otitis externa
- IV antibiotics
- Analgesia
- Discharged with oral antibiotics (+ topical drops)
What is the best imagining if suspecting necrotising otitis externa?
CT of temporal bone
Why are middle ear infections more common in children?
Shorter, more horizontal pharyngotympanic tube
Conditions affecting the middle ear
Acute otitis media (+/- effusion)
Mastoiditis
Cholesteatoma
What is acute otitis media?
Middle ear infection
Presentation of acute otitis media
- infants
- otalgia (child pulling ear as can’t communicate)
- fever
- red +/- bulging tympanic membrane
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
Complications of acute otitis media
- tympanic membrane perforation
- facial nerve involvement
- mastoiditis
- intracranial complications e.g. meningitis, sigmoid sinus thrombosis, brain abscess
Presentation of mastoiditis
- sharp angle behind hear lost (boggy oedema)
- pinna pushed down and forward
- unwell + fever
- signs + symptoms of acute otitis media
How can infection spread from the middle ear to the mastoid bone?
Middle ear > mastoid antrum > mastoid air cell (mastoid bone)
Presentation of otitis media with effusion
Well child
Hearing loss (like turning up the tv)
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
What is another name for otitis media with effusion?
Glue ear
Treatment of otitis media with effusion
- most resolve in 2-3 months
- grommets to maintain equilibration of pressures
Function of grommets
Act to maintain equilibration of pressures
What is cholesteatoma?
- congenital or acquired
- retraction pocket in tympanic membrane > dead skin accumulates
- grows into middle ear and beyond
Presentation of cholesteatoma
- foul smelling discharge from ear
- +/- progressive hearing loss
Treatment of cholesteatoma
Surgical treatment
(Mastoidectomy)
Conditions that affect the inner ear
- age related hearing loss (presbycusis)
- Benign paroxysmal positional vertigo
- Meniere’ disease
- acute labyrinthitis + acute vestibular neuronitis
What is presbycusis?
Age related hearing loss
Bilateral + gradual
Presentation of Ménière’s disease
- 40-60 years
- Unilateral
- Vertigo (potentially associated with aural fullness, N+V)
- Tinnitus
- Hearing loss
- between 20 mins to several hours
Typical history of a patient with BPPV
- older
- episodes of short lived vertigo in response to change in position
Treatment of BPPV
How does it work?
Epley manoeuvre
Moves the otoliths back into the utricle + saccule
How does BPPV happen?
Otoliths in semicircular canals move due to change in position which is perceived by the body as movement > vertigo
Diagnosis of BPPV
Dix-Hallpike manoeuvre
Where are otoliths normally located?
Utricle
Saccule
Triad of Ménière’s disease
Vertigo
Tinnitus
Hearing loss
Describe acute labyrinthitis
- prior history of URTI
- involvement of all inner ear structures
- hearing loss
- tinnitus
- vomiting
- vertigo
Presentation of acute labyrinthitis
Hearing loss
Tinnitus
Vomiting
Vertigo
Prior history of URTI
Presentation of acute vestibular neuronitis
- Sudden onset vomiting
- Severe vertigo lasting days
- No hearing loss or tinnitus
Compare the presentation of acute labyrinthitis + acute vascular neuronitis
- both present with vomiting + vertigo (more severe in AVN)
- only hearing loss + tinnitus in AL
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
Describe conductive hearing loss
Examples
Pathology involving the external or middle ear
e.g. wax, acute otitis media, otitis media with effusion, otosclerosis
Presentation of otosclerosis
Gradual hearing loss
Unilateral > bilateral overtime
Otherwise well
Tinnitus
Young female
What is otosclerosis?
Gradual hearing loss over years
Due to bony growth on stapes
Treatment of otosclerosis
Hearing aids
Surgical (replacing stapes with prosthesis)
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
What is an acoustic neuroma/vestibular schwannoma?
- Benign slow growing posterior cranial fossa tumour
- Involves Schwann cells of vestibular component of CN VIII
Presentation of acoustic neuroma
Unilateral hearing loss
Tinnitus
Vertigo
Facial nerve palsy
What is needed to diagnose acoustic neuroma?
MRI
Treatment of acoustic neuroma
Observe if small
Surgery
Radiation
Parts of the surface anatomy of the external ear
Helix
Antihelix
Concha
Tragus
Antitragus
Lobule
Is air or bone conduction better normally?
Air conduction is better
In conductive hearing loss, is air or bone conduction better?
Bone conduction
In sensorineural hearing loss is air or bone conduction better?
Air conduction
Normal findings of a Weber’s test
Centre
(Equal in both ears)
Findings of a Weber’s test in conductive hearing loss
Sound lateralises towards pathology
Findings of Weber’s test in sensorineural hearing loss
Sound lateralises away from pathology
A patient come to the GP complaining of a foul smelling discharge coming from their ear, what is the most likely diagnosis?
Cholesteatoma
What organism causes Ramsay Hunt syndrome?
Varicella zoster
Tympanic membrane pathologies
- perforations (wet vs dry)
- cholesteatoma
- tympano sclerosis
Wet vs dry tympanic membrane perforation
-
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
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
Describe what you would see during an otoscope exam in a child with otitis media without perforation or effusion
Bulging, red + inflamed tympanic membrane
Describe what you would see during an otoscope exam in a child with otitis externa
Oedematous, inflamed EAM +/- discharge
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
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
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
What is oscilloscia?
A vision problem which causes still objects to jump, jiggle or vibrate due to misalignment of eyes or balance system issue
Examples of vestibular function tests
- video-nystagmography
- rotational chair test
- caloric test
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
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
What test can you use to assess balance?
Romberg test
Standing up with eyes closed
Presentation of vestibular migraine
Migraine in combination with vertigo, imbalance, nausea + vomiting
What can trigger vestibular migraines?
- stress
- bright lights
- strong smells
- certain foods
- menstruation
- abnormal sleep patterns
Central vs peripheral vertigo
- central: pathology related to the cerebellum or brainstem
- peripheral: pathology in the inner ear
Common pathology causing central vertigo
- posterior circulation infarction (stroke)
- tumour
- multiple sclerosis
- vestibular migrainene
Common causes of peripheral vertigo
- BPPV
- Meniere’s disease
- Labyrinthitis
- Vestibular neuronitis
What examinations may you want to do on a person presenting with vertigo?
- cerebellar exam - DANISH
- romberg’s test
- dix-hallpike manoeurve
Drug management of peripheral vertigo
- prochlorperazine
- antihistamines
