Disorders of the Ear Flashcards
Describe the Weber test
Tuning fork placed atop of head.
If sound lateralizes to Crummy (bad) ear = Conductive hearing loss.
If lateralizes to Super (good) ear = Senorineural loss.
Describe the Rinne test
Tuning fork placed on mastoid process, once pt cannot hear move fork in front of ear canal, pt should then be able to hear sound again, this is normal bc AC > BC.
If BC > AC abnormal Rinne test.
List disorders of the external ear
Cerumen impaction
FBs
Otits Externa “swimmers ear”
Hematoma
When would you NOT irrigate for cerumen impaction?
if TM is not intact or if known hx or risk of perforation
Describe treatment options for cerumen impaction?
- Detergent ear drops - Debrox earwax removal kit, carbamide peroxide is generic
- Mechanical removal w curette
- Irrigation - if TM intact, body temp water only, canal must be dried after irrigation
Describe tx of FB in ears
Urgent if button batteries, live insects, or penetrating FB
Firm objects should be removed with loop or irrigation avoiding pushing closer to TM.
Organic FBs NOT irrigated but removed. Immobilize living insects - can use Lidocaine
Describe causes of Otitis Externa
- Infection * most common
Allergic
Dermatological conditions (psoriasis)
What is Otitis Externa (OE)?
Inflammation of external auditory canal (EAC)
Bacteria associated with otitis externa
1 Pseudomonas - gram neg rod
S areus
S epidermidis
Also.. fungi (2-10% cases) Aspergillus and Candida
Describe clinical presentation of otitis externa
- Otalgia (pain)
- Pruritis (more common in fungal infection)
- Purulent discharge
- Hearing loss
- Fullness
- Hx of recent water exposure, mechanical trauma, perforation, perforation bc of topical drops
PE findings of Otitis Externa
- Erythema/edema of ear canal skin
- Purulent exudate
- Tenderness
- TM may be mildly erythematous
- TM remains mobile with pneumatic otpscopy
DDx of otitis externa
Middle ear infection
Contact dermatitis
Psoriasis
Chronic suppurative otitis media
Squamous cell carcinoma of external canal
Radiation therapy
Herpes simplex virus - Ramsay Hunt Syndrome
What is Ramsay Hunt Syndrome?
An outer ear infection that is rare, characteristic vesicles on out ear canal with lateral facial paralysis, caused by herpes simplex virus
Tx of otitis externa
7-10 days topical aminoglycoside or fluoroquinolone Abx w or w/o corticosteroid (otic suspension)
Keep canal dry, avoid scratching, remove debris, can use wick if swelling significant
Severe OM w/ cellulitis of periauricular tissue need oral Abx
Refer to ENT if persistent OE or if pt immunocompromised or diabetic
Pts that are immunocompromised or diabetic are at risk for what complication of OE?
Malignant otitis externa aka necrotizing otitis externa -
increase risk for osteomyelitis of temporal bone/skull base
Describe presentation of malignant otitis externa?
Foul-smelling discharge, granulations in ear canal, deep otalgia, cranial nerve palsies, HA
Dx: CT – osseous erosion
Treatment-IV antibiotics (quinolones), surgery
Describe hematoma of external ear
often due to injury - wrestlers esp
traumatic auricular hematoma, must be recongnized promptly
Tx is drainage
Complication - cauliflower ear
Most common causative organisms of acute otitis media?
#1 Streptococcus pneumonia #2 Haemophilus influenza #3 Moraxella catarrhalis
and also
S. pyogenes (group A step)
S. aureus
recurrent cases often associated with allergies or second hand smoke exposure
Describe pathophysiology of Acute Otitis Media
- bacterial infections of middle ear, usu precipitated by URI - eustachian tubes obstruct, fluid/mucous accumulates becomes secondarily infected
- underlying poor drainage from eustachian tubes due to age, inflammation/edema, congenital malformation
Clinical presentation and epidemiology of AOM
Otalgia/pressure
Hearing loss
Fever (children > adults)
URI symptoms
Most common in children 4-24 months, increased during winter and fall.
A tympanic membrane with bullae is associated with what microorganism?
mycoplasma
PE of AOM
TM immobile
erythematous and bulging
possible TM rupture
1st line treatment of AOM**
high dose amoxicillin (80-90 mg/kg/day divided twice daily)
2nd line Tx of AOM
High-dose amoxicillin-clavulanate or 2nd or 3rd generation cephalosporin
Tx of AOM with perforated TM
Include topical antibiotic with low ototoxicity (ofloxacin)
Describe observation vs antibiotics for AOM
Observation
if 6 mo-2yr with unilateral AOM and mild sxs
if >2yr with unilateral or bilateral AOM and only mild sxs
Abx if worsening or no improvement in 48-72hrs
Immediate Abx if
under 6 mo
under 2yr with severe AOM, moderate or severe sxs, pain >48hrs, Temp > 102.2 F (39C), bilateral AOM
Complications of AOM
- Labyrinthitis. -inflammation into the semicircular canals
- Hearing loss
- Mastoiditis (high risk in immunocompromised, Tx IV Abx or mastoidectomy)
- Non-response to meds (resistant organisms, change Abx)
- Reccurent infections (may require tympanostomy - pressure equalizing tubes)
Describe presentation and PE of chronic otitis media
Chronic otorrhea (drainage) PE - perforated TM and conductive hearing loss
Tx for chronic otitis media
- Removal of infected debris
- Earplug use (recc to prevent water/moisture)
- Topical or oral antibiotics (that are not ototoxic)
-Surgery – TM repair
Describe serous otitis media aka otitis media with effusion
Eustachian tube stays blocked for a prolonged time, negative pressure moves fluid into middle ear.
Children > adults, tubes more narrow and horizontal
Adults occurs after URI, barotrauma, or chronic allergies
PE of serous otitis media
TM dull and hypOmobile
Bubbles visible
Conductive hearing loss
Describe a cholesteatoma
specific type of chronic otitis media
creates sac lined w squamous epithelium that produces keratin, can get secondarily infected (pseudomonas or proteus)
presentation may be asymptomatic or hearing loss, possible ear drainage
Describe tx and complications of a cholesteatoma
Tx- Abx drops, surgical removal
Complications- erosion into inner ear, facial nerve, brain, abscess
Describe eustachian tube dysfunction
edema of tubal lining traps air in middle ear causing negative pressure can be caused by viral URI or allergies
on PE retraction of TM and decreased mobility of TM on pneumatic otoscopy
Tx options for ET dysfunction
Decongestants (topical intranasal or systemic oral) Autoinflation Desensitization therapy (allergies) Intranasal corticosteroids Surgery
What is Labyrinthitis? Describe its presentation
inflammation into the semicircular canals - a possible complications of AOM, often occurs post viral infection
acute onset of severe continuous vertigo \+/- hearing loss and tinnitus N/V gait impairment *cerebellar hemorrhage/infarct risk?*
Describe conductive hearing loss
usually a dysfunction of external and middle ear in transmitting sound to inner ear (cochlea)
air conduction measures conductive hearing
Describe sensorineural hearing loss
Sensory loss – dysfunction of cochlea from loss of hair cells
Neural loss – dysfunction of CN 8 (vestibulocochlear) or central auditory pathway
Most common = presbycusis (aging)
Tinnitus is associated with what kind of hearing loss?
Sensory hearing loss
Tinnitus is perception of sound in ear or head. Variability exists in sound quality, pitch, and duration
Peripheral causes of vertigo
Vestibular neuritis/Labyrinthitis Meniere disease BPPV Ethanol intoxication Inner ear barotrauma Semicircular canal dehiscence
Central causes of vertigo
Seizure Multiple sclerosis Wernicke encephalopathy Chiari malformation Cerebellar ataxia syndromes
What should you be concerned of with Labyrinthitis/not miss?
cerebellar hemorrhage or infarct
- evaluate nystagmus
- other neuro sxs
- risk category
consider neuroimagining
Differentiate clinical presentation of Central vs Peripheral Vertigo
Central: gradual onset progressive increase in severity Nystagmus - usu vertical or torsional no auditory sxs
Peripheral: sudden onset acutely severe sxs N/V tinnitus, hearing loss Nystagmus- usu horizontal
When is Dix-Hallpike maneuver used?
When assessing vertigo.
Positive test: delayed onset fatigable nystagmus in most peripheral causes
if nystagmus not fatigable, indicates central cause
What is BPPV?
Benign paroxysmal positional vertigo
Peripheral cause of vertigo
caused by sediment in semicircular canals, provoked by changes in head position
- acute vertigo x 10-60 seconds, imbalance x several hours
- episodes brief in duration often recurrent
- appear in clusters lasting several days
Describe treatment options for BPPV
Particle repositioning maneuvers - Epley maneuver
PT/OT referral
Pharmaceutical agents (vestibular suppressants)
Bed rest if severe
Pt ed, risk for falls
What is another name for Meniere Disease
Endolymphatic hydrops
Describe Meniere Disease
Def: vertigo syndrome due to a peripheral lesion
Distention of endolymphatic compartment of inner ear, pressure rises and falls - sxs wax and wane. Can permanently damage inner ear structures.
Clinical presentation of Meniere Disease
-episodic vertigo, spells lasting 20 mins - several hrs
(vs BPPV vertigo lasting <1 min)
- fluctuating sensorineural hearing loss (low frequency!)
- tinnitus
- sensation of unilateral ear pressure (aural fullness)
Describe Pathophys of vestibular schwannoma aka acoustic neuroma
one of most common intracranial tumor; benign tumor of CN 8 begins in internal auditory canal, gradually grows to compress pons and causes hydrocephalus
usually unilateral
Clinical presentation, Dx, and Tx of acoustic neuromas
Unilateral hearing loss - most common
Continuous dysequlibrium
Tinnitus
Dx: Audiometry, MRI
Tx:
Observation, Surgical excision, Radiotherapy
Epley maneuver is used to treat what vestibular disorder?
BPPV
- pt upright, legs extended
- head rotated 45degrees (towards side of + Dix-Halpike test)
- pt quickly and passively forced down in supine position, 30 degrees neck extension
- observe for primary stage nystagmus, 1-2 minutes
- pt head rotated 90 degrees, held in position 1-2 mins
- pt roles on shoulder, pt looking down at 45 degree angle, remains here 1-2 mins
- pt slowly brought upright maintaining 45 degree rotation of head, for 30 secs
