E Flashcards
What is vertigo
An illusion of movement, usually rotatory
What happens if balance goes wrong?
Can’t stand up or walk straight
Nystagmus
Vomiting
What is nystagmus? 2 different types
Periodic rhythmic ocular oscillations - everyone gets at the extremes of gaze
Pendular - both directions at same speed
Jerk - fast and slow phase
Inputs of balance system
Eyes
Proprioception
Vestibular system
Central connections
Brainstem
Cerebellum
Output
Musculoskeletal
Eye movements
Things that can go wrong with central connections of balance
Migraine associated vertigo
Brain stem infarct
Cerebellum infarct
Tumours
Problems with output of vestibular system
PD
Arthritis
Problems with inputs of vestibular system
Eyes - blind
Neuropathy - proprioception
Vestibular - BPPV, labrynthitis, Ménière’s disease
What is BPPV?
Benign paroxysmal positional vertigo
Occurance of BPPV
Common, easily treatable
Presentation of BBPV
Short episodes of vertigo lasting seconds to minutes
Commonly precipitated by rolling over in bed - couple seconds later the room starts to spin
Pathology of BPPV
Debris in the posterior semicircular canal
Canalolithiasis
Loose in canal and cause excessive stimulation of hair cells
Dx of BPPV
History
Hallpikes test
Treatment of BPPV
Epleys manoeuvre
What is labyrinthitis
Single episode of vertigo lasting for several days
Often precipitated by URTI
Symptoms of labrynthitis
Vertigo, nausea and vomiting
So bad can’t get out of bed
No hearing loss
Nystagmus with labyrinthitis
Eyes will flick towards the affected ear - paralytic nystagmus
Or eyes will flick away from affected side - irritating nystagmus
Management of labyrinthitis
Hydration Benzodiazepines - vestibular sedatives Prochlorperazine - antiemetic Steroids if severe Antibiotics if bacteria cause suspected
What is menieres disease?
Attacks of vertigo, tinnitus, hearing loss and feeling of aural fullness/pressure
Multiple episodes often occur in clusters
Additional feature of Ménière’s disease
Drop attacks - tumarkin crisis
Suddenly fall to the ground with no loss of consciousness
Feel as though being pushed
Activations of hair cells - don’t know why
Not everyone gets them
Pathology of Ménière’s disease?
endolymphatic Hydrops - build up of endolymphatic fluid in the inner ear
Aetiology unknown
Dx of Ménière’s disease
History
Electrocochleography
Prevention of Ménière’s disease attacks
Low salt diet
Reduce caffeine and chocolate
Diuretics
Betahistamine
To abort Ménière’s disease attacks
Antiemetics - prochlorperazine or ondansetron
Antihistamines - Meclozine or drimethobenzamide
Treatment of Ménière’s disease
Intratympanic gentamicin (ototoxic therefore chemical labyrinthectomy- have severe vertigo for 2 weeks until body compensates for lack of vestibular input from that ear)
Intratympanic steroids
Endolymphatic surgery
Vestibular neurectomy
Labyrinthectomy
Features of migraine associated vertigo
Hearing normal
Not always a headache
Duration variable
Prophylactic agents work - acute migraine treatments don’t
What is dizziness?
The feeling that you are about to fall, instability and tendency to lose ones balance
What is otorrhoea
Discharging ear
Which hand do you use to hold the auroscope to examine the right ear
Your right hand
Where is ear wax produced and where should it normally be found?
Outer 1/3 of EAC and that is where it should be found
Shouldn’t see ear wax on the TM
Type of skin in EAC
Migratory epithelium - forms in centre of TM and then moves outwards
Cannot be normal skin because if you shed dead skin then the ear canal would get bunged up
Functions of ear wax
Natural protective layer
Keeps ear waterproof
Conditions the skin
Mild antibacterial
When does ear wax become pathological
When it gets completely compacted and occludes the ear canal
Treatment of pathological ear wax
Syringing it out - flood it with water - aim behind the wax - don’t aim at eardrum
Microsuction
What is otitis externa?
Acute inflammation of the skin of the EAC
Symptoms of otitis externa
Otalgia Itchy Otorrhoea Oedema Erythema Severe swelling can cause hear loss
Predisposing factors of otitis externa
Anatomical Occlusion (FB, hearing aid) Moisture (humidity or swimming) Skin condition such as eczema - lose the protective layer DM COM
Common bacteria in otitis externa and other common ones
Pseudomonas aeruginosa (pungent otorrhoea) + other gram negatives
When do you suspect fungal otitis externa?
When discharge is resistant to Ab ear drops
What is appearance of fungal otitits externa?
Fluffy “cotton wool” type debris or black spots (aspergillus niger)
How do you treat fungal otitis externa?
Can take several weeks of therapy to clear
Don’t stop anti-fungal therapy when you can’t see any more - need to do it for weeks or it will reoccur
What is furunculosis
Reccurent infected boil in the ear
Acute and really painful
Causes conductive hearing loss
Treated with systemic ab’s
Treatment of otitis externa
Keep it dry and do not put things down it
Topical antibiotic/steroid combination (steroids because it is inflammatory not just infectious)
If no improvement initially with medical treatment of otitis externa?
Microsuction or aural toilet
What is necrotising otitis externa? What organism causes it and symptoms?
Life threatening invasive pseudomonal infection of the bone
Severe constant pain
Who gets necrotising otitis externa?
Diabetics, elderly and immunocompromised
Treatment of necrotising otitis externa?
Antipseudomonal ab long term and ciprofloxacin ear drops
What can cause perforated ear drum?
Acute OM
Traumatic - blast injury
Iatrogenic
What does ear drum perforation cause
Hearing loss with recurrent discharge (OM )
Management of perforated ear drum
Keep it dry
Small and acute - wait and encourage healing and prevent infection
If larger - myringoplasty or tympanoplasty - surgical repair
What is cholesteatoma?
Keratinizing squamous epithelium in the middle ear - ball of skin trapped there
Can’t go anywhere therefore gets infected
Presentation of cholesteatoma
Foul-smelling otorrhoea
Hearing loss
What does examination of cholesteatoma show?
Tympanic membrane full of white cheesy material
Compliction of cholesteatoma
It grows and destorys structures - produces enzymes which break down bone eg. ossicles and inner ear
Can erode into facial nerve - cause palsy
Can also cause vertigo
Management of cholesteatoma
Mastoidectomy
Discharge in neoplastic lesions in the ear
Chronic pink (blood-stained) discharge
Usually presentation of neoplastic lesions
Very rare. Previous hx of skin cancer and they are painful
5 questions to ask if any ear symptoms
Tinnitus, hearing loss, pain, discharge and vertigo
When is fhx relavant in hearing loss
Significant HL before age of 60
What drugs are ototoxic?
Aminoglycosides Cisplatin Diuretics - furosemide Aspirin Quinine
Rhine’s normal test
AC > BC, also present if mild SN HR
Rhine’s negative test
Conductive hearing loss
BC > AC
Weber’s normal test
Can hear a faint buzzing everywhere
Weber’s if SN hearing loss
Bone conduction preferentially to side which is not affected
Weber’s if CH R
Bone conduction to the side with conductive HR
What is tympanometry
Measures the pressure across the tympanic membrane
Will be altered if perforation of compacted middle ear infection
Causes of congenital conductive hearing loss
Anotia - no outer ear
Atresia of ear canal - canal hasn’t opened up yet
Ossicular malformation
Management of congenital conductive hearing loss
Cochlear is frequently normal
Therefore rehab with hearing aid
Reconstruction surgery has poor results
Causes of acquired hearing loss
1) Wax/FB
2) Otitis Externa
3) TM perforation
4) Otitis media (because compacted and ossicles can’t move)
5) Glue ear
6) Otosclerosis
7) Ossicular discontinuity
Signs of OM
Severe pain and conductive hearing loss
Tinnitus
Children may get systemic symptoms
Otorrhoea if ear drum perforates
Commonest cause of OM
Viral eg. following cold
Bacterial causes of OM
Strep.pneumoniea
H/influenzae
Moraxella
Treatment of OM
Most settle within 72hours without treatment
If systemic features after 72 hours then give amoxicillin
What treatment is of no value in OM
Topical therapy
Complications of OM
Perforation (no more pain and otorrhoea)
Infection of mastoid bone - tenderness and swelling over mastoid bone
What is glue ear?
Otitis media with secondary effusion causing mucous plug in eustachian tube
Serous otitis media
Common in children because of Eustachian tube dysfunction
Normal development of glue ear
Usually resolves naturally but can persist giving HL
Also predisposes to reccurent attacks of OM
Treatment of glue ear
Grommet - tympanostomy tube - inserted into TM and ventilates the middle ear cavity - taking over eustachian tube function
Usually extruded from TM as it heals (over 6months to 2 years)
After what age to eustachian tube dysfunctions become rare
7-14 when middle 1/3 of face grows
What is otosclerosis?
Usually a hereditary disorder associated with new bony deposits within the stapes footplate and cochlea
When does otosclerosis present?
Normally 20-30s
F>M
Worse in pregnancy
Treatment of otosclerosis
Hearing aid
OR
Stapedectomy
Causes of congenital SN HR
Cochlear dysplasia
Auditory nerve aplasia
Most common acquired cause of SN HR
Presbyacusis
degenerative disorder of cochlea of old age
Can be due to loss of any part of SN pathway
Which sound frequencies most commonly affected in presbyacusis?
High frequency - consonants - therefore speech intelligible
Treat with high frequency hearing aid
Other causes of acquired SN HL
Noise exposure Ototoxic drugs (overdose or normal dose in susceptible individuals - eg. renal failure, pre-existing SN HR or old age)
Menieres disease
Vestibular schawannoma
