Ear Flashcards
1
Q
Describe the structure of the External Auditory Meatus
A
Sigmoid shaped tube
External 1/3 Cartilage
Internal 2/3 Temporal Bone
2
Q
Describe the structure of the Tympanic Membrane
A
Skin on the external surface and mucous membrane on the inside
Connected to surrounding temporal bone by cartilagenous ring
Parts include: Pars Tensa, Pars Flaccida, Anterior and Posterior Malleolar fold
3
Q
Describe the blood supply to the External Ear
A
Branches of ECA (Posterior Auricular, Superficial Temporal, Occipital, Maxillary)
4
Q
Name the four nerves innervating the External Ear
A
Auriculotemporal
Greater Auricular Nerve
Lesser Occipital
Auricular branch of vagus
5
Q
How would bites of the external ear be managed?
A
Wounds left open, irrigated, abx given
6
Q
Why does a Pinna Haematoma require urgent ENT referral?
A
Disrupts overlying vessels in the Perichondrium which can lead to avascular necrosis (and cauliflower ear)
7
Q
How is Tympanic Membrane perforation managed?
A
Traumatic - Watch and wait for 6 weeks, avoid water, after this if persisting then refer for myringoplasty
Non traumatic (eg post OM) - Antibiotics, water avoidance, and review in 6 months
8
Q
What is a Haemotympanum?
A
Blood in the middle ear often associated with Temporal Bone Fracture
Conservatively managed but followed up to check for residual damage
9
Q
Name the two parts of the middle ear
A
Tympanic Cavity (containing Malleus, Incus, Stapes)
Epitympanic Recess (superior to Tympanic Cavity near mastoid air cells)
10
Q
Where does Stapes connect to?
A
Oval Window of middle ear
11
Q
What is the purpose of Mastoid Air Cells?
A
Buffer system of air
Release air if pressure becomes too low
12
Q
Two muscles are involved in the Acoustic Reflex. What is this and name the muscles involved.
A
Protective muscles contract in response to loud noises
Tensor Tympani and Stapedius
13
Q
What is the role of the Eustacian Tube?
A
Connects middle ear to Nasopharynx, equalising pressure
14
Q
Otitis Media can be Acute or Chronic. How can Chronic Otitis Media be subclassified?
A
- Active Mucosal (discharge through perforation)
- Inactive Mucosal (perforation but no discharge)
- Active Squamous (cholesteotoma)
- Inactive Squamous (retraction pocket)
15
Q
What are the two main roles of the Inner Ear?
A
Converts mechanical signals into electrical
Maintains balance by detecting position and motion
16
Q
There are two main components of the Inner Ear. Describe the Bony Labyrinth
A
Cochlea, Vestibule and three Semicircular Canals
Lined internally with Periosteum and contains Perilymph
17
Q
There are two main components of the Inner Ear. Describe the Membranous Labyrinth
A
Lies within the Bony Labyrinth
Contains Endolymph
Cochlear duct, Semicircular Ducts, Utricle, Saccule
18
Q
Describe the structure of the Vestibule
A
Central part of the bony labyrinth
Separated from middle ear by oval window
Contains Saccule and Utricle
19
Q
Describe the structure of the Cochlea
A
Twists around a central portion of bone called the Midiolus
Spiral lamina bone attaches to cochlear duct
Two perilymph filled chambers (Scala Vestibuli, Scale Tympani)
20
Q
Describe the structure of the Semicircular Canals
A
Anterior, Lateral and Posterior
Swelling at one end known as Ampulla
21
Q
What is the Cochlear Duct?
A
Sits within the Cochlea and is the organ of hearing
Epithelial cells of hearing - Organ of Corti
22
Q
What are the Saccule and Utricle?
A
Two membranous sacs which are organs of balance
Utricle connects to Semicircular Canals and senses position side to side
Saccule recieves cochlear duct and senses upwards and downwards movement
Endolymph drains from here
23
Q
Describe the distribution of CNVIII
A
Forms Vestibular Ganglion which splits into superior and inferior parts to supply: Saccule, Utricle, Semicircular Canals
Cochlea portion: Enters at base of Mediolus to supply receptors of Organ of Corti
24
Q
What is the time frame description for Otitis Externa?
A
Acute <3 weeks
Chronic >3 months
25
Describe the protective mechanisms of the External Ear
- Elastic cartilage has protective hairs
- Self cleansing via Epithelial Escalator
- Ear wax
26
Ear wax is composed of Epithelial Cells, Lysozymes and Oily Secretions. Name four roles
- Cleaning and lubrication
- Protection from bacteria/dust/insects
- Acidic coat inhibits microbial growth
- Hydrophobic coat prevents water reaching canal skin
27
Name four risk factors for Otitis Externa
Hot and Humid Climates
Swimming
Immunocompromised
Insufficient or Excessive wax
28
What organisms are implicated in Otitis Externa?
90% Bacterial (S.Aureus, Pseudomonas)
10% Fungal (aspergillous - after prolonged abx)
Herpes Zoster
29
Name four non infective causes of Otitis Externa
Acne
Eczema
Psoriasis
Ear Plugs (irritants)
30
Name four symptoms of Otitis Externa
Pain
Itching
Hearing Loss
?Discharge
31
Name three signs OE of Otitis Externa
Inflamed External Canal
Scaly Skin
Pre-auricular LN
32
Necrotising Otitis Externa is a subtype of Otitis Externa. Define it
Extension into Mastoid or Temporal Bones (often in immunocompromised, elderly or diabetic)
33
How does Necrotising Otitis Externa present?
Discharge
Jaw Pain
Headache of great intensity
Facial nerve palsy - if osteomyelitis
34
How would you investigate Necrotising Otitis Externa?
Bone Scan
| CT
35
How would you manage Necrotising Otitis Externa?
Prolonged Abx
Piperacillin- Tazobactam
Ciprofloxacin if pen allergic
36
You would only investigate Otitis Externa if it was atypical or non responding. How would you do this?
Ear Swab
Test integrity of membrane - can they taste something put in ear, can they blow out when nose is pinched
37
How is Otitis Externa managed?
Remove any debris
Mild - Acetic Acid
Moderate - Topical Abx (Cipro)+/- Steroids
Severe - Oral Flucloxacillin (if systemically unwell)and Topical Abx
38
What general advise should you give patients with Otitis Externa?
Use ear plugs when swimming
Keep ears clean and dry
Avoid swimming for 7-10d
39
What is Recurrent AOM?
>3 distinct episodes of AOM in the past 6 months
40
Name the common organisms implicated in AOM
Haemophilus Influenza
Strep Pneumoniae
Rhinovirus
RSV
41
Name four risk factors for AOM
Smoking
URTI
Eustacian Tube Dysfunction
Craniofacial Abnormalities
42
Name three presenting features of AOM
Otalgia (tugging at ear)
Fever
Hearing Loss
43
Give three differentials for AOM
Trigeminal Neuralgia
TMJ dysfunction
GCA
44
What might you see on Otoscope of AOM
Red/Cloudy TM
| Air fluid level
45
How would you immedately managed AOM?
Simple analgesia
Delayed Abx (5d Amoxicillin - not delayed if systemic sx or at risk)
46
When would you admit patients with AOM?
Severely systemically unwell
Suspected complications
<3m with temp >38
47
When would you refer a patient with AOM to ENT?
If recurrent in the present of persistant symptoms/persistent cervical lymphadenopathy/unilateral epistaxis
48
Name three complications of AOM
Tympanic perforation
Hearing loss
Labyrinthitis
49
What is Otitis Media with Effusion?
Results from either incomplete resolution of AOM or non infective obstruction of Eustacian Tube
Relative negative pressure in the ear canal drops leading to fluid accumulation
50
Name four risk factors for Otitis Media with Effusion
Chronic allergy
Sinusitis
Deviated septum
Enlarged tonsils
51
Name four presenting features of Otitis Media with Effusion
Rarely Otalgia
Fullness
Pressure popping
Poor speech development
52
What would you see on Otoscopy of Otitis Media with Effusion
Retracted Straw Coloured Tympanic Membrane
53
Adults with Otitis Media with Effusion should be fully investigated as it is rare. Name two investigations
FNE
| Tympanogram
54
Tympanograms measure compliance of TM by inserting a probe. Describe the three possible results
Type A - Peaks at 0 (normal)
Type B - Flat (Middle ear effusion - eg OME or perforation)
Type C - Tracing peaks at negative pressure (Eustacian Tube Dysfunction)
55
Name the management options for Otitis Media with Effusion
Valsalva for temporary relief
Grommets
Adenoidectomy
Laser Myringotomy
Normally resolves in 6-12 weeks
56
Cholesteotomas normally form due to dysfunctional eustacian tube. Describe the formation
Negative pressure pulls Pars Flaccida backwards, allowing epithelial cells to become trapped and proliferate
Osteolytic enzyme release can cause bony destruction
57
The majority of cases of Cholesteotoma are Primary Acquired. Describe the aetiologies of Congenital and Secondary Acquired.
Congenital - Squamous epithelium becomes trapped in temporal bone during embryogenesis
Secondary - Insult to TM (as a result of trauma, surgery or Otitis Media)
58
Name four presenting features of Cholesteotoma
Progressive hearing loss
Foul smelling painless otorrhoea
Vertigo
Headache
59
How is a Cholesteotoma investigated?
Otoscope - pearly white mass behind TM, pus filled canal with granulation tissue
Audiological tests
CT - assesses bone invasion and how successful surgery would be
60
What are the two surgical options for Cholesteotoma?
Open (Tympanomastoidectomy)
| Closed (Tympanoplasty)
61
What is the difference between Vestibular Neuritis and Labyrinthitis?
Vestibular Neuritis only affect vestibular nerve
Labyrinthitis affects vestibular nerve and labyrinth
Vestibular Neuritis will not alter hearing
62
What causes Vestibular Neuritis?
Reactivation of latent type 1 HSV in Vestibular Ganglion
Commonly preceded by URTI
63
What causes Labyrinthitis?
Usually viral in origin
Bacterial is dangerous (passes between anatomical connections)
May be associated with systemic disease
64
How does Vestibular Neuritis present?
Sudden spontaneous vertigo
| Nausea and Vomiting
65
How does Labyrinthitis present?
Sudden spontaneous vertigo
Nausea and Vomiting
Hearing Loss
Tinnitus
66
Name three clinical investigations you could do for suspected Labyrinthitis/VN
Head Impulse Test
Nystagmus (consistent and unilateral)
Skew
67
What is the Head Impulse Test?
Fix patients gaze on your nose then move their head sharply
Patient should maintain gaze, not lag (saccades)
Not +ve in stroke
68
How is Labyrinthitis investigated?
Culture and sensitivity if middle ear effusions are present
CT - Mastoiditis
69
How is Labyrinthitis managed?
Sudden unilateral hearing loss - Emergency ENT
Reassurance - lie still in acute attacks and become mobile as soon as possible
Medication - Prochloperazine or Antihistamines
70
What is Menieres Disease?
Distension of membranous labyrinth due to excess endolymph
Risks - Allergies, Autoimmunity, Genetic succeptibility
71
Describe the diagnostic criteria for Menieres
2 x 20 minute vertigo
Hearing Loss
Tinnitus and /or aural fullness
72
Name five investigations for Menieres
```
Full Neurological exam
Pure tone audiometry
MRI IAM
Video Head Impulse testing
ECG
```
73
What is an important management step in Menieres?
Inform DVLA
74
How should acute attacks in Menieres disease be managed?
Prochlorperazine
| IM Steroid injection (followed by tapered oral)
75
Describe the prophylactic management of Menieres
Low salt
Low caffiene
Trial of betahistine or diuretics
76
Describe the surgical management of Menieres
Endolympatic Sac Decompression
| Labyrinthectomy (causes loss of hearing)
77
What does BPPV stand for?
Benign Paroxysmal Positional Vertigo
78
Describe the pathophysiology of BPPV
Hairs embedded in Otoliths experience the movement of endolymphs depending on position
If otoliths become detached, there will still be movement - vertigo
Normally idiopathic but can occur after head injury
79
Name four risk factors for BPPV
Older Age
Women
Menieres (co diagnosis in 30%)
Anxiety Disorders
80
How does BPPV present?
Vertigo promoted by head movement
Attacks are sudden onset and last 20-30 seconds
Nausea
Symptoms worse in morning
81
What would you want to examine in BPPV
Cranial Nerve
External Ear
Tympanic Membrane
82
What is the diagnostic test for BPPV?
Dix Hallpike
Sit patient up so they're looking at you at a 45 degree angle, then suddenly lower so head is off the bed
Observe for nystagmus
83
What does the direction of Nystagmus in BPPV indicate about the canals?
Vertical and Rotary - Posterior Canal
| Horizontal - Horizontal canal
84
BPPV is self limiting over a number of weeks but can reoccur. What should you advise the patient?
Notify DVLA
Get out of bed slowly
Epleys Manouvre (Dix Hallpike but wait for Nystagmus to subside then rotate 90 degrees and sit patient up)
85
Give a differential diagnosis for BPPV
Vestibular Migraine
86
Name two other causes of hearing loss
Acoustic Neuroma
| Otosclerosis
87
Otosclerosis is caused by the pathological increased bone turnover. Give four risk factors
Genetics (Autosomal Dominant)
Oestrogen
Viral
Lack of fluoride
88
How does Otosclerosis present?
Progressive hearing loss and tinnitus
Low volume speech
Stapes gradually becomes adhered to oval window
89
How is Otosclerosis managed?
Bilateral hearing aids
Bisphosphonates or NaF
Stapedectomy or Stapedotomy
90
What is Tinnitus?
The perception of sound when no external sound is present
Most people hear tinnitus at some pint but it is usually masked by external sounds
91
There are two types of tinnitus: Pulsatile and Non Pulsatile. What is Pulsatile tinnitus ?
Synchronous with heartbeat due to turbulent flow reaching cochlea
Causes: Carotid Atherosclerosis, AV Malformation, Pagets, Otosclerosis
92
There are two types of tinnitus: Pulsatile and Non Pulsatile. What is Non Pulsatile tinnitus ?
Buzzing/high pitched/clicking
Causes: Presbyacusis, Menieres, Drugs
93
Name three drugs associated with Tinnitus
Loop Diuretics
NSAIDs
Salicyclates
94
How is Tinnitus investigated?
MRI (if unilateral to exclude Acoustic Neuroma)
Pulsatile - CT/MR Angiography
Tinnitus Functional Index
95
How is Tinnitus managed?
Reassurance
Address underlying cause
Coping mechanisms/Noise generator
96
Name three causes of Conductive Hearing Loss
Excess earwax
OME
Otosclerosis
97
Name three causes of Sensorineural Hearing Loss
Presbyacusis
Noise Induced
Acoustic Neuroma
98
Aside from Webers and Rinnes, Pure Tone Audiometry is used to investigate reduced hearing. What is this?
Evaluates the quietest sound that can be heard in each ear
| Must exclude wax/infection beforehand
99
Describe the difference in audiometry graphs between Presbyacusis and Menieres
Menieres - hearing loss at a lower frequency
| Presbyacusis - hearing loss at a higher frequency
100
Describe four surgical management options for reduced hearing
Bone anchored hearing aid
Cochlea Implant
Stapedectomy and Prosthesis
Tympanoplasty
101
Give three management options for excess wax
Topical Olive Oil/Sodium Bicarbonate
Microsuction
Syringing
102
Name three congenital and two acquired causes of childhood deafness
Congenital - Rubella, Ear Atresia, Ossicular Abnormalities
Acquired - Hypoxia, Jaundice, Meningitis, Head Injury
103
What is Ramsey Hunt Syndrome?
Reactivation of Herpes Zoster in geniculate ganglion
104
What are the motor branches of the facial nerve?
Within facial canal - Nerve to Stapedius
Prior to Parotid - Posterior Auricular, Nerve to Digastic, Nerve to Omohyoid
Within Parotid - Temporal, Zygomatic, Buccal, Mandibular, Cervical
105
Name five clinical features of Ramsay Hunt Syndrome
- Vesicular rash on ipsilateral ear/hard palate/ anterior 2/3 of tongue
- Hearing loss
- Ipsilateral facial weakness
- Drooling
- Hyperacusis
106
How is facial paralysis graded?
House Brackmann (I - IV)
107
Ramsey Hunt Syndrome is a clinical diagnosis. What features would point towards an alternative?
Systemic Illness
Hearing abnormalities
Forehead sparing
108
What are the main management points for Ramsey Hunt Syndrome?
Analgesia
Steroids +PPI
Aciclovir
Eye care
109
What particular things would you want to note in a child with reduced hearing?
```
Age of first word
Milestones
Vocab extent
Pain/Discharge
Imbalance
DH
```
110
Name three syndromes that include deafness
Waadenberg (+Heterochromia and wide nasal bridge)
Jervell Lange Nielson
CHARGE
111
What is an electronic hearing aid?
Consists of ear piece, amplifier and microphone
T Setting - allows electromagnetic induction to block background noise
112
Why do Electronic Hearing Aids work better for conductive hearing loss?
Sensorineural causes recruitment - loud sounds are heard exceptionally loudly
113
Name three disadvantages to electronic hearing aids
Feedback
Otorrhoea
Dead Battery
114
Name two environmental aids to help deaf people
Doorbells changed to buzzers/flashing lights
Telephones can be fitted with T Induction
115
Name three conditions to avoid in someone who has to lip read
Poor background lighting
Beard and Moustache
Covering face with hand
116
What is a Cochlear Implant?
Processor converts speech into electrical signals, transmitted to electrode in cochlea which then stimulates nerve
Used when abnormal cochlea but normal cochlear nerve
117
What is a contraindication to Cochlear Implant?
Middle ear infection
118
Give four otological causes of Otalgia
Otitis Externa
Furunculosis
Otitis Media
Acute Ototic Barotrauma
119
Name a non otological cause of Otalgia
Referred pain (Tonsillitis, Teeth, TMJ)
120
Name two causes of watery otorrhoea
Eczema of external ear
| CSF
121
Name two causes of purulent otorrhoea
AOM
| Furunculosis
122
Name two causes of bloody otorrhoea
Trauma
| AOM
123
Name a cause of foul smelling otorrhoea
Cholesteotoma
124
Define Vertigo
Illusion of rotary movement - worse in the dark
125
The causes of vertigo can be diagnosed based on time frame. Give two causes of vertigo lasting 'seconds'
Postural Hypotension
| BPPV
126
The causes of vertigo can be diagnosed based on time frame. Give two causes of vertigo lasting 'mins to hours'
Menieres
| Labyrinthitis
127
The causes of vertigo can be diagnosed based on time frame. Give two causes of vertigo lasting 'hours to days'
Ototoxicity
| Central vestibular disease
128
Give three non otological causes of Vertigo
Migraine
TIA
Epilepsy
129
What are the three commonest causes of episodic vertigo?
BPPV
Menieres
Migraine
130
What would investigations of Otosclerosis show?
Tympanogram - normal type A
Pure Tone Audiometry - Carhart notch (dip at 2kHz)
131
Name five things you would want to determine in a Tinnitus History
PHUCD
```
Pulsation or non
Hearing Loss
Unilateral of Bilateral
Constant or intermittent
Dizziness
```
