Ear Flashcards
1
Q
Type of hearing loss associated with cholesteatoma:
A
Conductive
2
Q
Complications of cholesteatoma and cholesteatoma surgery
A
**Intra-temporal: **
bleeding infection
facial nerve damage
deafness
tinnitus
perilymph fistula.
Extracranial:
cellulitis
neck abscesses (Bezold, Citelle, Luc).
Intracranial:
Meningitis
brain abscess
CSF otorrhoea
sigmoid sinus thrombosis.
complications of cholesteatoma are
similar to the complications associated with acute otitis media.
3
Q
Symptoms of cholesteatoma (4 min)
A
Discharge (ottorhoea)
Hearing loss
Vertigo
Tinnitus
Facial weakness
Those associated with infection > Meningitis / Cerebral abscess / Mastoiditis / Petrositis
NOT Pain usually
4
Q
Treatment for cholesteatoma
A
Mastoid exploration > Mastoidectomy
5
Q
Complications of untreated cholesteatoma (min 5)
A
Deafness (CHL > SNHL > dead ear)
Vertigo
Tinnitus
Facial weakness
Meningitis
Intracranial abscess
Sigmoid sinus thrombosis
Taste disturbance
6
Q
Specific complications of mastoid surgery (min 4)
A
Hearing loss
Vertigo
Tinnitus
Facial Nerve Injury
7
Q
Surgery for cholesteatoma
A
- Atticotomy. Used when the disease is limited to the attic region i.e. is relatively small
- Modified radical mastoidectomy. Used when the disease extends backwards into the mastoid system. It is a more traditional procedure and is being replaced, by many surgeons, with…
- Combined approach tympanotomy (CAT). Increasingly performed for larger diseases.
8
Q
How is the diagnosis of cholesteatoma made?
A
Clinical examination, usually plus audiogram showing CHL (although it may not)
9
Q
Imaging for cholesteatoma
A
CT
10
Q
Signs of cholesteatoma
A
Attic crust
Attic retraction
Keratin / aural polyp in the attic region
11
Q
Audiogram key
A
O = Right, air conduction masked if necessary
X = Left, air conduction masked if necessary (X = bad lefties)
[ = Right, bone, masked
] = Left, bone, masked
Triangle = bone, not masked
B thing - sound field testing - not ear specific
12
Q
Describe how you would do an audiogram:
A
Describe how you would do an audiogram:
- Examine ear to ensure clear canal +/- clear of wax
- Start with air conduction in better ear at 1000Hz at 60dB, Reduce by 10dB until no response, Increase by 5dB until response 2/2, 3/4 (>50%)
Threshold is the lowest level at which responses at least 50% time
- Repeat for other frequencies, Repeat for bone conduction
13
Q
Conductive hearing loss audiogram with narrowing of the air bone gap at 2kHz?
A
Carhart notch (basically bone conduction is improved at 2kHz)
= Otosclerosis
Fixation of the stapes within the oval window.
At 2K there is a downward depression in bone conduction and narrowing of the air bone gap.
OLD, doesn’t make sense:
2 kHz is the resonant frequency of the ossicular chain, the largest increase in bone-conduction threshold (improves, narrowing air bone gap)
14
Q
Treatment options for otosclerosis (min 4)
A
Observation
Fluoride supplementation for labrythine disease
Coventional hearing aid
Stapes surgery (only option for restoring natural acoustic hearing levels)
Bone conduction implant / device
Cochlear implant in advanced cases
15
Q
Audiometric investigations for otosclerosis?
A
Audiometry (audiogram)
Tympanometry - shows a As curve (shallow peaks at 0daPa)
Stapedial/Acoustic reflexes (Absent stapedial reflex)
A speech audiogram (poor speech discrimina reflects likely cochlea involvement)
16
Q
What is associated with otosclerosis ?
A
Osetogenesis imperfecta
17
Q
Method of inheritamce of otosclerosis
A
AD (incomplete penetrance)
18
Q
How are acoustic reflex measured
A
Generally by tympanometry to see if the stapes stiffens the TM and therefore decreasig middle ear admittance in response to sound
19
Q
Otosclerosis - epidemiology, diagnosis, investigations
A
Commonest cause of hearing loss in young adults in UK
Genetic predisposition
Can affect one or both ears
Diagnosis
- Clinical: adult presenting with progressive CHL / mixed hearing loss with normal otoscope
Investigations
- Tuning fork tests
- Audiometry (PTA)
- Typanometry
- Speech audiometry
- Stapedial/Acoustic reflexes (Absent stapedial reflex)
- CT scan to rule out other pathology if
20
Q
Stapes surgery
- What is it
- Risks / Cautions
A
Only option for restoring natural acoustic hearing levels
Fitting of a prosthesis between incus and stapes footplate
0.5-1% SNHL
Infection is a containdication
Caution for this surgery in an only hearing ear
21
Q
Pathophysiology of otosclerosis
A
Portions of the dense enchondral layer of the bony labyrinth remodel into one or more lesions of irregularly-laid spongy bone.
Lesions reach the stapes then harden (sclerosis), limiting movement = hearing loss, tinnitus, vertigo
22
Q
Complications of otitis externa
A
Spread to temporal bone - osteomyeltis (malignant otitis externa)
Spread of the infection to
the petrous apex - Petrositis
> Gradenigo’s syndrome
Facial cellulitis
23
Q
Name for fungal otitis externa
A
Otomycosis
24
Q
Microorganisms that cause otitis externa (5)
A
Staphylococcus aureus
Pseudomonas aeruginosa
Proteus
Aspergillus niger
Candida Albicans
25
RFs for Otitis Externa
Similiar to otomycosis
Water exposure
Canal trauma (E.g. cotton buds)
Diabetes / immunosuppression
Humidity (e.g. hot countries)
Eczema
Inherited e.g. narrow ear canals, non atopic eczema
26
Otitis externa - Management
Assuming simple
Micro swab
Aural toilet
Topical abx + steroids drops
+/- pope wick
Water precauations
27
Causative organism of otomycosis
Aspergillus Niger (90%)
Candida Albicans (10%)
Actinomyces
28
Risk factors for otomycosis
Water exposure (E.g. swimmers - repeated exposure removes cerumen)
Canal trauma (E.g. cotton buds)
Antibiotics
Diabetes / immunosuppression
Humidity (e.g. hot countries)
Eczema
Abscence of cerumen
29
Symptoms otomycosis
Pruritis (more marked usually then other OE)
Pain
Ottorhoea
Conductive hearing loss
30
Management of otomycosis
Aural toilet
Water precautions
Topical antifungals (E.g. clotrimazole)
Analgesia
31
Causes UMN facial nerve palsy
Stroke
MS
MG
GBS
Gliomas
Sarcoid
Drugs
32
Causes of LMN facial palsy
Trauma - Temporal bone fracture
Malignant - E.g. Parotid malignancy, facial nerve schwannoma)
Infective - Herpes Zoster (Varicella Zoster Virus - Ramsey Hunt Syndrome), CMV, EBV, AOM, cholesteatoma
Autoimmune - ? Sarcoid ? MS
Idiopathic - Bell's palsy
Iatrogenic - Parotid surgery, middle ear surgery, mastoid surgery
33
Grading of LMN facial palsy, name of scale and details:
House-Brackmann Scale
I - Normal
Normal facial function in all areas.
II - Mild Dysfunction
Slight weakness noticeable on close inspection; may have very slight synkinesis.
III - Moderate Dysfunction
Obvious, but not disfiguring, differences between 2 sides. Noticeable, but not severe, synkinesis or hemifacial spasm.
Complete eye closure with effort.
IV - Moderately Severe Dysfunction:
Obvious weakness of disfiguring asymmetry, normal symmetry and tone at rest but,
unable to complete eye closure.
V - Severe Dysfunction
Only barely perceptible facial muscle motion, asymmetry at rest.
VI - Complete paralysis
No movement
34
Symptoms of Ramsey Hunt Syndrome (Herpes Zoster Oticus) (min 6)
Otalgia
Hearing loss (SNHL)
Pharyngeal / palate ulceration / vesicles
Facial weakness (LMN facial palsy)
Other cranial neuropathies
Altered taste / metallic taste
Tinnitus
Vesicular rash (pinna and outer ear canal)
Vertigo
Nausea / vomiting
Hyperacusis (stapedius muscle)
35
Where does Herpes Zoster Virus remain dormant in Ramsey Hunt Syndrome?
Geniculate ganglion of the facial nerve
36
Complications or Ramsey Hunt Syndrome:
SNHL
Change in taste perception,
Loss of vision caused by eye damage from corneal ulcers
Synkinesis: Abnormal reactions to facial movements caused by nerves growing back to the wrong muscles
Persistent pain (postherpetic neuralgia)
Facial weakness.
Immunocompromised patients:
Meningitis
Encephalitis
Disseminated spread of infection across multiple der- matomes
Atypical pneumonia.
37
Treatment options for Ramsey Hunt syndrome (min 4) … bonus 5th
APE AS (Analgesia, Pope wick (+steroid drop), Eye protection, Aciclovir, Steroids)
Anaglesia
Corticoteroids (prednisolone)
Antivirals (Aciclovir)
Eye protection (taping / patch / artificial tears)
Can splint ear canal with pope wick + abx / steroid drops to reduce otalgia
38
Investigations for LMN facial nerve palsy
High Resolution Computed Tomography or Magnetic Resonance Imaging to cinlude petrous temporal bone to exclude Cerebellopontine angle tumours
Evoked Electroymyogram (EEMG) - checks nerve response
39
Audiometric tests for Ramsey Hunt syndrome (min 3):
Pure-tone audiogram
Acoustic reflexes
Electroneurography
?Tympanometry
40
Serological test for Ramsey Hunt Syndrome?
Varicella Zoster IgG
41
Prognosis of RHS vs Bell's palsy?
Prognosis is poor in comparison
42
Parts of the temporal bone
Squamous
Petrous
Mastoid
43
Temporal bone fractures classification
Classified by orientation to long axis of petrous temporal bone (long axis is across / horizontal across head > ear to ear
- Transverse (e.g. forehead to occiput across temporal bone, 20% usually hit to front/back of head, higher energy, otic capsule more likely involved)
- Longitudinal (80% - hits to side of head, usually to squamous part)
- Mixed
44
Symptoms of temporal bone fracture (6)
* Hearing loss, generally (SNHL if transverse # CHL if longitudinal #)
* Vertigo (transerse)
* Facial palsy (transerse)
* Tinnitus
* CSF leak (longitudinal > transverse)
* Nystagmus to unaffected ear
* Focal neurological deficit
* CN 9-12 palsy
* Ottorhagia (bleeding from ear)
45
Signs of temporal bone # (5)
* Ruptured tympanic membrane
* Haemotympanum
* Damage to the canal in keeping with longitudinal #
*
* Battle's sign - ecchymosis post auricular skin (squamous part # (longitudinal #)
*
* Nystagmus (to unaffected ear)
* CSF Rhinorhoea or ottorhoea
46
Management of temporal bone fractures (specifically facial nerve palsy - delayed vs immediate)
ATLS Assessment and head injury management
Immediate Grade VI facial nerve palsy may require surgical repair/decompression
Incomplete / delayed palsies - Rx with steroids
47
Pathophysiology of otitis media with effusion (glue ear)
+ Contributing factors
Eustachian tube dysfunction = chronic reduction middle ear pressure = inflammatory response middle ear = glue (mucus rich in mucoproteins)
Adenoids recognised as important contributer due to it being source pathological bacteria (not due to size)
Contributing factors:
- Parental smoking
- Allergy
- Recurrent URTIs
- Reduced nasopharyngeal dimensions
48
Symptoms of glue ear
Generally just hearing impairment (noticed by parents, teachers etc.)
Recurrent infections and otalgia UNCOMMON
49
Signs of glue ear (Min 3)
Middle ear effusion - can be dull red / amber / grey coloured
Retraction or Tympanic bulge
AIr bubbles / fluid level
50
Investigations for otitis media with effusion
Pure-tone audiogram (CHL)
Typanometry (impedance audiometry) - (Flat trace - helps disting. from otosclerosis)
51
Three alternative diagnosis to a cerebellopontine angle lesion
Meningioma
Cholesterol granuloma
Facial schwannoma
Arachnoid cyst
Epidermid cyst
Cerebellar tumour
Aneurysm of basilar or verteberal arteries
52
Three treatments for vestibular schwannoma
Conservative (watch and wait)
Surgery
Stereotactic radiotherapy
53
Symptoms of vestibular schwannoma
(3)
Extra - otological phase, neurological phase symptoms
Unilateral hearing loss
Unilateral tinnitus
Other cranial neuropathies E.g. sensory changes to V
Otological phase symptoms (as lesoon compresses structures in meatus)
- Unilateral deafness (90%)
- Unilateral Tinnitus (70%)
- Sudden onset deafness (10%)
- Vertigo is UNUSUAL as compensation of vestibular nerve gen. keeps pace with damage
Neurological phase (as expands into cerebellopontine angle)
- Trigeminal nerve symptoms (sensory changes - pain/numbness)
- Headache
- Late symptoms: Ataxia / unsteadniess / diplopia (VI) / hoarsness & dysphagia (IX & X)
54
Investigations for vestibular schwannoma?
Magnetic resonance imaging with gadolinium enhancement
55
vestibular schwannoma - epidemiology and pathophysiology
% of intracranial tumours
% cerebellopontine angle tumours
Onset age
% bilateral
Imminent origin site
Cells of origin
8% of all intracranial tumours
80% of cerebellopontine angle lessions
M=F
Usually onset between 40-50 yrs age
Generally unilateral
Bilateral (5%) due to neurofibromatosis type 2 (Autosommal dominant)
1:100,000 annual incidence
Commonest origin is superior vestibular nerve
Arise from Schwann (neurolemmal) cells
56
Reddish blue mass behind the tympanic membrane - what's the sign and what's the pathology?
Glomus tympanicum (paraganglioma)
Ear drum has appearance of a setting or rising sun
57
What are paragangliomas?
Rare neuroendocrine tumour that forms from chromaffin cells.
Form tumours of the middle ear and skull base in head and neck. But e.g. when found in adrenal gland they are phaeochromocytomas.
Can effectively form where there is any chemoreceptor tissue associated with the autonomic nervous system e.g. tympanic plexus, carotid body etc.
Most are not secretory enough to be synptomatic though.
58
Name the four paragngliomas that form in the head and neck and which is most common?
What artery are they all supplied by?
Globus tympanicum
Globus jugulare
Globus vagale
Carotid body tumours (Most common)
Ascending pharyngeal artery
59
Presenting symptoms globus tympanicum?
CHL
***Pulsatile tinnitus***
Mass in ear or neck (if not tympanicum)
Destruictive lesions can cause lower cranial nerve palsies (e.g. 5 / 7) and Horner's syndrome
60
What is the classification system for paagangliomas?
Fisch classification
61
Management of paragangliomas
Observation with repeat scanning
Sterotactic radiosurgery
Surgical resection
62
Invesitigations / diagnostic workup for suspected paraganglioma
MRI
CT
PET
Skull base MDT
63
What is (approx) maximum conductive hearing loss and why?
Maximum conductive hearing loss = 60dB
At 60 dB SPL the bones of the skull begin to vibrate, bypassing the middle ear system. This direct vibration of the skull can cause the cochlea to vibrate and, thus, the hair cells to shear and to start the process of hearing.
64
Describe the classic noise induced hearing loss audiogram?
A bilateral SNHL with a bilateral tick / dip at 4kHz
65
Describe the classic Ménèires audiogram and what else should you do if you get this audiogram?
Generally unilateral (can be bilateral) SNHL - Menieres typically affects the lower frequencies first and hearing loss fluctuates.
However as it is often a unilaterasl hearing loss must rule out acoustive neuroma (MRI IAM with gadolinum enhancement)
66
Causes of Bilateral SNHL? (3)
mOtotoxicity e.g. AMinoglycosides, Furosemide (loop diuretics), Aspirin Overdose;
Trauma
Bilateral acoiutsiuc neuromas if have NF Type 2
67
What is the DB definition of hearing loss?
Bonus: what are the ranges?
Hearing loss is an inability to hear sounds of greater than 20DB.
Based on British Society of Audiology definitions of hearing loss, this is the decibel hearing level range each of these terms refer to:
mild (21–40 dB)
moderate (41–70 dB)
severe (71–95 dB)
profound (95 dB)
68
What Hz does a dead ear still usually respond to and why?
Dead ear - will still typically show a small response at 80Hz due to the vibrotactile response ( pt feels the vibrations and thinks they hear them)
69
What is interaural attentuation?
What is it (approx) for A-C vs B-C?
Is the amount of sound lost via transmission across the skull (cross hearing) from the test ear to the non test ear.
In air conduction it is between 40-60dB
In bone conduction is is approximately none, i.e. all the sound is conducted across the skull to the non-test ear without loss.
70
What is the definition of masking in audiometry?
Masking is the phenomenon by which one sound impairs the perception of another
In pure tone audiometry masking is used to raise the threshold in the non-test ear using air conducted sound. This therefore overcomes cross hearing.
(From video ...Masking = the process by which the threshold of audibilty of one sound is raised by the presence of another (masking) sounds)
71
What are the rules of masking?
Must use masking when:
1) when the best A-C is =>40dB better than the unmasked A-C in the worse ear
2) when the unmasked B-C is=>10dB than the worse A-C (of either ear)
3) When rule 1 not used, where B-C is =>40dB than the worse unmasked A-C (in the other ear)
Explanation:
1) Accounts for A-C cross hearing (Interaural attenuation 40dB)
2) Accounts for B-C cross hearing (IAT 10dB)
3) Accounts for the NON-TEST ear having a conductive problem meaning the NON-TEST cochlea may be picking up the A-C during the test, despite A-C testing of that ear not picking much up due to CHL.
72
Button battery in EAM - 2 consequences
Chemical burns to external auditory canal
Deafness
73
Surfer's ear is...
Caused by...
Boney exostosis of the external ear canal
Periostyeal reaction to repeated exposure to cold (swimming/surfing)
74
Differential (2) for ?boney exostosis of the external ear canal and how to delineate them
Soft tissue fibrosis
Osteomas (uncommon)- generally singular and pendunculated along suture lines
Exostosis usually multiple and bilateral, broad based
75
Symptoms of surfer's ear
Deafness
Wax impaction
Recurrent infections
Otalgia
76
Treatment options for boney exostosis and how to prevent progression
None if asymptomatic
Surgical boney meatoplasty
Earplugs when swimming/surfing
77
Acute suppurative otitis media aetiology
- Organisms (3-5)
- How does it occur
- Which age groups most affected
Organisms
- Streptococcus pneumoniae (40%)
- Haemophilus influenzae (30%)
- Moraxella catarrhalis (10%)
NON SUPPORATIVE: Adenovirus, respiratory syncytial virus
Other: Streptococcus pyogenes Staphylococcus aureus
Occurs either primarily or secondary to viral AOM infection.
Generally bacteria enter middle ear cleft via eustachian tube.
Infants have shorter, wider, more horizontal tubes allowing contamination from food, vomiting etc.
Children aged 3-7 highest incidence
78
Acute supputative otitis media
RFs (4)
RACE:
Recurrent / chronic rhinosinusitis
Adnoiditis
Chest disease
Eustachian tube dysfunction (caused by e.g. adenoidal hypertrophy, abnormal tube patency, cleft or submucous cleft, nasopharyangeal malignancy)
79
ASOM symptoms (4)
How may a child present (5)?
Otalgia (throbbing)
Pyrexia
Deafness
Ottorhoea and resolution of pain if perforation
Children present as:
systemic upset
excessive crying
irritability
poor feeding
ear pulling
80
ASOM signs (6 - but 3-4 related)
Dull TM initially (oedema)
Red/Hyperaemic TM (next)
Middle ear effusion
Bulging TM
Perforated TM
Mucopus in EAC
81
ASOM Management (4)
Rest
Analgesia
Antibiotics (PO e.g. Amoxicillin if no allergy)
82
Complications of ASOM (9)
Mucositis progressing to osteomyelitis (Mastoiditis)
Meningitis
Citelli's abscess / Bezold's abscess
Extra or subdural abscess
Cerebellar, temporal lobe, perisinus abscess
Sigmoid sinus thrombosis
LMN facial nerve paralysis
Labrynthitis
Otitis hydrocephalus
83
Possible sequelae (not complications) from ASOM
Non-suppurative middle ear effusion
Tympanic membane perforation
Tympanosclerosis
Errosions of ossicular chain
Adhesions between ossicles and TM
High-tone SNHL (possibly from toxins migrating into cochlaear)
Sequelae of ASOM complication....
84
What is Gradenigo's syndrome?
Petrositis (mastoiditis spreading to petrous apex) or Meningitis or Extradural abscess at petrous apex - compresses below CNs (as the are separated fropm petrous apex by Dura only.
Resulting in:
- ASOM
- Ipsilateral CN6 abducens nerve palsy (paralysis of lateral rectus)
- Pain in ipsilateral trigmeninal nerve distribution
85
What is? And what's the cause?
- ASOM
- Ipsilateral CN6 lateral rectus palsy
- Pain in ipsilateral trigmeninal nerve distribution
Gradenigo's syndrome
Petrositis or Meningitis or Extradural abscess at petrous apex
86
What is a Citelli's abscess?
Subperiosteal abscess which has spread through medial aspect of mastoid into digastric fossa
87
Subperiosteal abscess which has spread through medial aspect of mastoid into digastric fossa is a ?
Citelli's abscess
88
What is a Bezold's abscess?
Abscess which has tracked inferiorly within the SCM sheathto form a fluctuant mass along it's anterior border
89
Abscess which has tracked inferiorly within the SCM sheath to form a fluctuant mass along it's anterior border is a?
Bezold's abscess
90
Acute mastoiditis
Symptoms (3)
Signs (3)
Fever
Otalgia
Ottorhoea
Other signs from compolications e.g. meningism, neurological deficit, facial nerve palsy etc
Pinna protrusion
Loss of post auricualr skin crease
Post-aural erythema
Tenderness or fluctuance post aurally
Red bulging TM
91
Complications of acute mastoiditis
Same as ASOM really:
Meningitis
Citelli's abscess / Bezold's abscess
Extra or subdural abscess
Cerebellar, temporal lobe, perisinus abscess
Sigmoid sinus thrombosis
LMN facial nerve paralysis
Labrynthitis
Otitis hydrocephalus
92
Management of acute mastoiditis
IV antibiotics
Analgesia
Antipyretics
Surgery (cortical mastoidectomy+ grommet insertion) if signs of complications, systemic toxicity, failure of medical RX
**CT mandatory prior to surgery to exclude intracranial sepsis (e.g. intrcranial abscess) prior**
93
Bugs commonly causing acute mastoiditis
streptococcus pneumoniae,
haemophilus influenzae
moraxella catarrhalis
Group A beta haemolytic streptococcus (Strep Pyogenes)
94
Choice of Abx in Mastoidits and why
Co-amoxiclav (25mg/kg) because one of the 3 common bacteria responsible for this condition (haemophilus influenza) is resistant to amoxicillin
Pen allergy??
95
Differentials for acute mastoiditis?
Post auricular lymphadenoapthy
96
Post auricular lymphadenoapthy - condition which commonly causes ion childhood?
Rubella
Or other localised infection
97
What is Chronic Otitis Media (COM)
How can it be further defined?
Inflammatory disorder of the middle ear.
Characterised by persistent or recurrent ear discharge
**Mucosal / Chronic Suppuratuve Otitis Media**
- due to tympanic membrane perforation and subsequent inflammation of the middle ear mucosa
**Squamous**
- due to retraction of the tympanic membrane and is associated with the formation of cholesteatoma
98
Aeitiology of COM / Chronic Suppurative (Mucosal) Otitis Media
RISK FACTORS (4)
Recurrent acute otitis media
Other RFs
Previous traumatic perforation, Insertion of grommets
Craniofacial abnormalities
99
How does COM / Chronic Mucosal / Suppurative Otitis Media present (and findings on examination)
Chronically discharging ear >6 weeks IN ABSCENCE of
- fever
- otalgia.
If above present consider:, mastoiditis, or intracranial involvement.
O/E
Perforation
Patients will often have a history of recurrent AOM, previous ear surgery, or trauma to the ear.
100
Investigations and Rx of COM (Mucosal/Suppurative)
Otoscopy
Audiogram (Pure Tone)
Tympanometry
Microbiology swabs of discharge
CT Temporal bones if any concern re. cholesteatoma
**Medical**
Aural toileting
topical antibiotic or steroid treatments
**Surgical**
Myringoplasty
Tympanoplasty
101
Myringoplasty vs Tympanoplasty?
**Myringoplasty**
– closure of perforation in pars tensa
The closure is achieved by patching on an autologous graft, usually harvested from the tragal cartilage or temporalis fascia
**Tympanoplasty **
– a myringoplasty combined with reconstruction of the ossicular chain
102
Classification systems for TM retractions? (2)
Sade's classification for pars tensa Tos's classification for pars flaccida
Tense Sade (Stiff Sade)
Flaccid Tos
103
Type and dB range of hearing loss associatd with COM (mucosal)?
Conductive hearing loss (20-60dB).
104
Squamous Chronic Otitis Media
What is it?
Forms?
**Active squamous COM** = a cholesteatoma
**Inactive squamous COM** = retraction pocket (with potential to become active.
**Acquired disease** = pathophysiology unknown, thought to result from chronic negative middle ear pressure from Eustachian tube dysfunction > retractioin pocket
**Congenital disease** is seen in patients with no history of ear surgery, and no perforation or retraction of the tympanic membrane; indeed congenital cholesteatomas represent epidermoid cysts within the middle ear cavity
105
Squamous Chronic Otitis Media
Investigations (3) & Management (1)
Pure tone audiometry
Tympanometry
CT Petrous Temporal Bone to assess for cholesteatoma
Rx
Essentially all cholesteatoma is surgery of the mastoid as per prev notes
106
When is a stapes prosthesis used?
Any condition of stapes fixation e.g. otosclerosis
Generally inserted during any stapedectomy
107
How does a stapes prosthesis work?
It hooks around the long process of the incus and is inserted into the stapes footplate, recreating the joined ossicualr chain, transmitting sound vibrations into the inner
108
Risks of stapes prosthesis surgery? (Min 5)
Dead ear
Worsening or failure to improve hearing
Dizzyness
Tinnitus
Altered taste (chorda tympani damage)
Facial palsy
Perilymph leak
Prosthesis failure
Tympanic membrane perforation
Bleeding
Infection
109
When would you use a T-Tube over a Shah's grommet
When you want it to remain in the tympanic membrane longer. To permanently ventilate the middle ear space to prevent effusion / progressive retraction.
Usually used in adults, or some children who have needed repeated grommets due to chronic disease.
Note: Adults eustachian tube has matured and therefore will not resolve the negative middle ear pressure with growth.
110
Disadvantage of T-tubes over e.g. Shah's Grommet
Higher risk of residual tympanic perforation
111
Risks of grommet insertion (3)
Residual perforation
Tympanosclerosis
Infections
112
Treatment of post grommet insertion infection
Aural toilet
Antiobiotic / steroid ear drops
Grommet removal if conditon fails to settle / becomes severe
113
Grommet insertion aftercare instructions to patients
Can swim afterwards
Ear plugs should be worn when shampooing
Hearing test post insertion to check hearing improved
Generally extrude at 9-12months
FU once extrude to check ears and hearing again
25% children will require furthr insertion
114
What is the smallest part of a BAHA made of and why?
Titanium - osseointegrates
115
When is a BAHA more appropriate than a conventional hearing aid?
Unfavourable anatomy (e.g. microtia, congenital malformations or middle / external ear)
Chronic / recurrent infection
Patient preference
Any patient failing / unable to benefit from conventional hearing aid with sufficient cochlear reserve to benefit from sound amplification
Profound single sided deafness (to conduct sound to contralateral ear via bone conduction)
116
Types of BAHA
Aids (worn on headband)
Implants
- Percutaneous (skin piercing)
- Transcutaneous (magnetic processor)
Further subdivided into
- Active powered component under skin)
- Passive (powered component external to skin)
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What type of nystagmus does BPPV generally present with?
What other unique characteristics are there of BPPV nystagmus?
**Rotatory/torsional ** (often Geotropic towards ground) TOWARDS the affected ear
...or if lateral canal involvement the nystagmus beats in either a geotropic (toward the ground) or ageotropic (away from the ground) fashion
**Latency of onset:** there is a 5–10 second delay prior to onset of nystagmus (central causes instant!)
**Limited duration: Nystagmus lasts for 5–60 seconds**
**Positional: **the nystagmus occurs only in certain positions
**Fatiguable **- Repeated stimulation, including via Dix–Hallpike maneuvers, cause the nystagmus to fatigue or disappear temporarily
**Visual fixation suppresses** nystagmus due to BPPV
**Reverses** upon return to upright position
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When might you see pendular (see-saw) nystagmus?
Congentially blind person
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Describe the components that make up vestibular nystagmus?
What determines the direction (right/left)?
Fast (corrective) phase (Saccadic movement)
Slow phase (Smooth pursuit)
The fast phase
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What determines the fast phase / slow phase in nystagmus
Fast phase towards ear which is being stimulated more e.g. BPPV or the non- damaged ear
Slow phase towards less stimulated ear e.g. the deads ear or normal ear in e.g. BPPV
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Describe why you get a slow and fast phase in horizontal nystagmus?
Slow / drift phase is always in the same direction as that canal which is inhibited (and which therefore sends a reduced afferent response to the brain),
Fast phase is in the direction of the stronger canal / more stimulated canal (sends increased afferent response to brain)
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What is caloric testing, what does it test?
How do you interpret the results
Involves putting cold and wamt water into thr ear canal of the patient to tst the vestibulo-ocular reflex
**COWS** for direction of nystagmus which is normal on caloric testing
- Cold Opposite
- Warm Sam
Warm water = endolymph in the ipsilateral horizontal canal rises, causing an increased rate of firing in the vestibular afferent nerve.
Cold = endolymph falls = decreased firing of the nerve
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How do you classify horizonatal nystamgus?
1st degree - nystagmus only on gaze in direction of the fast phase
2nd degree - nystagmus on looking straight ahead and in the direction of the fast phase
3rd - the most serious, nystagmus on gazing in all 3 directions (left, right and straight ahead.
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Type of nystagmus most associated with BPPV? And why?
Geotropic rotatational nystagmus towards affected ear
Latency of onset (5-10 seconds)
Fatiguable (repeating test will result in less nystagmus)
Reversible (will eventually subside)
Posterior SCC's are the most likely to be involved
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Which area of the vestibualr system is generally involved in BPPV?
Posterior semicircular canal
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Patients right ear damaged in surgery resulting in a dead cochlea - describe the type of nsytagmus?
Left horizontal nystagmus
Paralysis / destruction of right lateral SCC (eg after right lateral semicircular fistula leak or iatrogenic right dead ear would result in a relatively higher afferent activity from left lateral SCC
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Where is the pathology in horizontal nystagmus?
Lateral SCC
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Tympanograms:
Horizontal (x) is unit and the normal range (adults and children)?
Vertical (y) axis unit and what is the normal range?
**daPa **(basically middle ear pressure)
- -50 - +50 daPa (decapascals) in adults (down to - 200in children)
**ml per equivalent air volume** (cubic cm)
(basically middle ear/ TM compliance) (
Admittance / compliance: 0.3-1.6ml - Adult canal vol 0.6-1.5, Children 0.4-0.9, 0.2 ok if under 6, and older than 6months
ECV
0.6-2.5cm in adults
0.4-1cm in children
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Tympanograms:
Intensity of sound used in 3m old child vs 3yr old child
1000Hz
226Hz
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What produces a bifid tympanogram and why?
A healed perforation with monomeric segment of tympanic membrane may give rise to a bifid tympanogram
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Flat line type trace on tympanogram. What type and what pathology could it be?
Type B
If high Y axis due to canal volume increase due perforation
If low volume canal vol then likely OME /Glue ear (fluid or infection)
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What type of tympanogram is normal
Type A
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Tymapnogram, normal morphology of peak but much lower volume. Type and possible pathology?
Type As.
Less compliant middle ear system (therefore less volume) e.g. otosclerosis
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Tympanogram, normal morphology of peak but much higher volume. Type and pathology?
Type Ad.
More compliant middle ear system (therefore greater volume) e.g. ossicular chain discontinuity
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Typanogram still shaped like a teepee, but are shifted negatively on the graph.
Type and pathology
Type C tympanogram indicates a significantly negative peak pressure, which is possibly caused by Eustachian tube dysfunction or a developing or resolving middle ear infection
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Differentials for unilateral SNHL in adult?
Traumatic
Noise induced hearing loss
Presbycusis
Meniere's disease
Acousticneuroma
Infective causes such as meningitis.
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Causes unilateral SNHL in child?
Congenital: Waardenburg's syndrome
CHARGE syndrome
Intrauterine infections: TORCHS (Toxoplasmosis, Rubella, CMV, Herpes simplex, Syphillis)
Neonatal/childhood infection eg meningitis
Maternal drug/alcohol abuse during pregnancy
Ototoxic drugs during childhood.
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Management of Menière's disease
**Management**
- Strong psychological suppotand reassurance
**Dietary changes**
Eating and drinking water at even intervals are specific measures patients can implement to reduce fluid retention.
- limit salt and monosodium glutamate
- Avoid caffeine
**Lifestyle changes**
- stopping smoking
- managing stress
**Medical - **
- Betahistine
- Thiazide diuretics
- Acute attackes - Prochlorperazine / cinarizine
- Vestibular rehabilitation
- Hearing aids
**Surgical **
- Grommet insertion
- steroid injection,
- intratympanic gentamicin,
- endolymphatic sac surgery,
- vestibular nerve section.
Bilateral profound hearing losses secondary to Meniere's
disease may be rehabilitated with cochlear implants, if air conduction hearing aids are inadequate.
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Episodic vertigo, fluctuating hearing loss & tinnitus?
Menière's disease
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Menière's disease symptoms & presentation
Episodic vertigo
SNHL (often fluctuating but stepwise decline)
Tinnitus
Aural fullness
Attacks often last 1-24hrs
N&V common
Nystagmus common
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Menieres investigations
PUre tone audiometry
Need to rule out other causes so if unilateral MRI to rule out acousti
