Ear Flashcards
What type of hearing is associated with the middle ear?
Conductive hearing
What type of hearing is associated with the inner ear?
Sensorineural hearing
What are the five cardinal signs of infection?
Rubor Callor Tumor Dolor Functio Laesa
What is Otorrhea?
discharge from the ear that can originate from:
External auditory canal
Middle ear
Mastoid
Inner ear
Intracranial cavity
May be no symptoms associated with this
What is otitis externa?
an infection of the external auditory canal
What is tympanometry?
measures acoustic immittance (transfer of acoustic energy) of the ear as a function of ear canal air pressure
What is tympanosclerosis?
healed perforation of tympanic membrane that loks white/sclerotic when examining the tympanic membrane
This occurs for life and patient wont have any symptoms
What is Otitis media with effusion also known as?
Chronic otitis media
What is the gold standard for diagnosing otitis media?
Pneumatic Otoscopy
What is the normal finding of pneumatic otoscopy?
tympanic membrane will move
What four things typically cause otitis media?
Allergy
Eustachian Tube Dysfunction
Bacterial Infection
Viral Infection
What is the clinical presentation of Acute otitis media (AOM)?
Rapid onset < 48 hours
Signs and symptoms of inflammation of the middle ear
What is the clinical presentation of Severe AOM?
Rapid onset < 48 hours
Signs and symptoms of inflammation of the middle ear
Moderate to severe otalgia (pain) or fever > 39C (102.2F)
What is the clinical presentation of otitis media with effusion (OME)?
Inflammation of the middle ear with liquid collected in the middle ear
Signs and symptoms of acute infection are absent
What is the clinical presentation of middle ear effusion (MEE)?
liquid in the middle ear without reference to etiology, pathogenesis, pathology, or duration
How is AOM diagnosed?
Tympanic membrane will have severe to moderate bulging or otorrhea may be present
OR
Mild bulging of tympanic membrane AND recent ear pain OR intense redness
How is OME diagnosed?
MEE without signs or symptoms of acute ear infection
Tympanocentesis
Pneumatic otoscopy
What is AOM caused by?
Strep pneumoniae* H. influenzae* M. Catarrhais* Viruses Ostiomeatal complex dysfunction
What is OME caused by?
Ostiomeatal complex dysfunction Sequelae of AOM Viral Unknown Bacterial Antigens Biofilm
What is Sequelae of AOM?
AOM that is treated properly will turn into OME overtime
Acute signs and symptoms are lost
Fluid just needs to drain and will take time
How do we treat OME?
Watchful waiting*
Tubes
Surgery
Prednisone oral or topical or antihistamines/decongestants
When is watchful waiting for OME not appropriate treatment?
If a child is at an increased risk for speech, language, or learning problem (kids about 1 or older)
If it has been three months from the date of effusion onset or diagnosis
What is the follow up treatment for kids with OME that have no evidence of hearing loss or non suspected structural abnormalities of the TM or middle ear?
every 3-6 months until fluid is gone
How do we treat Severe AOM in kids?
Antibiotics if > 6 months; not sure on < 6 months but most often give antibiotics
How do we treat Non-severe AOM in kids?
Anitbiotics or observe in 6-23 moths if unilateral and if you have good follow up
Antibiotics if < 24 months and bilateral
Antibiotics or observe if > 24 months
What antibiotic is First line for AOM?
Amoxicillin 80-90mg/kg/twice a day to max dose of 1000mg/dose
What is the alternate first line medication for AOM if child is allergic to amoxicillin or there is a perforation?
Quinolone drops
What is the second line medication for kids with AOM?
Augmentin ES 80-90mg/kg/twice a day
Why do we give Extended spectrum augmentin?
to decrease the diarrhea side effects
What are other choices of medications for kids with AOM?
Bactrim > 2months
2nd or 3rd gen ceph
Azithromycin or clindamycin if allergic to PCN
If a child is vomiting or can’t keep the amoxicillin down, what can medication can you give them?
50mg/kg/day dose of Ceftriazone IM
Often give one dose in office and then send child home with prescription for amoxicillin
Can do this even if patient is allergic to PCN but you should be prepared for potential allergic reaction
What is the treatment for AOM in adults?
Same as for kids but you must worry about secondary causes like tumors
FOLLOW UP IS MANDATORY
pt. education
More antibiotic choices
How do we generally manage AOM?
Pain relief with APAP, ibuprofen, or antipyrine/benzocaine drops
Topical decongestants for adults
Cold meds in kids older than 4
What is the follow up for AOM?
Improvement is expected within 24-48 hours, so you must follow up with patient within this timeframe even if it is just a phone call
Re-evalute in 2 weeks
How long can it take for MEE after Otitis Media to resolve?
Greater than 3 months
What prophylaxis can be given to prevent otitis media?
Vaccines
Breastfeeding
Smoke-free environment
No bottles in bed
Antibiotic prophylaxis isn’t recommended
What should a normal tympanic membrane look like?
Pearly gray with membrane and landmarks intact
What is pathognomonic for Otitis Externa?
tragus tug pain
What are the causes of Otitis externa?
Bacterial: Pseudomonas aeruginosa* P. vulagris S. aureus E. coli
Fungal:
Aspergillus
Candida albicans
Furuncles:
S. aureas and maybe MRSA
Inadvertent injury
Allergies
Psoriasis
Eczema
Seborrheic dermatitis
Decreased canal acidity
Irritants like hairspray and hair dye
What is the clinical presentation of Otitis externa?
Drainage that may be foul-smelling
Otoscopy exam is painful and difficult to conduct
Red, swollen ear canal littered with moist, purple, tissue debris and desquamated epithelium
Pruritis often with fungal cases
Furuncles
Exquisite tenderness accompanies traction of teh pinnacle or pressure over the tragus
Hearing loss
Crusting outside of the ear
What is the treatment for otitis externa?
Debridement
Topicals: May use wick Acetic acid Corticosteroids Antibiotics --> CiproDex, quinolone drops, nystatin or clotrimazole if fungal
Oral Quinolones, cephs, or antifungals if patient is immunocompromised
How do we prevent swimmers ear?
1:1 mixture of rubbing alcohol and white vinegar (if TM is intact) immediately after swimming
NO COTTON SWABS
How do we treat FB in the ear?
Wash it out
Suck it out
Alligator forceps
What are the causes of tympanic membrane perforation?
Infection
Trauma --> usually barotrauma Blow to the ear Severe atmospheric pressure Exposure to excessive water pressure Improper attempts at wax removal or ear cleaning
What is the treatment for tympanic membrane perforation?
Most heal on their own and treatment isn’t needed
Systemic antibiotics if otorrhea occurs
Paper patch method, Gelfoam, fibrin glue, or similar in office and is only done if perforation is bothersome
Surgical –> tympanoplasty
Ear drops
What ear drops should be avoided in tympanic membrane perforation?
Those containing:
Gentamycin
Neomycin
Sulfate
tobramycin
When should a tympanic membrane perforation be referred?
If the perforation lasts longer than 2 months
If there is significant hearing loss
If there is ossicles trauma
What is the follow up for tympanic membrane perforation?
1-2 months
What is auricular hematoma caused by?
Direct trauma
Shearing forces –> causes separation of the anterior auricular perichondrium from the cartilage
Rugby
Boxers
Wrestling
MMA
How does auricular hematoma present?
hematoma formation on ear
How do we treat auricular hematomas?
Early identification
Drainage with needle or I & D
Splints
Compression
What is mastoiditis?
infection of mastoid air cells
How does mastoiditis present?
welling behind ear
How is mastoiditis treated?
Consult
Medical
Surgical
Which semicircular canal detects yes motion?
Anterior
Which semicircular canal detects no motion?
Posterior
Which semicircular canal detects shoulder to ear motion?
Lateral
What tells us where we are in a plane?
macule
What are two symptoms of vertigo?
Tinnitus
Nystagmus
What is tinnitus?
Perception of sound when no actual external noise is present
Referred to as “ringing in ears” or can be a buzzing, hissing, whistling, swooshing, or clicking
Who does tinnitus most commonly occur in?
Smokers
Men
What is tinnitus caused by?
Ototoxic medications
Hearing loss –> sensorineural with aging or acquired high-frequency
Otosclerosis
Chairi malformations
Wax buildup or FB in outer ear
Infection, fluid, diseases of the ear bones or eardrum in middle ear
Noise exposure, drugs, or meniere’s disease in inner ear
Tumors and other problems affecting brain or nerves in retrocochlear area
What type of tinnitus is most common?
Subjective
What is subjective tinnitus?
head or ear oises that are perceivable only to the patient
Traceable to auditory or neurological reactions to hearing loss
Perceived noise by the patient and often occurs when patient has a URI
What is objective tinnitus?
More severe and rare
Head or noises are audible to others
Usually produced by the internal functions in the bodies circulatory (blood flow) and somatic (MSK movement)
What physical exams should be performed if patient comes in complaining of tinnitus?
Complete HEENT exam
Cranial nerve exam
Evaluate tympanic membrance
Asucultate the neck, periauricular area, temple, orbit, and mastoid
IF tinnitus is UNILATERAL, what must we do in order to diagnose tinnitus and why?
An MRI to rule out retrocochlear lesions such as vestibular schwannoma
How do we treat tinnitus?
NO cure
Avoid excessive noise, ototoxic drugs, and other drugs that might damage the cochlea
Correct identified comorbidities and mitigate their effect of tinnitus
Hearing aids to offset the hearing loss
Sound therapy
Behavioural therapy to decrease anxiety caused by tinnitus
TMJ treatment
Cochlear implants in severe sensorineural hearing loss
What is nystagmus?
Vision condition in which the eyes make repetitive, uncontrolled movements that will reduce vision and depth perception and can affect balance and coordination
Symptom usually of another eye or medical problem
What can make nystagmus worse?
Fatigue and stress
What is nystagmus caused by?
Neurological problems that are present at birth or develop in early adulthood
Aquired will be caused by symptoms of another condition or disease
Lack of development of normal eye movement in early life
Very high refractory error that is seen in nearsightedness or astigmatism
Congenital cataracts
Inflammation of inner ear
Medications like anti-epileptic drugs
CNS diseases
What are the types of nystagmus?
Infantile
Spasmus nutans
Acquired
What is infantile nystagmus?
Occurs at 2-3 months of age
Eyes will move in horizontal swinging fashion
Congential condition normally like the absence of iris, underdeveloped optic nerve, and congenital cataract
What is spasmus nutans nystagmus?
Occurs bewteen 6 months to 3 years of age
Improves on its own between 2 to 8 years of age
Often the child will nod and tilt their head
Eyes may move in ANY direction
Usually no treatment required
What is aquired nystagmus?
Develops later in childhood or adulthood
UNknown cause
Alcohol, drug toxicity, and CNS and metabolic disorders can cause it
How do we treat nystagmus?
Eye glasses or contact lenses
Improves with time typically
treat underlying causes
Surgery is rarely performed
What medication most commonly causes vertigo?
Aminoglycosides
What other medications may cause veritgo?
Antidepressants Anxiolytics Aminoglycosides Furosemide Amiodarone ASA
What are the central causes of vertigo?
Migraines Cerebral tumors of CN VIII Chairi malformations Brain ischemia --> cerebellar infarct/hemorrhage-stroke TIA MS
What are some other causes of vertigo?
Alcohol
Drugs like cocaine
Brain injury
Migraine
What type of vertigo does hypo function cause?
vestibular neuritis
What type of vertigo does hyperfunction cause?
Benign Paroxysmal Positional vertigo
What does central vertigo involve?
cerebellum and brainstem
What are the features of central vertigo?
ONSET IS GRADUAL Disproportionate gait --> walking drunk Visual field defects Hemisensory loss Limb weakness Diplopia Slurred speech Difficult swallowing Frequency and intensity will start to change over time
What does peripheral vertigo involve?
Semicircular canals and otolith organs
What are the features of peripheral vertigo?
Onset is SUDDEN Tinnitus Hearing loss Aural fullness Vestibular neuritis Labyrinthitis
What are the clinical manifestations of vertigo?
Nausea
Vomiting
Sweating
Pallor
What is the most common cause of severe spontaneous vertigo?
Vestibular neuritis and labyrinthitis
What is vestibular neuritis and labyrinthitis result from?
Infection that inflames inner ear or the nerves connecting the inner ear to the brain
Infection disrupts the sensory information from the ear to the brain which is when patient will develop vertigo, difficulties with balance, and hearing and/or vision loss
What is vestibular neuritis and labyrinthitis typically causes by 99% of the time?
virus
What is inflamed in labyrinthitis?
membranous labyrinth
What is inflamed in vestibular neuritis?
vestibular Nerve
What are the clinical manifestations of vestibular neuritis?
NO HEARING LOSS
balance is imparied resulting in dizziness or vertigo
What are the clinical manifestations of labyrinthitis?
HEARING LOSS
Infection will effect both vestibule-cochlear nerve which results in hearing changes and dizziness
Patients describe hearing as muffled
What are common clinical manifestations of both vestibular neuritis and labyrinthitis?
Rapid onset of severe, persistent vertigo N/V Gait instability \+/- horizontal nystagmus \+/- hearing loss
How is vestibular neuritis and labyrinthitis diagnosed?
By excursion
How is labyrinthitis and vestibular neuritis treated?
Steroids to reduce inflammation –> PREDNISONE
Antivert –> MECLIZINE
Antiemetic –> zofran
Antivirals –> Acyclovir
Antibiotics –> amoxicillin
Usually self-limiting and will resolve in a few days to a week
What is Benign Paroxysmal Positional Vertigo?
When crystalline deposits are displaced from utrical matrix and lodge in the semicircular canals
Short in duration and usually only lasting seconds to minutes
What is BPPV caused by?
excessive response to head movement and crystalline deposits in matricx
Who most commonly gets BPPV?
older than 60
Women
What are the clinical manifestations of BPPV?
Rapid onset of dizziness or spinning that may last second to hours
Clockwise, rotary nystagmus
Sensation of motion precipitated by sudden head movement or moving the head in a certain direction
Ear pain, hearing loss, and tinnitus are typically absent
What do we use to detect BPPV?
Dix-Hallpike maneuver
If you see rotary nystagmus upon dix-hallpike maneuver, where is the otolith in BPPV located?
posterior canal
If you see vertical nystagmus upon dix-hallpike maneuver, where is the otolith in BPPV located?
Superior canal
If you see horizontal nystagmus upon dix-hallpike maneuver, where is the otolith in BPPV located?
Lateral canal
How do we treat posterior canal otolith BPPV?
Eply maneuver
How do we treat superior canal otolith BPPV?
Deep head hanging maneuver
How do we treat lateral canal otolith BPPV?
Lamperet (BBQ) maneuver
If vertical nystagmus is not corrected with deep handing head maneuver, what should we do?
SEND PATIENT TO ER because the cause of this vertigo is NOT BPPV
What are other treatments for BPPV?
Electronystagmography done by ENT MRI/CT to rule out other causes like a CVA Syptomatic treatment --> Antihistamines Antiemetics Benzos Scopolamine
Neurology referral needed
Physical therapy
If patient has had for > 6 months, surgery is recommended
What are the dix-hallpike findings for periipheral nystagmus?
2 to 20 second latent period Less than one minute in duration Fatiguing with repetition One type of direction that may change direction with gaze Severe
What are dix-hallpike findings for central nystagmus?
No latent period > 1 min, in duration Nonfatiguing Direction may change with given head position Less sever
What is Meniere’s disease?
Vertigo
Tinnitus
Fullness or congestion of ear
Patient may have drop attacks from severe vertigo
UNILATERAL
Suddenly occurs and typically after episode of tinnitus
Single attack of dizziness separated by long period fo time or lots of attacks over a number of days then nothing for a few days, then more attacks –> NOT CONTINUOUS or worsening
What causes Meniere’s disease?
Buildup of fluid in the compartments of the inner ear = labyrinths
Who are more likely to get Meniere’s disease?
women
What are risk factors/associations with Meniere’s disease?
Allergies
stress
Viral
What are the clinical manifestations of Meniere’s disesae?
TWO OR MORE EPISODES OF VERTIGO LASTING AT LEAST 20 MINUTES EACH
TINNITUS
TEMPORARY HEARING LOSS
FEELING OF FULLNESS IN THE EAR
If you suspect a patient has meniere’s what should you first go?
send to ENT
What may cause similar symptoms of Meniere’s disease?
Syphilis
High Na content
How do we treat Meniere’s disease?
Dizziness medications –>
Meclizine
Diazepam
Lorazepam
Salt restrictions and diuretics
Dietary and behavior changes including decreasing caffeine, chocolate, and alcohol intake
Cognitive therapy to help cope with the unexpected nature of attacks and reduce anxiety about future attacks
Injected Gentamicin –> careful because this can raise risk of hearing loss
injections of steroids to reduce inflammation
Pressure pulse treatment
When does the eustachian tube fully develop?
by age 7/8
What causes eustachian tube dysfunction?
Blockage Swelling of lining of tubes Colds and other nasal, sinus, or throat infections Allergies Air travel
What are the clinical manifestations of dilatory eustachian tube dysfunction?
Tube will not dilate
Accompanying symptoms of hearing loss
Otoscope exam will show effusions, scarring, and thickening of TM
Treat the underlying condition
What are the clinical manifestations of Patulous eustachian tube dysfunction?
Valve incompetency
patient will hear their own voice amplified
Otoscope exam will show movement of TM
ONly need to treat if symptoms last longer than 6 weeks
What are the clinical manifestations of general eustachian tube dysfunction?
Patients report ear fullness
Mild to moderate hearing loss
Sometimes hear a “popping” sound during yawning or swallowing
Occasionally will complain of ear pain
How do we diagnose eustachian tube dysfunction?
Retracted TM on the affected side
Decrease in TM mobility
How do we treat eustachian tube dysfunction?
Swallow, yawn, or chew to increase air flow in and out of eustachian tube
Valsalva maneuver will gently push air into Eustachian tube
Medications --> Decongestant to decrease fluid: Sudafed Mucinex Afrin - no more than 3 days
Antihistamines if allergies are cause:
Zyrtec
Claritin
Allegra
Steroid nasal spray to reduce inflammation in the nose:
FLONASE
If symptoms of eustachian tube dysfunction persist due to treatment failure, what are your next steps?
Refer to ENT for nasal endoscopy, CT or MRI with contrast if > 3 months, or tube surgery
