Ear Flashcards
what is cholesteatoma
presence of keratinising squamous epithelium within the middle ear, or in other pneumatised areas of the temporal bone.
Rare in both adult and children
pathophysiology of cholesteatoma
This keratinising epithelium exhibits independent growth, leading to expansion and to resorption of underlying bone, eroding ossicles/mastoid etc.
Focal erosion of external canal bone with accumulation of keratin = external canal cholesteatoma
aetiology of cholesteatoma
• Acquired
o retraction of an area of the pars flaccid with or without associated atrophy of the pars tensa
o This epithelium becomes trapped and infected which then proliferated into a cholesteatoma
o Squamous membrane may also migrate through a defect in the tympanic membrane
o Can also happen if implantation of viable keratinocytes into the middle ear cleft following ontological surgery or after traumatic blast injury
• Congenital
o If no previous Hx of ear surgery, no perforation or retraction of tympanic membrane
clinical features of colesteatoma
Conductive hearing loss can have a mixed hearing loss
Ear discharge resistant to antibiotic therapy
Attic crust – crust or keratin in the upper part of the middle ear, pars flaccida or pars tensa
White mass begins intact tympanic membrane congenital
Other symptoms tinnitus, otagia, altered taste, dizziness, facial nerve weakness
Ix for cholesteatoma
audiogram - hearing loss
CT of petrous temporal bone
culture
Mx for cholesteatoma
Surgical canal wall up/down mastoidectomy + Abx cover post op
what is a acoustic neuroma
vestibular schwannoma
- A benign cerebellopontine angle tumour that grows from the superior vestibular component of the vestibulocochlear nerve, usually presenting with unilateral sensorineural hearing loss
- Affect female more than male
- Rare tumour
aetiology and pathophysiology of acoustic neuroma
Tumour suppressor gene abnor on chromosome p22
Familiar autosomal dominant form bilateral tumour + neurofibromatosis type 2
Tumour grows on the vestibular component of the vestibulocochlear nerve dec hearing and episodes of dizziness or vertigo
clinical features of acoustic neuroma
Asymmetrical hearing loss
Facial numbness facial nerve involvement, often in tongue/jaw and progress to entire face
Dizziness +/- nystagmus
Tinnitus difficulty localizing sounds
ix for acoustic neuroma
Audiogram
MRI head absence of a dural tail/uniformly enhanced, dense mass extending into internal acoustic meatus
Mx of acoustic neuroma
If small (<1 to 1.5cm) observation If any bigger focused radiation or surgery (middle fossa or rectosigmoid approach – both are hearing preserving option, translabyrinthine – does not preserve hearing)
what is otitis media
infection/inflammation of mucosa of middle ear cleft, common complications of viral resp illnesses
peak incidence of otitis media
6 and 18 yrs old
aetiology of otitis media
children - eustachian tube is shorter and so high risk of infection
bacterial - S. pneumonia
viral - H. influenza & moraxella catarrhalis
what is a red flag when suspecting otitis media
facial palsy
clinical features of otitis media
otalgia - ear pain
bulging tympanic membrane
myringitis - inflammed tympanic membrane
fever + preceding URTI
viral symptoms
if chronic infection - permanet abnor of pars tensa/flacida, pus
Ix for otitis media
clinical diagnosis
ear swab - if have grommets
mx of otitis media
acute
- regular analgesia
- amoxicillin/clarithromycin orally for 5-7 days if < 2 years, bilateral, systemically unwell, perforated
- supportive
failure of treatment - co-amoxiclic for 5-7 dys + referral to ENT
management of chronic otitis media
refer to ENT +/- removal of adenoids
keep ear dry
use topical therapy when needed
myringotomy
when will you refer a child to ENT specialist
fever of >38° if less than 3 months old/>39° if less than 6 months, complication of otitis media (see below)
complications of otitis media
- Ear drum perforation – due to ↑ pressure from pus
- Mastoiditis
- Middle ear effusion – self limiting, part of the recovery process
- Chronic: Glue ear – gromits indicated if effecting speech and language development, Down’s syndrome
definition of otitis externa
inflammation of the external ear canal which can involve the pinna or tympanic membrane
It is a form of cellulitis involves the skin and subdermis of the
what are the classification of otitis extena
localised
diffuse - swimmer/tropical ear - widespread inflammation of the skin and subdermis of the ear canal
Malignant/Necrotising - Aggressive Infection in immunocompromised
Aetiology of otitis externa
- most common bacterial
- Bacterial: pseudomonas aeruginosa, staphylococcus aureus
- Fungal: Aspergillus, candida
- Seborrheic/contact dermatitis
- Trauma, chemical irritatns, allergy
- Swimmers/cotton buds/trauma
Clinical features of otitis externa
- Itchy ear → becomes painful
- Discharge – also seen when looking inside the ear
- Hearing is okay but maybe dec
- Painful to move/touch pinna
- tragus pain
- Severe - swelling of the ear canal
- If fungal cause, discharge will look white and furry
- Intense itching
- No improvement after course of axb
ix for otitis externa
clinical diagnosis
differential for otitis externa
- Otitis media
- Foreign body in ear
- Ear wax
- Mastoiditis
- Malignant otitis
- Neoplasm
When would you refer to patient while suspecting an otitis externa
Not getting better
large amount of discharge
CanaI swelling
fungal infection
Management of otitis externa
Analgesia and heat on the area
1) Topical drop antibiotic and steroid combined e.g. aminoglycosides or ciprofloxacin/dexamethasone otic
1) Fungal: co-trimazole ear drops
2) Systemic abx e.g. flucloxacillin – systemic signs, cellulitis spreading beyond the ear, immunocompromised
2) Ear wicks – if canal is swollen
3) Drain pus – if severe pain and swelling (refer)
Complication of otitis externa
- Abscess
- Chronic otitis externa
- Regional dissemination of infection with: auricular cellulitis, chondritis, parotitis, spreading cellulitis
- Fibrosis, leading to stenosis of the ear canal and conductive deafness
- Myringitis (inflammation of the tympanic membrane)
- Tympanic membrane perforation
- Malignant otitis:
- Facial nerve paralysis
- Meningitis
what is ear wax
= combination of sheets of desquamated keratin squames (the dead flattened cells on the outer layers of the skin), cerumen (a wax-like substance produced by ceruminous glands, which are modified sweat glands), sebum (from sebaceous glands), and various foreign substances (for example cosmetics and dirt)
Pathophysiology of earwax
- Normal physiological substance that protects the ear canal:
- Aids removal of keratin from the ear canal (earwax naturally migrates out of the ear - aided by the movement of the jaw
- Cleans, lubricates, and protects the lining of the ear canal, trapping dirt and repelling water
- Mildly acidic and has antibacterial properties
- Pathological – excessive build up of wax → impaction
Aetiology of earwax
- Abnormal ear anatomy:
- Narrow or deformed ear canals
- Numerous hairs in their ear canals
- Benign bony growths in the external auditory canal (osteomata)
- Down’s syndrome — people with Down’s syndrome tend to have small ear canals and dry, scaly wax
- ↑ wax production/abnormal production:
- Dermatological disease of the peri-auricular area or scalp
- Elderly - as a person ages the cerumen glands atrophy causing the earwax to become drier
- Foreign bodies:
- Cotton buds
- Hearing aids
- Recurrent otitis externa
Features of earwax
- Pain
- Feeling of ‘fullness’ in the ear
- Reduced hearing
- Tinnitus
- Itchiness
- Vertigo
- Cough
differential for earwax
- Otitis externa
- Foreign bodies
- Keratosis obturans (rare, increase in keratin production)
- Polyps of the ear
- Osteoma of the ear canal
ix for earwax
clinical diagnosis when looking into ears
management of earwax
Olive oil/sodium bicarbonate/sodium chloride ear drops for 3-5 days – do not prescribe if suspecting perforated tympanic membrane
2) Ear irrigation - contraindicated in: perforation of tympanic membrane, Hx of perforation in the last 12 months, grommets, Hx of ear surgery, middle ear infection in the last 6 weeks
3) Use drops for a further 3-5 days then try irrigation again/instil water into the ear and try to irrigate 15 mins later/refer to ENT
• Removal of wax is indicated when there is: hearing loss, earache, tinnitus, vertigo, cough suspected to be due to earwax
complications for earwax
conductive hearing loss
vertigo
infection
definition of deafness
Anything that interferes with the movement of sound from the external ear to the middle ear to the inner ear, and then to the brain, can cause a hearing loss.
Different types of deafness
3 types:
• Conductive deafness: external/middle ear disease prevent sound waves from getting to the cochlea
• Sensorineural deafness: damage/abnormality of the cochlea, cochlea nerve or central centres of hearing
• Central: affecting central auditory pathway
aetiology of conductive hearing loss
earwax
osteomata - new piece of bone Growing on another piece of bone
glue ear
haemotympanum
ossicle dislocation/erosion
otitis media
foreign body
cholesteatoma
sensorineural causes of deafness
congenital - TORCH syndrome, prematurity, downs, jaundice, meningitis/encephalitis, chemo
ageing - presbycusis
trauma
acoustic neuroma
drugs - aminoglycosides, salicyates, loop diuretics, cisplatin
stroke
central causes of deafness
congenital
clinical features of deafness
- Depends on cause
- Children:
- Ignoring sounds
- Frustration/bad behaviour/poor school performance
- Poor speech and language development
investigation for deafness
UK national hearing screening programme
turning fork test
rinne’s test
weber’s test
MRI - localising symptoms/signs
general management of deafness
Sudden-onset/rapidly worsening/with additional symptom hearing loss in adults: refer to a specialist
Hearing difficulties suspected in adults:
1) Exclude impacted wax/acute infections
2) Arrange audiological assessment
3) Refer for additional diagnostic assessment if needed
mangement for sensorineural deafness
heading aids - if some hearing is still present
bone anchored hearing aids
severe to profound deafness - cochlear implants
- Idiopathic sudden hearing loss – consider steroids
- Support with speech and language e.g. gestures, visual content, Makaton, specialist teaching
management for conductive deafness
- Assistive listening devices e.g. personal hearing loops, personal communicators, TV amplifiers, vibrating devices
- Hearing aids
- Bone conduction implant
- Surgery
management for central deafness
auditory brainstem implant
definition of labrinthitis
inflammation of the labyrinth caused by bacterial or virus that affects the inner ear which consists of the cochlea and vestibular system
what is the function of the labyrinth?
- To convert mechanical signals from the middle ear into electrical signals, which can transfer information to the auditory pathway in the brain.
- To maintain balance by detecting position and motion.
what are some inner ear/peripheral causes of dizziness?
BBPV
labyrinthitis
vestibular neuritis
Meniere’s disease
what are some central/brain causes of dizziness?
migraine
stroke/TIA
acoustic neuroma
MS
what is the difference between labyrinthitis and vestibular neuritis?
vestibular neuritis - without hearing loss
labyrinthitis - with hearing loss
what are the clinical features of Meniere’s disease
recurrent episodes
spinning/rocking
can last up to several days
classic symptoms - vertigo low pitched tinnitus feeling of fullness in the ears unidirectional, horizontal torsional nystagmus hearing loss
what are some red flags for dizziness?
diplopia dysarthria dysphagia difficulty moving one side/limb dysesthesia on side/limb bowel/bladder distrubances raised ICP symptoms LOC prominent arrhythmia
ix for labyrinthitis
audiogram - sensorineural hearing loss
Weber + Rinne’s test
mx for labyrinthitis
- Reassure that symptoms will settle over several weeks
- Bed rest may be necessary for severe symptoms
- Alcohol/tiredness/intercurrent illness may make symptoms worse
- Prochlorperazine for nausea +/- prednisolone
- If bacterial follow the acute otitis media pathway
- Referral to balance specialist if symptoms don’t start to improve after a week – vestibular rehabilitation therapy
