Ear and Eye Flashcards
What are the general functions of the ear? Nerve?
o Balance and hearing
o CN VIII vestibulocochlear
• What hx questions would you ask for an ear complaint?
o pain: LMNOPQRST o any hearing loss? o any vertigo (dizziness)? o any tinnitus (ringing)? o any hx of recent infection? o any discharge? If so, how much (quantitative), what color? (qualitative)
• how do you do an ear PE?
o Vitals
o EENT, Otoscopic, insufflation, hearing tests (whispered voice, tuning forks), neurological, CVS
What labs might be indicated after an ear PE? Imaging?
o CBC, chemistry screen (CMP), culture any discharge
o x-ray, CT or MRI to evaluate masses
• what additional ear tests are there? What referral may be needed?
o audiology, tympanometry o EENT (otologist), neurologist, audiologist, etc.
• What are some general complaints regarding the ear (not always directly related to inner, middle, external?
o Hearing loss o Tinnitus o Vertigo o Earache (otalgia) o Ear discharge (otorrhea)
• What are the 2 types of hearing loss?
o Conductive and sensorineural (SNHL)
o 3rd type: mixed hearing loss (of C and S)
• What is conductive hearing loss?
o from (physical/mechanical) problems that limit movement of the sound wave through the external and middle ear.
• What are some causes of conductive hearing loss?
o obstructed external ear canal – eg. cerumen impaction, foreign body, exostosis, psoriasis
o perforated tympanic membrane – eg direct trauma, otitis media, or explosion
o dislocated ossicle (malleus, incus, or stapes) - trauma to the ear
o Otitis media or serous otitis media
o Otitis externa - infection of the ear canal that causes it to swell
o Otosclerosis or ossicular chain fixation
o Congenital: eg external auditory canal atresia
o Cholesteatoma: growth of squamous epithelium in middle ear
• What is sensorineural hearing loss?
o damage to the hair cells or nerves that sense sound waves (sensory problem in inner ear)
• what are some causes or associated conditions of SNHL?
o acoustic trauma - prolonged exposure to loud noises
o barotrauma (pressure trauma) or ear squeeze - eg divers, climbers
o head trauma - eg fracture of the temporal bone
o ototoxic drugs - Bilateral loss, hx of use.
o Infection – mumps, measles, influenza, herpes, mono, syphilis, meningitis
o Aging—presbycusis: progressive bilateral hearing loss (high pitches), normal neuro exam
o Acoustic neuroma - tumor in the auditory nerve.
o Sudden SNHL (SSNHL): unilateral hearing loss over 72 hr. Associated with microvascular event, head trauma
o Ménière disease - hearing loss, vertigo and tinnitus. Gradual onset, often progresses to deafness and severe vertigo
o vascular diseases eg sickle cell disease, diabetes, polycythemia, and excessive clotting
o Multiple sclerosis
• What are some examples of ototoxic drugs as causes of SNHL?
o antibiotics including aminoglycosides (gentamicin, vancomycin), erythromycin, and minocycline, tetracycline
o diuretics including furosemide
o salicylates (aspirin) and nonsteroidal anti-inflammatories (NSAIDs) ibuprofen, naproxen
o antineoplastics (cancer drugs)
o antimalarial drugs (quinine, chloroquine)
o cocaine—intranasal or IV
• what is tinnitus?
o perception of sound (eg buzzing, ringing, roaring clicks) in absence of an acoustic stimulus may be intermittent, continuous, pulsatile; unilateral or bilateral
• what are the types of tinnitus?
o Subjective- audible only to pt, high frequency, due to damage of fine hair cells
o Objective- rare, can be heard by listening directly over the patients ear
o other
• What is etiology of subjective tinnitus?
o Acoustic trauma; Presbycusis; Barotrauma; CNS tumors; Eustacian tube dysfunction; Infections (OM, labryinthitis, meningitis); Meniere disease; Ear canal obstruction (wax, foreign body, tumor); Drugs (salicylates, loop diuretics, cisplatin, aminoglycosides)
o Can accompany SNHL
• What is etiology of objective tinnitus?
o A-V malformations; Monoclonus (palatal ms, tensor tympani, stapedius); Turbulent flow in carotid A or jugular V; Vascular middle ear tumor (esp if unilateral—R/O by ordering CT)
• What are other types/causes of tinnitus?
o hyperlipidemia, allergies, diabetes, hypertension, hypotension, syphilis, cardiovascular, endocrine, and metabolic disease, TMJ disorders, cervical injuries, stress, dietary deficiencies, and intake of stimulants (nicotine, caffeine).
• What is the workup for tinnitus?
o Hx: get good description of “sound” (episodic/constant, pitch, quality)
o Ask re: noise exposure, head trauma, hearing problems, dizziness, loss of balance, recent dental problems/work, bruxism, stress, ototoxic drug use, smoking, caffeine, HTN, anxiety, insomnia
o PE: Otoscopic exam, cranial N VIII function and hearing (whispered, tuning fork tests)
o Check for: carotid artery bruits, HTN, oral exam, neck and jaw hypertonicity, TMJ dysfunction
o audiology, angiography
• what is vertigo?
o a type of dizziness; nonspecific term describing a sensation of altered spatial orientation “illusory movement”
o most often caused by dysfunction of the vestibular, visual, or proprioceptive (posterior column) systems, or by diffuse impairment of blood flow to the brain
what are subjective/objective vertigo? Common in which population?
o subjective if patient has the impression they are “moving in space” (self-motion)
o objective if objects “moving around” the patient (motion of the environment)
o more common in aging, increased incidence of falling in those > 65 years.
• What are the 2 classifications of vertigo?
o True vertigo- sensation of movt; most common; Caused by asymmetry in the vestibular system (CN8, inner ear, cerebellum)
o Non-vertigo - syncope, fainting or sensation of impending fainting
What are ssx of true vertigo?
o either surroundings are moving or patient is moving within surroundings
o Postural instability, nausea and vomiting common, sweating
o Vertigo is worse when moving head
o Nystagmus is commonly seen on eye exam (involuntary movements of the eye)
• What are some further classifications of true vertigo?
o i. Peripheral vertigo: labyrinth or CN VIII
o Central vertigo: cerebullum, vestibular cortex in temporal lobe
• Peripheral vs central vertigo: nystagmus?
o Peripheral: Unidirectional with fast component towards normal ear, horizontal with rotation
o Central: Any direction, sometimes changes direction
• Peripheral vs central vertigo: other neuro signs?
o Peripheral: Absent
o Central: Often present (ataxic gait, diplopia, slurred speech, numbness)
• Peripheral vs central vertigo: postural instability?
o Peripheral: Unidirectional instability, walking
o Central: Severe instability, patient can fall while walking
• Peripheral vs central vertigo: hearing loss/tinnitus?
o Peripheral: may be present
o Central: abent
• What are the types of non-vertigo?
o Lightheadedness
o Disequilibrium
o Miscellaneous
• What happens in lightheadedness non-vertigo?
o “graying out” of vision, pallor, and a roaring sound in the ears suggests hypoperfusion of the brain (global hypoperfusion) from: hypotension, drugs, decreased cardiac output hypoglycemia, shock, dehydration, severe anemia, cardiac arrhythmias
• What happens in disequilibrium non-vertigo?
o occurs only while standing or walking (gait impairing), unsteady without any dizziness
o pt says that “dizziness is in feet, not in head”
o Source of problem may be: cerebellum; basal ganglia; cervical spondylosis; frontal lobe tumor; stroke; motor neuron diseases
• What may happen in miscellaneous cases of non-vertigo?
o chronic hyperventilation syndrome; often unaware to patient; frequent deep breaths while relaxed
o new eyewear & diplopia
o phobias- agoraphobia, acrophobia
o extra-ocular muscular palsy results in diplopia
• what info about vertigo and its cause can you get in hx?
o Onset: sudden or gradual?
o Sudden onset and vivid memory of episodes are often due to inner-ear disease
o Gradual and ill-defined vertigo most common in CNS, cardiac, and systemic diseases
o Duration:
o Episodic true vertigo that lasts for seconds, associated with head or body position changes likely benign paroxysmal positional vertigo (BPPV)
o Vertigo of sudden onset that lasts for minutes can be due to brain or vascular disease
o Vertigo that lasts for hours or days probably caused by Ménière disease or vestibular neuronitis
• What is general PE for vertigo? Otological exam?
o vital signs, supine and standing BP, orthostatic BP, CVS
o oto: examine ears for cerumen, discharge, foreign body; TM - perforation may result in sudden vertigo
• what extraocular movts can you do in PE for vertigo?
o “H in space”
o check for nystagmus (eye jerking movements)
o horizontal plane - most common form
o vertical plane - always abN, brain stem function disorder
o pendular - often congenital or after prolonged period of blindness
• what hearing tests can you do in PE for vertigo? Sensory?
o Gross hearing—whispered voice test
o Weber/ Rinne to assess conductive or sensorineural loss
o Sensory exam to assess proprioception: polyneuropathies can impair balance
• How do you test for vestibular imbalance in PE for vertigo?
o Past-pointing with eyes closed, repeat several times.
o Romberg test: tend to fall toward the vestibular lesion
• What are red flag concomintants for vertigo?
o head or neck pain, ataxia, loss of consciousness, focal neurological deficit
• what are some extra tests for (true?) vertigo?
o Dizziness simulation battery for *True vertigo
o Caloric testing: cold water into external canal produces tonic eye deviation to side of cold water and horizontal nystagmus to opposite side (Otoscopy done first!); Test is positive for vestibular dysfunction if asymmetry > 20% with affected ear producing less severe nystagmus; pt has transient vertigo identical to usual dizziness
o Nylen-Bárány maneuver: pt sits at the end of the examining table and is laid back quickly, while the head is supported and the neck is carefully hyperextended. The head is first turned toward one shoulder; then, the maneuver is repeated with the head turned toward the other shoulder; look for nystagmus (there may be a 10-20 sec. latency period)
• What are some non-vertigo extra tests
o Lightheadheadness: orthostatic hypotension- increase in pulse by 30 bpm, systolic BP drop of 15-20 mm Hg; carotid sinus massage; valsalva maneuver
o disequilibrium: drifts toward side of lesion; cerebellar (coordination) and proprioception testing; observe walking and turning; forward & backward walking
o miscellaneous: hyperventilation: sitting, breathe quickly and deeply (2 minutes while observing for nystagmus)
• what are some causes of earache/ear pain/otalgia?
o external ear –impacted cerumen or foreign body, local trauma, otitis externa
o middle ear – eustacian tube obstruction, OM, neoplasms
o referred pain from TMJ, wisdom teeth
o local infections: tonsillitis, enlarged adenoids, peritonsillar abscess
o atlas/axis subluxation
o tumor in pharynx, tonsils, tongue, larynx; thyroiditis
o neuralgia: trigeminal, sphenopalatine, glossopharyngeal, geniculate
o colds, allergies, cold wind blowing in ear
• what are red flag concomitants for earache?
o Diabetes or immunocompromised pt, redness/pain over mastoid,
o Severe swelling of canal meatus, chronic pain with head/neck symptoms
• What are some causes of acute ear discharge (otorrhea)?
o Acute OM with TM perforation
o Post-tympanostomy tube
o CSF leak from head trauma
o OE—infection or allergy
• What are some causes of chronic otorrhea?
o Cancer of ear canal; Cholesteatoma; Chronic purulent OM; Foreign body (usu kids); Mastoiditis
• What are red flag concomitants of otorrhea?
o head trauma, cranial nerve dysfunction, fever, erythema of the ear, diabetes or immune compromised
• what are the complaints of the external ear?
o Obstruction o AOE o COE o Perichondritis o Tumors
• what can cause obstruction of the external ear?
o cerumen may block & cause itching, pain, conductive hearing loss
o foreign body, esp. with children- beads, erasers, insects, just about anything!
• What are main causes of acute otitis externa?
o 1) Infection- e.g. strep, staph, E. coli, pseudomonas, aspergillus
o 2) “swimmers ear”
o 3) forceful cleaning of the ear
o 4) trauma
• What are sx of AOE?
o itching, pain, discharge possible, loss of hearing if canal becomes swollen or filled with purulent debris
• what are some things found on PE for AOE?
o pinna & tragus painful when pressed or tugged (different from OM)
o external canal appears red, swollen
o TM (may not be visualized) is normal pearly gray
o Pseudomonas infx produces purulent green/ yellow otorrhea
o Aspergillus looks like a fine white mat topped by black spheres
o fever, swollen lymph nodes possible
• what is etiology of COE? Ssx?
o often follows psoriasis, seborrheic dermatitis, eczema
o allergy or fungus
o pruritis, redness, discharge
• what is found on PE for COE?
o pinna & tragus less likely painful
o external canal appears irritated, perhaps dry, flaking tissue
o TM not usually affected
o May get secondarily infected, increased pain and swelling
• What is perichondritis?
o External ear: trauma, insect bites may lead dec blood supply to ear cartilage: avascular necrosis/deformity
• What are some types of tumors on external ear?
o sebaceous cysts, osteomas (bony growths) may occlude ear canal
o gouty deposits (tophi on outer ear)
o basal cell (BCC) and squamous cell carcinomas (SCC)- hx of sun exposure on external ear
• what are the compaints of the middle ear?
o AOM o COM (COME, CSOM) o Myringitis o Cholesteatoma o Acute mastoiditis o Otosclerosis o tympanosclerosis
• what is etiology of AOM?
o 2nd most common dz of childhood (URI # 1); ~ 20 million annual physician visits
o Cause: Organism, anatomic position of eustacian tube and immunologic factors
o Common: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
o Less common: Group A streptococcus (older kids), Staph aureus, Gram neg bacilli (newborns, immunocompromised), viruses, Mycoplasma pneumoniae
o Can also be sterile effusions (no organism found)
• What are risk factors for AOM?
o daycare exposure. (also source for URI)
o bottle-feeding
o smoker(s) in the household
o AOM in the first year of life is risk factor for recurrent acute otitis media.
• What are ssx of AOM?
o throbbing pain (or maybe NO pain), fever, dec hearing, n/v, moodiness, irritability
o child may tug on ear; sleep may be disrupted due to pain
• what is found on PE for AOM?
o bulging, red (or cloudy) TM, possible fluid line (yellow-gray if pus)
o decreased mobility on pneumatic otoscopy (insufflation)
• what are the most useful test in the dx of AOM?
o Bulging TM
o Cloudy TM
o Decreased Mobility
• What are some complications of AOM?
o Otitis media with effusion most common.
o If bilateral, hearing loss with resultant speech delay may occur in infants.
o Mastoiditis used to be a common complication, but now rare.
o Perforation (rupture) of the TM is frequent, but usually not serious (unless peripheral)
o IF TM perforates: discharge and sudden loss of pain
o If perforation is peripheral, check regularly for cholesteatoma
o May persist during Abx treatment, or relapse within 1 mo
• What are 2 types of COM
o Otitis media with Effusion (OME)- sometimes listed as Serous OM
o Chronic suppurative OM (CSOM)
• What is OME? Risk factors?
o Effusion (fluid) in the middle ear--incomplete resolution of acute OM or due to inflammation o Prior tympanostomy tube placement; Allergy (often food – dairy, oranges, apples; environmental); adenoid hypertrophy; Summer or Fall months
• Wha are ssx of COM?
o Hearing impairment – child’s behavior may be described as inattentive (ADD misdiagnosis?)
o Mild otalgia - intermittent ear pain tends to worsen at night; ear fullness or popping
o May also have overlapping sx of common cold: nasal d/s, sore throat
• What is found on PE for COM?
o Amber or gray TM, INTACT but typically retracted or in the neutral position
o Impaired mobility of the TM during pneumatic otoscopy
o Bubbles or air/fluid level may be seen
o Chronic cervical LA
• What is the course of COM?
o can persist: (COME) fluid behind intact TM; Risk of infection, recurrent AOM and/or perforation
• what is CSOM? Etiology? Ssx?
o chronic inflammation of middle ear that persists at least 6 wks with TM perforation and otorrhea
o acute OM resulting in perforation - central perforation leading to conductive hearing loss
o trauma to ear, head
o ssx: hearing loss, chronic purulent d/c, painless
• what is found on PE for CSOM?
o Perforation of the tympanic membrane (pars flaccida in patients with atticoantral disease and pars tensa in patients with tubotympanic disease)
o May see: retraction pocket in the posterosuperior quadrant, choleseatoma, granuloma, polyps
• What is the course of CSOM?
o May have a perforation without ever getting any symptoms, but sometimes a chronic bacterial infection develops.
o May flare up after an URI or after water enters the middle ear while bathing or swimming. Usually, flare-ups result in a painless discharge of malodorous pus from the ear. Persistent flare-ups may result in the formation of polyps, from the middle ear through the perforation and into ear canal.
o Persistent chronic infection can destroy parts of the ossicles leading to conductive hearing loss. In a child, this can lead to delayed intellectual development
• What is ddx for CSOM?
o Otitis externa, cholesteatoma (congenital or acquired), myringits, chronic mastoiditis, impacted cerumen, tympanosclerosis, Wegener granulomatosis
• What are the 5 types of OM?
o AOM, persistent AOM, OME, COME, CSOM
• What are dx criteria for AOM?
o Acute onset AND
o Middle ear effusion (bulging TM), limited or absent mobility air-fluid level behind membrane AND
o SSx of middle ear inflammation (red TM, otalgia)
• What are dx criteria for persistent AOM?
o Persistent features of middle ear infection during antibiotic treatment OR
o Relapse within one month of treatment completion
• What are dx criteria for OME, COME, CSOM?
o OME: Fluid behind intact TM in the absence of features of acute infx
o COME: Persistent fluid behind intact TM in the absence of acute infx
o CSOM: Persistent inflammation of the middle ear or mastoid cavity; Recurrent or persistent otorrhea through a perforated TM
• What is myringitis?
o Inflammation and/or infection of the TM. Primary or Secondary, Acute or Chronic forms
• What are primary causes of myringitis?
o can accompany Mycoplasma pneumonia URI
o TM trauma (foreign body, cleaning, explosion)
o Acute bullous Myringitis: vesicles on TM from infx (S pneumoniae, herpes)
o Acute hemorrhagic myringitis: bact or viral infx
o Fungal and eczematous forms
o Myringitis granulosa—unclear cause
• What are secondary causes of myringitis?
o Acute otitis media, acute otitis externa
o Chronic otitis media, chronic otitis externa
What are ssx for myringitis? What is found on PE?
o Serosanguinous otorrhea, otalgia, hearing impairment
o if acute: sudden onset of ear pain that lasts 24 to 48 hours, fever
o PE: Vesicles develop on the TM in bullous form, granulomatous tissue in granulosa form
What is cholesteatoma? Etiology?
o Growth of keratinizing squamous epithelium in middle ear and/pars tensa, can enlarge
o congenital, primary acquired, and secondary acquired. (prev perforation, retraction pocket)
• what are ssx of cholesteatoma?
o painless otorrhea, either unremitting or frequently recurrent.
o Conductive hearing loss initially, then can grow into inner ear causing SNHL
o dizziness is relatively uncommon
• what is found on PE for cholesteatoma?
o canal filled with muco-pus and granulation tissue
o TM perforation is present in >90% of cases.
o May require surgical removal
• What is acute mastoiditis? Etiology?
o Suppurative infection in the mastoid air cells
o Complication of severe AOM
o Streptococcus pneumoniae (most common), Streptococcus pyogenes, Staphylococcus spp, Haemophilus influenza, Pseudomonas aeruginosa
• What are ssx of mastoiditis?
o redness, swelling, tenderness behind ear, fever, hearing loss, profuse creamy ear d/c
- throbbing pain
what is foud on PE for mastoiditis?
o Bulging erythematous TM
o Tenderness (redness, swelling) over the mastoid area
o Postauricular fluctuance
o Protrusion of the auricle, downward displacement of auricle
What are complications of mastoiditis? Referral?
o subperiosteal abscess, CN 7 palsy, hearing loss, osteomyelitis, meningitis, venous sinus thrombosis
o MRI or CT. Treatment with drainage and antibiotics
• What is otosclerosis? Ssx?
o Genetic (autosomal dominant) metabolic bone disease affecting otic capsule and ossicles, leads to overgrowth of footplate in stapes/dysfunction
o F>M 2:1; much more common in whites, most commonly appears 15-35 yrs.
o Ssx: Progressive bilateral (conductive) hearing loss and tinnitus (occasionally, vertigo)
• What is tympanosclerosis?
o Sclerosis of TM: from chronic OM, post T-tube
o Leads to stiffening of the tympanic membrane and impaired conductive hearing
• What are ssx of tympanosclerosis? Found on PE?
o SSX: early asymptomatic, but hearing loss progresses
o PE: Whitish plaques on TM (areas of hyalinization with deposition of calcium and phosphate crystals)
• What are the 2 classes of inner ear disorder?
o Peripheral vestibular disorders
o Central vestibular disorders
