Ear + balance

Question 1

What is otitis externa?

Answer 1

• Localised: folliculitis (infection of hair follicle), can progress to become furuncle (boil)
• Diffuse (aka swimmer’s ear): widespread inflammation of skin = subdermis, can extend to tympanic membrane

Question 2

Acute otitis externa causes

Answer 2

bacterial most common (Pseudomonas or S aureus)
fungal infection
seborrheic dermatitis (may also have dandruff/eyebrow scaling/blepharitis/facial redness)
contact dermatitis (allergic [sudden, red, itchy, oedema, exudate] or irritant [insidious, lichenification], both caused by ear drops/hearing aids/ear plugs)
trauma (e.g. cotton bud trauma, hearing aids)
environmental (humidity, perspiration, swimming esp in polluted water)

Question 3

Chronic otitis externa causes

Answer 3

allergic/irritant contact dermatitis
seborrheic dermatitis
fungal infection (due to long term topical antibacterials/steroids
bacterial low grade infection causing thickening of skin

Question 4

Malignant otitis externa

Answer 4

aggressive infection mostly immunocompromised/DM/elderly/radiotherapy to H+N, higher risk if irrigate ears with tap water, spreads into mastoid + temporal bones

granulation tissue, exposed bone, CNVII palsy, temp, ear/headache, vertigo, profound hearing loss. can spread causing meningitis

need emergency ENT r/v

Question 5

CF of AOE

Answer 5

red/swollen/eczematous canal/external ear, shedding, swelling (may have pus), discharge in canal, inflamed ear drum, itchy (typical), ear pain disproportionate to size of lesion (typical), pain worse when moving tragus/pinna/with otoscope (typical), tender when move jaw, lymphadenitis, sudden relief of pain if furuncle bursts (rare), may lose hearing if lots of swelling (rare)

check there isn’t a spreading cellulitis

Question 6

CF of COE

Answer 6

lack of earwax in external canal, dry hypertrophic skin, pain on manipulation of canal, constant itch, mild discomfort

Suspect fungal if whiteish strands (Candida) or small black/white balls (Aspergillus)

Question 7

Complications of OE

Answer 7

abscess, chronic OE, regional spread e.g. auricular cellulitis, fibrosis leading to CHL, myringitis (TM inflammation), TM perforation, MOE

Question 8

Differentials for otitis externa

Answer 8

• AOM: otorrhoea from OM causing OE, esp in children with grommets
• FB in ear, impacted wax (pain + DC)
• Cholesteatoma – discharge in canal
• Mastoiditis – v unwell, temp, HL, mastoid tenderness
• Neoplasm – esp if swelling bleeds easily on contact. Slower onset than localised OE
• Referred pain – sphenoid sinus, teeth, neck, throat
• Barotrauma – consider if diver/air travel/blow to ear
• Skin conditions – seborrheic dermatitis, psoriasis, acne, HZV, lupus

Question 9

Management of AOE

Answer 9

AOE resolves within 48-72h of treatment or within 7-10d may resolve without, folliculitis may heal on its own

Self-care adv: avoid damage (safely remove wax professionally, do not use buds etc), use ear plugs when swimming, don’t swim for 7-10d with infection, try low heat hair dryer after showers, if allergy identified avoid these things, control any long term skin conditions

Localised otitis externa: analgesia + flannel usually enough. Oral Abx rarely used, only if signs of severe infection/high risk. Consider I+D if pus causing severe pain (rare). Adv on how to reduce re-infection

Acute otitis externa: analgesia if needed, topical Abx +/- topical steroid (usually for 7d up to max 14d), topical acetic acid 2% spray for mild cases as fewer s/e, may need ENT referral to clear debris with microsuction/syringing appt at GP

Swab if not responding

Oral Abx rarely needed, usually if spreading cellulitis beyond canal

Question 10

Management of COE

Answer 10

Self-care adv: avoid damage (safely remove wax professionally, do not use buds etc), use ear plugs when swimming, don’t swim for 7-10d with infection, try low heat hair dryer after showers, if allergy identified avoid these things, control any long term skin conditions

o Fungal: topical antifungal e.g. clotrimazole 1%
o Dermatitis: avoid contact with the cause
o Seborrheic dermatitis: antifungal steroid combo
o No cause evident: give a 7d course of topical corticosteroid (without Abx) +/- acetic acid spray, if responding continue, if not try a topical antifungal. After 2/3m seek specialist advice

Question 11

Otitis media?

Answer 11

inflammation in ME + effusion, rapid onset of CF of ear infection

Question 12

Otitis media with effusion

Answer 12

fluid in ME without CF of acute ear infection).

see effusion + air fluid levels, normal TM landmarks

cause of CHL or chronic DC

Question 13

Chronic suppurative otitis media

Answer 13

persistent inflammation + perforation of TM with draining DC >2w

Question 14

Myringitis

Answer 14

erythema + injection of TM but no other features of OM

Question 15

Causes of AOM

Answer 15

virus or bacteria but often both at the same time. Often H influenza, S pneumonia, Moraxella catarrhalis, Strep pyogenes; and RSV, adenovirus, rhinovirus, influenza, parainfluenza virus

Question 16

RF for AOM

Answer 16

young, male, smoking, frequent contact with other kids, formula fed, craniofacial abnormalities, use of dummy, prolonged bottle feeding lying down, FH, GORD, not had pneumococcal vaccine, prematurity, recurrent URTI, immunodeficiency

Question 17

CF of AOM

Answer 17

acute onset, earache, tugging/rubbing ear in younger kids (and non-specific stuff like fever, crying, poor feeding, restlessness, cough, rhinorrhoea); red/yellow/cloudy TM, bulging of TM (lose normal landmarks, air-fluid level behind TM indicating ME effusion), perforation of TM/DC into EAM

Question 18

Management of AOM

Answer 18

• Admit immediately if <3m with temp 38+, severe systemic infection, suspected acute comps
• Adv usual course 3d but can be up to 1w, regular paracetamol/ibuprofen, adv no evidence for decongestants/antihistamines
• Abx usage depending on CF + patient, would give 5-7d course of amoxicillin (or clarithromycin/erythromycin if allergic)

Question 19

When are Abx indicated for AOM?

Answer 19

o Immediate prescription: systemically very unwell or high risk of comps
o People more likely to benefit from Abx are people with otorrhoea or kids <2y with b/l infection – depends on CF but may neeed no abx but come back if not better in 3d, delayed prescription if not starting to improve within 3d/sx worsening, or immediate
o Other people less likely to benefit + make little difference to sx or development of comps – may say no prescription and come back if worse, or backup

Question 20

Otological causes of balance disorders (vertigo)

Answer 20

o	ME disease
o	Trauma – temporal bone #, post-stapedectomy surgery
o	BPPV, Meniere’s disease, labyrinthitis
o	Otosclerosis
o	Ototoxic drugs
o	Vestibular schwannomas

Question 21

Non-otological causes of balance disorders (lightheaded rather than vertigo)

Answer 21

o Cervical spondylosis – v common. Arthritis in C spine – osteophytes constrict vertebral artery esp when hyperextend neck – fleeting imbalance cos of cerebral ischaemia. M – neck physio + NSAIDs
o Ageing – multifactorial. Poor proprioception (reduced vision + hearing), cervical spondylosis, more CV issues like hypotension/arrhythmia, meds. Best to avoid vestibular sedatives as they suppress what is normal
o Migraine – hemicranial headache, photophobia, aura, triggers
o CV causes – hypotension, arrhythmia
o Drugs – alcohol, antihypertensives, vestibular sedatives
o Epilepsy/neuro diseases. Clear history
o Hyperventilation/anxiety – a/w tingling in peripheries + tinnitus
o TIAs – imbalance, neuro deficit like dysarthria/amaurosis fugax/limb weakness
o Post-head injury

Question 22

How do you assess a pt p/w a balance disorder?

Answer 22

• History: clarify what they mean, ask about changes to hearing, tinnitus, relation to activity e.g. head movements, effect of darkness (lose eyes as an input), CV disease, DH, alcohol, anxiety; duration important; course over time (ear causes tend to improve over time cos of central compensation)
  o Vertigo – illusion of rotatory movement, worse in dark, usually peripheral vestibular disease
  o Light-headedness – feeling of fainting, CV, ototoxic drugs, psychiatric
  o Unsteadiness – difficulty with gait, veering to one side, falls. Ageing, sometimes neuro
  o Blackouts – usually clear-cut history of either neuro seizures or arrhythmias
  o Duration is important: seconds (cervical spondylosis, postural hypotension, BPPV), mins-hours (Meniere’s, labyrinthitis), hours-days (acute labyrinthine failure, ototoxicity, central vestibular disease); constant or episodic
• Examination: TM for ME disease, nystagmus + CN + cerebellar tests, Romberg’s test, lying + standing BP, positional test

Question 23

Management of sinusitis <10d?

Answer 23

don’t give Abx, adv self limiting virus (2% bacterial) takes 2-3w to resolve. Self care for sx, may want to try nasal decongestants/saline wash but evidence lacking, no evidence found for oral decongestants/antihistamines/steam inhalation/warm face packs/mucolytics. Come back if worsening sx, don’t improve in 3w

Question 24

Management of sinusitis >10d?

Answer 24

consider high dose nasal steroid for 14d for people aged 12+ (may improve sx but not duration and can cause systemic s/e and often not used properly), consider no abx/back up prescription depending on sx (say make ltitle difference to length, possible ADRs, withholding them unlikely to cause comps), consider referral if recurrent etc

Question 25

Explain Rinne’s + Weber’s test

Answer 25

Rinne’s is used to confirm the presence of conductive deafness and Weber’s is used to localise it. In conductive deafness rinne’s will be negative (BC>AC). In this question, since Rinne’s is + (AC>BC) in both ears it can’t be a conductive problem. Working out which ear is affected is then the job of Weber’s. Lateralisation to the affected ear in the conductive deafness and opposite ear in sensorineural deafness.

Question 26

Conductive hearing loss causes

Answer 26

Damage to the outer/middle ear

• Wax
• Perforated TM due to trauma or AOM/COM – depends on site + extent, traumatic ones heal spontaneously if kept dry, otherwise may end up needing a tympanoplasty using a graft of fascia
• Infections: AOM, otitis externa
• Glue ear (OME)
• Otosclerosis: abnormal bone forms around stapes footplate so it doesn’t move properly – conductive deafness. F>M, usually early adult, may have a FH, worsens in pregnancy. Can be treated by stapedectomy + prosthesis but risk of complete HL from the op
• Foreign body
• Less common stuff: ME trauma, congenital pathology like ossicle abnormalities, tumours

Question 27

Causes of sensorineural hearing loss

Answer 27

Damage to the cochlea or CN VIII, often unclear
- Presbyacusis: common, begins in early adult with high tones, progressive. Loss of sensitivity of cochlea hair cells, usually b/l but v variable, high frequency sounds, may affect discrimination, 2 hearing aids better than one
- Noise-induced SNHL: common, from sudden or prolonged exposure. Threshold shifts cause wooly hearing + tinnitus. M – avoid noise, ear defenders, hearing aid
- Congenital – genetic, maternal infection with CMV/rubella/toxoplasmosis, or neonatal jaundice/hypoxia/prematurity
- Childhood infections – measles, mumps, meningitis
- Drugs – aminoglycosides, aspirin, quinine, furosemide
o Ototoxicity because ME is v metabolic so drugs affect cochlea/labyrinth. Usually also renotoxic effects
- Vestibular schwannoma
o Tumour on vestibular nerve in IAM or cerebello-pontine angle at base of skull. Benign, usually u/l except in NF2, causes progressive SNHL, imbalance, may have encroachment on CN V (lose corneal sensation), if advanced can get RICP/brainstem displacement.
o Rare
o Always do MRI head for u/l SNHL
- Rarer stuff: brain things like MS, brain mets, metabolic like hypothyroidism, Meniere’s disease (see vertigo), perilymph fistula, inflammatory diseases
o Perilymph fistula: rupture of round/oval windows causing leakage of perilymph fluid. May also get imbalance. Usually a cause e..g RICP from straining to lift

Question 28

Sudden onset SNHL

Answer 28

• Sudden SNHL – rare, cochlear failure in a previously normal ear, may also have tinnitus/vertigo, usually considered viral/vascular in nature so give steroids to try to help, can try steroid injections, MRI head to r/o sinister cause

Question 29

Causes of otalgia

Answer 29

• ET dysfunction
• Infections
• Trauma - impacted wax, cotton bud usage, acute ototic barotrauma (e.g. descent in plane, can cause ruptured TM + bloody otorrhoea)
• Neoplasia - perichondritis, neural invasion
• Non-otological: referred from tonsillitis/teeth/URTI with ET dysfunction/malocclusion of teeth + spasm of joint muscles, TMJ dysfunction, cervical spondylosis, oesophageal/tracheal tumours

Question 30

Eustachian tube dysfunction

Answer 30

o Rupture of superficial vessels due to differences between ME + ambient pressure, and causes a secretory otitis media. Acutely painful, usually eustachian tubes open to allow pressure to equalise (yawning/sweets can help or nasal decongestants).
o CF: sensations of pressure, ear ‘popping’, hearing loss, ear discomfort
o O/E may see fluid behind TM, may have haemorrhagic areas in drum (severe)
o Usually fluid clears spontaneously over several weeks, nothing really been shown to improve it

Question 31

Ramsay Hunt syndrome

Answer 31

reactivation of VZV in geniculate ganglion of CN VII, causes auricular pain, CN VII palsy, vesicular rash around ear, tinnitus/vertigo. M – oral aciclovir + steroids

Question 32

What is vertigo?

Answer 32

Hallucination of movement a/w problem in vestibular system. May be a/w nystagmus – impulses from brainstem to ocular muscles to correct the balance.

Question 33

How may you test balance?

Answer 33

asking them to walk one foot in front of the other (like a tightrope), heel-toe, march on spot, march on spot with eyes closed (if start to go to one side this is side with the issue as reduced sense of where they are in space)

Question 34

Causes of vertigo?

Answer 34

• Episodic + ear sx – migraine, Menieres
• Episodic + no ear sx – migraine, BPPV, TIA, epilepsy, arrhythmia, postural hypotension, cervical spondylosis
• Constant + ear sx – chronic otitis media with labyrinthine fistula, ototoxicity, vestibular schwannoma
• Constant + no ear sx – MS, brain tumour, CV disease, degenerative disorder of vestibular labyrinth, hyperventilation, alcoholism
• Solitary acute attack + no ear sx – acute labyrinthitis, vasovagal faint, vestibular neuronitis, trauma

Question 35

BPPV

Answer 35

common, episodic, occurs with head movements, lasts short amount of time with resolution between

o Otoliths in semi-circular canals, abnormal stimulation of hair cells, hallucination of movement. Usually spontaneous but can follow URTI/head injury
o Dix-Hallpike can be negative in BPPV so negative doesn’t exclude it, but positive result is useful. Turn head to affected side, gently lower so head comes below rest of body. Nystagmus seen but repeated testing abolishes the vertigo
o Epley manoeuvre treatment – controlled movements of head aiming to dislodge the otoliths
o Vestibular sedatives don’t work. Usually resolves over weeks-months, can recur

Question 36

Meniere’s disease

Answer 36

rare, endolymphatic hydrops, typically people 40-60y, clusters of attacks

o Common features are vertigo, sensorineural deafness (becomes permanent over time), tinnitus and sensation of aural fullness. May also have nystagmus, vomiting and positive Romberg test. Usually u/l, then 25% progress to b/l
o Attacks from a few hours to several days long
o M: refer to ENT. Stuff like diet (Reduce salt, chocolate, alcohol, caffeine, Chinese takeaways (?this was legit in my ENT notes)), avoid smoking. Medical options include low dose thiazide diuretics, betahistine hydrochloride(reduces endolymphatic pressure), vestibular sedatives for acute attacks (e.g. prochlorperazine), anti-emetics. Surgical options include grommets, dexamethasone injection to ME, endolymphatic sac decompression, vestibular destruction (ME injection of gentamicin)
o Majority resolve but after 5-10y and majority have some HL + psychological distress
o Stop driving until symptom control satisfactory, inform DVLA

Question 37

Vestibular neuritis

Answer 37

inflammation in IE causing severe incapacitating vertigo, N+V, horiztonal nystagmus. Otherwise normal neuro exam, no hearing sx. Lasts several days.

M: symptomatic with vestibular sedatives e.g. prochlorperazine, fluids if needed, don’t take vestibular suppressants after attack as delays recovery. May lead to long-term vestibular deficit for a few weeks. Vestibular rehab may help – Cawthorne-Cooksey exercises

Question 38

Labyrinthitis

Answer 38

infection in vestibular labyrinth – rapid onset vertigo, horizontal nystagmus, HL (if cochlea involved), N+V. Bobbing oscillopsia if failure in both labyrinths.

A/w h/o ear infection, tinnitus or coryza

May be very unwell for first 24h then improves due to central compensation