Ear Conditions Flashcards
Tinnitus: Definition
Tinnitus is perception of sounds in the ears when there is no external auditory stimuli.
» ringing, rushing, roaring, buzzing, hissing, pulsing
Tinnitus is a symptom, not a diagnosis
Tinnitus: Epidemiology
1 in 7 adults in UK
Commonly associated with age-related hearing loss.
Tinnitus: Aetiology
Aetiology and pathophysiology poorly understood.
Usually believed to be due to damage to the cochlea and central processing of sounds.
Can be worsened by certain medications: aspirin, NSAIDS, diuretics, chemotherapy and aminoglycosides.
Some of these are reversable with cessation of medications, and others are not.
Tinnitus: Risk Factors
Noise induced is most common-
» Factory work
» Construction worker
» Military equipment
» Loud music at clubs or concerts
» Loud headphones
Strongly correlated with noise-induced hearing loss
Aneurysm
Hypertension
Diabetes
Obesity
High cholesterol
Anxiety disorders
Tinnitus: Investigation
Examination-
History»_space; unilateral/bilateral, with/without hearing loss
Full ENT Exam
Jaw Exam for TMJ
Neuro Exam
Otoscopy and audiometry exam
Blood tests- Glucose, FBC, thyroid function
Pulsation tests- check neck head, BP, heart beat and murmurs, vascular sounds
Tinnitus: Management
Urgent referral if worsening: ENT or Neuro
Treat underlying causes if known
Screen and manage medication
Hearing aids and sound therapy
Tinnitus-masking devices for management
Mastoiditis: Definition
Inflammation or infection of the mastoid bone.
Mastoiditis: Epidemiology
Rare, rising incidence due to antibiotic resistance
Mastoiditis: Aetiology
Infection from middle ear spreads to mastoid bone.
Leads to bone erosion and possible formation of a subperiosteal (below periosteum) abscess.
Mastoiditis: Risk Factors
Immunocompromised
Otitis Media
Cholesteatoma
Mastoiditis: Symptoms and Signs
A systemically unwell child with severe pain.
Protruding ear.
Erythema»_space; redness
Fluctuance»_space; soft and bouncy
Pain over the mastoid area
Fever
High WBC
Mastoiditis: Investigations
Clinical
Mastoiditis: Management
Admit for IV antibiotics
Consider head CT for confirmation
Mastoiditis: Complications
Potential for meningitis or labyrinthitis
Otitis Media with Effusion: Definition
Glue-like fluid behind tympanic membrane without signs of infection
Secondary to-
Incomplete resolution of AOM
Obstruction of Eustachian tube
Most common cause of acquired conductive hearing loss in children.
Otitis Media with Effusion: Epidemiology
Common in 6 months - 4 years
30% of children
Higher incidence in cleft palate and down syndrome
Most common in winter
Otitis Media with Effusion: Aetiology
Fluid build up in middle ear stops eardrum vibrating properly
Otitis Media with Effusion: Risk Factor
Winter
AOM
Down syndrome
Allergic rhinitis
Frequent URTI
Otitis Media with Effusion: Symptoms
Concerns with hearing
Speech and language development delay
Balance problems
Popping sounds
Mild otalgia
Aural fullness
Otitis Media with Effusion: Signs
TM may appear normal or:
Amber or grey in colour
Loss of light reflex
Opacification
Presence of air bubbles or an air-fluid level
Retracted TM with prominent malleus and incus
Otitis Media with Effusion: Investigation
Clinical examination
Pneumatic Otoscopy»_space; allows to push some air into ear»_space; should see reduced TM mobility
Audiometry»_space; determines presence and extent of hearing loss
Otitis Media with Effusion: Management
Refer to ENT
Watchful waiting for 3 months»_space; OME often resolves spontaneously.
Do NOT offer: Antibiotics, antihistamines, mucolytics, decongestants, or steroids.
Surgical Intervention: Myringotomy with grommet insertion may be considered to restore hearing.
Auto-inflation: Can be used as a non-invasive option to open up Eustachian tube.
Recurrent Cases: May require adenoidectomy»_space; remove adenoids to help drainage from middle ear.
TM Perforation: Definition
Hole or tear in tympanic membrane»_space; ear drum
TM Perforation: Epidemiology
Anyone
TM Perforation: Aetiology
Trauma
Abuse»_space; Red Flag
Foreign body
Forceful ear irrigation
Barotrauma
Acute Otitis Media (AOM)
Chronic Otitis Media (COM)
TM Perforation: Symptoms
Otalgia»_space; ear pain
Otorrhoea»_space; ear discharge
Sudden hearing loss
Tinnitus
Dizziness
TM Perforation: Signs
Bloody and/or purulent otorrhoea
Perforated tympanic membrane that is visible on otoscopy
Decreased hearing in the affected ear
TM Perforation: Investigation
Clinical examination
Otoscopy
TM Perforation: Management
Most TM perforations heal spontaneously within 2 months.
Avoid inserting anything into the affected ear.
Keep the ear dry; use caution while showering or bathing.
Apply a warm, moist compress for pain relief.
Use acetaminophen or ibuprofen for pain.
Consider antibiotics if the perforation is related to infection.
Refer for potential surgical intervention if the perforation does not heal.
Cholesteatoma: Definition
Accumulation of squamous epithelium (skin cells) and keratin debris in the middle ear.
Cholesteatoma: Aetiology
Long standing eustachian tube dysfunction
» retraction of eardrum
» can trapped epithelium infected and this can proliferates
» can become inflamed and infected
Cholesteatoma: Symptoms and Signs
Hearing loss
Chronic purulent aural discharge
Crust in upper part of eardrum
TM could be perforated
Cholesteatoma: Investigation
Ear exam»_space; Otoscopy
CT to find extent of lesion and to do surgical assessment
Cholesteatoma: Management
Urgent referral to ENT (2 week)
Surgical excision
Otitis Externa: Definition
Inflammation of external ear and ear canal
Localised»_space; inflammation of hair follicle»_space; can turn into a boil
Diffused»_space; inflammation of canal that spreads»_space; can be acute or chronic
Otitis Externa: Aetiology
Bacterial: Pseudomonas aeruginosa, Staphylococcus aureus.
Fungal: Aspergillus, Candida.
Skin diseases: Seborrheic dermatitis, allergic/contact dermatitis, psoriasis.
Physical trauma
Swimming: moisture trapped in the ear canal can contribute to infection.
Pseudomonas aeruginosa likes water»_space; swimmers at higher risk
Otitis Externa: Symptoms
Acute onset of pruritus»_space; itching
Otalgia»_space; ear pain
Hearing loss
Aural fullness
Otorrhoea»_space; ear discharge
Pain or discomfort when moving the jaw or chewing
Otitis Externa: Signs
Erythema (redness) and swelling of the ear canal and/or external ear
Ear canal oedema (swelling)
Purulent (pus-like) or serous (clear) discharge
Increased otalgia when the tragus or pinna is moved
Inflamed tympanic membrane (if visible; may be obscured by swelling)
Otitis Externa: Investigation
Clinical diagnosis
Ear swab for bacterial and fungal cultures in cases of treatment failure, recurrent or chronic infections, or when the infection extends beyond the external auditory canal.
Otitis Externa: Management
General self-care»_space; avoid swimming, painkiller, keep ears dry, avoid cotton buds
Localise OE»_space;
If abscess can create an incision and drain fluid.
Oral antibiotic if signs on systemic illness or boil formation
Diffuse OE»_space;
Topical antibiotic with/without topic corticosteroid-
Gentamicin, ciprofloxacin, neomycin // betamethasone or prednisolone
Ear wick if extensive swelling
Oral antibiotic if systemic illness or recurrent.
Malignant OE: Definition
Malignant Necrotising Otitis Externa
A severe form of otitis externa that progresses to osteomyelitis.
Osteo»_space; bone
mye»_space; muscle
litis»_space; inflammation
Malignant OE: Epidemiology
Increases due to predisposing conditions
Malignant OE: Risk Factors
Trauma
Alcohol
Drug
Chronic steroid use
TB
Immunosuppression
HIV
Malignant OE: Symptoms
Constant deep otalgia (pain)
Vertigo
Profound hearing loss
Malignant OE: Signs
Fever
Palsy of cranial nerves-
VII (facial nerve)
XII (glossopharyngeal nerve)
Malignant OE: Investigation
CT scan»_space; will show destruction of bone and muscle
Malignant OE: Management
Emergency Admission
IV antibiotics
Cerumen Impaction: Definition
Accumulation of cerumen»_space; earwax.
Also include sebum, dead cells, sweat, hair and dust.
Cerumen Impaction: Aetiology
Cerumen (earwax) naturally cleans, protects, and lubricates the external auditory canal.
Impaction occurs when an accumulation of cerumen leads to symptoms.
Cerumen Impaction: Symptoms and Signs
Conductive hearing loss
Aural fullness
Otorrhoea»_space; ear discharge
Tinnitus
Dizziness
Cerumen Impaction: Investigation
Visualisation and clinical otoscopy examination
Cerumen Impaction: Management
Manual removal: by a healthcare professional.
Aural irrigation: using a syringe, if no contraindications are present.
Cerumenolytic agents: topic agents to soften cerumen, aiding in manual removal or irrigation.
Micro-suction: For safe removal, particularly in more complex cases.
Complication if perforated TM, history of ear surgery, active dizziness, recurrent ear infections.
Vertigo: Definition
Vertigo is a feeling like you or everything around you is spinning.
It’s more than just feeling dizzy.
Vertigo: Epidemiology
Not a diagnosis»_space; a symptom
Can be central (brain) or peripheral (ear)
Peripheral Vertigo: Aetiology
Usually medically less serious, but potentially life-disrupting-
Benign Paroxysmal Positional Vertigo
Otitis Media
Labyrinthitis
Vestibular neuronitis
Foreign body or wax in ear
Acoustic Neuroma»_space; tumour of 8th cranial nerve»_space; vestibucochlear nerve
Motion Sickness
Central Vertigo: Aetiology
Usually more medically serious, can sometimes go undetected or less disruptive to lifestyle-
Stroke
Temporal Lobe Epilepsy
Tumor
Post-concussive syndrome
Vertebral Artery Insufficiency
Basilar Artery Migraine
Multiple Sclerosis
Peripheral Vertigo: Symptoms and Signs
Sudden onset
Severe intensity
Lasts for a few minutes and is intermittent
Unidirectional, horizontal nystagmus»_space; rapid, uncontrolled eye movement
Worse with specific head position
No focal neurological findings»_space; no peripheral weakness, haven’t speech fine, reflexes fine, sensations fine
Some hearing loss or tinnitus
Central Vertigo: Symptoms and Signs
Gradual onset
Mild intensity
Lasts for hours to days, and is constant in duration
Multidirectional and Vertical nystagmus»_space; rapid, uncontrolled eye movement
No particular head position worsens it
May have focal neurological findings»_space; peripheral weakness, loss of speech, reflexes, or sensation
Normal hearing
Benign Paroxysmal Positional Vertigo: Definition
Disorder of inner ear characterised by repeated episodes of positional vertigo
Benign»_space; doesn’t cause further illness
Paroxysmal»_space; temporary and sudden onset
Positional»_space; related to change in body position
Vertigo»_space; causes false sensation of spinning
Benign Paroxysmal Positional Vertigo: Aetiology
Caused by loose calcium carbonate debris in semi-circular canals of inner ear
With head movement, debris move in canals»_space; inner ear fluid (endolymph) movement disrupted
» induces symptom of vertigo
Benign Paroxysmal Positional Vertigo: Risk Factors
Head injury
Prolonged recumbent position»_space; rolling over in bed
Ear surgery
Previous of inner ear pathology
Age
Benign Paroxysmal Positional Vertigo:
Symptoms and Signs
Episodic vertigo
Nausea
Rare vomiting
Imbalance or falling
Worse in mornings
No hearing loss or tinnitus
No neurological abnormalities
Benign Paroxysmal Positional Vertigo: Investigation
Clinical»_space; take history
Dix - Hallpike Manoeuvre»_space; looking for nystagmus of eyes»_space; rhythmic oscillation of eyes»_space;
» patient sits on bed with legs out
» move face 45 degrees
» quickly lower them onto bed so head off bed
» check eyes for rapid movement
Benign Paroxysmal Positional Vertigo: Management
Epley Manoeuvres to reposition debris in semi-circular canals
» turn head 45 degrees towards affected side
» lie down keeping head turned for 30 seconds
» turn head 90 degrees towards unaffected side for 30 seconds
» turn another 90 degrees by moving body to unaffected side for 30 seconds
» sit up keeping head turned
If severely dehydrated from vomiting, may need IV fluids
Advice patient to avoid provoking movements
Help patient learn to “self-Eppley”
After 4 weeks, refer if symptoms not resolved-
No improvement with repeat manoeuvres
Atypical nystagmus
Consider imaging and further referral
Meniere’s Disease: Definition
Chronic long-term conditions affecting the inner ear, balance, and hearing
Meniere’s Disease: Aetiology
Cause unknown in most patients
Possible abnormal endolymph production and absorption»_space; accumulation of fluid
Meniere’s Disease: Risk Factors
Autoimmune disease
Metabolic disturbances involving balance of sodium/potassium levels of inner ear
Viral infection
Head trauma
Migraine headaches
Meniere’s Disease: Symptoms
Episodic attacks lasting from 20 minutes to an hour
Vertigo
Hearing loss
Tinnitus»_space; noise in ear
Aural fullness
Meniere’s Disease: Signs
Nystagmus during attacks
Meniere’s Disease: Investigation
Refer ENT or Audiovestibular medicine to confirm diagnosis
Diagnostic criteria includes-
More than 2 vertigo episodes lasting 20mins-12hrs
Fluctuating hearing, tinnitus, or aural fullness of affected ear
Hearing loss confirmed by audiometry testing
Meniere’s Disease: Management
No cure»_space; understanding of Meniere’s pathophysiology is limited
Rapid relief»_space; prochlorperazine eases dizziness and vomiting»_space; take medicine when attack starts
Betahistine»_space; antihistamine to prevent attacks
Lifestyle»_space; very low salt diet, avoid caffeine/alcohol/tobacco, regular exercise
Avoid heights, do not swim alone, DVLA must be alerted
SAFETY NETTING
Vestibular Neuritis: Definition
Infection or inflammation of the vestibular nerve
Vestibular Neuritis: Epidemiology
Most common in 30-60 year olds
Men and women equally affected
Vestibular Neuritis: Aetiology
Inflammation of vestibulocochlear nerve
Often occurs in conjunction with or after viral infection of body, head, or neck
Occasionally provoked by immunisation
Vestibular Neuritis: Symptoms and Signs
Abrupt onset of peripheral vertigo»_space; days-weeks
Cannot walk or balance without falling
Nausea and vomiting»_space; dehydration or electrolyte imbalances
Typically present at emergency care
Vestibular Neuritis: Management
No treatment»_space; wait for infection to clear
Prochlorperazine»_space; dopamine receptor blocker»_space; rapid relief
DO NOT USE STEROIDS»_space; don’t help and side effects are too severe to justify
Refer to ENT
