Ear conditions Flashcards
Name the 6 D’s
Deafness Discomfort Discharge Dizziness Din Din (tinnitus) Defective movement of the face (CN VII palsy)
Otitis externa - definition
Inflammation of the outer ear canal
Otitis externa - who commonly gets it?
Swimmers
Otitis externa - bacterial causes (2)
Staph aureus
Pseudomonas aerginosa
Otitis externa - fungal causes (2)
Aspergillus niger
Candida albicans
Otitis externa - clinical features
Redness and swelling of the skin of the outer ear canal
Initially itchy
Can become sore and painful
Discharge / increased amounts of earwax
Otitis externa - can hearing be affected?
Yes
- if the canal becomes blocked (e.g. by swellings or secretions)
Otitis externa - management
Suction clean the ear (instant relief)
Keep the ear clean and dry until it recovers
May need antimicrobials/antibiotics if bacterial
Otitis externa - malignant otitis - definition
Extension of the otitis externa into the bone surrounding the ear canal (mastoid and temporal bones)
Otitis externa - malignant otitis - cause
Pseudomonas aerginosa
Otitis externa - malignant otitis - clinical features
Pain
Headache
Otitis externa - malignant otitis - signs
Facial nerve palsy (drooping face on side of the lesion)
Otitis externa - malignant otitis - investigations
Inflammatory markers (raised) Imaging (to see extent of osteitis)
Acute otitis media - definition
Acute inflammation of the middle ear with/without an accumulation of fluid
Acute otitis media - who gets it
Infants and children
Acute otitis media - cause
Usually viral (URTI) Occasionally bacterial (strep pneumonia, haemophilus influenza, moraxella catarrhalis, strep pyogenes)
Acute otitis media - pathogenesis
Often an URTI which involves the middle ear due to the extension of infection up the eustachian tube. This causes fluid/pus accumulation in the middle ear.
Acute otitis media - clinical features
Screaming child in middle of night Earache (otalgia) Discharge (if tympanic membrane perforates) Conductive hearing loss Fever Lethargy
Acute otitis media - investigations
Otoscopy (red and inflamed ear drum)
Swab pus (if discharge present)
DO NOT regular biopsy (only if alternative differential diagnosis needs exclusion)
Acute otitis media - management (if less than 4 days)
Most self limiting, resolve within 4 days
Acute otitis media - management (if more than 4 days)
First line: oral amoxicillin
Second line: oral erythromycin
Acute otitis media - management with antibiotics should be topical/oral?
Oral
Otitis media with effusion - definition
Glue ear
This is not an infection
Accumulation of fluid behind an intact ear drum (without signs/symptoms of acute inflammation)
Otitis media with effusion - pathogenesis
Eustachian tube gets anatomically blocked and the middle ear is unable to equalise the pressure with the atmospheric environment (nasopharynx end of eustachian tube)
Build up of negative pressure and fluid accumulated in middle ear space
Otitis media with effusion - causes of eustachian tube blockage
Enlarged adenoid tonsils
Recurrent URTI
Recurrent AOM
Otitis media with effusion - who gets it
Children
Otitis media with effusion - clinical features
Hearing loss (conductive) NO earache, fever, irritability Middle ear effusion Impaired tympanic membrane mobility Speech delay
Otitis media with effusion - examinations
Otoscopy - tympanic membrane retraction - reduced tympanic membrane mobility visible middle ear fluid/bubbles Tuning fork test - conductive hearing loss
Otitis media with effusion - investigations
Audiometry
- conductive hearing loss
Tympanometry
- flat line due to presence of fluid suggests a middle ear effusion
Otitis media with effusion - initial management
Watchful waiting for 3 months
- may resolve naturally
Otitis media with effusion - management after 3 months duration
If bilateral and clinical features persist then refer to ENT
- under 3: grommets
- if grommets don’t work: re-insert grommets and adenoidectomy
Otitis media with effusion - complications
Recurrent attacks of AOM
Otitis media with effusion - complications of grommets
Infection Fall out early Fall into middle ear cavity Persistent perforation Swimming/bathing issues
Chronic otitis media - definition
Persisting acute otitis media causes a hole to form in the ear drum resulting in chronic otitis media
Cholesteatoma - definition
Keratinised squamous epithelium in the middle ear where it shouldn’t be
Abundant keratin production in the middle ear
Cholesteatoma - pathology
Lots of surface flakes
- large pink areas on histology slides
High cell turnover
Cystic swelling in middle ear (due to loss of movement of keratin)
Cholesteatoma - what should the normal lining of the middle ear be and what is it in this condition?
Normal: cuboidal/columnar glandular epithelium
Cholesteatoma: keratinised squamous epithelium
Cholesteatoma - what are the 2 types
Acquired
Congenital
Cholesteatoma - which is more common: acquired/congenital?
Acquired
Cholesteatoma - the tympanic membrane is in tact / perforated in acquired cholesteatoma?
Perforated
Cholesteatoma -the tympanic membrane is in tact / perforated in congenital cholesteatoma?
In tact
Cholesteatoma - clinical features
Associated inflammation
Lots of flakes
Discharge
Cholesteatoma - investigations
CT: densities of cholesteatoma
MRI: poor localisation of bony landmarks
Vestibular schwannoma - definition
Benign tumour of peripheral nerves (schwann cells)
Connective tissue tumour
Associated with the vestibular portion of CN VIII
Vestibular schwannoma - where are they found
Within temporal bone
At angle between pons and cerebellum
Causes significant compression of brain stem
Vestibular schwannoma - pathology
Lots of elongated, streaming nuclei
Spindle cell morphology
Verocey bodies
Vestibular schwannoma - what condition are they commonly associated with?
Neurofibromatosis
type 1 neurofibromatosis
Wide spread Bony defects Cafe au last spots Axillary freckling Lisch nodules in eye
type 2 neurofibromatosis
Young patient
BPPV - definition
Benign positional paroxysmal vertigo
Common inner ear balance disorder
BPPV - what usually happens to the granules of crystals that are attached to the hair cells in the utricle?
They fall to the bottom due to gravity
BPPV - what happens to the granules of crystals in the utricle in BPPV?
They become loose and float freely in the fluid
They collect in the cupola of the semicircular canal
BPPV - which semicircular canal is most commonly affected?
Posterior
BPPV - causes
Head trauma
Ear surgery
Idiopathic
BPPV - classic presentation
Patient turns over in bed and the room spins
Patient bends forward and room spins
Patient puts head up and room spins
BPPV - clinical features
Repeated, brief episodes of vertigo with movement
Vertigo usually lasts less than 1 minute
May have several attacks per day
No hearing loss or tinnitus
BPPV - examinations
Hallpike’s test
Epley manoeuvre
Semont manoeuvre
Brant-Daroff exeercises
BPPV - examinations - hallpike’s test
Pt lie down from sitting postion with head turned to one side
Patient must keep eyes open as you are looking for eye movements (nystagmus)
Patients with nystagmus will have BPPV
BPPV - Common diagnostic eye sign
Nystagmus
BPPV - management
Do the manoeuvres
Mineres disease - definition
Swelling of endolymph compartment which causes the perilymph and endolymph fluids to mix
Not common
Mineres disease - cause
Unknown
Mineres disease - clinical features
Recurrent spontaneous rotational vertigo
Tinnitus on affected side
Mineres disease - which type of hearing loss is it associated with?
Sensori-neural hearing loss
Mineres disease - management
Supportive treatment Tinnitus therapy Hearing aids Grommet insertion Intratympanic gentamicin/steroids Surgery
Vestibular neuronitis - definition
Affects the vestibular nerve (balance)
Vestibular neuronitis - cause
Viral
Vestibular neuronitis - clinical features
Prolonged vertigo for number of days
Nausea
No associated tinnitus or hearing loss
Vestibular neuronitis - management
Self limiting
Vestibular sedatives
Labrynthitis - definition
Affects the whole labyrinth (balance and hearing)
Labrynthitis - cause
Viral
Labrynthitis - clinical features
Prolonged vertigo - sudden onset vertigo on day 1 which improves over the following days Nausea Tinnitus Hearing loss
Labrynthitis - management
Self limiting
Oscillopsia - definition
When there is no vestibular output
Loss of the vestibular ocular reflex (VOR)
Oscillopsia - clinical features
Eyes constantly bouncing around as they can’t focus on the environment
Oscillopsia - cause
Gentamicin
Tinnitus - management
Try to adapt to the noise and ‘throw it away’
Mask the noise
Nystagmus - definition
Quick flickering of eyes
Serous discharge means middle ear pathology is MORE/LESS likely
Less
Cholesteatoma - management
Mastoid surgery
- to remove the squamous debris
Perforated tympanic membrane - causes
Trauma
Chronic middle ear infection
Otosclerosis - definition
New bony deposits occur in the base of the stapes
Otosclerosis - who gets it
Females, middle aged, hereditary
Otosclerosis - management
Hearing aids
Stapes surgery
What is the commonest cause of deafness?
Presbycusis
Presbycusis - definition
Degenerative disorder of the cochlea
Age related hearing loss
Presbycusis - what type of hearing loss does it produce
Sensorineural
Presbycusis - lower frequencies are affected most. True or false?
False
- higher frequencies are affected most
Vertigo which lasts seconds-minutes
BPPV
Vertigo which lasts minutes-hours
Meniures disease
Vertigo which lasts hours-days
Labrynthitis
Which semicircular canal is most affected by BPPV?
Posterior
BPPV symptoms become less severe on repeated movements. True or false?
True
What diagnoses BPPV?
A positive hallpike test
Management of BPPV ?
Epley manouevre
What does gentamicin do to the ear?
It destroys the vestibular epithelium
Can lead to hearing loss
What is another name for vestibular schwannoma?
Acoustic neuroma
Where does vestibular schwannoma usually occurs?
Angle between the pons and the cerebellum
Vestibular schwannoma clinical features?
Unilateral hearing loss
Vertigo occurs later on
CN palsies: CN V, VI, VII, IX, X
Vestibular schwannoma investigation
MRI scan