EAR- DIAGNOSTIC AND ASSESSMENT Flashcards
What is Hitzelberger’s sign?
Hypoesthesia of postauricular area associated with compression of VIIth nerve secondary to an acustic neuroma
How can one differentiate between relapsing polychondritis involving the ear and other causes of external otitis?
Relapsing polychondritis spared the lobule
What is the likdy diagnosis for someone who presents with vesicles on the pinna and external auditory canal
(EAC), facial nerve weakness, and sensorineural hearing loss (SNHL)?
Ramsey-Hunt syndrome
What is lobule colobomata?
Bifid lobule
What is cryptotia?
absence of retroauricular helix
What is cockleshell ear?
Type III cup ear where the ear is malformed in all directions.
Why is it particularly difficult to assess the auditory function in patients with bilateral aural atresia?
Masking dilemma.
What test should you use to assess audiotory function in patients with bilateral aural atresia ?
Auditory brainstem response ABR
What finding on pneumatic otoscopy is most specific for otitis medial?
Immobility of the tympanic membrane
What is the Brown sign?
Sign in glomus tympanicum tumors
pulsation of the glomus tumor in the middle ear when positive pressure is applied to the external auditory canal during otoscopy from pneumatic otoscope
What is the definition of auditory threshold?
The lowest level at which the patient can detect a sound 50% of the time
Where is bone-conducted sound transmitted?
directly to cochlea
Which part of the auditory system is assessed by air conduction tests?
entire auditory system
What is the signi6cance of a negative Rinne at 256Hz, 512Hz, and 1024 Hz ?
At least a 15 dB conductive hearing loss (CHL) , 25-30dB CHL, and 35 CHL respectivly
What percent of the time will the Rinne test miss an air-bone gap <30 dB
50%
A patient has a negative Rinne at 256 Hz AS. At 512 and 1024 Hz, it is positive as it is at all three frequencies
AD. The Weber test lateralizes to the left at all three frequencies. He hears a soft whisper AD and a soft to
medium whisper AS. What is his hearing loss?
15 dB CHL AS
What is the significance of the ability to hear a tuning fork placed on the teeth?
Indicates that cochlear reserve is present and surgery may be beneficial.
How are air and bone conduction thresholds measured?
By first obtaining a positive response, then lowering the intensity by 10 dB increments until no response is obtained.
What are the stimuli used to obtain a speech reception threshold (SRT)?
Spondees.
What is a spondee?
A two-syllable word spoken with equal stress on both syllables.
How is SRT measuredl
By starting at minimal intensity and ascending in 10 dB increments until the correct response is identified.
What is the definition of speech reception threshold (SRT) ?
The lowest hearing level at which half of the words are heard and repeated correctly, followed by at least two correct
ascending steps.
SRT should be within ____dB of pure tone a-verage (PTA)
10dB
What is the speech detection threshold (SDT)?
Hearing level at which SO% of the spondaic words are detected; usually 6-7 dB lower than the SRT
How is speech discrimination testing performed?
Phonetically balanced monosyllabic word lists (50) are administered at 30-50 dB above threshold and the correct
percentage is identified.
What is a normal word recognition score?
90-100%
What is the signi6cance of speech discrimination scores?
Patients with cochlear and retrocochlear pathology will have poor to very poor scores, respectively; those with only
CHL will have normal scores when the intensity level is sufficiently loud.
What is rollover?
A decrease in speech discrimination scores when presented at higher intensities; suggestive of a retrocochlear lesion.
A patient with an SRT of 55 dB HL and a speech discrimination score of 64% at 75 dB HL has what kind
of hearing loss?
sensorineural
What is interaural attenuation?
The reduction of sound when it crosses from one ear to another.
What is normal interaural attenuation of air-conducted tones?
40–80 dB depending on whether ear inserts or headphones are used and also on the frequency being tested.
What is the normal interaural attenuation value for bone conduction?
0 dB
When should masking be used?
When the air conduction threshold of the test ear exceeds the bone conduction threshold of the non test ear by a
value greater than interaural attenuation.
What is crossover ?
The attained responses represent the performance of the nontest ear rather than the test ear due to a large sensitivity
difference between the ears.
When does masking dilemma occur?
Bilateral 50 dB or greater air-bone gaps.
What is the Stenger’s test?
Test to see if the patient is malingering; appropriate to administer if there is >20 dB difference between ears in
voluntary thresholds.
Where is the peak pressure point in a normal tympanogram in an adult?
Between -100 and +40 daPa.
What would the tympanogram look like in an ear with an interrupted ossicular chain?
Very steep amplitude, high peak (typeAd).
What is the acoustic reflex threshold?
The lowest stimulus level that elicits the stapedial reflex.
In the normal ear, contraction of middle ear muscles occurs at which pure tones?
65-95 dB HL.
What are the neural pathways of the acoustic reflex?
VIII to the ipsilateral ventral cochlear nucleus to the trapezoid body to the motor nucleus ofVII to VII to the
ipsilateral stapedius.
VIII to the ipsilateral ventral cochlear nucleus to the trapezoid body to the ipsilateral medial superior olive to the
motor nucleus of VII to VII to the ipsilateral stapedius.
VIII to the ipsilateral ventral cochlear nucleus to the medial superior olive to the contralateral motor nucleus of VII
to the contralateral VII to the contralateral stapedius.
True/False: The acowtic reflex threshold is absent in patients with middle ear d.isease.
True
What does the finding of elevated acoustic reflex in the presence of normal hearing or mild SNHL and a
normal tympanogram suggest?
Retrocochlear pathology.
True/False: Brainstem lesions may abolish the acoustic reflex without affecting the pure tone thresholds.
True
What does acoustic reflex delay measure?
The ability of the stapedius muscle to maintain sustained contraction.
How is the acoustic reflex delay measured?
A signal is presented 10 dB above the acoustic reflex threshold for 10 seconds; if the response decreases to one half
or less of the original amplitude within 5 seconds, the response is considered abnormal and suggestive of
retrocochlear pathology.
What three audiometric test techniques are used to obtain behavioral response levels from a child?
Behavioral observation audiometry (BOA),
visual reinforcement audiometry (VRA),
and conditioned play
audiometry (CPA).
What is the best audiometric method to we when assessing the hearing level of a 15-month-old child?
BOA (observing reflexive/behavioral responses to sound stimuli at different frequencies) and VRA (employing
lighted transparent toys to reinforced responses (head turn) to auditory stimuli.)
What is the best audiometric method to we for a 4-year-oId child?
Conditioned play
audiometry CPA
where the child is trained to respond to auditory stimuli with a motor response (e.g., pointing to pictures).
What stimuli is used to evoke the ABR?
A simple acoustic click, between 2000 and 4000Hz.
What do the peaks of the ABR representl?
Synchronous neural discharge at various locations along the auditory pathway.
What does each wave represent? in ABR
I-Eighth nerve. II-Cochlear nucleus. III-Superior olivary complex. IV-Lateral lemniscus. V-Inferior colliculus. [Note: E. coli}
Which of the wave is the largest and most consistent?
V
True/Fahe: The ABR is unaffected by state of sleep or medications.
True
How is ABR most commonly used?
To test newborns, difficult to test children, and malingerers.
How is hearing threshold estimation performed using ABR?
Wave V is tracked with decreasing sound intensity until it can no longer be observed.
What does the interwave latency reflect?
The time necessary for neural information to travel between places in the auditory pathway; any pathology that
interferes with this transmission will prolong the latency.
When is the interaural latency difference of wave V important?
Used to document retrocochlear pathology when wave I is absent.
When is wave I absent?
When hearing loss exceeds 40-45 dB at higher frequencies.
When determining interpeak latencies, which waves are compared?
I-III, I-V.
What is the difference in these interpeak latencies?
Increased I-III intervals are almost always indicative of retrocochlear pathology, whereas increased 1-V intervals is
more likely associated with noise-induced SNHL.
How will a retrocochlear lesion affect the ABR?
Prolongation of absolute wave V latency, I-V latency, and interaural wave V latency.
What are the three types of evoked OAEs?
SFOAE (stimulus frequency).
TEAOE (transient evoked).
DPOAE (distortion product).
Which of OAEs evoked by two pure tones?
DPOAE (distortion product)
What are the typical objective auditory findings in patients with auditory neuropathy?
Decreased or absent ABR, normal OAEs, absent auditory reflexes, very poor speech discrimination,
mild-to-profound pure tone hearing loss.
Why are OAEs useful as a screening tool in infants?
Nearly 100% of people demonstrate evoked OAEs; testing is noninvasive and inexpensive; test time is short;
cochlear hearing loss exceeding 30 dB can be detected.
If otoacoustic emissions are present, can retrocochlear pathology be ruled out?
No
What test can be use to exclude the absence of aidable hearing when the ABR is absent at maximum levels?
ASSEP (auditory steady-state evoked potentials).
True/False: ASSEP has little predictive value for hearing levels in children with auditory neuropathy.
True.
True/False: ASSEP cannot distinguish between cochlear and retrocochlear hearing loss.
True.
What are the indications for performing hearing screening in neonates if universal screening is not
available?
Family history of hereditary childhood SNHL.
Congenital perinatal infection (TORCH).
Head or neck malformation.
Birth weight < 1500 g.
Hyperbilirubinemia requiring an exchange transfusion (>20).
Bacterial meningitis.
Apgar 0-4 at 1 minute or 0-6 at 5 minutes.
Prolonged ventilation (> 5 days).
Ototoxic medications.
What are the indications for performing hearing screening in infants 29 days to 2 years?
Parent concern.
Developmental delay.
Bacterial meningitis.
Head trauma associated with loss of consciousness or skull fracture.
Ototoxic medications.
Recurrent or persistent otitis media with effusion for at least 3 months.
What are the indications for hearing evaluation every 6 months until age 3?
Family history of hereditary childhood hearing loss.
In utero infection (TORCH).
Neurodegenerative disorders.
What does the audiogram typically look like in a child with SNHL secondary to rubella?
Cookie-bite pattern.
In the workup of congenital hearing loss, what test has the highest diagnostic yieldl
CT scan
What sort of hearing loss is most common in patients with Cogan’s syndrome?
Progressive to total deafness
In patients with chronic otitis media but no cholesteatoma, what level of hearing loss is associated with
ossicular chain disruption or fixation?
30 dB or more
What is the significance of hearing loss in the absence of middle ear effusion in patients with congenital
cholesteatoma?
Most lesions begin anterosuperiorly and extend posteriorly with growth. Hearing loss indicates posterior extension
with involvement of the stapes superstructure and/or the lenticular process of the incus.
What auditory tests are performed in tinnitus analysis?
Pitch matching, loudness matching, minimum masking level (MML), and residual inhibition.
How is the diagnosis of idiopathic intracranial hypertension (IIH) syndrome made?
Exclusion of lesions producing intracranial hypenension, lumbar puncture with CSF pressure of more than
200 mm H20 and normal CSF constituents.
What proportion of patients with idiopathic intracranial hypertension will have an abnormal ABR?
one third
In patients with (IIH), what is the usual pitch of the tinnitus?
Low frequency
What maneuvers on physical exam will decrease or completely eliminate pulsatile tinnitus of venous
origin?
Light digital pressure over the ipsilateral internal jugular vein and head turning toward the ipsilateral side.
What instrument is most helpful in examining nystagmus on physical exam?
Frenzel goggles.
What disorders are associated with down-beating nystagmus?
Arnold-Chiari, cerebellar degeneration, multiple sclerosis, brainstem infarction, lithium intoxication, and magnesium and thiamine deficiency.
What disorders are associated with up-beating nystagmus?
Brainstem tumors, congenital abnormalities, multiple sclerosis, hemangiomas, vascular lesions, encephalitis, and brainstem abscess.
What disorders are associated with bi-directional gaze-fixation nystagmus?
Barbiturate, phenytoin, and alcohol intoxication
What findings on video-nystagmography (VNG) are seen with central vestibular disorders?
Disconjugate eye movements, skew deviation, vertical gaze palsy, inverted Bell’s phenomenon, seesaw nystagmus,
bidirectional nystagmus, periodic alternating nystagmus, and nystagmus that is greater with eyes open and fixed on
a visual target than in darkness.
What finding on VNG is pathognomonic for a lesion at the craniocervical junction?
Spontaneous downbeat nystagmus with the eyes open, in the primary position that increases with lateral gaze or
head extension.
What is opsoclonus?
Rapid, uncontrolled, mulitvectorial, conjugate eye movements, usually seen on physical exam and difficult to detect on VNG.
What are the clinical features of benign paroxysmal positional vertigo (BPPV) ?
10-20-second attacks of rotational vertigo, precipitated by head movements, with spontaneous resolution after
several weeks to months in 80-90%.
What is “Schwartze’s sign”?
Reddish hue on the promontory associated with otosclerosis.
Is the acoustic reflex present in patients with otosclerosis?
Usually it is absent bilaterally, even if the disease is unilateral.
Is the acoustic reflex present in patients with superior semicircular canal dehiscence?
yes
What is Tullio’s phenomenon?
Vertigo with loud noise, commonly seen in patients with superior semicircular canal dehiscence.
How does the hearing impainnent from malleus ankylosis differ from that of otosclerosis?
In patients with malleus ankylosis, hearing impairment is mostly unilateral (78%); the air-bone gap is smaller
(majority less than 20 dB); SNHL is more frequent, particularly at 4kHz; acoustic reflex is more likely to be
present on the contralateral ear and absent on the impaired ear.
