Ear Disease Flashcards
Pinna anatomy
What is this?
- This is a normal tympanic membrane on a right ear (position of angle of malleus as it points up and out towards front
- SHould look pearly, white and healthy with light reflecting well
- FGluid level behind it or hole may be abnormal
Normal structures of tympanic membrane
What to ask when presenting with ear porblmes
- Otalgia - ea rpain
- Otorrhoea - discharge
- Hearing loss
- Tinnitus - sensation of sound in absence external stimulus
- Vertigo - sensation rotatory (room feels like its spinning)
What to look at when presenting ear compliant
- Look and feel of external ear - press tragus and mastoid process to check for swelling, reddness, obvious skin changes, scars
- Ear canal
- Tympanic membrane
- Facial Nerve - this runs through the temporal bone which houses the structure of ear so problems with the ear like nasty infection if it gets into temporal bone it can cause problems with facial nerve impairing its function causing weakness (tends to be LMN weakness so forehead not spared).
Herpes Zoster
Facial nerve palsy and vesicles on ear or palate
Ramsays syndrome - reactivation herpes zoster virus that can caus efacial paralysis.
Whta is this
Tympanic membrane perforation
Infection, trauma etc.
Small perforations will heal on own, if no signs infections etc then leave 6 weeks and check again
What is this
Tympanosclerosis - scarring of ear drum
Mostly incidental finding, people wotn know
What is this
Tympanic membrane slightly bulging and bubbles behind (ear effusion). SO fluid collection behind ear drum.
titis Media with Effusion
- Hsiotry - ear pressure/ congestion, sometimes otalgia, popping noises, hearing loss (conductive), disequilibrium, affects speech development in children
- O/E = pinna and canal NAD, TM dull/opaque, fluid level/ bubbles
- Mgmt =
- audiogram, ototoscopy, counsel patients
- Watch and wait, f/u in 3m
- Consider myringotomy/grommets, hearing aid
- In adults with unilateral middle ear effusion - consider nasopharyngeal malignancy.
Causes - Eustachian tube function impaired and doesnt open properly so infected fluid cant leak out and cant equilise pressure in ear so ear drum becomes retracted and sucked in
Longer fluid sits hear goes from fluid consistency to thick glue and hence why commonly referred to as glue ear.
Type hearing loss of otitis media with effusion you would see
Air conduction reduced
conductive hearing loss
Grommets
Tiny plastic tubes into ear drum to allow glue air to be sucked out and air can ventilate to equalise air pressure wihtout needing eustachian tube
12-18m it will work its way out of ear.
Different types and may also use p tube for exampke.
This is how eustachian tube equapises pressure etc and when its blcoked
Bulging red angry looking eardrum. Dull and not transcluent. Acute otittis media
Acute Otitis Media
- COmmon especially in under 7s
- Hx of increasing otalgia, no discharge red and bulging TM
- ASOM: crescendo pain then resolution (sometimes with ‘pop’) then discharge and TM perforation
- Associated hearing loss, tinnitus, fever common
- Children: unwell, crying, pulling the affected ear
- MGmt = often conservative, amoxicillin in severe case (or unresolving etc)
- Red flags = Systemic symptoms (high temp, increased pressure etc) , CN palsy, meningism
GROMMET EXAMPLE
What is this
Mastoiditis - infection spread to mastoid air cells. Redness overlying mastoid process and when you pressure on it, it will feel soft and feel like you can push it in.
Ear is pushed forward and normally crease behind ear, but this has been stretched out and lost. Sign of abscess within mastoid and this is emergency as if abscess progress can have complications and infection spread to brain etc so to be seen by EnT doctor
Can be complication from acute otitis media
Mastoiditis
Foruncle
Fornuncle - spot on ear canal, discharge
Chronic supparative otitis media
Chronic discharge from ear, long-standing infections of middle ear
In the image, ear drum completely perforated
Cna build up and form sac- cholesteatoma (sac of keratinous squamous cells that builds up). Classically in top part of middle ear.
Cholesteatoma
Cholesteatoma - can erode through any structures their in contact with for a long time. Can erode in any direction.
When see them give er drops with antibiotics and refer
Management: Ear drops (antibiotics/ steroids), regular ear cleaning (Microsuction) and surgery (mastoidectomy/ atticoantrostomy (various approaches)
Acute Otitis Externa
Red boggy inflamed in ear canal, can sometimes see shedding dead skin cells and flakes within inside ear.
Often come in with severe ear pain and discharge. Often been swimming in pool, been in humid area etc
Uusally bacterial but can get fungal one.
Infection of the pinna.
If this is alongside of otitis externa then drops and tablet antibiotivs.
Watch out for - in diabetes, immuncomprimised etc then malignant otitis externa where infection spreads into bone and can spread along temporal bone etc. Mostly when had it more than 6 weeks, massive pain, immunocomprimised.
Wic that you put into ear canal, you put drops on it and it swells up to get ear drops right into ear canal and allows it to give drops continusly.
For acute otitis externa
What is this
Fungal spores in ear canal - fungal acute otitis externa
Difficult to treat, often with topical cannisten and regular ear suction to get out infection material and fungal spores
Perichondritis - inflammation of the cartilage in-ear so sparing of the lobule.
- Red, swollen, tender ear
- RFs = piercing, laceration, otitid externa
- COmmon organisms - staph aureus, pseudomonas
- Can cause ‘cauliflower ear’
- Tx: antibiotics (oral/IV)
- Beware relapsing perichondritis (autoimmune condition, needs ot be referred to rheumatologist for further investigations)
WHat is this
Suffered trauma to ear and get collection blood under perichondrium (lining sits under cartilage).
Pinna haematoma
Won’t cause people problems but tend to drain with small cut or needle left untreated can cause cauliflower ear (collection blood between cartilage an perichondrium and as it separates off it disrupts blood supply to the cartilage of ear so cartilage will die, cartilage necrosis and once starts necrosing then forms deformity of cauliflower ear)
Cauliflower ear in below image.
What is this?
Foreign bodies in ear
Bugs can be problematic as scratches around, bites cause irritation and pain. If you try to get it out it will anger it more so drown it in olive oil before fishing it out.
Foreign body earL
- Examine
- EnT to remove (children may require GA and theatre)
- Live insects - olive oil
WHta is this
Button battery in contact with piece meat
Button batteries etc is a big problem with children and these are horrendous and longer in contact with organic surface, it will erode through it and cause perforation tympanic membranes, ossicles, etc…Can also damage external ear canal and cause scarring. ANy possibel button battery in body even if swallowed then immediately referred to hosopital?>
Whta is this
Axial CT on the temporal bone.
A: fracture through mastoid portion temporal bone, skull fracture
Here would be worried about conductive loss from blood in ear canal, disruption of tympanic membrane etc
B: would expect sensory neuronal loss hearing problems, assess hearing, facial nerve.
WHat expect to see with patients with Fractures temporal bone -
disruption ar canal, may see blood sat behind TM, battle sign ( blood and burising sitting under skin around mastoid process as shown)
Facila nerv epalsy
WHta is this
Axial MRI scan, internal acoustic meatus and cerebellopontine angle. Can see the white structure - large tumour growing off someones vestibular portion of vestibulocochlear nerve - vestibuloschwannoma (Benign tumour growing from schwann cells and slow-growing causing pressure on structures around the nerve).
Can grow and cause problems with vertigo and often grows on lower portion nerve. Can cause sensorineuronal hearing loss if presses on cochlear nerve and can cause facila weakness
Often unilateral with unilateral symptoms unless condition.
So summary - any ear problems then…
- Ear pain
- Discharge
- Hearing loss
- Tinnitus
- Vertigo
Check external ear, ear canal tympanic membrane, facial nerve function
Scary things - signs sepsis, meningitis, neurological signs then imemdiate assessment EnT
Common causes vertigo which are caused by problems with inner ear
- blaance problem in inner ear then rotatory spinnign sensation balance issue produced when problem usually affect semicricular canal or nerve supplying vestibuloportion cochlear nerve
- When you move around fluid within semicircular canals swishes around and tells eyes what direction head turning so the eyes move with it. Dislodgement otoconia and fall within semicircular canal when you turn head you get abnormal stimulation of canal s fluid move around but also have solid dense ototoconia moving with fluid. ABnormal stimualtion canal so brain thinks head moving and its not so sensaiton vertigo. Thi sis BPPV (benign paroxysmal positional vertigo) Room spins for 30secs etc when turning. Often do epley manouvre t0 rotate their hed to positions to turn semicircular canal allowing otoconia to drift around canal and back to right place.
- Vestibuloneuronitis - Inflammation of vestibular portion of vestibulocchlear nerve usually following viral infection and this is constant not episodic lik eBPPV.
- Labyrinthitis - virsl infeciton infecting hwole labyrinth not jsut nerve and you dont just get balance problems but get sensorineural hearing loss and affects cochlear.
Continuous vertigo to hospitalize them or other neurological symptoms always think…
IS THIS A STROKE
