Ear Disease Flashcards
what are the key ear symptoms you should ask about
Hearing loss Tinnitus Vertigo Otalgia - pain Discharge
List the different types of hearing loss
Conductive
Sensorineural - can be cochlear or retrocochelar (higher centres)
Mixed
What can cause referred ear pain
Teeth Tonsils Tongue TMJ Throat
What is otitis externa
Inflammation of the outer ear/ skin of ear canal
What causes otitis externa
Infection - bacterial, fungal etc Often occurs out of the blue Water or soap getting into the ear - more common in swimmer Cotton buds Skin conditions - psoriasis, eczema Itching and scratching of the ear Ear syringing
What other conditions can acute otitis media be associated with
Glue ear - otitis media with effusion
URTI’s
Symptoms of otitis media can improve when the ear drum bursts - true or false
TRUE
release of pressure = reduced pain
What causes otitis media with effusion
Fluid builds up behind ear drum and leads to inflammation - gradually thickens and becomes like glue
Eustachian tube dysfunction or obstruction
Common in children as they have short tubes
Can be associated with URTI, allergy, recurrent ear infection, anatomical abnormalities, large adenoids and immunodeficiency
Also nasopharyngeal cancers or lymphoma as this can impact on the eustachian tube - seen in adults
What are the signs of glue ear
Conductive hearing loss Flat tympanogram - reduced mobility of membrane Drum retraction Drum appears yellow/gold due to fluid Incus will be more visible May be mild pain
Delayed speech and language in young children
Poor school performance or behaviour
Due to hearing loss
How can you treat glue ear
Often resolves itself in 3-6 months once infection clears so treat conservatively - watchful waiting
If kids are having speech delay or school issues then can use hearing aids - refer to audiology
Grommet insertion - hole in the drum to allow the fluid to drain
Needs referral to ENT
If child has large adenoids which may be causing it these may be removed
What can lead to perforation of the ear drum
Acute otitis media
Trauma
Perforated ear drums do not heal - true or false
FALSE
The majority will heal on their own
What is cholesteatoma
Presence of keratin within middle ear - abnormal
Squamous epithelium gets into middle ear (possibly due to retracted drum) and dead keratinised skin cells build up
Erodes surrounding bone
Can also become infected
How does cholesteatoma present
Hearing loss
Discharge
Retracted ear drum with more visible ossicles
No perforation - membrane still in place Keratin build-up appears golden, may replace some of the bony structures as it erodes
Can erode into the bony wall of the ear canal
How do you treat cholesteatoma
Surgical excision - must remove it all to prevent recurrence
List complications of AOM and cholesteatoma
Superior spread:
- Brain abscesses
- Meningitis
Posterior spread:
- Infective thrombus and emboli due to spread to the venous sinuses
Lateral spread:
- Tinnitus
- Facial palsy or other CN palsy
- Vertigo
- Hearing loss - sensorineural
- mastoiditis
Describe otosclerosis
Get fixation of the stapes
Presents with gradual onset CHL
Common in women and gets worse in pregnancy
How do you treat otosclerosis
Can give hearing aid
Stapedectomy - removal of the stapes bone
Risks include dead ear or permanent hearing loss
What is presbycusis
Old age related hearing loss
High frequency sounds lost
What is the classic sign of noise induced hearing loss
Dip in hearing at 4kHz
Which drugs can cause hearing loss
Gentamicin and other aminoglycosides - ototoxic
Chemotherapy drug
Aspirin and NSAIDs
What is a vestibular schwannoma
Benign tumour arising in IAM
Presents with hearing loss, tinnitus and imbalance
Can have mass effects when large enough
What is a haemotympanum
When the middle ear fills with blood
Will be seen behind the tympanic membrane on otoscopy
Causes conductive hearing loss
Seen in trauma
What is Battle’s sign
Bruising over the mastoid - behind ear
Suggestive of base of skull fracture
How does a skull fracture present
Hearing loss - C or SN or mixed
Facial palsy
CSF leak - clear fluid from nose
Battle’s sign
What is the definition of dizziness
Non-specific term, which may cover vertigo, pre-syncope, disequilibrium, etc.
What is the definition of vertigo
A sensation of movement, usually spinning.
List cardiovascular causes of dizziness
Arrhythmias
Postural hypotension
Associated with syncope and palpitations
List visual causes of dizziness/loss of balance
Cataracts
List some vestibular causes of dizziness/loss of balance
BPPV
Meniere’s
Vestibular Neuronitis
Associated with vertigo
List some vestibulospinal or vestibulooccular causes of dizziness/loss of balance
Stress
Migraine
MS
The duration of vertigo with BPPV is…..
Seconds
The duration of vertigo with Meniere’s is……
Hours
The duration of vertigo with vestibular neuritis is…..
Weeks
Hearing loss or tinnitus associated with vertigo is suggestive of what
Inner ear problem
Dizziness when rolling over in bed is suggestive of what
BPPV
Vertigo associated with nausea and vomiting is suggestive of what
Vestibular neuritis
Vertigo associated with light-sensitivity is suggestive of what
Vestibular migraine
Dizziness associated with hearing loss is suggestive of what
Meniere’s
What is the vestibulo-ocular reflex
When you turn you head to the left, your eyes go right
Keeps you balanced
A defect in the vestibulo-occular pathway leads to which eye sign
Nystagmus
It moves in fast waves away from the effected ear
Will be bilateral if a central lesion
What is benign positional paroxysmal vertigo
Gives vertigo when looking up, turning over, bending over or moving head too fast
Also causes visual disturbance, weakness and numbness
Extremely common
Can be caused by head trauma, surgery etc
What causes BPPV
Otolith material from utricle displaced into semicircular canals
What test is done to diagnose BPPV
Dix Hallpike test
Turn their head to 45’ and then lie them down
There will be short delay and then symptoms appear
Which manoeuvre can be done to treat BPPV
Epley manoeuvres
Turn the head to move the crystals/debris to move them out of the semi-circular canal
Describe vestibular neuritis
Causes prolonged vertigo - days
Not associated with tinnitus or hearing loss
Probable viral cause
Describe labyrinthitis
Causes prolonged vertigo - days
Associated with tinnitus or hearing loss
Probable viral cause
How do you treat vestibular neuritis/labyrinthitis
Generally self limiting
Supportive management
Give vestibular sedatives to reduce symptoms - diazepam
What causes Meniere’s disease
High pressure in the endolymph system
If it ruptures it mixes with perilymph and causes attacks of dizziness
Describe the diagnostic criteria for Meniere’s disease
History of recurrent, spontaneous, rotational vertigo with at least two episodes >20mins
Occurrence of or worsening of tinnitus on the affected side
Occurrence of aural fullness on the affected side
Documented SNHL on at least one occasion
How do you manage Meniere’s disease
Supportive treatment during episodes Tinnitus therapy Hearing Aids Grommet insertion Intratympanic steroids or gentamicin Surgery Preventative measures: Salt restriction / Betahistine / caffeine / alcohol / stress
Describe symptoms of migraine
Phonophobia - dislike of loud sound Vertigo Ataxia Headache Fluctuating hearing loss
Describe the presentation of acute otitis media
Earache Fever Irritability May have bulging drum May have hearing loss
Who commonly gets otitis media with effusion
Common in children - often under 8
Trauma to which areas can lead to hearing loss
Direct to the ear
To the head
Can lead to conductive, mixed or SN hearing loss
What can cause conductive hearing loss
Earwax build-up Foreign body blocking the canal Genetic abnormalities of the ear canal - underdevelopment Perforation of tympanic membrane Otitis media Otosclerosis Glue ear - otitis media with effusion
What can cause sensorineural hearing loss
Presbycusis - age related
Most common
Meniere's disease Drug induced - ototoxicity from gent Regular and prolonged exposure to loud noise, Tumours - in ear or brain Strokes - damage the hearing centres Some infections like rubella Genetic predisposition Birth complications
How does acute otitis media present on otoscopy
Appears very red
Will be bulging (hard to visualize cone, malleus etc)
List complications of acute otitis media
Perforated eardrum
Mastoiditis
It is uncommon but very serious
How does mastoiditis present
- Pinna on affected side will stick out and be tender due to an underlying abscess
Acute otitis media is associated with which other condition
URTI
Commonly viral
How do you manange acute otitis media
As it is commonly viral you give supportive management and wait for it to improve
If ymptoms are present for >3 days and are complicated (discharge, fever etc) then antibiotics can be given as this suggests bacterial
When might a perforated eardrum need intervention
If there is evidence of infection around it such as discharge, inflammation
Needs to be clean and dry to heal on its own
What is a myringotomy
A surgical incision in the tympanic membrane to allow air to get in and fluid to get out
A myringotomy is a solution to glue ear - true or false
False
It will heal really quickly by itself so you insert a grommet to keep it open for a while
Grommets are a permanent implant - true or false
False
They will usually fall out by itself in about 9 months - 1 year
What does a flat tracing on a tympanogram suggest
Suggests a immobile tympanic membrane and therefore conductive hearing loss
How does a normal tympanogram look
Should see a bell curve shape around the 0 mark (normal pressure)
Nice peaked curve
What is an audiogram used for
Tells you the pattern of hearing loss
Measures the conduction of sound via bone and air
Air conduction:
Right ear is denoted by red circles, left is a blue cross
Bone conduction is denoted by another black symbol, usually triangle if unmasked
If masked you use brackets
A bone air gap on an audiogram is suggestive of what
Conductive hearing loss
Sound is not passing freely through canal to inner ear but nerves work fine
Considered a gap if more than 5dB apart
If both bone and air conduction are decreased on an audiogram what does this suggest
Sensorineural hearing loss
Issue with the nerves in inner ear not the conduction
What is the normal hearing range on an audiogram
20 to -20
Anything below this on the audiogram is considered a hearing loss
On an audiogram what is Cahart’s notch
A dip in conduction at 2 khz
It is a sign of otosclerosis
How does a normal tympanic membrane appear on otoscopy
Should be greyish pink in colour
Cone of light should be found beneath the umbo (anterior and inferior)
Handle of the malleus should be visible and should point towards the side you are examining - e.g. Points to left in the left ear
If the cone of light is not in the anterior/inferior position what does it suggest
Distention of the tympanic membrane
What does a shallow tracing on a tympanogram suggest
Otosclerosis
Technically still a type A as there is movement - just a much smaller peak
What is a type A tympanogram
The normal bell curve/peak Shows the Eustachian tube is functioning normally and eardrum is moving normally in response to pressure
What is a type B tympanogram
A flat tymp
Shows that something is restricting the movement of the eardrum - likely fluid behind it (glue ear)
May be associated with conductive hearing loss
What is a type C tympanogram
Still shaped like a teepee with peak, but are shifted negatively (left) on the graph
Shows the drum is moving but something is retracting it inwardly towards the middle ear (e.g. negative pressure from eustachian tube)
How is a pure tone audiogram carried out
Wear insert earphones, a bone conductor which sits behind the ear on the mastoid process and then a pair of over ear headphones - tones are played through them
For a pure tone audiogram the patient is asked to press a button every time they hear the tone
What is air conduction assessing in audiology
Air conduction assesses the entire auditory pathway
What is bone conduction assessing in audiology
Bone conduction bypasses the external and middle ear and transmits straight to the inner ear
Assessing the inner ear only
Can bone conduction be worse than air conduction
No
Bone conduction can never be worse than the air conduction.
May need to adjust the conductor if you get this result.
What is the purpose of masking in audiology
It allows a single ear to be isolated for testing
ts not always certain that the intended test ear is the one detecting the sound - i.e. The good side may pick up the noise and the person will indicate even if the bad ear would hear nothing
You can then mask the good ear by covering it and playing white noise through the earphones
This allows the bad ear to be tested on its own
How can tinnitus affect audiology results
Hard for those with tinnitus to differentiate high frequency tone from their tinnitus
Often use warble tones to overcome this - also used in kids
When is masking used in audiology
Used if the difference between ears is over 40dB on headphones or 55dB on insert earphones
Few other situations
This allows you to isolate one ear to test to ensure that the ‘good’ ear is not the one picking up the sound
If hearing loss is fluctuating it is likely which type
Typically conductive
Which structures are damaged in sensorineural hearing loss
Permanent SNHL is caused by damage to the hair cells in the cochlea or the hearing nerve or both
Damage to the cochlea occurs as part of the ageing process which is why we get presbycusis
What are the consequences of not masking in audiology
Incorrect diagnosis
Inappropriate treatment
Programming of hearing aids incorrectly
How does mixed hearing loss present on an audiogram
Both air and bone conduction will be below 20dB demonstrating a SNHL but there is also a significant air bone gap (greater than 10dB) which demonstrates a CHL as well
List potential causes of mixed hearing loss
Genetic factors Birth defects Infections Tumours Head injury Otosclerosis
Otosclerosis is more common in which type of patient
Female
Those with a family history - goes down the female side
Typically in 20s or 30s
Aggravated by pregnancy
How does acoustic neuroma present
Unilateral SNHL
Unilateral tinnitus
Unbalanced or vertigo
Which is primary otalgia
Pain coming from the ear itself
What are the 5 cardinal symptoms of ear disease
Hearing loss, tinnitus, discharge, pain, vertigo
What conditions of the pinna and external ear can cause primary otalgia
Infection - cellulitis of pinna or otitis externa Trauma Foreign bodies Earwax Malignancy - SCC
What conditions of the middle ear can cause primary otalgia
Otitis media +/- effusion
Cholesteatoma
Mastoiditis
What conditions of the inner ear can cause primary otalgia
Acoustic neuroma
Vestibular schwannoma
Infection - viral labyrinthitis
Young children who pull on their ears but have a normal ear exam may have what
Reflux!
May be referring from the larynx
If a patient presents with chronic otalgia but has a normal ear exam may have what
Deep tumours of the temporal bone - consider for MRI
How should you investigate otalgia
Do otoscopy, examine TMJ, oral cavity, neck, cranial nerve exam
What is secondary otlagia
When a patient presents with otalgia but there is no evidence of ear disease
It is being referred from a secondary location with a similar/overlapping nerve supply
The mandibular branch of the the trigeminal nerve can cause referred pain from which structures
Dentition
Jaw
The glossopharyngeal nerve can cause referred pain from which structures
Throat
The vagus nerve can cause referred pain from which structures
Larynx - reflux
The cervical plexus can cause referred pain from which structures
C-spine injury - stenosis etc.
Neck muscle injury
The facial nerve can cause referred pain from which structures
Salivary glands, nasopharynx etc.
How does otitis externa present
Itch
Ear discharge
Pain
Temporary dull hearing - CHL
How do you treat otitis externa
Steroid and antibiotic ear drops/spray
Standard analgesia to deal with the pain
What can cause tinnitus
Ears being blocked - cold or ear wax
It’s also very common and may have no cause
Stress can make it seem worse
What can cause epistaxis
High blood pressure Bleeding disorders Drugs - anticoagulation Nasal infections - sinusitis A broken nose Any growth in the nose Nose picking
Which conditions affecting nerves C2 and 3 can cause referred ear pain
Arthritis or cervical spondylosis
Soft tissue injuries
Which conditions affecting CNV - trigeminal can cause referred ear pain
Dental disease
TMJ dysfunction
Nasopharyngeal disease - viral infection, tumour etc.
Which conditions affecting CNIX - glossopharyngeal can cause referred ear pain
Almost any oropharyngeal infection - pharyngitis, tonsillitis etc.
Tongue base tumours
Which conditions affecting CNX - vagus can cause referred ear pain
Carcinoma of the larynx and hypopharynx
How does conductive hearing loss present on Rinne and Weber tests
Rinne Negative (Bone conduction louder than air conduction) Weber does not lateralise to either side
Why do many patient’s think their tinnitus is bad at night
Because there are no environmental sounds to “mask” the tinnitus sounds so they are more noticeable
How does sensorineural hearing loss present on Rinne and Weber tests
Rinne positive (Bone conduction NOT louder than air) If unilateral, weber will lateralise to the unaffected side
