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ENT > Ear Disease > Flashcards

Ear Disease Flashcards

1
Q

what are the key ear symptoms you should ask about

A 
Hearing loss 
Tinnitus 
Vertigo 
Otalgia - pain 
Discharge
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2
Q

List the different types of hearing loss

A

Conductive
Sensorineural - can be cochlear or retrocochelar (higher centres)
Mixed

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3
Q

What can cause referred ear pain

A 
Teeth 
Tonsils 
Tongue 
TMJ 
Throat
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4
Q

What is otitis externa

A

Inflammation of the outer ear/ skin of ear canal

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5
Q

What causes otitis externa

A 
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
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6
Q

What other conditions can acute otitis media be associated with

A

Glue ear - otitis media with effusion

URTI’s

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7
Q

Symptoms of otitis media can improve when the ear drum bursts - true or false

A

TRUE

release of pressure = reduced pain

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8
Q

What causes otitis media with effusion

A

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

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9
Q

What are the signs of glue ear

A 
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

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10
Q

How can you treat glue ear

A

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

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11
Q

What can lead to perforation of the ear drum

A

Acute otitis media

Trauma

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12
Q

Perforated ear drums do not heal - true or false

A

FALSE

The majority will heal on their own

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13
Q

What is cholesteatoma

A

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

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14
Q

How does cholesteatoma present

A

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

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15
Q

How do you treat cholesteatoma

A

Surgical excision - must remove it all to prevent recurrence

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16
Q

List complications of AOM and cholesteatoma

A

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
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17
Q

Describe otosclerosis

A

Get fixation of the stapes
Presents with gradual onset CHL
Common in women and gets worse in pregnancy

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18
Q

How do you treat otosclerosis

A

Can give hearing aid
Stapedectomy - removal of the stapes bone
Risks include dead ear or permanent hearing loss

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19
Q

What is presbycusis

A

Old age related hearing loss

High frequency sounds lost

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20
Q

What is the classic sign of noise induced hearing loss

A

Dip in hearing at 4kHz

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21
Q

Which drugs can cause hearing loss

A

Gentamicin and other aminoglycosides - ototoxic
Chemotherapy drug
Aspirin and NSAIDs

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22
Q

What is a vestibular schwannoma

A

Benign tumour arising in IAM
Presents with hearing loss, tinnitus and imbalance
Can have mass effects when large enough

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23
Q

What is a haemotympanum

A

When the middle ear fills with blood
Will be seen behind the tympanic membrane on otoscopy
Causes conductive hearing loss
Seen in trauma

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24
Q

What is Battle’s sign

A

Bruising over the mastoid - behind ear

Suggestive of base of skull fracture

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25
Q

How does a skull fracture present

A

Hearing loss - C or SN or mixed
Facial palsy
CSF leak - clear fluid from nose
Battle’s sign

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26
Q

What is the definition of dizziness

A

Non-specific term, which may cover vertigo, pre-syncope, disequilibrium, etc.

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27
Q

What is the definition of vertigo

A

A sensation of movement, usually spinning.

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28
Q

List cardiovascular causes of dizziness

A

Arrhythmias
Postural hypotension
Associated with syncope and palpitations

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29
Q

List visual causes of dizziness/loss of balance

A

Cataracts

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30
Q

List some vestibular causes of dizziness/loss of balance

A

BPPV
Meniere’s
Vestibular Neuronitis
Associated with vertigo

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31
Q

List some vestibulospinal or vestibulooccular causes of dizziness/loss of balance

A

Stress
Migraine
MS

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32
Q

The duration of vertigo with BPPV is…..

A

Seconds

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33
Q

The duration of vertigo with Meniere’s is……

A

Hours

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34
Q

The duration of vertigo with vestibular neuritis is…..

A

Weeks

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35
Q

Hearing loss or tinnitus associated with vertigo is suggestive of what

A

Inner ear problem

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36
Q

Dizziness when rolling over in bed is suggestive of what

A

BPPV

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37
Q

Vertigo associated with nausea and vomiting is suggestive of what

A

Vestibular neuritis

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38
Q

Vertigo associated with light-sensitivity is suggestive of what

A

Vestibular migraine

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39
Q

Dizziness associated with hearing loss is suggestive of what

A

Meniere’s

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40
Q

What is the vestibulo-ocular reflex

A

When you turn you head to the left, your eyes go right

Keeps you balanced

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41
Q

A defect in the vestibulo-occular pathway leads to which eye sign

A

Nystagmus
It moves in fast waves away from the effected ear
Will be bilateral if a central lesion

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42
Q

What is benign positional paroxysmal vertigo

A

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

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43
Q

What causes BPPV

A

Otolith material from utricle displaced into semicircular canals

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44
Q

What test is done to diagnose BPPV

A

Dix Hallpike test
Turn their head to 45’ and then lie them down
There will be short delay and then symptoms appear

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45
Q

Which manoeuvre can be done to treat BPPV

A

Epley manoeuvres

Turn the head to move the crystals/debris to move them out of the semi-circular canal

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46
Q

Describe vestibular neuritis

A

Causes prolonged vertigo - days
Not associated with tinnitus or hearing loss
Probable viral cause

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47
Q

Describe labyrinthitis

A

Causes prolonged vertigo - days
Associated with tinnitus or hearing loss
Probable viral cause

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48
Q

How do you treat vestibular neuritis/labyrinthitis

A

Generally self limiting
Supportive management
Give vestibular sedatives to reduce symptoms - diazepam

49
Q

What causes Meniere’s disease

A

High pressure in the endolymph system

If it ruptures it mixes with perilymph and causes attacks of dizziness

50
Q

Describe the diagnostic criteria for Meniere’s disease

A

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

51
Q

How do you manage Meniere’s disease

A 
Supportive treatment during episodes
Tinnitus therapy
Hearing Aids
Grommet insertion 
Intratympanic steroids or gentamicin 
Surgery 
Preventative measures: 
Salt restriction / Betahistine / caffeine / alcohol / stress
52
Q

Describe symptoms of migraine

A 
Phonophobia - dislike of loud sound 
Vertigo 
Ataxia 
Headache 
Fluctuating hearing loss
53
Q

Describe the presentation of acute otitis media

A 
Earache 
Fever 
Irritability 
May have bulging drum 
May have hearing loss
54
Q

Who commonly gets otitis media with effusion

A

Common in children - often under 8

55
Q

Trauma to which areas can lead to hearing loss

A

Direct to the ear
To the head
Can lead to conductive, mixed or SN hearing loss

56
Q

What can cause conductive hearing loss

A 
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
57
Q

What can cause sensorineural hearing loss

A

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
58
Q

How does acute otitis media present on otoscopy

A

Appears very red

Will be bulging (hard to visualize cone, malleus etc)

59
Q

List complications of acute otitis media

A

Perforated eardrum

Mastoiditis
It is uncommon but very serious

60
Q

How does mastoiditis present

A
  • Pinna on affected side will stick out and be tender due to an underlying abscess
61
Q

Acute otitis media is associated with which other condition

A

URTI

Commonly viral

62
Q

How do you manange acute otitis media

A

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

63
Q

When might a perforated eardrum need intervention

A

If there is evidence of infection around it such as discharge, inflammation

Needs to be clean and dry to heal on its own

64
Q

What is a myringotomy

A

A surgical incision in the tympanic membrane to allow air to get in and fluid to get out

65
Q

A myringotomy is a solution to glue ear - true or false

A

False

It will heal really quickly by itself so you insert a grommet to keep it open for a while

66
Q

Grommets are a permanent implant - true or false

A

False

They will usually fall out by itself in about 9 months - 1 year

67
Q

What does a flat tracing on a tympanogram suggest

A

Suggests a immobile tympanic membrane and therefore conductive hearing loss

68
Q

How does a normal tympanogram look

A

Should see a bell curve shape around the 0 mark (normal pressure)
Nice peaked curve

69
Q

What is an audiogram used for

A

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

70
Q

A bone air gap on an audiogram is suggestive of what

A

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

71
Q

If both bone and air conduction are decreased on an audiogram what does this suggest

A

Sensorineural hearing loss

Issue with the nerves in inner ear not the conduction

72
Q

What is the normal hearing range on an audiogram

A

20 to -20

Anything below this on the audiogram is considered a hearing loss

73
Q

On an audiogram what is Cahart’s notch

A

A dip in conduction at 2 khz

It is a sign of otosclerosis

74
Q

How does a normal tympanic membrane appear on otoscopy

A

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

75
Q

If the cone of light is not in the anterior/inferior position what does it suggest

A

Distention of the tympanic membrane

76
Q

What does a shallow tracing on a tympanogram suggest

A

Otosclerosis

Technically still a type A as there is movement - just a much smaller peak

77
Q

What is a type A tympanogram

A

The normal bell curve/peak Shows the Eustachian tube is functioning normally and eardrum is moving normally in response to pressure

78
Q

What is a type B tympanogram

A

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

79
Q

What is a type C tympanogram

A

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)

80
Q

How is a pure tone audiogram carried out

A

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

81
Q

What is air conduction assessing in audiology

A

Air conduction assesses the entire auditory pathway

82
Q

What is bone conduction assessing in audiology

A

Bone conduction bypasses the external and middle ear and transmits straight to the inner ear
Assessing the inner ear only

83
Q

Can bone conduction be worse than air conduction

A

No
Bone conduction can never be worse than the air conduction.
May need to adjust the conductor if you get this result.

84
Q

What is the purpose of masking in audiology

A

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

85
Q

How can tinnitus affect audiology results

A

Hard for those with tinnitus to differentiate high frequency tone from their tinnitus
Often use warble tones to overcome this - also used in kids

86
Q

When is masking used in audiology

A

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

87
Q

If hearing loss is fluctuating it is likely which type

A

Typically conductive

88
Q

Which structures are damaged in sensorineural hearing loss

A

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

89
Q

What are the consequences of not masking in audiology

A

Incorrect diagnosis
Inappropriate treatment
Programming of hearing aids incorrectly

90
Q

How does mixed hearing loss present on an audiogram

A

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

91
Q

List potential causes of mixed hearing loss

A 
Genetic factors 
Birth defects 
Infections 
Tumours 
Head injury 
Otosclerosis
92
Q

Otosclerosis is more common in which type of patient

A

Female
Those with a family history - goes down the female side
Typically in 20s or 30s
Aggravated by pregnancy

93
Q

How does acoustic neuroma present

A

Unilateral SNHL
Unilateral tinnitus
Unbalanced or vertigo

94
Q

Which is primary otalgia

A

Pain coming from the ear itself

95
Q

What are the 5 cardinal symptoms of ear disease

A

Hearing loss, tinnitus, discharge, pain, vertigo

96
Q

What conditions of the pinna and external ear can cause primary otalgia

A 
Infection - cellulitis of pinna or otitis externa
Trauma
Foreign bodies
Earwax
Malignancy - SCC
97
Q

What conditions of the middle ear can cause primary otalgia

A

Otitis media +/- effusion
Cholesteatoma
Mastoiditis

98
Q

What conditions of the inner ear can cause primary otalgia

A

Acoustic neuroma
Vestibular schwannoma
Infection - viral labyrinthitis

99
Q

Young children who pull on their ears but have a normal ear exam may have what

A

Reflux!

May be referring from the larynx

100
Q

If a patient presents with chronic otalgia but has a normal ear exam may have what

A

Deep tumours of the temporal bone - consider for MRI

101
Q

How should you investigate otalgia

A

Do otoscopy, examine TMJ, oral cavity, neck, cranial nerve exam

102
Q

What is secondary otlagia

A

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

103
Q

The mandibular branch of the the trigeminal nerve can cause referred pain from which structures

A

Dentition

Jaw

104
Q

The glossopharyngeal nerve can cause referred pain from which structures

A

Throat

105
Q

The vagus nerve can cause referred pain from which structures

A

Larynx - reflux

106
Q

The cervical plexus can cause referred pain from which structures

A

C-spine injury - stenosis etc.

Neck muscle injury

107
Q

The facial nerve can cause referred pain from which structures

A

Salivary glands, nasopharynx etc.

108
Q

How does otitis externa present

A

Itch
Ear discharge
Pain
Temporary dull hearing - CHL

109
Q

How do you treat otitis externa

A

Steroid and antibiotic ear drops/spray

Standard analgesia to deal with the pain

110
Q

What can cause tinnitus

A

Ears being blocked - cold or ear wax
It’s also very common and may have no cause
Stress can make it seem worse

111
Q

What can cause epistaxis

A 
High blood pressure 
Bleeding disorders 
Drugs - anticoagulation 
Nasal infections - sinusitis 
A broken nose 
Any growth in the nose 
Nose picking
112
Q

Which conditions affecting nerves C2 and 3 can cause referred ear pain

A

Arthritis or cervical spondylosis

Soft tissue injuries

113
Q

Which conditions affecting CNV - trigeminal can cause referred ear pain

A

Dental disease
TMJ dysfunction
Nasopharyngeal disease - viral infection, tumour etc.

114
Q

Which conditions affecting CNIX - glossopharyngeal can cause referred ear pain

A

Almost any oropharyngeal infection - pharyngitis, tonsillitis etc.
Tongue base tumours

115
Q

Which conditions affecting CNX - vagus can cause referred ear pain

A

Carcinoma of the larynx and hypopharynx

116
Q

How does conductive hearing loss present on Rinne and Weber tests

A 
Rinne Negative (Bone conduction louder than air conduction)
Weber does not lateralise to either side
117
Q

Why do many patient’s think their tinnitus is bad at night

A

Because there are no environmental sounds to “mask” the tinnitus sounds so they are more noticeable

118
Q

How does sensorineural hearing loss present on Rinne and Weber tests

A 
Rinne positive (Bone conduction NOT louder than air) 
If unilateral, weber will lateralise to the unaffected side

ENT (9 decks)

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