Ear Disease Flashcards
What is otitis externa?
Inflammation of the skin of the ear canal - usually infective - often bacterial infection which may be followed by a fungal infection
Common organisms in otitis externa? What may predispose to infection?
Staph and pseudomonas
May occur in swimmers (pseudomonas is found in soil and water) Other causes are trauma by cotton buds or susceptibility due to skin conditions e.g. psoriasis or eczema
Potential causes of conductive hearing loss?
Otitis externa Otitis Media acute or with effusion Perforated tympanic membrane Cholesteatoma Osteosclerosis
Presentation of otitis externa?
Redness and swelling of the skin of the ear canal
Itchy progressing to sore and painful ear
Discharge and/ or increased amounts of wax
If canal becomes blocked by swelling or secretions hearing can be affected
Treatment of otitis externa?
Topical treatment > antibiotic drops in combination with steroid May get topical gentamicin For fungal > clotrimazole Refer to ENT if associated cellulitis May need ear canal cleaned out
What is acute otitis media?
Inflammation of the middle ear that is extremely common in children (usually due to infection)
Common pathogens involved in acute otitis media in children?
Often viral with secondary bacterial infection
strep pneumonia, strep pyogenes, haemophilus influenza (as migrating from pharynx and URT think of common organisms from there)
Why are children more susceptible to acute otitis media?
Infection usually comes from the nose or pharynx via the eustachian tube which in children is shorter, wider and more horizontal so infection can track upwards more easily.
Presentation of acute otitis media?
A cold, then temperature and pain in ear
Otalgia, fever and loss of hearing is followed by otorrhoea (discharge from the ear) this caused by burst of ear drum which relieves pain
May see a bulging tympanic membrane and inflammation on otoscope
Treatment of acute otitis media?
Initially with NSAIDs
As usually viral in origin it should settle within 72 hrs without antibacterial treatment
Consider antibiotics if less than 2yo and bilateral or bulging membrane, systemic symptoms or ottorrhoea
1st line = amoxicillin and 2nd line= clarithromycin
1st line and 2nd line antibiotic for acute otitis media?
1st line= amoxicillin
2nd line= clarithromycin
Consider antibiotics in a child with AOM if…
less than 2yo, bilateral, bulging tympanic membrane, systemic symptoms, pyorrhoea or not clearing up
10 complications of acute otitis media?
Temporal lobe abscess Subdural abscess Extradural abscess Labyrinthitis Meningitis Facial Nerve Paralysis Cerebellar Abscess Venous Sinus Thrombosis Mastoiditis Chronic Otitis Media
Describe what otitis media with effusion/ glue ear is?
Common in children and associated with Eustachian tube dysfunction as this may lead to poorly ventilated middle ears.
The vacuum created by poor ventilation leads to a non-inflammatory effusion
The effusion resolves naturally in majority of cases but persist or recur causing a hearing loss that can impact on speech and education
Presentation of otitis media with effusion/ glue ear?
Usually complain of hearing loss or speech delay but little association with oltagia
Exam shows a dull tympanic membrane with loss of light reflex and occasionally fluid with air bubbles visible in the middle ear
Frequently adenoidal hypertrophy and nasal blockage are present in children
Dull tympanic membrane with loss of light reflex and occasionally fluid with air bubbles visible in the middle ear?
Otitis Media with effusion/ glue ear
Management of otitis media with effusion/ glue ear?
Active observation over 6-12 weeks for most children as spontaneous resolution is common
If no resolution grommets/ ventilation tubes be inserted allowing ventilation of the middle ear cavity
Grommets are extruded from the tympanic membrane as it heals over 6months-2yrs
May need reinserted but effusion may have resolved
Describe grommets?
They are ventilation tubes that can be inserted in children with otitis media with effusion that is not resolving and causing issues with hearing and speech delay
They allow ventilation of the cavity meaning the effusion resolves and hearing is better
They will be extruded from the tympanic membrane as it heals and will fall out after 6months -2yrs.
Would hope that the child no longer needs them as eustachian tube function should improve with age but they can be reinserted.
Describe presentation of a perforated tympanic membrane?
May be little or no symptoms
Likely to have some degree of hearing loss but may be only slight
2 causes of perforated tympanic membrane?
Most commonly due to AOM but may also occur after trauma
Describe treatment of perforated tympanic membrane?
Usually heal spontaneously
Some don’t heal particularly if infection and the ossicles may be eroded
The longer perforations are present the less likely they are to heal
May give topical antibiotic drops (beware of ahminoglycosides) or do myringoplasty to repair the defect
What is a cholesteatoma?
Abnormal mass of keratinising squamous epithelium growing in the middle ear or mastoid process
Causes of cholesteatoma?
Cause is uncertain can be congenital or acquired, repeated ear infections (metaplastic change of columnar epithelium) or trauma (perforated ear drum allows squamous epithelium to be planted in the wrong place)
Signs and symptoms of cholesteatoma?
May present with hearing loss, aching pain, vertigo or ottorhoea.
May present with complications such as erosion of the ossicles or facial nerve palsy.
What may you see on otoscope in someone with cholesteatoma?
Perforated tympanic membrane or retracted and stuck to the middle ear structures
Treatment of cholesteatoma?
Almost always removed surgically and reconstruction done due to high risk of complications
Complications of cholesteatoma?
Progressive hearing loss Acute mastoiditis Labyrinthitis Facial palsy Meningitis Intracranial abscess Venous sinus thrombosis
What is osteosclerosis?
Hereditary disorder (don’t know exact genetics) in which new bony deposits occur within the stapes foot plate and cochlea
Who is osteosclerosis common in?
Women in 2nd to 3rd decades and can get worse with pregnancy
Presentation of osteosclerosis?
Gradual onset of conductive hearing loss > may be some association with pregnancy
Treatment of osteosclerosis?
Surgery - stapedectomy
Hearing aids
What is the most common cause of deafness?
Presbycusis
Causes of sensorineural deafness?
Presbycusis
Noise damage
Trauma
Vestibular Schwannoma
What is presbycusis?
Degenerative disorder of the cochlea seen in old age
Loss of hair cells, ganglion or stroll atrophy
Due to environmental noise toxicity from over the years
What is the name for age related hearing loss?
Presbycusis
Treatment of presbycusis?
High frequency specific hearing aid
Acoustic neuroma =
vestibular schwannoma
What is schwannoma?
Benign tumour of schwann cells of nerve sheath
What is a vestibular schwannoma?
Benign tumour of vestibular nerve often arising in the internal auditory meatus
Most vestibular schwannoma are sporadic or non sporadic? Unilateral or bilateral?
Sporadic
Unilateral
Gross appearance of vestibular schwannoma?
Circumscribed tan/white/ yellow mass
Presentation of vestibular schwannoma?
Hearing loss (progressive and sensorineural), tinnitus and imbalance
Anyone with asymmetric or sudden sensorineural hearing loss should be …
investigated with MRI for vestibular schwannoma
Describe the difference between dizziness and vertigo?
Dizziness
non-specific term, which may cover vertigo, pre-syncope, disequilibrium, etc.
Vertigo
a sensation of movement, usually spinning.
Someone complains of dizziness - what may point you towards a diagnosis of cardiac condition?
Lightheadedness, syncope, palpitations
Someone complains of dizziness - what may point you towards a diagnosis of neuropathy condition?
Blackouts, visual disturbance, paraesthesia, weakness, speech & swallow problems
Vertigo episodes last for minutes, with no hearing loss, tinnitus or aural fullness, there are clear positional triggers?
BPPV
Vertigo episodes last for hours, there is associated hearing loss, tinnitus and aural fullness with no clear positional triggers?
Menieres disease
Vertigo episodes last for days/ weeks, there is associated tinnitus, hearing loss but no aural fullness and no clear positional triggers?
Labyrinthitis
Vertigo episodes last for days/ weeks, there is no associated tinnitus, hearing loss and no aural fullness and no clear positional triggers?
Vestibular Neuritis
Explain what BPPV is?
Benign paroxysmal positional vertigo is thought to occur when otoconia (tiny calcium carbonate crystals) are dislodged from the utricle into the semicircular canals.
Nystagmus that is __________ is a red flag for neuro
vertical or changes direction
Presentation of BPPV?
Vertigo is precipitated by head movements usually to a particular position and often occurs when turning in bed and or sitting up
Onset is sudden and distressing bu lasts seconds
Positive Hallpike Manoeuvre
Describe the hall pike manoeuvre?
Patients sits on couch with head turned towards 1 ear, head is supported by the examiner whilst they lie horizontal. Nystagmus (involuntary eye movements) is noted when head turned towards affected ear.
Most BPPV is cured by?
Epley manovre > series of movements that repositions otoconia as to not cause problems
Occasionally need it done a few times
What is Menieres disease?
Very rare condition with unknown cause. Pathophysiology is end-lymphatic hydrates (abnormal fluctuations in endolymph fluid)
2 common vestibular causes of dizziness?
BPPV and vestibular migraine
Is Menieres common?
No it is extremely rare
Presentation of Menieres disease?
Recurring, episodic, rotatory vertigo lasting 30 mins to a few hrs
Associated with a low frequency sensorineural hearing loss, aural fullness in affected ear, loss of balance, tinnitus and vomiting
What type of hearing loss is Menieres disease associated with?
Low frequency sensorineural
Management of Menierres disease?
Must exclude all other causes > MRI middle ear
Supportive management, tinnitus therapy and hearing aids
Prevention: low salt diet, beta Sistine, avoid caffeine
Intratympanic steroids - good evidence
Intratympanic gentamicin - kills inner ear but risks hearing
Sac surgery or vestibular nerve section
What drugs can cause sensorineural hearing loss?
Gentamicin and other aminoglycosides
Chemotherapeutic drugs - Cisplatin, Vincristine
Aspirin and NSAIDs (in overdose)
Describe vestibular migraines?
Migraine sufferers with spontaneous attacks of vertigo (or may not get a headache at all)
Phonophobia and sensitivity to light
Motion sickness
Treatment of vestibular migraines?
Lifestyle modifications to avoid triggers
Triptans for less frequent attacks
Propanolol or amitriptyline for prophylaxis
What is the difference between vestibular neuritis vs labyrinthitis?
Vestibular neuritis = infection of the vestibular nerve in inner ear
Labyrinthitis = infection affecting both branches of the vestibulocochlear nerve
Common pathogens in vestibular neuritis and labyrinthitis?
Usually viral and often follows a cold, bacterial infections can spread from the middle ear
Presentation of vestibular neuritis and labyrinthitis?
Vertigo that lasts for days
In labyrinthitis may get associated tinnitus or hearing loss
Treatment of vestibular neuritis / labyrinthitis?
Supportive management with vestibular sedatives (benzodiazepines)
Generally self limiting condition
May need helped by rehabilitation exercises
Rule of 3: 3 days in bed, 3 weeks off work, 3 months off balance
Rule of 3 for vestibular neuritis / labyrinthitis?
3 days in bed
3 weeks off work
3 months off balance
What symptoms would you ask about in a ear history?
Hearing Loss Tinnitus Vertigo Otalgia Ear Discharge
Facial Weakness Previous Ear Surgery Nasal symptoms Family History Specific paediatric history Neurological symptoms
A light reflex should be ….
anteroinferiorly on tympanic membrane
Describe Webers test?
Place the base of a vibrating tuning fork in the middle of the patient’s forehead. Ask her/him where she/he hears the sound better – on the right, on the left, or in the middle.
Conductive loss will cause the sound to be heard best in the abnormal ear. Sensorineural loss will cause the sound to be heard best in the normal ear.
Describe Rinne test?
This compares air conduction (AC) with bone conduction (BC). Place the vibrating tuning fork adjacent to the patient’s ear canal (AC ). Now place the base on the mastoid tip (BC) and ask her/him which sound is louder. If AC is louder than BC this is recorded as ‘Rinne positive’. If BC is louder, this is ‘Rinne negative’. Rinne negative usually means a conductive loss.
Noise induced hearing loss has a dip at?
4khz
Describe how you would tell the difference between conductive and sensorineural hearing loss on an audiogram?
Conductive - air bone gap
Sensorineural - no air bone gap
What colours are right and left on an audiogram?
Right= red Left = blue
Right air conduction =
Red circle (because you use your right hand)
Left air conduction=
Blue cross (left is crossed because not left handed)
What nerves could be involved in referred ear pain?
Vagus
Glossopharyngeal
Trigeminal
Facial
How could CNV3 cause referred pain to the ear?
Any lower mandibular pathology e.g. teeth or TMJ problems due to the auricotemporal nerve providing some sensation to the ear
How could the facial nerve cause referred pain to the ear?
The posterior auricular nerve
Sinus or nasal pathology
How could glossopharyngeal nerve cause referred pain to the ear?
Glossopharyngeal nerve provides sensation to the ear and some of the pharynx and palatine tonsils so any throat pathology or tonsillitis or anything with posterior 1/3 of tongue
How could the vagus nerve cause referred ear pain?
Vagus provides sensation to larynx so any laryngeal pathology could refer to the ear as vagus provides EAM
