Ear (ENT) Flashcards
List some signs and symptoms of ear disease
- Otalgia
- Tinnitus
- Hearing loss
- Vertigo / dizziness
- Discharge
- Facial nerve palsy
State which nerves carry general sensation from areas around the ear
CN 5, 9 and 10
- Vagus
- Trigeminal nerve (auriculo-temporal branch)
- Glossopharyngeal (tympanic branch)
- Branches of cervical spinal nerves C2 and C3
How long is the external acoustic meatus in length
2.5cm long (initial 2/3 is cartilage, then 1/3 bony inner ear)
List the 4 main outer ear conditions (from H&N module)
- Wax/foreign body
- Otitis externa (swimmer’s ear)
- Acute otitis media
- Otitis media with effusion (glue ear)
+ cholesteatoma
List some causes of conductive hearing loss
- Wax / foreign body
- Acute otitis media / otitis externa
- Tympanic membrane perforation
- Otitis media with effusion
- Otosclerosis
- Cholesteatoma
List some causes of sensorineural hearing loss
- Presbycusis
- Noise-related hearing loss
- Meniere’s disease
- Labyrinthitis
- Vestibular neuroma (acoustic neuroma)
- Ototoxic medications
- Neurological conditions e.g. MS or stroke
- Malignancy e.g. nasopharyngeal cancer, intracranial tumours
- Autoimmune conditions e.g. RA, SLE, Wegners granuloma (granulomatosis with polyangiitis)
List some causes of otalgia (ear pain)
Otological origin:
- Acute otitis media = most common
- Tympanic membrane perforation
- Otitis media with effusion / eustachian tube dysfunction
- Otitis externa
- Foreign body
- Cholesteatoma
- Skin lesions on pinna e.g. Ramsay-Hunt syndrome, BCC, SCC
Non-otological origin:
- TMJ dysfunction
- Referred pain e.g. oropharyngeal, larynx or pharynx
List some differentials for vertigo / balance disturbance (ear and non-ear origins)
Ear origin:
- BPPV (Benign paroxysmal positional vertigo)
- Meniere’s disease
- Vestibular neuritis / labyrinthitis
- Vestibular schwannoma (acoustic neuroma)
Central origin:
- Stroke
- Migraine
- Malignancy
- MS
- Ototoxic vestibulopathy
- Cerebellar disease e.g. alcohol intoxication
Otitis media with effusion (glue ear) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Chronic eustachian tube dysfunction
- Leads to poor equalisation of pressure, so middle ear becomes full of fluid
- Leads eventually to hearing loss in affected ear
Presentation:
- Hearing loss in affected ear
- Aural fullness / pressure
- Otalgia / ear aches
- Sensation ear popping
May have associated speech and language development
Investigations:
- Auroscope (dull tympanic membrane, air bubbles or fluid level or may look normal)
- Audiology (conductive hearing loss)
- Tympanogram (flat tracing)
Management:
Usually managed conservatively and should resolve within 3 months
- Hearing aids or grommets if hearing loss if affecting speech development or if there are any congenital abnormalities e.g. Down’s syndrome, Cleft palate
- Treat any secondary otitis media
How long does it take for grommets to fall out
Grommets should fall out within a year
Only 30% require persistent grommets
List some common congenital causes of childhood hearing loss
Maternal infections during pregnancy
- Rubella
- CMV (cytomegalovirus)
Genetic deafness (recessive or dominant)
Associated syndromes e.g. Down’s syndrome
List some common acquired causes of childhood hearing loss
Around time of birth:
- Prematurity
- Hypoxia during or after birth
After birth:
- Ear infections e.g. otitis media / otitis media with effusion
- Childhood meningitis and encephalitis
- Jaundice
- Chemotherapy
Outline some general management options for children with hearing loss
- Involvement of ENT specialist
- Hearing aids for children (if retain some hearing)
- Sign language
Therapies:
- Speech and language therapy
- Educational psychology
Vestibular neuritis / labyrinthitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Inflammation of the vestibulocochlear nerve (CN8)
- Distorts the signals travelling from the vestibular system to the brain, poor transmission confuses the brain leading to vertigo symptoms
- Usually viral cause
Presentation:
- Severe vertigo (acute onset) lasting days, triggered by head movements
- History of recent URTI
- N&V
- Balance problems
- Horizontal nystagmus
**Tinnitus and hearing loss are not features (features of Meniere’s)
Investigations:
- Head impulse test (can diagnose peripheral causes of vertigo e.g. vestibular problems)
Management:
Symptoms should gradually resolve over 2-6 weeks
Short term management for up to 3 days
- IV fluids
- Prochlorperazine
- Cyclizine
May benefit from Cawthorne-Cooksey exercises as vestibular rehabilitation
BPPV may develop after vestibular neuronitis
Meniere’s disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Chronic inner ear disorder, leading to triad of symptoms
- Imbalance between the production and absorption of endolymph = excessive build up of endolymph in the labyrinth of the inner ear = endolymphatic hydrops
- Symptoms can initially fluctuate, resolving completely between episodes, but over time hearing loss progresses and tinnitus becomes persistent
Presentation:
Primarily UNILATERAL
Typical patient is 40-50 years old, unilateral episodes of vertigo, hearing loss, and tinnitus
- Hearing loss (unilateral, sensorineural)
- Tinnitus (unilateral)
- Vertigo (recurrent attacks of up to 20 mins-hours, NOT triggered by movement / posture)
+ feeling of fullness in the ear
+ unidirectional spontaneous nystagmus
+ drop attacks without LOC
Investigations:
- Audiology for hearing loss assessment (usually unilateral, sensorineural)
Management:
- Prophylaxis with Betahistine
- Acute attack management with Prochlorperazine or antihistamines e.g. Cyclizine (alleviate nausea, vomiting, and vertigo)
- Dexamethasone middle ear injection
- Endolymphatic sac decompression
BPPV (Benign paroxysmal positional vertigo) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Formation of crystals (calcium carbonate) in the semicircular canals
- Disrupt the normal flow of endolymph through the canals, confusing the vestibular system
Presentation:
More common in older adults
- Vertigo triggered by head movements (20-60 seconds, asymptomatic between attacks)
**Hearing loss or tinnitus aren’t features
Investigations:
- Dix-Hallpike Manoeuvre (if positive, nystagmus and symptoms of vertigo)
Management:
- Epley Manoeuvre
Vestibular schwannoma (acoustic neuroma) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Benign tumour of the Schwann cells of the vestibulocochlear nerve (CN8)
- Tumours occur at the cerebellopontine angle
- Usually sporadic and unilateral (if bilateral, associated with neurofibromatosis type 2)
- Benign tumour with a very low potential for metastasis
Presentation:
Average 40-60 years
- Unilateral sensorineural gradual onset hearing loss
- Tinnitus
- Vertigo
- Aural fullness
+ facial nerve palsy if tumour is large enough
Investigations:
- Audiometry
- MRI brain + biopsy during surgery (if needed) for histological confirmation
Management:
- Conservative with monitoring if asymptomatic or not appropriate
- Surgery to remove tumour (partial or full removal)
- Chemotherapy / radiotherapy to reduce growth
State 2 risks of vestibular schwannoma (acoustic neuroma) surgery
2 main cranial nerves at risk: CN 7 and CN 8
Injury to vestibulocochlear nerve (CN8)
= hearing loss
= vertigo
Facial nerve injury
Acute otitis media - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Management
Pathophysiology:
- Infection of the middle ear space (made of respiratory epithelium)
- Common complication after viral URTIs
- Primarily affects children (related to eustachian tube dysfunction)
- Most commonly caused by strep pneumoniae
Presentation:
- Preceding upper respiratory symptoms
- Otalgia
- Aural fullness
- Hearing loss
- Fever
+/- symptoms of tympanic membrane rupture (discharge and otalgia)
+/- vertigo or tinnitus
Otoscope findings:
- Bulging tympanic membrane
- Surrounding erythema
- May have perforated tympanic membrane
Management:
Most cases resolve spontaneously within 3 days
- Supportive therapy mainly e.g. analgesics
- Keep ear dry
- If not improved in 3 days, may require oral antibiotics e.g. Amoxicillin 5-7 days (Clarithromycin if allergic)
- Immediate antibiotic prescription in immunocompromised or systemically unwell
State the 2 main types of chronic otitis media
Mucosal (active or inactive)
- Tympanic membrane perforation
Active = perforation with chronic discharge
Inactive = perforation without discharge
Squamous (active or inactive)
- Can develop after episode of acute otitis media and tympanic membrane perforation
Active = cholesteatoma
Inactive = retraction pocket (chance of cholesteatoma forming)
State the most common bacterial cause of otitis media
Strep pneumoniae
Other causes:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
State some complications of acute otitis media
- Hearing loss (usually temporary)
- Perforation of tympanic membrane
- Labyrinthitis
- Otitis media with effusion
Rare:
- Mastoiditis
- Meningitis
- Abscess
- Facial nerve palsy
Cholesteatoma - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Abnormal collection of squamous epithelial cells in the middle ear caused by eustachian tube dysfunction and chronic negative pressure
- Negative pressure causes a pocket of the tympanic membrane to retract into the middle ear
- Non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear
Presentation:
- Foul discharge from the ear
- Unilateral conductive hearing loss
(generally painless)
Investigations:
- Auroscope (whitish debris or crust in the upper tympanic membrane)
- Audiogram
- CT head (diagnose and plan surgery)
- MRI (soft tissue invasion)
Management:
- Surgical removal of cholesteatoma
- May need topical antibiotics prior to surgical treatment
When might you consider chronic suppurative otitis media (CSOM) and how might it be managed?
- Discharge > 2 weeks (without otalgia / fever)
- Unilateral hearing loss
- A history of ear problems e.g. acute otitis media, trauma, glue ear
Assumed to be a complication of acute otitis media
Consider serious complications for these patients e.g. meningitis or mastoiditis
Management:
- Keep ear dry
- Intensive cleaning of the affected ear
- Antibiotics
- Topical steroids
State 2 organisms most commonly causing otitis externa
- Pseudomonas aeruginosa
- Staph aureus
Otitis externa - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Investigations
- Management
Pathophysiology:
- Form of cellulitis, involving diffuse inflammation of the external ear canal
- Either bacterial or fungal
- Acute (< 3 weeks) or chronic (> 3 weeks)
Presentation:
- Otalgia
- Localised erythema or oedema
- Tenderness to pinna/tragus
- Itching
- Aural fullness
- Hearing loss (conductive)
- Lymphadenopathy
Otoscope findings:
- Oedematous/swollen external canal
- Surrounding erythema
- Often unable to see the tympanic membrane due to proximal swelling
Investigations:
- Auroscope
- Swab of external ear canal
Management - depends on severity:
- Supportive treatment e.g. analgesia
- Microsuction of pus or debris to allow ear drops to work
Mild: OTC Acetic acid 2% ear drops
Moderate: topical antibiotics (Gentamicin) + topical steroids e.g. Neomycin, dexamethasone and acetic acid (Otomize spray), may need wick to keep canal open
Symptoms should resolve within 48-72 hours
*consider topical antifungals if suspect fungal infection e.g. Clotrimazole
State the important complication to consider for otitis externa
Malignant otitis externa
Outline malignant otitis externa, how it presents differently to otitis externa and how it is managed
Severe and potentially life-threatening form of otitis externa
Involvement of bones surrounding the ear canal and skull
Can progress to osteomyelitis of the temporal bone
Presents differently:
- Symptoms are generally more severe
- Persistent headache and fever
Management:
- Hospital admission
- Imaging (e.g., CT or MRI head) to assess the extent of the infection
- IV antibiotics
- Topical treatment for a long period to eradicate the infection
Outline some underlying risk factors for malignant otitis externa
Immunosuppressed:
- Diabetes
- HIV
- Immunosuppressant medications (e.g. chemotherapy)
List some complications of malignant otitis externa if left untreated
- Facial nerve damage + involvement of other cranial nerves e.g. glossopharyngeal, vagus or accessory
- Meningitis
- Intracranial thrombosis
& death
Otosclerosis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Abnormal bone remodeling in the middle ear, fusing the bones and reducing sound wave conduction
- Genetic and environmental factors
- Often begins in young adults
Presentation:
Typically in adults 30-50 years old
- Progressive hearing loss (gradual, bilateral, painless)
- Tinnitus
May have a family history of hearing loss
Hearing is improved in noisy surroundings in early disease stages
Investigations:
- Auroscope (normal)
- Audiogram (conductive hearing loss with Carhart notch)
- Tympanogram (normal)
Management:
- Mild can be treated with hearing aids
- Surgery is often required (stapedectomy)
Outline some examinations to do for a patient presenting with hearing loss
- Visual examination esp. of pinna
- Auroscope
- Weber and Rinne tuning fork tests (conductive vs sensorineural)
- Cranial nerve exam and cerebellar function assessment
- Lymphadenopathy checks
- Audiometry
Outline the management of a tympanic membrane perforation
Mostly conservative, ‘watch and wait’ approach
Should resolve within 6 months
- Water precautions
If not resolved within 6 months:
- Surgery (myringoplasty)
Sudden onset sensorineural hearing loss - state the following:
- Investigations
- Management
Otological emergency
- Important to assess whether it is conductive or sensorineural
Investigations:
- Audiometry
- MRI scan (to exclude lesion along pathway e.g. acoustic neuroma)
Management:
- Steroids (oral or middle ear injection)
- Antiviral medication
State the rough prognosis for sudden onset sensorineural hearing loss (1/3rds)
1/3 = full recovery
1/3 = some recovery
1/3 = no recovery
Outline the expected findings for the Weber and Rinnes tests in the following scenarios
- Normal
- Conductive hearing loss
- Sensorineural hearing loss
Normal =
Weber: heard equally in both ears
Rinne: AC>BC
Conductive hearing loss =
Weber: heard better in worse ear
Rinne: BC>AC
Sensorineural hearing loss =
Weber: heard better in good ear
Rinne: AC>BC
Outline the type of hearing loss in the following scenario from a Weber and Rinne test
Weber: heard better in worse ear
Rinne: BC>AC
Conductive hearing loss
Outline the type of hearing loss in the following scenario from a Weber and Rinne test
Weber: heard better in good ear
Rinne: AC>BC
Sensorineural hearing loss
