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Year 4 - 5. Neurology & Special Senses > Ear (ENT) > Flashcards

Ear (ENT) Flashcards

1
Q

List some signs and symptoms of ear disease

A
  • Otalgia
  • Tinnitus
  • Hearing loss
  • Vertigo / dizziness
  • Discharge
  • Facial nerve palsy
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2
Q

State which nerves carry general sensation from areas around the ear

A

CN 5, 9 and 10
- Vagus
- Trigeminal nerve (auriculo-temporal branch)
- Glossopharyngeal (tympanic branch)
- Branches of cervical spinal nerves C2 and C3

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3
Q

How long is the external acoustic meatus in length

A

2.5cm long (initial 2/3 is cartilage, then 1/3 bony inner ear)

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4
Q

List the 4 main outer ear conditions (from H&N module)

A
  • Wax/foreign body
  • Otitis externa (swimmer’s ear)
  • Acute otitis media
  • Otitis media with effusion (glue ear)
    + cholesteatoma
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5
Q

List some causes of conductive hearing loss

A
  • Wax / foreign body
  • Acute otitis media / otitis externa
  • Tympanic membrane perforation
  • Otitis media with effusion
  • Otosclerosis
  • Cholesteatoma
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6
Q

List some causes of sensorineural hearing loss

A
  • 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)
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7
Q

List some causes of otalgia (ear pain)

A

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

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8
Q

List some differentials for vertigo / balance disturbance (ear and non-ear origins)

A

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

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9
Q

Otitis media with effusion (glue ear) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

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

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10
Q

How long does it take for grommets to fall out

A

Grommets should fall out within a year

Only 30% require persistent grommets

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11
Q

List some common congenital causes of childhood hearing loss

A

Maternal infections during pregnancy
- Rubella
- CMV (cytomegalovirus)

Genetic deafness (recessive or dominant)

Associated syndromes e.g. Down’s syndrome

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12
Q

List some common acquired causes of childhood hearing loss

A

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

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13
Q

Outline some general management options for children with hearing loss

A
  • Involvement of ENT specialist
  • Hearing aids for children (if retain some hearing)
  • Sign language

Therapies:
- Speech and language therapy
- Educational psychology

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14
Q

Vestibular neuritis / labyrinthitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

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

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15
Q

Meniere’s disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

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

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16
Q

BPPV (Benign paroxysmal positional vertigo) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

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

17
Q

Vestibular schwannoma (acoustic neuroma) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

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

18
Q

State 2 risks of vestibular schwannoma (acoustic neuroma) surgery

A

2 main cranial nerves at risk: CN 7 and CN 8

Injury to vestibulocochlear nerve (CN8)
= hearing loss
= vertigo
Facial nerve injury

19
Q

Acute otitis media - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Management

A

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

20
Q

State the 2 main types of chronic otitis media

A

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)

21
Q

State the most common bacterial cause of otitis media

A

Strep pneumoniae

Other causes:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus

22
Q

State some complications of acute otitis media

A
  • Hearing loss (usually temporary)
  • Perforation of tympanic membrane
  • Labyrinthitis
  • Otitis media with effusion

Rare:
- Mastoiditis
- Meningitis
- Abscess
- Facial nerve palsy

23
Q

Cholesteatoma - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

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

24
Q

When might you consider chronic suppurative otitis media (CSOM) and how might it be managed?

A
  • 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

25
Q

State 2 organisms most commonly causing otitis externa

A
  • Pseudomonas aeruginosa
  • Staph aureus
26
Q

Otitis externa - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Investigations
- Management

A

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

27
Q

State the important complication to consider for otitis externa

A

Malignant otitis externa

28
Q

Outline malignant otitis externa, how it presents differently to otitis externa and how it is managed

A

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

29
Q

Outline some underlying risk factors for malignant otitis externa

A

Immunosuppressed:
- Diabetes
- HIV
- Immunosuppressant medications (e.g. chemotherapy)

30
Q

List some complications of malignant otitis externa if left untreated

A
  • Facial nerve damage + involvement of other cranial nerves e.g. glossopharyngeal, vagus or accessory
  • Meningitis
  • Intracranial thrombosis
    & death
31
Q

Otosclerosis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

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)

32
Q

Outline some examinations to do for a patient presenting with hearing loss

A
  • 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
33
Q

Outline the management of a tympanic membrane perforation

A

Mostly conservative, ‘watch and wait’ approach
Should resolve within 6 months
- Water precautions

If not resolved within 6 months:
- Surgery (myringoplasty)

34
Q

Sudden onset sensorineural hearing loss - state the following:
- Investigations
- Management

A

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

35
Q

State the rough prognosis for sudden onset sensorineural hearing loss (1/3rds)

A

1/3 = full recovery
1/3 = some recovery
1/3 = no recovery

36
Q

Outline the expected findings for the Weber and Rinnes tests in the following scenarios
- Normal
- Conductive hearing loss
- Sensorineural hearing loss

A

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

37
Q

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

A

Conductive hearing loss

38
Q

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

A

Sensorineural hearing loss

Year 4 - 5. Neurology & Special Senses (7 decks)

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