Ear trauma

Question 1

auricular hematoma

Answer 1

-collection of blood within the cartilaginous auricle (outer ear)
-typically results from blunt trauma during sports
-prompt drainage and measures to prevent reaccumulation of blood
-can cause periostitis

Question 2

cauliflower ear

Answer 2

-permanent deformity caused by fibrocartilage overgrowth that occurs when an auricular hematoma is not fully drained, recurs, or is left untreated

Question 3

non-traumatic tympanic membrane rupture

Answer 3

-S/S- pain relieved after tympanic membrane rupture
-usually preceded by stabbing pain in the ear, followed by relief once rupture occurs with subsequent otorrhea
-precipitating factors- severe acute otitis media
-relieving factors- post rupture relief
-Dx- otoscopy reveals perforation with otorrhea and audiometry will usually document conductive hearing loss
-treatment- small perforation-> spontaneous repair
-precautions

Question 4

traumatic tympanic membrane perforation

Answer 4

-acute
-may have hx of:
-insertion of objects into ear canal
-concussion from an explosion or open handed slap across ear
-head trauma (with or without basilar fracture)
-sudden negative pressure (strong suction)
-barotrauma (during air travel or scuba diving)
-iatrogenic perforation during irrigation or foreign body removal

Question 5

traumatic TM perforation: signs and symptoms

Answer 5

-sudden severe pain
-followed by bleeding from the ear- blood can stay behind TM before rupture
-hearing loss*
-tinnitus*
-vertigo*- suggests injury to inner ear
-purulent otorrhea may begin in 24-48hrs particularly if water enters the middle ear

Question 6

traumatic TM perforation: diagnosis and treatment

Answer 6

-dx- otoscopy
-blood obscuring the ear canal is carefully suctioned
-treatment:
-irrigation and pneumatic otoscopy avoided
-no specific treatment needed
-ear should be kept dry
-routine antibiotic eardrops unnecessary
-prophylaxis with an oral broad spectrum antibiotic or antibiotic eardrops is necessary if contaminants have entered through the perforation as occurs in dirty injuries
-most perforations close spontaneously -> surgery indicated for perforation persisting > 2 mo

Question 7

hemotympanum

Answer 7

-presence of blood in tympanic cavity of middle ear
-often result of basilar skull fracture

Question 8

middle ear: cholesteatoma

Answer 8

-may be congenital, acute or chronic
-precipitating factors- chronic infection, trauma, Eustachian tube dysfunction
-extends from tympanic membrane into middle ear, possibly into bone
-co-morbidities- chronic middle ear infection, eustachian tube dysfunction

Question 9

cholesteatoma dx and treatment

Answer 9

-intermittent drainage with signs/symptoms of infection and hearing loss
-if untreated -> bone destruction, deafness, facial nerve paralysis, dizziness, abscess, systemic infection, death
-dx- audiogram- conductive (possible sensorineural) hearing loss
-CT- measures extend of spread
-treatment- antibiotics, ear cleaning, ear drops, surgery

Question 10

middle ear: mastoiditis

Answer 10

-complication of otitis media
-bacterial infection of mastoid air cells
-typically complication of AOM
-previous URI incompletely or inadequately treated otitis media
-pneumococcus- most common organism
-signs/symptoms:
-fever, postauricular pain, otorrhea
-postauricular swelling and tenderness to palpation
-lump behind ear
-downward or lateral pinna displacement
-edema of posterior portion of external canal
-destruction of bony septa- air cells coalesce on X-ray

Question 11

mastoiditis dx, treatment, complications

Answer 11

-dx- clinical, CT rarely necessary
-treatment with antibiotics
-IV antibiotics- myringotomy
-ceftriaxone IV
-mastoidectomy
-complications:
-infection may decompress through perforation in tympanic membrane
-can extend through the lateral mastoid cortex forming postauricular subperiosteal abscess
-rarely extend centrally causing temporal lobe abscess or septic thrombosis of the lateral sinus

Question 12

peripheral vertigo

Answer 12

-vertigo secondary to disorders of inner ear or 8th cranial nerve

Question 13

central vertigo

Answer 13

-vertigo secondary to disorders of the vestibular nuclei and their pathways in the brain stem and cerebellum

Question 14

vertigo

Answer 14

-false sensation of movement associated with difficulty in balance or gait
-typically perceived motion is rotary -> a spinning whirling sensation
-some pts simply feel they are being pulled to one side
-pt may feel as though he or the environment is moving
-symptoms may be acute and severe causing nausea and vomiting -> may occur episodically
-indicates disturbance of vestibular 8th nerve, brainstem, or rarely cortical function
-accompanying deafness and tinnitus- origin from ear or CN 13

Question 15

causes of vertigo

Answer 15

-benign positional vertigo
-drugs- aminoglycosides, chloroquine, furosemide
-tumors- acoustic neuroma and cerebellopontine angle tumor
-vascular- autoimmune ear disease and cholesteatoma
-infection:
-herpes zoster oticus
-labyrinthitis
-neurosyphilis
-otitis media
-vestibular neuronitis
-Meniere’s disease*
-panic attack
-trauma
-multiple sclerosis

Question 16

benign postural or postitional vertigo (BBPV)

Answer 16

-commonest cause of relapsing vertigo
-triggered by changing position
-displacement of otoconial crystals - Ca carbonate crystals normally embedded in the saccule and utricle
-short (<60sec) episodes of vertigo occur with certain head positions
-acute vertigo lasts only a few seconds to minutes
-nausea and nystagmus develop
-dx- clinical, dix-hallpike maneuver***
-treatment- involves canalith repositioning maneuvers, meclizine, benzodiazepines
-surgery rarely if ever indicated

Question 17

BPPV: Dix-Hallpike Maneuver

Answer 17

-turn head 45 degree to the side
-with help of examiner pt quickly lays down on her back and keeps her head hanging
-keeping head position at 45 degree to the side
-examiner watches pts eyes looking for positional nystagmus

Question 18

BPPV: Epley’s maneuver

Answer 18

-particles in semicircular canal
-clinician rotates pts head towards the affected ear then lowers pt backward to the supine position with head hanging over tables edge
-head is turned to other side
-head is turned further so ear is parallel to floor
-head may be rapidly turned even further to almost face the floor
-pt returned to upright position and head is rotates back to normal
-redistributed particles

Question 19

nystagmus

Answer 19

-rhythmic oscillation of eyes
-sign of disease of ocular or vestibular system
-true nystagmus- sustained and demonstrable
-horizontal nystagmus- peripheral and central
-peripheral- acute and transient -> Severe vertigo
-central- long lasting
-vertical nystagmus- cause is always a central lesion
-pendular nystagmus- to and fro movements
-ocular causes- long standing visual impairment
-congenital
-BBPV

Question 20

menieres disease

Answer 20

-characteristic quadrad of symptoms
-episodic attacks:
-vertigo*
-tinnitus*
-sensation of aural fullness
-hearing loss*
-latter three often manifest as a prodrome to vertigo attacks
-vertigo may last from 1 hour to day
-initial attacks usually more severe, frequent, longer in duration, and may be disabling
-hearing loss temporary during early attacks
-later becomes permanent starting in lower frequency
-attacks usually becomes less frequency and often less severe after 5 years, occurring every few months or years
-due to fluid in semicanal
-once hearing loss sets in usually vertigo goes away

Question 21

meniere’s disease management

Answer 21

-Furosemide- diuretic -> decrease fluid
-pharmacological treatments- prophylactic or symptomatic
-treatment aims to reduce the frequency and severity of attacks
-medication to alleviate symptoms of acute vertigo attacks
-antiemetic, antinausea, and antivertigo medication therapy
-low sodium diet -> decrease water retention
-restriction of caffeine and alcohol
-diuretic therapy (no effect on hearing loss)
-alleviate the symptoms of vertigo- antihistamines, prochlorperazine, scopolamine
-vestibular suppressants and antianxiety medications -> calms associated anxiety
-surgery- reserved foe refractory cases with no response to 1st line therapy

Question 22

eustachian tube dysfunction

Answer 22

-provides ventilation and drainage for the middle ear cleft
-generally closed
-often preceded by viral URI or allergic component
-with partial blockage- swallowing or yawning may result in popping or crackling sound
-C/O aural fullness
-fluctuating hearing
-discomfort with barometric pressure change
-at risk for serous titis media
-patulous Eustachian tube
-on exam retraction of TM and decreased mobility on pneumatic otoscopy

Question 23

eustachian tube dysfunction treatment

Answer 23

-systemic and intranasal decongestants
-auto-inflation by forced exhalation against closed nostrils
-not recommended with active intranasal infection
-balloon dilation of the eustachian tube
-caution against- air travel, rapid altitudinal change, and underwater diving

Question 24

Ramsay Hunt syndrome

Answer 24

-acute facial paralysis that occurs in association with herpetic blisters of the skin of the ear canal, auricle, or both is referred to as the Ramsay Hunt Syndrome or herpes zoster oticus
-syndrome also known as geniculate neuralgia or nervus intermedius neuralgia
-primary pathophysiology is located in the geniculate ganglion of the 7th cranial nerve (CN 7)
-nervus intermedius (sensory portion of CN 7)
-ganglia involved wit hearing and balance also affected (scarpa and corti)
-classically, ramsay hunt syndrome has been associated with VZV infection
-VZV- varicella zoster virus
-paroxysmal pain deep within ear
-pain often radiates outward into pinna of ear
-may be associated with more constant, diffuse, and dull background pain
-always develop after herpetic infection
-shingles infection to the ear nerve basically

Question 25

conditions associated with Ramsay Hunt Syndrome

Answer 25

-vertigo
-ipsilateral hearing loss
-tinnitus
-facial paresis- caused by inflammation of the facial nerve

Question 26

Ramsay Hunt Syndrome rash

Answer 26

-rash or blisters in distribution of the nervus intermedius
-anterior 2/3rd of tongue
-soft palate
-external auditory canal
-pinna
-herpetic blisters may become infected secondarily, causing cellulitis

Question 27

Ramsay Hunt Syndrome workup

Answer 27

-WBC count
-ESR
-viral studies
-VZV- cultured, vesicle fluid, serology

Question 28

Ramsay Hunt Syndrome treatment

Answer 28

-corticosteroids and oral acyclovir
-vestibular suppressants
-as with bell palsy, care must be taken to prevent corneal irritation and injury
-temporary relief of otalgia - local anesthetic
-carbamazepine may be helpful especially incases of idiopathic geniculate neuralgia