Ears Flashcards
Cranial Nerves
I Olfactory
V Facial sensation
VII Facial movement, tears, taste, acoustic reflex
VIII Hearing and Equilibrium
IX Taste
X Taste
XI Taste, swallowing
XII Tongue movements
Conductive hearing loss
Refers to impairment of the outer and/or middle ear conductive mechanism only.
Sensory hearing loss
Refers to damage to the cochlea (outer hair cells or outer and inner hair cells).
Mixed hearing loss
Refers to the presence of both conductive and sensory impairment.
Neural hearing loss
Refers to damage to the auditory neurons (spiral ganglia) and/or the auditory branch of the eighth nerve.
Auditory Neuropathy and dysynchrony are examples of neural hearing loss.
Central hearing loss
Refers to damage to auditory structures in the brainstem, thalamo-cortex and/or cortex.
How Common is Hearing Loss
- Profound
- 1-2 hearing loss in 1000 infants
- Significant hearing loss
- 1-2 have hearing loss that will impact on their well being and education
- 50% have no known risk
- 12% of NICU graduates develop some form of sensorineural hearing loss
- Newborn screening
- Otoacoustic emission (like a tympanogram listens for action potential of the cochlea (ear talk) and that is what it picks up—picks up cochlea function
- BAER more accurate (assesses wiring of auditory pathway—misses low and high frequency loss)
- Brain stem evoked response is the diagnostic test
- 33 babies are born every day with a hearing loss
- Hearing is about 30 among congenital defects
- 50% are contributed to genetic factors, likely to increase
Newborn Hearing Tests (2)
Otoacoustic Emission
Auditory Brainstem Response Training
Types of Hearing Loss
Conducive
Sensori-neural
Auditory Processing (Central)
Early Hearing Loss
- First trimester structure of ear highly metabolic and therefore exposure to metabolic and highly susceptible to illness and exposure to medication in the mother
- Maternal rubella
- Cytomegalovirus
- Genetic disorders leading to malformation of the cochlea
- Sepsis with prolonged acidosis
- Oxygen deprivation and hyperbilirubinemia
Universal hearing screening in the late 90’s
Mandated but not covered
Now linked to funding
Anatomic Early Hearing Loss
- Genetic Studies
- Meningitis
- Congenital hypothyroidism
- Medications—Lasix, aminoglycosides, vancomycin
Large Cochlear Aqueduct syndrome
- Onset of hearing loss 6 to 7 months with progressive worsening
- Balance is off, progressive loss
- Tends to stabilize at 50 decibels
- They need to not play football
Reasons for Hearing Loss
- Wax
- Foreign objects
- Deafness due to hyperbilirubinemia, CMV
- Cranial facial, tags
- Medications
- Deafness associated with aminoglycosides
Reasons for Hearing Loss
Genetic Syndromes
- Genetic Syndromes
- Deafness associated with white forelock and eye abnormalities
- Waardenburg syndrome
- Deafness associated with long QT syndrome
- Jervell Syndrome
- Lange Nielsen syndrome
- Ion channelopathies
- Progressive hearing loss
- 3% carrier rate (same of CF). Mild to moderate hearing loss
- Rest are autosomal dominant
- 80% are recessive
- Deafness associated with white forelock and eye abnormalities
History of Hearing Loss
- History of hearing loss is critical
- Looking at hearing loss early on
- Wear a hearing aide if they are younger than 60 year
- History of renal abnormalities (8 weeks in utero develop at the same time)
- Alport’s syndrome
- Genetic mediation for hearing loss in old age
Hearing Loss Progression
- Can progress throughout childhood
Gene Mutations associated with hearing loss
Both high- and low-frequency progressive hearing loss represent a wide diversity of gene mutations that are observed in a large number of syndromic and non-syndromic diseases
Human KCNQ4 mutations known as DFNA2 cause non-syndromic, autosomaldominant, progressive high-frequency hearing loss in which the cellular and molecular basis is unclear
Newborn screening
Repeated on follow up center
Goal: Early intervention by age 6 months
Genetic Screening
Syndromic vs. Non-syndromic
- Syndromic—1/3
- Non syndromic 2/3—mitochondrial defect
- Hereditary hearing loss may not be congenital
- Is it stable or progressive?
Non Genetic
CMV infections, high bili etc, trauma, meningitis, noise induce hearing loss
Conductive Hearing Loss
4 examples
- Eustachian tube dysfunction
- Ear fluid
- Hole in eardrum
- Fixed middle ear bone
Sensorineural Hearing Loss
4 examples
- Noise induced hearing loss
- Presbycusis
- Ménière’s Disease
- Tumors of the auditory nerve
Noise Levels of Sound
- Traffic - 80
- Automobile (at 20 meters) - 70
- Vacuum Cleaner - 65
- Conversational Speech (at 1 meter) - 60
- Quiet Business Office - 50
- Residential Area at Night - 40
- Whisper, Rustle of Leaves - 20
- Rustle of Leaves - 10
- Threshold of Audibility 0
History Factors
- Location
- Duration
- Severity
- Drainage
- Hearing loss
- Associated symptoms: fever, pain, URI, ST,
- Exposure to family illness
- Aggravating or alleviating factor
- Changes in behavior
Assessment of the External Ear (3)
Pliability
Direction of Canal
Illuminate the surface of TM
Assessment of external ear
Shape
- Size
- ***Large Ear found in Fragile X***
- Symmetry
- Variations from normal
- Abnormalities
Presence of dimples, tags, and nodules
Represents remnant of first brachial cleft
Position of auricle
- Should be along a straight plan with outer canthus of eye
- Low set ears can be associated with kidney or chromosomal abnormalities
External Ear assessments cont. (2)
- Presence of swelling, drainage, erythema, trauma
- Enlarged post auricular nodes and external otitis with cellulitis can make ear protrude
Assessment of the Ear
Child friendly
- Which ear should I check first?”
- This simple question gives the child a sense of control and an understanding of what is going to happen next.
Otoscope Basics
- Make sure your light is getting full power otherwise drum will look yellow
- Speculum should never enter the canal more than 10-15 mm
- Examine the canal before you try to look at drum—look for furuncle or vesicle
- Hold the otoscope firmly, rest the hand on child head or face
- Place the speculum just inside the ear to gain child’s confidence
Most common reason for redness when using an Otoscope
- touching the ear canal with the tip of the speculum
- Red reflex of the drum
- Red drum with normal landmarks
Otoscope size
Pick the right size
Bigger is better if you can
See through the hair
Canal Direction
- In newborns pull the auricle down and back
- In older children, canal faces downward and forward
- Pull the tip of auricle up and back
- If painful indicates furuncle or external otitis media
- Tell child that they must be quiet to ear the song. Then look in ear, ask if they heard the song
A quick and easy way to get rid of lots of wax
Instill a few cc’s of Colace and let it sit for 10-15min, then irrigate the ear with water like usual.
TM blocked by cerumen – OTC products for removal
Foreign Bodies
Solid objects such as stone, beads, paper, dead roaches are commonly found
Should be removed as soon as possible
External Otitis Media
Pain on movement of the auricle
Canal may be red, friable, and full of pus
Inspect the entire TM looking at landmarks, color, contour and perforations.
Infections of the External Ear Canal
- Related to changes in the pH of ear canal
- Any organism— fungal, viral, bacteria, yeast Pseudomonas is common***
TIPS for Ears
- Tenderness to palpation of the tragus is indicative of otitis externa
- Always look at the mastoid bone for redness and evaluate for tenderness
- Not everyone reads the book so if you cannot see the drum pull opposite than you normally would for that age
- Children are unique. Some children love having you look at their ears – find something cute inside.
Otorrhea
Otitis externa
- Alteration in acidic PH increase susceptibility to microbial invasion
- Severe pain
- Sense of fullness in the ear
Etiology of Otorrhea
- Excessive moisture, excessive cleaning disrupts the surface epithelium
- Bacterial, viral (HSV, Varicella), Fungal (candida, aspergillus niger)
Treatment of Otorrhea
- Debridement of ear canal
- Topical antibiotics (concentration are 100-1000 times greater than with systemic therapy
- Expandable methylcellulose Oto-Wick or sponge (ear wick)
- Change wick every 2 days
- Fungal infection: Acetic drops or antifungal drops
Pathophysiology of Otitis Media
- Middle ear cavity filled with air and is sterile under normal circumstances
- Air enters the middle ear when you swallow through the eustachian tube (ET)
- When the ET does not function, middle ear cavity does not ventilate normally
- Negative air pressure results as the air is absorbed ¡ Fluid effused in the middle ear
- Bacteria comes from nasopharynx into the middle ear cavity leading to AOM
Pathophysiology of Otitis Media under 3
- Eustachian tube is different
- Shorter
- Wider
- Straighter
- Makes it easier for the infection to travel up the Eustachian tube
- Assess the movement of the tympanic membrane to determine if a patient has otitis media
- Changes in the appearance of the tympanic membrane suggestive of acute infection
- Bulging or purulent material visualized behind the tympanic membrane
Tympanic Membrane
- Color
- Note the landmarks
- Malleus
- Borders of TM
- Light reflex
- Presence of perforation and of tympanostomy tubes
- Presence of fluid
Tympanic Membrane (5)
Color
Texture
Landmarks
Light reflex
Mobility
TM Color and Significance
Amber
Serous fluid
TM Color and Significance
Blue or deep red
Blood in the middle ear
TM Color and Significance
Chalky white
Thick TM indicative of recurrent infection
TM Color and Significance
Red
Infection
Mastoiditis
- Infection of the mastoid air cells
- Accumulation of the purulent exudate in middle ear does not drain through ET or perforated TM but spread to mastoid bone
- Air cells are destroyed and progresses to coalescent phase
- ENT referral
Acute Otitis Media
Bacterial
S. pneumoniae
H. Influenzae
Moraxella catarrhalis
Group A streptococcus
Enteric gram negative
Acute Otitis Media
Viral
RSV
Influenza
Mycoplasma pneumoniae
Fungal
Ear Trauma
- Can damage middle ear and/or inner ear.
- Results from fall or fight.
- Bleeding into the auricular cartilage may require drainage
- Hematomas need referral to ENT for evacuation
Dullness of TM
fibrosis
White areas of TM
Healed perforations or inflammation
Air bubbles
Middle ear fluid
