EENT Flashcards
oscillopsia
visual distortion
air conduction
gain from tympanum to oval window about 18 fold
bone conduction
temporal bone conduction has 60-dB loss
hair cells in ear
tonotopically organized on cochlear basilar membrane detect vib on membrane
Tympanosclerosis
calcification or scaring of TM and middle ear from inflammation
myringosclerosis
calcification of TM from OME and AOM, rarely hearing loss unless “porcelain eardrum”
myringosclerosis vs middle ear mass
pneumatic otoscopy shows diff as plaque moves with TM during insufflation
retraction pocket
invagination of pars tensa or pars flaccida from chronic inflamm and neg prssure in middle ear (atrophy, atelectaisis of TM)
adhesive otitis
continued inflammation between retracted TM and ossicles creating cholestetoma or fixation and erosion of ossicles
cholestetoma
pearly white mass seen in retraction pocket/ perforation… purulent drainage or granulation tissue/ polyps… SMELLS bad! keratinizing squamous epithelium in the middle ear and/or mastoid process
perforation from AOM: time frame, drug, limitations of patients behavior
heals within 2 wks, ototopical antibiotics for 10-14days referred to an otolarygologist 2-3 wks after rupture for hearing eval limit water activities/ use ear mold
tympanoplasty
repar eardrum after 7 when Eustachian tube reaches adult orientation
facial nerve
encased in temporal bone to stylomastoid foramen through middle ear
facial nerve paralysis…
not idiopathic Bell palsy until everything else excluded.
myringotomy
perforate TM to release fluid in middle ear with facial nerve paralysis, place tube
if cholesteatoma or mastoiditis is suspected
CT is indicated.
OME vs AOM
OM w/ effusion: fluid in the middle ear without inflammation, before/after an infection (few days - many weeks/ mths after AOM) common in young children.
tool to clear cerumen
ear curette or irrigation for hard/ flaky can add cerumen softener (H2O2)
tympanometry
measures TM compliance and volume of ear canal, displays as a graph, shows if perforated or intact TM
226 Hz tympanometry for kids older than 6 mths
1000hz for younger
chronic supperative OM (CSOM)
ongoing purulent ear drainage, TM perforation or tympanostomy tube …can be assoc. with cholesteatoma, chronic mucosal edema, ulceration, granulation tissue, polyp formation
risk factors for CSOM
history of OM, crowded living, day care, lg fam, P.aeruginosa, S. aureus, Proteus sp. Klebsiela penuoniae, diptheroids
key to Mgmt
determine cause, cleaning drainage, topical antimicrobial
possible causes of CSOM
foreign body, neoplasm, landerhans cell histiocytosis, TB, granulomatosis, fungal infection, petrositis (bone probs)
immediate referral to an otolaryngologist
facial palsy, vertigo, CNS signs
supperative OM
labrynthitis can be sequelae bony obliteration of inner ear, including cochlea–> hearing loss
mastoiditis
AOM present, postauricular pain and erythema (later ear protrusion) infection spreads from middle ear space to mastoid part of temporal bone–> abcess possible 60% >2yrs old
symptoms / signs of mastoiditis
mastoid red/indurated, swollen and fluctuant, pinna pushed forward from postauricular swelling, narrowed ear canal. except in younger pts swelling is superior, an pushes ear down vs out
incidence of mastoiditis in patients on antibiotics
2/100,000 person years U.S. vs. 4.2 in Netherlands where only 31% get antibiotics
diff diagnosis for mastitis
lymphadentitis, parotitis, trauma, tumor, histiocytosis, OE, furncle
complications of mastoiditis
meningitis when with high fever, stiff neck, severe headache… lumbar puncture for diagnosis. facial palsy, sigmoid sinus thrombosis, epidural abcess, cavernosu sinus thrombosis, thrombophlebitis
if no improvement after 48 hrs
surgical intervention: tympanostomy tube, with cultures taken. if subperiosteal abscess: incision and drainage preformed…culture directed antibiotic for 2-3wks.
how is a tympanostomy tube maintained
with continued otic drops until drainage abates.
4 types of conductive hearing loss
(1) obstruction (cerumen impaction),
(2) mass loading (eg, middle ear effusion),
(3) stiffness effect (eg, otosclerosis), and
(4) discontinuity (eg, ossicular disruption)
sensory hearing loss can be caused by …
can be from presbycusis, acoustic trauma, or acoustic neuroma, mumps, meningitis, head trauma, or ototoxic medications (ASA, erythromycin, quinine), or congenital (rubella, maternal diabetes, prematurity, hypoxia, genetics))
symptoms include tinnitis,
presbyacusis
advancing age… associated with sensory hearing loss
deterioration of the cochlea, from loss of organ of Corti (hairs) progressive, high-frequency loss because all sounds hit the area that processes high pitches (so they get more wear and tear through the years)
sudden sensory hearing loss
may respond to corticosteroids if delivered within several wks of onset
diseases of auricle
traumatic auricular hematoma,
skin cancer,
canal blockage from dissolution of cartilage,
cellulitis,
relapsing polychondritis (rheumatologic) (treat wit corticosteroids)
disease of ear canal
cerumen impaction, foreign bodies
avoid vestibular caloric response
use body temp water to avoid dizziness, aim at posterior ear canal wall near cerumen plug **only when TM intact!!
COWS : Cold opposite directed nystagmus, warm water causes nystagmus toward the same side
cerumen impaction
self induced releaved with drops, mechanical removal, suction, irrigation
foreign bodies
dont use water to flush, causes swelling. use microscopic guidance
Treatment for eustachian tube
systemic and intranasal decongestants (eg, pseudoephedrine, 60 mg orally every 4 hours; oxymetazoline, 0.05% spray every 8–12 hours) combined with autoinflation by forced exhalation against closed nostrils may hasten relief.
patulous eustachian tube
own breathing too loud, aural pressure hypofunction eustachian tube. can see excursions of TM during heavy breathing
serous OM
usually only in adults after an upper respiratory tract infection, with barotrauma, or with chronic allergic rhinitis. or nasopharyngeal carcinoma
treatment for serous OM
oral corticosteroids (eg, prednisone, 40 mg/day for 7 days) & oral antibiotics (eg, amoxicillin, 250 mg three times daily for 7 days)— or a combination of the two.
barotrauma
Oral decongestants (eg, pseudoephedrine, 60–120 mg) should be taken several hours before anticipated arrival time so that they will be maximally effective during descent. Topical decongestants such as 1% phenylephrine nasal spray should be administered 1 hour before arrival.
dive slowly to avoid…
hearing loss and acute vertigo…avoid the development of severely negative pressures in the tympanum that may result in hemorrhage (hemotympanum) or perilymphatic fistula. In the latter, the oval or round window ruptures
cant go diving
when upper respiratory tract infection or nasal allergy, or TM rupture, never dive. unbalanced thermal stimulus to the semicircular canals and may experience vertigo, disorientation, and even emesis.
Otosclerosis
Lesions involving the footplate of the stapes producing conductive hearing loss.–> hearing aid/ stapedectomy
Meniere’s Disease etiology
Excess accumulation of endolymph in membranous labyrinth causing distension of ductis.
6 subtypes (classic, cochlear- not dizzy, vestibular- no auditory, bilateral, subclinical, post-traumatic)
presentation of Meniere’s disease
tinnitus, aural fullness, vertigo can last minutes to days
can cause progressive unilateral hearing loss especially lower pitch.
acoustic trauma tx
eustachian tube dysfunction
tube fails to open and stays closed
common with kids since horizontal position
causes of Eustation Tube Dysfunction (ETD)
inability of hair cells to remove fluid and infection
narrow eustachian tube
adenoid tissue blocking ET
swollen nasal tissue or secretions (rhinorrhea)
nasopharyngeal tumor in adults
associated dysfunction with ETD
otitis media
barotrauma
cholesteatoma if IM burst (see on physical exam as pearl on TM) (can also lead to facial paralysis if compresses CN, destruction of the middle ear, labyrinth, mastoid air cells)
Presentation of ETD
ear pain, pressure
stuffiness
hearingloss/ tinnitis
rectracted TM
treatment of ETD
nasal decongestant
nasal steroid
possible tube placement to equalize pressure (myringotomy)
risk factor for Tinnitis and Treatment
male, old, smoking, CVD, noise exposure
Tx: oral steroids, chronic can be treated with masking (white noise), and minimize noise exposure
otosclerosis risk factors
female, caucasian
young adults to middle age
genetic predisposition
etiology for otosclerosis
abnormal spongy bone growth on oval window (by stapes)
presentation and Dx of otosclerosis
(type of conductive hearing loss which can progress to sensorineural)
worsening hearing loss over time as it growth ossifies, tinnitis
Dx: conductive hearing loss on audio exam, normal physical findings, may have absent cone of light
Dx with temporal bone CT or exploratory surgery
Other conductive hearing loss
cerumen impaction, OM, OE, TM perf, mastoiditis, foreign body, cholesteatoma, myringosclerosis, and tympanosclerosis
acoustic neuroma and risk factors for it
vestibular schwann cells growing a benign tumor
no symptoms until larger
risk factors: neurofibromatosis Type 2, (with cafe au lait spots), and ionized radiation
presentation of acoustic neuroma
unilateral hearing loss and tinnitus
headache, dizziness
facial numbness/ weakness
symptoms worsen over time
Dx Acoustic neuroma
audiogram shows a unilateral sensorineural hearing loss
speech discrimination harder than expected
brainstem response can be normal while tumor is small
get MRI
*Monitor with imaging and audiometry every 6 mths/ refer to ENT for surgery
Peripheral Vertigo vs. Central vertigo
peripheral has fast beating nystagmus which is suppressed by fixation,
central is slow onset and is NOT suppressed by fixation
Dx of vertigo
history and physical
Audiometry
Video/electronystagmography
calorics with COWS
auditory brainstem response
MRI
Electrocochelography (fluid pressure in ear to Diagnose Meniere’s or endolymphatic hydrops)
Tx Vertigo
Benzosdiazapine (Valium and Xanax to calm nervous system)
Meclizine
Transdermal scopolamine
oral steroid
salt/ caffeine restriction
vestibular rehab
interventional and surgical
BPPV
1 cause of vertigo (associated with head movement)
positional vertigo from crystalline structures becoming dislodged from hair cells from trauma or idiopathic
hearing INTACT
diagnose with Dix-Hallpike maneuver (nystagmus with supine, posterior/ 90degree head turn),
treat with Epley maneuver
vestibular neuritis presentation
(labrytinthitis)
suddent VIOLENT vertigo with nausea
lasts hours to days
with or with out hearing loss
usually after a viral upper respiratory infection
ototoxic meds
tx for labrytinthitis
steroid
benzos
meclizine
