ENT - Common conditions of the ear Flashcards
What are the degrees of hearing impairment? What are the implications for a hearing impaired child?
- Normal: hearing threshold is 20dB or less. Air = bone conduction
- Mild: 20-40dB. Manage in quiet situations with clear voices
- Moderate: 41-60dB: miss most of conversation
- Severe: 61-90dB. will NOT hear most conversational speech
- Profound: 91dB or worse. Cannot hear speech sounds. Need cochlear implant/hearing aid
What are the types of hearing losses?
-Sensorineural hearing loss. Air and bone conduction are similar
Hearing threshold is worse than 20 dB
- Conductive hearing loss: Air and bone conduction are different (better bone > air)
- Mixed hearing loss: Air and bone conduction are different
Describe otitis externa
- Px
- likely organism
- Mx
- very painful, blocked ear
- Fungal otitis externa, probably Aspergillus niger (e.g. due to swim in the river)
- Mx: analgesia, ear toilet/cleaning, topical ABx, specifically against fungal infections e.g. Clioquinol/Flumethasone
A 18month old baby presents with thick, purulent discharge from his ears & rubs his ears in context of a recent cold.
DDx?
Acute otitis media with perforation
Describe possible organisms & Mx of acute otitis media with perforation (name specific Abx)
Organisms:
•Streptococcus pneumoniae
•Haemophilus influenzae, non-typeable
•Moraxella catarrhalis
Mx:
•Analgesia
•Ear toilet/cleaning
•Antibiotics: AMOXYCILLIN.
- If allergic to penicillin: cefuroxime
- if recurrent/no improvement after 48 hours of amoxicillin: amoxicillin + clavulanate
•Arrange follow-up in 2-3 months to check for fluid
Who should be treated with oral antibiotics in acute otitis media in children?
- Is 2 years old or less
- Has a tympanic membrane perforation
- Is Indigenous
- Has a known immune deficiency
- Has a cochlear implant
- Has the only hearing ear infected
- Has a possible complication, e.g. Mastoiditis, Facial paralysis, Intracranial – infection or venous thrombosis
Discuss the role of topical antibiotic therapy in acute otitis media
ONLY effective if there is a tympanic membrane perforation
Use a non-ototoxic medication such as ciprofloxacin drops + ORAL antibiotics (e.g. amoxycillin)
How do you manage chronic otitis media (“glue ear”)? When should you consider insertion of middle ear ventilation tubes?
Audiogram to confirm the hearing loss and to determine if there is a sensorineural component
Middle ear Ventilation tubes to ventilate the middle ear if:
•OME (otitis media with effusion) for 4 months at least, with hearing loss or other signs and symptoms
•Recurrent or persistent OME in a child ‘at risk’ regardless of the hearing
•OME and structural damage to the tympanic membrane
The ventilation tube will correct hearing loss post op usually.
How can you manage otorrhoea/infected granuloma through a middle ear ventilation tube?
topical antibiotic drops, such as ciprofloxacin, rather than oral antibiotics
A 64 yo male Px with intermittent discharge from his left ear. His wife complains about the offensive smell, but he has not noticed it himself. He thinks he does not hear well on this side, and recently has felt off-balance when he sneezes.
DDx?
Cx?
Chronic suppurative otitis media with cholesteatoma
Cx:
•Hearing loss: Conductive from erosion of ossicles, Sensorineural from erosion into the labyrinth, Mixed
•Imbalance/vertigo from erosion into the labyrinth (lateral semicircular canal)
Describe Chronic suppurative otitis media (CSOM) & its 2 main types
‘deafness and discharge’
- Recurrent or persistent bacterial infection of the ear
- Destruction of the tympanic membrane and sometimes the ossicles
- Irreversible problems
- NO PAIN usually, but itchiness and discharge
- Conductive hearing loss
2 types:
- tubotympanic disease (‘safe’): central perforation
- atticoantral disease (‘unsafe’): cholesteatoma. Keratinising squamous epithelium present in the middle ear -> damages underlying bone.
think of middle ear disease as ‘active’ or ‘inactive’, as chronic infection in the ear can cause bone erosion, hearing loss and intracranial complications, whether or not there is cholesteatoma
Cx of cholesteatoma of Chronic suppurative otitis media (CSOM)
- CHL (conductive hearing loss) usually from ossicular erosion
- SNHL (sensorineural hearing loss) from erosion into the labyrinth
- Vertigo from labyrinthine fistula
•Facial paralysis
–may be acute if superimposed infection
–may be gradual and subtle
•Intracranial
–may be life-threatening
–neurosurgical management before/with ear surgery
Mx of Chronic suppurative otitis media (CSOM)
- Examination of the other ear as well as pt’s nose and throat
- Tuning fork examination
- Audiogram
- CT scan of the temporal bones
If erosion of the lateral semicircular canal seen on CT: mastoidectomy
Describe Weber’s & Rinne’s tests
Weber’s test: hold 512 Hz tuning fork in midline of forehead -> ask where the pt can hear buzzing noise (to DDx unilateral/bilateral hearing)
If asymmetrical hearing:
•If there is a conductive hearing loss, the sound is heard in the worse hearing ear.
•If there is a sensorineural loss, it is heard in the better ear
Rinne’s test: press a 512Hz tuning fork against the mastoid bone & then hold it 1cm away from the ear. ‘which is louder; behind the ear or in front?’
- Air conduction is better than bone conduction. (Rinne +; POSITIVE is normal)
- If bone conduction is better than air, there is a conductive hearing loss. (Rinne -; NEGATIVE is abnormal)
(5) causes of otorrhoea (ear discharge)
- Wax
- Otitis externa
- Foreign body in the ear canal
- Acute otitis media with perforation
- Chronic suppurative otitis media ± cholesteatoma
A 37yo female presents with severe ear pain for 3 weeks. Antibiotics gave no relief. Tympanic membrane is normal O/E.
DDx in external & middle ear?
External ear canal –Trauma –Otitis externa –Foreign body –Tumour, e.g. Squamous cell carcinoma
Middle ear
–Acute otitis media
–Chronic suppurative otitis media
–Middle ear tumour
(4) sources of referred otalgia (ear pain)
•Oropharynx (IXth nerve)
–Post-tonsillectomy
–Carcinoma of the tongue base
•Laryngopharynx (Xth nerve)
–Pyriform fossa
•Upper molar teeth, temporomandibular joint, parotid gland (Vc nerve)
–impacted wisdom teeth
•Cervical spine (C2, C3)
A 9 month old baby has a fever & is irritable. His face is abnormal on the left side.
DDx?
Mx?
Acute otitis media complicated by facial nerve palsy
Mx:
•Insertion of a ventilation tube to relieve pressure on the facial nerve
•Oral/systemic antibiotics
•Oral/systemic steroids
A 44 yo male presents with severe right ear pain for 2 days. He cannot close his eye today & dribbles from the R side of mouth. He has vesicles in his concha + LMN facial palsy.
DDx?
Mx?
Herpes zoster oticus = Ramsay Hunt syndrome from reactivation of the virus in the geniculate (facial) ganglion.
There may also be hearing loss and vertigo/imbalance if the VIIIth cranial nerve is also involved
Mx:
•Oral steroids
•If seen within three days of the onset of symptoms use anti-viral agent, e.g. acyclovir
•Audiology
•Protect the eye from exposure keratopathy with artificial tears and a pad
(3) symptoms of Ramsay-Hunt syndrome
- vesicular rash on external ear
- lower motor neuron paralysis of facial nerve
- loss of taste sensation over anterior 2/3 of tongue
Due to reactivation of herpes zoster oticus in the geniculate/facial ganglion
Mimics Bells palsy - differentiate by the presence of rash on ear
Discuss facial nerve in the ear
has a course through the middle ear and mastoid bone -> so can be damaged in diseases of the ear and surgery of the ear.
A 72 yo male presents with several episodes of vertigo. They occur when he rolls over in bed and onto his right side, and usually pass in a minute
DDx?
BPPV (benign paroxysmal positional vertigo).
Otoliths from the utricle become loose, and lodge in the posterior (usually) semicircular canal
How do you test for BPPV?
Dix-Hallpike manoeuvre
- The patient lies down with the head down and turned to one side.
- Turning the head to the right tests for right BPPV.
- After a latency period of a few seconds he has vertigo and rotational nystagmus towards the floor (geotropic).
- This lasts less than a minute
A 29 yo male presents with acute severe rotational vertigo after his honeymoon 3 weeks ago. Every time he rolled over he vomited. There was no tinnitus. He recovered after a week, but still feels off-balance when he walks in the dark
- His ear, nose and throat examination are unremarkable, and there is no nystagmus.
- On the Romberg test he tends to fall to the right side.
- There are no other neurological signs.
- On clinical and tuning fork tests he does not have a hearing loss, and his audiogram is normal.
- He is worried that he has a brain tumour.
DDx?
- Vestibular neuritis
- Vestibular migraine
- Brainstem tumour or stroke
- Multiple sclerosis
Describe vestibular neuritis
an abrupt onset of vertigo, possibly from a viral inflammation of the vestibular ganglion.
- There is no hearing loss or tinnitus, and it is expected that the balance will improve over the next few weeks.
- An MRI will exclude another diagnosis such as tumour or multiple sclerosis.
A 26yo female presents with 3 episodes of severe vertigo, each lasting several hours in the last 6 months. There is associated nausea and vomiting. There is tinnitus which is a roaring sound.
•She is not sure if there was hearing loss, but her left ear feels blocked for days after the attack. “But honestly, Doctor, I was too sick to notice.”
•She is afraid to go out on her own in case she gets dizzy.
•Her audiogram is normal.
•She has had an MRI which is also normal.
DDx?
Meniere’s disease (endolymphatic hydrops)
What are the features of Meniere’s disease?
The features are at least three of:
•Vertigo – lasts at least half an hour, but less than a day
•Fullness in the ear
•Roaring tinnitus
•Initially low-frequency sensorineural hearing loss that fluctuates and eventually becomes worse and permanent
Mx of Meniere’s disease
- acute episodes
- maintenance therapy
- surgical therapy
- if persistent symptoms
- Acute episodes
•Vestibular suppressants such as prochlorperazine or diazepam - Maintenance therapy
•Life-style - determine if there are any reversible stresses in her life
•Dietary advice - low salt diet
- medications: thiazide diuretic, betahistine - Surgery:
- intratympanic gentamicin (improves vertigo but not hearing loss)
- vestibular nerve section
- complete destruction of the inner ear - Hearing aids
Describe the step wise treatment of Meniere’s disease
Conservative:
- reassurance
- salt reduced diet
- diuretics
- middle ear ventilation tube
- treatment w/ local overpressure
Surgical +/- destructive:
- Endolymphatic sac surgery
- gentamicin injections
- vestibular nerve section
- complete destruction of the inner ear
What are the (3) common conditions in people with vertigo?
•positional (benign paroxysmal positional vertigo - BPPV)
–also called ‘positioning’
–lasts for less than a minute
- Meniere’s disease (endolymphatic hydrops): lasts a few hours, but less than 24h
- vestibular neuritis (aka neuronitis): lasts days to weeks
Conditions that may cause dizziness
- general medical
- neurological
General medical
- anaemia
- dysrhythmias
- hypoglycaemia
- drugs; antihypertensive
Neurological
- multiple sclerosis
- migraines
A 2 month old baby has severe sensorineural hearing loss in both ears confirmed by objective audiology. His mother had an uneventful pregnancy, and Timmy was born at term. There were no concerns about him in the newborn period.
Mx?
Referral for:
•Hearing aids at Australian Hearing. Aim is to have hearing aid use established by 6 months old
•Early intervention programme
•Ophthalmology referral
•Paediatrician
•Referral for Genetic counselling (if parents wish)
•Application for Centrelink benefits
There is now universal newborn hearing screening in Australia
The aim is to identify children who need early intervention by three months, and to establish hearing aid use by six months
A 47 yo male presents with “I was walking along the street and I went deaf in the left ear” •No vertigo but had tinnitus •General health is good •No medications •Non-smoker.
His audiogram shows: reduced left air conduction & bone conduction compared to the right.
DDx? Mx?
Dx: Sudden sensorineural hearing loss.
- occurs within 3 days,
- in at least 3 frequencies
- and is at least 30dB.
Pt had sensorineural hearing loss (same bone/air conduction) in his left ear
Mx: treated with oral prednisolone, 50mg per day for 5 days, then tapered off
Sudden hearing loss should be treated as early as possible with steroids to optimise the chance of hearing improvement
