ENT - Ear Flashcards
HEARING LOSS - EAR OVERVIEW
i) what does conductive hearing loss relate to? what can cause it? what is sensorineural hearing loss related to?
ii) what is the function of the eustachian tube? what are the three small bones in the middle ear?
iii) which area is responsible for sensing head movement? what does the cochlea do? what does the vestibulocochlea nerve do?
iv) what is done in webers test? what is a normal result? what will the result be in conductive or SN hearing loss?
v) what is done in rinnes test? what is a normal result? what is an abnormal result?
i) conductive - problem with sound travelling from enviro to inner ear (sound is not reaching the sensory system) - can be caused by ear plugs
SN - problem with sensory system or VC nerve in the inner ear
ii) eus tube - connects middle ear with throat to equalise pressure
malleus, incus, stapes
iii) semicirc canals sense head movement
cochlea converts sound vibration into nervous signal
HEARING TESTS
i) what is done in webers test? what is a normal result?
ii) what will webers result be in conductive or SN hearing loss?
iii) what is done in rinnes test? what is a normal result?
iv) what is an abnormal result in rinnes test? what type of hearing loss does this suggest?
i) webers - place vibrating tuning fork in centre of pts forehead > ask patient which ear they hear loudest
normal - equally heard in both ears
ii) SN - sound louder in niormal ear
conductive - sound louder in affected ear (more sensitive as less sound reaches it)
iii) rinnes - put vibrating tuning fork on mastoid to test bone conduction
then move fork next to ear (when cant hear it anymore) to test air conduction
normal - pt hears sound again when fork is moved from bone to ear as air conduction should be better than bone
iv) abnormal is when bone conduction is better than air condiction - sound not heard after moving fork from bone to next to ear
suggests conductive cause for hearing loss - sound travels through bone but less through air
CAUSES OF HEARING LOSS
i) name six causes of SN hearing loss?
ii) name three medications that can cause SN hearing loss?
iii) name six causes of conductive hearing loss
i) SN - age related, noise exposure, menieres, labrynthitis, acoustic neuroma, infections, stroke/MS/tumour
ii) loop diuretics (furos), aminiglycoside abx (gent), chemo (cisplatin)
iii) ear wax/something blocking canal, infection (otitis ext and media), fluid in middle ear, eustachian tube dysfunc, perf tymp membrane, otosclerosis, cholesteatma, extoses, tumours
PRESBYCUSIS
i) what is it? what type of HL is it? which pitch sounds are aff first? naame three mechs that may occur
ii) name four RF? how can one of these be addressed?
iii) how does it come on? what may be associated with it? what condition are patients more likely to develop?
iv) what is done to dx? what HL pattern is seen?
v) name three wys it can be supportively mx
i) age relayed hearing loss - sensorineural that affects high pitched sounds first
loss of hair cells in cochlea, loss of neurons in coch, atrophy of stria vascularis
ii) RF - age, male, FH, loud noise expos, diabetes, HTN, ototoxic meds, smoking
hearing protection to reduce exposure to loud noise
iii) gradual and insidious onset
may be assoc with tinnitus
more likely to develop dementia - treating the HL can reduce the risk
iv) audiometry - SN HL. pattern with normala at lower freq and worse hearing at higher freq
v) optimise enviro (reduce ambient noise), hearing aids, cochlea implants (if HA not suffic)
SUDDEN SENSORINEURAL HEARING LOSS
i) what is it defined as? what needs to be done? is it usually uni or bilateral?
ii) name five caauses of conductive rapid onset hearing loss
iii) what causes most cases of SSHL? name five other causes
iv) what is required to diagnose? what is seen? what may be done if a stroke or acoustic neuroma is suspected?
v) what must be done immediately? how may it be treated? name two routes of admin
i) hearing loss over <72 hours unexplained by other caauss
need emergency refer to on call ENT team - usually unilateral
ii) conductive = ear wax, infection, fluid in middle eaar, eustachian tube dysfunc, perf tymp membrane
iii) most SSHL is idiopathic
other causes are infection, menieres, ototoxic meds, MS, migraine, stroke, acoustic neuroma
iv) audiometry to diagnose > SSHL is loss of at least 30 decibels in 3 conseq frequencies on audiogram
do MRI or CT head
v) immed refer to ENT
idiopathic can be tx with steroids - oral or intra tympanic (inject steroids into tymp membrane)
EUSTACHIAN TUBE DYSFUNCTION
i) what is it? what does the ET do? what happens when it doesnt function properly? what happens to the middle ear?
ii) what can ETD be associated with? (3) name four ways it may px? when may these symptoms worsen?
iii) what may be seen on otoscopy? name three ways dx can be made?
iv) what does tympanometry involve? what is seen in ETD?
i) tube between middle ear and throat isnt functioning properly
ET equalises air pressure in middle ear and drains fluid from middle ear
dysfunc > air pressure cant equalise (air pressures unbalanced) and fluid cant drain > middle ear can become full of fluid
ii) assoc with viral URTI, allergies eg hayfever nd smoking
px with reduced/alt hearing, popping, fullness sensation in ear, pain, tinnitus
worsens when pressure cant equal to outside pressure eg flying, mountain, scuba
iii) otoscopy may be normal
can usuaally clinically dx but may need tympanometry, audiometry, nasopharyngeoscopy, CT scan
iv) tympanometry - device to ext aud canal, creates diff in air pressure, measures sound reflected back
ETD = air pressure in middle ear can be lower than outside pressure > more sound abs and negative ear canal pressure
MX OF EUSTACHIAN TUBE DYSFUNC
i) what may be done first? what manouvre cn be done?
ii) what tx can be used in the short term? whaat two things can be given if allergies are assoc?
iii) when may surgery be done? what are the three main options?
iv) what is otovent?
i) may start with no tx (eg wait to recover from viral URTI)
valsalva manouvre
ii) short term nasal decongestant sprays
antihistamines orr steroid nasal spray for allergies
iii) surgery is severe or persistent
sx: treat other pathology, grommets (tubes into tymp mem to allow fluid to drain out) or balloon dilation eustachian tubuloplasty (deflated baloon into ET > inflate to stretch it > GA)
iv) otovent = over the counter device > blow into balloon using single nostril > inflate ET, clear blockages and equalise pressure
OTOSCLEROSIS
i) what is it? what does it lead to? before what age does it usually present?
ii) what is inheritance pattern? what bone is particularly affected? what type of HL does it lead to?
iii) name two assoc symptoms it usually px with? what pitch sounds does it affect more? why may they talk quietly?
iv) what is seen on otoscopy? when may webers test be normal? what will rinnes test show?
i) remodelling of bones in middle ear > conductive HL
usually presents before 40
ii) auto dominant
aff base of the staapes > att to oval window causing stiffening and fixation > prevents transmission of sound effectively therefore causing conductive HL
iii) px with HL and tinnitus
affects lower pitched sounds more (opposite of age related HL)
patient hears voice as being loud due to CHL therefore speks quieter
iv) otoscopy - normal
webers = normal if oto is bilateral / if unilaterla sound will be louder in affected ear
rinnes = will show conductive HL
OTOSCLEROSIS IX AND MX
i) what is the initial ix of choice? what is seen?
ii) what will tympanometry show? what imaging may be done?
iii) what can be done for cons mx? whata cana be done for surgical mx? (2)
i) audiometry - CHL, normal bone readings, air conduction >20db
ii) tymp - reduced admittance (absorp) of sound
may do high res CT
iii) cons = hearing aids
sx: stapedectomy - remove whole stapes and replace with prothesis
steptotomy - remove part of stapes but leave base att to oval window then add in prosthesis > allows transmit of sound from incus to cochlea
OTITIS MEDIA
i) what is it? where does the middle ear sit? what is found within it? (3) how does bacteria enter? what type of infec often preceeds it?
ii) what organism is the most common cause? name two others?
iii) what is the most common px feature? nme three other ways it may px?
iv) what can it px with if infec affects the vestibular system? what may be seen in ear drum perf?
v) what is used to vis tympanic membrane? how should it look? what may it look in OM?
i) infection of middle ear - sits between tympanic membrane and inner ear
cochleaa, vestib apparaatus and nerves are found
bacteriaa can enter from back of throat rhough ET - often preceeded by viral URTI
ii) strep pneum is most common
also caused by haemoph influenzae, moraxella catarrhalis aand staph aureus
iii) ear pain is most common feature
also px with reduced hearing in aff ear, general unwell eg fever ,upper airway infec eg cough, coryza, sore throat
iv) px with balance issues and vertigo if vestib
see discharge if eaar perf
v) otoscopy - shold be pearly grey, transulcent and shiny
in OM - red, inflamed
if perf - discharge in ear canal and hole in tymp membrane
MX AND COMPLICATS OF OTITIS MEDIA
i) how long do most cases take to resolve? what should generally be given?
ii) when should immediate abx be given? (3) when may a delayed prescription be considered?
iii) what is first line abx? for how long? what can be given if pen allergic? what if pen allergic and pregnant?
iv) name four complications
i) most resolve without abx in 3 days (can take up to 1 week)
give analgesia for pain and fever
ii) immediate abx if signif co morbid, sys unwell or immunocomp
delayed prescrip if symp not improve or worsen
iii) first line is amox for 5-7 days
pen allergic - clarithro
pen and preg - erythro
iv) complications - otitis media with effusion, HL, perf tymp mem, labrynthitis, mastoiditis, abscesss, facial nerve palsy
OTITIS EXTERNA
i) what is it? what is it aka? name two other pre dis factors
ii) name three things that may cause the inflamm in OE? what are the two most common bacterial organisms?
iii) name four symptoms? what type of HL may be seen?
iv) name four things that might be seen on exam? how can a dx be made?
i) inflam of skin in external ear canal
swimmers ear - water in ear canal
ear wax and trauma can also predispose
ii) bac infec, fungal infec eczema, seb derm, contact derm
bacteria - pseudomonas aeruginosa and staph aureus
iii) ear pain, discharge, itchy, conductive HL if ear becomes blocked
iv) O/E - erythema and swelling of ear canal, tenderness, pus/discharge, lymphadenopathy
dx can be made by otoscopy
MX OF OTITIS EXTERNA
i) how can mild OE be treated? when may this also be given?
ii) how is moderate OE treated? (2) name an example of drugs given
iii) what must be excluded before prescribing aminoglycosides eg gent and neomycin? why?
iv) what may pts with severe/systemic symptoms need? what is an ear wick? when may it be used?
v) how can fungal infections be tx?
i) mild - acetic acid 2% (ear calm OTC) - antifungal and antibacterial
also use prophylactically eg before swimming
ii) mod - topical abx and steroid eg neomycin, dex, acetic acid (otomize spray)
neomycin and betamethaasone
gent and hydrcortisone
iii) amiglycosides cause hearing loss of they get past tympanic membrane so exclude a perf tmp mem before using
iv) severe - oraal abx eg fluxclox or clarithro
ear wick is made of sponge/gauz that contains topical tx - leave in for 48 hours
v) fungal - clotrimazole
MALIGNANT OTITIS EXTERNA
i) what is it? what can it progress to?
ii) name three underlying RF? name two symptoms
iii) what is a key finding? name three ways it should be emergency mx?
iv) name three complications
i) infection spreads to bones and surrounding ear canal/skull
can progress to osteomyelitis of temporal bone
ii) diabetes, imm supp meds eg chemo, HIV
more severe symp than OE - persistent headache, severe pain, fever
iii) key finding = granulation tissue at junc between bone nad cart in inner ear
emergency mx - admit under ENT, IV abx, imaaging to look at extent of infection
iv) facial nerve damage/palsy, meningitis, intracranial thrombosis, death
EAR WAX
i) name four things that impacted ear wax can lead to?
ii) what are the three main methods for removing?
i) conductive HL, discomfort, feeling full, pain, tinnitus
ii) ear drops (olive oil or sodium bicarb)
if that doesnt work then ear irrigation (squirt water in)
if irrigation is CI then do microsuction
TINNITUS
i) what is it? what is it thought to be caused by?
ii) what type of HL does primary tinnitus occ in? name four causes of secondary tinnitus? name two drugs that can cause it
iii) name two systemic conditions it may be assoc with?
iv) what is objective tinnitus? name three causes
i) persistent additional sound heaar but not present in surrounding enviro
thought to be caused by background sensory signal prod by cocchlea not filtered out effectively by central aud system
ii) primary occ with sensorineural HL
secondary - impacted ear wax, ear infec, menieres, noise expos, acoustic neuroma, MS
drugs - loop diuretics, gent, chemo eg cisplatin
iii) assoc with anaemia, diabetes, hypothyroid, hyperthyoid, hyperlipi
iv) objecive - patient can hear an actual sound
caused by carotid artery stenosis (bruit), aortic stenosis, AV malform (pulsatile sounds), eustachian tube dysfunc (popping or clicking noises)
TINNITUS IX AND MX
i) name three bloods that should be done? what can assess hearing in detail? which imaging may be done?
ii) name six red flags
iii) does it usually need intervention? name three ways symptoms can be mx
i) FBC, glucose, TSH, lipids
audiology
CT or MRI to look for underlying cause
ii) unilateral, pulsatile, unilat hearing loss, sudden onset HL, vertigo/dizzy, headaache, nerve palsy
iii) usually improves without intervention
can give hearing aids, sound therapy or CBT
VERTIGO
i) what is it? what does the vestibular system comprise of? what are these filled with? how is movement detected?
ii) what two types of problem can vertigo be caused by?
iii) name four most common causes of peripheral vertigo? which system does this involve?
iv) what causes central vertigo? name four causes? is it positional?
i) mismatch between sensory inputs (vision, proprioception, signals from vestib system)
vestib system - three loops of semicircular canals filled with endolymph
movement is det by fluid shift det by sterocilia
ii) peripheral problem affecting the vestib system
central problems affecting brainstem and cerebellum
iii) peripheral - BPPV, menieres, vestibular neuronitis and labrythitis
involves vestib system
iv) central affects breainstem or cerebellum
PCA infarction in stroke, tumour, MS, vestibular migraine
central vertigo is sustained and non positional
VERTIGO IX AND MX
i) what must be distinguished between when w pt present with dizziness?
ii) in relation to central/peripheral what is: onset, duration, HL/tinnitus?, co-ordination and nausea?
iii) what four things need to be examined when assessing vertigo? what part of the brain must also be examined?
iv) how can central and peripheral be distinguisehed? (HINTS)
v) what do pts with central vertigo need? name two short term mx for peripheral vertigo?
i) lightheadness and vertigo
ii) peripheral - sudden onset, short duration, HL and tinnitus, intact co ord and severe nausea
central - gradual onset, persistent, no HL/tinnitus, impaired co-ord, mild nausea
iii) ear exam, neurol, CV, special tests - romberg, dix hallpike, HINTS
also examine cerebelllar- DANISH
iv) head impulse (abormal in peripheral), nystagmus (central), test of skew (centrall cause)
v) central > refer for further ix to find cause
peripheral - prochlorperazine and anti histamines (cyclizine)
BPPV
i) what is it? what can trigger it? how long does it normally last? are patients symptomatic between attacks? does it cause HL or tinnitus?
ii) what is it caused by? what may cause this?
iii) which maneouvre can be used to diagnose BPPV? what does it involve? what will be seen in BPPV? (2)
iv) what manouvre is used to treat it? what does it do?
v) what are brandt daroff exercises?
i) common cause of vertigo triggered by head movement - peripheral cause of vertigo (problem in inner ear not brain)
common trigger is tuurning over in bed
lsats 20-60 seconds - asymp between attacks
doesnt cause HL or tinnitus
ii) caused by crystals of calcium carbonate (otoconia) becoming displaced into the semicirc canals (posterior most comon) - may be displaaced by viral infection, head trauma, ageing
crystals disrupt endolymph flow > confuses vestib system
iii) dix hallpike manouvre can dx
hang head backwards > moves endolymph through semicircular canals and triggers vertigo
in BPPV - triggers rotational nystagmus (towards aff ear) and symptoms of vertigo
iv) epley manouvre is used to treat
move crystals in SS caanal into a position that doesnt disrupt endolymph flow
v) brandt daroff - exercises done several times per day until symptoms relieve
LABYRHINTHITIS
i) what is it? what is it usually due to? give two common triggers
ii) how does it present? name two things it can be associated with?
iii) how is it dx? what test may be done?
iv) how is it managed? name two medications that may be given? how long for?
v) what can be given if bacterial cause? name a rare complication - what is this particularly assoc with?
i) inflammation of bony labyrinth of inner ear inc SS canals, vestible and cochleaa
usually due to viral URTI
otitis media and meningitis are common triggers
ii) presents with acute onset vertigo and assoc with HL and tinnitus
iii) clinical dx - ensure to exclude central cause of vertigo
may do head impulse test to dx peripheral cause of vertigo
iv) mx with supportive care and short term use of medication (up to 3 days)
prochloperazine and anti histamines
v) abx if bac cause
can lead to permanent hearing impair - especially if secondary to meningitis
MENIERES DISEASE
i) what is it? what does symptoms does it cause? (4) what is the triad of menieres
ii) what causes it? how does this affect ear pressures? what is this called?
iii) who is the typical pt it presents in? how long does vertigo normally last? how does it come on? is it triggered?
iv) describe the pattern of heading loss? what type of HL is it? name two other symptoms?
v) what may be seen in an acute attcak?
i) long term inner ear disorder > recurrent attacks of vertigo, hearing loss, tinnitus (triad) and fulness feeling in ear
ii) caused by excess build up of endolymph in labyrinth of inner ear > higher than normal pressure that disrupts sensory signals
inc pressure = endolymphatic hydrops
iii) typical px of 40-50yr old with unilateral episodes of vertigo, HL and tinnitus
vertigo comes in episodes > 20 mins then settles (clusters then prolonged time without) not trigg by movement or posture
iv) HL fluctuates first and assoc with vertigo then becomes more perm
SN HL > unilateral > aff. low freq first
may also have ear fullness, drop attacks (unexplained falls), imbalance
v) spont nystagmus may be seen in an acute attack
MENIERES DX AND MX
i) how is it dx? what other assessment will pts need?
ii) what two things does mx involve?
iii) name two tx for acute attacks
iv) what can be used for prophylaxis?
i) clinical dx by ENT
also do audiology asses for HL
ii) manage symptoms during acute attack
prophylactic meds to reduce attack frequency
iii) anti emetic - prochlorperazine and anti histamine (cyclizine, promethazine)
iv) prophylaxis with betahistine
ACOUSTIC NEUROMA
i) what is it? what cell does it affect? what are they aka? where do they occur?
ii) what may it be assoc with if bilateral? who is typical pt?
iii) name four ways a pt may present? what nerve palsy can it be assoc with? is the forehead spared?
iv) what investigation can be done? what will be seen? what imaging may be done?
v) what are three tx options? name two risks assoc with tx?
i) benign tumours of schwann cells surrounding auditory nerve > innervates inner ear
aka vestibular schwannoma and occ at cerebellopontine angle
ii) assoc with NF II is bilateral
patient 40-60yrs
iii) px with gradual onset of unilat SN HL, tinnitus, dizziness/imbalance, fullness in ear
assoc facial nerve palsy if tumour compresses facial nerve > LMN lesion > forehed not spared
iv) audiometry to assess HL > SN HL
brain MRI to look t features of tumour
v) cons mx
surgery to resect
RT to reduce growth
vestibulocochlea nerve injury w perm HL/dizzy or facial nerve injury w facial weakness
