ENT (ears) Flashcards
What is perichondritis and what commonly causes this?
Inflammation of the pericondria which lies over the top of the pinna of the ear. Normally due to piercings or bites.
What is a pinna haematoma and what commonly causes this?
When blood accumulates between the cartliage of the ear and the overlying perichondrium. This is normally due to blunt trauma (e.g. often in rugby players)
How is a pinna haematoma managed?
Drainage and reapposition of the two layers (cartilage and perichondrium).
What happens if a pinna haematoma is left untreated?
A cauliflower deformity of the ear occurs.
How does wax/foreign bodies affect hearing?
Reduced hearing as stops the air getting to the tympanic membrane
What is otitis externa?
Inflammation of the external acoustic meatus.
What can cause otitis externa?
Bacterial infections
Fungal infections (e.g. candida)
Eczema
Dermatitis (contact or seborrhoeic)
using hearing aids + swimming are risk factors
How does otitis externa present?
Ear pain
Discharge
Itchiness
Conductive hearing loss
What is seen on examination in otitis externa?
Erythema and swelling (oedema) in the ear canal
Tenderness in the ear canal
Pus/discharge in canal
Lymphadenopathy in the neck or around the ear
How is otitis externa diagnosed?
Otoscopy
Ear swab
How is otitis externa managed?
Mild - acetic acid (over the counter as EarCalm).
Moderate - topical antibiotic and steroid - e.g. betametasone.
Severe - oral antibiotics - 7 day course of flucloxacillin or clarithromycin.
What is malignant otitis externa?
Severe and potentially life threatening form of otitis externa. This spreads to bones surrounding the ear canal and skull. This can progress to osteomyelitis of the temporal bone.
What are risk factors for malignant otitis externa?
Diabetes
Immunosuppressant medications (chemotherapy)
HIV
What are the symptoms of malignant otitis externa?
Persistant headache Severe ear pain Fever Discharge from ear Hearing loss
How is malignant otitis externa treated?
Emergency admission
IV antibiotics
Imaging to assess extent of infection
What are the complications associated with malignant otitis externa?
Facial nerve damage and palsy. Cranial nerve involvement. Meningitis. Intracranial thrombosis.
What are the symptoms of impacted ear wax?
Conductive hearing loss Discomfort in ear A feeling of fullness Pain Tinnitus / crackling
How can impacted ear wax be treated?
Ear drops - olive oil or sodium bicarb.
Microsuction.
What is a cholesteatoma?
Abnormal collection of squamous epithelia cells in the middle ear due to retraction of the tympanic membrane when there is Eustachian tube dysfunction. It can invade local tissues, nerves and erode bones. It can predispose people to infections.
How does a cholesteatoma present?
Foul discharge
Unilateral conductive hearing loss
If expanding may cause
- infection
- pain
- vertigo
- facial nerve palsy
How does a cholesteatoma look on otoscopy?
Retraction pocket
Granulation tissue and skin debris
Crust or keratin in the upper part of the tympanic membrane
May have tympanic perforation
White mass may be present behind the tympanic membrane (congenital)
What is the management for a cholesteatoma?
Surgical removal
What is eustachian tube dysfunction?
The tube between the middle ear and throat isn’t working properly or becomes blocked. This means the air pressure cannot equalise and fluid cannot drain. This means the middle ear fills with fluid.
What is the function of the eustachian tube?
Equalises the air pressure in the middle and drains fluid from the middle ear.
What can cause eustachian tube dysfunction?
Viral upper respiratory tract infection
Allergies (hayfever)
Smoking
Obstruction - adenoids, tumour
How does eustachian tube dysfunction present?
Reduced or altered hearing Popping noises or sensations in the ear A fullness sensation Pain or discomfort Tinnitus (symptoms get worse when the external air pressure changes - e.g. flying, scuba diving)
What investigations are done for eustachian tube dysfunction?
Tympanometry
Audiometry
CT scan
What is tympanometry?
A device is inserted into the ear and creates different air pressures. This sends sounds to the tympanic membrane and the amount of sound reflected back off the tympanic membrane is measured.
What is the management for eustachian tube dysfunction?
No treatment - sometimes resolves spontaneously.
Valsalva manoeuvre - hold the nose and blow out to inflate the eustachian tube.
Decongestant nasal sprays.
Antihistamines.
Steroid nasal spray.
Surgery if severe or persistent.
What is otosclerosis?
There is remodelling of the ossicles (small bones in the middle ear). This leads to a conductive hearing loss. Can be unilateral or bilateral.
- often the stapes becomes fixed to the oval window
Name the three ossicles
Malleus
Incus
Stapes
How does otosclerosis typically present?
Progressive hearing loss (particularly lower pitched sounds) Tinnitus May have a family history (can be inherited - autosomal dominant)
How is otosclerosis managed?
Conservative - hearing aids
Surgery - stapedectomy
Surgical (stapedectomy or stapedotomy)
What is stapedectomy?
Surgical removal of the stapes and replacement with prosthesis to transfer sound from the incus to the cochlear.
What is otitis media?
An infection of the middle ear. bacteria can enter from the throat through the eustachian tube (hence is often preceded by an upper respiratory tract infection)
What bacteria commonly causes otitis media?
Streptococcus.
Haemophilius influenzae.
Moraxella catarrhalis.
Staphylococcus aureus.
How does otitis media normally present?
Ear pain
Reduce hearing in affected ear
Feeling generally unwell - e.g. fever
Symptoms of a upper airway infection - e.g. cough/sore throat
If it affects the vestibular system it can cause vertigo
What does otitis media look like on otoscopy?
Bulging red inflamed looking tympanic membrane. If perforation has occurred then you may see discharge in the ear canal and a hole in the tympanic membrane
How is otitis media managed?
Antibiotics - first line is amoxicillin. If not clarithromycin (in penicillin allergy) or erythromycin (in pregnancy).
Analgesia
What is mastoiditis?
An infection that affects the mastoid bone behind the bone. It mainly affects children.
What are some possible complications of otitis media?
Otitis media with effusion
Hearing loss (normally temporary)
Perforated tympanic membrane
Labyrinthitis
The follow are rare: Mastoiditis Abscess Facial nerve palsy Meningitis
What are the symptoms of mastoiditis?
Redness, tenderness and pain behind the ear. Swelling behind the ear Discharge Fever Headache Hearing loss in affected ear
Normally after a severe ear infection
What can cause mastoiditis?
Otitis media
Cholesteatoma
What is tinnitus?
A persistent sound which if often described as ringing, buzzing, hissing or humming noise in the ear.
What is primary tinnitus?
Tinnitus that has no identifiable cause. It often occurs with sensorineural hearing loss
What can cause tinnitus?
Impacted ear wax Ear infection Meniere's disease Noise exposure Certain medications (e.g. loop diuretics, gentamycin, chemo drugs) Acoustic neuroma Trauma Multiple sclerosis Depression Some systemic conditions may be associated.
What is objective tinnitus and what can cause this?
When an actual extra sound is heard within the patients head.
This can be caused by
- carotid artery stenosis (pulsatile carotid bruit)
- aortic stenosis (radiating pulsatile murmurs)
- arteriovenous malformations (pulsatile)
- eustactian tube dysfunction (popping or clicking noises)
What assessments and investigations can be done for tinnitus?
Otoscopy Weber's and Rinne's test Bloods Audiology Imaging if necessary
What questions should be asked in a history of a patient presenting with tinnitus?
Unilateral or bilateral
Frequency and duration
Severity
Pulsatile or non pulsatile
Any hearing loss or excessive noise exposure
Any associated symptoms - vertigo, pain, discharge
What systemic conditions may be associated with tinitus?
Anaemia
Diabetes
Hypo or hyperthyroidism
Hyperlipidaemia
What are the red flags to look out for if someone presents with tinnitus?
Unilateral tinnitus Pulsatile tinnitus Hyperacusis (hypersensitivity to sounds) Associated unilateral hearing loss Associated sudden hearing loss Vertigo and dizziness Headaches or visual symptoms Neurological symptoms - e.g. facial nerve palsy
What is hyperacusis?
Hypersensitivity, pain or distress to environmental sounds.
How is tinnitus managed?
Tends to be self limiting.
Treat underlying causes
Help improve and manage symptoms - hearing aids, sound therapy or CBT.
What is otitis media with effusion?
A condition where the middle ear becomes filled with fluid and causes hearing loss.
It is related to Eustachian tube dysfunction.
How can meniere’s disease be managed?
Manage symptoms during an acute episode - antihistamines such as cyclizine - prochlorperazine - vestibular sedative - during acute attacks!! Prophylaxis with betahistine Lifestyle - lie down and rest during and after attack. Limit salt, caffeine and alcohol intake. Can consider surgical management - e.g. grommets, dex. middle ear injections etc.
Why is otitis media with effusion more common in children?
As the Eustachian tube is more horizontal. Whereas in adults it is easier as goes with gravity.
How is otitis media with effusion managed?
Referral for audiometry
Often treated conservatively and resolves without treatment in 3 months.
Grommets may be needed
What is seen on otoscopy in otitis media with effusion?
dull tympanic membrane
Air bubbles
Visible fluid level
What is the main symptom of otitis media with effusion?
Hearing loss in the affected ear.
What is the pathophysiology of otitis media with effusion?
The eustachian tube that connects the middle ear and the back of the throat becomes blocked. This means the secretions from the middle ear build up in the middle ear.
What are grommets?
Small tubes that are inserted into the tympanic membrane to allow the fluid from the middle ear to drain into the eustachian tube.
They usually fall out naturally within a year.
What is Meniere’s disease?
A long term inner ear disorder that causes episodes of vertigo, hearing loss, tinnitus and a feeling of fullness.
What is the normal presentation of meniere’s?
40-50 year olds
Unilateral episodes of vertigo, hearing loss and tinnitus. There is also a feeling of fullness in the ear.
These episodes last between 20mins and several hours.
Over time there is sensorineural hearing loss and tinnitus that becomes more permanent.
Describe the hearing loss that occurs in Meniere’s disease?
Unilateral sensorineural hearing loss that normally affects low frequencies first.
Is worse during episodes of vertigo but declines progressively over time.
What is the pathophysiology behind meniere’s disease?
Excessive build up of endolymph in the labyrinth of the inner ear, causing a high pressure that disrupts sensory signals.
What is an acoustic neuroma?
A benign tumour of the Schwann cells (myelin sheath) that surround the vestibulocochlear (CN 8) nerve
What is another name for an acoustic neuroma?
Vestibular schwannoma
What do bilateral acoustic neuromas indicate?
Neurofibromatosis type 2 (genetic condition causing benign tumours to grow on nerves)
Where do acoustic neuromas occur?
At the cerebellopontine angle
How does an acoustic neuroma present?
Gradual onset of - unilateral sensorineural hearing loss - unilateral tinnitus - dizziness / imbalance - a feeling of fullness in the ear May also have a facial nerve palsy In 40-60 y.o.
What investigations are done for acoustic neuromas?
Audiometry
Imaging - CT or MRI
How is an acoustic neuroma managed?
Conservative if no symptoms - monitor over time.
Surgery for removal.
Radiotherapy to reduce growth.
What does BPPV stand for?
Benign paroxysmal positional vertigo
What is BPPV?
A inner ear condition where there are recurrent episodes of vertigo triggered by head movements
How does BPPV commonly present?
Attacks of vertigo upon head movements. Symptoms settle in 20-60 seconds.
Asymptomatic in-between attacks.
No impact on hearing and no tinnitus
What is the pathophysiology of BPPV?
Crystals of calcium carbonate become displaced in the semicircular canals of the inner ear. These disrupt the normal flow of endolymph when the head is moved hence triggering vertigo.
Causes of displacement can be viral infections, head trauma, old age or unknown.
What can be done to diagnose BPPV?
Dix-Hallpike manoeuvre
What is involved in the Dix-Hallpike manoeurve?
Move the patients head in order to move the endolymph through the semicircular canals. This should trigger vertigo as well as rotational nystagmus (towards the affected ear) in someone with BPPV.
What can be done to treat BPPV?
Epley manoeurve
GO AND WATCH VIDEOS ON EPLEY AND DIX HALLPIKE MANOEURVES
FOR BPPV
What are brandt-daroff exercises used for?
Exercises that can be done at home to improve the symptoms of BPPV.
What is vestibular neuronitis?
Inflammation of the vestibular nerve - normally due to a viral infection
What is the role of vestibular nerve?
Transmits signals from the vestibular system to the brain to help with balance.
What is the presentation of vestibular neuronitis?
Typically after a viral upper respiratory tract infection.
Balance problems, dizziness and vertigo (acute onset).
Nausea and vomiting.
Horizontal nystagmus
What anatomical structures make up the inner ear and what are their roles?
Semicircular canals - contain sterocilia that detect movement and rotation of the head.
Vestibule.
Cochlear - responsible for hearing.
How is vestibular neuronitis managed?
Prochlorperazine (antiemetic)
Antihistamines - e.g. cyclizine, promethazine
Vestibular rehabilitation therapy
What is labyrinthitis?
Inflammation of the labyrinth of the inner ear (cochlear, vestibule and semicircular canal).
How does labyrinthitis present?
Acute onset vertigo.
Hearing loss.
Tinnitus.
May have had a recent URTI.
How is labyrinthitis managed?
Prochlorperazine (antiemetic).
Antihistamines - cyclizine, promethazine.
What is tympanosclerosis?
Fibrotic scarring of the tympanic membrane
How does prochlorperazine work for nausea?
Blocks D2 receptors in the CTZ (chemoreceptor trigger zone)
What are the symptoms of a perforated eardrum?
Sudden hearing loss. Earache / pain. Itching . Discharge from the ear. Fever. Tinnitus.
What is the difference between a wet and dry perforated eardrum?
A wet perforation means there will be discharge and fluid in and leaking from the ear. Whereas dry there is no fluid.
What can cause a perforated tympanic membrane?
Ear infections - commonly otitis media.
Injury - e.g. poking a cotton bud too far in the ear.
Changes in pressure - e.g. flying or scuba diving.
A sudden loud noise - e.g. an explosion.
How is a perforated tympanic membrane managed?
Often heals by itself within a few weeks.
Ensure nothing is put in the ears - including any water.
Try not to blow nose too hard.
Take analgesics to manage any pain.
If caused by an infection, antibiotics may be required.
If large or doesn’t heal itself then surgery may be needed.
What surgery is performed for a perforated tympanic membrane?
Myringoplasty
What is a vestibular migraine?
A type of migraine where people experience vertigo, dizziness and balance problems alongside migraine symptoms
What are the symptoms of vestibular migraines?
Migraine symptoms - headache - nausea - photophobia Vestibular symptoms (lasting between 5 mins and 72 hours) - vertigo and dizziness - balance problems - sensitivity to sounds
How are vestibular migraines managed?
Preventative medications - e.g. amitriptyline
Analgesics - paracetamol, iBuprofen
Prochlorperazine - vestibular sedative/ suppressant (10mg)
Antiemetics - e.g. ondansetron
Avoid any triggers if known
What is the diagnostic criteria for vestibular migraines?
At least 5 episodes
A present or past history of migraines
Vestibular symptoms - vertigo and dizziness lasting between 5 mins and 72 hours
At least half of the episodes have migraine symptoms ( headache, flashing lights + aura, sensitivity to light or sound )
What things can trigger a vestibular migrane?
Stress Bright lights Strong smells Certain foods - such as chocolate, cheese and caffeine Dehydration Menstruation Abnormal sleep patterns
What are the three inputs that are responsible for balance?
Vision
Proprioception
Signals from the vestibular system
What are some causes of peripheral vertigo?
Peripheral vertigo is caused by the vestibular system.
- BPPV
- Meniere’s disease
- Vestibular neuronitis
- Labyrinthitis
- trauma to vestibular nerve
- acoustic neuromas
What are some causes of central vertigo?
Problems affecting the cerebellum or the brainstem - disrupting signals from the vestibular system
- stroke (posterior circulation infarction)
- tumous
- multiple sclerosis
- vestibular migranes
- medications / drugs
What are the differences between central and peripheral vertigo?
Central - caused by brainstem or cerebellar pathologies affecting transmission of signals from the vestibular system.
- This causes sustained, non positional vertigo.
- impaired co-ordination
- often gradual onset
Peripheral - to do with vestibular system
- often positional
- often sudden onset
- nausea
What examinations may be done when a patient presents with vertigo?
Ear examination Neuro examination Cerebellar examination - DANISH Romberg's test Dix - Hallpike manoeuvre (for BPPV) Look for signs of nystagmus - head impulse test
What is the difference between conductive and sensorineural hearing loss?
Conductive - the sound can’t reach the inner ear - may be due to problems with the outer or middle ear
Sensorineural - a problem with the vestibulocochlear nerve or sensory system in the inner ear
What is the role of the cochlear?
To convert sound vibrations into a nerve signal to allow us to process sound and hear.
What are the two main tuning fork tests used to differentiate between sensorineural and conductive hearing loss?
Rinne’s and Weber’s tests
How is Weber’s test performed?
- strike the tuning fork to make it vibrate
- place in centre of patients forehead
- ask patient if they can hear the sound and if it is louder in either ear
What is the normal result for Weber’s test?
The sound is heard equally in both ears
In sensorineural hearing loss, what will the Weber’s and Rinne’s tests show?
- Weber’s - the sound will be louder in the normal ear as it is better at sensing the sound (indicates other is affected).
- Rinne’s - air conduction will be better than bone conduction on both sides.
In conductive hearing loss, what will the Weber’s and Rinne’s tests show?
Weber’s - sound will be louder in the affected ear (as it is more sensitive).
Rinne’s - bone conduction will be greater than air conduction on the affected side.
How is Rinne’s test performed?
- strike the tuning fork to make it vibrate.
- place it on the mastoid process behind the ear and get the patient to tell you when they can no longer hear the humming.
- then move the tuning fork and hover it 1cm from the same ear.
- ask the patient if they can hear the sound now and which was louder.
What are some causes of sensorineural hearing loss?
Presbycusis. Noise exposure. Meniere's disease. Labyrinthitis. Acoustic neuroma. Neurological conditions - stroke, MS, tumours. Infections - meningitis. Certain meds.
What common medications may cause sensorineural hearing loss?
Loop diuretics - e.g. furosemide.
Aminoglycoside antibiotics - e.g. gentamycin.
Chemotherapy drugs - e.g. cisplatin.
What are some causes of conductive hearing loss?
Ear wax / obstruction. Infection. Fluid in middle ear (effusion). Eustachian tube dysfunction. Perforated tympanic membrane. Otosclerosis. Cholesteatoma. Exostoses. Tumours.
What is exostoses related to the ear?
When bone grows abnormally in the ear - due to repeated exposure to cold water.
What is used in audiometry to test bone and air conduction?
Bone conduction uses a oscillator.
Air conduction uses headphones.
GO OVER AUDIOMETRY!
Rewatch or read zero to finals?
What is presbycusis?
Age related hearing loss
Describe the hearing loss in presbycusis?
Sensorineural, normally affecting high pitched sounds first. The hearing loss occurs gradually and is symmetrical.
What are the risk factors for presbycusis?
Old age. Male. FH. Loud noise exposure!! Diabetes. Hypertension. Ototoxic medications. Smoking.
How is presbycusis managed?
Hearing aids.
Cochlear implants if hearing aids are not sufficient.
What is sudden sensorineural hearing loss?
Sudden hearing loss over less than 72 hours, unexplained by other (conductive) causes.
How may sudden sensorineural hearing loss be managed?
Immediate referral to ENT.
Treatment for underlying cause.
If idiopathic then give steroids - either oral or intra-tympanic.
Explain the steps which allow us to hear?
- Sound waves hit the tympanic membrane
- vibrations get passed through the ossicles
- the stapes articulates with the oval window, causing movement of lymph (peri and endolymph)
- movement of the hair cells, leads to depolarisation of neuronal fibres which is then transmitted to the brain via the cochlear nerve
In which bone is the inner ear found?
The petrous part of the temporal bone
What are the contents of the inner ear and their roles?
- cochlear - hearing
- vestibule and semi-circular canals - balance and position
What causes a haemotympanum?
Associated with a temporal bone fracture
