Eyes and Ears (2) Flashcards
Risk factors (in the Hx) to ear disorders/infections
- Itching, use of cotton buds, foreign body
- Skin disease, eg psoroiasis, eczema
- Excessive ear wetting, eg swimming
- Nasal obstruction/stuffiness
- Drugs, eg ototoxic agents
- Previous episodes
- Family history eg. presbycusis, otosclerosis, congenital deafness
What key questions to ask in Hx of ear problems?
- Hearing loss
- Onset and duration
- Unilateral or bilateral
- Otalgia (otologic vs. referred)
- Otorrhoea (blood/pus/serous fluid)
- Tinnitus
- Noise exposure (occupation, hobbies)
- vertigo (differentiate from ‘dizziness’)
What elements to include on external ear examination?
- Inspect pre and post auricular regions
- Inspect auricles and mastoid region (size, shape, symmetry, tenderness, swelling)
- Deformities, lesions, evidence of trauma
- Pre-auricular sinus or accessory auricles (appear as skin tags)
- Check for foreign body prior to inserting the auroscope
Anatomy of the external ear - look at the picture
Which ear (R or L) is it?
This is LEFT:
- lateral process of malleus points towards the left side
- the light reflex on the L side
What are we looking at/ considering while looking at the thympanic membrane (otoscopy)? (4)
•Shape of the eardrum – bulging or retracted
•Colour of the eardrum – red (infection), yellow (glue ear), brown (blood)
•Light reflex present or not? (usually absent in bulging TMs)
•Things that should not be there
- Perforations
- Bubbles (glue ear, resolving infection)
- Grommets/foreign bodies
How does normal tympanic membrane should look like?
The normal tympanic membrane should appear :
- pearly grey
- with a light reflex
- generally concave
- the malleus should be visible
What is this?
When to remove?
EAR WAX
Normal part of physiology
Reasons to remove wax:
- Impacted wax affecting hearing (conductive loss)
- audiometry
- Need to see the drum for some reason
- To make moulds for hearing aids.
Otherwise leave it alone
Treatment for ear wax (if we want to remove it)
Rx:
- Softeners (any - none is better than any other)
- Syringing - irrigation with motorised pump. Manual syringing has higher risk of perforation. Weak evidence that softening before helps - but in Liverpool the Treatment Rooms wont syringe unless used softener for the previous week.
- Microsuction – safe but more expensive and need more trained operator than for syringing (ENT)
- Foreign Body -> in this case, an ant.
- symptoms: pain, hearing loss / abnormal sounds, discharge (smelly if been there a long time)
Treatment:
- remove with forceps
- water irrigation
- microsuction
A. Otitis externa
B. Examine her
Otitis externa
c. Causative organisms: Pseudomonas aeruginosa or Staphylococcus aureus - but not all otitis externa is infective
d. Risk factors: Swimming, using cotton buds (which you should never put in your ears!)
e. Associated conditions: Psoriasis, eczema
f. Management:
1st line acetic acid spray as first line *acetic acid is an antiseptic, with activity against bacteria causing otitis externa
antibiotic / steroid drops -> more effective
2nd line acetic acid
*acetic acid ok if better by first week but if need longer rx then less effective
if no better after 1 week -> need steroid/antibiotic drop
Ciprofloxacin drops (sometimes eye drops but can use in the ear)
a. Examine him.
General examination of febrile child – temp / general condition / ears / throat / chest / rashes / urine if necessary
b. Bulging red ear drum. No landmarks obvious. No light reflex.
c. Acute Otitis Media (AOM)
d. Viral or bacterial. If bacteria isolated they include S. pneumoniae (25%), H. influenzae (25%) and Moraxella catarrhalis (15%).
e. Analgesia (paracetamol + / - ibuprofen). Usually self-limiting
*antibiotics to be prescribed in some instances
Treatment of Acute Otitis Media
- what’s the prognosis?
- Analgesic ear drops: benzocaine with phenazone (= analgesic, may potentiate anaesthetic)
*Not available in UK yet but is OTC in NZ and Australia
Prognosis: 60% are better after 24 hours and 80% are better after 3 days (without antibiotics)
Are antibiotics recommended for Acute Otitis Media?
Antibiotics may shorten the duration of illness by a few hours on average – but increased side effects plus creates antibiotic resistance. Not routinely recommended
SE: diarrhoea, vomiting, rash, and increase in subsequent episodes of AOM
- consider abiotics for children < 2 with bilateral OM, or children with ear discharge
b. Retracted drum (see next slide for why it is retracted with loss of light reflex.
c. Glue Ear (Otitis Media with Effusion - OME).
What’s the cause of retracted eardrum in children? How common is it?
- Fluid in middle ear and eustachian tube -> Chronic inflammation but no acute inflammation (recurrent ottitis media)
- Commonest cause of Hearing Loss (HL) in children
Common – 20% of 2 y olds. Drops with age (because eustachian tube changes size and shape - less prone to blockage. Also get fewer URTIs).
Pathophysiology of retracted eardrum in kids
Eustachian tube connects middle ear to back of nose - equalising pressure between them (normal air pressure in nose)
- Tube obstructed -> air in middle ear absorbed ->n egative pressure
- Increased production of fluid from mucosal lining of ear (?because mucosa deprived of oxygen?)
- Middle ear now filled with fluid -> reduces transmission of sound (conductive hearing loss).
Risk factors for chronic otitis media (and retracted tympanic membrane as a result)
Risk factors:
- children 1-6 y -> especially during wWinter following AOM
- Down’s syndrome
- Cleft palate
- Allergic rhinitis
- impaired ciliary motility (CF)
- boys
- daycare
- frequent URTI
- parents who smoke
- lower SE status
Symptoms of chronic otitis media leading to retracted tympanic membrane
Hearing loss (may manifest as poor behaviour, school problems, withdrawal, poor concentration, speech delay).
What is seen on examination of the child with perforated eardrum/retracted eardrum
o/e
- opaque drum
- loss of light reflex
- retracted drum
- bubbles or fluid seen behind drum
Pneumatic tympanogram shows immobile drum or negative middle ear pressure.
- Perforated ear drum (anterior)
- Causes: infection (otitis media), trauma (poking with a cotton bud or something more foolish), boxing the ear, barotrauma (sudden loud noise or explosion – bomb blast), cholesteatoma
Cholesteatoma - collection of ‘dead’ cells which can accumulate and destroy surrounding bone (or overgrowth of skin cells)
- Presents with hearing loss and foul-smelling discharge
- Needs urgent referral - treatment is surgical debridement.
*Note eardrum retracted. Lesion typically in attic region.
What is this?
Tympanosclerosis
‘Chalky white’ deposits on tympanic membrane. Notice the eardrum is retracted: Malleus clearly visible, margins clearly visible, looks sunken
What is the consequence of tympanosclerosis?
- These are white patches
- common in the elderly and usually safe
- represent deposition of calcium into the drum itself in response to trauma or infection
Not normally of any consequence unless severe, which can lead to a mild conductive hearing loss
Mastoiditis
Causes: spread of infection from the middle ear to the mastoid air cells.
Management: urgent treatment with antibiotics +/- mastoidectomy to prevent recurrence and further spread e.g. meningitis, epidural abscess and dural venous thrombophlebitis
Audiogram - general principles
- what does the 20 dB line mean?
- what can be seen in sensorineural hearing loss?
- what can be seen in mixed hearing loss?
Audiograms
- anything above the 20dB line is essentially normal (marked in red)
- in sensorineural hearing loss -> both air and bone conduction are impaired
- in conductive hearing loss -> only air conduction is impaired
- in mixed hearing loss -> both air and bone conduction are impaired (air conduction often being ‘worse’ than bone)
What does this audiogram show?
Normal hearing -> frequencies are heard above 20dB
What does this audiogram show?
Right side conductive hearing loss (only air conduction impaired, R side)
What does this audiogram show?
Right sensorineural hearing loss (air and bone conduction impaired, R side)
What does this audiogram show?
Bilateral sensorineural hearing loss (air AND bone conduction impaired bilaterally)
What does this audiogram show?
Left side mixed hearing loss (air and bone conduction impaired L side, with air conduction ‘worse’ than bone)
What is otosclerosis?
Otosclerosis
- replacement of normal bone by vascular spongy bone
- stapes is fixed on oval window
- inherited (autosomal dominant) progressive conductive hearing loss
- Usually bilateral
- onset 20-40 yrs oldN
- normal ear drum on examination
Treatment surgical (stapedectomy), hearing aids.
What’s Presbyacusis?
Presbyacusis
Multifactorial sensorineural loss in the elderly, frequently associated with central auditory processing disorder
Causes
- The precise cause is unknown however is likely multifactorial
- Arteriosclerosis: May cause diminished perfusion and oxygenation of the cochlea, resulting in damage to inner ear structures
- Diabetes: Acceleration of arteriosclerosis
- Accumulated exposure to noise
- Drug exposure (Salicylates, chemotherapy agents etc.)
- Stress
- Genetic: Certain individuals may be programmed for the early ageing of the auditory system
What’s acoustic neuroma?
- Benign tumour growing on vestibulocochlear nerve
- Arises from schwann cells of nerve fibre (aka schwannoma)
Risk factors for acoustic neuromas
Risk factors:
- neurofibromatosis
- high dose radiation (previously used to reduce size of tonsils and adenoid)
Investigations and Rx in acoustic neuroma
Ix – MRI
Rx.
- watch (annual MRI to monitor growth)
- Surgery (microsurgery)
- Stereotactic radiosurgery (may preserve hearing better but can cause radiation induced brain necrosis, cranial n injury, malignant change).
Pre-auricular sinus
What is this? Management
- developmental defect of 1st and 2nd pharyngeal arches
- presents as nodules or dimple (anywhere on the external ear)
- complication: may become infected
Management:
- drainage of the pus
- treatment of the infection
- if recurrent infection - surgery (but will often reoccur)
- surgery purely for cosmetic reasons - elective surgery
Accessory auricle
- what is this
- management
- present as an extra skin/nodule-like structure - usually an extension of an external auricle
- result of an abnormal congenital development
- the structure is cartilaginous - just like a normal ear
- Diagnosis: by histological examination - normal external auricle (differentials: squamous papilloma, teratoma - but structurally different)
- Management: excision is curative
