Hearing loss Diseases

Question 1

What is Otitis Media with Effusion (OME)?

Answer 1

Inflammation of the middle ear with fluid accumulation but without signs of acute infection

Question 2

What age group is most commonly affected by OME?

Answer 2

Children aged 2-8 years

Question 3

What is the main cause of OME?

Answer 3

Eustachian tube dysfunction or obstruction

Question 4

Name three common bacterial causes of OME

Answer 4

1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Moraxella catarrhalis

Question 5

What are key risk factors for OME?

Answer 5

(1) Daycare attendance
(2) Older siblings
(3) Smoking household
(4) Recurrent URTIs
(5) Craniofacial abnormalities
(6) Prematurity
(7) Immunodeficiency

Question 6

What is the most common symptom of OME?

Answer 6

Hearing loss

= can lead to speech delay and balance issues

Question 7

Does OME cause ear pain?

Answer 7

No, OME is usually painless

Question 8

What key signs are seen on otoscopy in OME?

Answer 8

(1) Middle ear effusion (fluid/bubbles)
(2) TM retraction
(3) Altered TM colour
(4) Impaired TM mobility

Question 9

What is TM retraction?

Answer 9

Inward pulling of the tympanic membrane due to negative middle ear pressure, often caused by Eustachian tube dysfunction

Question 10

Altered TM colour meaning

Answer 10

The tympanic membrane appears red, yellow, or blue instead of normal pearly grey, indicating infection or fluid

Question 11

What is Impaired TM mobility?

Answer 11

Reduced movement of the tympanic membrane, often due to fluid in the middle ear (glue ear) or Eustachian tube dysfunction

Question 12

What tuning fork test finding suggests OME?

Answer 12

Conductive hearing loss

Question 13

What audiological tests are used for OME?

Answer 13

1. Audiometry (shows conductive hearing loss)
2. Tympanometry (shows a flat tracing)

Question 14

What is the initial management for OME?

Answer 14

Watchful waiting for 3 months

Question 15

When should a child with OME be referred for surgery?

Answer 15

If OME persists for >3 months
(1) With bilateral conductive hearing loss >25dB

(2) or if speech, language, developmental, or behavioural problems occur

Question 16

What is the first-line surgical treatment for OME?

Answer 16

Grommet insertion
<3 years = grommets
>3 years = grommets ± adenoidectomy

Question 17

Name three complications of grommet insertion

Answer 17

1. Infection/discharge
2. Early extrusion
3. Persistent perforation

Question 18

What is the most common aetiology of a perforated tympanic membrane?

Answer 18

Acute otitis media, particularly in the younger population

Question 19

What other causes can lead to a perforated tympanic membrane?

Answer 19

Trauma, such as sudden negative pressure or the insertion of objects into the ear

Question 19

What are the typical clinical features of a perforated tympanic membrane?

Answer 19

(1) Sudden severe pain

Sometimes followed by
1. bleeding from the ear
2. hearing loss
3. tinnitus

Question 20

What is the most important investigation for diagnosing a perforated tympanic membrane?

Answer 20

Otoscopy
= which reveals a visible perforation of the tympanic membrane

Question 21

What does audiometry show in cases of a perforated tympanic membrane?

Answer 21

conductive hearing loss

Question 22

When does otosclerosis typically present?

Answer 22

2nd to 3rd decade of life

Question 23

How is a perforated tympanic membrane typically managed?

Answer 23

(1) Usually heals spontaneously

(2) Surgical repair is only indicated if the patient is symptomatic with recurrent discharge

Question 24

Which gender is more commonly affected by otosclerosis?

Answer 24

Women = Linked to high oestrogen levels. The condition can be triggered or worsen during pregnancy

Question 25

What is the main clinical presentation of otosclerosis?

Answer 25

(1) Gradual onset conductive hearing loss often starts unilaterally and then affects both ears (2) Tinnitus, often associated with the hearing loss (3) Vertigo, although this is less common

Question 26

What investigation is used to diagnose otosclerosis?

Answer 26

(1) Audiometry is used to diagnose otosclerosis, revealing conductive or mixed hearing loss (2) A classic feature is Carhart's notch at 2 kHz

Question 27

How is otosclerosis managed?

Answer 27

1. Hearing aids 2. Stapedectomy (surgical removal of the stapes bone)

Question 28

What is the most common cause of progressive deafness in young adults?

Answer 28

Otosclerosis

Question 29

A 37-year-old female presents with hearing loss in both ears that has been progressively getting worse over the last year. She denies any previous ear problems, vertigo, or tinnitus. She remembers that her father also has issues with his hearing. The otoscopy examination is normal. Rinne and Weber's tests are consistent with bilateral conductive hearing loss. A pure-tone audiogram confirms the bilateral conductive hearing loss with air-bone gaps What is the definitive management option for this patient?

Answer 29

Stapedectomy = Progressive hearing loss

Question 30

What is a vestibular schwannoma?

Answer 30

A benign tumour of the CN VIII nerve sheath that arises in the internal auditory meatus

Question 31

Which part of CN VIII is affected in vestibular schwannoma?

Answer 31

The vestibular portion of CN VIII

Question 32

Where do most vestibular schwannomas occur?

Answer 32

Within the temporal bone

Question 33

Are vestibular schwannomas usually unilateral or bilateral?

Answer 33

(1) 95% are sporadic and unilateral (2) Bilateral cases are associated with neurofibromatosis type 2

Question 34

What are the histological features of vestibular schwannoma?

Answer 34

(1) Encapsulated tumour (2) Two growth patterns = Antoni A and Antoni B

Question 35

What is the most common clinical presentation of vestibular schwannoma?

Answer 35

1. Progressive unilateral sensorineural hearing loss 2. Tinnitus 3. Imbalance (in larger tumours) 4. Facial numbness = if trigeminal CN V is compressed

Question 36

What is the best imaging modality for diagnosis?

Answer 36

MRI

Question 37

What is the gold standard investigation for vestibular schwannomas?

Answer 37

MRI head; the size = diameter of the cerebellopontine angle portion can then be measured to help guide management

Question 37

How is vestibular schwannoma managed?

Answer 37

1. Surgical excision = definitive treatment 2. Monitoring with MRI for small, non-growing lesions = initially at 6-month intervals

Question 37

What is the treatment of otosclerosis?

Answer 37

(1) Hearing amplification through hearing aids or surgical replacement of the stapes bone through a stapedectomy

Question 38

What are the features of Type 2 Neurofibromatosis?

Answer 38

This results in bilateral vestibular schwannomas (acoustic neuromas) resulting in a triad of 1. sensorineural hearing loss 2. tinnitus 3. vertigo 4. Cafe-au-lait spots may also be present

Question 39

A 28-year-old male presents to the GP with a two-month history of gradually worsening right-sided hearing loss. He has no loss of balance, no tinnitus, and no previous episodes of hearing loss. He is otherwise fit and well and takes no medications. The GP tests his hearing using a tuning fork: Rinne's Test: Air >Bone bilaterally Weber's Test: Localizes to left ear The GP proceeds to perform an otoscopy and notes it is difficult to visualise the tympanic membrane due to the wax Given the examination findings, what is the likely diagnosis?

Answer 39

Vestibular Schwannoma

Question 40

Why is it important to differentiate between conductive and sensorineural hearing loss in a patient with sudden onset hearing loss?

Answer 40

Because sudden-onset sensorineural hearing loss (SSNHL) is a potential emergency that requires urgent ENT referral, while conductive hearing loss is usually less urgent

Question 41

What investigation is typically performed in cases of SSNHL to rule out serious underlying pathology?

Answer 41

An MRI scan is performed to exclude a vestibular schwannoma (acoustic neuroma)

Question 42

What is the first-line medical treatment for SSNHL?

Answer 42

High-dose oral corticosteroids, prescribed and managed by ENT

Question 43

A 5-year-old with Down's syndrome is brought into your clinic for a health check. Although well in himself, for the past couple of weeks his parents have noticed difficulty hearing. Otoscopy reveals indrawn tympanic membranes with fluid levels and loss of light reflexes bilaterally. There is no evidence of inflammation and the examinations of the throat and nose are unremarkable. What is the most appropriate next step for the above patient?

Answer 43

Down syndrome = learning disability Also do this for a cleft palate too Therefore refer to ENT

Question 44

You are working in the emergency department. The first patient you see is a 50-year-old man complaining of hearing loss in the right ear that started 1 hour ago. Other than the hearing loss the patient feels well. He complains of no other symptoms and can continue his job of being a professional boxer. After taking a focused history, you perform Rinne's and Weber's tests. The results from the tests are shown below: (1) Rinne's test (right ear): positive. (2) Rinne's test (left ear): positive. (3) Weber's test = sound lateralises to the left ear. What is the most common cause of this patient's hearing loss?

Answer 44

The majority of sudden-onset sensorineural hearing loss is idiopathic

Question 45

Unilateral glue ear in an adult needs evaluation for what?

Answer 45

posterior nasal space tumour

Question 46

A 76-year-old male smoker attends his GP with persistent left-sided hearing loss. He is otherwise systemically well with no aural discharge or otalgia. His past medical history is significant only for hypertension for which he takes ramipril, and type 2 diabetes, which is diet-controlled. On examination, he has a left middle ear effusion only What does he have?

Answer 46

Unilateral glue ear = ENT referral under 2 weeks

Question 47

Adenoidectomy is performed on a 5-year-old girl for symptomatic adenoid hypertrophy (persistent otitis media with effusion, sleep apnoea, hyponasal voice). Shortly following the operation, the patient begins to bleed profusely from the nose and has a rising pulse rate What is the most appropriate management option?

Answer 47

Return to theatre