Hyperacusis/Vertigo/ear trauma Flashcards
Hyperacusis
general
Excessive sensitivity to sounds
May occur in
Normal hearing patients
Associated with ear disease
Following noise trauma
Migraines
Underlying psychological disease
“Recruitment”
Abnormal sensitivity to loud sounds despite reduced sensitivity to soft ones
hyperacusis
Tx
Normal hearing patients
Earplugs in noisy environments
Habituation
Patients with hearing devices
Compression circuitry to avoid overamplification
Vertigo
general
Cardinal symptom of vestibular disease
Differentiate peripheral from central etiologies of vestibular dysfunction
Ear vs nerve/brain
Typically experienced as a distinct “spinning” sensation or a sense of tumbling or of falling forward or backward
Sensation of motion when there is no motion
Exaggerated sense of motion in response to movement
Distinguish from imbalance, light-headedness, and syncope
Nonvestibular in origin
Duration of vertigo episodes and association with hearing loss are the key to diagnosis
Vertigo
Peripheral
Onset is sudden
Often associated with tinnitus and hearing loss
Horizontal nystagmus may be present
Vertigo may be more intense
Vertigo
Central
Onset is gradual
No associated auditory symptoms
Vertigo less intense
Vertigo
Diagnostics
Audiogram
Electronystagmography (ENG) or videonystagmography (VNG)
MRI head
Meniere Sydrome
general
(Endolymphatic Hydrops)
Classic syndrome: Episodic vertigo with discrete spells lasting 10 minutes to several hours
Etiology
Excess endolymph results in increased pressure within the semicircular canals
Precise cause of hydrops cannot be established in most cases
Two known causes are syphilis and head trauma
Meniere Disease
Symptoms
Symptoms wax and wane as the endolymphatic pressure rises and falls
Typically accompanied by
Unilateral aural fullness (feeling of pressure in the ear)
Tinnitus (low-tone or blowing sound)
Fluctuating low-frequency sensorineural hearing loss
Vertigo
Meniere Disease
PE
Physical Exam
Often normal
Sometimes pneumo-otoscopy will cause nystagmus
Meniere Disease
Dx
Diagnostic Studies
Audiometry at the time of an attack shows a characteristic asymmetric low-frequency hearing loss
Hearing commonly improves between attacks
Permanent hearing loss may eventually occur.
Meniere Disease
Tx
Patients suspected of having Meniere disease should be referred to an otolaryngologist for further evaluation
Initial treatment
Diuretics
Acetazolamide
Sodium restriction
For symptomatic relief of acute vertigo attacks
Meclizine (25 mg)
Diazepam (2–5 mg)
Meniere Disease
Refractory disease Tx
Injections of glucocorticoids or gentamicin into the middle ear may be considered
Non-ablative surgical options
Decompression
Shunting of the endolymphatic sac
Full ablative procedures
Vestibular nerve section
Labyrinthectomy
Labrynthitis
general
Acute onset of continuous, usually severe vertigo lasting several days to a week, accompanied by hearing loss and tinnitus
Etiology
The cause is often unknown
Can be linked at times to infection
Mainly in young to middle-aged adults
Sometimes gives a history of an antecedent upper respiratory infection
Labrinthitis
S/Sx
Nausea, vomiting
The need to remain immobile
During a recovery period that lasts for several weeks, the vertigo gradually improves.
Hearing may return to normal or remain permanently impaired in the involved ear.
If no hearing issues occur, it is simply known as vestibular neuritis
Labrinthitis
PE
Exam
Nystagmus (quick component) and a sense of body motion are to the opposite side, whereas falling and past pointing are to the side of the affected labyrinth.
Examination discloses vestibular paresis on one side, i.e., an absent or diminished response to motion of the horizontal semicircular canal. If the patient will tolerate small head movements, perform rapid–head-impulse test- see next slide
Labrinthitis
Dx
Diagnostic Studies
MRI Head w/contrast
Enhancement of the 8th nerve or the membranous labyrinth
Labyrinthitis
Tx
Antibiotics if the patient is febrile or has symptoms of a bacterial infection
Vestibular suppressants are useful during the acute phase of the attack but should be discontinued as soon as feasible
Diazepam (Valium)
Meclizine (Antivert)
During the acute stage may be helpful in reducing the symptoms:
Antihistamine drugs
Promethazine
Scopolamine
Benign Paroxysmal Positional Vertigo
general
Recurrent spells of vertigo, lasting a few minutes, associated with changes in head position
Example: Rolling over in bed
Etiology
More common in people over the age of 60 years
Usually caused by migration of inner ear otoliths (calcific particles) to the posterior semicircular canal.
The otoliths amplify any movement in the plane of the canal, resulting in brief episodes of vertigo following changes in head position.
BPPV
S/Sx
Symptoms typically occur in clusters that persist for several days
Intermittent dizziness
10-15 second latency period after head movement
Dizziness lasts usually up to 60 seconds
“The entire room spins”
Imbalance may last for several hours
Nausea
No associated
Headaches
Hearing loss
Focal neurologic symptoms
BPPV
PE and Dx
Exam
Nystagmus
Diagnostic Studies
Some CNS disorders can mimic BPPV (eg, vertebrobasilar insufficiency)
Recurrent cases warrant head MRI
BPPV
Tx
Treatment
PT
The Epley maneuver
For more refractory cases of BPPV, patients can be taught a variant of this maneuver that they can perform alone at home.
Often resolves spontaneously
No treatment is needed
Otosclerosis
general
Progressive disease affecting the bony otic capsule
Lesion involving stapes leads to decreased passage of sound through the ossicular chain
Conductive hearing loss
otosclerosis
Tx
Treatment
Hearing aids
Stapedectomy
Replacement of stapes with prosthesis
If involves the cochlea, permanent hearing loss
Middle ear trauma
TM perferation etiology
etiology:
Barotrauma
Acoustic trauma
Head trauma
Otitis media
Eustachian tube dysfunction
Foreign objects
TM perferation
S/Sx
Otorrhea
Clear
Bloody
Purulent
+/- ear pain with sudden relief
Conducive hearing loss
Tinnitus
Vertigo
Nausea/vomiting
TM perf
PE
Conductive hearing loss
Weber test
Rinne test
TM perf
pneumatic otoscopy
Pneumatic otoscopy should be deferred to ENT
May push air into the otic capsule if underlying injury
Lead to nystagmus, vertigo, nausea/vomiting
TM perf
Dx
Based on otoscopic examination
May note:
Conductive hearing loss
Decreased perception of whisper on affected side
Weber test
Rinne test
This is a right ear
TM perf
Tx
Usually heals spontaneously within 4 weeks
< 25% total drum surface
Water precautions
Cotton ball with petroleum jelly in ear while showering
Antibiotic ear drops for contamination
When the tympanic membrane is perforated, use of potentially ototoxic ear drops (eg,neomycin,gentamicin) is best avoided
Ofloxacin 5 drops in the affected ear BID x 3-5 days
Follow up exam with audiometry in 4 weeks
ENT referral for persistent perforation or hearing loss > 4 weeks
Tympanoplasty is highly effective (>90%) in the repair of tympanic membrane perforations.
TM Perf/otitis media
Referral
4Refer to ENT
Recurrent otitis media
> 2 episodes in 6 months
Persistent hearing loss
> 1-2 weeks post infection
Chronic tympanic membrane perforation
> 4 weeks
TM Perf
Complications
Persistent perforation
Cholesteatoma
Hearing loss
Recurring infections
Impact Injury/Explosive Acoustic Trauma
general
Conductive hearing loss >30 dB for more than 3 months after trauma, suspect ossicular chain disruption
Middle ear exploration with reconstruction of the ossicular chain, +/- TM repair
Restores hearing
