Inner Ear Disease Flashcards
What needs to be excluded for LMN CNV11 palsy?
-Herpes Zoster (Ramsay-Hunt Syndrome- vesicles in conchal bowl, vesicular rash around ear, facial nerve palsy, auricular pain, lower recovery, can affect more than one cranial nerve, oral Aciclovir and corticosteroids)
-Middle ear pathology (cholesteatoma= otoscopy)
-Parotid tumour (masses)
-Trauma
-CPA tumours
Treatment and assessment of Bell’s palsy
-Idiopathic!! acute unilateral LMN CNV11 palsy
=Peak incidence 20-40, pregnant women
=Forehead involved, dry eyes, altered taste, post-auricular pain, hyperacusis
-Extent assessment= House-Brackmann grade
-Prednisolone 50mg od 10/7 if <3/7 onset +/- antivirals (within 72 hours). Combination
-Eye protection (lacrilube, patch/ tape)
-Follow-up
if the paralysis shows no sign of improvement after 3 weeks, refer urgently to ENT
a referral to plastic surgery may be appropriate for patients with more long-standing weakness e.g. several months
Prognosis
most people with Bell’s palsy make a full recovery within 3-4 months
if untreated around 15% of patients have permanent moderate to severe weakness
Causes of sensori-neural hearing loss
-Presbyacuasis/ age related hearing loss
=slow gradual hearing loss usually bilateral
=normal otoscope, audiometry high frequency
– Iatrogenic (Surgery/Drugs)
– Congenital
- Infective
– Autoimmune
-Acoustic neuroma
– Idiopathic
Treatment of sensori-neural hearing loss
-Hearing tactics
-Conventional hearing aids
-Implantable hearing aids
-Cochlear implant
Causes of conductive hearing loss
-EAM (external auditory meatus)
=Wax (rare unless occlusive) impaction
=Atresia of ear canal (rare)
-Middle ear disease
=OME
=Ossicular discontinuity (COM)
=Ossicular fixation (otosclerosis/ COM)
-Otitis external
-Foreign body
-Tympanic membrane perforation
-Cholesteatoma
General categories of vertigo
-Central (brain issue)
-Peripheral (vestibular)
Overview of BPPV (benign paroxysmal positional vertigo)
The average age of onset is 55 years and it is less common in younger patients
-Transient (seconds) vertigo with movement (sudden onset), may be associated with nausea
-Following other inner ear disease/ head trauma
-Self-limiting
-Hall pike test= rotatory nystagmus and vertigo
-Epley manoeuvre treatment and vestibular rehabilitation (Brandt-Daroff)
Overview of Vestibular Neuronitis/ Labyrinthitis
-Vertigo pattern (long-term)
=Prostrating 3/7 (recurrent vertigo attacks lasting hours or days)
=Housebound 3/52
=Not right 3/12
-Nausea and vomiting
-Horizontal nystagmus
-NO HEARING LOSS OR TINNITUS
-Vestibular sedatives (prochlorperazine/ cinnarizine- buccal or intramuscular) for 3/7, physiotherapy (vestibular rehabilitation exercises)
-Differential diagnosis
viral labyrinthitis
posterior circulation stroke: the HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke
Overview of viral labyrinthitis
-Inflammatory disorder of membranous labyrinth; affects vestibular and cochlear end organs
-Labyrinthitis should be distinguished from vestibular neuritis as there are important differences: vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment; Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.
-40-70 y/o
-Acute onset: vertigo not triggered but exacerbated by movement), N&V, HL (uni/bilateral, varying severity), tinnitus, preceding or concurrent URTI
-Spontaneous unidirectional horizontal nystagmus towards unaffected side, SNHL, abnormal head impulse test (impaired vestibulo-ocular reflex), gait disturbance (fall towards affected side)
-Self-limiting, prochloperazine or antihistamines
Overview of Meniere’s Disease
-Episodic vertigo mins-hrs
-Fluctuating sensorineural hearing loss
-Fluctuating tinnitus (ALL HAPPENS TOGETHER)
-Aural pressure
-Low frequency SNHL (stabilises over years)
-Nystagmus and positive Romberg test
-Unilateral, bilateral develop after number of years
-Treat with low salt/ caffeine, betahistine, intratympanic injection
-Acute attacks: buccal or intramuscular prochlorperazine, betahistine prevention, vestibular rehabilitation exercises, DVLA
-Resolve 5-10 years, hearing loss, psychological distress
Overview of Vestibular Migraine
-Episodic vertigo mins-hrs
-No fluctuation in hearing/ tinnitus
-Other symptoms: headache, visual disturbance, numbness
-Personal/ FH of migraine
-Can be mistaken for Meniere’s disease
-Treat as per migraine
Describe tinnitus
-Sensation of sound in one or both ears
-Cause uncertain
-Most common with hearing loss (30% population)
-Drugs: aspirin/NSAIDs, aminoglycosides, loop diuretics, quinine
-Impacted ear wax
-If pulsatile vascular cause needs excluding
-If asymmetrical MRI scan for CPA tumour
-Treatment= reassurance, hearing aid/ therapy
Overview of Vestibular Schwannoma
-Unilateral sensori-neural HL, tinnitus, recurrent vertigo, absent corneal reflux
-Slow growing and benign
-MRI IAM cerebellopontine angle, audiogram
-1% of those with unilateral symptoms
-If growing and large= gamma-knife, surgery, radiotherapy, observation
-Bilateral vestibular schwannomas are seen in neurofibromatosis type 2.
What to examine if the ear is normal
-TMJ
-Throat
-Neck
-Nose
-Teeth
Describe Acoustic trauma
-Temporary threshold shift
=tinnitus, unilateral HL
=Resolves over hours-days
-Cumulative effect
=Permanent damage to hair cells
=4 kHz predominates
Control of noise at work regulations 2005
Sensorineural vs conductive hearing loss
-Rinne’s
=Conductive: bone>air
-Weber’s
=Conductive: sound louder on affected side
=Sensorineural: sound louder on unaffected side
What is sensorineural hearing loss?
Inner ear, cochlear or auditory nerve pathology impaired neuronal transmission to the brain
=Distorted sound +/- tinnitus
=No features of external ear pathology
=Volume of voice is loud, hearing worsens in noisy environment and high frequencies lost preferentially
What is conductive hearing loss?
External or middle ear pathology affects the conduction of sound into the inner ear
=Non-distorted sound
=Features of external ear pathology
=Volume of voice remains normal and hearing improves in noisy environment
Sudden onset sensorineural hearing loss
When a patient presents with sudden onset hearing loss it is important to examine them carefully to differentiate between conductive and sensorineural hearing loss → sudden-onset sensorineural hearing loss (SSNHL) requires urgent referral to ENT.
The majority of SSNHL cases are idiopathic.
An MRI scan is usually performed to exclude a vestibular schwannoma.
High-dose oral corticosteroids are used by ENT for all cases of SSNHL.
Suitability for cochlear implant
In children, audiological assessment and/or difficulty developing basic auditory skills.
In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months which they have been objectively demonstrated to receive limited or no benefit from.
Causes of severe-to-profound hearing loss in children
Genetic (accounts for up to 50% of cases).
Congenital e.g. following maternal cytomegalovirus, rubella or varicella infection.
idiopathic (accounts for up to 30% of childhood deafness).
Infectious e.g. post meningitis.
Causes of severe-to-profound hearing loss in adults
Viral-induced sudden hearing loss.
Ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics.
Otosclerosis
Meniere disease
Trauma
Contraindications to cochlear implant
Contraindications to consideration for cochlear implant:
Lesions of cranial nerve VIII or in the brain stem causing deafness
Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
Cochlear aplasia
Relative contraindications:
Chronic infective otitis media or mastoid cavity infections
Tympanic membrane perforation
Patients that may be seen to demonstrate a lack of interest in using the implant to develop enhanced oral communication skills.
Overview of presbycusis
-High frequency HL loss bilaterally
-Presbycusis progresses slowly, as sensory hair cells and neurons in the cochlea atrophy over time.
-Causes
=Arteriosclerosis (diminished perfusion and oxygenation of cochlea= damage)
=Diabetes
=Accumulated exposure to noise
-Drug exposure (salicylates, chemo)
=Stress
=Genetic
-Presentation
=Speech difficult to understand, loud telly, hard hearing on phone, loss of directionality of sound, worsening of symptoms in noisy environments, hyperacusis, sometimes tinnitus
-Otoscopy to rule out otosclerosis, cholesteatoma, conductive hearing loss
-Tympanometry
-Audiometry
-Blood tests (inflammatory, antibodies)
