Otology

Question 1

Describe Rinne’s test results that suggest both conductive and sensorineural hearing loss

Answer 1

• Normal ear: air > bone (test ‘positive’)
• Conductive hearing loss: bone > air (test ‘negative’)
• Sensorineural hearing loss: air > bone (test ‘positive’)

Question 2

Describe Weber’s test results that suggest both conductive and sensorineural hearing loss in the right ear

Answer 2

• Normal hearing both ears: left=right (test ‘central’)
• Sensorineural hearing loss right ear: left>right (test ‘lateralises to left’)
• Conductive hearing loss right ear: right>left (test ‘lateralises to right’)

Question 3

Describe pure tone audiogram

Answer 3

Pure tone audiogram - graph that shows the audible threshold for standardized frequencies as measured by an audiometer. The Y axis represents intensity measured in decibels and the X axis represents frequency measured in hertz. Can compare right and left ears, or compare air conductance and bone conductance

Question 4

Describe tympanometry/tympanograms

Answer 4

Tympanometry is an examination used to test the condition of the middle ear and mobility of the eardrum and the conduction bones by creating variations of air pressure in the ear canal.

Question 5

Give 4 examples of disorders of the outer ear

Answer 5

Otitis externa
Malignant otitis externa
Auricular haematoma
Foreign body

Question 6

What are some complications associated with auricular haematomas?

Answer 6

Auricular haematoma is a complication that results from direct trauma to the anterior auricle. Can lead to damage of the pinnas, abscesses and cauliflower ear

Question 7

Give 5 examples of disorders of the middle ear

Answer 7

Otitis media with effusion (gum ear)
Acute otitis media
Chronic suppurative otitis media
Tympanosclerosis
Osteosclerosis

Question 8

Give some examples of disorders affecting the inner eat

Answer 8

Presbyacusis
Noise induced hearing loss 
Ototoxic medications 
Ménière’s disease 
Head injury 
Infections
Vestibular schwannoma (acoustic neuroma)

Question 9

What is osterosclerosis?

Answer 9

Otosclerosis – formation of an extra bone that forms around the stapes, causing conductive hearing loss with a normal tympanic membrane

Question 10

What is tympanosclerosis?

Answer 10

Tympanosclerosis - a condition caused by hyalinization and subsequent calcification of subepithelial connective tissue of TM and middle ear, sometimes resulting in a detrimental effect to hearing

Question 11

List some ototoxic medications known to cause plermentant damage to the inner ear

Answer 11

Aminoglycoside antibiotics, e.g. gentamicin (family history may increase susceptibility)

Cancer chemotherapy drugs e.g. cisplatin and carboplatin.

Question 12

What is Ménière’s disease?

Answer 12

Ménière’s disease - a disorder of the inner ear that causes episodes in which you feel as if you’re spinning (vertigo), and you have fluctuating hearing loss with a progressive, ultimately permanent loss of hearing, ringing in the ear (tinnitus), and sometimes a feeling of fullness or pressure in your ear. Typically only one ear is affected, though both can be. Symptoms are believed to occur as the result of increased fluid build up in the labyrinth of the inner ear, resulting in the increased pressure in the endolymph compartment, leading to low frequency sensorineural hearing loss.

Question 13

What type of hearing loss is associated with Menieres disease?

Answer 13

Low frequency sensorineural hearing loss

Question 14

What type of hearing loss is associated with • Presbyacusis?

Answer 14

bilateral sensorineural hearing loss, most marked at higher frequencies

Question 15

When should vestibular schwannoma (acoustic neuroma) be suspected during a clinical history?

Answer 15

If anyone presents with sensorineural hearing loss in one ear, they should be sent for an MRI to check for this as it can grow to cause serious complications such as facial palsy.

Question 16

What is a serious complication associated with vestibular schwannoma?

Answer 16

Facial palsy

Question 17

Define tinnitus

Answer 17

Definition - any perception of sound that doesnt originate from outside the ear

Question 18

When would patients for tinnitus be referred?

Answer 18

Unilateral (vestibular schwannoma) or pulsatile (vascular problem in skull base)

Question 19

How is tinnitus treated?

Answer 19

o Sound enrichment e.g. sleep with music

o Stress management

Question 20

What are the differential diagnoses/4 main causes of vertigo?

Answer 20

o Benign positional vertigo
o Ménières disease
o Vestibular neuritis/labyrinthitis
o Migraine

Question 21

How can you distinguish between the possible causes of vertigo?

Answer 21

o Duration
o Frequency
o Associated symptoms
o Precipitating factors

Question 22

Describe the pathology behind benign positional vertigo

Answer 22

Pathology - otoconia in semicircular canals. Otoconia is a condition caused by small crystals of calcium carbonate in the saccule and utricle of the ear that under the influence of acceleration in a straight line cause stimulation of the hair cells by their movement, resulting in vertigo

Question 23

What are the clinical features of benign positional vertigo?

Answer 23

o	Vertigo precipitated by specific changes in head position
o	Duration: seconds
o	Frequency: several times per day
o	No associated symptoms
o	Positive Dix-Hallpike test

Question 24

How is benign positional vertigo treated?

Answer 24

Epley manoeuvre

Question 25

What is the Dix-Hallpike test and what does it test for?

Answer 25

The Dix–Hallpike test is a diagnostic maneuver used to identify benign paroxysmal positional vertigo (BPPV).

When performing the Dix–Hallpike test, patients are lowered quickly to a supine position with the neck extended by the clinician performing the maneuver. A positive test is indicated by patient report of a reproduction of vertigo and clinician observation of nystagmus (involuntary eye movements, “dancing eyes”).

If the test is negative, it makes benign positional vertigo a less likely diagnosis and central nervous system involvement should be considered

Question 26

What condition would cause a positive Dix-Hallpike?

Answer 26

Benign positional vertigo

Question 27

Describe the pathology of Vestibular neuritis / labyrinthitis?

Answer 27

Pathology: reactivation of latent HSV infection of vestibular ganglion, causing inflammation of the inner ear resulting in dizziness and vertigo

Question 28

Describe Vestibular neuritis / labyrinthitis

Answer 28

o Spontaneous vertigo
o No associated symptoms (vestibular neuritis)
o Associated unilateral hearing loss (labyrinthitis)
o Duration: days
o Frequency: few episodes (<10) with decreasing severity
o Residual motion-provoked vertigo following recovery after a few days

Question 29

How is Vestibular neuritis / labyrinthitis treated?

Answer 29

o Acute: vestibular sedatives

o Chronic: vestibular rehabilitation

Question 30

Describe the clinical features of Menieres disease

Answer 30

o Spontaneous vertigo
o + unilateral hearing loss / tinnitus / aural fullness
o Duration: hours
o Frequency: every few days / weeks / months
o + fluctuating, progressive unilateral hearing loss

Question 31

Describe the treatment of Menieres disease

Answer 31

o Betahistine
o Bendrofluazide
o Intratympanic dexamethasone
o Intratympanic gentamicin (ototoxic, kills nerve cells)

Question 32

Describe the clinical features of migraines

Answer 32

o	Spontaneous vertigo
o	Duration: variable
o	Frequency: variable
o	± headache, sensory sensitivity, auras
o	± precipitated by migraine triggers
o	± past history of migraine

Question 33

How are migraines treated?

Answer 33

o Avoid migraine triggers

o Prophylactic medication

Question 34

What can cause facial palsy?

Answer 34

o Infection – reactivation of latent herpes zoster virus
o Trauma – particularly fractures in the temporal bone
o Tumours – compress facial nerve causing paralysis
o Stroke
o Bell’s palsy (idiopathic, diagnosed by exclusion of other causes)
o Bilateral paralysis – sarcoidosis, Guillain–Barré syndrome, Moebius syndrome (underdevelopment of CN VII, present at birth)

Question 35

What two components should be considered if someone presents with facial nerve palsy in terms of trying to identify cause?

Answer 35

Facial nerve components: intratemporal, extratemporal (CN VII runs through temptoral bone)

Intratemporal pathology: cholesteatoma (benign squamous tumour of ear)

Extratemporal pathology: parotid gland tumour (CN VII runs through parotid gland so any tumour can impact on it)

Question 36

What is Bell’s palsy?

Answer 36

Bell’s palsy - acute, idiopathic facial palsy. Most common cause of one-sided facial nerve paralysis (70%).

Bell’s palsy is a type of facial paralysis that results in an inability to control the facial muscles on the affected side. Symptoms can vary from mild to severe.

Question 37

How is Bell’s palsy diagnosed?

Answer 37

Typically, symptoms come on over 48h hours, and the cause is unknown though pathology is linked to dysfunction of the cranial nerve (CN VII).

Diagnosed by exclusion of other potential causes e.g. brain tumor, stroke, Ramsay Hunt syndrome, and Lyme disease.

Question 38

Describe some symptoms that could be seen with Bell’s palsy

Answer 38

Bell’s palsy is a type of facial paralysis that results in an inability to control the facial muscles on the affected side. Symptoms can vary from mild to severe.

They may include muscle twitching, weakness, or total loss of the ability to move one or rarely both sides of the face. Other symptoms include drooping of the eyelid, a change in taste, pain around the ear, and increased sensitivity to sound.

Question 39

How is Bells palsy treated?

Answer 39

The condition normally gets better by itself with most achieving normal or near-normal function. Corticosteroids have been found to improve outcomes, while antiviral medications may be of a small additional benefit. The eye should be protected from drying up with the use of eye drops or an eyepatch. Surgery is generally not recommended.