Otology Flashcards
What the 6 common ear symptoms? [6]
- Hearing Loss
- Tinnitus
- Otalgia
- Otorrhoea
- Facial Weakness
- Vertigo
Clinical examination of the ears include: [4]
Physical:
- Otoscope
- Microscope
Hearing:
- Tuning fork (Rinne’s & Weber’s)
- Whispered Voice Tests
Rinnes test - explain what it demonstrates [1]
If BC>AC in Rinne’s test - clinical significance? [1]
Webers test - explain the clinical significance if the sound was lateralized ie the test was abnormal [2]
Explain why in conductive hearing loss, Webers test will show lateralization to same ear [2]
Rinnes:
- Tells us if Air conduction vs Bone Conduction - which one is better/louder
- IF B>A then theres conductive hearing loss in that ear
Webers:
- If its louder in one ear then its either conductive loss in that ear or sensorineural in the opposite
BC>AC in affected ear so the cochlea is more sensitized. [1] Both cochlea are working but it will be heard louder in the affected ear. [1]
What investigations can be done for hearing? [2]
- Pure Tone Audiogram
- Tympanogram
What are the result ‘types’ from a tympanogram? [3]
Type A - normal
Type B - Immobile Tympanic membrane
Type C - Low Middle Ear pressure
Common disorders of outer ear [4]
Auricular Haematoma
- ‘Cauliflower ear’
- Needs to be drained
Foreign Body
Otitis Externa
- Itching, pain, discharge & hearing loss
- Abx/steroid eardrops
Malignant Otitis Externa
- Osteomyelitis of the temporal bone
- Months of systemic Abx
List some common disorders of the middle ear? [5]
- Otitis Media with effusion (glue ear)
- Acute Otitis Media
- Chronic Suppurative Otitis Media
- Tympanosclerosis
- Otosclerosis
Otitis Externa Causes [5] Name 2 most common bugs Sequelae if untreated [2] Treatment [2] Appearance on examination of chronic otitis external [1]
Causes:
- Generalised skin conditions eg eczema, psoriasis
- Generalised skin infections eg impetigo
- Trauma eg dirty fingernail
- Local infection
- Middle ear discharge
Pseudomonas, staphylococcus - are common bugs if local infection was cause
Hearing loss and canal stenosis can occur
OE:
- Tenderness of auricle, trigs, behind ear if LN involvement
- EAM swollen, full of debris
- Skin cracked, crusting
- Fungal, hyphae and spores seen
Treatment:
- Aural toilet ie remove all debris with suction
- Local medication - abx or steroid drops, glycerine, aluminum acetate
Chronic otitis externa - skin of EAM thickened, fissured, moist
Glue ear or Otitis media with effusion Presentation [3] Otoscope appearance [3] Investigations [2] Course [1] Mx [3]
Presentation
- hearing loss eg poor listening, speech, lang delay, inattention, poor behaviour
- repeat ear infections/URTI
- balance problems
Otoscope:
- +/- retracted/bulging drum, looking dull grey or yellow, fluid level
Audiogram
- conductive defects
- Flat tympanogram on impedance audiometry - ddx from eustachian malfx and otosclerosis
Course: usually resolves over time
Management:
- Review in 3m
- Hearing aids
- Surgery ie grommets
Acute otitis media Presentation [4] Common organisms [3] Course [3] Treatment [3] Continuing discharge - possible sequelae [3]
Presentation
- Rapid onset
- Fever, ear pain, irritability (children)
- Anorexia, vomiting
- ppt by viral infection
Common organisms
- Pneumococcus, haemopilus, moraxella
Course: drum bulging causes pain > purulent discharge > perforation alleviates pain
Treatment: amoxicillin +/- clavulanate, analgesia
Sequelae:
- mastoiditis, petrositis
- labyrinthitis, facial palsy
- meningitis, intracranial abscess
What are the types of chronic suppurative otitis media? [2]
Either with:
- Perforated Tympanic Membrane
- Cholesteatoma
What is a cholesteatoma? [3]
Presentation [5]
Serious rare complications [2]
Treatment [1]
Abnormal skin growth in the middle ear. [1]
The skin forms a pouch so it doesnt shed, instead it builds up. [1] Eroding structures of the ear, facial nerve and into the brain [1]
Presentation
- Foul discharge
- Deafness
- Headache, otalgia
- Facial paralysis
- Vertigo
Serious rare complications:
- Meningitis
- Cerebral abscess
Treatment:
- Mastoid surgery needed to make a safe dry ear
List some common disorders of the inner ear [8]
Presbycusis Noise Induced Hearing Loss: Ototoxic Meds e.g. Gentamicin Meniere's Disease Head Injury Infection Vestibular Schwannoma (Acoustic Neuroma)
What is a vestibular schwannoma? [2]
A benign tumour of the vestibular nerve [1]
Causes sensorineural hearing loss in one ear [1]
Tinnitus Definition [2] Age of onset [1] Describe nature of noise heard and their respective clinical significance [2] Cause [1]
Sensation of non-verbal sound not due to stimuli outside body
Age of onset: 50-60y
Ringing, hissing, buzzing - inner ear
Popping, clicking - external/middle ear
Cause: ?damage to the cochlear hairs
Its associated with presbycusis, noise related hearing loss and stress.
How would we investigate tinnitus? [3]
When would you investigate further for acoustic neuroma [1]
We’d want to test for hearing loss. Tuning fork, audiogram
If its unilateral hearing loss or pulsatile we would want to do a MRI scan
Tinnitus treatment
Treatment approach [1]
Describe 5 modes of treatment
What is the role of surgery in tinnitus [1]
Treat the whole person not just a malfunctioning ear - avoid saying its untreatable
- Aids: if hearing loss >35 dB
- Psychological support
- Music, massage
- Intratympanic dexa + oral alprazolam
- Drugs: melatonin, betahistine for Meniere’s, Baclofen
- Surgery - limited role
Vertigo
Associated symptoms [3]
How can duration differentiate the type of vertigo [3]
Associated symptoms:
- nausea, vomiting
- hearing loss, tinnitus
- nystagmus
Duration:
- seconds to minutes BPPV
- 30 min to 30h Menieres/migraine
- 30h to a week - acute vestibular failure
List some common types/causes of vertigo
- Peripheral vertigo [5]
- Central vertigo [3]
- Drugs [4]
Peripheral vertigo
- Meniere’s disease
- BPPV
- Vestibular failure
- Labyrinthitis
- Cholesteatoma
Central vertigo
- Acoustic neuroma
- MS
- Head injury
Drugs
- Gentamicin
- Diuretics
- Cotrimoxazole
- Metronidazole
Pathogenesis of BPPV [3]
Causes of BPPV [5]
Otoconia (small crystals) in the semi-circular canals of the inner ear [1]
Its precipitated by changes in head position [1] causing the stones to stimulate the hair cells [1]
It only lasts a few seconds and occurs a few times a day
Causes:
- Middle ear disease
- Head injury
- Otosclerosis
- Postviral illness
- Stapes surgery
Benign Positional Vertigo
Investigations [2]
Treatment [3]
Describe last resort treatment for BPPV [1]
A Dix-Hallpike test will induce vertigo
The Epley Manoeuvre moves the particles out the canal so they wont stimulate the hair cells
Treatment
- Vestibular habituation exercises
- Reassurance, reduce alcohol intake
- Drugs - betahistine, prochlorperazine, antidepressants
- Last resort: posterior semicircular canal denervation or obliteration
What is vestibular neuritis/labyrinthitis?
A reactivation of a latent HSV infection [1] in the vestibular gangion. [1]
How do we treat Vestibular Neuritis/Labyrinthitis? [3]
- Vestibular sedative eg diazepam
- Anti-emetic eg prochlorperazine
- CCS
Meniere's disease Also known as endolymphatic hydrops Define [1] Clinical features [5] Ix [2]
Dilation of the endolymph spaces of membranous labyrinth [1]
Clinical features
- Vertigo with nausea/vomiting
- Aural fullness
- Uni/bilateral tinnitus
- Sensorineural hearing loss (fluctuates)
- Attacks occur in clusters >20 per month
Investigation:
- Electrocochleography
- Endolymphatic space MRI
How do we treat meniere’s disease? [1]
Surgical [2]
Betahistine or prochlorperazine
Surgical
- Endolymphatic shunts
- Labyrinthectomy
Migraine
Clinical features [3]
Spontaneous Vertigo +/-:
- Headache
- Sensory Sensitivity
Facial palsy Intracranial causes [4] Intratemporal causes [3] Infratemporal causes [1] One main cause
Intracranial
- Brainstem tumors
- Strokes
- Polio, MS
- Cerebropontine angle lesions eg acoustic neuroma
Intratemporal
- OM
- Ramsay Hunt syndrome
- Cholesteatoma
Infratemporal
- Parotid tumours
Bells palsy - idiopathic
Otitis Media management
Explain when you should offer surgery [4]
Steps [3]
Describe grommet [1]
Offer surgery if persistent bilateral OME + hearing level in better ear is <25-30 DBL
Confirmed over 3m, affecting ADL.
Myringotomy
Suction of fluid
Insert grommet
+/- adenoidectomy (tonsillectomy doesn’t help)
A Grommet is a tube through the ear drum that allows pressure to equalise in the middle ear
Otitis Media management
Complication of grommet [2]
Advice on living with grommets [3]
Long term plan [2]
Complications infections, tympanosclerosis
- OK to swim with grommets but diving is a no, use ear plug eg cotton wool and Vaseline
- Avoid forcing water into middle ear
- 25% need re-insertion
Long term plan
Grommets extrude after 3-12m
Recheck hearing then
Bells palsy treatment [3]
Protect eye with glasses, tape closed eyes during sleep, artificial tears
Lateral tarsorrhaphy
Prednisolone early
