Quiz 1

Question 1

What are the names of the ossicles?

Answer 1

Malleus, Incus, Stapes

Question 2

What opens the Eustachian Tube?

Answer 2

Active contraction of the tensor veli palantini during swallowing or yawning.

Question 3

Which Labyrinth is filled with perilymph?

Answer 3

The bony Labyrinth is filled with perilymph that is essentially extra cellular fluid (high in sodium and low in potassium).

Question 4

Which Labyrinth is filled with Endolymph?

Answer 4

The membranous labyrinth is filled with endolymph, the only extra cellular fluid in the body high in potassium and low in sodium.

Question 5

Functions of the cochlea?

Answer 5

Primarily for the conversion of sound energy into electrical energy. The vibrations from the ossicles set the endolymph into motion, which causes a flow of positive ions (K+), across the negatively charged hairs on the organ of Corti, causing a synapse to fire. This information is conveyed by the 8th cranial nerve to the auditory area of the temporal lobe where it is interpreted as sound.

Question 6

Functions of the vestibule?

Answer 6

Semi-circular canals: primarily for proprioception and balance

Question 7

Functions of stria vasicularis?

Answer 7

The inner ear has a unique vascular system. It is the only vascularized epithelium in the body. The cells of the stria vascularis are high in mitochondria.
Acts as a back up “battery for the organ of Corti, helps to maintain endolymph. Its vascular supply provides nutrients to the organ of Corti while keeping the vessels at a distance minimizing the distraction of noise from blood flow.

Question 8

LICHEN SIMPLEX CHRONICUS (Neurodermatitis)

Answer 8

Itch/scratch cycle continues after initial insult such as bug bite. Most commonly found in outer canal and concha.
Treatment: education, cut nails, soothing lotion

Question 9

SEBORRHEIC DERMATITIS

Answer 9

Scaly Erythema & lesions on scalp and eyebrows

Question 10

CONTACT DERMATITIS

Answer 10

Irritants to ear, such as perfume and earrings (nickel)

Question 11

ATOPIC DERMATITIS

Answer 11

Atopic Patient (eczema, asthma, hayfever). Look for lesion on flexion folds, ear canal. Can be confused with otitis externa, but is sterile, no WBC, not infected.

Question 12

What is the atopic dermatitis triad?

Answer 12

Eczema, Asthma, Allergies (Hayfever)

Question 13

ACUTE CELLULITIS

Answer 13

Secondary to another dermatitis or trauma. Cellulitis is a more superficial infection - small area that is red, hot usually caused by Group A β hemolytic streptococci (GABHS) less commonly by Staphylococcus aureus;

Question 14

ERYSIPELAS

Answer 14

Erysipelas is a deeper infection that spreads along facial planes and will involve the whole auricle. Patient will be sicker- fever, chills.

Question 15

INFECTIOUS CHONDRITIS

Answer 15

Deeper infection involving cartilage usually follows erysipelas. Entire ear red, hot, including lobe. Also systemic symptoms: fever, nausea, chills.

Question 16

RELAPSING POLYCHONDRITIS

Answer 16

Non-infectious systemic disease, bilateral auricular chondritis. Redness comes not from skin, but deeper; possibly autoimmune; Will have other symptoms, such as nasal chondritis, ocular chondritis or arthritis; * Spares the lobes; Redness is only where there is cartilage;

Question 17

AURICULAR HEMATOMA (TRAUMA)

Answer 17

Boxer, wrestlers, rugby players; Must treat quickly to prevent formation of cauliflower ear;
Treatment: remove fluid with 18g needle & 10 cc syringe then cover with compression dressing for 48 hrs.

Question 18

MALIGNANT OTITIS EXTERNA

Answer 18

Indolent (slow) progressive otitis externa that invades the underlying cartilage. Rare but dangerous. It affects immunocompromised individuals, particularly those who have diabetes., alcoholic, severe malnourished.

Question 19

S/Sxs of Malignant OE

Answer 19

ear pain, purulent d/c from canal, no fever, no swelling; Looks benign compared to the symptoms, but at junction of temporal bone inside canal you may see granulation tissue. The most common causative agent remains Pseudomonas aeruginosa. Can go through cartilage to bone causing osteomyelitis, hearing loss and facial nerve paralysis and death. Test facial nerve function.

Question 20

Management of Malignant OE

Answer 20

ENT referral: Definitive diagnosis requires a high index of suspicion. Diagnosis is aided with an abnormal MRI or CT scan showing extension of infection into bony structures. Biopsy may be performed to provide histologic exclusion of malignancy. Long-term oral antipseudomonal agents have proven effective; however, pseudomonal antibiotic resistance patterns have emerged.

Adjunctive therapies, such as aggressive debridement and hyperbaric oxygen therapy, are reserved for extensive or unresponsive cases.

Question 21

Acute otitis media (AOM)

Answer 21

Usually secondary to a URI, much more common in children under 10 years.
Usually unilateral, starts with a sensation of blockage, hearing loss Progresses to fever, pain increases < evening, causes deep severe pain Insomnia, irritability, anorexia (best clues in infants).

Question 22

Physical exam needed for AOM

Answer 22

(rectal Temp > 100.4o F or oral temperature > 99.5o F), Middle ear fluid as revealed by pneumatic otoscopy, tympanic erythema, loss of normal landmarks, light
reflex is smaller and distorted. May have fever and cervical lymphadenopathy. Fullness or bulging of the tympanic membrane(s) are insensitive but specific signs.

Question 23

OTIC BAROTRAUMA

Answer 23

Otic barotrauma occurs during air travel typically, less commonly scuba diving. Otic Barotrauma is defined as inflammation of the middle ear caused by the pressure difference between the air in the middle ear and the external atmosphere, developing after ascent or more commonly on descent. Predisposed by Eustachian Tube dysfunction (allergies, colds, serous otitis media) 5; Otalgia can be severe with ear fullness, < yawning, hearing loss and dizziness. Severe cases may result in tympanic membrane perforation and even round window membrane rupture

Question 24

IMPACTED CERUMEN

Symptoms:

Answer 24

Vague discomfort to severe pain; impaired hearing, other symptom can include dizziness, ear fullness, reflex cough. There may be a history of “Q-tip abuse”, and increased cerumen production.

Question 25

IMPACTED CERUMEN

Treatment: 3 recommended options?

Answer 25

cerumenolytic agents, irrigation, and manual removal.

Question 26

Impacted cerumen, Acute treatment:

Answer 26

In acute cases - use loop curette or alligator forceps; if not acute, send patient home with ear drops to soften wax (olive or calendula oil or OTC preparation of Carbamide peroxide 0.9% ® Debrox or Murine)8, then return to office for irrigation with warm water with 30 cc syringe and a te flexible tubing from a butterfly syringe

Question 27

Bleeding after removal treatment:

Answer 27

If you cause bleeding after dislodging a hard dry plug, rinse with 70 % calendula succus, 30 % water or 10% acetic acid rinse.

Question 28

IMPACTED CERUMEN

Contraindication:

Answer 28

do not use drops or irrigate if there is a non-intact tympanic membrane, AOM or otorrhea present. This can usually be ascertained by careful history. Modify management if there is ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy identified in history and physical assessment, consider referral to an ENT in these situation.

Question 29

IMPACTED CERUMEN

Complications:

Answer 29

Tympanic membrane perforation, ear canal laceration, infection of the ear, Other complications that have been reported include otitis externa and malignant otitis externa. (secondary to external auditory canal trauma), pain, and dizziness. Complications occur at a rate of one in 1000 ear irritations.

Question 30

Removal options for foreign bodies

Answer 30

water irrigation, forceps removal (alligator forceps). Roman loops, right angle ball hooks, and suction catheters

Question 31

Options for killing live insects in ear canal?

Answer 31

Live insects can be killed rapidly by instilling alcohol, 2% lidocaine, or mineral oil into the ear canal.

Question 32

When should you never irrigate?

Answer 32

Perforated TMs, hygroscopic bodies (beans) that can swell.

Question 33

Referral for foreign bodies?

Answer 33

Otolaryngology referral is indicated for patients requiring sedation, for non-graspable foreign bodies that are tightly wedged or after unsuccessful removal attempts.

Question 34

OSTEOMA OF THE CANAL

Answer 34

Osteomas are essentially exostoses of the external auditory meatus. Present as a gradual narrowing of the bony canal by mounds of bone that arise from the canal walls from the temporal bone.
They most often occur in individuals with a history of cold-water exposure (swimmers or surfers). The bone deposition is presumed to be caused by a chronic periostitis do to the cold exposure.
These are generally asymptomatic. Occasionally conductive hearing loss in otitis externa can arise if canal becomes occluded. Surgical removal is conventional treatment. Homeopathic Hekla lava is indicated for exostoses.

Question 35

Referred pain DDX for ear pain

Answer 35

Consider when patient presents with ear pain, with a normal otoscopic exam, and no loss of hearing.
DDX: TMJ dysfunction, molars, cervical spine, head and neck malignancies. TMJ is most common. Check for crepitus, malocclusion, tenderness of the temporomandibular muscles and joints and deviation during range of motion.

Question 36

Ear pain RED FLAGS

Answer 36

Patients who smoke, drink alcohol, are older than 50 years, or have diabetes are at higher risk of a cause of ear pain that needs further evaluation for a serious occult cause of ear pain. Further evaluation to consider: magnetic resonance imaging, fiberoptic nasolaryngoscopy, or an erythrocyte sedimentation rate measurement.

Question 37

Serous Otitis Media (OM with effusion)

Answer 37

History: Usually painless, popping or gurgling sounds, plugged feeling; aural fullness Allergies or VRI are common causes.

Opacity and retraction are the two characteristics of abnormal tympanic membrane that are associated with elevated hearing threshold in the patients with otitis media with effusion. Hearing test is suggested if opacity or retraction of the tympanic membrane is found.

PE: TM yellow, amber; not pearly grey; May see bubbles or fluid level Retraction- tenting over short handle of malleus; Tympanogram is flat-Type B Insufflation shows little or no movement Conductive hearing loss (Weber lateralizes to the bad ear, Rinne’ BC > AC).

Question 38

What are the 3 types of results from Tympanometry?

Answer 38

Type A: Normal
Type B: Fluid, early AOM, OME
Type C: Eustachian Tube dysfunction

Graphed as impedance (sound) vs. pressure (-200 to +200)

Question 39

Eosinophilic otitis media (EOM)

Answer 39

Intractable otitis media characterized by the presence of a highly viscous yellow effusion containing eosinophils. It occurs mainly in patients with bronchial asthma and is resistant to conventional treatments for otitis media.