Quiz 1 Flashcards
What are the names of the ossicles?
Malleus, Incus, Stapes
What opens the Eustachian Tube?
Active contraction of the tensor veli palantini during swallowing or yawning.
Which Labyrinth is filled with perilymph?
The bony Labyrinth is filled with perilymph that is essentially extra cellular fluid (high in sodium and low in potassium).
Which Labyrinth is filled with Endolymph?
The membranous labyrinth is filled with endolymph, the only extra cellular fluid in the body high in potassium and low in sodium.
Functions of the cochlea?
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.
Functions of the vestibule?
Semi-circular canals: primarily for proprioception and balance
Functions of stria vasicularis?
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.
LICHEN SIMPLEX CHRONICUS (Neurodermatitis)
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
SEBORRHEIC DERMATITIS
Scaly Erythema & lesions on scalp and eyebrows
CONTACT DERMATITIS
Irritants to ear, such as perfume and earrings (nickel)
ATOPIC DERMATITIS
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.
What is the atopic dermatitis triad?
Eczema, Asthma, Allergies (Hayfever)
ACUTE CELLULITIS
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;
ERYSIPELAS
Erysipelas is a deeper infection that spreads along facial planes and will involve the whole auricle. Patient will be sicker- fever, chills.
INFECTIOUS CHONDRITIS
Deeper infection involving cartilage usually follows erysipelas. Entire ear red, hot, including lobe. Also systemic symptoms: fever, nausea, chills.
RELAPSING POLYCHONDRITIS
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;
AURICULAR HEMATOMA (TRAUMA)
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.
MALIGNANT OTITIS EXTERNA
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.
S/Sxs of Malignant OE
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.
Management of Malignant OE
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.
Acute otitis media (AOM)
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).
Physical exam needed for AOM
(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.
OTIC BAROTRAUMA
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
IMPACTED CERUMEN
Symptoms:
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.
IMPACTED CERUMEN
Treatment: 3 recommended options?
cerumenolytic agents, irrigation, and manual removal.
Impacted cerumen, Acute treatment:
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
Bleeding after removal treatment:
If you cause bleeding after dislodging a hard dry plug, rinse with 70 % calendula succus, 30 % water or 10% acetic acid rinse.
IMPACTED CERUMEN
Contraindication:
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.
IMPACTED CERUMEN
Complications:
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.
Removal options for foreign bodies
water irrigation, forceps removal (alligator forceps). Roman loops, right angle ball hooks, and suction catheters
Options for killing live insects in ear canal?
Live insects can be killed rapidly by instilling alcohol, 2% lidocaine, or mineral oil into the ear canal.
When should you never irrigate?
Perforated TMs, hygroscopic bodies (beans) that can swell.
Referral for foreign bodies?
Otolaryngology referral is indicated for patients requiring sedation, for non-graspable foreign bodies that are tightly wedged or after unsuccessful removal attempts.
OSTEOMA OF THE CANAL
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.
Referred pain DDX for ear pain
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.
Ear pain RED FLAGS
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.
Serous Otitis Media (OM with effusion)
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).
What are the 3 types of results from Tympanometry?
Type A: Normal
Type B: Fluid, early AOM, OME
Type C: Eustachian Tube dysfunction
Graphed as impedance (sound) vs. pressure (-200 to +200)
Eosinophilic otitis media (EOM)
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.
