The Ear

Question 1

Acute Trauma to the Middle Ear

TM Perforation

Answer 1

**Causes: **

• head injuries, blow to ear canal, sudden impact with water, blast injuries, insertion of pointed instruments to ear canal, parental use of cotton-tipped swab (50% of serious penetrating injuries)

Damage:

• TM perforation, ossicular damage, hematoma of middle ear

Etiology of TM Perforation:

• trauma
  
  • physical abuse red flag, foreign body, forceful ear irrigation
• infection
  
  • otitis media
  • acute chronic otitis media
• middle ear barotrauma

S:

• otorrhea (pus, bloody)
• sometimes pain

**​O: **

• size perforation as % of membrane (% that is involved in perforation)
• traumatic perforations often lack d/c while infectious ones have d/c
• Weber lateralizes to side of perforation = conductive hearing loss

P:

• middle ear hematoma:
  
  • mainly watchful waiting
  • abx not necessary unless see signs of infection
  • prognosis for unimpaired hearing dependent on possible fractured ot dislocated ossicles
  • pt should be followed by audiometry or otolaryngologist until hearing return to normal (expected within 6-8 weeks)
• TM perforations
  
  • management =
    
    • ​keep ear dry
    • refer to ENT
  • TX of infectious etiology =
    
    • drop use + oral abx is controversial (drops protect from possible external infection; less common to do both in adults, just oral; more common to do both in kids)
    • Corticosporin Otic Suspension (1 drop QID)
    • Ciprofloxacin Ophthalmic (Ciloxan) (1 drop QID) (pH of this vs otic matches envirnment in ear better and less irritating to pt)
  • TX of traumatic etiology =
    
    • often do not heal spontaneously; pt should be referred to otolaryngologist
    • spontaneous healing may occur within 6 months of perforation
    • if it is clean and dry perforation and no hearing change, then no urgency for specialty eval
    • no abx needed unless signs of infection develop
    • perforations caused by foreign body should be attended to more urgently
    • urgent referral if accompanied by vertigo and/or hearing loss

Question 2

Ear Canal Foreign Body

Answer 2

Foreign Bodies:

• insects, food, cotton swabs, toys, pencil erasers, disk-type battery

**Causes: **

• usually put in by pt
• bugs crawl or fly in

TX:

• kill bugs first with mineral oil or Lidocaine (anesthetic to pt)
• may try to irrigate if intact (UNLESS battery)
• remove with forceps, suction, or adhesive skin glue (dab on Q-tip); balloon catheter (place past object in ear canal and then inflate, should push object out)
• if object is large, wedged into place, or difficult to remove with available instruments pt should be referred to otolaryngologist early rather than risk traumatizing child or ear canal or causing edema that will necessitate removal under anesthesia
• emergency condition if foreign body is a disk-type battery (ie those in watches, clocks) = electric current is generated in moist canal and severe burn w/ resultant scarring can occur in <4 hours

Question 3

Hematoma of the Pinna

Answer 3

**etiology: **

• trauma to ear can result in hematoma b/n perichondrium (dense membrane that is composed of fibrous connective tissue that closely wraps all cartilage) and cartilage
• blunt trauma to auricle

**O: **

• different than bruise which: doesnt change ear shape and blood is in soft tissue outside of the perichondrial layer
• hematoma
  
  • appears as a boggy purple swelling of the upper half of the ear
  • cartilage folds are obscured

**P: **

• warrants prompt drainage and application of molded dressing (to prevent cauliflower ear)
• if untreated, pressure necrosis of underlying cartilage may occur => “cauliflower ear” which is permanent
• should urgently refer to otolaryngologist for drainage and application of carefully molded pressure dressing

Question 4

Eustachian Tube Dysfunction

Barotrauma

Answer 4

etiology:

• two etiologies:
  
  • failure of tubal dilatory action = dilatory dysfunction (more common; tx with decongestants)
  • valve incompetency leading to chronic patency (stuck open) = patulous dysfunction (corrected with sx)
• air travel, scba diving, decompression, hyperbaric O2 chambers, rapidly descending elevator, blast injuries
• poor eustachian tube function (ie congenital narrowness or aquire mucosal edema) may lead to inability to equalize barometric stress exerted on middle ear by air travel, rapid altitudinal change, or underwater diving
• problem most acute generally during airplane descent, since negative middle ear pressure tends to collapse and block eustachian tube
• problem with underwater diving occurs most commonly during descent phase, when pain develops w/n the first 15 ft if inflation of middle ear via eustachian tube has not occured
• eustachian tube dysfunction can predispose to middle ear disease and complications like hearing loss, OM, TM rupture, and cholesteatomas

S:

• abrupt onset of pain, feeling of fullness in ear, conductive hearing loss, dizziness, tinnitus, vertigo, N/V, transient facial paralysis (facial nerve goes through middle ear), TM rupture with Valsalva maneuver, crying in children
• with valve incompetency, pt may c/o hearing themselves speak in a nasally voice and breathe

O:

• for underwater diving:
  
  • emesis due to acute labyrinthine dysfunction can be very dangerous during underwater dive
  • sensory hearing loss of vertigo, which develops during ascent phase of saturation dive may be first or only symptom of decompression sickness

A:

• DX made from history and PE

P:

• aimed at underlying etiology
• for during descent: ways to enhance eustachian tube function and avoid barotrauma =
  
  • swallow, yawn, and autoinflate frequently during descent, which may be painful if tube collapses
  • oral decongestants (ie pseudoephedrine, 60-120mg) should be taken several hours before arrival time to be max effective during descent
  • topical decongestants (ie 1% phenylephrine nasal spray) should be administered 1 hr before arrival
  • for acute negative middle ear pressure that persists on ground TX:
    
    • decongestants and attempts at autoinflation
    • myringotomy (creation of small eardrum perforation) provides immediate relief and is appropriate in setting of severe otalgia and hearing loss
    • repeated episodes of barotrauma in frequent flyers may be alleviated by insertion of ventilating tubes
• for underwater diving (may be greater barometric stress than flying)
  
  • divers must slowly descend and equilibrate in stages to avoid devp of severely negative pressures in tympanum that may result in hemorrhage (hemotympanum) or perilymphatic fistula (oval or round window ruptures, resulting in snesory hearing loss and acute vertigo)
  • immediate recompression will return intravascular air bubbles to solution and restore the inner ear microcirculation
  • pts should be warned to avoid diving when have URIs or episodes of nasal allergy
  • TM perforation is an absolute contraindication to diving, as pt will experience unbalanced thermal stimulus to semicircular canals and may experience vertigo, disorientation, and even emesis
• refer to ENT if severe sxs = hearing loss, persistent ear pain, persistent signs/sxs despite medical therapy or complication that may require surgical tx (ie cholesteatoma, perforated TM)

Question 5

Acute Trauma to Middle Ear

Middle Ear Hematoma

Answer 5

**Causes: **

• head injuries, blow to ear canal, sudden impact with water, blast injuries, insertion of pointed intruments to ear canal, parental use of cotton-tipped swab (50% of serious penetrating injuries)

S:

• pain

O:

• blood accumulation behind the TM
• may have fractured ossicles as well and if so, no return to normal of hearing

**P/TX: **

• watchful waiting (should spontaneously clear)
• no abx unless signs of infection (can happen because blood and bacteria love each other)
• f/u with ENT ad audiometry ALWAYS and continue to f/u to make sure it resolves

Prognosis

• hearing can go back to baseline if ossicles havent been fractured or dislocated
• hearing should return to normal in 6-8 weeks

Question 6

Cerumen Impaction

Answer 6

**Causes: **

• non-foreign body obstruction
• cerumen is protective substance
• not usually an emergency

**Epidemiology: **

• common in pts with hearing aids

S:

• can cause pain, pressure, vertigo, or hearing loss
• gets in way of seeing TM on inspection

P/TX:

• irrigation (best practice) with 50:50 mixture of hydrogen peroxide and water AT ROOM TEMP (so don’t induce vagal response)
• curettes or loops (be cautious)
• bulb syringe
• use ear wax softeners if cerumen is hard (Debrox, Cerumenex, Docusate) (topical laxatives/stool softeners too)
• pt may need to return if painful to remove on first visit
• DO NOT irrigate with TM perforation
• ENT outpatient referral for stubborn wax

Question 7

Mastoiditis

Answer 7

**essentials of DX: **

• complication of OM
• 60% younger than 2 yo
• often no prior h/o recurrent OM
• postauricular pain, ear protrusion

**etiology: **

• infection spreads from middle ear to mastoid portion of temporal bone which is filled with air spaces
• can range in severity from inflammation of mastoid periosteum to bony destruction of mastoid air cells (coalescent mastoiditis) and abscess development
• most common pathogens = Strep pneumoniae and Strep pyogenes with Staph aureus and H influenzae occasionally seen

**epidemiology: **

• can affect any age group, but more than 60% are younger than 2 yo
• many kids do not have prior h/o recurrent AOM

**S: **

• postauricular pain, fever, outwardly displaced pinna

**O: **

• on exam: mastoid area often appears swollen and red, with disease progression may become fluctuant
• earliest finding is severe tenderness on mastoid palpation
• AOM is almost always present
• late findings are pinna is pushed forward by postauricular swelling and ear canal that is narrowed due to pressure on posterosuperior wall from mastoid abscess
• in infants <1 yo, swelling occurs superior to ear and pushes pinna downward rather than outward
• complications:
  
  • meningitis can be complication of acute mastoiditis and hsould suspected in child with high ffever, stiff neck, severe HA, or other meningeal signs
    
    • LP should be performed for DX
  • brain abscess occurs in 2% of pts, may be ass w/ persistent HAs, recurring fever, or changes in sensorium
  • facial palsy, cavernous sinus thrombosis, thrombophlebitis may also be encountered
• imaging studies:
  
  • CT scan is best way to determine extent of disease
    
    • diffuse inflammatory clouding of mastoid cells occurs in acute phase and also in uncomplicated AOM
    • severe cases, bony destruction and resorption of mastoid air cells may occur

A:

• DDX: postauricular tenderness and ear protrusion are hallmarks of mastoiditis but significant external otitis may also present with these signs
• complications = can progress to sigmoid sinus thrombosis, epidural abscess, or intraparenchymal brain abscess

**P/TX: **

1. myringotomy w/ or w/o tube for mastoiditis w/o a subperiosteal abscess, followed by IV abx therapy plus ofloxacin or cipro ear drops
   
   • ceftriaxone plus nafcillin or clindamycin until cx results
   • cx directed abx therapy for 2-3 weeks
2. surgical drainage of mastoid if no clinical improvement in 24-48 hrs or if any signs or sxs of intracranial complications arise
   
   • needle aspiration or I&D of isolated subperiosteal abscess and not coalescent mastoiditis
3. cortical mastoidectomy is usually primary management for coalescent mastoiditis (w/ abscess formation and brkdwn of mastoid air cells)
4. after significant clinical improvement is achieved w/ parenteral IV therapy, oral abx are begun and continued for 3 weeks

Prognosis for full recovery is good. Kids for whom acute mastoiditis w/ abscess is first ear infection are not necessarily prone to recurrent OM.

Question 8

Otitis Externa

Answer 8

**epidemiology: **

• common, especially in summer or climates with high humidity (heat and moisture lead oto swelling and maceration of skin in EAC)
• swimming, esp in fresh water

**etiology: **

• Bacterial
  
  • Pseudomonas aeruginosa (usually problem for ppl w/immunocompromise) (G -)
  • Staph aureus (G + cocci)
  • can also see E. Coli and Proteus vulgaris
  • polymicrobial
• Fungal (problematic for immunosuppressed pts, DM)
  
  • Asperigillis (80-90%)
  • Candida albicans
• can see secondary to trauma (cerumen removal, fingernails, cotton swab use, poorly fitting hearing aids)
• may be ass w/ inflamm skin disorder and allergic rxns (eczema, psoriasis, Seb Derm)

S:

• otalgia - usually worse w/ movement of external ear
  
  • pain is sxs best correlated w/ severity of the disease
• pruritis (mild or severe)
• fullness
• hearing loss (conductive- increases BC)
• otorrhea
• mild fever may be present
  
  • T > 101 F suggests extension beyond auditory canal

O:

• EAC - erythema and edema
• may have decreased hearing if marked EAC swelling or significant d/c
• note appearance of TM and whether TM is intact
  
  • can cause erythema of TM, so pneumatic otoscope should be used
• discharge
  
  • Pseudomonas infection - green
  • Staph infection - yellow
  • fungal infection can be fluffy (“bread mold”) and either white or black
• T > 101 suggests extension beyond EAC

A:

• DX based on signs and sxs of canal inflammation

P:

• management
  
  • keep external auditory canal clean
    
    • remove debris to promote healing
    • irrigate w/ acetic acid 2% Otic Soln if TM intact (vinegar = +/- 8%) (do not use H2O2 b/c it is irritant)
    • clean ear under direct vision using either wire loop or cotton swab
    • may need to refer to ENT
  • tx underlying infection
    
    • topical abx (w/ or w/o steroids)- this is external (make sure TM is intact)
      
      • Ciprofloxacin and dexamethasone Otic Suspension (Ciprodex)
      • Polymixin, neomycin, and hydrocortisone (dec inflamm) otic Suspension (Corticosporin)
      • both are good if TM is not intact
      • oral abx reserved for when infection has spread beyond ear canal, uncontrolled DM, immunocompromise
  • Hydrocortisone 2%/acetic acid 1% (Vosol HC) (first line therapy) (if TM is intact only)
  • relieve pain (NSAIDs, Acetaminophen)
  • avoid triggers
  • cx d/c if severe or recurrent disease
  • most cases resolve in 5-7 days (don’t swim until resolved)
  • don’t overtreat; no refills on rx
    
    • may be complicated by atopic dermatitis, chemical dermatitis, or fungal infection
• TX:
  
  • Ear wick (Oto-wick) may be used if marked swelling of the EAC (way to get medicine in where need to be)
  • apply medication to ear wick 3-4x/day
  • remove ear wick after 48-72 hrs and continue meds as directed
• management of fungal OE
  
  • can still use vinegar soln
  • Sulfanilamide Powder (dusting x one)
  • Clotrimazole 1% Soln (3 drops BID x 14 days)
  • Acetic acid irrigation
• prevention of OE
  
  • 2% Acetic acid (VoSol) to acidify EAC
  • can make own vinegar soln (50:50 white vinegar and sterile water)
  • can use isopropyl alcohol or H2O2…can be irritating or drying (dilute if need to use these)
  • earplugs while swimming
• pt education:
  
  • keep canal dry
  • no swimming until infection resolved
  • vaseline-coated cotton ball in ear during bathing then remove after
  • when infection resolved and resuming swimming
    
    • consider bathing cap or custom ear plugs for recurrent problems
  • no Qtips
• complications of TX:
  
  • allergic contact dermatitis from neomycin sensitivity w/ prolonged use
  • ENT referrals for:
    
    • severe or refractory disease
    • DM pts
    • h/o radiation therapy
    • hx immunocompromise

Question 9

Necrotizing Otitis Externa

Answer 9

formerly known as malignant OE

**epidemiology: **

• seen in DM and immunocompromised pts

etiology:

• ass w/ Pseudomonas infection w/ involvement of the underlying bone
  
  • osteomyelitis can spread intra-cranially

S:

• fever
• increasing deep-seated otalgia that may worsen at night
• foul smelling and purulent otorrhea

O:

• foul smelling d/c w/ red granulation tissue in EAC
• CN palsies can be seen
  
  • CN7 most common
  • can also see CN 6, 9, 10, 11, and 12
• CN palsies consistent w/ intracranial complications (ie meningitis, brain abscess)
• can see lymphadenopathy and trismus

A:

• CT scan or MRI will show bony erosions
• elevated erythrocyte sedimentation rate

P:

• management:
  
  • hospital admission
  • IV abx
    
    • broad spectrum PCN, fluoroquinolone, or cephalosporin
  • ENT consultation for surgical debridement if needed

Question 10

Acute Otitis Media (AOM)

Answer 10

**etiology: **

• most common pathogens:
  
  • Strep pneumoniae (40-50%)
  • Haemophilus influenzae (30-40%)
  • Moraxella catarrhalis (10-15%)
  • % may vary geographically
• other pathogens:
  
  • Strep pyogenes, Strep viridans, Staph aureus, Pseudomonas aeruginosa, viruses (respiratory syncytial virus RSV)
• pathophysiology
  
  • complication of eustachian tube dysfunction that occured during viral URI
  • congestion causes obstruction w/ accumulation of mucus and fluid in middle ear that serves as a nidus for infection

**S: **

• peds pt:
  
  • irritability
  • decreased appetite
  • fever
    
    • if present, need to address it or indicate why not
    • untx temps > or equal to 101F can “burn” you as well as pt (be careful for febrile seizures)
    • document hydration status
      
      • last urine output?
        
        • how much?
      • skin turgor?
      • crying?
      • oral intake?
  • otalgia
    
    • “tugging on the ear” (not always means ear infection)
  • hearing loss
  • may also see:
    
    • conjunctivitis, rhinorrhea
    • V and D
    • Otorrhea w/ TM rupture
• adults:
  
  • otalgia
  • rare to have fever, but may subjectively feel warm

**O: **

• reddened TM with decreased TM mobility (pneumatic otoscopy) (looking for movement- will not be present if pus behind)
  
  • REMEMBER infection is behind TM
• TM may be distorted, inflamed, loss of landmarks
  
  • a bulging TM is hallmark for AOM
• check for conductive hearing loss

P/TX:

• criteria for abx therapy
  
  • any child < 6 mo
  • 6 mo - 2 yrs, abx recommended if dx is certain and B/L AOM
  • > 2 yo w/ b/l disease or otorrhea, abx
• guidelines for observation:
  
  • 6 mo - 23 mo w/ unilateral or mild sxs
  • over 2 yo w/ mild sxs, if unsure of dx or if unilateral disease present
  • need to ensure f/u so that abx can be started if sxs persist or worsen
    
    • f/u may be by phone or office visit
    • abx should be prescribed if no improvement in 48-72 hrs
• TX:
  
  • 1) high dose Amoxicillin remains (80-90 mg/day) for 10 day course
  • can also use: Augmentin = Amox/clavunate
  • PCN allergy: oral cephalosporins
    
    • Cefdinir (Omnicef)
    • Cefuroxime (Ceftin)
  • high dose Azithromycin (Zithromax) 5 day course
  • Clarithromycin (Biaxin)
  • IM or IV Rocephin
  • Bactrim (Trimethoprim- Sulfamethoxazole) NO LONGER EFFECTIVE (Strep pneumo resistance)
  • Symptomatic care of pain and fever
    
    • Acetaminophen, ibuprofen (preferred)
    • topical pain reliever - Auralgan
    • encourage oral fluids (popsicles)
  • OTC cold preps are of ltd value
  • decongestants are considered better better than antihistamines (drying) or mult-sxs preps
• pt education:
  
  • pain and fever should resolve after 3 days
  • if sxs dont resolve or worsen RTC for evaluation
  • re-check at a week for regular f/u
  • hearing loss may take up to a month to resolve (important to recognize….may contribute to speech delays
• complications:
  
  • ear: chronic OM, TM perforations, mastoiditis, hearing loss, labyrinthitis
  • neuro: meningitis, encephalitis, intracranial abscess
  • progression of sxs, new onset of neuro warning signs, stiff neck, persistent hearing loss warrant further eval
• tympanostomy tube placement = recurrent AOM w/ edvidence of middle ear effusion at time of assessment

Question 11

Chronic Otitis Media

Answer 11

definition:

• greater than or equal to 3 documented episodes/6 mo or greater than or equal to 4 episodes/12 mo

**etiology/O: **

• recurrent OM
• trauma
• cholesteatoma (tumor caused by cholesterol build up)
• = Pseudomonas, Proteus, Staph aureus, mixed
• TM perforation w/ purulent d/c
• conductive hearing loss
• may be lichenification on otoscopy
• itching and mild discomfort

P/TX:

• refer to ENT for eval for placement of tympanostomy tube(s)
  
  • myringotomy/tympanostomy tubes indications:
    
    • persistent sxs
    • hearing loss (>40 dB)
    • speech delays
    • evidence of TM damage

Question 12

Serous OM w/ Effusion

aka serous OM

Answer 12

**etiology: **

• middle ear effusion secondary to inflammation or eustachian tube dysfunction
  
  • considered to be “sterile” but approx half have bacteria present in effusion

epidemiology:

• may be seen follwoing viral URI, AOM or in association w/ allergic rhinitis

S:

• pts c/o ear fullness
• decreased hearing
• usually painless

**O: **

• afebrile
• amber-colored (straw) fluid behind TM
  
  • may see air-fluid lvl and bubbles
• retraction of TM produces prominent landmarks
• TM will not move on pneumatic otoscopy
• pt may have conductive hearing loss

**P: **

• majority of cases resolve spontaneously w/n 12 weeks
• abx may be used since 50% of pts have bacteria due to chronic OM
  
  • 10 day Amox course
• oral steroids may be used w/ or w/o abx
• re-eval in 4-6 weeks
• refer to ENT for persistent fluid and/or hearing loss
• watchful waiting for 3 months if:
  
  • no speech or language problems
  • no hearing loss > 20 dB
• re-eval at 3 mo; if persistent or evidence of hearing loss tx w/ abx
• must refer adults w/ unilateral sxs to ENT to r/o nasopharyngeal carcinoma

Question 13

Labyrinthitis

Answer 13

aka vestibular neuronitis

Otitis interna

= benign, acute inflammation or infection of vestibular system

**etiology: **

• most commonly associated w/ viral infections (preceding URI)
• may also follow AOM or meningitis

**epidemiology: **

• seen in young/middle-aged (30-60 yo)

S:

• acute onset of severe rotational vertigo
• N and V
• NO tinnitus, hearing loss, or CNS deficits
• sxs help distinguish from other causes of vertigo i.e. benign paroxysmal positional vertigo, Meniere’s Disease

**O: **

• peripheral vertigo
• acute onset of severe rotational vertigo
  
  • no relation to head position; severe vertigo w/ eyes open or closed
  • horizontal nystagmus
  • ataxia

**P/TX: **

• tx is symptomatic
  
  • bedrest, hydration
• benzos
  
  • Diazepam (valium) 2-10 mg po, TID
  • Lorezepam (ativan) 1-2 mg po, TID
• anti-cholinergics
  
  • prochlorperazine (Compazine) 5-10 mg, QID or 25 mg PR BID
• anti-histamines
  
  • Meclizine (Antivert) 25 mg TID
• steroids for decreasing inflammation

Question 14

Acoustic neuroma

(Vestibular Schwannoma)

Answer 14

essentials of DX:

• asymmetric unilateral SNHL
• tinnitus
• disequilibrium
• disproportionately diminished speech discrimination score relative to deterioration in pure-tone avg
• facial and trigeminal nerve sxs w/ larger tumors

etiology:

• benign slow growing tumor of acoustic nerve (CN 8)
• nerve sheath tumors of superior and inferior vestibular nerves
• arise in medial IAC or lateral CPA

epidemiology:

• Neurofibromatosis Type II (ass w/ cafe au lait spots)
• ionized radiation

S:

• may not cause mass effect sxs until many cm in diameter
• commonly presents w/ unilateral SNHL
• unilateral tinnitus
• disequilibrium
• self-limiting episodes of vertigo
• HA or dizziness may be present
• facial and trigeminal nerve dysfunction occurs after auditory and vestibular impairments
  
  • usually have midface (V2) numbness and often absent corneal reflex
  • motor supply of muscles of mastication is rarely affected
• sxs tend to worsen over time
• other sxs include: decreased visual acuity, diplopia, HA, altered mental status, N/V, increased intracranial pressure, papilledema
• compression of lower CNs = dysphagia, aspiration, hoarseness, poor gag reflex, vocal cord paralysis

O:

• Romberg/Tandem Romberg towards affected side
• generally w/ high frequency hearing loss

A:

• Audiogram shows unilateral sensorineural hearing loss
• speech discrimination can be worse than expected for degree of loss
• MRI is diagnostic of Cerebellopontine Angle (CPA) w/ gadolinium contrast
  
  • do MRI w/ presentation of unilateral SNHL
• CT scan w/ iodine contrast or ABR when MRI not available are good
  
  • ABR - auditory brainstem response (can be NL though with small tumors)

**P/TX: **

• surgical removal, observation, and irradiation
• monitoring w/ regular imaging/audiometry every 6 mo
• refer to ENT/Neurosx for surgical excision or sterotatic radiation (ie Gamma Knife)
  
  • stereotatic radiation = goal is to prevent further growth of VS while preserving hearing and facial nerve function
• if small enough, can try to preserve/restore hearing but if big it will not restore

Question 15

Cholesteatoma

Answer 15

essentials of DX:

• Squamous epithelium in middle ear or mastoid
• otorrhea
• CHL
• retraction of TM and squamous debris collection or whitish mass behind intact TM
• testing = CT scan, can be useful in delineating disease extent (not critical to making DX)

Classifications:

• acquired cholesteatoma
  
  • primary = retraction of TM
  • secondary = result of squamous epithelium into middle ear during sx
• congenital cholesteatoma (minority of cases)
  
  • embryonic rest of epithelial tissue in ear w/o TM perforation and h/o ear infection
  • usually asx until grow to substantial size to disrupt ossicles

**etiology: **

• special variety of chronic OM
• unknown but commonly ass w/:
  
  • Eustachian Tube Dysfunction - chronic negative middle ear pressure leads to retraction of TM which puts skin cells in middle ear
  • TM perforation - introduces skin cells to middle ear
  • chronic inflammation of middle ear (chronic OM)
• *Strep, staph, Proteus, Enterobacter, *and anaerobes can grow in environment
• can be VERY destructive, typically erode bone w/ early penetration of mastoid and destruction of ossicles
• overtime may erode inner ear, facial nerve, spread intracranially (rare)

epidemiology:

• h/o chronic ear infections

**S: **

• recurrent or persistent purulent otorrhea
  
  • ​may not develop for a long time
• conductive hearing loss
• tinnitus is common
• rare = vertigo, disequilibrium, facial nerve twitching/palsy

**O: **

• TM pearl (greasy-looking mass or pearly white mass seen in a retraction pocket or perforation)
• retraction of TM w/ matrix of squamous epithelium and keratin debris
• serous or purulent drainage seen if infection is superimposed and middle ear cavity may contain granulation tissue or even polyps
• external ear drainage
  
  • persistent, recurrent, or foul smelling otorrhea following approproate medical management (may indicate cholesteatoma)
• audio shows CHL (conductive hearing loss)
• CN function, especially CN 7, should be evaluated in all cases
• evaluation of nystagmus and balance function in pts who have any evidence of vestibular dysfunction

**A: **

• DX clear after history and PE usually
• DDX: chronic OM w/o cholesteatoma, OE, malignant OE, neoplasms, CSF otorrhea
• CT can be done to delineate extent of disease
  
  • suggestive of cholesteatoma = erosion of bone, scutum and ossicular chain
  • CT is not definitive dx regarding the nature of temporal bone disease
• audiogram should be obtained in all cases (CHL)

P:

• prevention = restoring eustachian tube dysfunction (but really no way of doing this directly)
• providing ventilation to middle ear space can reduce complications related to poor eustachian tube function by inserting ventilating tube
• initial goal of TX =
  
  • reduce lvl of inflamm and infectious activity
  • remove infected debris from ear canal, keep all water out of ear, apply ototopical agents that cover all usual bacteria (P aeruginosa, streptococci, staphylococci, Proteus, Enterobacter, and anaerobes)
• topical steroid agents to reduce inflammation
• surgical excision is necessary to prevent further middle ear destruction
  
  • reduces recurrence
• prognosis = high rate of recurrence and residual cholesteatoma disease after primary sx
  
  • TX options now cannot reverse underlying physiologic elements that caused original disease

Question 16

Eustachian Tube Dysfunction

Answer 16

(NL function of Eustachian tube = involves opening and closing w/ soft palate mvmnt; dysfunction = fails to open and remains closed)

**etiology: **

• usually ass w/ diseases of edema of tubal lining (viral URI or allergy)
• inability of tiny hairs inside ear to remove fluids and infection
• poor contractile function w/n the eustachian tube
• narrow eustachian tube - in infants
• adenoid tissue blocking eustachian tube especially in children
• swollen nasal tissue due to secretions that cause blockage in nose
• Nasopharyngeal tumors in adults - if there is a unilateral OM must check NP!

**epidemiology: **

• more common in kids b/c of horizontal position

S:

• otalgia or ear pressure
• stuffiness - doesnt clear w/ valsalva manuever
• mild to moderate hearing loss or tinnitus
• autophony

**O: **

• retracted TM on exam
• decreased mobility on pneumatic otoscopy
• Tympanogram is flat

**A: **

• problems ass w/ ETD:
  
  • OM
  • barotrauma (especially w/ flight) (pilots)
  • possibly cholesteatoma

P:

• intranasal nasal decongestants - Sudafed, Afrin for 3 days max (this is addictive medication)
• autofinflation by forecd exhalation against closed nostrils my hasten relief
  
  • not for pts w/ active intranasal infection => may precipitate middle ear infection
• nasal steroids - Flonase, nasonex; must be used properly to be effective
• air travel, rapid altitudinal change, and underwater diving should be avoided during active phase of disease
• ** in more significant cases, can use oral steroids or do myringotomy and place a tube

Question 17

Cerumen impaction

Answer 17

etiology:

• unkown why some pts tend to secrete more ear wax than others, or why ear wax may be an issue in only one ear
• Qtips interfere w/ self-cleaning process, as do hearing aids

epidemiology: anyone; some ppl more wax producers

S:

• hearing loss (worsens w/ time and water) - common for ears to clog after shower
• ear discomfort
• dizziness/tinnitus if impacted against TM

O:

• will visualize cerumen in canal on exam

P:

• H2O2 or OTC wax-dissolving agents
• irrigation (if intact TM), loop curette, suction, forceps
• refer to ENT:
  
  • failed debridement
  • removal of cerumen under brief sedation
  • audiogram should be considered if hearing does not return to NL after debridement

Question 18

Presbycusis

Answer 18

= SNHL ass w/ advanced age

**etiology: **

• loss of functional sensory hair cells in the cochlea
• degeneration of the neural pathway

**epidemiology: **

• 40-50% of adults over 75 yo
• genetic predisposition
• noise exposure
• DM/atherosclerosis

**S: **

• pts or spouses/adult kids c/o
  
  • worsening hearing loss over time in b/l ears
  • difficulty hearing conversations in social situation (lots of ambient noise)
  • difficulty localizing sounds
  • tinnitus
  • isolation due to inability to use the phone

**O: **

• PE is normal
• high-freq symmetrical SNHL on audiogram

**A: **

• DX of exclusion, r/o other causes of hearing loss

P:

• hearing amplification
• avoid excessive noise exposure, use hearing protection

Question 19

Otosclerosis

Answer 19

**essentials of DX: **

• slowly progressive unilateral or B/L CHL
• pts in 30s and 40s
• family h/o otosclerosis
• NL otoscopic exam
• audiogram w/ Carhart notch and abnormal stapedial reflexes

**etiology: **

• abnormal, spongy growth at the junction of the stapes to the oval window in the middle ear
• lesions involving footplate of stapes result in increased impedance to passage of sound, through ossicular chain => CHL
• worsens over time

**epidemiology: **

• genetic predisposition, runs in families
• female and Caucasian predominance
• young adults to middle-aged adults

**S: **

• slow progressing hearing loss that is usually b/l and asymmetric (can be unilateral) [CHL]
• may report improved hearing w/ background noise
• tinnitus is common complaint

**O: **

• goal of exam = to exclude other causes of CHL (like cholesteatoma, tympanosclerosis, middle ear effusion or mass)
• NL physical exam and NL tympanogram, NL movement w/ pneumatic otoscopy, may see absent reflexes
• CHL (Weber lateralizes to ear w/ greatest conductive deficit and negative Rinne)
• may see Schwartze sign = reddish bluish, in active disease

A:

• Conductive HL on audiogram possibly w/ a Carhart notch at 2000Hz
• Temporal bone CT/exploratory sx is diagnostic
• when lesions impinge on cochlea, permanent SNHL occurs (cochlear otosclerosis)
• audiometry is one of most important tools
• DX strongly suggested from hx, PE, audiometric findings, and CT scan

P:

• management =
  
  • observation (most inexpensive and least risky)(audiograms yearly)
  • pharm therapy
    
    • cochlear otosclerosis may be improved w/ PO sodium fluoride over prolonged periods of time (recommended in new onset)
    • bisphosphonates
  • amplification
  • surgery
• refer to ENT for middle ear exploration/stapedectomy/ossicular chain reconstruction
• alternatively, hearing amplification and monitoring

Question 20

Exotoses/osteoma

Answer 20

Exotoses = multiple and protrude into EAC under normal mucosa

Osteomas = single outgrowth of tympanic bone into auditory canal

**etiology/epidemiology: **

• exotoses ass w/ swimming in cold water as a child

S:

• non-draining

O:

• no drainage
• skin-covered bony mounds in medial ear canal obscuring TM to variable degree
• in EAC (distinguish from cholesteatoma which is closer to or on TM)

P:

• exotoses
  
  • monitor; if obstruct ear canal then refer to ENT
• osteomas
  
  • solitary, of no significance as long as do not obstruct canal
  • monitor; if it obstructs the ear canal then refer to ENT

Question 21

Noise induced hearing loss

Answer 21

etiology:

• gunfire
• explosions
• loud concerts
• long term exposure to loud machinery
• loud noise causes damage to hair cells in cochlea (85 dB or higher)
• high freq sounds more damaging than low

epidemiology:

• h/o noise exposure
• repetitive in ppl who work in above environments (ie military, construction)

S:

• hearing loss
• tinnitus

O:

• PE is normal
• not always symmetrical

A:

• audiometry - classic noise notch at 4K

P:

• monitor for spontaneous improvement if it was an acute event - steroid use is questionable but widely used
• hearing amplification
• prevention =
  
  • avoidance of loud noises/music
  • ear protection (plugs, muffs) during exposure to loud noises

Question 22

Tinnitus

Answer 22

= the perception of sound in the ear when there is no actual sound

etiology:
* idiopathic
* acoustic trauma
* acute - loud concert
* chronic - loud machinery at work
* Presbycusis (age related hearing loss) or other hearing loss
* neuro damage (MS, acoustic neuroma)
* circulatory disorders
* side effect of meds
* obstruction of ear canal
* serous or purulent OM
epidemiology:

• noise exposure
• males
• older
• smoking
• CV disease

S:

• ringing, whooshing, buzzing, roaring, clicking, machinery-like noise, or pulsing sounds in one or both ears
• intermittent tinnitus =
  
  • typically benign and requires no workup unless other sxs are associated
• persistent tinnitus =
  
  • requires evaluation, consider referral to Audiology/ENT
• pulsatile tinnitus =
  
  • rhythmic w/ pulse

O/A:

• refer to ENT for work-up
• subjective tinnitus:
  
  • dx based on p’s complaint and may be supported by hearing loss on audiogram
• objective tinnitus:
  
  • clinician can hear the sound as well (stapedial myoclonus - clicking sound due to rhythmic elevation of the soft palate- and some vascular disorders)
• MRA or carotid doppler to r/o vessel defect
• imaging, neuro-otologic studies as needed

P:

• acute = oral steroid taper
• chronic = lipoflavanoids, niacin/B complex vitamins (nerve regenerative), tinnitus masking, hearing amplification if ass w/ hearing loss, white noise machine
• tx underlying condition
• reduce noise exposure, caffeine, smoking, alcohol, stree
• prevention = minimize noise exposure (85 dB ass w/ damage); use ear plugs

Question 23

Vertigo

Answer 23

etiology:

S:

• pt senses they are spinning or that the world is spinning around them
  
  • movement is an illusion, the pt is in fact still
  • compared to dizziness (real movement causes sensation of spinning or discomfort)

O:

• hallmark is nystagmus
• peripheral vertigo (inner ear causes) =
  
  • sudden onset
  • ass w/ N/V
  • horizontal nystagmus w/ fast beats away from affected side
  • fixation causes suppression (when have them focus on finger, nystagmus and sensation cease)
• central vertigo (CNS involvement) =
  
  • slow onset
  • vertical nystagmus
  • does not suppress w/ fixation

A:

• hx and PE
• audiometry
• video/electronystagmography
  
  • used to test inner ear and CNS function
  • pt wears infrared goggles to track eye movements during positional changes and visual stimulation
    
    • follows moving dots
    • head position creates nystagmus
• caloric testing (COWS)
  
  • cold and warm water or air used to stimulate inner ear
  • response is nystagmus in the specific direction
  • COWS
    
    • cold water in ear, inner ear changes temp, should cause nystagmus in direction away from the cold water and slowly back
    • warm water, eyes should move toward warm water and slowly away
• electrocochleography
  
  • measures electric potentials in the cochlea in response to sound stimulation
  • used to determine fluid pressure of the inner ear
  • used to DX Meniere’s or endolymphatic hydrops
• MRI

P/TX:

• benzodiazepines (valium, xanax) (meds used to suppress CNS); use in acute phase
• Meclizine/Transdermal scopolamine
• oral steroids (Pred good for viral etiology)
• salt/caffeine restriction
• vestibular rehab
• interventional and sx therapies are available for persistent cases
  
  • intertympanic steroids
  • endolymphatic shunts

Question 24

Benign Paroxysmal Positional Vertigo (BPPV)

Answer 24

• # 1 cause of vertigo (peripheral)

**essentials of DX: **

• sudden vertigo lasting secs to mins w/ head movement
• no associated hearing loss
• characteristic nystagmus (latent, geotropic, fatigable) w. Dix-Hallpike test

**etiology: **

• theorized that crystalline structures have disengaged from hair cells in semicircular canals, move throughout the canal w/ position change, and cause conflicting signals to brain
• debris in semicircular canal
• otoconia from utricle > post semicircular canal
• commonly ass w/ head injury, car accident or idiopathic

**epidemiology: **

• avg pt in 50s

S:

• sudden onset of vertigo/room spinning sensation w/ changes in head position, usually in 1 direction
  
  • triggering positions = rolling over in bed, looking up and back (top-shelf vertigo), bending over
• peaks and resolves in 10-20 seconds; gone when keep head straight (when come in, act like have stiff neck because they dont want to move their head)
• **INTACT hearing **
• vertigo may be ass w/ N

O:

• No spontaneous nystagmus
• NL neuro exam
• DX: Dix-Hallpike Manuever
  
  • nystagmus develops when quickly turning pt’s head 90 degrees while pt is in supine position
  • latency of 1-2 secs before onset of nystagmus and vertigo
  • nystagmus is mixed w/ a torsional and vertical component and is geotropic (down-beating, rotary nystagmus)
  • nystagmus in plane of canal and fast phase is toward the stimulated canal
  • nystagmus is fatigable (reduced w/ repetitive manuevers)
• can do MRI if dont have characteristic nystagmus, have neuro findings, or dont respond to tx
• NL tympanogram and audiogram

P/TX:

• Epley maneuver - partible repositioning procedure (move around in different positions and leave in position until spinning resolves then move to next position); can repeat
• vestibular rehab
• antihistamines (motion sicness meds ie Benadryl, Dramamine) - helpful to control N
• benzo-diazapines

Question 25

Meniere’s Disease

Answer 25

**essentials of DX: **

• episodic vertigo lasting hours
• fluctuating hearing loss
• tinnitus
• aural pressure

etiology:

• unknown - allergic, Autoimmune disorders, migraine variant
• anatomic = premise that there is increased endolymphatic fluid owing to impaire reabsorption of endolymph fluid in endolymph duct and sac
• allergy
• immunology
• genetic

epidemiology:

• typically pts in 50s

S:

• **hallmarked by tinnitus, vertigo, and hearing loss**
  
  • ​1) unilateral, fluctuating SNHL
    
    • ​low frequency tilt is common (one day wake up and don’t hear well, then gone the next day then comes back) (low frequency sensorineural hearing loss)
  • 2) distinct episodic attacks of vertigo lasting mins to hrs
  • **3) constant or intermittent tinnitus typically increasing the intensity before or during the vertiginous attack **
  • 4) aural fullness
• acute attack ass w/ N/V and exhaustion x days after attack

A:

• now thought to be 6 subtypes
  
  • classical Meniere’s
  • cochlear Meniere’s (not dizzy - doesnt affect cochlea just vestibular, remember picture)
  • vestibular Meniere’s (no auditory sxs)
  • subclinical endolymphatic hydrops (aural fullness)
  • post traumatic (SNHL and yrs later get sxs of Meniere’s)
• DX based on longitudinal course of disease rather than on a single attack
• audiometry
• MRI
• autoimmune serologic tests
• DDX: in addn to vestibular system, dizziness may be caused by poor vision, decreased proprioception (DM), CV insufficiency, cerebellar or brainstem strokes, neurological sonditions (migraines, MS), metabolic disorders, medication side effects

P/TX:

• current TX focus on relieveing vertigo w/o further injuring the pt’s hearing
• primary management = salt/caffeine restrictions and diuretic
• benzos and antiemetics (acute phase)
• Diuretics (Triamterene/HCTZ)
• aminoglycoside therapy (intratympanic gentamicin)
• oral steroids - if acute
• intratympanic steroids to treat active disease and avoid systemic complications ass w/ oral steroids
• sx intervention if fail other TXs
• prognosis = remissions and exacerbations

Question 26

Vestibular neuronitis

Labyrinthitis

neuritis

Answer 26

essentials of DX:

• vertigo lasting days after a URI
• NO hearing loss
• No other neuro signs or sxs

etiology:

• usually preceded by viral URI
• vascular occlusion
• immunologic mechanisms

**epidemiology: **

• middle-aged ppl

S:

• sudden onset of violent vertigo
• commonly ass w/ N and intense V
• last for hours to days
• +/- hearing loss, **usually NL hearing **
• NL neuro exam
• may have postural instability toward affected ear but is able to ambulate w/o falling

O:

• spontaneous nystagmus characteristis of acute peripheral vestibular injury (usually horizontal w/ torsional component and is suppressed by visual fixation)
  
  • slow phase toward injured ear and fast phase awat from injured ear

P:

• primary management = sxs and supportive care during acute phase
• steroids, benzos, antiemetics like Meclizine to control vertigo, N/V
• some need vestibular rehab (esp those w/ residual sxs)

Question 27

Perilymphatic Fistula

Answer 27

**etiology: **

• abnormal connection (tear or defect) in 1 or both of windows separating the middle and inner ear; perilymph fluid leaks into middle ear
• changes in middle ear pressure now directly affect inner ear, stimulating balance and/or hearing structures
• most common cause is head trauma
• other common causes = ear trauma, objects perforating TM, descent in plane or w/ scuba, rapid increases in intracranial pressure

S:

• dizziness, tinnitus, and hearing loss
• most ppl’s sxs worsen w/ changes in altitude (elevators, airplanes, travel over mountain passes) or air pressure (weather changes) as well w/ exertion and activity

A:

• hx and PE
• audiogram

P:

• some self healing, others require sx repair
• avoid lifting, straining, bending over