Traumatic Injuries of the Ear, SSNHL and Tinnitus Flashcards
In auricular injuries, hematomas ______________________________________ where ___________________________________________
separate the perichondrium from the cartilage where the blood supply disrupted causing cartilage deformities
In this injury case:
What would be the symptoms related to her hearing?
Traumatic TM perf with cochlear damage
Bleeding
Decreased hearing
Dizziness
What is Barotrauma?
Any type of pressure induced trauma
Baro = pressure
What can cause barotraumas? (2)
Diving, valsalva, sneezing, elevation changes,…
Injury can be implosive or explosive
What is Caisson Disease?
Aka “the bends” or decompression sickness
Can occur with deep sea diving
Arises from dissolved gasses coming out of solution into bubbles inside the body on depressurization
What occurs with the gasses in Caisson disease?
Compressed nitrogen (N) -> soluble
Decompressed N -> gas emboli/bubble -> back, joint, muscles -> sickness
Treatment-hyperbaric oxygen
Fistula =
abnormal connection
Perilymphatic fistula =
= between inner and middle ear
Different locations
Round window
Oval window
Others
What is this condition?
Round Window Fistula
What can cause Perilymphatic Fistula?
Usually an inciting event
Blow to the head
Sneezing
Lifting a heavy object
Sudden changes in pressure (flying, diving)
Sometimes spontaneous
What is the high-risk population from perilymphatic fistula?
Post-stapedotomy
Inner ear anomalies (Mondini malformation and large vestibular aqueduct)
How can we diagnose perilymphatic fistula?
Difficult to diagnose
History
Exam - Hennebert’s sign and Tullio’s phenomenon
Audiogram - sudden or rapid progressive HL
Definitive - look in the operating room
Explain Hennebert’s sign related to perilymphatic fistula.
Hennebert’s sign (fistula test)
Nystagmus/dizziness produced by pressure applied to the EAC
Positive in PLF, syphilis
Explain Tulliio’s phenomenon related to perilymphatic fistula.
Tullio’s phenomenon
Dizziness induced by sound
Positive in PLF, SSCDS, Meniere’s disease
How can we treat perilymphatic fistula?
Refer to ENT
Strict bed rest
HOB elevated 30 degrees
Avoid lifting, straining or hard nose blowing
Stool softeners
Surgery if no improvement (middle ear exploration and patching of fistula)
What can cause Temporal Bone Fractures (TBF)?
MVA
Physical assaults
Falls
Motorcycle accidents
Pedestrian injuries
Bicycle accidents
How can TBF cause hearing loss?
Hemotympanum
Ossicular chain disruption
Inner ear fracture
Others (concussion, nerve injury, TM rupture,…)
What are the types of TBF and how are they defined and diagnosed?
Types
Longitudinal vs transverse
Otic capsule sparing vs otic capsule violating
Defined with respect to the long axis of the temporal bone
Diagnosed with CT scans
Which type of TBF is this?
Longitudinal orOtic Capsule Sparing
Which type of TBF is this?
Transverse orOtic Capsule Violating
What are the characteristics of longitudinal TBF?
Lateral blows
Blood in EAC
TM perforation
CHL
20% facial nerve weakness
What are the characteristics of Transverse TBF?
Front/back blows
Hemotympanum
Intact TM
SNHL (mixed)
50% facial nerve weakness
Vertigo
What can we see here?
Other signs of skull base fractures
What are the acute complications of TBF?
Hearing loss (CHL, SNHL, mixed)
Vertigo
Tinnitus
Facial paralysis
CSF leak/perilymphatic fistula
Vascular injury
What are ossicular injuries of TBF?
Separation of the incudostapedial joint
Dislocation of the incus
Fracture of stapedial arches
Fracture of malleus handle
Footplate fracture-dislocation
What are the delayed complications of TBF?
BPPV (most common)
Meniere’s disease
Tinnitus
Central vestibular disorders
Meningitis
Cholesteatoma
Pneumocranium
Psychogenic malingering
What constitutes a sudden onset of SNHL?
30 dB or greater SNHL
3 contiguous frequencies
Within 3 days or less
How can SNHL affect patients and providers?
Devastating to patients
Frustrating for healthcare providers
Definitive etiology and treatment still unknown
What are associated symptoms of SSNHL? (3)
Vertigo/dizziness
Aural (ear) fullness
Tinnitus
What can cause SSNHL?
Neurological symptoms and signs
Ototoxic medication use
Recent viral infections (colds)
Head trauma, straining, sneezing, nose blowing, intense noise exposure
Recent flying or scuba diving (sudden pressure changes)
What are past medical history diseases that can cause SSNHL?
Autoimmune diseases
Vascular diseases
Malignancies
Neurologic conditions
Hypercoagulable states
Sickle cell disease
What are past surgical history cases that can cause SSNHL?
Stapedectomy
Mastoidectomy
What are exams to help us diagnoses SSNHL?
- Ears (otoscopy)
Effusion, cholesteatoma, cerumen impaction - Tuning fork
- Neurologic exam
What investigative tests for SSNHL identification?
- Audiometry
- Laboratory tests
CBC (complete blood count)-infections
ESR (erythrocyte sedimentation rate)-inflammation
VDRL FTA-Abs (syphilis test)
Coagulation studies - Imaging tests MRI (magnetic resonance imaging)
Assess for brainstem (CPA) tumors
Multiple sclerosis
Ischemic (stroke) changes
10% of patients with vestibular schwannomas (acoustic neuromas) present with SSNHL*
Give etiological cases of SSNHL?
Idiopathic
Infectious (viral)
Autoimmune
Traumatic
Vascular
Neoplastic
Give SSNHL Autoimmune Etiology:
Cogan’s syndrome
Wegener’s granulomatosis
Polyarteritis nodosa
Temporal arteritis
Systemic lupus erythromatosis
Explain the pathophysiology of SSNHL from autoimmune complications.
Vasculitis of blood vessels of the inner ear
Autoantibodies attack the inner ear (cross-reacting antibodies)
Explain the etiology and causes of SSNHL from autoimmune complications.
Any causes that disrupts blood supply to the cochlea can lead to SSNHL
Cochlea is intolerant to ischemia (no collateral blood supply)
Causes
Strokes (vasospasms, embolism)
Blood clotting tendencies (Sickle-cell disease)
What are treatments for SSNHL?
Treatment depends on the cause
General treatment for idiopathic SSNHL
Steroids*
Antivirals (controversial)
Vasodilators (controversial)
Anticoagulants (controversial)
In SSNHL, there might be a worst prognosis if associated with:
Vertigo
Total deafness
Advanced age
Downsloping audiogram
Associated vascular risk factors
In SSNHL, there might better prognosis if associated with:
Minimal hearing loss
Low-frequency loss
Tinnere means:
Means “ringing” in Latin
What us Tinnitus?
Perception of sound in the absence of external stimuli
Usually described as originating in the ears or around the head
Can be extremely annoying and cause reduced quality of life
May be the first or only symptom of a serious disease (eg vestibular schwannoma)
Tinnitus symptoms can manifest from
- ringing, buzzing, hissing, roaring, clicking, pulsatile
- high or low pitched
- Unilateral or bilateral
What is subjective tinnitus?
Sound is only perceived by the patient
More commonly related to hearing loss
Pitch of tinnitus may correlate with frequency of hearing loss (3-5 KHz)
Little known about physiologic mechanism
Hyperactive hair cells or nerves
Reduced suppressive influence of CNS
What is objective tinnitus?
Sound can be detected by another person
Usually caused by an internal body sound or vibration
May be exacerbated by CHL
More commonly related to pathology
What is the difference between non-pulsatile and pulsatile tinnitus?
Pulsatile
Usually objective tinnitus
Possible vascular etiology (increased or turbulent blood flow)
Non-pulsatile
Usually subjective tinnitus
Ringing, buzzing,…
What are the possible causes of subjective tinnitus?
Presbycusis
-Medications
Noise exposure
-Middle ear effusion
Head trauma
-TMJ problems
Otosclerosis
-Syphilis
Meniere’s disease
-Depression
Acoustic neuroma
-Metabolic
-Meningitis -
-Cardiovascular
What drugs could help against subjective tinnitus?
Aspirin
Non-steroidal anti-inflammatory drugs (NSAIDs)
Aminoglycoside antibiotics
Antidepressants
Ototoxic drugs (+more)
What is the relationship between subjective tinnitus and depression?
Depression:
More prevalent in patients with chronic tinnitus than those without tinnitus
Increased severity of tinnitus reported for patients with depression
Tinnitus -> Depression or Depression -> Tinnitus
What is objective Tinnitus?
- Audible to other people/observers
- Evaluation
Pulsatile or non-pulsatile
Relation to heart rate, light exercise
Diligent otoscopy
Auscultate external auditory canal, mastoid, skull, neck
Audiometry, imaging
What are the possible causes of objective tinnitus?
Vascular tumors
Glomus jugulare
Glomus tympanicum
Abnormal vascular anatomy
Patulous Eustachian tube
Palatal myoclonus
Idiopathic stapedial muscle spasm
Benign intracranial hypertension
What can we say about objective tinnitus and vascular tumors?
Glomus jugulare and tympanicum
Otoscopy reveals redish mass behind TM
Tinnitus is not altered by compression of neck blood vessels
What can we say about Arteriovenous malformations (AVM) and objective tinnitus?
Arteriovenous malformations (AVM)
Pulsatile tinnitus synchronous with heartbeat
May be secondary to trauma
Managed with removal or blockage of AVM (embolization
