Tutorial 5 - ENT (A) - terminology and conditions

Question 1

How do you perform an ear examination ?

Answer 1

• General inspection
• Webers and riders test with 512 Hz
• Palpate pre and post auricular area, mastoid process and pinna.
• Otoscopy
• Audiometry

Question 2

What does the external, middle and inner ear each respectively contain ?

Answer 2

• External ear - Pinna, external acoustic meatus, tympanic membrane
• Middle ear - air filled, ossicles - malleus, incus, stapes
• Inner ear - fluid filled, cochlea and semi circular canals

Question 3

Name 3 structures of the pinna.

Answer 3

• Tragus
• Anti - tragus
• Meatus

Question 4

Name the parts of the tympanic membrane .

Answer 4

• Pars flaccid at top
• Pars tensa at the bottom
• Umbo is the tip of the malleus
• Cone of light is the anterior - inferior quadrant

Question 5

What is audiometry and describe high vs low frequency hearing loss

Answer 5

• Audiometry is a test conducted to access the type of hearing loss present - to better help find the cause of the hearing loss. ]
  -Hearing loss can present as high pitched or low pitched hearing difficulty - which essentially means that you can only hear the sound at volumes > 20 DB.

Question 6

Why may someone with high frequency hearing loss struggle to comprehend speech ?

Answer 6

• High frequency sound like that of the consonants F, H and s cannot be heard.
• Thus hearing difficulty

Question 7

1. What is otitis externa ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / test can you do ?
5. What is the management ?

Answer 7

1. Otitis externa is inflammation of the ear canal - can be due to infection i.e. pseudomonas areuginosa or due to skin conditions such as contact dermatitis from ear plugs.
2. Ear pain, ear discharge, hearing loss and ear canal itchiness.
3. Swimming and warm climates
4. Examine ear canal through otoscope, conduct webers and riders test ( conductive hearing loss pattern)
5. Treat with topical acetic acid 2 % spray for 7 - 14 days, next treat with topical antibiotic +/- topical corticosteroid, if severe consider oral antibiotic such as flucloxacillin for 7 days.

Tell patient to keep ear clean, dry, stop using anything that can cause contact dermatitis i.e. ear plugs. Prescribe analgesics for pain such as ibuprofen or codeine.

Question 8

1. What is noise related hearing loss ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 8

1. Damage to inner ear due to constant exposure to loud noises i.e. lawn mowers occupation or watching TV loud daily.
2. Gradual onset hearing loss (high frequency hearing loss ), tinnitus, saying “what” a lot in conversations, turning up volume on TV.
3. Occupation, exposure to loud sounds
4. Webers / riners, audiometry ( sensorineural hearing loss pattern ).
5. Hearing aids, cochlea implant (depending on severity).

Question 9

1. What is meniere’s disease ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 9

1. Ear disease affecting the inner ear.
2. Tinnitus, hearing loss( low to middle frequency sensorineural), vertigo ( 20 minutes - 12 hours, 2X episodes at least)
3. Autoimmunity, genetic susceptibility, head trauma
4. Webers / riners, audiometry ( sensorineural hearing loss pattern ).
5. Reassure that the attack should clear up within 24 hours, if persists for 5 - 7 days come back. Prescribe prochlorperazine or an antihistamine like cyclizine for N + V, prescribe betahistine to reduce frequency / severity of attacks.

Question 10

1. What is acute otitis media ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 10

1. Inflammation and infection of the middle ear ( S. pneumonia).
2. In older kids and adults usually presents with ear pain, in younger children they often come in holding their ear, crying, temperature etc.
3. Young age (shorter, more horizontal, thicker eustachian tube), smokers / second hand smokers.
4. Webers / riners ( conductive hearing loss ), otoscopy will show a bulging red / yellow tympanic membrane.
5. Check for serious complications i.e meningitis - admit to hospital, if systemically unwell consider oral antibiotics course i.e. amoxacillin for 5-7 days, otherwise reassure should be self limiting within a week and prescribe analgesia.

Question 11

1. What is age related hearing loss ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 11

1. Also knows as presbycusis. General every day sounds with age add up to cause sensorineural hearing loss.
2. Find it harder to hear higher pitched sounds, mens sound easier to hear than females (pitch), conversations hard to understand especially when there is background noise i.e. restaurant.
3. Age, family history, loud occupation / hobby.
4. Webers / riners, audiograms ( sensorineural).
5. Hearing aids / cochlea implant.

Question 12

1. What is chronic suppurative otitis media disease ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 12

1. Chronic inflammation of the middle ear, with persistent ear discharge through a perforated tympanic membrane.
2. Ear discharge for more than 2 weeks.
3. Acute / recurrent otitis media, younger age, second hand smoke.
4. Webers / riners - conductive hearing loss, history of AOM, ear discharge persisting for over 2 weeks, otoscope will show perforated tympanic membrane.
5. Treatment includes antibiotics, topical steroids and cleaning of the ear.

Question 13

1. What is mastoiditis ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 13

1. Mastoiditis is a serious bacterial infection of the mastoid bone air cells.
2. Redness / tenderness / swelling behind the ear.
3. Middle ear infection, cholesteatoma, ear discharge
4. Otoscope - if tympanic membrane normal than its not likely to be mastoiditis, ear discharge culture, head CT scan.
5. Urgent antibiotics IV, if failed, surgery ( drainage or mastoidectomy).

Question 14

1. What is a cholesteatoma ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 14

1. Often acquired - Eustachian tube dysfunction, middle ear negative pressure, TM retracts, squamous epithelium builds up, more likely infection, erosion into local structures pivotal for hearing / balance !
2. Foul smelling blood stained discharge, retracted crusty tympanic membrane, hearing loss, tinnitus.
3. Middle ear disease, eustachian tube dysfunction.
4. Webers / riners - conductive hearing loss, otoscope will show white mass, CT, MRI and audiology test.
5. Antibiotics (clear up any infection), followed by surgery to get rid of the cholesteatoma and a follow up surgery to fix any inner ear damage.

Question 15

1. What is otitis media with effusion ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 15

1. OME, also know as glue ear, is characterised by secretory build up in ear without the presence of an acute infection.
2. Feeling of fullness in ears, muffled hearing, fluid may drain into ear ( if perforated ), pain / tugging on ear.
3. Cleft palate, down syndrome smoking / second hand smoke, URTI, large adenoids.
4. Webers / riners - conductive hearing loss pattern, otoscopy - yellow, retracted, absent light reflex, air bubbles on tympanic membrane.
5. Watchful waiting for 3 months ( in which time should have regular audiology / tympanometry / speech and language testing), ENT may provide nasal ballon, hearing aids, myringotomy + grommet insertion.

Question 16

1. What is congenital deafness ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 16

1. Hearing loss which is present at birth or during childbirth.
2. Not being startled by loud sounds, by 6 months not turning around to a sound stimuli, by 1 year not saying single words like “mama”.
3. Family history, early infection i.e. rubella, drug / alcohol use during pregnancy.
4. N/A
5. Cochlea implant fitted at an early age to allow normal development of speech / hearing.

Question 17

1. What is referred ear pain ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 17

1. Otalgia caused by pathology of nerves which pass in close proximity of the ear, but no actual ear pathology necessarily.
2. Ear pain with normal otoscopy and webers / riners test.
3. Dental health ( Trigeminal - 5 ), sore throat / tonsillitis (glossopharyngeal - 9 ), jaw problems ( TMJ - 5 ).
4. Otoscopy, webers / riners.
5. Treat underlying disease.

Question 18

1. What is otosclerosis ?
2. How does it present ?
3. What are its risk factors ?
4. What examinations / tests can you do ?
5. What is the management ?

Answer 18

1. Otosclerosis is the abnormal bone growth between the 3 small (MIS) bones of the middle ear, consequently meaning they cannot vibrate / amplify sound as well.
2. Hearing loss that progressively gets worse, difficulty hearing low pitched sounds and whispers, speaking quietly as your voice may sound loud to you, finding it easier to hear in noisy environments (odd).
3. Family history, during pregnancy ( related to fluctuating hormone levels ? ).
4. Webers / riners - conductive hearing loss pattern, audiogram, tympanometry .
5. Hearing aids, or surgery such as stapedectomy ( implant directs sound from healthy bones straight to inner ear).