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w4 Flashcards

1
Q

portions of eustachian tube

A

2 portions 1/3 lateral= bony medial 2/3 = fibrocartilaginous portion to nasopharynx

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2
Q

Normal functions of ET

A
  1. Ventilation: aeration & pressure regulation of ME & nasopharynx
  2. Protection: from nasopharyngeal secretions ascending into ME and sudden pressure change
  3. Clearance: mucociliary action clears secretions from ME into nasopharynx
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3
Q

ET closed at rest but opens regularly

A

Swallowing evey 4-6 swallows, yawning, changes in atmospheric pressure

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4
Q

abnormal or impaired function ET

A

impaired opening or closing; defective mucociliary clearance

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5
Q

prevalence of ET dysfunction

A

generally 0.9% , new survey 4.6%

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6
Q

etiology of Obstructed ET or failure to open regularly

A

Obstruction: masses in ME or nasopharynx
o Inflammation due to allergy, infection or sinusitis, negative ME pressure & retraction of TM

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7
Q

Etiology of Patulous eustachian tube (open ET)

A

o Rapid weight loss
o Pregnancy
o Unknown

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8
Q

ET dysfunction can have additional pathologies like

A
  • Recurrent acute otitis media or om with effusion
  • Hearing loss
  • Chronic retraction of the MT
    o Adhesions to ossicles and retractions pockets
    o Retraction pocket can evolve into cholesteatoma
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9
Q

Acute otitis media

A

rapid onset inflammation and infection in ME

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10
Q

Middle ear effusion

A

fluid in the ME without reference to etiology, pathogenesis, pathology or duration

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11
Q

Otorrhea

A

discharge from 1 or more following sites: external auditory canal, ME, mastoid, inner ear or intracranial cavity

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12
Q

Otitis media with effusion

A

inflammation of ME with fluid; no signs and symptoms of acute infection (Redness, foul smell)

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13
Q

Recurrent AOM

A

: well documented & separate AOM episodes greater than or = to 3 in 6 months or 4 in 12

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14
Q

When to suspect ET dysfunction Obstructed or closed ET

A
  • Fullness or pressure
  • Otalgia (pain)
  • Difficulty popping ears
  • Baro-challenged: poor pressure equalization (flying, scuba diving)
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15
Q

Recurrent AOM

A

well documented & separate AOM episodes greater than or = to 3 in 6 months or 4 in 12

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16
Q

when to suspect ET dysfunction Patulous ET (constantly open ET)

A
  • Fullness
  • Pulsatile tinnitus including clicking sensation
  • Autophony of voice or breathing
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17
Q

Findings during audiological assessment for occluded ET

A

History: OM with effusion or acute
Otoscopy: retracted TM
Abnormal tympanogram: negative TPP, reduced static admittance
HL: conductive component
- Above all may be absent- additional testing may be necessary

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18
Q

Findings during audiological assessment for patulous ET

A

Oscillations in admittance during tympanometry or acoustic reflex testing
- Synchronized with pulsatile tinnitus and respiration

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19
Q

Valsalva procedure

A

record a pre-test tympanogram
- ET and Me are inflated by a forced but gentle expiration
- Re-measure tympanogram: ensure patient doesn’t swallow
- Tympanometric peak pressure shifts

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20
Q

valsalva procedure caution

A

Contraindications:
- Vascular/coronary disease or abnormal bp
- Retrinopathy or glaucoma
- 3rd trimester pregnancy
Violent exhalation during Valsalva could induce:
- Damage to the inner ear
- Fainting
- More serious problems for those with any of above medical conditions

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21
Q

Toynbee test

A
  • deflation test to assess changes vin resting ME pressure
    Procedure: record a pre-test tympanogram, perform closed nose swallowing, remeasure tympanogram, tympanometric peak pressure shifts, usually negative pressure change
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22
Q

ET dysfunction Audiological assessment

A

: standard audiometry, acoustic immittance (astatic admittance, TPP, inflation deflation tests to assess changes in resting ME pressure)
- Hold nose and blow, introduce positive pressure and tympanogram shifts to right

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23
Q

ET dysfunction: Medical examination

A

Otoscopy or pneumatic otoscopy:
Valsalva test: overpressure in ME can be observed as a budging TM
Toynbee test: observe changes in TM mobility during swallowing with nose closed

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24
Q

Politzer test

A

similar to the Valsalva test, but nasopharynx is passively inflated
1. Compress or block nostrils
2. Rubber tube attached to an air bag is inserted into 1 nostril and used to inject positive pressure
3. Patient then swallows or repeats “K K K” to open ET
4. TM is observed via otoscopy

25
Q

Flexible nasopharygoscope

A

Physical examination allows visualization of pharyngeal end of ET
- Goal: to investigate potential obstruction of ET by nasal or pharyngeal masses such as enlarged adenoids, soft tissue growths

26
Q

imaging

A

MRI & CT: visualize the ET
- Nasopharyngeal masses (carcinoma)
- ME masses (e.g, cholesteatoma)

27
Q

what is a cholestatoma

A
  • Middle ear mass described as cyst or tumour
    o Epidermal inclusion cyst formed from stratified squamous epithelium
    o Not a neoplasm (noncancerous)
  • Can erode ossicles and spread to invade and damage surrounding tissues (i.e., bony walls of ME cavity)
28
Q

mean age of aqcuired cholestotoma

A

9 years

29
Q

mean age of Congenital cholesteatoma

A

5.6 years

30
Q

Congenital cholesteatoma Pathology

A

residual embryonic cells trapped in ME
- Squamous epithelial cells that produce keratin

31
Q

Congenital cholesteatoma appearance

A

white mass medial to normal TM in ME cavity: “Keratin pearl”

32
Q

Congenital cholesteatoma clinical features

A

normal TM with no prior history of otorrhea, perforation or canal atresia

33
Q

Congenital cholesteatoma course of disease

A

chronic recurring inflammation and OM, permanent change in ME Mucosa

34
Q

acquired cholesteatoma pathology

A

TM retraction, TM perforation, skin and other debris enter ME

35
Q

acquired cholesteatoma presentation

A

history of poor ET function, chronic OM

36
Q

what is acquired cholesteatoma

A

Invasion of skin cells (squamous epithelia) into ME cavity
Cyst-like pouch forms with:
- Dead and viable squamous epithelial cells
- Keratin shed by viable cells
- Enzymes that erode bone
- Cholesterol crystals
- Bacteria

37
Q

acquired cholesteatoma subdivided into

A

primary and secondary

38
Q

Primary acquired cholesteatoma

A

ET dysfunction leading to negative ME Pressure
- Sucks in retraction pocket, Pouch or sac by stretching TM
- Pocket can contain epithelial cells that produce keratin and otorrhea
- Eventually invades ME forming cholesteatoma

39
Q

Secondary acquired cholesteatoma

A

: squamous cell migration through perforation in TM

40
Q

Common sites in ME for cholesteatoma

A

(1) Pars flaccida into posterior and anterior epitympanum (2) posterior pars tensa into mesotympaum

41
Q

Course of cohlesteatoma and complication

A
  • Capacity to invade & erode adjacent structures
42
Q

ME: erosion of saccules & wall

A

Posterior: extend into mastoid
Superior: invade brain cavity (meningitis & abscess)
Medial wall: erosion of bony labyrinth
Lateral scc: sudden vertigo
Cochlea: sudden SNHL
Inferior: below bony wall of ear canal bony lies facial nerve

43
Q

audiologic Case history complaints cholesteatoma

A

fullness/pressure in ear, HL, otorrhea, otalgia, dizziness or vertigo, muscle weakness on one side of face

44
Q

audiologic assessment

A

case history
- Standard audiometric procedures (otoscopy, PT, acoustic immittance)

45
Q

PT thresholds with cholesteatoma

A

vary with involvement of ME ossicles & cochlea, normal conductive or mixed loss of varying degree

46
Q

acoustic immitance with cholesteatoma

A

vary from normal to abnormal depending on involvement of ossicle and TM

47
Q

audiologic managment of cholesteatoma

A

: amplification, aural rehab

48
Q

medical management of cholesteatoma

A

cleaning ear (debridement) & antibiotics to reduce pain, stop drainage and control infection
Conservative management: regular follow with repeated cleaning when surgery contraindicated (anaesthetic risks, age and systematic disease)

49
Q

standard treatment of cholesteatoma

A

surgery to protect from serious complications
Goal of surgery: remove cholesteatoma & infected tissue, achieve infection free dry ear, preservation or restoration of facial function & hearing

50
Q

cholesteatoma surgery

A

Single or 2 stage:
1. Cholesteatoma removal
2. Follow up or revision surgery for
a. Reconstruction (rebuild walls of ME or canal, reduce size of mastoid cavity, facial nerve repair, repair or replace ossicles)
b. Removal of recurrence of cholesteatoma

51
Q

tympanoplasty

A

removal of cholesteatoma from ME through TM which is then repaired

52
Q

mastoidectomy

A

mastoid bone explored to remove any cholesteatoma that involves mastoid bone and ME

53
Q

2 types of mastoidectomy

A
  1. Canal wall up
  2. canal wall down
54
Q

canal wall up

A

posterior wall of External ear canal intact
a. Smaller
b. No mastoid cavity requiring cleaning
c. Higher risk of recurrence

55
Q

canal wall down

A

a. For med-large cholesteatomas
b. Much lower incidence of recurrence
c. Larger than normal ear canal opening & larger open cavity which can accumulate debris and cause issues with water (vertigo in cold or hot, need plugs for swimming)

56
Q

2 types of canal wall down

A

1) Radical mastoidectomy (2) modified radical mastoidectomy

57
Q

Radical mastoidectomy

A

extensive removal of bony structures (including TM & ossicles) to form common open space, obliteration of ET conductive/mixed with maximum conductive component HL

58
Q

modified radical mastoidectomy

A

less extensive surgery, more common, ME cavity intact, TM & ossicles retained or replaced with prosthesis, variable degree of post-op conductive or mixed HL

59
Q

Audiologic management& outcomes for cholesteotoma

A
  • counselling about expectations for hearing postop
  • troublesome cavities limit success with amplification, altering resonant frequency and inadequate aeration due to occlusion
  • can consider BAHA, reconstruction of mastoid cavity and EAC to reduce size and improve function

9530 (7 decks)

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