Week 3 'Ears' Flashcards
Conductive hearing loss
Etiologies
Make acronym: COPDOOOC
from (physical/mechanical) problems that limit movement of the sound wave through the external and middle ear; canal, tympanic membrane, auricular bones (Meatus, Incus, Stapes)
ETIOLOGIES:
i. obstructed external ear canal – eg. cerumen impaction, foreign body, exostosis, psoriais
ii. perforated tympanic membrane – eg direct trauma, otitis media, or explosion
iii. dislocated ossicle (malleus, incus, or stapes) - trauma to the ear
iv. Otitis media or serous otitis media
v. Otitis externa - infection of the ear canal that causes it to swell
vi. Otosclerosis or ossicular chain fixation
vii. Congenital: eg external auditory canal atresia
viii. Cholesteatoma: growth of squamous epithelium in middle ear
Sensorineural Hearing loss (SNHL)
Etiologies (11 of them)
Make an acronym: (SHABAM OVI BAM)
damage to the hair cells or nerves that sense sound waves in the inner ear
ETIOLOGIES:
i. acoustic trauma - prolonged exposure to loud noises
ii. barotrauma (pressure trauma) or ear squeeze - eg divers, climbers
iii. head trauma - eg fracture of the temporal bone
iv. ototoxic drugs - Bilateral loss, hx of use.
Examples include:
— antibiotics including aminoglycosides (gentamicin, vancomycin), erythromycin, and
tetracycline
— salicylates (aspirin) and NSAIDs (ibuprofen, naproxen)
— antineoplastics (cancer drugs)
— cocaine—intranasal or IV
v. Infection – mumps, measles, influenza, herpes, mono, syphilis, meningitis
vi. Aging—presbycusis: progressive bilateral hearing loss (high pitches), normal neuro exam
vii. Acoustic neuroma - tumor in the auditory nerve.
viii. Sudden SNHL (SSNHL): unilateral hearing loss over 72 hr. Associated with microvascular
event, head trauma
ix. Ménière disease - hearing loss, vertigo and tinnitus. Gradual onset, often progresses to
deafness and severe vertigo
x. Vascular diseases eg sickle cell disease, diabetes, polycythemia, and excessive clotting
xi. Multiple sclerosis
Mixed Hearing Loss
combination of both conductive and sensorineural loss
Approach to patient for the Ear
- PE
- Lab
- Imaging
- Other testing:
- Appropriate referral
- Physical exam
Vitals
EENT, Otoscopic, insufflation, hearing tests (whispered voice, tuning forks), neurological, CVS - Laboratory, if indicated
CBC, chemistry screen (CMP), culture any discharge - Imaging studies, if indicated
x-ray, CT or MRI to evaluate masses - Other testing: audiology, tympanometry
- Appropriate referral
EENT (otologist), neurologist, audiologist, etc.
Tinnitus
List the 2 main types:
perception of sound (eg buzzing, ringing, roaring clicks) in absence of an acoustic stimulus
- Subjective tinnitus
- Objective tinnitus
- Other types/causes
Subjective Tinnitus
Etiology
Subjective tinnitus - audible only to pt, due to damage of fine hair cells (MOST COMMON)
Etiology: Acoustic trauma, Presbycusis Barotrauma, CNS tumors Eustacian tube dysfunction, Infections (OM, labryinthitis, meningitis) Meniere disease, Ear canal obstruction (wax, foreign body, tumorDrugs (salicylates, loop diuretics, cisplatin, aminoglycosides
Objective tinnitus
rare, can be heard by listening directly over the patients ear
Etiology:
A-V malformations Turbulent flow in carotid A or jugular V
Vascular middle ear tumor (esp if unilateral—R/O by ordering CT)
Other causes of tinnitus
- Other types/causes: hyperlipidemia, allergies, diabetes, hypertension, hypotension, syphilis, CV disease, TMJ disorders, cervical injuries, stress, dietary deficiencies, intake of stimulants (nicotine, caffeine).
Work-up for tinnitus
History:
PE:
History: get good description of “sound” (episodic/constant, pitch, quality)
Ask re: noise exposure, head trauma, hearing problems, dizziness, loss of balance, recent dental problems/work, bruxism, stress, medications, smoking, caffeine, HTN, anxiety, insomnia
PE: Otoscopic exam, cranial N VIII function and hearing (whispered, tuning fork tests)
Check for: carotid artery bruits, HTN, oral exam, neck/jaw hypertonicity, TMJ dysfunction Additional work-up: audiology, angiography
Vertigo
a type of dizziness
sensation of altered spatial orientation “illusory movement”
most often caused by dysfunction of the vestibular, visual, or proprioceptive (posterior column)
systems
more common in aging, increased incidence of falling in those > 65 years.
List the two types of vertigo:
Types:
i. subjective if patient has the impression they are “moving in space” (self-motion)
ii. objective if objects “moving around” the patient (motion of the environment)
True Vertigo
SSX:
How do you tell if true vertigo is peripheral or central vertigo?
True Vertigo - sensation of movement (most common cz)
Caused by asymmetry in the vestibular system (CN8, inner ear, cerebellum)
SSX: either surroundings are moving or patient is moving within surroundings
Postural instability, nausea and vomiting, sweating
Vertigo is worse when moving head
Nystagmus is commonly seen on eye exam (involuntary movements of the eye)
Further classified as
i. Peripheral vertigo: labyrinth or CN VIII
ii. Central vertigo: cerebullum, vestibular cortex in temporal lobe
Peripheral vs. Central Vertigo (true vertigo)
Table in NOTES!
Non-vertigo-syncope, fainting
List the 3 types:
Non-vertigo - syncope, fainting
Types:
i. lightheadedness
“graying out” of vision, pallor, roaring sound in the ears
suggests hypoperfusion of the brain from:
hypotension drugs, decreased cardiac output, hypoglycemia,
shock dehydration, severe anemia, cardiac arrythmias
ii disequilibrium occurs while standing or walking (gait impairing), unsteadiness without dizziness Source of problem may be: Cerebellar dysfxn cervical spondylosis
frontal lobe tumor stroke motor neuron diseases
iii. miscellaneous chronic hyperventilation syndrome
new eyewear phobias: eg agoraphobia, acrophobia extra-ocular muscular palsy results in diplopia
Work up for vertigo:
- Hx
- PE
History:
–Onset: sudden or gradual?
i. Sudden onset and recall of episodes are often due to inner-ear disease,
ii. Gradual and ill-defined vertigo most common in CNS, cardiac, and systemic diseases
–Duration:
i Episodic true vertigo that lasts for seconds, associated with head or body position changes
eg. benign paroxysmal positional vertigo (BPPV)
ii. Vertigo of sudden onset that lasts for minutes can be due to brain or vascular disease
iii. Vertigo that lasts for hours or days probably caused by Ménière disease or vestibular
neuronitis
Physical Exam for Vertigo
i. General examination - vital signs, supine and standing BP, orthostatic BP, CVS
ii. Otological exam: examine ears for cerumen, discharge, foreign body TM - perforation may result in sudden vertigo iii Extraocular movements “H in space” check for nystagmus (eye jerking movements)
horizontal plane - most common form vertical plane - always abN, brain stem function disorder pendular - often congenital or after prolonged period of blindness iv. Hearing tests Whispered voice test Weber/ Rinne to assess conductive or sensorineural loss
v. Sensory exam to assess proprioception vi. Vestibular imbalance: Past-pointing with eyes closed
Romberg test: tend to fall toward the vestibular lesion
RED FLAG CONCOMITANTS for vertigo:
head or neck pain
ataxia
loss of consciousness
focal neurological deficit
Non-vertigo tests:
Non-vertigo tests:
i. lightheadheadness
orthostatic hypotension- increase in pulse by 30 bpm, systolic BP drop of 15-20 mm Hg
carotid sinus massage
valsalva maneuver
ii. disequilibrium: drifts toward side of lesion
cerebellar (coordination) and proprioception testing
observe walking and turning; forward & backward walking
iii. miscellaneous
hyperventilation: sitting, breathe quickly and deeply (2 minutes while observing for nystagmus)
Otalgia
Ear pain
List some causes of Otalgia:
EARACHE/ ear pain (otalgia)
Eg Causes:
external ear –impacted cerumen or foreign body, local trauma, otitis externa
middle ear – eustacian tube obstruction, OM, neoplasm
referred pain from TMJ, wisdom teeth
local infections: tonsillitis, enlarged adenoids, peritonsillar abscess
atlas/axis subluxation
tumor in pharynx, tonsils, tongue, larynx; thyroiditis
neuralgia: trigeminal, sphenopalatine, glossopharyngeal, geniculate
colds, allergies, cold wind blowing in ear
Red Flag concomitants with otalgia:
Red flag concomitants: Diabetes or immunocompromised pt, redness/pain over mastoid,
Severe swelling of canal meatus, chronic pain with head/neck symptoms
Otorrhea
Ear discharge
