Week 3: ENT (clinical approach to ear symptoms) Flashcards
key symptoms of the ear
- Hearing loss
- Tinnitus
- Otalgia
- Otorrhoea
- Dizziness and vertigo
history questions to ask in someone with hearing loss
- Sudden or gradual
- Unilateral or bilateral
- Associated otologigical or neuro-otological symptoms
investigation for hearing loss
- Pure tone audiogram (PTA) and tuning fork test (Rinnes and weber)- should be used together
types of hearing loss
conductive vs sensorineural
conductive hearing loss involves either
the external or middle ear
causes of conductive hearing loss
- wax
- acute otitis media
- otitis media with effusion
- otosclerosis
- TM perforation
- cholesteotoma
Wax- additional symptoms to hearing loss
- Additional symptoms: feeling blocked
- Signs: wax on otoscopy
- Investigations: n/a
otitis media with effusion -additional symptoms to hearing loss
- Additional symptoms: popping, clicking/pressure
- Signs: dull/ staw TM/ fluid level, bubbles on otoscopy
- Investigations: tympanogram will show flat trace
otosclerosis - additional symptoms to hearing loss
- Additional symptoms: can be unilateral or bilateral
- Signs
- Usually none
- Schwartz sign: red tinge to TM= flamingo sign
- Investigations: CT, PTA-2kHz raised BC threshold (carhart notch)
TM perforation- additional symptoms to hearing loss
- Additional symptoms- may have middle ear discharge if active infection
- Signs – TM perforation
- Investigations: n/a
cholesteatoma- additional symptoms to hearing loss
- Associated symptoms: chronic smelly discharging ear
- Signs: deep retraction pocket with keratin collection
- Investigations- CT
sensorineural hearing loss
pathology involving the inner ear structures or CN VIII
causes of sensorineural hearing loss
- presbucysus
- noise related hearing loss
- menieres disease
- acoustic neuroma
- ototic mediations
presbycusis - additional symptoms to hearing loss
- Symptoms: bilateral, gradual
- Signs: normal otoscopy
- Investigations: PTA
noise related hearing loss- additional symptoms to hearing loss
- Symtpoms: often tinnitus
- Signs: normal otoscopy
- Investigation: PTA
menieres disease - additional symptoms to hearing loss
- Symptoms: tinnitus and vertigo
- Signs: normal otoscopy
- Investigation: MRI, autoimmune screen
acoustic neuroma -additional symptoms to hearing loss
- Symptoms: asymmetrical hearing loss
- Signs: normal otoscopy
- Investigation: MRI
Management of hearing loss
Audiological
- Hearing aids for mild to prfound hearing loss
Surgical
- Tympanoplasty - Cartilage or temporalis fascia is used to repair a perforation in tympanic membrane.
- Stapedectomy - Prosthesis used to bypass fixed stapes/footplate in otosclerosis and allow transmission of sound into inner ear
- Bone anchored hearing aid – a transcutaneous or percutaneous device can be surgically implanted under general or local anaesthesia for a conductive, mixed conductive /sensorineural hearing loss or unilateral dead ear
- Cochlear implantation- sensorineural hearing loss.
- Middle ear implant – suitable for conductive and mixed hearing loss
Management of excessive ear wax
Management of excessive ear wax
tinnitus
- Perception of sound when no external sound is present*
- ‘sound of silence’- all people if sat in silence in a sound proof room will hear tinnitus
causes of tinnitus
- No identifiable cause in most cases
- Usually associated with hearing loss
types of tinnitus
- Non-pulsatile
- Pulsatile
Non-pulsatile tinnitus
- False perception of sound that is heard by affected individual only
- E.g. buzzing, high pitched tone
- Associated with noise induced hearing loss, presbycusis, Meniere’s, head injury, otitis media, drug related (salicylates, NSAIDs, loops)
pulsatile tinnitus
- Sound heard by individual that is synchronous with their heartbeat
- Cause is turbulent blood flow that reaches cochlear
- Vascular causes
- Atherosclerosis on internal carotid
- Vascular malformation
- Glomus tumours
- Non vascular causes
- Paget’s
- Otosclerosis
- Myoclonus of the muddle ear muscles (clicking noise)
investigations for tinnitus
-
MRI
- If unilateral and associated with hearing loss (exclude acoustic neuroma)
-
MRI or CT angiography
- If pulsatile tinnitus
treatment of tinnitus
- Reassurance that tinnitus is common and they will adapt to it
- Usually worse at quiet times e.g. at night and worrying about it generally makes it worse
- Addressing any underlying causes e.g. hypertension, carotid stenosis, side effects of mediation
- Behavioural therapy coping strategies
- A noise generator can be helpful with sleep
- Hearing aid may help if hearing loss is present through a masking effect
Otalgia
Otalgia is ear pain that can originate from the ear itself or can also be referred from elsewhere in the head or neck
Otalgia causes
Referred otalgia
Any pathology involving the cranial nerves V, VII, IX, and X and the upper cervical nerves C2 and C3 can cause the sensation of referred otalgia.
- Ask about other general symptoms
- Dental, nasal and throat symptoms
- Indicators of malignancy
which condition is the most common cranial neuralgia linked to referred otalgia
Trigeminal neuralgia
otorrhoea
- The ear can discharge wax, pus, blood, mucus and even cerebrospinal fluid.*
- Remember discharging wax should be reassured as normal.
The common bacterial pathogens in a discharging ear that can cause an infection include:
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Proteus spp.
- Streptococcus pneumonia
- Haemophilus influenza
- Moraxella catarrhalis
history taking in pt with otorrhea
- Duration of discharge – If chronic, think chronic otitis media including cholesteatoma especially if unilateral
- Is there associated otalgia (ear pain)?
- Associated fever or systemic symptoms indicates an infective aetiology
- Is there associated hearing loss or dizziness?
- Do not miss a history of putting foreign bodies in the ear especially in children
- Facial nerve palsy - May occur with acute or chronic otitis media especially if the facial nerve is dehiscent along its course in the middle ear (10% of the population)
- Check for history of trauma - CSF otorrhoea
- Has there been any recent history of topical antibiotics? This can in itself cause discharge or predispose to antifungal ear infections if there is prolonged usage
DD for otorrhea
Dizziness and vertigo
True vertigo is most often associated with a sensation of ‘spinning’ and movement of the surrounding environment. It is important to distinguish this from the more generalised dizziness of disequilibrium.
epidemiology of vertigo
Epidemiology: male: female 1:3
History
- Need to ascertain that this is true vertigo
- Duration and frequency of attacks
causes of vertigo
Benign Paroxysmal Positional Vertigo (BPPV)
- most common cause of true vertigo with typical age of onset 40-60 years
- Dix-hallpike test positive
- Rotatory vertigo on moving head
Vestibular neuritis
- Rotatory vertigo that is continuous for over 24 hours often associated with nausea and vomiting
- Confined to bed and takes days to weeks to recover
Meniere’s Disease
- Rotatory vertigo associated with fluctuating hearing loss often with low frequency threshold affected
- Tinnitus usually gets worse during an attack
- Patients classically gen an aural fullness before onset of vertigo
Vestibular migraine
- Rotatory vertigo can last minutes to hours to days
- Headaches
- Photophobia
- Visual disturbance
- Phonophobia
- Not always a headache or visual symptoms
- Can sometimes overlap (e.g. hearing loss) – hard to differentiate between conditions such as Meniere’s
invesrtigations for vertigo
Investigations
- Full neurological examination
- Pure tone audiometry
- Dix-Hallpike test
- MRI of internal auditory meatus may be appropriate with asymmetrical sensorineural loss to exclude an acoustic neuroma
- Video head impulse testing (vHiT) – this is performed using specialist equipment and can be used to assess the function of the semi-circular canals by measuring visual ocular reflex (VOR) function. It takes around 15minutes to perform and is a quick and sensitive measure of labrythine function
treatment of BBPV
Epley’s manoeuvre can be curative in up to 90% by repositioning of the displaced otoconia crystals. In persistent cases, Brandt-Daroff exercises may be advised. Surgical management is rarely required but posterior semi-circular canal occlusion is useful in resistant cases.
treatment of vestibular neuronitis
Treatment is expectant with anti-emetics during the acute phase
treatment of menieres disease
The underlying pathophysiology is thought to be endolymphatic hydrops.
Therefore “pressure reducing” therapies include:
- low salt diet,
- medications such as betahistine and diuretics although the
second line
- Intratympanic injection of steroid or gentamicin is used for those that fail conservative management.
other treatments
- saccus decompression, labyrinthectomy and vestibular nerve section.
treatment of vestibular migraine
Common trigger factors include dehydration, foods (classically chocolate, cheese), anxiety and a poor sleep pattern.
A symptom diary can help identify these. In those that do not respond to avoidance measures, there are a variety of migraine-preventative medications available.
