HEENT - Ears

The otoscopic diagram can be divided into what quadrants

posterosuperior, posteroinferior, anterosuperior, anteroinferior

In hearing conduction, sound waves enter via the ______ and are then transmitted through the ___

base of the cochlea into the cochlear duct; basilar membrane towards the apex

High-frequency sound waves are received by the _____, which is why high frequency hearing loss is ____

base of the cochlea; the first type of hearing we tend to lose

Otoscopic examination requires us to look at (COMPLETES)

C = color

O = other conditions

M = mobility

P = position

L = lighting

E = entire surface

T = translucency

E = external auditory canal and auditory

S = seal

The posterosuperior quadrant allows us to visualize ___

incudostapedial joint and pars flaccida

The anterosuperior quadrant allows us to visualize

lateral process and manubrium of malleus

The anterioinferior quadrant allows us to visualize the

light reflex

The posteroinferior quadrant allows us to visualize the

pars tensa and umbo

AOM epi

preschool age, declines with age

AOM risk factors

previous infections, pacifier, cigarettes

AOM etio

S. pneumoniae, H. influenzae, M. catarrhalis, viruses

AOM pathophys

inflammation obstructs the eustacian tube

AOM clinical presentation

children = crying, pulling on ear

otalgia

± fever

AOM PE findings

TM bulging (is MC), erythema or otalgia

middle ear effusion

AOM diagnoses

MEE (middle ear effusion) and inflammation

AOM tx

pain management, antibiotics? (if fever, inflammation, or purulence = give abx)

AOM complications

perforation, hearing loss, labyrinthitis, mastoiditis

AOM with Effusion epi

MC in children

AOM with Effusion risk factors

previous infections, pacifier, cigarettes

AOM with Effusion etiology

usually aseptic

AOM with Effusion clinical presentation

hearing loss (conductive), speech deficit

AOM with Effusion PE findings

TM - color; air fluid levels

mobility - pneumatic otoscopy (air puffer attachment for otoscope)

AOM with Effusion dx

MEE (middle ear effusion), no signs of infection

AOM with Effusion tx

3+ months or speech delay = audiology/speech eval

structural abnormalities = refer to ENT

generally abx are NOT a good option, maybe anithistamines

tympanostomy tubes = hearing loss/structural damage

AOM antibiotic guidance

< 6 months = give abx

6mo-2yr = unilat or bilat = give abx

> 2 yrs = maybe wait and see, look at duration, risk factors, etc

AOM with Effusion complications

conductive hearing loss, tympanosclerosis

Chronic AOM epi

MC in children

Chronic AOM risk factors

frequent AOM, socioeconomics

Chronic AOM etio/pathophys

P. aeruginosa, S. aureus

Eustachian tube

Chronic AOM clinical presentation

otorrhea >/= 2 weeks

hearing loss

usually painless

Chronic AOM PE findings

perforation with otorrhea

Chronic AOM dx

clinical; maybe get a culture

Chronic AOM tx

aural toilet/irrigation

antibiotics

surgery

Chronic AOM complications

mastoiditis, cholesteatoma

Cholesteatoma etio/patho

accumulation of squamous epithelium in middle ear/mastoid

Cholesteatoma epi

MC in children

not every perforation is

chronic otitis media

Cholesteatoma risk factors

recurrent AOM/MEE, frequent tubes, cleft palate, genetics

Cholesteatoma clinical presentation

MC is otorrhea > 2 weeks

new onset hearing loss

Cholesteatoma OE findings, otoscopy

white mass, retraction pocket, pocket of keratinized cells

Cholesteatoma dx

clinical suspicion, CT

Cholesteatoma tx

± tubes, excision

Cholesteatoma complications

hearing loss, CN palsies, venous thrombosis, meningitis

Mastoiditis clinical presentation

recent AOM, otalgia, fever

Mastoiditis patho

involves mastoid air cells

Mastoiditis epi

school aged children

Mastoiditis risk factors

prolonged AOM

Mastoiditis PE findings

postauricular findings, tenderness on the mastoid, more systemic

Mastoiditis dx

hx and PE (looking straight on, one ear can look asymmetric); CT

Mastoiditis tx

abx; refer to ENT

Perforated tympanic membrane cause

change of pressure, AOM, trauma (barotrauma = diving, flying, blast injuries, foreign bodies)

Perforated tympanic membrane hx

head injury, other

Perforated tympanic membrane PE findings

secondary survey (might see blood or other)

otoscopy

Perforated tympanic membrane management

infection = abx

trauma = maybe abx, not always depending on MOA

keep ears dry

ENT evaluation

otitis externa clinical presentation

pruritis, pain

otitis externa etio/patho

swimming, p. aeruginosa, s. aureus

otitis externa epi

older children

otitis externa risk factors

trauma to EAC (external auditory canal); Q-tips

otitis externa PE findings

EAC pain on movement, swelling

otitis externa dx

clinical (push/touch external ear/tragus = likely)

otitis externa tx

topical abx, wick

otitis externa complications

malignant OE, osteomyelitis

types of auditory disorders

bruits

endogenous, maskable tinnitus

exogenous tinnitus

slow brainstem tinnitus

bruits

objective sounds; hear rushing of blood

endogenous, maskable tinnitus

better when other stimuli masks ringing (think, noise bothering you is internally sourced, it gets better when it’s masked with external stimuli)

exogenous tinnitus

better when in silence (think exo is external, cut out all external noise)

slow brainstem tinnitus

among older patients, associated with vertigo, dizziness

auditory disorder treatments

instrumentation = ambient noise, hearing aids

pharmacotherapy = lidocaine, benzos, neurontin

other therapies = retraining, hypnosis, OMM

when irrigating an ear, always use….

warm (NOT hot) water, check for nystagmus afterwards

dizziness etio

heart, brain, or ear related issues

dizziness etio - more history

ROS = cardiovascular, neuro, ENT

medications

time and provoking/aggravating factors

dizziness PE findings/things to look for

orthostatic issues, neuro findings

lab studies should include EKG; ± labs and imaging, check for nystagmus

acute vestibular syndrome is ______; can be related to ____

acute onset of dizziness, persistent and continuous

posterior circulation ischemic stroke, vestibular neuritis/labyrinthitis, posterior fossa hemorrhage, Wernicke syndrome

vestibular neuritis patho

viral or postviral to CNVIII (vestibulocochlear n)

vestibular neuritis clinical presentation

vertigo, N/V, gait instability

vestibular neuritis PE findings

nystagmus - suppressed with visual fixation

gait instability, no neuro deficits

head thrust, rapidly turn head to one side to see if you can induce/stimulate nystagmus

vestibular neuritis dx

clinical; rule out other neuro bad things, can get CT/MRI if highly sus

vestibular neuritis tx

usually self-limited; can give steroids if needed to treat symptoms

Meniere’s disease definition

Idiopathic, distention of endolymph in inner ear

Meniere’s disease epi (syndrome vs disease)

Typically, middle age (20-40 y/o)

Meniere syndrome = identifiable cause

Meniere disease= idiopathic

Meniere’s disease pathophys

fluid build up, abnormal ion homeostasis

Meniere’s disease clinical presentation

episodic vertigo, tinnitus, hearing loss

Meniere’s disease dx

takes time, vertigo x2 episodes

SN hearing loss

tinnitus

Meniere’s disease tx

treat symptoms, ENT eval

watch triggers

meclizine, benzos, HCTZ

types of triggered episodic vestibular syndromes

benign paroxysmal positional vertigo (BBPV)

orthostatic hypotension

central paroxysmal positional vertigo

benign paroxysmal positional vertigo (BBPV) pathophys

canalithiasasis (little stone is semicircular canals)

benign paroxysmal positional vertigo (BBPV) clinical presentation

episodic vertigo provoked by head movements; no neuro complaints

benign paroxysmal positional vertigo (BBPV) exam

Dix-Hallpile manuever

benign paroxysmal positional vertigo (BBPV) dx

history and exam

benign paroxysmal positional vertigo (BBPV) tx

“particle repositioning”, Epley manuever

acoustic neuroma epi

not common, incidental

acoustic neuroma patho

Schwann cell tumor to CNVIII (vestibulocochlear)

acoustic neuroma risk factors

neurofibromatosis type II, occupational noise, radiation acoustic neuroma

acoustic neuroma clinical presentation

hearing loss, tinnitus

acoustic neuroma PE findings

SN loss, CN exam

acoustic neuroma dx

audiometry, CT/MRI if other CN deficits present

acoustic neuroma tx

surgery, radiation

AOM, bulging TM over malleus

AOM with effusion, can see bubble outlines, still has TM bulging over malleus

Cholesteatoma = white mass, retraction pocket