Ear Disorders

Conductive hearing loss: mechanism (Objective)

Sound cannot efficiently travel through the external or middle ear to reach the cochlea.

Conductive hearing loss: common causes (Objective)

Cerumen or foreign body, severe otitis externa, otitis media with effusion, tympanic-membrane perforation, cholesteatoma, and otosclerosis.

Conductive hearing loss: distinguishing features (Objective)

Muffled sound with preserved speech clarity when volume rises; abnormalities may be visible in the canal or tympanic membrane.

Conductive hearing loss: Weber and Rinne (Objective)

Weber lateralizes to the affected/pathologic ear; Rinne is abnormal with bone conduction greater than air conduction on that side.

Conductive hearing loss: management (Objective)

Treat the underlying cause; it is frequently reversible or mechanically correctable.

Sensorineural hearing loss: mechanism (Objective)

Damage to the cochlea, hair cells, CN VIII, or central auditory pathway.

Sensorineural hearing loss: common causes (Objective)

Presbycusis, noise exposure, ototoxic medications, Ménière disease, labyrinthitis, acoustic neuroma, genetics, and congenital CMV or rubella.

Sensorineural hearing loss: distinguishing features (Objective)

Both volume and speech clarity are impaired, especially in noisy environments; otoscopy is usually normal and tinnitus is common.

Sensorineural hearing loss: Weber and Rinne (Objective)

Weber lateralizes away from the affected/pathologic ear; Rinne remains positive with air conduction greater than bone conduction bilaterally.

Sensorineural hearing loss: management (Objective)

Often permanent because cochlear hair cells do not regenerate; treat correctable causes, prevent further injury, and use hearing aids or cochlear implants as appropriate.

Sudden unilateral sensorineural hearing loss (Objective)

Otologic emergency requiring urgent audiometry, ENT evaluation, and prompt corticosteroid treatment.

Conductive vs sensorineural hearing loss (Objective)

Conductive loss impairs sound transmission and Weber goes toward the affected ear; sensorineural loss impairs cochlear/neural function and Weber goes away from the affected ear.

Hearing-loss evaluation (Objective)

Use Weber/Rinne testing, otoscopy, and audiometry to distinguish conductive from sensorineural loss and identify the cause.

Auricular hematoma: mechanism (Objective)

Blood collects between auricular cartilage and perichondrium after blunt or shearing trauma, commonly in contact sports.

Auricular hematoma: distinguishing features (Objective)

Acute painful, ecchymotic, fluctuant deformity of the anterior pinna with a typically normal ear canal and tympanic membrane.

Auricular hematoma: management (Objective)

Prompt needle aspiration or incision and drainage followed by a firm compression dressing to prevent reaccumulation.

Auricular hematoma: ENT indications (Objective)

Refer when large, older than about 7 days, recurrent, or associated with extensive injury.

Auricular hematoma: complication (Objective)

Untreated hematoma may cause cartilage ischemia, necrosis, and permanent cauliflower-ear deformity.

Cerumen impaction: mechanism and risks (Objective)

Normal outward wax migration fails with excess production, narrow/tortuous or hairy canals, cotton-swab use, hearing aids/earbuds, or age-related dry cerumen.

Cerumen impaction: distinguishing features (Objective)

Ear fullness, muffled/decreased hearing, tinnitus, and brown/yellow/black wax obstructing the canal so the tympanic membrane cannot be seen.

Cerumen impaction: hearing tests (Objective)

Conductive pattern: Weber lateralizes to the affected ear and Rinne shows bone conduction greater than air conduction.

Cerumen impaction: treatment (Objective)

If symptomatic or obscuring the tympanic membrane, use manual curettage, cerumenolytics such as hydrogen peroxide or mineral oil, or saline irrigation.

Cerumen impaction: irrigation precaution (Objective)

Avoid irrigation when tympanic-membrane perforation is suspected.

Cerumen impaction: prevention (Objective)

Avoid cotton swabs and keep hearing aids clean.

Otitis externa: mechanism (Objective)

Disruption of acidic cerumen, the intact canal skin barrier, or the dry environment permits bacterial overgrowth in the external auditory canal.

Otitis externa: risks and pathogens (Objective)

Water exposure, humidity, cotton swabs, devices, excessive cleaning, skin disease, and diabetes; Pseudomonas is most common, followed by Staphylococcus aureus.

Otitis externa: distinguishing features (Objective)

Severe otalgia, fullness, pruritus, and purulent otorrhea with pain on pinna manipulation or tragus palpation and an erythematous, edematous canal.

Otitis externa: tympanic membrane (Objective)

The tympanic membrane is normal if it can be visualized, helping localize infection to the external canal.

Otitis externa: treatment (Objective)

Topical ofloxacin or ciprofloxacin with or without steroid; neomycin/polymyxin B/hydrocortisone only when the tympanic membrane is intact.

Otitis externa: ear wick (Objective)

Insert an ear wick when canal edema prevents topical drops from penetrating.

Aminoglycoside ear-drop precaution (Objective)

Neomycin-containing drops can be ototoxic and should be used only when the tympanic membrane is intact.

Malignant otitis externa: definition (Objective)

Invasive Pseudomonas infection spreading from the external auditory canal to the skull base and causing osteomyelitis.

Malignant otitis externa: risk profile (Objective)

Older adult with diabetes or an immunocompromised patient.

Malignant otitis externa: distinguishing features (Objective)

Severe otalgia out of proportion to examination, persistent otorrhea, failed topical therapy, granulation tissue at the bone-cartilage junction, and possible CN VII palsy.

Malignant otitis externa: diagnosis (Objective)

CT or MRI of the temporal bone, elevated ESR/CRP, and drainage culture.

Malignant otitis externa: treatment (Objective)

Hospital admission, IV antipseudomonal antibiotics, urgent ENT consultation, and glycemic control.

Ear foreign body: common presentations (Objective)

May be asymptomatic or cause unilateral pain/fullness, conductive loss, tinnitus, pruritus, bleeding, foul otorrhea, or distress from a live insect.

Ear foreign body: high-risk objects and situations (Objective)

Button batteries, magnets, sharp/deep or tightly impacted objects, objects near the tympanic membrane, poor cooperation, and repeated failed attempts increase risk.

Button battery in the ear (Objective)

Creates current in moist tissue, producing hydroxide and rapid liquefactive necrosis; remove immediately with emergency ENT involvement.

Ear foreign body: first-attempt principle (Objective)

The first attempt offers the best chance of success; repeated attempts increase edema, bleeding, and deeper impaction.

Soft or graspable ear foreign body: removal (Objective)

Use alligator forceps.

Smooth round ear foreign body: removal (Objective)

Use suction or place a right-angle hook behind the object.

Small loose inorganic ear foreign body: removal (Objective)

Warm-water irrigation may be used only if the tympanic membrane is intact.

Live insect in the ear: removal (Objective)

Immobilize with warm mineral oil or lidocaine, then remove.

Seed, bean, food, or foam in the ear: removal (Objective)

Use instrumentation or suction rather than irrigation.

Sharp, deep, or tympanic-membrane-adjacent foreign body (Objective)

Refer to ENT for removal.

Eustachian tube dysfunction: mechanism

Failure to equalize pressure or drain the middle ear causes negative pressure, tympanic-membrane retraction, effusion, and increased otitis-media risk.

Eustachian tube dysfunction: risks

Viral URI, allergic rhinitis, sinusitis, adenoid hypertrophy, smoke, and rapid pressure changes; children have shorter, more horizontal tubes.

Eustachian tube dysfunction: distinguishing features

Fullness or pressure, muffled hearing, popping/clicking, and worsening with altitude; retracted tympanic membrane with reduced mobility and possible air-fluid level.

Eustachian tube dysfunction: management

Treat the cause; observe and encourage swallowing, yawning, or gum. Use intranasal steroids/antihistamines for allergies or oxymetazoline for sinus congestion.

Eustachian tube dysfunction: referral

Refer if symptoms persist longer than 3 months or recurrent effusions/AOM suggest a need for tympanostomy tubes.

Otitis media with effusion: definition (Objective)

Nonpurulent middle-ear fluid without signs or symptoms of acute infection.

Otitis media with effusion: distinguishing features (Objective)

Fullness, muffled hearing, popping, little or no pain, no fever, and air-fluid levels or bubbles behind a neutral/slightly opaque tympanic membrane with reduced mobility.

Otitis media with effusion: management (Objective)

Observe because most resolve within 3 months; treat the cause and do not use antibiotics.

Otitis media with effusion: referral

Consider tympanostomy tubes when bilateral effusion persists longer than 3 months and affects hearing.

Acute otitis media: mechanism (Objective)

A viral URI causes eustachian-tube dysfunction and sterile effusion that becomes secondarily infected by nasopharyngeal bacteria.

Acute otitis media: common pathogens (Objective)

Streptococcus pneumoniae is most common; Haemophilus influenzae and Moraxella catarrhalis are also common.

Acute otitis media: distinguishing features (Objective)

Acute otalgia, fever, irritability, ear tugging, or muffled hearing with an erythematous bulging tympanic membrane and purulent effusion.

Acute otitis media: most specific finding (Objective)

A bulging tympanic membrane.

Acute otitis media: diagnosis (Objective)

Clinical diagnosis supported by reduced tympanic-membrane mobility on pneumatic otoscopy.

Acute otitis media: first-line treatment (Objective)

Analgesia plus high-dose amoxicillin; children receive 80-90 mg/kg/day divided twice daily, and adults receive 875 mg twice daily or 500 mg three times daily.

Acute otitis media: immediate-antibiotic indications (Objective)

Age under 6 months, otorrhea, moderate/severe pain, pain at least 48 hours, temperature above 102.2°F, bilateral disease at 6-23 months, immunocompromise, craniofacial abnormality, or unreliable follow-up.

Acute otitis media: observation option (Objective)

Reasonable only for mild symptoms after 6 months of age, with a safety-net prescription or reassessment if worsening or not improving within 48-72 hours.

Acute otitis media: amoxicillin-clavulanate indications (Objective)

Amoxicillin in the previous 30 days, purulent conjunctivitis, or recurrent AOM that failed amoxicillin.

Recurrent acute otitis media: ENT referral (Objective)

Consider tympanostomy tubes for at least 3 episodes in 6 months or 4 in 12 months, with at least 1 in the preceding 6 months.

Otitis media with effusion vs acute otitis media (Objective)

Effusion has sterile fluid, little/no pain, and no fever; AOM has acute infection, pain/fever, and a bulging inflamed tympanic membrane.

Ruptured tympanic membrane: causes

AOM, direct trauma or instrumentation, foreign body, barotrauma, temporal-bone fracture, or prior tympanostomy tube.

Ruptured tympanic membrane: distinguishing features

Sudden severe pain, conductive hearing loss, tinnitus, fullness, and bloody or purulent otorrhea with a visible membrane defect.

AOM-associated tympanic-membrane rupture

Increasing ear pain and fever followed by sudden otorrhea and often abrupt pain relief as middle-ear pressure releases.

Ruptured tympanic membrane: management

Most heal within weeks; keep the ear dry, avoid irrigation/instrumentation and forceful nose blowing, avoid aminoglycoside drops, and treat underlying AOM.

Mastoiditis: mechanism and significance (Objective)

AOM spreads into mastoid air cells, causing osteitis and bony-septal destruction with possible cortical or intracranial extension.

Mastoiditis: distinguishing features (Objective)

Recent/inadequately treated AOM with fever, worsening otalgia, purulent otorrhea, mastoid tenderness, postauricular erythema/edema, loss of the crease, and pinna displaced laterally and inferiorly.

Mastoiditis: diagnosis (Objective)

Clinical suspicion with leukocytosis and elevated ESR/CRP; confirm with contrast CT of the temporal bone.

Mastoiditis: treatment (Objective)

Hospitalize for IV antibiotics and obtain urgent ENT consultation for possible drainage.

Cholesteatoma: definition

Keratinizing squamous epithelium and debris abnormally collected within the middle ear or mastoid.

Acquired cholesteatoma: mechanism

Chronic eustachian-tube dysfunction or middle-ear disease creates negative pressure, retracting the tympanic membrane and trapping expanding keratin that erodes nearby bone.

Congenital cholesteatoma

White pearly mass behind an intact tympanic membrane in a child without prior surgery, perforation, or chronic infection.

Cholesteatoma: distinguishing features

Persistent or recurrent painless foul-smelling unilateral otorrhea with progressive conductive loss and pearly white keratin in a deep retraction pocket.

Cholesteatoma: management

ENT referral for surgical excision plus long-term surveillance because recurrence is common.

Otosclerosis: mechanism

Abnormal bone remodeling around the stapes and oval window fixes the stapes and causes progressive hearing loss.

Otosclerosis: distinguishing features

Age 20-40, often bilateral and familial, with progressive conductive loss, tinnitus, preserved early speech discrimination, and difficulty with low-frequency sounds.

Paracusis Willisii

Hearing speech better in noisy environments because other people speak louder; associated with otosclerosis.

Otosclerosis: diagnosis and management

Audiometry shows conductive loss without an external/middle-ear cause; use CT if uncertain. Observe/use hearing aids if mild-moderate or refer for stapedotomy/stapedectomy if severe.

Ear barotrauma: distinguishing features

Sudden pain or pressure, fullness, muffled hearing, and conductive loss during or after flying, diving, blast exposure, or another rapid pressure change.

Ear barotrauma: otoscopy

May show tympanic-membrane retraction, erythema, middle-ear hemorrhage, effusion, or perforation.

Ear barotrauma: management

Analgesics and gentle pressure equalization; avoid flying/diving until symptoms and the tympanic membrane heal.

Ear barotrauma: urgent ENT indications

Vertigo, sensorineural hearing loss, severe persistent tinnitus, or neurologic symptoms suggesting inner-ear injury.

Vertigo: definition (Objective)

False sensation of movement caused by vestibular dysfunction; patients describe spinning and may have nystagmus, nausea/vomiting, and imbalance.

Vertigo: peripheral clues (Objective)

Hearing loss, tinnitus, or aural fullness suggest inner-ear/CN VIII disease such as BPPV, neuritis, labyrinthitis, Ménière disease, or acoustic neuroma.

Vertigo: central clues (Objective)

Diplopia, dysarthria, weakness, numbness, or ataxia suggest brainstem/cerebellar disease such as stroke, MS, tumor, or vestibular migraine.

HINTS examination: appropriate setting (Objective)

Use in acute, continuous vertigo to distinguish peripheral vestibular neuritis from central vertigo, especially posterior-circulation stroke.

HINTS head-impulse: peripheral pattern (Objective)

Abnormal vestibulo-ocular reflex with a corrective catch-up saccade after rapid head rotation.

HINTS head-impulse: central pattern (Objective)

Normal head impulse with eyes remaining locked on target; in acute continuous vertigo, this raises concern for stroke.

HINTS nystagmus: peripheral pattern (Objective)

Horizontal, unidirectional regardless of gaze, and suppressed by visual fixation.

HINTS nystagmus: central pattern (Objective)

Vertical or direction-changing with gaze and not suppressed by fixation.

HINTS test of skew: peripheral vs central (Objective)

No vertical correction is a negative peripheral pattern; vertical realignment is a positive skew suggesting a brainstem lesion.

BPPV: mechanism (Objective)

Displaced otoconia enter a semicircular canal, shift with head movement, and create abnormal endolymph flow and transient vertigo/nystagmus.

BPPV: distinguishing features (Objective)

Brief, intermittent vertigo triggered by rolling in bed, looking up, or bending over; asymptomatic between episodes with no hearing loss, tinnitus, or focal deficits.

BPPV: diagnosis and treatment (Objective)

Positive Dix-Hallpike maneuver; treat with the Epley otoconia-repositioning maneuver.

Vestibular neuritis and labyrinthitis: shared presentation (Objective)

Sudden severe continuous peripheral vertigo after a viral URI, often with nausea/vomiting and difficulty walking; lasts 24-48 hours and improves gradually over weeks.