HEENT Ear Disorders

What does the external ear consist of?

Pinna and External Auditory Canal

Cerumen Impaction

Buildup of ear wax blocking ear canal

Cerumen Impaction Cause

Q-tip use

Cerumen Impaction findings

fullness in ear, conductive hearing loss

Cerumen Impaction treatment

Hydrogen peroxide 3% ear drops, softening drops, mechanical removal, suction or irrigation (only if Tympanic Membrane is intact***)

Otitis Externa

inflammation of the external auditory canal

Otitis Externa Cause

Swimmers ear or trauma like scratching

Gram negative rods or fungi in a moist, dark environment

Otitis Externa Signs and Symptoms

Otalgia (ear pain), Erythema and edema (swelling) of ear canal often with purulent exudate, puling ear pinnia illicia pain (indicitive of OE)

Important about Otitis Externa and Tympanic Membrane

Swelling in ear canal might be too severe to visualize Tympanic Membrane so patients need to come back in a few days after antibiotic treatment for us to look at it and make sure it is still intact.

Otitis Externa Treatment

First Line: Otic antibiotic solution (neomycin/polymyxin B or ciprofloxacin, Greater than 5 drops twice a day or 4 times a day)

Second Line: In recalcitrant cases, oral quinolones like Cipro 500mg twice a day for 7 days

Foreign Body in the Ear

Presents with otalgia, otorrhea, and/or decreased hearing. 1-6yo and comes in fussy.

Foreign Body Diagnosis

Inspection via otoscopy

Foreign Body Management/Treatment

Immobilize child and use irrigation, suction, or forceps.

IMPORTANT FOREIGN BODY OBJECT

BUTTON BATTERIES; will cause severe alkaline burns in ear canal

What are the types of outer ear disorders?

Cerumen Impaction, Otitis Externa, & Foreign Body in the Ear

What are the components of the inner ear?

Vestibular Nerve, Cochlear Nerve, Eustachian tube

Acustic Neuroma/Vestibular Schwannoma

Benign tumor on the vestibulocochlear nerve (8th CN). Unilateral symptoms

Acustic Neuroma symptoms

Unilateral hearing loss, difficulty with speech discrimination, tinnitus, facial numbness, or feeling of disequilibrium.

Acustic Neuroma Imaging

MRI

Acustic Neuroma Treatment

Observe, excise, or radiotherapy

Eustachian Tube Anatomy

- Connects the middle ear to the nasopharynx

- Ventilates middle ear space, allows drainage of middle ear secretions, and protects the middle ear from reflux of nasopharyngeal contents and sounds

- Usually closed and opens with yawning or swallow

Infrant vs Adult Eustachian Tube Anatomy

Infants have shorter, narrower, and horizontal. Adults have longer, wider, and angled downward at 45 degree angle.

Why is it bad to bottle feed infants laying flat?

Milk will travel straight into the eustachian tube and suction into the middle ear (because there is no downward slant preventing it from backflowing)

what is Eustachian Tube Dysfunction most caused by?

Most caused by upper respiratory infection or seasonal allergies

Eustachian Tube Dysfunction signs and symptoms

Fullness in ear, mild to moderate impairment, popping sensation with swallowing or yawning

Normal vs Abnormal Tympanic membrane when a patient has Eustachian Tube Dysfunction

Pneumatic Otoscope Exam: push a little bit of air into ear to see tympanic membrane move.

Abnormal if the TM is stiff and barely moving when air is blowed into ear

Eustachian Tube Treatment

- Systemic and nasal decongestants: pseudoepherdrine 60mg Q4-5hr, Oxymetazoline every 8-12 hr (This is Afrin so MAX 3 days)

- Self insufflation (Pinch nose, close mouth, blow air from nose)

- Second Line: Recalcitrant cases: tubes placed

Acute Unilateral Vestibulopathy (AUVP)

Sudden loss of balance function in one ear, causes severe spinnign vertigo, nausea, gait impairment

50% of patients who have this had a viral illness beforehand

IMPORTANT SYMPTOMS TO RULE OUT AUVP

Hearing loss, Dysarthria (speech problems), dysphagia (swalling difficulty), limb weakness, sensory loss, facial droop. If the pt has these symptoms, they do NOT have AUVP!!

Treatment for AUVP

Supportive care: nausea (zofran), dizzy (meclizine), Vestibular rehab therapy. Will resolve on their own.

Labyrinthitis

Inflammation of the inner ear labriynth. Acute onset of continuous, severe vertigo lasting several days, along with hearing loss in 1 yera or tinnitus

What can cause Labyrinthitis?

Most likely viral but bacterial illness is more severe and less common

Important note about Labyrinthitis and hearing loss

Can return to normal or can remain permanently impaired.

Labyrinthitis treatment

If viral: supportive care. If bacterial: antibiotics

Vertigo

the sensation of motion when there is no motion (dizziness or room spinning); indicates disturbance of vestibularcochlear nerve (CN 8).

Vertigo triggers

Stress, fatigue, bright-lights (migraine associated) or diet (increased NA intake in Menieres Disease)

Vertigo Peripheral Causes

-BPPV (benign paroxysmal positioning vertigo... MOST COMMON)

-Ethanol intoxication

-Inner ear barotraumas

-Meniere's Disease

-Semicircular Cancal dehiscence

-Vestibular neuritis/labyrinthitis

Vertigo Central Causes

- Cerabellar ataxia syndromes

- Chiari malformation

- MS

- Seizure

- Vernike encephalopathy

Vertigo Mixed Central and Peripheral Causes

-Hypothyroidism

- Lyme Disease

- Syphilis

- Meningioma

- Migraine

- Strokes

- MANY MORE...

benign paroxysmal positioning vertigo (BPPV)

condition of vertigo that is associated with changes in the position of the head

BPPV Cause

displacement of otoconia from macula into semicircular canal due to head movement

How long does vertigo spells last with BPPV?

10-60 seconds; pts may remain imbalanced for several hours

BPPV Imaging

Recurrent case swill warrant MRI/MRA

BPPV Treatment

PT - dix hallpike maneuver, epley maneuver, brandt-daroff exercise.

GOAL IS TO GUIDE THE LOOSE CRYSTALS BACK INTO CORRECT CHAMBER

dix hallpike maneuver

Turn head 45 degrees to one side, then lay head down at a 30 degree angle.

epley maneuver

45 degree head tilt sitting up, lay back and leave head tilted 45 degrees, Turn head 90 degrees (45 degrees facing other side), turn another 90 degrees of same side so ur face is touching the bed, then sit up.

brandt-daroff exercise

Sit up, turn head 45 degrees to left, lay quickly on right side, return to seated position, turn head 45 degrees to the right, lie down quickly on left side with head turned and wait 30 seconds, return to seated.

Nystagmus

Rhythmic oscillation of the eyes (can be horizontal, vertical, or rotary)

Nystagmus Causes

Family history, albinism, inner ear pathologies, head injurt, drug and alcohol use, or congenital

Nystagmus testing and Imaging

Need ophthalmology exam, ear exam, neuro exam, CI or brain MRI

Inner ear disorders

Acustic Neuroma/Vestibular Schwannoma, Eustachian Tube Dysfunction, Acute Unilateral Vestibulopathy (AUVP), Labyrinthitis, Vertigo (BPPV main cause).

Acute Otitis Media

Bacterial infection of the mucosal lined, air containing spaces of the middle ear; more common in children

Acute Otitis Media precipitated by what?

Upper resp. infection causing ET obstruction

Acute Otitis Media most common pathogens

Strep. pneumonie, Haemophilus influenzae, strept. pyogenes

Acute Otitis Media signs and symptoms

Otalgia (pain of ear) , Aural pressure, decreased/muffled hearing, fever

Acute Otitis Media physical exam findings

Redness of TM, buldging TM, opacification of TM

Aute Otitis Media Treatment

- Antibiotics (this is a bacterial infection)

- 1st Line: Amoxicillin or Augmentin

- 2nd Line: If patient has a Penicillin allergy: Cephalosporin (cefdinir or cefuroxime)

- 3rd Line: If allergic to PCN and cephalosporin: Doxycycline

Otitis Media with Effusion

Presence of middle ear yellow/clear fluid without infection

What is the difference between Otitis Media with Effusion and Acute otitis media?

Otitis Media with Effusion has fluid without signs of infection or illness.

Otitis Media with Effusion Treatment

Auto insufflation, antihistamines, systemic decongestants, nasal corticosteroids

Chronic Otitis Media

Subacute or chronic TM performation in setting of recurrent ear infections

Chronic serous otits media

Continuous straw colored drainage through a perforated TM.

Bullous myringitis

Blister/bullae or vesicles develop on the TM. Believed to be viral

Herpes Zoster

Vesticles within the auditory canal, ear pain, ipsilateral facial paralysis (ramsay hunt syndrome)

Otosclerosis

Abnormal bone growth in the middle ear that immobilizes the stapes. This prevents the bone from vibrating, leading to slow, progressive hearing loss (conductive)

How to diagnose Otosclerosis

Audiogram to reveal conductive hearing loss (Weber test should lateralize to the ear with greater conductive deficiency)

*Marked familial tendency

Otosclerosis treatment

Hearing aids, surgical replacement of stapes

Reminder about middle ear structures

MIS (Malleus, Incus, Stapes)

Tympanic Membrane perforation

A hole in or rupture of the eardrum

what does Tympanic Membrane perforation usually occur after?

After middle ear infection, barotrauma, blunt/penetrating/acustic trauma

Tympanic Membrane perforation symptoms

Pain and hearing loss without bloody discharge. Vertigo or tinnitus may also occur.

Tympanic Membrane perforation treatment

Most TM resolve spontaneously. No treatment listed.

Choleasteatoma

Overgrowth of epithelium or keratin tissue in middle ear or mastoid bone that can enlarge, perforate the TM, and destroy surrounding tissue.

Choleasteatoma caused by:

Chronic ear infections or ET tube dysfunction

What happens if Choleasteatoma is left untreated?

Hearing loss, foul smelling, purulent discharge, dizziness, facial paralysis

Choleasteatoma diagnosis/Imaging

Dx made by ENT and CT of temporal bone.

Choleasteatoma Treatment

Tymanoplasty (replace TM) and mastoidectomy to remove infection.

**THESE WILL RE-OCCUR!

Conductive hearing loss

Results from mechanical disruption of the external auditory canal or middle ear

Examples of conductive hearing loss disorders

Cerumen impaction, middle ear effusion, otosclerosis, ossicular disruption, perforation of TM.

What is the most common conductive hearing loss disorder?

Cerumen impaction

How to correct Conductive hearing loss disorders?

Hearing aid, repair of TM, surgery

Sensorineural Hearing Loss

- Deficit of the inner ear or central (brain) auditory pathway.

-Damage to the inner ear's tiny hair cells or nerve pathways that send sound signals to the brain

What are the types of sensorineural hearing loss disorders?

Age-related hearing loss, excessive noise exposure, head trauma, Ototoxic medications, Systemic diseases.

What is the most common type of sensorineural hearing loss?

Age-related hearing loss

How is sensorineural hearing loss corrected?

Surgery such as cochlear implant or treating underlying pathology (MS, acoustic neuroma)

How many decibals is a normal spoken voice?

60 decibals

What tool is used to determine between conductive and sensorineural hearing loss?

512-H tuning fork

Weber Test

Center of forehead. Conductive Hearing loss = LOUDER in ear with POORER hearing. Sensorineural Hearing loss = worse in ear with poorer hearing (like normal).

Rinne Test

Tuning fork on mastoid bone for bone conduction and in front of ear for air conduction. Conductive Hearing loss = BONE CONDUCTION (mastoid) louder than AIR CONDUCTION (front of ear).

Mastoiditis

inflammation of the mastoid bone caused by spread of organisms from middle ear spaces to mastoid air cells.

When is Mastoiditis most common?

Children under 2 years old

Mastoiditis is the most common complication following what disorder?

Acute otitis media. BUT can develop without it

What are the most common organisms involved in Mastoiditis?

S. pneumonia, Strep. phyogenes, H. influenza, S. aureus.

Mastoiditis pathogenesis

Middle ear and mastoid air spaces are continuous. Inflammation of mucosal lining causes material to accumulate within mastoid cavities and septae btwn air cells can be destroyed.

Mastoiditis clinical features

swelling, redness, bump, protrusion of ear, ear pain, recurrent, lethargy, fever, narrowing of EAC, Otorrhea.

Mastoiditis EXTRACRANIAL Complications

Abscess, facial nerve paralysis, hearing loss, labyrithitits, osteomyelitis (bone infection)

Mastoiditis INTRACRANIAL Complications

meningitis, temportal lobe, epudural or subdural abscess, venous sinus thrombosis

Mastoiditis imaging

CT of temporal bone

Mastoiditis imaging findings

CT will show opacification or clouding of the mastoid, fluid or mucosal thickening of the middle ear

How to differentiate between mastoiditis and lymphadenopathy

mastoiditis will be liquid and watery to the feel, whereas lymphadenopathy is a hard small ball.