ENT: Inner Ear

Tinnitus

Perception of non verbal sound in ears without a stimulus

Note that this is a SYMPTOM

The sound could be (whistling, hissing, buzzing, ringing, pulsating)

It can be unilateral or bilateral, acute or chronic, and intermittent or constant.

Frequently is associated with hearing loss and presbyacusis

Tinnitus is more common in which patients?

Men

Smokers

Objective vs subjective tinnitus

Objective tinnitus: tinnitus that can perceived by others, which is due to sounds created by the body (e.g., carotid artery stenosis, stapedial myoclonus). You would be able to auscultate this on a stethoscope

Subjective tinnitus: tinnitus that is only perceived by the affected individual, which can be due to a wide range of etiologies (e.g., otosclerosis, tumor, infections)

Outline the VASCULAR causes of tinnitus

- carotid artery stenosis

- carotid artery dissection

- gloms jugglers tumours, pulsatile tinnitus

Ototoxic drugs

Aspirin

Loop diuretics

Aminoglycosides

Chemotherapy e.g. cisplatin

Antimalarial drugs e.g. quinine

Tetracyclines

Slidenafil

ALACATS

Outline the otological, conductive causes of tinnitus

Cerumen impaction, otosclerosis, otitis media, infection, fluid

This mostly affects the middle ear and external ear

Outline the otological, sensorineural causes of tinnitus

This usually affects the inner ear and includes DRUGS, NOISE EXPOSURE, MENIERES DISEASE

Also presbyacusis

Metabolic causes of tinnitus

Hyperthyroid

Zinc

What tumour can cause tinnitus?

Acoustic neuroma

Neurological condition which can cause tinnitus

Multiple sclerosis

MSK causes of tinnitus

STAPEDIUS MYOCLONUS - objective tinnitus

TMJ joint dysfunction

Outline the most common, important causes of tinnitus

MOHAD

M - menieres disease

O - otosclerosis

H - hearing loss, chronic noise exposure, presbyacusis

A - acoustic neuroma

D - drugs: ALACATS

Meniere's disease

Idiopathic condition affecting the inner ear, in which impaired resorption of endolymphatic fluid causes it to accumulate in the membranous labyrinth (endolymphatic hydrops)

This leads to excessive pressure and dilation of the endolymphatic system

More common in females

Peak incidence: 40–60 years

Triad of symptoms in Menieres disease

Tinnitus

Vertigo

Sensorineural hearing loss - fluctuating, low-frequency loss increases with each episode that may lead to deafness after several years.

KEY SYMPTOM: AURAL FULLNESS

Also nausea and committing, HORIZONTAL NYSTAGMUS

Positive Romberg test

Describe the pattern of symptoms associated with meniere disease

Episodes are acute and recurrent

Acute attacks typically last minutes-hours, often 2-3 hours.

Acute episodes may occur in clusters of about 6-11 per year.

Remission of symptoms may last several months.

Most begin unilaterally and then develop into a bilateral pattern

Describe the nystagmus that is associated with menieres disease

The pattern of nystagmus in Ménière disease typically reverses during the course of an attack.

An initial brief period of irritative nystagmus towards the affected ear is usually followed by a period (20–30 minutes) of nystagmus towards the healthy ear or absence of nystagmus, which is then followed by a longer period (hours to days) of irritative nystagmus towards the affected ear (recovery nystagmus).

Nystagmus may also be absent during clinical examination.

Name the three key features required to confirm a diagnosis of Menieres disease

Two or more episodes of vertigo that last 20 minutes to 12 hours

Low-frequency to mid-frequency sensorineural hearing loss on audiometry

Fluctuating tinnitus or ear fullness

Describe the tuning fork results associated with Menieres disease

Weber test: lateralization to the healthy ear - Indicates sensorineural hearing loss in the opposite ear

Rinne test: bilaterally positive, normal conductive hearing.

DDX Meniere's disease

Other ENT causes:

Exclude acoustic neuroma in anyone with unilateral deafness, tinnitus and/or facial nerve palsy.

Otitis media.

Earwax.

Ototoxic drugs.

Intracranial pathology

Vertebrobasilar insufficiency, transient ischaemic attack (TIA), stroke, thrombosis of labyrinthine artery.

Intracranial tumours.

Migraine.

Systemic illness:

Anaemia

Hypothyroidism

Diabetes mellitus

Autoimmune disease

Syphilis

What blood tests would be important to perform when investigating a patient presenting with menieres disease?

Blood tests to exclude systemic illness

FBC, ESR, thyroid function, syphilis screen, fasting glucose, renal function, lipids.

Non pharmacological management of Meniere disease

- Patient must inform DVLA, - cease driving until satisfactory control can be achieved

- Avoid dietary and environmental triggers (caffeine, alcohol, smoking and stress).

- Low-sodium diet

- Vestibular rehabilitation therapy in patients with persistent disequilibrium symptoms between attacks, the programmes involve exercises such as learning to bring on the symptoms to 'desensitise' the vestibular system; learning to improve balance, co-ordination and coping skills.

- Hearing aids may be needed

- Safety - if prone to sudden vertigo, consider safety and risks with activities involving heights, dangerous machinery, swimming, etc

- Maintain mobility, After an acute attack of vertigo, patients naturally tend to sit still. Encourage them to move around to promote central compensation, where the brain uses vision and other senses to compensate for the loss of vestibular function.

Acute attack of Meniere disease management

Vertigo and nausea can be alleviated by prochlorperazine, cinnarizine, cyclizine, or VESTIBULAR SUPPRESSANT

Anti emetic: promethazine, ondansetron

Consider patient preference for both choice of drug and route of administration.

For severe symptoms, hospital admission may be needed to maintain hydration.

Drug prophylaxis for Meniere Disease

Trial of BETAHISTINE (initially 16 mg three times a day) to reduce the frequency and severity of attacks - note that this is a histamine analogue

Diuretics may be helpful but are not usually recommended for use in primary care e.g: (hydrochlorothiazide or triamterene)

NOTE: Betahistine is preferred over diuretics because diureticsrequire regular monitoring of blood pressure, kidneyfunction, and electrolytes.

What interventional/surgical treatment options are there for Meniere disease?

Intratympanic gentamicin injection: repeated application of gentamicin to the middle ear cavity through a small incision in the eardrum (paracentesis), damaging action of gentamicin on the sensorineural epithelium and labyrinthine cells to reduce vertigo, while preserving hearing (although there may be a risk of sensorineural hearing loss)

Local steroid injection - this is transtympanic or intratympanic dexamethasone injection

Sacculotomy: The endolymphatic sac and duct (part of the vestibular organ) are surgically exposed in order to promote drainage of endolymph, decompression of the endolymphatic sac and sigmoid sinus.

Vestibular neurectomy: Surgical lysis of the vestibular bundle entering the internal auditory canal. In some cases, the procedure is associated with hearing loss

Labyrinthectomy - this is a last option, as hearing in that ear would also be lost.

Prognosis of Meniere disease

There is no cure but most patients can be helped by the above treatments.

The Ménière's Society suggests that 80% of patients will have their symptoms alleviated by non-invasive treatments.

Vertigo

False sensation that you or environment is moving

Mismatch between the vestibular system as well as other sensory inputs such as vision and proprioception

Central causes of vertigo

Due to damage of the vestibular structures in the brainstem or cerebellum

- Infection

- Vertebral basilar artery insufficiency

- Subclavian steal syndrome

- Cerebellar hemorrhage or infarction

- Vertebral basilar migraine

- Post-traumatic injury

- Post-concussive syndrome

- Temporal lobe epilepsy

- Brainstem tumour eg pilocystic astrocytoma which can compress on vestibular structures of brainstem

- Multiple sclerosis

Peripheral causes of vertigo

This is due to damage of the vestibular apparatus/vestibular nerve

Benign paroxysmal positional vertigo (BPPV)

Meniere's disease

Labyrinthitis

Vestibular migraine

Choleasteatoma

What symptoms help indicate that vertigo is being caused by a central pathology?

The 4 Ds - DILPOLPIA, DYSPHAGIA, DYSARTHRIA or DYSMETRIA INDICATES CENTRAL VERTIGO

Loss of consciousness

Constant, unremitting

Vertical nystagmus

Cerebrovascular disease

Neurological symptoms eg hemiparesis, numbness, dysphagia, ataxia

Note that central causes of vertigo should be considered in any ELDERLY PATIENT WITH NEW ONSET OF ACUTE VERTIGO WITH NO OBVIOSU CAUSE

If there is vertigo with neurological signs, do MRI as this is sensitive for stroke

HINTS exam

Test which helps differentiate central vertigo from peripheral

If 1 of 3 parts of the exam are present than it indicates a central cause an a BRAIN MRI should be done to identify a posterior circulation stroke

- Head impulse test

- Nystagmus

- Test of skew

Head Impulse Test (HIT)

· Head impulse test, is there a lag time between when eyes remain fixed on your nose? A positive test indicates a peripheral cause of vertigo, normal, negative test indicates central cause eg stroke

· Tests vestibulo ocular reflex, checking if the nerve has been affected so if it is normal it means the nerve isn't affected, more indicative of a central cause of vertigo

Can peripheral vertigo cause vertical nystagmus?

No - BIDIRECTIONAL NYSTAGMUS IS HIGHLY SPECIFIC FOR A CENTRAL CAUSE OF VERTIGO & STROKE

Benign postional paroxysmal vertigo (BPPV)

VERTIGO LASTS SECONDS TO MINUTES

The presence of debris in the semicircular canals of the ears causes vertigo upon head movement.

BPPV is caused by semicircular canal dysfunction.

Dislodged particles (otoliths) disrupt the endolymph → stimulation of the hair cells on cupulas → signal sent to the brain through the vestibulocochlear nerve that is disproportional to current positioning and movement → severe vertigo attacks lasting several seconds

Features of BPPV

vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)

nystagmus towards the affected side

may be associated with nausea

no hearing or neurological symptoms

each episode typically lasts 10-20 seconds

positive Dix-Hallpike manoeuvre

Triggers of BPPV

Rolling over in bed, lying down quickly

Quick rotation of the head, reclining, etc.

Vertigo occurs with a latency of a few seconds

Diagnostic test for BPPV

DIX HALLPIKE MAOUVRE

Management of BPPV

Usually resolves spontaneously within a few weeks or months

Epley manoeuvre (successful in around 80% of cases)

Teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises

Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.

Around half of people with BPPV will have a recurrence of symptoms 3–5 years after their diagnosis

NOTE: Chronic use of antivertigo drugs (e.g., dimenhydrinate) are contraindicated in BPPV because they may exacerbate unsteadiness by inhibiting central compensation!

Labrynthitis

Inflammation of inner ear canals

Can be viral, bacterial or systemic but VIRAL IS THE MOST COMMON

It is often associated with a recent viral illness or a vascular lesion, in which case it may involve other cranial nerve deficits.

Clinical features of Labyrinthitis

- Acute onset

- Vertigo: not triggered by movement but exacerbated by movement

- N+V

- Hearing Loss

- Tinnitus

- Preceding or concurrent symptoms of upper respiratory tract infection

- Patient may fall towards affected side

- spontaneous unidirectional horizontal nystagmus towards the unaffected side

What type of hearing loss is associated with Labrynthitis ?

sensorineural hearing loss: shown by Rinne's test and Weber test

Head impulse test would reveal what in Labrynthitis?

abnormal head impulse test: signifies an impaired vestibule-ocular reflex but normal skew test (?)

What may you see in inspection of the ear canal in Labrynthitis?

abnormality on inspection of the external ear canal and the tympanic membrane e.g. vesicles in herpes simplex infection

Investigations in labrynthitis?

pure tone audiometry can be done to assess hearing loss

full blood count and blood culture: if systemic infection suspected

culture and sensitivity testing if any middle ear effusion

temporal bone CT scan: indicated if suspecting mastoiditis or cholesteatoma

MRI scan: helpful to rule out causes such as suppurative labyrinthitis or central causes of vertigo

vestibular function testing: may be helpful in difficult cases and/or determining prognosis

Treatment of Labrynthitis

It often resolves completely over a month, so treatment is conservative, although sedatives may help in severe cases.

Most common cause of labrynhtitis

VIRAL INFECTION

Vestibular Neuritis

Inflammation of the vestibular nerve which most commonly occurs after a viral infection (URTI)

Cause vertigo which can last for days

Clinical features of vestibular neuritis

recurrent vertigo attacks lasting hours or days

nausea and vomiting may be present

horizontal nystagmus is usually present

no hearing loss or tinnitus

NOTE: vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment; Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.

Investigations for vestibular neuritis

CLINICAL DIAGNOSIS

Imaging studies are indicated in patients older than 60 years, as well as those with persistent vestibular symptoms, headache, vascular risk factors, or focal neurologic symptoms to rule out a lateral medullary/cerebellar stroke - these include MRI, MRA, CT

Management of vestibular neuritis

Vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms

Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases

A short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases

Acoustic Neuroma (Vestibular Schwannoma)

Benign, slow-growing tumor of nerve sheath (schwan cells) of acoustic nerve.

Thery account for 90% of cerebellopointine angle tumours

Cerebellopontine angle

The junction at the base of the brain where the cerebellum, medulla, and pons communicate

CN 5,6,9,10

Bilateral acoustic neuromas are strongly associated with?

Bilateral vestibular schwannomas are seen in neurofibromatosis type 2, SCHWANN CELLS EXPRESS A GENE CALELD NEUROFIBROMIN 2 ENCODING A PROTEIN CALLED MERLIN WHICH IS A TUMOUR SUPRESSOR GENE) and in neurobromatosis there is deletion on chromosome 22 leading to mutation of in NF2 which inactivates merlin àuncontrollable division

But majority of tumours (90%) are unilateral

Clinical features of acoustic neuroma

Cochlear nerve involvement

- Unilateral sensorineural hearing loss (most common symptom)

- Tinnitus

Vestibular nerve involvement

- Dizziness

- Unsteady gait and disequilibrium

Later symptoms are caused by pressure of the tumour on adjacent structures of the cerebellopontine angle

Trigeminal nerve (CN V) involvement: paresthesia (numbness), hypoesthesia (decreased sensation), and/or unilateral facial pain, absent corneal reflex

Facial nerve (CN VII) involvement: peripheral, unilateral facial weakness that can progress to paralysis

Cerebellum: ataxia

Fourth ventricle: hydrocephalus

Management of Acoustic Neuroma

Patients with a suspected vestibular schwannoma should be referred urgently to ENT.

It should be noted though that the tumours are often slow growing, benign and often observed initially.

What is the investigation of choice for acoustic neuroma?

CONTRAST MRI as well as Audiometry as only 5% of patients will have a normal audiogram

Management options for acoustic neuroma

Management is with either surgery, radiotherapy or observation.

Observation of the tumor can be considered in patients with small tumors or minimal hearing loss, or if they are of advanced age. These patients should undergo MRI surveillance every 6-12 months.

Ramsay Hunt Syndrome (Herpes Zoster Oticus)

Caused by reactivation of Varicella in the GENTICULATE GANGLION OF CN 7 + 8

Essentially there is a herpetic infection of these cranial nerves

Clinical features of Ramsay Hunt Syndrome

- Auricular pain

- Facial nerve palsy

- Vestibular rash around the ear

- Vertigo

- Tinnitus

- Fever

Management of Ramsay Hunt Syndrome

ORAL ACICLOVIR + CORTICOSTEROIDS

Vestibular sedative drugs

Prochlorperazine - D2 antagonist

SE of prochlorperazine

QT prolongation

Parkinsonism

Tardive dyskinesia

Restlessness

Respiratory depression

Drug induced cholestasis

Causes of vertigo

Meniere's, vestibular neuritis, acoustic neuroma, MS, CN 8 lesions, brainstem or cerebellar tumors or bleeding

Conductive hearing loss

Hearing impairment caused by interference with sound or vibratory energy in the external canal, middle ear, or ossicles

BETWEEN OUTER EAR AND FOOT PLATE OF STAPES IN MIDDLE EAR

1) EXTERNAL CANAL OBSTRUCTION

· Wax impaction

· Discharge from otitis externa

· Glue ear (otitis media with effusion)

· Foreign bodies

· Developmental abnormalities (DOWNS SYNDROME)

2) PERFORATION OF EAR DRUM

· Trauma

· Barotrauma

· Infection – ear infections, otitis media with effusion (glue ear), chronic suppuratve otitis media (SECRETORY OTITIS MEDIA)

3) PROBLEMS WITH OSCULAR CHAIN

· Osteosclerosis - CARHARTS NOTCH WHERE THERE IS AN APPARENT LOSS OF BONE CONDUCTION AT 2000HZ (characteristic audiometric sign)

· Infection

· Trauma

4) INADEQUATE EUSTACHIAN TUBE VENTILATION

· With/without effusion

· Eg secondary to nasopharyngeal carcinoma

· Large adenoids

· Eustachian tube dysfunction

Sensorineural hearing loss

Hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness

THERE IS A POBLEM IN THE COHLEAR OR AUDITORY NERVE

Presbycusis

Noise-induced hearing loss

Congenital infections (e.g. rubella, CMV)

Neonatal complications (e.g. kernicterus or meningitis)

Drugs (aminoglycosides)

Post infection due to meningitis, measles, mumps, flu, herpes, syphillis

Vascular pathology (stroke, transient ischaemic attacks)

Rare causes: acoustic neuroma, vitamin B12 deficiency, multiple sclerosis, brain mets.

Noise-induced hearing loss (NIHL)

Condition caused by the destruction of hair cells due to exposure to loud noise

Workers in heavy industry are particularly at risk

Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz

This could be one time, called acoustic trauma (sounds greater than 180dB) – may cause ear drum rupture and ossicles fracture

Or this could be gradually over time for example at work that over time causes hearing loss – 8 hours of sound at 85dB is typically enough to cause damage

Symptoms:

- Bilateral, symmetrical

- Sensorineural hearing loss

- +/- tinnitus

- may be noise induced temporary threshold shift

- audiometry shows a notch at 3,4 or 6kHz with recovery at 8

Presbyacusis

Age related, bilateral sensorineural hearing loss

High frequency hearing is affected bilaterally -conversational difficulties in noisy environments (hearing is most affected in the presence of background noise)

Audiometry shows bilateral high-frequency hearing loss

Precise cause is unknown, is multifactorial

- Arteriosclerosis – diminished perfusion and oxygenation of cochlea, damage to inner ear structures

- Diabetes – accelerates arteriosclerosis

- Accumulated exposure to noise

- Drugs – salicylates, chemotherapy

- Stress

- Genetics

Outline how you would go about investigating a patient with hearing loss

BEDSIDE

- Whispered voice test and finger rub test: screening to determine the extent of hearing loss

- Rinne test and Weber test: to classify hearing loss as conductive or sensorineural

- Otoscopy: allows for visual assessment of the external ear and tympanic membrane

BLOODS

- FBC

- Glucose

- TSH

- Syphillis testing

IMAGING

- MRI or CT

AUDIOMETRY!!

Audiometry interpretation conductive hearing loss

In conductive hearing loss (damage to the middle or external ear) AIR CONDUCTION IS IMPAIRED

So the auditory threshold is increased in air conduction; however, the auditory threshold is normal in bone conduction

Audiometry interpretation in sensorineural hearing loss

Both air and bone conduction are impaired so hearing threshold increases for both

Mixed hearing loss audiogram

In mixed hearing loss both air and bone conduction are impaired, with air conduction often being 'worse' than bone

Audiogram in presbycusis

Increasingly deafer at high frequencies

They struggle to hear higher frequencies in both air and bone conduction

Otosclerosis audiogram

Carhart notch - notched hearing loss at 2000Hz with CONDUCTIVE HEARING LOSS so air conduction is impaired

Tympanometry finding in secretory otitis media

Normal middle ear function: maximum compliance of ∼0 Pa

Eustachian tube dysfunction: displacement of normal compliance in the region of negative pressure

Secretory otitis media: flat tympanometry curve without an identifiable maximum

Rinne and weber test

Rinne test: tuning fork on mastoid, then near ear

Weber test: tuning fork on top of head, then near ear

Normal: AC > BC in both ears

Abnormal Rinne test

• Right bone conduction problem => BC > AC on right (lateralization to right side)

• Left neural problem => AC > BC on both sides (lateralize to right side)

REMEMBER WITH WEBER TEST THE SOUND SHOULD NOT LATERALISE ! (if it does it means you either have sensorineural in other ear or conductive in that ear)

Types of hearing aids

HEARING AIDS

Behind the ear or in the ear

Low to high power amplification

Analogue/digital

BONE ANCHORED HEARING AIDS (BAHA)

This is for significant conducting hearing loss

Surgically implanted (mastoid) titanium base

Electronic amplification device attachment

Allows bone transmission of sound

Indications for this include:

- Significant conductive hearing loss

- Intolerance of hearing aids

- Congenital malformations

Single sided deafness

COCHLEAR IMPLANTS

For profound hearing loss

Electrically stimulates auditory nerve directly

NICE recommends implants for adults or children with PROFOUND SENSORINEURAL HEARING LOSS who do not benefit from traditional hearing aid

Electrode is inserted surgically into cochlea which will directly stimulate the auditory nerve when electrical signals are applied

Electrode is attached to external auditory processor through skin with magnetic coupler

Note that the signal is not normal sound which is why intensive therapy is needed to understand new sounds

The implants will help with lip reading, provision and recognition of environmental sounds and help relief isolation

Outer ear causes of otalgia

Perichondritis

Otitis externa

Furuncle

Causes of otalgia

50% have spontaneous resolution with no underlying detectable cause.

External ear causes:

- otitis externa

- foreign body

- trauma

- impacted cerumen (earwax)

- furuncle

- herpes zoster

- neoplasm

- otomycosis

- perichondritis of pinna

- Sjogren's syndrome

Middle ear causes:

- otitis media

- acute mastoiditis

- barotrauma

- acute Eustachian tube obstruction

- neoplasm

- trauma

- bullous myringitis

- furunculosis

Referred ear pain

- nasopharynx: adenoidectomy, infection, neoplasm

- salivary gland infection or calculi

- from teeth, jaw, oesophagus, larynx, oropharynx, tongue, cervical spine, cranial nerves, temporomandibular joints

- tonsillitis

- GCA

- thyroiditis

TMJ dysfunction

Temporomandibular joint; abnormality of joint where lower jaw hinges to upper jaw

· Ear ache

· Facial pain

· Joint clicking/popping related to teeth grinding

· Stress - makes it a biopsychological disorder which may lead to chronic pain syndrome

· Joint tenderness which is made worse by lateral movement of the jaw or trigger points in the pterygoids

Bullous Myringitis

Small vesicles containing blood on the drum; accompany mycoplasma pneumonia and virus infections

PAINFUL HAEMORRHAGIC BLISTERS OF TYMPANIC MEMBRANE

Which nerves are involved in referred ear pain?

Trigeminal nerve

Facial nerve

Glosopharyngeal nerve

Vagus nerve

Auricotemporal nerve is a branch of?

V3 of trigeminal

Supplies lateral upper half of pinna

May refer from dental disease or TMJ dysfunction, parotid, tongue, nose, sinuses

Pathologies:

- trigeminal neuralgia

- dental disease

- TMJ dysfunction

- parotid infection/tumour

What nerve supples external auditory meatus?

Auricular branch of the facial nerve

What nerve innervates the posterior auricle as well as skin overlying mastoid ?

GREAT AURICULAR NERVE C2,C3

think cervical spine pathology

- cervical spine degenerative disease: Osteoarthritis• Cervical facette disease• Spondylosis• Disc herniation• Spinal stenosis

- Whiplash (2%)• Cervical meningioma• Arnold-Chiari type I (1%)• Vascular (1%)• Fibromyalgia (1%)• Cervical nerve root cysts

What nerve innervates Middle ear• Upper Eustachian tube• Medial surface of tympanic membrane?

TYMPANIC BRANCH OF GLOSSOPHARYNGEAL NERVE , and arises from the inferior ganglion of the glossopharyngeal nerve. It also carries preganglionic parasympathetic fibres, from the inferior salivary nucleus, which eventually enter the otic ganglion.

Pathology:

- sinusitis

- tonsilitis

- pharyngitis

- pharyngeal tumour

- glossopharyngeal neuroma

Innervates

Nasal cavity

Nasopharynx

Paranasal sinuses

Palatine tonsils

Tonsillar fossa

Soft palate

Oropharynx

Posterior one-third of tongue

Infratemporal fossa

Posterior auricular nerve

Branch of the seventh cranial nerve that affects the muscles behind the ear at the base of the skull

Branch of facial nerve

Innervates:

Posterior wall of external auditory canal

Posterior lateral surface of tympanic membrane Posterior skin of auricle

Pathology

RAMSAY HUNT SYNDROME

Vestibular Schwannoma

Auricular innervation