Clin Med - Ear

What is cerumen impaction?

Buildup of earwax causing blockage

What is the most common cause of conductive hearing loss?

Cerumen impaction

What are the symptoms of cerumen impaction?

Hearing loss, tinnitus, otalgia, itching

What is cerumen?

Mixture of secretion and sloughed epithelial cells

What are cerumenolytic agents?

Substances like H2O2 and carbamide peroxide used to dissolve earwax

What is the treatment for cerumen impaction?

ObservationCerumenolytic agents (H2O2, carbamide peroxide (Debrox)Ear irrigationManual removal

What is a foreign body?

An object that is not normally found in the ear.

What are the symptoms of a foreign body in the ear?

Ear fullness, otalgia (ear pain), otorrhea (ear discharge), decreased hearing, otorrhagia (bleeding from the ear).

How is a foreign body in the ear removed?

Under binocular microscopy with or without otic drops.

How can an insect be paralyzed before removing it from the ear?

Using oil, lidocaine, 50/50 mixture of water and ethanol, or hydrogen peroxide.

What is Otitis Externa?

Skin infection of the external auditory canal.

What are the symptoms of Otitis Externa?

Otalgia (ear pain), edematous (swollen) and erythematous (red) skin, purulent (pus-filled) otorrhea (ear discharge), foul smell, hearing loss or ear fullness, tragal tenderness, itching (especially with fungal infection).

What is the causative agent of Otitis Externa?

Pseudomonas aeruginosa, which can be either bacterial or fungal.

What is the treatment for Otitis Externa?

Otic drops containing Ofloxacin for 10 days.

What is Malignant Otitis Externa?

A more severe form of Otitis Externa that is more common in immunocompromised and diabetic patients.

How is Malignant Otitis Externa diagnosed?

By performing a CT scan of the temporal bone without contrast.

What are the complications of Malignant Otitis Externa?

Necrotizing infection of the external auditory canal and osteomyelitis at the skull base due to inadequate treatment or prolonged infection.

What is the causative agent of Malignant Otitis Externa?

Pseudomonas aeruginosa.

What is the treatment for Malignant Otitis Externa?

Intravenous antibiotics (such as ciprofloxacin) and topical otic drops.

What is Acute Otitis Media?

An acute infection of the middle ear that lasts less than 3 weeks.

What are the risk factors for Acute Otitis Media?

Daycare attendance and being under 2 years old.

What are the symptoms of Acute Otitis Media?

Hyperemic (red) and erythematous (inflamed) thickened tympanic membrane (eardrum), presence of fluid in the middle ear, non-mobile or bulging tympanic membrane.

What are the common causative agents of Acute Otitis Media?

Streptococcus pneumoniae, Moraxella catarrhalis, and Hemophilus influenzae. (SMH)

What is the treatment for Acute Otitis Media?

Antibiotics for 7-10 days, such as Amoxicillin. Augmentin is the step-up treatment. Azithromycin can be used for penicillin-allergic patients.

What is Chronic Otitis Media?

A chronic and persistent middle ear infection that lasts for more than 3 months.

What are the symptoms of Chronic Otitis Media?

Ear drum perforation, purulent ear drainage, conductive hearing loss, and ear fullness.

What are the common causative agents of Chronic Otitis Media?

Pseudomonas aeruginosa, Staphylococcus aureus, Proteus, and anaerobes.

What is the treatment for Chronic Otitis Media?

Treatment can be either topical or oral antibiotics. In some cases, bilateral myringotomy with PE tube insertion may be necessary for recurrent or chronic cases.

Otitis media w/ effusion

Serous otitis media

Otitis media w/ effusion in kids

Most common cause of pediatric hearing loss Associated with speech/language delay

Otitis media w/ effusion "Serous otitis media" sx

Persistent fluid from acute OM or persistent ETD

Otitis media w/ effusion "Serous otitis media" Serous fluid characteristics

Amber, dull, gray; non-mobile TM; hearing loss (CHL

Otitis media w/ effusion "Serous otitis media" tx

Observation Auto-insufflation Nasal decongestant (Afrin) -SE: rebound congestion

Nasal decongestant (Afrin) side effect

Rebound congestion

Eustachian tube dysfunction

Blockage or narrowing of the eustachian tube

Symptoms of eustachian tube dysfunction

Ear drum retraction, ear fullness, popping/clicking, discomfort, fluctuating hearing

Causes of eustachian tube dysfunction

Allergies, nasal congestion, URI, flying, inability to equalize media eustachian pressure

eustachian tube dysfunction tx

• Oral/topical decongestants • Oral/topical antihistamines • Nasal steroids • Autoinflation/valsalva Tube placement if persistent • May require eustachian tube dilation

Mastoiditis

Suppurative infection of mastoid air cells

Most common intratemporal complication of acute otitis media

Mastoiditis

Diagnosis of mastoiditis

CT temporal bone without contrast

Symptoms of mastoiditis

Mastoid tenderness/edema/erythema, ear protruded forward, spiking fever, adenopathy/abscess

Common pathogens causing mastoiditis

S. pneumoniae, Group A strep, S. aureus, coagulase neg. staph

Tx procedure for mastoiditis

• EMERGENT •Tympanocestesis for culture & sensitivity • IV antibiotics: Ceftriaxone + Vancomycin • Myringotomy with insertion of tube • Tympanomastoidectomy if no response to tx above

Tympanic membrane perforation

• Hearing loss • Otorrhea • Otorrhagia • Otalgia • Tinnitus • Nausea/vomiting • Vertigo with an acute perforation

Tympanic membrane perforation Causes

Most common: Acute/chronic suppurative OM - Pseudomonas most commonly involved • Persistent perforation after extrusion of PE tube • Trauma • Iatrogenic • Cholesteatoma • Systemic (Wegener's granulomatosis, TB)

Dx for tympanic membrane perforation

• Otoscopy/microscopy • Tuning forks • Tympanometry • Audiogram

Tx for tympanic membrane perforation

• Start otic drops if wet/ infected - Ofloxin or Ciprodex • Consider referral to ENT for tympanoplasty

Pt education for tympanic membrane perforation

• Avoid diving - unable to compensate to thermal changes in the semicircular canals resulting in extreme dizziness, imbalance, emesis • Counsel on dry ear precautions • Most heal spontaneously in a few weeks

Causes of cholesteatoma

Collection of squamous epithelium that can result in bone and soft tissue erosion and recurrent infections Acquired due to severe ETD, trauma/surgery May also be congenital

Symptoms of cholesteatoma

Chronic painless otorrhea, conductive hearing loss, vertigo

Diagnosis of cholesteatoma

Granulation tissue, CT temporal bone without contrast

Characteristics of cholesteatoma

White pearly mass, squamous debris

Tx of cholesteotoma

surgery

Conductive hearing loss

Reversible hearing loss with preserved bone conduction due to impaired sound transmission to the inner ear Most common cause = wax impaction

Other causes of conductive hearing loss

• Middle ear effusion • Otosclerosis - (bony overgrowth of stapes bone) typically diagnosed in young adults, many cases inherited; audiogram and CT temporal bone; treat with surgery • Cholesteatoma • TM perforation • ETD

Weber test result in conductive hearing loss

Sound is louder in affected ear

Rinne test result in conductive hearing loss

Bone conduction greater than air conduction (negative/abnormal)

conductive hearing loss dx

Audiogram/ tuning forks

conductive hearing loss tx

• Treat the underlying cause • May require surgery

What causes acquired SNHL?

Presbycusis, Noise induced, Ototoxic medication exposure (Aminoglycosides, chemotherapeutic drugs (cisplatin), vancomycin, loop diuretics), Blunt Trauma to the head, Acoustic neuroma, Autoimmune conditions

What is the most common cause of acquired SNHL?

Presbycusis (Age related)

What are some examples of ototoxic medications?

Aminoglycosides, chemotherapeutic drugs (cisplatin), vancomycin, loop diuretics

What is the treatment for SNHL?

Treat underlying cause, standard hearing aids, BAHA, CI

What is the treatment for SNHL?

Oral Prednisone, Intratympanic steroids, Hyperbaric oxygen therapy (if diabetic), MRI acoustic protocol (if not ABR)

What is presbycusis?

Gradual, symmetric high frequency hearing loss associated with normal aging process

What is the characteristic finding in Weber test for SNHL?

Sound is heard better in the good ear

What is the characteristic finding in Rinne test for SNHL?

Air conduction is greater than bone conduction

What should be included in education for noise-related hearing loss?

Hearing protection and strategies to reduce exposure

Tx for SUDDEN onset of SNHL

EMERGENT- ENT referral STAT (Dx: MRI w/w/o contrast)

Subjective Tinnitus

Perception of sound in the absence of external source

Objective Tinnitus

Perception of sound caused by internal body sound/vibration

Peripheral Vertigo

Severe, but fatigable vertigo (sudden onset)

Central Vertigo

Mild, non-fatigable vertigo (gradual onset)

Benign Paroxysmal Positional Vertigo (BPPV)

Episodic vertigo

Meniere's Disease

Dx of Exclusion (r/o syphilis, virus, bacteria)

Vestibular Neuritis

Continuous vertigo (wks. to mo.)

M>F 10-15% pop.

Prevalence of tinnitus in the population

High pitch - ringing/hissing Low pitch- roaring/buzzing

Characteristics of tinnitus

Treatment for tinnitus

Supportive care: Evaluate medications, Broadband noise, Hearing aids (amplify sound from environment), Sound treatments (Tinnitus retraining therapy) Medications • Low-dose benzodiazepines • SSRIs • Tegretol • Gabapentin • Herbal supplements (B vitamin or lipoflavanoids)

Vascular ETD

Possible cause of objective tinnitus

Safety, Acute vestibular suppression (Meclizine)- short time periods (72H), High-dose steroids

Treatment for peripheral and central vertigo

Dx: Dix Hallpike Maneuver

Diagnostic maneuver for BPPV

Episodes last sec. to minutes w/ fatigable horizontal nystagmus or hearing loss/tinnitus

Characteristics of BPPV

Displaced otoliths (calcium carbonate particles attached to hairs cells in semicircular canals)

Cause of BPPV

Epley Maneuver, Vestibular rehab, Antihistamine (short-term)

Treatment for BPPV

Dx of Exclusion (r/o syphilis, virus, bacteria)

Diagnostic criteria for Meniere's Disease

Symptomatic Triad -vertigo (min. to hrs.) -low-freq. fluctuating SNHL -tinnitus Aural fullness

Symptoms of Meniere's Disease

Dilation of endolymphatic space (incr. pressure)

Cause of Meniere's Disease

Corticosteroids (acute exacerbation) Reduce stress/salt/avoid alcohol & caffeine Hydrochlorothiazide, Surgical (10-15%)

Treatment for Meniere's Disease

What is vertigo?

A sensation of spinning or dizziness.

What is vestibular neuritis' cause?

An assumption that a viral infection is causing inflammation of the vestibular nerve.

What is the treatment for presumed viral infection of vestibular nerve?

High dose steroids, Meclizine (limit 72H), Antiemetics.

Vestibular neuritis sx

Continuous vertigo (wks. to mo.)

Vertigo with no associated hearing loss

What is labyrinthitis?

Continuous vertigo with sensorineural hearing loss.

What are the treatment options for labyrinthitis?

High dose steroids, Meclizine, Antiemetics.

What is a vestibular schwannoma?

Benign tumor causing asymmetric high-frequency sensorineural hearing loss. sx Speech decline Tinnitus

Cont. vertigo (central or peripheral) imbalance

How is a vestibular schwannoma diagnosed?

Audiogram and MRI of internal auditory canal with gadolinium.

What are the symptoms of post-traumatic vertigo?

Vertigo, dizziness, lightheadedness, weakness, double vision, N/V.

What are the common causes of post-traumatic vertigo?

Falls, concussions, MVA, assault, contact sports.