ENT
Hearing Loss
Definitions of Hearing Loss
Hearing loss is classified into levels based on severity, measured in decibels (dB):
Mild: 25-40 dB
Sound equivalent: soft whisper
Potential issues: Difficulty with whispers, may miss up to 50% of speech
Typical age for diagnosis: 3-5 years old
Moderate: 41-55 dB
Sound equivalent: Conversation at home
Misses: 50-100% of speech
Voice and speech quality: Poor
Moderate to Severe: 56-70 dB
Sound equivalent: Vacuum cleaner
Loud shout heard as whisper
Education interventions required
Severe: 71-90 dB
Sound equivalent: Garbage disposal
Challenges: Difficulty using hearing aids
Profound: >90 dB
Sound equivalent: Motorcycle at 25 feet
Perception: Feels vibrations only, relies on vision for communication
Types of Hearing Loss
Conductive Hearing Loss: Interference with the mechanical transmission of sound through external and middle ear.
Sensorineural Hearing Loss (SNHL): Affects both air conduction (AC) and bone conduction (BC), but AC remains greater than BC.
Mixed Hearing Loss: A combination of conductive and sensorineural hearing loss.
Central Hearing Loss: Auditory processing abnormalities beyond the cochlear nucleus, leading to degradation of the signal when it reaches the level of the brainstem.
Congenital Hearing Loss: Present at birth, can be caused by genetic factors or prenatal infections.
Acquired Hearing Loss: Occurs after birth due to various factors.
Risk Factors for Hearing Loss
Pre-term birth
Low birth weight: Specifically less than 1500g
APGAR score of less than 3 at 5 minutes and less than 6 at 10 minutes
Prolonged mechanical ventilation: More than 10 days
In Utero TORCH infection: Includes Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus, and Herpes Simplex Virus.
Family history of sensorineural hearing loss (SNHL)
Craniofacial anomalies
Head trauma: Particularly basilar skull and temporal bone fractures
Post-natal infections that are associated with SNHL: such as meningitis
Chemotherapy or medications known to induce SNHL
Physical Implications of Hearing Loss
Developmental delays: Can affect all areas of development (motor skills, cognitive skills)
Speech and language deficits: Infants with profound deafness will typically show behaviors such as startling, laughing, or babbling.
Onset of hearing loss after age 5 years has less impact on language development, compared to earlier onset.
Conductive Hearing Loss
Causes:
Interference with the mechanical transmission of sound through the external and middle ear
Abnormal air conduction: BC > AC (normal hearing shows AC > BC)
Hearing loss: Typically 20-60 dB, often treatable
Acquired causes:
Middle ear effusion
Foreign body or cerumen impaction
Tympanic membrane perforation
Cholesteatoma
Ossicular disruption: Can occur after trauma or erosion due to chronic infections or cholesteatoma
Congenital/Inherited causes:
Microtia/atresia
Abnormal ossicles or tympanic membranes
Syndromes with ear/craniofacial abnormalities (e.g., Treacher-Collins syndrome, Down syndrome)
Sensorineural Hearing Loss
Characteristics: Both air and bone conduction are reduced, but air conduction remains greater than bone conduction.
Causes:
Acquired:
Childhood infections: e.g., Meningitis, MMR (measles, mumps, rubella), Lyme disease, syphilis
Acoustic trauma: e.g., exposure to loud music
Medications: e.g., Aminoglycosides (gentamicin), Furosemide, Vancomycin
Trauma
Congenital:
TORCH infections
Hereditary syndromes: e.g., Waardenburg syndrome, Usher syndrome, Alport syndrome
Inner ear conditions: e.g., inner ear dysplasia, enlarged vestibular aqueduct
Perilymph fistula: Leakage of inner ear fluid permits communication between the middle ear and inner ear.
Mixed and Central Hearing Loss
Mixed Hearing Loss: Characterized by abnormal bone and air conduction, with bone conduction being more than 10 dB better than air conduction.
Central Hearing Loss: Indicates auditory processing issues beyond the cochlear nucleus, resulting in degraded signals reaching the brainstem level. Lesions may be present in the central auditory pathway or auditory cortex.
Associations of Hearing Loss
Most common type of hearing loss: Conductive Hearing Loss
Most common acquired cause: Middle Ear Effusion
Most common non-syndromic genetic SNHL: Connexin 26 gene defect (autosomal recessive, bilateral, moderate to severe)
Most common congenital infection causing SNHL: Cytomegalovirus (CMV)
Most common acquired infection causing SNHL: Meningitis
Audiometry
Purpose: To test air and bone conduction, using pure tone audiometry to create an audiogram which determines individual hearing thresholds.
Types of Hearing Loss:
Conductive: Abnormal air conduction, normal bone conduction
Sensorineural: Abnormal air conduction, abnormal bone conduction
Mixed: Abnormal air and bone conduction
Diagnostic Thresholds:
Bone/Air conduction threshold <10 dB apart indicates conductive hearing loss
Bone/Air conduction threshold >10 dB apart indicates potential mixed or sensorineural hearing loss.
Newborn Hearing Screening
Methods:
Otoacoustic Emission (OAE): Tests cochlear function and is a quick test resulting in pass/fail, cannot determine degree of hearing loss. Identifies moderate/severe hearing loss but not mild.
Brainstem Auditory Evoked Response (BAER): Tests neurologic function, estimates ear-specific thresholds, and can be performed under sedation if necessary.
AAP/NIH Recommendations:
Universal screening by 1 month of age
Confirmation of results at 3 months
Early intervention at 6 months
Audiometry Behavioral Tests
Behavioral Observation Audiometry: Suitable for children less than 6 months; involves testing the child's response to external speakers while placed on a parent’s lap to observe reflexive behavior.
Conditioned Play Audiometry: For children aged 30 months to 5 years; sounds are played through headphones, and children perform tasks upon hearing specific sounds.
Conventional Audiometry: Used for children aged 3-5 years; headphones provide ear-specific information. Children are requested to respond to sounds by performing tasks (e.g., dropping a block into a bucket).
Visual Reinforcement Audiometry: For children older than 5 years; headphones provide ear-specific and both air and bone conduction information.
Treatment of Hearing Loss
Conductive Hearing Loss: Treatment focuses on addressing the underlying cause.
Sensorineural Hearing Loss: Options include:
Hearing Aids: Amplify sounds for auditory processing
Cochlear Implants: Inserted in cases of profound hearing impairments where patients are not candidates for hearing aids, utilizes electrical stimulation of the auditory nerve (best outcomes if implanted before 2 years of age).
Educational Interventions: Language-based early interventions yield superior results, with preferences for family involvement through verbal and nonverbal gesture communications.
Anatomy Review: The Ear
External Ear:
Auricle (pinna)
External auditory canal
Middle Ear:
Tympanic membrane
Ossicles: Malleus, Incus, Stapes
Eustachian tube
Inner Ear:
Cochlea
Semicircular canals
Nerves:
Facial nerve (CN VII)
Cranial nerve VIII
Bony Anatomy:
Mastoid bone
Congenital Ear Abnormalities
Types:
Microtia: folded over helix affecting triangular fossa
Low set and posteriorly rotated ears observed in conditions like Turner syndrome
Abnormally contoured cartilage resulting in protruding ears observed in children with Lop ear.
Ear Examination - 4 D's
Discharge:
May indicate acute otitis externa or acute otitis media with perforation.
Displacement: Pinna may be displaced away in cases of mastoiditis or foreign body with secondary infection.
Discoloration: Trauma shows “Battle's sign” from basilar skull fractures or hemotympanum.
Deformity: Identified via visible differences in ear shape or structure.
Acute Otitis Externa
Definition: Also known as “Swimmer’s Ear”, occurs due to exposure to excessive moisture allowing bacterial and fungal overgrowth.
Most common organisms:
Pseudomonas, Staphylococcus, various gram-negative bacteria, with some less common fungal causes.
Risk Factors:
Swimming, trauma, use of occlusive devices, allergic contact dermatitis.
Clinical Features:
Symptoms include pain, itching, erythema of the canal, and thick white discharge. Pain is induced by pulling on the pinna or pressing on the tragus.
Differential Diagnosis for Acute Otitis Externa
May need to differentiate from:
Foreign Body
Perforation of the tympanic membrane following acute otitis media.
Treatment of Acute Otitis Externa
First-line treatment: Topical otic antibiotics/steroid preparations.
For ages >6 months: Ciprodex (4 drops in the ear twice a day for 7 days).
For ages >2 years: Cortisporin (neomycin-polymyxin B sulfates-hydrocortisone otic solution) 3 drops 3-4 times daily for 10 days.
If TM is not visualized, options are: ofloxacin, ciprofloxacin, Ciprodex.
Systemic Antibiotics: Considered in cases of severe pain, evidence of acute otitis media, or uncertainty regarding AOM because TM is difficult to visualize.
Parenteral Antibiotics: Needed in cases of cellulitis of the periauricular tissues.
Acute Otitis Media
Causes: Eustachian tube dysfunction leads to inflammation and fluid accumulation, often following a viral upper respiratory infection (URI).
Typical pathogens include:
Viral: RSV, Rhinovirus, Influenza, Parainfluenza, Adenovirus, Enterovirus
Bacterial: S. pneumoniae, H. influenzae, M. catarrhalis
Peak Incidence: Children 6-19 months of age with seasonal peaks in the winter (associated with upper respiratory infections).
Acute Otitis Media - Risk Factors
Exposure to cigarette smoke
Attendance at daycare
Sick contacts
Bottle feeding while lying flat (bottle propping)
Allergic tendencies
Genetic factors and anatomical issues affecting Eustachian tube
First occurrence under 6 months is a higher risk for chronic cases
Immunocompromised states
Craniofacial anomalies (e.g., cleft palate).
Acute Otitis Media - Prevention
Recommendations:
Breastfeeding for at least 6 months
Avoid bottle propping
Minimize pacifier use after 6 months
No exposure to passive tobacco smoke
Vaccination with PCV 13 or PPSV 23 when indicated
Annual flu vaccine
Avoid daycare whenever possible and limit exposure to sick contacts.
Physical Exam - Acute Otitis Media
Tympanic Membrane Findings: May be erythematous, bulging, retracted, or perforated
Fluid Presence: Air-fluid levels may be visible behind the TM
Mobility: Diminished TM mobility can be assessed using an insufflator
Hearing Assessment: May indicate decreased hearing ability.
Treatment of Acute Otitis Media
Initial observation strategy (with analgesics) is reasonable for:
Children >2 years old
Temperature <39 °C
Mild to moderate pain manageable with analgesia
Unilateral infections
Absence of marked tympanic membrane bulging
Symptom onset within 72 hours of presentation
Reassessment: Recommended after 48-72 hours.
Immediate antibiotic treatment for children exhibiting:
Age <2 years
Temperature ≥39 °C
Severe pain persisting despite analgesics
Marked bulging of the tympanic membrane
Presence of otorrhea
Bilateral AOM
Symptoms exceeding 72 hours at the time of presentation
Immunocompromised state
Toxic appearance
Craniofacial abnormalities.
Symptom Relief Options:
Acetaminophen 10-15 mg/kg every 4-6 hours
Ibuprofen 10 mg/kg every 6-8 hours for patients over 6 months old.
Medications Used in Acute Otitis Media Treatment
Antibiotics:
Amoxicillin:
For age <2 months: 30 mg/kg/day (divided into two doses for 10 days)
For age >2 months: 80-90 mg/kg/day divided into two doses for 10 days (maximum 4g/day).
Augmentin:
Prescribed if no improvement in 48-72 hours following amoxicillin treatment, recent beta-lactam treatment within the last 30 days, or concurrent purulent conjunctivitis.
Penicillin Allergy:
Type 1 (anaphylaxis/angioedema): Use macrolide (Azithromycin 10 mg/kg for 1 day, then 6 mg/kg for 4 days) or Clindamycin (30-40 mg/kg every 8 hours for 10 days)
Non-Type 1: Use cephalosporins such as Cefdinir (14 mg/kg/day every 8 hours for 10 days) or alternative options like Cefpodoxime or Cefuroxime.
When to Refer for Acute Otitis Media
Referral criteria:
More than 3 episodes of AOM within less than 6 months
More than 4 episodes within a 12-month period with intermittent resolutions.
Recommended duration of treatment:
Under 2 years: 10 days
Ages 2-6: 7 days
Over 6 years: 5 days.
Complications of Acute Otitis Media
Possible complications:
TM perforation: Monitor for healing or refer to ENT if healing is not progressing.
Hearing loss: Can lead to conductive hearing loss.
Mastoiditis: An infection of the mastoid air cells.
Recurrent or chronic otitis media: May warrant consideration for tympanostomy tubes for >4 episodes in one year.
Cholesteatoma: Abnormal skin growth in the middle ear
Intracranial complications: Rare in developed countries, but may include meningitis, lateral sinus thrombosis, cerebral abscess.
Serous Otitis Media (OME)
Cause: Upper respiratory infections leading to serous effusions in the middle ear.
Clinical Features:
Effusion appears clear gray or yellowish behind the eardrum.
Pneumatic otoscopy reveals poor mobility of the tympanic membrane.
Longstanding effusions can impact hearing and are susceptible to bacterial infection.
Persistent effusions lasting >3-4 months with associated hearing loss may necessitate referral for myringotomy and tube insertion.
Differentiating AOM from OME
AOM: Characterized by a bulging tympanic membrane, antibiotics are necessary.
OME: Features opacification of the tympanic membrane or air-fluid levels, antibiotics are not indicated.
Chronic Recurrent Otitis Media
Characteristics: Common in young children, especially those with facial hypoplasia or deformities like cleft palate or Down syndrome.
Clinical Features:
Hearing impairment
Intermittent discomfort
Permanent myringosclerotic changes lead to thickened and scarred tympanic membranes.
Treatment: Consider tympanostomy tubes for children experiencing more than four episodes of AOM in 12 months, necessitating ENT referral.
Cholesteatoma
Overview: A serious lesion of the ear drum consisting of trapped epithelial tissue beneath the membrane's surface.
Causes: May be congenital or acquired due to chronic recurrent otitis media.
Findings:
Congenital: Typically presents in the anterior/superior quadrant of the middle ear with a white cyst. Can lead to perforation, chronic ear drainage, and hearing loss as it enlarges.
Acquired: Exhibits deep retraction pockets, white mass behind the tympanic membrane, granulation tissue at the TM’s periphery, with ear drainage and hearing loss.
Complications: Can result in progressive hearing loss, lateral sinus thrombosis, sepsis, or brain abscess.
Treatment: Surgical removal is often necessary.
Granulomas and Polyps
Overview: Aural polyps often arise from old, retained tympanostomy tubes.
Clinical Features: Polyps may enlarge and obstruct the ear canal, leading to compromised eardrum and ossicle function.
Risk Factors: More common in children with chronic middle ear infections.
Treatment: Involves topical and oral antibiotics if infection is present, surgical removal may be indicated.
Mastoiditis
Definition: A bacterial infection of the mastoid air cells, considered a rare complication of otitis media.
Common pathogens include:
S. pneumoniae, S. pyogenes, S. aureus, Pseudomonas aeruginosa associated with recurrent otitis media or recent antibiotic treatment.
Clinical Features:
Symptoms include pain, swelling, tenderness, and redness behind the ear where the mastoid bone is located.
Tenderness and redness may lead to obvious displacement of the pinna.
Diagnosis of Mastoiditis
Imaging: X-ray of the mastoid may show soft-tissue swelling and lytic lesions; CT scans are the most reliable for diagnosis.
Laboratory Tests: CBC with differential, blood cultures, and tympanocentesis may be utilized to assess infection.
Treatment of Mastoiditis
Without recurrent AOM or recent antibiotics:
Unasyn (Ampicillin-sulbactam) at 50 mg/kg IV every 6 hours.
With recurrent AOM or recent antibiotics:
Zosyn (Piperacillin-tazobactam) at 75 mg/kg every 6 hours IV to cover for Pseudomonas.
For severe penicillin allergies:
Vancomycin or linezolid plus metronidazole are alternatives.
Treatment duration: Usually spans 7-10 days IV, followed by oral antibiotics totaling about four weeks of treatment.
Foreign Bodies in the Ear Canal
Types of Foreign Bodies: Can include items like beads, seeds, or insects.
Management: Requires careful removal to prevent further trauma; may use olive oil or mineral oil to drown insects if the TM is intact.
Otic Foreign Bodies Removal Procedures
Methods of Segmenting Foreign Bodies:
Irrigation: Direct irrigation for small, inorganic objects or insects, excluded from use if TM is perforated.
Instrumentation under Direct Visualization: Requires careful restraint and adequate lighting; appropriate tools include:
Headlight or operating microscope
Ear speculum
Alligator forceps or suction tubings.
Nasal Exam
Procedure: Performed with the child sitting or supine; wide-bore speculum usage is essential for visualization; stabilization of the child's head is necessary to inspect the nasal cavity thoroughly.
Common Causes of Nasal Congestion
URI: Upper respiratory infections are a frequent cause.
Congenital causes: Such as choanal atresia or tumors.
Management: Saline drops, suction recommended; persistent discharge over 14 days requires further investigation.
Choanal Atresia
Cause: Blockage of the nasal opening.
Clinical Features:
Bilateral blockage leads to noisy breathing and worsening cyanosis during feeds.
Unilateral blockage presents later in life with nasal obstruction.
Diagnosis: Confirmatory tests include attempts to pass a catheter from the nose to oropharynx; CT scans provide definitive diagnosis.
Treatment of Choanal Atresia
Bilateral Choanal Atresia: Considered an emergency requiring airway management immediately.
Definitive Management: Surgical repair, usually via endoscopic resection of the posterior nasal septum with or without stenting involved.
Deviated Septum
Clinical Features: Resulting from trauma, presenting as nasal obstruction and causing long-term issues if not corrected.
Management: Surgical correction is advisable to prevent future deformities and relieve obstruction.
Nasal Polyps
Clinical Features: Typically presents as bilateral nasal obstruction, particularly in young children.
Significance: Any child with nasal polyps should be evaluated for underlying conditions such as cystic fibrosis or asthma.
Septal Hematoma Management
Procedure: Incision and drainage (I&D) under general anesthesia; benefits from concurrent nasal packing.
Antibiotic prophylaxis: Amoxicillin or Amoxicillin-clavulanate, taking bacteriological resistance into consideration depending on risk factors.
Sinusitis Overview
Anatomical Maturity: Ethmoid and maxillary sinuses at birth; sphenoid sinuses mature at age 5; frontal sinuses mature around ages 10-11.
Causes: Often a consequence of viral upper respiratory infections leading to obstruction and promoting bacterial proliferation.
Bacterial agents: S. pneumoniae, H. influenzae, M. catarrhalis are common culprits.
Clinical Features of Sinusitis
Symptoms: Lasting URI symptoms over 7-10 days, purulent rhinorrhea, facial pain, and possibly headaches.
Diagnosis: Uncomplicated sinusitis diagnosed clinically; complicated cases necessitate CT scans showing sinuses detailing edema with air-fluid levels.
Treatment of Sinusitis
Antibiotics for uncomplicated cases: Augmentin 45 mg/kg/day for 10-14 days, potentially increasing to 90 mg/kg/day based on resistance risk
Supportive care: Include saline nasal sprays, warm compresses, and patient education to avoid certain activities like diving.
Sinusitis Complications
Notable Complications:
Pott Puffy Tumor: Often involves frontal bone osteomyelitis related to subperiosteal abscesses.
Epidural abscesses: Extension of infection through the bony anatomy of the skull.
Periorbital and Orbital Cellulitis: Distinction made according to the diagnosed condition and referring hospital admission for IV antibiotics or possible surgical management.
Periorbital Cellulitis (Preseptal)
Clinical Features:
Confined to tissues outside or anterior to the orbital septum; characterized by unilateral erythema, swelling, and induration.
Diagnosis: Typically confirmed through non-contrast CT scans.
Initial Treatment: Administering Augmentin unless symptoms do not improve, at which point escalatory therapy may include linezolid.
Orbital Cellulitis (Septal)
Causes: Infection extending into the orbit; generally associated with treated ethmoid sinus infections.
Clinical Features: Systemic illness, proptosis, severe retro-orbital pain, diminished vision, and conjunctival injection are common responses.