CM- Ear Disease

Question 1

What evaluation technique is used for:

1. detailed testing of hearing
2. evaluation of balance function
3. inner ear fluid imbalance testing
4. facial nerve testing

Answer 1

1. audiogram
2. electronystagmogram [ENG]
3. electrocochleography [ECOG]
4. electroneurography [ENOG]

Question 2

What are the 2 large categories of otalgia?

Answer 2

1. Otogenic [50-60%] = true ear pain
   - acute otitis media
   - acute otitis externa [swimmer’s ear]
2. Non-otogenic = referred pain
   - myofacial pain dysfunction [TMJ]
   - tonsillitis
   - throat cancer

Question 3

Describe the features of myofacial pain dysfunction syndrome.
What will the patient have in their history?
What will their presenting complaints be?
What does audiometry show?

Answer 3

History:

1. clenching/gritting teeth; nocturnal grinding [bruxism]
2. malocclusion or history of facial trauma, prior dental work

Present with:

1. inflammation of muscles of mastication
2. pressure and fullness of the ear
3. subjective hearing loss [audiometry shows no objective hearing loss]
4. light headed and off-balance but not true vertigo

Question 4

Is hearing loss with myofacial pain dysfunction subjective or objective?

Answer 4

Subjective- the patient feels like they have hearing loss but auditometry does NOT document objective hearing loss

Question 5

How is the diagnosis of TMJ/myofacial pain dysfunction syndrome made?

What is treatment?

Answer 5

1. normal external auditory canal
2. normal tympanic membrane
3. tenderness of ipsilateral muscles of mastication and over the TMJ

Treat with:

• NSAIDS for 10 days to 2 wks
• soft diet/liquids to rest the jaw
• massage and warm compress
• occlusal guard if it persists

Question 6

A patient presents with normal exam of the external auditory canal and tympanic membrane and an abnormal examination of the tonsils and pharynx.
What is the cause of their ear pain and what is treatment?

Answer 6

Cause: tonsillitis or pharyngitis

Treat: antibiotic therapy if bacterial or supportive measures if viral

Question 7

Masses [malignancies or ulcerative lesions from what areas can present as otalgia?
What is are these tumors usually a consequence of?
What age individuals do they present in?

Answer 7

1. nasopharynx
2. larynx
3. lateral pharyngeal wall
4. pyriform sinus

Tumors in these areas are usually a consequence of heavy drinking and smoking and present in individuals 50-70
[also recently, HPV in men]

Question 8

What are the 4 things tested with audiogram?

Answer 8

1. pure tone test [air and bone]
2. speech reception threshold
3. speech discrimination score [word understanding]
4. typanometry [ear drum mobility]

Question 9

What age distribution is most affected by external otitis?
What is the causative agent in 50% of cases?
What are the 2 main predisposing factors?

Answer 9

Swimmer’s ear affects adults and children equally.
Pseudomonas is the cause in 50% of cases

1. swimming or other exposure to water
2. Q-tip trauma

Question 10

What is the pathophysiology of external otitis?

Answer 10

The normal pH of the external auditory canal is acidic which suppresses the growth of pseudomonas.
When water from other sources enter the ext. ear, it makes it alkaline –> psuedomonas

Question 11

A patient has experienced the development of otalgia over several hours. It is very intense and throbbing. His ear is so tender that any manipulation is painful. He has experienced mild hearing loss due to the swollen canal impeding soundwave movement.
On examination, you note a mucopurulent exudate, and his auditory canal is swollen shut.

What is the Dx?
What caused this?

Answer 11

External otitis- most likely caused by Pseudomonas after swimming or Q-tip trauma

Question 12

What can external otitis proceed to?

What can it proceed to in people with diabetes or immunocompromised states?

Answer 12

Normal people –> cellulitis of facial and retroauricular tissue

Diabetes/immunocomp –> malignant [necrotizing] otitis externa where the infection spreads to the temporal bone causing osteomyelitis

Question 13

A child presents with rapid onset severe otalgia that is aching with a feeling of pressure and fullness. He claims that he can’t hear, but audiogram shows no objective loss of hearing.
He has a fever, malaise and is lethargic.

What is the Dx?
What is the natural course of the problem?

Answer 13

Acute otitis media

1. 24-48 hours of pain, fever, subjective hearing loss, pressure
2. tympanic membrane spontaneously ruptures
3. mucupurulent drainage into external auditory canal
4. perforation of TM causes decreased pain
5. drum heals spontaneously in 90% of cases w/o antibiotics

Question 14

What are complications of acute otitis media in untreated individuals?

Answer 14

1. facial nerve paralysis
2. meningitis
3. epidural or brain abscess
4. sigmoid sinus thrombosis
5. acute labyrinthitis w/ violent rotational vertigo&complete hearing loss

Question 15

How is the diagnosis of acute otitis media made?

Answer 15

History and physical exam

PE:

1. bulging red tympanic membrane
2. pinna/external auditory canal are NOT painful

Question 16

Describe the pathophysiology of a middle ear effusion. What kind of hearing loss does it cause?

Answer 16

1. Eustachian tube gets obstructed
2. negative pressure in the middle ear space retracts the tympanic membrane
3. retracted tympanic membrane has limited movement –> hearing loss
4. negative pressure in middle ear causes it to fill with transudate from surrounding tissue–>middle ear effusion [serous otitis media]

Fluid in the middle ear space causes CONDUCTIVE hearing loss

Question 17

A 4 year old is having difficulty acquiring speech and language acquisition. His parents are very concerned so they take him to the pediatrician. On physical exam, a retracted dusky tympanic membrane is noted.

Audiometric evaluation shows conductive hearing loss.
Tympanometry shows poor movement.

What is the likely problem?

Answer 17

Middle ear effusion/ serous otitis media

Question 18

What are the 2 broad categories of hearing loss?

What parts of the auditory system are affected in each type?

Answer 18

1. Sensorineural
   - cochlea
   - CN8
   - brainstem
2. Conductive
   - external auditory canal
   - tympanic membrane
   - middle ear space
   - ossicular chain

[Mixed hearing loss can also occur]

Question 19

How do you distinguish between neurosensory and conductive hearing loss on physical exam?

Answer 19

Tuning fork test [512Hz]

Question 20

What is the difference between bilateral symmetrical neurosensory losses and unilateral losses in terms of most likely causes?
Which should be evaluated by an otolaryngologist?

Answer 20

Bilateral [both ears have same degree of hearing loss w/in 5-10 decibels at EACH frequency]

1. genetic/hereditary factors
2. environmental conditions [noise]

Unilateral:

1. acquired structural lesion
   * * evaluate by otolaryngologist b/c it should be presumed to be cerebellopontine angle tumor [acoustic neuroma] until proven otherwise

Question 21

All unilateral otologic symptoms [esp. hearing loss and tinnitis] should be considered to represent what until proven otherwise?

Answer 21

Cerebellopontine angle tumor [acoustic neuroma]

Question 22

A unilateral middle ear effusion that does not clear in 4-6 weeks in an adult may indicate what?
What should be done to further evaluate?

Answer 22

a tumor in the nasopharynx causing Eustachian tube dysfunction.

This should be evaluated by an otolaryngologist with:

1. flexible fiberoptic exam of nasopharynx
2. CT

Question 23

Describe the Weber test.

Answer 23

1. place 512Hz tuning fork on the patients forehead.
2. vibrations travel via bone directly to cochlea
3. if there is conductive hearing loss, sound through the external auditory canal and middle ear will be diminished in the affected ear
4. bone conduction tuning fork vibrations will be LOUDER in the ear WITH CONDUCTIVE LOSS

Question 24

Describe the Rinne test.

Answer 24

1. place the tuning fork on the mastoid tip behind the auricle pressed to bone
2. move it to an inch outside the auditory canal
3. if bone conduction is louder than air conduction, the patient has conductive hearing loss in that ear.

[rinne negative = abnormal = BC>AC]

Question 25

What is tinnitus? | What are the 2 categories?

Answer 25

Sound heard in one or both ears that is internally generated and not produced by any stimulus outside the body. 1. objective 2. subjective

Question 26

What is objective tinnitus? What are the 4 major causes? How is it appreciated by the examiner?

Answer 26

It is tinnitus that can be appreciated by an objective observer. The most common is vascular tinnitus [sound of blood rushing through blood vessels] 1. AVM 2. vascular tumor near inner ear/temporal bone 3. carotid with significant obstruction 4. palatal myoclonus It is appreciated by placing stethoscope near or around the ear

Question 27

What is subjective tinnitus? | What is it most frequently associated with?

Answer 27

When the patient hears sound that is inaudible to the examiner [even with amplification] It is frequently associated with hearing loss where the frequency of the tinnitus is the same frequency as the max hearing loss [thought to be cochlear or thalamic]

Question 28

What is vertigo?

Answer 28

The illusion of movement when none is actually occurring.

Question 29

Where does peripheral vertigo arise? | Where does central vertigo arise?

Answer 29

Peripheral: 1. semicircular canals of inner ear 2. CN8 3. brainstem vestibular nuclei Central: 1. supranuclear pathways 2. cerebellum

Question 30

A patient presents with vertigo that feels like rotational movement. She has nausea, vomiting, pallor and diaphoresis. She says the onset is usually intermittent and it lasts for a few hours. Is this more likely to be peripheral or central vertigo?

Answer 30

Peripheral

Question 31

A patient presents with vertigo that lasts for weeks/months at a time but is not very severe. She has blurred vision, diplopia, numbness in the extremities, focal motor weakness, headache and occasional syncope. Is this likely to be peripheral or central vertigo?

Answer 31

Central as noted by the CNS dysfunction of CN nerves, and sensory/motor changes

Question 32

A patient presents with sporadic, severe vertigo with unremitting nausea and vomiting. It lasts 1 or 2 days with gradual return of equilibrium. There is no tinnitus, hearing loss or aural fullness. What is the likely cause?

Answer 32

Viral labrynthitis

Question 33

A patient presents with vertigo that lasts 20 min to 4 hours. The vertigo is accompanied by low-pitched tinnitus, aural fullness and pressure, and fluctuating neurosensory hearing loss. What is the Dx? What causes this?

Answer 33

Meniere's disease - inner ear fluid imbalance and rupture of membrane

Question 34

A patient experiences vertigo when the left ear is in a downward position. The vertigo lasts 1 minute but recurs. What is the Dx and cause?

Answer 34

``` Dx = benign paroxysmal positional vertigo Cause= otoconia which is calcium carbonate crystals free floating in the balance canals ```

Question 35

What are the 2 phases of nystagmus? What is the direction of the nystagmus named for? When can nystagmus arising from an inner ear problem be seen?

Answer 35

1. Slow phase- inner ear to attempt to maintain visual fixation despite head movement 2. fast phase- brainstem returns the nystagmoid eye Named for the fast phase Viral labrynthitis and Meniere's can cause this, but visual fixation suppresses nystagmus from the inner ear so it can only be noted when the eyes are closed [NOT OBSERVABLE ON PE, must be measured with ENG which detects eye movement when the eye is closed]

Question 36

What are the 4 causes of peripheral labrynthine vertigo [not true vertigo]?

Answer 36

1. MEE 2. AOM 3. cholesteatoma [erodes semicircle canal] 4. acoustic neuroma

Question 37

What are the 4 main causes of otorrhea? | What do they look like?

Answer 37

1. External otitis -mucopurulent 2. Middle ear effusion with perforated tympanic membrane -mucopurulent 3. CSF otorrhea- clear and can be tested with beta2-transferrin-a 4. Cholesteatoma- mucopurulent but prolonged and unremitting

Question 38

A patient presents with clear otorrhea that tests positive for beta2-transferrin A protein. The patient has hearing loss, balance disturbance and facial paralysis. What is the Dx and what was the inciting factor?

Answer 38

CSF otorrhea caused by trauma or ear surgery

Question 39

What is cholesteatoma?

Answer 39

An epidermoid inclusion cyst growing within the temporal bone

Question 40

What are the 4 places a cholesteatoma can erode? | What will the associated symptoms be for each?

Answer 40

1. semicircular canal - vertigo and deafness 2. facial nerve- paralysis 3. ossicles- conductive hearing loss 4. subarachnoid space - brain abscess or epidural abcess

Question 41

An otorrhea is mucopurulent but resistant to oral and topical antibiotic therapy. What is the likely cause? How do you confirm diagnosis?

Answer 41

Cholesteatoma You need to see squamous epithelium within the confines of the middle ear space through a tympanic membrane perforation