Disorders of the Ear

Question 1

Describe the Weber test

Answer 1

Tuning fork placed atop of head.

If sound lateralizes to Crummy (bad) ear = Conductive hearing loss.

If lateralizes to Super (good) ear = Senorineural loss.

Question 2

Describe the Rinne test

Answer 2

Tuning fork placed on mastoid process, once pt cannot hear move fork in front of ear canal, pt should then be able to hear sound again, this is normal bc AC > BC.

If BC > AC abnormal Rinne test.

Question 3

List disorders of the external ear

Answer 3

Cerumen impaction
FBs
Otits Externa “swimmers ear”
Hematoma

Question 4

When would you NOT irrigate for cerumen impaction?

Answer 4

if TM is not intact or if known hx or risk of perforation

Question 5

Describe treatment options for cerumen impaction?

Answer 5

• Detergent ear drops - Debrox earwax removal kit, carbamide peroxide is generic
• Mechanical removal w curette
• Irrigation - if TM intact, body temp water only, canal must be dried after irrigation

Question 6

Describe tx of FB in ears

Answer 6

Urgent if button batteries, live insects, or penetrating FB

Firm objects should be removed with loop or irrigation avoiding pushing closer to TM.

Organic FBs NOT irrigated but removed. Immobilize living insects - can use Lidocaine

Question 7

Describe causes of Otitis Externa

Answer 7

• Infection * most common
  Allergic
  Dermatological conditions (psoriasis)

Question 8

What is Otitis Externa (OE)?

Answer 8

Inflammation of external auditory canal (EAC)

Question 9

Bacteria associated with otitis externa

Answer 9

1 Pseudomonas - gram neg rod

S areus
S epidermidis

Also.. fungi (2-10% cases) Aspergillus and Candida

Question 10

Describe clinical presentation of otitis externa

Answer 10

• Otalgia (pain)
• Pruritis (more common in fungal infection)
• Purulent discharge
• Hearing loss
• Fullness
• Hx of recent water exposure, mechanical trauma, perforation, perforation bc of topical drops

Question 11

PE findings of Otitis Externa

Answer 11

• Erythema/edema of ear canal skin
• Purulent exudate
• Tenderness
• TM may be mildly erythematous
• TM remains mobile with pneumatic otpscopy

Question 12

DDx of otitis externa

Answer 12

Middle ear infection
Contact dermatitis
Psoriasis
Chronic suppurative otitis media
Squamous cell carcinoma of external canal
Radiation therapy
Herpes simplex virus - Ramsay Hunt Syndrome

Question 13

What is Ramsay Hunt Syndrome?

Answer 13

An outer ear infection that is rare, characteristic vesicles on out ear canal with lateral facial paralysis, caused by herpes simplex virus

Question 14

Tx of otitis externa

Answer 14

7-10 days topical aminoglycoside or fluoroquinolone Abx w or w/o corticosteroid (otic suspension)

Keep canal dry, avoid scratching, remove debris, can use wick if swelling significant

Severe OM w/ cellulitis of periauricular tissue need oral Abx

Refer to ENT if persistent OE or if pt immunocompromised or diabetic

Question 15

Pts that are immunocompromised or diabetic are at risk for what complication of OE?

Answer 15

Malignant otitis externa aka necrotizing otitis externa -

increase risk for osteomyelitis of temporal bone/skull base

Question 16

Describe presentation of malignant otitis externa?

Answer 16

Foul-smelling discharge, granulations in ear canal, deep otalgia, cranial nerve palsies, HA

Dx: CT – osseous erosion
Treatment-IV antibiotics (quinolones), surgery

Question 17

Describe hematoma of external ear

Answer 17

often due to injury - wrestlers esp

traumatic auricular hematoma, must be recongnized promptly

Tx is drainage
Complication - cauliflower ear

Question 18

Most common causative organisms of acute otitis media?

Answer 18

#1 Streptococcus pneumonia 
#2 Haemophilus influenza 
#3 Moraxella catarrhalis 

and also
S. pyogenes (group A step)
S. aureus

recurrent cases often associated with allergies or second hand smoke exposure

Question 19

Describe pathophysiology of Acute Otitis Media

Answer 19

• bacterial infections of middle ear, usu precipitated by URI - eustachian tubes obstruct, fluid/mucous accumulates becomes secondarily infected
• underlying poor drainage from eustachian tubes due to age, inflammation/edema, congenital malformation

Question 20

Clinical presentation and epidemiology of AOM

Answer 20

Otalgia/pressure
Hearing loss
Fever (children > adults)
URI symptoms

Most common in children 4-24 months, increased during winter and fall.

Question 21

A tympanic membrane with bullae is associated with what microorganism?

Answer 21

mycoplasma

Question 22

PE of AOM

Answer 22

TM immobile
erythematous and bulging
possible TM rupture

Question 23

1st line treatment of AOM**

Answer 23

high dose amoxicillin (80-90 mg/kg/day divided twice daily)

Question 24

2nd line Tx of AOM

Answer 24

High-dose amoxicillin-clavulanate or 2nd or 3rd generation cephalosporin

Question 25

Tx of AOM with perforated TM

Answer 25

Include topical antibiotic with low ototoxicity (ofloxacin)

Question 26

Describe observation vs antibiotics for AOM

Answer 26

Observation if 6 mo-2yr with unilateral AOM and mild sxs if >2yr with unilateral or bilateral AOM and only mild sxs Abx if worsening or no improvement in 48-72hrs Immediate Abx if under 6 mo under 2yr with severe AOM, moderate or severe sxs, pain >48hrs, Temp > 102.2 F (39C), bilateral AOM

Question 27

Complications of AOM

Answer 27

- Labyrinthitis. -inflammation into the semicircular canals - Hearing loss - Mastoiditis (high risk in immunocompromised, Tx IV Abx or mastoidectomy) - Non-response to meds (resistant organisms, change Abx) - Reccurent infections (may require tympanostomy - pressure equalizing tubes)

Question 28

Describe presentation and PE of chronic otitis media

Answer 28

``` Chronic otorrhea (drainage) PE - perforated TM and conductive hearing loss ```

Question 29

Tx for chronic otitis media

Answer 29

- Removal of infected debris - Earplug use (recc to prevent water/moisture) - Topical or oral antibiotics (that are not ototoxic) -Surgery – TM repair

Question 30

Describe serous otitis media aka otitis media with effusion

Answer 30

Eustachian tube stays blocked for a prolonged time, negative pressure moves fluid into middle ear. Children > adults, tubes more narrow and horizontal Adults occurs after URI, barotrauma, or chronic allergies

Question 31

PE of serous otitis media

Answer 31

TM dull and hypOmobile Bubbles visible Conductive hearing loss

Question 32

Describe a cholesteatoma

Answer 32

specific type of chronic otitis media creates sac lined w squamous epithelium that produces keratin, can get secondarily infected (pseudomonas or proteus) presentation may be asymptomatic or hearing loss, possible ear drainage

Question 33

Describe tx and complications of a cholesteatoma

Answer 33

Tx- Abx drops, surgical removal Complications- erosion into inner ear, facial nerve, brain, abscess

Question 34

Describe eustachian tube dysfunction

Answer 34

edema of tubal lining traps air in middle ear causing negative pressure can be caused by viral URI or allergies on PE retraction of TM and decreased mobility of TM on pneumatic otoscopy

Question 35

Tx options for ET dysfunction

Answer 35

``` Decongestants (topical intranasal or systemic oral) Autoinflation Desensitization therapy (allergies) Intranasal corticosteroids Surgery ```

Question 36

What is Labyrinthitis? Describe its presentation

Answer 36

inflammation into the semicircular canals - a possible complications of AOM, often occurs post viral infection ``` acute onset of severe continuous vertigo +/- hearing loss and tinnitus N/V gait impairment *cerebellar hemorrhage/infarct risk?* ```

Question 37

Describe conductive hearing loss

Answer 37

usually a dysfunction of external and middle ear in transmitting sound to inner ear (cochlea) air conduction measures conductive hearing

Question 38

Describe sensorineural hearing loss

Answer 38

Sensory loss – dysfunction of cochlea from loss of hair cells Neural loss – dysfunction of CN 8 (vestibulocochlear) or central auditory pathway Most common = presbycusis (aging)

Question 39

Tinnitus is associated with what kind of hearing loss?

Answer 39

Sensory hearing loss Tinnitus is perception of sound in ear or head. Variability exists in sound quality, pitch, and duration

Question 40

Peripheral causes of vertigo

Answer 40

``` Vestibular neuritis/Labyrinthitis Meniere disease BPPV Ethanol intoxication Inner ear barotrauma Semicircular canal dehiscence ```

Question 41

Central causes of vertigo

Answer 41

``` Seizure Multiple sclerosis Wernicke encephalopathy Chiari malformation Cerebellar ataxia syndromes ```

Question 42

What should you be concerned of with Labyrinthitis/not miss?

Answer 42

cerebellar hemorrhage or infarct - evaluate nystagmus - other neuro sxs - risk category consider neuroimagining

Question 43

Differentiate clinical presentation of Central vs Peripheral Vertigo

Answer 43

``` Central: gradual onset progressive increase in severity Nystagmus - usu vertical or torsional no auditory sxs ``` ``` Peripheral: sudden onset acutely severe sxs N/V tinnitus, hearing loss Nystagmus- usu horizontal ```

Question 44

When is Dix-Hallpike maneuver used?

Answer 44

When assessing vertigo. Positive test: delayed onset fatigable nystagmus in most peripheral causes if nystagmus not fatigable, indicates central cause

Question 45

What is BPPV?

Answer 45

Benign paroxysmal positional vertigo Peripheral cause of vertigo caused by sediment in semicircular canals, provoked by changes in head position - acute vertigo x 10-60 seconds, imbalance x several hours - episodes brief in duration often recurrent - appear in clusters lasting several days

Question 46

Describe treatment options for BPPV

Answer 46

Particle repositioning maneuvers - Epley maneuver PT/OT referral Pharmaceutical agents (vestibular suppressants) Bed rest if severe Pt ed, risk for falls

Question 47

What is another name for Meniere Disease

Answer 47

Endolymphatic hydrops

Question 48

Describe Meniere Disease

Answer 48

Def: vertigo syndrome due to a peripheral lesion Distention of endolymphatic compartment of inner ear, pressure rises and falls - sxs wax and wane. Can permanently damage inner ear structures.

Question 49

Clinical presentation of Meniere Disease

Answer 49

-episodic vertigo, spells lasting 20 mins - several hrs (vs BPPV vertigo lasting <1 min) - fluctuating sensorineural hearing loss (low frequency!) - tinnitus - sensation of unilateral ear pressure (aural fullness)

Question 50

Describe Pathophys of vestibular schwannoma aka acoustic neuroma

Answer 50

one of most common intracranial tumor; benign tumor of CN 8 begins in internal auditory canal, gradually grows to compress pons and causes hydrocephalus usually unilateral

Question 51

Clinical presentation, Dx, and Tx of acoustic neuromas

Answer 51

Unilateral hearing loss - most common Continuous dysequlibrium Tinnitus Dx: Audiometry, MRI Tx: Observation, Surgical excision, Radiotherapy

Question 52

Epley maneuver is used to treat what vestibular disorder?

Answer 52

BPPV - pt upright, legs extended - head rotated 45degrees (towards side of + Dix-Halpike test) - pt quickly and passively forced down in supine position, 30 degrees neck extension - observe for primary stage nystagmus, 1-2 minutes - pt head rotated 90 degrees, held in position 1-2 mins - pt roles on shoulder, pt looking down at 45 degree angle, remains here 1-2 mins - pt slowly brought upright maintaining 45 degree rotation of head, for 30 secs