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Ear conditions Flashcards

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1
Q

What is vestibular neuritis?

A

Vestibular neuronitis is inflammation of the vestibular nerve

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2
Q

What are the clinical signs and symptoms of vestibular neuritis?

A

Symptoms
SUDDEN ONSET
Nausea & Vomiting
VIRAL AETIOLOGY IS COMMON (URTI)
ACUTE VERTIGO - sudden onset of constant dizziness lasting days to weeks - initially constant, later triggered or worsened by head movement
Balance problems
Sx worst in first 2-3 days and less severe over next few weeks
Resolution (compensation) over weeks
NO LOSS OF HEARING OR TINNITUS

Signs
Fast phase nystagmus to opposite unaffected side
Follows Alexander’s Law
Halmagyi head thrust – catch up saccade to the side of the affected labyrinth.
No other neurological signs

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3
Q

Why does vestibular neuronitis cause vertigo?

A

Inflammation of vestibular nerve (responsible for balance) distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head resulting in episodes of vertigo, where the brain thinks the head is moving when it is not

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4
Q

How to differentiate between vestibular neuronitis and labyrinthitis?

A

TINNITUS AND HEARING LOSS are NOT features of vestibular neuronitis, as the cochlea and cochlear nerve are not affected.

If tinnitus and hearing loss are also present, consider labyrinthitis or Ménière’s disease as differential diagnoses.

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5
Q

Central causes of vertigo?

A

Stroke
Infection - meningitis, encephalitis

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6
Q

Peripheral causes of vertigo?

A

BPPV
Vestibular neuronitis
Meniere’s disease
Acute otitis media
Acoustic neuroma
Vestibulotoxic medications

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7
Q

Systemic causes of vertigo?

A

Diabetes mellitus
Dehydration
Hypothyroidism

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8
Q

What is the head impulse test used for?

A

to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis)

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9
Q

Explain the steps and results of a head impulse test

A
  • patient sits upright and fixes gaze on the examiner’s nose
  • examiner holds patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose
  • move head back to centre and repeat in opposite direction.

!!! Ensure no neck pain or pathology before performing the test !!!

normal vestibular system = keep their eyes fixed on the examiner’s nose

Peripheral cause e.g. vestibular neuronitis or labyrinthitis = the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.

NYSTAGMUS = PERIPHERAL
NO NYSTAGMUS = CENTRAL / SYSTEMIC

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10
Q

Management of vestibular neuronitis

A

May need admission if dehydrated due to severe nausea and vomiting

For peripheral vertigo, short-term options for managing symptoms include:
- Prochlorperazine (if severe symptoms)
- Antihistamines (e.g., cyclizine, cinnarizine and promethazine) - less severe symptoms relief

Symptomatic treatment can be used for up to 3 days. Extended use may slow down recovery

Don’t drive
Discuss risk of falling
Symptoms should only be severe for 2-3 days then become mild for a few weeks (6 wks)
BPPV may develop after

Referral if the symptoms do not improve after 1 week or resolve after 6 weeks, as may require further investigation or vestibular rehabilitation therapy (VRT).

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11
Q

What is BPPV?

A

common cause of recurrent episodes of vertigo triggered by head movement

  • a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain
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12
Q

BPPV presentation

A

EPISODIC VERTIGO - head movements can trigger attacks of vertigo e.g. turning over in bed
- symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks
- Often episodes occur over several weeks and then resolve but can reoccur weeks or months later
- Nausea, vomiting
- Imbalance

NO HEARING LOSS OR TINNITUS

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13
Q

How is BPPV diagnosed?

A

Dix Hallpike manouvere

In patients with BPPV, it will trigger rotational nystagmus towards affected ear and symptoms of vertigo

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14
Q

How is BPPV treated?

A

Epley manouvere
Refer is sx don’t improve after 4 wks

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15
Q

Causes of BPPV

A

Head injury
Prolonged recumbent position (e.g. dentist visit)
Ear surgery
Episode of inner ear pathology (e.g. vestibular neuronitis)
Aging
No clear cause

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16
Q

Meniere’s disease presentation

A

usually 40-50 years old

EPISODIC ATTACKS OF vertigo, hearing loss, tinnitus and feeling of fullness in ear

Episodes last 20 mins to hours

Vertigo is not triggered by movement or posture

Hearing loss associated with vertigo attacks first, then gradually becomes more permanent - sensorineural hearing loss, generally unilateral and affects low frequencies first

Tinnitus also initially occurs with episodes of vertigo before eventually becoming more permanent - usually unilateral.

Spontaneous nystagmus during an acute attack - unidirectional

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17
Q

How is Meniere’s disease diagnosed?

A

Clinical diagnosis by ENT specialist.

Diagnostic criteria
- ≥ 2 vertigo episodes lasting 20 minutes to 12 hours
- Fluctuating hearing, tinnitus or aural
fullness of affected ear
- Hearing loss confirmed by audiometry

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18
Q

How is Meniere’s disease managed/treated?

A

To manage symptoms during acute attacks:
- Prochlorperazine
- Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Prophylaxis
- Betahistine
- Low-salt diet, avoid caffeine/chocolate/alcohol/tobacco

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19
Q

Sensorinueral hearing loss ddx

A

Meniere’s
Acoustic neuroma

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20
Q

Conductive hearing loss ddx

A

Cerumen impaction
Foreign body
Otitis externa
Otitis media
Tympanic membrane perforation
Masses (cysts / tumours)

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21
Q

What is acoustic neuroma?

A

Vestibular schwannoma - beningn slow growing tumour of schwann cells in the auditory nerve (vestibulocochlear nerve) - presses on the nerve to cause hearing loss

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22
Q

Presentation of acoustic neuroma

Study These Flashcards
A

typically 40-60

Gradual onset unilateral sensorineural hearing loss (often the first symptom)

Unilateral tinnitus

Dizziness or imbalance (gait disturbance)

A sensation of fullness in the ear

associated facial nerve palsy if the tumour grows large enough to compress the facial nerve - facial weakness / numbness

nystagmus

23
Q

Acoustic neuroma investigations / diagnosis

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A

Audiometry - assesses hearing loss - there will be a asymmetrical sensorineural pattern of hearing loss

MRI of internal auditory meatus (IAM) establishes the diagnosis

24
Q

Acoustic neuroma management/treatment

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A

Refer ENT
Dependent upon size & growth
- Watchful waiting
- Radiation
- Surgical resection

25
What are the bacterial / viral causes of otitis media?
most common bacterial cause is streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Viral - RSV, rhinovirus, adenovirus, influenza
26
Symptoms and signs of otitis media in children?
Preceding URTI symptoms - viral URTI often precedes bacterial otitis media (cough, sore throat) - Otalgia - Crying - Difficulty sleeping - Decreased appetite - Vomiting - Tugging/pulling at ear - Otorrhoea - Trouble hearing or responding to sounds - Fever - Bulging TM - Erythematous or cloudy TM - Loss TM landmarks
27
Symptoms and signs of otitis media in adults?
Preceding URI - viral URTI often precedes bacterial otitis media (cough, sore throat) - Otalgia - Headache - Otorrhoea - Trouble hearing or responding to sounds (reduce hearing in affected ear) - Fever - Bulging TM - Erythematous or cloudy TM - Loss TM landmarks
28
Management of otitis media
Ibuprofen/paracetamol for pain and fever - should self resolve in 3 days If not abx - Amoxicillin for 5-7 days first-line - Clarithromycin (in pencillin allergy) - Erythromycin (in pregnant women allergic to penicillin) - co-amoxiclav 2nd line and consider admission If immunocompromised immediate abx
29
What is mastoiditis and what causes it?
Inflammation or infection of the mastoid bone - bone erodes leading to abscess Caused by infection from middle ear spreading to mastoid bone
30
Mastoiditis presentation
Systemically unwell child – SEVERE pain Protruding ear Erythema/fluctuance/pain over mastoid
31
Mastoiditis management
Admit for IV antibiotics Consider head CT to confirm
32
What is glue ear? and when does it occur
Otitis media with effusion Glue-like fluid behind TM without signs of infection Secondary to incomplete resolution of AOM or obstruction of eustachian tube
33
Signs and symptoms of glue ear?
Hearing loss Speech development delay Balance problems Mild intermittent otalgia Aural fullness “Popping” Recurrent AOM, URIs Amber/yellow TM colour Loss of light reflex Air bubbles or air/fluid level
34
Otitis media with effusion diagnosis / investigations?
Pneumatic otoscopy - shows reduced mobility TM Audiometry - presence and level of hearing loss
35
Otitis media with effusion management?
Refer to ENT - Watchful waiting for 3 months - Often resolves spontaneously - DO NOT offer abx, antihistamines, mucolytics, decongestants or steroids - Myringotomy and insertion of grommet restores - Autoinflation - Recurrent cases may require adenoidectomy
36
Causes of TM perforation
Trauma Physical abuse Foreign body Forceful ear irrigation Otitis media
37
Symptoms and signs of tympanic membrane perforation
- Otalgia - Otorrhoea - Sudden hearing loss - Tinnitus - Dizziness - Bloody and/or purulent otorrhoea - Decreased hearing affected ear
38
TM perforation management
Spontaneously heal within 2 months Do not put anything in affected ear Avoid water ear - caution while showering Warm, moist compress for pain Acetaminophen or ibuprofen for pain Abx if related to infection Refer for potential surgery if not healing
39
What is cholesteatoma
Accumulation of squamous epithelium and keratin debris within the middle ear - life threatening and can cause permanent hearing loss
40
Presentation of cholesteatoma
typically 5-15 yr old Typically male Foul smelling discharge Unilteral conductive hearing loss (permanent) Eustachian tube dysfunction / recurrent ear infections Otalgia Otoscopy shows white crust in upper part TM +/- perforation Facial neurological symptoms if pressing on facial nerve
41
Cholesteatoma diagnosis and investigations and management
Otoscopy MRI Audiometry for hearing loss Refer for surgical excision
42
Common causative organisms of otitis externa
Bacterial (Pseudomonas aeruginosa, Staphylococcus aureus) Fungal (Aspergillus, Candida)
43
What is swimmer's ear?
Otitis externa
44
Risk factors for otitis externa
Seborrhoeic/allergic/contact dermatitis, psoriasis, eczema Trauma Swimming fungal infection in patients with multiple courses of topical antibiotics - “friendly bacteria” with protective effect against fungal infections gone
45
Symptoms and signs of otitis externa
Ear pain Discharge Itchiness Conductive hearing loss (if the ear becomes blocked) Aural fullness Pain when moving jaw Examination signs: Erythema and swelling in the ear canal Tenderness of the ear canal Tender pinna and tragus Ear swelling Scaly skin Pus or discharge in the ear canal Lymphadenopathy (swollen lymph nodes) in the neck or around the ear
46
Diagnosis of otitis externa
clinical diagnosis - (otoscopy) An ear swab can be used to identify the causative organism IF: - Treatment failure / oral abx required - Recurrent or chronic
47
Management of otitis externa
Avoid swimming/water for 7-10 days during treatment Analgesia No cotton bud use Topical antibiotic with or without topical corticosteroid x7-14 days - Gentamicin, ciprofloxacin, neomycin +/- betamethasone, prednisolone Ear wick if extensive swelling of canal Oral antibiotic (e.g., flucloxacillin or clarithromycin) if cellulitis beyond external ear canal, wick cannot be inserted, immunocompromised (eg diabetes), - ENT discussion and possible admission if severe/systemic
48
What is malignant otitis externa?
Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull.
49
Risk factors of malignant otitis externa
Diabetes Immunosuppressant medications (e.g., chemotherapy) HIV Prolonged Pseudomonas aeruginosa infection
50
Sx of malignant otitis externa
more severe than otitis externa persistent headache severe pain - constant deep otalgia fever vertigo hearing loss Palsy of cranial nerves VII-XII
51
Malignant otitis externa management
emergency management! Admission to hospital under the ENT team IV antibiotics - Piperacillin / Tazobactam (Tazocin) CT - assess the extent of the infection Strict glucose control
52
Cerumen impaction sx
Hearing loss (conductive) aural fullness otorrhoea, tinnitus dizziness
53
Cerumen impaction diagnosis
Clinica Otoscopy
54
Cerumen impaction management
Manual removal Aural irrigation using syringe - Contraindicated with perforated TM, ear surgery, active dizziness, history recurrent infections Cerumenolytic agents (Otex) Topical agents that soften cerumen and improve manual removal or aural irrigation Microsuction

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