Ear (ENT) Flashcards
(38 cards)
List some signs and symptoms of ear disease
- Otalgia
- Tinnitus
- Hearing loss
- Vertigo / dizziness
- Discharge
- Facial nerve palsy
State which nerves carry general sensation from areas around the ear
CN 5, 9 and 10
- Vagus
- Trigeminal nerve (auriculo-temporal branch)
- Glossopharyngeal (tympanic branch)
- Branches of cervical spinal nerves C2 and C3
How long is the external acoustic meatus in length
2.5cm long (initial 2/3 is cartilage, then 1/3 bony inner ear)
List the 4 main outer ear conditions (from H&N module)
- Wax/foreign body
- Otitis externa (swimmer’s ear)
- Acute otitis media
- Otitis media with effusion (glue ear)
+ cholesteatoma
List some causes of conductive hearing loss
- Wax / foreign body
- Acute otitis media / otitis externa
- Tympanic membrane perforation
- Otitis media with effusion
- Otosclerosis
- Cholesteatoma
List some causes of sensorineural hearing loss
- Presbycusis
- Noise-related hearing loss
- Meniere’s disease
- Labyrinthitis
- Vestibular neuroma (acoustic neuroma)
- Ototoxic medications
- Neurological conditions e.g. MS or stroke
- Malignancy e.g. nasopharyngeal cancer, intracranial tumours
- Autoimmune conditions e.g. RA, SLE, Wegners granuloma (granulomatosis with polyangiitis)
List some causes of otalgia (ear pain)
Otological origin:
- Acute otitis media = most common
- Tympanic membrane perforation
- Otitis media with effusion / eustachian tube dysfunction
- Otitis externa
- Foreign body
- Cholesteatoma
- Skin lesions on pinna e.g. Ramsay-Hunt syndrome, BCC, SCC
Non-otological origin:
- TMJ dysfunction
- Referred pain e.g. oropharyngeal, larynx or pharynx
List some differentials for vertigo / balance disturbance (ear and non-ear origins)
Ear origin:
- BPPV (Benign paroxysmal positional vertigo)
- Meniere’s disease
- Vestibular neuritis / labyrinthitis
- Vestibular schwannoma (acoustic neuroma)
Central origin:
- Stroke
- Migraine
- Malignancy
- MS
- Ototoxic vestibulopathy
- Cerebellar disease e.g. alcohol intoxication
Otitis media with effusion (glue ear) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Chronic eustachian tube dysfunction
- Leads to poor equalisation of pressure, so middle ear becomes full of fluid
- Leads eventually to hearing loss in affected ear
Presentation:
- Hearing loss in affected ear
- Aural fullness / pressure
- Otalgia / ear aches
- Sensation ear popping
May have associated speech and language development
Investigations:
- Auroscope (dull tympanic membrane, air bubbles or fluid level or may look normal)
- Audiology (conductive hearing loss)
- Tympanogram (flat tracing)
Management:
Usually managed conservatively and should resolve within 3 months
- Hearing aids or grommets if hearing loss if affecting speech development or if there are any congenital abnormalities e.g. Down’s syndrome, Cleft palate
- Treat any secondary otitis media
How long does it take for grommets to fall out
Grommets should fall out within a year
Only 30% require persistent grommets
List some common congenital causes of childhood hearing loss
Maternal infections during pregnancy
- Rubella
- CMV (cytomegalovirus)
Genetic deafness (recessive or dominant)
Associated syndromes e.g. Down’s syndrome
List some common acquired causes of childhood hearing loss
Around time of birth:
- Prematurity
- Hypoxia during or after birth
After birth:
- Ear infections e.g. otitis media / otitis media with effusion
- Childhood meningitis and encephalitis
- Jaundice
- Chemotherapy
Outline some general management options for children with hearing loss
- Involvement of ENT specialist
- Hearing aids for children (if retain some hearing)
- Sign language
Therapies:
- Speech and language therapy
- Educational psychology
Vestibular neuritis / labyrinthitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Inflammation of the vestibulocochlear nerve (CN8)
- Distorts the signals travelling from the vestibular system to the brain, poor transmission confuses the brain leading to vertigo symptoms
- Usually viral cause
Presentation:
- Severe vertigo (acute onset) lasting days, triggered by head movements
- History of recent URTI
- N&V
- Balance problems
- Horizontal nystagmus
**Tinnitus and hearing loss are not features (features of Meniere’s)
Investigations:
- Head impulse test (can diagnose peripheral causes of vertigo e.g. vestibular problems)
Management:
Symptoms should gradually resolve over 2-6 weeks
Short term management for up to 3 days
- IV fluids
- Prochlorperazine
- Cyclizine
May benefit from Cawthorne-Cooksey exercises as vestibular rehabilitation
BPPV may develop after vestibular neuronitis
Meniere’s disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Chronic inner ear disorder, leading to triad of symptoms
- Imbalance between the production and absorption of endolymph = excessive build up of endolymph in the labyrinth of the inner ear = endolymphatic hydrops
- Symptoms can initially fluctuate, resolving completely between episodes, but over time hearing loss progresses and tinnitus becomes persistent
Presentation:
Primarily UNILATERAL
Typical patient is 40-50 years old, unilateral episodes of vertigo, hearing loss, and tinnitus
- Hearing loss (unilateral, sensorineural)
- Tinnitus (unilateral)
- Vertigo (recurrent attacks of up to 20 mins-hours, NOT triggered by movement / posture)
+ feeling of fullness in the ear
+ unidirectional spontaneous nystagmus
+ drop attacks without LOC
Investigations:
- Audiology for hearing loss assessment (usually unilateral, sensorineural)
Management:
- Prophylaxis with Betahistine
- Acute attack management with Prochlorperazine or antihistamines e.g. Cyclizine (alleviate nausea, vomiting, and vertigo)
- Dexamethasone middle ear injection
- Endolymphatic sac decompression
BPPV (Benign paroxysmal positional vertigo) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Formation of crystals (calcium carbonate) in the semicircular canals
- Disrupt the normal flow of endolymph through the canals, confusing the vestibular system
Presentation:
More common in older adults
- Vertigo triggered by head movements (20-60 seconds, asymptomatic between attacks)
**Hearing loss or tinnitus aren’t features
Investigations:
- Dix-Hallpike Manoeuvre (if positive, nystagmus and symptoms of vertigo)
Management:
- Epley Manoeuvre
Vestibular schwannoma (acoustic neuroma) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Benign tumour of the Schwann cells of the vestibulocochlear nerve (CN8)
- Tumours occur at the cerebellopontine angle
- Usually sporadic and unilateral (if bilateral, associated with neurofibromatosis type 2)
- Benign tumour with a very low potential for metastasis
Presentation:
Average 40-60 years
- Unilateral sensorineural gradual onset hearing loss
- Tinnitus
- Vertigo
- Aural fullness
+ facial nerve palsy if tumour is large enough
Investigations:
- Audiometry
- MRI brain + biopsy during surgery (if needed) for histological confirmation
Management:
- Conservative with monitoring if asymptomatic or not appropriate
- Surgery to remove tumour (partial or full removal)
- Chemotherapy / radiotherapy to reduce growth
State 2 risks of vestibular schwannoma (acoustic neuroma) surgery
2 main cranial nerves at risk: CN 7 and CN 8
Injury to vestibulocochlear nerve (CN8)
= hearing loss
= vertigo
Facial nerve injury
Acute otitis media - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Management
Pathophysiology:
- Infection of the middle ear space (made of respiratory epithelium)
- Common complication after viral URTIs
- Primarily affects children (related to eustachian tube dysfunction)
- Most commonly caused by strep pneumoniae
Presentation:
- Preceding upper respiratory symptoms
- Otalgia
- Aural fullness
- Hearing loss
- Fever
+/- symptoms of tympanic membrane rupture (discharge and otalgia)
+/- vertigo or tinnitus
Otoscope findings:
- Bulging tympanic membrane
- Surrounding erythema
- May have perforated tympanic membrane
Management:
Most cases resolve spontaneously within 3 days
- Supportive therapy mainly e.g. analgesics
- Keep ear dry
- If not improved in 3 days, may require oral antibiotics e.g. Amoxicillin 5-7 days (Clarithromycin if allergic)
- Immediate antibiotic prescription in immunocompromised or systemically unwell
State the 2 main types of chronic otitis media
Mucosal (active or inactive)
- Tympanic membrane perforation
Active = perforation with chronic discharge
Inactive = perforation without discharge
Squamous (active or inactive)
- Can develop after episode of acute otitis media and tympanic membrane perforation
Active = cholesteatoma
Inactive = retraction pocket (chance of cholesteatoma forming)
State the most common bacterial cause of otitis media
Strep pneumoniae
Other causes:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
State some complications of acute otitis media
- Hearing loss (usually temporary)
- Perforation of tympanic membrane
- Labyrinthitis
- Otitis media with effusion
Rare:
- Mastoiditis
- Meningitis
- Abscess
- Facial nerve palsy
Cholesteatoma - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Abnormal collection of squamous epithelial cells in the middle ear caused by eustachian tube dysfunction and chronic negative pressure
- Negative pressure causes a pocket of the tympanic membrane to retract into the middle ear
- Non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear
Presentation:
- Foul discharge from the ear
- Unilateral conductive hearing loss
(generally painless)
Investigations:
- Auroscope (whitish debris or crust in the upper tympanic membrane)
- Audiogram
- CT head (diagnose and plan surgery)
- MRI (soft tissue invasion)
Management:
- Surgical removal of cholesteatoma
- May need topical antibiotics prior to surgical treatment
When might you consider chronic suppurative otitis media (CSOM) and how might it be managed?
- Discharge > 2 weeks (without otalgia / fever)
- Unilateral hearing loss
- A history of ear problems e.g. acute otitis media, trauma, glue ear
Assumed to be a complication of acute otitis media
Consider serious complications for these patients e.g. meningitis or mastoiditis
Management:
- Keep ear dry
- Intensive cleaning of the affected ear
- Antibiotics
- Topical steroids
