ENT - Ear Flashcards
(153 cards)
1
Q
Describe what happens during Weber’s test
A
1. Tap a 512Hz tuning fork and place in the midline of the forehead.
2. Ask the patient “Where do you hear the sound?
2
Q
What is a normal result of Weber’s test?
A
Sound is heard equally in both ears.
3
Q
What is the result of Weber’s test in conduction deafness?
A
Sound is heard louder on the side of the affected ear.
4
Q
What is the result of Weber’s test in sensorineural (nerve) deafness?
A
Sound is heard louder on side of intact ear
5
Q
Describe the steps of Rinne’s test
A
1. Place a vibrating 512 Hz tuning fork firmly on the mastoid process (apply pressure to the opposite side of the head to make sure the contact is firm). This tests bone conduction.
2. Confirm the patient can hear the sound of the tuning fork and then ask them to tell you when they can no longer hear it.
3. When the patient can no longer hear the sound, move the tuning fork in front of the external auditory meatus to test air conduction.
4. Ask the patient if they can now hear the sound again. If they can hear the sound, it suggests air conduction is better than bone conduction, which is what would be expected in a healthy individual (this is often confusingly referred to as a “Rinne’s positive” result).
6
Q
What would a Rinne’s negative result indicate?
A
Conductive deafness → Bone conduction > air conduction (Rinne’s negative)
7
Q
What would a Rinne’s positive result indicate?
A
- Normal result: air conduction > bone conduction (Rinne’s positive)
- Sensorineural deafness: air conduction > bone conduction (Rinne’s positive) – due to both air and bone conduction being reduced equally
8
Q
What is conductive hearing loss?
A
Caused by the obstruction of sound waves at any point in the outer ear and the foot plate of the stapes in the middle ear.
9
Q
What is the most common cause of conductive hearing loss?
A
Fluid accumulation is the most common cause of conductive hearing loss in the middle ear, especially in children e.g. ear infections
10
Q
Give some causes of conductive hearing loss
A
- Wax impaction
- Otitis media with effusion (glue ear)
- Eustachian tube dysfunction
- Ear infections
- Perforations of tympanic membrane
- Chronic suppurative otitis media
11
Q
Would wax impaction cause a conductive or sensorineural hearing loss?
A
Conductive
12
Q
Would otitis media with effusion (glue ear) cause a conductive or sensorineural hearing loss?
A
Conductive
13
Q
What is audiometry?
A
measurement of the range and sensitivity of a person’s sense of hearing
14
Q
How would conductive hearing loss present on audiometry?
A
This will present through indifferences in air conduction level and bone conduction level on the audiogram, with bone conduction being greater than air conduction
15
Q
Does otosclerosis cause conductive or sensorineural hearing loss?
A
Conductive
16
Q
What is an audiometric characteristic of otosclerosis?
A
Carhart’s notch where there is an apparent loss of bone conduction at 2000 Hz
17
Q
What is sensorineural hearing loss?
A
Caused by malfunction** or **disease within the cochlea or auditory nerve (i.e. inner ear)
18
Q
What is the most common cause of sensorineural hearing loss?
A
Presbycusis
19
Q
What is presbycusis?
A
Gradual loss of hearing in both ears, common problem linked to ageing
20
Q
Give some other causes of sensorineural hearing loss
A
- Noise-induced hearing loss
- Congenital infections e.g. rubella, CMV
- Neonatal complications (e.g. kernicterus or meningitis)
- Drug induced deafness (aminoglycosides)
- Vascular pathology (stroke, TIA)
21
Q
Which Abx can be responsible for drug-induced deafness?
A
Aminoglycosides e.g. gentamicin
22
Q
Audiogram results in sensorineural hearing loss?
A
- Sensorineural hearing loss on an audiogram presents with loss of hearing at high frequencies
- Characterised by symmetrical, progressive hearing loss over many years and can be seen on audiograms
23
Q
Audiogram results in sensorineural hearing loss?
A
- Sensorineural hearing loss on an audiogram presents with loss of hearing at high frequencies
- Characterised by symmetrical, progressive hearing loss over many years and can be seen on audiograms
24
Q
What type of frequencies are lost in sensorineural hearing loss?
A
High
25
What is vertigo?
A hallucination of movement of oneself or one’s surroundings. This movement is often rotatory, e.g. one may feel as though the floor is tilting.
26
Causes of vertigo?
* Benign positional paroxysmal vertigo (BPPV)
* Acute labyrinthitis
* Meniere’s disease
* Acoustic neuroma features
* Ramsay hunt syndrome
* Ototoxicity – caused by aminoglycoside antibiotics (e.g. gentamicin, vancomycin) and loop diuretics (e.g. furosemide) most commonly
27
What is the most common cause of vertigo?
Benign positional paroxysmal vertigo (BPPV)
28
What is otitis media?
A common infection causing inflammation of the middle ear.
29
Clinical features of otitis media?
Rapid onset of:
* Deep seated **pain**
* **Systemic** symptoms e.g. fever, irritability
* Vomiting
* **Impaired hearing**
* Onset is rapid with feeling of **_aural fullness_** followed by **discharge** when **tympanic membrane perforates with relief of pain**
* Tympanic membrane shows injection of blood vessels and then diffuse erythema
* Bacterial infection common particularly in young children
30
What does otitis media typically occur after?
A **viral** URTI
31
What is benign chronic otitis media?
Dry tympanic membrane perforation without chronic infection.
32
What feeling is often described in otitis media?
Aural fullness
33
Give some **intra-cranial** complications of otitis media
* Meningitis
* Sigmoid sinus thrombosis
* Brain abscess
34
Give some extra-cranial complications of otitis media
* Facial nerve palsy
* Mastoiditis
* Petrositis
* Labyrinthitis
35
How can otitis media lead to facial nerve palsy?
The nerve arises in the facial canal, and travels across the bones of the middle ear
36
How can otitis media lead to mastoiditis?
Infection spreads from middle ear to form **abscess in the mastoid air spaces** of the temporal bone
37
How can otitis media cause petrositis?
infection spreads to apex of petrous temporal bone
38
How can labyrinthitis caused by otitis media present?
can lead to inflammation of semiciruclar canals leading to vertigo, N&V and imbalance
39
What is the 1st line Abx in otitis media (when Abx indicated)?
High dose amoxicillin (oral NOT topical Abx unless 2ary otitis externa infection)
40
Give some indications for the requirement of Abx in otitis media
* Perforated eardrum
* \<2 years old and bilateral
* Present for \>/=4 days
* \<3 months old
* Systemically unwell
* High risk of complications e.g. immunocompromised
41
How can grommets be useful in otitis media?
thin tubes sitting in ear drum that allow fluid to pass
42
What is glue ear?
Middle ear become full of fluid, causing a **hearing loss** (conductive) in that ear.
43
What type of hearing loss does glue ear cause?
Conductive
44
Pathophysiology behind glue ear?
Eustachian tube connects the **middle ear to the back of the throat** and helps **drain secretions** from the middle ear. When it becomes blocked, this causes middle ear secretions (fluid) to build up in the middle ear space.
45
Why is glue ear more common in children?
as Eustachian tube more horizontal.
46
What is the main symptom of glue ear?
Reduction of hearing in that ear (
47
Potential complications of glue ear?
* Conductive hearing loss → can lead to speech delay
* Infection (otitis media)
48
1st line investigation in glue ear?
Otoscopy
49
Treatment of glue ear?
* Treated _conservatively_ – resolves within 3 months
* Children with co-morbidities affecting structure of ear (e.g. Down’s syndrome, cleft palate) → may require **hearing aids** or **grommets**
50
What are grommets?
Tiny tubes inserted into the tympanic membrane by an ENT surgeon
51
What is the purpose of grommets?
Allows fluid from middle ear to drain through membrane to the ear canal
52
How are grommets removed?
Usually fall out within a year
53
What is otitis externa?
Inflammation of the outer ear (pinna) and common cause of otalgia.
54
What is the most common cause of otalgia?
Otitis externa
55
What is perichondritis?
Infection of the skin and tissue surrounding the **cartilage** of the outer ear.
56
What are the 2 most common organisms causing otitis externa?
Pseudomonas spp. and Staph. aureus
57
What type of pathogen tends to cause **chronic** otitis externa?
Fungal
58
Clinical features of otitis externa?
* _Unilateral_ ear pain due to acute inflammation of the **skin of the external auditory meatus**
* Can also have itch
* Minimal discharge
* Hearing only impaired if the meatus becomes blocked by swelling or discharge → **conductive**
59
What may be present in a patient's history presenting with otitis externa?
**Patient may have recently gone swimming (swimmer’s ear), recent trauma to ear or recent insect bite**
60
What is swimmers ear?
Swimmer's ear (otitis externa) is **a bacterial infection typically caused by water that stayed in the outer ear canal for a long period of time**, providing a moist environment for bacteria to grow.
61
Topical or oral Abx for otitis externa?
**Topical** NOT oral Abx (unless there are complications)
62
Abx of choice in uncomplicated otitis externa?
Combined Abx (often aminoglycosides)/steroid drops (e.g. Gentamix), **acetic** **acid** etc
63
What can be used in the treatment of severe otitis externa?
* Strip of ribbon gauze known as ‘**Pope**’ **wicks** which can be used for application of topical Abx (gentamicin)
* Oral Abx in severe or immunocompromised
64
Why must caution be taken in otitis externa in immunocompromised patients?
due to risk of developing malignant/necrotising otitis externa
65
What is malignant otitis externa? What is the most common causative pathogen?
Necrotising external otitis is an infection involving the **temporal** and adjacent bones.
Most common organism → Pseudomonas aeruginosa
66
What is mastoiditis?
Infection spreads from the middle ear to form an abscess in the **mastoid air spaces** of the temporal bone. This leads to **postauricular** **swelling** pushing the auricle outwards and forwards.
67
What is mastoiditis usually a compliciation of?
Acute otitis media
68
Presentation of mastoiditis?
* **Pus** in ear canal & **bulging red eardrum**
* **Postauricular swelling** pushing the auricle forwards and outwards coming from the middle ear
* Mastoid tenderness
69
Investigation in mastoiditis?
* FBC, U&Es, CRP
* Blood cultures (if pyrexia)
* Ear swab if discharge
70
Are Abx indicated in mastoiditis?
yes (CAN BE FATAL)
71
1st line Abx in mastoiditis?
* IV antibiotics → IV **Ceftriaxone** OD + IV Metronidazole
* Consider topical treatment e.g. topical Abx drops (Ciprofloxacin)
72
Potential complications of mastoiditis?
* Hearing loss
* Blood clot
* Meningitis
* Brain abscess
* Can be fatal
73
Potential surgical management of mastoitits?
* Drain middle ear (myringotomy)
* Remove part of mastoid bone (mastoidectomy)
74
What is pinna cellulitis/pericondritis?
Infection of the skin and tissue surrounding the cartilage of the outer ear (i.e. perichondral lining of ear cartilage).
75
2 most common organisms causing pinna cellulitis?
Pseudomonas aeruginosa, Staph. aureus.
76
Risk factors for pinna cellulitis?
* Ear surgery
* Ear piercing (especially cartilage)
77
Presentation of pinna cellulitis?
* Erythematous
* Swollen
* Hot external ear
* Sparing of lobule
78
1st line Abx choice in pinna celullitis?
Topical fluoroquinolone (e.g. ciprofloxacin)
79
Potenital complications of pinna cellulitis?
Can progress to severe soft tissue or systemic infection.
80
What is the most common cause of **progressive deafness** in _young_ adults?
Otosclerosis
81
What is otosclerosis?
A condition in which there's abnormal bone growth inside the ear (otic capsule bony growth - stapes footplate).
82
Major risk factor of otoscerlosis?
Majority of patients have significant **family histories.**
Pregnancy can accelerate progression.
83
Inheritance pattern of otosclerosis?
Autosomal dominant condition.
84
Pathophysiology of otoscerlosis?
* Bone around the **base of the stapes** becomes thickened and eventually **fuses with the bone of the cochlea**
* This prevents the stapes natural function as a piston onto the cochlea → **conduction** gets progressively worse until a **maximal** **conductive** **hearing loss of 60dB** is reached
85
Does otosclerosis cause conductive or sensorineural hearing loss?
Conductive
86
What is the **maximal** **conductive** **hearing loss** seen in otosclerosis?
60dB
87
management of otosclerosis?
* Hearing amplification through **hearing aids**
* Surgical replacement of stapes bone through **stapedectomy**
88
What is a cholesteatoma?
A misnomer – neither a tumour nor has any relations to cholesterol.
**Abnormal accumulation of skin**, squamous epithelium (_keratin_) (squamous epithelial cells originate from the outer surface of the tympanic membrane) within the **middle ear** **cleft** and **mastoid air cells** (i.e. an abnormal collection of skin cells).
89
What is a cholesteatoma a complication of?
**chronic otitis media**.
90
Who does a cholesteatoma typically occur in?
Commonly occurs in younger patients (5-15 y/o)
91
Presentation of a cholesteatoma?
* Persistent **_foul-smelling discharge_**, headache, and otalgia
* **Unilateral** _conductive_ hearing loss
* As cholesteatoma continues to expand, further symptoms may develop:
* Infection
* Pain
* Vertigo
* Facial nerve palsy
92
Why is hearing loss **conductive** in a cholesteatoma?
Hearing loss is conductive as the ossicles conduct hearing to inner ear
93
What would be seen during otoscopy in a cholesteatoma?
* Abnormal buildup of **whiteish** **debris** or **crust** in the **upper tympanic membrane.** May not be possible to visualise eardrum if discharge or wax are blocking canal.
* **Tympanic membrane perforation** present in \>90% cases
94
What are the 2 most common symptoms in a cholesteatoma?
1. Persistent or recurring watery, often smelly, discharge from the ear
2. A gradual loss of hearing in the affected ear (unilateral)
95
Complications of a cholesteatoma?
* Can predispose to significant infections
* Can be **locally invasive** (local tissues) and **destructive** (erode bones of middle ear) which can lead to serious complications:
* Facial nerve palsy
* CNS complications – meningitis, epidural abscess, sigmoid sinus thrombosis
* Permanent hearing loss (sensorineural) → can damage ossicles
96
Managment of a cholesteastoma?
Surgical removal of cholesteatoma
97
Investigations of a cholesteatoma?
* CT head to confirm diagnosis
* MRI to help assess invasion and damage
98
What is a pinna haematoma?
A collection of blood within the cartilaginous auricle (outer ear).
99
Most common risk factor for a pinna haematoma?
Typically blunt trauma during sports (rugby players, footballers, wrestlers, cage fighters).
100
If not drained early, what can a pinna haematoma lead to?
* Haematoma can compromise viability of the auricular cartilage, leading to **avascular necrosis**.
* This can lead to ‘**cauliflower ear’** deformity due to new and asymmetrical cartilage growth.
101
What should be excluded in a pinna haematoma?
* Rule out other head injuries
* Ensure no superimposed infection
102
Management of a pinna haematoma?
Prompt drainage and measures to prevent reaccumulation
103
What is Meniere's disease?
A long term **_inner_** ear disorder that causes recurrent attacks of **vertigo**, and symptoms of **hearing** **loss**, **tinnitus**, and a feeling of **fullness** in the ear.
104
What are the typical 4 symptoms seen in Meniere's disease?
1. **Fluctuating hearing loss** (sensorineural, tends to be in low frequency level)
2. **Vertigo**
3. **Tinnitus**
4. **Sensation of ear (aural) fullness**
105
Is the hearing loss in Meniere's disease conductive or sensorineural?
Sensorineural (involves the inner ear)
106
What age group does Meniere's disease typically present in?
40-50 y/o
107
Pathophysiology behind Meniere's disease?
Associated with excessive buildup of **_endolymph**_ in the _**labyrinth_** of the **inner ear** (i.e. dilatation of the endolymphatic spaces of the membranous labyrinth), causing a **higher pressure** than normal and disrupts the sensory signals
108
What is **increased pressure of the endolymph** called?
**Endolymphatic hydrops**.
109
Describe the vertigo experienced in Meniere's disease
* Comes in episodes which last for 20 minutes – several hours
* Episodes can come in clusters over several weeks, followed by prolonged periods (often months) without vertigo symptoms
* Vertigo **NOT** triggered by **movement** or **posture**
110
Is vertigo in Meniere's triggered by movement/posture?
no
111
Describe the hearing loss seen in Meniere's disease
* Typically fluctuates at first, associated with vertigo attacks, then gradually becomes more permanent
* It is **_sensorineural_** hearing loss
* Generally **_unilateral**_ and affects _**lower frequencies_** first
112
What frequency does Meniere's disease affect first?
Lower frequencies
113
is the hearing loss in Meniere's disease unilateral or bilateral?
unilateral
114
Describe the tinnitus in Meniere's disease
* Initially occurs with episodes of vertigo become eventually becoming more permanent
* Usually unilateral
115
is the tinnitus in Meniere's disease unilateral or bilateral?
unilateral
116
Other symptoms seen in Meniere's disease?
* A sensation of ‘**fullness’** in the ear
* **Unexplained falls** (‘drop attacks’) without loss of consciousness
* **Imbalance** – can persist after episodes of vertigo resolve
* **Spontaneous nystagmus** may be seen during acute attack usually in one direction (unidirectional)
117
Pharmacological management of symptoms during acute attack of Meniere's disease?
* Prochlorperazine
* Antihistamine (e.g. cyclizine, cinnarizine, promethazine)
118
Purpose of prochlorperazine in an acute attack of Meniere's disease?
Anti-sickness
119
Purpose of antihistamines in an acute attack of Meniere's disease?
Antihistamines can be used to help relieve less severe nausea, vomiting and vertigo symptoms. They work by **blocking the effects of histamine**.
120
Pharmacological **prophylactic** management to reduce frequency of attacks in Meniere's disease?
Betahistine (this is an antihistamine)
121
What is acute labyrinthitis?
Acute inflammation of the **bony labyrinth** of the **inner ear**, including the **semicircular canals**, **vestibule** (middle section) and **cochlea** (i.e. problem with vestibular system).
122
Most common cause of acute labyrinthitis?
Inflammation usually attributed to a **_viral_** URT infection
123
What is acute labyrinthitis typically 2ary to?
Usually 2ary to **_otitis media**_ or _**meningitis_**
124
Vestibular neuronitis vs labyrinthitis?
Labyrinthitis is inflammation of the labyrinth – a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve – the nerve in the inner ear that sends messages to the brain.
125
Presentation of labyrinthitis?
* **Acute onset vertigo** (similarly to vestibular neuronitis)
* Unlike vestibular neuronitis, labyrinthitis can also be associated with:
* **Hearing loss**
* **Tinnitus**
* May have symptoms associated with **causative virus** e.g. cough, sore throat, blocked nose
126
What must be excluded in acute labyrinthitis?
EXCLUDE a **central** cause of vertigo (e.g. posterior circulation infarction).
127
Pharmacological management of acute labyrinthitis?
* Supportive care and short-term use (up to 3 days) of medication to suppress symptoms:
* Prochlorperazine
* Antihistamines e.g. cyclizine cinnarizine, promethazine
* Antibiotics are used to treat bacterial labyrinthitis
* Treat underlying infection
128
Link between meningitis and hearing loss?
Meningitis is one of the leading causes of acquired deafness and approximately 8% of survivors will experience some degree of permanent hearing loss.
129
How can meningitis lead to hearing loss?
Meningitis can cause **_sensorineural_** deafness in a number of ways. The most common cause is the **infection spreading in to the cochlea, damaging the hair cells**. Another possible cause is inflammation of the auditory nerve.
130
Complications of acute labyrinthitis?
Lasting symptoms are rare but can include permanent hearing loss (more common after bacterial cause, particularly associated with meningitis).
131
What is benign paroxysmal positional vertigo (BBPV)?
A common cause of vertigo **_triggered by head movement_**. It is a **peripheral** cause of vertigo – meaning the problem is located in the **inner ear** rather than the brain.
132
What is vertigo triggered by in BPPV?
Head movement e.g. turning over in bed
133
Risk factors for BPPV?
* Often no known cause
* Minor blow to head
* Ear surgery
* Migraines
134
Pathophysiology behind BPPV?
* Prescence of debris (crystals of **calcium carbonate** called **otoconia**) in the **semicircular canals** of ears causes vertigo upon head movement
* Most often occurs in posterior semicircular canal
* May be displaced by viral infection, head trauma, ageing or without a clear cause
* Crystals **disrupt the normal flow of endolymph** through the canals, confusing the vestibular system
* Head movement creates the **flow of endolymph** in the canals (which is disrupted by crystals), triggering episodes of vertigo
135
How long do vertigo symptoms take to settle in BPPV?
Symptoms settle after around 20-60 **seconds (unlike Meniere’s)**
136
How long do vertigo symptoms take to settle in Meniere's disease?
20 mins - several hours
137
Does BPPV cause hearing loss or tinnitus?
NO (unlike Meniere's disease)
138
Which manoeuvre is used to **diagnose** BPPV?
**Dix-Hallpike manoeuvre** (Dix for Diagnosis)
139
What does the **Dix-Hallpike manoeuvre** involve?
* Involves moving patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV, observe for nystagmus
* Check patient can do manoeuvre safely e.g. no neck pain
140
In patients with BPPV, what will the Dix Hallpike manoeuvre reveal?
Dix-Hallpike manoeuvre will trigger **rotational nystagmus** and **symptoms of vertigo** (the eye will have rotational beats of nystagmus _towards_ the affected ear i.e. clockwise with left ear and anti-clockwise with right ear BPPV)
141
Dix-Hallpike manoeuvre will trigger **rotational nystagmus** towards which ear in BPPV?
Towards the **affected** ear e.g. clockwise with left ear
142
Which manoeuvre is used to **treat** BPPV?
**Epley manoeuvres**
143
Purpose of the Epley manoeuvre?
To treat BPPV by moving the crystals in the semicircular canal into a position that does not disrupt endolymph flow
144
What is tympanosclerosis?
A condition characterised by **chronic inflammation** and **scarring** of the tympanic membrane leading to subsequent **calcification** of the tympanic membrane and associated structures.
145
Cause of tympanosclerosis?
* Aetiology not well understood
* Appears to be a number of factors associated with condition:
* **Long term otitis media**
* **Tympanostomy** (**grommet**) insertion
146
What is the medical term for grommets?
Tympanostomy
147
Presentation of tympanosclerosis?
* Significant hearing loss
* Otoscopy → chalky white patches on the tympanic membrane
148
Management of tympanosclerosis?
* Hearing aids
* In cases refractory to hearing aids → Excision of the sclerotic areas and repair of the ossicular chain
149
Audiogram results explained:
In _sensorineural_ hearing loss, **the thresholds for both air conduction and bone conduction** are affected such that the **air-bone gap** (air conduction minus bone conduction) is **close to zero**.
The presence of an **air-bone gap** signifies _conductive_ hearing loss.
150
What is the gold-standard diagnostic tool for cholesteatoma?
CT head
151
What is Prochlorperazine indicated in?
For **_vertigo_** in a) Meniere's disease b) labyrinthitis and other causes
152
What can conductive hearing loss in infants lead to?
Speech delay
153
What drug can reduce the risk of meningitis-associated hearing loss?
Dexamethasone
