Hearing Disorders COPY Flashcards
(89 cards)
1
Q
Sensorineural Hearing Loss: Most common population
A
- Sensorineural hearing loss risk increases with age
- Higher in men than women
_______________________
- Occur in the inner ear (sensory) or auditory nerve/auditory pathway (neural)
- Hearing levels for different frequencies are usually unequal, typically resulting in better hearing for low- than for high-frequency tones.
- Sensory hearing loss=deterioration of the cochlea, usually due to loss of hair cells from the organ of Corti.
- Neural hearing loss=Due to lesions which involve CN8, auditory nuclei, ascending tracts, or auditory cortex.
______________________
Assessment
- Weber: Lateralizes to the opposite side of the affected ear. Example: If Weber lateralizes right, then SNHL is likely present in the left ear.
- Rinne: AC>BC. But patient will indicate the sound has stopped earlier than a normal patient.
- Otoscopic exam is often normal
Common sensorineural hearing loss causes:
- Presbycusis (gradually progressive, predominantly high-frequency loss with advancing age)
- Ototoxic drugs
- Meniere Disease
- Noise-induced
- Acoustic neuroma
- Trauma (cochlear damage)
- Hereditary
Treatment
- Usually not correctable with medical or surgical therapy, but may be prevented or stabilized. Exception: sudden hearing loss may respond to corticosteroids if delivered within several weeks of onset.
2
Q
Physiology of hearing
A
- Sound waves enter outer ear, travel through ear canal to tympanic membrane (eardrum)
- Tympanic membrane vibrates with incoming sound and sends the vibrations to 3 tiny bones in middle ear
- Bones in middle ear amplify sound vibrations and send them to inner ear (cochlea). These activate tiny hair cells in inner ear.
- Hair cells release neurochemical messengers
- Auditory nerve carries this electrical signal to the brain, whicht ranslates it into sound
3
Q
Which division of the ear?
Otitis Externa
A
EXTERNAL
-
Pinna, Auditory Canal
4
Q
Which division of the ear?
Exostosis/Osteoma
A
EXTERNAL
-
Pinna, Auditory Canal
5
Q
Which division of the ear?
Cerumen Impaction
A
EXTERNAL
-
Pinna, Auditory Canal
6
Q
Which division of the ear?
Otitis Media,
A
MIDDLE
-
Tympanic Membrane, Ossicles, Eustachian Tube
7
Q
Which division of the ear?
Cholesteatoma
A
MIDDLE
-
Tympanic Membrane, Ossicles, Eustachian Tube
8
Q
Which division of the ear?
Otosclerosis
A
MIDDLE
-
Tympanic Membrane, Ossicles, Eustachian Tube
9
Q
Which division of the ear?
eustachian tube dysfunction (ETD)
A
MIDDLE
-
Tympanic Membrane, Ossicles, Eustachian Tube
10
Q
Which division of the ear?
Meniere’s
A
INNER
-
Cochlea, Semicircular canals, Auditory Nerve
11
Q
Which division of the ear?
Benign Paroxysmal Positional Vertigo (BPPV)
A
INNER
-
Cochlea, Semicircular canals, Auditory Nerve
12
Q
Which division of the ear?
Acoustic Neuroma
A
INNER
-
Cochlea, Semicircular canals, Auditory Nerve
13
Q
Which division of the ear?
Sensorineural HL
A
INNER
-
Cochlea, Semicircular canals, Auditory Nerve
14
Q
- The inner ear consists of a system of fluid-filled tubes and sacs called the ________.
- It serves two functions:
- ________
- ________
A
- Labyrinth
- hearing
- balance
15
Q
• The _______ is a snail-shaped tube filled with endolymph fluid and sensitive nerve endings that transmit sound signals to the brain in order to produce normal hearing.
A
cochlea
16
Q
- Balance is regulated by the ________.
- The _________ contain fluid and hair cells in a three loop structure.
- The sac-shaped _____ and ______ provide the brain with information about head movement and motion.
A
- vestibular organs
- semicircular canals
- utricle and saccule
17
Q
- Signals travel from the labyrinth to the brain via the cranial nerve __________, which has two branches.
- One branch (_______) transmits messages from the cochlea,
- while the other (________) transmits messages from the balance organs.
A
- vestibulo-cochlear nerve (CN VIII)
- the cochlear nerve=cochlea
- the vestibular nerve=balance
18
Q
What is a basic pathophysiogy of dizziness or vertigo?
A
- • The brain integrates balance signals sent through the vestibular nerve from the right ear and the left ear.
- When one side is affected (viral illness, otoconia or increased fluid pressure) it sends faulty signals.
- Thus the brain receives mismatched information, resulting in dizziness or vertigo.
19
Q
Weber lateralizes to RIGHT side: explain potential hearing deficits for right/left ears
A
- Right ear: potential CHL
- Left ear: potential SNHL
20
Q
Rinne test is AC>BC. What could this result mean?
A
Normal or SNHL
21
Q
Rinne test is BC>AC. What could this result mean?
A
Affected ear: CHL
22
Q
Identify:
- the perception of sound in the ear when there is no actual sound
A
Tinnitus
Risk factors
- noise exposure
- male gender
- increased age
- smoking
- cardiovascular disease
Presentation
- ringing, whooshing, buzzing, roaring, clicking, machinery like noise or pusling sounds
- Occurs in one or both ears
Presentation Types
- Intermittent: typically benign and requires no work-up unless other symptoms present
- Persistent: requires evaluation, consider referral
- Pulsatile tinnitus: rhythmic with pulse
Etiology
- Idiopathic (most common)
- Acoustic trauma (acute-loud concert/chronic-loud machinery at work)
- Presbycusis (age related hearing loss)
- Neurological damage (MS, acoustic neuroma)
- Circulatory disorders (arteriovenous malformation, turbulent bloodflow)
- Side effect of medications (ASA, erythromycin, quinine, etc)
- Obstruction of ear canal
- Serous or purulent otitis media
Diagnosis
- Refer to ENT
- Subjective: diagnosis is based on patient’s complaint and may be supported by hearing loss on audiogram
- Objective: clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
- If pulsatile: MRA or carotid doppler to rule out vessel defect
- Imaging, neuro-otologic studies as needed
Treatment
- Acute: oral steroid taper
-
Chronic:
- lipoflavinoids,
- niacin/B complex vitamins,
- tinnitus masking
- hearing amplification if associated with hearing loss
- white noise machine
- Treat underlying condition
- Reduce noise exposure, cafffeine, smoking, alcohol, stress
Prevention
Minimize noise exposure (85 dB or higher is associated with damage)
23
Q
Identify: Tinnitus
- Risk factors
A
Tinnitus: the perception of sound in the ear when there is no actual sound
Risk factors
- noise exposure
- male gender
- increased age
- smoking
- cardiovascular disease
Presentation
- ringing, whooshing, buzzing, roaring, clicking, machinery like noise or pusling sounds
- Occurs in one or both ears
Presentation Types
- Intermittent: typically benign and requires no work-up unless other symptoms present
- Persistent: requires evaluation, consider referral
- Pulsatile tinnitus: rhythmic with pulse
Etiology
- Idiopathic (most common)
- Acoustic trauma (acute-loud concert/chronic-loud machinery at work)
- Presbycusis (age related hearing loss)
- Neurological damage (MS, acoustic neuroma)
- Circulatory disorders (arteriovenous malformation, turbulent bloodflow)
- Side effect of medications (ASA, erythromycin, quinine, etc)
- Obstruction of ear canal
- Serous or purulent otitis media
Diagnosis
- Refer to ENT
- Subjective: diagnosis is based on patient’s complaint and may be supported by hearing loss on audiogram
- Objective: clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
- If pulsatile: MRA or carotid doppler to rule out vessel defect
- Imaging, neuro-otologic studies as needed
Treatment
- Acute: oral steroid taper
-
Chronic:
- lipoflavinoids,
- niacin/B complex vitamins,
- tinnitus masking
- hearing amplification if associated with hearing loss
- white noise machine
- Treat underlying condition
- Reduce noise exposure, cafffeine, smoking, alcohol, stress
Prevention
Minimize noise exposure (85 dB or higher is associated with damage)
24
Q
Identify: Tinnitus
- Presentation/Presentation types
A
Tinnitus: the perception of sound in the ear when there is no actual sound
Presentation
- ringing, whooshing, buzzing, roaring, clicking, machinery like noise or pusling sounds
- Occurs in one or both ears
Presentation Types
- Intermittent: typically benign and requires no work-up unless other symptoms present
- Persistent: requires evaluation, consider referral
- Pulsatile tinnitus: rhythmic with pulse
Etiology
- Idiopathic (most common)
- Acoustic trauma (acute-loud concert/chronic-loud machinery at work)
- Presbycusis (age related hearing loss)
- Neurological damage (MS, acoustic neuroma)
- Circulatory disorders (arteriovenous malformation, turbulent bloodflow)
- Side effect of medications (ASA, erythromycin, quinine, etc)
- Obstruction of ear canal
- Serous or purulent otitis media
Diagnosis
- Refer to ENT
- Subjective: diagnosis is based on patient’s complaint and may be supported by hearing loss on audiogram
- Objective: clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
- If pulsatile: MRA or carotid doppler to rule out vessel defect
- Imaging, neuro-otologic studies as needed
Treatment
- Acute: oral steroid taper
-
Chronic:
- lipoflavinoids,
- niacin/B complex vitamins,
- tinnitus masking
- hearing amplification if associated with hearing loss
- white noise machine
- Treat underlying condition
- Reduce noise exposure, cafffeine, smoking, alcohol, stress
Prevention
Minimize noise exposure (85 dB or higher is associated with damage)
Risk factors
- noise exposure
- male gender
- increased age
- smoking
- cardiovascular disease
25
Identify: **_Tinnitus_**
* Etiology
**_Tinnitus:_** the perception of sound in the ear when there is no actual sound
**_Etiology_**
1. Idiopathic (most common)
2. Acoustic trauma (acute-loud concert/chronic-loud machinery at work)
3. Presbycusis (age related hearing loss)
4. Neurological damage (MS, acoustic neuroma)
5. Circulatory disorders (arteriovenous malformation, turbulent bloodflow)
6. Side effect of medications (ASA, erythromycin, quinine, etc)
7. Obstruction of ear canal
8. Serous or purulent otitis media
**_Diagnosis_**
* Refer to ENT
* **Subjective:** diagnosis is based on patient's complaint and may be supported by hearing loss on audiogram
* **Objective:** clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
* **If pulsatile:** MRA or carotid doppler to rule out vessel defect
* Imaging, neuro-otologic studies as needed
**_Treatment_**
* **Acute:** oral steroid taper
* **Chronic:**
* lipoflavinoids,
* niacin/B complex vitamins,
* tinnitus masking
* hearing amplification if associated with hearing loss
* white noise machine
* Treat underlying condition
* Reduce noise exposure, cafffeine, smoking, alcohol, stress
**_Prevention_**
Minimize noise exposure (85 dB or higher is associated with damage)
**_Risk factors_**
* noise exposure
* male gender
* increased age
* smoking
* cardiovascular disease
**_Presentation_**
* ringing, whooshing, buzzing, roaring, clicking, machinery like noise or pusling sounds
* Occurs in one or both ears
**_Presentation Types_**
1. **Intermittent:** typically benign and requires no work-up unless other symptoms present
2. **Persistent:** requires evaluation, consider referral
3. **Pulsatile tinnitus:** rhythmic with pulse
26
Identify: **_Tinnitus_**
* diagnosis
**_Tinnitus:_** the perception of sound in the ear when there is no actual sound
**_Diagnosis_**
* Refer to ENT
* **Subjective:** diagnosis is based on patient's complaint and may be supported by hearing loss on audiogram
* **Objective:** clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
* **If pulsatile:** MRA or carotid doppler to rule out vessel defect
* Imaging, neuro-otologic studies as needed
**_Treatment_**
* **Acute:** oral steroid taper
* **Chronic:**
* lipoflavinoids,
* niacin/B complex vitamins,
* tinnitus masking
* hearing amplification if associated with hearing loss
* white noise machine
* Treat underlying condition
* Reduce noise exposure, cafffeine, smoking, alcohol, stress
**_Prevention_**
Minimize noise exposure (85 dB or higher is associated with damage)
**_Risk factors_**
* noise exposure
* male gender
* increased age
* smoking
* cardiovascular disease
**_Presentation_**
* ringing, whooshing, buzzing, roaring, clicking, machinery like noise or pusling sounds
* Occurs in one or both ears
**_Presentation Types_**
1. **Intermittent:** typically benign and requires no work-up unless other symptoms present
2. **Persistent:** requires evaluation, consider referral
3. **Pulsatile tinnitus:** rhythmic with pulse
**_Etiology_**
1. Idiopathic (most common)
2. Acoustic trauma (acute-loud concert/chronic-loud machinery at work)
3. Presbycusis (age related hearing loss)
4. Neurological damage (MS, acoustic neuroma)
5. Circulatory disorders (arteriovenous malformation, turbulent bloodflow)
6. Side effect of medications (ASA, erythromycin, quinine, etc)
7. Obstruction of ear canal
8. Serous or purulent otitis media
27
Identify: **_Tinnitus_**
* Treatment
**_Tinnitus:_** the perception of sound in the ear when there is no actual sound
**_Treatment_**
* **Acute:** oral steroid taper
* **Chronic:**
* lipoflavinoids,
* niacin/B complex vitamins,
* tinnitus masking
* hearing amplification if associated with hearing loss
* white noise machine
* Treat underlying condition
* Reduce noise exposure, cafffeine, smoking, alcohol, stress
**_Prevention_**
Minimize noise exposure (85 dB or higher is associated with damage)
**_Risk factors_**
* noise exposure
* male gender
* increased age
* smoking
* cardiovascular disease
**_Presentation_**
* ringing, whooshing, buzzing, roaring, clicking, machinery like noise or pusling sounds
* Occurs in one or both ears
**_Presentation Types_**
1. **Intermittent:** typically benign and requires no work-up unless other symptoms present
2. **Persistent:** requires evaluation, consider referral
3. **Pulsatile tinnitus:** rhythmic with pulse
**_Etiology_**
1. Idiopathic (most common)
2. Acoustic trauma (acute-loud concert/chronic-loud machinery at work)
3. Presbycusis (age related hearing loss)
4. Neurological damage (MS, acoustic neuroma)
5. Circulatory disorders (arteriovenous malformation, turbulent bloodflow)
6. Side effect of medications (ASA, erythromycin, quinine, etc)
7. Obstruction of ear canal
8. Serous or purulent otitis media
**_Diagnosis_**
* Refer to ENT
* **Subjective:** diagnosis is based on patient's complaint and may be supported by hearing loss on audiogram
* **Objective:** clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
* **If pulsatile:** MRA or carotid doppler to rule out vessel defect
* Imaging, neuro-otologic studies as needed
28
Identify: **_Tinnitus_**
* Prevention
**_Tinnitus:_** the perception of sound in the ear when there is no actual sound
**_Prevention_**
Minimize noise exposure (85 dB or higher is associated with damage)
**_Risk factors_**
* noise exposure
* male gender
* increased age
* smoking
* cardiovascular disease
**_Presentation_**
* ringing, whooshing, buzzing, roaring, clicking, machinery like noise or pusling sounds
* Occurs in one or both ears
**_Presentation Types_**
1. **Intermittent:** typically benign and requires no work-up unless other symptoms present
2. **Persistent:** requires evaluation, consider referral
3. **Pulsatile tinnitus:** rhythmic with pulse
**_Etiology_**
1. Idiopathic (most common)
2. Acoustic trauma (acute-loud concert/chronic-loud machinery at work)
3. Presbycusis (age related hearing loss)
4. Neurological damage (MS, acoustic neuroma)
5. Circulatory disorders (arteriovenous malformation, turbulent bloodflow)
6. Side effect of medications (ASA, erythromycin, quinine, etc)
7. Obstruction of ear canal
8. Serous or purulent otitis media
**_Diagnosis_**
* Refer to ENT
* **Subjective:** diagnosis is based on patient's complaint and may be supported by hearing loss on audiogram
* **Objective:** clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
* **If pulsatile:** MRA or carotid doppler to rule out vessel defect
* Imaging, neuro-otologic studies as needed
**_Treatment_**
* **Acute:** oral steroid taper
* **Chronic:**
* lipoflavinoids,
* niacin/B complex vitamins,
* tinnitus masking
* hearing amplification if associated with hearing loss
* white noise machine
* Treat underlying condition
* Reduce noise exposure, cafffeine, smoking, alcohol, stress
29
# Fill in the blank: **_Tinnitus_**
* Minimize noise exposure (\_\_\_\_\_ dB or higher is associated with damage)
Minimize noise exposure (**_85 dB_** or higher is associated with damage)
30
Identify: **_Tinnitus_**
* diagnosis is based on patient's complaint and may be supported by hearing loss on audiogram
* **Subjective:** diagnosis is based on patient's complaint and may be supported by hearing loss on audiogram
31
Identify: **_Tinnitus_**
* clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
* **Objective:** clinician can hear the sound as well (stapedial myoclonus and some vascular disorders)
32
Identify:
* SNHL associated with advanced age
* Loss is typically symmetrical (same in both ears) and high-frequency
**_Presbycusis_**
**_Risk factors_**
* Age: adults over 75
* Genetic predisposition
* Noise exposure
* Diabetes
* atherosclerosis
**_Pathophysiology_**
* Loss of functional sensory hair cells in cochlea
* Degeneration of neural pathway
**_Presentation_**
* Worsening hearing loss over time in both ears
* Difficulty hearing conversations in social situations (due to ambient noise)
* Difficulty localizing sounds
* Tinnitus
* Isolation due to inability to use the phone
**_Diagnosis_**
* Diagnosis of exclusion; rule out other causes
* Physical examination is normal
* High-frequency **symmetrical** SNHL on audiogram
**_Treatment_**
* Hearing amplification
* Avoid excessive noise exposure, use hearing protection
33
Identify: **_Presbycusis_**
* risk factors
**_Presbycusis_**
**_Risk factors_**
* Age: adults over 75
* Genetic predisposition
* Noise exposure
* Diabetes
* atherosclerosis
**_Pathophysiology_**
* Loss of functional sensory hair cells in cochlea
* Degeneration of neural pathway
**_Presentation_**
* Worsening hearing loss over time in both ears
* Difficulty hearing conversations in social situations (due to ambient noise)
* Difficulty localizing sounds
* Tinnitus
* Isolation due to inability to use the phone
**_Diagnosis_**
* Diagnosis of exclusion; rule out other causes
* Physical examination is normal
* High-frequency **symmetrical** SNHL on audiogram
**_Treatment_**
* Hearing amplification
* Avoid excessive noise exposure, use hearing protection
**_Key Characteristics_**
* SNHL associated with advanced age
* Loss is typically symmetrical (same in both ears) and high-frequency
34
Identify: **_Presbycusis_**
* pathophysiology
**_Presbycusis_**
**_Pathophysiology_**
* Loss of functional sensory hair cells in cochlea
* Degeneration of neural pathway
**_Presentation_**
* Worsening hearing loss over time in both ears
* Difficulty hearing conversations in social situations (due to ambient noise)
* Difficulty localizing sounds
* Tinnitus
* Isolation due to inability to use the phone
**_Diagnosis_**
* Diagnosis of exclusion; rule out other causes
* Physical examination is normal
* High-frequency **symmetrical** SNHL on audiogram
**_Treatment_**
* Hearing amplification
* Avoid excessive noise exposure, use hearing protection
**_Key Characteristics_**
* SNHL associated with advanced age
* Loss is typically symmetrical (same in both ears) and high-frequency
**_Risk factors_**
* Age: adults over 75
* Genetic predisposition
* Noise exposure
* Diabetes
* atherosclerosis
35
Identify: **_Presbycusis_**
* presentation
**_Presbycusis_**
**_Presentation_**
* Worsening hearing loss over time in both ears
* Difficulty hearing conversations in social situations (due to ambient noise)
* Difficulty localizing sounds
* Tinnitus
* Isolation due to inability to use the phone
**_Diagnosis_**
* Diagnosis of exclusion; rule out other causes
* Physical examination is normal
* High-frequency **symmetrical** SNHL on audiogram
**_Treatment_**
* Hearing amplification
* Avoid excessive noise exposure, use hearing protection
**_Key Characteristics_**
* SNHL associated with advanced age
* Loss is typically symmetrical (same in both ears) and high-frequency
**_Risk factors_**
* Age: adults over 75
* Genetic predisposition
* Noise exposure
* Diabetes
* atherosclerosis
**_Pathophysiology_**
* Loss of functional sensory hair cells in cochlea
* Degeneration of neural pathway
36
Identify: **_Presbycusis_**
* diagnosis
**_Presbycusis_**
**_Diagnosis_**
* Diagnosis of exclusion; rule out other causes
* Physical examination is normal
* High-frequency **symmetrical** SNHL on audiogram
**_Treatment_**
* Hearing amplification
* Avoid excessive noise exposure, use hearing protection
**_Key Characteristics_**
* SNHL associated with advanced age
* Loss is typically symmetrical (same in both ears) and high-frequency
**_Risk factors_**
* Age: adults over 75
* Genetic predisposition
* Noise exposure
* Diabetes
* atherosclerosis
**_Pathophysiology_**
* Loss of functional sensory hair cells in cochlea
* Degeneration of neural pathway
**_Presentation_**
* Worsening hearing loss over time in both ears
* Difficulty hearing conversations in social situations (due to ambient noise)
* Difficulty localizing sounds
* Tinnitus
* Isolation due to inability to use the phone
37
Identify: **_Presbycusis_**
* treatment
**_Presbycusis_**
**_Treatment_**
* Hearing amplification
* Avoid excessive noise exposure, use hearing protection
**_Key Characteristics_**
* SNHL associated with advanced age
* Loss is typically symmetrical (same in both ears) and high-frequency
**_Risk factors_**
* Age: adults over 75
* Genetic predisposition
* Noise exposure
* Diabetes
* atherosclerosis
**_Pathophysiology_**
* Loss of functional sensory hair cells in cochlea
* Degeneration of neural pathway
**_Presentation_**
* Worsening hearing loss over time in both ears
* Difficulty hearing conversations in social situations (due to ambient noise)
* Difficulty localizing sounds
* Tinnitus
* Isolation due to inability to use the phone
**_Diagnosis_**
* Diagnosis of exclusion; rule out other causes
* Physical examination is normal
* High-frequency **symmetrical** SNHL on audiogram
38
Identify: **_Presbycusis_**
* What do you expect with regard to audiogram results?
* High-frequency **symmetrical** SNHL on audiogram
39
# Fill in the blank:
* Loud noice causes damage to the hair cells in the cochlea (\_\_\_\_\_ dB or higher)
* _______ frequency sounds are more damaging than _____ frequency
* 85 dB
* High-frequency=more damaging
* Low-frequency=less damaging
40
What is a classic audiometry finding for noise induced hearing loss?
Classical noise notch at 4k
41
Is noise induced hearing loss symmetrical?
Not always (ex. rifle firing)
42
Treatment of Loud Noise Hearing Loss
* Monitor for spontaneous improvement if it was an acute event
* Steroid use is widely used, but questionable for acute events
* Hearing amplification
* Avoidance of loud noises/music
* Ear protection
43
Identify:
* Patients display **unilateral** hearing loss and **unilateral** tinnitus
* Headaches or dizziness may be present
* Facial numbness or weakness
* Symptoms worsen over time
**_Acoustic Neuroma (Vestibular Schwannoma)_**
**_Pathophysiology_**
* Slow-growing benign tumor that grows within the schwann cell layer of the vestibulocochlear nerve (CNVIII/8)
* May not cause mass effect symptoms until many centimeters in diameter
**_Risk factors_**
* neurofibromatosis type II
* ionized radiation
**_Diagnosis_**
* Audiogram shows unilateral sensorineural hearing loss
* Speech discrimination can be worse than expected for the degree of loss
* auditory brainstem response (ABR) can be normal with small tumors
* MRI of the cerebellopontine angle (CPA) with gadolinium contrast
IF PATIENT HAS UNILATERAL SNHL GET AN MRI!
**_Treatment_**
* monitor with regular imaging, audiometry (every 6 months)
* Refer to ENT/neurosurgery for surgical excision or stereotactic radiation (gamma knife)
44
Identify: **_Acoustic Neuroma (Vestibular Schwannoma)_**
* pathophysiology
**_Acoustic Neuroma (Vestibular Schwannoma)_**
**_Pathophysiology_**
* Slow-growing benign tumor that grows within the schwann cell layer of the vestibulocochlear nerve (CNVIII/8)
* May not cause mass effect symptoms until many centimeters in diameter
**_Risk factors_**
* neurofibromatosis type II
* ionized radiation
**_Diagnosis_**
* Audiogram shows unilateral sensorineural hearing loss
* Speech discrimination can be worse than expected for the degree of loss
* auditory brainstem response (ABR) can be normal with small tumors
* MRI of the cerebellopontine angle (CPA) with gadolinium contrast
IF PATIENT HAS UNILATERAL SNHL GET AN MRI!
**_Treatment_**
* monitor with regular imaging, audiometry (every 6 months)
* Refer to ENT/neurosurgery for surgical excision or stereotactic radiation (gamma knife)
**_Presentation_**
* Patients display **unilateral** hearing loss and **unilateral** tinnitus
* Headaches or dizziness may be present
* Facial numbness or weakness
* Symptoms worsen over time
45
Identify: **_Acoustic Neuroma (Vestibular Schwannoma)_**
* risk factors
**_Acoustic Neuroma (Vestibular Schwannoma)_**
**_Risk factors_**
* neurofibromatosis type II
* ionized radiation
**_Diagnosis_**
* Audiogram shows unilateral sensorineural hearing loss
* Speech discrimination can be worse than expected for the degree of loss
* auditory brainstem response (ABR) can be normal with small tumors
* MRI of the cerebellopontine angle (CPA) with gadolinium contrast
IF PATIENT HAS UNILATERAL SNHL GET AN MRI!
**_Treatment_**
* monitor with regular imaging, audiometry (every 6 months)
* Refer to ENT/neurosurgery for surgical excision or stereotactic radiation (gamma knife)
**_Presentation_**
* Patients display **unilateral** hearing loss and **unilateral** tinnitus
* Headaches or dizziness may be present
* Facial numbness or weakness
* Symptoms worsen over time
**_Pathophysiology_**
* Slow-growing benign tumor that grows within the schwann cell layer of the vestibulocochlear nerve (CNVIII/8)
* May not cause mass effect symptoms until many centimeters in diameter
46
Identify: **_Acoustic Neuroma (Vestibular Schwannoma)_**
* diagnosis
**_Acoustic Neuroma (Vestibular Schwannoma)_**
**_Diagnosis_**
* Audiogram shows unilateral sensorineural hearing loss
* Speech discrimination can be worse than expected for the degree of loss
* auditory brainstem response (ABR) can be normal with small tumors
* MRI of the cerebellopontine angle (CPA) with gadolinium contrast
IF PATIENT HAS UNILATERAL SNHL GET AN MRI!
**_Treatment_**
* monitor with regular imaging, audiometry (every 6 months)
* Refer to ENT/neurosurgery for surgical excision or stereotactic radiation (gamma knife)
**_Presentation_**
* Patients display **unilateral** hearing loss and **unilateral** tinnitus
* Headaches or dizziness may be present
* Facial numbness or weakness
* Symptoms worsen over time
**_Pathophysiology_**
* Slow-growing benign tumor that grows within the schwann cell layer of the vestibulocochlear nerve (CNVIII/8)
* May not cause mass effect symptoms until many centimeters in diameter
**_Risk factors_**
* neurofibromatosis type II
* ionized radiation
47
Identify: **_Acoustic Neuroma (Vestibular Schwannoma)_**
* treatment
**_Acoustic Neuroma (Vestibular Schwannoma)_**
**_Treatment_**
* monitor with regular imaging, audiometry (every 6 months)
* Refer to ENT/neurosurgery for surgical excision or stereotactic radiation (gamma knife)
**_Presentation_**
* Patients display **unilateral** hearing loss and **unilateral** tinnitus
* Headaches or dizziness may be present
* Facial numbness or weakness
* Symptoms worsen over time
**_Pathophysiology_**
* Slow-growing benign tumor that grows within the schwann cell layer of the vestibulocochlear nerve (CNVIII/8)
* May not cause mass effect symptoms until many centimeters in diameter
**_Risk factors_**
* neurofibromatosis type II
* ionized radiation
**_Diagnosis_**
* Audiogram shows unilateral sensorineural hearing loss
* Speech discrimination can be worse than expected for the degree of loss
* auditory brainstem response (ABR) can be normal with small tumors
* MRI of the cerebellopontine angle (CPA) with gadolinium contrast
IF PATIENT HAS UNILATERAL SNHL GET AN MRI!
48
What test should you order if patient has unilateral SNHL? Why?
IF PATIENT HAS UNILATERAL SNHL GET AN MRI!
**_May be an Acoustic Neuroma (Vestibular Schwannoma)_**
49
\_\_\_\_\_\_\_ occurs when sound is not conducted appropriately through the external ear canal to the tympanic membrane and the ossicles
conductive hearing loss
50
SNHL or CHL?
Tinnitus
likely SNHL
51
SNHL or CHL?
Presbycusis
SNHL
52
SNHL or CHL?
Noise induced
SNHL
53
SNHL or CHL?
Acoustic neuroma
SNHL
54
SNHL or CHL?
Cerumen Impaction
CHL
55
SNHL or CHL?
Otitis media or externa
CHL
56
SNHL or CHL?
tympanic membrane perforation
CHL
57
SNHL or CHL?
otosclerosis
CHL
58
SNHL or CHL?
mastoiditis
CHL
59
SNHL or CHL?
cholesteatoma
CHL
60
SNHL or CHL?
foreign body
CHL
61
SNHL or CHL?
exostoses/osteomas
CHL
62
Identify:
* Protects the ears by trapping particulate matter
* Provides a moisture barrier for the skin of the canal, protecting against dryness and itchiness
Cerumen (ear wax)
63
Identify the audiogram
64
Identify the audiogram
65
Identify the audiogram
66
Identify the audiogram
67
**_Cerumen impaction_**
Etiology
**_Etiology_**
* Unknown
* Qtips and hearing aids interfere with self cleaning
**_Presentation_**
* Hearing loss (worsens with time and water) (common for ears to clog after shower)
* Ear discomfort
* Dizziness/tinnitus IF impacted against TM
**_Treatment_**
* Hydrogen peroxide or OTC wax-dissolving drops
* Irrigation (ONLY IF INTACT TM)
* loop curette
* suction
* forceps
* Refer to ENT if: (1) failed debridement attempt (2) remove of cerumen requires brief sedation (3) audiogram should be considered if hearing does not return to normal after debridement
68
**_Cerumen impaction_**
Presentation
**_Presentation_**
* Hearing loss (worsens with time and water) (common for ears to clog after shower)
* Ear discomfort
* Dizziness/tinnitus IF impacted against TM
**_Treatment_**
* Hydrogen peroxide or OTC wax-dissolving drops
* Irrigation (ONLY IF INTACT TM)
* loop curette
* suction
* forceps
* Refer to ENT if: (1) failed debridement attempt (2) remove of cerumen requires brief sedation (3) audiogram should be considered if hearing does not return to normal after debridement
**_Etiology_**
* Unknown
* Qtips and hearing aids interfere with self cleaning
69
**_Cerumen impaction_**
Treatment
**_Treatment_**
* Hydrogen peroxide or OTC wax-dissolving drops
* Irrigation (ONLY IF INTACT TM)
* loop curette
* suction
* forceps
* Refer to ENT if: (1) failed debridement attempt (2) remove of cerumen requires brief sedation (3) audiogram should be considered if hearing does not return to normal after debridement
**_Etiology_**
* Unknown
* Qtips and hearing aids interfere with self cleaning
**_Presentation_**
* Hearing loss (worsens with time and water) (common for ears to clog after shower)
* Ear discomfort
* Dizziness/tinnitus IF impacted against TM
70
Identify:
* Typically multiple and protrude into the external auditory canal under normal mucosa
* Associated with swimming in cold water as a child
Exostoses
**Treatment:** monitor, if they obstruct ear canal then refer to ENT
71
Identify:
* single outgrowth of the tympanic bone into the auditory canal
Osteoma
**Treatment:** monitor, if obstructs ear canal then refer to ENT
72
**_Otosclerosis_**
Risk factors
**_Risk factors_**
* genetic predisposition
* female and caucasian
* young adults to middle age adults
**_Etiology/pathophysiology:_**
* abnormal, spongy bone growth at the junction of the stapes to the oval window in the middle ear
* worsens over time
**_Presentation_**
* worsening hearing loss over time in one or both ears
* may, may not have tinnitus
**_Diagnosis_**
* CHL on audiogram, possibly with a carhart notch at 2000 Hz
* Normal physical exam and normal tympanogram (may see absent reflexes)
* Temproal bone CT/exploratory surgery is diagnostic
**_Treatment_**
* Refer to ENT for middle ear exploration/stapedectomy/ossicular chain reconstruction
* Alternatively: hearing amplification and monitoring
73
**_Otosclerosis_**
etiology/pathophysiology
**_Etiology/pathophysiology:_**
* abnormal, spongy bone growth at the junction of the stapes to the oval window in the middle ear
* worsens over time
**_Presentation_**
* worsening hearing loss over time in one or both ears
* may, may not have tinnitus
**_Diagnosis_**
* CHL on audiogram, possibly with a carhart notch at 2000 Hz
* Normal physical exam and normal tympanogram (may see absent reflexes)
* Temproal bone CT/exploratory surgery is diagnostic
**_Treatment_**
* Refer to ENT for middle ear exploration/stapedectomy/ossicular chain reconstruction
* Alternatively: hearing amplification and monitoring
**_Risk factors_**
* genetic predisposition
* female and caucasian
* young adults to middle age adults
74
**_Otosclerosis_**
presentation
**_Presentation_**
* worsening hearing loss over time in one or both ears
* may, may not have tinnitus
**_Diagnosis_**
* CHL on audiogram, possibly with a carhart notch at 2000 Hz
* Normal physical exam and normal tympanogram (may see absent reflexes)
* Temproal bone CT/exploratory surgery is diagnostic
**_Treatment_**
* Refer to ENT for middle ear exploration/stapedectomy/ossicular chain reconstruction
* Alternatively: hearing amplification and monitoring
**_Risk factors_**
* genetic predisposition
* female and caucasian
* young adults to middle age adults
**_Etiology/pathophysiology:_**
* abnormal, spongy bone growth at the junction of the stapes to the oval window in the middle ear
* worsens over time
75
**_Otosclerosis_**
diagnosis
**_Diagnosis_**
* CHL on audiogram, possibly with a carhart notch at 2000 Hz
* Normal physical exam and normal tympanogram (may see absent reflexes)
* Temproal bone CT/exploratory surgery is diagnostic
**_Treatment_**
* Refer to ENT for middle ear exploration/stapedectomy/ossicular chain reconstruction
* Alternatively: hearing amplification and monitoring
**_Risk factors_**
* genetic predisposition
* female and caucasian
* young adults to middle age adults
**_Etiology/pathophysiology:_**
* abnormal, spongy bone growth at the junction of the stapes to the oval window in the middle ear
* worsens over time
**_Presentation_**
* worsening hearing loss over time in one or both ears
* may, may not have tinnitus
76
**_Otosclerosis_**
treatment
**_Treatment_**
* Refer to ENT for middle ear exploration/stapedectomy/ossicular chain reconstruction
* Alternatively: hearing amplification and monitoring
**_Risk factors_**
* genetic predisposition
* female and caucasian
* young adults to middle age adults
**_Etiology/pathophysiology:_**
* abnormal, spongy bone growth at the junction of the stapes to the oval window in the middle ear
* worsens over time
**_Presentation_**
* worsening hearing loss over time in one or both ears
* may, may not have tinnitus
**_Diagnosis_**
* CHL on audiogram, possibly with a carhart notch at 2000 Hz
* Normal physical exam and normal tympanogram (may see absent reflexes)
* Temproal bone CT/exploratory surgery is diagnostic
77
**_Cholesteatoma_**
Etiology/pathophysiology
**_Etiology/pathophysiology_**
* Middle ear cyst with keratin formation
* Expansion of cyst leads to:
* destruction of middle ear, labyrinth, mastoid air cells, and facial nerve
* can lead to invasion of middle cranial fossa of the brain in severe cases
* Etiology is unknown. Associated with:
* Eustachain tube dysfunction (chronic negative middle ear pressure leads to retraction of TM, putting skin cells in the middle ear)
* TM perforation-introduces skin cells to middle ear
* Congenital
**_Presentation_**
* Typically presents as chronic draining ear
* CHL
* dizziness
**_Physical exam_**
* TM pearl
* external ear discharge
* audio shows CHL
**_Diagnosis_**
* CT temporal bone
**_Treatment_**
* Surgical excision necessary to prevent further middle ear destruction
78
**_Cholesteatoma_**
presentation/physical exam
**_Presentation_**
* Typically presents as chronic draining ear
* CHL
* dizziness
**_Physical exam_**
* TM pearl
* external ear discharge
* audio shows CHL
**_Diagnosis_**
* CT temporal bone
**_Treatment_**
* Surgical excision necessary to prevent further middle ear destruction
**_Etiology/pathophysiology_**
* Middle ear cyst with keratin formation
* Expansion of cyst leads to:
* destruction of middle ear, labyrinth, mastoid air cells, and facial nerve
* can lead to invasion of middle cranial fossa of the brain in severe cases
* Etiology is unknown. Associated with:
* Eustachain tube dysfunction (chronic negative middle ear pressure leads to retraction of TM, putting skin cells in the middle ear)
* TM perforation-introduces skin cells to middle ear
* Congenital
79
**_Cholesteatoma_**
diagnosis/treatment
**_Diagnosis_**
* CT temporal bone
**_Treatment_**
* Surgical excision necessary to prevent further middle ear destruction
**_Etiology/pathophysiology_**
* Middle ear cyst with keratin formation
* Expansion of cyst leads to:
* destruction of middle ear, labyrinth, mastoid air cells, and facial nerve
* can lead to invasion of middle cranial fossa of the brain in severe cases
* Etiology is unknown. Associated with:
* Eustachain tube dysfunction (chronic negative middle ear pressure leads to retraction of TM, putting skin cells in the middle ear)
* TM perforation-introduces skin cells to middle ear
* Congenital
**_Presentation_**
* Typically presents as chronic draining ear
* CHL
* dizziness
**_Physical exam_**
* TM pearl
* external ear discharge
* audio shows CHL
80
**_Eustachian Tube Dysfunction_**
Why more common in children?
because of horizontal position
81
\_\_\_\_\_\_ is a thin muscular tube that is responsible for equalizing the pressure in the middle ear with the pressure outside the ear. It also drains mucous from the middle ear
Eustachian Tube
82
Normal function of eustachian tube
opening and closing with soft palate movement
(dysfunction=fails to open and remains closed)
83
dysfunction of eustachian tube
dysfunction=fails to open and remains closed
(normal=opening and closing with soft palate movement)
84
Causes of Eustachian Tube Dysfunction
1. Inability of tiny ahirs inside the ear to remove fluid and infection
2. Poor contractile function within the eustachian tube
3. Narrow eustachian tube-in infants
4. Adenoid tissue blocking eustachian tube especially in children
5. Swollen nasal tissue due to secretions that cause of blockage of the nose
6. Nasopharyngeal tumors in adults
\*\*if there is a unilateral OM must check NP\*\*
85
\*\*if there is a unilateral OM must check \_\_\_\_\_\*\*
nasopharynx for tumors; rare for adults to have UNILATERAL blockage
86
Problems associated with Eustachian Tube Dysfunction
1. Otitis media
2. Barotrauma--especially with flight
3. Possibly cholesteatoma
87
**_Eustachian Tube Dysfunction_**
Presentation
**_Presentation_**
* Ear pain or pressure
* Stuffiness-doesn't clear with valsalva
* Hearing loss or tinnitus
* Retracted TM on exam
* Tympanogram is flat
**_Treatment_**
* Nasal decongestants--sudafed, afrin for 3 days max
* nasal steroids (flonase, nasonex): nose, toes, eyes pie
* More significant: oral steroids or do myringotomy and place a tube
88
**_Eustachian Tube Dysfunction_**
treatment
**_Treatment_**
* Nasal decongestants--sudafed, afrin for 3 days max
* nasal steroids (flonase, nasonex): nose, toes, eyes pie
* More significant: oral steroids or do myringotomy and place a tube
**_Presentation_**
* Ear pain or pressure
* Stuffiness-doesn't clear with valsalva
* Hearing loss or tinnitus
* Retracted TM on exam
* Tympanogram is flat
89
Size of adult TM
8-10mm
