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Middle ear Flashcards

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1
Q

What epithelium on external ear

A

Stratified squamous keratinised

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2
Q

What epithelium in middle ear

A

Ciliated columnar epithelium with goblet cell

Can produce mucous which can cause glue ear

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3
Q

What are the three layers of the tympanic membrane

A

Outer = continuous with EAM
Middle fibrous
Inner layer of respiratory = same as middle ear

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4
Q

What structures of the tympanic membrane

A 
Paratensa - tense
Paraflaccid - flaccid 
Cone of light - anterior inferior
Umbo in the middle
Annulus surrounds
Look at photo
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5
Q

If small perforation of TM

A

Small hearing loss

If large = large loss

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6
Q

What does middle ear do

A

Transforms acoustic energy from air to fluid

Acts as sound amplifier

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7
Q

What are the bones in the middle ear

A

Malleus
Incus
Stapes which is attached to foot plate in oval window

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8
Q

How does middle ear do its job

A

TM bigger than footplate so gives more energy

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9
Q

What can disrupt the middle ear

A 
Trauma
Bony sclerosis 
Chronic infection can erode incus
Fibrous tissue between ossicles so don't conduct
Oteosclerosis
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10
Q

What is otosclerosis

A

AD bony deposition in annular ligament that surrounds oval window where staple plate is so sound doesn’t conduct into cochlea
CONDUCTIVE DEAFNESS
MAY HAVE TINNITUS AND TRANSINT VERTIGO
RX = HEARING AID OR SURGERY - STAPEDECTOMY

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11
Q

What is the role of the Eustachian tube

A

Connects middle ear to nasopharynx

Acts to equalise pressure in ear to that of EAM as middle ear needs to be at atmospheric pressure to work

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12
Q

What can cause dysfunction

A

Inflammation
Infection
Genetics
Blockage

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13
Q

What happens if dysfunction

A

-ve pressure develops inside ear
Causes transudate to be pulled out of mucosa
Increased pathogens

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14
Q

What is otitis media

A

Inflammation / infection of the middle ear
Occurs when Eustachian tube stops working and fluid builds up underneath the ear drum

OME - can be sequels of otitis media but is regarded as a difference non-infective condition

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15
Q

If adult what should you suspect

A

Is there a tumour blocking the ear drum causing Eustachian tube dysfunction
Do flexible nasal-endoscopy

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16
Q

How do you Rx

A

Grommet to equalise pressure if recurrent

Children do not require unless persistent and hearing loss is affecting development

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17
Q

Why are young children particularly prone / RF

A

Eustachian tube smaller
Adenoids much larger
Cleft palate
Down syndrome

Other RF

  • URTI / scarlet fever
  • Bottle fed / use of dummy
  • Passive smoking
  • Adenoids
  • Asthma
  • Malformations e.g. cleft palate
  • Reflux
  • GORD / obesity in adults
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18
Q

What causes acute otitis media

A 
Usually URTI (viral) induced effusion 2 to Eustachian dysfunction
- RSV
- Rhinovirus  
Can be bacteria
H.influenza
S.pneumonia = most common
M.catarrhalis
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19
Q

What is the history

A

Short history
Prodromal URTI
Increasing pain
Bulging red ear drum causing pain which is relieved if perforates
Perforation = discharge
Hearing loss
May have fever but don’t act sick
Ear drum can perforate and discharge released
Can be very non-specific in young children - fever, vomit, irritable, poor feed so always examine if unwell

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20
Q

How do you Dx

A

Otoscopy showing red infected ear or perforated membrane
Always examine ears and throat of unwell children
Consider MC+S swab if discharge
CT / MRI if complications

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21
Q

How do you Rx

A

Analgesia + anti-pyretic

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22
Q

When do you give Ax

A 
Symptoms 4+ days
Systemically unwell
Immunocompromsied
<2 + bilateral
Perforation or discharge
Admit if child <3 months
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23
Q

What Ax

A

Amoxicillin
Erythromycin 2nd line
5-10 days
Co-amox if no improvement

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24
Q

What do you do if recurrent or complicated

A

Grommet insertion

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25
What are extra-cranial complications of AOM
``` Perforation Acute mastoiditis / mastoid abscess Facial nerve palsy Labrynthitis Ossicular / cochlear nerve damage = Hearing loss Tympanosclerosis due to scarring Chronic perforation ```
26
What are intracranial complications
``` Febrile convulsion Brain abscess Meningitis Cavernous sinus thrombosis Sub or extradural empyema ```
27
What causes chronic otitis media
Cholesteatoma Perforated TM with persistent or repeated infection - Psuedomona - S.aureus
28
What are the symptoms and how do you Rx
``` Intermittent non-offensive discharge Hearing loss May have pain May develop 2 otitis externa due to discharge Complications = same as otitis media ``` Rx - Ax and steroid ear drop if infection present - Myringoplasty to repair drum and prevent infections
29
What is cholesteatoma
Abnormal collection of skin (keratinising squamous cells) in middle ear causing local destruction Usually present in childhood due to eustachian dysfunction but can be congenital
30
What are the symptoms
Hx repeated smelly watery discharge despite Ax Doesn't resolve Gradual unilateral hearing loss Headache Pain May get vertigo / facial nerve palsy if extends which suggests inmepnding CNS complications Other complications same as otitis media
31
How do you Dx
Otoscopy shows crust in upper part of ear drum May not see if wax so debridement needed before May see discharge if 2 infection If complications PTA CT temporal bone
32
How do you treat
Refer ENT for mastoidectomy to take away dead skin
33
What can cholestatoma lead too
``` Ear infection Hearing loss Mastoiditis Labrynthitiis Vertigo Tinnitius Damage to facial nerve Meningitis Brain abscess / paralysis Venous sinus thrombosis ```
34
What is otitis media with effusion 'glue ear'
Collection of fluid in middle ear Non-infective Occurs when an effusion is present after regression of symptoms of acute OM
35
What is most common cause of hearing loss in children
Otitis media with effusion
36
How do you Dx
Otoscope shows fluid level of bubbles behind the ear drum PTA = conductive loss Tympanometry = flat trace
37
What causes it
Eustachian tube dysfunction - More common in Cleft / Syndrome Adenoidal hypertrophy Resolving AOM
38
Who is more at risk
``` Day care Older siblings Parenteral smoking URTI Oversized adenoid Cleft palate Down syndrome ```
39
What are symptoms
``` Hearing loss Speech delay Behaviour problems Poor balance Can go on to develop otitis media ```
40
How do you Rx conservatively
Most improve by themselves so 3 months of active observation Autoinflation if >4 - blow balloon using nose to create pressure and open up tube Valsalva manoeuvre
41
What advise
Stop smoking Likely seasonal variation Breast feeding reduces risk
42
What are more invasive Rx What are risk of Grommet
Grommet insertion if bilateral >3 months and affecting hearing / Down's or cleft palate Adenoidectomy as last resort Hearing aids / bone implant if other options not effective Risk - Infection - Tympanosclerosis - TM perforation
43
What do you ask in history / examination of discharging ear
When did it start Associated Sx Otoscope
44
What further investigation
Refer for pure tone audiometry / appropriate hearing test for age Possible CT if continually discharge Must exclude a post nasal space tumour as cause of fluid in an adult
45
What causes perforated tympanic membrane
Infection = most common (Acute otitis media) Previous surgery e.g. grommet which doesn't close Baro trauma Blow to the ear
46
What may it cause
Ear pain when perforation occurs + discharge Hearing loss Recurrent discharge Increased risk of otitis media
47
How do you Rx
``` None in most usually heals 6-8 weeks Avoid getting water in Prescribe Ax if due to an episode of AOM - Avoid ototoxic - Ciprofloxacin = 1st line Myringoplasty if fails to heal by itself ```
48
What is tympanosclerois
Hyalinzation and calcification of connective tissue in middle ear or TM
49
What can it cause
White plaque on ear drum as calcified | Conductive hearing loss if affects the ossicles
50
What are RF
Recurrent middle ear infection | Perforated TM
51
How do you Rx
Hearing aid | Reconstruction of ear drum
52
What are mastoid air cell
Form love middle ear Air filled spaces in mastoid process of temporal bone Air released from mastoid Antrum into tympanic cavity when pressure is too low
53
What is mastoiditis
Inflammation of mastoid air cells
54
What causes
Persistent otitis media | Choleastoma
55
What are symptoms
``` Red ear Swelling around ear Tenderness External ear may protrude forward Discharge if perforates Fever Headache Hearing loss VERY UNWELL ```
56
How do you Dx
Refer ENT | CT
57
Complications of mastoiditis
Menignitis OM Hearing loss CN palsy
58
How do you Rx
IV Ax Myringotomy +- definitive mastoidectomy
59
Most common cause of otitis media / rhino sinusitis
Strep pneumonia
60
Most common cause of tonsillitis
Strep A
61
What is recommended to Rx motion sickness
Hyoscine (transdermal patch) | Non-sedating antihistamine
62
What are common bacterial pathogens in discharging ear
``` Psuedomona S>aureus S.pneumonia H.influenza M.catarrhalis ```
63
What do you want to know in HX
``` Duration Any ear pain Fever / systemic Sx suggesting infective Any hearing loss Any dizzy Any FB Any facial nerve palsy Any trauma Rx tried ```
64
What does trauma suggest discharge could be
CSF from basal skull fracture
65
What are other Dx
``` Cholesteatoma FB Malignant otitis externa Otitis externa Ottis media with effusion Perforated TM ```
66
What can middle ear infections cause
Facial nerve palsy
67
What is most common cause of this
Bell's but Dx of exclusion so need to actively exclude other causes
68
What are other causes
Trauma - Iatrogenic - Temporla fracture - Cholestatoma Infectious - Ramsay hunt - VZV reactivation - 2 to acute / chronic otitis media / malignant Neoplastic - Parotid or temporal bone tumour - Acoustic neuroma Congenital - CHARGE Inflammatory - Sarcoid - GBS - MS Other - CVA
69
How do you investigate
``` Examine - Ear - Throat - Parotid - Mass? Bloods Audiogram PTA MRI if suspect central cause ```
70
How do you manage
Eye care - tears / tape shut Refer ophthalmology Oral steroid for Bells -1 mg/kg Oral anti-viral for Ramsay
71
What is Ramsay Hunt
HAZ reactivation in ganglion of facial nerve | Intense pain, palsy and vesicles
72
What does facial nerve innervate in the eye
Orbicularis oculi So if palsy not able to close the eye If only mild some people will still be able to close
73
What nerve innervates eye opening
Oculomotor | So if damaged = ptosis as can't open ear
74
What grades facial nerve
House Brackmann
75
If forehead still moves what does this suggest
UMN | Scan brain to look for stroke
76
What path does facial nerve take
Through ear and parotid
77
If other branches are affected what can you get
Taste disturbance HYperacusis Lacrimation

ENT (14 decks)

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