SM_29b: Ear Infection and Pathology

Question 1

Microtia and aural atresia results in ____ conductive hearing loss but ____ bone conduction

Answer 1

Microtia and aural atresia results in maximal conductive hearing loss but normal bone conduction (normal sensorineural hearing)

• Type 1 to 4 microtia: with Type 1 having most landmarks and Type 4 having no ear (anotia)
• Aural atresia: missing ear canal
• Treated by rebuilding the external ear: osseointegrated implant for hearing uses bone conduction to restore hearing, or can drill out a new ear canal

Question 2

Describe cerumen

Answer 2

Cerumen

• Produced in outer third of external auditory canal
• Contains lysosomes, immunoglobulins, and polyunsaturated fatty acids
• Is slightly acidic (pH 6.1): controls growth of some bacteria especially Pseudomonas aeruginosa
• Has a waterproofing effect: reduces maceration of external auditory canal

Question 3

Cerumen impaction is treated with ____, ____, and ____

Answer 3

Cerumen impaction is treated with cerumen loop, irrigation, and peroxide

Question 4

Bacterial otitis externa is known as ____ and is usually caused by ____

Answer 4

Bacterial otitis externa is known as swimmer’s ear and is usually caused by Pseudomonas aeruginosa

Question 5

Bacterial acute otitis externa treatment includes ____, ____, and ____

Answer 5

Bacterial acute otitis externa treatment includes cleaning the canal, topical therapy with antibiotic and steroid ear drops, and suitable pain management

(systemic antibiotics generally not required for uncomplicated cases)

Question 6

Foreign body in the ear canal removal may require ____ and ____

Answer 6

Foreign body in the ear canal removal may require special equipment and general anesthesia

Question 7

Ear canal osteomas are ____, while exostosis are ____

Answer 7

Ear canal osteomas are pedunculated and single, while exostosis are broad-based and multiple (associated with cold water exposure)

• May require surgery if obstructive

Question 8

Acquired external auditory canal stenosis is usually acquired after ____ and may require ____

Answer 8

Acquired external auditory canal stenosis is usually acquired after infection and may require surgery

Question 9

Middle ear pathologies lead to ____

Answer 9

Middle ear pathologies lead to conductive hearing loss

Question 10

Tympanic membrane perforation may be caused by ____, ____, or ____ and results in ____

Answer 10

Tympanic membrane perforation may be caused by extruded ear tube, traumatic perforation, and underlying Eustachian tube dysfunction and may result in conductive hearing loss

Question 11

Tympanic membrane perforation is treated with ____

Answer 11

Tympanic membrane perforation is treated with tympanoplasty (repair)

• To protect middle ear and improve hearing
• Use graft

Question 12

Eustachian tube dysfunction causes ____ on ____ tympanogram

Answer 12

Eustachian tube dysfunction causes negative pressure (C) or no pressure (B) on tympanogram

Question 13

Eustachian tube dysfunction causes ____, causing ____ and interfering with ____

Answer 13

Eustachian tube dysfunction causes tympanic membrane retraction, causing conductive hearing loss and interfering with tympanic membrane vibration

Question 14

Middle ear pathology includes ____, ____, ____, and ____

Answer 14

Middle ear pathology includes otitis media, cholesteatoma, middle ear masses, and otosclerosis

Question 15

Describe acute otitis media

Answer 15

Acute otitis media

• Purulence behind tympanic membrane
• Pathogens enter middle ear from nasopharynx via Eustachian tube: S. pneumonia. H. influenzae, M. catarrhalis
• Symptoms: fever, otalgia, irritability, hearing loss
• Treatment: oral antibiotics (penicillin based)

Question 16

Serous otitis media (chronic otitis media with effusion) is ____ causing ____

Answer 16

Serous otitis media (chronic otitis media with effusion) is resolved purulent otitis media but persistence of middle ear fluid causing conductive hearing loss

Question 17

Tympanostomy tubes ____, ____, ____, ____, and ____

Answer 17

Tympanostomy tubes drain middle ear fluid, equalize pressure on either side of tympanic membrane, restore hearing, decrease ear infections, and make ear infections easier to treat (topical drops)

Question 18

Indications for tympanostomy tubes are ____ an d____

Answer 18

Indications for tympanostomy tubes are

• Recurrent otitis media: 3 in 6 months or 5 in 1 year
• Persistent effusions: longer than 3 months, speech delay

Question 19

Describe complications of acute otitis media

Answer 19

Complications of acute otitis media

• Facial palsy
• CN VI palsy (Gradenigo syndrome)
• Coalescent mastoiditis with subperiosteal abscess
• Intracranial complication: epidural abscess, subdural abscess, brain abscess
• Meningitis
• Sinus thrombosis

Question 20

Ossicular discontinuation / fixation results from ____, ____, ____, and ____ and is treated by ____

Answer 20

Ossicular discontinuation / fixation results from congenital fixation / malformation, erosion from retracted tympanic membrane, traumatic disarticulation, and otosclerosis and is treated by lifting up the eardrum and placing a spacer

Question 21

Otosclerosis causes ____ and results from ____

Answer 21

Otosclerosis causes progressive low frequency conductive hearing loss and results from absent stapedial reflexes

• Genetic disorder: autosomal dominant with variable pentrance
• Normal tympanogram

Question 22

Otosclerosis is managed with ____, ____, or ____

Answer 22

Otosclerosis is managed with observation, hearing aid, or stapedectomy with prosthesis

Question 23

Cholesteatoma is ____

Answer 23

Cholesteatoma is epithelial (skin) cyst in the middle ear that may extend into the mastoid

• Difficult dissection: inflamed and infiltrative
• Unpredictable, often long surgeries
• Relentless
• Often multiple surgeries
• Cannot leave a single cell behind

Question 24

Congenital cholesteatoma is most likely due to ____ and must be treated with ____

Answer 24

Congenital cholesteatoma is most likely due to epithelial cells trapped behind tympanic membrane during embryogenesis and must be treated with surgical excision

• Prognosis for recurrence and hearing is good

Question 25

Describe formation of acquired cholesteatoma

Answer 25

Acquired cholesteatoma formation 1. Chronic Eustachian tube dysfunction leads to chronic negative middle ear pressure 2. Atmospheric pressure pushes in the weakened tympanic membrane 3. Retraction pocket forms 4. Retraction pocket becomes so deep that desquamating epithelium cannot exist -\> forms cholesteatoma 5. Inflammatory reaction and enzymes from cyst cause bony erosion: ossicles (conductive hearing loss), otic capsule, tegmen, and facial nerve 6. Eventually extends from middle ear into mastoid cavity and / or down Eustachian tube

Question 26

Acquired cholesteatoma must be treated with \_\_\_\_

Answer 26

Acquired cholesteatoma must be treated with surgical resection with removal of entire cyst and rebuilding of ossicles and tympanic membrane

Question 27

Describe the history and physical exam findings for acquired cholesteatoma

Answer 27

History and physical exam findings for acquired cholesteatoma * Eustachian tube dysfunction (previous ear tubes), sniffing, chronic intermittent foul smelling ear drainage, conductive hearing loss * Retracted tympanic membrane with white / yellow mass in middle ear, often associated with granulation / inflammatory tissue

Question 28

Surgical procedure for acquired cholesteatoma is \_\_\_\_

Answer 28

Surgical procedure for acquired cholesteatoma is mastoidectomy

Question 29

Inner ear pathologies cause \_\_\_\_

Answer 29

Inner ear pathologies cause sensorineural hearing loss * Congenital sensorineural hearing loss: infectious (CMV, TORCH), genetic, cochlear malformations * Acquired sensorineural hearing loss: sudden * Meniere's disease * Tumors: vestibular schwannoma (acoustic neuroma), glomus jugulare

Question 30

Describe risk factors and workup for congenital sensorineural hearing loss

Answer 30

Congenital sensorineural hearing loss * Risk factors: ICU stay at birth / intubation, blood transfusion / hyperbilirubinemia, family history, perinatal infections * Current workup: CMV testing, genetic testing (GJB2 most common), imaging * Many etiologies

Question 31

Describe the critical speech and language learning window

Answer 31

Critical speech and language learning window * Central neuroplasticity plays a strong role in the development of language * Significant drop-off in ability to obtain oral speech if hearing loss persists after age 3 * Hearing loss should be diagnosed and treatment started before 6 months of age (screen at 1 month, diagnose at 3 months, treat before 6 months)

Question 32

Cochlear implantation involves an electrode typically placed through the ____ into the ____ of the cochlea

Answer 32

Cochlear implantation involves an electrode typically placed through the round window into the sinus tympani of the cochlea

Question 33

Sudden hearing loss is \_\_\_\_, presents with \_\_\_\_, results from \_\_\_\_, and is treated with \_\_\_\_

Answer 33

Sudden hearing loss is an acute change in hearing, presents with clogged ear, results from inflammation, and is treated with steroids (prednisone) * Recovery 50/50: should be treated in first week * Poor prognosis with severe hearing loss or vertigo * Most patients will have tinnitus

Question 35

Acoustic neuroma (vestibular schwannoma) presents with ____ and ____ and is treated with \_\_\_\_, \_\_\_\_, or \_\_\_\_

Answer 35

Acoustic neuroma (vestibular schwannoma) presents with sudden asymmetric hearing loss and tinnitus and is treated with observation, microsurgery, or Gamma knife

Question 36

Describe Meniere's Disease

Answer 36

Meniere's Disease * Characterized by episodic vertigo, fluctuating hearing less, aural pressure, and tinnitus - endolymphatic hydrops * Requires ≥ 2 episodes of vertigo lasting ≥ 20 minutes, audiometrically documented hearing loss on at least one occasion, and tinnitus or aural fullness in affected ear * Negative MRI * Endolymphatic hydrops * Cause unknown and course varies

Question 37

Meniere's Disease is treated medically with \_\_\_\_, \_\_\_\_, and ____ or surgically with \_\_\_\_, \_\_\_\_, \_\_\_\_, or \_\_\_\_

Answer 37

Meniere's Disease is treated medically with low salt diet, diuretics, and expectant treatment or surgically with nerve section, labyrinthectomy (drillout of entire inner ear), gentamicin injection, or endolymphatic sac drillout (decompression)