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Transcript of Otology 2011
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OtoloRhinoLaryngology
Mark Montgomery MD, FACS
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4/19/2012 Mark Montgomery, MD 2
What is an
Otolaryngologist?
General ENT
Pediatrics
Laryngology
Facial Plastics Allergy
Rhinology
Head/Neck
Neurotology
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Otolaryngology Topics
Otology Rhinology
Allergic Rhinitis
Rhinosinusitis Epistaxis, Foreign bodies, etc.
Oral and Oropharynx
Hypopharynx
Diseases of the Neck
Trauma of the Head & Neck
Tumors of the Head & Neck
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Objectives
Discuss clinical medicine of the ears andhearing & balance mechanisms withemphasis on the common conditions
Discuss diagnosis, treatment, referralindications and pitfalls in the managementof these conditions
Place emphasis on accurate, cost efficienttreatment and management of theseconditions
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Topics in Otology
Auricularhematoma
Foreign Body
Tympanicmembraneperforation
Eustacian tubedysfunction
Barotrauma
Otitis Media
Cholesteatoma
Mastoiditis
Hearing loss
Acoustic Neuroma
Tinnitus
Vertigo Benign positional Labyrinthitis
Menieres
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Credits
Photos from the ENT USA web siteare protected by the copyright lawsof the United States and other
countries. Copyright 1999-2003,Kevin T Kavanagh MD. All rights arereserved. They are used here with
permission from Kevin T KavanaghMD
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External Ear or Pinna
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External Ear Abnormalities
Congenital:
Microtia-
Protruding outstanding ears-
1st branchial cleft abnormalities-fistulas, cysts, sinuses
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Microtia
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1st branchial cleft abnormalities
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Pathology of theOuter Ear
Metabolic
Infectious Neoplasms
Traumatic
Vascular, iatrogenic
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Auricular Hematoma
Auricular hematoma:
Can lead to necrosisand permanentdisfigurement.
Hematoma between theperichondrium andcartilage
Does not respond toaspiration
REFER immediately toENT
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Cauliflower Ear
Caused by trauma(wrestling)
Needs (ENT) referral.
Differentiate Acute VsChronic
Hematoma vs deformity
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Auricular Hematoma Treatment
CauliflowerEar
Incision & Drainage withBolsters
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Keloid from pierced ear ring.
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Pseudomonas infection causingcellulitis
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Infection: Erysipelasor Celluitis Traumatic
Idiopathic
Chondrodermatitis nodularis helicus
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Dermatologic
Contact dermatitis:
Atopic dermatitis:
Skin lesions:
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Contact Dermatitis
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Relapsing Polychondritis
Inflammation ofcartilage
Treatment:antibiotics,may require surgicalresection
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Auricular Cancer
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Auricular cancer
Basal cell
Squamous cell
Malignant melanoma Cartilage tumors
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EXTERNAL CANAL ANATOMYCerumen production/canal maintenence
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Anatomy of the Ear Region
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Ear Canal Anatomy
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External Auditory Meatus
Curved tube of cartilage(lateral 1/3) & bone(medial 2/3) leadinginto temporal bone
Lined with skin
Ceruminous glandsproduce cerumen = ear
wax
Innervation by vagus(CN X) andauriculotemporal nerve
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Exostosis
Bony to palpation Frequently bilateral Surfers ears DDx: Cholesteatoma
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EXOSTOSIS OF EAR CANAL
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Cerumen S & S Tinnitus
Conductive hearingloss
Treatment:Removal under
dirct visualizaionbest
Complication TM perforation
Abrasion EAC
Contraindication tolavage Hx of TM perforation
Hx of prior ear surgery
PE tube in the ear
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Cerumen
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Foreign Body
Patient inserted Q tips beads
Removal may be difficult
Success depends on equipment,skill, and cooperation.
Complications of removal:laceration of the ear canal,rupture of tympanic membrane
Frequent referral to ENT
Post-extraction Topical antibiotics w/
corticosteroids
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FOREIGN BODY
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FOREIGN BODY
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FOREIGN BODY
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FOREIGN BODY
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FOREIGN BODY
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Foreign bodiesEar Candling
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Otitis Externa
Inflamationof the External earcanal
Inflamatory: Eczematous orseborrheic dermatitis
Infectious: Bacterial and/or fungal Symptoms:
Pain often severe
Tenderness with manipulation of auricle Muffled hearing
Discharge--purulent
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Otitis Externa
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Eczematous otitis externaAlso can be psoriasis
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CHRONIC OTITIS EXTERNA
Inflamation Swelling
Purulent
Debris Itching
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Otomycosis(fungal)
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OTOMYCOSIS
CANDIDA
ASPERGILLUS
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OTOTOXICITY OF OTIC GTTS
Cortisporin contains Neomycin OTOTOXICmay also aggravate itching
Acetic acid is not ototoxic but is painful ifTM is perforated.
Ciprofloxin-type drops: Safe for the middle
ear: eg. Floxin, Ciprodex
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OTITIS EXTERNA TX
Usually do not need oral antibiotics unlessassociated with cellulitis of auricle or face/neck.
NEVER treat with oral alone. Conc of otic dpshigher level to infected area. Oral could lead to
resistance. Most infections in FL are probably mixed bacterial
(Staph and/or pseudomonas AND fungal.
Bacterial: Intact TM- Neomycin or Fluoroquinolone
State of TM unknown: Fluoroquinolone
Most important is to ensure drops get in. Debris needsto be cleared. Most common reason for treatmentfailure is improper administration. With significantswelling, consider Wick insertion
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Otitis Externa Tx (con)
Treatment with antibiotic drops 7 days
Dry ear care/Avoid manipulation
Recheck in one weekremove debris
If no improvement: culture &sensitivity Consider pseudomonas orMRSA
May require change of drop and/oraddition of oral antibiotic
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OTITIS EXTERNA (FUNGAL)
Marked debris requiring careful cleaning of thecanal. Treatment:
Vosol otic drops (2% acetic acid in propolyeneglycol)
Vosol HC otic drops if swelling present. Lotrimin solution (clotrimazole) Cresylate Ciprodex frequently effective (acidic & steroid in
addition to the antibiotic).
Untreated or under-treated fungal infections arenasty and can ulcerate and perforate the TM(Rare)
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EAR CANAL PROPHALAXIS
To prevent Swimmers ear or fungus:Store preps are mainly alcohol. MixingTwo tablespoons of white vinegar in pint
rubbing alcohol probably better CHEAPER.Use after swimming or when ear feels wet.
Eczematous OE: Small amount of OTC1% hydrocortisone to outer ear canal with
Q-tip (depth 1 cm) when ear itches. Mayuse 50% white vinegar and distilled H20(Not alcohol) if ear canal feels wet.
Necrotizing (Malignant) Otitis
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Necrotizing (Malignant) OtitisExterna
Osteomyelitis of the skull base
Pseudomonas predominantly Immunocompromised/diabetic
patients Severe pain/discharge Granulation tissue in ear
canal Cranial neuropathies -
7,9,10,11
CT/nuclear medicine scan
Long-term intravenousantibiotics Antipseudomonals
Prognosis- 60% mortality Related to response to
therapy
Granulation in ExternalAuditory Canal
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T i M b
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Tympanic Membrane
Functions: Separates the
external ear fromthe middle ear
Transmits soundfrom air to theossicles
Someamplification ofsound wave
54
NORMAL TYMPANIC MEMBRANE
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NORMAL TYMPANIC MEMBRANE(Window to the Middle Ear)
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1
2
3
4 5
7
O
I
R
T
A
I= Incus
O=oval window
R=Round window
A=Annulus
T=Tensor tympani
1=pars flaccida
2=short process ofmalleus
3=handle of
malleus
4=umbo5=tubal oriface
7=hypotympanic
air cells
Anatomy
A
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Anatomy1= Pars flaccida2= Short process of maleus
3= Handle of maleus
4= Umbo5= Supratubal recess
6= Tubal orifice
7= Hypotympanic air cells
8= Stapedeus tendon
9= Pyramidal eminencef = facial nerve
co = cochleariform process
j = incudostapedial joint
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Tympanosclerosis
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Tympanosclerosis with inferior perforation
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TYPANOSCLEROSIS
Scaring of the TM due to chronic infections
Glomus Tumors
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Glomus Tumors(Chemodectomas)
Initial symptoms:Hearing loss, pulsatiletinnitus
Middle ear: promontory
Highly vascular mass
Glomus tympanicum
Glomus jugulare
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BULLOUS MYRINGITIS
PRESENTATION: pain with heaing loss
Etiology: Unknown, probably viral
PHYSICAL FINDINGS: Blebs &erythema of the tympanic membrane
Treatment: Supportive, topicalanesthetic drops, monitor forsecondary bacterial infection.
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Bullous Myringitis
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Ear Drum Perforation
Acute Otitis
Traumatic
Barotrauma
Chronic
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TRAUMATIC PERFORATION
TRAUMATIC PERF WITH NERVE
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TRAUMATIC PERF WITH NERVEEXPOSED
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Treatment: TM Perforatioin
Rule out ossicular discontinuity(audiogram)
Dry Ear Care!
Pain Medication Non-ototoxic antibiotic ear drops only if
the perforation occurred in wet conditionsand/or ear is draining
90% perforations heal in 6 weeks if non-infected!
Tympanoplasty for persistent perforation.
TM with Monolayer (Monomeric)
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TM with Monolayer (Monomeric)Previous perf or PE tube site
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Size
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Eustachian Tube Function
Protection of middleear
Clearance of middleear secretions
Ventilation of the
middle ear
Eusacian Tube ANATOMY
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Eusacian Tube ANATOMYCritical Valve ln Nasophaynx
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Tympanometer: Pressure
transducer Testing
function of theEustacian Tube
Measures bothmobility &volume
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Tympanogram Type A
NORMAL
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Tympanogram Type B
Volume?
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Tympanogram Type B
Volume: nl=Fluid Hi=perf
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Typanogram Type C
Negative Pressure
Eustacian Tube Dysfunction
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Eustacian Tube DysfunctionSmptoms
Clicking and/or popping in the ear
Hearing lossvariable
Vertigo
Discomfort
Symptoms aggravated with changein ambient pressure: elevators, flyingSCUBA diving
Eustacian Tube Dysfunction
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Eustacian Tube DysfunctionTreatment
Watchful waiting eg.URI
Correcting Rhinitis: smoking, allergies,sinusitis, pregnancy, decongestant spray
abuse, reflux Medication: antihistamine sprays and
steroidssome benefit. (decongestants,antihistamines, steroid spraysusually
ineffective) Eustacian tube exercises
PE tubes: usually not recommended
B Middl E
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Barotrauma Middle Ear
Cause: Changes in ambient pressurein the face of Eustacian TubeDysfunction
Sequelae: Hemotympanum
Ear Drum Rupture
Round Window Rupture Serous Otitis
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Mechanism of Barotrauma
C C f B t
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Common Causes of Barotrauma
Plane Flights Scuba Diving
Hemotympanum due to
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Hemotympanum due toBarotrauma
T t t f B t
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Treatment of Barotrauma
Behavior modificationno flying or SCUBAdiving until resolution!
Treat as Eustacian Tube Dysfunction
Antibiotic drops if TM perforation is wet Myringotomy and possible PE tube if no
resolution of serous otitis (6 wks approx)
Perilymphatic fistulapersistent vertigo &hearing lossemergency referral
O i i
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Otitis
Media Acute
Recurrent OM: If a child experiences threeor more episodes of AOM within 6 to 18
months
With Effusion(OME)
A t Otiti M di
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Acute Otitis Media
AOM develops after bacteria invade the middleear
most frequently occurring childhood diseasefollowing URI
leading cause of physician visits, antimicrobialtherapy, and pediatric surgery in severalcountries.
80% of cases occur in children, with the greatest
incidence occurring in those aged 6 to 9 months By 1 year of age, an estimated 75% of infants
will have encountered one episode of AOM, while17% will have suffered from at least three
episodes
Pathogenesis
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Pathogenesis
Otitis Media
Infection
Immature/Impaired
Immunology
Allergy
Eustachian Tube
Dysfunction
Day-care Centers
Lack of Breast FeedingPassive Smoking
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Di i f AOM
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Diagnosis of AOM
Three specific criteria need to be met:1. rapid onset
2. confirmed presence of middle-ear
effusion (MEE)3. signs and symptoms of middle-ear
inflammation
S mptoms of AOM
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Symptoms of AOM
Rapid onset of disease associated with oneor more of the following symptoms:
Otalgia
Fever Otorrhea
Recent onset of anorexia
Irritability Vomiting or Diarrhea
Otoscopic findings of Ear Drum
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p gIn AOM
Opacity
Bulging
Erythema Middle ear effusion (MEE)
Decreased mobility with pneumatic
otoscopy50% of all complaints associated with ear
pain will be associated with referred pain
from another site
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Acute Otitis Media
Microbiology of AOM
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gy
The most common bacterial pathogen inAOM is Streptococcus pneumoniae,followed by Haemophilus influenzae andMoraxella catarrhalis.
Responsible for more than 95% of all AOMcases with a bacterial etiology
Viruses most commonly associated withAOM are respiratory syncytial virus (RSV),influenza viruses, parainfluenza viruses,rhinovirus, and adenovirus
Treatment of AOM
http://emedicine.medscape.com/article/971488-overviewhttp://emedicine.medscape.com/article/971488-overview -
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Treatment of AOM
Consider no treatment except analgesics(topical & oral) if mild.
Antibiotics-oral, +/- antibiotic drops ifrupture of the tympanic membrane.
Amoxicillin
drug of choice initially. If noresolution: High-dose oralamoxicillin/clavulanate. Oral cefuroxime.Intramuscular (IM) ceftriaxone
Large-dose cefdinir (high efficacy againstpenicillin-susceptible S pneumoniae)
Steroids (usually not recommended)
Follow up exam for resolution. Is the fluidgone?
Complications of AOM
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Complications of AOM
Hearing loss
Chronic SOM
Adhesive OM
Ossiculardiscontinuity/fixation
Labyrinthitis Mastoiditis
Facial VII Paralysis
Petrositis
TM perforation Cholesteatoma
Tympanosclerosis
Intracranialcomplications- Rare Meningitis
Subdural empyema
Brain abscess
Complicated Otitis Media:
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pSuggestive Features
High-risk patientNeonate Immunocompromised state
Diabetes, HIV,neutropenia
Intracranial Severe headache, feverMeningeal signs, seizures,DMS
Otologic Pain (retro-orbital, mastoid) Severe vertigo, SNHL Cranial nerve involvement
(6,7,8)
Displaced pinna
CoalescentMastoiditis
AcuteCoalescent
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Mastoiditis :S & S
Doughy swelling Redness /
Tenderness
Auricular
prominence Purulent otorrhea
Progressive hearingloss
Fever VII paralysis
Intracranial signs
Acute Mastoiditis
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Acute Mastoiditis
Uncommon in US Diagnosis confirmed on
CT
Management Hospitalization High dose parenteral
antibiotics
Surgical drainage if noresolution or VII nerveparalysis
Axial CT Temporal bone: Left sidedopacity of mastoid air cell consistent with
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p ydiagnosis of Mastoiditis
Chronic Suppurative OM
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Chronic Suppurative OM
Chronic Mastoiditis
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Chronic Mastoiditis
Tympanic membrane perforationchronic
Absence of pain
History of intermittent ear discharge
Chronic Osteomyelitis of the Mastoid
Diagnosis confirmed by CT
Treatment: Mastoidectomy
Otitis Media with Efusion OME
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Otitis Media with Efusion OME fluid in the middle ear without signs or
symptoms of infection
Cause:blockage of the eustachian tubewith fluid trapped in the middle ear
May occur spontaneously as part ofrhinosinusitis (inflammation of the nasalcavity and sinuses), or it may succeed about of AOM.
90% of cases occur in children between 6months and 4 years of age
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OTITIS MEDIA WITH EFFUSION
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OTITIS MEDIA WITH EFFUSION
Treatment of Otitis Media with Efusion
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Treatment of Otitis Media with Efusion
Environmental (children) Day Care
Bottle feeding in supine position
Smoking in the home
Milk-free diet Consider reflux!
Watchful waitiing
Antibiotics, oral antihistamines, decongestants steroid
sprays
ineffectiveAntihistamine sprays (Astepro, Astelin, Patanase)
possibly effective
Consider PE tube placement if no resolution
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INDICATION FOR PE TUBE
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PLACEMENT
Failure of OME to resolve Hearing loss with speech & language delay
Recurrent Acute Otitis Media
Goal of typanostomy tubes (PE) is:Ventilation of the middle ear
Temporary bypass of the Eustacian Tube
PE stand for Pressure EqualizingVentilating NOTDrainage tubes
TYMPANOSTOMY TUBES
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TYMPANOSTOMY TUBES
SHORT TERM GROMMET LONG TERM T-TUBE
TYMPANOSTOMY TUBES
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TYMPANOSTOMY TUBES
PEARL
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PEARL
Unilateral otitis media with efusionin an adult, without a preceding
URI, is a nasopharyngealcarcinoma until provenotherwise.
CHRONIC OTITIS MEDIA
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CHRONIC OTITIS MEDIA
RETRACTED TM
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RETRACTED TM
TM RETRACTION
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With serous fluid
CHOLESTEATOMA
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CHOLESTEATOMA
Cholesteatoma
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Cholesteatoma Benign growth involving
middle ear and mastoid
Cause: Persistent negativepressure on the TM
Hearing loss most commonsymptom
Microbiology: pseudomonas
Management: surgicalmiddle ear with possibleremoval of ossicles,tympanoplasty, possiblemastoidectomy
Recurrence: common
CHOLESTEATOMAP fl id d
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Pars flaccidapost sup quadrant
Pearl
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Pearl
Suspected perforation of the
pars flaccida is acholesteatoma until provenotherwise.
Inner Ear
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Inner Ear Anatomy
Diseases of the Inner Ear
Hearing Loss
Tinnitus
Acoustic Neuroma Vertigo
Benign Positional Vertigo
LabyrinthitisMenieres
Ramsey Hunt Syndrome & Bells Palsy
A t f th I E
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Anatomy of the Inner Ear Bony Labyrinth Membranous Labyrinth
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Inner Ear---Bony Labyrinth
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Bony labyrinth = set of tubelike cavities intemporal bone lined with periosteum & filled with perilymph
Semicircular canals Vestibule Cochlea
surrounds & protects membranous labyrinth123
Inner Ear---Membranous Labyrinth
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Membranous labyrinth set of membranous tubes containing sensory receptors
Hearing (cochlea)
Balance (semicircular canals)
filled with endolymph
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Classification of Hearing Loss
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April 19, 2012 126
C ass cat o o ea g oss
Conductive Blockage of Outer Ear
Cerumen
Infection
Dysfunction of the Middle Ear
Perforation of Ear Drum
Fluid
Eustacian Tube Dysfunction Ossicle Malfunction
Maleus, Incus, Stapes
Classification of Hearing Loss(Cont)
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April 19, 2012 127
Neurosensory
Inner Ear (Nerve of Hearing)Genetic
Noise Induced
Medication Infection
Diseases (Menieres)
Growth Mixed loss
Combination of neurosensory andconductive
Genetic (Presbyacusis)
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April 19, 2012 128
( y )
Most common type of hearing loss Loss of nerve cells in the inner ear
Begins at different ages and at a
variable rate High frequency range is lost first
Ability to distinguish consonants
most affected (b, p, sh, t, etc)
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April 19, 2012 129
Noise Induced Hearing Loss
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April 19, 2012 130
Noise Induced Hearing Loss
Extremely common
May occur at any age
Additive effect
Common sources Guns Industrial type noise
Power tools
Music (ear puds etc.)
Prevention: earprotection
Decibel Levels of Common SoundsSafe Level: 85 dB or less
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April 19, 2012 131
Safe Level: 85 dB or less
20 Ticking watch
30 Quiet whisper
40 Refrigerator hum
50 Rainfall60 Sewing Machine
70 WashingMachine
80 Alarm clock attwo feet
85 Average traffic95 MRI
100- Blow dryer
105- Power mower,chain saw
110- Screaming child
130- Jackhammer,
Jet engine (100feet)
140- Shotgun,Airbag
Evaluation of Hearing loss
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g
History Physical Exam
Appearance of ear canal and ear drum
Tuning fork testing Weber Test
Rinne Test
Weber Test
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Hold a 512 Hz tuning fork on the middle of thepatient's forehead and ask them:
"Where do you hear this loudest;left, right, or in the middle?
Rinne Test
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Compares perception of sounds, astransmitted by air or by boneconduction through the mastoid
Heinrich Adolf Rinne (1819-1868)german otologist;
Rinne test
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Placing a vibrating tuning fork (512 Hz)initially on the mastoid
Then next to the ear and asking whichsound is loudest
Audiogram
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g
audiogram is a graphicalrepresentation of how well a certainperson can perceive different sound
frequencies normalized conversion of hearing
thresholds from dBSPL to dBHL,
where dB is decibel, SPL is soundpressure level and HL is hearing level
Audiogram
http://en.wikipedia.org/wiki/Charthttp://en.wikipedia.org/wiki/Soundhttp://en.wikipedia.org/wiki/Frequencyhttp://en.wikipedia.org/wiki/Decibelhttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Decibelhttp://en.wikipedia.org/wiki/Frequencyhttp://en.wikipedia.org/wiki/Soundhttp://en.wikipedia.org/wiki/Chart -
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g
Hearing Loss
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Conductive
Sensorineural
Mixed Sudden SNHL
REFER
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Tinnitus (Ringing in the Ears)
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CausesNeurosensory hearing loss
Medication (aspirin, etc.)
VascularTempomandibular Joint Syndrome
Idiopathic
Ref: American tinnitus Associationwww.ata.org
Tinnitus: Treatment
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April 19, 2012 143
Medication Biofeedback
Masking TMJ temporomandibular joint
therapy
Cognitive therapy
Tinnitus Treatment (cont)
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Alternative TherapyHypnosis
Accupuncture
Ginkgo biloba
Hyperbaric Oxygen
Vitamin B
Hearing Aids
Further w/u for pulsatile tinnitus
Acoustic Neuroma
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Benign neurolemmoma orschwannoma of the Eighth Cr. Nerve
Located in the internal acoustic canal
Usual presentation: Progressiveassymetric NSHL with poordiscrimination
Treatment: Observation, CyperKnife, Surgery
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Internal Acoustic Canal (IAC)
Acoustic Neuroma IAC
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Acoustic Neuroma IAC
MRI Coronal View
38 /
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38 yo c/ohearing loss
left ear 3moduration
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Same pt,8 monthslater
Acoustic NeuromaMRI Coronal View
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MRI Coronal View
Acoustic NeuromaAxial MRI
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Axial MRI
Idiopathic SuddenSensorineural Hearing Loss
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Sensorineural Hearing Loss Hearing loss
Sudden - no trauma history Rapidly progressive (
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Hearing LossWorkup - 90% no etiologyfound Complete audiogram CBC/platelets/ESR/RPR
MRI with gadolinium 1%-3% acoustic tumors
Management Urgent ENT referral Corticosteroids - proven
benefit. Oral vs. Perfusion Other therapies - controversial
Carbogen, Histamine,Heparin, Dextran
Prognosis - 2/3 recoverhearing Related to severity Improved if responsive to
steroids
Left AcousticNeuroma
Vertigo vs. Dizziness
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The hallucination of movementspinning sensation
Distinct symptom complex
Vertigo is not: light headedness,syncope, fainting, dysbalance
Central (brain) issues and
Cardiovascular issues frequentlyconfused with Inner Ear pathology
Objectives
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Differentiate the causes of vertigo Know the etiology of vertigo
Describe acute labyrinthitis
Describe Mnire's Disease
Describe Benign Positional Vertigo
Discuss the anatomy involved ininner ear pathology
Pattern of Presentation
http://www.google.com/url?sa=t&source=web&cd=1&sqi=2&ved=0CB4QFjAA&url=http://en.wikipedia.org/wiki/M%25C3%25A9ni%25C3%25A8re%27s_disease&ei=-2iRTNP9BdO6jAeViIHABQ&usg=AFQjCNH0yJQuax8zqTR_iuMkywoPgcI9Fg&sig2=L0o2q3IE0EI0NhXv7d9loghttp://www.google.com/url?sa=t&source=web&cd=1&sqi=2&ved=0CB4QFjAA&url=http://en.wikipedia.org/wiki/M%25C3%25A9ni%25C3%25A8re%27s_disease&ei=-2iRTNP9BdO6jAeViIHABQ&usg=AFQjCNH0yJQuax8zqTR_iuMkywoPgcI9Fg&sig2=L0o2q3IE0EI0NhXv7d9log -
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Duration of individual attack
Frequency
Effect of head movementsSpecific position inducing symptoms
Associated aural symptoms
Concomitant ear disease
Differential Diagnosis
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BPPV=benign paroxysmalpositional vertigo
VN=Vestibular neuronitis
Menieres
Diabetes
CPA tumor
Migraine
Otosclerosis
Hypothyroidism
Neuropathy
Pagets Disease ofthe skull (osteitisdeformans
Head trauma
Toxicvestibulopathy
Lipid abnormalities
Benign Positional Vertigo
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Transient Postitional
The most common type of vertigo in
older patients No associated nausea or vomiting
No associated hearing loss
Dix-Hallpike Maneuver: Nystagmus
BPV--continued
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Causes: Head trauma
Procedures
Medication eg. Gentamycin Pathophysiology: Otoconia (rocks)
from utricle displaced into the
posterior canal. Treatment: Responds to Physical
TherapyEpley maneuver
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Dix-Hallpike Maneuver for BPV
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Vestibular Neuronitis,
L b i thiti (VN)
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Labyrinthitis (VN)
Sudden onset severe vertigo incapacitating
Nausea and VomitingRecent or concurrent URI
Neurosensory hearing loss
commonSelf-limited
Labyrinthitis--continued
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Etiology---Viral infection inner earBacteria cause occasional
Treatment:
Antiemetics Corticosteroids: oral, IV, or perfusion of
the inner ear
Antivirals
Menieres Syndrome
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Histopathology
Clinical features
Causes
Refer!
Menieres Syndrome
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Idiopathic endolymphatic hydropsCharacterized by aHistory of increasing ear fullness
Roaring tinnitus followed by asensation of blocked hearing
Episodic with months or years symptomfree
Fluctuating Neurosensory Hearing Loss
REFER!
Menieres Syndrome
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Endolymphatic Hydrops: Increasedpressure in the inner ear
Possible causefailure of cellular
pump Symptoms caused by inability
membranous inner ear to swell
bony labyrinth Genetic propensity
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Management
Medical: Acute Prednisone 60 mg taper
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Medical: Acute- Prednisone 60 mg taper
over 10 daysChronic tx: Diuretic. Low salt, Low
caffeine diet
Allergic desensitization
Surgical (for intolerable vertigo) Trans tympanic Steroid Perfusion
Transtympanic Gentamicin Perfusion
Retrosigmoid vestibular nerve resection
Transmastoid endolymphatic sacprocedure
Transmastoid labyrinthectomy
Perilymph fistula
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PatternsVertigo episodes without hearing loss
Hearing loss without vertigoA Menieres syndrome pattern
Dysequilibrium without vertigo
Associated with barotrauma
Evaluation for Vertigo
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LaboratoryRadiographic studies
Vestibular function tests
Audiologic studies
Immunologic StudiesRefer
Electrocochleography (ECoG)
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ECOG is performed by placing an electrode thatconsists of a wire, into the ear canal as close aspossible to the cochlea.
The ear is then stimulated with alternating clicksof different polarities, or tone bursts.
These tone bursts are transformed intovibrations in the middle ear, your ear does thisnaturally and automatically all the time.
The vibrations are turned into electrical impulses
in the inner ear and are recorded and measuredusing computer software.
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Conclusion
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Accurate diagnosis
Suppression of nausea & vomiting
Preventive medical therapySurgery for failed medical therapy
Rehabilitative therapy
Ramsey-Hunt Syndrome
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Cause:Varicella-zoster virus (chicken pox)involving the VII facial nerve
Symptoms: Pain, Rash, Facial nerve palsy,Hearing loss
Treatment: Acyclovir
Steroids
Complications Permanent hearing loss
Permanent weakness of facial nerve
Eye damage
Post Herpetic Neuralgia
Ramsey-Hunt Syndrome
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Acute Facial Paralysis
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Facial paralysis workup CBC, ESR, Lyme titer Glucose tolerance test Audiogram CT/MRI - if atypical/recurrent
Diagnosis of exclusion Infectious
Zoster, Lyme, otitis media Neoplasm
Temporal bone, parotid
Systemic Sarcoid, diabetes,autoimmune
Etiology Herpes simplex virus Neural edema in bony
sheathAcute onset Rapid time course
No hearing loss or vertigo+/- Ear/facial painNormal examination Head and neck examination
Neurologic examination
Idiopathic (Bells) Palsy >50%
Bells Palsy
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y
Idiopathic (Bells) PalsyManagement
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Corticosteroids/acyclovir Decreases sequealae
Eye care - most important Educate patient
Ocular lubricants Exposure protection Early ophthalmology consultation
Prognosis - generally good 85% recover in 3 weeks