Assessment of Ear Disorders

25/1/2012

Dr.Wael Hasan

Special Lecturer / Clinical Tutor in Otorhinolaryngology

St.Vincents University Hospital
University College Dublin

Outline

Otitis Externa

Otitis Media

Petrositis

Hearing Loss Deafness

Pure Tone Audiogram

Ear Anatomy

External Ear
Pinna
Ear Canal
Lateral tympanic membrane

Middle Ear
Medial tympanic membrane
Ossicles

Malleus
Incus
Stapes

Eustachian tube
Oval Window

Inner Ear
Cochlea
Semicircular canals

Otitis Externa Swimmers Ear

An inflammation of the outer

ear and ear canal

Pathogenesis:
1. Inflammation with no infection
Atopic dermatitis
Seborrheic dermatitis
Psoriasis
2. Infection
Bacterial
Pseudomonas aeruginosa
Staphylococcus aureus
Fungal
Candida albicans
Aspergillus

Otitis Externa

Sings & Symptoms

Otalgia
Otorrhea
Hearing loss
Oedema
Tenderness

Otitis Externa

Classification
1. Acute
2. Chronic
3. Malignant

Diagnosis

Otoscopy

Management

Aural toilet (microsuction)

Culture swab
Topical Antibiotics
Topical Steroids
Ear Protection (Plugs)

Malignant Otitis Externa

Necrotizing Otitis Externa

Extension to bony canal and

Cartilage

Uncommon
Elderly
Diabetic
Immunocompromised

Hallmark Signs:
Severe pain interfering with sleep
and persist even after resolution
of ear canal oedema

Malignant Otitis Externa

Diagnosis

4.
1.

Clinical suspicion
Granulation or necrotic
tissue

2.

History
Follows otitis externa

3.

Serology
Normal in early stages

Imaging

CT
MRI
Gallium

Malignant Otitis Externa

Complications

Months (Oral)

Skull base osteomyelitis

Surgical debridement

Cranial nerves
Facial nerves
Vagus

Intracranial extension
Convulsions
Confusion
Fluctuating GCS

Management
Intravenous antibiotics

Necrotic tissue

Prevention
Early treatment of otitis
externa
Ear protection
Ear Dryness

Otitis Media

Inflammation or infection

Tympanic membrane to inner

ear

Pathogenesis
Bacterial

Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Moraxella catarrhalis

Viral

Respiratory syncytial virus

Fungal

Otitis Media

Signs & Symptoms

Nasal congection

Otalgia

Hearing Loss

Otorrhoea

Pathogenesis

URTI, Allergies or Eustachian

tube dysfunction

Middle ear air absorption

Middle ear negative pressure

Fluid accumulation in ME

Middle ear positive pressure

Otitis Media
1. Acute

Resistance and demarcation

lasting 38 days. Middle ear
discharge spontaneously,
reduced pain and fever

Viral self limiting

Bacterial

Stage 1:

Exudative inflammation lasting

12 days, fever, severe pain
and hearing loss

Stage 2:

Stage 3:
Healing phase lasting 24
weeks. Dry ears and restored
hearing

Otitis Media
2. Otitis Media with Effusion
Serous or Secretory

Nasopharyngeal obstruction
Otitic Barotrauma
Allergic Rhinitis

Can follows URTI or

bacterial otitis media

Symptoms
Hearing loss
Ear discomfort
Occasional tennitus

Signs
Middle ear effusion
Dull TM
Conductive hearing loss

Negative ear pressure

Fluid accumulate in the
middle ear
Can persists for months
Thickened
Glue ear
Conductive hearing Loss

Other causes of Glue Ear:

Otitis Media
3. Chronic Suppurative Otitis
Media (CSOM)
Two features
Tympanic membrane perforation
Active chronic bacterial Infection
Purulent discharge
Hearing loss
Late or inadequate treatment of
acute OM

4. Adhesive
Thin retracted TM sucked into the
middle ear
Stuck to the ossicles

Otitis Media

Management
Analgesia
Nasal decongestants
Systemic antibiotics
(penicillins)
Myringotomy tube (Grommet)
3 OME in 6 months
Or
4 OME in 1 year

Otitis Media

Complications

1.

Intratemporal
Hearing loss
Fluid in ME
Conductive
Developmental delay
Mastoiditis
(Emergencies in ENT Lecture)
Petrositis

Intracranial

2.

Meningitis

Abscesses

Venous sinus thrombosis

Otitis Media Petrositis

Infection and inflammation of the

apical portion of the petrous
temporal bone

The classical triad known as

Gradenigo's syndrome:
1. Otorrhoea

Close proximity of the:

Gasserian ganglion (of the Vth
cranial nerve)
The abducens (VIth cranial nerve)
nerve
The carotid artery

The dural venous sinuses

2. Trigeminal nerve involvement

1.
2.
3.

Deep retro-orbital pain

Facial pain
Headache

3. Abducens cranial nerve (VI)

palsy

leading to a lateral rectus palsy

Inability to look outwards with one eye
Diplopia

Otitis Media Petrositis

Management

Complications
Cranial nerve palsies

Conservative
Intravenous antibiotics

Surgical
Failure to respond
Intracranial extension
Mastoidectomy

Hearing loss (sensorineural

conductive)
Dural venous sinus
thrombosis
Carotid artery spasm,
occlusion, rupture or septic
emboli to the brain
Meningitis or intracranial
abscesses
Death

Hearing Loss Deafness

The ability to detect certain frequencies

of sound is completely or partially
impaired

Normal hearing thresholds are not

the same for all frequencies

If different frequencies of sound are

played at the same amplitude, some
will be perceived as loud, and others
quiet or even completely inaudible

This mechanisms extends from the

most outer part of the ear to the
nerves and tracts that convey the
nerve impulses of the auditory
centres in the brain

Types of Hearing Loss

1.

Conductive loss

2.

Defective function of the

cochlea or of the auditory
nerve, and prevents neural
impulses from being
transmitted to the auditory
cortex of the brain

Mechanical attenuation of sound

waves in the outer or middle ear,
preventing sound energy from
reaching the inner ear; the
cochlea
Hearing by bone conduction will
be normal in pure conductive
hearing loss

Ear Canal
TM
Ossicles

Sensorineural Loss (SNHL)

Mixed Hearing Loss

3.

A combination of
conductive and
sensorineural hearing loss in
the same ear

Pure Tone Audiogram

Measures hearing levels by Air

conduction and Bone conduction

The audiometer generates pure tone

signals ranging from 125Hz to
12000Hz

Ear phones for AC

Small vibrators applied to mastoid for

BC

The threshold of hearing at each

frequency is charted in the form of
audiogram, with hearing loss
expressed in dB

Conductive Hearing Loss

Left ear pure tone audiogram

Bone conduction preserved

Air conduction is impaired

Sensorineural Hearing Loss

Left ear pure tone audiogram

Both air conduction and bone

conduction are impaired
equally

Mixed Hearing Loss

Left ear pure tone audiogram

Bone conduction and air

conduction are both impaired
but with different levels of dB
loss

Sudden Onset SNHL

Definition:
SNHL 30 dB over 3
contiguous frequencies
within 3 days or less

Etiology :
1. Infectious
2. Traumatic

Mechanical, Acoustic

3. Autoimmune

RA, Sarcoidoses, SLE

4. Neurological
5. Vascular

Sudden Onset SNHL

Diagnosis

Pure tone audiogram

Cholesterol/triglycerides

FBC

T3, T4, TSH

ESR

PT, PTT

MRI (If Unilateral)

VDRL, RTA-ABS (MHA-TP)

Glucose

HIV

Lyme titer

Sudden Onset SNHL

Management

47 64 % spontaneous recovery

Therapy
Anti inflammatory
Anti viral

Treatment regimen is controversial

Diuretics

Calcium antagonists

Aimed at addressing the underlying

problem in each of these states
Decreasing cochlear inflammation
Improving inner ear blood flow
oxygenation
Re-establishing the endocochlear
potential

Vasodilatrors

Carbogen
5% Co2 with 95% O2

Practice in the UK

98.5% steroids alone or with

41% Carbogen
31% acyclovir
35% antihistamine

Assessment of Ear Disorders

25/1/2012

Dr.Wael Hasan

Special Lecturer / Clinical Tutor in Otorhinolaryngology

St.Vincents University Hospital
University College Dublin