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Clinical discussion Ear

A 16 year old male came to ENT

Department with complaints of earache


of 2 days which subsided after ear
discharge

of

one

day

which

was

pulsatile in nature on examination with

Day 1

sounds of air or water bubble cracking


in the ear during the entire period.
There was a sense of fullness of ear
with decreased hearing. There were no
history of previous episodes in the past.

Day 2

A 4 year old child was bought to


ENT Department with complaints
of swelling behind the ear with
earache

of

days

and

ear

discharge of one day with high


grade

fever

and

altered

sensorium. There was previous


history of scanty, foul smelling,
blood stained ear discharge in the
past.

A 60 year old female came


to ENT Department with
complaints

of

decreased

hearing with episodes of


ringing sensation in the ear
with spinning sensation of
head. The ear drum was
clear on examination with
positive fistula sign.

Earache
Discharge
Ringing sensation - Tinnitus
Hard of hearing - Deafness
Spinning sensation of head - Vertigo

Onset Sudden / Gradual


Duration Acute / sub acute / chronic
Progress
Resolution

External ear

Ear ache

Pinna Trauma, Perichondritis


EAC Wax, FB, Trauma,
Furuncle, Otitis externa, Herpetic, Otomycosis

Middle ear
Painless
Painful Acute (SOM, ASOM & Mastoiditis / Abscess)
& Barotrauma

Inner ear
Painless

Temporal bone
Trauma

Ear ache
Referred otalgia
Arthritis of TM Joint
Sinusitis & ET obstruction
CA Tongue
Tonsillitis
Carious molar tooth

Referred otalgia
Ear
ache
Auriculotemporal nerve (5th CN br)

Dental
Lingual of tongue
TM joint
Floor of mouth

Greater auricular nv & Facial nv


C spine lesions & Neck lesions
Herpes (Inflammatory)

Glossopharygeal Nv
Tonsillar
Base of tongue
Nasopharyngeal

Vagus Nv
Pharyngeal & Laryngeal lesions

External ear - copious


Serous / Serosanguinous

Ear
discharge

Traumatic / Otitis externa

Middle ear

Copious, non foul smelling

Mucoid - SOM, CSOM tubotympanic


Mucoid blood stained - trauma of middle & inner ear / temporal
bone without infn

Copious, foul smelling


Mucopurulent - CSOM - tubotympanic with acute infn.
Mucopurulent blood stained - ASOM, CSOM with retraction pocket,
trauma of middle & inner ear / temporal bone with infn

Middle ear & Mastoid

Ear
discharge

Scanty, foul smelling


Mucopurulent blood stained - CSOM -

atticoantral with retraction pocket

Purulent, Copious, foul smelling


Mastoid abscess
Intracranial/ Intratemporal / Extra temporal

complications of mastoid bone

Reservoir sign

Inner ear & temporal bone


Trauma
copious,
Serous / serosanguinous
Mucoid / Mucopurulent /
purulent
non foul smelling / foul
smelling

Ear
discharge

Deafness
Congenital
Maldevelopment of cochlea / retrocochlear
- SNHL
Ossicular chain defects

Acquired

Appreciated by the patient

Deafnes
s

SNHL

Appreciated by patients
Attendants
CDHL / Mixed -CSOM

Fluctuating
SOM / ASOM

Hears in noisy surroundings well


Otosclerosis (Paracusis willisi)

Deafness
Irritated by loud sounds with deafness to normal sounds
SNHL with recruitment

Acoustic trauma permanent / temporary


CDHL / Mixed

Ototoxicity
Drugs
Viral diseases
Pregnancy

Sudden / Gradual
Trauma
Vascular causes

Hard of hearing

Deafness

Term used when hearing is correctable

Deaf
When no residual hearing is present &
hearing is non correctable

Hyperacusis
Increased sound sensitivity
Congenital syphilis(Henneberts sign)
Stapedius muscle paralysis

External Ear
wax
Foreign bodies

Middle ear
SOM / ASOM / CSOM

Inner Ear
Menieres disease
Acoustic neuroma

Referred causes
Vascular
TM Joint

Tinnitus Ringing
sensation

Fluctuating

Tinnitus Ringing
sensation

SOM / ASOM
Drug over dosage salicylates
Menieres disease

Pulsatile
Glomus jugulare / vascular AV shunts

Continuous
SNHL
Acoustic trauma
Vascular

Central
Vertebro basilar insufficiency

Peripheral
Labyrinthitis
Vestibular neuronitis
Menieres disease
Acoustic neuroma

Positional
BPPV
Cervical spondylosis
Ocular

Syncopal

Vertigo

Central

Vertigo & Nystagmus

Vertebro basilar insufficiency Vertical nystagmus,


no latency

Peripheral Horizontal nystagmus, 10 to 20 second of


latency

Labyrinthitis
Vestibular neuronitis
Menieres disease
Acoustic neuroma

Positional only certain movements cause vertigo


BPPV
Cervical sponylosis

V Vascular (stroke, Migraine, anaemia,Menieres)


E - Epilepsy
R - tReatment / dRugs
T Tumor

(Ear- acoustic neuroma, brain / Cp angle)

T Trauma(Labyrinth, brain stem)

I Infections(Labyrinthitis, neuronitis bacterial, viral,


spirochaetal)

I - Imbalance
G Glial diseases
O Ocular diseases

PINNA

Perichondritis

Vestibulitis

Herpes

ASOM

CSOM

Foreign body In EAR

Foreign body ear removal instruments

Methods of removal

Facial nerve
Intracra
nial

1st
genu
2nd
genu

Intratempor
al

Extracra

Intracranial

Intratemporal

Extracranial

Facial nerve secreto motor pathway


1
2
3

4
5

Motor examination of facial nerve

Bells palsy

IMPROPER CLOSURE OF MOUTH


Inability to close the eye
Loss of naso labial angle

Diagnostic tests of facial


nerve
Schirmers test
Acoustic reflex
Electro diagnostic tests

Clinical History
Etio pathogenesis
Clinical features
Management
Investigations
Biochemical
radiological

Medical treatment
Surgical treatment

Method of examination
Pinna
Adult: Backwards & Upwards
Child: Forwards / Outwards &

Downwards

EAC
Congested / edematous
Filled with cheesy debris /

secretions
polypoidal

Method of examination
Tympanic membrane
Greyish white translucent, Cone of light seen, Pars tensa,
Pars flaccida
Pars tensa 4 quadrants

Method of examination
Tympanic membrane
Color changes
Pearly white normal
congested ASOM
Dull SOM
Blue Haemotympanum
Flamingo pink reflex
Otosclerosis - SCHWARTZ
SIGN

Method of
examination
Tympanic membrane
Position
Bulged Acute
Suppurative or non
suppurative OM
Retracted Adhesive
OM /SOM / Barotrauma

Method of examination
Tympanic membrane
Integrity - Intact
Perforated
Central /
tubotympanic /
safe(pars tensa)
Attic/ Unsafe(pars
flaccida with or without
retraction pocket)
Marginal / unsafe (Bony
Annulus absent)

Inspection
Pre auricular
Congenital Preauricular Sinus
Fistula Coloaural fistula

Methods of
examination of ear

Auricle shape
Congenital Atresia

Microtia & Macrotia

Bat ear - Antehelix more


prominent
Acquired
Inflammatory - Perichondritis of pinna
Traumatic

post auricular
Sinus & Fistula of mastoid bone - Mastoid
Abscess

Methods of examination of
ear

Palpation
Tragal

tenderness
Mastoid
tenderness
Fistula test

Methods of examination of
ear

Otoscopy

ET
Patency

Valsalva manouvre
Seiglisation
Politzerization
ET Cathetrization

Methods of examination of
ear

Otoscopy with
seiglisation

TFT
Principle
Frequency
Assessment of hearing type
Rinnes
Webers
ABC

Rinnes
Principle
AC compared with BC

Frequency
256, 512 & 1024

Assessment of hearing type


To quantify HL as mild, moderate &
severe
Cannot distinguish CDHL & SNHL

Weber
Principle
BC of both ears
compared

Frequency
Usually 512
256 & 1024 can be
used

Assessment of hearing
type
To distinguish CDHL,
SNHL and ossicular
fixation

ABC
Principle
Compare hearing of pt
with examiner

Frequency
Usually 512
256 & 1024 can be used

Assessment of hearing
type
Normal or defective
hearing can be assessed

EUM
Important for the
type of disease
In children most
important
Prefer to perform
under GA in children
Examination of
middle ear cleft

Posterior rhinoscopy & IDL

Posterior rhinoscopy & IDL

Posterior rhinoscopy & IDL

Diagnostic nasal endoscopy

Nystagmus eye
movements
Caloric test
Hot
Cold
Bithermal

Vestibular
system
examination

Fistula test
Rotation test
Optokinetic test

Vestibular
system
examination

Vestibular
system
Electronystagmograph examination
y

Vestibular system examination


Cerebellar fn
tests
Romberg test
Finger nose test
Past pointing

Cochlea

Auditory pathway

Pure Tone
Audiometry

Audiomet
ry

Audiomet
ry

Pure Tone
Audiometry

Conducti
ve

Sensorineural hearing
loss

Mixed

Audiomet
ry

Impedance
Audiometry

Mixed

X Ray Mastoid

Schullers view Most common

X Ray Mastoid

Laws view 2nd Most common

X Ray Mastoid

X Ray Mastoid

Townes view

CT & MRI In Menieres disease & Acoustic neuroma

Biochemical investigations

Haematological Hb%, TLC, DLC


RFT Bl.Urea, Sr. Creatinine
Sr.Electrolytes Na+, K+, Cl-,
Coagulation Profile BT, CT, PT,
APTT, INR
RBS

Culture and Sensitivity of the ear


discharge

Medical Management - ASOM


Diagnosed by URTI & Ac. Pain before discharge of
short duration
PTA CDHL , Impedance flat curve
Steam inhalation to the nose
Do not blow the nose
Valsalva after 2 days
Culture and sensitivity of the ear discharge once
appears
Aural toilet
avoid ear drops

Medical Management - ASOM


Antibiotics broad spectrum - penicillins amoxycillin
macrolides azithromycin
Cephalosporins - Cefpodoxime or cefuroxime axetil
Analgesics
Antihistamines - 2nd generation cetirizine,
levocetirizine
Antacids - PPI for gastric irritation as side effects
Decongestant nose drops oxymetazoline /
xylometazoline

Aural Toilet
Prefer to do under
microscope
Mopping
Dry
Wet

Suction & clearance


Syringing & irrigation
(Higgison syringe)

Medical Management CSOM safe type


Culture and sensitivity of the ear discharge
Aural toilet
Antibiotics broad spectrum penicillins amoxycillin
macrolides azithromycin
Cephalosporins - Cefpodoxime or cefuroxime
axetil

Medical Management - CSOM

Symptomatic management
Analgesics
Antihistamines - 2nd generation cetirizine,
levocetirizine
Antacids - PPI for gastric irritation as side effects
Broad spectrum antibiotic ear drops
Or
Broad spectrum antibiotic, antifungal, anesthetic
ear drops

Surgical management
Approach
Incision
complications

Myringotomy
I&D
Tympanoplasty
Mastoidectomy

Perichondritis of pinna
I&D
repeatedly
Window
surgery

SOM / ASOM
Myringotomy with or without grommet insertion

Pre requisites of myringoplasty

Dry ear 6 weeks


ET patent
Adequate cochlear reserve
No foci of infn elsewhere in nose
/pharynx

Types of grafts

TEMPORALIS FASCIA
Tragal perichondrium
Venous grafts
Cartilage graft
Autograft
Homograft
Allograft

CSOM Tubotympanic approach

CSOM Tubotympanic graft placement

Instruments ear surgery

Mastoid surgery
Cortical
MRM
Canal wall up
Canal wall down

Fracture skull base & temporal bone

Fracture temporal bone

Transvers
e

Longitudi
nal

A 16 year old male came to ENT

Department with complaints of earache


of 2 days which subsided after ear
discharge

of

one

day

which

was

pulsatile in nature on examination with

Day 1

sounds of air or water bubble cracking


in the ear during the entire period.
There was a sense of fullness of ear
with decreased hearing. There were no
history of previous episodes in the past.

Day 2

A 4 year old child was bought to


ENT Department with complaints
of swelling behind the ear with
earache

of

days

and

ear

discharge of one day with high


grade

fever

and

altered

sensorium. There was previous


history of scanty, foul smelling,
blood stained ear discharge in the
past.

A 60 year old female came


to ENT Department with
complaints

of

decreased

hearing with episodes of


ringing sensation in the ear
with spinning sensation of
head. The ear drum was
clear on examination with
positive fistula sign.

THAN Q