Ophthalmology and Otology Overview

Amblyopia (Crossing of the Eyes)

• Patients may complain of blind spots in their vision - negative scotomas
• May present with a decreased red reflex, pale optic disc with cupping that occurs due to thinning of the neuroretinal rim
• Patients generally have normal visual acuity until later in the course of the disease

Diabetic Retinopathy (DR)

• Presents with flame hemorrhages and soft exudates
• Retinal ischemia occurs, leading to microaneurysms that can develop and rupture
• Optic disc edema may be present (indistinct disc margins), with the optic disc appearing several times larger
• If left uncontrolled, a patient should seek an ophthalmologist

Otitis Media- Temporary Conductive Hearing Loss

• Most common cause is otitis media (pus and fluid can cause temporary conductive hearing loss)
• Other causes include a bacterial cause of meningitis and cytomegalovirus (CMV) infection that can become intrauterine, leading to deafness in an infant
• Otosclerosis is the most common inherited cause of conductive hearing loss (ossicle change)

Meniere's Disease

• Hearing loss, tinnitus, and vertigo are the hallmark symptoms

Noise

• Destroys cochlea hair cells (sensorineural loss)

Medications

• Aspirin toxicity, chemotherapy, and IV antibiotics can cause hearing loss

Other

• Severe cerebral palsy, tumors, and trauma to the head can also contribute to hearing loss

Tinnitus

• Perception of sound in the absence of a stimulus
• Can present as a ringing, tingling, intermittent, or continuous sound
• Etiology includes aspirin (ASA) toxicity, noise, trauma, and infection
• Other conditions include otosclerosis, hypothyroidism, Meniere's disease, cholesteatoma, and acoustic neuroma

Vertigo

• Sensation of moving around in space (subjective) or having objects move around the patient
• Bilateral vertigo points toward a peripheral cause while central vertigo points toward a CNS disease
• Etiology includes viral upper respiratory infection (URI), otitis media, medications, Meniere's disease, otosclerosis, and tumors

Inner Ear Disorders (Sensorineural)

• Meniere's disease is idiopathic endolymphatic hypertension (sensorineural)
• Meniere's syndrome is caused by conditions interfering with endolymph production or resorption, such as thyroid disease, autoimmune conditions like rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), syphilis, medications, trauma, and electrolyte imbalance

Meniere's Disease

• Onset is typically between 20 and 40 years of age and there is a familial predisposition
• Symptoms include sudden onset, severe vertigo that causes nausea (N/V) for several hours, isolated attacks that recur, progressive hearing loss (usually unilateral, 10-15% is bilateral), constant or intermittent tinnitus, and endolymphatic hypertension

Pathophysiology of Meniere's Disease

• The bony labyrinths are filled with perilymph, which contains the scala vestibuli and scala tympani
• The scala media is the membranous labyrinth that is filled with endolymph
• Perilymph is rich in sodium (Na+) while endolymph is rich in potassium (K+)
• The membrane separating these fluids can rupture, causing them to mix, leading to hearing loss and symptoms
• A blockage of depolarization in the vestibular nerve receptors leads to the sensation of vertigo
• Mechanical distortion of the organ of Corti can also occur due to hypertension/increased pressure, causing hearing loss and tinnitus

Hearing Loss in Meniere's Disease

• Hearing loss progresses and is usually unilateral
• 10-15% of cases are bilateral
• Low frequency sounds are lost first because the apex of the cochlea is more sensitive to increased pressure

Diagnostics for Meniere's Disease

• Weber test: sound lateralizes to the good ear (unaffected)
• Rinne test: AC > BC
• Neuro exam: Romberg test to check for balance (truncal stability), proprioception, and if a patient will sway or stand straight
• Diagnostic criteria:
  • ≥ 2 episodes of vertigo lasting 20 minutes to 12 hours
  • Documented low to mid frequency sensorineural hearing loss in the affected ear
  • Fluctuating symptoms
  • Symptoms not better explained by another vestibular illness
• Labs: thyroid studies, electrolytes, and glucose (CBC, ESR, ANA, fluorescent treponemal antibodies)
• Imaging: MRI of the brain to rule out a brain tumor or acoustic neuroma if central vertigo is suspected

Vestibular Neuronitis

• Inflammation of the vestibular division of cranial nerve VIII, usually viral
• Most common in those between 30 and 40 years of age
• Presents with abrupt onset of debilitating vertigo with a unidirectional horizontal nystagmus
• First attack is often the most severe, typically lasting for 7-10 days
• Can be accompanied by bad peripheral nystagmus
• Several more attacks over 12-18 months, which are less severe and shorter in duration
• No hearing loss or tinnitus

Vestibular Migraine

• The most common cause of recurrent vertigo
• 40-60% of patients with vestibular migraine experience a headache
• Other symptoms include sensitivity to light, noise, motion, and balance issues
• Can be treated with preventative medications or abortive medications

Viral Otitis Media

• Most common in children 6 months to 3 years old
• Can also occur in adults, but incidence is lower
• Most common cause of temporary conductive hearing loss (pus & fluid can also cause this)
• Causes: bacteria, viruses, and allergies
• Can be prevented with proper hygiene and vaccination
• Can be treated with antibiotics

Otitis Media with Effusion (OME)

• Serous effusion of the middle ear (not pus)
• Caused by allergies, enlarged adenoids, and eustachian tube obstructions
• Leads to hearing loss
• No antibiotics or antibiotic prophylaxis
• Tympanometry is used to determine if the middle ear space is filled with fluid

Bullous Myringitis

• A sudden onset of severe pain
• Vesicles can be seen on the TM
• Causes: viral or bacterial

Chronic Otitis Media

• Recurrent or persistent infections
• Usually associated with hearing loss
• The TM becomes scarred, or there is serous fluid buildup in the middle ear
• There may or may not be pain
• Commonly leads to perforation of the TM
• May need tympanoplasty or tubes

This quiz covers crucial topics in ophthalmology and otology, including amblyopia, diabetic retinopathy, and causes of temporary conductive hearing loss. Test your knowledge on visual and auditory disorders, their presentations, and implications for treatment.