6- AH Ear, Nose, Sinus PD Lec 2023.pptx

Dr. Ahmad Halimi DMSc, PA-C, CAQ-HM Email: [email protected] 1 2  Ear serves two purposes  HEARING  and EQUILIBRIUM Ear has 3 parts:  External ear – auricle and ear canal to tympanic membrane aka ear drum  Middle ear – air-filled, contains 3 ossicles  Inner ear – cochlea, ut...

Dr. Ahmad Halimi DMSc, PA-C, CAQ-HM Email: [email protected] 1 2  Ear serves two purposes  HEARING  and EQUILIBRIUM Ear has 3 parts:  External ear – auricle and ear canal to tympanic membrane aka ear drum  Middle ear – air-filled, contains 3 ossicles  Inner ear – cochlea, utricle, saccule and semicircular canals 3 4  Covered by cartilage  Firm, elastic  Components  Helix = Outer ridge  Antihelix  Lobule – inferior, fleshy  Tragus – nodular eminence points back over entrance to the canal  Antitragus  Concha = deepest 5  ~ 24mm long  Surrounded by cartilage  Skin is hairy and contains glands that produce cerumen  Inner portion surrounded by bone and lined by thin hairless skin  Tender to touch in this area  Tympanic membrane (ear drum) 6   Oblique membrane 2 chief landmarks are the handle and short process of the malleus  The ear drum meets the malleus at the umbo  From the umbo the “cone of light” fans downward and anteriorly  Pars flaccida  Lies above the short process of the malleus 7 Much of the middle ear and all of the inner ear are NOT accessible to Direct examination! 8  Air filled cavity containing 3 small bones, the ossicles  Malleus, incus, stapes  The ossicles articulate with each other transmitting sound waves from the TM to the fluid-filled cochlea  The malleus attaches to the TM & the stapes attaches to the oval window- the entrance to the cochlea Connected to the  9     Aka auditory tube Connects the tympanic cavity to the nasopharynx where it opens posterior to the inferior nasal meatus It is usually closed but opens by chewing or yawning Function  Equalize pressure in the middle ear with the atmospheric 1 The eustachian tube is opened by movement of the levator veli palatini and the tensor veli palatini. Because these are muscles of the soft palate, equalizing pressure (popping the eardrums) is commonly associated with activities such as yawning and swallowing 1  Deep within the temporal bone  Bony and Membranous labyrinth  Bony labyrinth contains:  Cochlea - hearing  Vestibular apparatus =  utricle, saccule &  Vital for 2 semicircular canals, functions: for balance  Hearing 1 1  Membranous labyrinth  Suspended within  bony Series labyrinth of communicating sacs and ducts Normal membranous labyrinth  Contains endolymph (~IC fluid composition)  Two  divisions Vestibular = utricle and saccule and semicircular ducts Dilated membranous labyrinth (hydrops) 1     Sound waves enter outer ear They reach the TM causing vibration of the ossicles Motion of the stapes against oval window sets up waves in the fluids of the cochlea which causes the basilar membrane to vibrate This stimulates sensory cells of the organ of     HEARING 3 fluid filled compartments  Upper  Scala vestibule  Middle  Scala media – cochlea duct  Lower  Scala tympani Fluid within cochlear duct = endolymph Fluid within scala vestibule and tympani Cross section of cochlea 1  Upper scala vestibule is sealed from middle ear by the oval window attached to stapes  Lower scala tympani sealed from middle ear by the round window  Helicotrema  Place where fluid from upper scala vestibule and lower 1  Thin vestibular membrane  Forms the ceiling of the cochlea duct and separates it from  Basilar membrane the scala vestibuli  Forms floor of cochlear duct & separates it from the scala tympani  Contains the Organ of Corti, the sense 1  The body’s “microphone”  Contains 3 rows of “hair cells” (~ 20,000)  Above the hair cells is the tectoral membrane  Responds to pressure variations in the fluid-filled tympanic and vestibular canals  Hair cells trigger an “action potential” down the associated nerve fiber – to the CN VIII to auditory areas of brain  Each hair cells has projections coming out of the cell that look like hairs  The hairs are actually called stereocilia  One larger stereocilia is called the kinocillium  Cilia are arranged short to tall  Movement of the 2  All have receptors that detect movement  Also contain hair cells  Respond to mechanical change triggered by movements of endolymph  Send impulses to the vestibular branch of CN VIII, 2  Info from hair cells goes to brain, cerebellum and CNs III, IV and VI  Info integrated from eyes, joints and muscles  Maintains balance and posture  Keeps eyes fixed despite head movement  Perceives motion 2  Superior, posterior and horizontal at Rt angles to one another  They occupy 3 planes of space  Each canal forms 2/3 of a circle and is 1.5mm diameter except at the ampulla where it is wider  Semicircular ducts lie within  Positioned and structured to sense  Detect rotational or angular acceleration of the head  Hair cells located in ampulla, a swelling at base of each canal  Hairs embedded in overlying cap-like gelatenous layer called the cupula  Acceleration or deceleration during movements of the head in any direction causes 2 2  Vibrations of sound pass through external ear and are transmitted through the eardrum and ossicles of the middle ear to the cochlea in the inner ear  The  cochlea senses and codes the vibrations the cochlea converts sound waves to electrical impulses  Nerve impulses go to the brain via the cochlea nerve  Conductive Phase  1st part of pathway – external ear thru middle ear  DEFECT HERE = CONDUCTIVE HEARING LOSS 2  Air conduction  1st phase of hearing path  Bone conduction  Bypasses external & middle ear  Used for testing  Vibrating tuning fork placed on the skull stimulates the cochlea directly In the normal person air conduction is more 2  How is your hearing?  Having any trouble with your ears?  Onset and duration of symptoms  Associated   symptoms Dizziness, nausea, tinnitus Two types hearing impairment  Conductive  Problem in external or middle ear  Sensorineural 2  Hearing loss  Vertigo  Otologic, neurologic, psychologic, iatrogenic (following dental or maxillofacial surgery)  Tinnitus  Otorrhea  Otalgia 2  How long are you aware of a hearing loss?  Was the loss sudden?  Is there a Family history (FH) of a hearing loss?  Occupational history  What type of work do you do? Past and present  What type of hobbies do you have?  Is your hearing better when it is noisy?  Medication history 3  Medications that effect hearing Aminoglycosides NSAIDs Quinine Furosamide (Lasix) Chemo (cyclophosphamide and cisplatinum) 3  Do you have any pain or discharge?  Associated  Otitis fever, ST, cough, URIs externa or otitis media  May be referred from mouth, neck or throat … (TMJ?)  Is your ear ringing? = tinnitus  Musical ringing or rushing noise or buzzing in the absence of environmental input  Often associated with conductive or sensorineural hearing loss  Unilateral Meniere’s or bilateral 3 LOCATION PULSATILE NON PULSATILE EXTERNAL EAR MIDDLE EAR Otitis externa Bullous myringitis, FB Cerumen, FB, TM perforation OM, Vasc abnormality, neoplasm, ETD Vascular anomalies Otosclerosis, SOM INNER EAR CNS Vascular anomalies, HTN Cochlear otosclerosis , Meniere’s, Labyrinthiti s, Barotrauma , Drug toxicity Syphilis, 3 Degenerative  Dizziness  Feeling of off balance, unsteady, pulled to one side  Are symptoms related to change in body position?  Room spinning = true vertigo 3  How long have you had this symptom?  Have you had repeated attacks?  How long do they last? (seconds/minutes/hours)  Is onset abrupt?  Are symptoms worsened by changes in position?  Is spinning sensation worse during attack?  Are there any positions that make you feel better?  Any double vision during the attack?  Loss of strength, decreased hearing, gait3             Hearing loss – Conductive vs Sensorineural Perforated ear drum Tympanosclerosis Otitis media – acute, serous Middle ear effusion Otitis externa, Cauliflower ear Bullous myringitis Cholesteatoma and Hemotypanum Carcinoma Meniere’s Disease Labyrinthitis Benign paroxysmal positional vertigo 3  CONDUCTIVE  External or middle ear disorder  Foreign body, otitis media, TM perforation, otosclerosis, cerumen impaction  SENSORINEURAL  Inner ear disorder Involves cochlear nerve & neuronal impulse to brain  Barotrauma, inner ear infection, trauma, tremors, congenital, familial, aging  3 CONDUCTIV SENSORINEU RAL E AGE Child, young adult Middle or later EAR DRUM Abnormal Problem not visible EFFECTS Better with noise Worse with noise WEBER Sound lateralized to impaired ear BC> AC Sound lateralizes to good ear AC>BC RINNE 3  Pinkish, pearly grey  Note handle and short process of malleus  Note cone of light  Tiny vessels along handle of malleus are normal  Usually result from infection of middle ear or trauma 3   Chalky white patch with irregular borders  Usually after viral URI or  Sudden change atmospheric pressure (flying or diving) Deposition hyaline follow severe infection   May  May see air-fluid level Serous fluid replaces air in middle ear – amber color 4     “swimmer’s ear” Acute or chronic Bacterial 90% (50% Pseudomonas), fungal 10% (usu chronic) Auricular motion pain, discharge, diminished hearing  Repeated trauma  Shears away cartilage, connection between skin and cartilage is disrupted  Liquid fills new space between and eventually hardens if not drained  Boxers, wrestlers, mixed martial arts 4   Viral (25%) or bacterial (75%) Symptoms   Pain, fever, hearing loss(conductive)   Painful hemorrhagic vesicles, bullae Signs  TM injected (red), loses landmarks, +/- bulging TM handbook.muh.ie/HE-ENT/ent/AOM_Children.html Viral or Mycoplasma pneumoniae  Symptoms  Earache, bloodtinged otorrhea, hearing loss Surgical procedure in which a tiny incision is created in TM to relieve pressure caused by excessive buildup of fluid, or pus from the middle ear. A myringotomy tube is inserted into the TM to keep the middle ear aerated for a prolonged time and to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks. Depending on the type, the tube is either naturally extruded in 6 to 124 4  Benign tumor of the middle ear  Often form with healing of perforated TM  Can destroy ossicles as they grow and cause deafness   Blood behind the eardrum  MC causes: therapeutic nasal packing for epistaxis, blood disorder, blunt head trauma, anticoagulation Symptoms  Hearing loss, recurrent otorrhea 4 Hemotympanum (mastoid ecchymosis) is an indication of fracture of middle cranial fossa of the skull, and may suggest underlying brain trauma. 4 4     Cancer of the ear is a rare cancer. Most of these cancers start in the skin of the outer ear. About 5 out of 100 skin cancers develop on the ear. Those that develop inside the ear are very rare. The most common type of ear cancer is basal cell cancer. Other types include Squamous cell cancer Melanoma 4   20% all primary melanomas are locate on the head and neck (14% on ear > L why?) Asymptomatic  Pearly, raised lesion with telangiectatic vessels  Slow growing, rarely metastasizes  More common in fairskinned people with sun exposure SCC: Exophytic, hyperkeratotic with central ulceration 5  Tophi uric acid crystals seen in gout  Lesions may discharge chalky white crystals thru the skin  Also seen joints, hands, feet…..   Deposit  Firm, nodular, hypertrophic mass of scar tissue May develop on any scarred area  After ear piercing 5  Disorder of inner ear  Endolymph  Etiology:  ?, vascular, viral, bacterial, autoimmune, genetic  Symptoms:  Severe vertigo  Tinnitus  Hearing loss  Feeling of fullness in ears  Can cause “Drop Fall due to otolithic crisis of Tumarkin. This is a very dangerous variant of Meniere's disease, which can result in abrupt falls. 5  Vestibular Neuritis  Viral infection of the vestibular nerve  Sxs: Vertigo, disequilibrium, imbalance, nausea  Labyrinthitis  Inflammation of vestibular nerve accompanied by hearing symptoms  Sxs: Vertigo, disequilibrium, imbalance, nausea  Causes: Infectious, autoimmune, vascular  Note: vestibular neurons are  VIRAL  Sudden, unilateral loss of vestibular function and hearing frequently assoc with n/v  URI precedes ~50% cases  Spontaneous nystagmus toward unaffected side  Vertigo can last weeks to months  Herpes zoster oticus = Ramsay-Hunt syndrome  BACTERIAL  Consequence of meningitis or otitis media  Invasion by bacteria or toxins  Profound hearing loss, severe vertigo, ataxia, and nausea and vomiting are common symptoms of bacterial labyrinthitis  AUTOIMMUNE  Bilateral, progresses slowly, local or systemic 5  Infection of the geniculate ganglion by human herpes virus 3 (varicellazoster virus)  Acute peripheral facial neuropathy  Associated with erythematous vesicular rash of the skin of the ear canal, auricle  +/- Tinnitus, deafness, vertigo, nystagmus, ataxia  Also termed herpes 5     MC cause vertigo in US  MC women and over age 50 Definition:  Abnormal sensation of motion that is elicited by certain critical provocative positions that often trigger nystagmus Cause  Free-floating “rocks”/particles in the semicircular canals or cupula of the inner ear Sudden onset, often upon awakening, lasts weeks/months/years.  Symptoms are intermittent and  positional positive 5 5  Upper 3rd of nose is supported by bone  Air enters nares, then into widened vestibule thru narrow nasal passage to nasopharynx  Vestibule is lined with hair-bearing skin, not mucosa 5  Turbinates  Covered by highly vascular mucous membrane  Below each turbinate is a groove (meatus)  Nasolacrimal duct drains into the inferior meatus  Most of the paranasal sinuses drain into the 5  Principal function of nasal cavities  Cleansing  Humidificatio n  Temperatu re control of inspired air 6  Inspection of nasal cavity is limited to  The vestibule  The anterior portion of the septum  Lower and middle turbinates 6  Air-filled cavities within bones of the face  Maxillary  Ethmoid approximately 6-12 small sinuses per side, located between the eyes  Frontal  Sphenoid  behind the ethmoid sinuses,  6 6 6 6  Obstruction  Unilateral or bilateral? How long? Any allergies?  Are symptoms worse with stress? Hx polyps?  Discharge  Unilateral or bilateral, thin & watery, thick and purulent, bloody, foul smelling (think FB!)  Bleeding (epistaxis)  Usually traumatic or spontaneous to rupture superficial vessels in Kiesselbach’s plexus (Little’s area) 6  Rhinorrhea = drainage from nose  Allergy,  viral, vasomotor, FB, tumor Rhinitis = nasal congestion  Excessive use of decongestants can worsen symptoms  RHINITIS MEDICAMENTOSA  Other drugs  Contraceptives, reserpine, quanethidine, alcohol  Septal hematoma Epistaxis  Trauma, dryness, FB, tumor, inflammation  Bleeding disorder  Sinusitis 6  Equipment  Otoscope, tongue blade, cotton tip applicator, gloves (ask about latex allergy)  Ears  Inspection, palpation, otoscopy, auditory acuity  Special tests: Weber and Rinne  Nose  Inspect,  palpation, rhinoscopy Sinus  Inspect, palpation, transillumination 6  Inspection Auricle for redness, lesions  Ear canal o Discharge, foreign bodies, redness, swelling  Tympanic membrane o Color, contour, landmarks   http://lessons4medicos.blogs pot.com/2008/07/inflammatio n-of-ear-canal.html Palpation  Auricle for lumps, tenderness 6  To straighten the ear canal, grasp the auricle firmly but gently and pull it upward, backward, and slightly away from the head  Brace your hand against the patient’s face  Insert the speculum gently into the ear canal  Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or 7     Inspect the eardrum Note its color and contour Note the cone of light Note bony landmarks  Handle  and Short process of malleus Mobility of ear drum can be shown with   Auditory acuity  Test one ear at a time  Whisper test, standing 1-2 feet behind patient, softly say “nine-four,” “baseball” Air and bone conduction  Weber o  Lateralization of sound to impaired ear; suspect unilateral conductive hearing loss Rinne o Compare time of air vs. bone conduction 7  Place vibrating fork firmly on top of patient’s head  Ask patient where they hear the sound  In midline, one or both sides  Note:  Patient’s with normal hearing may lateralize; thus, only use this test with abnormal 7    Place vibrating tuning fork over mastoid When sound no longer heard place “U” of tuning fork over ear canal Normal: sound through air is longer than through bone  AC> BC 7  Conductive loss  Sound lateralizes to affected “impaired” ear  BC>AC in affected ear   Air conduction impaired but vibrations thru bone bypass problem in outer or middle ear and reach cochlea Sensorineural loss  Sound lateralizes to unaffected “good” ear  AC>BC  Inner ear transmits impulses 7  Example 1  Rinne R ear: AC>BC (positive)  Rinne L ear: BC>AC (negative)  Weber: lateralization to the left  ear DX Conductive loss : LEFT  Example 2  Rinne R ear: AC> BC (positive)  Rinne L ear: AC>BC (positive)  lateralization toloss right  Weber: DX Sensorineural ear : LEFT 7  https://youtu.be/kNLBAuOQl hc 7  Inspection External: Anterior and inferior surface – asymmetry or deformity  Internal: Inside of nose o Mucosa – color, swelling, bleeding, discharge, exudate, ulcers, or polyps, odor o Septum – deviation, inflammation, or perforation o Turbinates – use otoscope to view middle and inferior turbinates (rhinoscopy)   Palpation  7 “ALLERGIC SHINERS”  Discoloration under the eyes seen with allergic conjunctivitis  “ALLERGIC SALUTE” Patients with allergic shiners frequently push the tip of their nose up with the back of their hand  Leads to formation of transverse nasal crease 7    Prominent hypertrophy of the sebaceous glands with overgrowth of soft tissue > men     “ adult acne” Papules, pustules and erythema of face Cause unknown Can advance to rhinophyma Worse with sunlight,hot drinks, spicy food, alcohol 8  Common, chronic skin disease. It often begins with a tendency to blush or flush more easily than other people. Three times more common in women.  The redness can slowly spread beyond the nose and cheeks to the forehead and chin. Even the ears, chest, and back can be red all the time.  Rosacea has four subtypes:  Erythematotelangiectatic rosacea: Redness, flushing, visible blood vessels.  Papulopustular rosacea: Redness, swelling, and acne-like breakouts.  Phymatous rosacea: Skin thickens and has a bumpy texture.  Ocular rosacea: Eyes red and irritated, eyelids can be swollen, and person may have what looks like a sty.   Dx on PE- naso-labial sparing (as opposed to lupus) Tx- Topical doxycycline………….Laser treatment 8  Tilt the patient’s head back  Insert the speculum gently into the vestibule of each nostril  avoiding contact with the sensitive nasal septum  Direct the speculum posteriorly, then upward & note:  inferior and middle turbinates  nasal septum  narrow nasal passage between them 8  Don’t forget to inspect for swelling, erythema or deformities  Palpate for tenderness on frontal and maxillary sinuses  Transilluminate frontal and maxillary sinus 8  Ears:  External ear without evidence of inflammation or lesions. Hearing is intact to whispered voice. WEBER is midline, AC>BC. External canals are patent. They are not swollen, crusted or injected. Tympanic membranes are intact, pearly grey and not injected with good cone of light.  Nose:  No deformity or swelling. No tenderness. Nasal mucosa pink without swelling. Septum midline, no discharge.  Sinuses:  Non tender, transillumination intact frontal and maxillary  8  65 yr old male with HX DMII and erythema , swelling and Discharge to external R ear  7 year old child with fever, ST , and worsening L ear pain for 2 days  84 year old with R sided hearing loss for 3 weeks. What could her weber and rinne test show? 36 year old female with dizziness 8  8