ENT First Part The Ear PDF

Page | 1 SECTION 1 PART 1 Chapter 1 Chapter2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 History taking & clinical examination of ear Diagnostic audiology The painful ear The discharging ear The deaf ear Vertigo Trauma to the ear Complications of otitis media Facial Nerve paralysis...

Page | 1 SECTION 1 PART 1 Chapter 1 Chapter2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 History taking & clinical examination of ear Diagnostic audiology The painful ear The discharging ear The deaf ear Vertigo Trauma to the ear Complications of otitis media Facial Nerve paralysis PAGE 15 24 42 50 68 75 80 87 Page | 2 THE EAR INTRODUCTION ❖ I. A- THE EXTERNAL EAR B- THE MIDDLE EAR C- THE INNER EAR 1- Auricle. THE NORMAL EAR ANATOMY OF THE EAR: 2- External auditory canal. Communicates with→ 1- Eustachian tube. 1- Bony labyrinth. 3- Tympanic membrane. 2- Mastoid air cells. 2- Membranous labyrinth. 3- Labyrinthine sensory end-organs. A. ANATOMY OF THE EXTERNAL EAR PARTS 1- The auricle. 2- The external auditory canal. 3- The tympanic membrane. 1. The Auricle (The Pinna) The auricle is attached to the side of the head. Its lateral surface has a series of ridges and depressions. It is formed of a single plate of fibro elastic cartilage, except the small lower part called the lobule which consists of fat. The covering skin is tightly adherent to the underlying perichondrium. 2. The External Auditory Canal (The external auditory meatus). It extends from the auricle to the tympanic membrane. It is about 24 mm. Its lateral 1/3 (8 mm) Its medial 2/3 (16 mm) is directed upwards, backwards and medially. is directed downwards, forwards and medially. is cartilaginous & is continuous with cartilage is bony & is continuous with bony walls of of the auricle. the middle ear. Lining skin is thick and contains hairs with Lining skin is thin and contains no hairs nor sebaceous and ceruminous (modified sweat) glands. glands which secrete cerumen (ear wax ). The whole canal skin  is tightly adherent to the underlying perichondrium and periosteum Page | 3 THE EAR INTRODUCTION 3. The Tympanic Membrane (The eardrum) The eardrum lies at the medial end of the external auditory canal at an angle of 55 with the floor of the external auditory canal. It separates the external auditory canal from the middle ear. It is oval in shape (about 10 x 8 mm), thin (about 0.1 mm), semi-transparent and pearly gray. It is Concave laterally. i.e. towards the external auditory canal. It is divided to two unequal parts: a) A major part called pars tensa. It is surrounded by a fibrous ring called the tympanic annulus. b) A small uppermost part called pars flaccida or Shrapnell’s membrane. - The two parts are separated by two folds the anterior and posterior malleolar folds. - The tympanic membrane consists of three layers  lateral epithelial (skin), middle fibrous and medial mucosal. 1. The lateral skin layer  is continuous with the skin lining of the external canal. 2. The medial mucosal layer  is continuous with the mucosal lining of the middle ear. 3. The middle fibrous layer  is well formed in pars tensa (therefore, it is tense) and is poorly formed in pars flaccida (therefore, it is flaccid). The handle of malleus (one of the ossicles) is embedded in this layer. Page | 4 THE EAR INTRODUCTION B. ANATOMY OF THE MIDDLE EAR (The tympanic cavity) The middle ear lies within the temporal bone between the external auditory canal and the inner ear. It is a six-walled cavity which has the shape of a bi-concave lens. All walls are bony, except the tympanic membrane. The Lining mucosa: Lined by mucous membrane with ciliated columnar epithelium except the postero -superior part which is lined by flattened squamous epithelium. COMPARTMENTS OF THE MIDDLE EAR: 1. Meso-tympanum Lies opposite the tympanic membrane. 2. Epi-tympanum (attic) Lies above the tympanic membrane. 3. Hypo-tympanum Lies below the tympanic membrane. CONTENTS OF THE MIDDLE EAR: 1. Filled with air. 2. Three small bones (called ossicles) Malleus, incus and stapes. 3. Two muscles; Tensor tympani muscle supplied by (the trigeminal nerve) a stapedius muscle (supplied by the facial nerve). 4. One nerve Chorda tympani nerve. WALLS OF THE MIDDLE EAR: 1. Lateral wall: Separates the middle ear from  the external auditory canal. Formed by  the tympanic membrane (mainly), with small bone above and below the tympanic membrane. Page | 5 THE EAR INTRODUCTION 2. Medial wall: o Separates the middle ear from  the inner ear. o Formed by  the inner ear. o Shows the following features: a) The promontory  a central rounded bulge which is produced by the first (basal) turn of the bony cochlea (of the inner ear). b) Two openings  which connect the middle ear (functionally) with the inner ear. I. The oval window: ▪ lies above and behind the promontory. ▪ It is closed by the footplate of stapes. II. The round window: ▪ lies below and behind the promontory. ▪ It is closed by the tympanic membrane. c) The horizontal part of the facial nerve  runs in a bony canal above the promontory and the oval window. 3. Superior wall: Separates the middle ear from the temporal lobe in the middle cranial fossa. Formed by a thin bony plate, called the tegmen tympani. 4. Inferior wall: o Separates the middle ear from  the bulb of internal jugular vein. o Formed by  a thin bony plate. 5. Anterior wall: Separates the middle ear from  the internal carotid artery. Has an opening  for the eustachian tube. The tensor tympani muscle  enters the middle ear through this wall. 6. Posterior wall: o Separates the middle ear from  the mastoid process. o Has an opening (called the aditus ad antrum) which connects the attic (epi-tympanum) with the mastoid antrum. o The stapedius muscle  enters the middle ear through this wall. o The vertical part of the facial nerve  runs in a bony canal in this wall. Page | 6 THE EAR INTRODUCTION COMMUNICATIONS OF THE MIDDLE EAR: 1. Anteriorly With the naso pharynx. How? Through the Eustachian tube. 2. Posteriorly With the mastoid air cells. How? Through the aditus ad antrum. The triad of the middle ear, the eustachian tube and the mastoid air cells forms  the middle ear cleft. 1. The Eustachian Tube (ET) - - - The ET connects the middle ear with the nasopharynx. Length  about 36 mm. Its lateral 1/3  is bony Its medial 2/3  is cartilaginous Directed  downwards, forwards and medially, from the anterior wall of the middle ear to the lateral wall of the nasopharynx. In children  the tube is shorter, wider and more horizontal than in adults. It is closed at rest (protective). It opens only during swallowing and yawning. How? It is opened by contraction of the tensor palati muscle. Why? It opens to allow inflow of air into the middle ear. Lining mucosa: Lined by mucous membrane with pseudo-stratified ciliated columnar epithelium. 2. - The Mastoid Air Cells The mastoid air cells are small air-filled bony cavities which lie within the mastoid process of the temporal bone. These Bony cavities are separated by thin bony septa. The mastoid process is pyramidal in shape, with its tip directed downwards. The first and largest air cell  is called the mastoid antrum. It lies immediately behind the attic and communicates with it through a small opening called the aditus ad antrum. Lining mucosa Lined by mucous membrane with flattened squamous epithelium. Page | 7 THE EAR INTRODUCTION C. ANATOMY OF THE INNER EAR It is also called The labyrinth because it has a complex convoluted shape. PARTS: 1) The bony labyrinth. 3) The labyrinthine sensory end organs. 2) The membranous labyrinth. 1) The Bony Labyrinth It lies within the temporal bone between the middle ear and the internal auditory canal. It is a hollow bony capsule. Which consists of compact bone. The bony labyrinth is the hardest bone in the body. The oval window & the round window open in this capsule. It consists of: 1- Bony cochlea A coiled canal that resembles a snail’s shell. It has 2.5 turns. 2- Three bony semi-circular canals (lateral, superior and posterior) Each canal forms 2/3 of a circle. They are perpendicular to each other. 3- Vestibule Between the cochlea and the semi-circular canals. 2) The Membranous Labyrinth o It is a series of delicate ducts and sacs. which lies within the bony labyrinth. o It consists of: 1- Membranous cochlear duct Within the bony cochlea. 2- Membranous semi-circular ducts Within the bony semi-circular canals. 3- Utricle & Saccule Within the vestibule. 4- Endolymphatic duct & sac. The membranous labyrinth is filled with a fluid called endolymph and is surrounded by a fluid called perilymph. The composition of the perilymph  is similar to the extra-cellular fluids. the composition of the endolymph  is similar to the intra-cellular fluids. Therefore  the endolymph is the only extra-cellular fluid in the body which has high potassium and low sodium concentrations. The membranous labyrinth contains  the labyrinthine sensory end-organs. Page | 8 THE EAR INTRODUCTION 3) The Labyrinthine Sensory End-organs They are the sensory end-organs of hearing and equilibrium within the membranous labyrinth. The sensory end-organ of the cochlea is called  the organ of Corti. The sensory end-organ of the semicircular duct is called  the crista. The sensory end-organ of the utricle and saccule is called  the macula. Each sensory end-organ contains special sensory hair cells. ANATOMY OF THE INTERNAL AUSITORY CANAL: It is bony canal in the petrous bone, between the structures of the inner ear and the cerebellopontine angle. Its length is about 10 mm. Contents: - Facial nerve - Cochleo-vestibular nerve - Internal auditory blood vessels. ANATOMY OF THE COCHLEO-VESTIBULAR NERVE It connects the inner ear  to the brain stem. At first it runs through the internal auditory canal  then it crosses the cerebello-pontine angle. It is intimately related to the facial (7th cranial) nerve. Consists of two parts  the cochlear nerve and the vestibular nerve. 1- The cochlear nerve  is connected to the cochlea. 2- The vestibular nerve  is connected to the vestibular parts of the inner ear i.e. the utricle, saccule and semi-circular canals. Page | 9 THE EAR INTRODUCTION ANATOMY OF THE FACIAL NERVE 1- Intra-cranial part Within the intra-cranial cavity. A- The facial motor nucleus lies in the pons. It is controlled by 1- Pyramidal fibers  from the cortical motor area. The upper part of the nucleus receives pyramidal fibers from both sides, while the lower part of the nucleus receives pyramidal fibers from only the contralateral side. 2- Extra-pyramidal fibers  for involuntary emotional movements as smiling & crying. B- The facial nerve winds around the nucleus of the 6th cranial (abducent) nerve  emerges from the pons  crosses the cerebello-pontine angle with the 8th cranial (cochleo-vestibular) nerve  enters the internal auditory canal. 2- Cranial part Within the temporal bone. A- Supra-geniculate segment The nerve passes through the internal auditory canal with the 8th cranial (cochleo-vestibular) nerve  then runs above the inner ear  reaches the medial wall of the middle ear, where it forms the geniculate ganglion. At the ganglion, it gives one branch  Greater superficial petrosal nerve  secretory to the lacrimal gland & the nasal and palatine sero-mucinous glands. B- Tympanic (horizontal) segment At the geniculate ganglion, the nerve turns (forming the first genu)  then runs horizontally backwards in the medial wall of the middle ear above the promontory and oval window. This segment does not give any branch. Page | 10 THE EAR INTRODUCTION C- Mastoid (vertical) segment When the nerve reaches the posterior wall of the middle ear  it turns (forming the second genu) →then runs vertically downwards in the posterior wall of the middle ear. This segment gives two branches  I. Nerve to stapedius muscle →motor to the stapedius muscle. II. Chorda tympani nerve → taste from the anterior 2/3 of the tongue & secretory to the submandibular and sublingual salivary glands. The tympanic and mastoid segments lie in a bony canal called  the fallopian canal. 3- Extra-cranial part Outside the skull. - The nerve emerges from the skull through the stylo-mastoid foramen  gives motor branches to the stylo-hyoid and posterior belly of digastric muscles  enters the parotid gland  divides into five terminal motor branches  Temporal, zygomatic, buccal, mandibular and cervical branches  motor to muscles of the scalp, muscles of the face and platysma muscle. Page | 11 THE EAR INTRODUCTION II. PHYSIOLOGY OF THE EAR A- HEARING 1- Conductive component. 2- Sensory-neural component. B- EQUILIBRIUM 1- Semi-circular ducts. 2- Utricle & saccule. A. PHYSIOLOGY OF HEARING DEFINITION: Hearing (audition) is the sensation of sound. What is sound? Sound is a type of energy which causes vibration of the surrounding medium. MECHANISM: The hearing (auditory) system is divided into two components: 1- Conductive component. 2- Sensori-neural component. 1) The Conductive Component: - It transmits sound waves as vibrations. - It consists of  the External ear and the Middle ear. A- THE EXTERNAL EAR: 1- The auricle collects the sound waves & directs them to the external auditory canal. 2- The external auditory canal transmits the sound waves to the tympanic membrane. 3- When the sound waves reach the tympanic membrane  it vibrates. B- THE MIDDLE EAR CLEFT: 1- The middle ear ossicles: a) They vibrate and transmit the sound waves from the tympanic membrane  to the oval window. b) They amplify the sound waves by two mechanisms: i. Areal ratio  between the vibrating area of the tympanic membrane and the area of the footplate of stapes. It is 17: 1. ii. Lever ratio  between the arm of malleus (its handle) and the arm of incus (its long process). It is 1.3: 1. The overall amplification  is 17 x 1.3 = 22 i.e. the intensity of sound at the oval window  is 22 times that at the tympanic membrane. Page | 12 THE EAR INTRODUCTION 2- The eustachian tube: a) It ventilates the middle ear  to equalize the middle ear & atmospheric pressures. This is important for proper vibration of the tympanic membrane and ossicles. b) It drains the middle ear. 2) The Sensory-neural Component It transmits sound waves as electrical impulses. It consists of  the Cochlea (of the inner ear) and the Cochlear nerve. A. THE COCHLEA - Converts the sound vibrations  to electrical impulses. How? Vibration of the footplate of stapes in the oval window  vibration of the cochlear fluids →vibration of the basilar membrane  stimulation of the cochlear hair cells which lie on the basilar membrane (in the organ of Corti)  conversion of the mechanical sound vibrations to electrical impulses. B. THE COCHLEAR NERVE Transmits the electrical impulses  to the cochlear nuclei (in the brain stem). Page | 13 THE EAR INTRODUCTION B. PHYSIOLOGY OF EQUILIBRIUM MECHANISM OF MAINTENANCE OF EQUILIBRIUM: Maintenance of equilibrium occurs in three steps  1) Initially  the brain receives sensory information from three sources: a) Vestibular part of the inner ear i.e. the semi-circular ducts, utricle and saccule. It is stimulated by head movements. b) Vision. c) Proprioceptors of the muscles, joints and tendons. ❖ These three sources provide the brain with information about position of the head and body in the space. 2) Then  the brain integrates this sensory information. 3) Then  the brain sends motor orders to two groups of muscles: a) The extra-ocular muscles  to keep the eyes stable. This is called  ocular equilibrium. b) The spinal muscles  to keep the limbs and trunk stable. This is called  postural equilibrium. Page | 14 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY HISTORY TAKING & CLINICAL EXAMINATION 1) History Taking Personal history (name, age, sex, occupation and address). The chief complaint and its duration (in patient’s own words). e.g. deafness, discharging ear, tinnitus, pain and vertigo. Present history: - Analysis of the complaint: Onset: sudden, acute or gradual. Course: progressive, regressive, stationary or intermittent. Duration: recent or longstanding. - Association with the onset: o Ask about other symptoms of the affected part. o Ask about other ENT symptoms (Pharyngeal, laryngeal and nasal symptoms) o Ask about investigations, medications or operations for the complaint. o Ask about symptoms of systemic diseases (tuberculosis, hypertension, diabetes) o Ask about symptoms of cranial nerve affection. Family history: positive family history, otosclerosis, deafness Consanguinity. - Past history: Trauma or operation e.g deafness after exposure to loud sound, or common cold Systemic diseases: Tuberculosis, diabetes. Hospitalization. Medications. ototoxic drugs may lead to deafness. 1) GENERAL EXAMINATION Temperature, pulse General features (adenoid facies) and glands in the neck. Neurological examination (motor, sensory and cranial nerves). Page | 15 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY 2) CLINICAL EXAMINATION Adult Patient: 1) The patient's body leans slightly forwards at the waist, his head projects slightly forwards, & his knees are close together. Many patients tend to slide their hips forwards in the chair. 2) The examiner adjusts the height of the patient's chair→to bring the patient's head level to the examiner's eye level. Child patient 1) 2) 3) 4) The assistant sits on the examination chair, with the child sitting on her lap. The child's legs are firmly grasped between the assistant's legs. The child's hands are firmly held against his abdomen, by one of the assistant's hands. The child's head is firmly held against the assistant's chest, by placing the other hand on the child's forehead. Infant patient 1) 2) 3) The assistant sits on the examination chair, with the infant lying on her lap. The infant's head is firmly held, by one of the assistant's hands. The infant's body is firmly held, by the assistant's other hand. Page | 16 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY Head light: The Head light The source of light  is mounted on a head band. It is placed  on the center of the forehead, just above the nasal bridge. The examiner  adjusts the light beam on the required area. Reflected light & Head Mirror: It is the traditional method of otolaryngologic examination. The Head Mirror The source of light  is a fixed examination lamp. It is placed slightly behind & above the patient’s left shoulder. its light beam is reflected by a concave head mirror mounted on a head band. The mirror is placed just in front of the examiner’s right eye. The mirror has a central hole to allow the examiner to look through this hole. The examiner  adjusts the mirror to center its hole over his right eye, and to focus the reflected light beam on the required area. This adjustment requires some training. The left eye remains uncovered. Therefore, during examination  the left eye sees directly and the right eye sees through the hole in the mirror. HOW TO EXAMINE EAR A. Examination of the auricle B. Examination of the pre-auricular & the post-auricular regions C. Examination Of the External Canal & The Tympanic Membrane D. Examination Of Hearing by Tuning fork tests A. Examination of the auricle: INSPECTION: Size, shape and position. PALPATION: Swelling and tenderness. B. Examination of the pre- auricular & the post-auricular regions: INSPECTION: Swelling, sinus and scar. PALPATION: Swelling and tenderness. Page | 17 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY C. Examination Of the External Canal & The Tympanic Membrane: The use of an ear speculum  is essential during examination of the external canal and tympanic membrane. Why? It holds open the cartilaginous part of the canal  allows the passage of both light and instruments. TYPES: The ear speculum is either: a. Hand-held i.e. held by the examiner’s hand. b. Attached to an otoscope. Handheld Speculum ILLUMINATION: 1. Headlight: Used for illumination of hand, held ear specula. Otoscope speculum 2. Reflected light: Used for illumination of hand-held ear specula. 3. Otoscope: The most commonly used method for examination of the ear. Why? a) Easy to use. b) Provides a magnified view. c) Allows free movement of the examiner. d) Portable  allows bed side examination. Head light Reflected light VISIBLE STRUCTURES: 1- The external auditory canal. 2- The tympanic membrane: The prominent landmarks on the membrane are  a) The handle of malleus b) The cone of light  which appears in the antro-inferior part of the membrane. It is due to reflection of light falling on the tympanic membrane from the otoscope. c) The anterior and posterior malleolar folds  which separate pars tensa. Page | 18 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY To examine the right ear, Hold the otoscope handle like a Pen between the thumb & index fingers of the right. The little finger rests on the patient’s face to stabilize the hand and otoscope and limit movement of the patient’s head. The left hand is used to pull the right auricle upwards, and backwards to straighten the external auditory canal. The reverse is done for examination of the left ear. The endoscope is recently used for visualization and performing many routine otologic procedures. INDICATIONS: 1- To assess mobility of the tympanic membrane. 2- To perform fistula test INSTRUMENT: A valveless rubber bulb is attached to an attached to an otoscope head  called pneumatic otoscope. TECHNIQUE: The air pressure in the external canal is changed by alternate compression & release of the rubber bulb. RESULT: The normal tympanic membrane and normal middle ear  the pressure changes produce crisp in & out movements of the tympanic membrane i.e. the tympanic membrane is freely mobile. Page | 19 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY D. Examination Of Hearing by Tuning fork tests: They are simple tests to assess the type of hearing loss (HL) i.e. whether conductive or sensori–neural, using a tuning fork. THE TUNING FORK: - Frequency: Commonest 256 and 512 Hz. - Activation: The prongs are struck on a firm surface as the elbow or patella. Rinne’s test Weber’s test: It compares hearing by AC with hearing by BC in the same ear. a) During hearing by air conduction (AC)  sound passes through the external ear  middle ear  It compares hearing by bone inner ear. Therefore  it gains the advantage of conduction in the two ears. Therefore middle ear amplification.  it is useful in case of unilateral hearing loss. b) During hearing by bone conduction (BC)  sound passes directly to the inner ear without passing through the middle ear. Therefore  it does not gain the advantage of middle ear amplification. a) To test hearing by air conduction (AC)  the prongs of the vibrating tuning fork are placed near the external canal. b) To test hearing by bone conduction (BC)  the base of the vibrating tuning fork is placed on the mastoid process. Normally: AC is better than BC. Called  Rinne positive. Conductive HL: BC is better than AC. Called  Rinne negative. Sensori-neural HL: AC is better than BC  but both are reduced. Called  reduced Rinne positive. The base of the vibrating tuning fork is placed on the midline of the forehead or on the upper central incisor teeth. Normally: Sound is heard in the midline or equally in both ears. Unilateral conductive HL: Sound is lateralized to the diseased ear. Unilateral sensori-neural HL: Sound is lateralized to the normal ear. Page | 20 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY DIAGNOSTIC AUDIOLOGY 1- Pure Tone Audiometry: ❖ PRINCIPLE: This test measures  the patient’s ability to hear pure tones. ❖ TECHNIQUE: The test material is  pure tones of different frequencies (250, 500, 1000, 2000, 4000 and 8000 Hz) and different intensities (0 – 120 dB). They are presented to the patient through  an earphone  to test hearing by air conduction & a bone vibrator  to test hearing by bone conduction. ❖ RESULTS: The examiner measures  the minimal sound intensity which the patient can hear at each frequency. This is called  the hearing threshold level. The results are recorded on a graph called  pure tone audiogram. ❖ The type of hearing loss: Conductive hearing loss The air conduction thresholds are elevated, while the bone conduction thresholds are normal there is an air-bone gap. Sensori-neural hearing loss Mixed hearing loss Both air conduction and Both air conduction and bone bone conduction thresholds conduction thresholds are are elevated to the same elevated, but air conduction degree. thresholds are more elevated there is no air-bone gap. than bone conduction thresholds there is an air-bone gap. Page | 21 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY Normal hearing Conductive HL Sensori-neural HL Mixed HL Normal Elevated Elevated Elevated Normal Normal Elevated Elevated – Absent Present Absent Present 2- Tympanometry: ❖ PRINCIPLE: This test measures: a) the middle ear pressure. b) the mobility (i.e. compliance) of the tympanic membrane and ossicles. ❖ RESULTS: The results are recorded on a graph called  tympanogram. ❖ TYPES OF TYMPANOGRAMS: 1- Type A 2- Type AD 3- Type AS 4- Type B 5- Type C Normal pressure (- 100 to + 100 mm water) and normal compliance (0.3 – 2 ml). Occurs in  normal middle ear. Normal pressure but increased compliance. Occurs in  ossicular discontinuity. Normal pressure but decreased compliance. Occurs in  ossicular fixation. Flat curve. Occurs in  secretory otitis media. Negative pressure and normal compliance. Occurs in  eustachian tube dysfunction. Page | 22 THE EAR Chapter 1: CLINICAL EAR EXAMINATION AND DIAGNOSTIC AUDIOLOGY 3- Electric Response Audiometry (ERA) ❖ PRINCIPLE: The cochlea converts sound waves to electrical impulses. These impulses are carried along the cochlear nerve  brainstem  cerebral cortex. ❖ RESULTS: This test measures  the electrical potentials which arise from the cochlea, cochlear nerve, brain stem or cerebral cortex in response to sound stimuli. ❖ VALUE: Useful for diagnosis of the degree of hearing loss. Page | 23 THE EAR Chapter 2: THE PAINFULL EAR THE PAINFULL EAR 1. LOCAL CAUSES (otodynia) - Hematoma of the auricle - Rupture of tympanic membrane - Otitic barotraumas - perichondritis Otitis externa ASOM Complicated Chronic SOM e.g mastoiditis, petrositis & extradural abscess. 2. REFERRED (otalgia): ❖ 5th Cranial Nerve: Nose: sinusitis. Nasopharynx: after adenoidectomy and tumors. Teeth: impacted lower wisdom tooth (common)., Dental caries, malocclusion ❖ 7th Nerve: Herpes zoster oticus. ❖ 9th Nerve: (which supplies the ear by Jacobson's nerve). Tongue: ulcers and tumors. Pharynx: quinsy, after tonsillectomy and tumors. ❖ 10th Nerve: (via Arnold's branch): Larynx: ulcers, especially T.B. ulcers, and cancer larynx. ❖ 2nd-3rd Cervical: Cervical spondylosis (disc lesion). ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Page | 24 THE EAR Chapter 2: THE PAINFULL EAR Auricular Haematoma Collection of blood  between the auricular cartilage and its perichondrium. AETIOLOGY Blunt trauma  commonly in boxers (called boxer’s ear). CLINICAL PICTURE The auricle is painful, reddish and cystic (if early i.e. the blood is still fluid) or soft (if late i.e. the blood has clotted) swelling. COMPLICATIONS 1- Cartilage necrosis  fibrosis  deformed auricle called cauliflower ear. 2- Secondary infection: perichondritis. TREATMENT 1) Antibiotic therapy. 2) Aspiration (if early) or incision. And evacuation (if late) under aseptic conditions  followed by firm pressure dressing to prevent re-collection of blood. Auricular Laceration AETIOLOGY - Sharp trauma  as knife injury, bite or pulling of an earring. CLINICAL PICTURE - Pain & Lacerations of the skin with or without involvement of the cartilage. - In severe cases  the auricle is partially or completely avulsed. COMPLICATION - Secondary infection  perichondritis. TREATMENT - Antibiotic therapy. - Immediate plastic repair. Page | 25 THE EAR Chapter 2: THE PAINFULL EAR Perichondritis ❖ DEFINITION Inflammation of the auricular perichondrium. ❖ AETIOLOGY 1- Infected haematoma or laceration. 2- Infected surgical incision. ❖ SYMPTOMS 1: Fever, headache, anorexia and malaise. 2: The auricle  is swollen and painful. ❖ SIGNS Fever. - The auricle  is swollen, reddish, hot and tender. The lobule  is free, because it has no cartilage. ❖ COMPLICATION - Cartilage necrosis  fibrosis  deformed auricle called ❖ TREATMENT - Antibiotic therapy. - Drainage (by multiple small incisions)  debridement i.e. removal of necrosed cartilage. that in erysipelas (a) the whole auricle, ear lobe are included, while in perichondritis (b) the ear lobule is normal. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Page | 26 THE EAR Chapter 2: THE PAINFULL EAR RUPTURE OF THE TYMPANIC MEMBRANE ❖ INCIDENCE Uncommon. Why? Because the tympanic membrane is naturally protected by  the tortuous course of the external auditory canal. ❖ AETIOLOGY A- Indirect trauma: Due to rapid and marked pressure changes in the external canal. - Hand slap (commonest). - Otitic barotrauma - Explosion. B- Direct trauma: Foreign body. Self-inflicted e.g. by a hair pin. Unskilled ear wash or instrumentation. Longitudinal temporal bone fracture. ❖ SYMPTOMS 1- History of trauma. 2- Earache  transient at the time of rupture. 3- Bloody otorrhea  mild and transient at the time of rupture. 4- Air comes out from the ear  on nose blowing. 5- Hearing loss and tinnitus. ❖ SIGNS 1. Speculum examination: Tympanic membrane perforation which is central in pars tensa. i.e. surrounded by a complete rim of the tympanic membrane & does not reach the annulus. It has any size, any shape and irregular hyperaemic sharp edges. 2. Tuning fork tests Conductive hearing loss. ❖ DIFFERENTIAL DIAGNOSIS: Pathological tympanic membrane perforation ❖ PROGNOSIS: In most cases  the perforation heals spontaneously within few weeks. ❖ TREATMENT: 1- Prophylactic antibiotic therapy. 2- Avoid forcible nose blowing, because it may rupture the healing perforation. 3- Avoid wetting of the ear  to avoid ear contamination. When the perforation fails to heal after three months. Avoid ear washing. Avoid the use of ear drops. Avoid entry of water into the ear canal during head wash and swimming. By putting an ear plug or a piece of cotton soaked with an ointment Myringoplasty operation i.e. repair of tympanic membrane perforation by a graft. Page | 27 THE EAR Chapter 2: THE PAINFULL EAR OTITIS EXTERNA ❖ DEFINITION Inflammation of the skin lining of the external auditory canal. ❖ TYPES A- Bacterial 1- Diffuse otitis externa. 2- Localized otitis externa (furunculosis). 3- Malignant otitis externa. B- Viral: 4- Bullous myringitis. 5- Herpes zoster oticus. C- Fungal 6- Otomycosis. 1. Diffuse Otitis Externa ❖ DEFINITION Diffuse inflammation of the skin lining of the external canal. ❖ PREDISPOSING FACTORS 1) Skin laceration: a- Self-inflicted  scratching the canal skin by a contaminated ear bud, hair grip b- Iatrogenic  unskilled ear wash or instrumentation. 2) Skin maceration: a- Hot humid atmosphere  excessive sweating and frequent bathing or swimming called tropical ear. b- Ear Discharge of chronic suppurative otitis media. ❖ SYMPTOMS 1- Earache  severe (because the skin is tightly attached to the perichondrium) and increases on moving the jaw. e.g. during mastication (because the external canal lies immediately behind the temporomandibular joint). 2- Hearing loss  when oedema is severe and occludes the external canal. ❖ SIGNS 1) Speculum examination: a) Diffuse redness, oedema and tenderness of the skin of the external canal. b) Otorrhoea  scanty and serous or purulent (never mucoid). 2) External examination: a) Tenderness  on pulling the auricle or pressure on the tragus. b) Pre-auricular and post-auricular lymphadenitis. Page | 28 THE EAR Chapter 2: THE PAINFULL EAR ❖ TREATMENT 1. Systemic treatment: Antibiotics & analgesics. 2. Local treatment: Aural toilet i.e. repeated removal of the ear discharge by suction or dry mopping. Packing the canal with a gauze strip soaked with antibiotics / steroids drops. Avoid entry of water into the external auditory canal during head wash & swimming. By putting an ear plug or a piece of cotton soaked with an ointment. 2. Furunculosis DEFINITION Localized suppurative infection of a hair follicle in the skin lining of the external canal. CAUSATIVE ORGANISM Staphylococcus aureus. PREDISPOSING FACTORS 1. Skin laceration Self-inflicted  scratching the canal skin by a contaminated ear bud, hair grip Iatrogenic  unskilled ear wash or instrumentation. 2. Debilitating diseases  as diabetes mellitus. SYMPTOMS 1- General symptoms Absent  because the area of suppuration is very small. 2- Local symptoms: a) Earache  severe (because the skin is tightly attached to the perichondrium throbbing and increases on moving the jaw e.g. during mastication (because the external canal lies immediately behind the temporo-mandibular joint). b) Hearing loss  when the furuncle is large and occludes the external canal. SIGNS 1- Speculum examination a- The furuncle  a localized red tender swelling in the outer cartilaginous 1/3 of the external canal. b- Otorrhoea  scanty and purulent (never mucoid when the furuncle ruptures). 2- External examination Tenderness  on pulling the auricle or pressure on the tragus. Pre-auricular and post auricular lymphadenitis. INVESTIGATION Blood sugar  especially in bilateral and recurrent cases. Page | 29 THE EAR Chapter 2: THE PAINFULL EAR DIFFERENTIAL DIAGNOSIS Acute mastoiditis. TREATMENT 1- Systemic treatment: Antibiotics & analgesics. 2- Local treatment: a. Aural toilet i.e. repeated removal of the ear discharge by suction or dry mopping. b. Packing the canal with a gauze strip soaked with antibiotics / steroids ear drops or glycerine ichthyol 10% (glycerin is hygroscopic  reduces oedema & ichthyol is counterirritant  reduces pain). 3. Malignant Otitis Externa (Necrotizing otitis externa) ❖ DEFINITION An invasive, and potentially fatal, bacterial infection of the skin lining of the external canal which extends beyond the external canal  to the base of the skull. ❖ P.F: DM IMMUNOCOMPROMISED PT. ❖ INCIDENCE: Rare. Most commonly  elderly uncontrolled diabetics. ❖ CAUSATIVE ORGANISM: - Pseudomonas aeruginosa. (COMMONEST) - Staghaeurus - Fungi: spragellus ❖ Pathogenisis Inflammation of skin of EAC →Spread to perichondrium and periostium →Chondritis, ostitis and osteomylitis →Spread to soft tissue and Intracranial complication ❖ SYMPTOM Starts as otitis externa with severe pain which does not respond to adequate treatment. Sever otalgia (more at night, not respond to TTT) Cr nerve affection (7th > 9,10,11,12 > 5,6). Page | 30 THE EAR Chapter 2: THE PAINFULL EAR ❖ SIGNS 1. Speculum examination (otoscopic examination): Edema & hypermia in EAC Otorrhoea  scanty, sanguineous and purulent. Granulation tissues in the floor of the external auditory canal, at the junction of its bony and cartilaginous parts. 2. External examination: Tenderness  on pulling the auricle or pressure on the tragus. Pre-auricular and post-auricular lymphadenitis. ❖ INVESTIGATIONS CT scan  of the temporal bone and skull base. SPECT (Single photon emission CT). Radio-isotope studies (Gallium and Technetium) (Tc99 & Gl 67)  to assess severity and prognosis. Biopsy  to exclude malignancy. Culture and sensitivity tests  of the discharge. ❖ COMPLICATIONS Spread of infection → Osteomyelitis of temporal bone and skull base→ Cranial nerves palsy→ VII, IX, X & XI. ❖ TREATMENT 1. Systemic treatment a- Control of diabetes. b- Massive antibiotic therapy e.g. quinolones or 3rd generation cephalosporins  should be continued till complete cure (usually for 6 weeks). c- Analgesics. 2. Local treatment a) Aural toilet +/- ear wick impregnated with AB (gentamycin) i.e. repeated removal of the ear discharge by suction or dry mopping. b) Antibiotics ear drops. 3. Surgical treatment Removal of granulations and debridement of necrotic tissues. Page | 31 THE EAR Chapter 2: THE PAINFULL EAR 4. Bullous Myringitis ❖ DEFINITION: Viral infection of skin lining of the external canal and the outer skin layer of the tympanic membrane. ❖ AETIOLOGY: Influenza virus. ❖ SYMPTOMS: 1- Severe earache. Sero-sanguinous otorrhoea  after rupture of the bullae. 2- No fever or hearing loss. ❖ SIGNS: - Speculum examination: Reddish bullae on the tympanic membrane and deep part of the external canal. After few days they rupture  a serosanguinous exudate & pain disappears. The tympanic membrane remains intact. ❖ TREATMENT: Analgesics. 5. Herpes Zoster Oticus DEFINITION Viral infection of the skin covering of the auricle and the skin lining of the external canal. AETIOLOGY Herpes zoster virus. 123- SYMPTOMS Severe earache. Sero-sanguinous otorrhea→ after rupture of the bullae. No fever or hearing loss. SIGNS Speculum & external examination 1- Reddish bullae on the auricle and in the external canal. 2- After few days they rupture a sero-sanguinou exudate & but pain persist. ✓ Herpes zoster oticus may be associated with ipsilateral  lower motor neuron facial nerve palsy  due to affection of the geniculate ganglion. sensori-neural hearing loss & vertigo  due to affection of the cochleo-vestibular nerve. Page | 32 THE EAR Chapter 2: THE PAINFULL EAR ✓ The triad of a) herpes zoster oticus, b) facial nerve palsy c) sensori-neural hearing loss and vertigo  is called Ramsay-Hunt syndrome. TREATMENT 1- Analgesics. 2- Anti-viral therapy as acyclovir (oral and local). 3- Corticosteroids  in severe cases with affection of the facial nerve and / or the cochleovestibular nerve. 6. Otomycosis DEFINITION Fungal infection of the skin lining of the external canal. AETIOLOGY Causative organisms: Aspergillus niger ( black ) and Candida albicans ( white ). Predisposing factor: Prolonged use of local antibiotics ear drops. SYMPTOMS 1- Itching  the main symptom. 2- Hearing loss  when the fungus mass occludes the external canal. SIGN Speculum examination: The lumen of the external canal contains a whitish mass with black spots which resembles a wet newspaper. TREATMENT 1- Removal of the fungus mass  by suction or ear wash. 2- Anti-fungal ear drops and creams e.g. clotrimazole, nystatin or 2% salicylic acid (keratolytic) in alcohol (fungicidal). Page | 33 THE EAR Chapter 2: THE PAINFULL EAR MIDDLE EAR CAUSES ❖ DEFINITION Acute inflammation of the muco-periosteal lining of the middle ear cleft i.e. the middle ear, eustachian tube and mastoid air cells. ❖ CAUSATIVE ORGANISMS: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. ❖ ROUTES OF INFECTION A. Through the eustachian tube the commonest route. B. Through tympanic membrane perforation Infected water enters the middle ear through tympanic membrane perforation. ❖ SOURCES OF INFECTION a) Through the eustachian tube: 1. Upper respiratory infection 2. Infected material passing through the tube e.g. Vomitus and milk regurge in infants b) Through tympanic membrane perforation During bathing, swimming and ear wash. ❖ PATHOLOGY & CLINICAL PICTURE Signs Sympt Pathology 1- Stage of tubal catarrhal (salpingitis) The mucosal lining of the eustachian tube becomes oedematous and hyperaemic eustachian tube obstruction  development of negative middle ear pressure. Hearing loss and tinnitus. (no earache) Speculum examination: Retracted tympanic membrane → the handle of malleus appears shortened (i.e. fore-shortened) → the lateral process of malleus is prominent, → the cone of light is distorted & Its mobility is restricted (by Siegle’s speculum or pneumatic otoscope). Tuning fork tests: Conductive hearing loss. 2- Stage of catarrhal otitis media - The infection spreads to the mucosal lining of the middle ear which becomes oedematous and hyperaemic  a serous exudate accumulates within its cavity. 1- Earache  dull. 2- Hearing loss and tinnitus. - Speculum examination: Hyperaemic tympanic membrane. The hyperaemia occurs mainly at the periphery and around the handle of malleus  cartwheel appearance. - Tuning fork tests: Conductive hearing loss. Page | 34 4- Stage of tympanic membrane perforation pathology The middle ear exudate becomes mucopurulent. The increased middle ear pressure  pressure necrosis of a part of pars tensa of the tympanic membrane  central perforation. General symptoms (of inflammation)  General symptoms (of inflammation) diminish. Fever, anorexia, headache and malaise. Local symptoms Local symptoms →Earache →severe 1. Otorrhoea  starts. and throbbing. →Hearing loss and 2. Earache  diminishes. tinnitus. 3. Hearing loss and tinnitus. Signs 3- Stage of suppurative otitis media Symptoms THE EAR Chapter 2: THE PAINFULL EAR General sign: Fever  diminishes. Local signs General sign Fever. - Speculum examination: Local signs: Perforated tympanic membrane. The Speculum examination: perforation is central in pars tensa. Bulging angry red tympanic membrane. Otorrhoea  muco - purulent, pulsating & Tuning fork tests: Conductive hearing is blood stained at the time of rupture. loss. The middle ear mucosa (through the perforation)  hyperaemic & oedematous. - Tuning fork tests: Conductive hearing loss. ❖ INVESTIGATIONS 1) Pure tone audiometry Conductive hearing loss 2) Imaging (plain x-ray or CT scan) Clouding (opacity) of the mastoid air cells (due to pus accumulation). However, their bony walls remain intact. 3) Culture and sensitivity tests of the ear discharge. Page | 35 THE EAR Chapter 2: THE PAINFULL EAR ❖ TREATMENT i. Before perforation a) Medical treatment Antibiotic therapy for 7-10 days. Analgesics / antipyretics. 1) Decongestive nasal drops  to reduce oedema around Eustachian tube orifice  improves ventilation and drainage of the middle ear. b) Surgical treatment: Myringotomy operation i.e. incision of the tympanic membrane. When? 1) Failure of medical treatment (i.e. persistent pain and fever) for 48 hours. 2) Bulging tympanic membrane  because myringotomy incision does not cause loss of substance  heals better than pathological perforation. 3) Development of cranial or intra-cranial complication. ii. Stage of perforation A. Medical treatment Antibiotic therapy  better according to the results of sensitivity tests. Aural toilet, by repeated suction or dry mopping  to remove the ear discharge. B. Surgical treatment Myringotomy operation i.e. incision of the tympanic membrane. When? Small or high perforation  insufficient for adequate drainage. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Specific types of Page | 36 THE EAR Chapter 2: THE PAINFULL EAR Specific types of Acute Otitis Media 1- Acute otitis media in children INCIDENCE Acute otitis media is more common in children. Why? Route of infection  is easier in children. Why? Because the eustachian tube is shorter, wider and more horizontal in children. Sources of infection  are more common in children. Why? Because: Upper respiratory infections  are more common in children. Infected materials passing through the tube are more common in children: a- Milk is more common in bottle-fed than breast-fed infants. Why? the supine position during bottle feeding  facilitates regurge of milk to the nasopharynx. Bottle milk  more liable to contamination. b- Vomitus Gastro-enteritis  is more common in infants and the vomitus can easily reach the eustachian tube in the supine position. c- General resistance  is lower in children. Why? Because of artificial feeding, teething and frequent gastro-enteritis. SYMPTOMS A- General symptoms: the main symptoms. 1- Fever  is higher in children. 2- Vomiting and diarrhea. It may be mistaken for gastro-enteritis. 3- Continuous crying and the child does not sleep well. B- Local symptoms: The child pulls or rubs his ear and moves his head from side to side. SIGNS Speculum examination: The tympanic membrane is hyperaemic with loss of lustre. The infantile tympanic membrane is thicker than in adults  resists bulging. Page | 37 THE EAR Chapter 2: THE PAINFULL EAR TREATMENT Similar to adults but myringotomy is done after failure of medical treatment (i.e. persistent pain and fever) for 48 hours. Do not wait for bulging of the tympanic membrane, because the infantile tympanic membrane is thicker than in adults  resists bulging. PROGNOSIS Complications more common in infants. Why? 1. Delayed diagnosis Why? a. The infant is unable to express his complaint --> absence of alarming symptoms. b. The infantile tympanic membrane is thicker than in adults → resists bulging→ absence of alarming signs. c. The manifestations may be misleading  misdiagnosed as gastro-enteritis. 2. Open cranial sutures  facilitate spread of infection. 3. Low general resistance. 2. Acute necrotizing Otitis Media It occurs in the course of excanthemata in children. It is characterized by severe acute inflammation of the mucoperichondrial lining of the middle ear cleft and necrosis of the tympanic membrane and ossicles. Presentation: total or subtotal perforation and marked conductive deafness. Inflammatory diseases of the middle ear are important because of their frequency and the lifethreatening complications associated with them due to the close relationship between the middle ear and the cranial cavity. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Page | 38 THE EAR Chapter 2: THE PAINFULL EAR OTOALGIA IN COMPLICATED OTITIS MEDIA ❖ DEFINITION Inflammation of the bony walls of the mastoid air cells. ❖ PATHOLOGY 1- Starts as osteitis of the bony walls of the mastoid air cells  necrosis of these bony walls  the air cells coalesce together  the mastoid process is converted to a single cavity full of pus  called coalescent mastoiditis 2- Pus then erodes the external surface (i.e. cortex) of the mastoid process  forming a sub-periosteal mastoid abscess. 3- Pus then bursts through the periosteum and skin  forming a mastoid fistula. ❖ SYMPTOMS - General symptoms Fever, headache, anorexia and malaise. - Local symptoms 1- Earache  severe and over the mastoid. 2- Otorrhoea  profuse. 3- Hearing loss and tinnitus  due to otitis media. - The symptoms of acute mastoiditis are similar to that of acute otitis media. Therefore mastoiditis is suspected in case of persistence or recurrence of symptoms of acute otitis media. Page | 39 THE EAR Chapter 2: THE PAINFULL EAR ❖ SIGNS A- General examination: Fever. B- External examination: 1) Coalescent mastoiditis Tenderness over the mastoid antrum (largest air cell), tip (most superficial cell) and posterior border (site of mastoid emissary vein). 2) Mastoid abscess  external fluctuant swelling. It may be: c) Post-auricular abscess: Behind the auricle  pushing it outwards and forwards d) Zygomatic abscess: Above and in front of the auricle e) Bezold’s abscess: In the upper part of the neck deep to sterno-mastoid muscle. 3) Mastoid fistula  discharging fistula. C- Speculum examination 1. Otorrhoea  muco-purulent or purulent, profuse and recurs rapidly after removal (called reservoir sign ( diagnostic sign). 2. Sagging i.e. bulging downwards of the postero-superior wall of the bony part of the external auditory canal. It is due to periosteitis of the adjacent mastoid antrum. It is an early and diagnostic sign 3. Tympanic membrane  usually perforated but may be intact and hyperaemic. ❖ INVESTIGATIONS 1. Imaging Plain x-ray or better CT scan  clouding (opacity) of the mastoid air cells 2. Culture and sensitivity tests of the ear discharge. ❖ DIFFERENTIAL DIAGNOSIS Furunculosis of the external auditory canal Page | 40 THE EAR Chapter 2: THE PAINFULL EAR ❖ TREATMENT A- Medical treatment Antibiotic therapy  better according to the results of culture and sensitivity tests. B- Surgical treatment a) Myringotomy operation  in case of intact tympanic membrane. b) Cortical mastoidectomy operation  in case of: Failure of conservative treatment (antibiotics & myringotomy) for 48 hours. Mastoid abscess. Mastoiditis with other cranial or intra-cranial complication. DEFINITION Inflammation of the bony walls of the petrous air cells; which lie in the petrous apex. CLINICAL PICTURE Gradenigo’s syndrome 1- Otorrhoea  due to chronic suppurative otitis media. 2- Severe facial pain  due to irritation of the trigeminal (5th cranial) ganglion. 3- Diplopia and squint  due to paralysis of the abducent (6th cranial) nerve  paralysis of the lateral rectus muscle  inability to abduct the eye. Page | 41 THE EAR Chapter 3 EAR DISCHARGE (Otorrhea) Mucoid and Mucopurulent discharge: Acute & Chronic Suppurative otitis media →copious discharge. Purulent discharge: - Cholesteatoma →fetid odor and scanty discharge. Watery discharge →Cerebrospinal otorrhea) Bloody discharge: o Traumatic: - Longitudinal temporal bone fracture - Rupture drum o Inflammatory: - bullous myringitis - Necrotizing OE (Malignant Otitis Externa) o Neoplastic: - Glomus, - squamous cell carcinoma. - Copious mucopurulent discharge after drum perforation ✓ DEFINITION Chronic purulent inflammation of the muco-periosteal lining of the middle ear cleft characterized by the presence of tympanic membrane perforation and intermittent or continuous otorrhoea. ✓ CAUSATIVE ORGANISMS Commonest  Pseudomonas aeruginosa and Proteus species. Page | 42 THE EAR Chapter 3 ✓ TYPES A- Tubo-tympanic disease or safe chronic suppurative otitis media Why is it called tubo-tympanic disease? Because it starts in the eustachian tube, mesotympanum and hypotympanum. Why is it called safe chronic suppurative otitis media? Because it is much less liable to cause complications. Why? Because the infection is limited to the muco-periosteal lining without bone erosion. B- Attico-antral disease or unsafe chronic suppurative otitis media o Why is it called attico-antral disease? Because it starts in the attic (epitympanum and mastoid antrum). o Why is it called unsafe chronic suppurative otitis media? Because it is much more liable to cause complications. o Why? Because it is commonly associated with cholesteatoma which causes bone erosion a) Tubo-tympanic disease PATHOLOGY Chronic non-specific inflammation of the muco periosteal lining of the middle ear cleft with permanent drum perforation. AETIOLOGY OVERVIEW In safe type, the discharge is It follows acute suppurative otitis media continuous or intermittent, Mucopurulent Odourless May be profuse Page | 43 THE EAR Chapter 3 SYMPTOMS 1- Otorrhoea  continuous or intermittent. 2- Hearing loss and tinnitus. SIGNS 1- Speculum examination f) Otorrhoea  muco purulent, odourless and may be profuse. g) Tympanic membrane perforation  is I. central in pars tensa II. i.e. surrounded by a complete rim of the tympanic membrane & does not reach the annulus. III. It has any size, any shape and smooth edges. 2- Tuning fork tests Conductive hearing loss. DIFFERENTIAL DIAGNOSIS Traumatic tympanic membrane perforation. INVESTIGATIONS 1) Pure tone audiometry Mild or moderate conductive hearing loss due to a. Tympanic membrane perforation. b. impaired mobility of the ossicles by the middle ear discharge and thickened mucosa. The ossicles are usually intact. 2) CT scan Shows accurate extent of the disease. 3) Culture and sensitivity tests  of the ear discharge. TREATMENT Tympanoplasty operation after control of infection. 1. Regular aural toilet to remove the ear discharge by suction or dry mopping with a cotton tipped probe. 2. Antiseptic (as 2% acetic acid) & antibiotic / steroid ear drops; avoid ototoxic drops. 3. Antibiotics therapy  better according to the results of sensitivity tests. 4. Avoid re-infection. How? a) Treatment of predisposing factors as adenoiditis and sinusitis. b) Avoid entry of water into the ear canal during head wash and swimming. How? By putting an ear plug or a piece of cotton soaked with an ointment. Page | 44 THE EAR Chapter 3 1) Tympanoplasty operation It has two aims a. Healing  by eradication of irreversibly diseased tissues in the middle ear as granulations and polypi. b. Hearing  by reconstruction of the middle ear hearing mechanism. 2) Cortical mastoidectomy operation  is performed when conservative treatment fails to control the otorrhoea. The operation is called  tympanoplasty with mastoidectomy b) Attico-antral disease (Cholesteatoma) DEFINITION Cholesteatoma is the presence of keratinizing stratified squamous epithelium (i.e. skin) in the middle ear cleft i.e. skin in a wrong place. PATHOLOGY Cholesteatoma is a sac which - is lined with  keratinizing stratified squamous epithelium i.e. skin (called matrix) - is filled with  concentric sheets of desquamated keratin (like onion) which may contain cholesterol crystals. OVERVIEW In cholesteatoma, the discharge is purulent (never mucoid or mucopurulent), offensive and scanty (never profuse). BEHAVIOR The cholesteatoma sac  expands gradually as a result of accumulation of keratin repeated infection. causes erosion of the surrounding bones. How? By enzymatic activity. How? Breakdown of the keratin and secondary bacterial infection of the cholesteatoma  secretion of demineralizing and osteolytic enzymes. Page | 45 THE EAR Chapter 3 SECONDARY EFFECTS - Active expansion of the cholesteatoma  destruction of the ossicles especially the long process of incus → may lead to complications. SYMPTOMS - Otorrhoea  continuous or intermittent. Due to bacterial infection of the keratin. - Hearing loss and tinnitus. SIGNS 1) Speculum examination a. Otorrhoea  purulent (never mucoid or muco-purulent), offensive (due to osteitis) and scanty (never profuse). b. Tympanic membrane perforation either - attic  in pars flaccida or - marginal (i.e. not surrounded by a complete rim of the tympanic membrane & reaches the annulus)  in the postero-superior part of pars tensa. c. Cholesteatoma  appears as a greyish sac filled with pearly white sheets of keratin. 2) Tuning fork tests Conductive hearing loss. INVESTIGATIONS 1) Pure tone audiometry →Severe conductive hearing loss due to necrosis of the ossicles. 2) CT scan →Shows accurate extent of the cholesteatoma and complications, if present. 3) Culture and sensitivity tests →of the ear discharge. TREATMENT ❖ Treatment of cholesteatoma is surgical removal. ❖ There is no place for medical treatment. How? - Classical radical mastoidectomy. - Modified radical mastoidectomy. Page | 46 THE EAR Chapter 3 Indication Principle Classical radical mastoidectomy To create a safe dry middle ear cleft, with no attempt to preserve hearing. How? a) Removal of the mastoid air cells (i.e. cortical mastoidectomy and all middle ear contents except the stapes (to avoid spread of infection to inner ear). Modified radical mastoidectomy Principle Similar to classical radical mastoidectomy, with an attempt to preserve hearing. How? a) Preservation of the healthy remnants of the tympanic membrane and ossicles. b) Conversion of the whole middle ear and mastoid process to a single cavity which is well ventilated and drained through the external auditory canal. b) Reconstruction of the middle ear conductive hearing mechanism i.e. tympanoplasty. The operation is called  tympanoplasty with mastoidectomy. a) Extensive cholesteatoma. b) Complicated chronic suppurative otitis media. Localized cholesteatoma with serviceable hearing. It is the operation of choice, whenever possible. AETIOLOGY Severe head trauma  as car accidents or fall from a height. INCIDENCE More common than transverse temporal bone fracture (4:1). PATHOLOGY The fracture line  is parallel to the longitudinal axis of the petrous part of the temporal bone  affects the external canal, tympanic membrane and middle ear. Page | 47 THE EAR Chapter 3 CLINICAL PICTURE 1- History of trauma. 2- Speculum examination - Laceration of the skin of the external canal. - Rupture of the tympanic membrane. - Otorrhoea  blood (due to a & b) and may be cerebro-spinal fluid. 3- Tuning fork tests →Conductive hearing loss due to rupture of the tympanic membrane and disruption of the ossicles. 4- Facial nerve paralysis Uncommon, delayed and partial. INVESTIGATIONS 1) CT scan Shows the fracture line and associated injuries. 2) Pure tone audiometry Conductive hearing loss. TREATMENT 1- Conservative treatment a) Similar to rupture tympanic membrane. b) In case of cerebro-spinal otorrhoea  bed rest with head elevated, avoid straining, cover the ear with sterile dressing and prophylactic systemic antibiotics that cross the blood brain barrier. 2- Surgical treatment Repair of tympanic membrane perforation, ossicles disruption, facial paralysis and cerebro-spinal fluid leak  if persistent. ✓ INCIDENCE o Frequency→ Rare. o Age → Commonly 40 - 50 years. o Sex → More common in females. ✓ ORIGIN Arises from the non-chromaffn paraganglionic tissues (chemo receptors) which lie: a) on the promontory  called glomus tympanicum. b) on the jugular bulb (near the floor of the middle ear)  called glomus jugulare. Page | 48 THE EAR Chapter 3 ✓ PATHOLOGY A highly vascular benign tumour. ✓ BEHAVIOUR Although microscopically benign  it is an aggressive locally destructive tumour. ✓ CLINICAL PICTURE A- Otological manifestations 1- Pulsating tinnitus  the earliest manifestation of glomus tympanicum. 2- Bloody otorrhoea  when it perforates the tympanic membrane. 3- Speculum examination  a) Initially  a red mass behind an intact tympanic membrane.  producing a characteristic sun-rising appearance. The mass blanches on compression by a pneumatic otoscope or Siegle’s speculum  called Brown’s sign. b) When the tumor perforates the tympanic membrane  a red vascular mass appears in the external auditory canal. It bleeds profusely on touch. 4- Gradual progressive hearing loss  initially conductive, then becomes mixed after invasion of the inner ear. B- Neurological manifestations 1) Jugular foramen syndrome (i.e. IX, X and XI cranial nerves paralysis)  the earliest manifestation of glomus jugulare. 2) Facial and hypoglossal nerves paralysis  later on. ✓ INVESTIGATIONS 1) CT scan & MRI→ To assess tumor extension. 2) Angiography & MR angiography→To confirm the diagnosis and show the feeding vessel. 3) Biopsy Better avoided, because it may cause profuse bleeding. ✓ TREATMENT: - Surgical excision. Better after embolization of the feeding vessel in order to decrease the intra-operative bleeding. Page | 49 THE EAR Chapter 4 THE DEAF EAR o Definition: Inability to hear clearly in circumstances where the normal person can do so. o Speech sounds range from 500-2000 Hz o Normally, the patient hears the normal conversation voice at 9 to 12 meters and whispers at (6 meters). o After 40 dB loss of hearing may be socially defective. o Types of Deafness: Conductive hearing loss.CD Sensori-neural hearing loss SNHL. Mixed, hearing loss i.e. association of both sensori-neural and conductive hearing loss. Functional deafness : psychogenic and malingering. THE DEAF EAR Otologic examination Tuning fork tests Pure tone audiogram Sensorineural Hearing loss Conductive Deafness Ask for ABR TO DIFFERENTIATE BETWEEN COCHLEAR AND RETROCOCHLEAR CAUSE Page | 50 THE EAR Chapter 4 A- CAUSES OF CONDUCTIVE DEAFNESS Congenital: Artesia of the external canal. Ossicular fixation or deformity. Aplasia of the middle ear. Traumatic: FB obstructing the external auditory canal. Inflammatory: Acute suppurative otitis media otitis media with effusion. Chronic suppurative otitis media Neoplastic: Tumors of the external auditory canal as exostosis Tumors of the middle ear as Glomus. - Patient with conductive deafness (CD) hears his voice magnified, through bone conduction (autophony) and so his voice is low. - Patient with perceptive deafness (SNHL) has a loud voice. Wax Accumulation: DEFINITION: - Abnormal accumulation of ear wax (cerumen) in the external auditory canal. What is ear wax (cerumen)? Production: It is an oily material which consists of mixture of secretions of the sebaceous and ceruminous (modified sweat) glands in the outer cartilaginous 1/3 & desquamated skin cells. Function: It protects the skin by its acidic reaction and lysozyme enzyme. FATE: It is spontaneously expelled outside the canal, in the form of flakes. How? By outward migration of the skin of the external canal. INCIDENCE: Wax accumulation is the commonest cause of conductive hearing loss in adults. Page | 51 THE EAR Chapter 4 AETIOLOGY: - Failure of the natural cleaning mechanism of the external canal. - May be due to: 1) Narrow external auditory canal. 2) Attempts of the patient to clean his ear with cotton buds. Why? These attempts usually push the wax deeper into the canal. SYMPTOMS: - Hearing loss and tinnitus when the wax occludes the canal. - This usually occurs after bathing and swimming, because the wax swells with water. SIGNS: - Speculum examination: A brownish mass in the external canal. TREATMENT: Removal by ear wash or instruments. If the wax is hard it is softened before ear wash. How? By a wax solvent as hydrogen peroxide or glycerine bicarbonate ear drops. What is the commonest cause of CD in children? otitis media with effusion. What is the commonest cause of CD in adults? Wax accumulation. Stapedial otosclerosis. EAR WASH: INDICATIONS: 1- Wax accumulation. 2- Otomycosis. 3- Foreign body in the external auditory canal. CONTRAINDICATIONS: 1) Impacted and large vegetable foreign body in the external auditory canal. 2) Tympanic membrane perforation (traumatic or inflammatory). 3) Bacterial otitis externa. Page | 52 THE EAR Chapter 4 TECHNIQUE: 1- The patient is seated with a basin under his ear (to avoid soiling his clothes). 2- The auricle is pulled upwards and backwards (to straighten the external auditory canal). 3- The used water should be sterile (to avoid infection) and at body temperature (to avoid caloric stimulation of the inner ear). 4- The jet of water should be gentle and is directed towards the postero-superior wall of the external auditory canal (to avoid injury of the tympanic membrane). 5- The external auditory canal is dried and examined. COMPLICATIONS: 1- Traumatic: a. Injury of the canal skin by the syringe. b. Rupture of the tympanic membrane  the patient feels sudden pain, hearing loss and water in his throat. 2- Infective: Otitis externa  due to use of unsterile water. 3- Reactive: a. Cough or syncope  due to stimulation of the auricular branch of the vagus nerve. b. Vertigo  due to caloric (thermal) stimulation of the inner ear by too cold or too warm water. Page | 53 THE EAR Chapter 4 ❖ CONGENITAL CAUSES OF CONDUCTIVE DEAFNESS ❖ ❖ - AETIOLOGY Failure of canalization of the external auditory canal. INCIDENCE Side: Unilateral or bilateral. May be associated with congenital anomalies of auricle, middle ear & rarely inner ear. ❖ CLINICAL PICTURE Conductive deafness because the external auditory canal is either completely absent or appears as a blind pit. ❖ INVESTIGATIONS Microtia with Atresia of External Canal 1- CT scan to assess the condition of the middle ear and inner ear. 2- Audiological evaluation Conductive hearing loss. ❖ TREATMENT 1. Hearing aid  for infants with bilateral atresia It is fitted as early as possible. 2. Surgical reconstruction of the external auditory canal  if the auditory system has normal structure (by CT scan) and normal function (by audiological evaluation). o Definition Complete absence of the middle ear. o Clinical Picture: Conductive hearing loss since birth. o Treatment: Hearing aid. ❖ Definition Absence, deformity or fixation of the ossicles. ❖ Clinical Picture Conductive hearing loss since birth. ❖ Treatment Ossiculoplasty i.e. surgical reconstruction of the ossicular chain. Page | 54 THE EAR Chapter 4 ❖ TRAUMATIC CAUSES OF CONDUCTIVE DEAFNESS INCIDENCE: Most commonly children. TYPES: 1- Animate foreign bodies  as flies and larvae. 2- Inanimate foreign bodies: a) Non-vegetable foreign body  as bead and button. b) Vegetable foreign body  as bean and pea. It swells with water  impacted. SYMPTOMS: 1. History of foreign body insertion  may be present. 2. Hearing loss  when the foreign body occludes the external canal. 3. Animate foreign body  causes severe irritation and noise in the ear. SIGN: The foreign body is easily detected on clinical examination. (see below, glass bead & insect FB): TREATMENT 1- Animate foreign body  is killed by alcohol or oil before removal by ear wash or instruments (as hooks and forceps). 2- Inanimate foreign body: a) Non-vegetable foreign body  can be removed by ear wash or instruments as hooks and forceps. b) Vegetable foreign body  is removed by instruments (as hooks and forceps). Page | 55 THE EAR Chapter 4 ❖ Ear wash is contraindicated because the foreign body may swell  impacted. ❖ - General anaesthesia  is necessary in case of: impacted foreign body uncooperative patients as children. COMPLICATION: - Injury of the external canal or the tympanic membrane. May be produced by the foreign body, or during unskilled attempts of removal. ❖ INFLAMMATORY CAUSES OF CONDUCTIVE DEAFNESS 1. Stage of tubal catarrh (salpingitis)→Hearing loss and tinnitus. 2. Stage of catarrhal otitis media →dull Earache, Hearing loss and tinnitus. 3. Stage of suppurative otitis media→throbbing earache, Hearing loss and tinnitus. 4. Stage of tympanic membrane perforation → Otorrhoea  starts. Earache  diminishes. Hearing loss and tinnitus. - Hearing loss and otorrhea Page | 56 THE EAR Chapter 4 Accumulation of a non-purulent sero-mucoid effusion in the middle ear. The commonest cause of conductive hearing loss in children. - Eustachian tube obstruction or dysfunction  improper middle ear ventilation  development of negative middle ear pressure. The middle ear mucosa tries to equalize this negative pressure by production of an effusion which consists of: transudate  from the blood vessels mucus  due to increased activity of themucus glands and goblet cells. 1- Eustachian tube obstruction a. Nasopharyngeal oedema  due to infection, allergy or radiotherapy. b. Nasopharyngeal tonsil hypertrophy i.e. adenoids. c. Nasopharyngeal tumours. d. Otitic barotrauma. 2- Eustachian tube muscles dysfunction: Cleft palate and paralysed palate. 3- Inadequate treatment of acute otitis media Inadequate antibiotic therapy (improper antibiotic) inadequate dose or short course  the infection is inactivated, but not resolved. 1. Hearing loss and tinnitus. 2. A bubbling sound may be heard in the ear. A. Speculum examination: - The tympanic membrane shows: I. Signs of retraction (due to negative middle ear pressure)  a. the handle of malleus appears shortened (i.e. fore-shortened) b. the lateral process of malleus is prominent, c. the cone of light is distorted d. its mobility is restricted (by Siegle’s speculum or pneumatic otoscope). Page | 57 THE EAR Chapter 4 II. Signs of middle ear effusion: a) its colour is yellow to dull grey, b) fluid level (called hair line) may appear as biconcave line & air bubbles may be present. B. Tuning fork tests Conductive hearing loss. i. Pure tone audiometry Conductive hearing loss. ii. Tympanometry Type B i.e. flat curve  diagnostic. ✓ a) b) c) Conservative treatment: Treatment of predisposing factors. Antibiotics therapy  to prevent recurrent infection. Auto-inflation of the eustachian tube by chewing gum and Valsalva’s manoeuvre i.e. forced expiration with both mouth and nose closed. d) Corticosteroids and mucolytics  controversial. ✓ Surgical treatment: How? Myringotomy and insertion of a ventilation tube. The tube is either: a) temporary (i.e. is extruded spontaneously after 3 – 6 months) as grommet tube. b) permanent as T - tube. When? After failure of conservative treatment for several weeks Why? To ventilate and drain the middle ear i.e. it is a substitute for the eustachian tube. Page | 58 THE EAR Chapter 4 DEFINITION Presence of fibrous adhesions in the middle ear. AETIOLOGY Inadequate treatment of secretory otitis media. How? Organisation of the middle ear fluid  formation of fibrous adhesions. SYMPTOMS Hearing loss and tinnitus. SIGNS 1- Speculum examination The tympanic membrane: a) is retracted (similar to secretory otitis media) b) its color is dull grey. 2- Tuning fork tests Conductive hearing loss. INVESTIGATIONS 1- Pure tone audiometry: Conductive hearing loss. 2- Tympanometry: Type AS. TREATMENT 1) Tympanoplasty operation and lysis of the fibrous adhesions. 2) Hearing aid  if necessary. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Page | 59 THE EAR Chapter 4 B- CAUSES OF SENSORI-NEURAL HEARING LOSS (SNHL) ❖ Causes of the cochlea 1) Congenital - Aplasia: complete absence of the inner ear. - Hypoplasia: incomplete development of the inner ear. 2) Traumatic: - Transverse fracture of the temporal bone. - Acoustic trauma 3) Inflammatory: labyrinthitis 4) Degenerative: presbyacusis 5) Toxic: Ototoxicity 6) vascular: (of labyrinthine vessels): - spasm - thrombosis - haemorrhage 7) Meniere’s disease 8) Cochlear otosclerosis. ❖ Causes of the 8th nerve: acoustic neuroma. Aplasia and Hypoplasia of the Inner Ear a- Aplasia: complete absence of the inner ear. b- Hypoplasia: incomplete development of the inner ear. Clinically: - Perceptive deafness since birth - Speech defects and affection of intelligence. - The child is deaf and dumb, i.e. deaf-mute. Treatment: Hypoplasia→auditory rehabilitation + cochlear implantation Aplasia →auditory rehabilitation. Acoustic Trauma ▪ DEFINITION Damage of the cochlear sensory end organ due to exposure to loud noise. ▪ AETIOLOGY 1- Acute acoustic trauma Due to brief exposure to a very loud noise  as gunfire and disco party. 2- Chronic acoustic trauma Due to prolonged exposure to a loud noise  as in factories and airports. ▪ CLINICAL PICTURE 1- History of acoustic trauma. 2- Sensori-neural hearing loss and tinnitus. The hearing loss can occur in the form of: a) Temporary threshold shift i.e. it recovers spontaneously within 1 - 2 days. b) Permanent threshold shift i.e. it is permanent. Page | 60 THE EAR Chapter 4 ▪ PREVENTION 1- Proper use of protective ear plugs or better head muffs. 2- Regular screening of hearing of workers in noisy occupations. A cotton wool plug does not protect against noise trauma to the ear. ▪ TREATMENT - Hearing aid  if necessary. Transverse Temporal Bone Fracture ❖ AETIOLOGY Severe head trauma  as car accidents or fall from a height. ❖ INCIDENCE Less common than longitudinal temporal bone fracture (1: 4). ❖ PATHOLOGY The fracture line  is perpendicular to the longitudinal axis of the petrous part of the temporal bone  affects the inner ear and the internal auditory canal. ❖ CLINICAL PICTURE 1. 2. 3. 4. 5. History of trauma. Sensori-neural hearing loss  due to injury of the cochlea and cochlear nerve. Vertigo and nystagmus  due to injury of the vestibular labyrinth and vestibular nerve. Facial nerve paralysis  common, immediate and complete. Loss of consciousness  common. ❖ INVESTIGATIONS 1. CT scan Shows the fracture line and associated injuries. 2. Pure tone audiometry Sensori-neural hearing loss. ❖ TREATMENT 1) 2) 3) 4) Systemic antibiotics that cross the blood brain barrier. Anti-vertigals (vestibular sedatives). Surgical repair of the facial nerve. Hearing aid  if necessary. Page | 61 THE EAR Chapter 4 Presbyacusis - Bilateral progressive sensorineural hearing loss due to aging. - It occurs due to degeneration of cochlear sensory end organs - Treatment: Hearing aids. Ototoxicity DEFINITION Degeneration of the labyrinthine sensory end-organs due to ototoxic drugs. AETIOLOGY - Aminoglycoside antibiotics (as gentamicin, amikin and streptomycin), cytotoxic drugs, diuretics (as frusemide), quinine, salicylates, etc. - The risk increases in case of poor kidney function. CLINICAL PICTURE 1- Bilateral sensori-neural hearing loss and tinnitus. 2- Dizziness. PREVENTION 1- Avoid ototoxic drugs as much as possible. 2- Regular monitoring of hearing and drug serum level. 3- Immediate withdrawal when any manifestation of ototoxicity develops. TREATMENT Hearing aid  if necessary. Causes of mixed hearing loss: a. b. c. d. e. Congenital: anomalies of external and/or middle ear + inner ear Traumatic: transverse+ longitudinal fracture of temporal bone. Inflammatory: Ch SOM+ labyrinthitis Tumors: of ME invading inner ear Unknown etiology: combined stapedial & cochlear otosclerosis. Otitic Labyrinthitis ❖ DEFINITION Inflammation of the labyrinth secondary to suppurative otitis media. ❖ TYPES Circumscribed peri-labyrinthitis (labyrinthine fistula). Diffuse serous labyrinthitis. Diffuse suppurative labyrinthitis. Page | 62 THE EAR Chapter 4 a) Circumscribed peri-labyrinthitis ❖ SYNONYM: Labyrinthine fistula. ❖ DEFINITION: Localized erosion of a part of the bony labyrinth  producing a fistula between the middle ear and inner ear. The endosteal layer of the bony labyrinth remains intact. ❖ AETIOLOGY: Most commonly  cholesteatoma. ❖ SITE: Most commonly  the lateral semi-circular canal. ❖ SYMPTOM: Otorrhoea, hearing loss and tinnitus  due to otitis media. Recurrent attacks of transient vertigo which are induced by pressure on the tragus. ❖ SIGNS: 1. Speculum examination Signs of chronic suppurative otitis media. a) Positive fistula test i.e. transient vertigo and nystagmus occur: when the pressure in the external canal is raised by pressure on the tragus. b) (by a pneumatic otoscope or Siegle’s speculum) on manipulating an aural polyp. 2. Tuning fork tests Conductive hearing loss. ❖ INVESTIGATIONS: 1- Pure tone audiometry Conductive hearing loss. 2- Culture and sensitivity tests of the ear discharge. ❖ TREATMENT: Immediate mastoidectomy operation  to remove the cholesteatoma and cover the labyrinthine fistula with a graft as temporalis fascia. Page | 63 THE EAR Chapter 4 b) Diffuse serous labyrinthitis ⚫ DEFINITION: Accumulation of serous exudate in the membranous labyrinth. ⚫ SYMPTOMS: the patient is bed ridden 1- Hearing loss and tinnitus. 2- Continuous spontaneous severe vertigo, with nausea and vomiting. ⚫ SIGNS: Speculum examination Signs of chronic suppurative otitis media. ⚫ INVESTIGATIONS: 1) Pure tone audiometry Mixed hearing loss. a) Conductive hearing loss  due to otitis media. b) Sensori-neural hearing loss  due to labyrinthitis. 2) Culture and sensitivity tests of the ear discharge. ⚫ TREATMENT: 1- Medical treatment a) Antibiotic therapy  massive, parenteral, better according to the results of culture and sensitivity tests and better can cross the blood brain barrier. b) Anti-vertigals (vestibular sedatives). 2- Surgical treatment Mastoidectomy operation  after subsidence of vertigo. c) Diffuse suppurative labyrinthitis ❖ DEFINITION Accumulation of purulent exudate in the membranous labyrinth  destruction of its sensory cells. ❖ CLINICAL PICTURE Similar to diffuse serous labyrinthitis. (Hearing loss and tinnitus). ❖ PROGNOSIS 1. Proper treatment  healing by fibrosis  dead ear i.e. permanent complete loss of hearing and vestibular function. 2. Improper treatment  spread of infection along the internal auditory canal  meningitis. Page | 64 THE EAR Chapter 4 ❖ DIFFERENTIAL DIAGNOSIS Differentiation between serous and suppurative labyrinthitis usually occurs retrospectively. o If hearing loss improves  the condition was serous labyrinthitis. o If hearing loss does not improve  the condition was suppurative labyrinthitis. ❖ TREATMENT 1. Similar to  diffuse serous labyrinthitis. 2. Labyrinthectomy operation  for drainage and destruction of the membranous labyrinth when  it is complicated by meningitis. Haematogenous & Meningogenic Labyrinthitis CAUSATIVE ORGANISMS 1- Viruses: Measles, mumps and influenza. 2- Bacteria: Meningococcus and syphilis. CLINICAL PICTURE 1- Sensori-neural hearing loss and tinnitus  unilateral or bilateral and partial or complete. 2- Vertigo and nystagmus may be present. TREATMENT 1. Of the causative organism  if possible. 2. Anti-vertigo (vestibular sedatives)  if necessary. 3. Vestibular rehabilitation exercises  if necessary. 4. Hearing aid  if necessary. Infection with the mumps virus is the most frequent cause of unilateral complete deafness in young children. Unilateral deafness in children often goes unnoticed by the child and by the parents. Audiologic tests during the course of the illness are therefore important. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Page | 65 THE EAR Chapter 4 Acoustic Neuroma ✓ DEFINITION A benign tumor which arises from Schwann cells of the vestibular division of the cochleovestibular cranial nerve. Therefore, it is better called vestibular schwannoma. ✓ INCIDENCE. Age 40 – 60 years. Side Unilateral, except in case of multiple neurofibromatosis. ✓ BEHAVIOUR Very slowly growing, Starts in the internal auditory canal  spreads to the cerebello pontine angle. ✓ CLINICAL PICTURE A. Otological phase Tumor within the internal auditory canal. 1. Unilateral persistent tinnitus  the earliest manifestation. 2. Unilateral slowly progressive sensori-neural hearing loss. 3. Dizziness is uncommon. Why? Because the tumor grows slowly  allows for central compensation to the unilateral lossof vestibular function. B. Neurological phase Tumor enters the cerebello-pontine angle. 1) Cranial nerves (V, VII, IX, X, XI and XII) palsies. The earliest sign is loss of the corneal reflex due to affection of the trigeminal nerve. 2) Cerebellar manifestations. ✓ INVESTIGATIONS 1. Audiological examination a) Pure tone audiometry  unilateral sensori-neural hearing loss. b) Speech audiometry  poor speech discrimination. c) Auditory brain stem response (ABR)  highly suggestive. 2. Nystagmography Reduced caloric response on the affected side. 3. CT scan and MRI Diagnostic. MRI is the best, because it can detect small tumors. ✓ TREATMENT: Surgical excision. Page | 66 THE EAR Chapter 4 Sudden SNHL is an ENT emergency. What is SNHL? SSNHL is Abrupt deterioration of hearing by 30 dB within 3 days. You should start treatment as soon as possible. What are the causes and how to treat? CAUSES: - The cause is not detected in most cases. - Traumatic: Acute acoustic trauma. Transverse temporal bone fracture. - Inflammatory: viral labyrinthitis, Meningitis. - Toxic: Ototoxicity - Vascular: Vascular spasm, embolism, thrombosis or labyrinthine hemorrhage. - Meniere's disease. - HOW to treat: Treatment of the cause Steroid therapy, high doses Vasodilators e.g histamine drip, inhalation of carbogen mixture (95% O2 and 5% CO2). How to differentiate between CD & SNHL? CD Pt. Voice Speech discrimination Recruitment TF test low good No - Rinne –ve - Weber lateralized to the side of CD - Air Bone gap PTA - The threshold of bone conduction is normal - The threshold of air conduction is elevated Tympanometry Different types according to the cause. SNHL loud Poor present - Rinne +ve (reduced) - Weber lateralized to the normal side - No air bone gap - Air &bone conduction thresholds are elevated normal Page | 67 THE EAR Chapter 5 VERTIGO Sensation of movement (usually in the form of rotation) either of the patient himself or his surroundings, due to a lesion of the labyrinth or of its central connections. Maintenance of equilibrium occurs in three steps How is normal equilibrium maintained? 1- Sensory information are sent from: o The vestibular part of the inner ear. o Vision. o Propioceptors of muscles, joints and tendons. 2- The brain integrates the information - 3- The brain sends motor orders to: The extra-ocular muscles to keep the eyeball stable. The spinal muscles to control the limbs and trunk. Taking history is the key step to diagnose the vertigo - Is it: true vertigo (sense of rotation) just pseudovertigo? central vertigo (nerologic synptoms) - - Is it Episodic? Associated symptoms: Otologic symotoms e.g (deafness, tinnitus, ear discharge) nausea, vomiting, diarrhea Neurological symptoms: headache, weakness, parasthesia, diplopia ataxia and Incoordination may suggest central cause Loss of consciousness? Should raise the possibility of epilepsy. History of: head trauma Drugs: tranquilizers, hypnotics, ototoxic drugs. The first step is to identify weather it is: Pseudo vertigo, central vertigo or Peripheral vertigo. Page | 68 THE EAR Chapter 5 - The patient may be found to suffer from: a) fainting sensation b) blacking out c) nausea d) even momentary loss of consciousness on getting out of bed. - It is due to: o Postural hypotension o Anaemia o Atherosclerosis - No otologic symptoms (deafness, tinnitus, ear discharge) No neurologic symptoms (cerebral or cerebellar) The patient is sent to the proper specialist. - ❖ The patient is suffering from: a) Dizziness b) Giddiness c) Unsteadiness d) Associated cranial nerves affection symptoms as dysarthria e) Associated cerebellar symptoms as gait disorder. ❖ The patient is sent to the Neurologist. a) It is suspected if the patient is suffering from rotatory sensation. b) No neurologic symptoms c) Usually associated with otologic symptoms (deafness, tinnitus, otorrhea). --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Page | 69 THE EAR Chapter 5 The second step is to differentiate the causes of peripheral vertigo Causes of vertigo Peripheral Central - due to affection of the vestibular nuclei or the vestibular connections in the brain stem or cerebellum. In the Labyrinth a. Meniere’s disease. b. Traumatic: fracture temporal bone (Transverse) labyrinthine membrane rupture c. Inflammatory: - It is associated with other Labyrinthitis neurologic manifestations. Vertebrobasilar insufficiency - viral: mumps, measles, influenza. Cerebrovascular strokes - Bacterial: Encephalitis, meningitis. Meningitis. Lateral medullary syndrome Complications of acute suppurative otitis (occlusion of posterior inferior media or cholesteatoma eroding the lateral cerebellar artery) semicircular canal. Basilar artery migraine. d. Degenerative: Multiple sclerosis. BPPV (benign paroxysmal Positional vertigo) Epilepsy. e. vascular: (of labyrinthine vessels) spasm thrombosis hemorrhage In vestibular nerve - vestibular neuronitis. Page | 70 THE EAR Chapter 5 How to examine a case of Vertigo? ⚫ ⚫ ⚫ - General examination: Blood pressure, pulse, pallor, ENT: examine the ear for otitis media, positive fistula sign Neurological examination: Examination of cranial nerves. Examination of Nystagmus: by Direct observation or Frenzel glasses In cerebellar lesions, nystagmus is coarse, slow, irregular and towards the side of the lesion. In the vestibular nystagmus consists of slow component (Vestibular) followed by a rapid component in the other direction (central). The Nystagmus is named according to the rapid component. What are the Investigations of a case of Vertigo? PTA. ABR. Hematological examination: Blood picture, serum cholesterol, triglycerides, urea, creatinine Radiological examination: for temporal bone internal auditory canal, cervical spines. Vestibular assessment: 1. Caloric Test. 2. Rotation Test. 3. Electronystagmography. - Benign Paroxysmal Positional Vertigo ❖ DEFINITION Recurrent transient attacks of vertigo in certain head positions as a result of degeneration of the vestibular sensory end organs. ❖ INCIDENCE The most common cause of vertigo. ❖ AETIOLOGY Unknown. May be head trauma or vascular disturbance. ❖ CLINICAL PICTURE 1- Recurrent sudden attacks of vertigo for seconds. They occur when the patient assumes certain positions as lying back or turning in bed 2- No hearing loss. Page | 71 THE EAR Chapter 5 ❖ INVESTIGATION Nystagmography Positive positional test. How? Transient vertigo and nystagmus occur when the patient is turned rapidly from the sitting position to the supine position with the head hanging and turned to one side. ❖ PROGNOSIS In most cases  the condition resolves spontaneously within few weeks i.e. it is benign. ❖ TREATMENT 1- Positional exercises  successful in most cases. 2- Surgical division of singular nerve (a branch of the vestibular nerve)  when persistent. Meniere’s Disease DEFINITION Distention of the membranous labyrinth due to increased volume of the endolymph i.e. endolymphatic hydrops. INCIDENCE - Frequency: Common cause of peripheral labyrinthine vertigo. - Age: 20 – 50 years. - Side: Unilateral but may become bilateral. AETIOLOGY Unknown  either 1- Decreased endolymph absorption  by the endolymphatic sac. 2- Increased endolymph production  due to increased capillary permeability as a result of endocrinal disturbance, autoimmune disturbance, sympathetic over-activity or allergy. SYMPTOMS (TRIADE) - Recurrent sudden attacks of a triad of symptoms  vertigo, hearing loss and tinnitus. - Each attack lasts for several minutes to several hours. 1- Vertigo  is usually associated with nausea, vomiting and sweating. Between the attacks  the patient is completely free. 2- Hearing loss and tinnitus  are initially reversible (i.e. fluctuant hearing loss), but later on they become permanent and progressive. Page | 72 THE EAR Chapter 5 SIGNS 1- Speculum examination: Normal tympanic membrane. 2- Tuning fork tests: Sensori-neural hearing loss. INVESTIGATIONS 1- Pure tone audiometry: Sensori-neural hearing loss. a) Initially  affects the low tones and is reversible. b) Later on  affects all tones and is irreversible. 2- Nystagmography: Reduced caloric response on the affected side. TREATMENT A- Medical treatment 1- Anti-vertigals (vestibular sedatives) as cinnerazine  during the attack. 2- Labyrinthine vaso-regulators as betahistine. 3- Labyrinthine decompressants as diuretics and salt restriction. B- Surgical treatment When medical treatment fails to control the disease  frequent incapacitating vertigo or progressive sensori-neural hearing loss. 1- When hearing is serviceable a) Decompression of the endolymphatic sac  to improve endolymph absorption. b) Selective section of the vestibular nerve i.e. vestibular neurectomy. 2- When hearing is not serviceable Surgical labyrinthectomy i.e. destruction of the membranous labyrinth. Vestibular neuritis ▪ ▪ ▪ It is characterized by sudden severe vertigo without deafness lasting for a few days. A viral cause is suspected. It is treated by antivertiginous drugs and vestibular rehabilitation exercise. Transverse temporal bone fracture ✓ CLINICAL PICTURE 1. History of trauma. 2. Sensori-neural hearing loss  due to injury of the cochlea and cochlear nerve. 3. Vertigo and nystagmus  due to injury of the vestibular labyrinth and vestibular nerve. 4. Facial nerve paralysis  common, immediate and complete. 5. Loss of consciousness  common. Page | 73 THE EAR Chapter 5 Serous and suppurative labyrinthitis - Complications of acute suppurative otitis media or cholesteatoma eroding the lateral semicircular canal. - SYMPTOMS The patient is bedridden closing his eys to avoid vertigo. 1) Hearing loss and tinnitus. 2) Continuous spontaneous severe vertigo, with nausea and vomiting. Haematogenous & Meningogenic Labyrinthitis - CLINICAL PICTURE 1- Sensori-neural hearing loss and tinnitus  unilateral or bilateral and partial or complete. 2- Vertigo and nystagmus may be present. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Page | 74 THE EAR Chapter 6 TRAUMATIC DISORDERS OF THE EAR A- TRAUMATIC DISORDERS OF THE AURICLE B-TRAUMATIC CONDITIONS OF EXTERNAL AUDITORY CANAL 1- Foreign Body (FB) Impaction: Glass bead Insect FB 2- Laceration Of the External Canal - AETIOLOGY 1- Self-inflicted Scratching the canal skin by an ear bud, hair grip, etc. 2- Iatrogenic Unskilled ear wash or instrumentation. - Clinically Mild bloody otorrhoea. - TREATMENT 1- Antibiotic ear drops. 2- Avoid entry of water into the external canal during head wash. By putting an ear plug or a piece of cotton soaked with an ointment. Page | 75 THE EAR Chapter 6 C- RUPTURE OF THE TYMPANIC MEMBRANE D- TRAUMATIC CONDITIONS OF THE MIDDLE EAR ❖ DEFINITION Middle ear trauma due to rapid & marked increase of the atmospheric pressure. ❖ PHYSIOLOGY At rest  the eustachian tube is closed. It opens only during swallowing and yawning to allow inflow of air into the middle ear. To equalize the middle ear and the atmospheric pressures. - - During airplane ascent  the atmospheric pressure decreases  the middle ear pressure becomes relatively positive. This can be easily corrected by  passive outflow of air from the middle ear along the eustachian tube. During diving and airplane descent  the atmospheric pressure increases  the middle ear pressure becomes relatively negative. This can be only corrected by  active opening of the eustachian tube (by swallowing) to allow inflow of air into the middle ear. Page | 76 THE EAR Chapter 6 ❖ AETIOLOGY Otitic barotrauma occurs when the patient fails to open the eustachian tube during diving or descent in a non-pressurized airplane. This may occur when: 1- the eustachian tube is obstructed e.g. due to upper respiratory infection or allergy 2- the patient does not swallow as during sleep ❖ PATHOGENESIS When the patient fails to open the eustachian tube during diving or descent in a nonpressurized airplane  air fails to enter the middle ear  rapid and marked decrease of the middle ear pressure  a) in mild cases  the tympanic membrane is retracted. b) in moderate cases  effusion or blood (haemo-tympanum) collects in the middle ear c) in severe cases  the tympanic membrane ruptures. ❖ SYMPTOMS 1- History of diving or flying. 2- Earache. 3- Hearing loss and tinnitus. ❖ SIGNS 1. Speculum examination the tympanic membrane: a. in mild cases  is retracted b. in moderate cases  shows signs of middle ear effusion or haemo-tympanum i.e. bluish tympanic membrane. c. in severe cases  is ruptured. 2. Tuning fork tests: Conductive hearing loss. ❖ INVESTIGATIONS 1- Pure tone audiometry Conductive hearing loss. 2- Tympanometry Type C in case of retracted tympanic membrane and Type B in case of middle ear effusion. Page | 77 THE EAR Chapter 6 ❖ PROPHYLAXIS 1- Avoid diving or flying with nasal obstruction. 2- Avoid sleeping during airplane descent. 3- Try to open the eustachian tube by repeated swallowing. This is aided by: a) chewing gum b) repeated auto-inflation of the middle ear by Valsalva’s maneuver i.e. forced expiration with both mouth and nose closed. c) use of vasoconstrictor nasal drops before flying  in case of rhinitis. ❖ TREATMENT 1. In mild cases (i.e. retracted tympanic membrane) a. Vaso-constrictor nasal drops  to reduce oedema around eustachian tube orifice. b. Auto-inflation of the middle ear by Valsalva’s manoeuvre. 2. In moderate cases (i.e. middle ear effusion) Myringotomy operation. 3. In severe cases (i.e. ruptured tympanic membrane) Similar to ruptured tympanic membrane. Page | 78 THE EAR Chapter 6 E- TRAUMATIC DISORDERS OF INNER EAR History of acoustic trauma. Sensori-neural hearing loss and tinnitus: 1) Temporary threshold shift i.e. it recovers spontaneously within 1 - 2 days. 2) Permanent threshold shift i.e. it is permanent. 1. History of trauma. 2. Sensori-neural hearing loss  due to injury of the cochlea and cochlear nerve. 3. Vertigo and nystagmus  due to injury of the vestibular labyrinth and vestibular nerve. 4. Facial nerve paralysis  common, immediate and complete. 5. Loss of consciousness  common. Page | 79 THE EAR Chapter 7 COMPLICATIONS OF OTITIS MEDIA COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA ❖ DEFINITION Spread of infection beyond the muco-periosteal lining of the middle ear cleft. ❖ AETIOLOGY 1- Cholesteatomatous chronic suppurative otitis media (commonest). 2- Acute suppurative otitis media, especially in children. 3- Acute exacerbation on top of tubo-tympanic chronic suppurative otitis media. ❖ TYPES - Mastoiditis. - Otitic labyrinthitis. - Otitic facial paralysis - Petrositis. - Extra-dural abscess. - Lateral sinus thrombo-phelibitis. - Meningitis. -Brain abscess. - Bezold’s abscess. ❖ ROUTES OF SPREAD OF INFECTION 1- Through bone: Bone erosion  by cholesteatoma and granulations. Preformed pathway  as congenital dehiscence, fracture line or opening in bone by previous surgery. Anatomical opening  as the oval window and round window (to the labyrinth). 2- Through veins: By retrograde thrombo-phlebitis of the draining veins. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Page | 80 THE EAR Chapter 7 COMPLICATIONS OF OTITIS MEDIA 1) 2) 3) 4) Mastoiditis (See page 24). Otitic Facial Nerve Paralysis (See page 94). Otitic Labyrinthitis (See page 62) Petrositis (See page 41) 1- Extradural abscess DEFINITION Collection of pus between the dura mater and adjacent temporal bone. CLINICAL PICTURE 1) Most cases are asymptomatic  are accidentally discovered during mastoidectomy. 2) Persistent ipsilateral temporal headache. 3) Low grade fever 4) Otorrhoea, hearing loss and tinnitus  due to chronic suppurative otitis media. 5) The discharge may be pulsating due to exposure of the dura. INVESTIGATIONS 1- CT scan & MRI Diagnostic. 2- Culture and sensitivity tests of the ear discharge. TREATMENT Medical