PANCE Blueprint EENT (6%)

Inner ear (PEARLS)

PANCE Blueprint EENT (6%)

NCCPA™ PANCE EENT Content Blueprint ⇒ ear disorders ⇒ inner ear

Acoustic neuroma	Patient will present as → a 42-year-old male with a history of neurofibromatosis type II, complaining of nausea, vomiting, headache, continuous disequilibrium, and a slowly progressive unilateral hearing loss in his right ear. On physical exam, the patient has decreased sensation to touch on the right side of his face. An MRI is performed, with results seen here. Benign tumor of the Schwann cells (the cells which produce myelin sheath) – most commonly affects the vestibular division of the 8th cranial nerve. Slowly progressive unilateral hearing loss, tinnitus, and disequilibrium DX: Definitive diagnosis is by MRI (Gold standard) An audiogram is the first test done during a physical examination to diagnose acoustic neuroma. It usually reveals an asymmetric sensorineural hearing loss and a greater impairment of speech discrimination than would be expected for the degree of hearing loss. TX: Surgery or stereotactic radiation therapy
Barotrauma	Patient will present as → a 17-year-old male who returned from a senior class trip to Mexico. While there, they decided to take scuba classes. After 3 days of shallow diving, they attempted their first 100-foot dive. After 5 minutes on their second dive, his equipment failed. He quickly shared the working breathing equipment of his friend, and they rose rapidly to the surface in a panic for air. The patient noticed immediate pain in his right ear, which resolved somewhat when he forcefully yawned and heard a “pop.” Since then, he reports dizziness and hearing loss in the affected ear. Barotrauma is injury from failure to equalize pressure across air-filled spaces, most commonly involving the middle ear due to Eustachian tube dysfunction Involves increased ambient pressure during descent leading to inability of the Eustachian tube to equalize pressure, creating negative pressure that pulls the tympanic membrane inward (“vacuum effect”), resulting in pain, edema, and possible bleeding or rupture Triggered by pressure changes such as flying or diving, especially during descent, with higher risk in patients with URI, allergies, or sinus congestion Most commonly affects the middle ear, but can also involve the paranasal sinuses, while inner ear involvement with perilymph fistula represents a severe complication Patients develop ear pain, fullness, hearing loss, and tinnitus, and the presence of vertigo is a red flag suggesting inner ear injury Exam shows a retracted tympanic membrane with decreased mobility, while severe cases may demonstrate hemotympanum or perforation Key distinguishing feature is the onset with pressure changes without infectious symptoms, helping differentiate from otitis media DX: Diagnosed clinically by trigger + symptoms Otoscopy may show TM retraction/hemorrhage/perforation TX: Prevention includes Valsalva maneuver, swallowing, or yawning during pressure changes, along with avoiding flying or diving when congested Pseudoephedrine or Afrin can be good for prophylaxis – you must be careful when recommending this to divers, depending on dive times ENT referral for severe symptoms such as vertigo or hearing loss, while tympanic membrane rupture is usually managed conservatively with dry ear precautions Dive hand signal-ear.plain.svg" by Thomei08 licensed under CC BY-SA 3.0 via Wikimedia Commons.
Dysfunction of the eustachian tube	Patient will present as → a 9-year-old female with right otalgia and a nonproductive cough for one day. The patient complains of constant ear popping and fluctuating conductive hearing loss with tinnitus. The patient has no significant past medical history, her immunizations are up to date, and both of her parents are non-smokers. On otoscopic examination, the tympanic membranes are grey with normal landmarks, including visualization of the middle ear ossicles. There is no evidence of bulging pus or exudate suggestive of an acute inflammatory process. Ear fullness, popping of ears, underwater feeling, intermittent sharp ear pain, fluctuating conductive hearing loss, and tinnitus. All children < 7 years old have some ET dysfunction (based on the angle of the Eustachian tube), which will resolve with age DX: An excellent otoscopic exam is the key to making this diagnosis – otoscopic findings are usually normal. May see fluid behind the TM if acute serous otitis media The definitive diagnosis is with a tympanogram TX: Often, no treatment is necessary Ibuprofen prn for pain Nasal steroids can be prescribed in more severe cases Systemic decongestants, such as pseudoephedrine or phenylephrine, may be helpful for nasal congestive symptoms Surgery is generally indicated when medical management fails
Labyrinthitis	Patient will present as → a 57 yo female with a six-day history of severe continuous dizziness associated with ataxia and right-sided hearing loss. She had an upper respiratory tract infection one week ago. Acute onset, continuous vertigo + hearing loss, tinnitus of several days to a week Associated with viral URI and an absence of neurologic deficits Associated with nausea and vomiting DX: Labyrinthitis is a clinical diagnosis in the absence of neurologic deficits May have a positive Romberg test - fall to the side of the affected ear Rule out other etiologies with imaging, audiograms, TSH levels MRI is required for patients with acute sustained vertigo whose examination is not entirely consistent with labyrinthitis, or in patients who are older (>60 years), or have a headache, any focal neurologic signs, or vascular risk factors TX: Vestibular suppressants (meclizine) and antiemetics (ondansetron or promethazine) to limit symptoms in the first 24 to 48 hours A 10-day course of prednisone: 60 mg daily on days 1 through 5, 40 mg on day 6, 30 mg on day 7, 20 mg on day 8, 10 mg on day 9, and 5 mg on day 10 Symptoms regress after 3-6 weeks Labyrinthitis is associated with CONTINUOUS vertigo along with hearing loss +/- tinnitus and is usually associated with an upper respiratory infection. This differentiates it from Meniere’s syndrome, which is EPISODIC and not typically associated with a viral infection. The features of acute labyrinthitis are similar to those of vestibular neuronitis, except labyrinthitis includes significant sensorineural hearing loss, which is NOT present in vestibular neuronitis.
Vertigo (ReelDx)	ReelDx Virtual Rounds (Vertigo ) Vertigo You are called to see a 55 y/o male with dizziness Patient Gender: Male Age: 77 years Weight: 181 lb/82.1 kg Height: 67.7 in/172 cm Vitals Temperature: 98.3 F/36.8 C Blood Pressure: 107/63 Heart Rate: 68 Respiratory Rate: 18 Pulse Oximetry: 97% RA Signs and Symptoms Dizziness with supine positioning; home blood pressure 80/50 supine Click here to work through this patient case simulation. Patient will present as → a 29-year-old male with intense nausea and vomiting that began yesterday. He states that he ran a 5K race in the morning and felt well while resting afterward. However, when he arose, he experienced two episodes of emesis accompanied by a sensation that the world was spinning around him. This lasted about one minute and subsided. He denies tinnitus or hearing changes but feels imbalanced. He has a PMH of migraines, but he typically does not have nausea or vomiting with migraine episodes. His temperature is 98.7°F, blood pressure is 132/82 mmHg, pulse is 75/min, and respirations are 13/min. The cardiopulmonary exam is unremarkable. Cranial nerves are intact, and gross motor function and sensation are within normal limits. When the patient’s head is turned to the right side and lowered quickly to the supine position, he claims that he feels “dizzy and nauseous.” Nystagmus is noted in both eyes. The sensation of movement (spinning, tumbling, or falling) in the absence of actual movement or an overresponse to movement Duration and presence of hearing loss or nystagmus can help with diagnosis and differentiation between central vertigo and peripheral vertigo Central vertigo Gradual onset, continuous nausea or vomiting, vertical nystagmus, no auditory symptoms; motor, sensory, or cerebellar deficits + Romberg Sign Etiology: brainstem vascular disease, arteriovenous malformations, multiple sclerosis, vertebrobasilar migraine, brain tumor, head injury, medications Peripheral vertigo (inner ear) Sudden onset, intermittent nausea/vomiting, tinnitus, hearing loss, nystagmus (horizontal with rotary component) Etiology: labyrinthitis, benign paroxysmal positional vertigo, endolymphatic hydrops (Ménière syndrome), vestibular neuritis, and head injury + Dix Hallpike DX: Dix-Hallpike maneuver Nonfatigable nystagmus = central cause Audiometry, caloric stimulation, ENG, MRI, evoked potentials Treatment: Peripheral - treat with Epley's maneuver. Vestibular suppressants help with acute symptoms: diazepam (Valium), meclizine Central—treat the source

Clinical features of peripheral versus central vertigo

	Peripheral	Central
Nystagmus
Features (direction and type)	Unidirectional, fast component toward the normal ear; never reverses direction Horizontal with a torsional component; never purely torsional or vertical	Sometimes reverses direction when patient looks in the direction of slow component Can be any direction; note that purely vertical or purely torsional nystagmus is a central sign
Effect of visual fixation	Suppressed	Not suppressed
Postural instability	Unidirectional instability, walking preserved	Severe instability, patient often falls when walking
Deafness or tinnitus	May be present	Usually absent
Other neurologic signs and symptoms	Absent	Often present (eg, diplopia, ataxia, dysarthria, dysphagia, focal or lateralized weakness)

Differential Diagnosis of Peripheral Vertigo & Ear Disorders

Disease	Pathophysiology & Characteristics	Symptoms	Diagnostic Test	Treatment
BPPV	Otoliths (crystals) displaced into semicircular canals; triggered by head movement.	Brief episodes of vertigo (seconds); No hearing loss or tinnitus.	Dix-Hallpike maneuver (observing nystagmus).	Epley maneuver (canalith repositioning); Meclizine is rarely effective.
Vestibular Neuritis	Inflammation limited to the vestibular nerve (the part of CN VIII responsible for balance); often follows viral URI.	Single acute episode of continuous vertigo; No hearing loss or tinnitus.	Clinical diagnosis; Head-impulse test.	Supportive (Meclizine, anti-emetics); Steroids.
Labyrinthitis	Inflammation affects the entire labyrinth (the "room" that houses both balance organs and the cochlea); often post-viral.	Continuous vertigo PLUS hearing loss and tinnitus.	Clinical diagnosis; Audiometry.	Meclizine + Steroids; Antibiotics if bacterial.
Meniere’s Disease	Endolymphatic hydrops (increased fluid pressure in the inner ear).	Episodic vertigo (hours), fluctuating hearing loss, tinnitus, and ear fullness.	Clinical; Audiometry shows low-frequency loss.	Low-salt diet, avoid caffeine/alcohol/nicotine, Diuretics.
Acoustic Neuroma	Benign tumor on CN VIII; associated with NF2 if bilateral.	Progressive unilateral hearing loss, tinnitus, ataxia, and facial numbness.	MRI of the Internal Auditory Canal (IAC).	Surgery or Radiation (Gamma Knife).

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