PANCE Blueprint EENT (7%)

Ear Disorders (PEARLS)

Cerumen Impaction
Patient will present as → a 25-year-old patient presents with unilateral hearing loss. Weber reveals lateralization to the right ear. Rinne test reveals the following: RIGHT: bone conduction = 10 seconds, air conduction = 5 seconds; LEFT: bone conduction = 5 seconds, air conduction = 10 seconds.

Cerumen impaction—buildup obstructs the auditory canal and is the most common cause of conductive hearing loss

  • Abnormal Rinne test—bone conduction is better than air conduction
  • Weber—sound lateralizes to the affected side (tuning fork is perceived more loudly in the ear with a conductive hearing loss)

DX: Diagnosis is clinical by otoscopy

TX: Irrigation after several days of softening with carbamide peroxide (Debrox) or triethanolamine (Cerumenex)

Otitis externa
Patient will present as → a 4-year-old girl who is brought to the clinic by her mother who states that the child has been complaining of progressively worsening ear pain and itchiness over the past week. Examination reveals left tragal tenderness and an edematous and closed canal. Weber lateralizes to the left.

Bacterial otitis externa "swimmer's ear"

  • Edema with cheesy white discharge, palpation of the tragus is painful
  • Ear pain especially with movement of tragus or auricle, pain with eating
  • Tuning fork - bone conduction > air conduction
  • Pseudomonas aeruginosa (swimmer’s ear), S. aureus (digital trauma)
  • Malignant otitis externa is commonly seen in diabetics

DX: Diagnosis is clinical by otoscopy

TX:

  • If perforated or chance of perforation: Ciprofloxacin 0.3% and dexamethasone 0.1% suspension: 4 drops BID × 7 days or ofloxacin: 0.3% solution 10 drops once a day × 7 days
  • Cortisporin otic drops

Fungal otitis externa

  • Pruritus, weeping, pain, hearing loss
  • Swollen, moist, wet appearance
  • Aspergillus niger (black), A. flavus (yellow) or A. fumigatus (gray), Candida albicans

TX:

  • Topical therapy, anti-yeast for Candida or yeast: 2% acetic acid 3–4 drops QID; clotrimazole 1% solution; itraconazole oral
Acoustic neuroma
Patient will present as → a 42-year-old male with a history of neurofibromatosis type II complains of nauseavomitingheadachecontinuous 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 this 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 8'th 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 presents with ear pain and hearing loss that persists past the inciting event, associated with pressure changes

  • A common injury in divers or while flying, sudden onset of pain that may resolve with a "pop"

DX: clinical diagnosis but sometimes requires imaging tests

  • On exam will see signs of trauma without signs of infection – redness without building, pus, or effusion

TX: Supportive (anti-inflammatories) then consider prophylaxis

  • Pseudoephedrine or Afrin can be good for prophylaxis – you must be careful when recommending this to divers, depending on dive times
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 popping in her ears and a 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, tinnitus.

  • All children < 7 years old have some ET dysfunction (based on the angle of the eustachian tube) 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 TM if acute serous otitis media

  • The definitive diagnosis is with a tympanogram

TX: Often no treatment is necessary

  • Ibuprofen prn 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 → 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 an absence of neurologic deficits
  • Associated with nausea and vomiting

DX: Labyrinthitis is a clinical diagnosis in 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

TX:

  • Diazepam or meclizine for vertigo, promethazine for nausea
  • 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 Virtual Rounds (Vertigo )

Duration and presence of hearing loss/nystagmus can help with the diagnosis

Central vertigo - more gradual onset and vertical nystagmus. Unlike peripheral vertigo, it does not present with auditory symptoms. Romberg Sign

Peripheral vertigo (inner ear) - sudden onset, nausea/vomiting, tinnitus, hearing loss, and horizontal nystagmus

  • Labyrinthitis, benign paroxysmal positional vertigo, endolymphatic hydrops (Ménière syndrome), vestibular neuritis, and head injury
  • Benign Positional VertigoDix Hallpike for diagnosis, treat using Epley's maneuver
Cholesteatoma
Patient will present as→ a 43-year-old male with a “lifelong” history of chronic ear infections and episodic purulent drainage from his right ear canal. The patient currently is without symptoms. Examination of the ear shows a clear external canal, but the tympanic membrane is retracted and there is a pocket of white material and an opacity of the pars flaccida. The Weber test lateralizes to the right and Rinne shows air conduction > bone conduction on the left and bone conduction > air conduction on the right. Preparations are made to undergo a non-contrast computed tomography (CT) scan of the temporal bone.

Cholesteatoma presents with painless otorrhea, brown/yellow discharge with a strong odor

  • Caused by chronic eustachian tube dysfunction which results in chronic negative pressure and inverts part of the TM causing granulation tissue that over time, erodes the ossicles and leads to conductive hearing loss

DX: Diagnosis can be made with otoscopic visualization of granulation tissue

  • Confirm with CT scan and audiogram to evaluate hearing loss

TX: Surgical removal

Otitis media
ReelDx Virtual Rounds (Otitis media)
Patient will present as → a 3-year-old previously healthy male is brought to your office by her mother. The mother reports the child has been crying and pulling at her right ear over the past 2 days and reports the patient has been febrile the past 24 hours. The patient’s past medical history is unremarkable, although the mother reports the patient had a “common cold” a week ago which resolved without intervention. His temperature is 101.6 F, blood pressure is 100/70 mmHg, pulse is 120/min, and respirations are 22/min. The otoscopic exam is seen here.

The clinical diagnosis of AOM requires 1) bulging of the tympanic membrane or 2) other signs of acute inflammation (eg, marked erythema of the tympanic membrane, fever, ear pain) and middle ear effusion

  • Age two and under limited mobility of the TM with pneumotoscopy
  • S. pneumoniae 25%, H. influenzae 20%, M. catarrhalis 10%
  • Tuning fork: bone conduction > air conduction

DX: Otoscopic examination may reveal bulging, loss of landmarks, redness, and injection of TM, pus. 

  • A key finding is limited mobility of the TM with pneumotoscopy
  • Building and eventual rupture of the TM can occur as well, leading to otorrhea and abruptly decreased pain

TX: First line amoxicillin, second-line augmentin, macrolides if penicillin-allergic

  • Treat < 2 y for 10 days and > 2 y for 5-7 days
  • Recurrent: tympanostomy, tympanocentesis, myringotomy
  • Complications: Mastoiditis and bullous myringitis
Tympanic membrane perforation
ReelDx Virtual Rounds (Tympanic membrane perforation)
Patient will present as → a 9-month-old female with nasal congestion and cough is brought to your clinic by her mother who reports that the child is very fussy, has been tugging at her right ear, and refuses to eat. On physical exam, you note copious green/yellow nasal discharge and right-sided otorrhea. An otoscopic exam reveals a significant amount of clear/white discharge obstructing your view. With careful examination, you are able to observe a ruptured right tympanic membrane. 

Tympanic membrane perforation presents with pain, otorrhea, and hearing loss/reduction

Diagnosis is based on otoscopy

TX: Most heal spontaneously, keep clean and dry, treat with antibiotics

  • The only class of antibiotics that are non-ototoxic are the Floxin drops and should be used if you are going to be prescribing drops with a perforated TM
  • Surgery if persists past 2 months
Hearing impairment
Patient will present as → a 72-year-old male with a progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 14/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient’s forehead, the sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. (presbycusis)

Hearing loss can be classified as conductive, sensorineural, or both (mixed loss)

Rinne and Weber Tests

Conductive loss

  • Abnormal Rinne test—bone conduction is better than air conduction
  • Weber—sound lateralizes to the affected side (tuning fork is perceived more loudly in the ear with a conductive hearing loss)

Sensorineural loss

  • Normal Rinne test—air conduction is better than bone conduction
  • Weber—sound lateralizes to the unaffected side

Sensorineural hearing loss

  • Presbycusis (most common cause): Gradual, symmetric hearing loss associated with aging— the most common cause of diminished hearing in elderly patients - degeneration of sensory cells and nerve fibers at the base of the cochlea
  • Noise-induced, infection, drug-induced, congenital, Meniere disease, CNS lesions

Conductive hearing loss

  • Cerumen impaction, otitis externa, exostoses (bony outgrowths of external auditory canal related to exposure to cold water)
  • Tympanic membrane perforation
  • Otitis media, otosclerosis, neoplasms

TX: Treat underlying cause, hearing aids, surgery, cochlear implants

Mastoiditis
ReelDx Virtual Rounds (Mastoiditis )
Patient will present as → a 10-year-old boy with otalgia, worsening over the last 5-days and associated with nasal congestion. The patient is afebrile with a temperature of 98 ° F. Examination reveals edema of the external auditory canal producing an anterior and inferior displacement of the auricle with percussion tenderness posteriorly. 

A complication of acute otitis media. Fever, otalgia, pain & erythema posterior to the ear, and forward displacement of the external ear

  • Organisms: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, S. pyogenes

DX: clinical; CT scan temporal bone with contrast for complicated/toxic appearing

TX: IV antibiotics (ceftriaxone), drainage of middle ear fluid

Meniere disease
ReelDx Virtual Rounds (Foreign body in ear)
Patient will present as → 41 yo female presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.

Vertigo attacks lasting hours, classic triad of low-frequency hearing loss, tinnitus with aural (ear) fullness, and episodic vertigo

"Meniere's disease is associated with EPISODIC vertigo and NOT associated with viral infections. This differentiates it from Labyrinthitis which is associated with CONTINUOUS vertigo along with hearing loss +/- tinnitus and is usually associated with an upper respiratory infection."

DX: Although audiometric testing is a required part of the diagnostic evaluation, there is no specific diagnostic test for MD

  • Imaging ( MRI with gadolinium enhancement), although not required for the diagnosis of MD, is frequently performed to exclude important disorders that can present with similar symptoms.

A clinical diagnosis of MD is made based upon the following criteria:

  • Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours
  • Audiometrically documented low- to mid-frequency sensorineural hearing loss in the affected ear
  • Fluctuating aural symptoms (reduced or distorted hearing, tinnitus, or fullness) in the affected ear
  • Symptoms not better accounted for by another vestibular diagnosis

TX: Low salt diet, diuretics (HCTZ + triamterene) to reduce aural pressure

Tinnitus
Patient will present as→ a 70-year-old female who states that her children and grandchildren have asked her to seek medical attention as she seems to be losing her hearing.  She also describes an occasional ringing, buzzing, and hissing sound. She is in generally good health and her only medications are a multivitamin along with calcium and vitamin D. You examine her ears and find the external auditory canals to be free of cerumen and the tympanic membranes to be normal in appearance.

A perceived sensation of sound in the absence of an external acoustic stimulus; often described as a ringing, hissing, buzzing, or whooshing.

  • 90% are associated with sensorineural hearing loss – caused by loud noise, presbycusis, medications (aspirin, antibiotics, aminoglycosides, loop diuretics, and CCBs), Meniere's disease, acoustic neuroma

DX: All patients with significant tinnitus should be referred for comprehensive audiologic evaluation to determine the presence, degree, and type of hearing loss.

  • In patients with unilateral tinnitus and hearing loss, acoustic neuroma should be ruled out by gadolinium-enhanced MRI
  • In patients with unilateral tinnitus and normal hearing and physical examination, MRI is not necessary unless tinnitus persists > 6 mo

TX: No pharmacologic agent has been shown to cure or consistently alleviate tinnitus

  • The goal is to try to identify the cause, i.e remove ototoxic medications, hearing aids
External Ear Trauma
Patient will present as → a 17-year-old on the high school varsity wrestling team who was injured during a match. On physical exam, you note a fluctuant, tender edematous lesion of the anterior-superior outer portion of the right pinna

Trauma includes hematoma, laceration, avulsion, and fracture

  • Subperichondrial hematoma (cauliflower ear): blunt trauma to pinna may ⇒ subperichondrial hematoma and accumulation of blood between perichondrium and cartilage; can interrupt blood supply to cartilage and render all or part of pinna shapeless, reddish-purple mass ⇒ avascular necrosis of cartilage ⇒ cauliflower ear
  • Laceration: can be partial or all the way through the ear
  • Avulsion: ear may be torn away from the head
  • Fracture: a forceful blow to the jaw may fracture bones around the ear canal and distort the canal’s shape, narrowing it

DX: of auricular hematoma made by the characteristic clinical appearance in pt with a history of blunt trauma to the auricle

  • Temporal bone CT without contrast for a pt with head trauma
  • Hearing tests

TX:

  • Cauliflower ear: refer immediately for I&D by ENT specialist ⇒ can result in permanent damage; prone to infection/abscess formation ⇒ oral antibiotic against staph (Keflex x 5 days)
  • Laceration: meticulous debridement of devitalized tissue and prophylactic abx; wounds < 12hrs can be closed but older wounds should heal secondarily with cosmetic deformities treated later
    • Laceration of pinna = skin margins sutured whenever possible
    • Cartilage penetration: externally splinted with benzoin-impregnated cotton with protective dressing; oral antibiotics
    • Human bite: high-risk infection; potentially severe complications
  • Avulsion: repaired by an otolaryngologist or facial plastic surgeon
  • Fracture: surgical correction of the shape
Ocular Foreign body (ReelDx) (Prev Lesson)
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