PANCE Blueprint EENT (7%)

Ear Disorders (PEARLS)

NCCPA™ PANCE EENT Content Blueprint  ear disorders

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 the 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


  • 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

DX: Diagnosis is clinical by otoscopy


  • Topical therapy, anti-yeast for Candida or yeast: 2% acetic acid 3–4 drops QID; clotrimazole 1% solution; itraconazole oral

Otitis externa

Erythema, edema, and purulent drainage due to otitis externa

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 to the external ear may result in hematoma, laceration, avulsion, or fracture

Subperichondrial hematoma (cauliflower ear)

  • Blunt trauma to the pinna may cause a subperichondrial hematoma and accumulation of large amounts of blood between the perichondrium and cartilage
  • This can interrupt the blood supply to the cartilage and render all or part of the pinna a shapeless, reddish-purple mass
  • Avascular necrosis of the cartilage may follow
  • The resultant destruction causes the characteristic cauliflower ear of wrestlers and boxers

Lacerations: Lacerations can be partial, or it may go all the way through the ear (complete)

Avulsions: The ear may be torn away from the head (avulsion). An ear may be partially or completely torn

Fractures: A forceful blow to the jaw may break (fracture) the bones around the ear canal and distort the canal’s shape, often narrowing it


The diagnosis of auricular hematoma is made by the characteristic clinical appearance in patients with a history of blunt trauma to the auricle

  • Temporal bone CT without contrast, including fine axial and coronal cuts, for patients with head trauma and/or who may require operative intervention
  • Tests for hearing may be warranted


  • The most appropriate course of action for this patient is to refer immediately for I & D by an ENT specialist for the best results
  • The cartilage of the pinna requires vascular supply from the perichondrium. If deprived of blood, the devascularized tissue can become permanently damaged, resulting in the so-called “cauliflower ear”

Hematoma ear

Acute hematoma of the right ear


Cauliflower 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 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

Blausen 0009 AcousticNeuroma

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. Described as a 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

Dive hand signal-ear.plain

Diving is a common cause of barotrauma

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 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

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 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


  • 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.
ReelDx Virtual Rounds (Vertigo )
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

Peripheral vertigo (inner ear)


  • Dix-Hallpike maneuver
    • Nonfatigable nystagmus = central cause
  • Audiometry, caloric stimulation, ENG, MRI, evoked potentials


  • Peripheral - treat with Epley's maneuver. Vestibular suppressants help with acute symptoms: diazepam (Valium), meclizine
  • Central—treat the source
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 is currently 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, injection of TM, and pus.

  • A key finding is the 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

Acute Otitis Media Stage of Resolution

Bulging, loss of landmarks, redness, and injection of TM, and pus

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, which should be used if you are going to be prescribing drops with a perforated TM
  • Surgery if it 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 the underlying cause, hearing aids, surgery, cochlear implants

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
Patient will present as → 41-year-old female with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.

Ménière syndrome is a disorder of the endolymphatic compartment with the classic triad of episodic vertigo, unilateral low-frequency sensorineural hearing loss, and tinnitus.

"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 on 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

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 is often described as 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

Foreign body in ear (ReelDx)
ReelDx Virtual Rounds (Foreign body in ear)

A foreign body in the ear is any object that gets stuck in the ear canal. This can include anything from small objects like beads and toys, to insects and food particles.

  • Patients may be asymptomatic or present with otalgia, hearing loss, bleeding, and discharge from the ear

DX: On exam, the provider should visually inspect the ear canal with an otoscope. This may reveal swelling, abrasions, and the foreign body itself

  • Foreign bodies can sometimes be difficult to visualize, so a normal-appearing exam does not exclude their presence

TX: Removal should be attempted under direct visualization using warm irrigation with a syringe or instruments like an alligator forceps or a right-angle hook

  • Referral to ENT is recommended if removal attempts are unsuccessful
  • Complications include canal lacerations, tympanic membrane perforations, and external auditory canal infections. Therefore prompt removal is ideal
  • Patients should follow up to ensure the foreign body has been fully removed
Ocular Foreign body (ReelDx) (Prev Lesson)
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