PANCE Blueprint EENT (7%)

Ear Disorders (PEARLS)


Cerumen Impaction 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)

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

Otitis externa 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

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 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
  • Diagnose with MRI

TX: Surgery or stereotactic radiation therapy

Barotrauma 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"

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 eustachian tube 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

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

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 Duration and presence of hearing loss/nystagmus can help with 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 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

TX: Surgical removal

Otitis media 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

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

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 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 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 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

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

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.
Tinnitus 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

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 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 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 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 (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Disorders of the Ear Part One and Two
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