PANCE Blueprint EENT (7%)

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

  • Cerumen may be pushed further into the ear canal and accumulate during patients' attempts to clean the ear canal with cotton swabs, resulting in obstruction or impaction

Rinne and Weber Tests

Conductive loss

  • Abnormal Rinne test—bone conduction is better than air conduction – b/c bone conduction bypasses problems in the external or middle ear
  • Weber—sound lateralizes to the affected side (tuning fork is perceived more loudly in the ear with a conductive hearing loss) – b/c compensatory neural mechanisms or mechanical factors increase the perceived volume on the side of the conduction problem

Sensorineural loss

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

Diagnosis is clinical by otoscopy

Cerumen impaction is best treated by irrigation after several days of softening with carbamide peroxide (Debrox) or triethanolamine (Cerumenex)

  • Carbamide peroxide (Debrox) - apply 5 to 10 eardrops twice daily up to four days, keeping drops in the ear for several minutes by keeping the head tilted and placing cotton in the ear
  • In patients with recurrent cerumen impaction and no significant ear disease - a cotton ball dipped in mineral oil and placed in the external canal once per week to help liquefy cerumen and aid the normal elimination mechanism

Question 1
A 35-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. Which of these other physical exam findings is to be expected?
A
cerumen impaction in the right ear
B
effusion in the left ear
Hint:
An effusion or otitis media could potentially cause a conductive hearing loss in the affected ear. The Weber test will lateralize to the left ear and bone conduction will be longer than air conduction in the left ear.
C
otitis media in the left ear
Hint:
See B.
D
pain on palpation of tragus or mastoid area
Hint:
Otitis externa and mastoiditis are not associated with hearing loss.
Question 1 Explanation: 
Cerumen impaction will block the ear canal. This would result in lateralization of the Weber test to the affected ear and would also cause bone conduction to be greater than air conduction in the same ear.
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References: Merck Manual · UpToDate

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