PANCE Blueprint EENT (7%)

Inner ear (PEARLS)

NCCPA™ PANCE EENT Content Blueprintear 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 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

Acoustic Neuroma

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

Image by Lecturio

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


  • 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 )
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

Clinical features of peripheral versus central vertigo

  Peripheral Central
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)
Disease Characteristics Symptoms Diagnostic Test Treatment
Benign positional vertigo Changes with position Vertigo without hearing loss, tinnitus, or ataxia MRI of the internal auditory canal Diagnosis: Dix-Hallpike maneuver

Treatment: Epley maneuver


Vestibular neuritis Vertigo without position changes Vertigo but no hearing loss or tinnitus (inflammation of vestibular portion of CN VIII) associated with URI Meclizine
Labyrinthitis Acute, self-resolving episode Continuous Vertigo

Hearing loss



Associated with URI

Meclizine + steroids
Meniere's disease Chronic remitting and relapsing episodes Episodic Vertigo

Hearing loss

Tinnitus and chronic remitting and relapsing manner

Not associated with URI


Salt restriction

Unilateral CN VIII ablation (severe cases)

Acoustic neuroma Ataxia

Neurofibromatosis type II

MRI findings

Facial numbness


Unilateral hearing loss

Tinnitus AND ataxia

Surgical intervention
External Ear Trauma (Prev Lesson)
(Next Lesson) Acoustic neuroma
Back to PANCE Blueprint EENT (7%)