Hx and PE - Ear
Acute Infection
Note the bulging of the tympanic membrane due to pressure from purulence (pus) behind it.
Normal eardrum
Notice the different shades of color yet the eardrum still remains an opaque translucent appearance
Normal eardrum (tympanic membrane)
Shiny and translucent, with pearly gray color
Type As
Stiffened middle ear system normal shape normal peak pressure low peak admittance (<.3 mL)
Acute OM: Agents
Strep H. flu M. cat Viral (can't distinguish)
microtia
gross hypoplasia of the pinna typically bilateral; auditory canal may or may not be open, may have a functioning cochlea that can be surgically corrected
children who present with moderate to severe bulging of the TM or new onset of otorrhea no due acute otitis externa
dx: acute otitis media AOM
what are many middle ear problems due to?
dysfunction of the eustatian tube (unable to equilibrate pressure between two cavities)
otitis externa
ear canal and pina external to the tympanic bulla
Type B with small physical volume
ear canal obstruction or misplaced probe tip
otalgia
ear pain
Otalgia
ear pain that may be caused directly by ear desease or may be referred pain from a problem in teeth or oropharynx
ENT
ear, nose, throat
tympanic membrane tissue
ectoderm, mesoderm and endoderm ectoderm: squamous epithelium layer if perforation sometimes only the epithelial (squamous) ectoderm heals. "monomeric membrane"
adiogram
graphic recording of hearing
Pure tones are
graphic waves to represent sound waves
otoscope
grasp auricle and have pt tilt head to opposite side. pull helix up, back and slightly out
compression
increase in sound pressure. peak-positive darker are on speech factor
Type B with normal physical volume
intact tm no ear canal obstruction no mobility of TM/ ME
External auditory meatus
intact, no lesions or keloids
loudness correlates with?
intensity (dB)
In SRT, what are you looking for?
lowest level at which speech can be understood or recognized 50% of the time. good for kids/ppl who cant do pure tone tests.
causes of external ottis?
maceration of skin (moisture) or damage to skin
example of a sensoneural hl
loud earphone damage this type of hl has equal thresholds. not repairable. say a cochlear implant could treat it, but not fixing it
eustachian tube dysfunction and OME with pneumatic otoscopy
movement only with negative pressure
gram negative rods =
much harder to treat situation this is why you need to do a gram stain
Fordyce Spots
mucosal sebaceous cysts small white or yellow spots on mucosa of lip, cheek, tongue painless, nonpathologic
Otitis is a ___ problem
multifactorial
tympanic membrane
pearly grey, clear and vascular with cone of light at 4 o-clock in right ear and 7 o-clock in left handle of malleolus also seen
positive fistula test
pressure on the tragus results in vertigo or eye deviation by inducing movement of the perilymph
prominent landmarks
refraction of drum-low pressure in middle ear from obstruction of eustachian tube
Peak Pressure
related to air pressure in the middle ear
causes of sensorineural loss
sustained exposure to loud noise, headphones use constantly, ototoxicity (damage to ear) due to drugs, syphilis, DM
what temperature is considered a fever
99.7
Negative pressure
<-150 daPa -reflects middle ear pressure negative relative to outer air pressure - usually eustachian tube dysfunction
Low Peak Admittance
<.3 -reflects low compliance or stiffness of middle ear system
Treatment Duration
</= 2 years --> 5-7 days > 2 years --> 10 days If using abx tx and no improvement after 48-72 hrs, change therapy
High Peak Admittance
>2.0 -reflects excessive compliance or flaccidity ofTM/ossicles
Exotosis
?
slope of the audiogram
?
Darwin's tubercle
A small, painless nodule at the helix. This is congenital variation and is not significant
Classification of Tympanograms
A, As, Ad, B, C
Self-management of epistaxis
Digital pressure over cartilagenous part of nose, head forward over a bowl, for 10-20 minutes; apply ice pack
Cholesteatoma
Dirty yellow/grey discharge, foul odor
30% of children fluid in the ears without presentation of infection
OM with effusion with stasis as this progresses organism may result with the creation of an infection
what is the most common cause for pediatric visit
OME and AOM
lack of fever otalgia irritability loss of hearing without signs of acute inflammation
OME: otitis media with effusion middle ear non purulent effusion due to: post AOM tube dysfunction inflammatory mediators increase mucin laryngopharyngeal reflux
Recruitment
A marked loss when speech is at low intensity, but sound actually becomes painful when speaker repeats in a loud voice
2 types of speech threshold testing
SDT also called (SAT-speech awareness threshold) and SRT
What correlates with PTA?
SRT (within 10dB)-has the same procedure as pure tones. another example of crosschecking.
SDT-Speech detection threshold
SRT speech recognition threshold
SNR
Signal to Noise ratio diff in intensity btw these. testing client in noise so set word lists to 45dBHL, use odB-meaning no difference) doesnt always have to b2e 45 just an ex.
Otitis Externa: Malignant
Emergent referral to ENT
Cholesteatoma
Epithelial migration into middle ear -Chronic TM perforation -Chronic ET dysfunction, negative pressure, and retraction pocket formation Internal desquamation, enzymatic degradation, osteitis Local complications: -Semicircular canal erosion/fistula -Labrynthitis -Facial nerve paralysis -Meningitis -Intracranial abscess -Mastoid abscess
chemical
EtOH toxicity hvy metals diuretics nicotine carbon monoxide salicylates quinine ototoxic drugs
Do tympanostomy tubes prevent acute otitis media?
No. They just reduce symptoms/severity.
Eustachian Tube Dysfunction based on Type C
Non specific testing May reflect an oncoming or resolving otitis media
Do antihistamines and decongestants help in acute otitis media?
Nope.
Do oral corticosteroids help in acute otitis media?
Nope.
Type A
Normal middle ear function Normal shape Normal peak pressure Normal peak admittance
Type C
Normal shape normal peak admittance Excessively -'ve peak pressure (<150 daPa) Reflects eustachian tube dysfunction
labyrinthectomy
surgical removal of labyrinth
stapedectomy
surgical removal of stapes
Whisper Voice Test
3 random numbers and letters standing 2 feet behind the person
sound transmitted in middle ear by
3 tiny bones (ossicles)
how long is the canal
3.7cm or 1.5 in
fluid hearing loss characteristics
30-40 dB can delay speech
The presence of bilateral fluid in ears may cause up to ____
30-40 dB conductive hearing loss
+5SNR
40dBHL -noise words at 45dBHL
-5SNR
45dBHL for the noise, words at 50dBHL noise=louder than words
cone of light in right ear should be at
5 o clock
Right Cone of light position
5 o'clock
where is the normal light reflex in the TM
5-7 anterior aspect
How long should the antibiotic course for acute otitis media be for children over age 2?
5-7 days
most important freq of speech are?
500-4000Hz
Examination of Hearing
512Hz Tuning Fork 1. Weber Test 2. Rinne
interpret what scores mean on table
53 in book dots represent where the auditory speech falls. count the number of dots above a patient's threshold.
OME and AOM
6 mo and 3 yrs mc: 2 mo to 12 yrs 16-20million office visits annually
Limit of tympanometry for children
7 months
cone of light in left ear should be at
7 o clock
Left cone of light position
7 o'clock
estimated what percentage of children experience AOM
75%
what should you give to lessen the pain on the way to the ER
capsicum heomeopathic
DMSO caution
carcinogenic rubber gloves
Mucoid otitis media with PE tube
gooey. Also called glue ear.
"monomeric membrane"
if perforation sometimes only the epithelial ectoderm heals.
tympanometer
instrument used to measure the middle ear
Integrity of Tympanic membrane
intact
Skin condition
intact
Voice test
intact
Tympanometry
peak admittance peak volume peak pressure
eardrum appearance
pearl grey, cone shape, rich in blood supply
Color and characteristics of Tympanic membrane
pearly grey
myringectomy, tympanectomy
surgical removal of tympanic membrane
otoplasty
surgical repair of ear
myringoplasty, tympanoplasty
surgical repair of tympanic membrane
bullous myringitis
-otalgia -erythematous TM -blisters -URI symptoms -*Mycoplasma pneumoniae*
What is the average length of time that a tympanostomy tube is in-place and functional?
9 to 18 months
Otitis Externa
"Swimmer's ear" Common in summertime Painful infection of skin Cellulitis of the canal Swelling, erythema of canal Pinna often edematous, red Narrowed lumen with purulent drainage Pseudomonas, and staph aureus common Diabetics may become very sick from this Tx: otic drops, but oral abx may required
acute otitis media
"bagel sign" bulging, pain, pressure, Children with acute otitis media frequently present with sudden onset of fever, ear pain, and fussiness. In patients with acute otitis media, the eardrum is bulging and yellow or white in color with dilated vessels, and there is decreased movement of the eardrum on pneumatic otoscopy
Otitis externa
"swimmer's ear" - itching in ear canal - pain with tugging on pinna - watery to pus discharge - hearing loss possible with swelling of canal
synthetic sentence identification
(SSI)-closed set test. have in front of them a card with a few sentences and the AuD asks the client to identify which sentence she said. Another ex. of real life issues.
Cortisporin Otic
(neomycin + polymyxin B sulfates + hydrocortisone) • used to treat *otitis externa* • 3 drops in ear TID-QID (max: 10 days) • keep in for 5 minutes, then let it drain into a tissue • causes contact dermatitis in 15% of patients due to neomycin *don't use with TM perforation*
WIPI-book
(show me house, dog) word intelligibility by pic identification. for children 3-5.
Necrotizing Otitis Externa
(used to be called malignant otitis externa) • skull base osteomytelitis • pseudomonal infection • usually occurs in immunocompromised, elderly, or diabetes
Otitis Externa
*"Swimmer's Ear* skin infection of the ear canal
Otitis Media Signs and Symptoms
***Pain (otalgia) May have fever Erythematous, Bulging TM -look angry Decreased TM mobility TM may rupture = purulent drainage in external auditory canal Decreased hearing Effusion behind TM
What is the dosage for ibuprofen when being used as pain management for acute otitis media?
*10*mg/kg *three times per day* (as needed for pain)
What is the dosage for acetaminophen when being used as pain management for acute otitis media?
*10-15*mg/kg *every 4-6 hours* (as needed for pain)
What is the mg/kg per day dosage augmentin for acute otitis media?
*80-90* mg/kg per day
What is the mg/kg per day dosage of high dose amoxilicillin?
*80-90*mg/kg per day (split into 2 doses - BID)
Acute OM: S/S
*Hearing loss is hallmark* - Ear pain - Ear fullness - Drainage with relief if ear drum is perforated - prior URI - Pulling at ears - Fever - Irritability
Ramsay Hunt Syndrome
*Herpes Zoster Oticus* • burning/pain • vesicles, crusting in a dermatomal distribution • facial weakness (due to involvement of the facial nerve)
Otitis Externa: Management- Bacterial
- *Neo/poly/HC only if TM intact* - FQ (use a wick if canal is swollen) - Systemic therapy if canal is swollen shut or patient is immunocompromised
Peritonsillar abscess
*PAIN* "hot potato voice" devation of uvula fever odynophagia LAD tx: I & D or abx (IV first)
Otorrhea
*discharge from the ear* • can be from the external canal, middle ear, inner ear, or intracranial cavity
Otomycosis
*fungal otitis externa* • presents similarly to bacterial otitis externa • often aspergillus or candida • more itchy than painful
Acute Otitis Media
*infection of the middle ear* • fever • otalgia • erythema • irritability • lethargy • hearing loss • dizziness • tinnitus • otorrhea
Physical Exam Findings of *Moderate* Otitis Externa
*moderate otitis externa* • more erythema • more edema • skin sloughing • squamous debris • cloudy otorrhea
s&S of AOM
*pain- otalgia* fever erythematous, bulging TM decrease DM mobility TM may rupture and drain purulent material decrease hearing
Tympanosclerosis
*scarring/calcification of the tympanic membrane* • usually due to past infections
Middle Ear Effusion (MEE)
*simply means liquid in the middle ear* (does not necessarily mean there is an infection) • persistent or chronic • liquid could be serous, mucoid, purulent, or a combination of these
What is the best and worst thing about Auralgan drops for pain management in otitis media?
*the good*: rapid improvement of pain *the bad*: can mask symptoms if the condition worsens
Normal Peak Pressure
+100 to -150 daPa
What is the normal flora of external ear canal
- Bacteria: Staphylococci, Micrococcus spp, Beta-streptococcus, Cornyebacerium - Malassezia pachydermatitis
Otitis Externa: Etiology
- Bacterial 90% of the time: Pseudomonas, Strep, Staph - Fungal: Aspergillus, Actinomyces, Candida - Eczema if chronic
Otitis Externa: S/S
- Pain with manipulation of tragus - Hearing loss - Otorrhea - Fullness - Itching - Recent exposure to water
What are the 2 membranes of choclea
- Reissner's membrane: floor of scala vestibuli and roof of scala media (cochlear duct) - basilar membrane (between cochlear duct and scala tympani)
What is an inner hair cell
- actual receptor cell for hearing - transmit signal to auditory nerve = NEED to work!
Define otitis externa
- acute or chronic inflam of external ear canal - may involve pinna
What are the 2 cartilages in external ear canal
- auricular - annular
What can be a variation seen in canine tympanic membranes
- bulging pars flaccida - does not necessarily indicate otitis media except in Cavalier King Charles Spaniel - no diff histopath - may indicate inc middle ear pressure
What is noxon's ridge
- cartilaginous protuberance - don't hit with otoscope, elevate pinna to avoid it and get under to rest of ear
What are the functions of the external ear
- collect sound waves - conduct sound waves to tympanic membrane - determine origin of sound waves
Describe the auditory n.
- connects cochlea to brainstem - relays info about intensity, freq, and timing of a sound - part of CN VIII - courses from cochlea through small canal in petrous temporal bone = internal auditory meatus IAM
by age 5 what percent of pt have OME
90% have OME by 5 yrs
How is a feline middle ear different from a dog
- divided by a septum into 2 separate tympanic cavities (connected through foramen between septum and petrous bone) - dorsolateral and ventromedial
Compare a dog and cat bulla septum
- dog: incomplete = Rosychuk's ridge = communication - cat: bulla septum complete = impossible to clean both compartments without damaging round window
What are the 2 tympanic cavities of the cat
- dorsolateral (smaller): auditory ossicles, ostrium of auditory tube, tympanic me - ventromedial: air-filled tympanic bulla
What is cerumen
- emulsion that coats ear canal - desquamatd keratinized epithelial cells, glandular secretions - removal by epithelial migration
What are the 3 parts of the tympanic cavity
- epitympanic recess (by incus) - ventral tympanic cavity (between malleus and round window) - tympanic cavity proper (actual big air filled part)
Describe the auricular cartilage
- expands to form pinna - funnel shape
Describe annular cartilage
- fits within base of auricular - overlaps osseous external auditory meatus - flexible (Hu do not have)
Describe tympanic membrane
- has outer and inner epithelium, collagen core, hairless, glandless - 45 deg angle to center - pars flaccida - pars tensa
What are the parts of the external ear canal and relative locations
- helix (rostral) - tragus (laterally) - antitragus (cuadally) - intertragic incisure
How is location sensed
- higher central auditory nervous centers - compares sounds from both ears to localize
What is the cochlea
- housed in petrous temporal bone - bony labyrinth - snail shell - oval and round windows
What is an outer hair cell
- important role in adjusting the tuning and sensitivity to IHC - dont send out signal but if they are not working can't tell differences in tones
What 3 pieces of sensory information is encoded by auditory system
- intensity - frequency - location
Describe the waves and inputs/outputs to the oval and round windows
- mechanical input from stapes to oval window - round window expands according to waves - compression wave = stapes in, RW out, BM down - rarefaction wave = stapes out, RW in, BM up - vibratory input sets up traveling wave TW
Normal middle ear flora
- negative ear cultures in 50% ear swabs - orgs: Yeast, E. coli, Staphylococcus, Cornyebacterium, Streptococcus
Which hair cell is most susceptible to damage
- outer hair cell
What fills each duct of the cochlea
- perilymph = scala vestibuli and scala tympani - endolymph = scala media
What are the 5 components of the ear
- pinna - external ear canal - tympanic membrane - middle ear - inner ear
Hair in external ear canal
- present in external ear canal in most breeds - dec in number from distal to proximal
What 3 openings are in the tympanic cavity
- round window (connects from stapes to inner ear) - oval window (outlet for inner ear) - eustachian tube
List the ducts and membranes of the cochlea in order of appearance from superior to inferior
- scala vestibuli - Reissner's membrane - scala media = cochlear duct - Basilar membrane - scala tympani
What are the 3 ducts of the membranous labryrinth of the cochlea
- scala vestibuli = supeior - scala media (cochlearduct) = medial - scala tympani = inferior
What is the pars tensa
- semitransparent - concave due to tension - of tympanic membrane - large ventral part with striations - stria mallearis = manubrium of malleus on other side of membrane
Ceruminous glands in external ear canal
- simple, coiled tubular glands - modified apocrine glands - located in deeper dermis below sebaceous glands - ducts open into either hair follicle or onto surface of external ear canal
What is located on the outer wall of the ducts in the cochlea
- spiral ligament - stria vascularis = blood vessels, endolymph - keeps electrolytes in check to be ready to fire depols
What are stereocilia and kinocilium
- stereocilia "cingular tower" arrangement leaning toward kinocilium - kinocilium = tall one that depolarizes and sends signal
Sebaceous glands in external ear canal
- superficial - ducts open into hair follicle
When does the eustachian tube open?
- swallow - holding nose and blowing - seation or anesthesia
What structures make up the organ of corti
- tectorial membrane on top - reticular lamina (tight seal at inner/outer hair cells) - inner hair cells = 1 row - outer hair cells = 3 rows - supporting cells - basilar membrane (bottom)
Components of middle ear
- tympanic membrane - auditory ossicles - tympanic cavity - eustachian tube
What are the 3 auditory ossicles and muscles
- tympanic membrane to malleus to incus to stapes to oval window - tensor tympani inserts on malleus - stapedius muscle inserts on stapes
What are the two external ear canals
- vertical ear canal (vertical, then rostral, medial turn - horizontal ear canal - Noxon's Ridge
scurvy
-*Vit C Def* -deep red/purple swollen gums -tender, bleed easily
intensity goes on y axis (dB)
-10 - 120 (deaf)
Indications for abx
-All children <6 m/o w/ findings consistent w/ AOM -Children <2 y/o w/ bilateral AOM -Children w/ AOM w/ otorrhea -Children 6 m/o to 2 y/o when dx is certain -Children >2 y/o w/ severe infection/illness (moderated otalgia w/ temp >/=39C)
Otitis Media: ABX therapy or Observation critera
-Antibiotic therapy OR close observation for : -Children, 6-23 months, unilateral AoM without severe s/s -Children 24 months or older, bilateral or inulateral AOM, without severe s/s -When observation used, ensure follow up and begin antibiotic therapy if the child worsens or fails to improve within 48-72hours
Hearing loss: Conductive Sensorineural
-Conductive: impairment in external or middle ear, weber lateralizes to ear with conductive LOSS, BC>AC -Sensorineural: inner ear defect, sounds distorted, speech misinterpreted, weber lateralized to GOOD ear, AC>BC but less than 2:1
Otitis Media: TX duration
-Duration of therapy for children <2 years and children with severe symptoms: -10 day course of antibiotics -2-5 year old, mild or mod AOM: -7 day course of ABX -6 years and older, mild or mod AOM: -5-7 day course antibiotics
Sinusitis: Treatment if allergic to PCN
-If allergic to PCN -Adults: 1. Doxycycline 2. Respiratory fluorquinolone -levofloxacin -moxifloxacin -Children: -levofloxacin -Adjunct therapy: -nasal irrigation -intranasal corticosteroids
Otitis Media: ABX therapy meds
-If no amoxicillin in previous 30 days, no purulent conjunctivitis, no PCN allergy: -Amoxicillin 80-90mg/kg/d PO BID -Cefdinir 14mg/kg/d PO BID -If amoxicillin in previous 30 days, or + purulent conjunctivitis, or hx of AOM unresponsive to amoxicillin: -Beta-lactamase coverage -amox-clavulanate 30mg/kg/d of amox with 6.4 mg/kg/d of clavulanate PO BID -cefriaxone 20mg/kg IM 3 days -Clindamycin 30-40mg/kg/d PO TID with or without third gen cephilosporin
Sinusitis: No improvement with therapy
-If no improvement in 3-5 days or worsening symptoms in 78-72hours: -Adults: -amoxicillin-clavulanate 2G/125mg PO BID -levofloxacin 500mg PO QD -Moxifloxacin 400mg PO QD -Children: -Augmentin 30mg/kg/d TID plus cefixime 8mg/kg/d BID OR cefpodozime 10mg/kg/d BID -levofloxacin 10-20mg/kg/d QD-BID *** same drugs and amounts given if there is a risk for antibiotic resistance
Common ear abnormalities: Middle ear effusion Cholesteatoma
-MEE: inflamm with fluid behind TM, crackling in ear, conductive loss, TM retracted, less mobility, often have Eustachian tube dysfunction -Cholesteatoma: benign growth behind TM, white, shiny plaque, can erode through TM, high cholesterol content, affects hearing & equilibrium
Acute Otitis Media (AOM) Complications
-Mastoiditis -Sphenoid sinus thrombosis -Meningitis -Facial Nerve involvement -Osteomyelitis
Sinusitis: NO risk for ABX resistance -Treatment
-No risk for resistance -Amoxicillin-clavulante -Adults:500/125 mg TID or 875/125 mg BID -Children: 45mg/kg/d BID -"high dose" if high rate DRSP risk factors. -Adults: 2g BID -Children: 90mg/kg/d BID -Treat for 5-7 days for adults, 10-14 for children
Complete History: PMH FH SH
-PMH: childhood ear problems, surgery, ear dz, abx use, head trauma -FH: hearing problems -SH: environ. hazards, protective devices
cauliflower ear
-caused by repeated trauma to auricle -produced subperichondrial separation with focal generation of fibrous tissue and scar formation -lose normal landmarks -suspect potential hearing loss -can be surgically corrected
Otitis Externa
-Pseudomonas aeruginosa, S. aureus -Topical antibiotic and corticosteroid -addition of corticosteroid yields more rapid improvement in symptoms -acetic acid 2%, 4-6 days -do not use if perf of tympanic memb. -ciprofloxacin 0.3%/dexamethason 0.1% (Ciprodex0), BID -expensive, $160 for 7.5ml
foreign body
-Q tips common or bean, peas, jewelry -dont irrigate if material suspected or insects -be careful not to perf TM -can cause hearing loss
HPI of common ear complaints: Hearing loss
-RFs: q-tip, occupational hazards (ex: loud noises) -Cerumen impaction (gradual), vascular disruption (sudden), infection (onset couple of days) -environ. for best hearing -word discrimination/garbled sounds - 1 on 1 talking vs. hearing in a crowd -cant make out words but can hear sounds? -ototoxin meds include: aminoglycosides, ASA, furosemide, streptomycin, quinine, cisplatin
Indications for Referral
-Recurrent AOM (4 bouts of AOM in one year or 3 in 6 months) -Chronic serous OM w/ conductive HL -Complications of acute OM -Questionable exam
Indications for Myringotomy/Tympanostomy Tube Placement
-Recurrent OM -Chronic OM w/ persistent bilateral effusion & conductive HL -Negative middle ear pressure and impending cholesteatoma -Presence of complications Notes: -Do not prevent AOM, but reduce severity** -Avg duration is 9-18 months -Otorrhea is common -Complications: Chronic perforation, early extrusion, granulation tissue formation
Otitis Media: ABX therapy criteria
-S. pneumoniae, H. influenzae, M. cattarhalis -Antibiotic therapy for: -children 6 months and older, bilateral or unilateral AOM with SEVERE s/s (mod to severe otalgia, otalgia for at least 48 hrs, temp higher than 102) -Children <24months, bilateral AOM, without severe s/s (,ild otalgia, <48hrs, temp <102)
What are the structures and function of the middle ear?
-Structures: ossicles (malleus, incus, stapes), communicates with mastoid area of temporal bone, Eustachian tube leads to nasopharynx -Functions: ossicles transmit sound from TM to inner ear *An untreated infection can travel to mastoid= mastoiditis and potentially travel to the brain
What separates the middle and inner ear?
-TM
Otitis Externa: topical therapy
-Topical therapy -hyrdocortisone 2%/acetic acid 1%, 4-6 days: 220 for 10ml. may cause pain and irritation -neomycin/olymyxin B/hydrocortizone, TID-QID: ototoxic, higher risk of hypersensitivity -Ofloxacin 0.3% QD-BID
Protective mechanisms
-Tragus/Antitragus -Curve/isthmus of canal -Cerumen coated skin -Acidic env't
Sinusitis Patho
-URI lasting longer than 10 days -Severe symptoms after 3-4 days -Patho -s. pneumoniae (most common), h. influenzae, m. catarrhali -rarely staphylococcus
Causative Agents OM
-Viruses -Strep pneumo -Haemophilus influenza -Moraxella catarrhalis -GAS -Staphylococci -Gram- rods Notes: -Changes expected sine introduction of pneumococcal and Hib vaccines
hematomas
-accumulation of blood between skin and cartilage mostly from blunt trauma -inspect & palpate head for other trauma & assume neck injury -check hearing -may get cauliflower ear
What are the changes in hearing that occur with aging?
-after 50, hair cells degenerate in organ of corti = sensorineural hearing loss: presbycusis. affects high pitch sounds first -Conductive hearing loss results from: Cerumen impaction from decreased sebaceous secretions, thickening/hardening of TM
outstanding ears
-angle between auricle and side of head is greater than normal -no pathologic consequence -easily surgically corrected
preauricular pits
-autosomal dominant -mostly unilateral -can become infected and be surgically excised if repeated
What is hemotympanium?
-bleeding into the middle ear pushing TM forward -think head trauma
hemotypanum
-blood in middle ear behind TM because head trauma or severe barotrauma - painful? -maybe conductive hearing loss -spontaneous resolution over several weeks
Inspection of external ear: Unusual size and shape
-cauliflower ear: cartilage on cartilage -tophi: uric acid deposits -sebaceous cyst: greasy deposits -Darwin tubercle: normal variant, thickening on helix -preauricular pits: increase incidence of hearing loss
Techniques of the otoscopic examination
-choose proper speculum size, properly position pt, the otoscope and hands, pull auricle to straighten canal -hold scope in thumb & index finger, support scope on middle finger, remainder of hand on pts face, handle can be up or down -inspect auditory canal from meatus to TM: discharge, redness, scaling, lesions, foreign bodies, Cerumen, hair -inspect TM landmarks
What is the Eustachian tube?
-communication btwn middle ear and nasopharynx -closed, but when swallow, yawn, etc. it opens up -equalizes middle ear and atmospheric pressure -clears small amounts of mucus produced by middle ear -if not opening up: pts complain of pressure & pain bc fluid builds up --> serous otitis
What is the A&P of the tympanic membrane?
-concave with umbo at center, translucent (see through but not clearly), grayish -Tense (pars tensa) except for superior aspect (pars flaccida)- if TM bulging: flaccid area will look tense and cone of light will be out of place -light reflex at 5:00 AD (right ear), 7:00 AS (left ear) -normal TM structures: malleus, pars tensa, pars flaccida, light reflex, umbo
HPI of common ear complaints: Earache
-concurrent URI, frequent swimming, trauma to head -associated symptoms: fever, discharge (green & foul smell= foreign body), decreased hearing, vertigo, dizzy -medications
Choanal atresia
-congenitally closed orifice -most common malformation of nasal airway -identify in infants w/ diff breathing during first URI -if bilateral, resp distress at birth
Immittance testing purpose
-detecting middle ear disorders -differentiating different types of middle ear pathology -differentiating cohclear from retrocohclear pathology -facial nerve reflexes and eustachian tube function
Pneumatic otoscopy
-done if loss of motility of TM suspected -puff of air creates a + pressure and should move TM inward and return to normal quickly -if NO movement or decrease, then increase press within middle ear is suspected -maybe poor fx of eusch tube or fluid in middle ear
tympanic membrane scarring
-from previous trauma, infection, or perf -may cause decrease in hearing over time due to decrease mobility of TM from thick scar
Tympanic membrane perforations
-from trauma, infection, or barotrauma -increase risk for infection
microtia
-gross hypoplasia of pinna -typically bilateral -may have blind or absent auditory canal, completeled formed and functioning cochlea, and may be helped with hearing aids or surgery
battle sign
-hematoma behind the ear -*indicator of base of skull fracture* -look for fluid out of ear and nose-CSF or blood
acute otitis media (AOM)
-history of recurrent URI -bacterial or viral - *Strep p, H influenza, or M. Cattarhalis* -infants/child -unilateral
Weber Test
-if hearing loss in history or detected -vibration tuning fork on midline of head -should ear it equally in both ears -*conductive hearing loss*: loss in laterizing ear -*sensorineural loss*: loss in ear opposite the lateralizing ear
anosmia
-inability to smell -infection, tumor, trauma, polys, allergies, diabetes, sjorgrens, zinc or Vit A def, preg, septal deviation, schizophrenia
hyperosmia define & causes
-increase ability to smell -nausea, addisons D, hunger, allergies
What are the tests of hearing? ****examine the ears first
-initial screen: spoken voice "are you having trouble hearing me so far" -whispered voice: tested 1-2ft w/ opposite ear blocked, close eyes, whisper a variety of words -soft sound: rub fingers together from 4-6in from ear -weber test: BC -Rinne test: compares AC to BC
Kaposi sarcoma
-malignant vascular origin -red/blue plaques and nodules -commonly on skin -seen in adv AIDS
complications of AOM
-mastoiditis -sigmois sinus thrombosis -meningitis -facial N involvement -osteomyelitis
cerumen impaction
-may be painful -may cause hearing loss -elderly and children -TX: debrox drops, irrigation, curette/otoloop
Serous otitis media
-maybe poor eustachian tube fx -maybe concurrent with URI -common with allergies -look for fluid/bubble -can procede AOM -*TM is NOT inflamed/red*
Hairy tragus
-mostly men -occurs with aging -mostly indian people
Common ear abnormalities: Otitis externa Acute otitis media
-otitis externa: bacterial or fungal cause, itching, pain, discharge, conductive loss, canal inflamed, cant see TM -AOM: common in childhood, fever, pain, feels blocked, conductive loss w/ effusion, TM red, bulging, decreased mobility, wont see reflection
Common ear abnormalities: Otosclerosis Meniere's Disease Labyrinthitis
-otosclerosis: hereditary, fixation of stapes, Sx in late teens to 30s, tinnitus, conductive loss -Meniere's dz: affects vestibular labyrinth (semicircular canals), uncertain cause, brief duration, vertigo, nystagmus, tinnitus, temp. sensorineural loss -Labyrinthitis: complication of URI, affects inner ear, long duration, vertigo, nystagmus, tinnitus, sensorineural loss
What equipment is used to examine the ears?
-otoscope with pneumatic attachment -tuning fork (512 hz)- spoken word vibrations
cholesteatoma
-overgrowth of epidermal tissue -most commonly in pt's with chronic otitis media -arise from canal or middle ear -can be painful & erode into bone -may cause conductive or sensorineural hearing loss
Palpation of the ear
-palpate auricles (bottom to top), preauricular and mastoid/postauricular areas: tenderness, pain, swelling, nodules, nodes -auricle should be firm and mobile, no nodules -tug on lobule: any pain? if yes most commonly swimmers ear
paranasal sinus
-palpate frontal and maxillary -palpate and percuss -if pain or tenderness or swelling, may have infection or obstruction
function or oropharynx
-passageway for food, liquid, saliva, and vomit -emission of air -initiate digestion through mastication and salivary enzymatic activity -identify taste
Otoscopic Inspection
-performed before tympanometry -assist in interpreting other audiological evaluation relusts
Rinne Test
-place base of vibrating tuning fork on mastoid bone -time how long they can ear it for (bone conduction) -then quickly place 1-2cm away from canal and time (=air conduction) -bone >air conduction
Inspection of external ear: position of auricle external canal
-position: draw imaginary line from outer canthus of eye to occipital protuberance, should be at or above and vertical. If below = assoc. w/ chromosomal abnormalities -external canal: discharge, odor, look behind ear at mastoid process -if bloody discharge= w/ trauma skull fracture, without trauma q-tip or foreign body, purulent = otitis externa
keloid ear
-produced by abnormal wound healing -excessive bulk- hyalinized collagen -mostly AA - >20 yr old
otosclerosis
-progessive hearing loss -deposition of bone in cochlea/stapes foot -*NO PAIN* -tinnitus common -normal TM, patent euschacian tube -females, 30-40 -tx: stapedectomy
Vincent Stomatitis (Acute necrotizing ulcer gingivity, trench mouth)
-punched out ulcers covered with gray-yellow membrance -BAD halitosis -ANAEORBIC --> Fusobacterium -pt may be systemically ill -pain, increase salivation
Too small of peak volume
-reflects an obstruction of the ear canal/ improper probe placement
Peak Admittance
-related to mobility of middle ear -in mL, c^3, or mmho
Sinusitis: risk for ABX resistance
-risk for antibiotic resistance -age <2 or >65 -prior antibiotic use in past month -prior hospitalization in past 5 days -comorbidities -immunocompromised
Inspection of the external ear: comparison note color
-size, shape, landmarks -nodules, skin abnormalities -blue (deoxygenated blood increase, decrease Hgb & O2 carrying capacity), pallor (BV constrict, vasomotor response, bilateral), hyperemic (BV dilate, vasomotor response, bilateral, if unilateral think infection, insect bite, etc.), extreme pallor (think frostbite)-color should match the color of the face -look in the ear BEFORE doing the hearing test
exostosis
-small bone growths of canal -benign -usually multiple and b/l -aris more commonly near TM -no TX unless recurrent cerumen impactions
Darwin's tubercle
-small cartilagenous protuberance mostly along concave edge of posterosuperior helix -normal variation
cacosmia define & causes
-smelling foul but not present -sinusitis, tumor, psych, tetracyclines
polyps
-soft protrusions of mucosa -pale, edematous, nontender -seen in chronic allergic rhinitis + relationship with asthma
What is bone conduction?
-sound waves transmitted by bone DIRECTLY to inner ear, to CN8, to brain -blocked TM (ex: earwax) and otosclerosis affect AC, not BC -pt w/ inner ear problem (damage to cochlea) will lose both -loud bass on music affects BC
What is air conduction?
-sound waves travel through outer, middle, then inner ear to CN8, to the brain -AC better than BC -CN8: 2 branches (vestibular=balance, cochlear=hearing)
HPI of common ear complaints: Dizziness or vertigo
-spinning of things in the environ. -time of onset, duration -description: unsteadiness, loss of balance, falling, spinning sensation -associated symptoms -medications
What are the structures and functions of the inner ear?
-structures: vestibule, semicircular canals, cochlea, bony labyrinth (all 3 structures together) -functions: cochlea transmits sound to CN8 (vestibulocochlear), semicircular canal & vestibule involved in vestibular function (balance, equilibrium)
saddle nose
-sunken bridge -from loss of cartilage from septal hematoma or abscess -congential or acquired syphillis
periapical abcess
-tender swelling in adjacent gums -sinus tract may be draining pus -common cause of toothache -pain from tapping tooth with tongue blade
What is the relationship between CN7 and CN8?
-they are in close proximity to each other -if pt has tumor of CN8 that is large enough to invade CN7, they may have weakness of face and not be able to make facial expressions
Rinne test
-time BC by striking tuning fork and placing on mastoid. When pt no longer hears vibration, place tuning fork 1in from auditory canal and time AC -normal: AC 2x greater than BC
Weber test
-tuning fork placed at midline of head -will lateralize to side of conductive hearing loss -normally equal "weber midline" "weber does not lateralize" -check reliability by testing with 1 ear occluded: should be louder on occluded ear
Insufflation of the TM
-use pneumatic attachment , must have a good seal in ear canal -watch for movement of cone of light to assess mobility -decreased mobility: Otitis media, blocked Eustachian tube
Too large of peak volume
-usually reflects that the TM is not intact -perforation
Whisper Test
-whisper a word or ask question -should be able to hear 1-2 away from ear -dont let them see your lips
Normal Peak Admittance
.3 ~ 2.0
Normal peak volume
.6 to 2.5 mL
Normal hearing is between?
0 and 20dB
Most acoustic energy is passed at
0 daPa
What happens to children with recurrent OME if tubes are not placed? Why?
1 year behind in school by 18. Hearing loss results in developmental delays.
Pathophysiology of Otitis Media
1) an upper respiratory infection causes edema and congestion of the respiratory mucosa which results in narrowing of the eustachian tube lumen 2) unopposed resorption of middle ear gases leads to increased negative middle ear pressure 3) influx of bacteria and viruses from nasopharynx where the eustachian tube opens causes an inflammatory response - leads to mucosal edema, capillary engorement, and infiltration by inflammatory cells
What are the three main functions of the eustachian tube?
1) pressure regulation 2) protection from nasopharyngeal sound, pressure, and secretions 3) clearance of secretions produced within the middle ear space
tonsil grading
1+ viable 2+ halfway between tonsillar pillar and uvula 3+ touch uvula 4+ touch eachother
If the ear canal is stenotic how should you treat
1- consider oral pred 2- treat empirically
Neurologic examination for otitis includes what two things
1- cr nerve eval 2- BAER test
Where to start with otitis
1- ear swab cytology (gram stain) 2- otoscopic exam (tympanum status)
compounded meds that are off label examples
1- lg animal strength baytril (12ml) 2- tris EDTA (4oz) 3- Dex (16mg)
what should you do when re-evaluating an otitis case
1- sedate 2- clean 3- evaluate (tympanum!) 4- ear culture if otitis media
topical steroids
1- synotic 2- momestaone 3- betamethasone
what N for smell
1-olfactory
Approach
1. At the same level as the patient 2. Pull the pinna upwards and backwards to straighten ear canal 3. Ulnar boarder of otoscope hand on the zygomatic arch 4. Watch the end of the speculum until it is inside the ear canal 5. Advance through the cartilagenous canal to just past the boarder with the bony canal 6. Keep the speculum still and adjust own viewpoint
Signs of TM Inflammation
1. Erythema 2. Oedema (Shiny) 3. Prominent blood vessels (Radial spokes)
Weber Test - Process - Results
1. Firmly tap ends on own patella 2. Place on a bony midline structure of the face 3. Can they hear the vibration? 4. Louder on one side or the other? Results - Conductive hearing loss - louder on affected side - Sensorineural hearing loss - louder on unaffected side
Rinne Test - Process - Results
1. Firmly tap ends on own patella 2. Place on mastoid process (bone conduction) 3. Relocate to the ear (air conduction) 4. Louder on bone or in air? Results - Conductive hearing loss - louder on bone - Sensorineural hearing loss - louder in air
Signs to look for on otoscopy
1. Inflammation 2. Nature of the TM 3. Position of the TM 4. Middle Ear Signs
Nature of the TM
1. Perforation or intact? 2. Thinning or thickening? 3. Tympanosclerosis? 4. Ventilation tube in situ?
Position of the TM
1. Retracted? 1.1 Whole TM indrawn - Angulated handle of malleus and extra anatomy seen 1.2 Patchy retraction - Cholesteatoma 2. Bulging?
Management of persistent epistaxis
1. Spray nostril with local anaesthetic vasoconstrictor spray (lignocaine and adrenaline) 2. Clear nostril and use silver nitrate stick on small area around bleeding site 3. Use Rapid Rhino device (45deg then horizontal along hard palate) 4. Local anaesthetic, Foley catheter to nasopharynx; grasp balloon with forceps and inject saline; pull back into nose
Preparation
1. Wash hands 2. Left hand for left ear, right hand for right ear 3. Hold the otoscope like a pen 4. Index and middle fingers on the speculum 5. Tip of the speculum in line with MIP joints 6. Sweep hair away with other hand
direction of canal in adults vs children?
1. adults: curved, pointing inward, forward and upward 2. children: pointed forward but not upward
What are the 2 portions of the external ear?
1. auricle: cartilage. Landmarks: helix, antihelix, tragus, antitragus, lobule, concha, external auditory meatus 2. External auditory canal: passage to middle ear; S-shaped; 2.5cm in adults; outer 1/3 hair follicles, sebaceous glands, and ceruminous glands. Cartilage covered by skin; inner 2/3 bone covered by skin, no hair follicles
What causes external otitis.
1. damage to skin of external ear (trauma via Q-tips) 2. maceration due to prolonged exposure to moisture (swimming) 3. occlusion (from draining)- iPods, bony exostosis
when should we see improvement
3 days
What are conditions that could causes sensorineural hearing loss?
1. hair cell damage (loud noises or medication) 2. CN 8 damage (acoustic shwannoma) 3. old age (presbycusis) 4. Meniere's disease
different types of tympanogram?
1. normal: rise and fall at 0 2. otitis media (lots of fluid) - no movement 3. retraction? : early movement 4. fixed: small movement 5. perforated: exponential movement
bony landmarks visible behind TM?
1. umbo/end of malleus 2. handle of malleus 3. short process of malleus 4. incus SHOULD NOT SEE STAPES
pars flaccida
1/3 superior portion of TM, loosely stretched
How long should the antibiotic course for acute otitis media be for children under age 2?
10 days
how long does tris EDTA need to be in contact for it to work
10min contact
after prescribing a topical when should you recheck
14d
when should you re-evaluate
14d
some microbial facts in AOM
16-30% of cases: no pathogen 6%: viral 20% both viral and bacterial - RSV Rhinovirus Coronavirus Parainfluenza Adenovirus Enterovirus for recurrent AOM and chornic OME for greater than 3 mo duration consider BIOFILMS
what is the pred dose for otitis with stenotic ear canal
1mg/kg bid for 14d
surgical options - TECA cost
2,000/ear
if you have normal hearing through __ you will be okay.
2,000Hz
external auditory canal is how long? where does it narrow and widen? made of?
2.5-3 cm, narrows toward middle and widens near eardrum, bone & cartilage covered w/ thin sensitive skin
What is the average length of an adult ear canal?
2.5cm
viral infections have been found with concommitnat bacterial infections
20% of the time RSV rhinovirus coronavirus parainfluenza adenovirus enterovius
the frequency range for humans is between?
20-20,000 Hz
where do tactile responses occcur?
200 and 250 Hz
Probe tone
226 Hz
SL
25-40 dBSL. Not a dial on the audiometer. Not a measurement out of the sound level meter! We are using 30dbHL above reference
Tinnitus
A " phantom sound" that originates within the person; it occurs with cerumen impaction, middle ear infection, and other ear disorders.
shorter
A child's external auditory canal is ________ than an adult.
125-8,000 Hz
AC
Rhine's test
AC should be > MC unless conductive loss
Normal for Rinne Test
AC>BC
Causes of Otalgia
AKA ear pain most often from acute otitis media may also develop from referred pain from teeth, TMJ, pharynx, cervical spine, inflammation
External otitis media
AKA swimmers ear. Very painful/smelly. Infection occurs in the outer ear.
Otorrhea
AKA: discharge from ear inner ear disease such as Meniere's disease noise truama Drugs: ASA and systemic aminoglycosides
what is the mc organism responsible for myringitis
Bacterial strep pneumoniae (mc) viral influenza, herpes mycoplasma pneumoniae: rare
what does ANSI stand for?
American national standards institute (like audiometers)
Preauricular Pits
Autosomal dominant Unilateral in 75% cases Can become infected May need to be surgically excised if repeated infections occur -may just look like an old piercing
acute otitis media
AOM: usually bulging cone of light; when displaced or absent then we have bulging
Ear Hematomas
Accumulation of blood between skin and cartilage Blunt trauma most common cause Inspect, palpate head for other trauma (assume neck injury until ruled out!!) Check hearing May rupture "Cauliflower ear" is late sequela
Otitis Externa: Fungal
Acetic acid/HC drops Clotrimazole drops
Presbycusis
Age related sensorineural loss
Middle Ear Fluid
Air (Normal) is dark Air fluid level = Bubble 1. Pus = Purulent Effusion 2. Mucus = Glue Ear 3. Serous Fluid 4. Blood = Haemotympanum 5. CSF = BAD
Rinne test
Air conduction greater than bone conduction
Anatomy of the middle ear
Air-filled cavity in temporal bone lined with living cells TM is the external border Contains the ossicles: malleus, incus, stapes Closed system except for connection to nasopharynx by eustachian tube
Otitis Externa (Swimmer's ear)
An infection of the outer ear, with severe painful movement of the pinna and tragus, redness and swelling of pinna and canal, scanty purulent discharge, scaling, itching, fever, and enlarged tender regional lymph nodes. Hearing normal but slightly diminished. Severe swelling of canal, inflammation tenderness.
Outstanding Ears
Angle between auricle and side of head is greater than normal No pathologic consequences Easily surgically corrected, only a vanity problem
How do you follow the normal angle of the ear canal?
Angle the otoscope towards the patient's nose slightly
OME treatment child
Antibiotic therapy is not usually indicated for children with OME. Patients with OME are sometimes treated with a short course of oral or topical nasal steroids, to decrease the swelling in the eustachian tube and allow ventilation of the middle ear space. Referral to an otolaryngologist should be considered for children with at least three months of persistent middle ear effusion. Placement of PE tubes is often entertained for such children whose effusions are associated with hearing loss.
Health History
Any ear infections? Any discharge from ears? Any hearing loss? Any ringing or buzzing in ears?
Medication that cause ototoxic sequele
Aspirin, aminoglycosides ( gentamicin, tobramusin, amikacin), ethacrinyc acid, furosemide, indomethacin, naproxen, quinine, vancomycin
meds that cause hearing loss
Aspirin, when large doses (8 to 12 pills a day) are taken. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. aminoglycosides Certain antibiotics, especially amioglycosides (such as gentamicin, streptomycin, and neomycin). Hearing-related side effects from these antibiotics are most common in people who have kidney disease or who already have ear or hearing problems. Loop diuretics used to treat high blood pressure and heart failure, such as furosemide (Lasix) or bumetanide. Medicines used to treat cancer, including cyclophosphamide, cisplatin, and bleomycin.
Medications causing hearing loss or reduction
Asprin Aminoglycosides
The Romberg Test
Assesses the ability of the vestibular apparatus in the inner ear to hep maintain standing balance.
Hemotympanum
Associated w/ temporal bone fx Appears black behind TM Will resolve over time Causes conductive loss while present
Where does normal speech occur?
At 250-8,000 Hz. This is why we test at these frequencies.
nutritional causes and tx of tinnitus
B12 def zinc def CoQ10 100 mg bid niacin 100 mg/day - dilated blood vessels vitamin E 800 IU / day gingko biloba 120 - 240 mg qd caffeine exacerbates hypo/ hyperglycemia
250-4,000 Hz
BC
Conductive hearing loss for Rinne Test
BC=AC or BC>AC
how often do you need to apply a topical for otitis
BID
Pulling open External auditory canal ADULT
Back Out Up
Where does Eustachian tube drain
Back of the troat
Serous fluid otitis media. This diagnosis must be done by a doctor.
Behind the ear drum is infection and fluid. Middle ear problem. Shows only a dot of the cone of light. Can also cause water bubbles
Conductive hearing loss
Blocks sound transmission somewhere in the external auditory canal, tympanic membrane, or middle ear
Hemotympanum
Blood in middle ear behind TM Result of head trauma or severe barotrauma May or may not be painful Spontaneous resolution over several weeks is normal Conductive hearing loss possible -may perforate the TM
Exostoses
Bumps on the canal wall. Happens a lot to divers because of cold water. DOESN'T typically cause hearing loss. But cant see the landmarks.
Systemic antibiotic tx choice is based on
C+S MIC eval
dipthera
C. diptheriae sore throat, hoarsness, malaise, fever, nasal discharge *Gray membrane on pharynx, tonsil, palate, uvula* causes complia of myocarditis or neuropathies
Otitis Externa: Bacterial vs fungal?
CASH powder covers both
sensation to the ear
CN 5 CN 7 CN 9 CN 10 C1-2 plexus
what CN innervate the ear
CN 5, 7, 10
other materials consonant nucleus consonant
CNC words-high freq emphasis lists. like sss, zzz, ch, sh sounds)
cronic otorrhea otitis media
CSOM
dx
CT best xray: of temporal bone: clouding of the air mastoid cells with fussiness of bony partition culture
ear surgery indications
Calcified ear Neoplasia Stenosis Proliferative
External auditory canal
Canal to TM S Shaped about 2.5 cm long Pulling on the helix will cause straightening of the canal covered by fragile skin that bleeds easily Well inneervated outer third is cartilage - becomes bone deeper Outer 1/3 of canal also has sebaceous and ceruminous cells and hair
Necrotizing/Malignant OE
Cause: -Psuedomonal infection Signs/Sx: -Deep pain -Fever -Granulation tissue -Exposed bone or cartilage -Cranial neuropathies -Meningeal signs Death Notes: -Skull base osteomyelitis -Immunocompromised, elderly, or DM pt's
Cauliflower Ear
Caused by repeated trauma to auricle (boxers, wrestlers, etc.) Produces subperichonrial separation with focal generation of fibrous tissue and scar formation Lose normal landmarks Suspect potential hearing loss Can be surgically corrected
Otitis Media
Causes: -Eustachian tube dysfunction -Allergy -Immunocompromise -Ciliary dysfunction Pathophys: -URI causing edema/congestion of respiratory mucosa --> narrowing of eustachian tube -Unopposed resorption of middle ear gases leads to increased negative pressure middle ear -Influx of bacteria/viruses from nasopharynx when ET opens --> inflammatory response --> mucosal edema, capillary engorgement, infiltration by inflammatory cells -Cycle continues Eustachian tube dysfunction --> serous OM --> AOM --> OM w/ effusion --> Potential persistent MEE Dx: -Acute onset of signs/sx --Fever, otalgia, irritability, lethargy --Other: Hearing loss, dizziness/tinnitus, otorrhea -Presence of MEE --Bulge of TM --Limited TM mobility --Air/fluid level behind TM --Otorrhea -Signs/sx of middle-ear inflammation --Erythema --Distinct otalgia Tx considerations: -Resolves spontaneously in 60-80% of cases w/o abx -Reasons to give abx --Pt distress --Reduce complications (meningitis, mastoiditis, irreversible HL) --Reduce MEE --Increased resolution of infection? -Observation --Uncomplicated course -- >6 months of age, caution <2 years --Responsible caregiver --MANDATORY 24-72 Hr FOLLOW-UP Tx: -Systemic Abx (10 days) --High-dose amoxicillin --Augmentin/2nd gen cephalosporins (cefuroxime, ceftriaxone) = 2nd line --Can use topical in pt w/ PE tubes or perforation Prevention: -Eliminate exposure to 2nd hand smoke -Alter day-care attendance -Breast feed especially for first 6 months -Avoid supine bottle feeding -Vaccines Notes: -Sx are worse @ nigh b/c ET is less functional when lying down -Looking for all 3 for true OM dx (can have MEE w/o OM infection) -Can for blebs on TM which can rupture w/o perforation -MEE after resolution of AOM does not mean tx failure (follow Q3-6 mos)
Tympanic Membrane Perforation
Causes: -Water sports -Blow to head/ear -Explosions -Iatrogenic Evaluate w/ audiogram (sensorineural loss, ossicular disruption) Tx: -Topical abx -Keep clean/dry w/ cotton ball -Avoid cleaning until healed Notes: -If not healed after one month, can try to patch in office -No improvement = myringoplasty
Anatomy of the inner ear
Cavity containing vestibule, semicircular canals and cochlea
Where are the hearing receptors located?
Cochlea
Causative Agents OE
Common: -Pseudomonas aeruginosa -Staph aura Less common: -Proteus -Strep -Coag-neg Staph Various Gram- rods
Antibiogram
Community resistance pattern
Loss or reduction of hearing
Conduction - Commonly caused by cerumen impaction Also possible from perforation of TM, infection or scarring -- anything that makes it not flexible or tight preventing vibration from being sent to nerve Sensorineural - often a result of trauma from noise insult, or temporal bone injury (as nerve passes through) - also possible from tumor, metabolic disorders, medications
diagnostic procedures for otitis
Cytology Skin scraping Fungal culture Bacterial culture Biopsy neuro exam CT/MRI Myringotomy
VIral pharyngitis
DO NOT TX mortrin or tylenol warm salt water gargles lots fluid and rest
what color of the TM after a recent trauma
Dark red
NSAIDs
Drugs: -Ibuprofen -Acetaminophen Indications: -Pain mgm't (AOM) Mechanism: SE: CI: Notes: ***Ibuprofen 10mg/kg PO TID PRN pain*** ***Acetaminophen 10-15 mg/kg Q 4-6hrs PRN pain (no inflammatory control)*** -Can add topical benzocaine (Auralglan) w/ caution (reduces pain and increases risk of perforation if pt stops abx tx) -Antihistamines, decongestants, and corticosteroids not helpful with AOM
CSOM
EAC: -possible edematous, typically non tender -variable d/c: cheese, clear or serous -granulation tissue possible middle ear: mucosa maybe visualized through perforation and possible pasle, erythema or polypoid
Ear Wax
Ear canal is occluded, This can be very harmful in a young child that is just learning to speak due negative affects hearing loss can have on speech development.
Normal Ear Canal
Ear canals vary in size, shape, and color. The ear canal is skin-colored and contains small hairs and usually some yellowish brown or reddish brown earwax.
Example of attentuation
Ear wax
Macrotia
Ears larger than 10 cm
Microtia
Ears smaller than 4 cm vertically
Mastoiditis
Extension of suppurative process into mastoid air cells Signs/sx: -Obvious post-auricular swelling -Erythema -Tenderness Dx: -CT scan of temporal bone will show bony breakdown
auricle, should be equal in
External ear, size and height
3 Parts of the Ear
External, Middle, INternal
simple vibration is described by?
FAP freq amplitude and starting phase
What is the incident wave?
First arriving wave
OM with effusion
Fluid behind TM *without presence of infection* - Result of chronic eustachian tube dysfunction, previous AOM, or barotrauma
Serous Otitis
Fluid buildup behind the eardrum. This is common in children with chronic allergies and/or inflammation of the Eustachian tube.
pitch correlates with?
Frequency (Hz) highness/lowness of sound
Chronic suppurative OM
Frequent AOM with otorrhea as a result of TM perforation or tube placement
Eustachian Tube
Functions: -Pressure regulation -Protection (nasopharyngeal sound pressure and secretions) -Clearance (secretions produced in middle ear)
Otomycosis
Fungal OE Causes: -Aspergillus -Candida Sx: Often asx -Pruritus -Frothy, white discharge Tx: -Cleaning/drying (Boric acid powder, Domeboro solution) -Topical antifungals --Clotrimazole --Tolnaftate (TM perforation) Notes: -Stop any abx
Tympanic Membrane Scarring
Generally from previous infections, trauma, perforations May cause decreased hearing over time due to ↓ mobility of TM from thick scar
Wax color
Golden -> Rusty (blood)
Microtia
Gross hypoplasia of the pinna May have blind or absent auditory canal Typically bilateral May have completely formed and functioning cochlea May be helped with hearing aides and surgery External ear is not externally developed
URTI: upper respiratory tract infection bacterial
H influenza: 20+% cases are resistant to amoxicillin moraxella: 75+% is amoxicillin resistance 3mo greater consider pseudomonas
Do hard or soft surfaces absorb sound better?
Hard. ex. singing in bathroom vs. living room where there is carpet, furniture, etc.
AOM in children
Head and neck -otalgia - otorrhea - HA - URI symptoms, recent or concurrent General: - fever: 2/3 AOM if greater than 104 eval for bacteremia - irritability and feeding difficulty: may be sole early symptoms in infant or toddle - a hx of lethargy GI: - anorexia -N/V/D
Battle Sign
Hematoma behind the ear Indicator of base of skull fracture
Ramsay Hunt Syndrome
Herpes Zoster Oticus Sx: -Brining/[ain -Vasicles, crusting -Dermatomal distribution -Facial weakness Tx: Valcyclovir -Systemic steroids -Drying agent -+/- surgical decompression of facial n. -Eye care
TM Perforations
Holes in the ear drum
Risk Factors for Otitis Media
Host factors: -Immature/impaired immunology -Familial disposition -Method of feeding (breast < bottle) -Sex (male > female) -Race (Native americans & eskimos) Anatomic/Physiologic factors: -Eustachian tube dysfunction -->Default is closed position, swells/occludes during infection -->More horizontal in children -Cleft palate, sub mucous cleft Environmental factors: -Day-care attendance -Smoking in households Infection Allergy
Up 5 Down 10
Hughson/westlake procedure now called asha procedure
dx for myringitis
Hx and PE pain relieved by aseptic puncturing - bleb 8% of children age 6 mo to 2 yrs with AOM have bullous myringitis self limiting improvement with 24 to 48 hours
OM: Management- obvious infection
If infection is obvious, or fever is present - Tx with 10-14 days of high dose amoxicillin, erythromycin, Augmenting, Septra, ceftriaxone
begin at 30dB (70 if suspect HL)
If no response, increase in 20dB steps. After 1st response drop 10dB, until no response (NR) At inaudibility, ascend (increase in 5dB) 2/3 tries
OME adult
If of recent origin and unilateral, should prompt an examination of the nasopharynx for a disease process affecting the eustachian tube. Early nasopharyngeal carcinoma is well known for its silent nature—often the only sign is unilateral OME. Refer for endoscope eval.
Immitance reflects what two terms
Impedance and Admittance
Pneumatic Otoscopy
Important for TM mobility testing Mobile w/ positive & negative pressure = Normal No mobility = Perforation or patent PE tube Decreased mobility = Middle ear effusion Mobile only w/ negative pressure = ET dysfunction
non antibiotic tx
In healthy children older than two years of age who present with less severe symptoms, observation for 48 hours may be considered pain tx- topical benzocaine (if no perforation only) 48 hr follow up
pars flaccida
In human anatomy, the Pars flaccida of tympanic membrane or Shrapnell's membrane (also known as Rivinus' ligament) is the small, triangular, flaccid portion of the tympanic membrane, or eardrum. It lies above the malleolar folds attached directly to the petrous bone at the notch of Rivinus. On the inner surface of the tympanic membrane, the chorda tympani crosses this area. relevant pathology: some patients do not outgrow their eustachian tube dysfunction, and they go on to suffer from chronic negative middle ear pressure. This can result in retraction of the superior part of the ear drum, known as pars flaccida, back into the middle ear space. The outside of the eardrum is actually lined with squamous epithelium, which desquamates and produces keratin. Over time, the keratinous debris can get caught in the pars flaccida retraction pocket. This can continue to accumulate, expanding the pocket, and is then called a cholesteatoma
Amoxicillin (PO)
Indications: -AOM Mechanism: -Inhibits cell wall synthesis -Bactericidal (time-dependent killing) SE: -Hypersensitivity -Diarrhea -Interstitial nephritis -Seizures (CKD pt's) -Cytopenias CI: -Caution in CKD pt's (eliminated by kidney) Notes: ***High-dose Amoxicillin 80-90 mg/kg PO BID (adults = 10 days, children (2-6) = 5-7 days)***
Amoxicillin/Clavulanic Acid
Indications: -AOM Mechanism: -Inhibits cell wall synthesis -ß-lactamase inhibitor -Bactericidal (time-dependent killing) SE: -Hypersensitivity -Diarrhea -Interstitial nephritis -Seizures (CKD pt's) -Cytopenias CI: -Caution in CKD pt's (eliminated by kidney) Notes: ***Augmentin 80-90 mg/kg/day for 10 days***
Ceftriaxone (3rd gen, IV, IM)
Indications: -AOM (2nd line) Mechanism: -Inhibits cell wall synth -Bactericidal (time-dependent killing) SE: -Hypersensitivity -Diarrhea -Interstitial nephritis -Cytopenias -Cross-reactivity w/ PCN*** CI: -Do not give to pt who experienced anaphylactic rxn or SJS w/ PCN or cephalosporin Notes: -50mg/kg IM daily for 3 days -No CKD precautions (eliminated in bile) -Crosses BBB
Cefuroxime (2nd gen, IV, PO)
Indications: -AOM (2nd line) Mechanism: -Inhibits cell wall synth -Bactericidal (time-dependent killing) SE: -Hypersensitivity -Diarrhea -Interstitial nephritis -Seizures (CKD pt's) -Cytopenias -Cross-reactivity w/ PCN*** CI: -Caution in CKD pt's (eliminated by kidney) -Do not give to pt who experienced anaphylactic rxn or SJS w/ PCN or cephalosporin Notes: -30mg/kg/day BID x 10days
Ciprofloxacin/Dexamethasone (gtt) (Ciprodex)
Indications: -Acute otitis externa (perforated TM) -Acute otitis media (>6 months w/ tympanostomy tubes) Mechanism: -Cipro = abx -Dex = corticosteroid anti-inflammatory SE: -Pruritus -Otalgia -Auditory impairment -Oral candidiasis CI: -Hypersensitivity -Viral infection Notes: -Safe with perforated TM but not 1st line
Antypyrine/Benzocaine/Glycerin (Auralgan)
Indications: -OM -Ear wax removal Mechanism: -Antipyrine = analgesic -Benzocaine = local anesthetic -Glycerin = decreases middle ear pressure by osmosis SE: CI: -Perforated TM -Ear discharge Notes:
Polymyxin B sulfate/Neomycin/Hydrocortisone (Cortisporin)
Indications: -Otitis externa (bacterial) Mechanism: -Hydrocortison = anti-inlammatory -Neomycin = Abx that inhibits protein synth (30s subunit) -Polymixin B = Binds to phospholipids, alters permeability, and damage bacterial membrane permitting leakage of contents SE: -Contact dermatitis, sensorineural HL (neomycin) -Can make sx (stinging/burning) worse (but not the infection) CI: -***TM perforation*** -HSV/VZV -SULFA ALLERGY Notes: -Poor staph coverage
Olfloxacin (Floxin)
Indications: -Otitis externa (perforated TM) Mechanism: SE: CI: Notes: -4 gtt BID x 5 days
Azithromycin (Zithromax) (IV, PO)
Indications: -Persistent AOM Mechanism: -Irreversible binding to 50s subunit to inhibit protein synth -Cidal at high doses SE: -GI upset (N/V) -Diarrhea -QT prolongation CI: -COPD pt's Notes: -Active metabolite -Secreted in bile -Small increased risk of cardiac arrest
otitis media
Infection of the middle ear, middle concavity will bulge out (convex). May loose cone of light. Pus and fluid in eardrum that pushed eardrum out, non-tender to palpate. Looks red and bulging drum, loss of landmarks, dilate blood vessels may cause spontaneous rupture and conductive hearing loss
Tympanic membrane
Inflammation, fluid, performation, bulging, redness, dishcharge, cone of light, handle of maleus
External ear
Inflammation, swelling, discharge, wax, bleeding, brusing, mastoid scars or bogginess
what are the complication of AOM acute otitis media
Intratemporal intracranial systemic Danger signs
Middle Ear Effusion
Liquid in middle ear (no reference to cause, duration, or pathogenesis) Descriptors: -Serous = thin, watery fluid -Mucoid = thick, viscid, mucus-like -Purulent = pus -Combination Persistent MEE = persistent fluid in middle ear after episodes of AOM Chronic MEE = Persistent MEE greater than 3 months duration Otorrhea = discharge from ear
In SDT, what are you looking for?
Listening for hearing, not understanding. dB at which listener is aware of speech 50% of time
Where is the most common site of epistaxis?
Little's area
External examination of ears
Look for deformities, nodules, lesions or signs of inflammation Palpate for pain or tenderness
Signs and Symptoms of Ear Disease
Losing or reduction of hearing Otalgia (ear pain) Otorrhea (discharge from ear) Tinnitus Itching (ringing in the ear)
neurological
MS neuropathy depression
Which ossicles can be seen best
Malleus
Creased Lobe
May be associated with ↑ risk for coronary artery dz
Serous Otitis Media
May be due to poor Eustachian Tube Function May be concurrent with URI's Common in people with allergies Look for fluid, bubbles behind TM Can procede AOM -can develop an infection TM is NOT inflamed**
Tympanic Membrane Perforations
May be due to trauma, infection,barotrauma (divers, airplanes change in pressure) Conductive hearing loss -won't transmit air like normal ↑ risk of infection
Cerumen Impaction
May be painful depending upon extent of cerumen Can cause conductive hearing loss Very common in elderly and children Tx: Debrox drops, irrigation, curette/otoloop
SL is always going to refer to SRT?
No, refers to word scoring.
Tuning Fork Tests
Measure hearing by air conduction or bone conduction, in which the sound vibrates through the cranial bones to the inner ear
Most common material used is phonetically balanced word lists:
Monosyllabic words. Called PB. contains all phonetic elements of english discourse. 50 word lists. determine % correct.
MCL
Most comfortable loudness level. NOT A THRESHOLD. where do we need to have your amplification set at? varying levels up/down until they are comfortable with hearing speech like that everyday. Looking at 40-55dB above their threshold. ex. 30dB HL change to 70dB.
Hairy Tragus/Pinna
Most common in men Occurs with aging More common in people of Indian descent
naturopathic tx for OME and AOM
NAC: mucolytic and antioxidant xylitol: anti microbial
should we prescribe steriods, antibiotics or antihistamines for OME
NO
complications of ear surgery
Nerve damage (horners) Hearing deficits Chronic infection
Retrograde flow of Eustachian Tube
Occurs when nose is plugged - virus grows in this area
Malignant otitis externa
Osteomyelitis of temporal bone as a result of chronic infection in DM - Not cancerous
Bullous Myringitis
Otalgia Erythematous TM more hemorrhagic that AOM Blisters May accompany URI symptoms Mycoplasma pneumoniae or virruses are causative organisms
what parasites are primary factors of otitis
Otodectes Scabies Demodex Ticks Fleas (cats>dogs) Flies
before you begin testing, what is the first thing you do?
Otoscopic examination
Cholesteatoma
Overgrowth of epidermal tissue, most commonly in pts. with history of chronic otitis media Can arise from canal or middle ear Can be painful and erode into bone May cause either conductive or sensorineural hearing loss
Keloid
Overgrowth of scar tissue, which invades original site of trauma. It is more common in dark skinned people, although it also occurs in Whites. In the ear it is the most common at lobule at site of a pierced ear.
otitis media signs and symptoms
PAIN, erythematous, bulging TM and decreased mobility; can have fever, ruptured TM and decreased hearing; effusion behind TM
ALWAYS use AC to obtain what?
PTA (peer tone average) at 500, 1000 and 2,000 Hz.
Patent T Tube
Patent means open . Pressure tubes should be open to drain out of the ear.
Romberg Test
Pathological reflex - visual system, proprioception and vestibular system of inner ear contribute to our ability to remain still and upright - 2 of 3 systems must be functioning to do so
The sensation of vertigo may indicate... ?
Pathology in the semicircular canals
Otitis Externa
Pathophys: -Disruption of normal skin/cerumen -Often cause by instrumentation -"itch-scratch" cycle -Progresses to edema, purulence, soft tissue infection Sx: -Pain (early) -Fullness (early) -Pruritus -Hearing loss -Tenderness Signs: -Erythema -Edema -Debris -Ulceration -Narrowing of canal Acute OM: -Erythema -Mild edema -Squamous debris -Cloudy otorrhea Tx: -Atraumatic removal of debris -Topical steroids/abx --> Neomycin/ Polymyxin B/Hydrocortisone -->Fluoroquinolones (Floxin and Cipro/dex) -->Systemic abx if surrounding tissue involved or immunocompromised -Symptomatic tx of pain/inflammation -->Steroids (hydrocortisone/dexamthasone) -Future dry ear precautions Notes: -Avoid macrocodes w/ perforated TM (ototoxic)
Negative Romberg test
Patient can remain upright and steady - indicating inner ear and proprioceptive tracks are working correctly
Otoscopy evaluation of TM
Pearly grey appearance Light reflex in antero-inferior of TM Check for bubbles or fluid behind membrane
During the history: Do you have difficulty hearing now? If yes...
Perform or refer to audiometric test
Subjective vertigo
Person feel as if he or she spins
Objective vertigo
Person feels as if room spins
Insertion of tympanostomy tubes
Polyethylene tubes are inserted surgically into the eardrum to receive middle ear pressure and promote drainage of chronic or recurrent middle ear infections.
Landmarks by quadrant
Posterosuperior (PS) Quadrant Handle of the malleus Posteroinferior (PI) Quadrant Tympanic Membrane Anterosuperior (AS) Quadrant Short process of the malleus Anteroinferior (AI) Quadrant Light Reflex
Keloid
Produced by abnormal wound healing Excessive bulk (highly compacted bundles of hyalinized collagen) produced at site of cutaneous injury More common in AA More common >20 yo Hypertrophic scars from surgical scars, tattoos, piercings more of a vanity issue
Excessive Cerumen
Produced or is impacted because of narrow, tortuous canal or poor cleaning method.
Otosclerosis
Progressive hearing loss over years Due to deposition of bone in cochlea/stapes foot NO pain Tinnitus common Normal TM, patent Eustachian tube More common in females Usually noticed in 30s and 40s Familial tendency May be corrected surgically (stapedectomy)
Otoscopy - Function
Provides a magnified, illuminated view of structures being evaluated Speculum narrows and directs light onto area of interest Speculum also allows minor manipulation of ear canal Use the largest speculum that will comfortably fit into the patient's ear canal
down
Pull the auricle _____ on an infant or child younger than 3 years
up and back
Pull the auricle ________ on an adult or older child
How do you visualize the ear canal in order to straighten it and improve visualization
Pull the ear up and back
Retracted TM
Pulled into the middle ear space. Lateral process pulled out and there isnt a good light reflex. Altering the shape of the ear drum.
External otitis
Purulent (pus), sanguineous (bloodred), or watery discharge
Acute OM (otitis media) with perforation
Purulent discharge
Chronic ottis externa
Puss, smelly, another name for swimmers ear.
Foreign Body
Q-tips common, Beans, peas, seeds,jewelry, etc. common in kids, psych pts. Don't irrigate if organic material suspected Be careful not to cause TM perforation -try not to pouch it in farther Can cause complete conductive hearing loss: ability to conduct sound to inner ear
OM: Management- when to refer to ENT
Refer for surgical management if there is bilateral effusion >3 months and bilateral hearing deficiency
culture technique
Remove debris Insert sterile cone Instill sterile saline Withdraw fluid-->Red rubber catheter Submit for culture
Which hand holds the otoscope
Same hand as ear being checked Support hand somewhere on the head
Tympanosclerosis
Scarring/calcification of TM d/t past acute infections Pneumatic otoscopi will discern this from acute infection
General
Scars, stretch marks, skin discolouration, swelling, suffering, photophobia, syndromes, lymph nodes, swelling of parotid and salivary glands, tender sinuses
otosclerosis
Schwartz sign: pinkish/red hue behind eardrum (aka. flamingo's pink sign)
During the history: Do you have difficulty hearing now? If no...
Screen usin Whispered Voice Test
Chronic OE
Signs/Sx: -Thickened skin -Superficial flaking & ulceration -Usually itchy > pain -Allergic/psoriatic Tx: -Topical steroids -Repeated cleaning -Identify contact irritant -Dry ear -Acidifying agents (acetic acid, ethyl alcohol, boric acid)
Complication of OM
Signs: -Very high fever (>40 C) --> bacteremia? -HA/malaise/somnolence (look for meningismus/papilledema, CT scan, LP) --> meningitis? -Continued fever, signs of toxicity w/ tx -Retro-orbital pain, focal near signs, facial paralysis Intratemporal: -HL -TM perforation -Cholesteatoma -Mastoiditis -Petrositis -Labrynthitis -Facial paralysis Intracranial -Meningitis -Subsural,epidural brain abscess -Lateral sinus thrombosis -Otitic hydrocephalus
Nose
Skin appearance, bleeding, bruising, scars, discharge, symmetry, septum, hematoma (Little's area), polyps, turbinates, adenoids, sense of smell
Anatomy of the external ear
Skin covered cartilage Flexible without pain Auricle (pinna) External auditory canal
Exostosis
Small bony growths of canal Benign Usually multiple and B/L Aris more commonly near TM Usually no treatment necessary unless recurrent cerumen impactions
Darwin's Tubercle
Small cartilagenous protuberance, most commonly along the concave edge of posterosuperior helix Normal variation
Tophi
Small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contain greasy, chalky material of uric acid crystals and are a sign of gout.
Foreign Body
Something not normally seen in the ear canal
compression and rarefaction fall under?
Sound transmission
surgical options
TECA Vertical canal bulla osteotomy
pathway of sound?
TM > ossicles > oval window > hair cells of organ of court?
along the edge is more complication due to
TM heals to the EAC
chronic suppurative otiti media: performated TM with chronic otorrhea greater 6-12 weeks
TM is perforation is present due to: AOM Trauma Choleastatoma Tube placement - 1-2% of pt with tubes or craniofacial anomalies bacterial translocation from EAC to middle ear
Type B with large physical volume
TM not intact
Tympanometry intro
TM vibrates most easily and best when air pressure is equal on both sides
what are the 10 t's dz to consider elsewhere in the head and neck and the ear
TMJ Tonsils Tube: eustachian Teeth Tongue Tic: glossopharyngeal Trachea Thyroid Tendons Trigger points rule out cancer if dysphagia and cervical adenopathy
Throat
Teeth and gingivae, buccal mucosa and tongue, tonsils, retromolar space, post-nasal drip, pharynx, inflammation of uvula ('ah')
firm and mobile without nodules
The consistency of the auricle should be
Gouty Tophi
gouty deposits uric acid crystallization untreated gout feel like little pebbles under the skin
Normal Eardrum (tympanic membrane)
The eardrum is pearly white or light gray, and you can see through it. You can see the tiny bones of the middle ear pushing on the eardrum. You see a cone of light, known as the "light reflex," reflecting off the surface of the eardrum. This cone of light is at the 5 o'clock position in the right ear and at the 7 o'clock position in the left ear.
Ear drum perforation
The eardrum itself is compromised
conjunctiva
The epithelium covering the inner surface of the eye-lids and the outer surface of the eye is called the ________
whitish haze
The incus may be visualized as a ________ to the manubrium
Abnormal Eardrum (tympanic membrane)
The light reflex on the eardrum is dull or absent The eardrum is red and bulging. You can often see amber liquid or bubbles behind the eardrum. You can see a hole in the eardrum (perforation). You can see whitish scars on the surface of the eardrum. If your child has had a tube placed in an ear, you may also see the tiny plastic tube, which is usually blue or green. The eardrum is blocked by earwax or an object, such as a bean or a bead.
eustaschian tube
The middle ear is connected to the nasopharynx by the
shiny and translucent pearly-gray color, flat, and intact
The normal eardrum is
malleus, the incus, and the stapes.
The three auditory ossicles are the
completely out of phase looks like?
The waveforms look like mirror images of one another.
eustaschian
This tube helps to equalize the pressure in the middle ear with external atmospheric pressure
20 feet
To test far vision Have the patient stand _____ away from the Snellen eye chart, if the patient wears glasses or contacts have them keep it on
14inches
To test near vision: Hold a pocket card _______ from the patient
Weber's test
Tone should be equal; conductive lateralises to bad ear and sensorineural lateralises to good ear
what are the other symptoms of OME
Tonsillary hypertrophy nasal: rhinorrhea, PND, boggy turbinates allergic symptoms
name the 3 types of waves
Transverse, longitudinal, and sinusoidal
Otitis Externa: Chronic
Treat eczema with steroid cream, then use vinegar/water washes and avoid Q-tips
Topical therapy for cleaning the ears
Tris EDTA BID
The cochlea is the starting point to the brain?
True
wave motion-do sound waves radiate in all directions?
True
Zero decibels is not the absent of sound ? T/F
True bc it is equal to the min audibility curve
OM: Management- Chronic
Tx with 10days of FQ - Consider chronic therapy with daily amoxicillin during winter and spring with monthly f/u
Major test of Immitance
Tympanometry Acoustic Reflex thresholds
Acute Otitis media (AOM)
Typically associated with infections May have concurrent conjunctivitis Often presents with fever Deep-seated earache conductive hearing-loss Bulging TM
Occluded ECA
Typically cerum filled blocking your view of the ear drum
What is a common cause of purulent otitis media and how does it occur?
URT infection that causes eustachian tube dysfunction. this causes N2 and O2 to be absorbed by mucous membranes, creating negative pressure in the middle ear. This can cause retraction of tympanic membrane or transudation of fluid from capillaries - the fluid allows for bacteria to grow?
Carcinoma
Ulcerated, crusted nodule with indurated base that fails to heal. Bleeds intermittently. Must refer to biopsy. Usually appears on the superior rim of the pinna, which has the most sun exposure. May occur in ear canal and show chronic discharge that is either serosanguineous or bloody.
UCL
Uncomfortable loudness level 100-110dB both these are continuous discourse
Which direction is the otoscope handle?
Upwards
Ear tubes (myringotomy tubes)
Use to continually drain fluid from behind the eardrum, can stay in place several years, often fall out on their own.
Barotrauma
Usually d/t sudden decompression while diving Signs/Sx: -Ear pain -Transient vertigo -Decreased hearing -Effusion and TM hemorrhage Tx: -Decongestants and ear drops if perforation
Acute Otitis Media (AOM)
Usually h/o recent URI Bacterial or Viral etiology Strep pneumoniae, Haemophilus influenzae, M. cattarhalis most common bacterial pathogens More common in infants and children Usually unilateral
beta lactamase
Usually produced by Streptococcus pneumoniae strain. Treated with augmentin (amoxicillin-clavulanate)
Auditory Acuity test for CN
VIII, vestibulocochlear Whisper test, ticking watch, weber test, done with pt occluding 1 ear with finger/hand
Why is retrograde flow of eustachian tubes less of a problem for adults?
Very steep slope for flow to go up
why do you do a otoscopic exam?
Want to check the status of the ear canal. is anything blocking? ear canal curves, so manipulate by pulling the pinna up and back and secure the head.
OM: Management- Mild
Watchfully with with NSAIDs for pain relief as long as patient is >2years
a whispered voice or rubbing fingers
We evaluate auditory function by asking for response to questions and directions. Testing with ________________________
meatus, tympanic membrane
We inspect the auditory canal from the ______ to the ________ checking for discharge, redness, scaling, lesions, foreign bodies, and cerumen
Hearing
Whisper 99 and 66 in ear whilst rubbing auricle of oppsite (distraction)
Examination of Auditory Acuity
Whispering, rubbing fingers or tuning fork Rinne and Weber tests (more in neurological testing) Block one ear so sound only presented to one side
Abnormal Ear Canal
Wiggling or pulling on the outer ear causes pain. The ear canal is red, tender, swollen, or filled with pus.
How is inner ear evaluated
With hearing acuity
acoustic neuroma vestibular schwannoma
a benign tumor of CN 8 in the internal auditory canal or cerebellar pontine angle symptoms: sensorineural: hearing loss with or without vertigo and facial paralysis dx: audiogram with asymmetrical high frequency loss, MRI acoustic neuroma: consider in all patients with unilateral hearing loss, vertigo or paralysis always get an MRI
cholesteatoma
a cyst like mass of dequamating epithelial cell and debris including cholesterol complication: erosion of ossicles sensorineural hearing loss labyrinthitis CN8 paralysis meningitis brain abscess sinus thrombophlebitis neck abscess - bezold refer out
Otorrhea
a discharge from the ear that suggests infected canal or perforated ear drum
Forein body
a piece of glass etc.
blue or dark red color
blood behind the ear drum-trauma/skull fracture
decibel
a relative measure of intensities or pressures
Tragus
a small pointed eminence of the external ear, situated in front of the concha, and projecting backward over the meatus.
Hematoma
blood clot or formation in the ear canal
spondee
a word with 2 syllables that receive equal stress
otomycosis
abnormal condition of fungus in ear
otorrhagia
abnormal flow from ear
Otosclerosis
abnormal growth of bone near the middle ear. It can result in conductive hearing loss (common hearing loss in young adults 20-40 yo)
keloid
abnormal wound healing that causes excessive collagen growth; very common in african americans younger than 20
Phase is defined:
according to degree. 0, 90, 180, 270, 360
pharyngitis
accounts for 20% outpt sick and 50% outpt abx causes: strep py, N. honorrhea, advenovirus, rhinovirus, echovirus, HSV, EBV, CMB, parainflu, allergies, C. dip, peritonsilar abscess, sinusitis, GERD, carinoma, fungal infection
hematomas
accumulation of blood between skin and cartilage usually from blunt trauma; inspect and palpate for other head/neck injury and check hearing
Admittance
acoustic energy passed by the TM into the middle ear
TM which is red indicates...
acute otitis media, trauma, or hemorrhage
mastoiditis
acute purulent otitis extends to mastoid antrum cell apparent after 2 weeks untreated AOM due to strep pneumoniae s. pyogenes s. aureus beta hemolytic strep group A - immigrants r/o TB rare with antibiotics, increase the multi drug resistant MDR ddx: posterior auricular cellulitis severe otitis externa neoplasm
Tympanometry determines
admittance if sound into the middle ear at varying degrees of positive and negative pressure in the EAC -related to compliance of the TM and ossicular chain
Peak Admittance is
admittance of sound at the peak of the tympanometry race
otoscopy adult vs child
adult: hold pinna upward and backward child <3: hold lobe downward and backward
eustachian tube dysfunction
aerates middle ear pressure equalization clears mucus due to relflux/gerd allergy obstructive sleep apnea large adenoids inflammation from infection barotrauma: plane, diving smoking anatomic less than 7yr fullness dizziness pain predispose to OME and AOM
Children with persistent otitis media with effusion need tubes
after three to four bouts of acute otitis media in six months or five to six bouts in a single year.
Treatment of Necrotizing Otitis Externa
aggressive surgery and antibiotics
what is rinne test comparing
air and bone conduction
normal hearing pathway
air conduction
middle ear is ___ filled cavity in _____ bone separate from external ear by ______
air, temporal, tympanic membrane
function of nose
airway warms air filters dust and pathogen humidification of air receives secretions from sinuses/eyes
What things increase likelihood of serous otitis media?
allergic inflammation of eustachian tube or overgrown adenoidal tissue
reasons for water discharge
allergies, viral rhinitis, URI, CSF leak, medicamentoas
primary factors of otitis
allergy parasites
Tympanostomy Tubes
allows for drainage
Extended PE Tubes
also called ventilation tubes
period
amount of time required for the completition of one cycle
what is the recommended first line tx for AOM
amoxicillin 80-90 mg/kg/d in 2 divided doses
acute otitis media tx-
amoxicillin large dose 90 mg per day first line or azithromycin if allergic to penicillin
Which antibiotic is *first-line* for acute otitis media?
amoxillicin (high dose)
The middle ear
an air-filled cavity that transmits sound via the auditory ossicles
menieres dz idiopathic endolymphatic hydrops
an episodic condition in which the membranous lab traid of symptoms - typically intermitten but severe - vertigo: 2 + for greater 20 min - hearing loss with noise distortion - continuous or intermitten tinnitus nausea vomiting anxiety nystagmus less than 1/3 pt present with triade at onset
Swimmer's Ear (external otitis)
an infection of the ear canal itself. Notice the swelling of the ear canal.
conductive hearing loss?
an interruption in transmisison in external canal or middle ear
vascular
aneurysm vascular intracranial tumor CVD - HTN, atheroma, cardiac hyperlipidemia artherosclerosis
NUCHIPS
another book. both WIPI and NUCHIPS are closed response! meaning they can only pick from a select choice of words
Meniere's disease
another form of peripheral vertigo. - consists of the triad of findings (hearing loss, vertigo and tinnitus). It is caused by over-produciton or under absorption of endolymphatic fluid in the membranous labyrinth. Hydraulic pressure in the cochlea increases and causes shield to tear and hair cell death. Lasts for hours.
epistaxis types
anterior (90%) or posterior
which quadrant is the COL located?
anterior inferior quadrant
Ear drainage in patients with tubes in should be tx with?
antibiotic ear drops
open response
anything from their vocabulary. list of words they do not know where it is coming from. typically for adults but normed for all ages.
Leukoplakia
anywhere in oral cavity CANNOT WIPE OFF painless white plaque on mucous membrane PREMALIG lesion prominent in: AIDS/HIV, smoker, alcohol, autoimmune DO
paranasal sinuses
are air-filled chambers that open into the nasal cavities and are contained within the frontal, sphenoid, ethmoid, and maxillary bones.
Dont do tympanometry for kids who
are hyperactive, child who is crying,yawning,or continually talking
Peak pressure is
at what pressure (daPa) does the peak admittance occur
atropic glossitis
atropy of papillae dryness, intermittent burn, paresthesias of taste smaller, SLICK AND GLISTENING may have small punctate red dots *b/c poor nutrition of vit def folic acid or B *
vertibular neuronitis
attack of severe vertigo with nausea and vomiting no auditory symptoms present - unlike labyrinthitis frequently viral in origin most severe acute phase is usually two weeks but may take twelve weeks to resolve nystagmus: spontaneous horizontal with or without rotary nystagmus
0-115 dB on
audiogram
conductive hearing and structures
auricle to tympanic to inner hear bones
preauricular pits
autosomal dominant small holes just where the auricle meets the scalp superior; can get infected and if reoccurring can be surgically removed
what can we do to change lifestyle wise to address tinnitus therapeutics
avoid caffeine noise machine fan to sleep tinnitus retraining therapy - device producing low level sound behavioral cognitive therapy
HSV
b/c HSV1 or HSV2 groups of vesicles filled with clear fluid on erthematous base painful and burn develop during illness or stress and can never get rid of the virus
Periodonitis (pyorrhea)
b/c untreated gingivitis, receding and painful gums halitosis maybe pus pockets *ANEROBES* common cause of teeth loss
what are the systemic complication of AOM
bacteremia septic arthritis bacterial endocarditis
BNT - examples
baytril nizoral triamcinolone NOT a fan
sometimes in SRT testing, the patient gets anxiety why?
bc they are able to catch the words they are missing. (they see through your speech)
right sided high fever 103+ red hot face worse at 3PM
belladonna
REfraction
bending of a sound wave, occurs when speed of sound is altered.
Where is the organ of corti?
between the tectorial and basilar membranes
outstanding ears
big ears; no pathologic consequence and can be corrected surgically
Ear canal abnormalities
blood effusion drainage inflammation excessive cerumen or foreign object
hemotympanum
blood in middle ear behind TM; from trauma or extreme pressure changes; can be painful with spontaneous resolution over several weeks; conductive hearing loss possible
Peutz Jegher's syndrome
blue/black patches of pigment on skin, mucosa, fingers/hands, and face -assocaited with Familial Polyposis of intestine and intestinal bleed/anemia
mastoid process
bone behind & below the ear canal (mastoid part of temporal bone)
exostosis
bony growths that develop beneath the skin of the inner ear canal who have hx of exposure to cold water -
Torus palatinus (mandibularis)
bony outgrowth of palate nonpainful benign arise in puberty 25% women, 15% men
AU
both ears
mixed hearing loss
both types combined
blood supply of ear
branches of auriculo-temporal branch of inferior maxillary A
Tris EDTA works how
breaks down the LPS - the cell wall of the gram neg bact
battle sign
bruising behind the ear indicating fracture at the base of the skull
why can you use tris EDTA with aminoglycosides
buffered to pH=8
cerumen impaction
build up of ear wax that can be painful and cause conductive hearing loss; common in old and young; use softening drops, irrigation, and a curette to remove
pneumatic otoscopy?
bulb attaches to otoscope and can inject air to see the tympanic membrane mobility?
rhinophyman
bulbous enlargement of distal 2/3 of nose from multiple sebacceous adenomas -may follow long standing rosacea
absent or distorted light reflex
bulging of the ear drum- acute otitis media
what is the mc cause for sensory neuro hearing loss
bullous myringitis
what tx helps with this
calcium carbonate with vitamin D
what is the allopathic tx for otosclerosis
calcium carbonate with vitamin D sodium fluoride 20-120 mg/day : halts or retards progression sugery: stapedotomy or stapedectomy, middle ear prostheis s
haemophilus influenzae
can produce beta-lactamase - provides resistance to penicillin
cerumen
canal blockage (complete or partial)
*What should you suspect if adult has serous otitis media? (without URI)?*
cancer- *nasopharyngeal* carcinoma blocking eustachian tube
mineralized ears - important facts
cannot revert pathology painful
atresia
cannot test
Where to make an inciison for middle ear surgery
caudal ventral quadrant of tympanic membrane to avoid any important structures
infectious mononucleosis
caused by EBV or CMV fatigue, malaise, fever, LAD, pharyngitis, HA, hepatosplenomegaly tx: rest, fluid, no abx or contact sport or heavy lifting `
cauliflower ear
caused by repeated trauma to auricle; generation of fibrous tissue and scar formation, lose normal landmarks; can have hearing loss and can be surgically corrected
uvula deviation
causes: peritonsillar abscess, lesion/defect CN X say "aahhhh" and uvula will deviate AWAY from lesion/defect and soft palate will not rise
tx of anterior epistaxis
cauterize with silver nitrate sticks or nasal packing
what can cause changes in the color of the TM
cerumen irritation of the external auditory canal coughing nose blowing crying fever
ceruminoma
cerumen mass
angry and cross child pain so intense they are screaming hot to tough want to be help but does not feel better
chamomila
conductive hearing loss happens when
changes in outer or middle ear impairs conduction of sound to inner ear
what do we expect to see with cbc with allergic rxn
high eosinphiles elevated basophiles with paracites
humming
china phos
if drainage persists you are referred to rule out
cholesteatoma
ddx of otosclerosis
chronic OM labyrinthitis presbycussis - bilaterally cholestatoma
What is commonly going on with OME?
chronic dysfunction of eustachian tube Children with OME are often asymptomatic, although they may complain of ear fullness or muffled hearing. On physical examination, there may be an air-fluid level behind the eardrum and decreased mobility of the eardrum.
what iatrogenic things will predispose an animal to otitis
cleaning agents
risk factors
cleft palate - tube asap at 2 months Native american and eskimo heritage allergies young age second hand smoke adenoid infection daycare with more than 8 kids past history not breast feeding - maternal antibodies at least 4 months immunocompromised family history downs cranio facial anomalies male much higher risk Jan Feb March 3 worst months of year propping bottle
perpetuating factors for otitis
cocci bacteria rod bacteria yeast organisms (malatheszia) contact allergy
sensory neural hearing and structures
cochlea - nerve (CN VIII) - brain
What makes up the auditory system?
cochlea and cochlaear portion of eight nerve
contents of inner ear?
cochlea, internal auditory canal and semicuclular canal
risk for anterior epistaxis
cold, dry, trauma, dehydration, blood thinners
cold water irrigation vs warm?
cold: cuases nastyagymus in direciton opposite of where water is poured. warm: nastagymus in direction of where water was poured COWS
otitis media
collection of fluid in middle ear space; bubbles may be present; fluid is clear and watery
cholesteatoma
collection of skin that builds up behind the eardrum
Tympanic Membrane abnormalities
color bulging or retraction fluid line or bubbles perforation mass
what are the characteristics of the TM
color position mobility perforation
cholesteatoma
complication of acute otitis media An abnormal skin growth in the middle ear behind the eardrum is called cholesteatoma. Repeated infections and/or a tear or pulling inward of the eardrum can allow skin into the middle ear. Cholesteatomas often develop as cysts or pouches that shed layers of old skin, which build up inside the middle ear. chronic ear drainage, often due to Pseudomonas or Proteus bacteria. sloughing skin gets trapped and continues to grow and secretes enzymes that erodes incus bone can erode right into brain TX: referral - not antibiotics, needs excision CT best diagnostics
meningitis
complication of acute otitis media Meningitis originating from otitis media is believed to occur by blood-borne spread of the bacteria from the middle ear space into the meninges. Haemophilus influenzae was most prevalent pathogen but has decreased with vaccinations. Meningitis caused by otitis media is most often treated with intravenous antibiotics. A potential complication of pediatric meningitis is hearing loss.
acute mastoiditis
complication of acute otitis media drug resistant bacteria can cause inflammation of mastoid ear protrudes swelling Patients with acute mastoiditis present with fever, ear pain, and a protruding auricle. Over the mastoid bone, the patient may have erythema of the skin, tenderness, and even a fluctuant mass TX: Intravenous antibiotics may initially be used to treat patients with acute mastoiditis. Surgery, including PE tube placement or mastoidectomy, may be necessary in patients who do not respond to medical therapy.
off label meds for otitis
compounded meds ticarcillin BNT
what is another word for compression?
condensation. mean the same thing.
what type of hearing loss do we see with CSOM
conductive haring loss lateralization to effective ear bone is greater than air
what type of hearing loss do we find iwth OME
conductive hearing loss
children who present with mild bulging of the TM and recent <48 hours onset of ear pain holding tugging rubbing ear in a nonverbal child or intense erythema of the TM
dx: AOM
vertigo worse when turning head to quickly
conium calc-carb homeopathics
worse when turning in bed, lying down and moving eyes
conium homeopathics
eustachian tube
connects middle ear to posterior portion of nasopharynx; allows neutralization of internal and external air pressures; in children more horizontal --> middle ear infection
treatment
consult with otolaryngologist and neurosurgeon refer for antibiotics and or surgical intervention
cochlea contains ____ which...
contains organ of corti which transmits sound impulses to CNVIII (acoustic)
Systemic antibiotics two cons to use are ____ and ____
cost side effects
What are the findings of central vertigo?
cranial neuropathies (eye momevments, dysarthria, ataxia), usually purely horizontal or vertical, no torsional component. Nystagmus does not change with maintennance of position and not inhibited by visual fixation
Malocclusion
crowding of teeth causes: congenital, trauma, jaw pain, thumb sucking
a ____ is important when the ear drug is ruptured
culture
dx of labyrinthitis
culture ct temporal scan
salpingotomy
cutting into auditory tube
labyrinthotomy
cutting into labyrinth
myringotomy, tympanotomy
cutting into tympanic membrane
frequency
cycles per second
Cholesteatoma
cystlike mass composed of epithelial cells and cholesterol occurring in the middle ear; may be associated with chronic otitis media
hearing level
dBHL used on audiograms
what is color of the TM with acute otitis media (AOM)
dark pink or lighter red more redness with infection
dental caries
decay of teeth from alcohol, tobacco, poor hygiene at risk for poor nutrition and sepsis bactermic after dentist appt
rarefaction
decrease in sound press. Less molecules per volume. Lighter area.
attentuation
decrease in strength of a sound. Symptom of conductive hl. dampen/block sound from getting through.
Gouty tophi
deposit of uric acid crystals
tophi
deposits of uric acid crystal in helix, occurs with gout
When do you test the 1/2 octave?
difference is 20dB or greater is seen between 500 and 2000 HZ and for noise exposure-add 3000 and 6000 to what you would normally test
ear cytology - what is the first stain you will always do
dip-quick
otopyorrhea
discharge of pus from ear
wavelength
distance between any point on a sinusoid to the same point on the next cycle of the wave
how to diagnose benign posiitonal vertigo?
dix-hallpike- which is when pt.s head is extended, move head to one side , then have pt placed supine rapidly so that head hangs over edge of bed -- see if nystagmus occurs. raise pt. check for nystagmus in both positions
false negative
do not respond
when we say greater..what do we mean?
double poor
sensorineural hearing loss?
due to a problem with organ of coli, hair cells, CN 8 or auditory cortex
laryngopharyngeal reflux
due to the presin in 60 -80% with OME
Tube dysfunction
due to: allergies URTI anatomic trauma
post AOM
effusion can be present for 1 mo in 45% of cases
example of mixed hl
elderly with old damages hair cells and cerum
rare complications of acute otitis media
epidural and brain abscesses sigmoid sinus thrombosis, and facial nerve paralysis
Weber test
equal bilaterally without lateralization
Size and shape
equal bilaterally; appropriately placed on head
BC tests can be
equal or better, but never poorer
A mobile TM with *only* negative pressure indicates...
eustachian dysfunction
COWS testing
evaluation of inner ear function Warm H2O over 1 ear, cold for the other Causes: nystagmus and vomiting
air conduction can be impeded by
excessive cerumen, foreign body, otitis media, tumor of middle ear, otitis external, fluid in middle ear (more common in 40 year old), headphones
Type Ad
excessively compliant middle ear system normal shape normal peak pressure high peak admittance (>2.5mL)
What is sensorineural hearing loss due to in young people?
exposure to loud noise
it is common to have otitis -___ and ___ together
externa and media the externa can cause the media
3 parts of ear
external (ear canal), middle (3 ossicles), inner (cochlear)
EAC
external auditory canal
vibrations of sound transmitted to...
external ear -> eardrum -> ossicle of middle ear -> cochlea -> vibrations cause organ of corti to stimulate impulses in CN VIII which are transmitted to temporal lobe for interpretation
EENT
eye, ear, nose, throat
why place tube in lower hemisphere of tympanic membrane
facial nerve 7 and 8 run through ear and ossicles run in upper half of tympanic membrane function: pressure equalization tubes
what is a complication of labrythinthitis
facial nerve paralysis if infective cochlear damage
dx of otosclerosis
family hx with conductive hearing loss CT scan of temporal bone audiometric evaluation
what are the complication of CSOM
fever, vertigo pain petrositis, facial paralysis, labrinthitis, meningitis , intracranial abscess
important for clinician to :
figure out a way for the patient to respond if they do repeat you.
clove oil
good for tooth aches
cheilosis (angular stomatitis)
fissures/cracks at angles of lips caused by: dehydration, nervous habit, ill fitting dentures, riboflavin def, meds (chemo), malignancy
Type B
flat tympanogram no peak very low admittance
synotic topical steroids- trade name, contains ___, strength
flucinolone Contains DMSO VERY STRONG!!
Rinne test
follow up after weber; place base of vibrating tuning fork on mastoid bone; start timing and ask patient to tell you when they don't hear sound (= bone conduction); quickly place tuning fork 1-2 cm from ear and ask when they stop hearing sound (= air conduction); it is normal for air conduction to the 2x bone conduction, if a conductive hearing loss BC > AC, if sensorineural hearing loss AC > BC
what are primary factors of otitis (5)
food allergy atopy autoimmune neoplasia vasculitis
melissa
good taste good for the gut good for depression
What does a pt c/o with serous otitis media?
fullness in ear, decreased hearing
a carrier phrase
gets them ready to hear -say the word chair
what is the naturaopathic tx for labryinthitis
gingko intratympanic installation: minimizes associated cochlear damage
children aged 6-24 mo with high fever >102.2 or 39 C within the last 24 hr or severe otalgia or if reassessment is not possible if the conditions worsen
give antibiotics
children less than 6 mo, even if symptoms are not severe and fever is not high, due to increase complication risk
give antibiotics
children with predisposing dz for Acute otitis cleft palate immune def
give antibiotics
Cerum
glandular secretions of apopilosebaceous unit combined with sloughed epithelial cells
examine what ear first?
good ear
black or white dots on drum or canal
growth of fungal infection
hairy tragus/pinna
hair growth in ears, common in men of Indian descent
oral HIV/AIDs manifest
hair leukoplakia oral candidiasis Kaposi's sarcoma herpes simplex apthous ulcers periodontal disease
tonotopic
hairs of oval window are tonotopic or arranged to conduct certain frequencies
otosclerosis
hardening of ear
Romberg Test: Procedure
have patient stand with feet together and close eyes, while attempting to remain in still and upright as possible for 20-30 s Be prepared to catch (or guide into chair)
other
head trauma fever stress insomnia thyroid dz
HEENT
head, eye, ear, nose, throat
communication history
hearing at church, tv, ppl. Parent-when were first words/do they only hear select ppl?
presbycusis
hearing condition of old age
what is the most common cause of tinnitus?
hearing loss
intratemporal complication of AOM
hearing loss, TM perforation - acute and chronic chronic suppurative OM - with or without cholesteatoma cholesteatoma, mastoiditis, petrositis, labyrinthitis facial paralysis
cranial nerve VIII vestibulocochlear nerve
hearing loss, loss of balance,
What are complication of untreated purulent otitis media?
hearing loss, meningitis and *mastoiditis*
function of ear
identify, locate, interpret sound and maintain equilibrium
children and adults older than 3 yr with greater than 104 rectal temp
high risk
children and adults older than 3 yrs with greater 103 oral and toxic appearing
high risk
what do we expect to see with cbc with cocci
high wbc high lymphocytes high eosinophil
what do we expect to see with cbc with EBV
high wbc high lymphocyts
what do we expect to see with CBC with bacteria
high wbc low lymphocytes high PMN
You can hear a __freq at a ___decibel.
higher, lower
electroacoustic calibration vs. biological
hire out-happens yearly. visual/listening check of equipment done everyday.
vertigo
history: provoking agnets, timing, duration , associated signs and symptoms viral infection hx medical hx: cardiac endocrine infection neurologic changes in head position stress barometric changes trauma
weber test (lateralization)
hold fork at its base and tap it lightly against heel of palm. place base of vibrating fork on midline vertex of clients head or middle of forehead. ask client if he or she hears the sound equally in both ears of better in one ear.
Probe tones measures
how much sound is absorbed and how much is reflected back into ear canal
validity
how well it measures what it is supposed to measure
changes in smell
hyperosmia, cacosmia, anosmia
children 3 mo - 3 yr
if pt is toxic appearing and greater than 102.2 rectal : send pt for outpatient workup if WBC greater than 15000 use empiric abx if nontoxic and less than 102.2 rectal the observe at home
when do we do CT or MRI
if suspicion of neoplasm or intratemporal or intracranial complications
when should we follow up for AOM
if symptoms do not resulve with 48 hours of tx consider anatomical issues audiometry if effusion > 3 mo
risk of otitis
immunocompromised, not breast feeding, smoke, jan- march, day care, siblings with hx, cranio facial abnormalities, adenoids, male, hx of allergies, native american, eskimo, adenoids
OME with pneumatic otoscopy
impaired mobility
AOM with pneumatic otoscopy
impaired movement with both positive and negative pressure
Define
impedance, free/forced vibration
what is a common cause for serous otitis media?
in children due to horizontle eustachian tube- causes eustachian tube dysfunction and negative pressure in middle ear.
If 2 tones coincide in the same place in their cycles=
in phase
Group A Strep pharyngitis (strep throat)
incub 2-5 days sore throat, fever, chills, headache, N/V, abd pain physical erthemia of pharynx/uvula enlarged tonsils with patchy white exudate enlarged and tender LN rapid strep test or cultre TX: pen VK, amox, erthromyocin
what are the causes for tympanic membrane perforaion
infection choleastoma air pressure of EAC (barotitis) trauma ear irrigation myringotomy
otitis externa
infection of ear canal, change in pH in ear and ear canal swells up, tender to palpate
bright red color
infection of middle ear-acute otitis media
What is external otitis?
infection of the external auditory canal
Define otitis media
inflam of middle ear
salpingitis
inflammation of auditory tube
labyrinthitis
inflammation of labyrinth
tympanitis
inflammation of tympanic membrane
gingivitis
inflammtion of gums, erthematous, swollen, bleed easily causes: poor hygiene, systemic infection, leukemia, DM, preg, oral contraceptives, vitamin def
What are symptoms of cholesteatoma?
initial drainage, foul odor, full feeling, hearing loss, ache behind ear, dizziness, muscle weakness on that side of face
Examining external ear
inspect each auricle & surrounding tissue for deformities, lumps, discharge, tophi
tympanometer
instrument to measure tympanic membrane
audiometer
instrument to mesure hearing
otoscope
instrument to visually examine the ear
otoscope
instrument used for visual examination of the ear
audiometer
instrument used to measure hearing
Geophragic tongue/migratory glossitis
irregular patches of bright red denuded epith no papillae heal then develop new ones harmless
chronic suppurative otitis media
is a chronic inflammation of the middle ear and mastoid cavity. Clinical features are recurrent otorrhoea through a tympanic perforation, with conductive hearing loss of varying severity.
tympanosclerosis
is a condition caused by scaring of tissues in the middle ear, sometimes resulting in a detrimental effect to hearing.
Sensorineural loss (presbycusis)
is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after the age of 50 years. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled. The ability to localize sound is also impaired.
Purulent ear drainage
is likely due to eardrum, or tympanic membrane, perforation. The eardrum is the path of least resistance in the ear; thus, a build-up of middle ear purulence during an episode of acute otitis media can result in spontaneous tympanic membrane (TM) rupture
pneumatic otoscopy
is loss of TM mobility is suspected; puff air off otoscope -> TM should move inward then back quickly; if no or decreased movement probably increased pressure in middle ear (maybe fluid in there)
otoscope
is used to inspect the external auditory canal and the middle ear.
describe the auditory canal?
it is about 1 in. long, with the outer 1/3 surrounded by cartilage (hairy with cerumen glands). the inner 2/3 is surrounded by bone, hairless, glandless and SENSITIVE to pain
perforated eardrum
location of perforation: pars tens, pars flaccida, central perforation, marginal perforation size: can be recorded in % of TM that is involved or in diameter (mm)
CNs of the external ear?
it is innervated by CN V, VII, IX, X
how to prevent external ottis?
keep ear dry- alcohol after water exposure with vinegar (acidity retards bacterial growth).
symptoms of serous otitis media?
lack of pain, straw colored fluid behind TM- possible conductive hearing loss. skin should not be red/infected like in purulent
macrotia
large ear condition
eustachian tube
leads to nasopharynx, allows for equalization of air pressure with atmospheric pressure (swallowing)
AS
left ear
central vertigo cause?
lesion of brainstem or cerebellum (or stroke), acoustic neuroma
central perforation
less complicated due to tm heals by coming together
Bullous myringitis infection of the TM
malaise HA with fever URI: myalgia, sore throat, cough and sever otalgia signs: acute: moderate to severe unilateral ear pain unilateral sensorineural hearing loss fever inflamed TM and adjacent canal with bullae, which may be hemorrhagic, crackles and erythematous throat
the ossicles are
malleous, incus, stapes
what do you see when you look in the ear?
malleus, cone of light, lateral process of malleus
ossicles
malleus, incus, stapes; augment vibrations and distribute energy to chochlea
figure 5.4
many low freq sounds are vowels. Higher are fricatives
cycle
max pressure to min pressure and back to max is called__
creased lobe
may be associated with increase risk for CAD
serous otitis media
may be due to poor eustachian tube draining, look for air, bubbles, in fluid behind TM (NOT inflamed)
posterior epistaxis & risk
may cause loss of anemia HTN, coagulopathies, blood thinners, carcinomas
bifid uvula
may indicated inderlying cleft palate need to palpate palate to assure bony closeure
Acoustic reflex thresholds
measure stapedial muscle refle stiffening middle ear system when elicited by high intensity sounds
audiometry
measurement of hearing
tympanometry
measurement of movement of the tympanic membrane
Fissured tongue
median sulcus is deepened dorsal surfaces interrupted with transverse furrows harmless, inherited distinguish between furrow -- syphilitic glossitis
Ventilation tube
medical procedure done by the doctor. Kids go under anesthesia, adults do not have to. Lasts about a year or 2 and falls out naturally.
ddx of labyrinthitis
menieres neoplasm MS trauma bppv
what are the intracranial complication of AOM
meningitis dencephalitis brain abcess
otosclerosis
metabolic bone dz affecting the otic capsule and ossicles particularly the stapes footplate with may be fixed to oval window and unable to vibrate typically bilateral progressive conductive hearing loss primarily with normal otoscopic exam less common sensorineural if otic capsule involved etiology: AD hereditary dz, viral or autoimmune hormonal - familial - teens - female onset 11-30 2/3 female pregnancy
Decreased TM mobility with positive *and* negative pressure indicates...
middle ear effusion
TM which is yellow or blue indicates...
middle ear effusion
What is the most common cause of conductive hearing loss in children?
middle ear effusion (due to eustatian tube dysfunction)- middle ear infection
Position of Tympanic membrane
midline
weber test normal
midline hear
Cleft palate
midline opening in hard palate b/c congenital failure of fusion of maxillary processes complications: breathing, speech, hearing, chronic otitis media, improper teeth, feeding issues, deglot def
hearing loss and tx for otosclerosis
mild hearing loss may be corrected with hearing aid stapedectomy
absolute threshold
min level at which a stimulus can be detected
when to quit treatment
mineralized ears
TECA hearing
minimal after
Prdisposing factors for otisis
moisture anatomical defects iatrogentic trauma
Otitis media with effusion
more common in adults with viral URI often asymptomatic, but hearing loss common "Crackling" sound when swallowing/chewing conduction hearing loss decongestants may be useful very vascularized
umbo
most depressed part of the TM. at the end of the malleus
pars flaccida?
most superior part of tM
anterior epistaxis due to
mostly b/c trauma to *Kiesselbach's plexus*
tetracycyling staining
mother took it during preg or child did graying of teeth before 1980
common history complaints about nose
nasal obstruction discharge epistaxis change in smell trauma itching olfactory hallucinations
if an adult has recurrent unilateral otitis media with effusion what should we evaluate for this is not common in adults
nasopharyngeal mass at min: we should do indirect mirror examination or flexble nasopharyngoscopy should be performed. Imaging studies and possibly even bx may be indicated
Adult onset unilateral pt should have...
nasopharynx examined
vertigo with tendency to fall to the left side
nat mur homeopathics
otitis interna
neuro signs
BAER test allows for you to determine what
neurologic ability to hear (not the extent that they can hear)
chidren who do not have middle ear effusion based on pneumatic ototscopy or tympanometry
no dx of AOM
External canal
no lesions, bleeding, or drainage
TM perforamtion or Tympanostomy tube with otoscopy
no movement
OME otitis media with effusion
no pain, fluid continues, unilateral send to ENT can be sign of nasopharyngeal carcinoma
30% of the cases of AOM
no pathogen was isolated
Gingival hypertrophy
non pain or pathologic caused by *dilantin*, cyclosporin, leukemia, preg, oral concraceptives, genetic disorders, Crohns, sarcoid
squamous cell carcinoma
non painful, lesion grows slowly often bleed and do not heal sun exposure history MOST COMMON ORAL TUMOR
Tenderness
none palpated
includes imbalance light headedness unteady tilting sensation more often associated with CNS, CV or systemic dz
nonvertigo - dizziness
A mobile TM with positive *and* negative pressure indicates...
normal TM
TM which is gray and translucent indicates...
normal TM
what is the normal color to the TM
normal is translucent pale gray
Varicose veins
normal, elders, no associated pathology
In acute otitis media the eardrum will move....
not at all
quinolones (cipro)
not by mouth under 18 and over 65 with caution
Purpose of otoscopic inspection
not to diagnose a disorder but to assess the outer ear and Middle ear/TM for something this atypical
Hutchinson teeth
notching of the permanent upper central incisors smaller than normal, tips resemble a cone result from congenital syphilis (mother)
perforation
note location and cause pus or other fluid d/c multiple perforation and otorrhea with negative bacterial culture: consider TB
Otoscopy evaluation of Ear Canal
obstructions, inflammation, discharge
whisper test
occlude opposite ear and whisper a sentence for patient to repeat without them seeing your lips; repeat on opposite ear with different phrase; patient should hear you from 1-2 feet away
CT - helps with prognosis of
otitis
Tenderness to palpation of the tragus is indicative of what condition?
otitis externa
when do you want to do a culture? why?
otitis media +/- systemic meds
Oto
otology
sensorineural hearing loss
occurs with impairment of organ of corti, cilia no longer function as they should and no longer pick up frequency and pitches. As people age, no longer pick up mid-higher freq
hypercuim
oil in ear or rub on
other tx ideas
onion pultice for ear pain garlic with oil drops cranial manipulation
where is cerumen produced
only outer ear, not middle or inner canal
what is the color middle ear effusion
opaque yellow or blue
Impedance
opposition to flow of acoustic energy at the middle ear resistance of acoustic energy in middle ear
what are the signs and symptoms of mastoiditis
otorrhea > 3 weeks presistent throbbing pain profuse creamy otorrhea pyrexia tenderness marked over mastoid antrum swelling in the post auricular region of the mastoid process, pinna pushed down and foward bulging TM, TM may be perforated or red bulging progressive hearing loss
What is the most common cause of conductive hearing loss in adults?
otosclerosis (degenrative condition with fixation of sapes to oval window)
Pneumatic Otoscopy
otoscopic observation of the tympanic membrane as air is released into the external auditory meatus; immobility can indicate the presence of middle ear effusion
if the ear drum is ruptured there is increased risk of
ototoxicity
Pulling open External auditory canal CHILD
out back DOWN
do not coincide in the same place in their cycles=
out of phase
cholesteatoma
overgrowth of epidermal tissue from canal or middle ear; can be painful and erode into bone and cause conductive of senorineural hearing loss
hairy tongue
overgrowth of filiform papillae yellow, brown, green, black, bacterial or fungal overgrowth nonpatho precip factors: poor oral hygiene, antibio, smokers, coffee, alcohol
what are the signs and symptoms of tympanic membrane perforation
pain conductive hearing loss tinnitis vertigo - rare bleeding or serous fluid from ear blood clot in meatus visible tear in TM
symptoms of external otitis?
pain, and pain with movement of tragus and pinna, ear discharge (if not swollen shut), erythema, swelling of canal treat topically
What are symptoms of purulent otitis media?
pain, conductive hearing loss, fever, TM bulges out, and red. TM may rupture (pain subsides) and there will be purulent fluid
bullous myringitis
pain, erythematous TM, BLISTERS, may accompany URI symptoms; caused by viruses or M. pneumoniae
Owner compliance - major factors
painful ears odor Quality of life
otitis externa
painful infection of outer skin causing swelling and erythema of canal; lumen will be narrowed with purulent drainage; usually caused by Pseudomonas and S. aureus
Apthous ulcer (canker sore)
painful, small, round ulcers with white floor and yellow margins on erythrematous base -tip tongue or labial/buccal mucosa causes: virus, malnutrition, stress
gouty tophi
painless and benign buildups of uric acid in the crura of the anti-helix
vertical canal ablation is _____
palliative
palpation of the ear
palpate for any nodules, swelling, tenderness, warmth, or lesions
what is the prognosis of tympanic membran perforation
par tensa pars flaccida - more complicated
tinnitus
perception of sound in the head or the ears etiology local vascular neurological chemical other
what are the complication of ear tubes
perforation 3% do not heal post extrusion less than 1% become middle ear foreign body shorter acting tubes cause perforation in about 1% to 2% of pt CSOM
dark oval areas
perforation (drum rupture)
complications of acute otitis media
perforation of the eardrum, tympanosclerosis, mastoiditis meningitis
What is the most common type of vertigo?
peripheral
Persistent Middle Ear Effusion
persistent fluid in the middle ear space after episodes of acute otitis media
Chronic Middle Ear Effusion
persistent middle ear effusion lasting longer than *3 months* in duratoin
binaural
pertaining to both ear
acoustic, auditory
pertaining to hearing
monaural
pertaining to one ear
cochlear
pertaining to the cochlea
aural, auricular
pertaining to the ear
otic
pertaining to the ear
tympanic
pertaining to the tympanic membrane
vestibular
pertaining to the vestibule
sound of the wind
phos
reverberaing
phos caust
what does dBSPL measure?
physical sound that is coming out. use a Sound Level Meter to measure
supra threshold-above, not their softest level
picking 1 level and give all the words at that level -SRT tests
Rinne Test
place vibrating fork at base of mastoid (bone behind ear), when sound no longer heard place it at ear canal and see if pt can hear
Bulla osteotomy - when is this indicated
polyps masses
tx of posterior epistaxis
posterior packing which is very uncomfortable and drop O2 sats, maybe transfusion and hospitalization
betamethasone is very ____
potent
Concha
potential space infront of canal
Triangular Fossa
potential space under helix
successful treatment of canine otitis involved resolution of all
predisposing primary perpetuating factors
What are the key components of otitis pathophys
predisposing factors primary factors perpetuating factors
local
presbycussis meniere's noise induced deafness otosclerosis chronic otitis eustachian tube obstruction hearing loss
Chancre
primary lesion of syphilis-trep pallidum -painless, raised border -button like -can be crusted or ulcerated
monitored live voice (vu meter) vs recorded materials
pro for live is its faster -must present at 60! recorded pro-no accent good for repeating patients
audiometry
process of measuring hearing
tympanometry
process of measuring the tympanic membrane
electrocochleography
process of recording the electrical activity in the cochlea
otoscopy
process of visually examining the ear
otosclerosis
progressive hearing loss from deposition of bone in cochlea; not painful and tinnitus common; TM is normal and eustachian tube is open; more common on 30-40 y/o female with genetic tendancy
what is a common microbe to culture
pseudomonas
what is the mc organism tied to labyrinthitis
pseudomonas
what is the mc cause of CSOM
pseudomonas aureus 30% fungi 25% aspergillus
infant 2-3 mo with greater than 100.4 rectal
pt is nontoxic appearing outpatient evaluation acceptable toxic requires hospitalization
ticking watch
pt should be able to hear it from 2 ft away
left sided, yellow green d/c worse at night better in open air child is weepy and wants to be held clingy thirstless
pulsatilla
Purulent
pus
maxillary sinuses
pyramid shaped and is the largest of the paranasal sinuses, drains into the middle meatus of the nose.
labryinthitis
rare complication of AOM and COM or meningitis which may reach the labyrinth via erosion of a fistula or choleseatoma may be due to ototoxic drugs or local inflammation vertigo nausea vomiting CN 8 paralysis hearing loss in affected ear signs: positive fistula test nystagmus to opposite side sensorineural loss in purulent labryinthitis
How is intensity sensed
rate of action potentials firing
when should we followup with middle ear perforation
re eval 4-6 weeks
audiogram
record of hearing
tympanogram
record of tympanic membrane
SRT reports
record srt, material, and method used. report if SRT and PTA were in agreement. BC SRT
For SRT results the teacher does?
recorded word lists
glomus tumor
red behind eardrum (blood); may be able to see the tumor pulsate
external otitis
red, painful; inflammation/infection of the outer ear
mastoiditis
red, swollen, and tender (from external exam)
what do we expect to see with CBC with viral
reduced wbc high lymphocytes low PMN
what is a spundee word?
redundant or predictable. like cowboy hotdog or baseball
2 mo old infants rectal temperature of 100.4 or greater
referral to ER
if at the end of 14d and there is still stenosis what might need to be done
surgery
What are causes of cholesteatoma?
repeated infection and presence of chronic negative pressure in middle ear that allows overgrowth of skin on the TM
false positive
respond when there is no sound. can occur bc of ringing in ear
propagation
result of the back and forth movement of air molecules. has to occur through some type of mediation-air, water.
calibration
results are valid
what is the mc cause of AOM virally
rhinovirus
red blue 1-2 sec for presentation
right circle left x continuous or pulse
AD
right ear
What structure don't you want to damage if you are doing anything in middle ear
round window
when to tube
rule of 3's 3 infections in 6 months persistent fluid in both ears after 3-6 months - refer consider time of year and other risk factors
tympanic membrane perforations
rupture of ear drum from trauma, infection, or extreme pressure change; causes conductive hearing loss, sclerosis, and scarring; very painful but will heal on its own
tympanorrhexis
rupture of the tympanic membrane
what are the danger signs of complication of AOM
sagging posterior canal wall puckering of superior portion of the TM - attic swelling of post auricular areas with loss of skin crease
tympanic membrane scarring
scarring of the ear drum from previous infections, trauma, or perforations, can cause decrease of hearing loss from decrease of mobility
white dense areas
scarring-sequelae of infections
period=
seconds per cycle
chamomile
sedative nervine soothing
Ear tubes
seen in kids with lots of effusion usually in posterior portion
what is the allopathic tx for labyrinthitis
self limiting antibiotics mastoidectomy for chronic drainage
What makes up the vestibular system?
semicucular canals (rotational movement) , utricle, saccules ( linear/gravitational movement) and vestibular division of 8th nerve.
dBSL
sensation level (means 30dB above the reference point)
bone and air the same?
sensiorneural hl
another term for bc?
sensory/neural mechanism
air/fluid level or air bubbles
serous fluid-serous otitis media
yellow amber
serum/pus-serous otitis media or chronic otitis media
Benign paroxysmal positional vertigo
severe transient vertigo precipitated by head movement - seconds following movment, such as extension and lateral rotation due to canalith, stimulating vestibular sense organs no changes in hearing increased in middle age and women 2:1 to men
gingiva
sharp edge adherant to surface of teeth look for color, swelling, bleeding, hyperplasia, masses, lesions
cone of light?
should be directed anteriorly and interiorly, radiating from umbo. If large, may be due to fluid accumulation
Type C leads to what kind of middle ear pressure?
significantly negative
what is the most common type of perforation
single perforation
frontal sinuses
situated behind the brow ridges
middle ear anatomy
small and air-filled lined with squamous epithelium; runs from TM oval window to round window of cochlea; opens posteriorly to mastoid sinuses and anteriorly to nasopharynx via eustachian tubes; TM vibrates transmitting sound through ossicles
when collecting biopsies it is important to keep the samples
small and delicate
exostosis
small benign, boney growths of canal that usually arise near TM; usually multiple and bilateral, only problematic if they cause recurrent cerumen impaction
darwin's tubercle
small cartilagenous protuberance on superoposterior helix
microtia
small ear condition
creased lobe
small fold in lower lobe; may be associated with increased risk of CAD
Tympanostomy Tube
small tube inserted bypassing the tympanic membrane allowing for prolonged aeration of the middle ear; common procedure for recurring ear infections
tubes
small, temporary in TM middle ear pressure stays same as ambiet allow draining and prevents accumulation producer: 3 mm incision in anterior 1/2 TM middle ear effusion aspirated ventilated tube inserted 15 min procedure
minimum audibility curve
softest sound pressure level that humans can hear
glossitis
sore, painful, tender, erythroma causes: ribofl or Fe def, autoimmune, chemo, smoking, alcoholic, infection, trauma, dehydration
Sensorineural Hearing Loss
sound hear longer through air AC>BC (normal)
sensorineural loss
sound heard in good ear
conductive hearing loss
sound lateralizes to impaired ear
dBSPL
sound pressure level
SDT
speech just detected. level of speech raised and lowered in intensity until the patient indicates that he can barely detect the speech/recognize it as speech
The outside of the tympanic membrane is lined with?
squamous cell epithelium / ectoderm
whisper test
stand 1-2 ft behind pt, whisper 2 syllable words
List the freq order
start at 1000 work way up to higher freq, then 1,000 again, then lower freq.
Tympanoplasty
surgery to repair tympanic membrane
anatomy of auditory canal
starts at external auditory meatus ends and conducts sound waves to TM; TMJ makes up part of posterior wall; skin on 1/3 contains hairs and cerumen glands (not produces in middle on inner ear); innervated by the branches on CN V and blood supply by auriculo-temporal branch of inferior maxillary artery
what are the antamonical defects that predispose an animal to ottis
stenotic canals polyps
What is the most common organism to cause a middle ear infection?
strep pneumoniae and/or hemophilus influenae, or a viral infection
bacteria most associated with acute otitis media
streptococcal pneumonia, haemophilus influenzae Moraxella catarrhalis (MCAT) (less pathogenic, fewer complications)
momestaone is very _____and is a ____
strong and is a steroid
otorhinolaryngology
study of ear, nose, throat
audiology
study of hearing
psychoacoustics
study of the relationship btw physical stimuli and the psychological response to which they rise. Auditory experience to which ppl perceive sound
waves
succession of molecules being shoved together and then pulled apart.
angioedema
swelling of 1 or both lips b/c allergic rx, anaphalyxis, or infection -concern about inflamm of pharynx
What things refer pain to the ear?
teeth, pharynx, larynx, cervical lymph nodes, tonsils
vesicular eruption on tm give which hemeopathic
tellurium
hearing is processed by what part of brain?
temporal lobe (area 41)
Visual acuity
test with a vision screening card, such as a rosenbaum pocket vision screen or a Snellen vision chart.
Umbo
the concavity on the tympanic membrane (in the center) where the tip of the malleus is attached
air conduction represents what?
the entire hearing loss as sound travels through outer, middle, and inner ear to the brain.
pars tensa?
the main portion of the TM visible on otoscope?
What makes up the external ear?
the pinna/auricle and the auditory (external) canal
Hz
the unit of one cycle per second . 1,000Hz=a pressure wave that repeats itself 1,000 times in 1 second. (pure tone)
exostosis?
they can block clearance leading to conductive hearing loss. retain water which can lead to infection
ppl with hearing loss are exhausted at the end of the day because?
they have to focus really hard on what ppl are saying in order to understand
pars tensa
thick, taut, central/inferior section of tympanic membrane
Pars Tensa
thick, taut, central/inferior section of tympanic membrane (most of the TM)
Mucoid
thick, viscid, and mucus-like
diminished or absent landmarks
thickened drum (chronic otitis media)
Serous
thin, watery fluid
mastoiditis
this is a complication of otitis media. - tenderness over mastoid bone and red/swelling over mastoid bone/process.
acute labyrinths?
this is a peripheral vertigo which occurs due to viral infection of inner ear. can be severe for days and then resolves completely. may cause nausea and vomitting
cholesteatoma
this is a skin growth that occurs in the middle ear - take the form of a cyst that will shed layers of skin that build up in ear. Will also release enzymes that destroy tympanic membrane, ossicular chain, facial nerve, mastoid bone or inner ear apparatus.
tinnitus
this is a sound heard by pt's but not by others. may be ringing or clicking.
suppurative (purulent) otitis media?
this is an acute infection of the middle ear- due to bacterial or viral infections.
benign posiitonal vertigo?
this is due to ca2+ debris in posterior semicircular canal - causes recurrent vertigo which may last for a few minutes and recurs for several weeks. is provoked by head movement. most often the posterior semicircular canal is affected
serous otitis media?
this is fluid in middle ear (no infection) - clear fluid - also called otitis media with effusion
presbycusis
this is sensorineural hearing loss that occurs that is age-related.
peripheral vestibulopathy?
this is vertigo that - due to problems with semicircular canals - usually horizontal nystagmus, with torsional component. The quick phase is away form affected side. - visual fixation usually surpasses
objective tinnitus
this is when examiner can also hear sound with stethoscope head to external auditory canal. may be due to tonic muscle contraction of pharyngeal or inner ear muscle or due to vascular conditions (arterial bruits, AV fistulas or venous hums) - arteriovenous malformation
subjective tinnitus?
this is when the sound is not heard by the physician with stethescope. hearing loss, Menie'res disease, acoustic neuroma, diabetes, MS, *aspirin* or antibiotics.
malignant external otitis?
this occurs in diabetics after external otitis occurs. the usual organism is pseudomonas aeruginosa- can lead to osteomyelitis (inflammation) of temporal bone - can lead to severe systemic infection. --all due to poor immune system
auditory ossicles
three tiny bones in the middle ear through which sound vibration is transferred
why give pred
to open up the ear canal
why do an otoscopic exam
to see if the ear drum is intact
what tx are you going to use for otitis externa
topical ONLY
how to treat stenotic ear canal empiricially
topical med ear cleaning
what is the complication of otosclerosis
total hearing loss dizziness balance issues persistent tinnitus
Location of light reflex
towards chin
what should you rx when the animal has painful ears
tramadol
role of TM?
transducer of sound converting sound to mechanical energy through ossiclcles. amplifies sounds 20 x.
Cochlea
transmits sound impulses to CN VIII
sanginous (bloody)
trauam, coagulopathies, carcinoma, HTN, vasculitis, ulcerations, cocaine
serosanginous (yellow/orange)
trauma or neoplasm
Chlesteatoma
tumor in the middle ear space. It Is Not common. Truly bluish in color. Growth inside middle ear
otitis media
tympanic bulla is involved
eardrum
tympanic membrane, shiny, translucent and pearly grey
other causes of conductive hearing loss?
tympanosclerosis (scarring of TM due to constant ear infections), otosclerosis (fixation of stapes to oval window), cerumen, perforated eardrum, foreign body, otitis external or otitis media
otitis media with effusion
typically retracted or neutral position
SRT
understood.
hyaluronic acid
use for vagnial dryness eyes - sjogren and it heals the cornea
If you get a 5-10dB change when doing reliability check at 1000 Hz, what do you do?
use that new threshold.
weber test
used if hearing loss is already noted; place vibrating tuning fork on middle on patients head and ask if they hear or feel on one particular ear; conductive hearing loss will be heard on same side, sensorineural loss will be heard on ear opposite problem
Pure tone audiometry
uses these bc it's easy to produce/calibrate. We look for patterns of HL as a function of freq. Trying to find the softest level a person can hear
acute otitis media (AOM)
usually after recent URI's of bacterial or viral etiology (S. pneumonia, H. influenzae); more common in infants/children and usually unilateral; complications: mastoiditis, meningitis, osteomyelitis, sigmoid sinus thrombosis, or involve facial nerve
What is the pars flaccida
vascular bed of the tympanic membrane DONT HIT IT
responses can be
verbal, written, pointing
true rotational movement of self or surroundings may be associated with pallor, vomiting, sweating more often associated with inner ear dz
vertigo
triade of meniere's disease
vertigo tinnitis hearing loss
Semicircular canals involved with
vestibular function
what is water irrigation of the ear used for?
vestibular function
inner ear consists of (3 things)
vestibule, semicircular canals, cochlea
reasons for purulent discharge
viral URI, bacterial sinusitis, foreign body
otoscopy
visual examination of the ear
Ear canal volume/Physical volume
volume of the ear canal beyond the probe
allopathic treatment for OME
watchful waiting for 3 mo from dx using otoscopy and tympanometry if uncertain hearing test > 3 mo speech and language testing if bilateral surgery: tympanystomy and or adenoidectomy if other complications such as adenoiditis and nasal obstruction
diffraction
wave is partially obstructed and changes shape around obstruction
weber test and rinne test?
weber: hold tuning fork over forehead (center)- if either form of the hearing loss will localize to one side (conductive to its side, sensorineural to other side) rhinne: hold over mastoid process then in front of ear. if AC>BC in both ears- sensorneural, vs in conductive, affected ear will have BC>AC
How is frequency sensed
what part of the organ of Corti is stimulated
reflection
when incident wave encounters obstruction, it is reflected back to itself.
constructive interference
when reflected wave and the next incident wave add together- ADD
destructive interference
when reflected wave and the next incident wave cancel each other out -CANCEL
Absorption
when the sound is absorbed by the surface of obstruction. Sound doesn't bounce off.
when should you consider TB with perforation
when there are multiple perforation and otorrhea with negative bacterial culture
myringotomy
when you puncture the tympanic membrane and collect a sample
manubrium of tympanic membrane
where malleus rests against mem
tympanosclerosis
white plaques (bone-like calcification)
Oral candidiasis
white, raised exudate may interfere with taste and eating ABLE TO WIPE OFF risks: antibiotics, cancer (chemo), autoimmune, HIV/AID, DM, steroids
anacusis
without hearing
marginal perforation of tympanic membrane
won't heal as well it can lead to cholesteatoma
WRT
word recognition testing WRS-score
2.2 million new cases of OME are diagnosed
yearly
speech audiometry
you tested hearing now looking at how they are able to hear speech
when adenoidectomy ?
young children in puberty they resorb naturally if a child requires a second set of PE tubes, or with the first set of tubes if the child has significant nasal symptoms.
What are the most common pathogens which cause otitis media?
• *Strep penumoniae* • Hib • Moraxella catarrhalis • Group A strep
What are second-line antibiotics for acute otitis media?
• Augmentin • cefuroxime axetil (Ceftin) • ceftriaxone (Rocephin)
Signs of Middle Ear Effusion
• Bulging • Limited TM Mobility • Air-Fluid Levels • Ororrhea
Medications for Pain Management with Acute Otitis Media
• Ibuprofen (best - more anti-inflammatory effect) • Acetaminophen • Auralgan (topical benzacaine)
Protective Mechanisms of the Ear
• Tragus and antitragus • Curve/isthmus of canal • Cerumen coated skin • Acidic environment
Who is antibiotic treatment recommended for in acute otitis media?
• all children < 6 m/o with findings consistent with AOM • children < 2 y/o with bilateral AOM • children with AOM with otorrhea • children 6 months to 2 years when the diagnosis is certain • children > 2 y/o with severe infection/illness, moderate otalgia, and of temp ≥39°C
Ofloxacin (otic)
• antibiotic used to treat *otitis externa* • 4 drops BID for 5 days • *can* use with TM rupture
Polymyxin B
• antibiotic used to treat *otitis externa* • 4 drops in ear QID x 5-7 days • poor staph coverage • has sulfa - careful with allergies *don't use with TM perforation*
CiproDex
• antibiotic+steroid used to treat *otitis externa* • *can* use with TM rupture
Which antibiotics should be considered for treatment of persistent acute otitis media?
• azithromycin • augmentin • clindamycin
Bleb
• bubble on the TM - kind of like a blister • can rupture and drain *without* causing a perforation of the TM itself
Possible Complications of Tympanostomy Tubes
• chronic perforation • early extrusion • granulation tissue formation
Treatment of Otomycosis
• clean canal and use acidifying/drying drops • can use topical antifungals
How should an afebrile and nontoxic patient with otitis externa be treated?
• clean the ear • apply a wick if the canal is edematous • use 2% *Acetic Acid* drops and antibiotic drops (Polymixin B, Cortisporin Otic, Ofloxacin)
What are the benefits of delayed antibiotic therapy for acute otitis media?
• decreased treatment cost • decreased antibiotic side effects • decreased emergence of resistant antibiotic strains
Signs/Symptoms of Necrotizing Otitis Externa
• deep pain • fever • granulation tissue • exposed bone or cartilage • cranial neuropathies • meningeal signs (can result in death)
What causes otitis externa?
• disruption of the normal skin/cerum layer - increases risk of infection • often secondary to instrumentation (like Q-tips)
Symptoms of Otitis Externa
• feeling of fullness, plugging • itching • edema • pain • purulence • hearing loss
Risk Factors for Otitis Media
• immature/impaired immune function • familial predisposition • breast or bottle fed • sex (males) • race (esp. native americans) • eustachian tube dysfunction • cleft palate, submucous cleft • day-care attendance • smoking in households • infection • allergies
Ear Wick
• inserted into canal to keep it open and to facilitate medication administration • medication stays in the wick
Possible Complications of Otitis Media
• meningitis • mastoiditis • irreversible hearing loss
Otitis Media with Effusion
• middle ear infection with fluid accumulation • fluid can last for 40 days after the infection has resolved
How should a persistent middle ear effusion (following otitis media) be managed?
• monitor and reassurance every 3-6 months • may try oral or nasal steroids to help with short-term resolution • refer to ENT for possible tube placement if not resolving
What factors can be used to help determine empiric antibiotic therapy?
• most common pathogens • community resistance pattern • cost of therapy • recent antibiotic use • age of patient • weight of patient
Hemotympanum
• often in association with temporal bone fracture • appears black behind full TM • will resolve over time • causes conductive hearing loss while present
How should febrile/toxic patient with otitis externa be treated?
• oral antibiotics (Dicloxacillin) • IV antibiotics if severe pain & granulation tissue • consider fungal otitis externa • possible ENT referral
Reasons to Give Antibiotics for Acute Otitis Media
• patient distress • reduction of possible complications • reduce middle ear effusion • increased resolution of infection
A TM which is *not* mobile positive *and* negative pressure indicates...
• perforation • patent ear tubes
Pars Flaccida
• portion of the eardrum above the short process of the malleus
What are the two most common pathogens which cause otitis externa?
• pseudomonas aeruginosa • staph aureus
Indications for Referral
• recurrent acute otitis media (4 in one year or 3 in six months) • chronic serous otitis media with conductive hearing loss • complication of acute otitis media • questionable exam
Indications for Tympanostomy Tube Placement
• recurrent otitis media • chronic otitis media with persistent bilateral effusion and conductive hearing loss • negative middle ear pressure and impending cholesteatoma • presence of complications
TM Retraction
• retracted portions of the TM indicate chronic eustachian tube dysfunction - unable to regulate pressure in the middle • TM is thickened and immobile
How the eustachian tube different in an infant than in an adult?
• shorter in infants • infant tube is more horizontally angled • more mucosal folds in infant tube • small lumen diameter in infant tube
Physical Exam Findings of *Mild* Otitis Externa
• tenderness • erythema • edema • debris • ulceration
Eustachian Tube
• tube that connects the middle ear space with the nasopharynx • soft tissue, fibrous • has cartilage on the outside which muscles attach to • normally *closed* but opens with certain movements, such as swallowing, yawning, and sneezing
2% Acetic Acid
• used to restore normal flora in the external auditory canal for treatment of acute otitis externa • used with a wick • make sure that the TM is not perforated if using!
Barotrauma
• usually due to sudden decompression while diving • ear pain, transient vertigo, decreased hearing • effusion and TM hemorrhage
Prevention of Acute Otitis Media
• vaccines (Hib, influenza, pneumococcal) • environmental (tobacco, pets, allergies) • need to avoid bottle-feeding in bed
When can you consider delaying antibiotic treatment for otitis media?
• very mild otitis media • patient/parents seem to be very reliable with follow-up, if need be
Common Causes of Acute Tympanic Membrane Perforation
• water sports • blow to hear/ear • explosions • iatrigenic