Hx and PE - Ear

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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


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