Diseases of the Ear

Hearing Loss

Tinnitus

Dizziness

Hearing Impairment

Hypoacusis

Diminished hearing ability

Dysacusis

Distortion of hearing, imprecise comprehension,

sound distortion

anacusis- pt is not able to hear at all

difference of pitch perceptikn

Tinnitus

An auditory sensation

that occurs in the

absence of an external

acoustic electrical

stimulus and has no

subjective information

content

noise in the system

subjective and objective tinnitus (examiner hears the ringing trhu stet in the ear)

impacted serumen

vestibular psamomma

endolymphatic hydrops _ more fluid than usual

rising sun appearance- globus formation =pulse is synchronous with the tinnitus

myoclonal contraction of the muscles = myogenic tinnitus

respiratory tinnitus = abnormally patent eustachian tube; synchronous to the respiration

Diagnostic Evaluation

History

Noise exposure, trauma, COM, family history,

ototoxic medications

Clinical examination

Normal inspection and otoscopy

Audiometry

SNHL, OAE (-)

CT scan or MRI

chronic otitis media

negative findings on otoscopy = sensory neural hearing loss

------air conduction is normal

otoacoustic emission = sound is transmitted and allows the sound hair cells tk transmit these sounds; negative in sensory neural loss

Typical Audiometric Profile of SNHL

The hearing threshold in the PTA is increased for AC and BC high tone loss

Sound conduction is not impaired: AC=BC thresholds

Immittance measurements are normal

OAEs are absent

high frequency hearing loss, no S sounds

Imaging Studies

High resolution temporal bone CT scan Detect changes in the

bony labyrinth or other bone diseases

MRI Examination of the

auditory nerve

Method of choice for diagnosing a retrocochlear lesion

vestibular schwannoma = most common vestibulo ponine angle tumor = MRI with galladinium is the gold standard for dx

Retrocochlear Disorders

Etiology

Tumors of the IAC and CPA

Compression of 8th nerve by

vascular loops

Inflammatory processes

Diagnosis

ABR

Most sensitive and useful

MRI

Audiometry

SNHL

Poor speech discrimination

scores

internal auditory canal

auditory brainstem response

gold standard for dx of acoustic lesions or tumors

air and bone fxn are abnormal

Cochlear Hearing Loss with Known Causes

Hereditary SNHL

Noise Induced Hearing Loss

Traumatic Injury to the Inner Ear

Labyrinthitis

Ototoxicity

temporal bone fracture,

patent aqueduct = can produce labyrinthitis, or sometimes it can be caused by viral

aminoglycossides mos t commkn cause

Hereditary SNHL

Pendred Syndrome

Thyroid dysfunction with

severe SNHL

Usher Syndrome

Retinitis pigmentosa and

SNHL

prgressive blindness and then eventually hearing loss

Congenital Hearing Loss

Hearing impairment is the single most

common condition affecting newborns

1-3 per 1,000 in well-baby

2-4 per 100 in the NICU

High Risk Registry

Apgar

Auditory Milestones

Age

(Months)

Description

0-3 Startles at a loud sound or noise

Stops moving or crying when you call

3-6 Turns head or moves eyes to a familiar

sound

6-10 Responds to his/her own voice

10-15 Repeats simple words and sounds you make

15-18 Understand simple phrases and can point to

body parts

18-24 Should have at least 150 spoken vocabulary

Detection of Hearing LossOtoacoustic Emissions Auditory Brainstem Response

absence of motility of hair cells go for diagnostic test ==> ABR

Management

Hearing Aids Cochlear Implant

surgcially implanted that gets to stimulate cochlear nerve directly

depends on the hair cells; if hair cells are not fxnal the hearing aids are useless

Noise Induced Hearing Loss Acute acoustic trauma

Exposure to a sudden,

intense sound event of

short duration

Loudness level exceeds

140 dB SPL in < 1.5 ms

Gunshot, firecrackers,

aerial fireworks

Blast injury

Ear and body are

subjected to the

pressure wave from an

explosive blast

Loudness level exceeds

140 dB SPL in >2 ms

Usually a TM perforation

occurs

Noise Induced Hearing Loss

3-6kHz Notch

everytime you increase the decibells by 5, exposure time decrease by 50 percent

4,000 hz = has weqlest bld supply

Traumatic Injury to the Inner Ear

Longitudinal Temporal

Bone Fracture

More common

Fracture runs along the

EAC and anterior border

of the petrous pyramid

Caused by a diffuse,

lateral traumatizing

force

oerforation of tympanic membrane and csf may leak out = conductive hearing loss

halo sign = to check if csfbeta 2 transferrin test = most definitive for csf id

Longitudinal Temporal Bone Fracture

Symptoms

Aural discharge (pure

blood/mixed with CSF)

10-20% have facial

paralysis (delayed onset)

Bloody rhinorrhea

(sphenoid sinus involved)

Otoscopy

Torn meatal skin with TM

perforation and bleeding

from canal

Management

Do not manipulate ears

Plug with sterile

cotton/dressing

Antibiotic therapy

Corticosteroids if with

facial nerve paralysis

Surgical exploration if

needed

Traumatic Injury to the Inner Ear

Transverse Temporal

Bone Fracture

Fracture runs along the

petrous pyramid along

the IAC through the

labyrinth

Caused by a traumatic

force in the frontal plane

May not have otorrhea

especially if EAC has not

been directly affected

trauma may be in occiput or frontal areacuts transversely along the petrous bone

vestibular organ may be affected therefore px may experience vertigo

mixed type of hearing loss

Transverse Temporal Bone Fracture

Symptoms

Severe vertigo, with

nausea and vomiting

Severe hearing loss or

even deafness

Otoscopy:

hemotympanum

Treatment

Conservative

Antibiotic therapy

Restore vestibular

functions

Surgery when necessary

Labyrinthitis

Infection of the labyrinth and its surrounding

structures

Labyrinthitis

Routes by which

infection can spread

into the labyrinth

Tympanogenic

Meningeal

Hematogenous

Signs and Symptoms

Hearing loss

Tinnitus

Vertigo

Labyrinthitis

Treatment

Careful decompression of the middle ear with a

myringotomy tube

High doses of antibiotics

Corticosteroids

Surgical intervention if needed

Ototoxicity

Toxic damage may

affect both cochlear

and vestibular functions

Generally symmetrical

Except for toxic effects

of substances applied

directly to tympanic

cavity

Symptoms

Hearing loss

Tinnitus

Disequilibrium

Oscillopsia

oscillation of the visual field

reversible = salicylates

macrolides, nsaids = potentially ototoxic but are reversible

Pre-treatment

Post-treatment

Ototoxicity of Cisplatin

Cochlear Hearing Loss with an

Unknown Cause

Presbycusis Age-related (>50 years old)

Symmetrical SNHL

Affects high frequencies

Speech recognition is impaired

Disturbance of the sensory elements in the cochlea

Management Hearing aid fitting

normal wear and tear of the orban

symmettricak sensory neural hearing loss usually affecting high frequency

Cochlear Hearing Loss with an

Unknown Cause

Sudden SNHL

Immediate, unilateral,

with no apparent

external cause unilateral

HL of SN origin but with

no

Management: depends

on the cause

Prognosis: good if

addressed early

30 db occuring in 3 days; possible reversible --- steroids

most are viral in nature

Sudden Sensorineural Hearing Loss

Cochlear Hearing Loss with an

Unknown Cause

Chronic, progressive idiopathic SNHL Bilateral, occurs between 30-50 years of age

Cause: unknown

Management: early rehabilitation, hearing aids, cochlear implant

50 is the age cutoff of presbytusis

Dizziness

Nystagmus Testing

label nystagmus based on the direction of the beating

rotatory nystagmus = px with BPPV

fast compnent is a central mechanism slow component is ?

pure vertical nystagmus = centrak disorder

Induction of Nystagmus

Caloric Stimulation

Rotational Stimulation

caloric test is the most informative = use cold or warm air; checks the vestibulo ----

cold = nystagmus OPPOSITE side of the irrigated ear (due to fluid density) warm = nystagmus SAME SIDE of the irrigated ear

Spinal Motor Function and Coordination

Tests

ubterberger = ask px to march in place

swaying = disprderno direction = centraldisorder

finger to nose test - eyes closed - fast pointing ----miss in no direction = central disorder---- miss in 1 direction = site of disorder same as uterberger test

Two Important Questions:

1. Is the vertigo INTERMITTENT or

PERSISTENT?

2. Is there associated HEARING LOSS?

INTERMITTENT PERSISTENT

With

Hearing

Loss

MENIERES

DISEASE

ACOUSTIC

NEUROMA

No

Hearing

Loss

BPPVVESTIBULAR

NEURITIS

aggravated bu change in position

accompanied by tinitus and vertigo

persistent and progressive

persistent only

BPPV versus Vestibular NeuritisBPPV VESTIBULAR NEURITIS

Precipitating Factors Head trauma, vestibular

neuritis, infection, surgery,

prolonged bed rest

Recent Viral Illness

Pathophysiology Otoconial debris in SCC Vestibular nerve

inflammation (immune

mediated)

Vertigo Episodes Recurrent/Episodic

Lasting Seconds

Persistent/Continuous

Lasting Days

Symptom Onset Acute Acute

Hearing Loss None None

CNS Symptoms None None

Treatment Particle Repositioning Therapy Medical Steroids; Vestibular

Rehabilitation

Dix Hallpike Maneuver

head in 45 degrees

Epley Maneuver

turn head 90 defrees to the opposite side

return the otoliths to where they should initiallt be

Menieres Disease

fluid more than usual in the inner ear = HPN OF INNER EAR

endolymphatic hydrops

Acoustic Neuroma

Thank You!