Balasubramanian Thiagarajan

Clinical Otology

Symtoms

• Deafness• Discharge• Tinnitus• Pain• Vertigo

Deafness

Onset

Sudden GradualTrigger

Sudden hearing loss (SN)

• Loss of atleast 30 dB in atleast three contiguous frequencies over a period of less than 3 days.

• Viral causes• Vascular causes• Hearing loss is the only symptom• High dose prednisolone may be useful

Sensorineural hearing loss (Sudden)

• Transverse fracture of pertrous bone• Auto immune reaction following trauma / infection• Inflammatory reaction (Viral infections)• Vascular compromise

Conductive hearing loss - (Sudden)

• Ossicular disruption• Haemotympanum (transient)• Failed attempts to remove cerumen

Mixed hearing loss - (Sudden)

• Fractures involving petrous bone• Auto immune reaction to proteins released due to

traumatic injury

Gradual progressive hearing loss

• Inflammatory• Degenerative

Fluctuating hearing loss

• Impacted cerumen• Meniere's disease• Perilymph fistula

Differentiating Conductive / SN loss

• Difficulty in comprehending spoken words• Deafness associated with tinnitus• Intolerance to loud sounds• Tuning fork tests

Discharge

• Quantity• Quality• Duration of discharge• Aggravating / releiving factors

Ear discharge - quality

• Mucoid - CSOM• Mucopurulent - CSOM with mastoiditis• Serous - ASOM• Serosanguinous - ASOM, Otitis externa, trauma• Watery - CSF otorrhoea

Ear discharge - causes

• ASOM• CSOM• Otomycosis• CSF otorrhoea

Tinnitus

• Wax• Active otosclerosis• Sensorineural hearing loss• Ototoxic drugs• Objective tinnitus - Patulous ET, Palatal myoclonus

Pain

• Otalgia• Referred otalgia

Ear pain

Otalgia

Referred otalgia

5,6,10th cranial nervesC2 & C3

Otomcosis

Tragaltenderness +

Myringitis granulosa

Tragal tenderness -

Keratosis obturans

Tragal tenderness +

AOM

Tragal tenderness -

Furuncle

Tragal tenderness +

impated waxTragaltenderness +

Vertigo

• Sensation of unsteadiness / rotation• Diseases if inner ear cause vertigo• Associated with tinnitus and hard of hearing• Peripheral vertigo

Nystagmus

• Spontaneous / evoked• Direction of nystagmus -

Right beating, left beating, geotrophic, ageotrophic.

• Plane - Horizontal, rotatory or vertical

• Intensity - (I, II and III degree)

Spontaneous nystagmus

• Eye movements without congnitive, visual, vestibular stimulus

• Commonly induced by vestibular imbalance• Vestibular nystagmus is typically inhibited by visual

fixation• It follows Alexander's law (nystagmus is greater in

the direction of fast phases)

Alexander's nystagmus grading

• I degree - Present only during gaze in the direction of fast phase

• II degree - Present during straight gaze and also increases in the direction of fast phase

• III degree - Present during all fields of gaze, but greatest in the direction of fast phase

History should include

• Previous ear surgery• Previous head injury• Systemic diseases like diabetes / Hypertension• Use of ototoxic drugs• Noise exposure• Family h/o deafness• H/o atopy / allergy

Inspection of external ear

• Shape and size of pinna• Presence of tags, preauricular sinus and pits• Evidence of trauma to pinna• Skin condition over pinna and external canal• Presence of operative scar in post aural area and end

aural region• Neoplastic lesions of pinna• Discharge from external canal

Drug history / Occupation

• Drugs like gentamycin, Streptomycin, and Aspirin can cause extensive damage to hair cells of cochlea

• Noise exposure can cause damage to outer hair cells of cochlea

• May be reversible during early phases

Drug induced ototoxicity - Features

• Bilateral sensorineural hearing loss• Bilaterally symmetrical hearing loss• Onset time - ???• Can occur even after a single large dose• Vestibular injury - common (aminoglycosides)• Positional nystagmus - a feature of vestibular injury

Aminoglycosides

• Cleared more slowly from inner ear fluids than serum• There exists a latency - deafness may occur even 2

months after cessation of the treatment• Pts on potentially ototoxic aminoglycoside

medications should be monitored atleast for a period of 6 months following cessation of the offending drug.

Discharge

• Duration• Quantity• Quality• Aggravating & releiving factors

Acute ear discharge - Causes

• ASOM - Blood tinged• Otomycosis - Itchy ear, fungal mass seen• CSF otorrhoea

Profuse ear discharge - Causes

• Chronic mastoiditis - Mastoid tenderness + May lead to formation of subperiosteal abscess

• Mastoid reservoir - Mastoid tenderness on deep palpation +

• Extradural abscess

Quality of ear discharge

• Mucoid - CSOM• Mucopurulent - CSOM with mastoiditis• Serous - asom• Serosanguinous - ASOM, Otitis externa• Watery - CSF

Tinnitus

• Subjective - perceived by the patient• Objective - perceived by both the pt and examiner

Otalgia

• Pain in the ear• Could be due to inflammatory pathology affecting

the ear• Referred otalgia due to pathology elsewhere

Three finger test

• Index, middle and thumb are used.• Index finger is applied over mastoid process -

tenderness indicates mastoiditis• Middle finger is applied over well of the concha -

tenderness indicates inflammation in the mastoid antrum area

• Thumb is used to apply pressure over mastoid process. Tenderness indicates mastoid emissary vein thrombophlebitis

Peripheral vertigo

• Is defined as sensation of unsteadiness / rotation• Commonly caused by inner ear disorders• Associated with tinnitus / ear block

Peripheral vertigo - Features

• It is fatigable• It is positional• Horizontal nystagmus• Cerebellar signs absent

External ear

• Shape / size of pinna• Tags / sinuses / pits• Evidence of trauma to pinna• Perichonditis• Seroma• Skin of pinna / external canal• Discharge from external canal• Evidence of previous surgery• Neoplasm

External canal - Straightening

• Aural speculum• Adults - Pinna is pulled

postero superiorly• Infants - pinna is pulled

posteriorly and downwards

Ear drum

• Oval / pearly white in color• Pars tensa• Attic• Cone of light• Handle / lateral process of malleus• Perforations

Cone of light

• Present in the antero inferior quadrant

• Cone shaped• Caused due to orientation

of middle fibrous layer• Broken up in retracted ear

drums• Broken up / lost when ear

drum bulges

Color of ear drum

• Pearly white - normal• Red drum - Glomus jugulare, AOM• Blue drum - SOM, Hemotympanum• Pink drum - Flamingo sign• Chalky drum - Tympanosclerosis

Retraction pocket features

• Prominent anterior and posterior malleolar folds

• Apparent foreshortening of handle of malleus

• Prominent lateral process of incus

• Decreased / absent mobility of ear drum

• Presence of pockets of retraction

Siegel's speculum

• Convex lens• Magnifies 2.5 times• Mobility of ear drum• To suck out secretions from

middle ear• To apply ear drops by

displacement method

Tuning fork tests

• Three frequencies are used• 256Hz, 512 Hz, 1024 Hz• These frequencies fall within speech range• Rinne, Weber and ABC

Prerequisites of a good tuning fork

• It should be made of good alloy• Should vibrate for one full minute• Should not produce overtones

Rinne test

• All three frequencies can be used

• + Rinne (Air conduction better than bone conduction)

• -ve Rinne (Bone conduction better than air conduction)

• False positive Rinne (occurs in unilateral total hearing loss due to opposite ear hearing)

Weber test

• 512 Hz fork is used• Lateralized to worse ear• Useful in indentifying

conductive deafness• Can identify even 5 dB

hearing difference between two ears

ABC test

• Helps in identifying s/n loss• Pts hearing is compared to that of the examiner• It is not reduced in normal ears

Fistula test

• Performed by applying +ve - ve pressure to ear drum using penumatic speculum.

• Nystagmus can be visualized by the examiner or recorded using ENG machine

• Positive in the presence of fistula / vestibular fibrosis• Nystagmus occuring with tragal compression of

valsalva maneuver is caused by superior semicircular canal dehiscence syndrome

+ve fistula test causes

• Oval / round window fistulae• Post stapedectomy perilymph leak• Horizontal canal fistula• Meniere's disease• Labyrinthitis

Hennebert's sign

• +v e fistula test in the presence of intact ear drum• No evidence of middle ear disease• Seen in syphilis and hyper mobile foot plate status• Meniere's disease

Tullio phenomenon

• Sound induced vestibular symptoms - vertigo, nystagmus, Oscillopsia and postural imbalance

• Seen in - Superior canal dehiscence, Meniere's disease, vestibulo fibrosis, perilymph fistula, post fenestration surgeries (i.e. stapedectomy)

Head shake test

• pts head is positioned with chin inclined down 30 degrees

• Head is rotated rapidly to one side.• Normal response includes no nystagmus / few beats

of nystagmus• In unilateral labyrinthine dysfunction - nystagmus is

present with slow phase directed towards the direction of dysfunctional labyrinth

Thank You

Otolaryngology onlinePublished by drtbalu