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-Talley and O’Connor clinical exami...
EAR, NOSE AND THROAT
Audiometry
Establishing the diagnosis and extent of hearing loss.
Legend/key
• X – Left-sided air conduction
• ] – Left-sided bone conduction
• O – Right-sided air conduction
• [ – Right-sided bone conduction
Conductive hearing loss Sensorineural hearing loss Mixed hearing loss
Audiometry: • Audiometry both air and bone conduction • Audiometry Both air and bone conduction
• Air conduction readings will be greater than 20 readings will be more than 20 dB readings > 20 dB in patients
dB • Do not know if both sides, or just one-sided • PLUS difference of > 15 dB between the two
(bone conduction > air conduction).
Examination Examination Examination
• sound will be louder in the affected ear. (weber’s • louder in the normal ear (weber’s test) • Mixed
test) • air conduction > bone conduction (Rinne’s
• bone conduction > air conduction (Rinne’s positive)
negative)
Causes Causes: Mixture of both
• Ear wax (or something else blocking the canal) • Sudden sensorineural hearing loss (<72 hours)
• Infection (e.g., otitis media or otitis externa) • Presbycusis (age-related) Exam (age-specific)
• Fluid in the middle ear (effusion) • Noise exposure • Otoscopy ® conductive hearing
• Eustachian tube dysfunction • Ménière’s disease • Tympanometry ® middle ear
• Perforated tympanic membrane • Labyrinthitis • Speech discrimination score® tests CN8 nerve
• Otosclerosis • Acoustic neuroma • < 6mths = Auditory Brainstem Response Testing
• Cholesteatoma • Neurological conditions (e.g., stroke, MS or brain • 6mths – 3 years ® Visual Reinforcement Orientation
• Exostoses tumours) Audiometry (VROA/ puppet show test)
• Tumours • Infections (e.g., meningitis) • Children (3-7 years) ® Pure Tone Play Audiometry
• Medications (e.g. loop diuretics, aminoglycoside • Children (> 7 years) ® Full standard adult test battery
ABx, chemo drugs)
TYMPANOMETRY
, PRESBYACUSIS SUDDEN
EAR WAX EUSTACIAN TUBE OTITIS EXTERNA
[age-related SENSORINEURAL OTOSCLEROSIS OTITIS MEDIA
[cerumen impaction] DYSFUNCTION “swimmer’s ear”
hearing loss] HEARING LOSS
• Impacted wax accumulation Gradual and symmetrical Ø Hearing loss over < 72 Ø Unable to equalise air Ø Remodelling of ossicle bones Ø Infection of middle ear Ø Infection of outer ear
and stuck to eardrum loss of high pitched hours pressure in middle ear and in middle ear -® affects Ø Swimmer’s ear”
PP / sounds 1st drain fluid from middle ear
• ear wax = normally protective Ø Almost always base of stapes ®
comp. unilateral conductive hearing loss
to prevent infection in
external ear Ø Otological emergency Ø Autosomal dominant
• Cotton bud usage • Advanced age • Most idiopathic (90%) Causes • FHx – aut. dominant URTI - Tonsillitis, rhino-sinusitis • Swimming
• Male Other causes: • Idiopathic • Women • Viral URTI (mainly) • Humid environments
• FHx Ø Infection (AOM, AOE, • Post-URTi • Bacterial URTI • Ear polyps
• Loud noise OME, meningitis, • AOM DDx: exostoses o HiB • FB in ear
exposure Mumps) DDx: cholesteatoma Ø Deep diving or swimming Moraxella catarrhalis
o • Bacterial infection
• DM Ø Perforated TM Ø Non-cancerous abnormal cause due to pressure o S. aureus (pseudomonas aeruginosa,
RF / Ø Eustacian tube dysfn changes
• HTN growth of squamous • Passive smoking S. aureus)
causes Ø MS, Stroke, Migraine epithelium in middle ear
• Smoking • Previous ear infections • Fungal infection (e.g. aspergillus, candida) ®
Ø Acoustic neuroma eroding ossicles after ABx usage
• Ototoxic meds Ø Assoc. w/ recurrent infections
Ø Meniere’s • eczema
Ø Cogan’s syndrome and foul d/c
• seborrheic dermatitis
(autoimmune inflam. of Ø Uni conductive hearing loss
Ø Nystagmus, vertigo if invades • contact dermatitis
eyes and inner ear)
semicir. canals
• Conductive hearing loss • Asymptomatic • Unilateral hearing loss < 72 • Reduced hearing • Conductive hearing loss • Otalgia • Otalgia
• Aural fullness (since gradual hrs • Popping noises (lower pitched sound • Unwell + fever • Aural discharge
Clinical hearing loss) affected more)
• Pain • Aural fulness • URTi – cough, coryza and sore • Itchiness
Sx • Tinnitus Rinne negative throat
• Tinnitus • Pain • Conductive hearing loss (blocked ears)
• Tinnitus • +/- vertigo and d/c
• Tinnitus
AOM Ø Irreversible • Permanent hearing loss Ø AOM ® OME • OME Malignant otitis externa ® osteomyelitis in
hearing loss If cholesteatoma: • Perforated TM temporal bone (diabetes, immunsupp. HIV)
Ø Risk of dementia Ø Infection • Labyrinthitis Ø Facial nerve damage
Comp.
Ø Pain • Mastoiditis/abscess ® Ø CNIX, CNX, CNXI damage
Ø Vertigo meningitis Ø Meningitis
Ø Facial nerve palsy Ø Intracranial thrombosis
Otoscope - CERUMEN Audiometry - • Audiometry – diagnosis if Otoscope – normal Otoscope – normal Ø Otoscope – inflamed bulging • Otoscope – inflamed red swollen outer ear with
IMPACTION sensorineural hearing loss>30db in 3 consecutive Ø Tympanometry (check TM Ø Audiometry = conductive red tympanic membrane narrowed external canal
loss (worse at higher frequencies function) ® peak admittance hearing loss • Ear swab - M/C/S and PCR (identify causative
frequencies) • MRI / CT brain - ?acoustic with negative ear canal Ø Tympanometry (reduced organism)
Ix neuroma pressures admittance – stiff, non-
Ø Audiometry compliant TM)
Ø Nasopharyngoscopy Ø HRCT – bony changes
Ø CT scan (structural causes) detected (not useful)
1) Avoid cotton bud usage 1) Hearing protection • Immediate referral to On- 1) NO Rx – allow for self- Conservative Conservative Mild Otitis externa
2) Ear drops (olive oil or 5% 2) Optimise home call ENT within 24 hrs resolution Ø Hearing aids • Reassure - ear toilet and dry • Ear toilet and dry ear (avoid headphone and
Bicarb) environments (e.g • Rx underlying cause 2) Valsalva manoeuvre (to re- ear + avoid swimming swimming for 10 days)
3) Saline irrigation reduce ambient • Idiopathic SSNHL – oral or inflate eustacian tube) Surgical • Simple analgesia (2x Panadol • OTC acetic acid 2% (antifungal and antibacterial
(CI = if perforated eardrum noise during intra-typmanic steroids 3) Anti-histamines or steroid PO tds for 7 days) effect) ® used therapeutically or
Ø Stapedectomy - remove
or infection) conversations) nasal spray for allergic rhinitis entire stapes bone and prophylactically
4) Microsuction 3) Hearing aids 4) Otovent – OTC device where replace with prosthesis Medical – ABx Moderate Otitis externa [use ear wick]
4) Cochlear implants single nostrila blown to inflate attached to oval window • 30mg/kg Amoxicillin PO bd for No Sofradex (dex, framycetin +
eusatican tube Ø Stapedotomy - remove part 5 days perf gramicidin) ear drops (3x drops daily
5) Surgery of stapes and leave base of • Clarithromycin (penicillin for 7 days)
o Grommets stapes attached to oval allergy) or erythron (if pregnant)
Mx o Adenoidectomy window ® new prosthesis Perf Ciloxan (cipro 0.3% ear drops) ® 5x
• Erythromycin (penicllin allergy
o Balloon dilatation attached to connect incus drops bd for 7 days
in pregnant)
eustacian tuboplasty with stapes base
Comp. Ciproxin HC (cipro + hydrocortisone)
Indications for ABx ® 3x drops bd 2 days
For cholesteatoma:
Ø 6/12 old Fungal Triamcinolone (neomcycin + nystatin,
Ø CT head
Ø ATSI gramicidin) 3x drops tds for 7days
Ø Surgicla removal of
Ø Immunocompromised
cholesteatoma y *If severe –Admit to hospital and give IV ABx
Ø Hearing aids (cochlear)
Medical – malignant otitis externa
Ø Only hearing ear
Ø Admit under ENT
Ø IV ABx
Ø CT or MRI (identify extent of infection)
When to refer or follow-up?
• F/U = 8 weeks esp. if recurrent OME, AOM or hearing difficulties
• ENT referral = uncontrolled pain, failure to rsolve w/ AB or ≥6 x episodes in
past 12 months
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