Clinical Otology

1. Clinical Otology Balasubramanian Thiagarajan

2. Symtoms • Deafness • Discharge • Tinnitus • Pain • Vertigo

3. Deafness Onset Gradual Sudden Trigger

4. 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

5. Sensorineural hearing loss (Sudden) • Transverse fracture of pertrous bone • Auto immune reaction following trauma / infection • Inflammatory reaction (Viral infections) • Vascular compromise

6. Conductive hearing loss - (Sudden) • Ossicular disruption • Haemotympanum (transient) • Failed attempts to remove cerumen

7. Mixed hearing loss - (Sudden) • Fractures involving petrous bone • Auto immune reaction to proteins released due to traumatic injury

8. Gradual progressive hearing loss • Inflammatory • Degenerative

9. Fluctuating hearing loss • Impacted cerumen • Meniere's disease • Perilymph fistula

10. Differentiating Conductive / SN loss • Difficulty in comprehending spoken words • Deafness associated with tinnitus • Intolerance to loud sounds • Tuning fork tests

11. Discharge • Quantity • Quality • Duration of discharge • Aggravating / releiving factors

12. Ear discharge - quality • Mucoid - CSOM • Mucopurulent - CSOM with mastoiditis • Serous - ASOM • Serosanguinous - ASOM, Otitis externa, trauma • Watery - CSF otorrhoea

13. Ear discharge - causes • ASOM • CSOM • Otomycosis • CSF otorrhoea

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

16. Pain • Otalgia • Referred otalgia

17. Ear pain 5,6,10th cranial nerves C2 & C3 Tragal tenderness + impated wax Referred otalgia Tragal tenderness - Tragal tenderness + Otalgia Otomcosis Myringitis granulosa Tragal tenderness + Tragal tenderness - AOM Keratosis obturans Tragal tenderness + Furuncle

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

19. Nystagmus • Spontaneous / evoked • Direction of nystagmus - Right beating, left beating, geotrophic, ageotrophic. • Plane - Horizontal, rotatory or vertical • Intensity - (I, II and III degree)

20. 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)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. Discharge • Duration • Quantity • Quality • Aggravating & releiving factors

28. Acute ear discharge - Causes • ASOM - Blood tinged • Otomycosis - Itchy ear, fungal mass seen • CSF otorrhoea

29. Profuse ear discharge - Causes • Chronic mastoiditis - Mastoid tenderness + May lead to formation of subperiosteal abscess • Mastoid reservoir - Mastoid tenderness on deep palpation + • Extradural abscess

30. Quality of ear discharge • Mucoid - CSOM • Mucopurulent - CSOM with mastoiditis • Serous - asom • Serosanguinous - ASOM, Otitis externa • Watery - CSF

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

33. Otalgia • Pain in the ear • Could be due to inflammatory pathology affecting the ear • Referred otalgia due to pathology elsewhere

34. 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

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

37. Peripheral vertigo - Features • It is fatigable • It is positional • Horizontal nystagmus • Cerebellar signs absent

38. 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

40. External canal - Straightening • Aural speculum • Adults - Pinna is pulled postero superiorly • Infants - pinna is pulled posteriorly and downwards

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

42. 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

43. Color of ear drum • Pearly white - normal • Red drum - Glomus jugulare, AOM • Blue drum - SOM, Hemotympanum • Pink drum - Flamingo sign • Chalky drum - Tympanosclerosis

45. 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

46. 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

48. Tuning fork tests • Three frequencies are used • 256Hz, 512 Hz, 1024 Hz • These frequencies fall within speech range • Rinne, Weber and ABC

49. Prerequisites of a good tuning fork • It should be made of good alloy • Should vibrate for one full minute • Should not produce overtones

50. 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)