Symptoms of ear diseases

Deafness

• Decrease in ability to hear

• Normal hearing – up to 25dB
• Mild deafness – 26-40dB
• Moderate – 41-55dB
• Moderately severe – 56-70dB
• Severe – 71-91dB
• Profound/stone - >91dB

1] conductive:

• Impacted wax or big foreign body in canal

• Otomycosis
• Large boil
• Tumors - Osteoma
• Congenital atresia
• Acute and chronic otitis media
• Trauma – ear drum perforation, ossicle dislocation
• Otosclerosis and tympanosclerosis
• Iatrogenic – surgery
• Eustachian tube dysfunction
• COM with effusion

2] sensorineural:

• Congenital – genetic, non-genetic [ototoxic drugs, birth hypoxia, premature]

• Labyrinthitis
• Trauma to inner ear or cochlear nerve
• Acoustic trauma and blast injury
• Perilymph or endolymph leak
• Meniere disease
• Presbycusis
• Ototoxicity
• Systemic disease – diabetes

3] mixed:

• Otosclerosis – first conductive then sensory

 • Cholesteatoma – same as above

4] non-organic:

• Functional deafness is another name

• due any pathology in any part of hearing

Otalgia:

A] External ear

• Boils
• Acute diffuse otitis externa
• Otomycosis
• Herpes zoster oticus
• Impacted wax
• Trauma or foreign body
• Neoplasia
• Bullous myringitis
• Malignant otitis externa

B] mid ear

• Acute and chronic otitis media

• mastoiditis and mastoid abscess
• Neoplasia
• Trauma
• Otitic barotrauma

referred otalgia:

• Post tonsillectomy and adenoidectomy

• Dental disease or extraction
• Nasal and PNS disease
• Acute tonsilitis
• Mouth and pharynx ulcer
• Salivary gland disease
• TMJ dysfunction
• Peritonsillar abscess
• Tonsil carcinoma

otorrhea/ ear discharge:

 • Acute and chronic suppurative OM
• Acute diffuse OM
• malignant and seborrhic otitis externa
• Otomycosis
• Boils after rupture
• Carcinoma
• CSF otorrhea

Itching/ irritation:

• Otitis externa
• Otomycosis
• Impacted wax

Swelling or deformity:

• Perichondritis of pinna
• Mastoid abscess
• Infected preauricular cyst or sinus
• Boil and osteoma in canal
• Congenital or trauma for deformity

Hyperacusis and autophony:

• Hyperacusis – increase sensitivity to sound

• Causes – ototoxicity, Meniere disease, head injury, migraine, CN7 palsy
• Autophony – unusual loud auditory perception of person own voice and sometimes
breathing sounds
• Causes – abnormally patent auditory tube, fluid in mid ear, blocked canal

Bleeding:

• Trauma
• Hemangioma
• Glomus jugulare

Tinnitus:

• Subjective sensation of sound or noises in ear or head

A] with deafness:

• Presbycusis
 • Meniere disease
• Ototoxicity
• Acoustic trauma or blast injury
• Noise induced hearing loss
• Labyrinthitis
• Otitis media
• auditory tube dysfunction
• Impacted wax or foreign body
• Glomus tumors
• Acoustic neuroma

B] without deafness:

• Idiopathic [ most common]

• Hyper or hypotension
• Anemia
• Hypoglycemia
• Vascular
• Migraine
• Epilepsy

1] objective tinnitus:

• Audible to everyone as well as patient

• muscular or vascular etiology

2] subjective tinnitus:

• Only audible to patient

• more common

Congenital malformations of external ear

1] Preauricular sinus/cyst:

• Failure of complete fusion between 1st and 2nd branchial arch

• Located between tragus and crus helix
• Usually no symptoms except a visible opening
• If infected so pain, swelling, redness and discharge
• Treat infection and then complete surgical excision of cyst and sinus tract
2] Atresia of external auditory meatus:

• Non canalization of it
• Associated with microtia [small pinna]
• Treated by reconstructive surgery

3] Auricle complete/partial absence

• Failure of development of 6 auricular tubercles

• Anotia is complete absence
• Treated by reconstructive surgery

4] Accessory auricle:

• Surgically removed

5] Anomaly of pinna size and shape:

• Microtia
• Macrotia
• Bat ear/ lop ear [ big and outward] [ plastic reconstructive surgery]

Congenital malformation of middle ear

1] treacher collins syndrome:

• Also called first arch syndrome

• Genetic malformation of lower face

2] abnormal ossicles:

• Deformed [mostly incus and malleus] or fused together or to the bony wall
• Remove ossicles followed by tympanoplasty

3] congenital fixation of stapes:

• Footplate fixed to window

• Treated by stapes mobilization operation

4] others:

• Dehiscence of facial nerve canal or persistent stapedial artery

Congenital malformation of inner ear

1] scheibe dysplasia:
 • Saccule and cochlea involve
• 70% of cases of hereditary deafness

2] mondini dysplasia:

• Cochlear duct reduced and organ of corti may be absent

3] bing siebenmann dysplasia:

• Underdeveloped membranous labyrinth

4] micheal dysplasia:

• Total absence of both labyrinths

External ear injuries

1] Pinna hematoma:

• Pinna injury -> blood vessels rupture -> hematoma under perichondrium -> cartilage
necrosis -> fibrous tissue forms -> deformed ear called cauliflower or boxer’s ear
• For small, aspiration with wide bore needle
• For large, incision and drainage

2] frostbite:

• Excessive cold -> ear swells and painful -> gangrene of pinna
• Early stages, do gentle rewarming
• Late stages, remove gangrene by surgery

3] laceration/cuts:

• Primary sutures or reconstruction

4] foreign body:

• Animate – insects
• Inanimate – hygroscopic [absorbs water] like seeds, non-hygroscopic like metals,
plastic etc.
• Most foreign bodies stuck in isthmus

Features:

• Usually, children or mentally retarded ppl

 • History of foreign body introduction
• Pain
• Deafness
• Tinnitus
• Ear bleeding or clots

Treatment:

• Smooth/round body removed by a ring probe

• Insects killed by oil, spirit or chloroform before syringing
• Small body by suction
• If difficult so post aural incision and extract thru post wall of canal

Middle ear injuries

1] traumatic rupture of ear drum:

Causes:

• Foreign body esp. sharp

• Unskilled instrumentation
• Temporal bone fracture
• Sudden air compression eg. hard slap, bomb blast
• Sudden fluid compression eg. Underwater with no protection

Features:

• History of trauma to ear

• Deafness
• Tinnitus
• Bleeding
• Vertigo

Exam:

• Ruptured membrane with irregular margins and fresh bleeding or clots

Treatment:

• Prophylactic antibiotic
• Ear drops contraindicated
• Avoid swimming, valsalva maneuver
• Plug ears with sterile lubricated swab
 • Majority heals naturally, if fails to heal after 4-6 wks then myringoplasty

Traumatic dislocation of the ossicular chain:

• Trauma to head and temporal bone

• Most common site is incudostapedial joint
• History of trauma and mod to severe deafness
• On exam normal membrane
• PTA shows conductive deafness with air bone gap
• Impedance audiometry shows type Ad graph
• Treatment is tympanoplasty

Temporal bone fracture:

1. Longitudinal fracture:
• 80%
• Along long axis petrous temporal bnone
• Can involve mid ear, tymp membrane, EAM
• Conductive deafness

2. Transverse fractures:
• 20%
• Right angle to long axis of petrous temporal bone
• Can involve labyrinth and Internal auditory canal
• Senso neural deafness, facial nerve paralysis

Inner ear injuries

1] fractures of temporal bone:

2] direct trauma:

• To labyrinth
• Eg bullets, sharp foreign body
• History of trauma, deafness, vertigo

Diseases of external ear

Otitis externa:
 • Acute or chronic inflammation of the whole or part of skin of the external ear
• Mostly caused by local factors in ext ear and secondary to otitis media
• Risk factors – dandruff, allergy, syringing, trauma, dirty object, bad instrumentation,
swimming in dirty water

Types:

• Boils/furuncle
• Otomycosis
• Diffuse otitis externa
• Bullous myringitis
• Seborrheic otitis externa
• Eczematous otitis externa
• Malignant otitis externa
• Herpes

1] Boils/furuncle:

• Acute staph infection of hair follicle

• Only in cartilaginous part
• Risk factors – diabetes, scratching ear, swimming
• Very painful

Features:

• Itching [first]
• Intense pain
• Lymphdenitis
• Discharge if boil burst
• Low fever
• tenderness at tragus and pinna
• Conductive deafness if big boil

DD

• Mastoiditis
• Exostosis [painless, hard and in bony part of ear]

Treatment:

• Antibiotics and Analgesics

• 10% ichthamol in glycerine wick locally
 • Incision and drainage for large boils

2] Otomycosis:

• Fungal infection in the lining skin of EAM

• Mostly aspergillus
• Risk factors – dirty water swimming, cont discharge due to otitis media

Features:

• Itching
• Conductive deafness
• Secondary bacterial infection so pain and discharge
• On exam, wet newspaper or blotting paper like mass

DD:

• Other types of externa

Treatment:

• Meatus cleaning by dry mopping or suction cleaning

• Local antifungal lotion eg. Clotrimazole

3] Diffuse otitis externa:

• Diffuse inflammation of the lining skin of EAM

• Mostly acute and gram + bacteria

Features:

• Pain [ inc by jaw movement]

• Purulent discharge
• Deafness [rarely]
• On acute exam, meatus skin inflamed, tender and enlarged lymph nodes
• On chronic exam, thick and edematous meatus skin

DD:

• Suppurative otitis media [ eardrum hole, mucoid discharge, pronounced deafness,

hazy mastoid on x ray with normal canal]

Treatment:

• Keep ear dry

 • Avoid scratching
• Regular cleaning
• Topical antibiotic drops

4] Bullous myringitis:

• Also called otitis externa hemorrhagica

• Inflammation of tymp membrane with blebs, swelling and redness
• Cause is influenza virus

Features:

• Pain [predominant]
• Deafness
• Hemorrhagic blebs on eardrum and deep canal
• Fluids if they rupture

Treatment:

• Analgesics
• Prophylactic antibiotics
• Ear dry with repeated aural toilet

5] Seborrheic otitis externa:

• Greasy and crusting condition of skin of EAM and pinna

• Due to pityrosporon fungus
• Associated with dandruff

Features:

• Itching [predominant]
• Secondary infection by scratching
• On exam, greasy yellow to white scales in canal, scalp full of dandruff

Treatment:

• Antidandruff shampoo eg. Selenium sulphide

• Local antifungal cream eg. Ketoconazole

6] Eczematous otitis externa:

• Allergic dermatitis involving canal and pinna skin

• Due to jewelry, creams, cosmetics, antibiotic drops
Features:

• Irritation
• Redness
• Edema
• Vesicles
• Secondary bacterial infection
• Scaling, fissuring and canal stenosis in canal in chronic

Treatment:

• Antihistamine and remove allergic source

• Meatoplasty for stenosis

7] Malignant otitis externa:

• Peusodomonal infection
• Commonly in elders with poor diabetes
• Can cause oesteomyelitis
• Spread – stylomastoid foramen [facial nerve paralysis], petrous apex [ 5 and 6
nerve], jugular foramen [ last 4 CN]

Features:

• Pain and discharge [Sero-purulent or purulent, foul, blood]

• On exam, granulation tissue in canal
• Cranial nerve palsies
• Gradenigo syndrome [petrous apex involve]

Treatment:

• systemic and topical Antibiotics

• Control diabetes
• Surgical - Remove granulation tissue and necrotic bone

8] Herpetic lesion:

• Herpes simples or zoster

• Zoster – ear pain, vesicles on pinna, canal and membrane, 7 and 8 CN [ramsay hunt
syndrome]
• Treat by systemic antiviral eg acyclovir
Wax:

• Mix of secretions of ceruminous and pilo sebaceous glands

• Only in cartilaginous part
• Fresh golden brown
• Symptoms only when wax touch tymp membrane

Features:

• Fullness in ear
• Itching
• Pain
• Deafness
• Reflex cough
• Vertigo

Treatment:

• Syringing with if soft

• Softening of wax with 5% soda bicarb in glycerine eardrops when hard
• If hard and dry so removal with hook or ring probe
• Syringing is contraindicated so suction is safe

Ear syringing:

• Washing the ear with normal saline at body temp

• Indications – wax, otomycosis, foreign body

Contraindicated:

• All ear infections, hole in eardrum

Complications:

• Trauma
• Hole in eardrum
• Otitis externa due trauma
• Vertigo [if saline not at body temp]

Perichondritis of pinna:

• Infection of auricular cartilage

• Causes – frostbite, trauma, operations
Features:

• Pain and swelling

• Abscess with fluctuation

Treatment:

• Systemic antibiotics
• Incision and drainage if fluctuation
• Pressure bandage
• Remove necrotic cartilage
• Reconstructive surgery

Acquired stenosis of EAM:

• Meatus narrowing due to excess fibrous or bony tissue

• Chronic otitis externa most common cause
• Other causes – operation, perichondritis, tumors, trauma, tympanic plate fracture,
burns

Features:

• Unclean ear so wax so symptoms

• Deafness [complete stenosis]

Treatment:

• Meatoplasty if deafness

Maggots in ear:

• Larvae of housefly
• Hatch in 24 hrs
• Pain, swelling, foul and bloody discharge
• On exam, maggots seen or soft tissue necrosis
• Treatment – kills with maggot oil and chloroform water and remove with forceps

Keloids:

• Overgrowth of fibrous tissue after any kind of injury

• Most common after ear piercing
• Smooth, round and localized swelling with firm of hard consistency
 • Treatment – surgical excision with steroid inj to prevent reoccurrence

Otosclerosis

• Localized disease of the otic capsule

• New spongy bone form -> ankylosis of stapes footplate to oval window margin
• Also called otospongiosis
• Between 20 and 30 years

Causes:

• Heredity [50% cases]

• Viral infection
• Autoimmune against type 2 collagen
• Biochemical [secondary remodeling reactivates]

Features:

• Conductive Deafness [predominant]

• Sensorineural deafness if abnormal bone invades cochlea
• Paracusis willisii – hears better in noisy place
• Tinnitus
• On exam, pink tissue seen in tymp membrane in 10% cases due to hyperemia of
promontery [schwartz sign]
• -ve rinnie test on affected side, weber localized to that side

Investigations:

• PTA – air bone gap seen, Bone conduction curve shows dip called cahart’s notch
• Impedance audiometry [type As graphy, stapedial reflex absent]
• CT scan and tomography [ thick stapes footplate]

DD:

• Tympanosclerosis [white chalky patches]

• Otitis media with effusion [flat curve in Impedance audiometry]
• Ossicular dislocation [Ad graph]
• Adhesive or healed suppurative otitis media [scar in membrane]

Treatment:

• Medical – fluoride therapy [ stop bone deposition but controversial]

• Surgical – hearing aid when surgery not possible, stapedectomy, stapedotomy
 • Surgery when there is large air bone gap
• In stapedectomy, footplate replaced by prosthesis
• in stapedotomy, hole in footplate and Teflon piston inserted

Neoplasia

Benign:

1] osteoma/exostosis:

• Benign neoplasm of bony origin projecting into lumen of canal

• Most common benign tumor of canal

Types:

• Sessile [most common]

• Pedunculated [true osteoma]
• Diffuse

Features:

• Deafness
• Irritation
• On exam, bony hard, skin covered swelling seen in deep bony part of canal

Treatment:

• Clean ear regularly so no debris

Other benign tumors of EAM:

• Ceruminoma [ tumor of ceruminous gland in outer part of canal]

• Adenoma
• Papilloma

Ext and mid ear carcinoma:

• Tumor of epithelial lining

• Squamous cell, basal cell and adenocarcinoma
• Basal cell [ rodent ulcer] more on pinna than EAM and related to more sunlight

Features:

• Deafness
• Bloody discharge
 • Pain and swelling
• Sometimes facial paralysis
• On exam, fungating mass in canal and usually bleeds on contact
• Diagnosis by punch biopsy, CT and MRI for extent

Treatment:

• Surgical excision, radiation therapy

Glomus tumor:

• Tumor of Glomus bodies present on dome of bulb on internal jugular vein [glomus
jugulare] or promontory along tympanic branch of CN9 [glomus tympanicum]
• Arising from non-chromaffin paraganglionic chemoreceptors tissues
• Locally invasive
• May involve last 4 CN

Features:

• Deafness
• Tinnitus [pulsatile nature]
• Vertigo
• Ear pain
• Bloody discharge
• Cranial nerve palsies
• On exam, red mass behind tymp membrane [rising sun appearance] or in canal if it
perforated membrane

Diagnosis:

• Jugular and carotid angiography

• CT and MRI
• Not biopsy cuz heavy bleeding

Treatment:

• Surgical excision [choice]

• In severe case, radiotherapy then surgery

Acoustic neuroma:

• Neurofibroma originating from schwann sheath of CN8

• Non invasive and benign
 • Yellowish tumor

Features:

• Symptoms appear in following order;

• Acoustic symptoms – deafness [sensorineural], tinnitus or sometimes vertigo
• Trigeminal symptoms – pain, tingling and numbness, reduced corneal sensation
and reflex
• Headache
• Cerebellar symptoms
• Diplopia - due to raised ICP
• Facial paralysis
• Terminal symptoms – blindness from papilledema and coma

DD:

• Meningioma, neuroma of CN8, congenital cholesteatoma, aneurysm of vertebral

artery

Investigations:

• CT and MRI [ mass in cerebellopontine angle]

• Brainstem evoked response audiometry [BERA]

Treatment:

• Surgical excision
• Gamma knife

Otitis media

• Inflammatory conditions of middle ear

• Includes eustachian tube, mid ear cavity, aditus, mastoid antrum and air cells

Types:

1. Suppurative
❖ Acute otitis media [AOM]
❖ Chronic otitis media [COM]
i. Tubo tympanic
ii. Attico-antral
 2. Non-suppurative
❖ Otitis media with effusion
❖ Acro-otitis

Acute otitis media:

• Acute inflammation of lining mucous membrane of mid ear

• More common in children due to adenoids regression, reduced URTI and
eustachian tube dysfunction

Causes:

• Extension of infection from nasopharynx

• Perforated eardrum
• Bacterial – streptococci, pneumococci, H influenzae, Moraxella, catarrhalis,
staphylococci
• Often starts with viral infection
• Risk factors – rhinosinusitis, tonsillitis, pharyngitis, enlarged adenoids

Features:

• Pain
• Conductive deafness
• Discharge after eardrum perforation [mucopurulent or purulent or bloody]
• Fever, malaise and headache
• on exam, tymp membrane normal initially then congestion esp along handle of
malleus then intense congestion of whole membrane then membrane bulge due to
pus and then perforate, and pus comes out in EAM

DD:

• Diffuse otitis externa [serous discharge, normal membrane, no deafness]

• Furuncle
• Conditions causing referred otalgia
• Herpetic zoster oticus
• Postauricular adenitis

Treatment:
 • Antibiotics
• Symptomatic – rest, analgesics, nasal decongestant
• Myringotomy if pus present [posteroinferior part of tymp membrane incision]
• Aural toilet and antibiotic eardrops after perforation
• Tympanoplasty if perforation persists

Chronic otitis media:

• Another classification is;

1. Inactive mucosal COM
2. Active mucosal COM
3. Inactive squamous COM
4. Active squamous COM
5. Healed COM

Tubo tympanic COM:

• More common type of COM

• Mostly always a complication of AOM where there is persistent eardrum hole

Features:

• Mucopurulent discharge [not foul or bloody]

• Conductive deafness
• Pain
• On exam, central perforation

Investigations:

• Aural swab
• X ray mastoid [law’s view] - cellular bone
• Audiometry
• Temporal bone CT

Treatment:

• Systemic antibiotics
• Aural toilet
• Topical antibiotic drops with or without steroids
• Analgesics
• Elimination of foci of infection
 • Cortical mastoidectomy if infection in mastoid air cells
• Tympanoplasty when the ear is dry

Complications:

• Chronic discharge cause polyp, otitis externa or rarely ossicles necrosis

Attico antral COM:

• Dangerous type
• Associated with cholesteatoma

Features:

• Discharge [purulent, foul and blood stained]

• Deafness [conductive or mixed]
• Pain
• Headache, vertigo and facial paralysis are complications
• on exam, granulation tissue and cholesteatoma and postsuperior perforation

Investigations:

• X ray mastoid [radiotranslucent with clear bony margin cholesteatoma seen]

• CT temporal bone
• Audiometry

Treatment:

• Surgery in all cases of cholesteatoma

• Canal wall up procedures [post meatal wall intact]
1. Simple mastoidectomy
2. Posterior tympanotomy or combined approach tympanoplasty [CAT]
• Canal wall down procedures [post meatal wall removed]
1. radical mastoidectomy
2. modified radial mastoidectomy
3. atticotomy

Simple mastoidectomy:

• Also called cortical or schwartz mastoidectomy

• Mastoid antrum open and air cells cleared
• Only if disease limited to antrum
 • Only in tubo tympanic COM

Modified radial mastoidectomy:

• When both mid ear and mastoid antrum are involved

Radical mastoidectomy:

• When all ossicles are also involved

• All ossicles removed except stapes footplate

Atticotomy:

• When attic involved only

Post tympanoplasty:

• Opening between facial nerve and chorda tympani [facial recess]

Tympanoplasty:

• Reconstruct hearing mechanism of mid ear

• Type 1 – reconstruction of tymp membrane with ossicles intact [myringoplasty]
• Type 2 – malleus handle absent with perforation and membrane reconstructed
• Type 3 – incus and malleus absent with perforation and membrane reconstructed
[myringostapediopexy]
• Type 4 – only stapes footplate present
• Type 5 – footplate of stapes is fixed and lat semicircular canal fenestration is done
[ fenestration operation]

Surgical approaches:

• Trans canal – cut on post meatal wall, only mid ear access
• Endaural – cut on post meatal wall, mid ear and mastoid access
• Post aural – cut behind ear, all mastoidectomy, CN5 and semicircular canal surgery
• Endoscopic mostly done thru trans canal

Graft materials:

• Autograft for tymp membrane repair - temporalis fascia, ear lobule fat, veins, tragal
perichondrium
• Homograft for myringoplasty – temporalis fascia [most common], veins, fascia lata,
serosa, cadaveric tymp membrane or dura mater
• Ossicles reconstruction
 1. Autograft - malleus, incus, septal or conchal cartilage
2. Homograft – ossicles
3. Prosthetic – total ossicular replacement prosthesis [TORP], partial ossicular
replacement prosthesis [PORP]

Myringoplasty techniques:

• Onlay/overlay graft method – graft on top or lateral to membrane after removing

epithelium
• Inlay/underlay graft method – graft medial to membrane

Complications of mastoid and mid ear surgery:

• Facial nerve injury

• Dura mater injury
• Sigmoid sinus injury – heavy bleeding
• Ossicles injury – conductive deafness
• Internal ear injury – neural deafness
• labyrinthitis

Cholesteatoma:

• Bag of stratified squamous epithelium which contains keratin debris and shed
epithelium
• Congenital – mid ear, petrous apex or cerebellopontine angle
• Acquired
1. Primary – pars flaccida defect, no history of previous otitis media or perforation
2. Secondary – pars tensa defect, there is history

Tuberculous otitis media:

• Secondary to lungs or tonsil TB

• Spread thru eustachian tube or blood
• Symptoms like COM
• Anti TB drugs along with treatment as COM
Otitis media with effusion:
• Non purulent fluid in mid ear
• Also called as secretory/serous/catarrhal/mucinous/exudative OM and glue ear

Causes:
 • Eustachian tube dysfunction – large adenoids, inflammation, strictures, space
occupying lesion in nasopharynx, palatal muscles paralysis
• Allergy
• Viral infection – adeno or rhinovirus
• Unresolved AOM
• Cleft palate

Features:

• Conductive deafness [main and often the only one]

• Tinnitus with crackling and bubbling noise and fluid sensation
• On exam, dull and retracted membrane with crescentic line on it showing fluid level
in mid ear, blocked auditory tube

Investigations:

• PTA – air bone gap

• Tympanometry – type C graph early then type B graph later

Treatment:

• Treat predisposing factors

• Steam inhalation
• Nasal decongestant drops
• Myringotomy with insertion of grommet in anteroinferior part of membrane

Aero otitis:

• Non infective inflammation in lining of mid ear because of –ve intratympanic

pressure
• Also called as otitic barotrauma

Features:

• Pain and discomfort

• Conductive Deafness
• Tinnitus
• Vertigo sometimes
• Sensation of fluid and autophony
• On exam, retracted and congested membrane and fluid level with bubbles

Treatment:
 • no flying if URTI
• During landing no sleep and auto inflation by valsalva performed
• Nasal decongestant before flight

Complications of suppurative OM

Transmission routes:

• Natural defects – round or oval window, sutures lines

• Artificial defects – fractures, surgical, cholesteatoma tract
• Vessels – infection
• Lymphatics

Extracranial complications:

1] mastoiditis:

• Inflammation of mastoid bone

• When infection extends beyond mastoid air cells to bone
• Acute from AOM and chronic from COM
• in severe case, bone resorption occurs and subperiosteal/post aural abscess forms
• Abscess can extend to;
1. Laterally to mastoid antrum causing post aural fistula
2. Anterior to causes discharge in EAM
3. digastric muscle [citelli’s abscess]
4. Sternocleidomastoid [bezold’s abscess]
5. Zygomatic bone [zygomatic abscess]
6. Petrous apex [politzer’s abscess]

Features:

• Pain behind ear and tenderness over mastoid region

• Discharging fistula
• Subperiosteal abscess
• Fever and deafness

Investigations:

• Pus for culture

• x ray mastoid [haziness in mastoid area cuz of pus]
• CT temporal

Treatment:
 • Early stage with antibiotics
• If abscess so drainage
• Cortical mastoidectomy to clear antrum and air cells
• In attico antral COM, canal wall down mastoidectomy is done

2] otitis externa:

• When pus in canal

3] thrombosis of internal jugular vein:

4] petrositis:

• Spread to petrous bone

• Severe unilateral headache in temporal, supra or retro-orbital region [CN5]
• CN6 so diplopia
• All this makes gradenigo’s syndrome [discharge, headache, diplopia]
• Treatment as of COM

5] chronic adhesive OM:

• Atrophy or thick tymp membrane

• Conductive deafness
• Treatment – tympanotomy and place silastic sheet in mid ear

Intracranial complications:

1] extradural abscess:

• Between bone and dura mater

• Pain, fever and tenderness over temporal bone
• Discovered only at time of mastoidectomy
• Drainage

2] subdural abscess:

• Very rare
• Raised ICP and midline shift
• Severe headache with fever
• Drowsy turns to coma
• Epileptic fits
• If cerebral cortex involves so hemiplegia
• Drainage
3] brain abscess:

• Most common complication due to ear disease [otogenic brain abscess]

1. Cerebellar abscess:
• Either from mastoid or sigmoid sinus thrombosis and labyrinth
• Headache [most imp], vomiting, drowsy, confusion, lethargy, papilledema, high
fever with rigors and slow pulse, focal cerebellar signs like ataxia, nystagmus,
+ve romberg
• CT/MRI, CSF exam, EEG and COM investigation
• Drainage and antibiotics, treat ear infection
2. Temporal lobe abscess:
• More common
• Same symptoms and tests as cerebellar abscess
• Nominal aphasia, homonymous hemianopia, contralateral limb paralysis,
epileptic fits
• Sudden coma with high fever upon rupture

4] sigmoid sinus thrombosis:

• Fever with rigors

• High pulse
• Headache with vomiting
• High CSF pressure
• DD is malaria, typhoid, bronchopneumonia
• Antibiotics, anticoagulants, surgical removal

5] otitic hydrocephalus:

• Due to sigmoid sinus thrombosis

• Very rare
• High ICP
• Severe headache with ALOC and vomiting
• Papilledema [CN6]
• CT, MRI and lumbar puncture
• Steroid and diuretics for high ICP, if persists so surgical decompression and
ventriculoperitoneal shunt

6] meningitis:

• Second most complication

 • Headache, neck stiffness
• +ve kernig sign, focal neuro signs with CN palsy later on
• Raised ICP and visual symptoms
• Lumbar puncture, CSF exam
• Antibiotics, other measures to reduce ICP, surgery for primary ear condition

Facial nerve paralysis:

Causes:

• Supranuclear paralysis – only lower half face affected

• Nuclear – motor nuclear affected and same concept as infranuclear
• Infranuclear – whole face affected along with parts supplied by nerve
1. Intracranial:
• Brainstem tumors
• Polio
• Multiple sclerosis
• Vascular injury
• Cerebellopontine angle tumors
2. Intratemporal:
• Otitis media
• Bell's palsy
• Herpes zoster oticus
• Mid ear tumors
• Mastoid and mid ear surgery
• Temporal trauma

3. extracranial/temporal:

• Parotid tumors
• Birth trauma
• Parotid surgery

Investigations:

• Minimal nerve excitability test

• Electromyography [EMG] - detect nerve regeneration
• Electroneurography [ENoG] - % of degenerated nerve fibres

Otogenic facial paralysis:

 • Acute OM
• Chronic OM
• Malignant ear tumors
• Malignant Otitis externa
• Herpes zoster oticus
• Surgeries eg. Mastoidectomy

Bell's palsy:

• Most common facial nerve paralysis cause

• LMN lesion, sudden onset, one whole side of face
• Chorda tympani – taste affected
• Nerve to stapedius – hyperacusis
• Greater superficial petrosal nerve – less lacrimation
• On exam, full or partial face paralysis on one side
• Test for taste, lacrimation and stapedius function

Treatment:

• General – reassurance, analgesics, eye care [artificial tears, topical antibiotic],

physiotherapy
• Steroids [prednisolone]
• Antiviral eg. acyclovir
• Surgical decompression

Sensorineural deafness

• Sesnsoray – pathology in cochlea or organ of Corti

• Neural – pathology can be in cochlear nerve to higher center or auditory cortex

Presbycusis:

• Hearing loss from degenerative changes of aging

• Also called senile deafness
• Bilateral and slowly progressive
• Above 60

Features:

• Difficulty in understanding speech in presence of background noise in group convo

• All mainly due to high frequency loss
• Recruitment present
Investigations:

• PTA – slopping curve

• Speech audiogram – marked reduction in speech discrimination score

Treatment:

• Reassurance
• Lip and auditory training
• Hearing aids

Ototoxicity:

• Damage to cochlear, vestibular or both inner ear parts by drugs

• Aminoglycosides
• Diuretics – mainly loop
• anti-malarial – quinine, chloroquine
• Salicylates - aspirin
• cytotoxic drug - cisplatin
• anti epileptic - phenytoin
• NSAIDs – ibuprofen
• Risk factors – parenteral route, kidney fail, high serum level, concomitant use of
other ototoxic drug, topical eardrops

Features:

• Tinnitus [first]
• Deafness
• Vertigo if vestibulotoxic

Investigations:

• History
• Serum drug level
• Kidney tests
• PTA
• Vertigo test
• Oto acoustic emission [detect ototoxicity early in neonates]

Treatment:

• Mainly preventive
 • Hearing aid and auditory rehabilitation

Acoustic trauma:

• Sensorineural loss due to brief exposure to very loud sound

• Deafness, tinnitus
• DD – blast deafness of conductive type [traumatic rupture of membrane and
ossicles dislocation due to pressure changes]
• Prevention by earplugs or earmuffs, rest and sedation, hearing aid and auditory
training [if permanent loss]

Noise induced deafness:

• Prolong exposure to a loud sound

• Only cochlea affected
• Above 85 dB
• Industries, transport, markets, loud music constant use
• Deafness [max at 4k Hz] and tinnitus
• Prevention by earplugs, proper sound insulation and use silencer on machines
• In established case, avoid further exposure, rest, hearing aid, change work

Idiopathic sudden sensorineural hearing loss:

• Sudden origin which develops over a period of few hrs to 2-3 days with no known
cause
• Mostly unilateral
• Could be viral, autoimmune, vascular issue
• Empirical treatment like high dose steroids

Vertigo

• Subjective sense of movement either in the individual himself or his surroundings

• Physiological or pathological
• Due to stimulation of labyrinth
• Vertigo of heights – visual stimulation
• Vertigo after spinning – semicircular canals stimulated
• Vertigo from sudden change in floor texture – skin and deep tissues of feet
stimulated

Peripheral vertigo:

• Pathology in vestibular organ or nerve

 • Causes are;
• Labyrinthitis
• Meniere disease
• Trauma
• Vestibulotoxic drugs
• Acoustic neuroma
• Vestibular neuronitis
• Perilymph fistula
• Benign paraoxysmal positional vertigo

Central vertigo:

• Pathology in CNS
• Causes are;
• Epilepsy
• Multiple sclerosis
• Migraine
• Brainstem ischemia
• Drugs
• Cerebellopontine angle tumors
• Cerebrovascular injury

Labyrinthitis:

• Inflammation of membranous labyrinth of inner ear

1] otogenic labyrinthitis:

• Due to otitis media and bullous myringitis

• Bacterial or viral
• One of the most common complication of COM
• Circumscribed labyrinthitis – bony erosion due to cholesteatoma
• Diffuse serous labyrinthitis – peri and endolymph space distended with transudate
and no organism in perilymph
• Diffuse purulent labyrinthitis – purulent infection in both spaces and distended with
pus
• Dead labyrinth – [last stage] fibrous tissue in these spaces, later replaced by bone

Features:

• Vertigo [predominant]
 • Vomiting
• Sensorineural deafness
• Nystagmus

Treatment:

• Antibiotic and Anti vertiginous drugs if acute infection

• COM leading to labyrinthitis by fistula so surgery

2] hematogenic labyrinthitis:

• Infection enters by blood or secondary to diseases like typhoid, scarlet fever and
syphilis or viral infection eg. Influenza, measles, mumps and herpes
• Same features as otogenic
• Treatment – anti vertiginous drugs, rest, avoid head movement and treat primary
infection

3] meningitic labyrinthitis:

• Secondary to meningitis
• Infection enters thru internal auditory canal
• Meningococcal, pyogenic meningitis, TB meningitis
• Features and treatment same as others

Vestibular neuronitis:

• Inflammation of vestibular nerve

• Cochlea normal
• Probably due to influenza virus
• Vertigo [predominant], vomiting
• on exam, spontaneous nystagmus in acute stage, caloric test shows canal paresis,
normal hearing
• Treatment – anti vertiginous drugs, rest, avoid moving head, vestibular sedative,
reassurance

Benign paroxysmal positional vertigo [BPPV]:

• Recurrent paroxysmal, short lived attacks of vertigo in certain critical positions of

head
• Probably caused by head injury causing macula to release otoconial debris which
settles in post semicircular canal

Features:
 • Sudden vertigo attacks when head in certain direction
• Turning head during sleep may awaken patient cuz of vertigo
• Head turn on affected side so nystagmus [dix hallpike test]
• Nystagmus is delayed onset

Treatment:

• Avoid certain head positions

• Epley maneuver
• Semont maneuver
• Surgery – [persistent disease] canal plugging, singular nerve section, vestibular
nerve section and labyrinthectomy

Meniere's disease:

• disorder of endolymphatic labyrinth

• Both cochlea and vestibule affected

Causes:

• Sodium and water retention

• Allergy
• Hypothyroidism
• Vasomotor disturbance
• Local ischemia
• Viral infection and autoimmune

Features:

• Between attacks, no symptoms and normal exam

• Sudden paroxysmal attacks of vertigo
• Sensorineural deafness
• Tinnitus and sense of fullness or pressure
• Nystagmus in acute stage on exam
• Vomiting
• Pallor, sweating, hypotension, headache

Investigations:

A] Audiometry – PTA [recruitment present], speech audiometry [55-85% score]

B] Caloric test
 • shows canal paresis in affected side
• contraindicated during acute attack so done in between attacks

C] Glycerol or diuretic test

• reduces endolymph pressure

• audiometry done before and 1-2 hrs after
• 1.5ml/kg glycerol given with an equal amount of water
• Cause an improvement in hearing, tinnitus and sense of fullness

D] electrocochleography

• Normal SP/AP ratio – 30%

• In Meniere – greater than 30%

Variants:

1] cochlear hydrops:

• Only cochlear and Meniere symptoms present

• No vertigo

2] vestibular hydrops:

• Normal cochlear function but episodic vertigo

• With time Meniere disease typical signs will develop

3] drop attacks:

• Sudden drop attack with no consciousness loss

• No vertigo or fluctuations in hearing loss

4] lermoyez syndrome:

• Reverse order
• First progressive hearing loss, then vertigo attack at which hearing recovers

Diagnosis:

• Certain – histopathology
• Definite – 2 or more spontaneous vertigo attacks lasting 20 mins or more, hearing
loss on audiometry on at least 1 occasion, tinnitus fullness, all other causes
excluded

DD:
 • Labyrinthitis
• Vestibular neuronitis
• Acoustic neuroma
• BPPV
• Multiple sclerosis

Treatment:

A] General

• Reassurance
• Avoid smoking and stress
• Avoid heavy water intake
• low salt diet
• Avoid over caffeine

B] acute management

• Reassurance
• Bed rest
• IV fluids and electrolytes
• Vestibular sedative - diazepam
• Vasodilators – carbogen

C] chronic management

• Vestibular sedative - prochlorperazine

• Vasodilator - betahistine
• Diuretics
• Eliminate allergy
• Hormones
• Propantheline bromide

D] Surgery

1. Conservative [useful hearing present]

• Endolymphatic sac decompression [ more popular]
• Vestibular neurectomy
• Endolymphatic shunt
• Sacculotomy [ficks surgery]
2. Destructive [no useful hearing present]
 • labyrinthectomy
• intratympanic gentamicin therapy [chemical labyrinthectomy]

3. intermittent low-pressure pulse therapy [meniett device therapy]

Auditory rehabilitation

1. Training
• Speech/lip reading
• Auditory training
• Speech conservation
2. Devices
• Hearing aid
• Cochlear implant
• Auditory brainstem implant
• Assistive devices

Speech/lip reading:

• Useful in deaf ppl who have high frequency sensorineural loss and have difficulty in
understanding speech in noisy backgrounds

Auditory training:

• Understand speech after cochlear implant and used after fitting hearing aids in
some ppl

Speech conservation:

• Sudden or severe hearing issue so trained to monitor their own speech by tactile or
proprioceptive feedback

Hearing aids:

• Device used for amplification of sound and helps in hearing

• Mechanism – collect sound, amplify and deliver to ear
• Microphone – collect
• Amplifier - amplifies
• Receiver or speaker – delivers

Types:

1] air conduction hearing aids:

 • Sound is delivered using normal mid ear conductive apparatus
• Body worn type – other parts in pocket and receiver fitted in ear canal and
connected to main unit thru cord
• Behind the ear type [BTE] - hearing aid behind ear and sound delivered thru tube
connected to ear mould placed in canal
• Spectale type – hearing aid unit in glasses
• In the ear type [ITE] - hearing aid in an ear mould in the ear
• In the canal type [ITC] - entire unit in EAM
• Completely in the canal [CIC] - hearing aid completely in canal

2] bone conduction hearing aids:

• Sound delivered thru bone vibrator placed on mastoid bone and cochlea stimulated
• Used in ppl where air conduction aid is contraindicated eg. Discharging ear or EAM
atresia
• Bone anchored hearing aid [BAHA] - vibrator surgically implanted in temporal bone
and sound directly sent to cochlea

Cochlear implant:

• Restoration of hearing in ppl having severe sensory or cochlear hearing loss

• Elements;
1. Microphone – catch sound and send forward
2. Speech processor - convert sound to electrical impulse and send forward
3. Transmitter coil – send impulse forward
4. Receiver coil – [ under skin] send forward
5. Array of electrodes - [within cochlea] stimulate 1st order neuron of cochlear
nerve
• Useful in ppl having bilateral profound sensory deafness with no speech
discrimination and hearing aids not effective or post lingually adults and children
and pre lingually deaf adults

Audiometry

• Measuring of hearing acuity

1] Subjective:

• entire system function and need patient response

Pure tone audiometry [PTA]:

• Most common method

• Frequencies from 250Hz – 8000Hz
• Intensities from 0dB – 120dB
• Normal – air and bone conduction within 0-25dB
• Conductive loss – air line down and bone line within normal [air-bone gap]
• Sensorineural loss –both lines down and no air-bone gap
• Mixed loss – both lines down and air-bone gap present
• Air bone gap shows severity of conductive loss
• Sensorineural loss measured by bone conduction line

Speech audiometry:

• Patient ability to understand speech

• Speech discrimination score – total % of words correctly repeated by patient
• Normal – 100% score
• Conductive – 100% or near but at higher intensity
• Sensory – between 50-70%
• Neural – 30% or less
• Speech reception threshold – min intensity at which 50% of double syllable words
correctly repeated by patient

2] Objective:

• response to sound stimuli at lower neuro and peripheral level and does not need a
patient response

Impedance audiometry:

• Measurement of middle ear

• Use – measure compliance and pressure in mid ear [tympanometry], stapedial or
acoustic reflex
• Compliance – how much sound is absorbed and how much is reflected back
• Stapedial reflex – protective reflex against a loud sound causing stapedius
contraction and ossicles stiffness
• Type A graph – normal compliance and pressure
• Type As – low comp but normal pressure [otosclerosis, tympanosclerosis]
• Type Ad – high comp but normal pressure [ossicles dislocate, thin ear drum]
• Type B – flat curve with -ve pressure [perforation, OM with effusion]
 • Type C – max comp or peak and –ve pressure – auditory tube dysfunction

Brainstem evoked response audiometry [BERA]:

• Also called audiometry brainstem response [ABR]

• For integrity of central connection of hearing
• Effective in evaluation of suspected retrocochlear pathology
• For intraoperative monitoring during neuro-otologic surgery
• For monitoring of hearing status in ICU or comatose patient
• Determination of hearing threshold in malingering cases
• Mostly used in determining threshold in children, infants and newborns

Otoacoustic emissions [OAE]:

• Signals made by cochlear outer hair cells

• Spontaneous [SOAE] or evoked [EOAE]
• Absent – outer hair cells disorder [ototoxicity, congenital deafness, acoustic
trauma]
• Normal in retrocochlear hearing loss cuz outer hair cells are normal
• Screening of neonates and uncooperative patients
• Distinguish cochlear and retrocochlear deafness