Clinical Otology

Balasubramanian Thiagarajan
Symtoms
•
•
•
•
•

Deafness
Discharge
Tinnitus
Pain
Vertigo
Deafness
Onset

Sudden

Trigger

Gradual
Sudden hearing loss (SN)
• Loss of atleast 30 dB in atleast three contiguous
frequencies over a period of less than 3 days...
Sensorineural hearing loss (Sudden)
•
•
•
•

Transverse fracture of pertrous bone
Auto immune reaction following trauma / ...
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
traum...
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
...
Discharge
•
•
•
•

Quantity
Quality
Duration of discharge
Aggravating / releiving factors
Ear discharge - quality
•
•
•
•
•

Mucoid - CSOM
Mucopurulent - CSOM with mastoiditis
Serous - ASOM
Serosanguinous - ASOM,...
Ear discharge - causes

•
•
•
•

ASOM
CSOM
Otomycosis
CSF otorrhoea
Tinnitus
•
•
•
•
•

Wax
Active otosclerosis
Sensorineural hearing loss
Ototoxic drugs
Objective tinnitus - Patulous ET, Pa...
Pain

• Otalgia
• Referred otalgia
Ear pain
Tragal
tenderness
+

5,6,10th cranial nerves
C2 & C3
impated wax

Referred otalgia

Tragal tenderness -

Tragal
t...
Vertigo
•
•
•
•

Sensation of unsteadiness / rotation
Diseases if inner ear cause vertigo
Associated with tinnitus and har...
Nystagmus
• Spontaneous / evoked
• Direction of nystagmus Right beating, left beating,
geotrophic, ageotrophic.
• Plane - ...
Spontaneous nystagmus
• Eye movements without congnitive, visual, vestibular
stimulus
• Commonly induced by vestibular imb...
Alexander's nystagmus grading
• I degree - Present only during gaze in the direction of
fast phase
• II degree - Present d...
History should include
•
•
•
•
•
•
•

Previous ear surgery
Previous head injury
Systemic diseases like diabetes / Hyperten...
Inspection of external ear
•
•
•
•
•

Shape and size of pinna
Presence of tags, preauricular sinus and pits
Evidence of tr...
Drug history / Occupation
• Drugs like gentamycin, Streptomycin, and Aspirin can
cause extensive damage to hair cells of c...
Drug induced ototoxicity - Features
•
•
•
•
•
•

Bilateral sensorineural hearing loss
Bilaterally symmetrical hearing loss...
Aminoglycosides
• Cleared more slowly from inner ear fluids than serum
• There exists a latency - deafness may occur even ...
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 absces...
Quality of ear discharge

•
•
•
•
•

Mucoid - CSOM
Mucopurulent - CSOM with mastoiditis
Serous - asom
Serosanguinous - ASO...
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 ...
Three finger test
• Index, middle and thumb are used.
• Index finger is applied over mastoid process tenderness indicates ...
Peripheral vertigo

• Is defined as sensation of unsteadiness / rotation
• Commonly caused by inner ear disorders
• Associ...
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
Sero...
External canal - Straightening

• Aural speculum
• Adults - Pinna is pulled
postero superiorly
• Infants - pinna is pulled...
Ear drum
•
•
•
•
•
•

Oval / pearly white in color
Pars tensa
Attic
Cone of light
Handle / lateral process of malleus
Perf...
Cone of light
• Present in the antero
inferior quadrant
• Cone shaped
• Caused due to orientation
of middle fibrous layer
...
Color of ear drum
•
•
•
•
•

Pearly white - normal
Red drum - Glomus jugulare, AOM
Blue drum - SOM, Hemotympanum
Pink drum...
Retraction pocket features
• Prominent anterior and
posterior malleolar folds
• Apparent foreshortening of
handle of malle...
Siegel's speculum
•
•
•
•

Convex lens
Magnifies 2.5 times
Mobility of ear drum
To suck out secretions from
middle ear
• T...
Tuning fork tests
•
•
•
•

Three frequencies are used
256Hz, 512 Hz, 1024 Hz
These frequencies fall within speech range
Ri...
Prerequisites of a good tuning fork

• It should be made of good alloy
• Should vibrate for one full minute
• Should not p...
Rinne test
• All three frequencies can be
used
• + Rinne (Air conduction
better than bone
conduction)
• -ve Rinne (Bone co...
Weber test

• 512 Hz fork is used
• Lateralized to worse ear
• Useful in indentifying
conductive deafness
• Can identify e...
ABC test

• Helps in identifying s/n loss
• Pts hearing is compared to that of the examiner
• It is not reduced in normal ...
Fistula test
• Performed by applying +ve - ve pressure to ear drum
using penumatic speculum.
• Nystagmus can be visualized...
+ve fistula test causes
•
•
•
•
•

Oval / round window fistulae
Post stapedectomy perilymph leak
Horizontal canal fistula
...
Hennebert's sign

•
•
•
•

+v e fistula test in the presence of intact ear drum
No evidence of middle ear disease
Seen in ...
Tullio phenomenon
• Sound induced vestibular symptoms - vertigo,
nystagmus, Oscillopsia and postural imbalance
• Seen in -...
Head shake test
• pts head is positioned with chin inclined down 30
degrees
• Head is rotated rapidly to one side.
• Norma...
Thank You

Otolaryngology online
Published by drtbalu
Clinical otology
Clinical otology
Clinical otology
Clinical otology
Clinical otology
Clinical otology
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Clinical otology

  1. 1. Clinical Otology Balasubramanian Thiagarajan
  2. 2. Symtoms • • • • • Deafness Discharge Tinnitus Pain Vertigo
  3. 3. Deafness Onset Sudden Trigger Gradual
  4. 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. 5. Sensorineural hearing loss (Sudden) • • • • Transverse fracture of pertrous bone Auto immune reaction following trauma / infection Inflammatory reaction (Viral infections) Vascular compromise
  6. 6. Conductive hearing loss - (Sudden) • Ossicular disruption • Haemotympanum (transient) • Failed attempts to remove cerumen
  7. 7. Mixed hearing loss - (Sudden) • Fractures involving petrous bone • Auto immune reaction to proteins released due to traumatic injury
  8. 8. Gradual progressive hearing loss • Inflammatory • Degenerative
  9. 9. Fluctuating hearing loss • Impacted cerumen • Meniere's disease • Perilymph fistula
  10. 10. Differentiating Conductive / SN loss • • • • Difficulty in comprehending spoken words Deafness associated with tinnitus Intolerance to loud sounds Tuning fork tests
  11. 11. Discharge • • • • Quantity Quality Duration of discharge Aggravating / releiving factors
  12. 12. Ear discharge - quality • • • • • Mucoid - CSOM Mucopurulent - CSOM with mastoiditis Serous - ASOM Serosanguinous - ASOM, Otitis externa, trauma Watery - CSF otorrhoea
  13. 13. Ear discharge - causes • • • • ASOM CSOM Otomycosis CSF otorrhoea
  14. 14. Tinnitus • • • • • Wax Active otosclerosis Sensorineural hearing loss Ototoxic drugs Objective tinnitus - Patulous ET, Palatal myoclonus
  15. 15. Pain • Otalgia • Referred otalgia
  16. 16. Ear pain Tragal tenderness + 5,6,10th cranial nerves C2 & C3 impated wax Referred otalgia Tragal tenderness - Tragal tenderness + Otalgia Myringitis granulosa Otomcosis Tragal tenderness + Tragal tenderness - AOM Keratosis obturans Tragal tenderness + Furuncle
  17. 17. Vertigo • • • • Sensation of unsteadiness / rotation Diseases if inner ear cause vertigo Associated with tinnitus and hard of hearing Peripheral vertigo
  18. 18. Nystagmus • Spontaneous / evoked • Direction of nystagmus Right beating, left beating, geotrophic, ageotrophic. • Plane - Horizontal, rotatory or vertical • Intensity - (I, II and III degree)
  19. 19. 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)
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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.
  26. 26. Discharge • • • • Duration Quantity Quality Aggravating & releiving factors
  27. 27. Acute ear discharge - Causes • ASOM - Blood tinged • Otomycosis - Itchy ear, fungal mass seen • CSF otorrhoea
  28. 28. Profuse ear discharge - Causes • Chronic mastoiditis - Mastoid tenderness + May lead to formation of subperiosteal abscess • Mastoid reservoir - Mastoid tenderness on deep palpation + • Extradural abscess
  29. 29. Quality of ear discharge • • • • • Mucoid - CSOM Mucopurulent - CSOM with mastoiditis Serous - asom Serosanguinous - ASOM, Otitis externa Watery - CSF
  30. 30. Tinnitus • Subjective - perceived by the patient • Objective - perceived by both the pt and examiner
  31. 31. Otalgia • Pain in the ear • Could be due to inflammatory pathology affecting the ear • Referred otalgia due to pathology elsewhere
  32. 32. 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
  33. 33. Peripheral vertigo • Is defined as sensation of unsteadiness / rotation • Commonly caused by inner ear disorders • Associated with tinnitus / ear block
  34. 34. Peripheral vertigo - Features • • • • It is fatigable It is positional Horizontal nystagmus Cerebellar signs absent
  35. 35. 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
  36. 36. External canal - Straightening • Aural speculum • Adults - Pinna is pulled postero superiorly • Infants - pinna is pulled posteriorly and downwards
  37. 37. Ear drum • • • • • • Oval / pearly white in color Pars tensa Attic Cone of light Handle / lateral process of malleus Perforations
  38. 38. 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
  39. 39. Color of ear drum • • • • • Pearly white - normal Red drum - Glomus jugulare, AOM Blue drum - SOM, Hemotympanum Pink drum - Flamingo sign Chalky drum - Tympanosclerosis
  40. 40. 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
  41. 41. 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
  42. 42. Tuning fork tests • • • • Three frequencies are used 256Hz, 512 Hz, 1024 Hz These frequencies fall within speech range Rinne, Weber and ABC
  43. 43. Prerequisites of a good tuning fork • It should be made of good alloy • Should vibrate for one full minute • Should not produce overtones
  44. 44. 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)
  45. 45. 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
  46. 46. ABC test • Helps in identifying s/n loss • Pts hearing is compared to that of the examiner • It is not reduced in normal ears
  47. 47. 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
  48. 48. +ve fistula test causes • • • • • Oval / round window fistulae Post stapedectomy perilymph leak Horizontal canal fistula Meniere's disease Labyrinthitis
  49. 49. 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
  50. 50. 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)
  51. 51. 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
  52. 52. Thank You Otolaryngology online Published by drtbalu

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