Disorders of ear

1. DISORDERS OF EAR
INTRODUCTION
The ear is the organ of hearing. The parts of the ear include:
-yes and Ear
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External or outer ear, consisting of:
Pinna or auricle - the outer part of the ear.
External auditory canal or tube - the tube that connects the outer ear to the inside or middle
ear. Tympanic membrane - also called the eardrum. The tympanic membrane divides the external ear
from the middle ear.
Middle ear (tympanic cavity), consisting of:
Ossicles - three small bones that are connected and transmit the sound waves to the inner ear.
The bones are called:
Malleus

2. Incus
Stapes
Eustachian tube - a canal that links the middle ear with the throat area. The eustachian tube helps to
equalize the pressure between the outer ear and the middle ear. Having the same pressure allows for
the proper transfer of sound waves. The eustachian tube is lined with mucous just like the inside of the
nose and throat.
Inner ear, consisting of:
Cochlea (contains the nerves for hearing)
Vestibule (contains receptors for balance)
Semicircular canals (contain receptors for balance)
Physiology of Hearing
665
Hearing starts with the other external en a sound is made outside the outer ear, the sound waves or
Vibrations, travel down the external auditory canal and strike the eardrum (tympanic membrane) vite
eardrum vibrates. The vibrations are then passed to three tiny bones in the middle ear called the psicles.
The ossicles amplify the sound and send the sound waves to the inner ear and into the fluid-filled
hearing organ (cochlea).

3. Once the sound waves reach the inner ear, they are converted into electrical impulses which the
auditory nerve sends to the brain. The brain then translates these electrical impulses as sound
Common Childhood External Ear Problems
A. Common Childhood External Ear Problems are:-
1. Otitis Externa (Swimmer's Ear)
2. Foreign Bodies in the Ear
1. OTITIS EXTERNA (SWIMMER'S EAR)
Definition
Otitis Externa, also called swimmer's ear, is an inflammation of the external ear canal. Otitis Extema is
caused by fungi or bacteria. Water that remains trapped in the ear canal (when swimming, for example)
may provide a source for the growth of bacteria and fungi.
Etiology
Many factors can increase the chance of developing Otitis Externa. As the name implies, one of the
factors is excessive wetness as with swimming, although it can occur without swimming. Other possible
causes of this infection include the following:
Being in warm, humid places

4. Harsh cleaning of the ear canal
Trauma to the ear canal
Dry ear canal skin
Foreign body in the ear canal
Lack of cerumen (ear wax)
Eczema and other forms of dermatitis
Clinical Features
The following are the most common symptoms of Otitis Exterma:
Redness of the outer ear
Itching in the ear
Pain, especially when touching or wiggling the ear lobe
Drainage from the ear
Swollen glands in the neck

5. Swollen ear canal
Conductive hearing loss
Diagnostic Evaluation
Otitis Externa may be diagnosed with a complete medical history and physical examination. An otoscope
helps to examine the ear and to aid in the diagnosis of ear disorders.
A culture of the drainage from the ear may be taken to help determine proper treatment.
Management
Otitis Externa, when properly treated by a physician, usually clears up within 7 to 10 days. Specific
treatment for swimmer's ear will be determined on the basis of the child's age, overall health and
medical history, severity of the condition and the child's tolerance for specific medications, procedures,
or therapies. The treatment may include:
Disorders of Skin, Eyes and Ear
Antibiotic ear drops or oral antibiotics
Corticosteroid ear drops (to help decrease the swelling)
Pain medication

6. Keeping the ear dry, as directed.
Placing a wick in the ear (a piece of sponge may be placed in the child's ear if there is a lot of swelling.
This wick helps the antibiotic drops work more effectively in the ear canal.)
Prevention
The following measures may help prevent Otitis Externa:-
Place two to three drops of a mixture of vinegar/isopropyl alcohol/ water into the child's ear after the
ears come in contact with water.
Use ear plugs for swimming or bathing.
Do not aggressively clean the child's ear canal.
2. FOREIGN BODIES IN THE EAR
Foreign body in the ear sometimes occurs in children. Foreign bodies refer to any object that is placed in
the ear, nose, or mouth that is not meant to be there and can cause harm in absence of medical
attention.
Foreign body can either be in the ear lobe or in the ear canal. Objects usually found in the ear lobe are
earrings, either stuck in the lobe from infection or placed too deep during insertion. Foreign bodies in
the
sound the ear en place things in their sea toys, buttons, pieces of crayed the items that are the reason
children place things in their ears is usually because they are bored cutterer etering other hiden,
sometimes, ingential hit has in another child's ear during play. Insects may also fly tite the ear canal

7. causing potential ham, it has also been noted that children with chromate fly infections tend to place
things in their ears more often.
Clinical Features
Some objects placed in the ear may not cause symptoms, while other objects, such as food and insects,
may cause pain in the ear, redness, or drainage. Hearing may be affected if the object is blocking the ear
canal.
Management
The treatment for foreign bodies in the ear is prompt removal of the object by the physician. The
following are some of the techniques that may be used by the physician to remove the object from the
ear canal:-
Instruments may be inserted in the ear.
Magnets are sometimes used if the object is metallic.
Cleaning the ear canal with water.
A machine with suction to help pull the object out.
After removal of the object, the physician will re-examine the ear to determine if there has been any
injury to the ear canal. Antibiotic drops for the ear may be prescribed to treat any possible infections.
B) OTITIS MEDIA (MIDDLE EAR INFECTION)

8. Definition
Otitis media is the inflammation of middle ear.
Incidence and Etiology More than 80% of children have at least one episode of otitis media by the time
they are three year
the. Nearly half of these to have at least one episodere episodes by the time they are three years of age,
Otitis media can af these children have three of sprimantly a condition that occurs in children. It caus
more often in the winter and Mister fectionister and early spring of malfunction of the Eustathian tube,
and the times the siste er elections are usually a result of malfunction on the entire here are here that
which the Eustachian tube may not work properly are- a cold or allergy which can lead to swelling and
congestion of the lining of nose, throat and Eustachian tube (this swelling prevents the normal flow of
fluids) and a malformation of the Eustachian tube.
Disorders of Skin, Eyes and Ear
Risk Factors
While any child may develop an ear infection, the following are some of the factors that may increase
the risk of developing ear infections:
being around someone who smokes
family history of ear infections
a poor immune system

9. time spent in a daycare setting
absence of breastfeeding
having a cold
bottle feeding in supine position
Types of Otitis Media
Different types of otitis media include the following:
i) Acute otitis media (AOM)-The middle ear infection occurs abruptly causing swelling and redness. Fluid
and mucous become trapped inside the ear, causing the child to have fever, ear pain and hearing loss. ii)
Otitis media with effusion (OME)-Fluid (effusion) and mucous continue to accumulate in the middle ear
after an initial infection subsides. The child may experience a feeling of fullness in the ear and hearing
loss.
Clinical Features
The following are the most common symptoms of otitis media. However, each child may experience
symptoms differently. Symptoms may include:
Unusual irritability
Difficulty sleeping or staying asleep

10. Tugging or pulling at one or both ears
Fever
Fluid draining from ear(s)
Loss of balance
Hearing difficulties
Ear pain
Nausea and vomiting
Diarrhea
Decreased appetite
Congestion
The symptoms of otitis media may resemble other conditions or medical problems.
Diagnostic Evaluation

11. In addition to a complete medical history and physical examination, an inspection of the outer ear(s) and
eardrum(s) using an otoscope is done. The otoscope is a lighted instrument that allows the physician to
see inside the ear. A pneumatic otoscope blows a puff of air into the ear to test eardrum movement.
Tympanometry, is a test that is performed by most physicians to determine how the middle ear is
functioning. It does not tell if the child is hearing or not, but helps to detect any changes in pressure in
the middle ear. This is a difficult test to perform in younger children because the child needs to remain
still and not cry, talk or move.
A hearing test may be performed for children who have frequent ear infections,
Treatment
Specific treatment for otitis media will be determined on the basis of child's age, overall health and
medical history, extent of the condition and child's tolerance for specific medications, procedures or
therapies.
Treatment may include:
Antibiotic medication by mouth or ear drops
- Analgesics (for pain)
If fluid remains in the ear(s) for longer than three months, small tubes may be placed in the ear(s). This
surgical procedure, called Myringotomy, involves making a small opening in the eardrum to drain the
fluid and relieve the pressure from the middle ear. A small tube is placed in the opening of the eardrum
to ventilate the middle ear and to prevent fluid from accumulating. The child's hearing is restored after
the fluid is drained. The tubes usually fall out on their own after six to twelve months. The surgeon may
also recommend removal of the adenoids (lymph tissue located in the space above the soft roof of the
mouth, also called nasopharynx) if they are infected. Removal of the adenoids has shown to help some
children with otitis media.

12. Complications
Untreated otitis media can result in any/all of the following:
Infection in other parts of the head
Permanent hearing loss
6 Problems with speech and language development
C) HEARING LOSS IN BABIES
Approximately 2 to 3 out of every 1,000 children born are either deaf or have hearing loss. More
children lose hearing later in childhood. However, without screening or testing, hearing loss may not be
noticed until the baby is more than one year old. If hearing loss is not detected until later years, there
will be no stimulation of the brain's hearing centers. This can affect the maturation and development of
hearing and can delay speech and language. Social and emotional development and success in school
may also be affected.
Most hearing loss is congenital (present at birth), but some babies develop hearing loss after they are
born. Hearing loss is more likely in premature babies and babies with respiratory problems who have
required long-term use of breathing machines, those with previous infections and those taking certain
medications.
Because of these risks, many health organizations including the National Institutes of Health (NIH) and
the American Academy of Pediatrics (AAP) now recommend universal infant hearing screening. This
means all newborn babies should be screened for hearing loss. Most often, the parents are the first to
detect hearing loss in their child.
Age-Appropriate Hearing Milestones

13. Hearing problems may be suspected in children who are not responding to sounds or who are not
developing their language skills appropriately. The following are some age-related guidelines that may
help to decide if the child is having hearing problems. It is important to remember that not every child is
the same and children reach milestones at different ages. The National Institute on Deafness and Other
Communication Disorders (NIDCD) and other experts list the following age-appropriate hearing
milestones-
Birth to 3 months
Reacts to loud sounds with startle reflex.
Is soothed and quieted by soft sounds.
Turns head towards the speaker.
Is awakened by loud voices and sounds.
Smiles in response to voices when spoken to,
Seems to know mother's voice and quiets down if crying.
Looks or turns toward a new sound.
Responds to "no" and changes in tone of voice.
Imitates his/her own voice.

14. Enjoys rattles and other toys that make sounds. Begins to repeat sounds (such as ooh, aah, and ba-ba).
Becomes scared by a loud voice or noise.
cont...
3 to 6 months
Signs of Problems in Speech, Language, Hearing Development Children develop speech, language and
hearing skills at different ages. However, hearing loss can lead to delays in child's ability to make sounds,
learn to speak, and communicate. A physician must be concerned if any of the following is noted:
. No response to sound at any age.
. Infant does not move or jump when a loud sound is made.
. No babbling by the time the infant is 9 months old.
. No words spoken by the age of 18 to 24 months.
Does not follow simple commands by 2 years of age.
Stuttering continues past 5 years of age.
Poor voice quality at any age.

15. Types of Hearing Loss
Hearing loss can be categorized by many different types. Two types of hearing loss are sensorineural and
conductive. Both types of hearing loss can be congenital (present at birth) or acquired.
a) Sensorineural a loss of function within the inner ear or with connection to the brain.
➤
Congenital Sensorineural loss
Causes of this type of hearing loss include:
Infection by the mother with toxoplasmosis, rubella, cytomegalovirus, herpes or syphilis.
Genetic factors and syndromes that the child has at birth.
. Low birth weight
Hereditary in the family
A Acquired Sensorineural loss
Causes of this type of hearing loss include:
Loud noise exposure
Trauma

16. Infections
Damage from certain medications that can be harmful to the ears.
b) Conductive hearing loss - a problem in the outer or middle ear where sound waves are not sent to the
inner ear correctly. Conductive hearing loss is the most common type of hearing loss in children and is
usually acquired. Factors that may cause this type of hearing loss are:
.Congenital factors
Causes of this type of hearing loss include:
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Anomalies of the pinna (the outside of the ear)
Anomalies of the tympanic membrane (eardrum)

17. Anomalies of the external ear canal
Anomalies of the ossicles (the three tiny bones that deliver the sound waves to the middle ear)
➤
Acquired
Causes of this type of hearing loss include:
. Excessive wax
. Foreign bodies in the ear canal, such as beads or popcorn kemeis.
. Tumors of the middle ear
Problems with the eustachian tube
Ear infections such as otitis media
Chronic ear infections with fluid in the middle ear
. Perforation of the eardrum
Diagnosis of hearing loss

18. In order to evaluate the child's hearing, physician may take a complete medical history and perform
physical examination. In addition, there are many different types of hearing tests that can be used to
check the child's hearing. Some of them may be used on all ages, while others are used based on the
child's age and level of understanding.
➤
Hearing tests for the newborn:
There are two primary types of hearing screening methods for newborns. These may be used alone or
together.
a. Evoked Otoacoustic Emissions (EOAE) - a test that uses a tiny, flexible plug that is inserted into the
baby's ear. Sounds are sent through the plug. A microphone in the plug records the otoacoustic
emissions (responses) of the normal ear in reaction to the sounds. There are no emissions in a baby with
hearing loss. This test is painless and is usually completed within a few minutes, while the baby sleeps.
b. Auditory Brainstem Response (ABR) - a test that uses electrodes (wires) attached with adhesive to the
baby's scalp. While the baby sleeps, clicking sounds are made through tiny earphones in the baby's ears.
The test measures the brain's activity in response to the sounds. As in EOAE, this test is painless and
takes only a few minutes.
If the screening tests identify that the child has a hearing loss, further testing is needed, an
legommended that all babies with hearing loss be identified by 3 months of age so that treatment can
begin before that all babies with hearing los ant time for speech and language development
.Hearing tests for the infant:
Evaluation of hearing in the infant may include the use of the above mentioned EOAE and ABR tests.
Also, the following may be used:
a. Behavioral Audiometry - a screening test used in infants to observe their behavior in response to
certain sounds. Additional testing may be necessary.

19. ➤
Hearing tests for the toddler:
Evaluation of hearing may include the above mentioned tests, along with the following:
a. Play Audiometry - a test that uses an electrical machine to transmit sounds at different volumes and
pitches into the child's ears. The child usually wears some type of earphones. This test is modified
slightly in the toddler age group and made into a game. The toddler is asked to do something with a toy
(i.e. touch a toy, move a toy) every time the sound is heard. This test relies on the cooperation of the
child, which may not always be given.
b. Visual Reinforcement Audiometry (VRA) - a test where the child is trained to look toward a sound
source. When the child gives a correct response, the child is "rewarded" through a visual reinforcement
such as a toy that moves or a flashing light. The test is most often used for children between six months
to two years of age.
Hearing tests for the older child:
Evaluation of hearing for the child older than 3 to 4 years may include the above mentioned tests, along
with the following:
a. Pure Tone Audiometry - a test that uses an electrical machine that produces sounds at different
volumes and pitches in the child's ears. The child usually wears some type of earphones. In this age
group, the child is simply asked to respond in some way when the tone is heard in the earphone.
b. Tympanometry (also called Impedance Audiometry) - a test that is performed to help determine how
the middle ear is functioning. It does not tell if the child is hearing or not, but helps to detect any
changes in pressure in the middle ear. This is a difficult test to perform in younger children because the
child needs to sit very still and not be crying, talking, or moving.
Management of Hearing Loss

20. Early intervention and detection of hearing loss is necessary to prevent additional problems with speech
and language development. A healthcare team approach is normally used when a child is diagnosed
with some degree of hearing loss. Team members include the following:
➤
Audiologist - a professional who specializes in the evaluation and management of hearing and balance
problems in people of all ages. Audiologists are also involved with the fitting and management of
hearing aids and other assistive devices.
> Otolaryngologists - a physician with special training in medical and surgical treatment for children who
have disorders of the ear, nose, and throat.
> Speech pathologist - a professional who helps evaluate and manage speech, language, and hearing
problems in the child.
Specific treatment for hearing loss will be determined by the child's physician based on the child's age,
overall health and medical history, extent of the condition and child's tolerance for specific medications,
procedures or therapies.
Management of hearing loss may include one or more of the following:
i. Use of hearing aids- electronic or battery-operated devices that can amplify and change sound. A
microphone receives the sound and converts it into sound waves. The sound waves are then converted
into electrical signals.
ii. Cochlear implants - a surgically placed appliance that helps to transmit electrical stimulation to the
Inner ear. Only certain children are candidates for this type of device.
iti. Training in sign language and lip reading.
Hearing Aids

21. Hearing aids can help improve hearing and speech, especially in children with sensorineural hearing loss
thearing loss in the inner ear due to damaged hair cells or a damaged hearing nerve). Sensorineural
hearing loss can be caused by noise, injury, infection, certain medications, birth defects, tumors, and
problems with blood circulation.
Hearing aids are electronic or battery-operated devices that can amplify and change sound. A
microphone receives the sound and converts it into sound waves. The sound waves are then converted
into electrical Signals. Children as young as two months can be fitted with hearing aids.
Different types of hearing aids- The type of hearing aidine commended for the child will depend on
several factors including his/her
thereal limitations, med recommended for the schmal preference. There are many different types of
they sentations, medical condition and personal oudly inventing newer, improved rainy s
However, there are market: wies of hearing aids available today. These are:-
In-the-ear (ITE) hearing aids
These hearing aids come in plastic cases that fit in the outer ear. Generally used for mild to severe
hearing loss, ITE hearing aids can accommodate other technical hearing devices, such as the telecoil, a
mechanism used to improve sound during telephone calls. However, their small size can make it difficult
to make adjustments. In addition, ITE hearing aids can be damaged by ear wax and drainage.
Behind-the-ear (BTE) hearing aids
Behind-the-ear hearing aids, as the name implies, are worn behind the ear. This type of hearing aid,
which is in a case, connects to a plastic earmold inside the outer ear. These hearing aids are generally

22. used for mild to severe hearing loss. However, poorly fitted BTE hearing aids can cause an annoying
"whistling" sound, in the ear.
car
Canal aids
Canal aids fit directly in the ear canal and come in two styles: in-the-canal (ITC) aid and completely-in-
canal (CIC) aid. Customized to fit the size and shape of the individual's ear canal, canal aids are generally
used for mild to moderate hearing loss. However, because of their small size, removal and adjustment
may be more difficult. In addition, canal aids can be damaged by ear wax and drainage.
Body aids
Generally reserved for profound hearing loss, or if the other types of hearing aids will not accommodate,
body aids are attached to a belt or pocket and connected to the ear with a wire.
Parental Education in the Use of Hearing Aid
A
Be patient and give the child time to get used to hearing aid and the sound it produces.
Start in quiet surroundings and gradually build up to noisier environments.
Taking care of hearing aids: