EAR DISORDERSSUBMITTED BY: Ligi Xavier

First year Msc nursing

Review of anatomy• The ear has external, middle, and inner portions.

The outer ear is called the pinna and is made of ridged cartilage covered by skin. Sound funnels through the pinna into the external auditory canal, a short tube that ends at the eardrum (tympanic membrane).

• Sound causes the vibration of eardrum and its tiny attached bones in the middle portion of the ear, and the vibrations are conducted to the nearby cochlea. The spiral-shaped cochlea is part of the inner ear; it transforms sound into nerve impulses that travel to the brain.

  

Infections of the External Ear

• Otitis Externa is an infection of the external auditory canal (EAC) that can be divided according to the time course of the infection: acute, subacute, or chronic

• Acute: less than 6 weeks of duration.

Types • Chronic OE – This is the same as acute diffuse OE but is of

longer duration (>6 weeks)• Eczematous (eczematoid) OE – This encompasses

various dermatologic conditions (eg, atopic dermatitis , psoriasis, systemic lupus erythematosus, and eczema) that may infect the EAC and cause OE

• Necrotizing (malignant) OE – This is an infection that extends into the deeper tissues adjacent to the EAC; it primarily occurs in adult patients who are immunocompromised (eg, as a result of diabetes mellitus or AIDS) and is rarely described in children; it may result in cases of cellulitis and osteomyelitis

• Otomycosis - Infection of the ear canal secondary to fungus species such as Candida or Aspergillus

Causes• Swimming• Constriction of the ear canal from

bone growth (Surfer's ear)• Saturation diver• the use of objects such as cotton

swabs or other small objects to clear the ear canal

Pathophysiology• OE is a superficial infection of the skin in the EAC.

The processes involved in the development of OE can be divided into the following 4 categories:

• Obstruction (eg, cerumen buildup, surfer’s exostosis, or a narrow or tortuous canal), resulting in water retention

• Absence of cerumen, which may occur as a result of repeated water exposure or overcleaning the ear canal

• Trauma• Alteration of the pH of the ear canal

• The two factors that are required for external otitis to develop are (1) the presence of germs that can infect the skin and (2) impairments in the integrity of the skin of the ear canal that allow infection to occur

• atopic dermatitis , psoriasis • otomycosis

Symptoms• Drainage from the ear - yellow, yellow-green, foul

smelling, persistent• Ear pain - felt deep inside the ear and may get

worse when moving head• Hearing loss• Itching of the ear or ear canal• Fever• Trouble swallowing• Weakness in the face• Voice loss

Diagnosis

• When the ear is inspected, the canal appears red and swollen in well-developed cases.

• physical examination • Otoscope :narrowing of the ear canal

from inflammation and the presence of drainage and debris.

• Culture of the drainage

Treatment • Aural toilet

• Aural toilet must be performed and can be done most conveniently by dry mopping. The ear is cleaned with a gentle rotatory action. Once the cotton wool is soiled it is replaced.

• DressingsIf the otitis externa is severe, a length

of 1 cm ribbon gauze, impregnated with appropriate medication, should be inserted gently into the meatus, and renewed daily until the meatus has returned to normal

• The following medications are of value on the dressing:

• 8% aluminium acetate;• 10% ichthammol in glycerine;• ointment of gramicidin, neomycin,

nystatin and triamcinolone• (Tri-Adcortyl);

• other medication may be used as dictated by the result of culture.

• If fungal otitis externa is present, dressings of 3% amphotericin, miconazole

• or nystatin may be used.

Otitis media• Inflamation of te middle ear.

Types Acute

suppurativenon suppurative

Chronic suppurative

Acute Otitis Media• Acute otitis media, i.e. acute inflammation

of the middle-ear cavity, is a common condition and is frequently bilateral. It occurs most commonly in children and it is important that it is managed with care to prevent subsequent complications. It most commonly follows an acute upper respiratory tract infection and may be viral or bacterial.

Pathology• Acute otitis media is an infection of

the mucous membrane of the whole of the middle-ear cleft Eustachian tube, tympanic cavity, attic, mastoid antrum and air cells.

• The bacteria responsible for acute otitis media are: Streptococcus pneumonia 35%, Haemophilus influenzae 25%, Moraxella catarrhalis 15%. Group A streptococci and Staphylococcus aureus may also be responsible.

• .

• The sequence of events in acute otitis media is as follows:

• organisms invade the mucous membrane causing inflammation, oedema, exudate and later, pus;

• oedema closes the Eustachian tube, preventing aeration and drainage;

• pressure from the pus rises, causing the drum to bulge;

• necrosis of the tympanic membrane results in perforation;

• the ear continues to drain until the infection resolves

Causes• Common cold• Acute tonsillitis• Influenza• Coryza of measles, scarlet fever,• whooping cough

Symptoms, signs

• Earache• DeafnessIt is conductive in nature and may be

accompanied by tinnitus• Pyrexia• TendernessThere is usually some tenderness to

pressure on the mastoid antrum.

contd…….• The tympanic membrane varies in

appearance• Loss of lustre and break-up of the

light reflex.• Redness and fullness of the drum;.• Bulging, with loss of landmarks.

Purple colour..• Perforation with otorrhoea.• Mucoid discharge

Treatment• Antibiotics:, amoxycillin will be

more effective. Co-amoxiclav is useful in Moraxella

infections.

• Analgesics• Nasal vasoconstrictors• Ear drops• Myringotomy is necessary when

bulging of the tympanic membrane persists, despite adequate antibiotic therapy

Chronic suppurative otitis media(CSOM)

• CSOM is a chronic inflammatory process involving the middle ear cleft producing irreversible pathological changes .

causes• Late treatment of acute otitis media.• Inadequate or inappropriate

antibiotic therapy.• Upper airway sepsis.• Lowered resistance, e.g.

malnutrition, anaemia,immunological impairment.

• Particularly virulent infection, e.g. measles.

Classification• It is of two types.

Tubotympanic(safe)

Attico antral(dangerous)

Types of CSOM Mucosal disease with tympanic

membrane perforation (tubo-tympanic disease, relatively safe).

Bony:cholesteatoma—dangerous (attico-

antral disease).

• Tubo tympanic : this is a benign type of CSOM confined only to the middle ear cleft.

• Attico antral: this involves the attic, antrum and the posterior tympanum. It is characterized by bone eroding cholesteatoma.

Mucosal infectionSymptoms• Discharge- mucopurulant,non foul

smelling• Deafness• Earache

• Signs:discharge, tympanic membrane perforation,

• Tuning fork test:rinne-negative• Weber-lateralised to one side• ABC- normal

Investigations

• Culture and sensitivity• Examination under microscope• Pure toneaudiogram:mild conductive

loss between 20 to 30dB• X-ray of mastoid, PNS, neck lateral

view• Nasal endoscopy

Treatment of mucosal-type csom

• Removal of septic foci: tonsillectomy,adenoidectomy, sinus wash

• Myringoplasty if hearing loss below 40dB

• Tympanoplasty:if above 40dB

Attico antral type – clinical features

• Ear discharge: foul smelling scanty,, blood stained, no relation with URTI

• Deafness:progressive conductive deafness

• Itching and pain in the ear• Tinnitus and giddiness•

Sign

• In Otoscopic examination: foul smelling discharge in the ext. Auditory canal

• Granulation tissue in the meatus• Attic or marginal perforation oftymanic

membrane• Cholesteatoma• Mastoid tenderness• Tuning fork test-Rinne negative, weber

localised to lateral side, ABC normal

Investigations

• Examination under microscope• Culture and sensitivity• Rigid oto-endoscopy• Audiogram(PTA)• Imaging- X-ray mastoid,CT scan,MRI

scan

Management• Goal – to make the ear safe and dry• To restore and improve hearing• Surgical management• Main line treatment.• 1. canal wall down

mastoidectomy:consists of radical and modified radical mastoidectomy. These procedures ensures safety and dry ear but functional improvement may not be achieved.

• 2. Canal wall up mastoidectomy: or combined approach tympanoplasty, where functional improvement can be achieved but not the safety.

Medical management• It is used only for patient who are

unfit for surgery. Topical antibiotic and steroid are used.

• In some cases 5- flurouracil used.

Complications-CSOM• Brain abscess• Lateral sinus thrombosis• Otitic hydrocephalus• Meningitis• Mastoiditis• Labyrynthitis• Petrositis• Cerebellar abscess

Difference between TTD&AADTTD AAD

Parts involved Antero inferior Postero superior

Discharge Mucoid, profuse, non foul smelling

Purulent, scanty, foul smelling

Perforation Central Marginal, Involving attic

Polyp Usually pale Pink, fleshy

Granulation tissue Rare Common

Cholesteatoma Absent Common

Complications Rare Common

audiogram Mild- moderate conductive hearing loss.

Conductive/mixed

Otosclerosis • Otosclerosis is a hereditary localised

disease of the bone characterised by alternating phases of bone resorption and new bone formation.  The mature lamellar bone is removed by osteoclasis and replaced by woven bone of greater thickness, cellularity and vascularity

Pathophysiology•      The primary pathological change occurs in

the bony labyrinth with secondary effects upon middle ear and inner ear function.  The otosclerotic focus may be asymptomatic, or if present in the area of foot plate of stapes it may give rise to ankylosis of foot plate with resultant conductive deafness.  Otosclerotic foci may involve other portions of labyrinth causing sensori neural hearing loss and vestibular abnormalities.  

Causative factors / etiology

•   Many theories have been proposed to explain the etiological factors of otosclerosis.  They are:

1. Metabolic

2. Immune disorders

3. Vascular disease

 

• 4. Infection  (Measles) currently accepted5. Trauma : The petrous bone doesnot have regenerative capacity.  This is because of the fact that the enzymes released during reparative

phase are very toxic to the inner ear hair cells.  • 6. Temporal bone abnormalities

(congenital)

• Genetic factors predisposing to otosclerosis:  The tendency for otosclerosis to run in families has been seen.Otosclerosis is associated with osteogenesis imperfecta in 0.15 % of cases.  This is known as Van der Hoeve syndrome or Adair - Dighton syndrome.

Clinical features• Deafness:  Typically deafness in

otosclerosis is bilateral and gradually increasing in nature. In majority of cases the deafness is conductive in nature.  These patients may hear better in noisy environment because the speaker has a tendency to raise his voice because of excessive ambient noise.  This phenomenon a feature of otosclerosis is known as Paracusis Willisii.        

   

• Tinnitus:  is a common symptom and occasionally could be the only presenting feature.   Mostly tinnitus indicates sensorineural degeneration.  Tinnitus may be unilateral or bilateral.  It is usually roaring in nature.

Vertigo:  Transient attacks of vertigo is not uncommon in patients with otoslerosis. .  These patients may even have coexisting Meniere's disease. 

Clinical examinationThe ear drum in these patients is

normal (mint condition).  Rarely during active phase of the disease the increased vascularity of the promontory may be seen through the ear drum.  This sign is known as Flemingo's flush sign or Schwartz's sign.  This indicates otospongiosis (active otosclerosis). 

• Hearing assessment done using tuning forks.  Pure tone auditometry will show precisely the amount and type of hearing loss.  The presence of Carhart's notch is a classic audiometric feature in these patients.   In cochlear otosclerosis audiometry reveals sensorineural hearing loss

• Impedence audiometry is an useful investigation to diagnose otosclerosis.  Middle ear compliance is often reduced.  When stapes is fixed stapedial reflex is absent.  The typical impedence curve is As curve. 

Management• Medical:  The aim of medical

management is to convert an active otosclerotic foci into an inactive or quiscent foci.  Fluride is the drug of choice. 

Surgical treatment: • Stapedectomy• Hearing aids:  These patients will

benefit from the use of hearing aids if surgery is not acceptable to the patient or if it is risky.  There is always a 1% risk of producing a dead ear during surgery even in the best of hands.

Tympanic Membrane Perforation

• A tympanic membrane perforation is a condition where your eardrum has a tear or hole in it.

Causes Changes in ear pressure: Changes

in ear pressure may occur when travelling on an airplane, or if you are involved in an explosion. Underwater sports such as swimming or scuba diving may also cause pressure changes in your ears.

• Direct trauma to your eardrum• Ear infection• Head trauma• Past ear surgery or procedure

signs and symptoms • Clear, Mucoid (phlegm-like), thick

and yellowish, or bloody ear discharge.

• Hearing loss in involved ear.• Pain in involved ear.• Tinnitus (ringing or buzzing sound in

your ear).• Vertigo (dizziness).

Diagnosis• History • Otoscopic examination

Surgery– Myringoplasty: This type of surgery uses a

tissue graft to cover torn eardrum. A tissue graft may be taken from own body, another person, an animal, or is man-made. A procedure called a mastoidectomy may also be done with a myringoplasty.

– Tympanoplasty: This surgery repairs torn eardrum and any damage to inner ear. A tympanoplasty also helps prevent chronic ear infections. The hole in eardrum will be covered with a tissue graft

Infections of the Inner Ear• Labyrinthitis and Vestibular

Neuritis• Vestibular neuritis and labyrinthitis are

disorders resulting from an infection that inflames the inner ear or the nerves connecting the inner ear to the brain. This inflammation disrupts the transmission of sensory information from the ear to the brain. Vertigo, dizziness, and difficulties with balance, vision, or hearing may result.

signs and symptoms• A prominent and debilitating

symptom of labyrinthitis is severe vertigo.

• (nystagmus)• Nausea• Anxiety• general ill feeling.

Diagnosis• No specific tests exist to diagnose vestibular

neuritis or labyrinthitis. Therefore, a process of elimination is often necessary to diagnose the condition. Because the symptoms of an inner ear virus often mimic other medical problems, a thorough examination is necessary to rule out other causes of dizziness, such as stroke, head injury, cardiovascular disease, allergies, side effects of prescription or nonprescription drugs (including alcohol, tobacco, caffeine, and many illegal drugs), neurological disorders, and anxiety

Treatment• Vestibular rehabilitation therapy

is a highly effective way to substantially reduce or eliminate residual dizziness from labyrinthitis. VRT works by causing the brain to use already existing neural mechanisms for adaptation, neuroplasticity, and compensation.

• Rehabilitation strategies most commonly used are:

• Gaze stability exercises - moving the head from side to side while fixated on a stationary object (aimed to restore the Vestibulo-ocular reflex)

• Habituation exercises - movements designed to provoke symptoms and subsequently reduce the negative vestibular response upon repetition.

• Functional retraining - including postural control, relaxation, and balance training.

Ménière's disease• Ménière's disease is a disorder of the

inner ear that can affect hearing and balance to a varying degree. It is characterized by episodes of vertigo, low-pitched tinnitus, and hearing loss. The hearing loss is fluctuating rather than permanent, meaning that it comes and goes, alternating between ears for some time, then becomes permanent with no return to normal function.

Causes •  Ménière's disease is idiopathic, but it is believed to

be linked to endolymphatic hydrops, an excess of fluid in the inner ear.It is thought that endolymphatic fluid bursts from its normal channels in the ear and flows into other areas, causing damage. This is called "hydrops."

• The symptoms may occur in the presence of a middle ear infection, head trauma, or an upper respiratory tract infection,

• aspirin, smoking cigarettes, or drinking alcohol. • excessive consumption of salt in some patients. • herpes virus.

Symptoms• Attacks of rotational vertigo • Fluctuating, progressive, unilateral

(in one ear) or bilateral (in both ears) hearing loss

• Unilateral or bilateral tinnitus• A sensation of fullness or

pressure in one or both ears

• Parasympathetic symptoms , These are typically nausea, vomiting, and sweating which are typically symptoms of vertigo, and not of Ménière's

• nystagmus, • Migraine

Diagnosis • Complaints and medical history.• otolaryngological examination,

audiometry, and • head MRI scan should be performed

to exclude a vestibular schwannoma or superior canal dehiscence which would cause similar symptoms.

Management

• stopping to have coffee which contains caffeine & stopping to have tea

• .Recommended salt intake is often around one to two grams per day. One source recommends taking two grams of potassium or more daily

• Diuretics have traditionally been prescribed to facilitate a Low sodium diet although there is no definite supportive evidence.

• Both prescription and over-the-counter medicine can be used to reduce nausea and vomiting during an episode. Included are antihistamines such as meclozine or dimenhydrinate, trimethobenzamide and other antiemetics, betahistine, diazepam, or ginger root.

Surgery• Non destructive surgeries include

those which do not actively remove any functionality, but rather aim to improve the way the ear works

• Intratympanic steroid treatments involve injecting steroids (commonly dexamethasone) into the middle ear in order to reduce inflammation and alter inner ear circulation.

• Surgery to decompress the endolymphatic sac has shown to be effective for temporary relief from symptoms.

• Conversely, destructive surgeries are irreversible and involve removing entire functionality of most, if not all, of the affected ear. The inner ear itself can be surgically removed via labyrinthectomy although hearing is always completely lost in the affected ear with this operation

• Alternatively, a chemical labyrinthectomy, in which a drug (such as gentamicin) that "kills" the vestibular apparatus is injected into the middle ear can accomplish the same results while retaining hearing.

• In more serious cases surgeons can cut the nerve to the balance portion of the inner ear in a vestibular neurectomy. Hearing is often mostly preserved, however the surgery involves cutting open into the lining of the brain, and a hospital stay of a few days for monitoring would be required

• Physiotherapy• In vestibular rehabilitation, physiotherapists use

interventions aimed at stabilizing gaze, reducing dizziness and increasing postural balance within

the context of activities of daily living.

 

Hearing Loss

• Hereditary disorders - some types of deafness are hereditary, which means parents pass on flawed genes to their children. In most cases, hereditary deafness is caused by malformations of the inner ear.

• Genetic disorders - genetic mutations may happen: for example, at the moment of conception when the father’s sperm joins with the mother’s egg. Some of the many genetic disorders that can cause deafness include osteogenesis imperfecta, Trisomy 13 S and multiple lentigines syndrome.

• Prenatal exposure to disease - a baby will be born deaf or with hearing problems if they are exposed to certain diseases in utero, including rubella (German measles), influenza and mumps. Other factors that are thought to cause congenital deafness include exposure to methyl mercury and drugs such as quinine.

• Noise - loud noises (such as gun shots, firecrackers, explosions and rock concerts), particularly prolonged exposure either in the workplace or recreationally, can damage the delicate mechanisms inside the ear.

• Trauma - such as perforation of the eardrum, fractured skull or changes in air pressure (barotrauma).

• Disease - certain diseases can cause deafness, including meningitis, mumps, cytomegalovirus and chicken pox. A severe case of jaundice is also known to cause deafness.

• Other causes - other causes of deafness include Meniere’s disease and exposure to certain chemicals like ototoxic drugs

Conductive hearing loss• It is characterized by an obstruction

to air conduction that prevents the proper transmission of sound waves through the external auditory canal and/or the middle ear. It is marked by an almost equal loss of all frequencies. The auricle (pinna), external acoustic canal, tympanic membrane, or bones of the middle ear may be dysfunctional.

Sensorineural hearing lossOccurs when the sensory receptors of the inner ear

are dysfunctional. Sensorineural deafness is a lack of sound perception caused by a defect in the cochlea and/or the auditory division of the vestibulocochlear nerve. This type of hearing loss is more common than conductive hearing loss and is typically irreversible. It tends to be unevenly distributed, with greater loss at higher frequencies.

• Sensorineural hearing loss may result from congenital malformation of the inner ear, intense noise, trauma, viral infections, ototoxic drugs (e.g., cisplatin, salicylates, loop diuretics), fractures of the temporal bone, meningitis, ménière's disease, cochlear otosclerosis, aging (i.e., presbycusis), or genetic predisposition, either alone or in combination with environmental factors. Many patients with sensorineural hearing loss can be habilitated or rehabilitated with the use of hearing aids.

Mixed hearing loss• Have both conductive and sensory

dysfunction. Mixed hearing loss is due to disorders that can affect the middle and inner ear simultaneously, such as otosclerosis involving the ossicles and the cochlea, head trauma, middle ear tumors, and some inner ear malformations. Trauma resulting in temporal bone fractures may be associated with conductive, sensorineural, and mixed hearing loss

Degree of hearing loss• Deaf/Deafness refers to a person who has a profound

hearing loss and uses sign language.• Hard of hearing refers to a person with a hearing

loss who relies on residual hearing to communicate through speaking and lip-reading.

• Hearing impaired is a general term used to describe any deviation from normal hearing, whether permanent or fluctuating, and ranging from mild hearing loss to profound deafness.

• Residual hearing refers to the hearing that remains after a person has experienced a hearing loss. It is suggested that greater the hearing loss, the lesser the residual hearing.

Assessment• Hearing loss is confirmed using a

battery of audiologic tests, with the specific tests and measures selected according to the age of the patient. However, in general, comprehensive hearing assessment designed to confirm hearing loss usually includes a hearing history, physiological procedures, and behavioral procedures

Components of a Comprehensive Hearing Assessment and Hearing History

• General concern about hearing and

communication

• Auditory behaviors (reacting to and

recognizing sounds)

• History of otological diseases and other

risk factors for hearing loss

Physiological procedures or acoustic admittance measurements

• Otoacoustic emissions (OAE)• Auditory brainstem response (ABR)• Middle ear muscle reflexes• Tympanometry• Behavioral audiometry testing• Behavioral Observation

Audiometry (BOA

• Visual Reinforcement Audiometry (VRA)

• Conditioned Play Audiometry (CPA)

• Speech Audiometry

Management• Interventions for most infants and young

children with hearing loss are primarily focused on the following goals:

• Preventing or reducing the communication problems that typically accompany early hearing loss.

• Improving the child's ability to hear.• Facilitating family support and confidence

in parenting a child with a hearing loss.

• Communication approach options for young children with hearing loss range from sign language alone to auditory/verbal (spoken language) or various combination approaches. Parents also must choose a means for improving their child's access to sound.

•

Hearing aid• A hearing aid is an electroacoustic

device which is designed to amplify sound for the wearer, usually with the aim of making speech more intelligible, and to correct impaired hearing as measured by audiometry. Ordinary small audio amplifiers or other plain sound reinforcing systems cannot be sold as "hearing aids".

Types• There are many types of hearing aids (also known

as hearing instruments), which vary in size, power and circuitry. Among the different sizes and models are:– Body worn aids– Behind the ear aids (BTE)– "Mini" BTE (or "on-the-ear") aids– Receiver in the canal/ear (CRT/RIC/RITE)– Earmolds

• In the ear aids (ITE)• Invisible in canal hearing aids

(IIC)• Extended wear hearing aids• Open-fit devices• Personal, user, self, or consumer

programmable• Disposable hearing aids

• Bone anchored hearing aids (BAHA)

• Eyeglass aids– Spectacle hearing aids– Bone conduction spectacles– Air conduction spectaclesStetho-Hearing Aid

Bone anchored hearing aids (BAHA)

Eyeglass aids

• Other assistive devices include FM systems and tactile aids. Some children with severe to profound hearing loss who have demonstrated little benefit from conventional hearing aids may receive a cochlear implant, an electronic device that is surgically placed in the inner ear.

• A cochlear implant (CI) is a surgically implanted electronic device that provides a sense of sound to a person who is profoundly deaf or severely hard of hearing. Cochlear implants are often called bionic ears.

Parts of the cochlear implant

• The implant is surgically placed under the skin behind the ear. The basic parts of the device include:

• External:• one or more microphones which picks up

sound from the environment• a speech processor which selectively filters

sound to prioritize audible speech, splits the sound into channels and sends the electrical sound signals through a thin cable to the transmitter,

• a transmitter, which is a coil held in position by a magnet placed behind the external ear, and transmits power and the processed sound signals across the skin to the internal device by electromagnetic induction,

• Internal:• The internal part of a cochlear implant (model Cochlear

Freedom 24 RE)• a receiver and stimulator secured in bone beneath the

skin, which converts the signals into electric impulses and sends them through an internal cable to electrodes,

• an array of up to 22 electrodes wound through the cochlea, which send the impulses to the nerves in the scala tympani and then directly to the brain through the auditory nerve system.

Aural rehabilitation • Refers to the services and procedures needed to

facilitate adequate receptive and expressive communication in individuals with hearing impairments [American Speech-Language-Hearing Association (ASHA), 1984]. It is also called auditory or audiologic rehabilitation. Aural rehabilitation is typically an integral component used in the overall management of individuals with hearing loss and is often an interdisciplinary endeavor involving physicians, audiologists, and speech-language pathologists. For school-age children, therapy may also be coordinated with

the school system.

Services involved in the provision of aural rehabilitation include

• Identification and evaluation of sensory capabilities, including the extent of impairment and the fitting of auditory aids.

• Interpretation of the audiological findings, plus counseling and referral.

• Development and provision of an intervention program for communicative disorders in order to facilitate expressive and receptive communication.

• Re-evaluation of the patient's status.• Evaluation and modification of the intervention

program.

Thank

you