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Conductive Hearing Loss Temporal Bone Anatomy – External Ear Conductive Pinna/Auricle Hearing Loss Abraham Jacob, MD Department of Otolaryngology – Head & Neck Surgery Otology, Neurotology, and Cranial Base Surgery The Ohio State University Images used in this lecture were obtained from the presenter’s collection, various textbooks and internet websites. Their use is for educational purposes only. Objectives Temporal Bone Anatomy – External Ear • To understand the basic functional The External Auditory Canal anatomy of the ear • To describe components of a • Body’s only skin-lined cul-de-sac comprehensive audiogram and define • Keratinizing stratified squamous conductive hearing loss by audiometric epithelium and physical exam parameters • 2.5 cm long • 1/3 cartilaginous; 2/3 bony • To recall the common causes of • The cartilaginous ear canal has conductive hearing loss and appreciate hair follicles, sebaceous glands, their medical/surgical management and ceruminous glands • The bony ear canal has skin • To describe options for aural rehabilitation directly overlying periosteum in patients with conductive hearing loss 1 Temporal Bone Anatomy – External Ear Temporal Bone Anatomy – Middle Ear Space The Tympanic Membrane • Mesotympanum • Epitympanum • The tympanic membrane has 3 layers • Protympanum 9 Squamous, fibrous and mucosal • Hypotympanum layers • Made up of the pars tensa and pars flaccida • Visible light reflexes during otoscopy are the primary and secondary light reflex Temporal Bone Anatomy – Middle Temporal Bone Anatomy – Eustachian Tube Ear Ossicles • Connects protympanum (ME) to nasopharynx (NP) • Medial 2/3 fibrocartilage; lateral 1/3 bony • Equalizes ME pressure with atmospheric pressure • Lined with respiratory epithelium 9 Mucociliary clearance towards the NP • Usually closed to prevent reflux of NP contents into ME • Malleus: umbo, manubrium, head, neck, anterior and lateral 9 Opens during palate movement processes • 13 mm @ birth; 36 mm in adulthood • Incus: body, short process, long process, and lenticular process • More horizontal at birth; elongates and • Stapes: head, footplate and two crura descends over time 2 Temporal Bone Anatomy – The Mastoid Region Physiology of Hearing • The mastoid region of the temporal bone is posterior to the bony ear canal • Surgical landmarks include the tegmen, sinodural angle, sigmoid sinus, horizontal semicircular canal, incus, & the vertical segment of the facial nerve www.colorado.edu/intphys/Class/IPHY3430-200/image/10-19.jpg Temporal Bone Anatomy – The Inner Ear Conductive Hearing Loss! Hearing mechanism: Cochlea Balance mechanism: Utricle, saccule, and 3 semicircular canals www.colorado.edu/intphys/Class/IPHY3430-200/image/10-19.jpg 3 Sensorineural Hearing Loss! The Normal Audiogram www.colorado.edu/intphys/Class/IPHY3430-200/image/10-19.jpg Mixed Hearing Loss! The Normal Audiogram • PTA (pure tone average): An average for pure tone thresholds at 500, 1000, and 2000Hz • 4-tone PTA: An average for pure tone thresholds at 500, 1000, 2000 and 3000Hz • SRT (speech reception threshold) – Uses spondee words having equal emphasis on each of 2 syllables – Threshold should agree within 7 dB of PTA – Usually lower threshold than PTA (our auditory system is more sensitive to spoken words than to tones • WRS (word recognition score): uses standardized phonemically balanced words representing phonemes in the English language – Reported as % correct www.colorado.edu/intphys/Class/IPHY3430-200/image/10-19.jpg 4 Audiometry – Conductive Hearing Loss Immittance Testing: Tympanogram Air Conduction Stimuli (sounds): delivered by over-the-ear or insert earphones Bone Conduction Stimuli: delivered through a bone conduction vibrator placed on mastoid region Audiometry – Sensorineural Hearing Loss Tuning Fork Tests Air Conduction Stimuli • Used to confirm audiogram (sounds): delivered by results (512 Hz tuning fork) over-the-ear or insert earphones • Weber: Lateralizes to the poorer ear with a Bone Conduction Stimuli: delivered through a bone conductive HL or the better conduction vibrator placed ear with sensorineural on mastoid region hearing loss • Rinne: A positive Rinne indicates that air conduction is greater than bone conduction. A negative Rinne indicates that bone conduction is greater than air conduction 5 Foreign Bodies in the Ear Canal • Objects 9 Plastic toys or beads; Cotton, paper 9 Insects 9 Organic material (popcorn kernels or vegetable material) Causes of Conductive 9 Button batteries (caustic!) 9 Ear wax (cerumen impaction) http://www.ent.usa.com • Symptoms: pain, ear drainage, Hearing Loss conductive hearing loss • Treatment: Removal 9 Risks tympanic membrane injury 9 Kill live insects rubbing alcohol or mineral oil 9 Use otologic microscopes with microinstruments and suction 9 Ear irrigation (do not use if organic foreign body or button battery) 9 Otic antibiotic drops Otitis Externa • Inflammation of the external auditory canal 9 acute and chronic types • Ear canal defenses 9 Cerumen Diseases of the • Acidic • Contains lysozyme and immunoglobulins External Auditory • Lipid rich and forms a moisture barrier for underlying skin 9 Epithelial migration from center of tympanic membrane outward (0.07 Canal mm/day) to meatus 9 Curvature of the ear canal • Excessive moisture predisposes OE 9 elevates can pH 9 removes ear wax 9 keratin debris absorbs moisture and http://www.ent.usa.com creates medium for microbial growth 6 Otitis Externa Keratosis Obturans • Majority of OE is bacterial but OE can also be fungal • Disruption of normal epithelial migration in the ear canal 9 Staphylococcus aureus and Pseudomomnas aeruginosa – common • Results in a cast of skin debris and wax bacteria 9 Candida and aspergillus – common • Can cause remodeling/erosion of underlying bone fungi • Results in aural fullness, conductive hearing loss, and can • Presenting symptoms: pruritis to severe pain; ear drainage; conductive hearing loss otitis externa http://www.ent.usa.com 9 Can require narcotics to control the pain • Treatment 9 Aural debridement +/- ear wick 9 Ototopical antibiotic/antifungal drops 9 Systemic antibiotics for immunocompromised patients 9 Do not irrigate the ear canal if the status of the ear drum is unknown http://lh5.ggpht.com/bharatsiddharth Otitis Externa Keratosis Obturans - Treatment Antifungal • Frequent aural debridement • STRICT dry ear precautions • Treat underlying infections ¾Ototopical antibiotic/antifungal drops • Treat underlying skin conditions Antibacterial ¾Eczema ¾Atopic dermatitis ¾Seborrheic dermatitis ¾Psoriasis 7 Acquired Ear Canal Stenosis Congenital Ear Canal Atresia • Formation of a fibrous • Failure in development of the external plug in the ear canal with auditory canal recurrent ear drainage and • Spectrum of severity progressive conductive hearing loss – Complete • Etiology unknown – Stenosis (narrow canal) ¾ ? Dermatologic condition ¾ ? Fungal infection • Epidemiology ¾ ? Abnormal wound healing – 1:10,000-20,000 response • Treatment options – 3-6:1 Unilateral ¾ Non-intervention – R > L ¾ Conventional hearing – M > F aids ¾ Bone anchored hearing • Etiology unknown aids • Adjacent regions may be affected ¾ Surgical excision of scar with canal reconstruction – Syndromes: Goldenhar, Treacher-Collins, Hemifacial microsomia Tympanoplasty with canalplasty and split thickness skin grafting Congenital Atresia Surgery 8 Congenital Atresia Surgery: Pearls Atresia Surgery: Complications • Stay anterior (near TMJ) and superior (near tegmen/ middle fossa dura) when drilling open the ear canal • Re-stenosis – 4-12% • Avoid entering mastoid air cells • Careful dissection of atretic plate (without • Infection drill) after indentifying incus • Facial nerve injury • Avoid prosthetics if possible • Hearing loss – 12-28% • Fashion 1.5 cm diameter canal • Silastic button to prevent lateralization of ear 9 Scar, lateralization, OCR, OM drum reconstruction • Center meatus by mobilizing the auricle as needed Atresia Surgery: Outcomes • Goal - restore hearing to an SRT (speech reception threshold) of 15-25 dB. Tympanic Membrane • Approximately 50% of patients have an SRT less than 25 dB after surgery. and/or Middle Ear • 1/3 of patients require revision surgery for hearing loss Pathology 9 Approximately 50% obtain an SRT of ≤ 25 dB 9 Approximately 66% obtain an SRT of ≤ 30 dB 9 The Middle Ear Impedance Matching System Chronic Granular Myringitis • The impedance of fluid in the cochlea is 30 times that of air • If sound were applied directly to the oval window (at the stapes footplate), about 97% would be reflected. • The lever formed by the malleus and incus has a pivot point farther from the tympanic membrane than from the stapes at a ratio of 1.3:1 • The area of the pars tensa is 0.55 cm2, whereas that of the oval window is only 0.032 cm2. • The area difference (16x) and the lever arm (1.3), create a • Inflammation with mucosalization of the ear drum surface 21-fold (about 13 dB) increase in pressure from tympanic ¾ Can have progressive involvement of the ear canal membrane to the oval window membrane (under the stapes ¾ Leads to chronic canal wetness and pruritis footplate). • Progressive tympanic membrane thickening impedes vibration • With an ear drum and intact ossicular chain, 60% of the ¾ Leads to conductive hearing loss signal is transmitted as compared to 3% transmission without a tympanic membrane and ossicles. • Treatment: similar to otitis externa; may require surgical excision Tympanosclerosis Tympanic Membrane Perforation • Hyalinization of the middle layer of the ear drum and/or
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