Overview • Auditory Problems • Vestibular Problems – Otitis Externa – Benign Paroxysmal • Malignant Otitis Externa Positional Vertigo (BPPV) – Ear Canal Foreign Body – Meniere’s Disease Auditory Problems –Exostosis – Migraine Associated Vertigo – Otitis Media – Labyrinthitis • Acute Otitis Media • Serous Otitis Media – Vestibular Neuritis • Chronic Otitis Media – Tympanosclerosis – Tympanic Membrane Perforation • Facial Nerve Problems – Tympanic Membrane Atelectasis – Facial Nerve Paralysis – Cholesteatoma • Bell’s palsy – Sudden Sensorineural Hearing • Ramsey – Hunt syndrome Loss – Ototoxicity – Noise Induced Hearing Loss –Presbycusis Otitis Externa Malignant Otitis Externa • Inflammation of the ear canal • Also called swimmer’s ear – Extremely dangerous version of otitis externa – Water exposure – Almost always in diabetic or immunocompromised • Ear culture to direct therapy – Infection becomes invasive destroying adjacent bone – Pseudomonas Aeruginosa – Quite ill, toxic patient • Fluoroquinolones – Cranial Neuropathies – MRSA • Facial, Vestibulocochlear • Bactrim, Doxycycline • Lower Cranial nerves • Ear wick if canal swollen closed – Admission • Frequent debridement of ear canal • Ear wick with daily ear debridement • CT scan to delineate extent • Keep ear dry • Synergistic IV ABX usually against pseudomonas Foreign Body Exostosis • Various objects • Asymptomatic – Beware batteries unless occlusive • If difficult to extract OR or nearly occlusive • If causing hearing loss or recurrent infections consider surgical excision Acute Otitis Media Acute Otitis Media Presentation Complications • Inflammation of middle ear space • Mastoiditis – Usually a bacterial infection – Postauricular pain, edema • Less than 3 weeks – Subperiosteal abscess • Fluctuance • Presentation • CT scan – Otalgia – Coalescent mastoiditis – Otorrhea (depends on TM perf) • Erosion of the bony septations – Conductive Hearing Loss • Facial paralysis – Flat tympanogram • Inner Ear Involvement – CT (if done) – SNHL • Opacification of middle ear and mastoid – Vertigo – Ever increasing resistant bacteria • Meningitis Serous Otitis Media Serous Otitis Media • Serous fluid in middle ear space – From Eustachian tube • Treatment: dysfunction – From prior ear infection – May resolve • Not actively infected spontaneously • No otalgia – Nasal/oral steroids, • Hearing loss (conductive) decongestants – If persists consider • In adults, must exclude myringotomy with underlying tube insertion nasopharyngeal mass – Either by imaging or a flexible scope exam Chronic Otitis Media Tympanosclerosis • Inflammation of the middle ear space • No treatment – Longer than 6 weeks required if – Usually bacterial asymptomatic • Presentation • If involves – Otalgia ossicular • Less severe than acute otitis media chain causes • May be ear fullness only CHL – Otorrhea – Difficult but – Conductive Hearing Loss possible to – Sequelae correct surgically • Tympanosclerosis • TM Perforation • Atelectasis • Cholesteatoma TM Perforation Atelectasis • Persists >6wks • Profound thinning of eardrum from chronic unlikely to heal negative pressure spontaneously • Can be stable or progress to retraction • Tympanoplasty pocket or perforation • TX –Temporalis – Observe graft – Ear tube +/- – Tympanoplasty with –Cartilage graft cartilage Cholesteatoma Sudden Sensorineural Hearing Loss • Squamous ingrowth into middle ear cavity • Acute onset of EAR FULLNESS and – Chronic otorrhea HEARING LOSS – Frequent ear infections – Vestibular symptoms variable – Hearing loss • DO not assume its an allergy/Eustachian • Erosive destroying bone tube problem!! – Can erode ossicles (hearing loss) – Can invade facial nerve (facial paralysis) • Treatment is time sensitive – Can erode into skull base (meningitis, – Within first few weeks ideal abscess) – Can erode into labyrinth (dizziness, deafness) – Pointless if more than 6wks • Treatment: hi dose corticosteroids (oral +/- • Requires surgical excision intratympanic) • MRI imaging standard evaluation Ototoxic Exposures Noise induced hearing loss • Antibiotics • Diuretics – OSHA requires hearing protection – Aminoglycosides – Loop • Damage occur at 8 hrs. of • Cochleotoxic exposure at 85db • Vestibulotoxic • Heavy Metals • Every 3dB increase in sound – Vancomycin – Arsenic, gold, lead, level halves exposure time – Minocycline mercury • 109dB is under 2 minutes! – Clarithromycin • Sound is loud enough it can kill – Erythromycin • Opiates you (blast explosion) – Chloramphenicol – High doses only • Chemotherapeutic – Usually notching (sensorineural) at – Cisplatin 4kHz • Hi frequency SNHL – Vincristine – Limit exposure via behavioral • Vestibulotoxic modifications and ear protection – Bleomycin – Can pretreat with N-acetylcysteine • Vestibulotoxic BEFORE noise exposure Presbycusis Nerves • Hearing Loss due to age • The earth is 40,000km around • Quite common • The nerves in your brain when added • Highest frequencies lost first up are 180,000km • Impossible to predict progression or severity • So they would go around the earth • Treatments: 4.5 times!!! – Hearing Aid – Cochlear Implant if severe to profound Cochlear Implants Cochlear Implants • Indications: • Externally worn processor picks – Bilateral profound deafness up sound and codes it into a ”map” – Just starting for single sided deafness • Signal is sent across the skin by FM radio waves • Computer chip under skin behind • An electrode is surgically placed into the cochlea, the ear sends signals to takes over function of inner ear electrodes in cochlea • Electrodes stimulate auditory nerve • Brain learns to interpret signal as meaningful sound Acute Vestibular Problems Vestibular Problems Timing is Crucial! • Seconds BPPV • Hours Meniere’s and Migraine • Days (Weeks) Labyrinthitis and Neuritis Acute Vestibular Problems BPPV (Benign Paroxysmal Positional Vertigo) Exclude Stroke – Other neurologic deficits • Acute vertigo lasting for 15-30 seconds – Imaging if needed • From debris within the posterior semicircular canal Cerebellar stroke can mimic peripheral • Provoked by head position changes vestibular lesions without other neurologic – Head tilting up and back “tennis serve” deficits – Lying down in bed with head to side cerebellar signs – nystagmus changes in direction with gaze • NO auditory or other neurologic – profound ataxia symptoms – dysmetria of extremities BPPV (Benign Paroxysmal • Provoked by Dix-Hallpike maneuver Positional Vertigo) • Treated with Epley maneuver • Some cases initiated by head trauma • Usually self limiting BPPV • Dix-Hallpike test to confirm • Eppley Maneuvers to treat From Baloh 1998 Meniere’s Disease Meniere’s Disease • Treatment: • Inner ear dysfunction of UNKNOWN – HCTZ 25mg PO BID with KCL etiology (workup: MR, bloodwork) supplement 10meq PO BID • Symptoms: Aural fullness, SNHL, – Low salt diet tinnitus, vertigo attacks – Steroids sometimes effective • Oral • Usually a low frequency fluctuating • Intratympanic SNHL – Vertigo • Unilateral 90% of patients • Symptomatic (meclizine, lorazepam) • Ablative (Intratympanic gentamicin, • Severe spells of vertigo lasting Vestibular nerve section) several hours Migraine Associated Labyrinthitis Dizziness • Acute vertigo attack with sensorineural • Vertigo attacks lasting for several hours hearing loss – Without hearing loss • Severe for first 24-48 hours – May have Migraine history or family history – Significant nausea, vomiting • Treatment: • Resolves over a few weeks slowly – Trigger avoidance • Treatment – Usual treatments for Migraine headaches NOT effective • Corticosteroids – Calcium channel blockers and Beta-blockers • Hydration, anti-emetics effective at preventing attacks (verapamil • Vestibular suppressants 120mg SR once daily) – Meclizine, scopolamine patch, benzodiazepines – Vestibular suppressants during attacks • May result in permanent hearing loss but vestibular symptoms resolve Vestibular Neuritis • Same as labyrinthitis EXCEPT WITHOUT Facial Nerve Problems sensorineural hearing loss • Acute vestibular symptoms resolve over weeks but balance compensation can take months – Some need physical therapy for balance (vestibular rehabilitation) Facial Nerve Paralysis Facial Nerve Paralysis • Differential Diagnosis • MUST exclude includes: pathology along entire • Bell’s Palsy – Malignancy course of nerve • Direct extension – MRI crucial – Viral inflammation of facial nerve within the – Skin cancer bony canal inside the temporal bone • Local nodal extension or metastasis • Treatment – Parotid tumors – high dose corticosteroids – Intracranial Schwannomas – Antivirals controversial in efficacy – Neurologic diseases, stroke – Supportive measures – Many, many others » Eye care to prevent corneal abrasions Pics courtesy Dr. Irene Kim – Prognosis is very good with >90% chance of recovery to normal • Remaining 10% at risk for synkinesis after recovery (muscles all move simultaneously instead of individually) Bell’s Phenomenon Facial Nerve Paralysis Summary • Ramsey – Hunt syndrome • Clinical pearls – Viral inflammation of facial nerve within the bony canal inside the – Any acute cranial neuropathy should have MRI temporal bone evaluation to exclude concerning pathologies – Due to Zoster infection – vesicles on pinna – Serous otitis media in adult think nasopharyngeal – Treatment tumor – high dose corticosteroids – Antivirals more evidence then for Bell’s – Cholesteatomas present at the TOP part of the – Supportive measures eardrum – look up! » Eye care to prevent corneal abrasions – Prognosis is worse than Bell’s – Any acute hearing loss will also have ear fullness as palsy presentation – don’t be tricked! • 70% recovery to normal References – Dizziness, Hearing Loss and Tinnitus, Baloh, R, F.A. Dais Company, 1998. – Fundamental Otology: Pediatric and Adult Practice, Jaypee publishers, 2013..