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OtoloRhinoLaryngology

Mark Montgomery MD, FACS

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4/19/2012 Mark Montgomery, MD 2

What is an

Otolaryngologist?

General ENT

Pediatrics

Laryngology

Facial Plastics Allergy

Rhinology

Head/Neck

Neurotology

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Otolaryngology Topics

Otology Rhinology

Allergic Rhinitis

Rhinosinusitis Epistaxis, Foreign bodies, etc.

Oral and Oropharynx

Hypopharynx

Diseases of the Neck

Trauma of the Head & Neck

Tumors of the Head & Neck

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Objectives

Discuss clinical medicine of the ears andhearing & balance mechanisms withemphasis on the common conditions

Discuss diagnosis, treatment, referralindications and pitfalls in the managementof these conditions

Place emphasis on accurate, cost efficienttreatment and management of theseconditions

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Topics in Otology

Auricularhematoma

Foreign Body

Tympanicmembraneperforation

Eustacian tubedysfunction

Barotrauma

Otitis Media

Cholesteatoma

Mastoiditis

Hearing loss

Acoustic Neuroma

Tinnitus

Vertigo Benign positional Labyrinthitis

Menieres

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Credits

Photos from the ENT USA web siteare protected by the copyright lawsof the United States and other

countries. Copyright 1999-2003,Kevin T Kavanagh MD. All rights arereserved. They are used here with

permission from Kevin T KavanaghMD

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External Ear or Pinna

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External Ear Abnormalities

Congenital:

Microtia-

Protruding outstanding ears-

1st branchial cleft abnormalities-fistulas, cysts, sinuses

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Microtia

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1st branchial cleft abnormalities

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Pathology of theOuter Ear

Metabolic

Infectious Neoplasms

Traumatic

Vascular, iatrogenic

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Auricular Hematoma

Auricular hematoma:

Can lead to necrosisand permanentdisfigurement.

Hematoma between theperichondrium andcartilage

Does not respond toaspiration

REFER immediately toENT

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Cauliflower Ear

Caused by trauma(wrestling)

Needs (ENT) referral.

Differentiate Acute VsChronic

Hematoma vs deformity

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Auricular Hematoma Treatment

CauliflowerEar

Incision & Drainage withBolsters

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Keloid from pierced ear ring.

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Pseudomonas infection causingcellulitis

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Infection: Erysipelasor Celluitis Traumatic

Idiopathic

Chondrodermatitis nodularis helicus

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Dermatologic

Contact dermatitis:

Atopic dermatitis:

Skin lesions:

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Contact Dermatitis

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Relapsing Polychondritis

Inflammation ofcartilage

Treatment:antibiotics,may require surgicalresection

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Auricular Cancer

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Auricular cancer

Basal cell

Squamous cell

Malignant melanoma Cartilage tumors

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EXTERNAL CANAL ANATOMYCerumen production/canal maintenence

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Anatomy of the Ear Region

24

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Ear Canal Anatomy

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External Auditory Meatus

Curved tube of cartilage(lateral 1/3) & bone(medial 2/3) leadinginto temporal bone

Lined with skin

Ceruminous glandsproduce cerumen = ear

wax

Innervation by vagus(CN X) andauriculotemporal nerve

27

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Exostosis

Bony to palpation Frequently bilateral Surfers ears DDx: Cholesteatoma

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EXOSTOSIS OF EAR CANAL

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Cerumen S & S Tinnitus

Conductive hearingloss

Treatment:Removal under

dirct visualizaionbest

Complication TM perforation

Abrasion EAC

Contraindication tolavage Hx of TM perforation

Hx of prior ear surgery

PE tube in the ear

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Cerumen

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Foreign Body

Patient inserted Q tips beads

Removal may be difficult

Success depends on equipment,skill, and cooperation.

Complications of removal:laceration of the ear canal,rupture of tympanic membrane

Frequent referral to ENT

Post-extraction Topical antibiotics w/

corticosteroids

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FOREIGN BODY

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FOREIGN BODY

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FOREIGN BODY

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FOREIGN BODY

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FOREIGN BODY

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Foreign bodiesEar Candling

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Otitis Externa

Inflamationof the External earcanal

Inflamatory: Eczematous orseborrheic dermatitis

Infectious: Bacterial and/or fungal Symptoms:

Pain often severe

Tenderness with manipulation of auricle Muffled hearing

Discharge--purulent

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Otitis Externa

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Eczematous otitis externaAlso can be psoriasis

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CHRONIC OTITIS EXTERNA

Inflamation Swelling

Purulent

Debris Itching

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Otomycosis(fungal)

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OTOMYCOSIS

CANDIDA

ASPERGILLUS

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OTOTOXICITY OF OTIC GTTS

Cortisporin contains Neomycin OTOTOXICmay also aggravate itching

Acetic acid is not ototoxic but is painful ifTM is perforated.

Ciprofloxin-type drops: Safe for the middle

ear: eg. Floxin, Ciprodex

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OTITIS EXTERNA TX

Usually do not need oral antibiotics unlessassociated with cellulitis of auricle or face/neck.

NEVER treat with oral alone. Conc of otic dpshigher level to infected area. Oral could lead to

resistance. Most infections in FL are probably mixed bacterial

(Staph and/or pseudomonas AND fungal.

Bacterial: Intact TM- Neomycin or Fluoroquinolone

State of TM unknown: Fluoroquinolone

Most important is to ensure drops get in. Debris needsto be cleared. Most common reason for treatmentfailure is improper administration. With significantswelling, consider Wick insertion

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Otitis Externa Tx (con)

Treatment with antibiotic drops 7 days

Dry ear care/Avoid manipulation

Recheck in one weekremove debris

If no improvement: culture &sensitivity Consider pseudomonas orMRSA

May require change of drop and/oraddition of oral antibiotic

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OTITIS EXTERNA (FUNGAL)

Marked debris requiring careful cleaning of thecanal. Treatment:

Vosol otic drops (2% acetic acid in propolyeneglycol)

Vosol HC otic drops if swelling present. Lotrimin solution (clotrimazole) Cresylate Ciprodex frequently effective (acidic & steroid in

addition to the antibiotic).

Untreated or under-treated fungal infections arenasty and can ulcerate and perforate the TM(Rare)

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EAR CANAL PROPHALAXIS

To prevent Swimmers ear or fungus:Store preps are mainly alcohol. MixingTwo tablespoons of white vinegar in pint

rubbing alcohol probably better CHEAPER.Use after swimming or when ear feels wet.

Eczematous OE: Small amount of OTC1% hydrocortisone to outer ear canal with

Q-tip (depth 1 cm) when ear itches. Mayuse 50% white vinegar and distilled H20(Not alcohol) if ear canal feels wet.

Necrotizing (Malignant) Otitis

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Necrotizing (Malignant) OtitisExterna

Osteomyelitis of the skull base

Pseudomonas predominantly Immunocompromised/diabetic

patients Severe pain/discharge Granulation tissue in ear

canal Cranial neuropathies -

7,9,10,11

CT/nuclear medicine scan

Long-term intravenousantibiotics Antipseudomonals

Prognosis- 60% mortality Related to response to

therapy

Granulation in ExternalAuditory Canal

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T i M b

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Tympanic Membrane

Functions: Separates the

external ear fromthe middle ear

Transmits soundfrom air to theossicles

Someamplification ofsound wave

54

NORMAL TYMPANIC MEMBRANE

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NORMAL TYMPANIC MEMBRANE(Window to the Middle Ear)

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1

2

3

4 5

7

O

I

R

T

A

I= Incus

O=oval window

R=Round window

A=Annulus

T=Tensor tympani

1=pars flaccida

2=short process ofmalleus

3=handle of

malleus

4=umbo5=tubal oriface

7=hypotympanic

air cells

Anatomy

A

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Anatomy1= Pars flaccida2= Short process of maleus

3= Handle of maleus

4= Umbo5= Supratubal recess

6= Tubal orifice

7= Hypotympanic air cells

8= Stapedeus tendon

9= Pyramidal eminencef = facial nerve

co = cochleariform process

j = incudostapedial joint

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Tympanosclerosis

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Tympanosclerosis with inferior perforation

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TYPANOSCLEROSIS

Scaring of the TM due to chronic infections

Glomus Tumors

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Glomus Tumors(Chemodectomas)

Initial symptoms:Hearing loss, pulsatiletinnitus

Middle ear: promontory

Highly vascular mass

Glomus tympanicum

Glomus jugulare

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BULLOUS MYRINGITIS

PRESENTATION: pain with heaing loss

Etiology: Unknown, probably viral

PHYSICAL FINDINGS: Blebs &erythema of the tympanic membrane

Treatment: Supportive, topicalanesthetic drops, monitor forsecondary bacterial infection.

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Bullous Myringitis

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Ear Drum Perforation

Acute Otitis

Traumatic

Barotrauma

Chronic

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TRAUMATIC PERFORATION

TRAUMATIC PERF WITH NERVE

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TRAUMATIC PERF WITH NERVEEXPOSED

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Treatment: TM Perforatioin

Rule out ossicular discontinuity(audiogram)

Dry Ear Care!

Pain Medication Non-ototoxic antibiotic ear drops only if

the perforation occurred in wet conditionsand/or ear is draining

90% perforations heal in 6 weeks if non-infected!

Tympanoplasty for persistent perforation.

TM with Monolayer (Monomeric)

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TM with Monolayer (Monomeric)Previous perf or PE tube site

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Size

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Eustachian Tube Function

Protection of middleear

Clearance of middleear secretions

Ventilation of the

middle ear

Eusacian Tube ANATOMY

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Eusacian Tube ANATOMYCritical Valve ln Nasophaynx

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Tympanometer: Pressure

transducer Testing

function of theEustacian Tube

Measures bothmobility &volume

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Tympanogram Type A

NORMAL

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Tympanogram Type B

Volume?

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Tympanogram Type B

Volume: nl=Fluid Hi=perf

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Typanogram Type C

Negative Pressure

Eustacian Tube Dysfunction

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Eustacian Tube DysfunctionSmptoms

Clicking and/or popping in the ear

Hearing lossvariable

Vertigo

Discomfort

Symptoms aggravated with changein ambient pressure: elevators, flyingSCUBA diving

Eustacian Tube Dysfunction

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Eustacian Tube DysfunctionTreatment

Watchful waiting eg.URI

Correcting Rhinitis: smoking, allergies,sinusitis, pregnancy, decongestant spray

abuse, reflux Medication: antihistamine sprays and

steroidssome benefit. (decongestants,antihistamines, steroid spraysusually

ineffective) Eustacian tube exercises

PE tubes: usually not recommended

B Middl E

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Barotrauma Middle Ear

Cause: Changes in ambient pressurein the face of Eustacian TubeDysfunction

Sequelae: Hemotympanum

Ear Drum Rupture

Round Window Rupture Serous Otitis

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Mechanism of Barotrauma

C C f B t

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Common Causes of Barotrauma

Plane Flights Scuba Diving

Hemotympanum due to

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Hemotympanum due toBarotrauma

T t t f B t

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Treatment of Barotrauma

Behavior modificationno flying or SCUBAdiving until resolution!

Treat as Eustacian Tube Dysfunction

Antibiotic drops if TM perforation is wet Myringotomy and possible PE tube if no

resolution of serous otitis (6 wks approx)

Perilymphatic fistulapersistent vertigo &hearing lossemergency referral

O i i

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Otitis

Media Acute

Recurrent OM: If a child experiences threeor more episodes of AOM within 6 to 18

months

With Effusion(OME)

A t Otiti M di

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Acute Otitis Media

AOM develops after bacteria invade the middleear

most frequently occurring childhood diseasefollowing URI

leading cause of physician visits, antimicrobialtherapy, and pediatric surgery in severalcountries.

80% of cases occur in children, with the greatest

incidence occurring in those aged 6 to 9 months By 1 year of age, an estimated 75% of infants

will have encountered one episode of AOM, while17% will have suffered from at least three

episodes

Pathogenesis

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Pathogenesis

Otitis Media

Infection

Immature/Impaired

Immunology

Allergy

Eustachian Tube

Dysfunction

Day-care Centers

Lack of Breast FeedingPassive Smoking

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Di i f AOM

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Diagnosis of AOM

Three specific criteria need to be met:1. rapid onset

2. confirmed presence of middle-ear

effusion (MEE)3. signs and symptoms of middle-ear

inflammation

S mptoms of AOM

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Symptoms of AOM

Rapid onset of disease associated with oneor more of the following symptoms:

Otalgia

Fever Otorrhea

Recent onset of anorexia

Irritability Vomiting or Diarrhea

Otoscopic findings of Ear Drum

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p gIn AOM

Opacity

Bulging

Erythema Middle ear effusion (MEE)

Decreased mobility with pneumatic

otoscopy50% of all complaints associated with ear

pain will be associated with referred pain

from another site

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Acute Otitis Media

Microbiology of AOM

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gy

The most common bacterial pathogen inAOM is Streptococcus pneumoniae,followed by Haemophilus influenzae andMoraxella catarrhalis.

Responsible for more than 95% of all AOMcases with a bacterial etiology

Viruses most commonly associated withAOM are respiratory syncytial virus (RSV),influenza viruses, parainfluenza viruses,rhinovirus, and adenovirus

Treatment of AOM

http://emedicine.medscape.com/article/971488-overviewhttp://emedicine.medscape.com/article/971488-overview

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Treatment of AOM

Consider no treatment except analgesics(topical & oral) if mild.

Antibiotics-oral, +/- antibiotic drops ifrupture of the tympanic membrane.

Amoxicillin

drug of choice initially. If noresolution: High-dose oralamoxicillin/clavulanate. Oral cefuroxime.Intramuscular (IM) ceftriaxone

Large-dose cefdinir (high efficacy againstpenicillin-susceptible S pneumoniae)

Steroids (usually not recommended)

Follow up exam for resolution. Is the fluidgone?

Complications of AOM

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Complications of AOM

Hearing loss

Chronic SOM

Adhesive OM

Ossiculardiscontinuity/fixation

Labyrinthitis Mastoiditis

Facial VII Paralysis

Petrositis

TM perforation Cholesteatoma

Tympanosclerosis

Intracranialcomplications- Rare Meningitis

Subdural empyema

Brain abscess

Complicated Otitis Media:

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pSuggestive Features

High-risk patientNeonate Immunocompromised state

Diabetes, HIV,neutropenia

Intracranial Severe headache, feverMeningeal signs, seizures,DMS

Otologic Pain (retro-orbital, mastoid) Severe vertigo, SNHL Cranial nerve involvement

(6,7,8)

Displaced pinna

CoalescentMastoiditis

AcuteCoalescent

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Mastoiditis :S & S

Doughy swelling Redness /

Tenderness

Auricular

prominence Purulent otorrhea

Progressive hearingloss

Fever VII paralysis

Intracranial signs

Acute Mastoiditis

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Acute Mastoiditis

Uncommon in US Diagnosis confirmed on

CT

Management Hospitalization High dose parenteral

antibiotics

Surgical drainage if noresolution or VII nerveparalysis

Axial CT Temporal bone: Left sidedopacity of mastoid air cell consistent with

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p ydiagnosis of Mastoiditis

Chronic Suppurative OM

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Chronic Suppurative OM

Chronic Mastoiditis

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Chronic Mastoiditis

Tympanic membrane perforationchronic

Absence of pain

History of intermittent ear discharge

Chronic Osteomyelitis of the Mastoid

Diagnosis confirmed by CT

Treatment: Mastoidectomy

Otitis Media with Efusion OME

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Otitis Media with Efusion OME fluid in the middle ear without signs or

symptoms of infection

Cause:blockage of the eustachian tubewith fluid trapped in the middle ear

May occur spontaneously as part ofrhinosinusitis (inflammation of the nasalcavity and sinuses), or it may succeed about of AOM.

90% of cases occur in children between 6months and 4 years of age

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OTITIS MEDIA WITH EFFUSION

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OTITIS MEDIA WITH EFFUSION

Treatment of Otitis Media with Efusion

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Treatment of Otitis Media with Efusion

Environmental (children) Day Care

Bottle feeding in supine position

Smoking in the home

Milk-free diet Consider reflux!

Watchful waitiing

Antibiotics, oral antihistamines, decongestants steroid

sprays

ineffectiveAntihistamine sprays (Astepro, Astelin, Patanase)

possibly effective

Consider PE tube placement if no resolution

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INDICATION FOR PE TUBE

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PLACEMENT

Failure of OME to resolve Hearing loss with speech & language delay

Recurrent Acute Otitis Media

Goal of typanostomy tubes (PE) is:Ventilation of the middle ear

Temporary bypass of the Eustacian Tube

PE stand for Pressure EqualizingVentilating NOTDrainage tubes

TYMPANOSTOMY TUBES

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TYMPANOSTOMY TUBES

SHORT TERM GROMMET LONG TERM T-TUBE

TYMPANOSTOMY TUBES

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TYMPANOSTOMY TUBES

PEARL

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PEARL

Unilateral otitis media with efusionin an adult, without a preceding

URI, is a nasopharyngealcarcinoma until provenotherwise.

CHRONIC OTITIS MEDIA

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CHRONIC OTITIS MEDIA

RETRACTED TM

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RETRACTED TM

TM RETRACTION

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With serous fluid

CHOLESTEATOMA

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CHOLESTEATOMA

Cholesteatoma

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Cholesteatoma Benign growth involving

middle ear and mastoid

Cause: Persistent negativepressure on the TM

Hearing loss most commonsymptom

Microbiology: pseudomonas

Management: surgicalmiddle ear with possibleremoval of ossicles,tympanoplasty, possiblemastoidectomy

Recurrence: common

CHOLESTEATOMAP fl id d

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Pars flaccidapost sup quadrant

Pearl

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Pearl

Suspected perforation of the

pars flaccida is acholesteatoma until provenotherwise.

Inner Ear

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Inner Ear Anatomy

Diseases of the Inner Ear

Hearing Loss

Tinnitus

Acoustic Neuroma Vertigo

Benign Positional Vertigo

LabyrinthitisMenieres

Ramsey Hunt Syndrome & Bells Palsy

A t f th I E

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Anatomy of the Inner Ear Bony Labyrinth Membranous Labyrinth

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Inner Ear---Bony Labyrinth

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Bony labyrinth = set of tubelike cavities intemporal bone lined with periosteum & filled with perilymph

Semicircular canals Vestibule Cochlea

surrounds & protects membranous labyrinth123

Inner Ear---Membranous Labyrinth

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Membranous labyrinth set of membranous tubes containing sensory receptors

Hearing (cochlea)

Balance (semicircular canals)

filled with endolymph

124

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Classification of Hearing Loss

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April 19, 2012 126

C ass cat o o ea g oss

Conductive Blockage of Outer Ear

Cerumen

Infection

Dysfunction of the Middle Ear

Perforation of Ear Drum

Fluid

Eustacian Tube Dysfunction Ossicle Malfunction

Maleus, Incus, Stapes

Classification of Hearing Loss(Cont)

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April 19, 2012 127

Neurosensory

Inner Ear (Nerve of Hearing)Genetic

Noise Induced

Medication Infection

Diseases (Menieres)

Growth Mixed loss

Combination of neurosensory andconductive

Genetic (Presbyacusis)

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April 19, 2012 128

( y )

Most common type of hearing loss Loss of nerve cells in the inner ear

Begins at different ages and at a

variable rate High frequency range is lost first

Ability to distinguish consonants

most affected (b, p, sh, t, etc)

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April 19, 2012 129

Noise Induced Hearing Loss

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April 19, 2012 130

Noise Induced Hearing Loss

Extremely common

May occur at any age

Additive effect

Common sources Guns Industrial type noise

Power tools

Music (ear puds etc.)

Prevention: earprotection

Decibel Levels of Common SoundsSafe Level: 85 dB or less

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April 19, 2012 131

Safe Level: 85 dB or less

20 Ticking watch

30 Quiet whisper

40 Refrigerator hum

50 Rainfall60 Sewing Machine

70 WashingMachine

80 Alarm clock attwo feet

85 Average traffic95 MRI

100- Blow dryer

105- Power mower,chain saw

110- Screaming child

130- Jackhammer,

Jet engine (100feet)

140- Shotgun,Airbag

Evaluation of Hearing loss

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g

History Physical Exam

Appearance of ear canal and ear drum

Tuning fork testing Weber Test

Rinne Test

Weber Test

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Hold a 512 Hz tuning fork on the middle of thepatient's forehead and ask them:

"Where do you hear this loudest;left, right, or in the middle?

Rinne Test

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Compares perception of sounds, astransmitted by air or by boneconduction through the mastoid

Heinrich Adolf Rinne (1819-1868)german otologist;

Rinne test

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Placing a vibrating tuning fork (512 Hz)initially on the mastoid

Then next to the ear and asking whichsound is loudest

Audiogram

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g

audiogram is a graphicalrepresentation of how well a certainperson can perceive different sound

frequencies normalized conversion of hearing

thresholds from dBSPL to dBHL,

where dB is decibel, SPL is soundpressure level and HL is hearing level

Audiogram

http://en.wikipedia.org/wiki/Charthttp://en.wikipedia.org/wiki/Soundhttp://en.wikipedia.org/wiki/Frequencyhttp://en.wikipedia.org/wiki/Decibelhttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Sound_pressurehttp://en.wikipedia.org/wiki/Decibelhttp://en.wikipedia.org/wiki/Frequencyhttp://en.wikipedia.org/wiki/Soundhttp://en.wikipedia.org/wiki/Chart

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g

Hearing Loss

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g

Conductive

Sensorineural

Mixed Sudden SNHL

REFER

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Tinnitus (Ringing in the Ears)

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April 19, 2012 142

CausesNeurosensory hearing loss

Medication (aspirin, etc.)

VascularTempomandibular Joint Syndrome

Idiopathic

Ref: American tinnitus Associationwww.ata.org

Tinnitus: Treatment

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Medication Biofeedback

Masking TMJ temporomandibular joint

therapy

Cognitive therapy

Tinnitus Treatment (cont)

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Alternative TherapyHypnosis

Accupuncture

Ginkgo biloba

Hyperbaric Oxygen

Vitamin B

Hearing Aids

Further w/u for pulsatile tinnitus

Acoustic Neuroma

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Benign neurolemmoma orschwannoma of the Eighth Cr. Nerve

Located in the internal acoustic canal

Usual presentation: Progressiveassymetric NSHL with poordiscrimination

Treatment: Observation, CyperKnife, Surgery

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Internal Acoustic Canal (IAC)

Acoustic Neuroma IAC

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Acoustic Neuroma IAC

MRI Coronal View

38 /

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38 yo c/ohearing loss

left ear 3moduration

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Same pt,8 monthslater

Acoustic NeuromaMRI Coronal View

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MRI Coronal View

Acoustic NeuromaAxial MRI

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Axial MRI

Idiopathic SuddenSensorineural Hearing Loss

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Sensorineural Hearing Loss Hearing loss

Sudden - no trauma history Rapidly progressive (

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Hearing LossWorkup - 90% no etiologyfound Complete audiogram CBC/platelets/ESR/RPR

MRI with gadolinium 1%-3% acoustic tumors

Management Urgent ENT referral Corticosteroids - proven

benefit. Oral vs. Perfusion Other therapies - controversial

Carbogen, Histamine,Heparin, Dextran

Prognosis - 2/3 recoverhearing Related to severity Improved if responsive to

steroids

Left AcousticNeuroma

Vertigo vs. Dizziness

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The hallucination of movementspinning sensation

Distinct symptom complex

Vertigo is not: light headedness,syncope, fainting, dysbalance

Central (brain) issues and

Cardiovascular issues frequentlyconfused with Inner Ear pathology

Objectives

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Differentiate the causes of vertigo Know the etiology of vertigo

Describe acute labyrinthitis

Describe Mnire's Disease

Describe Benign Positional Vertigo

Discuss the anatomy involved ininner ear pathology

Pattern of Presentation

http://www.google.com/url?sa=t&source=web&cd=1&sqi=2&ved=0CB4QFjAA&url=http://en.wikipedia.org/wiki/M%25C3%25A9ni%25C3%25A8re%27s_disease&ei=-2iRTNP9BdO6jAeViIHABQ&usg=AFQjCNH0yJQuax8zqTR_iuMkywoPgcI9Fg&sig2=L0o2q3IE0EI0NhXv7d9loghttp://www.google.com/url?sa=t&source=web&cd=1&sqi=2&ved=0CB4QFjAA&url=http://en.wikipedia.org/wiki/M%25C3%25A9ni%25C3%25A8re%27s_disease&ei=-2iRTNP9BdO6jAeViIHABQ&usg=AFQjCNH0yJQuax8zqTR_iuMkywoPgcI9Fg&sig2=L0o2q3IE0EI0NhXv7d9log

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Duration of individual attack

Frequency

Effect of head movementsSpecific position inducing symptoms

Associated aural symptoms

Concomitant ear disease

Differential Diagnosis

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BPPV=benign paroxysmalpositional vertigo

VN=Vestibular neuronitis

Menieres

Diabetes

CPA tumor

Migraine

Otosclerosis

Hypothyroidism

Neuropathy

Pagets Disease ofthe skull (osteitisdeformans

Head trauma

Toxicvestibulopathy

Lipid abnormalities

Benign Positional Vertigo

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Transient Postitional

The most common type of vertigo in

older patients No associated nausea or vomiting

No associated hearing loss

Dix-Hallpike Maneuver: Nystagmus

BPV--continued

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Causes: Head trauma

Procedures

Medication eg. Gentamycin Pathophysiology: Otoconia (rocks)

from utricle displaced into the

posterior canal. Treatment: Responds to Physical

TherapyEpley maneuver

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Dix-Hallpike Maneuver for BPV

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Vestibular Neuronitis,

L b i thiti (VN)

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Labyrinthitis (VN)

Sudden onset severe vertigo incapacitating

Nausea and VomitingRecent or concurrent URI

Neurosensory hearing loss

commonSelf-limited

Labyrinthitis--continued

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Etiology---Viral infection inner earBacteria cause occasional

Treatment:

Antiemetics Corticosteroids: oral, IV, or perfusion of

the inner ear

Antivirals

Menieres Syndrome

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Histopathology

Clinical features

Causes

Refer!

Menieres Syndrome

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Idiopathic endolymphatic hydropsCharacterized by aHistory of increasing ear fullness

Roaring tinnitus followed by asensation of blocked hearing

Episodic with months or years symptomfree

Fluctuating Neurosensory Hearing Loss

REFER!

Menieres Syndrome

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Endolymphatic Hydrops: Increasedpressure in the inner ear

Possible causefailure of cellular

pump Symptoms caused by inability

membranous inner ear to swell

bony labyrinth Genetic propensity

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Management

Medical: Acute Prednisone 60 mg taper

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Medical: Acute- Prednisone 60 mg taper

over 10 daysChronic tx: Diuretic. Low salt, Low

caffeine diet

Allergic desensitization

Surgical (for intolerable vertigo) Trans tympanic Steroid Perfusion

Transtympanic Gentamicin Perfusion

Retrosigmoid vestibular nerve resection

Transmastoid endolymphatic sacprocedure

Transmastoid labyrinthectomy

Perilymph fistula

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PatternsVertigo episodes without hearing loss

Hearing loss without vertigoA Menieres syndrome pattern

Dysequilibrium without vertigo

Associated with barotrauma

Evaluation for Vertigo

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LaboratoryRadiographic studies

Vestibular function tests

Audiologic studies

Immunologic StudiesRefer

Electrocochleography (ECoG)

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ECOG is performed by placing an electrode thatconsists of a wire, into the ear canal as close aspossible to the cochlea.

The ear is then stimulated with alternating clicksof different polarities, or tone bursts.

These tone bursts are transformed intovibrations in the middle ear, your ear does thisnaturally and automatically all the time.

The vibrations are turned into electrical impulses

in the inner ear and are recorded and measuredusing computer software.

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Conclusion

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Accurate diagnosis

Suppression of nausea & vomiting

Preventive medical therapySurgery for failed medical therapy

Rehabilitative therapy

Ramsey-Hunt Syndrome

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Cause:Varicella-zoster virus (chicken pox)involving the VII facial nerve

Symptoms: Pain, Rash, Facial nerve palsy,Hearing loss

Treatment: Acyclovir

Steroids

Complications Permanent hearing loss

Permanent weakness of facial nerve

Eye damage

Post Herpetic Neuralgia

Ramsey-Hunt Syndrome

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Acute Facial Paralysis

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Facial paralysis workup CBC, ESR, Lyme titer Glucose tolerance test Audiogram CT/MRI - if atypical/recurrent

Diagnosis of exclusion Infectious

Zoster, Lyme, otitis media Neoplasm

Temporal bone, parotid

Systemic Sarcoid, diabetes,autoimmune

Etiology Herpes simplex virus Neural edema in bony

sheathAcute onset Rapid time course

No hearing loss or vertigo+/- Ear/facial painNormal examination Head and neck examination

Neurologic examination

Idiopathic (Bells) Palsy >50%

Bells Palsy

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y

Idiopathic (Bells) PalsyManagement

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Corticosteroids/acyclovir Decreases sequealae

Eye care - most important Educate patient

Ocular lubricants Exposure protection Early ophthalmology consultation

Prognosis - generally good 85% recover in 3 weeks