ASSESSMENT OF Deafness

CLINICAL EXAMINATION OF EAR

1. Assessment of Deafness Dr. AJAY MANICKAM JR – DEPT OF ENT RG KAR MEDICAL COLLEGE

2. History taking Name Age Sex Age group Disease Infancy to adulthood COM causes CHL 6months – 6 years Recurrent AOM School going children OME causes CHL 10 – 40 years Otosclerosis (CHL) Male Female Meniere’s disease Otosclerosis Acoustic neuroma Glomus tumours In india otosclerosis more common in males Acoustic neuroma

3. History taking Name Age Sex Occupation – P ersons /Professionals exposed to noise trauma

4. History of presenting illness Hard of hearing / deafness Tinnitus Ear ache Ear discharge

5. Hard of hearing Present history of deafness Onset of deafness – congenital / acquired Duration of deafness Severity of deafness – mild/moderate/mod severe/profound - found only in audiometry Progression of deafness

6. Present history contd …. Hearing impairment Onset Sudden – impacted wax, vascular/viral, acoustic trauma Gradual – presbycusis,CSOM , acoustic neuroma, otosclerosis , NIHL Unilateral - COM, mumps, Herpes zoster oticus , acoustic neuroma Bilateral – presbycusis , meniere’s disease, otosclerosis , NIHL Progressive – meniere’s disease,presbycusis , otosclerosis , acoustic neuroma. tympanosclerosis Fluctuating – meniere ’ disease, perilymph leak

7. Hearing impairment Autophony – hearing ones voice louder Paracusis willsi - hearing better in noisy place Diplaucusis – difference in pitch of ear in meniere.s disease

8. Otalgia Onset Duration Nature Aggravating factors / relieving factors

9. Otalgia – ear ache Pain in ear can be local or referred Onset Sudden - AOM, furunculosis , otitic barotrauma Gradual – OE secondary to COM, malignancy, malignant OE Duration Short – AOM, perichondritis pinna Long – malignancy Nature of pain Dull – eczematous OE, secretory OE, wax Sharp – furunculosis , otitic barotrauma Throbbing – AOM Aggravating factors with swallowing – AOM With yawning furunculosis . On pulling pinna – OE Relieving factors – relieves on discharge from ear - AOM

10. Referred otalgia Referred pain via 5 th nerve Dental – caries, impacted molar, malocclusion Oral cavity – benign / malignant ulceration TM joint disorders – costen syndrome, arthritis Referred pain via 9 th nerve BOT malignancy, acute tonsillitis, peritonsillar abscess, ulcers of soft palate, elongated styloid process (Eagle’s syndrome) Referred pain via 10 th nerve Ulcerative lesions of vallecula , epiglottis, larynx, laryngopharnx Referred pain via C2,3 cervical spondylosis , caries spine

11. Ear discharge Onset Duration Type Consistency Odour Quantity Associated conditions

12. Ear discharge - otorrhoea Onset Sudden – AOM, otomycosis , OE Gradual – COM Duration Long COM, Eczematous OE Short –AOM, ruptured furunculosis Intermittent – tubotympanic COM Type Watery – CSF otorrhoea , OE Serosanguinous – fungal, diffuse OE Mucopurulent – COM tubotympanic , tuberculous COM Mucoidal – COM tubotympanic , granular myringitis , fungal Purulent – furunculosis , mastoiditis , malignant OE, unsafe COM Blood stained – COM with granulation, glomus tumour, malignant OE

13. Ear dischage contd … Consistency of discharge viscous & tenacious in tubotympanic variety of COM Odour Odourless – allergic OE, COM safe type Foul smelling – unsafe COM Quantity Profuse – tubotympanic COM Scanty – unsafe COM Associated conditions Discharge increases with cold, head bath, pharyngitis, tonsillitis, adenoiditis seen in tubotympanic variety of COM

14. Past history H/O ototoxic medications H/O trauma or head injury H/O viral infection (Ramsay Hunt syndrome) H/O ear surgery

15. Personal history Hypertension Smoking & alcohol Diabetes Family history of deafness

16. Examination of the EAR Examination of external ear - pinna – inspection & palpation of pinna, pre & post auricular region . Look for deformity, thickening, preauricular sinus, scar mark, tenderness Tenderness over tragus / tenderness over mastoid

17. Examination Examination of EAC – look for wax, stenosis, deformity, mass, sagging of post wall of meatus

18. Examination of the TM Colour , position, mobility, changes in surface. Perforation if present- shape of the perforation, ant inf , post sup quadrant Discharge present / not Margins of perforation regular / irregular. Part of ME mucosa seen through perforation – edematous / congested/ healthy

19. Neuro otological examination To rule out symptoms like Fever Headache Stiffness of neck Facial palsy Vomiting Diplopia Cervicofacial pain

20. Investigations Complete hemogram Biochemical reports Thyroid function test

21. Audiological Tuning fork test – R inne , Weber, Absolute bone conduction test PTA Tympanometry Speech audiometry BERA OAE

22. Tuning fork test Rinne Weber ABC

23. Pure Tone Audiometry Measurement of hearing acuity by using pure tones to estimate the air conduction & bone conduction thresholds of hearing for various frequencies

24. PTA Gives a graphical representation of different hearing loss both quantity & quality can be studied Normal hearing (0-25dB) Mild hearing loss (26-40dB) Moderate hearing loss (41-55dB) Moderately severe (56-70dB) Severe hearing loss (71-90db) Profound hearing loss (>90dB)

25. Tympanometry Main objective audiometric test Three factors impede the flow of sound Stiffness of the TM Mass provided by the ossicles Friction or resistance by ligaments in the ME 2 apparatus Apparatus 1 – ear probe containing 3 tubes Tube for delivering tone Microphone to pick up energy Manometer to change pressure Apparatus 2 – in the opposite ear used to measure acoustic reflex

26. Tympanometry Jerger described 5 types of tympanograms

27. BERA Measurement of tiny physiological electric events occuring in response to sound stimulation are assessed by this audiometry BERA – Brain Stem Evoked Response Audiogram Sound waves entering cochlea transmitted through VIII nerve to brain stem, these electrical responses are picked up by surface electrodes and represented graphically Wave 1 – E ighth nerve Wave 2 – C ochlear nuclei Wave 3 - superior O livary nuclei Wave 4 – L ateral lemniscus Wave 5 – I nferior colliculus ( E COLI )

28. Vestibular functions test Romberg’s test Sharpened Romberg’s test Heal – toe walking test Unterberger test Caloric test

29. Romberg’s test Patient asked to stand with feet together and arms by the sidewith eyes open first and then eyes closed In peripheral system lesion patient sways to the side of the lesion but in central lesion patient shows instability

30. Sharpened Romberg’s test If R omberg’s test is normal, the patient is asked to stand with one heel of one foot in front of the toes of the other arm folded across chest. Inability to perform indicates peripheral system impairment

31. Gait test The patient is asked to walk along a straight line to a fixed target with eyes opened and then eyes closed. In case of peripheral lesion patient deviates to the affected side

32. Unterberger test Patient asked to stand hands outstretched and closed eyes He will be asked to march on the spot inside a circle Patient having unilateral vestibular lesion will deviate towards that side

33. Caloric test Patient will be in a couch with head end elevated 45 degrees and each ear will be irrigated with hot and cold water to stimulate vestibular labyrinth Hot water 44 degree causes nystagmus with quick component to the simulated side Cold water 30 degree produces nystagmus in the opposite direction Normal duration of nystagmus is 3-4 minutes CANAL PARESIS – nystagmus is reduced. If no nystagmus that indicates a dead labyrinth

34. Radiological investigations X-Ray mastoids bilateral lateral oblique view HRCT temporal bone MRI brain

35. Diagnosis History & complaint Disease Investigations Ear ache, itching, decreased hearing Wax/ otomycosis Otoscopy , CHL Ear ache & bleeding FB living/dead Otoscopy , EUM – CHL Severe tenderness Furuncle Otoscopy , CHL Otorrhoea COM, AOM Otoscopy , EUM PTA, C/S of pus, CT scan, Tinnitus & vertigo BPPV, SNHL, Labyrinthitis , Meniere’s disease, acoustic neuroma, otosclerosis ENG, PTA, Tympanometry, ECoG , Caloric test, MRI Tragal tenderness OE Clinical examination

36. Syndromes Waardenburg’s syndrome – widest eyes, white forelock, progressive hearing loss Alport’s syndrome – deafness & kidney disease Crouzon’s syndrome – craniofacial dysostosis Apert’s syndrome – syndactyly + crouzon syndrome Vander Hoeve’s syndrome – osteogenesis imperfecta , blue sclera, hearing loss Stickler’s syndrome – small jaw, cleft palate, myopia, cataract, SNHL Down’s symdrome Goldenhar’s syndrome – oculo - auriculo -vertebral syndrome

37. THANK YOU