Clinical otology

This presentation discusses clinical otology

1. Balasubramanian Thiagarajan
Clinical Otology

2. Symtoms
•Deafness
•Discharge
•Tinnitus
•Pain
•Vertigo

3. Deafness

Onset
Sudden
Gradual
Trigger

4. Sudden hearing loss (SN)
•Loss of atleast 30 dB in atleast three contiguous
frequencies over a period of less than 3 days.
•Viral causes
•Vascular causes
•Hearing loss is the only symptom
•High dose prednisolone may be useful

5. Sensorineural hearing loss (Sudden)
•Transverse fracture of pertrous bone
•Auto immune reaction following trauma / infection
•Inflammatory reaction (Viral infections)
•Vascular compromise

6. Conductive hearing loss - (Sudden)
•Ossicular disruption
•Haemotympanum (transient)
•Failed attempts to remove cerumen

7. Mixed hearing loss - (Sudden)
•Fractures involving petrous bone
•Auto immune reaction to proteins released due to
traumatic injury

8. Gradual progressive hearing loss
•Inflammatory
•Degenerative

9. Fluctuating hearing loss
•Impacted cerumen
•Meniere's disease
•Perilymph fistula

10. Differentiating Conductive / SN loss
•Difficulty in comprehending spoken words
•Deafness associated with tinnitus
•Intolerance to loud sounds
•Tuning fork tests

11. Discharge
•Quantity
•Quality
•Duration of discharge
•Aggravating / releiving factors

12. Ear discharge - quality
•Mucoid - CSOM
•Mucopurulent - CSOM with mastoiditis
•Serous - ASOM
•Serosanguinous - ASOM, Otitis externa, trauma
•Watery - CSF otorrhoea

13. Ear discharge - causes
•ASOM
•CSOM
•Otomycosis
•CSF otorrhoea

15. Tinnitus
•Wax
•Active otosclerosis
•Sensorineural hearing loss
•Ototoxic drugs
•Objective tinnitus - Patulous ET, Palatal myoclonus

16. Pain
•Otalgia
•Referred otalgia

17. Ear pain
Otalgia
Referred otalgia
5,6,10th cranial nerves
C2 & C3
Otomcosis
Tragal
tenderness +
Myringitis granulosa
Tragal tenderness -
Keratosis obturans
Tragal tenderness +
AOM
Tragal tenderness -
Furuncle
Tragal tenderness +
impated waxTragal
tenderness
+

18. Vertigo
•Sensation of unsteadiness / rotation
•Diseases if inner ear cause vertigo
•Associated with tinnitus and hard of hearing
•Peripheral vertigo

19. Nystagmus
•Spontaneous / evoked
•Direction of nystagmus -
Right beating, left beating,
geotrophic, ageotrophic.
•Plane - Horizontal, rotatory
or vertical
•Intensity - (I, II and III
degree)

20. Spontaneous nystagmus
•Eye movements without congnitive, visual, vestibular
stimulus
•Commonly induced by vestibular imbalance
•Vestibular nystagmus is typically inhibited by visual
fixation
•It follows Alexander's law (nystagmus is greater in
the direction of fast phases)

21. Alexander's nystagmus grading
•I degree - Present only during gaze in the direction of
fast phase
•II degree - Present during straight gaze and also
increases in the direction of fast phase
•III degree - Present during all fields of gaze, but
greatest in the direction of fast phase

22. History should include
•Previous ear surgery
•Previous head injury
•Systemic diseases like diabetes / Hypertension
•Use of ototoxic drugs
•Noise exposure
•Family h/o deafness
•H/o atopy / allergy

23. Inspection of external ear
•Shape and size of pinna
•Presence of tags, preauricular sinus and pits
•Evidence of trauma to pinna
•Skin condition over pinna and external canal
•Presence of operative scar in post aural area and end
aural region
•Neoplastic lesions of pinna
•Discharge from external canal

24. Drug history / Occupation
•Drugs like gentamycin, Streptomycin, and Aspirin can
cause extensive damage to hair cells of cochlea
•Noise exposure can cause damage to outer hair cells
of cochlea
•May be reversible during early phases

25. Drug induced ototoxicity - Features
•Bilateral sensorineural hearing loss
•Bilaterally symmetrical hearing loss
•Onset time - ???
•Can occur even after a single large dose
•Vestibular injury - common (aminoglycosides)
•Positional nystagmus - a feature of vestibular injury

26. Aminoglycosides
•Cleared more slowly from inner ear fluids than serum
•There exists a latency - deafness may occur even 2
months after cessation of the treatment
•Pts on potentially ototoxic aminoglycoside
medications should be monitored atleast for a period
of 6 months following cessation of the offending
drug.

27. Discharge
•Duration
•Quantity
•Quality
•Aggravating & releiving factors

28. Acute ear discharge - Causes
•ASOM - Blood tinged
•Otomycosis - Itchy ear, fungal mass seen
•CSF otorrhoea

29. Profuse ear discharge - Causes
•Chronic mastoiditis - Mastoid tenderness + May lead
to formation of subperiosteal abscess
•Mastoid reservoir - Mastoid tenderness on deep
palpation +
•Extradural abscess

30. Quality of ear discharge
•Mucoid - CSOM
•Mucopurulent - CSOM with mastoiditis
•Serous - asom
•Serosanguinous - ASOM, Otitis externa
•Watery - CSF

32. Tinnitus
•Subjective - perceived by the patient
•Objective - perceived by both the pt and examiner

33. Otalgia
•Pain in the ear
•Could be due to inflammatory pathology affecting
the ear
•Referred otalgia due to pathology elsewhere

34. Three finger test
•Index, middle and thumb are used.
•Index finger is applied over mastoid process -
tenderness indicates mastoiditis
•Middle finger is applied over well of the concha -
tenderness indicates inflammation in the mastoid
antrum area
•Thumb is used to apply pressure over mastoid
process. Tenderness indicates mastoid emissary vein
thrombophlebitis

36. Peripheral vertigo
•Is defined as sensation of unsteadiness / rotation
•Commonly caused by inner ear disorders
•Associated with tinnitus / ear block

37. Peripheral vertigo - Features
•It is fatigable
•It is positional
•Horizontal nystagmus
•Cerebellar signs absent

38. External ear
•Shape / size of pinna
•Tags / sinuses / pits
•Evidence of trauma to pinna
•Perichonditis
•Seroma
•Skin of pinna / external canal
•Discharge from external canal
•Evidence of previous surgery
•Neoplasm

40. External canal - Straightening
•Aural speculum
•Adults - Pinna is pulled
postero superiorly
•Infants - pinna is pulled
posteriorly and downwards

41. Ear drum
•Oval / pearly white in color
•Pars tensa
•Attic
•Cone of light
•Handle / lateral process of malleus
•Perforations

42. Cone of light
•Present in the antero
inferior quadrant
•Cone shaped
•Caused due to orientation
of middle fibrous layer
•Broken up in retracted ear
drums
•Broken up / lost when ear
drum bulges

43. Color of ear drum
•Pearly white - normal
•Red drum - Glomus jugulare, AOM
•Blue drum - SOM, Hemotympanum
•Pink drum - Flamingo sign
•Chalky drum - Tympanosclerosis

45. Retraction pocket features
•Prominent anterior and
posterior malleolar folds
•Apparent foreshortening of
handle of malleus
•Prominent lateral process of
incus
•Decreased / absent mobility
of ear drum
•Presence of pockets of
retraction

46. Siegel's speculum
•Convex lens
•Magnifies 2.5 times
•Mobility of ear drum
•To suck out secretions from
middle ear
•To apply ear drops by
displacement method

48. Tuning fork tests
•Three frequencies are used
•256Hz, 512 Hz, 1024 Hz
•These frequencies fall within speech range
•Rinne, Weber and ABC

49. Prerequisites of a good tuning fork
•It should be made of good alloy
•Should vibrate for one full minute
•Should not produce overtones

50. Rinne test
•All three frequencies can be
used
•+ Rinne (Air conduction
better than bone
conduction)
•-ve Rinne (Bone conduction
better than air conduction)
•False positive Rinne (occurs
in unilateral total hearing
loss due to opposite ear
hearing)

51. Weber test
•512 Hz fork is used
•Lateralized to worse ear
•Useful in indentifying
conductive deafness
•Can identify even 5 dB
hearing difference between
two ears

52. ABC test
•Helps in identifying s/n loss
•Pts hearing is compared to that of the examiner
•It is not reduced in normal ears

53. Fistula test
•Performed by applying +ve - ve pressure to ear drum
using penumatic speculum.
•Nystagmus can be visualized by the examiner or
recorded using ENG machine
•Positive in the presence of fistula / vestibular fibrosis
•Nystagmus occuring with tragal compression of
valsalva maneuver is caused by superior semicircular
canal dehiscence syndrome

54. +ve fistula test causes
•Oval / round window fistulae
•Post stapedectomy perilymph leak
•Horizontal canal fistula
•Meniere's disease
•Labyrinthitis

55. Hennebert's sign
•+v e fistula test in the presence of intact ear drum
•No evidence of middle ear disease
•Seen in syphilis and hyper mobile foot plate status
•Meniere's disease

56. Tullio phenomenon
•Sound induced vestibular symptoms - vertigo,
nystagmus, Oscillopsia and postural imbalance
•Seen in - Superior canal dehiscence, Meniere's
disease, vestibulo fibrosis, perilymph fistula, post
fenestration surgeries (i.e. stapedectomy)

57. Head shake test
•pts head is positioned with chin inclined down 30
degrees
•Head is rotated rapidly to one side.
•Normal response includes no nystagmus / few beats
of nystagmus
•In unilateral labyrinthine dysfunction - nystagmus is
present with slow phase directed towards the
direction of dysfunctional labyrinth

58. Thank You
Otolaryngology online
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