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About This Presentation
Full Textbook latest edition
Slide Content
Diseases of
N EAR,
> NOSE
ano THROAT
S HEAD and NECK SURGERY
PL Dhingra | Shruti Dhingra ME
LES,
Assisted by Dheeksha Dhingra
N EAR,
> NOSE
ano THROAT
S HEAD and NECK SURGERY
PL Dhingra | Shruti Dhingra ME
LES,
Assisted by Dheeksha Dhingra
Diseases of Ear,
Nose and Throat
& Head and Neck Surgery
mebooksfree.com
Nose and Throat
& Head and Neck Surgery
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Page ot intentional blank
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SEVENTH EDITION
Diseases of Ear,
Nose and Throat
& Head and Neck Surgery
PL DHINGRA, MS, DLO, MNAMS, FIMSA
Emeritus Consultant, Indraprastha Apollo Hospital, New Delhi
Formerly Director, Professor & Head, Department of Otolaryngology
and Head & Neck Surgery, Maulana Azad Medical College and
Associated LNJP & GB Pant Hospitals, New Delhi
‘SHRUTI DHINGRA, MS (MAMC), DNB, MNAMS
Member, International Medical Sciences Academy; Flow, Laryngology
and Voice Disorders; Head of Department of Otolaryngology and
Head & Neck Surgery, ESIC Medical College, Faridabad, Haryana
Assisted by
DEEKSHA DHINGRA, MD, PGDHA, MPH (UNIVERSITY OF SYDNEY)
ELSEVIER
Diseases of Ear,
Nose and Throat
& Head and Neck Surgery
PL DHINGRA, MS, DLO, MNAMS, FIMSA
Emeritus Consultant, Indraprastha Apollo Hospital, New Delhi
Formerly Director, Professor & Head, Department of Otolaryngology
and Head & Neck Surgery, Maulana Azad Medical College and
Associated LNJP & GB Pant Hospitals, New Delhi
‘SHRUTI DHINGRA, MS (MAMC), DNB, MNAMS
Member, International Medical Sciences Academy; Flow, Laryngology
and Voice Disorders; Head of Department of Otolaryngology and
Head & Neck Surgery, ESIC Medical College, Faridabad, Haryana
Assisted by
DEEKSHA DHINGRA, MD, PGDHA, MPH (UNIVERSITY OF SYDNEY)
ELSEVIER
ELSEVIER
[ett OM 18 8h Nt Ideas ung 21, scams Rod Nor Deh 1001
LEE 208 REX ag o nam ei a
Riad 2016 ice), 2018, 2014, 205, 2012, 201 wc.
A ro
opt pn ma e pod ame ay farm by any mm, de où
Emisión in wating om te uber Det on ow to ek peri be neti oat the
Abe persons pices and ur atangemens mt gations sc a the Copy Crane
Center dhe Cop Licensing. Agency, cat ound a our mbites mc sone,
‘Ths took andthe nds colon conti nt ate potted unde copy y the her
Nowe
Fractttoners and searchers must avy ely on thee owe esprence and knowledge in evaluating
and sing any tora, methods compounds o pates dsc her. Because a rapid
vam tb medica scence In parta, Independent vrlaton of don and arg doses
Shout made To theta extent of hela no ons assured by Ese aos eters
ren any nny anor damage ns Poo) oa mat pc iy
gh alae material expected conform to cal nea stands non ins
soda nto scm a al ore im pa ore
Pease cosa fl prc information before suing preston for any produc mentioned in
this ation
Mnager—Canet Stes en Rawat
ono soie ram Ama
mag at Stato Die Sr Soga
‘ect Ee dr Sa
‘yest by Thomson Dial
CT
mebooksfree.com
[ett OM 18 8h Nt Ideas ung 21, scams Rod Nor Deh 1001
LEE 208 REX ag o nam ei a
Riad 2016 ice), 2018, 2014, 205, 2012, 201 wc.
A ro
opt pn ma e pod ame ay farm by any mm, de où
Emisión in wating om te uber Det on ow to ek peri be neti oat the
Abe persons pices and ur atangemens mt gations sc a the Copy Crane
Center dhe Cop Licensing. Agency, cat ound a our mbites mc sone,
‘Ths took andthe nds colon conti nt ate potted unde copy y the her
Nowe
Fractttoners and searchers must avy ely on thee owe esprence and knowledge in evaluating
and sing any tora, methods compounds o pates dsc her. Because a rapid
vam tb medica scence In parta, Independent vrlaton of don and arg doses
Shout made To theta extent of hela no ons assured by Ese aos eters
ren any nny anor damage ns Poo) oa mat pc iy
gh alae material expected conform to cal nea stands non ins
soda nto scm a al ore im pa ore
Pease cosa fl prc information before suing preston for any produc mentioned in
this ation
Mnager—Canet Stes en Rawat
ono soie ram Ama
mag at Stato Die Sr Soga
‘ect Ee dr Sa
‘yest by Thomson Dial
CT
mebooksfree.com
Dedicated to all my students: post, present and futur who are the
Inspiring force behind his work,
| reproduce below the invocation from our great ancient senpturethe
Kathopanishad which shows the relationship Between the teacher and the taught.
Sot aq owt or
ar aid woah dar A oni oe
bs ena: af:
“0 God, the almighty, bess us both (the teacher and the student)
together, develop us bot together, give us strength together. Let the
knowledge acquired by us be bright and iluminant, and second to none.
Le both of us Ive together with love, action and harmony. O God let
there be physical, mental and spintual pace.”
mebooksfree.com
Inspiring force behind his work,
| reproduce below the invocation from our great ancient senpturethe
Kathopanishad which shows the relationship Between the teacher and the taught.
Sot aq owt or
ar aid woah dar A oni oe
bs ena: af:
“0 God, the almighty, bess us both (the teacher and the student)
together, develop us bot together, give us strength together. Let the
knowledge acquired by us be bright and iluminant, and second to none.
Le both of us Ive together with love, action and harmony. O God let
there be physical, mental and spintual pace.”
mebooksfree.com
Page ot intentional blank
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Preface
Its a matter of pride and pleasure to bring out the ser
Ibe ein of ur book “Diseases of Er, Nose and Tout
{8 Head and Neck Suey.” The book was fst published
in 1992 and has been well accepted and appreciated by
the students and teachers al ver the county as well a
in adjining South Asan counties, During Uns period of
25 years, sx editions and sever reprints were bought
‘out This was the result of growth ofthe specially, in
ovations in technology and sugkal techniques but be
Fin té was students’ Burning deine to know the subject
and quest for knowledge. They tely interacted Uwough
‘malls letter and other types of socal media to clay,
“nd send suggestions, omissions, commissions and thelr
interes in the subject to farther add Ihe topics of their
reed. We complied practialy with allo them afar as
pose.
‘Our basic alm in writing this book has been 10 build
concepts in disorders of ENT, superstructured withthe
Student earlier Knowledge of anatomy and physiology
feat in previous professionals. Since Otolaryngology,
common called ENT, i a full-tedged subject MBBS
‘examination and i o recognized in Various universes
in India and Medical Council of Ind, we did not lose
sight ofthe fact that students have to clear the exams too.
‘The book covers disorders of ENT, surgical instruments,
Imaging techniques, operative surgery, recent and newer
modales of treatment in a concise Luc and student
friendly manner, The chapter on “Nuggets for Rapid
Review" covers most of the questions that are often set
in postgraduate entance and Diplomat of National Board
(DNB) examinations
The present edition i reis, updated and expand.
Several new clinical photographs, diagrams, tables and
Aovecharts ave been added to make the subject cle À
‘unique feature of this edition is white board lecture and
videos (9), depicting through animations, the Surgical
procedures.
"Ns hope that dhe present edition would continue to
serve the needs of MBBS student, residents and pact.
ones. The postgraduate students ofthe DLO, MS and
DNB wil nd usta as à foundation book before ting
‘recourse to comprehensive volumes onthe subject.
“The students of allied subjects Audiology and Speech
‘Therapy, Physiotherapy and these studying alternative
medicine (Ayurveda, Sia, Unant and Homeopathy) will
A nd weft learn basic and concepts of ENT.
“The authors wil gatehuly accept any suggestions
and comments from the lcamed teachers and students
at pldhingrasgmallcom or shralocehotmalcom or
PL Dixons,
Simon Dina,
m
mebooksfree.com
Its a matter of pride and pleasure to bring out the ser
Ibe ein of ur book “Diseases of Er, Nose and Tout
{8 Head and Neck Suey.” The book was fst published
in 1992 and has been well accepted and appreciated by
the students and teachers al ver the county as well a
in adjining South Asan counties, During Uns period of
25 years, sx editions and sever reprints were bought
‘out This was the result of growth ofthe specially, in
ovations in technology and sugkal techniques but be
Fin té was students’ Burning deine to know the subject
and quest for knowledge. They tely interacted Uwough
‘malls letter and other types of socal media to clay,
“nd send suggestions, omissions, commissions and thelr
interes in the subject to farther add Ihe topics of their
reed. We complied practialy with allo them afar as
pose.
‘Our basic alm in writing this book has been 10 build
concepts in disorders of ENT, superstructured withthe
Student earlier Knowledge of anatomy and physiology
feat in previous professionals. Since Otolaryngology,
common called ENT, i a full-tedged subject MBBS
‘examination and i o recognized in Various universes
in India and Medical Council of Ind, we did not lose
sight ofthe fact that students have to clear the exams too.
‘The book covers disorders of ENT, surgical instruments,
Imaging techniques, operative surgery, recent and newer
modales of treatment in a concise Luc and student
friendly manner, The chapter on “Nuggets for Rapid
Review" covers most of the questions that are often set
in postgraduate entance and Diplomat of National Board
(DNB) examinations
The present edition i reis, updated and expand.
Several new clinical photographs, diagrams, tables and
Aovecharts ave been added to make the subject cle À
‘unique feature of this edition is white board lecture and
videos (9), depicting through animations, the Surgical
procedures.
"Ns hope that dhe present edition would continue to
serve the needs of MBBS student, residents and pact.
ones. The postgraduate students ofthe DLO, MS and
DNB wil nd usta as à foundation book before ting
‘recourse to comprehensive volumes onthe subject.
“The students of allied subjects Audiology and Speech
‘Therapy, Physiotherapy and these studying alternative
medicine (Ayurveda, Sia, Unant and Homeopathy) will
A nd weft learn basic and concepts of ENT.
“The authors wil gatehuly accept any suggestions
and comments from the lcamed teachers and students
at pldhingrasgmallcom or shralocehotmalcom or
PL Dixons,
Simon Dina,
m
mebooksfree.com
Page ot intentional blank
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Acknowledgements
‘We profusely thank all the Heads of Departments of ENT.
and the teaching aclty members of medical institutions
‘who appreclated our cor and sent words of encour
“agement. In particular we mention Prol (D) SA Jags
Kumar, ECDVC (aa), IMT Univesity of Tanzania, who
spent several hous in going through the book and true
{ons abiding interest inthe special, sent valuable Sug.
cations which we have tied to Incorporate,
thank Dr GK Jadhav and DrSapna Manch Verma,
Senior Consultant, Department of Radatlon Oncology,
Tndaprastha Apolo Hospitals, Di, in contbuting the
chapter on Radiotherapy in Head and Neck Cancers
We also thank Dr Tarun San, Head of Hyperbaric
‘oxygen Therapy Unit, Indraprastha Apollo Hospital for
ns contbution to Hyperbaric Oxygen Therapy chapter.
Wethank the entireteam of RELX India Pvt Ltd: or.
ment known as Reed Eller India Pv LD or thee up.
port and excellence in publication, We especialy pre.
te cheertl and professional approach and hard work put
in by Ms Sabina Nasim, Senior Manager: Ms Shivan! Pal,
‚Content Projet Manager, and Ms Sheenam Aggarwal,
Content statist.
PL Dive
Sn uve,
mebooksfree.com
‘We profusely thank all the Heads of Departments of ENT.
and the teaching aclty members of medical institutions
‘who appreclated our cor and sent words of encour
“agement. In particular we mention Prol (D) SA Jags
Kumar, ECDVC (aa), IMT Univesity of Tanzania, who
spent several hous in going through the book and true
{ons abiding interest inthe special, sent valuable Sug.
cations which we have tied to Incorporate,
thank Dr GK Jadhav and DrSapna Manch Verma,
Senior Consultant, Department of Radatlon Oncology,
Tndaprastha Apolo Hospitals, Di, in contbuting the
chapter on Radiotherapy in Head and Neck Cancers
We also thank Dr Tarun San, Head of Hyperbaric
‘oxygen Therapy Unit, Indraprastha Apollo Hospital for
ns contbution to Hyperbaric Oxygen Therapy chapter.
Wethank the entireteam of RELX India Pvt Ltd: or.
ment known as Reed Eller India Pv LD or thee up.
port and excellence in publication, We especialy pre.
te cheertl and professional approach and hard work put
in by Ms Sabina Nasim, Senior Manager: Ms Shivan! Pal,
‚Content Projet Manager, and Ms Sheenam Aggarwal,
Content statist.
PL Dive
Sn uve,
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Page ot intentional blank
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Contents
Dedication y
Preface vi
Acknowledgements x
SECTION 1
DISEASES OF EAR 1
Chapter 1
‘Anatomy of for 3
Chapter 2
Perpheral Receptors and Physiology of Auditory
(nd Vestbular Systems 19
Chapter 3
“aulology and Acoustics 21
Chapter 4
Assessment of Hearing 23
[2] Meoringtets and turing fork est
chapter 6
‘Assessment of Vestibular Functions 43
Chapter 7
Disorders of Vesiulor System 47
chapter 8
‘Diseoses of Extemol Ear $1
[El toririgation
Chapter 9
Fustachian Tube and ts Disorders 61
Chapter 10
"Disorders of Mile or 67
[2] Myringctomy
Chapter 11
\Cholesteatoma and Chronic Otis Medio. 73
[2] Origin ofchatestetama
Chapter 12
Complcaons of Suppuraive Ottis Medio 83
[2] choksteatemo and ts complications
chapter 13
loser (5n. Otepongoss) 95
[Oasis ond ts monogement
Chapter 14
Facial Neve and ns Disorders 99
[2] ser pasy
[2] anatomy and funcions of facil nerve
Chapter 15
Ménieres Disease 111
Chapter 16
Tumours of External Er 117
Chapter 17
Tumours of Middle Eorond Mostoë 121
chapter 18
Acoustic Neurome 125
Chapter 19
The Deaf Cid 129
Chapter 20
úRehobilttion of the Hearing Impañed 135
[5] Haig as
Chapter 21
‘Olga (Earache) 143
Chapter 22
Tenis 145
SECTION u
DISEASES OF NOSE AND PARANASAL
SINUSES 147
Chapter 23
‘Anatomy of Nose 149.
Chapter 24
Physiology of Nose 157
Chapter 25
‘Diseases ol Extemol Nose and Nosol Vestibule 161
Chapter 26
‘Nasal Septum and ts Diseases. 165
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Dedication y
Preface vi
Acknowledgements x
SECTION 1
DISEASES OF EAR 1
Chapter 1
‘Anatomy of for 3
Chapter 2
Perpheral Receptors and Physiology of Auditory
(nd Vestbular Systems 19
Chapter 3
“aulology and Acoustics 21
Chapter 4
Assessment of Hearing 23
[2] Meoringtets and turing fork est
chapter 6
‘Assessment of Vestibular Functions 43
Chapter 7
Disorders of Vesiulor System 47
chapter 8
‘Diseoses of Extemol Ear $1
[El toririgation
Chapter 9
Fustachian Tube and ts Disorders 61
Chapter 10
"Disorders of Mile or 67
[2] Myringctomy
Chapter 11
\Cholesteatoma and Chronic Otis Medio. 73
[2] Origin ofchatestetama
Chapter 12
Complcaons of Suppuraive Ottis Medio 83
[2] choksteatemo and ts complications
chapter 13
loser (5n. Otepongoss) 95
[Oasis ond ts monogement
Chapter 14
Facial Neve and ns Disorders 99
[2] ser pasy
[2] anatomy and funcions of facil nerve
Chapter 15
Ménieres Disease 111
Chapter 16
Tumours of External Er 117
Chapter 17
Tumours of Middle Eorond Mostoë 121
chapter 18
Acoustic Neurome 125
Chapter 19
The Deaf Cid 129
Chapter 20
úRehobilttion of the Hearing Impañed 135
[5] Haig as
Chapter 21
‘Olga (Earache) 143
Chapter 22
Tenis 145
SECTION u
DISEASES OF NOSE AND PARANASAL
SINUSES 147
Chapter 23
‘Anatomy of Nose 149.
Chapter 24
Physiology of Nose 157
Chapter 25
‘Diseases ol Extemol Nose and Nosol Vestibule 161
Chapter 26
‘Nasal Septum and ts Diseases. 165
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xl Contents
Chapter 27
Acute ond Chronic Rhintis 171
Chapter 28
‘Granulomotous Diseases of Nose 175
(2) Granulomatous diseases of nose!
[2] Granulomatous diseases of nose
Chapter 29
Miscellaneous Disorders of Nasal City 181
Chapter 30
‘Ali Rhinits 187
©) Ag eis
Chapter 31
Vosomotor and Other Forms of Nonalergi hints 191
[BJ Other forms of nonallrg minis
Chapter 32
‘Nasal Pohpi 193
[2] Poster minoscopy
(2) pa
Chapter 33
axis 197
{External and internal coroti ore
Chapter 34
Trauma tothe Foce 203
Chapter 35
“Anatomy and Physiology of Paronasal Suses 209
Chapter 36
‘ute Rhinosiuss 213
Chapter 37
Chronic Rhinsinsits 217
Chapter 38
‘Complications o Smusiis 223
Chapter 39
Benin and Maignant Necplsms
(of Nasal Coty 227
Chapter 40
‘Neoplasms of Pranasal Sinuses 231
Chapter 41
Proptods 237
SECTION
DISEASES OF ORAL CAVITY AND SALIVARY
GLANDS 241
Chapter 42
Anatomy of OrolCovty 243
cn
a
‘Common Disorders of Oral Cavity 245
Chapter 44
Tumours of Oral Cavty 251
Chapter 45
"Non-neqplstc Disorders of Solvery Glands 259
Chapter 46
‘Neoplasms ol Solvary lands 263
SECTION IV
DISEASES OF PHARYNX 267.
Chapter 47
“Anatomy ond Physiology of Phorynx 269.
Chapter 48
“Adenoids and Other nlammations
(of Nosopharynx. 275
Chapter 49
Tumours of Nesopharyne 279
LS] Benign tumeurs ofthe nosopharynx
LS) Nosophanmgea!forema
[E] Malignant tumours of nasopharynx
Chapter so
‘ute and Conic Pharyngits 287
Chapter 51
Acute and Chronic Toni. 291
Chapter 52
Head and Neck Space infections 297
Chapter 53
Tumours ol Oropharynx 305
Chapter 54
Tumours of the Hypapharynx ond Pharyngeal
Pouch 309
cn
55
‘snoring and Sep Apnoea 313
SECTION V
DISEASES OF LARYNX AND TRACHEA. 317
Chapter 56
Anatomy and Physiology of Lan 319
laryngotracheal Touma 325,
cn
Chapter 58
cute and Chronic inflammations
allan 327
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Chapter 27
Acute ond Chronic Rhintis 171
Chapter 28
‘Granulomotous Diseases of Nose 175
(2) Granulomatous diseases of nose!
[2] Granulomatous diseases of nose
Chapter 29
Miscellaneous Disorders of Nasal City 181
Chapter 30
‘Ali Rhinits 187
©) Ag eis
Chapter 31
Vosomotor and Other Forms of Nonalergi hints 191
[BJ Other forms of nonallrg minis
Chapter 32
‘Nasal Pohpi 193
[2] Poster minoscopy
(2) pa
Chapter 33
axis 197
{External and internal coroti ore
Chapter 34
Trauma tothe Foce 203
Chapter 35
“Anatomy and Physiology of Paronasal Suses 209
Chapter 36
‘ute Rhinosiuss 213
Chapter 37
Chronic Rhinsinsits 217
Chapter 38
‘Complications o Smusiis 223
Chapter 39
Benin and Maignant Necplsms
(of Nasal Coty 227
Chapter 40
‘Neoplasms of Pranasal Sinuses 231
Chapter 41
Proptods 237
SECTION
DISEASES OF ORAL CAVITY AND SALIVARY
GLANDS 241
Chapter 42
Anatomy of OrolCovty 243
cn
a
‘Common Disorders of Oral Cavity 245
Chapter 44
Tumours of Oral Cavty 251
Chapter 45
"Non-neqplstc Disorders of Solvery Glands 259
Chapter 46
‘Neoplasms ol Solvary lands 263
SECTION IV
DISEASES OF PHARYNX 267.
Chapter 47
“Anatomy ond Physiology of Phorynx 269.
Chapter 48
“Adenoids and Other nlammations
(of Nosopharynx. 275
Chapter 49
Tumours of Nesopharyne 279
LS] Benign tumeurs ofthe nosopharynx
LS) Nosophanmgea!forema
[E] Malignant tumours of nasopharynx
Chapter so
‘ute and Conic Pharyngits 287
Chapter 51
Acute and Chronic Toni. 291
Chapter 52
Head and Neck Space infections 297
Chapter 53
Tumours ol Oropharynx 305
Chapter 54
Tumours of the Hypapharynx ond Pharyngeal
Pouch 309
cn
55
‘snoring and Sep Apnoea 313
SECTION V
DISEASES OF LARYNX AND TRACHEA. 317
Chapter 56
Anatomy and Physiology of Lan 319
laryngotracheal Touma 325,
cn
Chapter 58
cute and Chronic inflammations
allan 327
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chapter 59
‘Congenta Lesons of Larynx and Stidor 333
Chapter 60
Laryngeal Paros 337
Ellarıngea poraysis
Chapter 61
Tumour of op 343
hen mans oy
Chapter 62
Cancer Lynx 347
[2] Treatment oflormgeol cancer
Chapter 63
Voie and Speech Disorders 355
Chapter 64
Tracheostomy and Other Procedures for Away
Management 359
[e] Macheosiomy
Chapter 65
Foreign Bodies of Air Passages 365
SECTION VI
THYROID GLAND AND ITS DISORDERS 369.
Chapter 66
Trad ond and ts Diordes 371
El Psy of tyro gland
SECTION vu
DISEASES OF OESOPHAGUS 383
Chapter 67
‘Anatomy and Physiology of Oesophogus 385
Chapter 68
‘Disorders of Oesophagus 387
Chapter 69
Dysphagia 393
Chapter 70
Foreign Bodies of Food Passage 395
SECTION vu
RECENT ADVANCES 399
Chapter 71
Laser Surgery, Radilrequency Surgery,
‘Hyperbaric Oxygen Therapy and Coblation 401
Chapter 72
‘Chyosurgery 409
Chapter 73
Rodotheropyin Head ond Neck Cancers 411
Contents xl
‘Chemotherapy for Head and Neck Cancer 419
Chapter 75
"HV Infcton/AIOS and ENT Monfestovons 421
SECTION Ix
CLINICAL METHODS IN ENT
AND NECK MASSES 425,
Chapter 76
"Cinco Methods in ENT 427
Chapter 77
Neck Moses 445
SECTION x
‘OPERATIVE SURGERY 451
Chapter 78
Myingtomy (Sm. Tympanostomy) 453
Chapter 79
ar Surgery ond Approaches 455
Chapter 80
Conical Mostidectomy 457.
Chapter 81
Radical Mostaidectomy 459
Chapter 82
‘Modified Rodiol Mostoidctomy 461
Chapter 83
Myringoposty 463
Chapter 84
Proof Puncture (Sn, Antal Lavage) 465
Chapter 85.
tronos Interior MeotolAnrostomy 467
Chapter 86
(Coldwel-Luc (Anterior Anuostomy) Operation 469
Chapter 87
Submucous Resection of Nasal Septum
(ue Operation) 471
Chapter 88
Septoplsty 473
Chapter 89
‘Diagnostic Nasa Endoscopy 475
“Endoscopic Sinus Surgery 477
Chapter 91
Direct Lonngoscopy 481
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‘Congenta Lesons of Larynx and Stidor 333
Chapter 60
Laryngeal Paros 337
Ellarıngea poraysis
Chapter 61
Tumour of op 343
hen mans oy
Chapter 62
Cancer Lynx 347
[2] Treatment oflormgeol cancer
Chapter 63
Voie and Speech Disorders 355
Chapter 64
Tracheostomy and Other Procedures for Away
Management 359
[e] Macheosiomy
Chapter 65
Foreign Bodies of Air Passages 365
SECTION VI
THYROID GLAND AND ITS DISORDERS 369.
Chapter 66
Trad ond and ts Diordes 371
El Psy of tyro gland
SECTION vu
DISEASES OF OESOPHAGUS 383
Chapter 67
‘Anatomy and Physiology of Oesophogus 385
Chapter 68
‘Disorders of Oesophagus 387
Chapter 69
Dysphagia 393
Chapter 70
Foreign Bodies of Food Passage 395
SECTION vu
RECENT ADVANCES 399
Chapter 71
Laser Surgery, Radilrequency Surgery,
‘Hyperbaric Oxygen Therapy and Coblation 401
Chapter 72
‘Chyosurgery 409
Chapter 73
Rodotheropyin Head ond Neck Cancers 411
Contents xl
‘Chemotherapy for Head and Neck Cancer 419
Chapter 75
"HV Infcton/AIOS and ENT Monfestovons 421
SECTION Ix
CLINICAL METHODS IN ENT
AND NECK MASSES 425,
Chapter 76
"Cinco Methods in ENT 427
Chapter 77
Neck Moses 445
SECTION x
‘OPERATIVE SURGERY 451
Chapter 78
Myingtomy (Sm. Tympanostomy) 453
Chapter 79
ar Surgery ond Approaches 455
Chapter 80
Conical Mostidectomy 457.
Chapter 81
Radical Mostaidectomy 459
Chapter 82
‘Modified Rodiol Mostoidctomy 461
Chapter 83
Myringoposty 463
Chapter 84
Proof Puncture (Sn, Antal Lavage) 465
Chapter 85.
tronos Interior MeotolAnrostomy 467
Chapter 86
(Coldwel-Luc (Anterior Anuostomy) Operation 469
Chapter 87
Submucous Resection of Nasal Septum
(ue Operation) 471
Chapter 88
Septoplsty 473
Chapter 89
‘Diagnostic Nasa Endoscopy 475
“Endoscopic Sinus Surgery 477
Chapter 91
Direct Lonngoscopy 481
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xiv Contents
Chapter 92 Chapter 96
Bronchoscopy 483 ‘Some imaging Techniques in ENT 493
Chapter 93 APPENDICES
Oescphagescopy 485 Appendix 1
Chapter 94 ‘Some Memorable Nuggets for Rapid Review 507
Tonslctomy 487 Appendix it
chars Instruments 513
‘Adenoidectomy 491
index 529
[E] Flow the instructions on the font inner cover to access and view the videos, whiteboard lectures and animations.
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Chapter 92 Chapter 96
Bronchoscopy 483 ‘Some imaging Techniques in ENT 493
Chapter 93 APPENDICES
Oescphagescopy 485 Appendix 1
Chapter 94 ‘Some Memorable Nuggets for Rapid Review 507
Tonslctomy 487 Appendix it
chars Instruments 513
‘Adenoidectomy 491
index 529
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SECTION I
Diseases of Ear
SECTION OUTLINE
1 Anatomy of Ea, 3
2 Peripheral Receptors and Physiology of Auditory and Vestibular Systems, 15
3 Audiology and Acoustics, 21
4 assessment of Hering, 23
$ Hearing Los, 31
6 Assessment of Vestibule Functions, 43
7 Disorders of Vestbubr System, 47
8 Diseases of External Er, $1
9 Eustachian Tube and its Disorder, 61
10 Disorders of Middle ay, 67
11. Cholesteatoma and Chronic Otis Media, 73
12 Complications of Supuratv Os Media, 83
13. Otosceross (Syn. Otospongiosi), 95
14 Facil Nerve and ls Disorders, 99
15, Ménite’s Diese, 111
16 Tumour of Eten Ea, 117
17 Tumours of Md ar and Mast, 121
18 Acoustic Nauroma, 125
19 The Deal Child, 129
20 Rehabilitation the Hesring impaired, 135
21 Olga (arche) 143
22 Tinnitus, 145
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Diseases of Ear
SECTION OUTLINE
1 Anatomy of Ea, 3
2 Peripheral Receptors and Physiology of Auditory and Vestibular Systems, 15
3 Audiology and Acoustics, 21
4 assessment of Hering, 23
$ Hearing Los, 31
6 Assessment of Vestibule Functions, 43
7 Disorders of Vestbubr System, 47
8 Diseases of External Er, $1
9 Eustachian Tube and its Disorder, 61
10 Disorders of Middle ay, 67
11. Cholesteatoma and Chronic Otis Media, 73
12 Complications of Supuratv Os Media, 83
13. Otosceross (Syn. Otospongiosi), 95
14 Facil Nerve and ls Disorders, 99
15, Ménite’s Diese, 111
16 Tumour of Eten Ea, 117
17 Tumours of Md ar and Mast, 121
18 Acoustic Nauroma, 125
19 The Deal Child, 129
20 Rehabilitation the Hesring impaired, 135
21 Olga (arche) 143
22 Tinnitus, 145
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Chapter 1
Anatomy of Ear
“The eas divided into:
1. External cae
2: Middle car
3 Internal et or the ayant
‘THE EXTERNAL EAR
termal ar consis ofthe () auricle or pina,
{couse canal and GH) Empate membrane
in
igure
A. AURICLE OR PINNA
‘The entire plana except Is bulk and the outer par of
external acoustic canal are made up of à famework of à
Single piece of yellow clastic carla covered with skin.
Ir is closely adheren tothe perichondelum on
Surface while ü is slightly loose on the me
1) surface. The various elevations and depres
Sons seen on the lateral surface of pina are shose I
Figure LI
There Is no cartilage between the tragus anders
of the ee, and this areas called incisor temas
gun 130). Am incision made in this rca will no cut
Aou the cariage and 5 used for endaural approach
In surgery of the external aultory canal or the mastold.
Pinna lo the soute of several geat mates forthe
surgeon. Cartage rom the tus, perichondelum from
‘the tagus or concha and fat from the Tobule are te
‘quent se for constructive surgery ofthe mide ea.
"he conchal cartlage has aso been use to comet the
pres nasal ridge while the composite grafts of the
‘Skin and cartilage from the pina are sometimes use for
‘eal of defects of nasal la
EXTERNAL ACOUSTIC (AUDITORY) CANAL
Ieextnd fom th bottom a the conch tothe yn
Je membrane and measures about 24 aim long o poste:
for wa. nota ag tub; Hs outer part deste
pas, backers ad medal whe o ance pat
“ected downwands, forwards and medial, Therefore to
Sethe tympanic membrane he pia ás De plied
pars, Dre and acral 0 st bring het
pats agent
he cana e idea into two parts: (D cartaginous
and i bony.
1. Cartilaginous Part
1 forms outerone-hird (8 mm) of he can, Care sa
‘continuation ofthe lage which forms the framework
the plans. has two defikences—ihe “fi
{orn thi part of the carla and tho
Para or superficial mastoid infections can appear in the
anal or vice vera. Ihe sin covering the corlaginons ca
ati thick and contains cerainons and pilosehaceons
lands which secrete ax Hari only confined to the
‘ter canal and therefore furancie staphylococcal infec
ton of hae folic) are een only In he out
ofthe canal
2. Bony Part
li forms inner two=hirs (16 man). Skin ing the Bony
‘anal Is thin and continuous over the (ympanie mem
brane. eis devo otha and ceraminows glands. Aout
{mm lateral to eympanic membrane, the bony mea.
tus presents a marovaing called stuns. Foreign bodes,
hs, get impacted, and are cit
io pt ofthe deep meats,
"beyond the Isthmus, presents a recess called ateo e
(55, which acts as cesspool or discharge and debes In.
ass of external and mile car ineeions(igu:e 12)
‘Amteroinferior par ofthe bony canal may present de.
cien foramen of Hache in children up to the age of
four or sometimes even in aus, permiting infecuons to
and fom the parti
. TYMPANIC MEMBRANE OR
THE DRUMHEAD
At forms the partition between the external acoustic canal
and the mide car. I 15 obliquely set and as a result, ts
Dosterosuperor par more lateral than is aneroimferior.
pares 9-10 mm tall, 8-9 mun wideand 0.1 mn tick,
Fympanic membrane can be divided into two parts
1. Pars Tensa
11 forms most of tympanic membrane. Its periphery ls
thicken to form a fbrocorilaginows ing called ane
dus pas, which fs in the tympanic sulcus
‘The central part of pars tensa I tent Amar at ie
{evel ofthe ip of malleus and called uno. A br
cone of ight
Teas to the periphery in the anteroin
igure 13)
2. Pars Flaccida (Shrapnell's Membrane)
This Is situated above the lateral process of malleus be.
ven the notch of fins and the anterior and posterior
malt folds (ale called malleoar fois). I ls not so
{au and may appear slightly pinkish. Various lndmacks
Sen on the lateral surface of tympanic membrane are
Shown in gun bs
Anatomy of Ear
“The eas divided into:
1. External cae
2: Middle car
3 Internal et or the ayant
‘THE EXTERNAL EAR
termal ar consis ofthe () auricle or pina,
{couse canal and GH) Empate membrane
in
igure
A. AURICLE OR PINNA
‘The entire plana except Is bulk and the outer par of
external acoustic canal are made up of à famework of à
Single piece of yellow clastic carla covered with skin.
Ir is closely adheren tothe perichondelum on
Surface while ü is slightly loose on the me
1) surface. The various elevations and depres
Sons seen on the lateral surface of pina are shose I
Figure LI
There Is no cartilage between the tragus anders
of the ee, and this areas called incisor temas
gun 130). Am incision made in this rca will no cut
Aou the cariage and 5 used for endaural approach
In surgery of the external aultory canal or the mastold.
Pinna lo the soute of several geat mates forthe
surgeon. Cartage rom the tus, perichondelum from
‘the tagus or concha and fat from the Tobule are te
‘quent se for constructive surgery ofthe mide ea.
"he conchal cartlage has aso been use to comet the
pres nasal ridge while the composite grafts of the
‘Skin and cartilage from the pina are sometimes use for
‘eal of defects of nasal la
EXTERNAL ACOUSTIC (AUDITORY) CANAL
Ieextnd fom th bottom a the conch tothe yn
Je membrane and measures about 24 aim long o poste:
for wa. nota ag tub; Hs outer part deste
pas, backers ad medal whe o ance pat
“ected downwands, forwards and medial, Therefore to
Sethe tympanic membrane he pia ás De plied
pars, Dre and acral 0 st bring het
pats agent
he cana e idea into two parts: (D cartaginous
and i bony.
1. Cartilaginous Part
1 forms outerone-hird (8 mm) of he can, Care sa
‘continuation ofthe lage which forms the framework
the plans. has two defikences—ihe “fi
{orn thi part of the carla and tho
Para or superficial mastoid infections can appear in the
anal or vice vera. Ihe sin covering the corlaginons ca
ati thick and contains cerainons and pilosehaceons
lands which secrete ax Hari only confined to the
‘ter canal and therefore furancie staphylococcal infec
ton of hae folic) are een only In he out
ofthe canal
2. Bony Part
li forms inner two=hirs (16 man). Skin ing the Bony
‘anal Is thin and continuous over the (ympanie mem
brane. eis devo otha and ceraminows glands. Aout
{mm lateral to eympanic membrane, the bony mea.
tus presents a marovaing called stuns. Foreign bodes,
hs, get impacted, and are cit
io pt ofthe deep meats,
"beyond the Isthmus, presents a recess called ateo e
(55, which acts as cesspool or discharge and debes In.
ass of external and mile car ineeions(igu:e 12)
‘Amteroinferior par ofthe bony canal may present de.
cien foramen of Hache in children up to the age of
four or sometimes even in aus, permiting infecuons to
and fom the parti
. TYMPANIC MEMBRANE OR
THE DRUMHEAD
At forms the partition between the external acoustic canal
and the mide car. I 15 obliquely set and as a result, ts
Dosterosuperor par more lateral than is aneroimferior.
pares 9-10 mm tall, 8-9 mun wideand 0.1 mn tick,
Fympanic membrane can be divided into two parts
1. Pars Tensa
11 forms most of tympanic membrane. Its periphery ls
thicken to form a fbrocorilaginows ing called ane
dus pas, which fs in the tympanic sulcus
‘The central part of pars tensa I tent Amar at ie
{evel ofthe ip of malleus and called uno. A br
cone of ight
Teas to the periphery in the anteroin
igure 13)
2. Pars Flaccida (Shrapnell's Membrane)
This Is situated above the lateral process of malleus be.
ven the notch of fins and the anterior and posterior
malt folds (ale called malleoar fois). I ls not so
{au and may appear slightly pinkish. Various lndmacks
Sen on the lateral surface of tympanic membrane are
Shown in gun bs
4 SECTION! — Discos of far
Trans
pare 2. An cof de man. e notan to den
rs and debra tom se
Figure 13. Corn scion dough more membrane and
rats cna hong situ o! pu toa ps ae
‘opr membrane, Som omo pnt ote sta
Layers of Tympanic Membrane
‘ympanic membrane consists of thee layers:
+ Outer epithelia aye, which is continuous with the
‘Sin fining the meatus (ue
+ Inner mucosal ayer, which Is continuous with the mu-
cos of the mide car
+ Middle Abrous layer, which encloses the handle of
‘malleus and has three pes of reste rad ru
la and parabole (Agur 15).
yous layer in the pars acid s tin and not organ
tac nto various bres in par ens,
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Trans
pare 2. An cof de man. e notan to den
rs and debra tom se
Figure 13. Corn scion dough more membrane and
rats cna hong situ o! pu toa ps ae
‘opr membrane, Som omo pnt ote sta
Layers of Tympanic Membrane
‘ympanic membrane consists of thee layers:
+ Outer epithelia aye, which is continuous with the
‘Sin fining the meatus (ue
+ Inner mucosal ayer, which Is continuous with the mu-
cos of the mide car
+ Middle Abrous layer, which encloses the handle of
‘malleus and has three pes of reste rad ru
la and parabole (Agur 15).
yous layer in the pars acid s tin and not organ
tac nto various bres in par ens,
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Poe ss
Figura 1 ud, And proc re tp en
RELATIONS OF EXTERNAL ACOUSTIC MEATUS
+ Supeioriy: Mid cranial fossa
3 Poster: Mastold ar cs and the facial nerve
2 intro: Parotid gland
+ Anteroriy Temporomandibula joint
Posterosuperor part of deeper canal near the tympanic
membrane relate tothe mastoid antrum. “Sagging” of
thisarea may be noticed in acute maso.
[NERVE SUPPLY OF THE EXTERNAL EAR
1. Greater auricular nerve (Co) supplies most of the
‘medial surface of pinna and only posterior part of the
Tatra surface (ie 10)
2. Lesser occipital (C2) supplies upper part of med
surface
3. Aurculotemporal (Y) supplies tragus, rus of helix
and the adjacent part ofthe helix
4. cular banch of vagus (CN 3), als called Arnold
nee, supplies the concha and corresponding emt
‘ence on the medial Stace
Facial nerve, which is dstbuted with bres of auricu-
lar branch of vagus, supplies the concha and retro
‘ular groove
Chapter — Anatomy olor 5
External Auditory Canal
1. Anterior wall and root auiculotemporal (Va.
2. Posterior wall and Moor: auricular branch of vagus
(NN,
3. Posterior wall of the auditory canal also reeves sen.
Sory bres of CN VI ough auricular branch of vagus
{Gee Hitzelbergers sign on p 125)
Im herpes zoster oics, lesions ae sen inthe dst
‘bution of facial nerve, Le. concha, posterior part of tym
panic membrane and postauricuar region.
Tympanic Membrane
1. Anterior half of lateral surface auriclotemporl (Va.
2. Poster hal of lateral sulac: auricular branch Of Va.
gus (CN).
3. Media surface tympanic branch of
nero,
NIX Gacobson's
‘THE MIDDLE EAR
‘The middle car together withthe eustachian tube, ad
us, antrum and mastoid ale cells called midi cr et
(igure 1) Tes lined by mucous membrane and filed
‘sth ai
“The middle ca extends much beyond the limits of
tympanic membrane which forms it lateral boundary
And s sometimes divided into: () mesetmparnun (5
ing opposite the pars tensa), (i) ellympanım or the
attic (ving above the pas tensa but medal 10 Shrap-
ells membrane and the bony lateral attic wall) and
(0 Inpotympanu (ing below the level of pars tensa)
(inact 129, The portion of middle ar around the ym
Panic orice of the eustachian tube is sometimes called
Protmpanım.
Nike car canbe end to a sided box with a
too, a floor, medial, lateral, anterior and posterior walls
ge 19)
“The ro is formed by a thin plate of bone called te
men tympani. ls extends posteñory to form he root
fF the ats and antrum. I separates tympanic caviy
rom the middle canal fossa,
The floor i aso a thin plat of bone, which separates
ympanic cavity ftom the ugular bub. Sometimes, 1
congenitally deficient and the jugular bulb may then
ratetoegor nee)
A a ita aed ek
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Figura 1 ud, And proc re tp en
RELATIONS OF EXTERNAL ACOUSTIC MEATUS
+ Supeioriy: Mid cranial fossa
3 Poster: Mastold ar cs and the facial nerve
2 intro: Parotid gland
+ Anteroriy Temporomandibula joint
Posterosuperor part of deeper canal near the tympanic
membrane relate tothe mastoid antrum. “Sagging” of
thisarea may be noticed in acute maso.
[NERVE SUPPLY OF THE EXTERNAL EAR
1. Greater auricular nerve (Co) supplies most of the
‘medial surface of pinna and only posterior part of the
Tatra surface (ie 10)
2. Lesser occipital (C2) supplies upper part of med
surface
3. Aurculotemporal (Y) supplies tragus, rus of helix
and the adjacent part ofthe helix
4. cular banch of vagus (CN 3), als called Arnold
nee, supplies the concha and corresponding emt
‘ence on the medial Stace
Facial nerve, which is dstbuted with bres of auricu-
lar branch of vagus, supplies the concha and retro
‘ular groove
Chapter — Anatomy olor 5
External Auditory Canal
1. Anterior wall and root auiculotemporal (Va.
2. Posterior wall and Moor: auricular branch of vagus
(NN,
3. Posterior wall of the auditory canal also reeves sen.
Sory bres of CN VI ough auricular branch of vagus
{Gee Hitzelbergers sign on p 125)
Im herpes zoster oics, lesions ae sen inthe dst
‘bution of facial nerve, Le. concha, posterior part of tym
panic membrane and postauricuar region.
Tympanic Membrane
1. Anterior half of lateral surface auriclotemporl (Va.
2. Poster hal of lateral sulac: auricular branch Of Va.
gus (CN).
3. Media surface tympanic branch of
nero,
NIX Gacobson's
‘THE MIDDLE EAR
‘The middle car together withthe eustachian tube, ad
us, antrum and mastoid ale cells called midi cr et
(igure 1) Tes lined by mucous membrane and filed
‘sth ai
“The middle ca extends much beyond the limits of
tympanic membrane which forms it lateral boundary
And s sometimes divided into: () mesetmparnun (5
ing opposite the pars tensa), (i) ellympanım or the
attic (ving above the pas tensa but medal 10 Shrap-
ells membrane and the bony lateral attic wall) and
(0 Inpotympanu (ing below the level of pars tensa)
(inact 129, The portion of middle ar around the ym
Panic orice of the eustachian tube is sometimes called
Protmpanım.
Nike car canbe end to a sided box with a
too, a floor, medial, lateral, anterior and posterior walls
ge 19)
“The ro is formed by a thin plate of bone called te
men tympani. ls extends posteñory to form he root
fF the ats and antrum. I separates tympanic caviy
rom the middle canal fossa,
The floor i aso a thin plat of bone, which separates
ympanic cavity ftom the ugular bub. Sometimes, 1
congenitally deficient and the jugular bulb may then
ratetoegor nee)
A a ita aed ek
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6 SECTION! — Discos of for
Figure 1.8. Dhs a mse a io pl me and pa
Figure 19. Voss el mie eu an e sur ed to them (1) Cal rest mp. 2) Opening latin tte, 9) Om
don Roun window 6) Process aces, (6) Morata aa, 7 Foal nen 8) Pom) AB (10) Chad mp
AS
project into the middle cor; separated from the caviy
‘nly by the mucosa
“Te anterior wall has thin plat of bone, which sp-
rates the cavity om Internal Eaot artery. I also has
Summit of which appears the tendon of the sted
‘muscle to get attachment to the neck of stapes Ad,
An opening through which atic communicates with the
Antrum, les above the pyramid. Facial nerve runs in the
posterior wall jst behind the pyramid. Facil cess or
{he putero sm ia depresion in the posterior Wal L
al the pyramid. iis bounded medal bythe vertical
art of Vi nerve, aer by the chorda tympani and
ove, bythe fossa incuds (ur 1.10). Surgiealy aca
{eves is important, as dct access canbe made tough
this into the middie ear without disturbing posterior ca
al all intact anal wall technique, ee. 80).
‘The medial wall (sure 1.1) Is formed by the
à bulge called promontary which
1 basal coll of cochlen; oval window Into
which Is fixed the footplate of stapes: round window oF
the fenestra cochlcae whichis covered by the second
By tympanic membrane. Above the oval window is
the canal for cal env. its bony covering may some.
times be congenitally dehiscent and the nerve may lle
exposed making it very vulnerable to injures or tee
tion, Above the canal for facial nerves the prominence
fof lateral semichcular canal Just anterior to the oval
‘window, the medial wall presents à hookiike projee-
{on called processus cocleanformis. The tendon often.
Sor eympant takes turn here to get attachment tothe
neck of malleus The cochleasform process also marks.
the level ofthe fist genu ofthe facial nerve whlch is
an important fandmatk for surgery ofthe facial nerve.
Medal tothe pyramid isa deep recess called sinus me
‘pani, which is bounded bythe sub below and the
Ponts above (Faure À 10),
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Figure 1.8. Dhs a mse a io pl me and pa
Figure 19. Voss el mie eu an e sur ed to them (1) Cal rest mp. 2) Opening latin tte, 9) Om
don Roun window 6) Process aces, (6) Morata aa, 7 Foal nen 8) Pom) AB (10) Chad mp
AS
project into the middle cor; separated from the caviy
‘nly by the mucosa
“Te anterior wall has thin plat of bone, which sp-
rates the cavity om Internal Eaot artery. I also has
Summit of which appears the tendon of the sted
‘muscle to get attachment to the neck of stapes Ad,
An opening through which atic communicates with the
Antrum, les above the pyramid. Facial nerve runs in the
posterior wall jst behind the pyramid. Facil cess or
{he putero sm ia depresion in the posterior Wal L
al the pyramid. iis bounded medal bythe vertical
art of Vi nerve, aer by the chorda tympani and
ove, bythe fossa incuds (ur 1.10). Surgiealy aca
{eves is important, as dct access canbe made tough
this into the middie ear without disturbing posterior ca
al all intact anal wall technique, ee. 80).
‘The medial wall (sure 1.1) Is formed by the
à bulge called promontary which
1 basal coll of cochlen; oval window Into
which Is fixed the footplate of stapes: round window oF
the fenestra cochlcae whichis covered by the second
By tympanic membrane. Above the oval window is
the canal for cal env. its bony covering may some.
times be congenitally dehiscent and the nerve may lle
exposed making it very vulnerable to injures or tee
tion, Above the canal for facial nerves the prominence
fof lateral semichcular canal Just anterior to the oval
‘window, the medial wall presents à hookiike projee-
{on called processus cocleanformis. The tendon often.
Sor eympant takes turn here to get attachment tothe
neck of malleus The cochleasform process also marks.
the level ofthe fist genu ofthe facial nerve whlch is
an important fandmatk for surgery ofthe facial nerve.
Medal tothe pyramid isa deep recess called sinus me
‘pani, which is bounded bythe sub below and the
Ponts above (Faure À 10),
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Figure 1.10. (A) Facil cs ls eo aná ss pan ato
Chapter? — Anatomy olor 7
CR
fi aan
8
ne praia mince and veia pr el nee. (poste
‘tac! cos vou petete mpanciony a een mo Se SC, Sem an
‘Te ater wall formed largely by the tympan men
‘rane and 1 a lesser extent bythe bony outer ate wall
alle scam ire 1) Te fmpante membrane sm
transparent and forms a "window ino the middle ca. I
Is pol to se some structures ofthe mid eae rough
‘the normal tympanic membrane, e, Ihe long process of
Incas tnewdostapedia joint and he ound window.
MASTOID ANTRUM.
leis large, al-containing space in the upper part of mas
toidand communicates withthe atte tough the adits.
Il 100 formed by tegen ant, which Ia continuation
ofthe tegme
ramal fos,
plate of bone which fon an average 15 cm tick inthe
dul Te marked externally on the sulae of mastoid by
SuprmeatalacEven9) tage (te 1-12)
ADITUS AD ANTRUM
Adu isan opening through which the attic communi
‘ates with theantrum. The bony prominence ofthe hot
Figure 1.1. Me wa of mie u (0) Pronto, D Mes
52 narra) CN VI 9 Ova wo (3) Horn cn
‘(Pyro (7) Porc. (9 Sos ma, (7) Sc,
(00) Rod window (1) Til
zontal ana es on its medal side while the osa incu,
0 whichis attached the short proces of incu, es ater
ally. Facial nerve courses just below the aus.
‘THE MASTOID AND ITS AIR CELL SYSTEM
(FIGURE 1.13)
‘The mastoid consists of bony cortex with a “honeycomb
i els underneath Dopending on development of ae
thee types of mastoid have Been described,
1. Welt pneumatized or cellular. Mato cells are wel
develope and intervening sepa are
2. Diploetk. Mastoid consists of marrow spaces and a
for alce
3. Selerotie or ac I or marrow
spaces
‘With any type of mastoid preumatzation, antrum is
always present in sclerotic mastoid, antrum usually
Small and the sigmoid sinus is ateposed.
‘Depending on the location, mastoid air cells are die
vided into:
1. Zygomati cells (in the toot ofzygoma).
2: Tegmen cells (extending into the tegmen tympan).
3, Peisinus cl overying the sinus plate)
4 Retrofacial cells (round the acl nerve).
Figure 1.12. Macs Cora range is bardem
rin opel rent oboe ann
{0 and ei aon angen the evel Ona (Lan
Ep rimar ace mato aun mtd age,
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Chapter? — Anatomy olor 7
CR
fi aan
8
ne praia mince and veia pr el nee. (poste
‘tac! cos vou petete mpanciony a een mo Se SC, Sem an
‘Te ater wall formed largely by the tympan men
‘rane and 1 a lesser extent bythe bony outer ate wall
alle scam ire 1) Te fmpante membrane sm
transparent and forms a "window ino the middle ca. I
Is pol to se some structures ofthe mid eae rough
‘the normal tympanic membrane, e, Ihe long process of
Incas tnewdostapedia joint and he ound window.
MASTOID ANTRUM.
leis large, al-containing space in the upper part of mas
toidand communicates withthe atte tough the adits.
Il 100 formed by tegen ant, which Ia continuation
ofthe tegme
ramal fos,
plate of bone which fon an average 15 cm tick inthe
dul Te marked externally on the sulae of mastoid by
SuprmeatalacEven9) tage (te 1-12)
ADITUS AD ANTRUM
Adu isan opening through which the attic communi
‘ates with theantrum. The bony prominence ofthe hot
Figure 1.1. Me wa of mie u (0) Pronto, D Mes
52 narra) CN VI 9 Ova wo (3) Horn cn
‘(Pyro (7) Porc. (9 Sos ma, (7) Sc,
(00) Rod window (1) Til
zontal ana es on its medal side while the osa incu,
0 whichis attached the short proces of incu, es ater
ally. Facial nerve courses just below the aus.
‘THE MASTOID AND ITS AIR CELL SYSTEM
(FIGURE 1.13)
‘The mastoid consists of bony cortex with a “honeycomb
i els underneath Dopending on development of ae
thee types of mastoid have Been described,
1. Welt pneumatized or cellular. Mato cells are wel
develope and intervening sepa are
2. Diploetk. Mastoid consists of marrow spaces and a
for alce
3. Selerotie or ac I or marrow
spaces
‘With any type of mastoid preumatzation, antrum is
always present in sclerotic mastoid, antrum usually
Small and the sigmoid sinus is ateposed.
‘Depending on the location, mastoid air cells are die
vided into:
1. Zygomati cells (in the toot ofzygoma).
2: Tegmen cells (extending into the tegmen tympan).
3, Peisinus cl overying the sinus plate)
4 Retrofacial cells (round the acl nerve).
Figure 1.12. Macs Cora range is bardem
rin opel rent oboe ann
{0 and ei aon angen the evel Ona (Lan
Ep rimar ace mato aun mtd age,
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B SECTION! — Discos of for
apo.
igure 1.13, Ae cnt tong bone
5, Perbbyrinhine cll located above, below and be:
Find the labyrinth, some of Mem poss throug the
auch of superior semiccular canal. These cells may
ommuntcite withthe pettus apes)
6, Peitubl (around the estachian tube. Along with hy:
potympani ells they also communicate with the pe
ous apex),
7. Tip eels (ich ate quite lage and ie medial and a
eral tothe digastric ie in the tip of mastoid).
8 Marginal eels dying behind the sins plate and may
extend into the occipital bone).
3. Squamosal cell ing in the squamous part of tempo:
ral bones)
Absceses may form
may sometimes be oct
relation to these ai cells and
far rom the mastoid region.
Development of Mastoid
‘Mastotd develops from the squamous and petrous bones,
‘Te petrosquamosal suture may pers as à ony plate
the Komo pum, separating superficial um a
tom the deep perrsal el Kornersseptum i surgically
om
A
Important as lt may cause deity in locating the an-
trum and the deeper cl; and thus may Tead to incom
pete removal of disease at mastoldetom (gore 1.1),
sto antrum cannot be reached unless the Komers
septum has been removed
Petrous apex and its cel system
‘The peros apex ks anterior and medal tothe laby-
singh may be pneumatic in 30% oF nait, wat
fall acts running either tom the mastoid or hypotym-
num (gane 119). They run inferior, superior or an-
{erior tothe bony capsul ofthe labyrinh and cochlea
Thus various surgical approaches have Deen use to dai
the inamenatory or est lesions ofthe trous ape.
1. Inferior route This ls the most common route, Two
approaches are used:
2 Tntalabyeithine. Access is through mastod, and
‘ll tact un below the labyrinth,
bo Infracochica. Acces I through the ear canal, and
tract runs tom te hypotympanum 10 the bony
cochlea 0 ptr apes
Soon
Figure 1.14. Xomor ptm) on must epson, (in ral cn mai Ink poe tre iy oa,
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apo.
igure 1.13, Ae cnt tong bone
5, Perbbyrinhine cll located above, below and be:
Find the labyrinth, some of Mem poss throug the
auch of superior semiccular canal. These cells may
ommuntcite withthe pettus apes)
6, Peitubl (around the estachian tube. Along with hy:
potympani ells they also communicate with the pe
ous apex),
7. Tip eels (ich ate quite lage and ie medial and a
eral tothe digastric ie in the tip of mastoid).
8 Marginal eels dying behind the sins plate and may
extend into the occipital bone).
3. Squamosal cell ing in the squamous part of tempo:
ral bones)
Absceses may form
may sometimes be oct
relation to these ai cells and
far rom the mastoid region.
Development of Mastoid
‘Mastotd develops from the squamous and petrous bones,
‘Te petrosquamosal suture may pers as à ony plate
the Komo pum, separating superficial um a
tom the deep perrsal el Kornersseptum i surgically
om
A
Important as lt may cause deity in locating the an-
trum and the deeper cl; and thus may Tead to incom
pete removal of disease at mastoldetom (gore 1.1),
sto antrum cannot be reached unless the Komers
septum has been removed
Petrous apex and its cel system
‘The peros apex ks anterior and medal tothe laby-
singh may be pneumatic in 30% oF nait, wat
fall acts running either tom the mastoid or hypotym-
num (gane 119). They run inferior, superior or an-
{erior tothe bony capsul ofthe labyrinh and cochlea
Thus various surgical approaches have Deen use to dai
the inamenatory or est lesions ofthe trous ape.
1. Inferior route This ls the most common route, Two
approaches are used:
2 Tntalabyeithine. Access is through mastod, and
‘ll tact un below the labyrinth,
bo Infracochica. Acces I through the ear canal, and
tract runs tom te hypotympanum 10 the bony
cochlea 0 ptr apes
Soon
Figure 1.14. Xomor ptm) on must epson, (in ral cn mai Ink poe tre iy oa,
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igure 1.15, Apress pers open
2. Superior route. Various approaches are used. They ae
from themadlecranial fon through the ach of sped:
nak through heat region trot fo.
‘Anterior route. Anterior cl tract runs from the hypo:
‘tympanum, anterior o the cochlea towards the pets
apex. Various approaches have earned the eponyms of
Lempert, Ramadir or Eagleton approaches.
a to petrous apex isthe trnsabyin
labyrinth ao removed. This results
{in total sensorineural los and Is ed when clar
Teasing already nonexistent
OSSICLES OF THE MIDDLE EAR
‘There ae thee ossicles inthe middle ear—the malleus,
incus and stapes (ur 119)
The malleus has head, neck, handle ¢anubeium), a
lateral and an anterior proces. Head and neck of malleus
le in the ati. Manubrlam is embedded the Abou
layer of the tympanic membrane, The lateral process
forms a Knab ke projection on the outer surface ofthe
tympanic membrane and ives atachment 10 the ante
or and posterior malla! (malela) folds
has a body and a short process, both of
"atic and a Jong process which hangs
tachs to the head of stapes,
apes has a head, neck, anterior and posterior
rra, and a footplte. The fotplte i held inthe oval
‘window by annular ligament
“The ossicles conduet sound energy from the tympanic
membrane tothe oval window and then 10!
INTRATYMPANIC MUSCLES
"Tere ae two muscles—temortympant and the stpe-
is; the former attaches to the neck of malleus and
tenses the tympanie membrane while the latter attaches
to'the neck of stapes and helps to dampen very loud
Chapter 1 — Anatomy oftar 9
ma — | >
= N tana
=MY KS
m. A —
rece
Figure 1.16 roses ad rps
sounds thus preventing noise trauma tothe inner co.
pedis l 4 second arch muscle and 1 supplied by à
ranch of CN VII while tensor tympani develops from
the first arch and is supplied by à branch of mandibular
nerve (Vy
‘TYMPANIC PLEXUS
teles
ftom
panic pletus supplies inneevation to the medial sudace
ff the tympanic membrane tympanic cavity, mastod alt
land the bony custachia tube. Te also cases ect.
motor Abres forthe parotid gland. Section of tympanic
branch of glossopharyngeal nee can be card out in
‘the middle cr In cas of Frys syndrome,
(Cours of secretomotor Ares othe paroi
Inferior salivary nucleus “> CN IX => Tympanie
branch = Tympanic plexus» Leser peros nerve» Ole
ganglion > Auriculotemporal nerve = Parotid gland
n the promontory and is formed by () tympanic
CHORDA TYMPANI NERVE
ch of the facial nerve which enters the mile
sand runson the medi
Surac of the sympanic membrane between the handle
of malls and long process of incu, above the attach
ment of tendon of tensor tympan cases taste from
anterior no-ird of tongue and supplies secretomotor
‘bes tothe submailary and sublingual salivary glands
igure 12, p00).
LINING OF THE MIDDLE EAR CLEFT
Mucous membrane of the nasopharyas is continuous
ih that of the mide ey, ias, antrum and U
is. IE wraps the middle eat structure
es, muscle, ligaments and nerve pentone
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2. Superior route. Various approaches are used. They ae
from themadlecranial fon through the ach of sped:
nak through heat region trot fo.
‘Anterior route. Anterior cl tract runs from the hypo:
‘tympanum, anterior o the cochlea towards the pets
apex. Various approaches have earned the eponyms of
Lempert, Ramadir or Eagleton approaches.
a to petrous apex isthe trnsabyin
labyrinth ao removed. This results
{in total sensorineural los and Is ed when clar
Teasing already nonexistent
OSSICLES OF THE MIDDLE EAR
‘There ae thee ossicles inthe middle ear—the malleus,
incus and stapes (ur 119)
The malleus has head, neck, handle ¢anubeium), a
lateral and an anterior proces. Head and neck of malleus
le in the ati. Manubrlam is embedded the Abou
layer of the tympanic membrane, The lateral process
forms a Knab ke projection on the outer surface ofthe
tympanic membrane and ives atachment 10 the ante
or and posterior malla! (malela) folds
has a body and a short process, both of
"atic and a Jong process which hangs
tachs to the head of stapes,
apes has a head, neck, anterior and posterior
rra, and a footplte. The fotplte i held inthe oval
‘window by annular ligament
“The ossicles conduet sound energy from the tympanic
membrane tothe oval window and then 10!
INTRATYMPANIC MUSCLES
"Tere ae two muscles—temortympant and the stpe-
is; the former attaches to the neck of malleus and
tenses the tympanie membrane while the latter attaches
to'the neck of stapes and helps to dampen very loud
Chapter 1 — Anatomy oftar 9
ma — | >
= N tana
=MY KS
m. A —
rece
Figure 1.16 roses ad rps
sounds thus preventing noise trauma tothe inner co.
pedis l 4 second arch muscle and 1 supplied by à
ranch of CN VII while tensor tympani develops from
the first arch and is supplied by à branch of mandibular
nerve (Vy
‘TYMPANIC PLEXUS
teles
ftom
panic pletus supplies inneevation to the medial sudace
ff the tympanic membrane tympanic cavity, mastod alt
land the bony custachia tube. Te also cases ect.
motor Abres forthe parotid gland. Section of tympanic
branch of glossopharyngeal nee can be card out in
‘the middle cr In cas of Frys syndrome,
(Cours of secretomotor Ares othe paroi
Inferior salivary nucleus “> CN IX => Tympanie
branch = Tympanic plexus» Leser peros nerve» Ole
ganglion > Auriculotemporal nerve = Parotid gland
n the promontory and is formed by () tympanic
CHORDA TYMPANI NERVE
ch of the facial nerve which enters the mile
sand runson the medi
Surac of the sympanic membrane between the handle
of malls and long process of incu, above the attach
ment of tendon of tensor tympan cases taste from
anterior no-ird of tongue and supplies secretomotor
‘bes tothe submailary and sublingual salivary glands
igure 12, p00).
LINING OF THE MIDDLE EAR CLEFT
Mucous membrane of the nasopharyas is continuous
ih that of the mide ey, ias, antrum and U
is. IE wraps the middle eat structure
es, muscle, ligaments and nerve pentone
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10 SECTIONI — Diseases of ar
Con, gos oa ng and stem tps car
Lo id tag
He and ant
‘wraps various visera in the abdomen-—raising several
{olds and dividing the middle ea into various compart-
‘ments. Middle car contains nothing but the al all the
Structure lie outside the mucous membrane
Histology, the eustachian tube & ined by elated
pihelum, whichis pseudostatied columnar in the
Esrilaginous part, columnar in he bony part with se
‘rl mocous and in the submucosa, Tyran caviy it
lined by ciated columnar epithelium in ts anterior and
interior part which Changes to cuboid type in he poste:
torpor kpiympanum and mastoid a els are ined by
‘at, nonelated epithelium.
BLOOD SUPPLY OF MIDDLE EAR
Mid car i supplied by six arteries, out of which two
ae the main, Le
1. Anterior tympanic branch of maxilry artery which
supplies tympanic membrane.
2. Siylomastoid branch of posterior auricular artery
eh supplies middle car and mastoid ar cls.
Four minor vessel are:
Parosal branch of middle meningeal artery (uns along
seater petsoal ment),
2, Superior tympanie branch of middle meningeal artery
teaversing along the Coal or tensor tympani muscle
3. Branch of “anal runs along eus.
4. mpanie Branch of interna carotid
‘eins drain into pterygoid venous plexus and superior.
porosa sinus.
LYMPHATIC DRAINAGE OF EAR
Lymphatic drainage of the eae is shown in Tabl 1.1. The
Inner ear doesnt have any Iymphate
oxi \
©
Ss ena Cons
A AS —
Nodes
Prestar and pride
roms
Poster nes, dep ur and spn acces nodes
Reponse mde upper our cn
Nehmen
THE INTERNAL EAR
‘The Interna er or the labyrinth Is an Important organ
of hearing and balance. I consist of bony anda mem
bramous Labyrinth. The membranous Ibytint is Bled
with a ar Ml called eniohmph while the space De-
lucen membranous and bony labyints i Billed with
pesiymph.
BONY LABYRINTH (FIGURE 1.178)
consists of thre parts
ana and the cochlea,
he vestibule, the semicircular
1. Vesna.
Is the central chamber of the laby-
singh. In is lateral wall lies the oval window. The ne
Side of ts medial wal presents two eceses, a sphere
rss, which lodges the saceue, and an etc ces,
ich Jodges the utile. Below the eliptcal recess i
the opening of aqueduct of vestibule through which
passes the endolymphatic duct. In the posterosuperior
part of vestibule ae the Ave openings of semiciculr
nals (igure 1170
2. SEMICIRCULAR CANAS. They ar these in number, the
lateral, posterior and Superor, and le in planes at fight
angles to one another. Each canal has an ampullatod
end which opens independently into the vestibule and
$ onampullated end. Nhe nonampullated ends of poste
flor and superior canals une to form common channel
{alle rs commune. Thus the thie canals open nto the
‘Nestle by ve openings.
3. CocHLEA. The bony cochlea sa coiled tube making
25510275 tuns ound a central pyramid of bone called
‘modiols. Te base of modus rected towards inter
‘al acoustic meatus and transmits vessels and nerves 10
the cochlea. Around the modiolus and winding spall
a
veu
ee te
gore 1.17. A) Ll bony bythe embassy.) cut cn the ny ua.
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Con, gos oa ng and stem tps car
Lo id tag
He and ant
‘wraps various visera in the abdomen-—raising several
{olds and dividing the middle ea into various compart-
‘ments. Middle car contains nothing but the al all the
Structure lie outside the mucous membrane
Histology, the eustachian tube & ined by elated
pihelum, whichis pseudostatied columnar in the
Esrilaginous part, columnar in he bony part with se
‘rl mocous and in the submucosa, Tyran caviy it
lined by ciated columnar epithelium in ts anterior and
interior part which Changes to cuboid type in he poste:
torpor kpiympanum and mastoid a els are ined by
‘at, nonelated epithelium.
BLOOD SUPPLY OF MIDDLE EAR
Mid car i supplied by six arteries, out of which two
ae the main, Le
1. Anterior tympanic branch of maxilry artery which
supplies tympanic membrane.
2. Siylomastoid branch of posterior auricular artery
eh supplies middle car and mastoid ar cls.
Four minor vessel are:
Parosal branch of middle meningeal artery (uns along
seater petsoal ment),
2, Superior tympanie branch of middle meningeal artery
teaversing along the Coal or tensor tympani muscle
3. Branch of “anal runs along eus.
4. mpanie Branch of interna carotid
‘eins drain into pterygoid venous plexus and superior.
porosa sinus.
LYMPHATIC DRAINAGE OF EAR
Lymphatic drainage of the eae is shown in Tabl 1.1. The
Inner ear doesnt have any Iymphate
oxi \
©
Ss ena Cons
A AS —
Nodes
Prestar and pride
roms
Poster nes, dep ur and spn acces nodes
Reponse mde upper our cn
Nehmen
THE INTERNAL EAR
‘The Interna er or the labyrinth Is an Important organ
of hearing and balance. I consist of bony anda mem
bramous Labyrinth. The membranous Ibytint is Bled
with a ar Ml called eniohmph while the space De-
lucen membranous and bony labyints i Billed with
pesiymph.
BONY LABYRINTH (FIGURE 1.178)
consists of thre parts
ana and the cochlea,
he vestibule, the semicircular
1. Vesna.
Is the central chamber of the laby-
singh. In is lateral wall lies the oval window. The ne
Side of ts medial wal presents two eceses, a sphere
rss, which lodges the saceue, and an etc ces,
ich Jodges the utile. Below the eliptcal recess i
the opening of aqueduct of vestibule through which
passes the endolymphatic duct. In the posterosuperior
part of vestibule ae the Ave openings of semiciculr
nals (igure 1170
2. SEMICIRCULAR CANAS. They ar these in number, the
lateral, posterior and Superor, and le in planes at fight
angles to one another. Each canal has an ampullatod
end which opens independently into the vestibule and
$ onampullated end. Nhe nonampullated ends of poste
flor and superior canals une to form common channel
{alle rs commune. Thus the thie canals open nto the
‘Nestle by ve openings.
3. CocHLEA. The bony cochlea sa coiled tube making
25510275 tuns ound a central pyramid of bone called
‘modiols. Te base of modus rected towards inter
‘al acoustic meatus and transmits vessels and nerves 10
the cochlea. Around the modiolus and winding spall
a
veu
ee te
gore 1.17. A) Ll bony bythe embassy.) cut cn the ny ua.
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ans
sn.
An
Slap
Figure 1.18. section though the caches 10a at me
(Gea det) seo sel aná eta mp
like the thread of ere, ia thin plat of Bone called
asus spial amina. divides the boay cochlea icon
pletely and gives attachment tothe ball membrane,
‘The bony bulge in the medial wall of middle car, the
promontory, I du tothe basal coil ofthe cochlea, The
Bony cochia contains thee compartments
(a) Scala vs,
(0) Sala tympani,
(e) Scala media orthemembranouscochlea (sure 1.10)
‘The scala vestbull and scala tympani ace file wit
pellymph and communicate with each other atthe apex
Of cochlea through an opening called hlictema. Scala
‘estibull closed by the footpat af tapes which separ
rats from the are middle car The scala tympan is
lose by secondary tympanic membrane; Its aso con.
rected withthe subarachnoid spc tough the alert
of cache (gure 1.19)
MEMBRANOUS LABYRINTH (FIGURE 1.178)
Ie consists ofthe cochlear duct, the utile and sale,
the three semer ducts, andthe endolymphatie duct
and ae
1. Cocutean Duer (Fic 1.18). Also called membre
nous cochlea o the cla media is blind colle te,
a
A ten
a EE
we E o a
Figure 119 À drama presentation ol ne pep
‘phen, SF site seo mp oa e al
Chapter 1 — Anatomy ofa 11
Ie appears triangular on crossection and is tre wall
are formed y:
(a) the basilar membrane, which supports the organ of
Cont
(©) the Rétaners membrane, which separates it from the
seal vestibule; and
{he sa vascular, which contains vascular epithe
im and is concerned with secretion of endohymph.
Cochlear duct is connected to the saccule by ducs
reins sure 1.178). The length of hallar membrane
Increases as we proceed fom the basal coll o the apical
(ol tis fortis reason that higher feguenctes of sound
Ste heard atthe basal cll while lower ons ae heard at
‘the apical ol.
©
2. Urmicaz ano Saca The utile lies in the posterior
partof bony vestibule Ie receive the five openings of the
thee semicincuar du. I i aio connected tothe se
‘ule through utreulosacculr duc. The sensory epithe:
Tum ofthe nl is called macula and Is concer with
Tinea acciration and deceleration. The seele also Hes
in te ny vestibule anterior tothe tril and oppesite
the stapes footplate. ts sensory epithelium Is lso called
‘macula ts exact function fs not known I probably also
responde to linear aceeration and deceleration. In Me
‘ges disease, the distended sccule les against the sta
pes footplate and can be surgical decompresed BY eee
Torating te oorplat.
3. SESMICIRCULAR Ducrs. They ate thee in number and
‘orrespond exactly to the three bony canal. They open
in the ride, The ampullated end ol eich duet contains
2 thickened rige of neuroepithelium called cst apie
Tar.
4. Exnoisurmarıe Ducr axo Sac. Endolymphaticduct
ds formed by the union of two ducs, one each from the
saccule and the utile. puse through the vestibular
squeduet Is terminal part 5 diated to form endo.
[hati ac, which is betwen the two layers of dura on
{he posterior surface ofthe ptrous bone.
"Endolymphatic sac s surgically important, I 1 ex
posed for drainage or shunt operation in Minlses
diese.
INNER EAR FLUIDS AND THEIR CIRCULATION
“There are two main st
endolymph,
Winner ear peilymph and
1. Pemuysen. It resembles extacelllar Mid and à
sich in Na fons I ils the space between the bony and
he membranous labyint lt communicates with CSF
through the aqueduct ol cochlea which opens into the
Scala tympani mar te round window In fat his dc
Sue resembling arachnoid through which perlmph per.
Coates. There are two views regarding the formation of
Deslymph 6) Isa fate of blood ser
Dy capillaries of the spial hgament and
‘continuation of CSF and teaches the labyrinth va aque
‘duct of cochlea.
mebooksfree.com
sn.
An
Slap
Figure 1.18. section though the caches 10a at me
(Gea det) seo sel aná eta mp
like the thread of ere, ia thin plat of Bone called
asus spial amina. divides the boay cochlea icon
pletely and gives attachment tothe ball membrane,
‘The bony bulge in the medial wall of middle car, the
promontory, I du tothe basal coil ofthe cochlea, The
Bony cochia contains thee compartments
(a) Scala vs,
(0) Sala tympani,
(e) Scala media orthemembranouscochlea (sure 1.10)
‘The scala vestbull and scala tympani ace file wit
pellymph and communicate with each other atthe apex
Of cochlea through an opening called hlictema. Scala
‘estibull closed by the footpat af tapes which separ
rats from the are middle car The scala tympan is
lose by secondary tympanic membrane; Its aso con.
rected withthe subarachnoid spc tough the alert
of cache (gure 1.19)
MEMBRANOUS LABYRINTH (FIGURE 1.178)
Ie consists ofthe cochlear duct, the utile and sale,
the three semer ducts, andthe endolymphatie duct
and ae
1. Cocutean Duer (Fic 1.18). Also called membre
nous cochlea o the cla media is blind colle te,
a
A ten
a EE
we E o a
Figure 119 À drama presentation ol ne pep
‘phen, SF site seo mp oa e al
Chapter 1 — Anatomy ofa 11
Ie appears triangular on crossection and is tre wall
are formed y:
(a) the basilar membrane, which supports the organ of
Cont
(©) the Rétaners membrane, which separates it from the
seal vestibule; and
{he sa vascular, which contains vascular epithe
im and is concerned with secretion of endohymph.
Cochlear duct is connected to the saccule by ducs
reins sure 1.178). The length of hallar membrane
Increases as we proceed fom the basal coll o the apical
(ol tis fortis reason that higher feguenctes of sound
Ste heard atthe basal cll while lower ons ae heard at
‘the apical ol.
©
2. Urmicaz ano Saca The utile lies in the posterior
partof bony vestibule Ie receive the five openings of the
thee semicincuar du. I i aio connected tothe se
‘ule through utreulosacculr duc. The sensory epithe:
Tum ofthe nl is called macula and Is concer with
Tinea acciration and deceleration. The seele also Hes
in te ny vestibule anterior tothe tril and oppesite
the stapes footplate. ts sensory epithelium Is lso called
‘macula ts exact function fs not known I probably also
responde to linear aceeration and deceleration. In Me
‘ges disease, the distended sccule les against the sta
pes footplate and can be surgical decompresed BY eee
Torating te oorplat.
3. SESMICIRCULAR Ducrs. They ate thee in number and
‘orrespond exactly to the three bony canal. They open
in the ride, The ampullated end ol eich duet contains
2 thickened rige of neuroepithelium called cst apie
Tar.
4. Exnoisurmarıe Ducr axo Sac. Endolymphaticduct
ds formed by the union of two ducs, one each from the
saccule and the utile. puse through the vestibular
squeduet Is terminal part 5 diated to form endo.
[hati ac, which is betwen the two layers of dura on
{he posterior surface ofthe ptrous bone.
"Endolymphatic sac s surgically important, I 1 ex
posed for drainage or shunt operation in Minlses
diese.
INNER EAR FLUIDS AND THEIR CIRCULATION
“There are two main st
endolymph,
Winner ear peilymph and
1. Pemuysen. It resembles extacelllar Mid and à
sich in Na fons I ils the space between the bony and
he membranous labyint lt communicates with CSF
through the aqueduct ol cochlea which opens into the
Scala tympani mar te round window In fat his dc
Sue resembling arachnoid through which perlmph per.
Coates. There are two views regarding the formation of
Deslymph 6) Isa fate of blood ser
Dy capillaries of the spial hgament and
‘continuation of CSF and teaches the labyrinth va aque
‘duct of cochlea.
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12 SECTION! — Diseases of ar
Nes tan) s
Renta) iu
Pro moi) 1
coe ma) o
Perth a
is »
es ae nen and my te sy Cb se attend (ch, te, a pep pn rs
2. ENDOLYMnH I fils the entre membranous labyrinth
Sd resembles intracelular id, Being ich in K fons. It
1 secre bythe secretory cells ofthe sr vascular of
the cochlea and by the dark cell (present inthe utile
and also near the ampullate ends of semicircular cts,
There ate two views regarding flow: () longitudinal ke
endolymph from the cochlea reaches saul, uti and
‘endolymphatic duc and gets absorbed trough endolym
‘hati sc, which les in the sural space and i) ra
al Le endolymph secreted by sia vascular and
es absorb bythe sta vascular This view presumes
{hat endolymphatic sac a Vesti Structure in man and
plays no pat In endolymph absorption. Composition of
fndolymph, perilymph and CSP is given in Table 12.
BLOOD SUPPLY OF LABYRINTH
The entire labyrinth receives its arterial supply’ ough
Labyrintine ater, which 1a branch of anerorinienor.
cacher artery but sometimes fom the basa. Inthe
Internal auditory canal vides in the manner shown in
Figures 1.20 and 121
‘enous drainage through three veins, namely inter
al auditory vein, vein of cochlear aguedct and ein of
vestibular aqusduet, which ultimately dain Into inferior
Petros sinus and lateral venous sinus.
Teisto be noted that
1. Blood supply tothe inner ea is independent of blood
supply to middle car and bony ote capsule, and there
‘Soros circulation betwee
ao ane
Ces
ns nt
| rs
‘troy tect, 60%)
ected an Poser sitar ary
GE NS) oso wd poser sana)
iger 1.20. Onions the byte ay which pp lod
a par Deby
2. Blood supply to cochlea and vestibular Labyrinth is
Segmental, therefore, independent ischaemic damage
{an occur to these organs causing either cochlear or
‘estat symptoms.
DEVELOPMENT OF EAR
Avnicke, First branchial cet isthe precursor of external
<uditory canal. Around the th weck of embryonic Ie,
2 sis of x tubercles appear around the est branche
A let. They progressively coalesce to form the auricle
(igure 1.22. Tragus develops from the tubercle of the
Fist arch while the test of the plana develops fom the
remaining ve tubercles ofthe second ach, Faulty fusion
Pen the fst and the second arch ES causes
preouicular sinus or ct, which is commonly seen be
{Breen the tragus and crus of helix. By the 20th week,
inna achieves adult shape. tal, he pinna i located
low on the se ofthe neck and then moves oa toa more
lateral and cranial position.
[Exrewyat Avprrony MEATUS It develops rom the fist
branchial cet. By about the 16th embryonic week, cells
proliferate rom the Bottom of ectodermal deft and form
meatal pg. Recsnatzation of this plug forms the pl.
{hella ining ofthe bony meats. Recanalzation begins
rom the deeper part near the tympanic membrane and
progress outwards, and that explains why deeper mea
8 sometimes developed while there 15 aci anal
In ne outer ar. External var canal sal formed by the
Pain week of gestation.
TIME Mesa. I develops fom all the thee ger-
ses, Outer epithelial aver s formed by the «=
Tamer mucosa layer by the endoderm and the
‘mid bus layer by the mesoderm:
Minous Ean Cuerr. The eustachian tube, tympanic
‘ity, atl antrum and mastoid alr cells develop from
{he endoderm of tubotympanie reses which rss from
{the Hes and partly (om the second pharyngeal pouches
igure 129.
Mateus and incus are derived from mesoderm ofthe
fst arch white the stapes develop om the second atch
excep its fotplate and anna igament which ae de
‘ved from the ote cape
Mrnmeanous INNER Ear. Development of the inner ear
"Nats in the 3rd week of fetal life and is complete By the
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Nes tan) s
Renta) iu
Pro moi) 1
coe ma) o
Perth a
is »
es ae nen and my te sy Cb se attend (ch, te, a pep pn rs
2. ENDOLYMnH I fils the entre membranous labyrinth
Sd resembles intracelular id, Being ich in K fons. It
1 secre bythe secretory cells ofthe sr vascular of
the cochlea and by the dark cell (present inthe utile
and also near the ampullate ends of semicircular cts,
There ate two views regarding flow: () longitudinal ke
endolymph from the cochlea reaches saul, uti and
‘endolymphatic duc and gets absorbed trough endolym
‘hati sc, which les in the sural space and i) ra
al Le endolymph secreted by sia vascular and
es absorb bythe sta vascular This view presumes
{hat endolymphatic sac a Vesti Structure in man and
plays no pat In endolymph absorption. Composition of
fndolymph, perilymph and CSP is given in Table 12.
BLOOD SUPPLY OF LABYRINTH
The entire labyrinth receives its arterial supply’ ough
Labyrintine ater, which 1a branch of anerorinienor.
cacher artery but sometimes fom the basa. Inthe
Internal auditory canal vides in the manner shown in
Figures 1.20 and 121
‘enous drainage through three veins, namely inter
al auditory vein, vein of cochlear aguedct and ein of
vestibular aqusduet, which ultimately dain Into inferior
Petros sinus and lateral venous sinus.
Teisto be noted that
1. Blood supply tothe inner ea is independent of blood
supply to middle car and bony ote capsule, and there
‘Soros circulation betwee
ao ane
Ces
ns nt
| rs
‘troy tect, 60%)
ected an Poser sitar ary
GE NS) oso wd poser sana)
iger 1.20. Onions the byte ay which pp lod
a par Deby
2. Blood supply to cochlea and vestibular Labyrinth is
Segmental, therefore, independent ischaemic damage
{an occur to these organs causing either cochlear or
‘estat symptoms.
DEVELOPMENT OF EAR
Avnicke, First branchial cet isthe precursor of external
<uditory canal. Around the th weck of embryonic Ie,
2 sis of x tubercles appear around the est branche
A let. They progressively coalesce to form the auricle
(igure 1.22. Tragus develops from the tubercle of the
Fist arch while the test of the plana develops fom the
remaining ve tubercles ofthe second ach, Faulty fusion
Pen the fst and the second arch ES causes
preouicular sinus or ct, which is commonly seen be
{Breen the tragus and crus of helix. By the 20th week,
inna achieves adult shape. tal, he pinna i located
low on the se ofthe neck and then moves oa toa more
lateral and cranial position.
[Exrewyat Avprrony MEATUS It develops rom the fist
branchial cet. By about the 16th embryonic week, cells
proliferate rom the Bottom of ectodermal deft and form
meatal pg. Recsnatzation of this plug forms the pl.
{hella ining ofthe bony meats. Recanalzation begins
rom the deeper part near the tympanic membrane and
progress outwards, and that explains why deeper mea
8 sometimes developed while there 15 aci anal
In ne outer ar. External var canal sal formed by the
Pain week of gestation.
TIME Mesa. I develops fom all the thee ger-
ses, Outer epithelial aver s formed by the «=
Tamer mucosa layer by the endoderm and the
‘mid bus layer by the mesoderm:
Minous Ean Cuerr. The eustachian tube, tympanic
‘ity, atl antrum and mastoid alr cells develop from
{he endoderm of tubotympanie reses which rss from
{the Hes and partly (om the second pharyngeal pouches
igure 129.
Mateus and incus are derived from mesoderm ofthe
fst arch white the stapes develop om the second atch
excep its fotplate and anna igament which ae de
‘ved from the ote cape
Mrnmeanous INNER Ear. Development of the inner ear
"Nats in the 3rd week of fetal life and is complete By the
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oon vets ann,
(uve Sp oral a)
‘Chapter — Anatomy alar 13
pti ane
Common coca ay
Figure 1.21. ond spy fhe byt
igure 1.22 Degen ir, St hc of Hs wound the
it Bandai det and te corespondng pr pla wc e.
eeprom tem
16th week Ectoderm inthe region of hindbra
to form a ana plod, whic ia
auditory vesicle or the oft. Te later then diferent
ts into the endolymphatic duct and sac; the ute t
Seiceular dect and sacle and the cochlea. Devel:
‘opment of pilogenetically older pat of bye purs
‘Spero (emicrular canal and utc) takes place caller
‘than prs infor sul and cochlea)
The embryologic source and the tie of development
‘of external and mide ers ae quite independent of the
usarán ec
Figure 1.23. Dip el eter ur cal and md.
evelopment ofthe inner car Is therfore not unusual
{ose malformed and nonfunctional inner eatin the pes:
face of normal external and middle ers and vice vera.
“The cochlea Is developed Sufiient by 20 weeks of
gestation (RL andthe ets can hear in the womb
St the mother. This probably explains how Abhimanyu,
‘while til unborn, could have heard the conversation be
een his mother and father (Aruna) In the legend given
in ine Great Indian epic of Mahabharata ten thos
Sands of yeas ago
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(uve Sp oral a)
‘Chapter — Anatomy alar 13
pti ane
Common coca ay
Figure 1.21. ond spy fhe byt
igure 1.22 Degen ir, St hc of Hs wound the
it Bandai det and te corespondng pr pla wc e.
eeprom tem
16th week Ectoderm inthe region of hindbra
to form a ana plod, whic ia
auditory vesicle or the oft. Te later then diferent
ts into the endolymphatic duct and sac; the ute t
Seiceular dect and sacle and the cochlea. Devel:
‘opment of pilogenetically older pat of bye purs
‘Spero (emicrular canal and utc) takes place caller
‘than prs infor sul and cochlea)
The embryologic source and the tie of development
‘of external and mide ers ae quite independent of the
usarán ec
Figure 1.23. Dip el eter ur cal and md.
evelopment ofthe inner car Is therfore not unusual
{ose malformed and nonfunctional inner eatin the pes:
face of normal external and middle ers and vice vera.
“The cochlea Is developed Sufiient by 20 weeks of
gestation (RL andthe ets can hear in the womb
St the mother. This probably explains how Abhimanyu,
‘while til unborn, could have heard the conversation be
een his mother and father (Aruna) In the legend given
in ine Great Indian epic of Mahabharata ten thos
Sands of yeas ago
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14 SECTIONI — Diseases of Ear
“tye A Opens hy ft cad Sangh oy fs Pie Wan Congo
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“tye A Opens hy ft cad Sangh oy fs Pie Wan Congo
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Chapter 2
Peripheral Receptors and Physiology
of Auditory and Vestibular Systems
‘AUDITORY SYSTEM
ORGAN OF CORTI (FIGURE 2.1)
Organ of Cont
Sted on the basilar
the organ of Cot ar:
nse organ of heating and is
bane. important compone
1. TUNEL OF Conti. is formed by the inner and outer
rods. contains a id called cot The exact fune.
tion ofthe rods and cortlymph snot known.
2. Haim Crus. They are important receptor cals of
heating and transduce sound energy into electrical en
era. Inner hale cells form a single row while outer hair
eal ct hal cells
Fy impulses. Outer hai els mainly receive efferent in.
eration from the olivary complex and are concerned
‘with modulating the function 8 inner hai cells. Dit
ferences between inner and outer hal el are given in
be 2
3. Surponrine Cut. Deiter’ cells ae situated between
theouterhaircels and provide Support 10 the later Cells
‘of Hensen lle outside the Deiter cells
a, TecroniaL Mestmnat. It consists of gelatinous ma-
tra with delicate bes. lovelies the organ of Cor The
Shearing force betwen the hat cll and tctoril mem
brane produces the stimulus to har cells
[NERVE SUPPLY OF HAIR CELLS
Ninety-five per cent of afferent fibres of piral ganglio
supply the nner hae cls whi only Bee pee cent sup
the outer har cells ferent bres 0 Ihe har cells come
from the olvocochier bund, Their cel bodies rest
sted in superior ovary comple Fach cochlea sends in.
iervation to both sides ofthe brain
AUDITORY NEURAL PATHWAYS AND THEIR
NUCLEI (FIGURE 2.2)
Haie cells are innervated by dendele of bipolar calls of
spa ganglion which fs situated in Rosentha's canal (a
nal running along the oscous spiral lamina). Avon of
these bipolar els form the cochlear division of CN VII
and end inthe cochlear nude, the donal and venta,
‘on each sie ofthe medalla. Further course of auditor
pathways is complex. From cochlear nucl, the main
hcl inthe ascending autor pathways, sequently,
{rom below upwards ae
1. Superior olívary com
2: Nucleus of lateral emniscus
À inferior colis
B
Auditor cortex
The auditor bres travel via the ipsilateral and con:
raaerl routes and have multiple decusstion points
Ths each eats represented n both cerebral hemispheres.
‘The area ol comex, concerned with hearing stated in
he superior temporal gyrus (Brodmannı'sara 1) For au:
‘itor’ pathway, remember the mnemonic ECOLLMA
Eighth nerve, Cochlear nucle, Olary complex, Latta
lemniscus, Inferior cllcuus, Medal genteulaie body
and itor corte
body
PHYSIOLOGY OF HEARING
Any vibrating object causes waves of compression and
‘clacton and is capable of producing sound. In the a,
AR °C and at sea love, sound wavelsat a speed of 44m
Te travel faster in qui and solis
Re aie Also, een sound energy has 0 pass from
alto lguld medium, most ot let because of the
impedance offered by the quid
MECHANISM OF HEARING
A sound signal in the environment is collected by the
pina, pases through externa audtory canal and shes
{he tympanic membrane. Vibrations of the tympanic
‘membrane are transmitted 0 stapes footpate tough
a chain of ossicles coupled to the tympanic membrane
‘Movements of stapes footpate cau presure changes
‘rane. This stimulates the hair cel ofthe organ of Cort
Tis these hair els which act as transducers and conver
the mechanical energy into elect impulses, which
ave along the auditory nerve. Thus, the mechanism of
hearing ean be broadly divided into
1. Mechanical conduction of sound (conductive appara
2. Transduction of mechanical energy 0 electrical im.
ples (sensory system of eochle
3, Conduction of electrical impulses 0 the brain (neural
pathway.
15
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Peripheral Receptors and Physiology
of Auditory and Vestibular Systems
‘AUDITORY SYSTEM
ORGAN OF CORTI (FIGURE 2.1)
Organ of Cont
Sted on the basilar
the organ of Cot ar:
nse organ of heating and is
bane. important compone
1. TUNEL OF Conti. is formed by the inner and outer
rods. contains a id called cot The exact fune.
tion ofthe rods and cortlymph snot known.
2. Haim Crus. They are important receptor cals of
heating and transduce sound energy into electrical en
era. Inner hale cells form a single row while outer hair
eal ct hal cells
Fy impulses. Outer hai els mainly receive efferent in.
eration from the olivary complex and are concerned
‘with modulating the function 8 inner hai cells. Dit
ferences between inner and outer hal el are given in
be 2
3. Surponrine Cut. Deiter’ cells ae situated between
theouterhaircels and provide Support 10 the later Cells
‘of Hensen lle outside the Deiter cells
a, TecroniaL Mestmnat. It consists of gelatinous ma-
tra with delicate bes. lovelies the organ of Cor The
Shearing force betwen the hat cll and tctoril mem
brane produces the stimulus to har cells
[NERVE SUPPLY OF HAIR CELLS
Ninety-five per cent of afferent fibres of piral ganglio
supply the nner hae cls whi only Bee pee cent sup
the outer har cells ferent bres 0 Ihe har cells come
from the olvocochier bund, Their cel bodies rest
sted in superior ovary comple Fach cochlea sends in.
iervation to both sides ofthe brain
AUDITORY NEURAL PATHWAYS AND THEIR
NUCLEI (FIGURE 2.2)
Haie cells are innervated by dendele of bipolar calls of
spa ganglion which fs situated in Rosentha's canal (a
nal running along the oscous spiral lamina). Avon of
these bipolar els form the cochlear division of CN VII
and end inthe cochlear nude, the donal and venta,
‘on each sie ofthe medalla. Further course of auditor
pathways is complex. From cochlear nucl, the main
hcl inthe ascending autor pathways, sequently,
{rom below upwards ae
1. Superior olívary com
2: Nucleus of lateral emniscus
À inferior colis
B
Auditor cortex
The auditor bres travel via the ipsilateral and con:
raaerl routes and have multiple decusstion points
Ths each eats represented n both cerebral hemispheres.
‘The area ol comex, concerned with hearing stated in
he superior temporal gyrus (Brodmannı'sara 1) For au:
‘itor’ pathway, remember the mnemonic ECOLLMA
Eighth nerve, Cochlear nucle, Olary complex, Latta
lemniscus, Inferior cllcuus, Medal genteulaie body
and itor corte
body
PHYSIOLOGY OF HEARING
Any vibrating object causes waves of compression and
‘clacton and is capable of producing sound. In the a,
AR °C and at sea love, sound wavelsat a speed of 44m
Te travel faster in qui and solis
Re aie Also, een sound energy has 0 pass from
alto lguld medium, most ot let because of the
impedance offered by the quid
MECHANISM OF HEARING
A sound signal in the environment is collected by the
pina, pases through externa audtory canal and shes
{he tympanic membrane. Vibrations of the tympanic
‘membrane are transmitted 0 stapes footpate tough
a chain of ossicles coupled to the tympanic membrane
‘Movements of stapes footpate cau presure changes
‘rane. This stimulates the hair cel ofthe organ of Cort
Tis these hair els which act as transducers and conver
the mechanical energy into elect impulses, which
ave along the auditory nerve. Thus, the mechanism of
hearing ean be broadly divided into
1. Mechanical conduction of sound (conductive appara
2. Transduction of mechanical energy 0 electrical im.
ples (sensory system of eochle
3, Conduction of electrical impulses 0 the brain (neural
pathway.
15
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16 SECTION — Diseases of Ear
Figure 2.1. Sucre ono ori
ner ar co ‘Outer tects
Tour. 30 1200
Pe nero Te or ou ro
Spe Fa pes ges
Nerea mat leen res nd very leu lent erent ves nd vey earn
Deep Developer Da ite
Pac Tone to sind ste ncn mer ar cts
Wray Movers sy damage y tots ds ná hh nens nose
Cocca Tapenitnay
Figure 22. tor panes om he ight cohen. Note iba
‘ou Dic iia ae otc econ
1. Conduction of Sound
A person under water cannot er any sound made in
the air because 99.996 of the sound energy i elected
Away from the surface of water because of the imped-
ance offered by It À similar situation exist In the ear
hen airconducted sound has to travel to cochlear
us, Nature has compensated for this oss of sound
energy by interposing the middle car which converts
Sound of greater amplitude but lesser force, to that of
ser amplitude but greater force. This function of the
‘mite cr scaled impedance matching mechanism or the
Fraser action.
leis accomplshed by:
times longer than long proces ofthe incas, provi
Inga mechanical advantage of 13
yale action of tympanic membrane. The ara of
tympanic membrane fs much larger than the are OF
Sapesfootplat, the average rato between the two.
being 21:1 As the effective vibratory tea of tye
ane membrane s only wwo.hinds, the effective ar
fa aio is reduced to LT, and this is the meta
‘al advantage provided by the tympanic membrane
igure 23)
‘The product of aca ato and lever ation of 05:
sices IL
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Figure 2.1. Sucre ono ori
ner ar co ‘Outer tects
Tour. 30 1200
Pe nero Te or ou ro
Spe Fa pes ges
Nerea mat leen res nd very leu lent erent ves nd vey earn
Deep Developer Da ite
Pac Tone to sind ste ncn mer ar cts
Wray Movers sy damage y tots ds ná hh nens nose
Cocca Tapenitnay
Figure 22. tor panes om he ight cohen. Note iba
‘ou Dic iia ae otc econ
1. Conduction of Sound
A person under water cannot er any sound made in
the air because 99.996 of the sound energy i elected
Away from the surface of water because of the imped-
ance offered by It À similar situation exist In the ear
hen airconducted sound has to travel to cochlear
us, Nature has compensated for this oss of sound
energy by interposing the middle car which converts
Sound of greater amplitude but lesser force, to that of
ser amplitude but greater force. This function of the
‘mite cr scaled impedance matching mechanism or the
Fraser action.
leis accomplshed by:
times longer than long proces ofthe incas, provi
Inga mechanical advantage of 13
yale action of tympanic membrane. The ara of
tympanic membrane fs much larger than the are OF
Sapesfootplat, the average rato between the two.
being 21:1 As the effective vibratory tea of tye
ane membrane s only wwo.hinds, the effective ar
fa aio is reduced to LT, and this is the meta
‘al advantage provided by the tympanic membrane
igure 23)
‘The product of aca ato and lever ation of 05:
sices IL
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(Chapter 2 — Peripheral Receptor and Physio f Autor and Vestibule Systems 17.
Fan ae SE
Fee mo 1 à 1 1024
Des sie
igure 23. Tandomer cin le mie u ate ec of
pe membrane alee acon of esis mb compen:
he he sound eng lo ving o amm fom ar Lo
According to some workers (Wever and Lawrence)
out of to of 90 mm? are of human Eympanic
‘membrane, only SS mm? is functional and given the
Ara of stapes fooplate 8.2 mm), the area rato ls
174 and total transformer ato (17% 1.3) 22.1
19) Canal mombrane ct. Movement of tympanic
‘membrane ate more a the periphery than a the ce
tte where malleus handle fe attached. This 100 pro:
ies some leverage
Puase Durexex Tit Berwers Ova avo Roux» Wax:
Dow. Sound waves striking the tympanic membrane do
hot reach the oval and round windows simultaneously
Tier i peeerentil pathway tothe oval window be:
cause ofthe ossicular chain. Thus, when oval window 5
receiving wave of compresion, the round window Is at
the phase of rartaction, I the sound waves wer to ske
both the windows simultaneous}, they would cancel
‘ach others effect with no movement of the peliymph
Sd no hearing This acoustic separation of windows is
achieved by the presence of Intact tympanic membrane
nd a eshion of arin the mide ar around the ound
‘windows Phase dferenta betwee
Utes when tympanic membrane nt
Inherent anatomic and physiologic properties of the ex
termal and mide car alow cera frequencies of sound
to pass more easly tothe Inner ear due to ther nat
ral resonances Natural resonance of extemal eur canal is
3006 Hz an that of middle car 800 Hz, Frequencies most
ficiently tansmited by ossicular chain are between
500 and 2000 He while that by tympanic membrane is
‘500-1600 Hz. Tus greatest ent of the sound tans
mission is between 500 and 3000 He and these ate the
Frequencies most important to man in day-to-day conver
sation (bi
Feat asin na
impar mente
a
un DA a
Figure 24, frequency catan in cc Haaren
SET um nn ron do ch
2. Transduction of Mechanical Energy to
Electrical impulses
Movements of he stapes footpat
Cochlear fds, move the basar membrane and set up
Sheaing force between the tector membrane and the
air cel The dstrton of hal cells gives se to cochlear
‚microphonis, which tiger the nerve impulse.
À sound wave, depending on ds frequency, reaches
maximum amplitude on a particular place on the star
‘membrane and stimulates that segment (aveling wave
an of son Boke). Higher frequencies ae represented
{nthe bisa urn ofthe caches and the progress low
er ones towards the apex Fur 2 14
3. Neural Pathways
Hair cells get innervation from the bipolar cells of
spiral ganglion. Central axons ofthese cells collet 10
Form the cochlear nerve which goes to the ventral and
¿dorsal cochicar nuclel From there, both crossed and
luncrossed bes travel tothe supetior olivary nucleus,
lateral lemnisus, inferior eolieutus, medal geniculate
body and finaly reach the auditory cortex of the tem
poral lobe (Brodmant's area 41 situated at he superior
Aspect of the temporal abc aang the floor ofthe lateral
era sure
ELECTRICAL POTENTIALS OF COCHLEA
AND CN Vili
Four types of potentials have been recorded; three from
the cochlea and one from CN VII res, Ty are
1. Endocochlear potential
2: Cochlear microphonic 7
3. Summating potential J
À: Compound action potential 7
from cochlea
from nerve fibres
1. Expococutean Porerin. Its a dee current (DC)
potential recorded from scala media. is +80 mV and
IS generated fom the sna vascular by Na AT
pump and provides source of energy for cochlcar tans:
Suction (igure 2). I is present at rest and does not
require sound stimulus, This potential provides a sort of
“hate” to drive the current through har ells when
they’ move ln response to a sound stimulus
mebooksfree.com
Fan ae SE
Fee mo 1 à 1 1024
Des sie
igure 23. Tandomer cin le mie u ate ec of
pe membrane alee acon of esis mb compen:
he he sound eng lo ving o amm fom ar Lo
According to some workers (Wever and Lawrence)
out of to of 90 mm? are of human Eympanic
‘membrane, only SS mm? is functional and given the
Ara of stapes fooplate 8.2 mm), the area rato ls
174 and total transformer ato (17% 1.3) 22.1
19) Canal mombrane ct. Movement of tympanic
‘membrane ate more a the periphery than a the ce
tte where malleus handle fe attached. This 100 pro:
ies some leverage
Puase Durexex Tit Berwers Ova avo Roux» Wax:
Dow. Sound waves striking the tympanic membrane do
hot reach the oval and round windows simultaneously
Tier i peeerentil pathway tothe oval window be:
cause ofthe ossicular chain. Thus, when oval window 5
receiving wave of compresion, the round window Is at
the phase of rartaction, I the sound waves wer to ske
both the windows simultaneous}, they would cancel
‘ach others effect with no movement of the peliymph
Sd no hearing This acoustic separation of windows is
achieved by the presence of Intact tympanic membrane
nd a eshion of arin the mide ar around the ound
‘windows Phase dferenta betwee
Utes when tympanic membrane nt
Inherent anatomic and physiologic properties of the ex
termal and mide car alow cera frequencies of sound
to pass more easly tothe Inner ear due to ther nat
ral resonances Natural resonance of extemal eur canal is
3006 Hz an that of middle car 800 Hz, Frequencies most
ficiently tansmited by ossicular chain are between
500 and 2000 He while that by tympanic membrane is
‘500-1600 Hz. Tus greatest ent of the sound tans
mission is between 500 and 3000 He and these ate the
Frequencies most important to man in day-to-day conver
sation (bi
Feat asin na
impar mente
a
un DA a
Figure 24, frequency catan in cc Haaren
SET um nn ron do ch
2. Transduction of Mechanical Energy to
Electrical impulses
Movements of he stapes footpat
Cochlear fds, move the basar membrane and set up
Sheaing force between the tector membrane and the
air cel The dstrton of hal cells gives se to cochlear
‚microphonis, which tiger the nerve impulse.
À sound wave, depending on ds frequency, reaches
maximum amplitude on a particular place on the star
‘membrane and stimulates that segment (aveling wave
an of son Boke). Higher frequencies ae represented
{nthe bisa urn ofthe caches and the progress low
er ones towards the apex Fur 2 14
3. Neural Pathways
Hair cells get innervation from the bipolar cells of
spiral ganglion. Central axons ofthese cells collet 10
Form the cochlear nerve which goes to the ventral and
¿dorsal cochicar nuclel From there, both crossed and
luncrossed bes travel tothe supetior olivary nucleus,
lateral lemnisus, inferior eolieutus, medal geniculate
body and finaly reach the auditory cortex of the tem
poral lobe (Brodmant's area 41 situated at he superior
Aspect of the temporal abc aang the floor ofthe lateral
era sure
ELECTRICAL POTENTIALS OF COCHLEA
AND CN Vili
Four types of potentials have been recorded; three from
the cochlea and one from CN VII res, Ty are
1. Endocochlear potential
2: Cochlear microphonic 7
3. Summating potential J
À: Compound action potential 7
from cochlea
from nerve fibres
1. Expococutean Porerin. Its a dee current (DC)
potential recorded from scala media. is +80 mV and
IS generated fom the sna vascular by Na AT
pump and provides source of energy for cochlcar tans:
Suction (igure 2). I is present at rest and does not
require sound stimulus, This potential provides a sort of
“hate” to drive the current through har ells when
they’ move ln response to a sound stimulus
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18 SECTIONI — Diseases ofr
Figure 25. Om’ tery model of cotos ns, Sala
Imes as» DC pent! 189 mi Staton oh ees po.
‘ices cedo potent of 240 mi. Tas po Yow lc
2. Cocuean Micnormoxic (CM). When basilar mom.
‘ane moves in response o sound stimulus, electcal re
sistance atthe tips of hai cel changes allowing Now of
through har ces and produces voltage Nuctuations
called cochlear microphone. isan aerating current
AC) potential
3. SUMMATING POTENIIAL (SP). [ts à DC potential and
follows “envelope” of simulating sound. Is produce
by har calls. I may be negative or positive. SP ha been
‘ted in dlagnosts of Ménièe disease. Its superimposed
‘on VIT nerve action potenti
oth CM and SP are receptor potentials as sen in othe
er sensory end-organ. They dir from action potentials
In that () they ae gad eather than al or none phe-
‘pomenon, (i) have no latency, (i) are not propagated
and (iv) ave no postesponse Factory peris,
4. Cowrounn Action Potexmat. Its an al or none
response of auditory nerve Rites.
VESTIBULAR SYSTEM
PERIPHERAL RECEPTORS
Thy ar of two types
1. Cristae
‘Tey are located in the ampullated ends of the three
semicircular ducts. These RON respond o angular ac:
‘eration.
2. Maculae
‘They ae located in otolith organ (Le. utile and sac
ui, Maul of the uct lies in ts Noor in a horizontal
plane. Macula ofthe saccule Hes in is medal wall in à
vertical plane. They sense postion of head in response to
gravity and linear acceleration.
(4) Stmucrune oF A Gusta (Hove 2.6). 1a crest
Ike mound of connective issues on which ete sensory
«pill ells The ella ofthe sensory hate cells project
Into the cupula, which is a gelatinous mass extending
eat amas
Figure 2.6, cure amplia en semi dut Orr
ht eses leer wi sopping cals. Fam
Simon et peto guano naan pla
kom the suce of cit to the ceiling ofthe ampulla
and forms a watertight partition, only to be dispaced to
‘ne or the other side like swing door, ith movements
‘ot endolymph Me gelatinous mas of cupula consists of
polysaccharide and contains canals into which project
A la of sensory cells
cel are of wo types (igure 27). ip els are
à Single large cupske ner terminal
1 base. pe I cals are onde with
‘multiple nerve terminals atthe base. From the upper sut.
face ofeach cell projet a single halt, the kinocilum and
& number of other ea, the stereo. The Kincitum is
thicker ands located on the edge ofthe cel. Sensory calls
aresutrounded by supporting cells which show mine
On thle upper ends
(0) STRUCTURE oF A MACULA. A macula consists may
‘of two parts) 2 sensory neuroepitheium, made up of
{ype land type I eel similar to those in the crt)
Srotolthic membrane, which 5 made up ofa gelatine
‘mass and on the top, the esas ol calcium carbonate
Called tots or ac (sre 23). The la of haces
igure 27. Ses he ces We estas ons. Type | at)
Sra ype on,
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Figure 25. Om’ tery model of cotos ns, Sala
Imes as» DC pent! 189 mi Staton oh ees po.
‘ices cedo potent of 240 mi. Tas po Yow lc
2. Cocuean Micnormoxic (CM). When basilar mom.
‘ane moves in response o sound stimulus, electcal re
sistance atthe tips of hai cel changes allowing Now of
through har ces and produces voltage Nuctuations
called cochlear microphone. isan aerating current
AC) potential
3. SUMMATING POTENIIAL (SP). [ts à DC potential and
follows “envelope” of simulating sound. Is produce
by har calls. I may be negative or positive. SP ha been
‘ted in dlagnosts of Ménièe disease. Its superimposed
‘on VIT nerve action potenti
oth CM and SP are receptor potentials as sen in othe
er sensory end-organ. They dir from action potentials
In that () they ae gad eather than al or none phe-
‘pomenon, (i) have no latency, (i) are not propagated
and (iv) ave no postesponse Factory peris,
4. Cowrounn Action Potexmat. Its an al or none
response of auditory nerve Rites.
VESTIBULAR SYSTEM
PERIPHERAL RECEPTORS
Thy ar of two types
1. Cristae
‘Tey are located in the ampullated ends of the three
semicircular ducts. These RON respond o angular ac:
‘eration.
2. Maculae
‘They ae located in otolith organ (Le. utile and sac
ui, Maul of the uct lies in ts Noor in a horizontal
plane. Macula ofthe saccule Hes in is medal wall in à
vertical plane. They sense postion of head in response to
gravity and linear acceleration.
(4) Stmucrune oF A Gusta (Hove 2.6). 1a crest
Ike mound of connective issues on which ete sensory
«pill ells The ella ofthe sensory hate cells project
Into the cupula, which is a gelatinous mass extending
eat amas
Figure 2.6, cure amplia en semi dut Orr
ht eses leer wi sopping cals. Fam
Simon et peto guano naan pla
kom the suce of cit to the ceiling ofthe ampulla
and forms a watertight partition, only to be dispaced to
‘ne or the other side like swing door, ith movements
‘ot endolymph Me gelatinous mas of cupula consists of
polysaccharide and contains canals into which project
A la of sensory cells
cel are of wo types (igure 27). ip els are
à Single large cupske ner terminal
1 base. pe I cals are onde with
‘multiple nerve terminals atthe base. From the upper sut.
face ofeach cell projet a single halt, the kinocilum and
& number of other ea, the stereo. The Kincitum is
thicker ands located on the edge ofthe cel. Sensory calls
aresutrounded by supporting cells which show mine
On thle upper ends
(0) STRUCTURE oF A MACULA. A macula consists may
‘of two parts) 2 sensory neuroepitheium, made up of
{ype land type I eel similar to those in the crt)
Srotolthic membrane, which 5 made up ofa gelatine
‘mass and on the top, the esas ol calcium carbonate
Called tots or ac (sre 23). The la of haces
igure 27. Ses he ces We estas ons. Type | at)
Sra ype on,
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(Chapter 2 — Peripheral Receptor and Physlogy f Auditory and Vestibular Systems 19
Oammenerbem
Figure 22. Svcure mac emo en oran one ce and te ace
prole into the gelatinous layer. The liner, gravitational
And head it movements eae displacement of otlithie
membrane and thus stimulate the ha cells which hein
teren: panes.
VESTIBULAR NERVE
Vesibuar or Scapas ganglion is situated inthe atera
par of the intemal acoustic meats. I contains bipolar
els. The distal processes of bipolar cel innervate the
Sensory epithelia of the labyrinth weit central pro.
eses agregate 10 form the vestibular nerve
CENTRAL VESTIBULAR CONNECTIONS
“Te fibres of vestibular nerve end in vestibular nucle! and
Some goto the cerebellum directly.
“Vestibular nude are four in number, the superior,
medial, lateral and descending. Aero 10 these ute
come fom
1. Peripheral vestibular receptors (semicircular canals,
utile and Sacco)
2. Cerebellum
3. Retcuar formation
4. Spinal cord
5, Contalteral vestibule cle
‘Ths, Information received from the abyeithine re
‘ceptors is integrated with information rom the som
totensory systems.
“eens rom vestibular nell go to:
1. Nutt of CN, IV VI via medal longitudinal buna
tis the pathway for vestibuo-ocuar reflexes and this
explains the genesis of nystagnus,
2. Motor pat of spinal cor (vestibulospinal Abres) Tis
ooedimates the movements of head, neck and body in
the maintenance of balance.
3, Corebellum (estibuloerebellar Are) I helps to co-
‘ordinate input information to maintain he body bal
4. Autonomic nervous system. This explains nausea,
vomiting, palpitation, sweating and pallor sen in es
bar disorders (e. Ménieres disease.
$. Vestibular mue ofthe opposite side
6, Cerebral cortex (temporal lobe). This ls responsible for
Subjective awareness of motion,
PHYSIOLOGY OF VESTIBULAR SYSTEM
‘Vestibular system is conveniently divided int:
1. Peripheral which s made up of membranous labyrinth
(semicircular ducts, utile and Saccule) and vestibular
2. Cota, which is made up of nucle and fre tacts in
the central nervous system to Integrate vestibular Im
pulses with other stems to maintain body balance
SEMICIRCULAR CANALS
They respond to angular acceleration and desert
‘The the canals ie at sight angles o each other but the
fone which le at right angles o the ais of rotation Is
Stimulated the most Thus horizontal canal wil respond
‘maximum to rotation onthe vertical axis and soon, Due
o this arrangement ofthe thee canal in three diferent
planes, any change in postion of hend can be detected
Simulation of semicrular canals produces nystagmus
and the direction of nystagmus Is determined by the
plane ofthe canal being stimulated. Ths, nystagmus is
"horizontal from horizontal canal, rotatory (rom the supe
flor anal and vertical from the posterior canal
"The stimulus to semicircular canal is How of endo-
Amp eich displaces the cupula. The Now may beto.
‘wards the cupula (ampullopea) or away fom I (am.
pullofuga, better called teculopetl and utriulolugal-
[Ampullopetal How is more effective than ampulotagal
for the horizontal cana. The quick component of nys
{agmus is always opposite tote dicton of ow of e.
dolymph. Thus, Ifa person Is rotated to the right for
Sometime and then abruptly stopped, the endolyn
Continues 10 move to the right due to meta (Le. ame
Pullopeal for Tet canal, the nystagmus will be hor
Zontal and directed tothe left (igure 29). Remember
‘nystagmus in the direction opposite to the direcion
‘of flow of endalymph
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Oammenerbem
Figure 22. Svcure mac emo en oran one ce and te ace
prole into the gelatinous layer. The liner, gravitational
And head it movements eae displacement of otlithie
membrane and thus stimulate the ha cells which hein
teren: panes.
VESTIBULAR NERVE
Vesibuar or Scapas ganglion is situated inthe atera
par of the intemal acoustic meats. I contains bipolar
els. The distal processes of bipolar cel innervate the
Sensory epithelia of the labyrinth weit central pro.
eses agregate 10 form the vestibular nerve
CENTRAL VESTIBULAR CONNECTIONS
“Te fibres of vestibular nerve end in vestibular nucle! and
Some goto the cerebellum directly.
“Vestibular nude are four in number, the superior,
medial, lateral and descending. Aero 10 these ute
come fom
1. Peripheral vestibular receptors (semicircular canals,
utile and Sacco)
2. Cerebellum
3. Retcuar formation
4. Spinal cord
5, Contalteral vestibule cle
‘Ths, Information received from the abyeithine re
‘ceptors is integrated with information rom the som
totensory systems.
“eens rom vestibular nell go to:
1. Nutt of CN, IV VI via medal longitudinal buna
tis the pathway for vestibuo-ocuar reflexes and this
explains the genesis of nystagnus,
2. Motor pat of spinal cor (vestibulospinal Abres) Tis
ooedimates the movements of head, neck and body in
the maintenance of balance.
3, Corebellum (estibuloerebellar Are) I helps to co-
‘ordinate input information to maintain he body bal
4. Autonomic nervous system. This explains nausea,
vomiting, palpitation, sweating and pallor sen in es
bar disorders (e. Ménieres disease.
$. Vestibular mue ofthe opposite side
6, Cerebral cortex (temporal lobe). This ls responsible for
Subjective awareness of motion,
PHYSIOLOGY OF VESTIBULAR SYSTEM
‘Vestibular system is conveniently divided int:
1. Peripheral which s made up of membranous labyrinth
(semicircular ducts, utile and Saccule) and vestibular
2. Cota, which is made up of nucle and fre tacts in
the central nervous system to Integrate vestibular Im
pulses with other stems to maintain body balance
SEMICIRCULAR CANALS
They respond to angular acceleration and desert
‘The the canals ie at sight angles o each other but the
fone which le at right angles o the ais of rotation Is
Stimulated the most Thus horizontal canal wil respond
‘maximum to rotation onthe vertical axis and soon, Due
o this arrangement ofthe thee canal in three diferent
planes, any change in postion of hend can be detected
Simulation of semicrular canals produces nystagmus
and the direction of nystagmus Is determined by the
plane ofthe canal being stimulated. Ths, nystagmus is
"horizontal from horizontal canal, rotatory (rom the supe
flor anal and vertical from the posterior canal
"The stimulus to semicircular canal is How of endo-
Amp eich displaces the cupula. The Now may beto.
‘wards the cupula (ampullopea) or away fom I (am.
pullofuga, better called teculopetl and utriulolugal-
[Ampullopetal How is more effective than ampulotagal
for the horizontal cana. The quick component of nys
{agmus is always opposite tote dicton of ow of e.
dolymph. Thus, Ifa person Is rotated to the right for
Sometime and then abruptly stopped, the endolyn
Continues 10 move to the right due to meta (Le. ame
Pullopeal for Tet canal, the nystagmus will be hor
Zontal and directed tothe left (igure 29). Remember
‘nystagmus in the direction opposite to the direcion
‘of flow of endalymph
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20 SECTION! Diese of far
<» <»
me
G )
Figure 29. tata e Ai df tation tthe gh emi
‘arcana so tt and Conta to mor toe igh Le
‘Sree amp ney tome ing la
Lenco
UTRICLE AND SACCULE
Ver is stilted by tiene acceleration and dcr
tion or gravitational pall during the head tls. The sen“
Sony hae ells ofthe macul ie diferent plants and ae
Stimulated by displacement of otlithie membrane dur
Ing the head us,
“ihe function of saccle is similar o that of uti as
the structure of maculae inthe two organs is similar but
experimental, the saccule Is alo seen to respond lo
Sound vibrations,
“The vestibular system thus registers changes in the
head position, linear or angular acceleration and deel
ration, and gavtational fects. This Information ls sent
to the central nervous system where information om
‘ther sstems—visual, auditor, somatosensory (muscles,
joints, tendons shin) slo received Al UNS informa:
tion 5 integra and used inthe regulation of equ
Am and body posture
erebeilum, which i aso connected to vestibular end
Organs, futher coordinates muscle movements in their
fate, range, force and duration and thus helps ln the
maintenance of balance.
MAINTENANCE OF BODY EQUILIBRIUM
A useful clinical approach to understand the physiology
‘oF equim so Imagine thatthe balance system (es.
‘bale, val and somatosensory) is a worded push
and pul sytem. In state neutral position, cach side con
{nutes equal sensor information, Le. push and pull sys.
tem of onesie ls equal to that of the other side fone
Side pul more than the other, balance ofthe body is
stud. During movement, Le. tuming or tt, there 1
temporary change in the push and pul sistem, which
ls corete by appropriate les and motor outputs to
the eyes (vesibulo-ocular reflex), neck (esibuloervea
‘een, and trunk and limbs (vestibulspinal rele) to
‘maintain new position of head and body, Dut any com.
[ponent of push and pull system of one side i disturbed
fora longer time due to disease, vertigo and ataxia will
develop.
VERTIGO AND DIZZINESS
Disorentation in space causes vertigo or dizziness and
an ats fom disorders of any of the three systems ves-
{uly sua or somatosensory. Normal, the impulses
reaching the brain from the thre systems are equal and
‘opposite. I any component on one sde i inhibite or
Smulated, the information reaching the Conex i mis-
‘matched, resulting in dlsorentation and vertigo. The
vestibular inhibition on one side (eg. acute vestibular
Hallar, Iabyinhectomy Ménicres disease, Vill nerve
Section) cause vertigo. Similar, stimulation of brin
by thermal or rotational stimulus cases vertigo, Diz
‘ess ca slay rest fom the ocular cause. high
‘rors of reaction or acute extraocular muscle paralysis
‘wth plop.
Venigo and ls causes are discussed in detail in
chapter.
MOTION SICKNESS
Its characterized by nausea, vomiting pallor and sweat
ing during sa, aig Dus or ar travel in cet susceptible
Individuals I can be induced by both vel and apparent
thought to aise rom the mismatch of In-
ing he vestibular cll and eerbelum
ine and somatosensory systems
ean be contrôle by the usual labyrinthine sedatives.
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<» <»
me
G )
Figure 29. tata e Ai df tation tthe gh emi
‘arcana so tt and Conta to mor toe igh Le
‘Sree amp ney tome ing la
Lenco
UTRICLE AND SACCULE
Ver is stilted by tiene acceleration and dcr
tion or gravitational pall during the head tls. The sen“
Sony hae ells ofthe macul ie diferent plants and ae
Stimulated by displacement of otlithie membrane dur
Ing the head us,
“ihe function of saccle is similar o that of uti as
the structure of maculae inthe two organs is similar but
experimental, the saccule Is alo seen to respond lo
Sound vibrations,
“The vestibular system thus registers changes in the
head position, linear or angular acceleration and deel
ration, and gavtational fects. This Information ls sent
to the central nervous system where information om
‘ther sstems—visual, auditor, somatosensory (muscles,
joints, tendons shin) slo received Al UNS informa:
tion 5 integra and used inthe regulation of equ
Am and body posture
erebeilum, which i aso connected to vestibular end
Organs, futher coordinates muscle movements in their
fate, range, force and duration and thus helps ln the
maintenance of balance.
MAINTENANCE OF BODY EQUILIBRIUM
A useful clinical approach to understand the physiology
‘oF equim so Imagine thatthe balance system (es.
‘bale, val and somatosensory) is a worded push
and pul sytem. In state neutral position, cach side con
{nutes equal sensor information, Le. push and pull sys.
tem of onesie ls equal to that of the other side fone
Side pul more than the other, balance ofthe body is
stud. During movement, Le. tuming or tt, there 1
temporary change in the push and pul sistem, which
ls corete by appropriate les and motor outputs to
the eyes (vesibulo-ocular reflex), neck (esibuloervea
‘een, and trunk and limbs (vestibulspinal rele) to
‘maintain new position of head and body, Dut any com.
[ponent of push and pull system of one side i disturbed
fora longer time due to disease, vertigo and ataxia will
develop.
VERTIGO AND DIZZINESS
Disorentation in space causes vertigo or dizziness and
an ats fom disorders of any of the three systems ves-
{uly sua or somatosensory. Normal, the impulses
reaching the brain from the thre systems are equal and
‘opposite. I any component on one sde i inhibite or
Smulated, the information reaching the Conex i mis-
‘matched, resulting in dlsorentation and vertigo. The
vestibular inhibition on one side (eg. acute vestibular
Hallar, Iabyinhectomy Ménicres disease, Vill nerve
Section) cause vertigo. Similar, stimulation of brin
by thermal or rotational stimulus cases vertigo, Diz
‘ess ca slay rest fom the ocular cause. high
‘rors of reaction or acute extraocular muscle paralysis
‘wth plop.
Venigo and ls causes are discussed in detail in
chapter.
MOTION SICKNESS
Its characterized by nausea, vomiting pallor and sweat
ing during sa, aig Dus or ar travel in cet susceptible
Individuals I can be induced by both vel and apparent
thought to aise rom the mismatch of In-
ing he vestibular cll and eerbelum
ine and somatosensory systems
ean be contrôle by the usual labyrinthine sedatives.
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Chapter 3
Audiology and Acoustics
“Tis section aims to introduce certain terms which are
frequently used in audiology and acoustic
Sous. Its form of energy produced by a vibrating
‘object. A sound wave consis of compression and rarac
tion of molecules of the medium (ay, quid or sli) in
‘which ittavels.Velodty of sound is diferent in ifr
‘ent media: In the a, at 20°C at sea eve, sound travels
S44 (11201) per second, ands aster in quid and Sl
faster in a sold medium.
FREQUENCY. ts the number of yes per second. The
unit of frequency is Hertz (Hz) named alter the German,
scientist Heinrich Rudolf Hertz. A sound of 1000 Hz
means 1000 yes per second
Pune Tone. single frequency sound is calle à pure
tone ea sound of 250, $00 or 1000 Hz. In pure tone
audiometry, we measure the threshold of hearing in dec
els fr varios pure tones from 125 to 8000 Hz.
Comex Souvo; Sound with more than one frequency
ls called a complex sound, Human vole à complex
Prrcn. sa subjective sensation produced by ft
‘of sound: Higher the frequency, rates the p
OVERONES. A complex sound has à fundamental fre
{quency Le te lowest Frequency at which à source Va.
rates Al frequencis above hat ton are called the over
tones. The fatter determine the quality or the timbre of
[yresstry. Is the strength of sound whieh determines
is Tous. Kis usualy measured in decibel. At ds
tance of 1m, intensity of
Whisper
Normal conversation =
Discomfort ofthe ar
Pain in the ee
2040
dan
nods
mode
LOUDNESS I isthe subjective sensation produced by in.
tensity More the intensity of sound, greater he loudness
Ducinea (AB). I is 1/10 of a bel and is named after
Alexander Graham Be, the inventor of telephone. is
hot an absolute pure but represents à logarithme alo
between two sounds, namely the sound being described
and the reference sound. Sound can be measured as
Power, Le. wanslem or as pressure Le. dyesiem® In au-
‘Slology, sound is measured as sound pressure level (SP),
Tes compared with the reference sound which us an
SP. 01.0.0002 dynesfem® or 20 ua (micropascais which
‘oughly eoresponds 10 the threshold of hearing in nor
‘nal Subjects at 1000 Hz. Decbel notation was introduced
in audiology to avoid dealing with are figures of sound
pressure level (0.0002 dymesiem? at normal threshold of
Ihering to 200 dynesfem? which causes pain in the ca.
‘The later ls 1,000,000 times the formen)
Formula for decibels
Foner,
Si Sound being described
Sp erence sound
(orto,
(sors)
because power of sounds proportional tosquare Of SPL)
mus
a sound has an SPL of 1000 Le (10) times the eter
cence sound, ii expressed as 20 > 3 60 dB Si, à
Sound o 1,000,000, Le. (10) times the reference sound
SPL expressed simply as 120 8 and soon
cion
Nos. Is defined as an aperodic complex sound. There
ate three types of nos:
a. White mois, 1t contains all frequences in audible
spectrum and comparable 0 the white light which
<omtalns al he colours of the visible spectrum, It a
broad-band nots and is use for masking,
o Nano hand oie we nose With certain re.
‘quencies, above and below the given noise, tered
fut. Thu, Ie has a frequency range smaller than the
trod white nie. eis used o mask the test fe
uen in pure tone audiometry:
«Speech ase, Te ira noise having frequencies in the
speech range (300-3000 He) All her frequencies are
fered out
Masse. It isa phenomenon to produce inauaibilty of
‘one sound by the presentation of ante In clinical au
‘lometry, one eas kept busy bya sound while the other
ds being tested. Masking of montes cat essential in all
bone conduction test, but for ar conduction tests I
required only when difference of hearing between tuo,
cars exceeds 40 dB
a
mebooksfree.com
Audiology and Acoustics
“Tis section aims to introduce certain terms which are
frequently used in audiology and acoustic
Sous. Its form of energy produced by a vibrating
‘object. A sound wave consis of compression and rarac
tion of molecules of the medium (ay, quid or sli) in
‘which ittavels.Velodty of sound is diferent in ifr
‘ent media: In the a, at 20°C at sea eve, sound travels
S44 (11201) per second, ands aster in quid and Sl
faster in a sold medium.
FREQUENCY. ts the number of yes per second. The
unit of frequency is Hertz (Hz) named alter the German,
scientist Heinrich Rudolf Hertz. A sound of 1000 Hz
means 1000 yes per second
Pune Tone. single frequency sound is calle à pure
tone ea sound of 250, $00 or 1000 Hz. In pure tone
audiometry, we measure the threshold of hearing in dec
els fr varios pure tones from 125 to 8000 Hz.
Comex Souvo; Sound with more than one frequency
ls called a complex sound, Human vole à complex
Prrcn. sa subjective sensation produced by ft
‘of sound: Higher the frequency, rates the p
OVERONES. A complex sound has à fundamental fre
{quency Le te lowest Frequency at which à source Va.
rates Al frequencis above hat ton are called the over
tones. The fatter determine the quality or the timbre of
[yresstry. Is the strength of sound whieh determines
is Tous. Kis usualy measured in decibel. At ds
tance of 1m, intensity of
Whisper
Normal conversation =
Discomfort ofthe ar
Pain in the ee
2040
dan
nods
mode
LOUDNESS I isthe subjective sensation produced by in.
tensity More the intensity of sound, greater he loudness
Ducinea (AB). I is 1/10 of a bel and is named after
Alexander Graham Be, the inventor of telephone. is
hot an absolute pure but represents à logarithme alo
between two sounds, namely the sound being described
and the reference sound. Sound can be measured as
Power, Le. wanslem or as pressure Le. dyesiem® In au-
‘Slology, sound is measured as sound pressure level (SP),
Tes compared with the reference sound which us an
SP. 01.0.0002 dynesfem® or 20 ua (micropascais which
‘oughly eoresponds 10 the threshold of hearing in nor
‘nal Subjects at 1000 Hz. Decbel notation was introduced
in audiology to avoid dealing with are figures of sound
pressure level (0.0002 dymesiem? at normal threshold of
Ihering to 200 dynesfem? which causes pain in the ca.
‘The later ls 1,000,000 times the formen)
Formula for decibels
Foner,
Si Sound being described
Sp erence sound
(orto,
(sors)
because power of sounds proportional tosquare Of SPL)
mus
a sound has an SPL of 1000 Le (10) times the eter
cence sound, ii expressed as 20 > 3 60 dB Si, à
Sound o 1,000,000, Le. (10) times the reference sound
SPL expressed simply as 120 8 and soon
cion
Nos. Is defined as an aperodic complex sound. There
ate three types of nos:
a. White mois, 1t contains all frequences in audible
spectrum and comparable 0 the white light which
<omtalns al he colours of the visible spectrum, It a
broad-band nots and is use for masking,
o Nano hand oie we nose With certain re.
‘quencies, above and below the given noise, tered
fut. Thu, Ie has a frequency range smaller than the
trod white nie. eis used o mask the test fe
uen in pure tone audiometry:
«Speech ase, Te ira noise having frequencies in the
speech range (300-3000 He) All her frequencies are
fered out
Masse. It isa phenomenon to produce inauaibilty of
‘one sound by the presentation of ante In clinical au
‘lometry, one eas kept busy bya sound while the other
ds being tested. Masking of montes cat essential in all
bone conduction test, but for ar conduction tests I
required only when difference of hearing between tuo,
cars exceeds 40 dB
a
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22 SECTION! Diese of far
SOUND PRESSURE LEVEL The SPL of sound in decibels
‘S20 times the logarithm to the base 10, of the presur of
2 Sound othe werence pressure. The referente pressure
ls taken as 0.0002 dynes/ems or 20 Pa (micropascal) for
Frequency of 1000 Hz and represents the threshold of
hearing in normally hearing young aus.
son can hear truencies of 20-20,000 1
audiometi testing only 125-8000 Hz are evaluated
Srescn Parures. Frequencies of 500, 1000 and
2000 I ae called speech frequencies as most of human
voice falls within thi ange. PTA pure one average) E
the average threshold of heating in these Ihre speech
frequencies. It roughly corresponds to the speech Tec
tion threshold
AUDIOMEFIAC Zeno. Threshold of hearing, Le. the fant
‘intensity which a normal healthy person an Nea will
Vary fom person to person. The Intemational Standards
‘Organization (SO) adopted a standard for this, wh
represented as the aero level on the audiometer According
{0180 aud zs he mean ol of minimal audi
Intensity na group of normally ean hey young alls
amine Leves (HH). Is the sound pressure Level pro-
duced by an audiometer ata spel fequeney Is meas
{red in decibels with reference to audiometie zero. Han
Stlometer delivers a sound at 70 dB, fs represented as
soa.
SENSATION LEVEL (SD. It fers 10 the level of sound
above the threshold of hearing for an individual some.
‘ones tested a 40d SL, it means he was teste at 10 4
above his resol, Fora normal person, this would be
sound of 0 + 40, Le. 40 dB HL, but for one witha heat
ing loss of say 30 it would be 30+ 40, Le 70 AB HL.
‘ther words, sens level fers othe Sour which wi
produ the same sensation, tn normaly hewn person
In Speech audiometry, discrimination scores are tested at
130.108 SL. Stapel ele ected with sound of
70-100 dBi.
Most Conronrants LEVEL (MCL). It 5 the intensity
level of sound that ls mos comfortale forthe person.
Lovpnsss Discowronr LEVEL. Its the level of sound
‘which produces discomfort in the ext, Usually i Is 90-
105 dB SL. tis important 1 find the loudness discomfort
level ofa person when prserbing à hearing a
Dye RANGE. I Is the difference between the most
‘Comfortable level and the loudness discomfort eve, The
mamie range i reduced in patients with postive te.
‘ultment pienomenon, as is the ease in Cochlar type
cin loss
SOUND LEVEL METER, I isan instrument 10 measure
level of nose and other sounds. Sound level meters have
diferent weighting networks (eg. A,B oF C) for erent
Sensitivities at diferent frequencies. When describing à
Sound measured by a sound level mete, Ihe weighting
neo must be indicated
Noise levels are often expresse as dB(A) which refers
to sound presa level measured with network where
the low and extremely high frequencies are given much
less weightage compured to those in the middle ran
which are more important and ar responsible for noise:
Induced hearing los.
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SOUND PRESSURE LEVEL The SPL of sound in decibels
‘S20 times the logarithm to the base 10, of the presur of
2 Sound othe werence pressure. The referente pressure
ls taken as 0.0002 dynes/ems or 20 Pa (micropascal) for
Frequency of 1000 Hz and represents the threshold of
hearing in normally hearing young aus.
son can hear truencies of 20-20,000 1
audiometi testing only 125-8000 Hz are evaluated
Srescn Parures. Frequencies of 500, 1000 and
2000 I ae called speech frequencies as most of human
voice falls within thi ange. PTA pure one average) E
the average threshold of heating in these Ihre speech
frequencies. It roughly corresponds to the speech Tec
tion threshold
AUDIOMEFIAC Zeno. Threshold of hearing, Le. the fant
‘intensity which a normal healthy person an Nea will
Vary fom person to person. The Intemational Standards
‘Organization (SO) adopted a standard for this, wh
represented as the aero level on the audiometer According
{0180 aud zs he mean ol of minimal audi
Intensity na group of normally ean hey young alls
amine Leves (HH). Is the sound pressure Level pro-
duced by an audiometer ata spel fequeney Is meas
{red in decibels with reference to audiometie zero. Han
Stlometer delivers a sound at 70 dB, fs represented as
soa.
SENSATION LEVEL (SD. It fers 10 the level of sound
above the threshold of hearing for an individual some.
‘ones tested a 40d SL, it means he was teste at 10 4
above his resol, Fora normal person, this would be
sound of 0 + 40, Le. 40 dB HL, but for one witha heat
ing loss of say 30 it would be 30+ 40, Le 70 AB HL.
‘ther words, sens level fers othe Sour which wi
produ the same sensation, tn normaly hewn person
In Speech audiometry, discrimination scores are tested at
130.108 SL. Stapel ele ected with sound of
70-100 dBi.
Most Conronrants LEVEL (MCL). It 5 the intensity
level of sound that ls mos comfortale forthe person.
Lovpnsss Discowronr LEVEL. Its the level of sound
‘which produces discomfort in the ext, Usually i Is 90-
105 dB SL. tis important 1 find the loudness discomfort
level ofa person when prserbing à hearing a
Dye RANGE. I Is the difference between the most
‘Comfortable level and the loudness discomfort eve, The
mamie range i reduced in patients with postive te.
‘ultment pienomenon, as is the ease in Cochlar type
cin loss
SOUND LEVEL METER, I isan instrument 10 measure
level of nose and other sounds. Sound level meters have
diferent weighting networks (eg. A,B oF C) for erent
Sensitivities at diferent frequencies. When describing à
Sound measured by a sound level mete, Ihe weighting
neo must be indicated
Noise levels are often expresse as dB(A) which refers
to sound presa level measured with network where
the low and extremely high frequencies are given much
less weightage compured to those in the middle ran
which are more important and ar responsible for noise:
Induced hearing los.
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Chapter 4
Assessment of Hearing
Heating loss can be of thee types
1. CONDLCTIVE HEARING Loss. Its caused by any discos
process interfering withthe conduction of sound on
{he extemal ea tothe stipediovestibule joint. Ths the
‘use may ein the termal ear (obsteuctions tympanic
membrane (perforation), middle ear (ld, ossicles (ia
tion or disruption) or the eustachian tube (struction)
2. SENsoRINEURAL (SN) HEARING Loss. I results from
lesions of the cochlea (sensory type) or VIII nerve and
is central connections (neural ype). Te ter etc
Tears used when heating os due o lesions of VI
nerve, and central defies, when Its due o leon of
‘ental auditory connections.
3. MIXED HEARING Loss. In this ype, elements of bo
‘conductive and sensorineural dates ae present in the
same ear. There ls al-bone gap indicating conductive el
ment, and impairment of bone conduction indica
ss of otosclerosis and chronic sappuraive otitis media
‘While assessing the auditory function Its important
to find out
(a) Tipe of Hearing ls conductive, sensorineural or
med,
(oy Dee of hearing los mil, moderate, moderatcy e
cre severe profound or tua.
(0 Ste of Ian conductive the leon may bea x
temal ea tympanic membrane, mide cr, ss
Sr custachian tbe Clica examination and tym
‘ometry canbe hepfl tnd teste of sch eons
marine, nd ot whether the leon I cc
tear etocochla or central Special tests of hosting
vil be required to diferente these type,
(ay Cann hornos The cause maybe congenital, a
mat, infective, neoplastic, degenerative, metabolic,
Site, vascular of aufolmmune proces Detaled
story an laboratory investigations ae reed
ASSESSMENT OF HEARING.
Hearing ofan individual can be teste by clinical and au
diometi et,
A. CLINICAL TESTS OF HEARING
1. Finger tion test
2 Watch test,
5, speech tests
À Taig ook ests
1. Finger Friction Test
Its a rough but quick method of screening and consis
fof rubbing or saapping the thumb and a Anger else to
patient ea
2. Watch Test
‘clicking watch is brought close to the car and the dis-
‘ance ati heard measured. ha been popular
a screening ts before the audiometric ea but prac
tally obsolete now. Clieking watches are also abso
3. Speech (Voice) Tests
‘Normally, a person hears conversational voice at 12 m
(401 an whisper (ith res ar after normal exp
tion) arm (20 1) but or purposes of test, 6m taken as
‘normal for both conversation and whispe.
“he test 3 conducted in reasonably quit surround
ing. The patient stands with is test dar towards the
examiner at a distance of 6 m. His eyes ate shielded to
prevent lip rading and the montes car Is blocked by
Intermitet pressure on the tragas by an assistant. The
‘examiner uses spondee words (eq, black night, football,
area) or numbers with letters (38,242, MOD) and
gradual walls towards the patient
“The distance at which conversational voice and the
‘whispered vole are heard is measured, The disadvantage
(speech tests lack o standardization in intensity and
pitch of voice used for testing and the ambient noise of
the testing place
4, Tuning Fork Tests
‘These tots ae performed with tuning fos of ie
nt regents Sha 12 250,512 102, 2048 aná
SGN but or routine cna pate, tuning (rk of
Sto He sal ons of loner rence
a bone vibration wile how of Nghe equenls have
shoe decay time and ate thus stay peered
‘tuning fork atte by sing LB SE
tne examiners om he of hand or the uber Net of
Ines
“ts a conduction A) gu 4.1 [B), a wating
2m away tom the opening ol extemal auto canal
“he sound waves are ananá trough the rpanic
‘membrane, middle ar and seso am ar Th,
te ar conduction tes the üncton of tah the con
‘iting mechanism and Ihe coches ae teste, Normal,
es through ar conduction loader an heard tee
ong sra the bone conduction ute
To comm (PC) the pat of wing
tuning ors placed my on the mask bone. Coles
at recy by batons conde though
2
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Assessment of Hearing
Heating loss can be of thee types
1. CONDLCTIVE HEARING Loss. Its caused by any discos
process interfering withthe conduction of sound on
{he extemal ea tothe stipediovestibule joint. Ths the
‘use may ein the termal ear (obsteuctions tympanic
membrane (perforation), middle ear (ld, ossicles (ia
tion or disruption) or the eustachian tube (struction)
2. SENsoRINEURAL (SN) HEARING Loss. I results from
lesions of the cochlea (sensory type) or VIII nerve and
is central connections (neural ype). Te ter etc
Tears used when heating os due o lesions of VI
nerve, and central defies, when Its due o leon of
‘ental auditory connections.
3. MIXED HEARING Loss. In this ype, elements of bo
‘conductive and sensorineural dates ae present in the
same ear. There ls al-bone gap indicating conductive el
ment, and impairment of bone conduction indica
ss of otosclerosis and chronic sappuraive otitis media
‘While assessing the auditory function Its important
to find out
(a) Tipe of Hearing ls conductive, sensorineural or
med,
(oy Dee of hearing los mil, moderate, moderatcy e
cre severe profound or tua.
(0 Ste of Ian conductive the leon may bea x
temal ea tympanic membrane, mide cr, ss
Sr custachian tbe Clica examination and tym
‘ometry canbe hepfl tnd teste of sch eons
marine, nd ot whether the leon I cc
tear etocochla or central Special tests of hosting
vil be required to diferente these type,
(ay Cann hornos The cause maybe congenital, a
mat, infective, neoplastic, degenerative, metabolic,
Site, vascular of aufolmmune proces Detaled
story an laboratory investigations ae reed
ASSESSMENT OF HEARING.
Hearing ofan individual can be teste by clinical and au
diometi et,
A. CLINICAL TESTS OF HEARING
1. Finger tion test
2 Watch test,
5, speech tests
À Taig ook ests
1. Finger Friction Test
Its a rough but quick method of screening and consis
fof rubbing or saapping the thumb and a Anger else to
patient ea
2. Watch Test
‘clicking watch is brought close to the car and the dis-
‘ance ati heard measured. ha been popular
a screening ts before the audiometric ea but prac
tally obsolete now. Clieking watches are also abso
3. Speech (Voice) Tests
‘Normally, a person hears conversational voice at 12 m
(401 an whisper (ith res ar after normal exp
tion) arm (20 1) but or purposes of test, 6m taken as
‘normal for both conversation and whispe.
“he test 3 conducted in reasonably quit surround
ing. The patient stands with is test dar towards the
examiner at a distance of 6 m. His eyes ate shielded to
prevent lip rading and the montes car Is blocked by
Intermitet pressure on the tragas by an assistant. The
‘examiner uses spondee words (eq, black night, football,
area) or numbers with letters (38,242, MOD) and
gradual walls towards the patient
“The distance at which conversational voice and the
‘whispered vole are heard is measured, The disadvantage
(speech tests lack o standardization in intensity and
pitch of voice used for testing and the ambient noise of
the testing place
4, Tuning Fork Tests
‘These tots ae performed with tuning fos of ie
nt regents Sha 12 250,512 102, 2048 aná
SGN but or routine cna pate, tuning (rk of
Sto He sal ons of loner rence
a bone vibration wile how of Nghe equenls have
shoe decay time and ate thus stay peered
‘tuning fork atte by sing LB SE
tne examiners om he of hand or the uber Net of
Ines
“ts a conduction A) gu 4.1 [B), a wating
2m away tom the opening ol extemal auto canal
“he sound waves are ananá trough the rpanic
‘membrane, middle ar and seso am ar Th,
te ar conduction tes the üncton of tah the con
‘iting mechanism and Ihe coches ae teste, Normal,
es through ar conduction loader an heard tee
ong sra the bone conduction ute
To comm (PC) the pat of wing
tuning ors placed my on the mask bone. Coles
at recy by batons conde though
2
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24 SECTION! Diese of far
Figure. Tuning leks Teiglororcoducin Ting
lee enden (Web te
[Sc ly ar Tes a ain For Te.
the skull bones. Thus, BC Is a measure of the cochlear
function onl.
"Tine cially sch
tuning fork tests include
(4) RINNE Test. In tists air conduction of the ear is
‘compared with its bone conduction. À vibrating tuning
{orks placed on the patients mastoid and when he stops
ari, iis bought Deid the meatus. Ihe Sul hes
AAC Is more than BC. Alternatively, the patient is asked
to compar the loudnes of sound heard through lr and
Done conduction. Rinne tt i called positive when AC
"longer or louder than BC. Is seen in normal persons
‘or thote having sensorineural deafness. À negative Rinne
AC > AC) i seen in conductive desíness A native
Rinne indicate à minimum air bone ¿apo 15-20 dB.
À prediction of slebone gap can be made 14
forks! 256,512 and 1024 He ae wed,
+ A Rinne test equal or negative for 256 Hz but positive
for 12 He indicas slrbone gap of 20-30 dB.
test negative for 256 and 512 Hz ut postive
À Hz indiates ar bre gap of 30-48 dl
negative forall he Ihre tuning forks of 256,
Stand 1084 Hz indicates le one gp of 45-00 dB.
Remember that a negative Rinne for 256, $12 and
1024 Hz indicates a minimum AB gap of 15, 30,45 A,
SE Nicanie RINNE. es sen in severe unilateral
sensorineural heating loss. Patient does not perceive any
Sound of tuning fork by alr conduction but responds
to bone conduction testing. This response 10 bone con
ing
ranseranial transmision of sound. In such cases, comet
dagnoss can be made by masking the nontest car with
Trany’s noise box stile testing for bone conduction,
‘Weber ts wil farther Map gets atric o the
beter can
(0) Wenen Tasr. In this test, a vibrating tuning fork ks
placed in the middle ofthe forehcad or the vertex and
{he patents ashe in which er the sound is heard Nowe
‘mally its heard equally ln Doth cas. Its neralzed to
{the won car in conductive deafnes and to the better eat
in sensorineural deans, In weber ts sound traves die
ct tothe cochlea va bone, Lateralization of sound in
‘weber test witha tuning fork of $12 Hz implies aconduc-
tive loss of 15-25 din alta ear or à sensorineural
loss in the contralateral ear,
(©) Ansorum Bove CoNDUCTION (ABC) Test. Bone
«onducion sa measure of cochlear function In ABC test
Patents bone conduction ls compared ith that of the
‘Examines (peesuming tht the examiner has normal hear
Ing) External auditory meatus of both the patent and ex.
miner shou be cad by pressing the tags Inward)
prevent ambient nose entering rough AC rote. In
eonductive deines, the patent and the examiner ear
{he fork fr the same dation of time. In sensorineural
cate, the patent hes the fork fra shower duration,
(0) Scuwansew’s Test. Here again BC of patient i com-
pared with that ofthe normal hearing person examines
But meatus is mot orcad, has the sme significance
3 absolute bone conduction es Schwabach I reduced
neural deaess and lengthened in conduct
Table 41 summasizes the interpretation of tuning fork
(9 Bine Test. It sa test of bone conduction and exam
Ins the effect of clon of cr canal on the hearing. A
ibrating tuning forks placed on the mastoid while the
Ssaminer altematly closes and opens the ear anal by
pressing on the tragas inwards. À normal person or one
vith sensorineural hearing os ears lowe when carca-
all cluded and softer when the canal open (ing
postive) A patient with conductive hearing los will ap
prelate no change (ing negate)
(9 Gre’ Test, Is also a est of one conduction and
rames the effect of increased arpesre in car canal on
the heating, Normally, when ar pressure tncressed in
the ca cana y Siegel speculum I pushes the tympanic
membrane and oies inward, aes the intalbyrin
thine pressure and causes immobility ol base mem.
‘duction 1, in reality, kom the opposite car because of brane and decreased hearing, but no change in hearing
Ten Nes Conde deinen SN estes
ine AC > BC (nme poste) BC> AC ane gt) AC > ac
Wer Naam {otra por ar Do beter
ne Pers Sime a emer Reseed
Seon EN tar Shonen
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Figure. Tuning leks Teiglororcoducin Ting
lee enden (Web te
[Sc ly ar Tes a ain For Te.
the skull bones. Thus, BC Is a measure of the cochlear
function onl.
"Tine cially sch
tuning fork tests include
(4) RINNE Test. In tists air conduction of the ear is
‘compared with its bone conduction. À vibrating tuning
{orks placed on the patients mastoid and when he stops
ari, iis bought Deid the meatus. Ihe Sul hes
AAC Is more than BC. Alternatively, the patient is asked
to compar the loudnes of sound heard through lr and
Done conduction. Rinne tt i called positive when AC
"longer or louder than BC. Is seen in normal persons
‘or thote having sensorineural deafness. À negative Rinne
AC > AC) i seen in conductive desíness A native
Rinne indicate à minimum air bone ¿apo 15-20 dB.
À prediction of slebone gap can be made 14
forks! 256,512 and 1024 He ae wed,
+ A Rinne test equal or negative for 256 Hz but positive
for 12 He indicas slrbone gap of 20-30 dB.
test negative for 256 and 512 Hz ut postive
À Hz indiates ar bre gap of 30-48 dl
negative forall he Ihre tuning forks of 256,
Stand 1084 Hz indicates le one gp of 45-00 dB.
Remember that a negative Rinne for 256, $12 and
1024 Hz indicates a minimum AB gap of 15, 30,45 A,
SE Nicanie RINNE. es sen in severe unilateral
sensorineural heating loss. Patient does not perceive any
Sound of tuning fork by alr conduction but responds
to bone conduction testing. This response 10 bone con
ing
ranseranial transmision of sound. In such cases, comet
dagnoss can be made by masking the nontest car with
Trany’s noise box stile testing for bone conduction,
‘Weber ts wil farther Map gets atric o the
beter can
(0) Wenen Tasr. In this test, a vibrating tuning fork ks
placed in the middle ofthe forehcad or the vertex and
{he patents ashe in which er the sound is heard Nowe
‘mally its heard equally ln Doth cas. Its neralzed to
{the won car in conductive deafnes and to the better eat
in sensorineural deans, In weber ts sound traves die
ct tothe cochlea va bone, Lateralization of sound in
‘weber test witha tuning fork of $12 Hz implies aconduc-
tive loss of 15-25 din alta ear or à sensorineural
loss in the contralateral ear,
(©) Ansorum Bove CoNDUCTION (ABC) Test. Bone
«onducion sa measure of cochlear function In ABC test
Patents bone conduction ls compared ith that of the
‘Examines (peesuming tht the examiner has normal hear
Ing) External auditory meatus of both the patent and ex.
miner shou be cad by pressing the tags Inward)
prevent ambient nose entering rough AC rote. In
eonductive deines, the patent and the examiner ear
{he fork fr the same dation of time. In sensorineural
cate, the patent hes the fork fra shower duration,
(0) Scuwansew’s Test. Here again BC of patient i com-
pared with that ofthe normal hearing person examines
But meatus is mot orcad, has the sme significance
3 absolute bone conduction es Schwabach I reduced
neural deaess and lengthened in conduct
Table 41 summasizes the interpretation of tuning fork
(9 Bine Test. It sa test of bone conduction and exam
Ins the effect of clon of cr canal on the hearing. A
ibrating tuning forks placed on the mastoid while the
Ssaminer altematly closes and opens the ear anal by
pressing on the tragas inwards. À normal person or one
vith sensorineural hearing os ears lowe when carca-
all cluded and softer when the canal open (ing
postive) A patient with conductive hearing los will ap
prelate no change (ing negate)
(9 Gre’ Test, Is also a est of one conduction and
rames the effect of increased arpesre in car canal on
the heating, Normally, when ar pressure tncressed in
the ca cana y Siegel speculum I pushes the tympanic
membrane and oies inward, aes the intalbyrin
thine pressure and causes immobility ol base mem.
‘duction 1, in reality, kom the opposite car because of brane and decreased hearing, but no change in hearing
Ten Nes Conde deinen SN estes
ine AC > BC (nme poste) BC> AC ane gt) AC > ac
Wer Naam {otra por ar Do beter
ne Pers Sime a emer Reseed
Seon EN tar Shonen
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Figure 42, Tween ome scup Ashemiscan matches
‘pant fhe par ting a gis prin.
Is observed when ossicular cha is fixed or disconnected
Geles tests performed by placing a vibrating fork on the
mastoid wie changes in air pressure in the ar canal ae
Drought about by Siegel speculum. Gees test Is pos
tive in normal persons and in those with sensorineural
hearing toss. It fe negative when ossicular chain À fixed
or disconnected. I was a popular tet to find out stapes
fiction in otosclerosis but has now Been superceded By
‘ympanomety.
B. AUDIOMETRIC TESTS
1. Pure Tone Audiometry
An audiometer Is an electronic device which produces
pure tom, the intensity of which can be increased or de.
Crease in dB steps (sur. 1). Ustally ar conduction
thresholds are measured for tone of 125, 250,500, 1000,
2000, 4000 and 8000 Hz and bone conduction thresholds
for 250, 00, 1000, 2000 and 4000 Hz. The amount of
Intensity that has 10 be alse above the normal level is à
measure ofthe degre of easing impairment at that e
‘quency Its charted Inthe form of graph cll nao
gram. The threshold of bone conduction Isa measure of
{och Function. The diference inthe thresholds of ait
“nd bone conduction (AB gap) sa measut ofthe degree
of conductive deafness. I may be noted that audlometer
150 calibrate that the hearing ofa normal person, bot
foe air and bone conduction, 5 at 0 dB and there no
ACB gap, while tuning fork ts normaly show AC > BC.
‘When aliference between the two cars ls 40 dB or
above in ae conduction thresholds, the better car Is
mashed toavold getting a shadow curve rom the nontest,
Detter ear Similar, mashing 1 essential in al bone con:
<uction studies. Masking s done by employing arrow.
band noise to the monte ca.
Uses or Pune Tone Auniocnant
(a) lt sa measure of threshold of hearing by air and bone
conduction and thus the degree and type of hearin
tose
0) cord can be kept or future reference.
(e) Audlogram is senil for prescription of hearing ad.
(a) Helpe to Bad degree of handicap for medicolegal
purposes.
Chapter — Assessment of Mewing 25
(Helps to predict spoch reception threshold,
2. Speech Audiometry
In ts test, the patients ability 0 hear and understand!
speech is measured. Two parameter are studied: (speech
reception threshold aná (i) isrimination sore
(4) Srta RECHFTION Turtsmoto (SRT). ts th mink
mum intensity au wich SON ofthe wonds are repeated
come y the patient. À set of sponde words (o Sl“
ble words with equal stes on each syllable, e. base,
Sunlight, daydream, ec) s delivered to each ear through
theheadphone of an audiometer. The word ists are di.
{ed in the form of recorded tapes oF monitored voice and
thee intensity varied in 5 dB steps tl half of them ar or
rectly heard, Normal ST is thin 10 AB ofthe average
‘of pure tone threshold of mee speech frequencies (S00,
1000 and 2000 He). An SRT better than pure tone average
‘by more than 10 dB suggests functional heaing los
(8) Srusen DiscraMINATION SCORE. Also called spect
ection o word recon core Is measure ol fe
tent’ ability to understand speech. Het, a Us of pho-
neially balanced (PB) words (single ylabie words
pin in, day, bs, ct) 5 delivered to the patients cach
ar separately at 30-40 dB above his SRT and the percent
Sac of words correctly and by the patient recorded In
Formal persons and those wilh conductive hering oss
{high store 01 90-100% canbe obtained (sun A,B
ana lea)
Prayonsanex INTESSIEY FUNCTION son PB Wow
PB Max, Instead of using a single suprathreshold in
tensity of 30-10 dB above SRT as desc above, i Is
ss 2
i
a see
i LA
E CEE EE
hit 28
igure 43 Speech aura.
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‘pant fhe par ting a gis prin.
Is observed when ossicular cha is fixed or disconnected
Geles tests performed by placing a vibrating fork on the
mastoid wie changes in air pressure in the ar canal ae
Drought about by Siegel speculum. Gees test Is pos
tive in normal persons and in those with sensorineural
hearing toss. It fe negative when ossicular chain À fixed
or disconnected. I was a popular tet to find out stapes
fiction in otosclerosis but has now Been superceded By
‘ympanomety.
B. AUDIOMETRIC TESTS
1. Pure Tone Audiometry
An audiometer Is an electronic device which produces
pure tom, the intensity of which can be increased or de.
Crease in dB steps (sur. 1). Ustally ar conduction
thresholds are measured for tone of 125, 250,500, 1000,
2000, 4000 and 8000 Hz and bone conduction thresholds
for 250, 00, 1000, 2000 and 4000 Hz. The amount of
Intensity that has 10 be alse above the normal level is à
measure ofthe degre of easing impairment at that e
‘quency Its charted Inthe form of graph cll nao
gram. The threshold of bone conduction Isa measure of
{och Function. The diference inthe thresholds of ait
“nd bone conduction (AB gap) sa measut ofthe degree
of conductive deafness. I may be noted that audlometer
150 calibrate that the hearing ofa normal person, bot
foe air and bone conduction, 5 at 0 dB and there no
ACB gap, while tuning fork ts normaly show AC > BC.
‘When aliference between the two cars ls 40 dB or
above in ae conduction thresholds, the better car Is
mashed toavold getting a shadow curve rom the nontest,
Detter ear Similar, mashing 1 essential in al bone con:
<uction studies. Masking s done by employing arrow.
band noise to the monte ca.
Uses or Pune Tone Auniocnant
(a) lt sa measure of threshold of hearing by air and bone
conduction and thus the degree and type of hearin
tose
0) cord can be kept or future reference.
(e) Audlogram is senil for prescription of hearing ad.
(a) Helpe to Bad degree of handicap for medicolegal
purposes.
Chapter — Assessment of Mewing 25
(Helps to predict spoch reception threshold,
2. Speech Audiometry
In ts test, the patients ability 0 hear and understand!
speech is measured. Two parameter are studied: (speech
reception threshold aná (i) isrimination sore
(4) Srta RECHFTION Turtsmoto (SRT). ts th mink
mum intensity au wich SON ofthe wonds are repeated
come y the patient. À set of sponde words (o Sl“
ble words with equal stes on each syllable, e. base,
Sunlight, daydream, ec) s delivered to each ear through
theheadphone of an audiometer. The word ists are di.
{ed in the form of recorded tapes oF monitored voice and
thee intensity varied in 5 dB steps tl half of them ar or
rectly heard, Normal ST is thin 10 AB ofthe average
‘of pure tone threshold of mee speech frequencies (S00,
1000 and 2000 He). An SRT better than pure tone average
‘by more than 10 dB suggests functional heaing los
(8) Srusen DiscraMINATION SCORE. Also called spect
ection o word recon core Is measure ol fe
tent’ ability to understand speech. Het, a Us of pho-
neially balanced (PB) words (single ylabie words
pin in, day, bs, ct) 5 delivered to the patients cach
ar separately at 30-40 dB above his SRT and the percent
Sac of words correctly and by the patient recorded In
Formal persons and those wilh conductive hering oss
{high store 01 90-100% canbe obtained (sun A,B
ana lea)
Prayonsanex INTESSIEY FUNCTION son PB Wow
PB Max, Instead of using a single suprathreshold in
tensity of 30-10 dB above SRT as desc above, i Is
ss 2
i
a see
i LA
E CEE EE
hit 28
igure 43 Speech aura.
mebooksfree.com
26 SECTION! — Diseases of far
SD core Ry to understand pec
Des Sonate
com Wey poor
bete to char PB scores against several levels of speech
intensity and ind the maximum sore (PB max).
max satined, à ef et Cini to sc the ol
fume of heating ad (ue + 10) Maximum volume of
Dearing ald should not be set above PB man.
ROLL Ovan PHINOMENON. Is seen in retrocochlear
heating los. With increase in spocch intensity above à
particular level, the PB word score falls rather than main
{alma plateau 3 in cochlear typeof sensorineural hearing
loss (gue 43D),
Thus speech audiomeuy ls seul in several ways:
(0) To ind speech reception threshold which covcates
swell with average of three speech frequencies of pure
tone sudogam.
6) To aittrentiate organic fom nonorgani (unction-
al heating ess.
To nd the intensity at which discrimination score
Dest This is helpful for Biting a hearing ad and et
ting ts volume for maximum discrimination
09) To diferente a coches from a retrocochlear sen
sorineural hearing os.
3. Bekesy Audiometry
luisa self reording audiometry where various pure tone
requendes automatically move from low to high whi
the patient controls the intensity through a button, Deo
ttacngs, one with continuous and the other with pulsed
tone, ate obtained. The tracings help to diferentate a
‘chica fom a retrocochicar andan organi rom a func
tional hearing los
Various types of tracings obtained are
Type Continuous and pulsed tracings overlap. Seen
in normal hearing or conducto hearings.
Continuous and puted tracings overlap up
10 1000 Hz and then continuous racing all
‘Ste cochlear las.
‘Continuous tracing falls below pulsed tracing
3 100-500 He even up to 40-30 db. Seen in
Trace ln.
Continuous tracing falls below puise lesion
at requencies up to 1000 Hz by more than
25 dh Seen bn retocar cura so,
‘Continuous tracing ls above pulsed one Seen
in nonaganic hea oss.
Typelt
Type
Type
Bckesy audlomein eo performed these days
4. Impedance Audiometry (Figure 4.4)
is an objective test widely used in clinical practic and
‘particularly señal in children. e consists ot
(a) ympanomeury
(0) Acoustic ren measurements
(9) Toarwoserar. es based
Le: when a sound Strikes tympanic
{the sound energy isabsorbed while the est tete A
Ste tympanic membrane would reflect more of sound
‘one. By changing the presures
ory canal and then measuring
lected sound energy, Its posible to And the com-
lance or Stiines ofthe tympano-osicular system and
thus Hd the healthy or diseased satus of the middle
Essential, the equipment consists of a probe which
snugly ts into the extemal auditory canal and has tro
‘hanes 0) to deliver tone of 20 i) o pickup the
selected sound through à microphone and (1) to bring
bout changes in ar pressure In the car canal tom pos
tive to normal and then negative (gute 1). By chat
ing the compliance of Gino vil system against
various presure changes, lernt types of graph called
simple principle,
igure 44 (9 Inpec mudiometyn pres. (9) mpecnce arte
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SD core Ry to understand pec
Des Sonate
com Wey poor
bete to char PB scores against several levels of speech
intensity and ind the maximum sore (PB max).
max satined, à ef et Cini to sc the ol
fume of heating ad (ue + 10) Maximum volume of
Dearing ald should not be set above PB man.
ROLL Ovan PHINOMENON. Is seen in retrocochlear
heating los. With increase in spocch intensity above à
particular level, the PB word score falls rather than main
{alma plateau 3 in cochlear typeof sensorineural hearing
loss (gue 43D),
Thus speech audiomeuy ls seul in several ways:
(0) To ind speech reception threshold which covcates
swell with average of three speech frequencies of pure
tone sudogam.
6) To aittrentiate organic fom nonorgani (unction-
al heating ess.
To nd the intensity at which discrimination score
Dest This is helpful for Biting a hearing ad and et
ting ts volume for maximum discrimination
09) To diferente a coches from a retrocochlear sen
sorineural hearing os.
3. Bekesy Audiometry
luisa self reording audiometry where various pure tone
requendes automatically move from low to high whi
the patient controls the intensity through a button, Deo
ttacngs, one with continuous and the other with pulsed
tone, ate obtained. The tracings help to diferentate a
‘chica fom a retrocochicar andan organi rom a func
tional hearing los
Various types of tracings obtained are
Type Continuous and pulsed tracings overlap. Seen
in normal hearing or conducto hearings.
Continuous and puted tracings overlap up
10 1000 Hz and then continuous racing all
‘Ste cochlear las.
‘Continuous tracing falls below pulsed tracing
3 100-500 He even up to 40-30 db. Seen in
Trace ln.
Continuous tracing falls below puise lesion
at requencies up to 1000 Hz by more than
25 dh Seen bn retocar cura so,
‘Continuous tracing ls above pulsed one Seen
in nonaganic hea oss.
Typelt
Type
Type
Bckesy audlomein eo performed these days
4. Impedance Audiometry (Figure 4.4)
is an objective test widely used in clinical practic and
‘particularly señal in children. e consists ot
(a) ympanomeury
(0) Acoustic ren measurements
(9) Toarwoserar. es based
Le: when a sound Strikes tympanic
{the sound energy isabsorbed while the est tete A
Ste tympanic membrane would reflect more of sound
‘one. By changing the presures
ory canal and then measuring
lected sound energy, Its posible to And the com-
lance or Stiines ofthe tympano-osicular system and
thus Hd the healthy or diseased satus of the middle
Essential, the equipment consists of a probe which
snugly ts into the extemal auditory canal and has tro
‘hanes 0) to deliver tone of 20 i) o pickup the
selected sound through à microphone and (1) to bring
bout changes in ar pressure In the car canal tom pos
tive to normal and then negative (gute 1). By chat
ing the compliance of Gino vil system against
various presure changes, lernt types of graph called
simple principle,
igure 44 (9 Inpec mudiometyn pres. (9) mpecnce arte
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Figure 45. incl mpedace atoms ( Oita oro
he à of 220s A) Ar pomp tote or eee pes
Siren he a carl (€) Napa to ik up a mesa snd
rst vel ete tom Di ran mentar
ymnpanegrams are obtained wi
tain middle ear pathologs
Types of tympanograms (eue 4.0)
ate diagnostic of cer
{Type A Normal tympanogram,
Type As Compliance is lower a or near ambient air
pressure. Seen in ation of ossicles, e. ot
loss or males ation
‘Type Ap High complance at or near ambient pressure
‘Seen in ossicular dscontinuity or hin and lx
‘tympani membrane
‘Type A Hat or dome-shaped graph. No change in
compllance with pressure changes. Seen in
middle eae Mud o thick tympanic membran
Maximum compliance occurs with negative
pressure In exces of 100 mm HLO. Seen in
Rated tympanic membrane and may show
Some Mu in middle ear,
mec
o
Figure 6. pa a ympanograns
NET]
Chapter 4 — Assessment af Meing 27
toy as aso been usd ond function of eustachian tbe
in orar nator proto monic membrane. À
‘eat or poe pre (2000,20) mm HO) e
“rate inthe mide andthe person ask to a
Jon ve mes I 205. The bio cult he pes
Sire ici noma bai nc, Hest an ao De
Sn of the patency of the grommet pace nthe
e A seems outs dl
(8) Acoustic Rena. Is based on the ac that aloud
Sound, 70-100 dB above the threshold of hearing of à
parila ar, causes lateral contraction ofthe stapedial
muscles whieh can be detected by Iympanamauy Tone
‘an be delivered to one car amd the rele picked fom the
‘Same or the contralateral ear The reflex are involved is
plat CN VII > ventral cocher nucleus > CN
‘Vilnuctes ipsaterlstapedlus muscle
Carla CN VI ventral cochlear mucleus >
contralateral medial superior say macs y contrat
Sal CN Vil nucleus > contralateral sapedias muscle
Figure
“hs si useful in several ways
(® Totes the hearing in infants and young children. Ie
San objective metho.
{To ind malingerers. À person who figs total dat
ness and does not give any response on pure tone
audiometry but shows a postive Stapel fen Ica
smalingeree
(lu) To detect cochlear pathology. Presence of stapedlat
reflex at lower intensities, eg. 40-60 dB than the
‘sual 70 db indicates recruitment and thus à och
Tear type of hearing los
iv To detec VI nerve son, If sustained tone of
5000 1000 Hz, delivered 10 AB above acoustic ex
threshold fora period of 105, brings here ample
tude to SON, 1 shows abnormal adaptation and in.
‘icatve of Vil nerve lesion taped reflex decay)
(9 Lesions of facial nerve, Absence of tapedal rele.
‘when hearing is normal indicates lesion ofthe facial
here, proximal to the nerve to stapedius. The rl
‘an abo be used to find prognosis of facial paralysis
5 the appearance of reflex, after I was absent, nd
‘ats return of function and a favourable prognosis.
(i Lesion of brainstem. I ipstateal efx is present but
the contralateral rele absent, lesion fein the ar
fosse pathiaysin the branstem,
=
=
SÍ >
Faure 47, Arie
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he à of 220s A) Ar pomp tote or eee pes
Siren he a carl (€) Napa to ik up a mesa snd
rst vel ete tom Di ran mentar
ymnpanegrams are obtained wi
tain middle ear pathologs
Types of tympanograms (eue 4.0)
ate diagnostic of cer
{Type A Normal tympanogram,
Type As Compliance is lower a or near ambient air
pressure. Seen in ation of ossicles, e. ot
loss or males ation
‘Type Ap High complance at or near ambient pressure
‘Seen in ossicular dscontinuity or hin and lx
‘tympani membrane
‘Type A Hat or dome-shaped graph. No change in
compllance with pressure changes. Seen in
middle eae Mud o thick tympanic membran
Maximum compliance occurs with negative
pressure In exces of 100 mm HLO. Seen in
Rated tympanic membrane and may show
Some Mu in middle ear,
mec
o
Figure 6. pa a ympanograns
NET]
Chapter 4 — Assessment af Meing 27
toy as aso been usd ond function of eustachian tbe
in orar nator proto monic membrane. À
‘eat or poe pre (2000,20) mm HO) e
“rate inthe mide andthe person ask to a
Jon ve mes I 205. The bio cult he pes
Sire ici noma bai nc, Hest an ao De
Sn of the patency of the grommet pace nthe
e A seems outs dl
(8) Acoustic Rena. Is based on the ac that aloud
Sound, 70-100 dB above the threshold of hearing of à
parila ar, causes lateral contraction ofthe stapedial
muscles whieh can be detected by Iympanamauy Tone
‘an be delivered to one car amd the rele picked fom the
‘Same or the contralateral ear The reflex are involved is
plat CN VII > ventral cocher nucleus > CN
‘Vilnuctes ipsaterlstapedlus muscle
Carla CN VI ventral cochlear mucleus >
contralateral medial superior say macs y contrat
Sal CN Vil nucleus > contralateral sapedias muscle
Figure
“hs si useful in several ways
(® Totes the hearing in infants and young children. Ie
San objective metho.
{To ind malingerers. À person who figs total dat
ness and does not give any response on pure tone
audiometry but shows a postive Stapel fen Ica
smalingeree
(lu) To detect cochlear pathology. Presence of stapedlat
reflex at lower intensities, eg. 40-60 dB than the
‘sual 70 db indicates recruitment and thus à och
Tear type of hearing los
iv To detec VI nerve son, If sustained tone of
5000 1000 Hz, delivered 10 AB above acoustic ex
threshold fora period of 105, brings here ample
tude to SON, 1 shows abnormal adaptation and in.
‘icatve of Vil nerve lesion taped reflex decay)
(9 Lesions of facial nerve, Absence of tapedal rele.
‘when hearing is normal indicates lesion ofthe facial
here, proximal to the nerve to stapedius. The rl
‘an abo be used to find prognosis of facial paralysis
5 the appearance of reflex, after I was absent, nd
‘ats return of function and a favourable prognosis.
(i Lesion of brainstem. I ipstateal efx is present but
the contralateral rele absent, lesion fein the ar
fosse pathiaysin the branstem,
=
=
SÍ >
Faure 47, Arie
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2B SECTION! Deer of far
‘Puysicat VOLUME oF EAR CANAL Acoustic immitance
an also measure the physical volume of ar between the
probe tip and tympanic membrane. Normal up to
Tio min children and 2 ml in adults Any increase In
volume, >2 mL in children and >28 ml in adults in-
its perforation of the tympanic membrane (because
middle car volume is added upto the volume of external
far canal), Ths has also been sed to ind patency ol the
‘entltion tbe,
. SPECIAL TESTS OF HEARING
1. Recruitment
Ii à phenomenon of abnormal growth of loudness. The
far which does not hea fw intensity sound begins to
Fear greater intensity sounds a loud or even louder than
normal nearing cr: is, lou sound which olerable
In normal ear may grow to abnormal levels of loudness
inthe recruiting car and thus becomes Intolerable. The
patents with recruitment ae poor Candidates fr I
Ing als. Recruitment pay seen in Lions of the
cochlea (eg: Ménieres disease and presbycuss) and th
els to ilierentate a cochlear rom a eocochlear sen
Sonneural her os
Atemat naa nes balance ts se to detect
cnument in unilateral cas. A tone, say ol 1000 Hz, is
Played altematly to Une normal and the affected ea and
ne intensity inthe affected cari adjusted to match the
loudness in normal eat The test started at 20 dB above
thethresholdof deat er and then repeated at every 20.
rise until the loudness fs matched or the limits of au
‘meter sache conductive and neural desiess, he
Initia ference ls maintained throughout while in och
{ea lesions, para, complete or onerrerultment may be
seen (igure)
2, Short Increment Sensitivity Index
(Gist Test)
Patients with cochlear tons distinguish smaller chang
{in intensity of pure tone better than normal persons
And those with conductive or rerocochlear pathology
SS testis thus sed to differentiate a cochlear from a
troc lesion
In this test, à continuous tone is presented 20 dB above
thethesholdandsusained fr about Zain. Every Ss the
ones incensed by 1 dB and 20 such Dips ate presente
Patient indicates the lips heard In conductive deates,
neseeses
Figure 48, Atome Dual oe sce te
SISI score is Seldom more than 19% is 70-100 in
‘cochlear deafness and 0-20% in neve estres.
3. Threshold Tone Decay Test
A à measure of nerve fatigue and suse to detect et
‘overhear lion, Normally a person can hear à tono
nina fr sin nera agus he stops eating
fair The tesi tone decay tet simple ands per
forme in he following manne:
"tone of 4000 Hz presented at $ JB above the pa-
tien’ thro of hearing, continuously fora period of
05. patent tops hearing care, ners is nero
ty another db. The procedure is coninuc ul patent
an ear the one continuously fr 603, or no eve exists
Se the threshold here tone audible or fll 00
The rest pres as number a dB of decay. A decay
‘more than 25 dbs dagnostc of rtrococ hear Ion.
4. Evoked Response Audiometry
Risa objective test which measures electrical activity in
the auditry patieays in response to auditory simul K
requires special equipment with an averaging computer,
‘There are several components of evoked elect response
ut only two have gad clinical acceptance. They ae
(a) Hlectrocochteography (EcoG). I mesures lta
potetatsasingin he cochlea and CN Vin response
fo auditory still within fst 8 ms. The response fs
in the form of three phenomena: cochlear microphon-
les summating potentials and the action potent of
Vil nerve. The recording electrodo 1 usualy à thin
ree passed through the tympanic membrane onto
the promontory adult, it can be done under local
“ancha but in children or anxious persons sda
tion or general anaesthesia Is require. Sedation does
not interfere in these responses. Ecos useful (D 10
Fin treshod or hearing young infants and.
Figure 49, eecvocciconpy. (Norma or. @) ar wh it
‘ie ne otage of sting poeta 5) compu
Sern petty Nom Sn a
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‘Puysicat VOLUME oF EAR CANAL Acoustic immitance
an also measure the physical volume of ar between the
probe tip and tympanic membrane. Normal up to
Tio min children and 2 ml in adults Any increase In
volume, >2 mL in children and >28 ml in adults in-
its perforation of the tympanic membrane (because
middle car volume is added upto the volume of external
far canal), Ths has also been sed to ind patency ol the
‘entltion tbe,
. SPECIAL TESTS OF HEARING
1. Recruitment
Ii à phenomenon of abnormal growth of loudness. The
far which does not hea fw intensity sound begins to
Fear greater intensity sounds a loud or even louder than
normal nearing cr: is, lou sound which olerable
In normal ear may grow to abnormal levels of loudness
inthe recruiting car and thus becomes Intolerable. The
patents with recruitment ae poor Candidates fr I
Ing als. Recruitment pay seen in Lions of the
cochlea (eg: Ménieres disease and presbycuss) and th
els to ilierentate a cochlear rom a eocochlear sen
Sonneural her os
Atemat naa nes balance ts se to detect
cnument in unilateral cas. A tone, say ol 1000 Hz, is
Played altematly to Une normal and the affected ea and
ne intensity inthe affected cari adjusted to match the
loudness in normal eat The test started at 20 dB above
thethresholdof deat er and then repeated at every 20.
rise until the loudness fs matched or the limits of au
‘meter sache conductive and neural desiess, he
Initia ference ls maintained throughout while in och
{ea lesions, para, complete or onerrerultment may be
seen (igure)
2, Short Increment Sensitivity Index
(Gist Test)
Patients with cochlear tons distinguish smaller chang
{in intensity of pure tone better than normal persons
And those with conductive or rerocochlear pathology
SS testis thus sed to differentiate a cochlear from a
troc lesion
In this test, à continuous tone is presented 20 dB above
thethesholdandsusained fr about Zain. Every Ss the
ones incensed by 1 dB and 20 such Dips ate presente
Patient indicates the lips heard In conductive deates,
neseeses
Figure 48, Atome Dual oe sce te
SISI score is Seldom more than 19% is 70-100 in
‘cochlear deafness and 0-20% in neve estres.
3. Threshold Tone Decay Test
A à measure of nerve fatigue and suse to detect et
‘overhear lion, Normally a person can hear à tono
nina fr sin nera agus he stops eating
fair The tesi tone decay tet simple ands per
forme in he following manne:
"tone of 4000 Hz presented at $ JB above the pa-
tien’ thro of hearing, continuously fora period of
05. patent tops hearing care, ners is nero
ty another db. The procedure is coninuc ul patent
an ear the one continuously fr 603, or no eve exists
Se the threshold here tone audible or fll 00
The rest pres as number a dB of decay. A decay
‘more than 25 dbs dagnostc of rtrococ hear Ion.
4. Evoked Response Audiometry
Risa objective test which measures electrical activity in
the auditry patieays in response to auditory simul K
requires special equipment with an averaging computer,
‘There are several components of evoked elect response
ut only two have gad clinical acceptance. They ae
(a) Hlectrocochteography (EcoG). I mesures lta
potetatsasingin he cochlea and CN Vin response
fo auditory still within fst 8 ms. The response fs
in the form of three phenomena: cochlear microphon-
les summating potentials and the action potent of
Vil nerve. The recording electrodo 1 usualy à thin
ree passed through the tympanic membrane onto
the promontory adult, it can be done under local
“ancha but in children or anxious persons sda
tion or general anaesthesia Is require. Sedation does
not interfere in these responses. Ecos useful (D 10
Fin treshod or hearing young infants and.
Figure 49, eecvocciconpy. (Norma or. @) ar wh it
‘ie ne otage of sting poeta 5) compu
Sern petty Nom Sn a
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dows
Figure 4.10 rte str eve potenti.
within S-10 and i) to diferente lesions of coh
Tes om thos ofthe VII nerve Fe 1.0
0) Auditory brainstem response (ABR). Also called BAER
‘or BAER (brainstem autor evoked response or poten:
{ab ar BERA (altem evoked response audiometry)
151 ec brainstem responses to auditory stimulation
by li or tone bursts I 153 noninvasive technique to
find the inte of central auditory pathways tros
the Vth nerve, pons and midbrain, tn this method,
electrical potential ae generate in response to several
‘liek still or tone bursts and picked up om the vere
tex by surface electrodes, R measures heating sens
ity in the range of 1000-1000 Hz tha normal person,
seven waves ae produced inthe ist 10 ms. The Bist
{hind and fith waves are most stable and are used in
measurements, The waves are studied for absolute a
tency, interme laten (aay between wave Land Y)
nd the ample 10)
‘The exact anatomic ste of neural generators for var
fous waves sdisputed but the atest studs indicate the
following se:
Wave!
Distal part of CN VII
Proximal part of CN VII near
the brainstem
Wave t Cochlear nucleus
Wave tv Superior olivar complex
Waves and VIE Inferior olleulus
Asan ade memor remember the mnemonic EE COÏ
(Gig, ight, cochlear nucleus, ovary complex, lateral
Temniseus, Inferior coliculus) compare E COLEMA In
pathways of he
‘ABRs use
(0 Asa screening procedure fr infants.
Ui) To determine the threshold of hearing infants;
lo im children and adults who do not cooperate
and in malingeress.
un To dagnose retocochlear pathology particular
(69) To diagnose brainstem pathology eg. multiple sl
rosisor pontine tumour
9) To monter CN VII introperativch in surgery of
acoustic neuromas to preserve the Function ol coh
Tear nerve
Chapter — Assessment of Heaing 29
5. Auditory Steady State Response (ASSR)
“Thou ABR, conducted with tone bursts of various fe-
quencies, can produce frequency spec thresholds of
Hearing in infants ot hearing ad ata young age, has
limitations. cannot est Bearing losses above $0 dB.
lt cannot detect heating sensitivity in severe 10 pro
foundly dest infants, AS is useful in such situations.
TEs, ike ABR, an eectrophysiological test which uses
steady tae pur tone signals instead of tansent signals
fof tone bursts or clicks used in ABR. The steady state
Signals ae also modulated rapidly in amplitude and fe
{quency and thus gives frequency specific audiogram.
Hearing losses exceeding 80 dB can be detected. I can
help in selection of children for cochlear implantation
tan early age,
6. Otoacoustic Emissions (OAEs)
‘They are low-intensity sounds produced by outer hair
calls 0f a normal cochlea and can De eiched by à ery
Sensitive microphone placed in the extemal car ana and
analyzed by a computer Sound produced by outer halt
‘lls travels in a reverse direction outer hal ells = base
Jar membrane > penlymph = ova window > ossicles >
‘tympanic membrane > ar canal. ONE are present when
‘ter ha cll are healthy and are abet when they ae
“damage and thus help 0 test the funcion of cochlea
‘They do not disappear In VI nerve pathology as och
‘TYRES oF OAES. Broadly OAES are of two types: spon:
tancous and evoked. The latter are elicited By a sound
stimulus
(a) Spontaneous OAES. They are present in healthy nor
imal hearing persons where hearing loss docs not
seed 30 db. They may be absent in 0% of normal
persons.
(Evoked OAs. They are further divided into two types
depending on the sound stimulus usd o ele them,
(6 Transent evoked OAES(TEOAES)- Evoked by ichs.
A series of lick stil represented a 80-85 dB
SPL (sound pressure level and response recorde
(in Distoin product OAES (DPOAES Two tones are
simultaneously presented to the cochlea 10 p
‘dace distortion products. They have been US 10
test nearing inthe range of 1000-8000 Hz.
sis
AA) OAES are used as screening test of heating in neo-
ate and 1 est hearing In uncooperative or mentally
<halleged individuals after sedation. Sedation does
ot inerte with As
(0 They Hp 10 distinguish cochlear from retrocochicar
sing os. OAES are absent in cochlea lesions, ©.
ototone sensorineural heating os. They detect oto
tone effects earlier than pure tone audiometry.
(6 ONES areas usell to dagnose retocechlear pathol
gy especial auditory neuropathy. Auditory newop-
Athy isa neurologie disorder of CN VIT, Audiometrie
tess, eg. SNHTL for pare tones impaired speech dis.
imination score, absent or abnormal auditory Da.
Stem response, show a reuocochlear typeof sion but
OA are normal
mebooksfree.com
Figure 4.10 rte str eve potenti.
within S-10 and i) to diferente lesions of coh
Tes om thos ofthe VII nerve Fe 1.0
0) Auditory brainstem response (ABR). Also called BAER
‘or BAER (brainstem autor evoked response or poten:
{ab ar BERA (altem evoked response audiometry)
151 ec brainstem responses to auditory stimulation
by li or tone bursts I 153 noninvasive technique to
find the inte of central auditory pathways tros
the Vth nerve, pons and midbrain, tn this method,
electrical potential ae generate in response to several
‘liek still or tone bursts and picked up om the vere
tex by surface electrodes, R measures heating sens
ity in the range of 1000-1000 Hz tha normal person,
seven waves ae produced inthe ist 10 ms. The Bist
{hind and fith waves are most stable and are used in
measurements, The waves are studied for absolute a
tency, interme laten (aay between wave Land Y)
nd the ample 10)
‘The exact anatomic ste of neural generators for var
fous waves sdisputed but the atest studs indicate the
following se:
Wave!
Distal part of CN VII
Proximal part of CN VII near
the brainstem
Wave t Cochlear nucleus
Wave tv Superior olivar complex
Waves and VIE Inferior olleulus
Asan ade memor remember the mnemonic EE COÏ
(Gig, ight, cochlear nucleus, ovary complex, lateral
Temniseus, Inferior coliculus) compare E COLEMA In
pathways of he
‘ABRs use
(0 Asa screening procedure fr infants.
Ui) To determine the threshold of hearing infants;
lo im children and adults who do not cooperate
and in malingeress.
un To dagnose retocochlear pathology particular
(69) To diagnose brainstem pathology eg. multiple sl
rosisor pontine tumour
9) To monter CN VII introperativch in surgery of
acoustic neuromas to preserve the Function ol coh
Tear nerve
Chapter — Assessment of Heaing 29
5. Auditory Steady State Response (ASSR)
“Thou ABR, conducted with tone bursts of various fe-
quencies, can produce frequency spec thresholds of
Hearing in infants ot hearing ad ata young age, has
limitations. cannot est Bearing losses above $0 dB.
lt cannot detect heating sensitivity in severe 10 pro
foundly dest infants, AS is useful in such situations.
TEs, ike ABR, an eectrophysiological test which uses
steady tae pur tone signals instead of tansent signals
fof tone bursts or clicks used in ABR. The steady state
Signals ae also modulated rapidly in amplitude and fe
{quency and thus gives frequency specific audiogram.
Hearing losses exceeding 80 dB can be detected. I can
help in selection of children for cochlear implantation
tan early age,
6. Otoacoustic Emissions (OAEs)
‘They are low-intensity sounds produced by outer hair
calls 0f a normal cochlea and can De eiched by à ery
Sensitive microphone placed in the extemal car ana and
analyzed by a computer Sound produced by outer halt
‘lls travels in a reverse direction outer hal ells = base
Jar membrane > penlymph = ova window > ossicles >
‘tympanic membrane > ar canal. ONE are present when
‘ter ha cll are healthy and are abet when they ae
“damage and thus help 0 test the funcion of cochlea
‘They do not disappear In VI nerve pathology as och
‘TYRES oF OAES. Broadly OAES are of two types: spon:
tancous and evoked. The latter are elicited By a sound
stimulus
(a) Spontaneous OAES. They are present in healthy nor
imal hearing persons where hearing loss docs not
seed 30 db. They may be absent in 0% of normal
persons.
(Evoked OAs. They are further divided into two types
depending on the sound stimulus usd o ele them,
(6 Transent evoked OAES(TEOAES)- Evoked by ichs.
A series of lick stil represented a 80-85 dB
SPL (sound pressure level and response recorde
(in Distoin product OAES (DPOAES Two tones are
simultaneously presented to the cochlea 10 p
‘dace distortion products. They have been US 10
test nearing inthe range of 1000-8000 Hz.
sis
AA) OAES are used as screening test of heating in neo-
ate and 1 est hearing In uncooperative or mentally
<halleged individuals after sedation. Sedation does
ot inerte with As
(0 They Hp 10 distinguish cochlear from retrocochicar
sing os. OAES are absent in cochlea lesions, ©.
ototone sensorineural heating os. They detect oto
tone effects earlier than pure tone audiometry.
(6 ONES areas usell to dagnose retocechlear pathol
gy especial auditory neuropathy. Auditory newop-
Athy isa neurologie disorder of CN VIT, Audiometrie
tess, eg. SNHTL for pare tones impaired speech dis.
imination score, absent or abnormal auditory Da.
Stem response, show a reuocochlear typeof sion but
OA are normal
mebooksfree.com
30. SECTION! — Diseases of ar
(OES are absent in 50% of normal individuals, sions
of cochlea, middle ear disorders (as sound travelling in
reverse direction cannot be picked up) and when hearing
loss exceeds 30 dB
7. Central Auditory Tests
Patients with central auditory disorder have duel.
{in hearing ln nosy surroundings or when the spect ie
stored and not ciar spoken. Thee diferent types Of
Speech discrimination tests are used
16) Mono st is presented with speech message which
ds distri, Patients with lesions of brain and cortex
have fly to understand the message
(©) Dicho ts. Two ferent speech messages ae pre.
sented simultaneously, one 9 cach ea and patient Is
ashe to identity both. Staggered spondale word tests
theone more often sed. ais of spondale word along
‘eth digit or nonsense words are simultaneously pre
“ene to the us, Patients eth temporal lobe lesions
Wil have dificult dentying these words when pre.
Sented tothe ear opposite to that ofthe ide of Keston.
(0 Binal 5. They are used to tently integration of
information from both ers, Such test are normal ln
oral lesions but affected in sions of brainstem
And tus help to ocalize the site of lesion. Most com.
mon test used isbinaurl masking evel direc test
Cental auditory tess ae not used routinely
8. Hearing Assessment in Infants and
Children (see p. 132)
mebooksfree.com
(OES are absent in 50% of normal individuals, sions
of cochlea, middle ear disorders (as sound travelling in
reverse direction cannot be picked up) and when hearing
loss exceeds 30 dB
7. Central Auditory Tests
Patients with central auditory disorder have duel.
{in hearing ln nosy surroundings or when the spect ie
stored and not ciar spoken. Thee diferent types Of
Speech discrimination tests are used
16) Mono st is presented with speech message which
ds distri, Patients with lesions of brain and cortex
have fly to understand the message
(©) Dicho ts. Two ferent speech messages ae pre.
sented simultaneously, one 9 cach ea and patient Is
ashe to identity both. Staggered spondale word tests
theone more often sed. ais of spondale word along
‘eth digit or nonsense words are simultaneously pre
“ene to the us, Patients eth temporal lobe lesions
Wil have dificult dentying these words when pre.
Sented tothe ear opposite to that ofthe ide of Keston.
(0 Binal 5. They are used to tently integration of
information from both ers, Such test are normal ln
oral lesions but affected in sions of brainstem
And tus help to ocalize the site of lesion. Most com.
mon test used isbinaurl masking evel direc test
Cental auditory tess ae not used routinely
8. Hearing Assessment in Infants and
Children (see p. 132)
mebooksfree.com
Chapter 5
Hearing Loss
CLASSIFICATION
onde tome
ee al
men) (Gal mien
ico mpeg —
‘CONDUCTIVE HEARING LOSS
[AND TS MANAGEMENT
Any disease process which interferes with the conduction
‘of sound to reach cochlea causes conductive beating os.
“The Ion may lie inthe extemal ear and tympanic mem:
brane, middle arr sis uptostapediovestbular
The characteristics of conductive hearing loss re
Negative Rinne test Le. BC > AC.
‘Weber lateral to poorer cr
Normal absolute bone condition.
Low frequencies affected more
Audiomeiry shows bone conduction beter than air
conduction with airbone gap. Greater the alr-bone
ap, more ithe conductive loss (nur 5 D
6. Fons femot more than 60.
7. Speech discrimination s good.
AETIOLOGY
‘The cause may be congenital (able 5.) or acquired
(hes).
AVERAGE HEARING LOSS SEEN IN.
DIFFERENT LESIONS OF CONDUCTIVE
APPARATUS
1. Complete obstruction of earcanal: 304
2 Pedonation of ympaniemembrane 104048
(le vares and is directly proportional to
ee of perforation
a stan
4. Ossicular nterupton with perforation: 38 dB
5. Males nation: 10-25 a8
crn
$. Clone of oval window
Note here that ossicular interuption with inact drum
‘causes more loss than ossicular Interruption with peto.
rated dum,
MANAGEMENT
Most cases of conductive hearing los can be managed by
medical or Surgical means. Treatment ofthese conditions
idee in respective sections. Belly, consists of
Removal of canal obstructions impyeted wax,
foreign body, enteoma o exostoso, atole mas, e:
‘ign or malignant tumor, or meatal ares,
2. Removal of Muid. Myringotomy with or without
a. Removal of mass from middle ea. Tympanotomy
and removal of small middle car tumours ot cholet
{oma behind intact tympanic membrane.
4. Stapedectomy, as In eoscerte fixation of stapes
hole.
5. Tympanoplast. Repair of perforation, oscar chain
or bth
6, Hearing aid In cases, whe
refed ras fad
Tympanoplasty
Tes an operation to (9 eradicte disease in the middle
a and (i) to reconsiruc hearing mechanism. I may be
combined with mastoldectomy If disease process so de
‘ands. Type of mile cr reconstruction depends on the
‘damage present inthe eat. The procedure may be limited
‘only to repair of tympani membrane impropias), or
19 teconsruction ‘of osicular” chain escapa),
‘rbot mangas, Reconstructive surgery ofthe car
as been greatly facitated by development of operating
microscope, mierosurical instruments and Diocompat-
bie implant materials
From the physiology of hearing mechani, the follow:
ing principles cam be deduced t restore hearing surgical
(a) An intact tympanic membrane, to provide large ydrau-
li ratio between the tympan membrane and stapes
footplate
9 Osta chain, to conduct sound fom tympanic
membrane tothe oval window:
(0 Two fnctoning windows one on the cla vestibul o
receive sound vibrations) andthe other on the Scala
urgery not possible,
a
mebooksfree.com
Hearing Loss
CLASSIFICATION
onde tome
ee al
men) (Gal mien
ico mpeg —
‘CONDUCTIVE HEARING LOSS
[AND TS MANAGEMENT
Any disease process which interferes with the conduction
‘of sound to reach cochlea causes conductive beating os.
“The Ion may lie inthe extemal ear and tympanic mem:
brane, middle arr sis uptostapediovestbular
The characteristics of conductive hearing loss re
Negative Rinne test Le. BC > AC.
‘Weber lateral to poorer cr
Normal absolute bone condition.
Low frequencies affected more
Audiomeiry shows bone conduction beter than air
conduction with airbone gap. Greater the alr-bone
ap, more ithe conductive loss (nur 5 D
6. Fons femot more than 60.
7. Speech discrimination s good.
AETIOLOGY
‘The cause may be congenital (able 5.) or acquired
(hes).
AVERAGE HEARING LOSS SEEN IN.
DIFFERENT LESIONS OF CONDUCTIVE
APPARATUS
1. Complete obstruction of earcanal: 304
2 Pedonation of ympaniemembrane 104048
(le vares and is directly proportional to
ee of perforation
a stan
4. Ossicular nterupton with perforation: 38 dB
5. Males nation: 10-25 a8
crn
$. Clone of oval window
Note here that ossicular interuption with inact drum
‘causes more loss than ossicular Interruption with peto.
rated dum,
MANAGEMENT
Most cases of conductive hearing los can be managed by
medical or Surgical means. Treatment ofthese conditions
idee in respective sections. Belly, consists of
Removal of canal obstructions impyeted wax,
foreign body, enteoma o exostoso, atole mas, e:
‘ign or malignant tumor, or meatal ares,
2. Removal of Muid. Myringotomy with or without
a. Removal of mass from middle ea. Tympanotomy
and removal of small middle car tumours ot cholet
{oma behind intact tympanic membrane.
4. Stapedectomy, as In eoscerte fixation of stapes
hole.
5. Tympanoplast. Repair of perforation, oscar chain
or bth
6, Hearing aid In cases, whe
refed ras fad
Tympanoplasty
Tes an operation to (9 eradicte disease in the middle
a and (i) to reconsiruc hearing mechanism. I may be
combined with mastoldectomy If disease process so de
‘ands. Type of mile cr reconstruction depends on the
‘damage present inthe eat. The procedure may be limited
‘only to repair of tympani membrane impropias), or
19 teconsruction ‘of osicular” chain escapa),
‘rbot mangas, Reconstructive surgery ofthe car
as been greatly facitated by development of operating
microscope, mierosurical instruments and Diocompat-
bie implant materials
From the physiology of hearing mechani, the follow:
ing principles cam be deduced t restore hearing surgical
(a) An intact tympanic membrane, to provide large ydrau-
li ratio between the tympan membrane and stapes
footplate
9 Osta chain, to conduct sound fom tympanic
membrane tothe oval window:
(0 Two fnctoning windows one on the cla vestibul o
receive sound vibrations) andthe other on the Scala
urgery not possible,
a
mebooksfree.com
32 SECTION! — Diseases of Ear
(© unetoning astahian te, o provide aeration to the
middle ea
(© À fnctining sensorineural apparatus, Le. the cochlea
‘Tyres oF Typanortasty. Wulltin clas tmp
os into ve types (ise 2)
Banner te
sas 20 S00 200 cw u
¡===
22
| o
BB) oo
en er
de] hd cara
E Pr ea
am hemues | À 0
(come) < | >
fomes | c | 2
IES
Figure 5. A ogame ria conducive hen
BA guy.) root din suda cut
enla
À Fon tapes ote
Fain à mba
car icon
emi My cion tee cal e, wa,
"ero boy und, ate mnt
‘ing big or gant mar
Mite ear (a een mp membrane,
uma are
ua inte má c 9 ae
emote
ON mai e. ign ot
nan ama
ain l rie e. voumato
cr ui beni span ot
o Taten sides 29, css,
"moscas, soe os ma,
(0 nan ibe ico, on ine
AS
ympanl (to ac as a relief window). It ls only one
‘window sin stapes ation o closure ol round win:
‘ov, there willbe no movement of cochlear Mads te.
Sulting in conductive heating os.
(a) Ana separation of to windows, so that sound docs
‘ot reach both the windows simultaneously It can De
“achieved by providing an intact tympanic membrane
Preferential pathway o one window (usualy the ova)
by providing ossicular chain and by the presence ol
arin the mide ar
Typel Defect is perforation of tympanic mem.
brane whith i repair with a grat 1s
also called myringoplsty.
Detect is perforation of tympanic mem.
brane with erosion of malleus. Graft is
placed on the ncus or remnant of malleus
tls" and incus ate absent. Grat is
placed drealy on the stapes head, eis
lso called myingostapediapeny columella
‘ympanoptasty.
Only the fooplae of stapes I present I
Is exposed tothe external car, and gra is
placed between the oval and ound win.
flows. À arrow middle car (avum mi.
‘on à thus Created to have an ar pocket
round the round window. À mucoss ined
Space extend fom the eustachian tube to
the found window Sound waves in
ease act dicey on the Fooplate while the
round window hasbeen shield,
Stapesfootplat xed bat round window
is functioning. In such cases, another win.
¿low I created on horizontal semicircular
anal and covered with à rat. Alo called
Fenestration penton.
Typett
Type mt
Typelv
Several modifications have appeared in the above cas.
slicaton and they mainly pertain o the types of osicu-
reconstruction.
MyRINGOPLASTY. It i repair of tympanic membrane,
Graft materias of choice are temporal fasca or the
perchondrium taken from the patient. Sometimes, h
Mograts such as dura, vin, fascia or cadaver tympan
le membrane are also used. Repair can be done by two
techniques he underlay or the vera: In the wey
ech, margins of peroration ae freshened and the
fate place medial to perforation or tympanic annulus,
Marge, ands supported by gelfoam in the middle car
(ur 5A. In the overlay éme the gat paced
lateral to Bbrous layer ofthe tympanic membrane ater
rel removing al squamous epithelia rom the Lt.
{al surface of tympanic membrane emnant (iure 5.38
and Chapter 83.
ossicutan Recoxsmaucnios. Osiles ae essential for
ansmision of sound from tympanic membrane to laby-
in Several types of prosthesis are avalable to replace
sico depending on the ossleular defects (hi 5)
‘Rutorat asics can be sculptured to bridge the gap,
HHomogeatt preserved ose with or without tympanic
membrane have been used but are ficult to procure and
ave danger of transmission o disease (i 5.0)
mebooksfree.com
(© unetoning astahian te, o provide aeration to the
middle ea
(© À fnctining sensorineural apparatus, Le. the cochlea
‘Tyres oF Typanortasty. Wulltin clas tmp
os into ve types (ise 2)
Banner te
sas 20 S00 200 cw u
¡===
22
| o
BB) oo
en er
de] hd cara
E Pr ea
am hemues | À 0
(come) < | >
fomes | c | 2
IES
Figure 5. A ogame ria conducive hen
BA guy.) root din suda cut
enla
À Fon tapes ote
Fain à mba
car icon
emi My cion tee cal e, wa,
"ero boy und, ate mnt
‘ing big or gant mar
Mite ear (a een mp membrane,
uma are
ua inte má c 9 ae
emote
ON mai e. ign ot
nan ama
ain l rie e. voumato
cr ui beni span ot
o Taten sides 29, css,
"moscas, soe os ma,
(0 nan ibe ico, on ine
AS
ympanl (to ac as a relief window). It ls only one
‘window sin stapes ation o closure ol round win:
‘ov, there willbe no movement of cochlear Mads te.
Sulting in conductive heating os.
(a) Ana separation of to windows, so that sound docs
‘ot reach both the windows simultaneously It can De
“achieved by providing an intact tympanic membrane
Preferential pathway o one window (usualy the ova)
by providing ossicular chain and by the presence ol
arin the mide ar
Typel Defect is perforation of tympanic mem.
brane whith i repair with a grat 1s
also called myringoplsty.
Detect is perforation of tympanic mem.
brane with erosion of malleus. Graft is
placed on the ncus or remnant of malleus
tls" and incus ate absent. Grat is
placed drealy on the stapes head, eis
lso called myingostapediapeny columella
‘ympanoptasty.
Only the fooplae of stapes I present I
Is exposed tothe external car, and gra is
placed between the oval and ound win.
flows. À arrow middle car (avum mi.
‘on à thus Created to have an ar pocket
round the round window. À mucoss ined
Space extend fom the eustachian tube to
the found window Sound waves in
ease act dicey on the Fooplate while the
round window hasbeen shield,
Stapesfootplat xed bat round window
is functioning. In such cases, another win.
¿low I created on horizontal semicircular
anal and covered with à rat. Alo called
Fenestration penton.
Typett
Type mt
Typelv
Several modifications have appeared in the above cas.
slicaton and they mainly pertain o the types of osicu-
reconstruction.
MyRINGOPLASTY. It i repair of tympanic membrane,
Graft materias of choice are temporal fasca or the
perchondrium taken from the patient. Sometimes, h
Mograts such as dura, vin, fascia or cadaver tympan
le membrane are also used. Repair can be done by two
techniques he underlay or the vera: In the wey
ech, margins of peroration ae freshened and the
fate place medial to perforation or tympanic annulus,
Marge, ands supported by gelfoam in the middle car
(ur 5A. In the overlay éme the gat paced
lateral to Bbrous layer ofthe tympanic membrane ater
rel removing al squamous epithelia rom the Lt.
{al surface of tympanic membrane emnant (iure 5.38
and Chapter 83.
ossicutan Recoxsmaucnios. Osiles ae essential for
ansmision of sound from tympanic membrane to laby-
in Several types of prosthesis are avalable to replace
sico depending on the ossleular defects (hi 5)
‘Rutorat asics can be sculptured to bridge the gap,
HHomogeatt preserved ose with or without tympanic
membrane have been used but are ficult to procure and
ave danger of transmission o disease (i 5.0)
mebooksfree.com
Chapters — Mesingloss 33
“ype hogs)
pe opos) yee ‘pe Fenster)
igure 52 Types ympanplasy. The gals progr nach mass (pens Ce, ape (ype, apes tate
(pet er ten inher serch an ype Vm cal pe the go wa alada Porto, is prod oa po
{econ fr round window hae ope vs dec por.
Zu. |
con BS
A
EL a U arg D a om
Sere pre sc @) Oy ee toe
gases onan sr ete sueo yo |
A
pce meca mals Rande to presen ter
Fos pt (Figure 5,4. Ossicular reconstruction. Sculptured autograt or homo-
SESE eee
EN a Cc meee pee se
+ Cortal bone om + Lowest Fonte emo Matt males connect mals and wh
Er sn ce ee
PNR a has tig sooo
ie tore ME
E E
e, Seh nc old ct.
nee Mist rs ay and re of mics ie and
dons dsseune
cu + scan fe funcions god. Aa mide
fmm, {Sesh por cstachian te function,
+ Emme
An ass of anal valu mastectomy done fr cho:
ee tema Se mice doe the Porte de
Hs e aout non D nr ar core
A — Paname ane promets
Le ade. roumac or dsupton
Sun on pre)
Earl Canal wall down procedures when there Is no mucosal
‘dicate or cholesteatoma
mebooksfree.com
“ype hogs)
pe opos) yee ‘pe Fenster)
igure 52 Types ympanplasy. The gals progr nach mass (pens Ce, ape (ype, apes tate
(pet er ten inher serch an ype Vm cal pe the go wa alada Porto, is prod oa po
{econ fr round window hae ope vs dec por.
Zu. |
con BS
A
EL a U arg D a om
Sere pre sc @) Oy ee toe
gases onan sr ete sueo yo |
A
pce meca mals Rande to presen ter
Fos pt (Figure 5,4. Ossicular reconstruction. Sculptured autograt or homo-
SESE eee
EN a Cc meee pee se
+ Cortal bone om + Lowest Fonte emo Matt males connect mals and wh
Er sn ce ee
PNR a has tig sooo
ie tore ME
E E
e, Seh nc old ct.
nee Mist rs ay and re of mics ie and
dons dsseune
cu + scan fe funcions god. Aa mide
fmm, {Sesh por cstachian te function,
+ Emme
An ass of anal valu mastectomy done fr cho:
ee tema Se mice doe the Porte de
Hs e aout non D nr ar core
A — Paname ane promets
Le ade. roumac or dsupton
Sun on pre)
Earl Canal wall down procedures when there Is no mucosal
‘dicate or cholesteatoma
mebooksfree.com
34 SECTIONI — Diseases of ar
ss Was AP
Figure 5.5 droga TOW and FOR (A) ented nd)
‘Pope 6) Ta TOR (0) Farm POM
‘Types of prosas (igure 5)
1. news prosthesis, Usd when ncus is missing ut han
dle of malleus and stapes with supentructue ate pres
Sent and functional
2, Ineus-atapes prosthess, Used when Incus and stapes
Supertrcture are missing, Malle and stapes foot
pte are functional
Partial ossicular replacement prosthesis (PORP)
‘Used when malleus and inc ae absent Stopes I re
sent and mobile. PORP i placed between tympanic
‘membrane and stapes had,
4. Total “ossicular replacement prosthesis (FORD),
Used when malleus, incus and stapes superstructure
are absent. Only the stapes footplate present and ls
mobile
SENSORINEURAL HEARING LOSS
‘AND ITS MANAGEMENT.
Sensorineura hearing los (SNHL) results fom lesions of
‘the cochlea, Vil mere or central auditory pathways. I
‘may be present at but (congenital) or start later in I
suited
“he characteristics of sensorineural heating los ar:
1. A poste Rinne test Le AC > BC
2: Weber era to beter a.
3 Bone conduction reduced on Schwabach and absolute
Bone conduction tes
Moreen involving high frequence.
No gap between ai and bone conduction curve on a
dlomety (sure 9)
6. Loss may exced 60
8 Theres ul in heuing in the presence of n
Fran nore
oar es in
Bssasssesse
Figure 5.6. Agra ct a showing esoo st
ba
AETIOLOGY
Congenital
{Ris present at bith and isthe result of anomalies of the
{nner ear or damage o the hearing apparatus by prenatal
or perinatal factors (ep. 129)
Acquired
A appears ater in ie. The cause may be genetic or non
genetic: The genetic hearing loss may manes late (de.
Eyed onset) and may afec only the hearing, or bea part
(ofa larger syndrome affecting other sytem ofthe body
ds well syndromal). Common causes of acquired NHL
include:
1. Infections of labyrinth—vira
2. Trauma to labyrinth or VI nerve, e. factures of
temporal bone or concussion ofthe abyrim or the
cry
Noiseinduced heating oss
Otto drugs
Presbycusis
Meniere's disease
‘Acoustic neuroma
Sader hearing loss
Familial progressive SNHL
Systemic disorders, eg. diabetes, hypothyridism,
‘ney disease, ausimmune disorders multiple sl:
os blood dyserasas.
bactrlal or spin:
DIAGNOSIS
1. Mistony. Is important to know whether disease I
ngenital or acquit, stationary or progressive, ach
ed with other Syndiomes or not, involvement of other
member of the family and posible aciologi actos.
2. Stvmıry or Drarsess (MILD, Mopmart, MoDER-
[ATELY SEVERE, SEVERE, PROFOUND OR TOTAL) This can
found out om sudlometry.
mebooksfree.com
ss Was AP
Figure 5.5 droga TOW and FOR (A) ented nd)
‘Pope 6) Ta TOR (0) Farm POM
‘Types of prosas (igure 5)
1. news prosthesis, Usd when ncus is missing ut han
dle of malleus and stapes with supentructue ate pres
Sent and functional
2, Ineus-atapes prosthess, Used when Incus and stapes
Supertrcture are missing, Malle and stapes foot
pte are functional
Partial ossicular replacement prosthesis (PORP)
‘Used when malleus and inc ae absent Stopes I re
sent and mobile. PORP i placed between tympanic
‘membrane and stapes had,
4. Total “ossicular replacement prosthesis (FORD),
Used when malleus, incus and stapes superstructure
are absent. Only the stapes footplate present and ls
mobile
SENSORINEURAL HEARING LOSS
‘AND ITS MANAGEMENT.
Sensorineura hearing los (SNHL) results fom lesions of
‘the cochlea, Vil mere or central auditory pathways. I
‘may be present at but (congenital) or start later in I
suited
“he characteristics of sensorineural heating los ar:
1. A poste Rinne test Le AC > BC
2: Weber era to beter a.
3 Bone conduction reduced on Schwabach and absolute
Bone conduction tes
Moreen involving high frequence.
No gap between ai and bone conduction curve on a
dlomety (sure 9)
6. Loss may exced 60
8 Theres ul in heuing in the presence of n
Fran nore
oar es in
Bssasssesse
Figure 5.6. Agra ct a showing esoo st
ba
AETIOLOGY
Congenital
{Ris present at bith and isthe result of anomalies of the
{nner ear or damage o the hearing apparatus by prenatal
or perinatal factors (ep. 129)
Acquired
A appears ater in ie. The cause may be genetic or non
genetic: The genetic hearing loss may manes late (de.
Eyed onset) and may afec only the hearing, or bea part
(ofa larger syndrome affecting other sytem ofthe body
ds well syndromal). Common causes of acquired NHL
include:
1. Infections of labyrinth—vira
2. Trauma to labyrinth or VI nerve, e. factures of
temporal bone or concussion ofthe abyrim or the
cry
Noiseinduced heating oss
Otto drugs
Presbycusis
Meniere's disease
‘Acoustic neuroma
Sader hearing loss
Familial progressive SNHL
Systemic disorders, eg. diabetes, hypothyridism,
‘ney disease, ausimmune disorders multiple sl:
os blood dyserasas.
bactrlal or spin:
DIAGNOSIS
1. Mistony. Is important to know whether disease I
ngenital or acquit, stationary or progressive, ach
ed with other Syndiomes or not, involvement of other
member of the family and posible aciologi actos.
2. Stvmıry or Drarsess (MILD, Mopmart, MoDER-
[ATELY SEVERE, SEVERE, PROFOUND OR TOTAL) This can
found out om sudlometry.
mebooksfree.com
3. Type oF AUDIOGRANM. Whether loss shah frequency,
Tow frequency midrequeney or Hat typ
4, SITE OF Liston. Le. cochlear, rtrocochlcar or central
5. Lanonarony st. They depend on the aetiology
Sispected, eg Xray or CT scan of temporal bone for
{evidence of Done destruction (congenital cholesteatoma,
‘slomus tumour, middle ear malignancy or acoustic neu
Toma), blood counts (leukaemia) blood Sugar diabetes),
Serology for sypis,thyeoud functions (hypothyr
¡sm Kidney function es, ete
MANAGEMENT
Early detection of SNHL Is Important as measures can be
taken to stop is progres reverse to to start an ey te:
habitation programme, s essential for communication
‘Sips ofthe inner car is table with igh doses of
pericia and steroids with improvement in hearing. Heat:
Ing ss of payin can be reversed with replacement
therapy. Srs arts can be reversa by atenton o
ride car infection. Fay management of Méntr ds
an present further episodes of Vertigo and hearing Los.
SNL due to peibmph fistula can be comeced surgically
by cling he tala the oval or round endoso et a,
Otero ds sould be used with cae and discon.
ued if causing hearing loss. In many such ass, le may be
possible to regain heating. oal oe part the dg is
Stopped. Nolse induced hearing loss can be prevented rom
further deterioration ifthe person is removed fom the
noisy suroundings.
‘Rehabilitation of hearing impaired with heating aids
and other devices is dscssed per 2,
SPECIFIC FORMS OF HEARING LOSS
A. INFLAMMATIONS OF LABYRINTH
Lemay be viral bacteria or spi
1. Vat Lanvarsrmeri. Vrsses usually rech the in
ner sr by biood steam affecting sra vascular and then
{the endolymph and organ of Cort. Meases, mumps and
‘ytomealoviises are well documented 10 cause lay
nhs Several other viruses, e, rubella, herpes zoster,
herpes simple, nluenza and Epstein-Bre are cintaly
known o cause deafness but direct prof of their Ina
Son of abyenth i chung,
2. BACTEMIAL. Bacterial infections reach labyrinth
throug the mide eae (ympanogenic) or through CSF
(men
le car
a my. Bert cam invade the labyrinth along nerves,
‘esses, cochlear aqueduct or the endolymphatic Sc
Membranous abyrinth i total desteoyed.
3. Syrumuic. Sensorincural caring loss cause bo
by congenital and acquired syphilis, Congenital yp
1.108 two types the ear fom, manifesting at the age
Chapters — Hewingtoss 35.
12 os the late form, manifesting atthe age of 8-20 yeas
Syphilic involvement of the inner er can cause:
(a) Sudden sensorineural hearing ss, whieh may be un
lateral or bilateral. The ters way symmetrical
high frequencieso is a Mat type
(0) Mine syndrome with episode vertigo, uctat
Ang heating los tinnitus and aural flinss—a picture
simulating Mena’ disease.
(0 Mennebert’s sign postive fistula sign in the absence
‘of a fistula This is due to fibrous adhesions benne
the stapes footplate and the membranous brin
(Tullo phenomenon In which loud Sounds produce
er
Diagnosis of otosyphils can be made by other clinical
evidence of late acquired or congenital ph (mera
erat Hutchinson tet saddle nose nasal Septal per
{oration and frontal essing) and the laboratory tests. Pl
‘escent eponemaaopton es (FTA-ABS) and venereal
lose research laboratory (VD) or api plasma rein
{kPa ests from CSF are wet to establish he diagnos
Treament of orosyphiis includes Lx. paie and
steroids
FAMILIAL PROGRESSIVE SENSORINEURAL
HEARING LOSS.
lisa genetic disorder in which theres progressive degen
ration of the cochlea stating in late childhood cry
Sule ie Hearing oss bilateral with Mat or basin shaped
Audlogram but an excellent speech discrimination,
€. OTOTOXICITY
Various drugs and chemicals can damage the inner cor
and case sensorincural heaving loss, units and some:
times vertigo Table D.
1. AMINOGINCOSIDE. ANTIMOTICS. Streptomycin, gen
{min and tobramycin are primary. vesulotoxi.
‘They selectively destroy type I Male cll of the esta am-
pulls bt, administered in lange doses, can lo damage
{he coche,
‘Neomyein, kanamyein, amikacin, ssomyein and die
yurostreptomycin ae cochleotone. They cause sleeve
struction of outer hair cells staring at the basal cll
And progressing onto the apex of coche,
‘Patents particularly tk are those:
(a) having impaired renal function,
(0 elderly people above the age of 65,
(© concomitantly reeaving other ototoxic drugs
(0 ho have already ceived aminoglycosile anti,
(e) who are receiving high doses of ototoxte drugs with
high serum level of drug, and
(0 wo have genetic suscepti
Here the antibiotic binds to
fers with ps
cochlea el
Symptoms of ototoxic, heating loss, tinnitus and/or
giddinessmay manifest during treatment or ater comple
fiom of ne treatment (layed toni).
y to aminogtycosdes
ribosome and inter.
mebooksfree.com
Tow frequency midrequeney or Hat typ
4, SITE OF Liston. Le. cochlear, rtrocochlcar or central
5. Lanonarony st. They depend on the aetiology
Sispected, eg Xray or CT scan of temporal bone for
{evidence of Done destruction (congenital cholesteatoma,
‘slomus tumour, middle ear malignancy or acoustic neu
Toma), blood counts (leukaemia) blood Sugar diabetes),
Serology for sypis,thyeoud functions (hypothyr
¡sm Kidney function es, ete
MANAGEMENT
Early detection of SNHL Is Important as measures can be
taken to stop is progres reverse to to start an ey te:
habitation programme, s essential for communication
‘Sips ofthe inner car is table with igh doses of
pericia and steroids with improvement in hearing. Heat:
Ing ss of payin can be reversed with replacement
therapy. Srs arts can be reversa by atenton o
ride car infection. Fay management of Méntr ds
an present further episodes of Vertigo and hearing Los.
SNL due to peibmph fistula can be comeced surgically
by cling he tala the oval or round endoso et a,
Otero ds sould be used with cae and discon.
ued if causing hearing loss. In many such ass, le may be
possible to regain heating. oal oe part the dg is
Stopped. Nolse induced hearing loss can be prevented rom
further deterioration ifthe person is removed fom the
noisy suroundings.
‘Rehabilitation of hearing impaired with heating aids
and other devices is dscssed per 2,
SPECIFIC FORMS OF HEARING LOSS
A. INFLAMMATIONS OF LABYRINTH
Lemay be viral bacteria or spi
1. Vat Lanvarsrmeri. Vrsses usually rech the in
ner sr by biood steam affecting sra vascular and then
{the endolymph and organ of Cort. Meases, mumps and
‘ytomealoviises are well documented 10 cause lay
nhs Several other viruses, e, rubella, herpes zoster,
herpes simple, nluenza and Epstein-Bre are cintaly
known o cause deafness but direct prof of their Ina
Son of abyenth i chung,
2. BACTEMIAL. Bacterial infections reach labyrinth
throug the mide eae (ympanogenic) or through CSF
(men
le car
a my. Bert cam invade the labyrinth along nerves,
‘esses, cochlear aqueduct or the endolymphatic Sc
Membranous abyrinth i total desteoyed.
3. Syrumuic. Sensorincural caring loss cause bo
by congenital and acquired syphilis, Congenital yp
1.108 two types the ear fom, manifesting at the age
Chapters — Hewingtoss 35.
12 os the late form, manifesting atthe age of 8-20 yeas
Syphilic involvement of the inner er can cause:
(a) Sudden sensorineural hearing ss, whieh may be un
lateral or bilateral. The ters way symmetrical
high frequencieso is a Mat type
(0) Mine syndrome with episode vertigo, uctat
Ang heating los tinnitus and aural flinss—a picture
simulating Mena’ disease.
(0 Mennebert’s sign postive fistula sign in the absence
‘of a fistula This is due to fibrous adhesions benne
the stapes footplate and the membranous brin
(Tullo phenomenon In which loud Sounds produce
er
Diagnosis of otosyphils can be made by other clinical
evidence of late acquired or congenital ph (mera
erat Hutchinson tet saddle nose nasal Septal per
{oration and frontal essing) and the laboratory tests. Pl
‘escent eponemaaopton es (FTA-ABS) and venereal
lose research laboratory (VD) or api plasma rein
{kPa ests from CSF are wet to establish he diagnos
Treament of orosyphiis includes Lx. paie and
steroids
FAMILIAL PROGRESSIVE SENSORINEURAL
HEARING LOSS.
lisa genetic disorder in which theres progressive degen
ration of the cochlea stating in late childhood cry
Sule ie Hearing oss bilateral with Mat or basin shaped
Audlogram but an excellent speech discrimination,
€. OTOTOXICITY
Various drugs and chemicals can damage the inner cor
and case sensorincural heaving loss, units and some:
times vertigo Table D.
1. AMINOGINCOSIDE. ANTIMOTICS. Streptomycin, gen
{min and tobramycin are primary. vesulotoxi.
‘They selectively destroy type I Male cll of the esta am-
pulls bt, administered in lange doses, can lo damage
{he coche,
‘Neomyein, kanamyein, amikacin, ssomyein and die
yurostreptomycin ae cochleotone. They cause sleeve
struction of outer hair cells staring at the basal cll
And progressing onto the apex of coche,
‘Patents particularly tk are those:
(a) having impaired renal function,
(0 elderly people above the age of 65,
(© concomitantly reeaving other ototoxic drugs
(0 ho have already ceived aminoglycosile anti,
(e) who are receiving high doses of ototoxte drugs with
high serum level of drug, and
(0 wo have genetic suscepti
Here the antibiotic binds to
fers with ps
cochlea el
Symptoms of ototoxic, heating loss, tinnitus and/or
giddinessmay manifest during treatment or ater comple
fiom of ne treatment (layed toni).
y to aminogtycosdes
ribosome and inter.
mebooksfree.com
36 SECTION! — Diseases ofr
2. Diuwerics. Furosemide, bumetanide and ethacrynie
ci are called loop duets 3 they Dock transport of 0.
‘dum and chloride fons inthe ascending loop of Henle
They are known to cause osdema and Jste Changes in
the Aria vascularis ofthe cochlear duct. Im most cases
the eect is mveibe but permanent damage may occur
Hearing loss may be bilateral and symaetial or some:
time siden in one.
3. Saucvuanss Symptoms of saliylte ottonicty are
tinnitus and Dlateral sensorineural hearing loss partic
er frequencies, Site of Lion testing
olvement, but light and electeon
microscopy have falled to how any morphologie chang
Sin the hal cls. Possibly they interfere at enzymatic
level, Hearing los due o salles i reverse after the
rugs discontinued. SNHL ha also Deen noted with oth:
eC NSAIDS, eg, naproxen, piroxam and Ketorolac but is
teenie
4. Quinta. Ototosi symptoms due to quinine ae tin
‘its and sensorineural hearing Tos, both of which are
revele. Higher doses may cause permanent los The
Symptoms generally appear with prolonged medication
‘but may occur with smaller doses in those who are sus.
‘ceptible. Congenital deatness and hypoplasia of coche
ave been reported in children whose matters received
"is drug during the st trimener of pregnancy, rate
fet ol quinine av due to vasoconstricio sn the small
Yes of tn cochlea and sta vasca.
5. CHLOROGUINE AND HYDROXYCHLOROQUINE: Elec
ls similar to that of quinine and cause reversble SNHL
Sometimes permanent dates cn HU,
6. Cyroroxie Davos, Nitrogen mustard, ciplain and
boat can cause cochlear damage. They affect the
Suter har cells the cochlea.
7. DEFEROXAMAINE (DISTERRIOXAMIND. I Is an iron
<helating substance used in Ihe treatment ofthalssacmic
patient who reese repeated blood transfusions and in
{urn have high iron load, Like platin and aminogly-
‘cones, deferoxamine also causes high-frequency seño
Final hearing los, Onse of hearing los is sudden or
‘elyed. I is permanent but in some eases it can De ree
‘ele when the drug s discontinued. I cause toxicity
Lo news: children are affected more.
8. Miscruunstous. folate ase of deafness have been
‘eported with erthromycn, ampclin and chloram-
phenicol, indomethacin, phenylbutazone, Ibuprofen,
tan antitoxin, propranolol and propythioura
Alcohol, tobacco and marijuana aso cause damage to
einer ea
9. Tomcat Ean Dors. Topical use of drugs inthe mi
ie car an also cause damage 10 the cochlea by absorp.
on through oval and round windows. Detiness has
occurred with the use of ehlorhexldine which was used
inthe preparation of ear canal before surgery or use of
«ar drops containing aminoglycoside antibiotics, eg. ne-
man, famycetin and gentamicin. Ottone potential
‘Sats present in car drops containing plymyxinB,pro-
pylene glycol and antifungal agent. Use only approved
‘lotoptal drops for middle eat fection,
D. NOISE TRAUMA
Hearing oss associated with exposure to noise has been
wenoo in boiler makes, on. and coppersiths,
and anllery men. Lately, nose tauma has assumed
rete significance because ofits being an occupational
Bazar the compensations asked for andthe esponsibil-
thrust upon the employer and the employee 10 con
serve hearing Hearing Tos caused by excessive nose can
be vided into two groups:
1. ACOUSTIC TRAUMA. Permanent damage to hear
ing can De caused by single bi exposure to very in.
tense sound without this Deng preceded bya temporary
{heshold shift Also called Impulse nos, such nase can
arise from an explosion, gun fre ora powerful cracker
And may reach or cross 140 dB, Nose level of gun or
file may reach 140-170 dB SPL (sound pressure level,
Sich bret and loud noses mechanically damage organ.
Of Cont, tea Ressner's membran
¿lowing mixing of peniymph and endolymph. À severe
blas, in addition, may concomitantly damage the ym
nic membrane and disapt osils futher adding con:
¡active los Impulse noise may be as rit ä 02 ms. No
pulse noise more tha 140 (As permitted
2. Nonst-INDUCID HEARING Loss (VIH). Hearing loss,
in tis as, follows croc xp tes tense sous
than seen in acoustic trauma and ts mainly à hazard of
oi occupations.
(@) Temporary sad sift TTS. The caring impair
Immediately after exposure o nose but recovers alter
an interval of fw minutes to a few hours even up
102 weeks. Amount of TTS depends on the noises
intensity, requeney and dation,
mebooksfree.com
2. Diuwerics. Furosemide, bumetanide and ethacrynie
ci are called loop duets 3 they Dock transport of 0.
‘dum and chloride fons inthe ascending loop of Henle
They are known to cause osdema and Jste Changes in
the Aria vascularis ofthe cochlear duct. Im most cases
the eect is mveibe but permanent damage may occur
Hearing loss may be bilateral and symaetial or some:
time siden in one.
3. Saucvuanss Symptoms of saliylte ottonicty are
tinnitus and Dlateral sensorineural hearing loss partic
er frequencies, Site of Lion testing
olvement, but light and electeon
microscopy have falled to how any morphologie chang
Sin the hal cls. Possibly they interfere at enzymatic
level, Hearing los due o salles i reverse after the
rugs discontinued. SNHL ha also Deen noted with oth:
eC NSAIDS, eg, naproxen, piroxam and Ketorolac but is
teenie
4. Quinta. Ototosi symptoms due to quinine ae tin
‘its and sensorineural hearing Tos, both of which are
revele. Higher doses may cause permanent los The
Symptoms generally appear with prolonged medication
‘but may occur with smaller doses in those who are sus.
‘ceptible. Congenital deatness and hypoplasia of coche
ave been reported in children whose matters received
"is drug during the st trimener of pregnancy, rate
fet ol quinine av due to vasoconstricio sn the small
Yes of tn cochlea and sta vasca.
5. CHLOROGUINE AND HYDROXYCHLOROQUINE: Elec
ls similar to that of quinine and cause reversble SNHL
Sometimes permanent dates cn HU,
6. Cyroroxie Davos, Nitrogen mustard, ciplain and
boat can cause cochlear damage. They affect the
Suter har cells the cochlea.
7. DEFEROXAMAINE (DISTERRIOXAMIND. I Is an iron
<helating substance used in Ihe treatment ofthalssacmic
patient who reese repeated blood transfusions and in
{urn have high iron load, Like platin and aminogly-
‘cones, deferoxamine also causes high-frequency seño
Final hearing los, Onse of hearing los is sudden or
‘elyed. I is permanent but in some eases it can De ree
‘ele when the drug s discontinued. I cause toxicity
Lo news: children are affected more.
8. Miscruunstous. folate ase of deafness have been
‘eported with erthromycn, ampclin and chloram-
phenicol, indomethacin, phenylbutazone, Ibuprofen,
tan antitoxin, propranolol and propythioura
Alcohol, tobacco and marijuana aso cause damage to
einer ea
9. Tomcat Ean Dors. Topical use of drugs inthe mi
ie car an also cause damage 10 the cochlea by absorp.
on through oval and round windows. Detiness has
occurred with the use of ehlorhexldine which was used
inthe preparation of ear canal before surgery or use of
«ar drops containing aminoglycoside antibiotics, eg. ne-
man, famycetin and gentamicin. Ottone potential
‘Sats present in car drops containing plymyxinB,pro-
pylene glycol and antifungal agent. Use only approved
‘lotoptal drops for middle eat fection,
D. NOISE TRAUMA
Hearing oss associated with exposure to noise has been
wenoo in boiler makes, on. and coppersiths,
and anllery men. Lately, nose tauma has assumed
rete significance because ofits being an occupational
Bazar the compensations asked for andthe esponsibil-
thrust upon the employer and the employee 10 con
serve hearing Hearing Tos caused by excessive nose can
be vided into two groups:
1. ACOUSTIC TRAUMA. Permanent damage to hear
ing can De caused by single bi exposure to very in.
tense sound without this Deng preceded bya temporary
{heshold shift Also called Impulse nos, such nase can
arise from an explosion, gun fre ora powerful cracker
And may reach or cross 140 dB, Nose level of gun or
file may reach 140-170 dB SPL (sound pressure level,
Sich bret and loud noses mechanically damage organ.
Of Cont, tea Ressner's membran
¿lowing mixing of peniymph and endolymph. À severe
blas, in addition, may concomitantly damage the ym
nic membrane and disapt osils futher adding con:
¡active los Impulse noise may be as rit ä 02 ms. No
pulse noise more tha 140 (As permitted
2. Nonst-INDUCID HEARING Loss (VIH). Hearing loss,
in tis as, follows croc xp tes tense sous
than seen in acoustic trauma and ts mainly à hazard of
oi occupations.
(@) Temporary sad sift TTS. The caring impair
Immediately after exposure o nose but recovers alter
an interval of fw minutes to a few hours even up
102 weeks. Amount of TTS depends on the noises
intensity, requeney and dation,
mebooksfree.com
CONTINUOUS NOISE OR A NUMBER OF SHORT:
MINISTRY OF LABOUR MODEL RULES UNDER
FACTORES ACT 1948 (CORRECTED UPTO 31:87)
ES ite
ne a
us va
0) Permanent threshold shift (PTS). The heating. impair
menti permanent and does not cover al,
‘The damage caused by noise trauma depends on sev-
enlace:
{D Frequency of oise. A fequency of 2000-3000 Hz
uses more damage than lower or higher frequen
(4 Intensity and tin of rose. A he intensity in
Gases, permisible time for exposure Is reduced.
“ise Y gies the permissibie mis of tine for
various intensity levels or the safety of ea
¡iy Contos ys iterrapted ose. Continuous noise Is
‘more harm
(09 Ssccptlay ofthe individual, Degree of TTS and
PS varies in diferent Individual
(9 Preexisting ear disease,
Anois of 90 dB(A) SPL, 8 à day for $ days per Weck
is the maximum safe limit a recommended by Ministry
of Labour, Govt. of Inda, Model Rules under Factores
At (fae 5.5). No exposure in exces of LISA (A) 5 0
‘be permitted. No Impulse noise of intensity greater than
1408 (A) Is permitted.
‘The Noise Pollution (Regulation and Control) Rules
2000, Ministry of Environment and Forest, Got. of India
iss defined permise limits of oise for various zones
or areas (able 54). According to which silence Zone Us
100 m around the premises of hospital, nursing home,
«educational institutions and cours. Also manufacture,
Sale and use of re crackes generating sound level above
125 dB (AD or 145 dB (©) Prom 4 m distance fom the
Point of busting are not permite (Environment Pro-
{ection Rules 2006) [dB (A = Asweighted pulse sound
pressure level in deuels dB (C) pk = Cwelghted peak
Sound pressure in decibels.
“he audiogram in NL shows à typical notch, at
Kl, both for ie and bone conduction (gano) It
is usually symmetrical on both sides At this sage, pa
tient complains of high-pitched tinnitus and dic in
hearing In noisy suroundings but no dificlty in day-to-
day hearing. Ae the duration of noise exposure increase,
‘the notch deepens and also widens o involve lower and
higher frequencies. Hearing impalrment becomes clin
cally apparent to the patient when the frequencies of
Chapters — Hewingtoss 37
AND CONTROL) RULES 2000, MINISTRY OF
ct
so
Figure 57. ay co of sic tg ln ot pt
Fee
Norn so
Note e ptt rin mor arte n ap Ian.
25:40 eo vo 1030 e cat Ll
‘rape a So
500, 1000 and 2000 He (he speech frequencies are aso
let
NIHL causes damage to hal cl, starting inthe basal
tum of cochlea Outer hat cells ar affected before the
inner hair ells
Nolselnducsd hearing los Is preventable. Persons
who have to work at places where nose is above BS dB
{A should have pre employment and then annual audio.
‘grams fr any detection. ar protectors (ar plugs or car
mul) should be used where oks Level exceed 8S di
(2). They provide protection upto 36 dB ee hie). It
heating impairment has already occured, rehabilitation
18 similar to that employed for other sensorineural hear
ing losses,
3. Noxauprrony ESTECIS oF NOISE Apart from hear
ing los, noise can affect other systems of the body. It
Interes with Fest and ice using coi argue and
mebooksfree.com
MINISTRY OF LABOUR MODEL RULES UNDER
FACTORES ACT 1948 (CORRECTED UPTO 31:87)
ES ite
ne a
us va
0) Permanent threshold shift (PTS). The heating. impair
menti permanent and does not cover al,
‘The damage caused by noise trauma depends on sev-
enlace:
{D Frequency of oise. A fequency of 2000-3000 Hz
uses more damage than lower or higher frequen
(4 Intensity and tin of rose. A he intensity in
Gases, permisible time for exposure Is reduced.
“ise Y gies the permissibie mis of tine for
various intensity levels or the safety of ea
¡iy Contos ys iterrapted ose. Continuous noise Is
‘more harm
(09 Ssccptlay ofthe individual, Degree of TTS and
PS varies in diferent Individual
(9 Preexisting ear disease,
Anois of 90 dB(A) SPL, 8 à day for $ days per Weck
is the maximum safe limit a recommended by Ministry
of Labour, Govt. of Inda, Model Rules under Factores
At (fae 5.5). No exposure in exces of LISA (A) 5 0
‘be permitted. No Impulse noise of intensity greater than
1408 (A) Is permitted.
‘The Noise Pollution (Regulation and Control) Rules
2000, Ministry of Environment and Forest, Got. of India
iss defined permise limits of oise for various zones
or areas (able 54). According to which silence Zone Us
100 m around the premises of hospital, nursing home,
«educational institutions and cours. Also manufacture,
Sale and use of re crackes generating sound level above
125 dB (AD or 145 dB (©) Prom 4 m distance fom the
Point of busting are not permite (Environment Pro-
{ection Rules 2006) [dB (A = Asweighted pulse sound
pressure level in deuels dB (C) pk = Cwelghted peak
Sound pressure in decibels.
“he audiogram in NL shows à typical notch, at
Kl, both for ie and bone conduction (gano) It
is usually symmetrical on both sides At this sage, pa
tient complains of high-pitched tinnitus and dic in
hearing In noisy suroundings but no dificlty in day-to-
day hearing. Ae the duration of noise exposure increase,
‘the notch deepens and also widens o involve lower and
higher frequencies. Hearing impalrment becomes clin
cally apparent to the patient when the frequencies of
Chapters — Hewingtoss 37
AND CONTROL) RULES 2000, MINISTRY OF
ct
so
Figure 57. ay co of sic tg ln ot pt
Fee
Norn so
Note e ptt rin mor arte n ap Ian.
25:40 eo vo 1030 e cat Ll
‘rape a So
500, 1000 and 2000 He (he speech frequencies are aso
let
NIHL causes damage to hal cl, starting inthe basal
tum of cochlea Outer hat cells ar affected before the
inner hair ells
Nolselnducsd hearing los Is preventable. Persons
who have to work at places where nose is above BS dB
{A should have pre employment and then annual audio.
‘grams fr any detection. ar protectors (ar plugs or car
mul) should be used where oks Level exceed 8S di
(2). They provide protection upto 36 dB ee hie). It
heating impairment has already occured, rehabilitation
18 similar to that employed for other sensorineural hear
ing losses,
3. Noxauprrony ESTECIS oF NOISE Apart from hear
ing los, noise can affect other systems of the body. It
Interes with Fest and ice using coi argue and
mebooksfree.com
38 SECTIONI — Diseases ofr
sts. Through activation ofthe autonomic nervous 595:
em and pititary-adrenal ais, causes annoyance and
Arab Hypertension and peptic ules have also been
tributed 0 also adversely affects task performance
‘where communication through speech is required. Laya
al problems have been noticed In workers who have to.
Speak loudly in persistently nosy suroundings
E. AUTOIMMUNE (IMMUNE-MEDIATED)
INNER EAR DISEASE
Immuncmedbted inner cor disease (Syn. autoimmune
SNHL) causes progressive bilateral sensorineural Marins
Jos. It occurs between 40 and SO years ith equal Inch
sence In both sexs. Nearly 50% of patents a exper:
fence vestibular symptoms ike dscqullbriom, motion
Intolerance, positional or episode vertigo. About 15% of
patients have evidence of other autolmmune disorder sich
ulcerative colts systemic lupus heamaoidartrlisor
multiple sclerosis, MOSCA etal defined the condition a
"lateral NHL = 30 dB at any frequency and evidence
‘of progression in at last one ea on two tal audiograms
that are done at equal 10 or less than 3 months apart
Progression defined 3s threshold shift of = 15 Bat one
ftequeney or 10 dB at two or more consecutive frequen:
eso significant change ln speech discrimination
Investigations
1. Audiogram. To establish above cite, repeated au
iograms can be taken at one month intervals. Audi:
¡am may show los at high and low frequencies,
2, Speech audiogram. Speech discrimination is afecte
‘hough threshold of pare tones remains the same
3. Evoked response audiometry. To exclude acoustic
neuroma or multiple sceross.
Contrastenhanced MR
blood tests to exclude systemic autoimmune dio
des. Total and differential counts, ESR, rheumatoid
factor, antinuclear antibodies, C3 and CA compl
ment levels, Raj cell asay for chelating inmune
complexes.
6, Western bot essay for antiHsp 70 (ant-heat shock
protein 70) antbodie. A this st is
rude protein extract fom
pestes for ions but correlates o bot
se and sterod responsivenes-
Treatment
Prednsolone 1 mg/kg/day up to à toa of 60 mgíday or
dul or À weeks. Sometimes response ls ate. If no rc
Sponse isn in Awecks steroids per off in 12daya.
sponds continue tl a platea 3 reached and then
‘continue on maintenance dose ol 10-20 mg every other
‘iy for about 6 months Side effects and sks of long.
{ecm steroid therapy shouldbe kept in mind,
"Those who cannot take sers can be given metho:
resate 15 m/week for 6-8 weeks and tthe patient 1e.
Spends, continue i for 6 months, I no response I 0.
‘ined for 6-8 weeks tral, dug Is dscontinued.
Alternative to methotrexate is eylophosphamide but
‘Other treatments include intratympanie steroid ine
tion, systemic IgG Injection and pasmapheress
E. SUDDEN HEARING LOSS.
Sudden SNHL Is defined as 30 dB or more of SNHL over
at least three contiguous frequencies occurring within a
period of 3 days or less. Mostly is unlatea, I may be
ecompanicd by Hnnitus or temporary spell of vertigo.
Aetiology
Most often the cause of sudden deafness remains obscure,
in which Case calle the Idiopathic var In such
‘sey, the aetilogeal factors ae considere rl, vas:
‘ilar e the rupture of coclear membranes Spontaneous
perilymph ste may form in the valor ound window.
ther aclogial factors which cause sudden als
and must be excluded are sted below. Remember the
Inemonie In The Very Tar Too No Major Pathology”
1. Infections. Mumps herpes zoster, meningitis, enceph-
it syphilis, os med,
2. Trauma, Head injury, car operations, noise trauma,
harotrauma, spontaneous rupture of cochlar mem.
ban.
3. Vascular. Haemorthage (eukaemia), embolism or
(hrombonis of labyrinthine or cochlear artery or their
‘asospasm, They may be associated with diabetes hy
pertension,polyeythaema, macroglobinaemla or sck-
cil at
4. Tar (olologi). Ménière disease, Cogan’s syndrome,
large vestibular aqueduct
5. Toxic. totoxte drugs, insecticides
6, Neoplastic. Acoustic neuroma, Metastases
Topontin ange, arcinomatous neuropathy.
7. Miscellaneous. Multiple sleros, hypothyroidism,
sarcoidosis
8. Psychogenic.
Management
As far as posible, the aetiology of sudden caring los
Should be discovered by detailed history physical exam
ation and laboratory investigations. The investigation:
‘may include audiometry, vestibular tes, imaging studies
‘of temporal bones, sedimentation rate, tests fr syphilis,
‘betes, hypotyroism, blood disorders and ip po:
ls. Some cases may regule exploratory tympanotomny
‘where perilmph fistulas strongly suspected. Where the
‘se sll remains obscure, treatment S empiial and
Consist of
1. Med rest.
2 Steroid therapy, Preinsolone 40-60 mg in a single
morning dose for 1 week and then tailed Hi a prio
83 weeks, Steroids ae anfnflammatory and flee
‘edema. They have been found usell In Aopathic
Sten hearing los of moderate degree.
3. Inhalation ofearbogen (CO, #95960.) lt incras-
‘scochksar blood foe and improves oxygenation.
4. Vasodilator drugs
$ Low molecular weight destran. I decreases blood
viscosiy ls contraindicated in cardiac fallure and
Dowding disorder
6. Hyperbaric oxygen therapy. Avallble only in select
‘Centres, hyperbaric oxygen raises concentration of
‘oxygen in labyrinthine Huis and improves cochicar
function Gee p 408,
cer
mebooksfree.com
sts. Through activation ofthe autonomic nervous 595:
em and pititary-adrenal ais, causes annoyance and
Arab Hypertension and peptic ules have also been
tributed 0 also adversely affects task performance
‘where communication through speech is required. Laya
al problems have been noticed In workers who have to.
Speak loudly in persistently nosy suroundings
E. AUTOIMMUNE (IMMUNE-MEDIATED)
INNER EAR DISEASE
Immuncmedbted inner cor disease (Syn. autoimmune
SNHL) causes progressive bilateral sensorineural Marins
Jos. It occurs between 40 and SO years ith equal Inch
sence In both sexs. Nearly 50% of patents a exper:
fence vestibular symptoms ike dscqullbriom, motion
Intolerance, positional or episode vertigo. About 15% of
patients have evidence of other autolmmune disorder sich
ulcerative colts systemic lupus heamaoidartrlisor
multiple sclerosis, MOSCA etal defined the condition a
"lateral NHL = 30 dB at any frequency and evidence
‘of progression in at last one ea on two tal audiograms
that are done at equal 10 or less than 3 months apart
Progression defined 3s threshold shift of = 15 Bat one
ftequeney or 10 dB at two or more consecutive frequen:
eso significant change ln speech discrimination
Investigations
1. Audiogram. To establish above cite, repeated au
iograms can be taken at one month intervals. Audi:
¡am may show los at high and low frequencies,
2, Speech audiogram. Speech discrimination is afecte
‘hough threshold of pare tones remains the same
3. Evoked response audiometry. To exclude acoustic
neuroma or multiple sceross.
Contrastenhanced MR
blood tests to exclude systemic autoimmune dio
des. Total and differential counts, ESR, rheumatoid
factor, antinuclear antibodies, C3 and CA compl
ment levels, Raj cell asay for chelating inmune
complexes.
6, Western bot essay for antiHsp 70 (ant-heat shock
protein 70) antbodie. A this st is
rude protein extract fom
pestes for ions but correlates o bot
se and sterod responsivenes-
Treatment
Prednsolone 1 mg/kg/day up to à toa of 60 mgíday or
dul or À weeks. Sometimes response ls ate. If no rc
Sponse isn in Awecks steroids per off in 12daya.
sponds continue tl a platea 3 reached and then
‘continue on maintenance dose ol 10-20 mg every other
‘iy for about 6 months Side effects and sks of long.
{ecm steroid therapy shouldbe kept in mind,
"Those who cannot take sers can be given metho:
resate 15 m/week for 6-8 weeks and tthe patient 1e.
Spends, continue i for 6 months, I no response I 0.
‘ined for 6-8 weeks tral, dug Is dscontinued.
Alternative to methotrexate is eylophosphamide but
‘Other treatments include intratympanie steroid ine
tion, systemic IgG Injection and pasmapheress
E. SUDDEN HEARING LOSS.
Sudden SNHL Is defined as 30 dB or more of SNHL over
at least three contiguous frequencies occurring within a
period of 3 days or less. Mostly is unlatea, I may be
ecompanicd by Hnnitus or temporary spell of vertigo.
Aetiology
Most often the cause of sudden deafness remains obscure,
in which Case calle the Idiopathic var In such
‘sey, the aetilogeal factors ae considere rl, vas:
‘ilar e the rupture of coclear membranes Spontaneous
perilymph ste may form in the valor ound window.
ther aclogial factors which cause sudden als
and must be excluded are sted below. Remember the
Inemonie In The Very Tar Too No Major Pathology”
1. Infections. Mumps herpes zoster, meningitis, enceph-
it syphilis, os med,
2. Trauma, Head injury, car operations, noise trauma,
harotrauma, spontaneous rupture of cochlar mem.
ban.
3. Vascular. Haemorthage (eukaemia), embolism or
(hrombonis of labyrinthine or cochlear artery or their
‘asospasm, They may be associated with diabetes hy
pertension,polyeythaema, macroglobinaemla or sck-
cil at
4. Tar (olologi). Ménière disease, Cogan’s syndrome,
large vestibular aqueduct
5. Toxic. totoxte drugs, insecticides
6, Neoplastic. Acoustic neuroma, Metastases
Topontin ange, arcinomatous neuropathy.
7. Miscellaneous. Multiple sleros, hypothyroidism,
sarcoidosis
8. Psychogenic.
Management
As far as posible, the aetiology of sudden caring los
Should be discovered by detailed history physical exam
ation and laboratory investigations. The investigation:
‘may include audiometry, vestibular tes, imaging studies
‘of temporal bones, sedimentation rate, tests fr syphilis,
‘betes, hypotyroism, blood disorders and ip po:
ls. Some cases may regule exploratory tympanotomny
‘where perilmph fistulas strongly suspected. Where the
‘se sll remains obscure, treatment S empiial and
Consist of
1. Med rest.
2 Steroid therapy, Preinsolone 40-60 mg in a single
morning dose for 1 week and then tailed Hi a prio
83 weeks, Steroids ae anfnflammatory and flee
‘edema. They have been found usell In Aopathic
Sten hearing los of moderate degree.
3. Inhalation ofearbogen (CO, #95960.) lt incras-
‘scochksar blood foe and improves oxygenation.
4. Vasodilator drugs
$ Low molecular weight destran. I decreases blood
viscosiy ls contraindicated in cardiac fallure and
Dowding disorder
6. Hyperbaric oxygen therapy. Avallble only in select
‘Centres, hyperbaric oxygen raises concentration of
‘oxygen in labyrinthine Huis and improves cochicar
function Gee p 408,
cer
mebooksfree.com
‘Cod prognosis od prog
{and mec tequeny Hg equals
‘on
Re sang 2 ms ee do satin
obit of ego sry vertigo
‘unger pate (tte patents
Element petted
7. Lovesalt dit and a diuretic. Ii empirical and has
same benefit as in cases of Ménière disease
8. Intratympanie steroids. therapy. It ass, the lo.
«al concentration af sterods in cochlea Mids, thus
voiding side effects of systeme therapy.
‘Treatment
Many treatment protocols have been suggested fr a
‘pathic sensorineural sudden hearing los but none has
own signicant beneht over the beneht oF spontane“
‘us recovery which occurs in 50,60% cases within fst
Zeeks: None ofthe drugs, dextran 4, vaselator, car
bogen inhalation (5% CO; with 95% Oz), datrizcne me.
slumine, have shown significant bene.
‘Generally prescribed meticines include:
1. Steroids.
2: Inhalation of carbogen.
3. Low dit and a diuretic
4. Hyperbaric oxygen,
Prognosis
Fortunately, about half the patients of opathic sensor
neural eating los recover spontaneously within 15 day.
‘Chances of ecovery ae poor after | month. Severe hea
ing los and that associate wth vertigo have poor prog.
nosis, Younger patients below 40 and those seth moar:
st loses have better prognosis (se ab.)
G. PRESBYCUSIS
Sensorinewal hearing loss associated with physiological
ging proces in the cars called pesbyeuss, I usually
manifests at the age of 6S yeas Dut may do so early If
theres Herr preposition, chronic noise exposure
or generale vascular disease
Four pathologial types of presbycusis have been iden:
tine.
1. Sexson. This characterized by degeneration of the
‘organ of Cort, starting tthe basal col and progressing
gradual tothe ape. Higher requis ae acted ut
Speech discrimination remains good.
2. Neumat. This is characterized by degeneration ofthe
‘lls of spiral ganglion, starting atthe basal co and pro-
rss to the apex. Neuron of higher audtory pat
trays may also be afecte This manifests with high tone
Tews but speech discrimination fs poor and out of propor
tion tothe pe tone loss
Chapters — Hewingtoss 39
3, SERIAL OR Merasoe, This is characterized by aro-
‘iy’ of stra vascular nal ums of coclea in this, the
Physical and chemical processes of energy production are
fected. runs in fam. Audiogram fs Hat but speech
‘crimination is good.
4. Coca COXPUCTIVE. This is due 0 sttlening of
the basilar membrane thus afecting its movements. Au-
‘logram ls sloping type
Patents of presbyeusis have great ificaly in hearing
in the presence of background noise though they may
Fear well in quier surroundings. They may complain of
speech being heard but not understood Reratment phe
‘nomenon postive anal the sounds suddenly become
Intolerable when volume is raised. Tinnitus & another
[bothersome problem and in some isthe only complaint
atea of presbycusis can be helped by a heating
‘They should also have lessons in speech reading though
visual cues, Curtailment of smoking and stimulants ke
{ea and coffee may help to decrease ini
NONORGANIC HEARING LOSS (NOHL)
In this type of hearing los, there ls no organ sion.
Tess either due to malingeing or is psychogenc. In the
former, usually her Isa motive o claim some compen:
sation for being exposed to Industria nos, head Inury
fr ototoxic mediation. Patent may present with any oF
the thre clinical stations:
(0 Total hearing os in both ears, (total os in only
one car ori) exaggerated 105 in one or both cas. The
‘esponsbiity ofthe physician sto nd out the patient
‘malingering? Iso, what his actual theeshokd of ear
Ang? This Is accomplished by
1. Mon INDEX oF Suspicon. Suspicion further miss
‚Shen the patent makes exaggerated dor to hau, Ic
{quently making requests to epcat the question or placing
Suppl hand to the ar
Srezcu Aubiomero Tests, Normal; the results o e
peat estare within 25. A variation greater tha Sd
diagnostic of NOHL
3. ABSENCE OF SHADOW CURVE Normally, shadow
eve can be obtained while testing bone conduction if
the healthy car snot masked. Tiss due to wanscranial
transmission of sound tothe healthy car Absence o his
‘curve in a patient complaining of unilateral deans Is
“lagnostc of NOHL.
4. INCONSISTENOY IN PTA AND SIRT. Normally, pure
ne average (TA) of thee speech fequencie 500, 1000
nd 2000 Hei within 10 dB of spoch reception ees
‘ld (SK) An SRT better than PEA by more than 10 dB
points to NOHIL.
5. SreNcen Test. can be done with ptr of identical
{ning forks or adoublechannelaudlometer. Principe in
‘volves that fa tone of two Intensiies, one greater than
{the othe, diver to two cas smutancously, ony the
(ar whlch receives tone f grater intensity will har. To
mebooksfree.com
{and mec tequeny Hg equals
‘on
Re sang 2 ms ee do satin
obit of ego sry vertigo
‘unger pate (tte patents
Element petted
7. Lovesalt dit and a diuretic. Ii empirical and has
same benefit as in cases of Ménière disease
8. Intratympanie steroids. therapy. It ass, the lo.
«al concentration af sterods in cochlea Mids, thus
voiding side effects of systeme therapy.
‘Treatment
Many treatment protocols have been suggested fr a
‘pathic sensorineural sudden hearing los but none has
own signicant beneht over the beneht oF spontane“
‘us recovery which occurs in 50,60% cases within fst
Zeeks: None ofthe drugs, dextran 4, vaselator, car
bogen inhalation (5% CO; with 95% Oz), datrizcne me.
slumine, have shown significant bene.
‘Generally prescribed meticines include:
1. Steroids.
2: Inhalation of carbogen.
3. Low dit and a diuretic
4. Hyperbaric oxygen,
Prognosis
Fortunately, about half the patients of opathic sensor
neural eating los recover spontaneously within 15 day.
‘Chances of ecovery ae poor after | month. Severe hea
ing los and that associate wth vertigo have poor prog.
nosis, Younger patients below 40 and those seth moar:
st loses have better prognosis (se ab.)
G. PRESBYCUSIS
Sensorinewal hearing loss associated with physiological
ging proces in the cars called pesbyeuss, I usually
manifests at the age of 6S yeas Dut may do so early If
theres Herr preposition, chronic noise exposure
or generale vascular disease
Four pathologial types of presbycusis have been iden:
tine.
1. Sexson. This characterized by degeneration of the
‘organ of Cort, starting tthe basal col and progressing
gradual tothe ape. Higher requis ae acted ut
Speech discrimination remains good.
2. Neumat. This is characterized by degeneration ofthe
‘lls of spiral ganglion, starting atthe basal co and pro-
rss to the apex. Neuron of higher audtory pat
trays may also be afecte This manifests with high tone
Tews but speech discrimination fs poor and out of propor
tion tothe pe tone loss
Chapters — Hewingtoss 39
3, SERIAL OR Merasoe, This is characterized by aro-
‘iy’ of stra vascular nal ums of coclea in this, the
Physical and chemical processes of energy production are
fected. runs in fam. Audiogram fs Hat but speech
‘crimination is good.
4. Coca COXPUCTIVE. This is due 0 sttlening of
the basilar membrane thus afecting its movements. Au-
‘logram ls sloping type
Patents of presbyeusis have great ificaly in hearing
in the presence of background noise though they may
Fear well in quier surroundings. They may complain of
speech being heard but not understood Reratment phe
‘nomenon postive anal the sounds suddenly become
Intolerable when volume is raised. Tinnitus & another
[bothersome problem and in some isthe only complaint
atea of presbycusis can be helped by a heating
‘They should also have lessons in speech reading though
visual cues, Curtailment of smoking and stimulants ke
{ea and coffee may help to decrease ini
NONORGANIC HEARING LOSS (NOHL)
In this type of hearing los, there ls no organ sion.
Tess either due to malingeing or is psychogenc. In the
former, usually her Isa motive o claim some compen:
sation for being exposed to Industria nos, head Inury
fr ototoxic mediation. Patent may present with any oF
the thre clinical stations:
(0 Total hearing os in both ears, (total os in only
one car ori) exaggerated 105 in one or both cas. The
‘esponsbiity ofthe physician sto nd out the patient
‘malingering? Iso, what his actual theeshokd of ear
Ang? This Is accomplished by
1. Mon INDEX oF Suspicon. Suspicion further miss
‚Shen the patent makes exaggerated dor to hau, Ic
{quently making requests to epcat the question or placing
Suppl hand to the ar
Srezcu Aubiomero Tests, Normal; the results o e
peat estare within 25. A variation greater tha Sd
diagnostic of NOHL
3. ABSENCE OF SHADOW CURVE Normally, shadow
eve can be obtained while testing bone conduction if
the healthy car snot masked. Tiss due to wanscranial
transmission of sound tothe healthy car Absence o his
‘curve in a patient complaining of unilateral deans Is
“lagnostc of NOHL.
4. INCONSISTENOY IN PTA AND SIRT. Normally, pure
ne average (TA) of thee speech fequencie 500, 1000
nd 2000 Hei within 10 dB of spoch reception ees
‘ld (SK) An SRT better than PEA by more than 10 dB
points to NOHIL.
5. SreNcen Test. can be done with ptr of identical
{ning forks or adoublechannelaudlometer. Principe in
‘volves that fa tone of two Intensiies, one greater than
{the othe, diver to two cas smutancously, ony the
(ar whlch receives tone f grater intensity will har. To
mebooksfree.com
40 SECTION! — Dicas of far
¿do set take two tuning forks of qual queno, ste
and keep them say 25 cm rom each car Patient wl aim
do hear it in the normal car. Now bring the tuning fork
fn the sid of Feige dunes to within 8 em, Jaxping
the tuning fork on the normal side atthe same distance
‘The paient will deny hearing anything even though tun:
{ng ork on normal sels where coul be hard ete À
Denon with true defies shoul continue 1 ea onthe
‘oral id. Patient sould e Pdf ring ste
“his same test can be performed wih à two-channel
audiometer using pure tone or speech signals.
6. Acoustic Rex TunesHoLD. Normally, stapediat
files ls elisted at 70-100 dB SL patient claims total
‘eames but the reflex can e cite, ndicaes NOHIL
7. Eiserne Response AUDIOMETRY (ERA). I is very
{ful in NOHL and can establish hearing aculty of the
Person to within 5-10 dB of actual rss
SOCIAL AND LEGAL ASPECTS
(OF HEARING LOSS,
HEARING LOSS AND DEAFNESS
Hearn os mpaemen of hearing and its seventy may
‘ary fom mild to severe or profound, while the term
ss und, when there UE or no Beating a al
in some counties, this ig differentiation snot made
‘hey use the tem deafness to denote any degre of hea.
Ing loss respective oft seventy In 1980, WHO recom
Mendes thatthe tem “eat” should be applied ony to
that they ate unable to benefit rom any type of ampli
ation. similar definition is sein Ina wile extend
ts 10 the hearing hanes
DEFINITION OF DEAF
(Ministry of Social Welfare, Government of India
Scheme of Assistance to Hearing Handicap.
"the deat are those in whom the sense of hearing ls
‘nonfunctional for ordinary purposes of ie." They do not
"heartunderstand sounds a al even with amplified speech,
‘Te cases included in the category wil be those having
"ring os more than 90 dB in the beter ar (profound
impatient or total los of heating in both as
‘The partially hearing are define as those fling un
der amy one ofthe following categories
Category
ik impatrment
‘Hearing acuity
More than 30 but not more han
db in beter car
More than 45 but not more than
din better cr
More than 60 but not more than
SUB In beter ar
Serious impalement
Severe impairment
DEGREE OF HEARING LOSS.
(WHO CLASSIFICATION)
"WHO (1980) recommended the following cissifaión
‘on the basis of pute tone audiogram taking the average
9 Mimi (16-250) soe 26-0 20)
a $5 en pr
Er
I Save (1-91 68) Proud ie 91
Pre 58, anton rio Nowy pren
ofthe thresholds of hearing for frequencies of 500, 1000
and 2000 Hz with reference to SO: 389-1970 {interna
tonal Calibration of Audometets)
Degree of hearing loss (Figure 5.8)
1 Mu 26-40 db
2 Moderate essa
3 Mouertey severe 56704
À Snes 3-91 db
5 Profound More than 91.48
6 Tout
From thisit is imple that her sno apparent Impale-
ment of hearing fom 1025 A.
“The isbiliy 10 understand speech with different de-
res of hearing los le given in 1201599.
IMPAIRMENT, DISABILITY AND HANDICAP
When a disease process strikes an organ or a system it
‘Causes an impuinent either in structure or funcion, but
Als palet may or may nt become cally man
festa. When impairment affects the ability to perform
he range considered normal or that
individual ts cala disability. The dsabity fuer te
str the duties and roles expected roman Individual By
Society and called a handicap
“To exempt, injury (sas) 0 the ear may result in
heating impairment which, depending on lts sever,
vil affect the individuals ability to her and perform
Certain activites (Habit and wil be termed handicap
by the society
Disease Impairment» Disability > Handicap
mebooksfree.com
¿do set take two tuning forks of qual queno, ste
and keep them say 25 cm rom each car Patient wl aim
do hear it in the normal car. Now bring the tuning fork
fn the sid of Feige dunes to within 8 em, Jaxping
the tuning fork on the normal side atthe same distance
‘The paient will deny hearing anything even though tun:
{ng ork on normal sels where coul be hard ete À
Denon with true defies shoul continue 1 ea onthe
‘oral id. Patient sould e Pdf ring ste
“his same test can be performed wih à two-channel
audiometer using pure tone or speech signals.
6. Acoustic Rex TunesHoLD. Normally, stapediat
files ls elisted at 70-100 dB SL patient claims total
‘eames but the reflex can e cite, ndicaes NOHIL
7. Eiserne Response AUDIOMETRY (ERA). I is very
{ful in NOHL and can establish hearing aculty of the
Person to within 5-10 dB of actual rss
SOCIAL AND LEGAL ASPECTS
(OF HEARING LOSS,
HEARING LOSS AND DEAFNESS
Hearn os mpaemen of hearing and its seventy may
‘ary fom mild to severe or profound, while the term
ss und, when there UE or no Beating a al
in some counties, this ig differentiation snot made
‘hey use the tem deafness to denote any degre of hea.
Ing loss respective oft seventy In 1980, WHO recom
Mendes thatthe tem “eat” should be applied ony to
that they ate unable to benefit rom any type of ampli
ation. similar definition is sein Ina wile extend
ts 10 the hearing hanes
DEFINITION OF DEAF
(Ministry of Social Welfare, Government of India
Scheme of Assistance to Hearing Handicap.
"the deat are those in whom the sense of hearing ls
‘nonfunctional for ordinary purposes of ie." They do not
"heartunderstand sounds a al even with amplified speech,
‘Te cases included in the category wil be those having
"ring os more than 90 dB in the beter ar (profound
impatient or total los of heating in both as
‘The partially hearing are define as those fling un
der amy one ofthe following categories
Category
ik impatrment
‘Hearing acuity
More than 30 but not more han
db in beter car
More than 45 but not more than
din better cr
More than 60 but not more than
SUB In beter ar
Serious impalement
Severe impairment
DEGREE OF HEARING LOSS.
(WHO CLASSIFICATION)
"WHO (1980) recommended the following cissifaión
‘on the basis of pute tone audiogram taking the average
9 Mimi (16-250) soe 26-0 20)
a $5 en pr
Er
I Save (1-91 68) Proud ie 91
Pre 58, anton rio Nowy pren
ofthe thresholds of hearing for frequencies of 500, 1000
and 2000 Hz with reference to SO: 389-1970 {interna
tonal Calibration of Audometets)
Degree of hearing loss (Figure 5.8)
1 Mu 26-40 db
2 Moderate essa
3 Mouertey severe 56704
À Snes 3-91 db
5 Profound More than 91.48
6 Tout
From thisit is imple that her sno apparent Impale-
ment of hearing fom 1025 A.
“The isbiliy 10 understand speech with different de-
res of hearing los le given in 1201599.
IMPAIRMENT, DISABILITY AND HANDICAP
When a disease process strikes an organ or a system it
‘Causes an impuinent either in structure or funcion, but
Als palet may or may nt become cally man
festa. When impairment affects the ability to perform
he range considered normal or that
individual ts cala disability. The dsabity fuer te
str the duties and roles expected roman Individual By
Society and called a handicap
“To exempt, injury (sas) 0 the ear may result in
heating impairment which, depending on lts sever,
vil affect the individuals ability to her and perform
Certain activites (Habit and wil be termed handicap
by the society
Disease Impairment» Disability > Handicap
mebooksfree.com
Chapters — Hewing toss 41
Hearing Weald in eter ear Degree at impairment
(Senge oS toon) 0 sation) pay to understand speech
035 Net scan No rica ty wit it psec
Seto ds Dirty it pec
ass Nee Frege thet remote
pe drt eee Frege cay even ode
Br po den 0 sated e amp speech
don Proteins ‘tay cont underand rn ame pee
DEGREE OF HANDICAP In the above caution only three speech frequencles
Sometimes it is desired 10 express the impairment and
handicap in tems of percentage for the purposes of
‘compensation, Different counties and profesional bod:
les have adopted their own system to calelate tis per
centage
‘One ofthe methods to find hearing handicap Is given
elon
(D Tse an audiogram and calculate the average of
thresholds of hearing or requencis of 800, 1000
and 2000 Hz a
(4) Deswc fom i 25 A (a there Is no imparment
upto 25 dB), Le. A= 25,
à Multiply iby 1.8, bes (A = 25) 18,
‘This I he percentage of heating impairment for that
a. Similarly cakulate the percentage of hearing impair.
ment forthe other es.
“otal percentage handicap of an individual
Meter er XS) wong
0
Example
500 He 1000 Hz 2000112 Average
fer @ | Te
leer OSA
Impäement Right car 75 ~ 25 = 0; 50 1. 75%
Impalement Lett ear 43 — 25 20,20% 1.8 30%
2
Goxse7s
‘Toutnantcap = HE
asso
¿500,100 nd 2000 He) ae ten nto acon Det ts
{et at gene of 3000 Hes important for heating
in the presence of noise and should so be taken Into
count American Academy of Opthalmology and Oo.
Jarymgolgy recommends and takes into acount the av
«rage o our eguencies 500, 1000 2000 and 3000 Te
‘sen eatelaing the handicap
‘Goverment of India reserved certain percentage of
vacances in Group Cand D in favour o he philly
Handicapped and has extended certain other benef
ith ato recommended the casifeation based on
percentage of impalment and the tex require to be
performed (e Tube = 10), (Brochure on Reservations
Sind Concessions for Physically Handicapped in Cental
Govt. Series published by Ministry of Personnel, Pub.
Tie Grevances and Pensions, Dept of Personnel and
Training)
UNILATERAL HEARING LOSS
Unilateral los of hearing, even though total, does n
produce a serious handicap or affect speech but it in-
pals localization of the sound source, difeulty in dis
rmination of speech in the presence of background
oise and some difhculty at a meeting or in classroom
‘when the speaker ion the side of afected ar. Should
Also ae the individual that he does not have “spare
Or reserve ear” and has to take all precautions for the
Safety of the only hearing ar also the surgeon should
bear when hei called upon to operate on this only
hearing car. Bone-anchored heating aks are the eat.
ment of choice for management of single-sided deafness
Gen 137)
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Hearing Weald in eter ear Degree at impairment
(Senge oS toon) 0 sation) pay to understand speech
035 Net scan No rica ty wit it psec
Seto ds Dirty it pec
ass Nee Frege thet remote
pe drt eee Frege cay even ode
Br po den 0 sated e amp speech
don Proteins ‘tay cont underand rn ame pee
DEGREE OF HANDICAP In the above caution only three speech frequencles
Sometimes it is desired 10 express the impairment and
handicap in tems of percentage for the purposes of
‘compensation, Different counties and profesional bod:
les have adopted their own system to calelate tis per
centage
‘One ofthe methods to find hearing handicap Is given
elon
(D Tse an audiogram and calculate the average of
thresholds of hearing or requencis of 800, 1000
and 2000 Hz a
(4) Deswc fom i 25 A (a there Is no imparment
upto 25 dB), Le. A= 25,
à Multiply iby 1.8, bes (A = 25) 18,
‘This I he percentage of heating impairment for that
a. Similarly cakulate the percentage of hearing impair.
ment forthe other es.
“otal percentage handicap of an individual
Meter er XS) wong
0
Example
500 He 1000 Hz 2000112 Average
fer @ | Te
leer OSA
Impäement Right car 75 ~ 25 = 0; 50 1. 75%
Impalement Lett ear 43 — 25 20,20% 1.8 30%
2
Goxse7s
‘Toutnantcap = HE
asso
¿500,100 nd 2000 He) ae ten nto acon Det ts
{et at gene of 3000 Hes important for heating
in the presence of noise and should so be taken Into
count American Academy of Opthalmology and Oo.
Jarymgolgy recommends and takes into acount the av
«rage o our eguencies 500, 1000 2000 and 3000 Te
‘sen eatelaing the handicap
‘Goverment of India reserved certain percentage of
vacances in Group Cand D in favour o he philly
Handicapped and has extended certain other benef
ith ato recommended the casifeation based on
percentage of impalment and the tex require to be
performed (e Tube = 10), (Brochure on Reservations
Sind Concessions for Physically Handicapped in Cental
Govt. Series published by Ministry of Personnel, Pub.
Tie Grevances and Pensions, Dept of Personnel and
Training)
UNILATERAL HEARING LOSS
Unilateral los of hearing, even though total, does n
produce a serious handicap or affect speech but it in-
pals localization of the sound source, difeulty in dis
rmination of speech in the presence of background
oise and some difhculty at a meeting or in classroom
‘when the speaker ion the side of afected ar. Should
Also ae the individual that he does not have “spare
Or reserve ear” and has to take all precautions for the
Safety of the only hearing ar also the surgeon should
bear when hei called upon to operate on this only
hearing car. Bone-anchored heating aks are the eat.
ment of choice for management of single-sided deafness
Gen 137)
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42 SECTION! Dies of for
Percentage of
Sm Category Typeotimpaiment ave andior Speech dsciminaton pme
1 1 Mishengimpimen 20 RDA Boum Lan
2 u Modertehnsingimpsiment 41-55 Binbetereer Semen 40-50%
i A Seve sing imputar SE OB Main E24 pet
palm beter o
“ ” © Toul dees pores No cinco 100%
0 ones Malo éoenteus er oon,
{© Poo eng n'es sta do bete 75-10%
parent, 2
een mg cf gt, 20 y conc en rinnen ern
er Kun note at
“a When Ice nya land hung preset in neo wo ques in beter aX he core a ales of
ring
0) nee hero spore ay dh 3 een 50, 1002000 Ma, it shove conse as quant 130 6
losa the pues of san a bly and naming a e average Tse on tat mam Ie
msn men the sore 10 and some mais have aon ais fr 20 ei,
11 Recommendations about the categories of abiity Hearing impaiment Physical aspect ony Tet recommended).
6) Pa tone om (SO 39-1970 pren, tng sodas timer Sudan in me ote audi Fence te
me edi tng ri be ac Cee) Tre a age 0) 100 nd 2000 He by Ar Condon
(oy witb ede geraten
10) nee pose pue one asoma resus sould be supplemented bye spech dsc sorted sean
lev (SL. soso mation ts cond at 0-10 the patents Nang eh hea rd be eee
hat} bance morse pre ngnge euer ma At esto ae nan nage ne
‘ara rc tral orig, Hence ver e Hurgar et motera nn mola ter nu nn sg
Tes coude made un of wth Eli nowy polen equal rater P be und
Winer cide ae sed aná pure ane iy ot posible fe fd ir ou beep.
suggestion ofthe facies to be offered tothe able fr rehbitation,
“Gage! No spel ents
ego Contre Hing its ae or cncsiona cs on,
tn Mean, re of ot rt concessional ts, J rs —bení of peal Employment change Solis
chat Sige gag formal
Category IV Msg A der lso spel employment exchange peal lisa schoo Be seuss.
ag exempte rm 3agusz rma tose recommended Sige ange)
Stet nator Conan admin under sec ae 17 corded eto he inn ste Teto
D age (a my mr ran y
We have considered the deren types of heating afin, i, conduce vers sensormeual, and age thatthe say wi
"eos y cons rol the pate the ie orto an examination nen re ol y e ar
nena fe pen wi be era nd Cepal ey Dc lol recorren es
en te eg OEM us en y aa
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Percentage of
Sm Category Typeotimpaiment ave andior Speech dsciminaton pme
1 1 Mishengimpimen 20 RDA Boum Lan
2 u Modertehnsingimpsiment 41-55 Binbetereer Semen 40-50%
i A Seve sing imputar SE OB Main E24 pet
palm beter o
“ ” © Toul dees pores No cinco 100%
0 ones Malo éoenteus er oon,
{© Poo eng n'es sta do bete 75-10%
parent, 2
een mg cf gt, 20 y conc en rinnen ern
er Kun note at
“a When Ice nya land hung preset in neo wo ques in beter aX he core a ales of
ring
0) nee hero spore ay dh 3 een 50, 1002000 Ma, it shove conse as quant 130 6
losa the pues of san a bly and naming a e average Tse on tat mam Ie
msn men the sore 10 and some mais have aon ais fr 20 ei,
11 Recommendations about the categories of abiity Hearing impaiment Physical aspect ony Tet recommended).
6) Pa tone om (SO 39-1970 pren, tng sodas timer Sudan in me ote audi Fence te
me edi tng ri be ac Cee) Tre a age 0) 100 nd 2000 He by Ar Condon
(oy witb ede geraten
10) nee pose pue one asoma resus sould be supplemented bye spech dsc sorted sean
lev (SL. soso mation ts cond at 0-10 the patents Nang eh hea rd be eee
hat} bance morse pre ngnge euer ma At esto ae nan nage ne
‘ara rc tral orig, Hence ver e Hurgar et motera nn mola ter nu nn sg
Tes coude made un of wth Eli nowy polen equal rater P be und
Winer cide ae sed aná pure ane iy ot posible fe fd ir ou beep.
suggestion ofthe facies to be offered tothe able fr rehbitation,
“Gage! No spel ents
ego Contre Hing its ae or cncsiona cs on,
tn Mean, re of ot rt concessional ts, J rs —bení of peal Employment change Solis
chat Sige gag formal
Category IV Msg A der lso spel employment exchange peal lisa schoo Be seuss.
ag exempte rm 3agusz rma tose recommended Sige ange)
Stet nator Conan admin under sec ae 17 corded eto he inn ste Teto
D age (a my mr ran y
We have considered the deren types of heating afin, i, conduce vers sensormeual, and age thatthe say wi
"eos y cons rol the pate the ie orto an examination nen re ol y e ar
nena fe pen wi be era nd Cepal ey Dc lol recorren es
en te eg OEM us en y aa
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Chapter 6
Assessment of Vestibular Functions
Assessment of vestibular functions can be divided into
two groups
1. linia tests
2 Laboratory tests
1. CLINICAL TESTS OF VESTIBULAR
FUNCTION
A. SPONTANEOUS NYSTAGMUS
Nystpms ls an Important sen inthe evaluation of
hear sytem, I dine Ss voluntary, shyt
Solar, movement ol ees, moy De han,
‘rt or room Ver aysiagmus as aw aná
{Yast component, and by convention, the ection of
nystagmus indicated by the rein of he fst com
ponent. Imensty of nya indie bys degre
Pico.
To lic nystagmus patient is seated in rot ofthe ex
amineror espe on the bed. The examiner ep is
finger bout 30 om fom he patients cy in the cea
postion and moves tthe gtr let op o down, ut
ot moving at any time mor than 3° frm te ental
Presence of spontane:
‘te ag ay inlets an onan eon
‘bul ntogmun ale pope we ts due
to lesion of aby or Vi pere and cna, sehen
lesions in tect neural pathways esla node,
‘waintem, cerebellum)
Tre Teons of he Haynes lyn
ts cause nystagmus tothe si of leon Pare lesions
{punto tesama to Isbyinth section of
Vit nese) ease niga tothe healthy de Nya
ms af peripheral org can be sopprsa by optic Bs
ton by looking ata fed pin, and enced dins
Soy the we of Fenzl gas (80 opt ase) bo
which abolish opi ato,
sagas of eral origin cannot be suppresed
ty op on. Parey toa! steps Inle le
Son ol the bastos mice and à en
Syringomyelia nat stag ints on
ccoo! gion such as old-chianmatlorna
ton or degenerative leon ofthe cerebellum, Verka ap
that stag seen In sons at the Junco of pos
and madlax pors and dra, Par tp
‘Str congenital or aqu, The ltr i sen in mul
ple san Pendle ysgnus muy ao De sca
{pte fe. vertal in one cye and host nthe oer
BC som diente nystagmus peripheral
and central ia”
B. FISTULA TEST.
basis of this test ls to induce nystagmus by pro:
ducing pressure changes in the external canal which
fare then transmitted to the lbyeinth. Stimulation of
Tabyrinth results In nystagmus and vertigo. Ti
perform by applying intermittent pressure o
us or by using Siegel speculum. Normally, the test Is
egaive because the pressure changes inthe external
Audltory canal cannot be transmite to the layin
its postive when there fs erosion of horizontal sem
‘ecu anal asin cholesteatoma ora surgialy crested
‘window in the horizomal canal (fenestration opera
on), abnormal opening In he oval window (post.
Dedectomy stl) or the round window (rupture of
{ound window membrane). À positive fistula aso im-
ples thatthe Labyrinth s stil functioning As absent
‘when labyrinth dead. ale negative fist ess aso
Seen when cholesteatoma covers the site of fistula and
805 not allow pressure changes tobe transmitted to the
labyrinthe
À fae peste fist test (Le. postive fistula test with
‘out the presence ofa sui) ac in congenital syphilis
Sha in about 259% eases of Minis disease (embers
sign In congenital syphilis, stapes footpate is hyper:
mobile while in Mönieres dicas Is due tothe lous
bands connecting urcula macula tothe stapes footplate
In both these conditions, movement of stapes result in
Simulation ofthe usicular macula
C. ROMBERG TEST
The patient asked to stand with fet together and arms
by the side with eyes Bist open and then closed. Wi
the eyes open, patent can sil compensate the imbal
ance but ith jes closed, vestibular system is at more
advantage. In peripheral vestibular lesions, the po
tient sways to the sie of lesion, In central vestibular
sonder, patent shows stability. IE patent can pee
{orm this test without sway, “sharpened Romberg estr
ls performed. tn this the patient stands with one Reet in
front of toes and rms folded across the chs. ab
to perform the sharpened Romberg test indicates vestir
‘lar Impalemen,
D.GAIT
The patent is ske to walk along straight line toa fixed
point ist with eyes open and then closed. In case of un.
Compensated leon of perpherl vestibular ystem, with
‘yes closed, the patient deviates othe alfected si
“a
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Assessment of Vestibular Functions
Assessment of vestibular functions can be divided into
two groups
1. linia tests
2 Laboratory tests
1. CLINICAL TESTS OF VESTIBULAR
FUNCTION
A. SPONTANEOUS NYSTAGMUS
Nystpms ls an Important sen inthe evaluation of
hear sytem, I dine Ss voluntary, shyt
Solar, movement ol ees, moy De han,
‘rt or room Ver aysiagmus as aw aná
{Yast component, and by convention, the ection of
nystagmus indicated by the rein of he fst com
ponent. Imensty of nya indie bys degre
Pico.
To lic nystagmus patient is seated in rot ofthe ex
amineror espe on the bed. The examiner ep is
finger bout 30 om fom he patients cy in the cea
postion and moves tthe gtr let op o down, ut
ot moving at any time mor than 3° frm te ental
Presence of spontane:
‘te ag ay inlets an onan eon
‘bul ntogmun ale pope we ts due
to lesion of aby or Vi pere and cna, sehen
lesions in tect neural pathways esla node,
‘waintem, cerebellum)
Tre Teons of he Haynes lyn
ts cause nystagmus tothe si of leon Pare lesions
{punto tesama to Isbyinth section of
Vit nese) ease niga tothe healthy de Nya
ms af peripheral org can be sopprsa by optic Bs
ton by looking ata fed pin, and enced dins
Soy the we of Fenzl gas (80 opt ase) bo
which abolish opi ato,
sagas of eral origin cannot be suppresed
ty op on. Parey toa! steps Inle le
Son ol the bastos mice and à en
Syringomyelia nat stag ints on
ccoo! gion such as old-chianmatlorna
ton or degenerative leon ofthe cerebellum, Verka ap
that stag seen In sons at the Junco of pos
and madlax pors and dra, Par tp
‘Str congenital or aqu, The ltr i sen in mul
ple san Pendle ysgnus muy ao De sca
{pte fe. vertal in one cye and host nthe oer
BC som diente nystagmus peripheral
and central ia”
B. FISTULA TEST.
basis of this test ls to induce nystagmus by pro:
ducing pressure changes in the external canal which
fare then transmitted to the lbyeinth. Stimulation of
Tabyrinth results In nystagmus and vertigo. Ti
perform by applying intermittent pressure o
us or by using Siegel speculum. Normally, the test Is
egaive because the pressure changes inthe external
Audltory canal cannot be transmite to the layin
its postive when there fs erosion of horizontal sem
‘ecu anal asin cholesteatoma ora surgialy crested
‘window in the horizomal canal (fenestration opera
on), abnormal opening In he oval window (post.
Dedectomy stl) or the round window (rupture of
{ound window membrane). À positive fistula aso im-
ples thatthe Labyrinth s stil functioning As absent
‘when labyrinth dead. ale negative fist ess aso
Seen when cholesteatoma covers the site of fistula and
805 not allow pressure changes tobe transmitted to the
labyrinthe
À fae peste fist test (Le. postive fistula test with
‘out the presence ofa sui) ac in congenital syphilis
Sha in about 259% eases of Minis disease (embers
sign In congenital syphilis, stapes footpate is hyper:
mobile while in Mönieres dicas Is due tothe lous
bands connecting urcula macula tothe stapes footplate
In both these conditions, movement of stapes result in
Simulation ofthe usicular macula
C. ROMBERG TEST
The patient asked to stand with fet together and arms
by the side with eyes Bist open and then closed. Wi
the eyes open, patent can sil compensate the imbal
ance but ith jes closed, vestibular system is at more
advantage. In peripheral vestibular lesions, the po
tient sways to the sie of lesion, In central vestibular
sonder, patent shows stability. IE patent can pee
{orm this test without sway, “sharpened Romberg estr
ls performed. tn this the patient stands with one Reet in
front of toes and rms folded across the chs. ab
to perform the sharpened Romberg test indicates vestir
‘lar Impalemen,
D.GAIT
The patent is ske to walk along straight line toa fixed
point ist with eyes open and then closed. In case of un.
Compensated leon of perpherl vestibular ystem, with
‘yes closed, the patient deviates othe alfected si
“a
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44 SECTION! Dies of for
va eg
Tis west ptas and present hen
eat eon
(Eger ante a dere namen
lis pen en per ol est
Se
Ie ronge tan the 2 ge tags
rent ven wen pen ol the
‘Section oft Sow Coon.
2nd date
e
ee gs e sadn to Aksande man moy it
ect saga cnica
‘OF VESTIBULAR SYSTEM. POSITIONAL
MANOEUVRE (VIDE INFRA)
erp Cena
bany 20s Ne eng,
Don dano Nove amg
Brno Did Dream changing
res id
Fasci agb, osas
comparo Sevaeverigo None or sgh
mom
E PAST-POINTING AND FALLING
The pastpoining, fling and the sow component of
nystagmus are alin the same direction. thee Is acute
vestibular Blue, say on he igh ide, nystagmus fo
the ltt but the past pointing and fling wil be towards
the right, Le, toward sie of the slow component
E. DIX-HALLPIKE MANOEUVRE (POSITIONAL TEST)
This tt is particulary wsefl when patient complains of
vertigo in certain head positions. lo helps to teen:
ate peripheral from à ental sion.
Method
Patient sts on a couch, Examiner hold the patient's head,
turns AS to the right and then places the patent in à
us The tes repeated with ead turned 1 eft and then
gal insight head hanging position. Four parameters
{of nystagmus are observed: latency, drain, ection and
Fab (ee Table 02). tn benign paroxysmal pot.
{ional vertigo, nystagmus appears after à latent period of
2-20, laste for les than a minute and is always in one
“direction, towards the eat that is undermost. On rep.
tion ote test, nystagmus may sil be elicited Dut sts
{ora shorter period. On subsequent repetitions i disap,
eats altogether, Le. nystagmus Is faiguable. Patient aso
‘Complains of vertigo when the head sin rial postion,
Figure 6.1, Dale mane
An central lesions (tumours of IV vente, cerebelo
um, temporal lobe, multiple scletoss, venebrobasiar
Insuifiteney or raised intracranial tension) nystagmus is
produced immediately, a soon a the head isin eit
postion without any latency and lat as long as head is
In that ra poston. Direction of nystagmus also vate
dos ferent test positions (direction changing) and is
‘onfatiguable on repetition of test (able 52)
G. TEST OF CEREBELLAR DYSFUNCTION
A caes of giddiness should be tested for cerebellar dsor-
‘ers, Disease of the cerebellar hemisphere causes
1. Asymerga (abnormal finger-nose test)
2 Dyamet aby rl ange of moon)
3. Adladochokinesta(Inablty o perform rapid lternat-
ing movements)
4. Rebound phenomenon (nabilty to control move.
ment of extremity when opposing forceful restraint is
suddenly released)
Mine dicas of cerebellum causes:
1. Wide base gait
2 Falling in any ection
3. Inability to make Sudden turns while walking
À Trunea ataxia
Systagmus observed in midline or hemispheral disorder
fof cerebellum includes gaze evoked nystagmus, rebound
fystagmus and abnormal opiokineti nystagmus
mebooksfree.com
va eg
Tis west ptas and present hen
eat eon
(Eger ante a dere namen
lis pen en per ol est
Se
Ie ronge tan the 2 ge tags
rent ven wen pen ol the
‘Section oft Sow Coon.
2nd date
e
ee gs e sadn to Aksande man moy it
ect saga cnica
‘OF VESTIBULAR SYSTEM. POSITIONAL
MANOEUVRE (VIDE INFRA)
erp Cena
bany 20s Ne eng,
Don dano Nove amg
Brno Did Dream changing
res id
Fasci agb, osas
comparo Sevaeverigo None or sgh
mom
E PAST-POINTING AND FALLING
The pastpoining, fling and the sow component of
nystagmus are alin the same direction. thee Is acute
vestibular Blue, say on he igh ide, nystagmus fo
the ltt but the past pointing and fling wil be towards
the right, Le, toward sie of the slow component
E. DIX-HALLPIKE MANOEUVRE (POSITIONAL TEST)
This tt is particulary wsefl when patient complains of
vertigo in certain head positions. lo helps to teen:
ate peripheral from à ental sion.
Method
Patient sts on a couch, Examiner hold the patient's head,
turns AS to the right and then places the patent in à
us The tes repeated with ead turned 1 eft and then
gal insight head hanging position. Four parameters
{of nystagmus are observed: latency, drain, ection and
Fab (ee Table 02). tn benign paroxysmal pot.
{ional vertigo, nystagmus appears after à latent period of
2-20, laste for les than a minute and is always in one
“direction, towards the eat that is undermost. On rep.
tion ote test, nystagmus may sil be elicited Dut sts
{ora shorter period. On subsequent repetitions i disap,
eats altogether, Le. nystagmus Is faiguable. Patient aso
‘Complains of vertigo when the head sin rial postion,
Figure 6.1, Dale mane
An central lesions (tumours of IV vente, cerebelo
um, temporal lobe, multiple scletoss, venebrobasiar
Insuifiteney or raised intracranial tension) nystagmus is
produced immediately, a soon a the head isin eit
postion without any latency and lat as long as head is
In that ra poston. Direction of nystagmus also vate
dos ferent test positions (direction changing) and is
‘onfatiguable on repetition of test (able 52)
G. TEST OF CEREBELLAR DYSFUNCTION
A caes of giddiness should be tested for cerebellar dsor-
‘ers, Disease of the cerebellar hemisphere causes
1. Asymerga (abnormal finger-nose test)
2 Dyamet aby rl ange of moon)
3. Adladochokinesta(Inablty o perform rapid lternat-
ing movements)
4. Rebound phenomenon (nabilty to control move.
ment of extremity when opposing forceful restraint is
suddenly released)
Mine dicas of cerebellum causes:
1. Wide base gait
2 Falling in any ection
3. Inability to make Sudden turns while walking
À Trunea ataxia
Systagmus observed in midline or hemispheral disorder
fof cerebellum includes gaze evoked nystagmus, rebound
fystagmus and abnormal opiokineti nystagmus
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LABORATORY TESTS OF VESTIBULAR
FUNCTION
A. CALORIC TEST
Tie basis of this est to induce nystagmus by thermal
stimulation of the vestibular system, Advantage of the
{ests that each labyrinth can be ested Separately. Patient
Isalso asked whether vertigo induced by the caloric test 6
‘qualitatively similar to the type experienced by him dur.
Ing the epsode of vertigo. lye, proves labyrinthine
‘origin of vertigo,
1. Moni Kontak Test. Is a quick office proce:
ares Patient is seated with ea ite! 60° Backwards to
place horizontal canal in vertical postion Bars rate
fet ice water for 0 fst with 5 nl and if there no
response, 10,20 and 40 mL. Normal, nystagmus beating
towards he opposite car willbe seen with Sm of ke wa
ter If response sen with increased quantities of water
‘between Sand 40 mi labyrinth s considered hypoactse
No response to AOL of water indicates dead labyrinh.
2. Przomauo-Nauarıe Test (orina, CALORIC
‘Fest. ns ts, patient les supine with head tte 30°
forward so that horizontal canal I vertical (is 02).
as are rat for 40 alternately with water at 30 °C
igure 62. get Hal es (A) ant in spe postion
‘eed eased 3010 mate hot can veri) ston
mala deca ow enh
Chapter — Assessment of Vestibule Functions 45
and at 44 °C (Le. 7° below and above normal body
temperature) and eyes observed for appearance of my.
tagmus til is end point. Time taken trom the start of
tation tothe end point of nystagmus seconded and
Charta on a claim (gute 9.3) U no nystagmus Is
feted from any ca, tests repeated with water at 20°C
{or 3 min before labeling the Labyrith dead. A gap of
S min should be allowed between two eats Cold wate in
ces mstagmns o opposites and warm ater o the
Same side (remember mnemonic COWS: cold opposite,
‘watn-same). Depending on response to the calor test,
swe can find canal pressor dead labyrinth aretional
preponderance, Le. nytagmus à more in one pa
‘ection than inthe other, or both canal paresis and dl
rectonal preponderance
a) CANAL Paws. indicate that response (meas:
red as duration of nystagmus) elite fom a particular
anal (abyrinth, right or ef after stimulation With cold
Sind warm water les than that from the opposite side. It
an also be expressed as percentage ofthe total response
rom both ea
Response from the eta =
Responsefromtherightear=
‘Where hs response from lft sde with waterat 30°C
And Ty is response from et car aftr stimulation with
sat water at 4°C. Less oro response rom a particular
Side Is indicative of depressed funcion of the pslatral
labyrinth, vestibular nerve or vestibular atl an is sce
in Menires disease, acoustic neuroma, postabyinthee:
tomy or vestibular nerve section
(®) DIRECTIONAL PREFONDHIANCE. I takes ito con
sideration the duration of mstagnus o the righ oF kt
Fnrespective of whether ie (6 elicit from the ight or
Tew Laye, We Know that right beating nystagmus
e rs ii
wel x wel (120 00)
me Sn
Pence easel
nn e
m n
8 ‘Normal 5 Len canal pares
RE em
wel 120460)
man Kite
SA
© tenen picaro
Figure 63. gen.
mebooksfree.com
FUNCTION
A. CALORIC TEST
Tie basis of this est to induce nystagmus by thermal
stimulation of the vestibular system, Advantage of the
{ests that each labyrinth can be ested Separately. Patient
Isalso asked whether vertigo induced by the caloric test 6
‘qualitatively similar to the type experienced by him dur.
Ing the epsode of vertigo. lye, proves labyrinthine
‘origin of vertigo,
1. Moni Kontak Test. Is a quick office proce:
ares Patient is seated with ea ite! 60° Backwards to
place horizontal canal in vertical postion Bars rate
fet ice water for 0 fst with 5 nl and if there no
response, 10,20 and 40 mL. Normal, nystagmus beating
towards he opposite car willbe seen with Sm of ke wa
ter If response sen with increased quantities of water
‘between Sand 40 mi labyrinth s considered hypoactse
No response to AOL of water indicates dead labyrinh.
2. Przomauo-Nauarıe Test (orina, CALORIC
‘Fest. ns ts, patient les supine with head tte 30°
forward so that horizontal canal I vertical (is 02).
as are rat for 40 alternately with water at 30 °C
igure 62. get Hal es (A) ant in spe postion
‘eed eased 3010 mate hot can veri) ston
mala deca ow enh
Chapter — Assessment of Vestibule Functions 45
and at 44 °C (Le. 7° below and above normal body
temperature) and eyes observed for appearance of my.
tagmus til is end point. Time taken trom the start of
tation tothe end point of nystagmus seconded and
Charta on a claim (gute 9.3) U no nystagmus Is
feted from any ca, tests repeated with water at 20°C
{or 3 min before labeling the Labyrith dead. A gap of
S min should be allowed between two eats Cold wate in
ces mstagmns o opposites and warm ater o the
Same side (remember mnemonic COWS: cold opposite,
‘watn-same). Depending on response to the calor test,
swe can find canal pressor dead labyrinth aretional
preponderance, Le. nytagmus à more in one pa
‘ection than inthe other, or both canal paresis and dl
rectonal preponderance
a) CANAL Paws. indicate that response (meas:
red as duration of nystagmus) elite fom a particular
anal (abyrinth, right or ef after stimulation With cold
Sind warm water les than that from the opposite side. It
an also be expressed as percentage ofthe total response
rom both ea
Response from the eta =
Responsefromtherightear=
‘Where hs response from lft sde with waterat 30°C
And Ty is response from et car aftr stimulation with
sat water at 4°C. Less oro response rom a particular
Side Is indicative of depressed funcion of the pslatral
labyrinth, vestibular nerve or vestibular atl an is sce
in Menires disease, acoustic neuroma, postabyinthee:
tomy or vestibular nerve section
(®) DIRECTIONAL PREFONDHIANCE. I takes ito con
sideration the duration of mstagnus o the righ oF kt
Fnrespective of whether ie (6 elicit from the ight or
Tew Laye, We Know that right beating nystagmus
e rs ii
wel x wel (120 00)
me Sn
Pence easel
nn e
m n
8 ‘Normal 5 Len canal pares
RE em
wel 120460)
man Kite
SA
© tenen picaro
Figure 63. gen.
mebooksfree.com
46 SECTION! Diese of far
{5 caused by Lay and Ray and left eating nystagmus is
‘assed by Ry and Ly, Thetefore,
Right beating nystagmus = eu x 100
teftbeaing nystagmus» nta
«100
ne nystagmus is 25-30% or more on one side than
the other itis called direclonal preponderance to that
se
tis believed that directional preponderance occus 10
ward the sie fa central sion, away from the sie in à
peripheral sons however, dos not heiptolocaize the
Aion in central vestibular pathway,
Canal pares and directional preponderance can aso
bescen together
‘Canal pars on one side with directonalpreponder
ance tothe oppoute sde is seen in lateral Mère
‘ease while canal preis with diectional preponder-
neto Isle! side is seen in acoustic neurom,
3. Courant Catone Tasr. This tests done when ther
{cooled by pouring cy corde an
theca IS nly a rough qualitative test.
B. ELECTRONYSTAGMOGRAPHY
Its a method of detctng and rcording of n
tic spontaneous or induced y calor, postion,
{otatonal or optokinetie stimulus. The test depends on
{the presence of comeoetinal potentials which are record
‘sly placing electrodes at sullable places round the eyes
‘Te tests also useful 0 detec nystagmus, which I mot
seen with the nak eye. tao permits to Keep pernos
nent econ of nya,
. OPTOKINETIC TEST
Patient is asked to follow a srl of vertical stipes on a
drum moving fist fom right to Tet and then from Tet
lo ght. Normally ir produces nystagmus with slow
component in the direction of moving stripes and fast
“component in the opposte direction. Optokinete abnor
males ae sen in brainstem and cerebral hemisphere
lesions. Thus this te fu to dignos ental ein,
D. ROTATION TEST
Patient i seated inBarany’s revolving che with his hcad
tite! 30° fonward and then rotated 10 turns in 203. The
hal is stopped abruptly and nystagmus observed. Noe
mall theres nystagmus fr 25-40 The st Is useful as
{can be performed in eases ol congenital abnormalities
‘where car anal has alld to develop and not pose
Lo perform the caloric test Disadvantage ofthe ts sha
both the labyrinths are simultaneously stimulated during
the rotation process and cannot be tested individual
The test has now een made more sophisticated y the
te of torsion swings, electonystagmography and com
puter analysts ofthe results
E.GALVANIC TEST
[Ris the only vestibular test which helps in iferentating
an end organ lesion from that of vestibular neve, Patient
Stands with his fet together, eyes closed and ams out
fetched and then a current of 1 mA I passed to one
fa. Normally, person sways towards the ide of anodal
‘Stent Body say ca De studied By à special platform.
E. POSTUROGRAPHY
Isa method 0 evaluate vstibular function by measut
ing postural stabity and based on the fact tat maine.
man of posture depends on tree sensory Inputs vl,
vestibular and somatosensory. uses either à aed or à
‘moving platform, Visual cues can also be are. The cin
«al application! posturogaphy ssl under investigation,
G. VESTIBULAR EVOKED MYOGENIC
POTENTIALS (VEMP)
Thisis test study function of otolthongans—thesae-
cle and unio. Nowmally thee function i ar accel
‘ration, They can also be stimulated by loud sound of air
rhone conduction Even tapping the head can stimulate
them Myogeni potentials can De piched up fom ether
the sternoceldomastld {cervical} muscle or ocular mus-
le inferior oblique or superior rectus) and have respec
{ely been called eVEMP and OUEN
Since sacule is supplied by the inferior division of
nerve and utile by the superior division, study of VEMP
in neuroma can help us 10 nd ts origin rom Ihe supe
foro inferior division
Rees ae
From saccule—infrior vestibular—vestibular nucc
pate vestibular spinal tact—spinal accessory
serve (CN X0}—sternocendomastld
From utde-superor vestibular nerwe—vestbular
ciel medial Tongltudinalfascculss oculomotor
(CNI nerve inferior oblique muscle
Alrconducted sounds primary activate the saccule,
while boneconducted sounds activate both the sacle
Sd the ute
VEMP study isbeing use cliicallyana
‘also available but needs further reser
ing used to find the origin of an acoustic neurons (Hom
superior or inferior vestibular nerve). Ménières disease,
Superior canal dehiscence, vestibular neuritis and local
‘Stions of sions of poste canal fossa, Le om the
"upper of lower brainstem. Vstibulo ocular res s med
Sted through upper brainstem, while vestibulospinal are
Esos the lower brainstem
'VEMP studies ar stil in Investigaive state
mebooksfree.com
{5 caused by Lay and Ray and left eating nystagmus is
‘assed by Ry and Ly, Thetefore,
Right beating nystagmus = eu x 100
teftbeaing nystagmus» nta
«100
ne nystagmus is 25-30% or more on one side than
the other itis called direclonal preponderance to that
se
tis believed that directional preponderance occus 10
ward the sie fa central sion, away from the sie in à
peripheral sons however, dos not heiptolocaize the
Aion in central vestibular pathway,
Canal pares and directional preponderance can aso
bescen together
‘Canal pars on one side with directonalpreponder
ance tothe oppoute sde is seen in lateral Mère
‘ease while canal preis with diectional preponder-
neto Isle! side is seen in acoustic neurom,
3. Courant Catone Tasr. This tests done when ther
{cooled by pouring cy corde an
theca IS nly a rough qualitative test.
B. ELECTRONYSTAGMOGRAPHY
Its a method of detctng and rcording of n
tic spontaneous or induced y calor, postion,
{otatonal or optokinetie stimulus. The test depends on
{the presence of comeoetinal potentials which are record
‘sly placing electrodes at sullable places round the eyes
‘Te tests also useful 0 detec nystagmus, which I mot
seen with the nak eye. tao permits to Keep pernos
nent econ of nya,
. OPTOKINETIC TEST
Patient is asked to follow a srl of vertical stipes on a
drum moving fist fom right to Tet and then from Tet
lo ght. Normally ir produces nystagmus with slow
component in the direction of moving stripes and fast
“component in the opposte direction. Optokinete abnor
males ae sen in brainstem and cerebral hemisphere
lesions. Thus this te fu to dignos ental ein,
D. ROTATION TEST
Patient i seated inBarany’s revolving che with his hcad
tite! 30° fonward and then rotated 10 turns in 203. The
hal is stopped abruptly and nystagmus observed. Noe
mall theres nystagmus fr 25-40 The st Is useful as
{can be performed in eases ol congenital abnormalities
‘where car anal has alld to develop and not pose
Lo perform the caloric test Disadvantage ofthe ts sha
both the labyrinths are simultaneously stimulated during
the rotation process and cannot be tested individual
The test has now een made more sophisticated y the
te of torsion swings, electonystagmography and com
puter analysts ofthe results
E.GALVANIC TEST
[Ris the only vestibular test which helps in iferentating
an end organ lesion from that of vestibular neve, Patient
Stands with his fet together, eyes closed and ams out
fetched and then a current of 1 mA I passed to one
fa. Normally, person sways towards the ide of anodal
‘Stent Body say ca De studied By à special platform.
E. POSTUROGRAPHY
Isa method 0 evaluate vstibular function by measut
ing postural stabity and based on the fact tat maine.
man of posture depends on tree sensory Inputs vl,
vestibular and somatosensory. uses either à aed or à
‘moving platform, Visual cues can also be are. The cin
«al application! posturogaphy ssl under investigation,
G. VESTIBULAR EVOKED MYOGENIC
POTENTIALS (VEMP)
Thisis test study function of otolthongans—thesae-
cle and unio. Nowmally thee function i ar accel
‘ration, They can also be stimulated by loud sound of air
rhone conduction Even tapping the head can stimulate
them Myogeni potentials can De piched up fom ether
the sternoceldomastld {cervical} muscle or ocular mus-
le inferior oblique or superior rectus) and have respec
{ely been called eVEMP and OUEN
Since sacule is supplied by the inferior division of
nerve and utile by the superior division, study of VEMP
in neuroma can help us 10 nd ts origin rom Ihe supe
foro inferior division
Rees ae
From saccule—infrior vestibular—vestibular nucc
pate vestibular spinal tact—spinal accessory
serve (CN X0}—sternocendomastld
From utde-superor vestibular nerwe—vestbular
ciel medial Tongltudinalfascculss oculomotor
(CNI nerve inferior oblique muscle
Alrconducted sounds primary activate the saccule,
while boneconducted sounds activate both the sacle
Sd the ute
VEMP study isbeing use cliicallyana
‘also available but needs further reser
ing used to find the origin of an acoustic neurons (Hom
superior or inferior vestibular nerve). Ménières disease,
Superior canal dehiscence, vestibular neuritis and local
‘Stions of sions of poste canal fossa, Le om the
"upper of lower brainstem. Vstibulo ocular res s med
Sted through upper brainstem, while vestibulospinal are
Esos the lower brainstem
'VEMP studies ar stil in Investigaive state
mebooksfree.com
Chapter 7
Disorders of Vestibular System
ide into:
1. Peripheral, which involve vestibular end organs
and thee Ist order neurons ue the vestibular nerve). The
suse lis in te intemal ea or the Vil nerve They are
responsible for 859 ofall eases of vertigo
2. Central, which Involse central nervous system ater
the entrance of vestibular nerve inthe brainstem and in
volve vestibulo-ocule vestibulospinal and other central
oros system patitas
Table st the common causes of vertigo of periph
cra and central org
vestibular system cause vertigo and are die
|. PERIPHERAL VESTIBULAR DISORDERS
1. Mésitae’s Disease (EXpornernatie HyDxors). I
Is characterized by vertigo, uctuating fearing lo, tn
nits and sense of pressure inthe involved car Vertigo fs
‘Or sudden onset lat fora few minutes to 24 horso. (The
case has ben discus on. 111)
2. Bunton PAROXYSMAL Postrioxa Vento (BPP).
itis characterized by vertigo when the
neurologie symptoms Postional testi
¿lagos and helps o diferente rom positional
‘ertigo o ental origin (Table 7.1). Disease saute by
3 dhsorder of posterior semicircular canal though many
Patients have history of head trauma and ea Infection.
"hos been demonstrated that otoconia cbr, con
sisting of tal of alum carbonate, less om
the degenerating macul oft oats recy in
the endohymph. When i setts on the cupula of poste
tor em canal in aca head postion use
“placement ofthe copala and vertigo. The wert sf
tiguable on asuming the same postion repeatedly det
peral ofthe otoconia Put can e nce ager à
Peripheral (Lesions fe organ vestir nee)
+ Mies ie
nues ot eto
es
Eee dun
‘Pema
sip
peri of est. Thus, typical history and Hs
‘re etablishes the diagnos,
“The condition can be treated by performing Epleys ma
nce. The principe of his manocuve to repenition
{the otoconia deb tom the posterior semicicuar canal
back into the utile. The doctor stands behind the patient
and the assistant on the side, The patient is made 10 ton
‘the table so that when ets made to He down, his head
IS beyond the edge ofthe table ss done in Dice
manoeuvre His fae i tuned 45°10 the allected sie
The manoeuvre consists of Ave positions (sur):
+ Position 1. With the head turned 45, the patient Is
‘made to ie down in head hanging potion (Dix Hal
pike manoeuvre). It wi cause vertigo and nystagmas
‘Wait tl vertigo and nystagmus subside
Postion 2 Head is now turned 2 that affected ar is
facing up at 907 rotation.
Postion The whole body and hend are now rotated
aa tom the affected ear 1 atraleecumbent pos
tion in a 90-rotation facedown postion,
Pasion 4 Patent I now brought toa sitting postion
vit ea sl turned o the unaffected side by 45"
Postion $. The head now tumed forvard and chin
brought down 20°
‘Tere should bea pause at each position til here Is
no nystagmus or there 3 slowing of nystagmus, before
‘hanging tothe next position. After manoeuvre I 0
plete, patent should maintain an upright posture for
38h. Eighty per cent ofthe patients wil be cured by à
Single manoeuvre. Ifthe patient remains symptomatic,
the manoeuvre can be repeated. À bone vibrator placed
fon the mastold bone helps to loosen the db.
pike manocu-
3. Vestimutan NEUnONIES. Is characterized by severe
vertigo of sudden onsct with no cochlear symptoms.
Attack may last fom a few days 10 2 or 3 we Ts
‘thought to occur due to à vis hat attacks vestibular
‘Cental (Lions of astm and central connections)
Venecia
2 Pie be Gebel moy prior
cos
2 one ot em out voice
Be
Calvo
a
mebooksfree.com
Disorders of Vestibular System
ide into:
1. Peripheral, which involve vestibular end organs
and thee Ist order neurons ue the vestibular nerve). The
suse lis in te intemal ea or the Vil nerve They are
responsible for 859 ofall eases of vertigo
2. Central, which Involse central nervous system ater
the entrance of vestibular nerve inthe brainstem and in
volve vestibulo-ocule vestibulospinal and other central
oros system patitas
Table st the common causes of vertigo of periph
cra and central org
vestibular system cause vertigo and are die
|. PERIPHERAL VESTIBULAR DISORDERS
1. Mésitae’s Disease (EXpornernatie HyDxors). I
Is characterized by vertigo, uctuating fearing lo, tn
nits and sense of pressure inthe involved car Vertigo fs
‘Or sudden onset lat fora few minutes to 24 horso. (The
case has ben discus on. 111)
2. Bunton PAROXYSMAL Postrioxa Vento (BPP).
itis characterized by vertigo when the
neurologie symptoms Postional testi
¿lagos and helps o diferente rom positional
‘ertigo o ental origin (Table 7.1). Disease saute by
3 dhsorder of posterior semicircular canal though many
Patients have history of head trauma and ea Infection.
"hos been demonstrated that otoconia cbr, con
sisting of tal of alum carbonate, less om
the degenerating macul oft oats recy in
the endohymph. When i setts on the cupula of poste
tor em canal in aca head postion use
“placement ofthe copala and vertigo. The wert sf
tiguable on asuming the same postion repeatedly det
peral ofthe otoconia Put can e nce ager à
Peripheral (Lesions fe organ vestir nee)
+ Mies ie
nues ot eto
es
Eee dun
‘Pema
sip
peri of est. Thus, typical history and Hs
‘re etablishes the diagnos,
“The condition can be treated by performing Epleys ma
nce. The principe of his manocuve to repenition
{the otoconia deb tom the posterior semicicuar canal
back into the utile. The doctor stands behind the patient
and the assistant on the side, The patient is made 10 ton
‘the table so that when ets made to He down, his head
IS beyond the edge ofthe table ss done in Dice
manoeuvre His fae i tuned 45°10 the allected sie
The manoeuvre consists of Ave positions (sur):
+ Position 1. With the head turned 45, the patient Is
‘made to ie down in head hanging potion (Dix Hal
pike manoeuvre). It wi cause vertigo and nystagmas
‘Wait tl vertigo and nystagmus subside
Postion 2 Head is now turned 2 that affected ar is
facing up at 907 rotation.
Postion The whole body and hend are now rotated
aa tom the affected ear 1 atraleecumbent pos
tion in a 90-rotation facedown postion,
Pasion 4 Patent I now brought toa sitting postion
vit ea sl turned o the unaffected side by 45"
Postion $. The head now tumed forvard and chin
brought down 20°
‘Tere should bea pause at each position til here Is
no nystagmus or there 3 slowing of nystagmus, before
‘hanging tothe next position. After manoeuvre I 0
plete, patent should maintain an upright posture for
38h. Eighty per cent ofthe patients wil be cured by à
Single manoeuvre. Ifthe patient remains symptomatic,
the manoeuvre can be repeated. À bone vibrator placed
fon the mastold bone helps to loosen the db.
pike manocu-
3. Vestimutan NEUnONIES. Is characterized by severe
vertigo of sudden onsct with no cochlear symptoms.
Attack may last fom a few days 10 2 or 3 we Ts
‘thought to occur due to à vis hat attacks vestibular
‘Cental (Lions of astm and central connections)
Venecia
2 Pie be Gebel moy prior
cos
2 one ot em out voice
Be
Calvo
a
mebooksfree.com
48 SECTION! Dicas of far
w
A
Figure 7.1. ne mangeur or PV poner aa sole postion a ale an coegond posto oth drin he pos
daño cold canting Lon tras.) Fan ng dows D ip pon wath had hanging and ted 48 o ig os
ad pr A Ml hy te on o rca D
ganglion. Management of acute attacks similar to that
In Menitres sense. The disease usual set-dimiting.
4. Lanvttns thas been discussed in detail np. 8.
2 Girumscrbed labyrinths is seen in cases of unsafe
type of chronic soppurative ons media (CSOM) and
aula ts is postive
Sera Tabs caused by trauma or infection
(ital or bacterial) adjacent 10 Inner car Put without
Actual invasion, There severe vertigo and sensores
fal hearing Los. A partial or fll ecovery of inner cr
functions ls possible 1 treated eu.
Puit brins sa complication of CSOM. There
‘actual bacterial invasion of inner car with total los
fof cochlear and vestibular functions. Vertigo in this
Condition ls due to acute vestibular flute. There is
Severe nausea and vomiting. Nystagmus is seen to
the opposite side due to desiruction of Ue acte
Boya
5. Vistinctoroxte PGS, Several drugs cause ototoie
ity by damaging he hair cl ol the inne et Some pie
‘marly affect the cochlea while others affect he vestibular
Aübyrinth, Aminoglycoside anibiotes particularly srep-
{omyei, gentamicin and lanamyein have been shown to
lier hat cells ofthe sta ampullasandtosome extent
those of the maculae. Cetin other drugs which cause
zinss or unsteadiness are antinypertensives, Lbyrin.
thine sedatives, oxstrogen preparations, diuretic anti.
ob nalidixic aid, metronidazole) and animal
However, thelr mode of action may be diferent.
6. Heap Traun. Head injury may cause concussion of
[bbyrinth, completely irupt the bony ibyinth or VII
en, of cause a peniymp st. Severe acoustic tru
‘ma, such as that couse by an explosion, can also dtr
the vestibular end organ (hs) and result in vertigo.
7. Penuyern Fisteta. In this condition, perlymph
leaks into the middle ear through the oval or round win
on. can follow as a compliation of stapedecto oF
fr surgery when stapes Is acidenaly dislocated. ca
ho result fom sudden pressure changes in the middle
ar (eg barotrauma, diving forcet Vala) or raised
Intracanial pressure (weghiiting or vigorous cough
Ing A erlymph tua causes intermittent vertigo and
Atuating Sensorincural hearing 10, sometimes with
tinnitus and sense of fullness in the car (compare ME:
nite disease
Swrmus. syphilis of inner car, both acquired and
congenital, causes dizziness in ation to sensorineural
mebooksfree.com
w
A
Figure 7.1. ne mangeur or PV poner aa sole postion a ale an coegond posto oth drin he pos
daño cold canting Lon tras.) Fan ng dows D ip pon wath had hanging and ted 48 o ig os
ad pr A Ml hy te on o rca D
ganglion. Management of acute attacks similar to that
In Menitres sense. The disease usual set-dimiting.
4. Lanvttns thas been discussed in detail np. 8.
2 Girumscrbed labyrinths is seen in cases of unsafe
type of chronic soppurative ons media (CSOM) and
aula ts is postive
Sera Tabs caused by trauma or infection
(ital or bacterial) adjacent 10 Inner car Put without
Actual invasion, There severe vertigo and sensores
fal hearing Los. A partial or fll ecovery of inner cr
functions ls possible 1 treated eu.
Puit brins sa complication of CSOM. There
‘actual bacterial invasion of inner car with total los
fof cochlear and vestibular functions. Vertigo in this
Condition ls due to acute vestibular flute. There is
Severe nausea and vomiting. Nystagmus is seen to
the opposite side due to desiruction of Ue acte
Boya
5. Vistinctoroxte PGS, Several drugs cause ototoie
ity by damaging he hair cl ol the inne et Some pie
‘marly affect the cochlea while others affect he vestibular
Aübyrinth, Aminoglycoside anibiotes particularly srep-
{omyei, gentamicin and lanamyein have been shown to
lier hat cells ofthe sta ampullasandtosome extent
those of the maculae. Cetin other drugs which cause
zinss or unsteadiness are antinypertensives, Lbyrin.
thine sedatives, oxstrogen preparations, diuretic anti.
ob nalidixic aid, metronidazole) and animal
However, thelr mode of action may be diferent.
6. Heap Traun. Head injury may cause concussion of
[bbyrinth, completely irupt the bony ibyinth or VII
en, of cause a peniymp st. Severe acoustic tru
‘ma, such as that couse by an explosion, can also dtr
the vestibular end organ (hs) and result in vertigo.
7. Penuyern Fisteta. In this condition, perlymph
leaks into the middle ear through the oval or round win
on. can follow as a compliation of stapedecto oF
fr surgery when stapes Is acidenaly dislocated. ca
ho result fom sudden pressure changes in the middle
ar (eg barotrauma, diving forcet Vala) or raised
Intracanial pressure (weghiiting or vigorous cough
Ing A erlymph tua causes intermittent vertigo and
Atuating Sensorincural hearing 10, sometimes with
tinnitus and sense of fullness in the car (compare ME:
nite disease
Swrmus. syphilis of inner car, both acquired and
congenital, causes dizziness in ation to sensorineural
mebooksfree.com
heating os. Late congenital syphilis usually manifesting
between 8 and 20 yeas, mimes Ménière disease with
episodes of acute veri, sensorineural hearing los and
Unitus Henmeber sin, hea postive sta test nthe
presence ofan intact tympanic membrane Is present in
Congenital syphilis. Newrosyphils etary acquired) can
use cent ype of vestibular dystunetion
9. Acoustic NEUROMA. I has ben clase in pri
‘rl vestibular disorders a it ae from CN VI within
Internal acoustic meats, I causes only unsteadiness or
vague sensation of motion, Severe episodic vertigo, 36
Seen in the end organ disease, i usualy missing dor de.
taster Chapter 9.
‘Other tumours of temporal bone (eg. glomus tumour,
arcinoma of external or middle car and seconde), de.
Soy the labyrinth directly and cause vertigo.
CENTRAL VESTIBULAR DISORDERS
1. VERIEBROMASILAR IQSUIHIEIENEY. I is a commor
use cent vertigo in patents over the age of 50 years.
‘Theres transent decease in cerebral blood flow. Com:
mon cause I heroicos. Ischacmia in these patients
may also be precipitated by hypotension or neck move
ments when cervical osteophytes press on the vetbral
“nene during rotation and extension of head
‘Vertigo I abrupt in onset, [ais several minutes and is
associated with maust and vomiting. Other neurological
Symptoms ike visual disturbances, drop attack, diplopia,
Remanopia, dysphagia and hemiparesis resulting Wom
Ischaeml to other arcs of brain may also accompany
veri,
Some patients only complain of intermittent attacks
of dizziness or vertigo on lateral rotation and extension
‘or iad
Pan
gure 7.2. uni mad none
ir cor peice
Homes
ER ambos ON 0)
Wicd et pa
2 Dose ds tt CNY
1 orate pate ac Gone re)
Chapter 7 — Diorders of Vestibular Sytem 49
2. PosteRoIsERIOR CERERELLAR ARTERY SYNDROME
WALLENBERG SYNDROM). Thrombosis of the posterior
Inferior cerebellar artery cis off bod supply to lateral
medalay area. There violen vertigo along with plo:
Pia dysphagia, Noarseness, Homer syndrome, sensory
{oss on ipsilateral ade of face and contralateral de of
he body; and ataxia, There may be horizontal or rotatory
nystagmus to the side ofthe lesion (gut: 2)
3. BASILAR MIGRAINE. Migraine i a vascular syndrome
producing recurrent headaches with symptom fre inte
Vale Headache is usually unilateral and of the theobbing
{ype Basar artery migraine produces occipital headache
‘Visual disturbances diplopia and severe vertigo which
IS abrupt and may las or 8-60 min. Baslae migraine is
common In adolescent gis th strong menstrual tela
Honship and postive family history
4. CensmeiiaR DISEASE. Cerebellum may be affected
by haemesthage (hypertension, infarction (octusion of
anenal suppl), Infection (otogenic cerbelar abscess)
or tumours (fom, teratoma or haemangioma). Acute
echelle disease may cause severe vertigo, vomiting and
taxa simulating an acute peripheral labysinthine dis
order. Tumours ae slow growing and produce casa
features of cerebellar disease, Le. incoordination, past.
pointing, adidochokinesa, rebound phenomenon and
debas gat
5. Muurirus Sctamosts. I Is a demyelinating disease
atfeting young adults. Vertigo and dizimess are co
mon complaints There are other multiple neuroiogcal
Signs and symptoms, eg. During or 105 of vision, de
plopia,dysarta, paraesthesia and taxa, Spontaneous
nystagmus may be seen. Acquired pendular nystagmus,
¿located nystagmus and vertical Upbeat nystagmus are
Important features ln diagnosis
Vigo, ue, emi and paga
{Girt pn and umpentun a peace
Pan ar nei er pairs ae
Content pan temper, ek lo
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between 8 and 20 yeas, mimes Ménière disease with
episodes of acute veri, sensorineural hearing los and
Unitus Henmeber sin, hea postive sta test nthe
presence ofan intact tympanic membrane Is present in
Congenital syphilis. Newrosyphils etary acquired) can
use cent ype of vestibular dystunetion
9. Acoustic NEUROMA. I has ben clase in pri
‘rl vestibular disorders a it ae from CN VI within
Internal acoustic meats, I causes only unsteadiness or
vague sensation of motion, Severe episodic vertigo, 36
Seen in the end organ disease, i usualy missing dor de.
taster Chapter 9.
‘Other tumours of temporal bone (eg. glomus tumour,
arcinoma of external or middle car and seconde), de.
Soy the labyrinth directly and cause vertigo.
CENTRAL VESTIBULAR DISORDERS
1. VERIEBROMASILAR IQSUIHIEIENEY. I is a commor
use cent vertigo in patents over the age of 50 years.
‘Theres transent decease in cerebral blood flow. Com:
mon cause I heroicos. Ischacmia in these patients
may also be precipitated by hypotension or neck move
ments when cervical osteophytes press on the vetbral
“nene during rotation and extension of head
‘Vertigo I abrupt in onset, [ais several minutes and is
associated with maust and vomiting. Other neurological
Symptoms ike visual disturbances, drop attack, diplopia,
Remanopia, dysphagia and hemiparesis resulting Wom
Ischaeml to other arcs of brain may also accompany
veri,
Some patients only complain of intermittent attacks
of dizziness or vertigo on lateral rotation and extension
‘or iad
Pan
gure 7.2. uni mad none
ir cor peice
Homes
ER ambos ON 0)
Wicd et pa
2 Dose ds tt CNY
1 orate pate ac Gone re)
Chapter 7 — Diorders of Vestibular Sytem 49
2. PosteRoIsERIOR CERERELLAR ARTERY SYNDROME
WALLENBERG SYNDROM). Thrombosis of the posterior
Inferior cerebellar artery cis off bod supply to lateral
medalay area. There violen vertigo along with plo:
Pia dysphagia, Noarseness, Homer syndrome, sensory
{oss on ipsilateral ade of face and contralateral de of
he body; and ataxia, There may be horizontal or rotatory
nystagmus to the side ofthe lesion (gut: 2)
3. BASILAR MIGRAINE. Migraine i a vascular syndrome
producing recurrent headaches with symptom fre inte
Vale Headache is usually unilateral and of the theobbing
{ype Basar artery migraine produces occipital headache
‘Visual disturbances diplopia and severe vertigo which
IS abrupt and may las or 8-60 min. Baslae migraine is
common In adolescent gis th strong menstrual tela
Honship and postive family history
4. CensmeiiaR DISEASE. Cerebellum may be affected
by haemesthage (hypertension, infarction (octusion of
anenal suppl), Infection (otogenic cerbelar abscess)
or tumours (fom, teratoma or haemangioma). Acute
echelle disease may cause severe vertigo, vomiting and
taxa simulating an acute peripheral labysinthine dis
order. Tumours ae slow growing and produce casa
features of cerebellar disease, Le. incoordination, past.
pointing, adidochokinesa, rebound phenomenon and
debas gat
5. Muurirus Sctamosts. I Is a demyelinating disease
atfeting young adults. Vertigo and dizimess are co
mon complaints There are other multiple neuroiogcal
Signs and symptoms, eg. During or 105 of vision, de
plopia,dysarta, paraesthesia and taxa, Spontaneous
nystagmus may be seen. Acquired pendular nystagmus,
¿located nystagmus and vertical Upbeat nystagmus are
Important features ln diagnosis
Vigo, ue, emi and paga
{Girt pn and umpentun a peace
Pan ar nei er pairs ae
Content pan temper, ek lo
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50 SECTION! — Diseases of far
6: TOMOUKS OF BRAINSTEM AND FLOOR OF 1VIM VES:
“Tete. Gomis and astrocyiomas may rise from pons
and midbrain; medulloblastoma, ependymomas, epider:
{old ests or teratomas may arise rom floor of Vth ven
ce. These tumours cause other neurologicl signs and
symptoms in addition to vertigo and dlzzins. Positional
vertigo and nystagmus may aso be the presenting fe
tres. CT scan and magnetic resonance imaging ate wet
In tele dlagnosi
7. Ermursv. Vertigo may occur as an aura in tempo:
‚al lobe eplepsy. The history of slzure and/or uncon:
Sciousness following the aura may help in the diagnosis
Sometimes, vertigo the only symptom of epilepsy and
that may pose a dificult diagnostic problem. Electro»
encephalography may show abnormalities during the
stack,
8. CenvicaL Vexrico. Vertigo may follow injures of
‘neck 7-10 days after the accident. I usualy provoked
th movements of neck to the side of injury. Examina
tion shows tendemes of neck, spasms of ervcal muscles
nd limitation of neck movements. ays show los of
cervical lodos, Exact mechanism of cervical vertigo is
ot known. I may be de to disturbed verebrobuslar te
lation, involvement of sympathetic vertebral plexus or
eration of tonic neck reten
(OTHER CAUSES OF VERTIGO
1. OcuLan Vrxnico. Normally, balance is maintained by
integrated information received rom the eye, labyrinths
and somatosensory system. À mismatch of Information
from any ofthese organs causes vertigo and in this case
ftom the eyes. Ocul vertigo may occur in cas of acute
Ssrancular muscle pass or high eos of refrclon.
2. PsvcHOGENIC VERTIGO. This diagnosis is suspected
in patients sutfering tom emotional tension and ani
«y. Often other symptoms of neurosis, e. palpation,
Brathlessnes, Katar, Insomnla, profuse sweating and
remors are aso present. Symptom of vertigo Is often
‘gue inthe form of Hosting or Swimming sensation or
light hendednes, Mere s no nystagmus of heating 105%
{Gore test shows an exaggerated response,
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6: TOMOUKS OF BRAINSTEM AND FLOOR OF 1VIM VES:
“Tete. Gomis and astrocyiomas may rise from pons
and midbrain; medulloblastoma, ependymomas, epider:
{old ests or teratomas may arise rom floor of Vth ven
ce. These tumours cause other neurologicl signs and
symptoms in addition to vertigo and dlzzins. Positional
vertigo and nystagmus may aso be the presenting fe
tres. CT scan and magnetic resonance imaging ate wet
In tele dlagnosi
7. Ermursv. Vertigo may occur as an aura in tempo:
‚al lobe eplepsy. The history of slzure and/or uncon:
Sciousness following the aura may help in the diagnosis
Sometimes, vertigo the only symptom of epilepsy and
that may pose a dificult diagnostic problem. Electro»
encephalography may show abnormalities during the
stack,
8. CenvicaL Vexrico. Vertigo may follow injures of
‘neck 7-10 days after the accident. I usualy provoked
th movements of neck to the side of injury. Examina
tion shows tendemes of neck, spasms of ervcal muscles
nd limitation of neck movements. ays show los of
cervical lodos, Exact mechanism of cervical vertigo is
ot known. I may be de to disturbed verebrobuslar te
lation, involvement of sympathetic vertebral plexus or
eration of tonic neck reten
(OTHER CAUSES OF VERTIGO
1. OcuLan Vrxnico. Normally, balance is maintained by
integrated information received rom the eye, labyrinths
and somatosensory system. À mismatch of Information
from any ofthese organs causes vertigo and in this case
ftom the eyes. Ocul vertigo may occur in cas of acute
Ssrancular muscle pass or high eos of refrclon.
2. PsvcHOGENIC VERTIGO. This diagnosis is suspected
in patients sutfering tom emotional tension and ani
«y. Often other symptoms of neurosis, e. palpation,
Brathlessnes, Katar, Insomnla, profuse sweating and
remors are aso present. Symptom of vertigo Is often
‘gue inthe form of Hosting or Swimming sensation or
light hendednes, Mere s no nystagmus of heating 105%
{Gore test shows an exaggerated response,
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Chapter 8
Diseases of External Ear
1. DISEASES OF THE PINNA
Te pinna may be afccd by congenital, traumatic in
ammatory oF neoplastic disorder
A. CONGENITAL DISORDERS
‘The developmental abnormalities of the pinna may be
Just mino variations rom the normal or maja abnormall
tes
1. Anona. It is complete absence of pinna and lob-
Ui and usualy forms part ofthe fst arch syndrome
Care
2. Micnona (Fruta 8.2). sa major develop
I Doge of micrt may vay. es frequen
sith anomalies of extemalaudiory Canal, mid
internal at. The condition may be unilateral or
lateral Hearing os is frequnt, Peanut cars form of
3. MACKONA. Is excessively age pin.
4. Bar sar (Sr. PRoMINENT Exa on PROTRUDING
ag) This san abnormally protruding car. The concha
is are with poorly developed antic and sepia. The
etormlıy can be corected sugkaliy any time ater the
‘age oF 6 Years, Ieosmelc appearance so demand
AE"
Figure 4. An. Note oa enc pira nd extra u
$. Cur Ean où Lor Ean. I hypoplasia of upper third
‘ofthe auricle Upper portion of hell or pina ie cupped.
{Coehlesell ar or snllshei ea are greater deformities
ocupar
6. Cavrrorı (Sy. Pocker Ean). Upper this! of the
Sure Is embedded under the scalp sin It can be cor
rected by mobilizing the pinna to normal postion and
‘covering the a area bya skin galt
7. Coronoma. There sa transverse cleft inthe pina In
the middle
8. Minor Drromrris, Absence of tags, Dann’ tu
Devt, additional ods (tah ea) and Satyr cr
+ Darwin’ tubercle is à pointed tuberle on the upper
par of ex and epresents apex of pins of ower ane
mal
in Sta ca, helix which should normally be folded
5 Hat and the upper rus of anihel duplicated and
teaches rim of heli, cam be conecte by a mould in
the fist 6 weeks of ie
tle, lage lobule,
They are absence of ob
fd lobule ora pied attached) lobule
skin-covered tags that appear on a line drawn from the
agas co the angle of mouth. They may contain small
pee of anlage gute 5)
11. PREALRICULAR PIT OR Sines, Presuricule pt à de
presion in ont ol the crus Of helix or above the tags
Figure 8.2, cre ight (ent e)
si
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Diseases of External Ear
1. DISEASES OF THE PINNA
Te pinna may be afccd by congenital, traumatic in
ammatory oF neoplastic disorder
A. CONGENITAL DISORDERS
‘The developmental abnormalities of the pinna may be
Just mino variations rom the normal or maja abnormall
tes
1. Anona. It is complete absence of pinna and lob-
Ui and usualy forms part ofthe fst arch syndrome
Care
2. Micnona (Fruta 8.2). sa major develop
I Doge of micrt may vay. es frequen
sith anomalies of extemalaudiory Canal, mid
internal at. The condition may be unilateral or
lateral Hearing os is frequnt, Peanut cars form of
3. MACKONA. Is excessively age pin.
4. Bar sar (Sr. PRoMINENT Exa on PROTRUDING
ag) This san abnormally protruding car. The concha
is are with poorly developed antic and sepia. The
etormlıy can be corected sugkaliy any time ater the
‘age oF 6 Years, Ieosmelc appearance so demand
AE"
Figure 4. An. Note oa enc pira nd extra u
$. Cur Ean où Lor Ean. I hypoplasia of upper third
‘ofthe auricle Upper portion of hell or pina ie cupped.
{Coehlesell ar or snllshei ea are greater deformities
ocupar
6. Cavrrorı (Sy. Pocker Ean). Upper this! of the
Sure Is embedded under the scalp sin It can be cor
rected by mobilizing the pinna to normal postion and
‘covering the a area bya skin galt
7. Coronoma. There sa transverse cleft inthe pina In
the middle
8. Minor Drromrris, Absence of tags, Dann’ tu
Devt, additional ods (tah ea) and Satyr cr
+ Darwin’ tubercle is à pointed tuberle on the upper
par of ex and epresents apex of pins of ower ane
mal
in Sta ca, helix which should normally be folded
5 Hat and the upper rus of anihel duplicated and
teaches rim of heli, cam be conecte by a mould in
the fist 6 weeks of ie
tle, lage lobule,
They are absence of ob
fd lobule ora pied attached) lobule
skin-covered tags that appear on a line drawn from the
agas co the angle of mouth. They may contain small
pee of anlage gute 5)
11. PREALRICULAR PIT OR Sines, Presuricule pt à de
presion in ont ol the crus Of helix or above the tags
Figure 8.2, cre ight (ent e)
si
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52 SECTION! Deer of far
Figure 84. nected prat ios with us eig Hor the
Preaurculr sins s an epithelial track and Is due 10 in
complete fusion of vertes. e may get repeat in
{ected causing purulent dacharge, Abscess may also form,
Treatments surglcl excision of te tac te sinus els
repeatedly infected (zur 3).
B. TRAUMA TO THE AURICLE
1. HAIMATOM OF THE AURICLE. I is collect
tion between the auricular crtlage and it per
rium, Often ii the result of bunt trauma seen ln
boxers rester and rugby players. Extavasated blood
may clot and then organizo, resulting in a type de
formity called Cauliflower cur (puit or boxers car)
(Cisuce 89). I haematoma. gts infected, severe per
ona may stn,
Treatment asprtion0f the haematoma under strict
septic precautions and à pressure dressing Carola
Packing al concavitie of the auricle to prevent react
mution. Aspiration may need to be repeated. When as
Piration fails incision and drainage shouldbe done and
Pressure applied by dental rolls tied with through and
rough sts Ale nu eee proc
2. LACERATIONS (cine 56). They are repaire as
say as possible, The perichondnum is stitched with
Figure, acer tp
absorbable suturs Special care ls taken o prevent stip
of perichondrium fom calage for fear ofavascular
‘necrosis Sin 5 closed with Ane nonabsorbable sutures
‘roud-spectrum antibiotics are given for 1 werk,
3. AVULSION or Prosa. When pinna is stil attached to
‘he heu by a small pedicle of kn, primary cattachment
Should be considered and ts usually successful, Com
pletely avulsd pinna can be reimplantd in select as
by ine microvascular techniques in others, the skin of
the avulsed segment of plnna ls removed and the cart
[age implanted under the postauriular skin for ter re.
rosrarre, Injury dueto fostbite varies between ee
Jima and oedema, bullae formation, necrosis of Sn
Bind subcutaneous tuo, and complete necrosis with Tost
ofthe acts par
Treatment ob ostiten ar consists of
(6) rewarming with moist cotton plegets at a tempera
tore of 842 C,
(9) application oF 0 8% silver nitrate soaks or superficial
intecuon,
(©) analgesic for pan; rapid rewarming of frotbiten ear
suse considerable pain,
(& protection of bullae kom rupture,
(e) systemic altes for deep infection, and
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Figure 84. nected prat ios with us eig Hor the
Preaurculr sins s an epithelial track and Is due 10 in
complete fusion of vertes. e may get repeat in
{ected causing purulent dacharge, Abscess may also form,
Treatments surglcl excision of te tac te sinus els
repeatedly infected (zur 3).
B. TRAUMA TO THE AURICLE
1. HAIMATOM OF THE AURICLE. I is collect
tion between the auricular crtlage and it per
rium, Often ii the result of bunt trauma seen ln
boxers rester and rugby players. Extavasated blood
may clot and then organizo, resulting in a type de
formity called Cauliflower cur (puit or boxers car)
(Cisuce 89). I haematoma. gts infected, severe per
ona may stn,
Treatment asprtion0f the haematoma under strict
septic precautions and à pressure dressing Carola
Packing al concavitie of the auricle to prevent react
mution. Aspiration may need to be repeated. When as
Piration fails incision and drainage shouldbe done and
Pressure applied by dental rolls tied with through and
rough sts Ale nu eee proc
2. LACERATIONS (cine 56). They are repaire as
say as possible, The perichondnum is stitched with
Figure, acer tp
absorbable suturs Special care ls taken o prevent stip
of perichondrium fom calage for fear ofavascular
‘necrosis Sin 5 closed with Ane nonabsorbable sutures
‘roud-spectrum antibiotics are given for 1 werk,
3. AVULSION or Prosa. When pinna is stil attached to
‘he heu by a small pedicle of kn, primary cattachment
Should be considered and ts usually successful, Com
pletely avulsd pinna can be reimplantd in select as
by ine microvascular techniques in others, the skin of
the avulsed segment of plnna ls removed and the cart
[age implanted under the postauriular skin for ter re.
rosrarre, Injury dueto fostbite varies between ee
Jima and oedema, bullae formation, necrosis of Sn
Bind subcutaneous tuo, and complete necrosis with Tost
ofthe acts par
Treatment ob ostiten ar consists of
(6) rewarming with moist cotton plegets at a tempera
tore of 842 C,
(9) application oF 0 8% silver nitrate soaks or superficial
intecuon,
(©) analgesic for pan; rapid rewarming of frotbiten ear
suse considerable pain,
(& protection of bullae kom rupture,
(e) systemic altes for deep infection, and
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Figur 87, Ki ling paring of pn fer omens,
(0) surgical debridement should walt several m
the te demarcation betwee the dead and i
Sues appear quite late
5. Ketow oF AURICLE. It may flow trauma or pe
ing ofthe ea (or ormaments, Usual its ae the lle or
hex (sure 87). Surgical exchion ofthe hold usual
results in recurrence. Recurrence of helo can Be aod
00-800 rad delivered In Tour divided doses, Some peter
Toca injection of steroid after exi
C. INFLAMMATORY DISORDERS
1. Prnucnonpernis (Fic 83). le sults from infec
tion secondary o aceratons, haematoma or surgical in
¿ise otitis externa or furanci of the meats, Psew
‘domonis and mixed Hora are the common pathogens
Initial symptoms are red, hot and pinful pinna ich
feos sith. Later abscess may form between the cartilage
“amd perichondrium with necrosis of camila tthe cat
Tage survives only on the blood supply rom its prion
hum Treatment in any sages consis of systemic an.
Chapter 8 — Diseases of Extemal Ear 53
Libis and local application of 4% aluminium acetate
‘compresses. When abscess has formed, it must be dained
Promptly and culture and sensitivity ofthe pus obtained
Tneision Is made inthe natural fold and devitalized car
Ange removed. Some prefer to place a catheter in the
abscess and administra continuons rip of anbleies,
Selected by Culture and sensi for 7-10 das.
disorder involving cartilage of the car. Other cartilages,
Septal, laryngeal, ach, costal may also be Involve,
Tih entre ariel except it lobule becomes named and
consists of high doses of sstemicsterid,
3. CUONDRODERMATITIS NODULARIS ChRONICA HELLIS
Small palma nodules appear nea the fee border of he
Ii in men about the age of SO years, Nogles ae tender
And the patient is unable to sleep on the affected side
eatment is excision of the nodule with its skin and
D. TUMOURS
Sep. 117
DISEASES OF EXTERNAL AUDITORY
CANAL
The diseases of extemal auditory canal re grouped as
+ Conge
1 itammation
amour
1 Miscellaneous conditions
A. CONGENITAL DISORDERS
1. Amasın oF EXTERNAL CANAL, Congenital atria of
iemeatus may occu alone or in association sith micro:
tion of the ectodermal core that fills the dorsal pat of
the frst branchlal elt. The outer meatus, in these cases,
isblitrted with fibrous tissue or bone while the deep
‘with microta is more common. It may be associated with
normales of the middle var, internal eat and other
2. Coutaunat Fisruza. This san abmormality ofthe ist
‘branchial et. The tua has two opening: one stated
inthe eck just below and bein the ange of mandibe
‘Wack ofthe fistula traseros through the parotid ln close
relation o the fall neve
B. TRAUMA TO EAR CANAL
Minor lacerations of canal skin result from Qetip injury
(sertching the car with hal pins, needles or matchstick)
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(0) surgical debridement should walt several m
the te demarcation betwee the dead and i
Sues appear quite late
5. Ketow oF AURICLE. It may flow trauma or pe
ing ofthe ea (or ormaments, Usual its ae the lle or
hex (sure 87). Surgical exchion ofthe hold usual
results in recurrence. Recurrence of helo can Be aod
00-800 rad delivered In Tour divided doses, Some peter
Toca injection of steroid after exi
C. INFLAMMATORY DISORDERS
1. Prnucnonpernis (Fic 83). le sults from infec
tion secondary o aceratons, haematoma or surgical in
¿ise otitis externa or furanci of the meats, Psew
‘domonis and mixed Hora are the common pathogens
Initial symptoms are red, hot and pinful pinna ich
feos sith. Later abscess may form between the cartilage
“amd perichondrium with necrosis of camila tthe cat
Tage survives only on the blood supply rom its prion
hum Treatment in any sages consis of systemic an.
Chapter 8 — Diseases of Extemal Ear 53
Libis and local application of 4% aluminium acetate
‘compresses. When abscess has formed, it must be dained
Promptly and culture and sensitivity ofthe pus obtained
Tneision Is made inthe natural fold and devitalized car
Ange removed. Some prefer to place a catheter in the
abscess and administra continuons rip of anbleies,
Selected by Culture and sensi for 7-10 das.
disorder involving cartilage of the car. Other cartilages,
Septal, laryngeal, ach, costal may also be Involve,
Tih entre ariel except it lobule becomes named and
consists of high doses of sstemicsterid,
3. CUONDRODERMATITIS NODULARIS ChRONICA HELLIS
Small palma nodules appear nea the fee border of he
Ii in men about the age of SO years, Nogles ae tender
And the patient is unable to sleep on the affected side
eatment is excision of the nodule with its skin and
D. TUMOURS
Sep. 117
DISEASES OF EXTERNAL AUDITORY
CANAL
The diseases of extemal auditory canal re grouped as
+ Conge
1 itammation
amour
1 Miscellaneous conditions
A. CONGENITAL DISORDERS
1. Amasın oF EXTERNAL CANAL, Congenital atria of
iemeatus may occu alone or in association sith micro:
tion of the ectodermal core that fills the dorsal pat of
the frst branchlal elt. The outer meatus, in these cases,
isblitrted with fibrous tissue or bone while the deep
‘with microta is more common. It may be associated with
normales of the middle var, internal eat and other
2. Coutaunat Fisruza. This san abmormality ofthe ist
‘branchial et. The tua has two opening: one stated
inthe eck just below and bein the ange of mandibe
‘Wack ofthe fistula traseros through the parotid ln close
relation o the fall neve
B. TRAUMA TO EAR CANAL
Minor lacerations of canal skin result from Qetip injury
(sertching the car with hal pins, needles or matchstick)
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S4 SECTION! — Diseases of far
‘or unskilled instrumentation bythe physician. They us
ly heal without sequel,
Major actions result from gunshot wounds, aut:
mobile accidents or fights. The condyle of mandibl may
force through the anterior canal wall These eases require
‘ef treatment. Alm so attain a skinned meats of
‘Mlquate diameter Stenos of the car canal fsa common
Complication.
€. INFLAMMATIONS OF EAR CANAL
Otitis extema may be divided, o actiologica! basis, nto:
1. Infective Group
alar ce eur,
po ore a
Vo Gs eden mortis
2. Reactive Group
+ Bezematous otitis externa
1 Schormoce outs externa
+ Nesrodermatts
(4) Femenctz (Locauzen Acure Orms Extensa). À
rune 1a staphylococeal infection of the hale lice.
AS the ar re confined only to the cartilaginous par of
‘the meatus fund 5 see only this par ol metas.
"Usually singe the furuncis may be multiple
Patient usually presents with severe pain and tender
ess which ae ot of proportion to the ie ofthe ran.
Se. Movements ofthe pina are painful Jaw movements,
3 in chewing, also cause pain in the ea. A furunle of
posterior meatal wall causes oedema over the mastld
‘with obiteation of the retoauricular groove, Peru
‘lr ph nodes (anteson posteñor and interior) may
kobe enlarged and tender
Trament in early cases, without abscess formation,
consists of systemic antbiois, analgci and local hat
‘Ament pack of 10% ichthammol lyccine provides spin:
{age and reduces pain. Hygoscopic action of glycerine re
dues oedema, iammol i milly anisepic. I
Ses ha form, Inciso and drainage shouldbe done,
In cate of eur fran, diabetes should be 0x
cued, and attention pad 10 the patients nas vest
bules which may arbour staphylococ and the Infection
tansemed by patents fingers. Saphylococal infections
fof the shin as à possible source should abo be excluded
Sind suitably tree
(0) Darse Orrnis Extra. Is diffuse inflammation
Of mental skin which may spread to invole the plana
nd epidermal layer of tympanie membrane,
“etl Disease ls common seen in hot and humid
«mate and in swimmers. Excessive sweating changes
the pl of meatal skin fom that of aid to laine which
{avout growth of pathogens. Two factors commonly te.
sponsible for this condition are
© uma to the meatal skin and
{i Invasion by pathogenic organisms.
Trauma can result rom seratching the ea canal with
hair pins or matchs, unskilled instrumentation 10
remove foreign bodies or vigorous cleaning of ear canal
itera swim whem mental shin arcady macerated. Brak
in continuity of meatal lining sts the ground for organ:
tems to invade,
Common arganisns responsible for outs externa are
Saphylcocns aureus, Pseudomonas ponts, Bacs
rote ad Escherichia cal but more ofen the inkction
init.
Some cases of tits extema are secondary t infection
ofthe middle ear, ‘opie
ar dps used for chronic suppurative otitis media.
“Clinical tus. Dituse ots externa may be acute or
‘onic with varying degrees of every
“late phase is characterized by Hot burning sen
tion in ie cr, fellow by pain which i aggravated by
‘movements of aw, Ea starts oozing thin serous discharge
which ner becomes thick and purulent: Meat ning
becomes inflamed and swollen. Collection of debris and
“charge accompanied with meatal swelling gives rc 10
feonductve hearing los In severe cases, regional Iympl
‘odes become enlarged and tender with cells ofthe
Surounding tissues.
Chronic phase is character by tation and strong
desc o ch. This responsible for acute exacrbations
and reinfecion. Discharge Is scanty and may dry up to
form crust. Metal skin which thick and wollen may
Also show scaling and fsuring. Rarely, the skin becomes
Inypertophie lading to meatal stenoss (rene senaic
alts em,
Treatment Acute phase i treated as follows
(©) Fartll tis the most important singe actor in the
treatment of diffuse orita externa. Al exudate and
{ders should be meticulously and gently removed
Special attention should be paid 10 anteroinfenor
tal ees, which forms bind pocket where di.
‘charge I accumulatd. Ear toilet can be done by dy
‘mopping. suction clearance or ligating the canal
Sith warm, tel normal saline.
(& Mate wis. Alter thorough til, a gauze wick
Soaked in antibiotic steroid preparation stnserted in
{he ear canal and patient advised to keep lt mois by
{nstling the same drops twice or ice a day, Wick
IS changed dally for 2-3 days when I can be subst
tuted by car drops Local steroid drops hp to relieve
‘edema, erythema and preven thing. Aluminium
coat (9%) or Silver eae (3%) are mild ase
sents and can be usd in the form of ik o orm
3 protective coagulum 1 dej-up an org meatus
(ay Anodes Bron spectrum systeme antbleties are
sed when there celts and cute tener Im
piden.
(0) Analgsks. For elle of pal,
Chronic phase. Treatment aims at) eduction of meatal
selling so that car toilet ean be ete done and (i)
alleviation of tching so that scratching s stopped and
further recurrences controlled
‘gi wick soaked in 10% ihthammol glycerine and
inserted ito the canal helps to reduce swing. Tis ls
followed by ea tot with particular attention to antero-
inferior meatal res, Itching can be controlled by Op.
{application of ansible trol exam,
mebooksfree.com
‘or unskilled instrumentation bythe physician. They us
ly heal without sequel,
Major actions result from gunshot wounds, aut:
mobile accidents or fights. The condyle of mandibl may
force through the anterior canal wall These eases require
‘ef treatment. Alm so attain a skinned meats of
‘Mlquate diameter Stenos of the car canal fsa common
Complication.
€. INFLAMMATIONS OF EAR CANAL
Otitis extema may be divided, o actiologica! basis, nto:
1. Infective Group
alar ce eur,
po ore a
Vo Gs eden mortis
2. Reactive Group
+ Bezematous otitis externa
1 Schormoce outs externa
+ Nesrodermatts
(4) Femenctz (Locauzen Acure Orms Extensa). À
rune 1a staphylococeal infection of the hale lice.
AS the ar re confined only to the cartilaginous par of
‘the meatus fund 5 see only this par ol metas.
"Usually singe the furuncis may be multiple
Patient usually presents with severe pain and tender
ess which ae ot of proportion to the ie ofthe ran.
Se. Movements ofthe pina are painful Jaw movements,
3 in chewing, also cause pain in the ea. A furunle of
posterior meatal wall causes oedema over the mastld
‘with obiteation of the retoauricular groove, Peru
‘lr ph nodes (anteson posteñor and interior) may
kobe enlarged and tender
Trament in early cases, without abscess formation,
consists of systemic antbiois, analgci and local hat
‘Ament pack of 10% ichthammol lyccine provides spin:
{age and reduces pain. Hygoscopic action of glycerine re
dues oedema, iammol i milly anisepic. I
Ses ha form, Inciso and drainage shouldbe done,
In cate of eur fran, diabetes should be 0x
cued, and attention pad 10 the patients nas vest
bules which may arbour staphylococ and the Infection
tansemed by patents fingers. Saphylococal infections
fof the shin as à possible source should abo be excluded
Sind suitably tree
(0) Darse Orrnis Extra. Is diffuse inflammation
Of mental skin which may spread to invole the plana
nd epidermal layer of tympanie membrane,
“etl Disease ls common seen in hot and humid
«mate and in swimmers. Excessive sweating changes
the pl of meatal skin fom that of aid to laine which
{avout growth of pathogens. Two factors commonly te.
sponsible for this condition are
© uma to the meatal skin and
{i Invasion by pathogenic organisms.
Trauma can result rom seratching the ea canal with
hair pins or matchs, unskilled instrumentation 10
remove foreign bodies or vigorous cleaning of ear canal
itera swim whem mental shin arcady macerated. Brak
in continuity of meatal lining sts the ground for organ:
tems to invade,
Common arganisns responsible for outs externa are
Saphylcocns aureus, Pseudomonas ponts, Bacs
rote ad Escherichia cal but more ofen the inkction
init.
Some cases of tits extema are secondary t infection
ofthe middle ear, ‘opie
ar dps used for chronic suppurative otitis media.
“Clinical tus. Dituse ots externa may be acute or
‘onic with varying degrees of every
“late phase is characterized by Hot burning sen
tion in ie cr, fellow by pain which i aggravated by
‘movements of aw, Ea starts oozing thin serous discharge
which ner becomes thick and purulent: Meat ning
becomes inflamed and swollen. Collection of debris and
“charge accompanied with meatal swelling gives rc 10
feonductve hearing los In severe cases, regional Iympl
‘odes become enlarged and tender with cells ofthe
Surounding tissues.
Chronic phase is character by tation and strong
desc o ch. This responsible for acute exacrbations
and reinfecion. Discharge Is scanty and may dry up to
form crust. Metal skin which thick and wollen may
Also show scaling and fsuring. Rarely, the skin becomes
Inypertophie lading to meatal stenoss (rene senaic
alts em,
Treatment Acute phase i treated as follows
(©) Fartll tis the most important singe actor in the
treatment of diffuse orita externa. Al exudate and
{ders should be meticulously and gently removed
Special attention should be paid 10 anteroinfenor
tal ees, which forms bind pocket where di.
‘charge I accumulatd. Ear toilet can be done by dy
‘mopping. suction clearance or ligating the canal
Sith warm, tel normal saline.
(& Mate wis. Alter thorough til, a gauze wick
Soaked in antibiotic steroid preparation stnserted in
{he ear canal and patient advised to keep lt mois by
{nstling the same drops twice or ice a day, Wick
IS changed dally for 2-3 days when I can be subst
tuted by car drops Local steroid drops hp to relieve
‘edema, erythema and preven thing. Aluminium
coat (9%) or Silver eae (3%) are mild ase
sents and can be usd in the form of ik o orm
3 protective coagulum 1 dej-up an org meatus
(ay Anodes Bron spectrum systeme antbleties are
sed when there celts and cute tener Im
piden.
(0) Analgsks. For elle of pal,
Chronic phase. Treatment aims at) eduction of meatal
selling so that car toilet ean be ete done and (i)
alleviation of tching so that scratching s stopped and
further recurrences controlled
‘gi wick soaked in 10% ihthammol glycerine and
inserted ito the canal helps to reduce swing. Tis ls
followed by ea tot with particular attention to antero-
inferior meatal res, Itching can be controlled by Op.
{application of ansible trol exam,
mebooksfree.com
‘when the meatal shin is thickened tothe point ofob-
striction and resists al forms of medial treatment, Le.
Chronie stenotic ots externa, It is surgically excised,
Dany meatus i widened with à dll and indy spit
shin gat
(0 oromrcoss. tomycoss ls fungal infection of the
Sr canal na often aco due to Apes ni A.
‘natu où Cand aan His sce ot and ham
‘mat of topical and subiopical oui. Secondary
fungal growth ao sen ln tiro using tpi ant
bots for raten of tts externa or mide ar sup
’ ‘The clinical features of otomycosis include intense iteh-
ing dscomfort or pa nthe ca watery discs wi
sty odour and ar Bocage. The Tanga man may
Sppear white, brown or black has bee Ind o à
‘epee of iter pape
“amined wi an otscope, ner appears as back
head mento growth A. umi spe Be or
een and Candida ss wie or eeamy dept, Mes
Si app sodden, ed amd ondematos
“rent onto hor er ot rem all
charge and pion dns which ate conducive 10
the gro ol Tangas. can be done by singing suc.
ton or mopping Specie anttangl agents cn be ap
pid. Nystatin {100,000 unis of propyene ca)
À ce agit Can, Other bond apct an
fungal agent include coimas and povidone odie
‘wo percent sally aed in alcool ao fective.
iss tot agent which removes perl ayers of
“permis and along with thatthe fungal myec gro
igi them, AN wesent shuld be contac
fota week even ster apparent cue to avoid roues.
Ear mus be ep dy. Btn infections ae often amo
ed with otomyeous and teste wth an abel
Sterol preparation heps to rede iflammaton and
dma and thus permitting better penis of an
fg a.
(0) Ours Extra Harwonmnacien. Is character
Tae by formation of haemorrhage bullae on te ty.
panic membrane and deep meatus Its probably vial
In origin and may be seen In influenza epidemics. The
ondiion cases severe pain in the ear and blood stained
üscharge when the bullae rupee Treatment with ale
gels Is lected 10 give rele rom pain. Anti are
ven for secondary infection of the ae canal, or middle
ar the balla has raptor into the mide ei.
(9 Henves Zosren Omeus. Is characterized by forms
Hon of vesicles on the tympanic membrane, metal kn,
«concha and postauricular groove. The Vil and VII
“rail nerves may be involved,
(9 Mauser (Nucnomzine) Orrris Extra Isar
Inammatory condition cased by pscudomonas inte
ton usually in the elderly abet, or in those on im.
munosuppressve drugs. cal manifestations resemble
‘hfs ott externa but there exerucating pain and
“appearance of granulatons in the car canal. Fac para
ysis common. Infection may spread to the shall base
“nd jugular foramen causing multiple cranial nerve pal
Sis. Antenor, infection spreads 10 temporomandibular
Chapter 8 — Diseases of Entemal Eur 55
ss, posteriorly to the mastoid and medial ino the
‘mid eat and petous bone.
Diggs. Severe ota in an dry abet patent
‘th grata ts the external car cana a te
{laginour-bony junction should ale the physician of
Deren otis extern, CT can may show Dany de
$trcton but often not hep Gallium 67 s more us.
{ulin dagnoss and follow-up of the patient. Ts taken
{up by monocytes and retculoendothtal cl, and isn
ale of st tate infection an be repeated every
Sesh to monitor the eve and response to atmen!
che 99 bone san eas bone infection ut
remains positive fora year or 30 and cannot be ud o
‘monitor the dea
“rent const of
(Control of diabetes
A Tot of car canal. Remove discharge, debris and
granultions or any dead tissue or bone
(i) Antibiotic treatment against causative organism,
"organismo which can be found y culture adsense
tity Abit treatment continue or 6-8 weeks,
Sometimes more Anibioi found ce are
Gentamicin combined with tcareilin They are
given intatenously. Gentamicin Is bots ototoxic
And nephrotoxic, and rein may produce pen:
ice reactions,
+ Third generation cephalosporins, eg. eetiaxone
1-2 glday bv or celazidime 1-2 gia Lv ae wt
ally combined with an aminoglycoside,
+ Quinolones (ciprofloxacin, ofloxacin and levo-
oxacin) ae als fective and can be given oral
‘They can be combined with lampin. Ciprolloxa.
«in 750 mg OD orally can be used. Oral therapy
‘nth quinolones obsats the need for admission
Fortarinjections
ll patent is not responsive, culture and senstvity’ of
(ar üscharge should guide the surgeon.
‘rolonged antibiotic treatment has replaced radical
surgery and resections done earlier fo his condition.
(6) Ecamatous Orrnis Extensis the result of by:
Dersens to infective organisms or topa car ops
Such as chloromyeetin or neomycin, ete Its marked by
Intense iitaton, vesicle formation, oozing and esting
{athe cal Treatment withdrawal of topical antibiotic
‘causing sensitivity and application of steroid cream,
{00 Semommnorte Oris EXTERSA. ts associated with
seborocie dermatitis ofthe Sal. thing i the main
Complaint. Greasy yellow seats ae seen In the external
‘anal, over te ul and postauriulr sulcus Treatment
Sonst ol ea talle, application of a cream containing
Sally acid and suite, and attention to the scalp for
born.
9 NIURODERMATTIS I is caused by compulsive
scratching due to Psychological factors. Patients main
Complaint ls intense Mching. Out externa o bacterial
{ype may follow infection of raw are ef by scratching.
Treatments sympathetic paychotherapy and that meant
{or any Secondary infection. Er pack and Dandage 10 the
‘ar are helpulto prevent compulsive scratching,
mebooksfree.com
striction and resists al forms of medial treatment, Le.
Chronie stenotic ots externa, It is surgically excised,
Dany meatus i widened with à dll and indy spit
shin gat
(0 oromrcoss. tomycoss ls fungal infection of the
Sr canal na often aco due to Apes ni A.
‘natu où Cand aan His sce ot and ham
‘mat of topical and subiopical oui. Secondary
fungal growth ao sen ln tiro using tpi ant
bots for raten of tts externa or mide ar sup
’ ‘The clinical features of otomycosis include intense iteh-
ing dscomfort or pa nthe ca watery discs wi
sty odour and ar Bocage. The Tanga man may
Sppear white, brown or black has bee Ind o à
‘epee of iter pape
“amined wi an otscope, ner appears as back
head mento growth A. umi spe Be or
een and Candida ss wie or eeamy dept, Mes
Si app sodden, ed amd ondematos
“rent onto hor er ot rem all
charge and pion dns which ate conducive 10
the gro ol Tangas. can be done by singing suc.
ton or mopping Specie anttangl agents cn be ap
pid. Nystatin {100,000 unis of propyene ca)
À ce agit Can, Other bond apct an
fungal agent include coimas and povidone odie
‘wo percent sally aed in alcool ao fective.
iss tot agent which removes perl ayers of
“permis and along with thatthe fungal myec gro
igi them, AN wesent shuld be contac
fota week even ster apparent cue to avoid roues.
Ear mus be ep dy. Btn infections ae often amo
ed with otomyeous and teste wth an abel
Sterol preparation heps to rede iflammaton and
dma and thus permitting better penis of an
fg a.
(0) Ours Extra Harwonmnacien. Is character
Tae by formation of haemorrhage bullae on te ty.
panic membrane and deep meatus Its probably vial
In origin and may be seen In influenza epidemics. The
ondiion cases severe pain in the ear and blood stained
üscharge when the bullae rupee Treatment with ale
gels Is lected 10 give rele rom pain. Anti are
ven for secondary infection of the ae canal, or middle
ar the balla has raptor into the mide ei.
(9 Henves Zosren Omeus. Is characterized by forms
Hon of vesicles on the tympanic membrane, metal kn,
«concha and postauricular groove. The Vil and VII
“rail nerves may be involved,
(9 Mauser (Nucnomzine) Orrris Extra Isar
Inammatory condition cased by pscudomonas inte
ton usually in the elderly abet, or in those on im.
munosuppressve drugs. cal manifestations resemble
‘hfs ott externa but there exerucating pain and
“appearance of granulatons in the car canal. Fac para
ysis common. Infection may spread to the shall base
“nd jugular foramen causing multiple cranial nerve pal
Sis. Antenor, infection spreads 10 temporomandibular
Chapter 8 — Diseases of Entemal Eur 55
ss, posteriorly to the mastoid and medial ino the
‘mid eat and petous bone.
Diggs. Severe ota in an dry abet patent
‘th grata ts the external car cana a te
{laginour-bony junction should ale the physician of
Deren otis extern, CT can may show Dany de
$trcton but often not hep Gallium 67 s more us.
{ulin dagnoss and follow-up of the patient. Ts taken
{up by monocytes and retculoendothtal cl, and isn
ale of st tate infection an be repeated every
Sesh to monitor the eve and response to atmen!
che 99 bone san eas bone infection ut
remains positive fora year or 30 and cannot be ud o
‘monitor the dea
“rent const of
(Control of diabetes
A Tot of car canal. Remove discharge, debris and
granultions or any dead tissue or bone
(i) Antibiotic treatment against causative organism,
"organismo which can be found y culture adsense
tity Abit treatment continue or 6-8 weeks,
Sometimes more Anibioi found ce are
Gentamicin combined with tcareilin They are
given intatenously. Gentamicin Is bots ototoxic
And nephrotoxic, and rein may produce pen:
ice reactions,
+ Third generation cephalosporins, eg. eetiaxone
1-2 glday bv or celazidime 1-2 gia Lv ae wt
ally combined with an aminoglycoside,
+ Quinolones (ciprofloxacin, ofloxacin and levo-
oxacin) ae als fective and can be given oral
‘They can be combined with lampin. Ciprolloxa.
«in 750 mg OD orally can be used. Oral therapy
‘nth quinolones obsats the need for admission
Fortarinjections
ll patent is not responsive, culture and senstvity’ of
(ar üscharge should guide the surgeon.
‘rolonged antibiotic treatment has replaced radical
surgery and resections done earlier fo his condition.
(6) Ecamatous Orrnis Extensis the result of by:
Dersens to infective organisms or topa car ops
Such as chloromyeetin or neomycin, ete Its marked by
Intense iitaton, vesicle formation, oozing and esting
{athe cal Treatment withdrawal of topical antibiotic
‘causing sensitivity and application of steroid cream,
{00 Semommnorte Oris EXTERSA. ts associated with
seborocie dermatitis ofthe Sal. thing i the main
Complaint. Greasy yellow seats ae seen In the external
‘anal, over te ul and postauriulr sulcus Treatment
Sonst ol ea talle, application of a cream containing
Sally acid and suite, and attention to the scalp for
born.
9 NIURODERMATTIS I is caused by compulsive
scratching due to Psychological factors. Patients main
Complaint ls intense Mching. Out externa o bacterial
{ype may follow infection of raw are ef by scratching.
Treatments sympathetic paychotherapy and that meant
{or any Secondary infection. Er pack and Dandage 10 the
‘ar are helpulto prevent compulsive scratching,
mebooksfree.com
$6 SECTION! Diese of far
9) Prato CHOLISTEATOMA or EXTERNAL AUDITORY
Can In contras to milde car cholesteatoma, que
‘mous epithelium of the external canal invades is bone
‘Usually there is some abnormality of bone of external ca
‘al which is conducive or epithelium to invade Te may
‘be posttraumatic or postsurgical. Clinical features include
purent ofrehoea and pain: tympanic membrane being
Bora. Granulations associated with saquestated Done
‘ed histoogial examination to diferente from care
‘noma, necotirng otitis externa and a benign sequstram,
“Treatment consists of removal oF necrotic bone and
holesteatoma, and ning the defect with asl,
D. TUMOURS
sons
E. MISCELLANEOUS CONDITIONS
2. Iupacten WAX on Centatex. Wax is composed of
Séeretion of sebaceous glands, ceruminous lands, hal,
‘esquamated epithelial debi, Keratn and dirt.
Sebaceous and ceruminous {modiied seat glands)
lands open into the space of the hal foie (is
res), Sebaceous glands provide luldich in fatty aci
wile seretion of eruminous gland isch in lipids and
Pigment granules Secretion of both these glands mixes
th the desquamated epithelia cells and keratin shed
om the tympanic membrane and deep bony ments to
form vax
"Wax has a protective function sit Jubricates the car
canal and enttaps any foreign material that happens to
fete the canal ag aie pH and ls bacteriostatic and
Fungi.
Normal, only a small amount of wax is secrete,
which dis up and is er expelled from the meats by
‘movements ofthe jaw. As some people sweat more than
‘others, the activity of ceaminows gland also var; e
Save wax may be seid and deposited as a plug in
{the meatus. Certain other factors Ike narow and tort
‘us ear cana, sf har or obstructive lesion of the canal,
exostosis may favour retention of wax IE may dry up
nd form à hard impacted mass
Patient usualy presents with impalement of heating
or sense o blocked eat Tinnitus and pales may result
Ron penesunomn
Sobacci et
Sera gem
Dr
from impaction of wax against the tympanic membrane,
Reflex cough dueto stimulation of auricular branch Of va
us may sometimes occur. The onset of the symptoms
may be sudden when water enter the ear canal during
Bathing or swimming and the wax swells up. Long sand.
Ing Impactos wax may ulerat the meatal Sn and sul
in granaloma formation (wae granulo
‘Treatment of wax consists in Is removal by yrining
‘or instrumental manipulation. Hard impacted mass may,
Sometimes require prior softening with wax solvents
Technique of singing the ear Patient s seated with car
to be syinged towards the examiner, A towel fe placed
round his neck, Line tay placed over Ihe shoulder
and held snugly by the patient. Patients head is slighty
Ud over the tay to coll the return fd
Finas pulled upseards and backwards and a stream of
water fom the car syringe directed along the poster»
Superior wall of the meatus, Pressure of watt, bull up
Seeper tothe Wa, expels the wax out ("sue 8.10
Iran sigh impacted I necessary to create a space
beiwocn and the meat wall for he jt Of water o pass
there singing il De inellcive or may even push
‘the wax deeper, Ear canal should be Inspected fom time:
Lo time to see all wax has Deen removed. Unnecessary
ring should be avoided.
AC the end ofthe procedure, ear canal and tympanic
membrane must be inspected and dled with a pledget
coton. Any Action Seen in mestl sala rosal
‘of impacted wax ls protected by application of suitable
Antibiotic ointment. Normal, bolle tap water cooled
{o body temperature s used. I Ii 100 cold oF 100 hot
1 would stimulate the labyinh, as in calorie testing,
Sind ease vertigo. Too much force usod in syringing may
rupture the ympanie membrane especialy when ft has
already been weakened by previous disease Patient com.
plains of intense pan and may become giddy and even
Hain. is necessary before singing to 0% the patient
forany past history of car discharge or an existing por
foration’ A qulesent ots meta may be reactivas by
ringing
Tsuen! manipulation. 1 should always be done
by shld hands and under direct vision, Cerumen hook,
Coop or Jona me pe ar oe usd Fi a pace
À crated between the wax and metal wall, the Int
ment is passed beyond the wax, and whole plug then
mebooksfree.com
9) Prato CHOLISTEATOMA or EXTERNAL AUDITORY
Can In contras to milde car cholesteatoma, que
‘mous epithelium of the external canal invades is bone
‘Usually there is some abnormality of bone of external ca
‘al which is conducive or epithelium to invade Te may
‘be posttraumatic or postsurgical. Clinical features include
purent ofrehoea and pain: tympanic membrane being
Bora. Granulations associated with saquestated Done
‘ed histoogial examination to diferente from care
‘noma, necotirng otitis externa and a benign sequstram,
“Treatment consists of removal oF necrotic bone and
holesteatoma, and ning the defect with asl,
D. TUMOURS
sons
E. MISCELLANEOUS CONDITIONS
2. Iupacten WAX on Centatex. Wax is composed of
Séeretion of sebaceous glands, ceruminous lands, hal,
‘esquamated epithelial debi, Keratn and dirt.
Sebaceous and ceruminous {modiied seat glands)
lands open into the space of the hal foie (is
res), Sebaceous glands provide luldich in fatty aci
wile seretion of eruminous gland isch in lipids and
Pigment granules Secretion of both these glands mixes
th the desquamated epithelia cells and keratin shed
om the tympanic membrane and deep bony ments to
form vax
"Wax has a protective function sit Jubricates the car
canal and enttaps any foreign material that happens to
fete the canal ag aie pH and ls bacteriostatic and
Fungi.
Normal, only a small amount of wax is secrete,
which dis up and is er expelled from the meats by
‘movements ofthe jaw. As some people sweat more than
‘others, the activity of ceaminows gland also var; e
Save wax may be seid and deposited as a plug in
{the meatus. Certain other factors Ike narow and tort
‘us ear cana, sf har or obstructive lesion of the canal,
exostosis may favour retention of wax IE may dry up
nd form à hard impacted mass
Patient usualy presents with impalement of heating
or sense o blocked eat Tinnitus and pales may result
Ron penesunomn
Sobacci et
Sera gem
Dr
from impaction of wax against the tympanic membrane,
Reflex cough dueto stimulation of auricular branch Of va
us may sometimes occur. The onset of the symptoms
may be sudden when water enter the ear canal during
Bathing or swimming and the wax swells up. Long sand.
Ing Impactos wax may ulerat the meatal Sn and sul
in granaloma formation (wae granulo
‘Treatment of wax consists in Is removal by yrining
‘or instrumental manipulation. Hard impacted mass may,
Sometimes require prior softening with wax solvents
Technique of singing the ear Patient s seated with car
to be syinged towards the examiner, A towel fe placed
round his neck, Line tay placed over Ihe shoulder
and held snugly by the patient. Patients head is slighty
Ud over the tay to coll the return fd
Finas pulled upseards and backwards and a stream of
water fom the car syringe directed along the poster»
Superior wall of the meatus, Pressure of watt, bull up
Seeper tothe Wa, expels the wax out ("sue 8.10
Iran sigh impacted I necessary to create a space
beiwocn and the meat wall for he jt Of water o pass
there singing il De inellcive or may even push
‘the wax deeper, Ear canal should be Inspected fom time:
Lo time to see all wax has Deen removed. Unnecessary
ring should be avoided.
AC the end ofthe procedure, ear canal and tympanic
membrane must be inspected and dled with a pledget
coton. Any Action Seen in mestl sala rosal
‘of impacted wax ls protected by application of suitable
Antibiotic ointment. Normal, bolle tap water cooled
{o body temperature s used. I Ii 100 cold oF 100 hot
1 would stimulate the labyinh, as in calorie testing,
Sind ease vertigo. Too much force usod in syringing may
rupture the ympanie membrane especialy when ft has
already been weakened by previous disease Patient com.
plains of intense pan and may become giddy and even
Hain. is necessary before singing to 0% the patient
forany past history of car discharge or an existing por
foration’ A qulesent ots meta may be reactivas by
ringing
Tsuen! manipulation. 1 should always be done
by shld hands and under direct vision, Cerumen hook,
Coop or Jona me pe ar oe usd Fi a pace
À crated between the wax and metal wall, the Int
ment is passed beyond the wax, and whole plug then
mebooksfree.com
Chapter 8 — Disease of Entemal Ear 57
re 8.10. (ration a ena) Moran Lo show ho at of water sp er bo
Sento pay ar gan,
tagged out in a single piece. It breaks, syringing may
‘beused to remove the gent.
‘Occasionally I the wax 5100 hard and Impacted, to
be removed by ssringing or instrament, hou be ot
{ened by drops of Sb sam bicarbonate in equal pats
‘of glycerine and water ised two or tree times a day
foea few days Hydrogen peroxide guid paraffin or olive
‘oll may also achieve the same result Commercial drops
Containing ceruminolyti agents like pardichloroben.
‘ene 2% can also be used and above methods te gain
2. FonuieN Bons or Ext. (a) Nonfvng. Children may
insert a variety of foreign bodies in the car, Ihe comma
‘ones often sen are a piece of paper or sponge, grin
Seeds rice, what, maze, slate pen, piece of chalk or
metallic ll bearings. An alt may present wit a Bro
Ken end of matchstick use for scratching the er or am
‘overlooked cotton sab, Vegetable foreign bodies end 10
Sell up with time and get üghüly impacted in the car
‘anal or may even suppurat.
‘Methods of removing a foreign body include:
Forceps removal
Singing
(il) Suetion
(19) Microscopi removal with special instru
(9) Postural approach
Soft ad ira foreign bodies ike a pie of pape,
ab or piece ofspongecan be removed with in rato.
‘ile ore Cure STD,
Most of the seed grains and smooth objects can be
removed with syrnging. Smooth and hard objects lke
‘tea all bearing should not be gasped with fone as
hey tend to move inwards and may ture the tympanic
membrane all impact foe Bes or in these wher
‘ier attempt at extraction have Bcn ma, fable
Lo use goal anaesthetic and un operating mince. Oe
<asionaly postal approach i sed to remove forlgn
bodies impacted in deep meatus, medial tothe sthmus or
those which have bee usted into the mide ar
Figure IN. other matt of wa fr body removal:
(secon (9 fraps emo
Unskled attempts at removal of foreign bodies may
lacerate the meatal lining, damage the tympanic me
brane or the ear asis
(©) Living. Flying or crawling insects ke mosquitos,
beets, cockroach of an ant may enter the car canal
and cause intense ration and pain (ite 3.12) No
Sttempt should be made to catch them alive. Fist the
sect should be killed by desing ola Household rem.
ay), sin or chloroform water. Once hile, the insect
‘an be removed by any of the methods described above,
Figure 8.12. Endoscopic vow a an ci er anal oro.
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re 8.10. (ration a ena) Moran Lo show ho at of water sp er bo
Sento pay ar gan,
tagged out in a single piece. It breaks, syringing may
‘beused to remove the gent.
‘Occasionally I the wax 5100 hard and Impacted, to
be removed by ssringing or instrament, hou be ot
{ened by drops of Sb sam bicarbonate in equal pats
‘of glycerine and water ised two or tree times a day
foea few days Hydrogen peroxide guid paraffin or olive
‘oll may also achieve the same result Commercial drops
Containing ceruminolyti agents like pardichloroben.
‘ene 2% can also be used and above methods te gain
2. FonuieN Bons or Ext. (a) Nonfvng. Children may
insert a variety of foreign bodies in the car, Ihe comma
‘ones often sen are a piece of paper or sponge, grin
Seeds rice, what, maze, slate pen, piece of chalk or
metallic ll bearings. An alt may present wit a Bro
Ken end of matchstick use for scratching the er or am
‘overlooked cotton sab, Vegetable foreign bodies end 10
Sell up with time and get üghüly impacted in the car
‘anal or may even suppurat.
‘Methods of removing a foreign body include:
Forceps removal
Singing
(il) Suetion
(19) Microscopi removal with special instru
(9) Postural approach
Soft ad ira foreign bodies ike a pie of pape,
ab or piece ofspongecan be removed with in rato.
‘ile ore Cure STD,
Most of the seed grains and smooth objects can be
removed with syrnging. Smooth and hard objects lke
‘tea all bearing should not be gasped with fone as
hey tend to move inwards and may ture the tympanic
membrane all impact foe Bes or in these wher
‘ier attempt at extraction have Bcn ma, fable
Lo use goal anaesthetic and un operating mince. Oe
<asionaly postal approach i sed to remove forlgn
bodies impacted in deep meatus, medial tothe sthmus or
those which have bee usted into the mide ar
Figure IN. other matt of wa fr body removal:
(secon (9 fraps emo
Unskled attempts at removal of foreign bodies may
lacerate the meatal lining, damage the tympanic me
brane or the ear asis
(©) Living. Flying or crawling insects ke mosquitos,
beets, cockroach of an ant may enter the car canal
and cause intense ration and pain (ite 3.12) No
Sttempt should be made to catch them alive. Fist the
sect should be killed by desing ola Household rem.
ay), sin or chloroform water. Once hile, the insect
‘an be removed by any of the methods described above,
Figure 8.12. Endoscopic vow a an ci er anal oro.
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58 SECTION! Dicas of far
Maggots the car. Flies may be ateacted to the low
smelling ar discharge and ay eggs which hach out into
larvae called maggots. They are commonly seen in the
month of August, September and October There is seve
pain with swelling found the car and blood stained wa:
{ery discharge. Maggots may be seen filing the ear canal,
Treatment consists of Insiling cHorolorm water to
fall the maggots, which can later Be removed by forceps,
Usually set patents have discharging ers with perfor
tion of the tympanie membrane and yringing may not
beadviable
3. Kenarosts Onrenass. Collection of ply white
‘nas of desquamated epithelial cll the deep meatus
le Keston bras. Th, by ts pressure ee,
uses absorption of bone Leading to widening of the
‘eats so much so that facial ner may De expose an
alyzed
(a) Acie eis commonly seen between 5 and
20 years amd may affect one or both eas. I may some
times be asoited sith bronchiectasis and Chrome e
‘nisi Normally epithelium from suce of tympanic
"membrane migrates nto the posteñor meatal wal al
Ac ofthis migration or mon to migration cad
by wax may lead to accumulation of the epithelia peg
In the deep ments
(0) China fortes. resenting symptoms may be pain
An the ea, ing 106, nites and sometimes cr dl
charge
Om examination, ear canal maybe ful o pay white
mas of keratin material disposed In several ayers Re
‘moval of tis mass muy show widening of bony meatus
(6) Toten. Keaton mas i removed either By sy:
singing or instrumentation similar to the techniques em
‘led for impact wax, Secondary oitisexterna may be
cent and shold be weated. Patt should be pao
Cay checked and any reaccumulations removed! Recut.
‘ence can be chelo some extent by the ane of ento
Mc agen such 3529 sale acid in alcohol
4. ACQUIRED ASIA AND STENOSIS oF MEATES. It can
slt tom
(6) Infections, eg. chronic otitis externa—an important
cause (ur 13.
Figure B13, Net senos folowing vo at exter
(©) Trauma, eg. lacerations, fracture of tympanic plate,
Surgery on ear canal or mastod
(6) Barmethermal or chemical
Treatment is meatoplasy. Using à postaral incision,
seat issue and thickened meatal skin are excised, bon
‘meatus Is enlarged and the raw meatal Done ls coveted
‘with pediced Maps fom meatus or spit skin graf.
IL, DISEASES OF TYMPANIC MEMBRANE
Diseases of tympanic membrane may be primary or sc-
‘ondary to conditions affecting exteral car nile car oF
estacion tube
‘Normal panic membrane, 1 is shiny and pearly
rey in colour with à concavity om its Lateral saco,
‘ore marked a the tp of malleus, e umbo. A begin
‘cone of light can be seen in the antroinerlor quadrant
(igure 8.13). At area les above the lateral process of
‘malleus ans sghty pinkish, Transparency var Some
middle ear structures can be seen through a transparent
‘membrane. A normal tympanic membrane is mobile
tne teste with pneumatic otoscope oF ele Spec
tum (Figure 814),
RernacteD Tirar Mestant It appa ll nd
stress Cone fights absent or interrupted. Hane of
ales appears freshortened Lateral proces of males
becomes more prominent. Anterior an posterior mall
folds become ekleshaped (gue 5 15): retractd ym
panic membrane fs the result of negative ntratympante
pressure when the eustachian tube is blocked,
2. Munineris BULLOSA, Its painful condition charac-
er y formation of hacmormhagie Debs on the ym.
fe membrane and deep meats. ts probably caused
Ey a virus or Mycoplasma ponia
Figure 234, Noma panic membrane a e eg Note a
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Maggots the car. Flies may be ateacted to the low
smelling ar discharge and ay eggs which hach out into
larvae called maggots. They are commonly seen in the
month of August, September and October There is seve
pain with swelling found the car and blood stained wa:
{ery discharge. Maggots may be seen filing the ear canal,
Treatment consists of Insiling cHorolorm water to
fall the maggots, which can later Be removed by forceps,
Usually set patents have discharging ers with perfor
tion of the tympanie membrane and yringing may not
beadviable
3. Kenarosts Onrenass. Collection of ply white
‘nas of desquamated epithelial cll the deep meatus
le Keston bras. Th, by ts pressure ee,
uses absorption of bone Leading to widening of the
‘eats so much so that facial ner may De expose an
alyzed
(a) Acie eis commonly seen between 5 and
20 years amd may affect one or both eas. I may some
times be asoited sith bronchiectasis and Chrome e
‘nisi Normally epithelium from suce of tympanic
"membrane migrates nto the posteñor meatal wal al
Ac ofthis migration or mon to migration cad
by wax may lead to accumulation of the epithelia peg
In the deep ments
(0) China fortes. resenting symptoms may be pain
An the ea, ing 106, nites and sometimes cr dl
charge
Om examination, ear canal maybe ful o pay white
mas of keratin material disposed In several ayers Re
‘moval of tis mass muy show widening of bony meatus
(6) Toten. Keaton mas i removed either By sy:
singing or instrumentation similar to the techniques em
‘led for impact wax, Secondary oitisexterna may be
cent and shold be weated. Patt should be pao
Cay checked and any reaccumulations removed! Recut.
‘ence can be chelo some extent by the ane of ento
Mc agen such 3529 sale acid in alcohol
4. ACQUIRED ASIA AND STENOSIS oF MEATES. It can
slt tom
(6) Infections, eg. chronic otitis externa—an important
cause (ur 13.
Figure B13, Net senos folowing vo at exter
(©) Trauma, eg. lacerations, fracture of tympanic plate,
Surgery on ear canal or mastod
(6) Barmethermal or chemical
Treatment is meatoplasy. Using à postaral incision,
seat issue and thickened meatal skin are excised, bon
‘meatus Is enlarged and the raw meatal Done ls coveted
‘with pediced Maps fom meatus or spit skin graf.
IL, DISEASES OF TYMPANIC MEMBRANE
Diseases of tympanic membrane may be primary or sc-
‘ondary to conditions affecting exteral car nile car oF
estacion tube
‘Normal panic membrane, 1 is shiny and pearly
rey in colour with à concavity om its Lateral saco,
‘ore marked a the tp of malleus, e umbo. A begin
‘cone of light can be seen in the antroinerlor quadrant
(igure 8.13). At area les above the lateral process of
‘malleus ans sghty pinkish, Transparency var Some
middle ear structures can be seen through a transparent
‘membrane. A normal tympanic membrane is mobile
tne teste with pneumatic otoscope oF ele Spec
tum (Figure 814),
RernacteD Tirar Mestant It appa ll nd
stress Cone fights absent or interrupted. Hane of
ales appears freshortened Lateral proces of males
becomes more prominent. Anterior an posterior mall
folds become ekleshaped (gue 5 15): retractd ym
panic membrane fs the result of negative ntratympante
pressure when the eustachian tube is blocked,
2. Munineris BULLOSA, Its painful condition charac-
er y formation of hacmormhagie Debs on the ym.
fe membrane and deep meats. ts probably caused
Ey a virus or Mycoplasma ponia
Figure 234, Noma panic membrane a e eg Note a
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Figure 15. Arent ympanc membrane
3. Heures Zosten Oricus. esa viel infection invols
ing geniculate ganglion of facial nerve. I is characte.
tae by appearance of vesicles on the tympanic men
brane, deep meatus, concha and retroauriular sucus.
It may Invole Vi (more often andthe VEN cranial
4. Muancrs GraNttosa, Nonspecific granuations
Form on the outer surface of tympani membrane. ma
be associated ith impacted war, longstanding ore
‘body or external ea infection,
5. Tune Rurrune, Tympanic membrane may be
ruptured by:
(a) Trauma due toa hal pn, matchstick or unskilled at
tempts to remove foreign boy
(0) Sudden change in ar pressure, eg. asap ora iso
ne car or a sudden Das Porcel Valse may ru.
urea thin arophie membrane,
{Pressure by auld column, e, diving watersports or
forceful singing
14) Fracture of temporal bone.
Chapter 8 — Disease of Extemal Ear 59
Treatment. In a majority of cases, edges of perforation
get inverted towards the middle ea In such cases, the car
Should be examined under operating microscope and the
‘les of pectoration repositioned and splinted (sep 46),
injuries of tympanic membrane may be associated
‘with facil paralysis or subluxation of tapes vertigo and
nystagmus) and sensorineural heating los In such eases,
‘gent exploration may be required.
6. Armor Tomas MewnRAne. À normal tympanic
‘membrane consis of outer epithe, middle Abrous and
Inner mucosal aye. In serous ots media, the mide
‘ros layer gets absorbed leaving a Lin drumhead which
cally gets collapsed with eustachian tube Insuficeney
À perforation of tympanic membrane also heals only by
7. RETRACTION Pockers AND ATELECTASI, When the
{ympanie membrane Is thin and atrophc a segment of
or the entire membrane may collapse invards dueto
ftstachian tube insufficiency. may form a reaction.
pocket or get plastered onto promontory and aso Wrap
round the asics. A deep retraction pocket may accumu,
Tate kratin deri and form a cholesteatoma,
8. Tyapanoseuenosts. Is hyalinization and ater cle
cation in the hrous ler 0
pars as cally white plague. Mostly remains asympeo
mati. Its frequently seen in cases of serous otis media
3 complican of ventilation tube. Tympanosceross
mostly affects tympane membrane but may be seen in
‘olving ligaments, joints of osiles, muscle tendons and
Submucosa layer of middle car et, and interes in the
‘conduction of sound
9. Prnvonsrt0%s. They may be central, tie or marginal
And are asotated with chronic ots media sep. 88),
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3. Heures Zosten Oricus. esa viel infection invols
ing geniculate ganglion of facial nerve. I is characte.
tae by appearance of vesicles on the tympanic men
brane, deep meatus, concha and retroauriular sucus.
It may Invole Vi (more often andthe VEN cranial
4. Muancrs GraNttosa, Nonspecific granuations
Form on the outer surface of tympani membrane. ma
be associated ith impacted war, longstanding ore
‘body or external ea infection,
5. Tune Rurrune, Tympanic membrane may be
ruptured by:
(a) Trauma due toa hal pn, matchstick or unskilled at
tempts to remove foreign boy
(0) Sudden change in ar pressure, eg. asap ora iso
ne car or a sudden Das Porcel Valse may ru.
urea thin arophie membrane,
{Pressure by auld column, e, diving watersports or
forceful singing
14) Fracture of temporal bone.
Chapter 8 — Disease of Extemal Ear 59
Treatment. In a majority of cases, edges of perforation
get inverted towards the middle ea In such cases, the car
Should be examined under operating microscope and the
‘les of pectoration repositioned and splinted (sep 46),
injuries of tympanic membrane may be associated
‘with facil paralysis or subluxation of tapes vertigo and
nystagmus) and sensorineural heating los In such eases,
‘gent exploration may be required.
6. Armor Tomas MewnRAne. À normal tympanic
‘membrane consis of outer epithe, middle Abrous and
Inner mucosal aye. In serous ots media, the mide
‘ros layer gets absorbed leaving a Lin drumhead which
cally gets collapsed with eustachian tube Insuficeney
À perforation of tympanic membrane also heals only by
7. RETRACTION Pockers AND ATELECTASI, When the
{ympanie membrane Is thin and atrophc a segment of
or the entire membrane may collapse invards dueto
ftstachian tube insufficiency. may form a reaction.
pocket or get plastered onto promontory and aso Wrap
round the asics. A deep retraction pocket may accumu,
Tate kratin deri and form a cholesteatoma,
8. Tyapanoseuenosts. Is hyalinization and ater cle
cation in the hrous ler 0
pars as cally white plague. Mostly remains asympeo
mati. Its frequently seen in cases of serous otis media
3 complican of ventilation tube. Tympanosceross
mostly affects tympane membrane but may be seen in
‘olving ligaments, joints of osiles, muscle tendons and
Submucosa layer of middle car et, and interes in the
‘conduction of sound
9. Prnvonsrt0%s. They may be central, tie or marginal
And are asotated with chronic ots media sep. 88),
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Page ot intentional blank
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Chapter 9
Eustachian Tube and Its Disorders
ANATOMY
Eustachian tub, also called auto o pansy mpanic
fb, connect naophryn with the parie ca I
An adult is about 36 mm long and uns downwards
forwards and medial fom its tympanic end, forming
an ange of 45" withthe Horizontal es ide Into
{we pars: Dry, wich I posterlteral, fons one hid
(12 mm) ofthe total england fbcartlagnoy which
15 anteromedal, forms Eos (24 mm The no
parte mt Ems which fs the men par ofthe
tube (suse #1). Te Hbeocatagious porto the tube
Is made of a single piece of carte folded pon Hse
in such a vay that forms the whole of media Lani
Tamina is made of brous membrane.
The ‘mpanic end of the tube is Bony, measures
52 mm and ls situated in the anterior wall of middle
a, te above the level of floor The plana! end of
the tube is sie, vertical. The catage a this end
rales an elevation called ons tubs, which is stuated
in te lateral wall ofthe nasopharyns, 11.25 em behind
the posterior end o inferior turbina.
STRUCTURE
MUSCLES RELATED TO EUSTACHIAN TUBE
(FIGURE 9.2)
"Tire muss are related to
levator vel plat
tbe: tensor vi alain,
and salpingopharyngeus. The medial
Fibres ofthe tensor vel paa are attached tothe atera
lamina of the tube and hen they contract help to open
the tuba lumen, These brs have also Den called dor
Tube muscle. The exact role ofthe Tevator vel alain
and the salpingopharyngeus muscles to open the tube 5
Uncertain {ts belived thatthe levator vel alain mus
de, which runs inferior and paralelo the eartlaginous
Par of the tube forms bulk under the med I
And during contraction pushes it upward and m
thus assting in opening the tube.
“he elastin hinges The crag, at th
(al, and atera lamina atthe wol, ri
‘which form a hinge. By ts roll lt helps to keep Ihe
Tube closed when no longer ated upon by dilator tube
muscle
‘Ostman’ pad oft. sa mass of fatty tissu rt
cd aterally to the membranous pat oF the carlainoss
tube. I lo helps to Keep the tbe closed and thus pro
tect om the feux of nasopharyngeal secretions
LINING OF THE EUSTACHIAN TUBE
Histologically the mucosa shows puewdostratifod ciated
columnas epithliam interspersed with mucoussecreting
goblet call submucosa, particularly inthe caraginous
pat ofthe tube, rc ero
beatin the diction of nat
ra secrets
naopharnx
NERVE SUPPLY
Tympante branch of cranial nerve (CN) IX supplies sen.
soy as wells patasympatheteseretomotor resto the
tubal mucosa, Tensor vel pati muscle supplied by
mandibular branch of tigeminal (3) nerve. Levator vel
Paitin’ and sapingopharyngeus muscles receive motor
‘herve supply throug phryagel plexus (rani part of
CN tough vagas,
DIFFERENCES BETWEEN THE INFANT AND
ADULT EUSTACHIAN TUBE
The eustachian tube of infants is wide shorter and more
horuontal thus infections Wom the nasopharynx can
ssl reach the mile cr. Even the milk may eegugltate
into the middle ar the infants are not fod in head
Poston Isle)
FUNCTIONS
Fhysiologialy, eustachian tube performs thre mu
functions
1. Ventilation and thus elation of mile ea pressure.
2. Protection against () nasopharyngeal sound pressure
and) ea of nasopharyngeal secretions.
4, Clearance of middle car seereions
1. VENTILATION AND REGULATION OF MIDDLE Ea
sure on two sides ofthe tympanic
qual: Negative or positivo pres nil car a
fects hearing. Ts, eustachian tube should open per
dial to equilbrate the ale pressure In the middle car
‘sth the ambient pressure, Normally, he eustachian tube
tent during sallow:
Ing yawning and sneezing. Posture as affects the fune
tion tubal opening ses cfiient in recumbent position
nd during steep due to venous engorgement, Tabl func
tion ao poor in infants and young children and thus
a
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Eustachian Tube and Its Disorders
ANATOMY
Eustachian tub, also called auto o pansy mpanic
fb, connect naophryn with the parie ca I
An adult is about 36 mm long and uns downwards
forwards and medial fom its tympanic end, forming
an ange of 45" withthe Horizontal es ide Into
{we pars: Dry, wich I posterlteral, fons one hid
(12 mm) ofthe total england fbcartlagnoy which
15 anteromedal, forms Eos (24 mm The no
parte mt Ems which fs the men par ofthe
tube (suse #1). Te Hbeocatagious porto the tube
Is made of a single piece of carte folded pon Hse
in such a vay that forms the whole of media Lani
Tamina is made of brous membrane.
The ‘mpanic end of the tube is Bony, measures
52 mm and ls situated in the anterior wall of middle
a, te above the level of floor The plana! end of
the tube is sie, vertical. The catage a this end
rales an elevation called ons tubs, which is stuated
in te lateral wall ofthe nasopharyns, 11.25 em behind
the posterior end o inferior turbina.
STRUCTURE
MUSCLES RELATED TO EUSTACHIAN TUBE
(FIGURE 9.2)
"Tire muss are related to
levator vel plat
tbe: tensor vi alain,
and salpingopharyngeus. The medial
Fibres ofthe tensor vel paa are attached tothe atera
lamina of the tube and hen they contract help to open
the tuba lumen, These brs have also Den called dor
Tube muscle. The exact role ofthe Tevator vel alain
and the salpingopharyngeus muscles to open the tube 5
Uncertain {ts belived thatthe levator vel alain mus
de, which runs inferior and paralelo the eartlaginous
Par of the tube forms bulk under the med I
And during contraction pushes it upward and m
thus assting in opening the tube.
“he elastin hinges The crag, at th
(al, and atera lamina atthe wol, ri
‘which form a hinge. By ts roll lt helps to keep Ihe
Tube closed when no longer ated upon by dilator tube
muscle
‘Ostman’ pad oft. sa mass of fatty tissu rt
cd aterally to the membranous pat oF the carlainoss
tube. I lo helps to Keep the tbe closed and thus pro
tect om the feux of nasopharyngeal secretions
LINING OF THE EUSTACHIAN TUBE
Histologically the mucosa shows puewdostratifod ciated
columnas epithliam interspersed with mucoussecreting
goblet call submucosa, particularly inthe caraginous
pat ofthe tube, rc ero
beatin the diction of nat
ra secrets
naopharnx
NERVE SUPPLY
Tympante branch of cranial nerve (CN) IX supplies sen.
soy as wells patasympatheteseretomotor resto the
tubal mucosa, Tensor vel pati muscle supplied by
mandibular branch of tigeminal (3) nerve. Levator vel
Paitin’ and sapingopharyngeus muscles receive motor
‘herve supply throug phryagel plexus (rani part of
CN tough vagas,
DIFFERENCES BETWEEN THE INFANT AND
ADULT EUSTACHIAN TUBE
The eustachian tube of infants is wide shorter and more
horuontal thus infections Wom the nasopharynx can
ssl reach the mile cr. Even the milk may eegugltate
into the middle ar the infants are not fod in head
Poston Isle)
FUNCTIONS
Fhysiologialy, eustachian tube performs thre mu
functions
1. Ventilation and thus elation of mile ea pressure.
2. Protection against () nasopharyngeal sound pressure
and) ea of nasopharyngeal secretions.
4, Clearance of middle car seereions
1. VENTILATION AND REGULATION OF MIDDLE Ea
sure on two sides ofthe tympanic
qual: Negative or positivo pres nil car a
fects hearing. Ts, eustachian tube should open per
dial to equilbrate the ale pressure In the middle car
‘sth the ambient pressure, Normally, he eustachian tube
tent during sallow:
Ing yawning and sneezing. Posture as affects the fune
tion tubal opening ses cfiient in recumbent position
nd during steep due to venous engorgement, Tabl func
tion ao poor in infants and young children and thus
a
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62 SECTION! Diese of far
responsible for more cr problems in that age group. normal hearing, Normally, the eustachian tube remains
‘uly normalizes bythe age of 7-10 years “dose and protects the middle ear against these sounds.
À normal eustachian tube also protects the mide ear
2. Pnotscrive FUNCTIONS. Abnormally, high sound fom teles of asophayngelseteions sto the middle
pressures fem the nasophaeynx can be transmitted to eae This rl occus more ready ithe tube is wide in
the middle ear Ifthe tube I open thus Interfering with diameter patuous tube), shor in length (a In able) or
the tympanic membrane i perforated (cause or pers.
tence of mide ea infections in caes of ympanie mem.
brane perforations.
High pressures in the nasopharynx canals force na.
(of adenoids or ilateral nasal ebstection.
ÓN Tea 3. CLIARANCE OF MIDDLE Baw SteRETIONS. Mucous
membrane of the custachian tube and anterior part of
lo Te
cepa gim the mie car 5 lined by ciated column
‘ila beatin the direction of nasopharynx. This helps
Ko clear the sections and debis In the middle eat tor
Ward the nasopharyns. The clearance function i fut.
ss ther augmented y acte opening and closing ofthe
foment EUSTACHIAN TUBE FUNCTION TESTS
1. Vasatva Test. The principle of this est, as also of
Figure 91. Var section tough he uta tube sowing _politeivaton, 1 o Du postive pressure In the puso:
Fay clon mas Ion nd Pare Par so tar enters the eustachian tube, To dots
Toner va pats
cru mnt)
\
gare 9.2. etc cn oa thin a, Nate Cage eue ors al roc a ar atra wal si at
ru acon ol eal ond nera aná hs me neo rep lana poston sue (A) schon he
ose nena potion (be à open an er ve pain (nr ud) muse Cot
ant ‘A
Length 13-18 mm ti bout Pl sorgo) Some (3-38 mm
CA Morehonona A br rm nl at 10” Fa a ange oth ehrt
hte or tape Yana AS"
gun asus Do onguton rogar
any ses agus pon By at Sgh lenge tan one bi theory pn e Cris par wo is
‘alginate be and yy ee
a ge ci Reto ru nas Compantiay gi Remains dosed and protect
norton oca ‘hema sin rue
Deny sin tt hinge LS dns Le doesnt tient cy eal Deny ls mare and ps hep the ube
sed by ellos
ss os ot Lesin ome Large and ps weep eae dosed
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responsible for more cr problems in that age group. normal hearing, Normally, the eustachian tube remains
‘uly normalizes bythe age of 7-10 years “dose and protects the middle ear against these sounds.
À normal eustachian tube also protects the mide ear
2. Pnotscrive FUNCTIONS. Abnormally, high sound fom teles of asophayngelseteions sto the middle
pressures fem the nasophaeynx can be transmitted to eae This rl occus more ready ithe tube is wide in
the middle ear Ifthe tube I open thus Interfering with diameter patuous tube), shor in length (a In able) or
the tympanic membrane i perforated (cause or pers.
tence of mide ea infections in caes of ympanie mem.
brane perforations.
High pressures in the nasopharynx canals force na.
(of adenoids or ilateral nasal ebstection.
ÓN Tea 3. CLIARANCE OF MIDDLE Baw SteRETIONS. Mucous
membrane of the custachian tube and anterior part of
lo Te
cepa gim the mie car 5 lined by ciated column
‘ila beatin the direction of nasopharynx. This helps
Ko clear the sections and debis In the middle eat tor
Ward the nasopharyns. The clearance function i fut.
ss ther augmented y acte opening and closing ofthe
foment EUSTACHIAN TUBE FUNCTION TESTS
1. Vasatva Test. The principle of this est, as also of
Figure 91. Var section tough he uta tube sowing _politeivaton, 1 o Du postive pressure In the puso:
Fay clon mas Ion nd Pare Par so tar enters the eustachian tube, To dots
Toner va pats
cru mnt)
\
gare 9.2. etc cn oa thin a, Nate Cage eue ors al roc a ar atra wal si at
ru acon ol eal ond nera aná hs me neo rep lana poston sue (A) schon he
ose nena potion (be à open an er ve pain (nr ud) muse Cot
ant ‘A
Length 13-18 mm ti bout Pl sorgo) Some (3-38 mm
CA Morehonona A br rm nl at 10” Fa a ange oth ehrt
hte or tape Yana AS"
gun asus Do onguton rogar
any ses agus pon By at Sgh lenge tan one bi theory pn e Cris par wo is
‘alginate be and yy ee
a ge ci Reto ru nas Compantiay gi Remains dosed and protect
norton oca ‘hema sin rue
Deny sin tt hinge LS dns Le doesnt tient cy eal Deny ls mare and ps hep the ube
sed by ellos
ss os ot Lesin ome Large and ps weep eae dosed
mebooksfree.com
tes, patient pinches his nose between the |
‘dex finger takes deep breath, closes his mouth and wies
to blow ai int the cas air entes the middle car, the
tympanic membrane will move outwards, which can be
‘ated by otoscope or the microscope. ln the presence
of a tympanic membrane perforation, a hising sound
15 produced or i ischarge also present In the middle
a, cracking sound wil De heard. allure ofthis test does
hot prove blockage ofthe tube because only about 68%
of persons can succesfully perform this test. This test
Should be avoided 0) In the presence of atrophi sear of
tympanic membrane which can rupture and (i) in the
Presence of infection of nose and aasparyns where in
fected secretions ae key to be pushed into the mide
ar causing tts media.
2. Pousrzen Test. This testis done in children who ae
unable to perform Valsalva test. In this es, live shape
Up of the Politzer’ bag is introduced into the patients
host on the side of which the tubal function 1 desired
toe teste. Other ost is closed, and the bag com
pressed while atthe same time the patient swallows (he
an be given ps of water orsays ik ik, IK BY MEARS Of
an auscultation tube, connecting the patient car under
testo that of the examiner, a hissing sound is heard it
tube is patent. Compressed ar can aso be sed instead
of Polivers bag. The ts 6 also used therapeutically 10
entité the mid eae
3. Cammerunszarıon. In this est, nose ls fst anesthe
died by topical spray of lignocaine and then a eustachian
tube catheter, the tp of which ls bent is passed along the
Moor of nose alt reaches the nasopharynx. Hee i 0
tated 0" medially and gradualy pulled buck Ul tenga
Son the posterior border of nasal septum (ise.
TES nn fated 180° laterally so thatthe tp les against
the tubal opening (suse 938). A Polite’ bags now
‘connected fo the catheter and ar insulated. Entry ofr
into the middle car Is vered by an auscutation tube.
The procedure of eathetertion should be gente as is
‘nove 10 cause complications such as
10) Injury to eustachian tube opening which causes scar
ring ater.
cu
sali
(Chapter 9 — Eustachian Tube ands Diodes 63
(D) Meeting om the nose
(9 Transmision of nasal and nasopharyngeal infection
Into the middle car causing ots medi
(9 Rupture of atophie arca of tympanic membrane if
190 much presse used
44, Torwner’s Test, While the above thie tests use à
positive pressure, Toynbee manoeuvre causes negative
Dresure. ia more physiological es Iti performed
by asking the patient to swallow while nose has bee
Pinched. This draws al rom the middle car Into the na
Sopharyn and causes inward. movement of tympanic
‘membrane, which is verd by the examiner OP.
ally or wih a microscope
5. Twwranowrrny (Atso CaLLED INHLANON-DEANOS
‘Tesi inthis tet postive and negative presu ar ce
tan the external car anal a th
peat Te abit ofthe tube to egulbratepetive and
‘negative pressure to the ambient Pressure indicates nor
‘na tba function, Me tet cam be done Bot
‘sith perforated or inact tympan membranes (ie p20,
6. RADIOLOGICAL Test, A radiopaque dye, «by:
aque or pol instilled ino the mide cr through à
preexisting perforation and Xrays taken should deine:
At the tube and any obstucton. The time taken by the
‘ye to each the nasopharyny also indiats its clearance
function, This test fo longer popular now.
7. SaccwAMINE OR METHYLENE BLUE Test. Sacharine
solution is placed into the middle car through a pre:
[sting perforation. The time taker by eto reach the phar
syne and imparta set taste also à mure clearance
Funcion.
Similar, methylene blue dye an be
‘mille ea and he ine taken by € 0
seal secretions can be noted
direct evidence of drsinge/ccorance function is +
tablished when car dops insted into the ear wa ym
Panic membrane perforation cause bad taste in threat.
tilled into the
re phar
8. Soxorunowerny. À tone i presente to the nose and
A6 recording taken from the extemal canal. The tone Is
À
y
igre 9.2. Cate e cta be ae tx
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‘dex finger takes deep breath, closes his mouth and wies
to blow ai int the cas air entes the middle car, the
tympanic membrane will move outwards, which can be
‘ated by otoscope or the microscope. ln the presence
of a tympanic membrane perforation, a hising sound
15 produced or i ischarge also present In the middle
a, cracking sound wil De heard. allure ofthis test does
hot prove blockage ofthe tube because only about 68%
of persons can succesfully perform this test. This test
Should be avoided 0) In the presence of atrophi sear of
tympanic membrane which can rupture and (i) in the
Presence of infection of nose and aasparyns where in
fected secretions ae key to be pushed into the mide
ar causing tts media.
2. Pousrzen Test. This testis done in children who ae
unable to perform Valsalva test. In this es, live shape
Up of the Politzer’ bag is introduced into the patients
host on the side of which the tubal function 1 desired
toe teste. Other ost is closed, and the bag com
pressed while atthe same time the patient swallows (he
an be given ps of water orsays ik ik, IK BY MEARS Of
an auscultation tube, connecting the patient car under
testo that of the examiner, a hissing sound is heard it
tube is patent. Compressed ar can aso be sed instead
of Polivers bag. The ts 6 also used therapeutically 10
entité the mid eae
3. Cammerunszarıon. In this est, nose ls fst anesthe
died by topical spray of lignocaine and then a eustachian
tube catheter, the tp of which ls bent is passed along the
Moor of nose alt reaches the nasopharynx. Hee i 0
tated 0" medially and gradualy pulled buck Ul tenga
Son the posterior border of nasal septum (ise.
TES nn fated 180° laterally so thatthe tp les against
the tubal opening (suse 938). A Polite’ bags now
‘connected fo the catheter and ar insulated. Entry ofr
into the middle car Is vered by an auscutation tube.
The procedure of eathetertion should be gente as is
‘nove 10 cause complications such as
10) Injury to eustachian tube opening which causes scar
ring ater.
cu
sali
(Chapter 9 — Eustachian Tube ands Diodes 63
(D) Meeting om the nose
(9 Transmision of nasal and nasopharyngeal infection
Into the middle car causing ots medi
(9 Rupture of atophie arca of tympanic membrane if
190 much presse used
44, Torwner’s Test, While the above thie tests use à
positive pressure, Toynbee manoeuvre causes negative
Dresure. ia more physiological es Iti performed
by asking the patient to swallow while nose has bee
Pinched. This draws al rom the middle car Into the na
Sopharyn and causes inward. movement of tympanic
‘membrane, which is verd by the examiner OP.
ally or wih a microscope
5. Twwranowrrny (Atso CaLLED INHLANON-DEANOS
‘Tesi inthis tet postive and negative presu ar ce
tan the external car anal a th
peat Te abit ofthe tube to egulbratepetive and
‘negative pressure to the ambient Pressure indicates nor
‘na tba function, Me tet cam be done Bot
‘sith perforated or inact tympan membranes (ie p20,
6. RADIOLOGICAL Test, A radiopaque dye, «by:
aque or pol instilled ino the mide cr through à
preexisting perforation and Xrays taken should deine:
At the tube and any obstucton. The time taken by the
‘ye to each the nasopharyny also indiats its clearance
function, This test fo longer popular now.
7. SaccwAMINE OR METHYLENE BLUE Test. Sacharine
solution is placed into the middle car through a pre:
[sting perforation. The time taker by eto reach the phar
syne and imparta set taste also à mure clearance
Funcion.
Similar, methylene blue dye an be
‘mille ea and he ine taken by € 0
seal secretions can be noted
direct evidence of drsinge/ccorance function is +
tablished when car dops insted into the ear wa ym
Panic membrane perforation cause bad taste in threat.
tilled into the
re phar
8. Soxorunowerny. À tone i presente to the nose and
A6 recording taken from the extemal canal. The tone Is
À
y
igre 9.2. Cate e cta be ae tx
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64 SECTION! — Discos of far
‘near ouder when Hewes patent (compare paul eae
tachan tube) I lo tls the duration for which the tube
remains open. is a noninvasive technique and provides
information on active taal opening Accor! sounds
produced in the nasopharyn, during swallowing, may in.
{ever with the txt elt The tet under development
DISORDERS OF EUSTACHIAN TUBE
1. TUBAL BLOCKAGE Normally, eustachian tube is
closed opens intermittent during swallowing awn.
Ingand sneezing though the active contraction of tensor
vel plan musce Al, composed of oxygen, carton dl
‘oxide nitrogen and water vapour normally ils
¿ler and mastoid. When tubeis blocked, st oxygen is
bsorbed, but later other gases, COs and nitrogen also di
fase out into the blood. This results in negative presse
in the middle car and retraction of tympanic membrane
I negative pressure I Sl farther increased, teases
“rocking” of the tube with collection of tansudste and
Later exudate and even haemorthage. fects of acute and
mg term tual blockage are shown in able 92.
ustachian tube abstraction can be mechanical, fune»
tional or both. chanical abstraction can result from
AD intense cases suc as inflammation or allergy or)
extinto causes such a tumour in the nasopharynx or
‘Mlenoids. Function! obsintion caused by collapse ol
the tube due to increased cartilage compliance, which re
Sits opening ofthe tube or lu of active tual opening
mechanism due to poor Function of tensor vel alain
The common clinical conditions which can cause tual
obstruction are listed in Table.
‘Symptom of tubal occlusion include otlga, which
‘may be mild to severe, hearing los, popping sensation,
tinnitus and disturbances of equilibrio or even vertigo.
Signs of tubal occlusion will vary and depend upon
the acutenes ofthe condition and severity. They include
non pus
eg pee
Den
:
ntm D
rent
yom ee)
ern
tarados
roo of cooper
de: TM MIL an,
Upper repair econ ror bos)
qe
retracted tympanic membrane, congestion along, the
handle of males and the pas tens, wansudate behind
the tympanic membrane, imparting it an amber colour
and sometimes ald level with conductive heaeng loss
In severe ass, as in arotauma, tympanic membrane
ls marked retracted with acmorages in subepithelial
layer hacmotympanum or sometimes perforation
2. ADINOWS AND EUSTACINAN TUBE FUNCHION. Ade
folds case tubal dysfunction by:
(6) Mechanical obstruction ofthe tuba opening.
(0) Acting as reservoir for pathogenic organisms
(e) In eases of ale, mast els ofthe adenoid Hs re.
[ease inlamımatory medators which cause tubal lock
ax.
‘Thus, adenoids can cause ots media with effusion
or recurrent acute outs meda. Adenoidectomy can help
both these conditions.
3. Guerr PALATE AND Tuna FUNCTION. Tubal funcion
is stud in ef palate patients duet:
(a) Abnormalities of tors tubarus, which shows high
{ati density making tube dificult o open
0) Tensor vel palta muscle does not insert ino the
tons bars in 0% cases ol cet palate and where
It docs inser its function I poo
Otis media with effusion is common in these par
tients. Even after repair oF the cleft plate defor,
‘many of them requir insertion of grommets to vente
ine middle ee,
4. Dow Stxoxowr asp Tunat. Fuxcnion. Function of
cistachian tube Is defective possibly due to poor tone of
tensor vl patti) muscle and abnormal shape of aso:
playa: Children with this syndrome are prone o Ke.
{quent tits media or otitis media with effusion,
5. Bawornatat. Se p.71
RETRACTION POCKETS AND EUSTACHIAN
TUBE
In ventilation of the mide ea clef, air passes from eus
tachlan tube to mesotympanum, rom there toate al
vis, antrum and mastodaircellsystem. Mesotympanum
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‘near ouder when Hewes patent (compare paul eae
tachan tube) I lo tls the duration for which the tube
remains open. is a noninvasive technique and provides
information on active taal opening Accor! sounds
produced in the nasopharyn, during swallowing, may in.
{ever with the txt elt The tet under development
DISORDERS OF EUSTACHIAN TUBE
1. TUBAL BLOCKAGE Normally, eustachian tube is
closed opens intermittent during swallowing awn.
Ingand sneezing though the active contraction of tensor
vel plan musce Al, composed of oxygen, carton dl
‘oxide nitrogen and water vapour normally ils
¿ler and mastoid. When tubeis blocked, st oxygen is
bsorbed, but later other gases, COs and nitrogen also di
fase out into the blood. This results in negative presse
in the middle car and retraction of tympanic membrane
I negative pressure I Sl farther increased, teases
“rocking” of the tube with collection of tansudste and
Later exudate and even haemorthage. fects of acute and
mg term tual blockage are shown in able 92.
ustachian tube abstraction can be mechanical, fune»
tional or both. chanical abstraction can result from
AD intense cases suc as inflammation or allergy or)
extinto causes such a tumour in the nasopharynx or
‘Mlenoids. Function! obsintion caused by collapse ol
the tube due to increased cartilage compliance, which re
Sits opening ofthe tube or lu of active tual opening
mechanism due to poor Function of tensor vel alain
The common clinical conditions which can cause tual
obstruction are listed in Table.
‘Symptom of tubal occlusion include otlga, which
‘may be mild to severe, hearing los, popping sensation,
tinnitus and disturbances of equilibrio or even vertigo.
Signs of tubal occlusion will vary and depend upon
the acutenes ofthe condition and severity. They include
non pus
eg pee
Den
:
ntm D
rent
yom ee)
ern
tarados
roo of cooper
de: TM MIL an,
Upper repair econ ror bos)
qe
retracted tympanic membrane, congestion along, the
handle of males and the pas tens, wansudate behind
the tympanic membrane, imparting it an amber colour
and sometimes ald level with conductive heaeng loss
In severe ass, as in arotauma, tympanic membrane
ls marked retracted with acmorages in subepithelial
layer hacmotympanum or sometimes perforation
2. ADINOWS AND EUSTACINAN TUBE FUNCHION. Ade
folds case tubal dysfunction by:
(6) Mechanical obstruction ofthe tuba opening.
(0) Acting as reservoir for pathogenic organisms
(e) In eases of ale, mast els ofthe adenoid Hs re.
[ease inlamımatory medators which cause tubal lock
ax.
‘Thus, adenoids can cause ots media with effusion
or recurrent acute outs meda. Adenoidectomy can help
both these conditions.
3. Guerr PALATE AND Tuna FUNCTION. Tubal funcion
is stud in ef palate patients duet:
(a) Abnormalities of tors tubarus, which shows high
{ati density making tube dificult o open
0) Tensor vel palta muscle does not insert ino the
tons bars in 0% cases ol cet palate and where
It docs inser its function I poo
Otis media with effusion is common in these par
tients. Even after repair oF the cleft plate defor,
‘many of them requir insertion of grommets to vente
ine middle ee,
4. Dow Stxoxowr asp Tunat. Fuxcnion. Function of
cistachian tube Is defective possibly due to poor tone of
tensor vl patti) muscle and abnormal shape of aso:
playa: Children with this syndrome are prone o Ke.
{quent tits media or otitis media with effusion,
5. Bawornatat. Se p.71
RETRACTION POCKETS AND EUSTACHIAN
TUBE
In ventilation of the mide ea clef, air passes from eus
tachlan tube to mesotympanum, rom there toate al
vis, antrum and mastodaircellsystem. Mesotympanum
mebooksfree.com
‘communicates with the attic via anterior and posterior
Isthn, situated in membranous diaphragm between the
mesonympanum and the atc. Anterior im sit
ted teen tendon of tensor tympani and the stapes.
Posterior isthmus is situated between tendon of sapedhus
muscle and pyramid, and the short process of incu. In
Some case, Middle car can aso communicate directly
‘withthe mastld air cells through the rewofacal cel
Any obstruction in the pathways of w
suse reaction pockets or atelectasis tympanic men
brane, eg:
braco of eustachian tube = Total atest of
2. Obtuation im md ar» Retraction pocket in poste
‘or par fm ar hi neo ar vente.
3. Oisracton of tm At rio pocket,
4 Obstucion at dis => Cholesterol granuloma and
Collection of mucoid sarge in masold alr cel
‘whe mile cr and ati appear normal
Depending on the location of pathologic proces, ot
er changes such as thin atopic tympanic membrane,
Pata or total (due to absorption of middle brows lye),
‘holesteatom ossicular necrosis and ympanoxcirot
‘changes may ls be found,
Principles of management of reaction pockets and
atelectasis of middle ear would ental coreeion ep of
the reversible pathologic procesos and establishment of
the ventilation
PATULOUS EUSTACHIAN TUBE
In his condition, the eustachian tube is abnormally pat
ent Most ofthe time tis dlopathle ut api weight os,
pregnancy especially third trimester, or multiple lero
"Patents chief complaints are hearing his own voice
{astophony, even hi own breath sounds which is very
<isurbing, Due to abnormal potency, pressure changes
Inthe nasopharyns ar easly ann td tothe middle
ar so much so that the movements of tympanic ean be
Seem with inspiration and expiration; these movements
fave futher exaggerated If patient breathes after loin
‘Acute condition of patulous tube is self-limiting and
does not require tatment. In offers, weight gal oral
Chapter 9 — Eustachian Tube ands Diordes 65
administation of potassium iodide is helpful but some
Tongstanding cases may require cautenkaton of the
tubes or insertion ofa grommet
EXAMINATION OF EUSTACHIAN TUBE
‘Pharyngea end ofthe eustachian tube can be examined
by posterior minoscopy, gd nasal endoscope or flexible
nasopiarymgoscope The ANS causes which obstruct
thisend cn de excluded (re 9).
“Tympani end ofthe tube can be examined by mico:
scope or endoscope, I theres a pre-existing pronation
Eustachian tube endoscopy or mide ear endoscopy can
done with very ne exile endoscopes. Simple exam
Scope may teva reaction pokes id inthe mile
ts Simiay, movements of tympanic membrane ith
‘espiration point to ptulous eustachian tubo
Further assesses of function ofthe tube an be made
by Vabalva, politereatin, Toynbee and other test a
ready described
Atl causes of eustachian tube dysfunction can be
asec by thorough nasal examination including endo
copy test of llego, CT scan of temporal bones and of
faranasal sinuses. MÍ may be required to exclude mull:
Die sclerosis in patulows eustachian tbe
Figure 94 Endoop oo nsopay rong tus batas
Inthe ng ia va of noun Ree ao he fons of ere
con d'écrans nope
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Isthn, situated in membranous diaphragm between the
mesonympanum and the atc. Anterior im sit
ted teen tendon of tensor tympani and the stapes.
Posterior isthmus is situated between tendon of sapedhus
muscle and pyramid, and the short process of incu. In
Some case, Middle car can aso communicate directly
‘withthe mastld air cells through the rewofacal cel
Any obstruction in the pathways of w
suse reaction pockets or atelectasis tympanic men
brane, eg:
braco of eustachian tube = Total atest of
2. Obtuation im md ar» Retraction pocket in poste
‘or par fm ar hi neo ar vente.
3. Oisracton of tm At rio pocket,
4 Obstucion at dis => Cholesterol granuloma and
Collection of mucoid sarge in masold alr cel
‘whe mile cr and ati appear normal
Depending on the location of pathologic proces, ot
er changes such as thin atopic tympanic membrane,
Pata or total (due to absorption of middle brows lye),
‘holesteatom ossicular necrosis and ympanoxcirot
‘changes may ls be found,
Principles of management of reaction pockets and
atelectasis of middle ear would ental coreeion ep of
the reversible pathologic procesos and establishment of
the ventilation
PATULOUS EUSTACHIAN TUBE
In his condition, the eustachian tube is abnormally pat
ent Most ofthe time tis dlopathle ut api weight os,
pregnancy especially third trimester, or multiple lero
"Patents chief complaints are hearing his own voice
{astophony, even hi own breath sounds which is very
<isurbing, Due to abnormal potency, pressure changes
Inthe nasopharyns ar easly ann td tothe middle
ar so much so that the movements of tympanic ean be
Seem with inspiration and expiration; these movements
fave futher exaggerated If patient breathes after loin
‘Acute condition of patulous tube is self-limiting and
does not require tatment. In offers, weight gal oral
Chapter 9 — Eustachian Tube ands Diordes 65
administation of potassium iodide is helpful but some
Tongstanding cases may require cautenkaton of the
tubes or insertion ofa grommet
EXAMINATION OF EUSTACHIAN TUBE
‘Pharyngea end ofthe eustachian tube can be examined
by posterior minoscopy, gd nasal endoscope or flexible
nasopiarymgoscope The ANS causes which obstruct
thisend cn de excluded (re 9).
“Tympani end ofthe tube can be examined by mico:
scope or endoscope, I theres a pre-existing pronation
Eustachian tube endoscopy or mide ear endoscopy can
done with very ne exile endoscopes. Simple exam
Scope may teva reaction pokes id inthe mile
ts Simiay, movements of tympanic membrane ith
‘espiration point to ptulous eustachian tubo
Further assesses of function ofthe tube an be made
by Vabalva, politereatin, Toynbee and other test a
ready described
Atl causes of eustachian tube dysfunction can be
asec by thorough nasal examination including endo
copy test of llego, CT scan of temporal bones and of
faranasal sinuses. MÍ may be required to exclude mull:
Die sclerosis in patulows eustachian tbe
Figure 94 Endoop oo nsopay rong tus batas
Inthe ng ia va of noun Ree ao he fons of ere
con d'écrans nope
mebooksfree.com
Page ot intentional blank
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Chapter 10
Disorders of Middle Ear
ACUTE SUPPURATIVE OTITIS MEDIA
I is an acute inflammation of middle car by pyogenic
‘organisms. Here, middle car implies mide ar dit, Le
<ustachian tube, middle ear, ati, aus, antrum and
mastoid ae cll
AETIOLOGY
Its more common especially in infants and children of
lower socioeconomic group. Typical the disease follows
‘ial tntecion of upper respiratory tac but soon the po
‘genic organisms invade the middle cur.
ROUTES OF INFECTION
1. VIA EXSTACHIAN TUNE, I the most common route
Infection teves vi the lamen ofthe tube or along ab
‘epithelia pertuballymphats. Eustachian tube in nants
“nd young ehren & shorter wider amd more horiontal
“nd thus may account for higher incidence of infections
this age group, Breast or bole feeding in a young Infant
in horn postion may force Mus through tube
Into the middle car and hence the ned to keep the infant
Propped up sth hed ite higher Simming and diving
‘Canalo force water though the tube int he mile ar
2. VIA EXTERNAL Ean. Traumatic perforations of tym
panic membrane due o any cause open route to middle
rinfection
3. Bioon-Bonst. This san uncommon route.
PREDISPOSING FACTORS.
Anything that interferes with normal functioning of us
tachian tube predisposes to mide ar infection. It could
1. Recurent attacks of common cold, upper respiratory
{tact infections and exanthematous fevers ke mes
sles, diphtheria or whooping cough
Iniections of tonsils and adenoids
Chronic rhinitis and sinus
at allergy
mous of nasopharynx, packing of nose or naso-
pharynx for pistas
6, Cie palate
BAcTERoLoGy. Most common organisms in infants
and young children are Srptcacus prewnonie (30%),
Hacmopilasinflunane (20%) and Moraxeia catarrhalis
(135) Other omantsms include Stpiwoccus pyogenes,
Stapiiocacs auras and sometimes Flament argh
‘non In abot 18-20%, no growth is sen. Many strains of
at and M cata ae lactamase producing.
PATHOLOGY AND CLINICAL FEATURES
‘The disease runs through the following stages:
1. STAGE or TUnAL OCCLUSION. Oslema and hype
‘nia Of nasopharyngeal end of eustachian tube blocks the
{ube leading to absorption of air and negative intatyi
panic presse, There retraction of tympanic membrane
{sith some degree of cion inthe middle car but ud
may not be clinical appreciable.
“Symptoms, Deafnes and earache ar the two symptoms
ut they are not marked. There ls generally no fever
‘gms. Tympunic membrane fs retracted with handle
of malleus assuming a more horizontal postion, promi:
‘hence a tea process of malleus aná os of light eles.
‘Tuning fork test show conductive deafness
2. Stok oF Paeserremarion. If tuba ocluson is pro-
Tonge pyogente organisms invade tympanic cavity sus
ing hyperacmia of lts ining. Inflammatory exudate ap
peas inthe middle car Tympanie membrane becomes
Congested.
‘Symptoms, There marked earache which may distr
sleep and i of Ihrobbing nature. Deafness and tnnltus
re ls present ut complained only by adults, Usually,
‘hd runs high degr of fever and rss
Signs. To begin with, there is congetion of pars tensa
Leash of blood vessels appear along the handle of malleus
And a the periphery of ymponie membrane imparting e
caras appearance: Late, whole of tympanic mem
‘rane including pas accida becomes untormiy red.
Tuning fork tess will agin show conductive type of
heating los
3. Sraca or Surrunarıon. Mis marked by formation
Gi pus nthe mide er and to some extent In mastoid
SicestTympanic membrane stars bulging to he point
optar
Smploms Earache becomes excruciating. Dafne ne
«reap child may run fever of 102-108 This may De
‘Sccompanied by vomiting and even convlsons
Son. Tympanie membrane appears re and bulging
with loss Of fanaa Handle of malleus may bee
led by the swollen and protruding tympanic
Frame and may not be duceible. A yellow spot may De
a
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Disorders of Middle Ear
ACUTE SUPPURATIVE OTITIS MEDIA
I is an acute inflammation of middle car by pyogenic
‘organisms. Here, middle car implies mide ar dit, Le
<ustachian tube, middle ear, ati, aus, antrum and
mastoid ae cll
AETIOLOGY
Its more common especially in infants and children of
lower socioeconomic group. Typical the disease follows
‘ial tntecion of upper respiratory tac but soon the po
‘genic organisms invade the middle cur.
ROUTES OF INFECTION
1. VIA EXSTACHIAN TUNE, I the most common route
Infection teves vi the lamen ofthe tube or along ab
‘epithelia pertuballymphats. Eustachian tube in nants
“nd young ehren & shorter wider amd more horiontal
“nd thus may account for higher incidence of infections
this age group, Breast or bole feeding in a young Infant
in horn postion may force Mus through tube
Into the middle car and hence the ned to keep the infant
Propped up sth hed ite higher Simming and diving
‘Canalo force water though the tube int he mile ar
2. VIA EXTERNAL Ean. Traumatic perforations of tym
panic membrane due o any cause open route to middle
rinfection
3. Bioon-Bonst. This san uncommon route.
PREDISPOSING FACTORS.
Anything that interferes with normal functioning of us
tachian tube predisposes to mide ar infection. It could
1. Recurent attacks of common cold, upper respiratory
{tact infections and exanthematous fevers ke mes
sles, diphtheria or whooping cough
Iniections of tonsils and adenoids
Chronic rhinitis and sinus
at allergy
mous of nasopharynx, packing of nose or naso-
pharynx for pistas
6, Cie palate
BAcTERoLoGy. Most common organisms in infants
and young children are Srptcacus prewnonie (30%),
Hacmopilasinflunane (20%) and Moraxeia catarrhalis
(135) Other omantsms include Stpiwoccus pyogenes,
Stapiiocacs auras and sometimes Flament argh
‘non In abot 18-20%, no growth is sen. Many strains of
at and M cata ae lactamase producing.
PATHOLOGY AND CLINICAL FEATURES
‘The disease runs through the following stages:
1. STAGE or TUnAL OCCLUSION. Oslema and hype
‘nia Of nasopharyngeal end of eustachian tube blocks the
{ube leading to absorption of air and negative intatyi
panic presse, There retraction of tympanic membrane
{sith some degree of cion inthe middle car but ud
may not be clinical appreciable.
“Symptoms, Deafnes and earache ar the two symptoms
ut they are not marked. There ls generally no fever
‘gms. Tympunic membrane fs retracted with handle
of malleus assuming a more horizontal postion, promi:
‘hence a tea process of malleus aná os of light eles.
‘Tuning fork test show conductive deafness
2. Stok oF Paeserremarion. If tuba ocluson is pro-
Tonge pyogente organisms invade tympanic cavity sus
ing hyperacmia of lts ining. Inflammatory exudate ap
peas inthe middle car Tympanie membrane becomes
Congested.
‘Symptoms, There marked earache which may distr
sleep and i of Ihrobbing nature. Deafness and tnnltus
re ls present ut complained only by adults, Usually,
‘hd runs high degr of fever and rss
Signs. To begin with, there is congetion of pars tensa
Leash of blood vessels appear along the handle of malleus
And a the periphery of ymponie membrane imparting e
caras appearance: Late, whole of tympanic mem
‘rane including pas accida becomes untormiy red.
Tuning fork tess will agin show conductive type of
heating los
3. Sraca or Surrunarıon. Mis marked by formation
Gi pus nthe mide er and to some extent In mastoid
SicestTympanic membrane stars bulging to he point
optar
Smploms Earache becomes excruciating. Dafne ne
«reap child may run fever of 102-108 This may De
‘Sccompanied by vomiting and even convlsons
Son. Tympanie membrane appears re and bulging
with loss Of fanaa Handle of malleus may bee
led by the swollen and protruding tympanic
Frame and may not be duceible. A yellow spot may De
a
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68 SECTION! Deer of far
seen on the tympanic membrane where rupture i im-
minent In preantbioue era, one could sce a nipple ke
protrsion of tympanic membrane with a yellow spot on
As summit. Tendemess may be lita ove the mastoid
‘crys of mastol will show clouding of ar cells be
cause of exudate,
4. Sac or Resorumon. The tympanic membrane ru
{res with release of pus and subsidence of symptoms In
‘ammatory process begins to resolve. It proper treatment
[Started any oF ifthe infection was mid, resolution
may Sar even without rapture of tympanic membrane
Symptom. With evacuation of pus, carache reed,
fever comes down and hil ech Bet
Sis. External auditory canal may contain blood
tinged discharge which Tater becomes mucopurulent.
Usually, a small perforation Is seen In anteroinfeior
quant of pars tensa. Hyperaemia of tympanic mem
ane begins to subside with return to normal colour and
indimarks
5. Sraû oF Courucarion. I virulence of organism Is
high or resistance of patient poor, resolution may not
take place and disease spreads beyond the contes of
mie car It may ead to cute mastoid, subperosteat
abscess, facial parti, aby
¿oral abscess, meningitis, bri
{thvombophtehits
‘TREATMENT
1. ANTIBACTERIAL THERAPY CT)
ited in al cases
1041). 116 indi
h ever and severe earache, As the
most common organisms ar 5. pneumonie and I. inf
fan, the drugs which are effective In acute otitis mea
‘Ste ampicilin (80 mg/kgiday in our divided doses) and
Amos (40 mg/kg/day in three divided doses). Mose
Serie to these penis can be given cefacor, co
‘oxazole or erytromyen. In cases where lactamase:
producing HL influenzae or M. catahals are late,
ntbioties lke amosicilin clavulanate, augmentin ce
{urosime axetl or cetisime may be used. Antibacteral
therapy must be continued for a minimum of 10 days,
tll ympunie membrane seins normal appearance and
heating seur to normal. Early discontinuance ol het.
apy with rei o earache and fever, or therapy given In
Inadequate doses may lead to secretory otis meda and
residual eating los
2. Diconcrstaxt NASAL Dors. Ephedrine nose drops
{iin adults and 0.9% in children) or oxymetara
(Nasvion) or xylometazoline (Otis) shoul be used 10
releve eustachian tube oedema and promote ventilation
fm eu.
3. ORAL NASAL DECONGESTANTS.Peudoephedine (Sue
‘ate 30 mg twice daly of a combination of decongest
Stand anthistaminic(aominis) may achieve he same
result without resort to nasal drops which are dificult ©
minister in children.
ANALGESICS AND ANTIPVRENIS, Paracetamol helpsto
ie pain and bring down temperature
5. Eau Toner. I there is discharge inthe ea, its dy:
‘opped with see cotton buds and a wick moistened
‘with antibiotic may be inserted,
6. Day Loca Hear. Helps to elev pan.
7. MyRINGoTOMy: It is incising the drum to evacuate
ps and indicated when () drum bling and theres
eue pan, (i) there an incomplete solution despite
antbiodes when drum remains fll with persistent son:
“ductive hearing less and (i) there is persistent fusion
beyond 12 weeks.
Al ases of acute suppurative otis media should be
carta foowed til tympanic membrane eturs o 1.
‘normal appearance and conductive hearing os dap
pears (igure 10.)
ACUTE NECROTIZING OTITIS MEDIA
Ati a variety o acute suppurative ots medi, often seen
In children sufering from measles, scarlet fever or Inf
fea. Casative orgnisn is Pahaemolyi streptococci
Theres rapid destruction of whole of tympanic mem.
brane with Is annulus, mucos of promontory, ossicular
‘hain and even mastoid air cells, There ls profuse olor
hoca. In these ase, healing is followed By Abross or
ingrowth of squamous epithelium from the meat (ec
lary aqui cost).
"Treatment 5 early institution of atibacteal therapy.
Its continued fora last 7-10 days, eve Hf esponse fe
seen ey. Cortal mastidectomy may be indicated if
‘medical treatment fall to contol or the condition gets
Complicated by acute masts.
rg Trade names Tota daly dose Died dove
Anos Noamon Bomex Aamasıa 3
Angie, Pe Sag A
Cote ‘agen Eon Koma, bs
Eon Eo loo 30 Ogg a
Cr generton) ee 2mny 2
Came genen) Tama Boo Bmghg Tee
pedo promt Cépaden, Cloro malig (ma. mg 2
Eten orton) Preto mah ;
CotsmourceCanebopin + Sumar) Clin Sepang TMP) +40mgQSMZYg 2
“olen dog a nacion ae manche
mebooksfree.com
seen on the tympanic membrane where rupture i im-
minent In preantbioue era, one could sce a nipple ke
protrsion of tympanic membrane with a yellow spot on
As summit. Tendemess may be lita ove the mastoid
‘crys of mastol will show clouding of ar cells be
cause of exudate,
4. Sac or Resorumon. The tympanic membrane ru
{res with release of pus and subsidence of symptoms In
‘ammatory process begins to resolve. It proper treatment
[Started any oF ifthe infection was mid, resolution
may Sar even without rapture of tympanic membrane
Symptom. With evacuation of pus, carache reed,
fever comes down and hil ech Bet
Sis. External auditory canal may contain blood
tinged discharge which Tater becomes mucopurulent.
Usually, a small perforation Is seen In anteroinfeior
quant of pars tensa. Hyperaemia of tympanic mem
ane begins to subside with return to normal colour and
indimarks
5. Sraû oF Courucarion. I virulence of organism Is
high or resistance of patient poor, resolution may not
take place and disease spreads beyond the contes of
mie car It may ead to cute mastoid, subperosteat
abscess, facial parti, aby
¿oral abscess, meningitis, bri
{thvombophtehits
‘TREATMENT
1. ANTIBACTERIAL THERAPY CT)
ited in al cases
1041). 116 indi
h ever and severe earache, As the
most common organisms ar 5. pneumonie and I. inf
fan, the drugs which are effective In acute otitis mea
‘Ste ampicilin (80 mg/kgiday in our divided doses) and
Amos (40 mg/kg/day in three divided doses). Mose
Serie to these penis can be given cefacor, co
‘oxazole or erytromyen. In cases where lactamase:
producing HL influenzae or M. catahals are late,
ntbioties lke amosicilin clavulanate, augmentin ce
{urosime axetl or cetisime may be used. Antibacteral
therapy must be continued for a minimum of 10 days,
tll ympunie membrane seins normal appearance and
heating seur to normal. Early discontinuance ol het.
apy with rei o earache and fever, or therapy given In
Inadequate doses may lead to secretory otis meda and
residual eating los
2. Diconcrstaxt NASAL Dors. Ephedrine nose drops
{iin adults and 0.9% in children) or oxymetara
(Nasvion) or xylometazoline (Otis) shoul be used 10
releve eustachian tube oedema and promote ventilation
fm eu.
3. ORAL NASAL DECONGESTANTS.Peudoephedine (Sue
‘ate 30 mg twice daly of a combination of decongest
Stand anthistaminic(aominis) may achieve he same
result without resort to nasal drops which are dificult ©
minister in children.
ANALGESICS AND ANTIPVRENIS, Paracetamol helpsto
ie pain and bring down temperature
5. Eau Toner. I there is discharge inthe ea, its dy:
‘opped with see cotton buds and a wick moistened
‘with antibiotic may be inserted,
6. Day Loca Hear. Helps to elev pan.
7. MyRINGoTOMy: It is incising the drum to evacuate
ps and indicated when () drum bling and theres
eue pan, (i) there an incomplete solution despite
antbiodes when drum remains fll with persistent son:
“ductive hearing less and (i) there is persistent fusion
beyond 12 weeks.
Al ases of acute suppurative otis media should be
carta foowed til tympanic membrane eturs o 1.
‘normal appearance and conductive hearing os dap
pears (igure 10.)
ACUTE NECROTIZING OTITIS MEDIA
Ati a variety o acute suppurative ots medi, often seen
In children sufering from measles, scarlet fever or Inf
fea. Casative orgnisn is Pahaemolyi streptococci
Theres rapid destruction of whole of tympanic mem.
brane with Is annulus, mucos of promontory, ossicular
‘hain and even mastoid air cells, There ls profuse olor
hoca. In these ase, healing is followed By Abross or
ingrowth of squamous epithelium from the meat (ec
lary aqui cost).
"Treatment 5 early institution of atibacteal therapy.
Its continued fora last 7-10 days, eve Hf esponse fe
seen ey. Cortal mastidectomy may be indicated if
‘medical treatment fall to contol or the condition gets
Complicated by acute masts.
rg Trade names Tota daly dose Died dove
Anos Noamon Bomex Aamasıa 3
Angie, Pe Sag A
Cote ‘agen Eon Koma, bs
Eon Eo loo 30 Ogg a
Cr generton) ee 2mny 2
Came genen) Tama Boo Bmghg Tee
pedo promt Cépaden, Cloro malig (ma. mg 2
Eten orton) Preto mah ;
CotsmourceCanebopin + Sumar) Clin Sepang TMP) +40mgQSMZYg 2
“olen dog a nacion ae manche
mebooksfree.com
|
Corto somo
Bee
Compl reso | Perte Ns but
a et
1 " 1
Figure 10.1. Tstentot ac oti med.
‘OTITIS MEDIA WITH EFFUSION
SYN. SEROUS OTITIS MEDIA, SECRETORY
OTITIS MEDIA, MUCOID OTITIS MEDIA,
"GLUE EAR”
Tiss an insidious condition characterize by accumula:
tion of monpuralent effusion in the male er dat. OL.
ten the eftsion stick and viscid but sometimes may
‘be thin and serous, The fd scaly stele. The cond
tion is commonly sen in schoolgong children
PATHOGENESIS
To main mechanisms ae thought tobe responsible
1. MALRUNCHIONING oF Fustacian Tune. Eustachi
tube fis to aerate the middle ear and Is aso unable lo
‘ain the Hl
2. INCREASED SECRETORY ACTIVITY OF MIDDLE. Ear
‘Mucosa. Biopsie of middle car mucosa In these cases
have confrmeal increase in number of mucus or ru
secreting call
AETIOLOGY
1. MALRUNCTIONING OF EUSTACHIAN TURE. The causes:
(a) Adenoid hyperplasia,
(0) Chronic hints and sinus,
Chapter 10 — Diorde of Middle kr 69
(© Chronic tonsils. Enlarged tonsils mechanically
‘obstruct the movements of soft palate and Interfere
the pbysiologlcal opening of eustachian tube.
(9 Fenig and malignant tumours of nasopharynx. This
cause should always be excluded in unilateral serous
‘otitis media in an adult
(9 Pla defects eg lef palate, palatal paralysis.
2. AuLERoY. Seasonal or perenniaallegy to inhalants or
(ost common in children, This not only obstucts
‘tstachlan tube by oedema ut may als ead 1 increased
Secretory activity as mide ear mucosa ets 35 à shock
‘organ in such case,
3. Usnisomven Orris MEDIA. Inadequate antibiotic
‘therapy in acute suppurative otis medi may inactivate
infection but fail ta resolve completely Lovegrade ine
fection lingers on. This acts as stimulus for mucosa tose
fete more ui, The numberof goblet eels and mucous
lands aso increase. Recent Increase in the incidence of
his disease seems go be dueto this factor
4, Vinat Issterions, Various adeno- and ehinoviuses
‘of upper respiratory ac may invade mid car mucosa
Sd timate 10 increase secreory activi
CLINICAL FEATURES
1. Swurrous. The dicas children of 5-8 ycrsof
age: The symptoms include:
(a) Hearing los. This ls the presenting and sometimes
the only symptom. Iti nidos in onset and rarely
‘exceeds 40 dB. Deafness may pass noticed by
parents and may be acidemally discovered during
Bdiometrc screening tests
Delayed amd defective speech. Because of hearing os,
‘evelopment of speech is delays or detective
Mild araches. There may be history of upper resp
©)
©
2. Oroscoric Frvpines. Tympanie membrane i often
ul and opaque wit 105 08 light reflex. Te may appear
Yalow, gy or blush in colour
Thin cash of blood vessels maybe sen along the han:
‘te of malleus or athe periphery of tympanic membrane
nd dis rom marked congestion of acute suppurative
‘ots media
Tympanic membrane may show varying degree of re.
traction, Sometimes may appear fullor sight Baling
ins posterior part dueto efi
Fuld level and ai bubbles may e seen whe Ma
Ain and tympanic membrane transparent (zur: 102)
‘Mobility of the ympanic membrane Is restricted.
HEARING TESTS
1. Tuning fork tests show conductive hearing Loss
2. Audiomeuy. Theres conductive hening los of 20-
40 dB. Sometimes, there 1 associated Sensorincural
cing Toss due to ud pressing on the round win
dow membrane. This disappear with evacuation Of
fui
mebooksfree.com
Corto somo
Bee
Compl reso | Perte Ns but
a et
1 " 1
Figure 10.1. Tstentot ac oti med.
‘OTITIS MEDIA WITH EFFUSION
SYN. SEROUS OTITIS MEDIA, SECRETORY
OTITIS MEDIA, MUCOID OTITIS MEDIA,
"GLUE EAR”
Tiss an insidious condition characterize by accumula:
tion of monpuralent effusion in the male er dat. OL.
ten the eftsion stick and viscid but sometimes may
‘be thin and serous, The fd scaly stele. The cond
tion is commonly sen in schoolgong children
PATHOGENESIS
To main mechanisms ae thought tobe responsible
1. MALRUNCHIONING oF Fustacian Tune. Eustachi
tube fis to aerate the middle ear and Is aso unable lo
‘ain the Hl
2. INCREASED SECRETORY ACTIVITY OF MIDDLE. Ear
‘Mucosa. Biopsie of middle car mucosa In these cases
have confrmeal increase in number of mucus or ru
secreting call
AETIOLOGY
1. MALRUNCTIONING OF EUSTACHIAN TURE. The causes:
(a) Adenoid hyperplasia,
(0) Chronic hints and sinus,
Chapter 10 — Diorde of Middle kr 69
(© Chronic tonsils. Enlarged tonsils mechanically
‘obstruct the movements of soft palate and Interfere
the pbysiologlcal opening of eustachian tube.
(9 Fenig and malignant tumours of nasopharynx. This
cause should always be excluded in unilateral serous
‘otitis media in an adult
(9 Pla defects eg lef palate, palatal paralysis.
2. AuLERoY. Seasonal or perenniaallegy to inhalants or
(ost common in children, This not only obstucts
‘tstachlan tube by oedema ut may als ead 1 increased
Secretory activity as mide ear mucosa ets 35 à shock
‘organ in such case,
3. Usnisomven Orris MEDIA. Inadequate antibiotic
‘therapy in acute suppurative otis medi may inactivate
infection but fail ta resolve completely Lovegrade ine
fection lingers on. This acts as stimulus for mucosa tose
fete more ui, The numberof goblet eels and mucous
lands aso increase. Recent Increase in the incidence of
his disease seems go be dueto this factor
4, Vinat Issterions, Various adeno- and ehinoviuses
‘of upper respiratory ac may invade mid car mucosa
Sd timate 10 increase secreory activi
CLINICAL FEATURES
1. Swurrous. The dicas children of 5-8 ycrsof
age: The symptoms include:
(a) Hearing los. This ls the presenting and sometimes
the only symptom. Iti nidos in onset and rarely
‘exceeds 40 dB. Deafness may pass noticed by
parents and may be acidemally discovered during
Bdiometrc screening tests
Delayed amd defective speech. Because of hearing os,
‘evelopment of speech is delays or detective
Mild araches. There may be history of upper resp
©)
©
2. Oroscoric Frvpines. Tympanie membrane i often
ul and opaque wit 105 08 light reflex. Te may appear
Yalow, gy or blush in colour
Thin cash of blood vessels maybe sen along the han:
‘te of malleus or athe periphery of tympanic membrane
nd dis rom marked congestion of acute suppurative
‘ots media
Tympanic membrane may show varying degree of re.
traction, Sometimes may appear fullor sight Baling
ins posterior part dueto efi
Fuld level and ai bubbles may e seen whe Ma
Ain and tympanic membrane transparent (zur: 102)
‘Mobility of the ympanic membrane Is restricted.
HEARING TESTS
1. Tuning fork tests show conductive hearing Loss
2. Audiomeuy. Theres conductive hening los of 20-
40 dB. Sometimes, there 1 associated Sensorincural
cing Toss due to ud pressing on the round win
dow membrane. This disappear with evacuation Of
fui
mebooksfree.com
70 SECTION! — Diseases o far
ge 2 Ost pr in Nee ape bs
3. Impedance audiometry ts an objective test use
in Infants and children, Presence of ld ls indicated
by reduced compliance and dat curve with 3 shit to
régate side
4. Kay mastoids. There is clouding of air cells due to
ful
‘TREATMENT
‘The alm of treatment is removal of fad and prevention
ofits wem.
1. Medical
(A) Deconcrstavrs. Topical decongestants inthe form
Of nasal drops, sprays or systemic decongestants help to
9) ANTIALLERGIE MEASURES. Antihistamines or some:
times steroids may be use in cases of aller. 1 possible
legen should be found and desensitization done.
(0 ANMIBIONCS. They are useful in ass of upper es
[ratory tact infections or unresolved acute spurte
‘tts mea
(0) Minots Ean Armarios. Patient should repeatedly
perform Valsalva maneuvre Sometime, politzeszation
fr eustachian tube catheterization has 0 be done. Th
helps to ventilate middle ear and promote drainage
Auld. Children can be given chewing gum to encourage
repeated swallowing which opens the tube
2. Surgical
‘when fu thick and media! rest
Delp ud must be surgically removed
alone docs not
(4) Mymincoromy AND ASPIRA TON or FLUID. An inc
Sion is made in tympanic membrane and Td aspirar
‘Stith suction. Thick mucus may require installation
fof sine or a mucolytc agent like chymotrypsin Sol:
tion toliguely mucus before it can be aspirated. Some.
tims, two incisions are made in the tympanic mem
branc, one in the antroinferior and the other In the
Figure 103. o spate tick mc tw nos oy bee
‘nthe mai membrane
ikea pl ego.
A 8
Figure 104. Grommmtinthe gui membrane (ná)
<amterosuperir quadran o aspiat thik, lue ie secre:
tions (gut 10 [9] on “beercan” principe
(©) Gros Isern. If myringotomy andaspration
Combined with medial measures have not heped and
Auld recur, a grommet s inserted to provide continued
eration of mide er (te 10.9), es Tete place for
‘weeks or months or li I pontancously extruded,
(© Tamaorou or Corricau Mastowectowy: Its
Sometimes required for removal of located thick Au
or other associated pathology such as cholesterol gan
(0) SURGICAL TREATMENT OF CAUSAFIVE FACTOR. Ade-
okdectomy tonsillectomy and/or washout of maxillary
“nica may be required. This usually done a he time of
myringotomy
BIOFILM
is protective mechanism of bacteria which ensures
thelr survival and propagation. Bacteria fist ete to an
Organ or inorganic material and then secrete a prtic-
tise ayer of complex polysaccharides. This ayer permi
fusion of mutlents int the bacterial cells and! ext to
bacterial excretory products but prevents the action of
‘nite blood calls, antibodies and antbiotic on the uc
{era cll Smal proportions of bacterial colones can aso
mebooksfree.com
ge 2 Ost pr in Nee ape bs
3. Impedance audiometry ts an objective test use
in Infants and children, Presence of ld ls indicated
by reduced compliance and dat curve with 3 shit to
régate side
4. Kay mastoids. There is clouding of air cells due to
ful
‘TREATMENT
‘The alm of treatment is removal of fad and prevention
ofits wem.
1. Medical
(A) Deconcrstavrs. Topical decongestants inthe form
Of nasal drops, sprays or systemic decongestants help to
9) ANTIALLERGIE MEASURES. Antihistamines or some:
times steroids may be use in cases of aller. 1 possible
legen should be found and desensitization done.
(0 ANMIBIONCS. They are useful in ass of upper es
[ratory tact infections or unresolved acute spurte
‘tts mea
(0) Minots Ean Armarios. Patient should repeatedly
perform Valsalva maneuvre Sometime, politzeszation
fr eustachian tube catheterization has 0 be done. Th
helps to ventilate middle ear and promote drainage
Auld. Children can be given chewing gum to encourage
repeated swallowing which opens the tube
2. Surgical
‘when fu thick and media! rest
Delp ud must be surgically removed
alone docs not
(4) Mymincoromy AND ASPIRA TON or FLUID. An inc
Sion is made in tympanic membrane and Td aspirar
‘Stith suction. Thick mucus may require installation
fof sine or a mucolytc agent like chymotrypsin Sol:
tion toliguely mucus before it can be aspirated. Some.
tims, two incisions are made in the tympanic mem
branc, one in the antroinferior and the other In the
Figure 103. o spate tick mc tw nos oy bee
‘nthe mai membrane
ikea pl ego.
A 8
Figure 104. Grommmtinthe gui membrane (ná)
<amterosuperir quadran o aspiat thik, lue ie secre:
tions (gut 10 [9] on “beercan” principe
(©) Gros Isern. If myringotomy andaspration
Combined with medial measures have not heped and
Auld recur, a grommet s inserted to provide continued
eration of mide er (te 10.9), es Tete place for
‘weeks or months or li I pontancously extruded,
(© Tamaorou or Corricau Mastowectowy: Its
Sometimes required for removal of located thick Au
or other associated pathology such as cholesterol gan
(0) SURGICAL TREATMENT OF CAUSAFIVE FACTOR. Ade-
okdectomy tonsillectomy and/or washout of maxillary
“nica may be required. This usually done a he time of
myringotomy
BIOFILM
is protective mechanism of bacteria which ensures
thelr survival and propagation. Bacteria fist ete to an
Organ or inorganic material and then secrete a prtic-
tise ayer of complex polysaccharides. This ayer permi
fusion of mutlents int the bacterial cells and! ext to
bacterial excretory products but prevents the action of
‘nite blood calls, antibodies and antbiotic on the uc
{era cll Smal proportions of bacterial colones can aso
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detach and set up new colonies. Biofilms ar respon
be for bactra resistance and persistance of infection.
In ENT, they are implicated in chronic outs media e
‘usin, chronic inosinusit, and tonsil and adenoid
infections They lso form on tympanostomy tubes, st
tents and catheters kept fora long ie io formation
an be prevented by antiote-coated tubes and stents
Sand an early removal of tubes and stents, 1 no longer
required,
SEQUELAE OF CHRONIC SECRETORY OTITIS
MEDIA
1. ATROPMIC TVMPANIC MEMBRANE AND ATELECEASIS
‘OF THE MibDut BAR. In prolonged fusions, there sd
Solution of ross layer of tympanic membrane. be.
‘comes thin and atrophic and rtrci nto the middle car
2. OSSICULAR NECROSIS, Most commonly, long process
of incus gets necrsed. Sometimes, stapes superstructure
lso ets necrosed This increases the conduce hese
dos to more than $0 4.
3. TywpaNosctemosts. Hyalinized collagen with chalky
“posts may be sten in tympanic membrane, around the
“ses or thee fins leading o thelr ation,
Atrophie port of pars tensa may get Invaginated 10 form
retraction pockets or cholesteatoma, Similar pockets may
Dessen in the tie
5. COLESTEROL GRANULOMA. This is due o stasis of se
‘tions in middle ear and maso.
RECURRENT ACUTE OTITIS MEDIA,
Infants and children betwen the age of 6 months and
6 years may get recurrent episodes of acute outs mea,
Such episodes may occur fur to fiv
‘hey occur afer acute upper respiratory
ine child being fee of symptoms between the episodes.
Recurrent middle infections may sometimes be super
posed upon an exiting middle cr fusion. Sometimes,
the underying cause I current sinusitis, vlopharyn.
sea insufficiency hypertrophy of adenoid infected ton.
Sis allergy and immune dein. Feeding the babes
Supine positon without propping up the head may ao
‘tse he mil to enter the mide ae direct tht can
Tend to middle car infection
‘Management of such children involves
Finding he cause and eliminating it, possible
2. Antimicrobial propytais. Amoxicilin (20 mgikg for
3-6 months) or sulisoxaole have been used ut they
prevent only 1-2 bouts of ets media in a year and
have the disadvantage of cresting antimicrobial rst
ance or hyperensiity reaction and thus not pre.
{erred by many ln favour of early insertion of yapa
ostomy tubes.
3. Myringatomy and insertion of Iymparastamy tbe. the
‘hil has 4 bouts of acute outs media in 6 months or
Chapter 10 — Disorders of Mide Er 71
6 bouts in 1 year, insertion ofa tympanostomy tube is
recommended.
‘Adenoidectomy with or veithouttomsiictomy,
Management oFinhalant or food arg
AERO-OTITIS MEDIA (OTITIC
BAROTRAUMA)
lisa nonsuppurative condition resulting fom falle of
ustachlan tube to maintain middle car pressure at amb
À atmosphere level. The usual ase rap descent
‘during ae Bight, underwater diving or compression in
Dresure chamber.
MECHANISM,
Fustachan tube allons easy and passive eres air fom
‘mile ea tothe pharynx i mide eae presse shih
in the reverse station, where nasopharyngeal ar pre
see high, aircannot enter the mide car unless ube is
ciel opened by the contraction of muscles as in sale
Towing. yawning’ Valsalva manoeuvre. When atmos
‘hele presse Is higher than tht of mide car by cit
{level of 90 men Hg. eustachian tube ges “locked,” Le
Soft tissues of pharyngeal end ofthe tube are fore into
lis lumen. in the presence of eustachian tube oedema,
¿ven smaller pressure differentials cause “locking” of the
tube. Sudden negative pressure in the middle car causes
traction of tympanic membrane, hyperaemi and en.
gorgement of vs, transudation and haemoeages.
Sometimes, though rarely, there Is rupture of labyrin
thine membranes wth ero and seminal Hn
CLINICAL FEATURES
Severe earache, heating loss and tinnitus are common
‘complains. Vertigo s uncommon. Tympanic membrane
appear retracted and congested. I may get ruptured
‘Mile car may show air bubbles or Memorial
ion. Hearing los ls usualy conducive but sensoincu.
val pe of loss may also be seen
‘TREATMENT
‘The alm so restore middle ear aeration, This Is done by
‘athetrztion or poltzerztion In mild ease, econ:
estan! nasal drops or orl nasal decongestant with ant
Histaminics are helpful Inthe presence o ui ole
fof the above methods, myeingotomy may be performed
o “unlock the tube and aspire the Al.
PREVENTION
-Aero-titiscan be prevented by the following measures:
1. Avoid ale travel in the presence of upper respiratory
infection or aleg
2. Swallow repeatedly during descent Sucking sweets or
chewing gum is wet
3. Do mot permit sleep during descent as numberof sal.
lows normally decease during sleep.
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be for bactra resistance and persistance of infection.
In ENT, they are implicated in chronic outs media e
‘usin, chronic inosinusit, and tonsil and adenoid
infections They lso form on tympanostomy tubes, st
tents and catheters kept fora long ie io formation
an be prevented by antiote-coated tubes and stents
Sand an early removal of tubes and stents, 1 no longer
required,
SEQUELAE OF CHRONIC SECRETORY OTITIS
MEDIA
1. ATROPMIC TVMPANIC MEMBRANE AND ATELECEASIS
‘OF THE MibDut BAR. In prolonged fusions, there sd
Solution of ross layer of tympanic membrane. be.
‘comes thin and atrophic and rtrci nto the middle car
2. OSSICULAR NECROSIS, Most commonly, long process
of incus gets necrsed. Sometimes, stapes superstructure
lso ets necrosed This increases the conduce hese
dos to more than $0 4.
3. TywpaNosctemosts. Hyalinized collagen with chalky
“posts may be sten in tympanic membrane, around the
“ses or thee fins leading o thelr ation,
Atrophie port of pars tensa may get Invaginated 10 form
retraction pockets or cholesteatoma, Similar pockets may
Dessen in the tie
5. COLESTEROL GRANULOMA. This is due o stasis of se
‘tions in middle ear and maso.
RECURRENT ACUTE OTITIS MEDIA,
Infants and children betwen the age of 6 months and
6 years may get recurrent episodes of acute outs mea,
Such episodes may occur fur to fiv
‘hey occur afer acute upper respiratory
ine child being fee of symptoms between the episodes.
Recurrent middle infections may sometimes be super
posed upon an exiting middle cr fusion. Sometimes,
the underying cause I current sinusitis, vlopharyn.
sea insufficiency hypertrophy of adenoid infected ton.
Sis allergy and immune dein. Feeding the babes
Supine positon without propping up the head may ao
‘tse he mil to enter the mide ae direct tht can
Tend to middle car infection
‘Management of such children involves
Finding he cause and eliminating it, possible
2. Antimicrobial propytais. Amoxicilin (20 mgikg for
3-6 months) or sulisoxaole have been used ut they
prevent only 1-2 bouts of ets media in a year and
have the disadvantage of cresting antimicrobial rst
ance or hyperensiity reaction and thus not pre.
{erred by many ln favour of early insertion of yapa
ostomy tubes.
3. Myringatomy and insertion of Iymparastamy tbe. the
‘hil has 4 bouts of acute outs media in 6 months or
Chapter 10 — Disorders of Mide Er 71
6 bouts in 1 year, insertion ofa tympanostomy tube is
recommended.
‘Adenoidectomy with or veithouttomsiictomy,
Management oFinhalant or food arg
AERO-OTITIS MEDIA (OTITIC
BAROTRAUMA)
lisa nonsuppurative condition resulting fom falle of
ustachlan tube to maintain middle car pressure at amb
À atmosphere level. The usual ase rap descent
‘during ae Bight, underwater diving or compression in
Dresure chamber.
MECHANISM,
Fustachan tube allons easy and passive eres air fom
‘mile ea tothe pharynx i mide eae presse shih
in the reverse station, where nasopharyngeal ar pre
see high, aircannot enter the mide car unless ube is
ciel opened by the contraction of muscles as in sale
Towing. yawning’ Valsalva manoeuvre. When atmos
‘hele presse Is higher than tht of mide car by cit
{level of 90 men Hg. eustachian tube ges “locked,” Le
Soft tissues of pharyngeal end ofthe tube are fore into
lis lumen. in the presence of eustachian tube oedema,
¿ven smaller pressure differentials cause “locking” of the
tube. Sudden negative pressure in the middle car causes
traction of tympanic membrane, hyperaemi and en.
gorgement of vs, transudation and haemoeages.
Sometimes, though rarely, there Is rupture of labyrin
thine membranes wth ero and seminal Hn
CLINICAL FEATURES
Severe earache, heating loss and tinnitus are common
‘complains. Vertigo s uncommon. Tympanic membrane
appear retracted and congested. I may get ruptured
‘Mile car may show air bubbles or Memorial
ion. Hearing los ls usualy conducive but sensoincu.
val pe of loss may also be seen
‘TREATMENT
‘The alm so restore middle ear aeration, This Is done by
‘athetrztion or poltzerztion In mild ease, econ:
estan! nasal drops or orl nasal decongestant with ant
Histaminics are helpful Inthe presence o ui ole
fof the above methods, myeingotomy may be performed
o “unlock the tube and aspire the Al.
PREVENTION
-Aero-titiscan be prevented by the following measures:
1. Avoid ale travel in the presence of upper respiratory
infection or aleg
2. Swallow repeatedly during descent Sucking sweets or
chewing gum is wet
3. Do mot permit sleep during descent as numberof sal.
lows normally decease during sleep.
mebooksfree.com
72 SECTION! Dicas of far
4. Autoinfation ofthe tube by Valsalva shouldbe per- 6. In recurrent barotrauma, attention should be pad to
formed intermittently during descent ‘nasal polyp, septa deviation, nasa allergy and chron.
5. Use vasoconstrictor nasal spray and a tablet of ant le sims Imcctions
minie and systemie decongestant, hall an hour
before decent in persons with previous History ofthis
episode.
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4. Autoinfation ofthe tube by Valsalva shouldbe per- 6. In recurrent barotrauma, attention should be pad to
formed intermittently during descent ‘nasal polyp, septa deviation, nasa allergy and chron.
5. Use vasoconstrictor nasal spray and a tablet of ant le sims Imcctions
minie and systemie decongestant, hall an hour
before decent in persons with previous History ofthis
episode.
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Chapter 11
Cholesteatoma and Chronic
Otitis Media
CHOLESTEATOMA
nile car left lined by diferent types of
In dent regions cited columnar inthe
anterior and inferior par, cuboidal in the middle part
nd pavementke inthe ate, The middle car no
‘where lined by heatniing squamous epithelia. I
the presence of ater type of epithelium in the middle
‘ir or mastoid that conatitutes a cholesteatoma In other
‘words chaesteatoma 15 “Sn Inthe wong place” the
{erm cholesteatoma a misnomer because neithercan-
tains cholesterol era nor itis à amour to me the
Saft “oma” However, the term has ben retained be:
‘ase of te wer usage,
Essentially choletestoma consists of two pets: (he
‘mati which is made up of kratinang samoss pie
{helium resting on a thin sroma of bros sus and UI)
‘scent white mass, consisting of keratin debris produce
Dy he max (ue 111 LO) For this reason, tha als
‘ben name epiermosts or Raton
ORIGIN OF CHOLESTEATOMA
¡Genesis o chalesteatoma isa matter of debate, Any theo:
{of genesis mus explain how squamous epithelium
ppeated inthe middle ear cet Ihe Various vies ex
presse are
1. Presence of congenital cel ests.
2. Invaginaton of tympanie membrane from the attic
for posterosuperior part of pars ten in the form of
oe
retraction pockets (Figure 112) Wittman’ tm
The outer surface of tympanic membrane is med by
stratified squamous epthelum which after invagina
‘on forms the mati of cholesteatoma nls oven
keratin in te pocket.
sa cel hyperplasia (Ali the). The basal els of
‘germinal ayer of skin proliferate under he Influence
‘of nection and ly down Keatiniang «quamous cie
‘liom.
4. Epithel invasion (Habermann teary). The epithe-
lium om the meatus or outer drum surface ROWS
Into Ihe muddle car through a pre-enising perforation
‘specially of the marginal ype where pat OF annulus
tympanicus has already been dest
Metaplaia (Sad thoy). Middle ear mucos, ke es
[ratory mucosa elsewhere, undergoes metaplasia due
{o repeated infections and transforms Int squamous
‘epithelia,
A +4
€
os
pt aso tough postrer pron
Figure 1.2. Goes cle.
7
Cholesteatoma and Chronic
Otitis Media
CHOLESTEATOMA
nile car left lined by diferent types of
In dent regions cited columnar inthe
anterior and inferior par, cuboidal in the middle part
nd pavementke inthe ate, The middle car no
‘where lined by heatniing squamous epithelia. I
the presence of ater type of epithelium in the middle
‘ir or mastoid that conatitutes a cholesteatoma In other
‘words chaesteatoma 15 “Sn Inthe wong place” the
{erm cholesteatoma a misnomer because neithercan-
tains cholesterol era nor itis à amour to me the
Saft “oma” However, the term has ben retained be:
‘ase of te wer usage,
Essentially choletestoma consists of two pets: (he
‘mati which is made up of kratinang samoss pie
{helium resting on a thin sroma of bros sus and UI)
‘scent white mass, consisting of keratin debris produce
Dy he max (ue 111 LO) For this reason, tha als
‘ben name epiermosts or Raton
ORIGIN OF CHOLESTEATOMA
¡Genesis o chalesteatoma isa matter of debate, Any theo:
{of genesis mus explain how squamous epithelium
ppeated inthe middle ear cet Ihe Various vies ex
presse are
1. Presence of congenital cel ests.
2. Invaginaton of tympanie membrane from the attic
for posterosuperior part of pars ten in the form of
oe
retraction pockets (Figure 112) Wittman’ tm
The outer surface of tympanic membrane is med by
stratified squamous epthelum which after invagina
‘on forms the mati of cholesteatoma nls oven
keratin in te pocket.
sa cel hyperplasia (Ali the). The basal els of
‘germinal ayer of skin proliferate under he Influence
‘of nection and ly down Keatiniang «quamous cie
‘liom.
4. Epithel invasion (Habermann teary). The epithe-
lium om the meatus or outer drum surface ROWS
Into Ihe muddle car through a pre-enising perforation
‘specially of the marginal ype where pat OF annulus
tympanicus has already been dest
Metaplaia (Sad thoy). Middle ear mucos, ke es
[ratory mucosa elsewhere, undergoes metaplasia due
{o repeated infections and transforms Int squamous
‘epithelia,
A +4
€
os
pt aso tough postrer pron
Figure 1.2. Goes cle.
7
74 SECTION! Dicas of far
CLASSIFICATION OF CHOLESTEATOMA
(FIGURE 11.3)
The cholesteatoma is cased ito:
1. Congenital
2 Nogales, primary
3 Acquired Secondary
1. Concentra CUOLESTEMONA, It asc fom the em
biyonie epidermal cell ests in the middle ear cle or
temporal bone, Congenital cholesteatoma occur tthe
“importan sites middle er jetous apex and the cer
ponte angle and prodes symptomatology depend:
ing on cation.
"A middle car congenital cholesteatoma presents as à
white mass behind an intact tympanic membrane and
uses conductive hearing Tos. I may sometimes be
“covered on routine examination of children or at the
time of myringotomy:
nay aso spontancousy rupture through the ym
panic membrane and present with a discharging car in.
{stinguishable rom a case of chron suppurative ots
mai
2. Panuy AcquinED CuoLEsMEArOMA (Pic 11.2) It
{Scaled primary as there 1 no history of previous otitis
‘media or a pre-existing perforation. Theo on is gen
(a) Imagination of pars acid. Persistent negative pes
Sure in Ihe attic causes retraction pocket which se
‘cumulates beatin debi. When infected, the keratin
mass expands towards the mile car. Tus ati per
foration isin fact the proximal end ofan expanding
invaginated sc
ction ocacion
Prcatemenpa esas cr
Abe or posent errant pct
penca cs _ „| Prnaiyacqued |, prnennonot
ee cena ss
Since cine
epee recon eta neta
‘neon pero mes
+
rar poten
+
ais peta ten
masse co mon ‘hong
sl
Figure 1.3. Cons ot pay and candy cheat,
(©) Basal cl prplaia. There is proleration of the ba:
sal layer of pars Mets induced by selina cid
(©) Simona maple. Normal parement epithelia
of attic undergoes metaplası, Keatinzingsqua-
‘ous citen dueto aubelinical infections Such
change ha aso been demonstrated in ease of ots
ined with efuson
3. Stconpany ACQUIRED CuoLIstEATOMA. In these
‘ies, there already à pre-existing perforation in par
tensa. This soften asocian with posterosuperior mar-
final perforation or sometimes large central perforation,
none on I genesis Include
(@) Migration of squamous epi. Krainizing sau.
mous epithelium of external auditory canal or outer
Surface ol tympanic membrane migrates through the
perforation into the middle ca, Perforatons, invole-
Ing tymponie annulus as in acute necrotizing ots
media, are more Ukely to allow in-growth of squae
mous epithelium.
(9) Mapa. Middle car mucosa undergoes metaplasia
ue fo repeated Infections of middle ar through the
preexisting poration.
EXPANSION OF CHOLESTEATOMA
AND DESTRUCTION OF BONE
One chokteatoma enter the mite ale, ivades
{he suounding race fst by flowing the path of
Let resistance and then byenzymatichone dstratn.
An atu cholesteatoma may extend chad Ino the
its, anrum and maso: donors into he meso
gmponum medal à may sutround the incas and/or
Rs ot malus.
Ghotetetoma has te propery to destroy bone,
may cause destruction of sr ose coso of bony be
‘i, canal ol facial neve sims pla or gm ps
(yes as bon abad to ars enzymes
Sich as collagenase, a phosphate and proteolytic en.
mes bei one and mononuclear
ter cl seen In asocio with cholesteatoma. The
‘Sree theory that cholesteatoma cases destacton of
tee by pressure cons snot espe hes day.
‘CHRONIC SUPPURATIVE OTITIS MEDIA
Chronic suppurative ots media (CSOM) ia Iongstand-
ing infection of par or whole ofthe middle ear cleft
‘hhracterzed by er discharge and a Permanent pero:
tion. À perforation becomes permanent when is es
te covered by squamous epithelium and it doesnot heal
Spontancously. A permanent perforation can be likened
{an pit lned tulo track (iure 1.0)
EPIDEMIOLOGY
idence of CSOM ls higher in developing counties be-
‘use of poor socioeconomic standards, poor nutrition
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CLASSIFICATION OF CHOLESTEATOMA
(FIGURE 11.3)
The cholesteatoma is cased ito:
1. Congenital
2 Nogales, primary
3 Acquired Secondary
1. Concentra CUOLESTEMONA, It asc fom the em
biyonie epidermal cell ests in the middle ear cle or
temporal bone, Congenital cholesteatoma occur tthe
“importan sites middle er jetous apex and the cer
ponte angle and prodes symptomatology depend:
ing on cation.
"A middle car congenital cholesteatoma presents as à
white mass behind an intact tympanic membrane and
uses conductive hearing Tos. I may sometimes be
“covered on routine examination of children or at the
time of myringotomy:
nay aso spontancousy rupture through the ym
panic membrane and present with a discharging car in.
{stinguishable rom a case of chron suppurative ots
mai
2. Panuy AcquinED CuoLEsMEArOMA (Pic 11.2) It
{Scaled primary as there 1 no history of previous otitis
‘media or a pre-existing perforation. Theo on is gen
(a) Imagination of pars acid. Persistent negative pes
Sure in Ihe attic causes retraction pocket which se
‘cumulates beatin debi. When infected, the keratin
mass expands towards the mile car. Tus ati per
foration isin fact the proximal end ofan expanding
invaginated sc
ction ocacion
Prcatemenpa esas cr
Abe or posent errant pct
penca cs _ „| Prnaiyacqued |, prnennonot
ee cena ss
Since cine
epee recon eta neta
‘neon pero mes
+
rar poten
+
ais peta ten
masse co mon ‘hong
sl
Figure 1.3. Cons ot pay and candy cheat,
(©) Basal cl prplaia. There is proleration of the ba:
sal layer of pars Mets induced by selina cid
(©) Simona maple. Normal parement epithelia
of attic undergoes metaplası, Keatinzingsqua-
‘ous citen dueto aubelinical infections Such
change ha aso been demonstrated in ease of ots
ined with efuson
3. Stconpany ACQUIRED CuoLIstEATOMA. In these
‘ies, there already à pre-existing perforation in par
tensa. This soften asocian with posterosuperior mar-
final perforation or sometimes large central perforation,
none on I genesis Include
(@) Migration of squamous epi. Krainizing sau.
mous epithelium of external auditory canal or outer
Surface ol tympanic membrane migrates through the
perforation into the middle ca, Perforatons, invole-
Ing tymponie annulus as in acute necrotizing ots
media, are more Ukely to allow in-growth of squae
mous epithelium.
(9) Mapa. Middle car mucosa undergoes metaplasia
ue fo repeated Infections of middle ar through the
preexisting poration.
EXPANSION OF CHOLESTEATOMA
AND DESTRUCTION OF BONE
One chokteatoma enter the mite ale, ivades
{he suounding race fst by flowing the path of
Let resistance and then byenzymatichone dstratn.
An atu cholesteatoma may extend chad Ino the
its, anrum and maso: donors into he meso
gmponum medal à may sutround the incas and/or
Rs ot malus.
Ghotetetoma has te propery to destroy bone,
may cause destruction of sr ose coso of bony be
‘i, canal ol facial neve sims pla or gm ps
(yes as bon abad to ars enzymes
Sich as collagenase, a phosphate and proteolytic en.
mes bei one and mononuclear
ter cl seen In asocio with cholesteatoma. The
‘Sree theory that cholesteatoma cases destacton of
tee by pressure cons snot espe hes day.
‘CHRONIC SUPPURATIVE OTITIS MEDIA
Chronic suppurative ots media (CSOM) ia Iongstand-
ing infection of par or whole ofthe middle ear cleft
‘hhracterzed by er discharge and a Permanent pero:
tion. À perforation becomes permanent when is es
te covered by squamous epithelium and it doesnot heal
Spontancously. A permanent perforation can be likened
{an pit lned tulo track (iure 1.0)
EPIDEMIOLOGY
idence of CSOM ls higher in developing counties be-
‘use of poor socioeconomic standards, poor nutrition
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Chapter 11 — Choetetoma and Chronic Ottis Media 75
Figure 114. Barc mp menta ih ti reac packet row) due to eg presu he mi se
and lack of health education. affect both sexes and all
ge groups. In Ind, the overall prevalence ate 46 and
16 persons per thousand in rural and urban population,
respectively. tis ao the single most important cause of
hearing impairment in rural population,
‘TYPES OF CSOM
Clinical
divided into two types:
1. TUnOTVMPANIC. Also called the safe or beni type: it
Involves aneroinfeir pat of middle car dl, Lee
lachlan tube and mesotympanum and is associated with
central perforation. Theres no sk ol serious complica.
tions,
2. Arricoasmnat. Also called unsafe or dangerous type:
i involves posterosuperor par of the cleft (Le. ate,
antrum and mastoid) and 1 associated with an ati or
3 marginal peeoration. The disease i often associated
Ath à Done-eroding process such as cholesteatoma,
ranulations or otitis. Rsk of complications high in
this variety
Table 171 shows differences between the two types of
som.
A. TUBOTYMPANIC TYPE
Aetiology
Tie disease stats in childhood and therefore common
in that age group.
1. Its the sequela of acute ons media usually follow
tous fever and leaving behind a large
2. Ascending infections via the eustachian tube. Inec
on tom tonsils, adenolds and infected sinuses may
be response fr persistent or recurring ot. AS
ending infection to middle sar occur more eal in
the presence of nection
Persistent mucoid otorthoea is sometimes the result of
allergy to ingestanssuch a milk, es, fish, ste
Pathology
‘The tubotympanic disase remain cáliz to the mu:
osa and, that 100, mostly to anteroinfror part of the
mide eat cleft Like any other chronie safection,
processes of healing and destruction go hand in hand
And either of them may take advantage over the othe,
‘gpening on the virulence of organism and resistance
‘ofthe patent Thus, acute exacerbations are nt unco
mon. The pathological changes seen in this type of CSOM
1. Prnsorario oF Pans Tensa, lts a central poor
tion and is sz and postion vas (ute 11)
2. Mipour Eur Mucosa. It may be normal when dis
‘ise is quiescen or native. It is osdematous and velvety
sten dhenseis ative
3. Pouvr. A polyp isa smooth mas of oedematous and
md mucosa which has pro Hough a prior
in contrast to pink, fleshy polyp seen in aticoatal di
ese (sure 110)
a. Ossicutan Ca. I usually intact and mobile but
may show some degree of necrosis, particularly of the
Tong proces of nes
Tiyan of safe pe
ico runa pe
De tu mot totes Se, a fo on
rip ne Fada ey
moto te Core
rie M o modems conduce dia Condiciones
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Figure 114. Barc mp menta ih ti reac packet row) due to eg presu he mi se
and lack of health education. affect both sexes and all
ge groups. In Ind, the overall prevalence ate 46 and
16 persons per thousand in rural and urban population,
respectively. tis ao the single most important cause of
hearing impairment in rural population,
‘TYPES OF CSOM
Clinical
divided into two types:
1. TUnOTVMPANIC. Also called the safe or beni type: it
Involves aneroinfeir pat of middle car dl, Lee
lachlan tube and mesotympanum and is associated with
central perforation. Theres no sk ol serious complica.
tions,
2. Arricoasmnat. Also called unsafe or dangerous type:
i involves posterosuperor par of the cleft (Le. ate,
antrum and mastoid) and 1 associated with an ati or
3 marginal peeoration. The disease i often associated
Ath à Done-eroding process such as cholesteatoma,
ranulations or otitis. Rsk of complications high in
this variety
Table 171 shows differences between the two types of
som.
A. TUBOTYMPANIC TYPE
Aetiology
Tie disease stats in childhood and therefore common
in that age group.
1. Its the sequela of acute ons media usually follow
tous fever and leaving behind a large
2. Ascending infections via the eustachian tube. Inec
on tom tonsils, adenolds and infected sinuses may
be response fr persistent or recurring ot. AS
ending infection to middle sar occur more eal in
the presence of nection
Persistent mucoid otorthoea is sometimes the result of
allergy to ingestanssuch a milk, es, fish, ste
Pathology
‘The tubotympanic disase remain cáliz to the mu:
osa and, that 100, mostly to anteroinfror part of the
mide eat cleft Like any other chronie safection,
processes of healing and destruction go hand in hand
And either of them may take advantage over the othe,
‘gpening on the virulence of organism and resistance
‘ofthe patent Thus, acute exacerbations are nt unco
mon. The pathological changes seen in this type of CSOM
1. Prnsorario oF Pans Tensa, lts a central poor
tion and is sz and postion vas (ute 11)
2. Mipour Eur Mucosa. It may be normal when dis
‘ise is quiescen or native. It is osdematous and velvety
sten dhenseis ative
3. Pouvr. A polyp isa smooth mas of oedematous and
md mucosa which has pro Hough a prior
in contrast to pink, fleshy polyp seen in aticoatal di
ese (sure 110)
a. Ossicutan Ca. I usually intact and mobile but
may show some degree of necrosis, particularly of the
Tong proces of nes
Tiyan of safe pe
ico runa pe
De tu mot totes Se, a fo on
rip ne Fada ey
moto te Core
rie M o modems conduce dia Condiciones
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76 SECTION! — Diseases of far
Peer tympani trar
——<—<$<— 2%
7
2 Sia Ve ag parton trae
A poto
asian
epa, henge
Encore nung
re. Pen Lynn werben ot Ai paper mar pane nn geo pe SOS
‘ype ot mag peak by emitan an cn a diene. Tre, majos pen we Co
alo a comidos ects a ey not maite MAN em
Figure 11.6 (ap he cr cal.) Schema Murat 1 pop ring rom he promartony ping tough the era
$. Tinirsosciamosts, ts yalinizaton and subsequent
«scan of Sabepiinil connective tue es cen
In semnants of tympanic membrane or under Ihe muco-
à of mile ca. e seen as white chalky deposit on the
promontory, ossicles, joint, tendons and oval and sound
Sindows, Tympanosclerti masses may inter ith the
‘obit ofthese structures and cause condutive deans
6: FanmostS AND ADIESIONS. They ae the sult of hal
ing process and may further impair mobllty of eur
Bacteriology
Pas culture in both types of aerobic and anaerobic CSOM
may hos mile ogni Common sro og
and Stpiyloccus aus, while anaerobes include Bace-
‘olds fags and anaerobic Streptococh
Alternative Classification of Chronic
Otitis Media
Tubotympanie disease of middle ear is à mucosal disease
sth no evidence of invasion of squamous epithe
Its called “ache” when thee à perforation of pas
tensa with inflammation of mucosa and mucopuru
charge. ts called “the” when there I 2 perma
perforation of pas tensa but middle ear mucosa Is
‘ot indamed and there no dscharge. Pormane pero
ro imples that squamous epithelium on the external
Surface of pas tensa and mocena lining its Inner surface
ave used across sedge. Hef toni ats medias he
‘condition when tympanic membrane has heated (tally
by two layers atop and easly retraced here fe
régate pressure in the middle eat Healed ots meda
‘may also have patches of tympanoscletoss in tympanic
jembrane, or In middle ar involving promontory, 0
Seles, tendons ol stapes and tensor tympani, Holic
{issue may appear in middle <a. 1 i always sociated
‘vith some degre of conductive hearing los
Aicoantal disease has ben called squumosl disease
of mide er. may be "nette when there are eta
ton pockets in pars tensa (usually the posterosuperior
region) or pas flaccida, There fs no discharge but there
‘Sa possiblity of squamous debs in retraction pockets
to become infected and srt charging. Some rete
ton pockets ae shallow and self-cleansing. “Actes
mosal disease of middle er implies presence of che.
{oma of postrosupelor segon of pars tensa or inthe par
mebooksfree.com
Peer tympani trar
——<—<$<— 2%
7
2 Sia Ve ag parton trae
A poto
asian
epa, henge
Encore nung
re. Pen Lynn werben ot Ai paper mar pane nn geo pe SOS
‘ype ot mag peak by emitan an cn a diene. Tre, majos pen we Co
alo a comidos ects a ey not maite MAN em
Figure 11.6 (ap he cr cal.) Schema Murat 1 pop ring rom he promartony ping tough the era
$. Tinirsosciamosts, ts yalinizaton and subsequent
«scan of Sabepiinil connective tue es cen
In semnants of tympanic membrane or under Ihe muco-
à of mile ca. e seen as white chalky deposit on the
promontory, ossicles, joint, tendons and oval and sound
Sindows, Tympanosclerti masses may inter ith the
‘obit ofthese structures and cause condutive deans
6: FanmostS AND ADIESIONS. They ae the sult of hal
ing process and may further impair mobllty of eur
Bacteriology
Pas culture in both types of aerobic and anaerobic CSOM
may hos mile ogni Common sro og
and Stpiyloccus aus, while anaerobes include Bace-
‘olds fags and anaerobic Streptococh
Alternative Classification of Chronic
Otitis Media
Tubotympanie disease of middle ear is à mucosal disease
sth no evidence of invasion of squamous epithe
Its called “ache” when thee à perforation of pas
tensa with inflammation of mucosa and mucopuru
charge. ts called “the” when there I 2 perma
perforation of pas tensa but middle ear mucosa Is
‘ot indamed and there no dscharge. Pormane pero
ro imples that squamous epithelium on the external
Surface of pas tensa and mocena lining its Inner surface
ave used across sedge. Hef toni ats medias he
‘condition when tympanic membrane has heated (tally
by two layers atop and easly retraced here fe
régate pressure in the middle eat Healed ots meda
‘may also have patches of tympanoscletoss in tympanic
jembrane, or In middle ar involving promontory, 0
Seles, tendons ol stapes and tensor tympani, Holic
{issue may appear in middle <a. 1 i always sociated
‘vith some degre of conductive hearing los
Aicoantal disease has ben called squumosl disease
of mide er. may be "nette when there are eta
ton pockets in pars tensa (usually the posterosuperior
region) or pas flaccida, There fs no discharge but there
‘Sa possiblity of squamous debs in retraction pockets
to become infected and srt charging. Some rete
ton pockets ae shallow and self-cleansing. “Actes
mosal disease of middle er implies presence of che.
{oma of postrosupelor segon of pars tensa or inthe par
mebooksfree.com
Chapter 11 — Cholestetoma and Chronic Ottis Media 77.
I
esl nee eile
t 1 1 3 4
ie mn AS
pd, Se Qi Rens Le.
a Se QUES,
Figure 117. Conan lon ta meso.
opter
ae
tea arten
ri ere
Toul petaten oe pero Poo mare
“Son sence o
A
Figure 1.8. peo! pion sen nthe mani membrane in CSOM.
Maccda. I erodes bone, forms granulation tissue and has
purulen offensive discharge (11)
Clinical Features.
1. EAR DISCHARGE Its nonotfensive, mucoid or mucoy-
rent, constant of intermitent The discharge appears
mostly at time of upper respiratory tat infection or on
accidental entry of water Into the ca.
2, HEARING Loss. Its conductive types seventy varies
‘but rarely exceeds 80 JB. Sometimes, the patient reports
fa paradoxical effect, ke. hears beter in he presence ol
charge than when the eri ey. This ls due to “rund
indi shcig ect” produced by charge which
helps to maintain phase diferent In the dy ea wi
Perforation, sound waves tke Doth the oval and round
‘windows simultaneously, thus cancelling each others e
ect ser Physiology of hearin
in long standing cases, cochlea may sfr damage due
Lo option of toxins from the oval and round windows
and hearing loss Becomes mixed ype
3, PERIORATION, Always central, may le anterio,
posterior or inferior tothe handle of malleus I may be
Smal, medium or ge or extending upto the annulus,
He subtotal (girs PU 5d 119)
4. Miober Ean MUCOSA. Is seen when the perfora:
tion is lage. Normally, it ple pink and moist when
ame looks rd, oedematous and swollen, Occasion
ly, polyp may be sen
Figure 1.9, Auge co peroo
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I
esl nee eile
t 1 1 3 4
ie mn AS
pd, Se Qi Rens Le.
a Se QUES,
Figure 117. Conan lon ta meso.
opter
ae
tea arten
ri ere
Toul petaten oe pero Poo mare
“Son sence o
A
Figure 1.8. peo! pion sen nthe mani membrane in CSOM.
Maccda. I erodes bone, forms granulation tissue and has
purulen offensive discharge (11)
Clinical Features.
1. EAR DISCHARGE Its nonotfensive, mucoid or mucoy-
rent, constant of intermitent The discharge appears
mostly at time of upper respiratory tat infection or on
accidental entry of water Into the ca.
2, HEARING Loss. Its conductive types seventy varies
‘but rarely exceeds 80 JB. Sometimes, the patient reports
fa paradoxical effect, ke. hears beter in he presence ol
charge than when the eri ey. This ls due to “rund
indi shcig ect” produced by charge which
helps to maintain phase diferent In the dy ea wi
Perforation, sound waves tke Doth the oval and round
‘windows simultaneously, thus cancelling each others e
ect ser Physiology of hearin
in long standing cases, cochlea may sfr damage due
Lo option of toxins from the oval and round windows
and hearing loss Becomes mixed ype
3, PERIORATION, Always central, may le anterio,
posterior or inferior tothe handle of malleus I may be
Smal, medium or ge or extending upto the annulus,
He subtotal (girs PU 5d 119)
4. Miober Ean MUCOSA. Is seen when the perfora:
tion is lage. Normally, it ple pink and moist when
ame looks rd, oedematous and swollen, Occasion
ly, polyp may be sen
Figure 1.9, Auge co peroo
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7B SECTION! Diese of far
Assessment
1. EXAMINATION UNDER Micwoscore (Feu 11.10).
ds essential in every case and provides useful Informa
tion regarding presence of granulations, n-growth of
Squamous epithelium from the edges of portion, sta.
{us of osicular chain, tympanoscerosß and adhesions
[An car which appears ey may Show hidden discharge
under the microscope. Rarely, cholesteatoma may coe
Ist with a central perforation and can be seen under à
microscope
igure 11.10. Eamaton at ear under moe
2. Aumocan, It gives an assessment of degree of hear
Ing toss and its type. Usually the Tosi conductive but a
sensorineural element may De pesen,
3. CULTURE AND SexstrVi or En Discuaner.
els to select proper antibiotic ear drops
4. Masrom X.mavs/CT scaN TEMPORAL HONE. Mastoid
'S usualy slot but may be pneumatize with cloud:
ing far cells There so evidence of bone destruction
Presence of bone destruction 1 feature of aticoantral
disease.
Treatment
The aim isto control infection and eliminate cr di
charge and ata later tage to Core the heating los by
Surgical means
1. Avnar Totter, Remove al discharge and debris fom
the ear It can be done by dry mopping with absorbent
Soon uds suction sleranee under microscope ori
ation not force Singing) with tele normal saline
Far must be dried after ligation,
2. Eau Duors. Antibiotic car drops containing neomy:
in, polymyxin, chloromyeetin or gentamicin are used
‘The’ are combined saith serolds which have local ant
ntlammatory ec. To use ie drops, patient lis down.
sith thedseased car up, ante drop are insti and
en intermittent pressure applied on the trgus for an-
"boe solution to reach the middle car. This should be
done throc or four times day: Aid pH helps to eliminate
Pseudomonas infection, and gations with 1.8% ace
Rd ar useful.
Care should be taken as er drops are Hey to cause
‘maceration of canal sin, local alley, growth of fangs
orresstance of organisms. Some ear drops are potentially
3. SYStIMIC ANTIMOTICS. They are sel in cute ex
aceation of chronically infected car, otherwise role
fof systemic antibiotics In the treatment of CSOM Is
Tite
4. Pascaunons. Patients ae instructed to keep water
‘ut ofthe ear during bathing, swimming and har wash,
Rubber inserts an be use. Hard nose blowing can also
push ine Infection from nasopharynx to middle ea and
Should be avoided
5. TREATMENT oF CoNTRINUTORY CASES. Attention
Should be paid to teat concomitantly nected tons,
‘Mlenois, mailay antra and nasal alley
6. SURGICAL TREATMENT. Aural polyp or granulstions,
dí present, should be removed before local treatment
‘uth antibiotics wil faciitat car tllt and permit eat
{rops tobe used effectively. An aural polyp should never e
sedas may bearing fom the tapes, taal nerve or
horizontal canal and ths ead to facial parlyal or by
‘inthis,
7. RUCONSIRUCHIE SURGERY. Once car Is diy, min
opt with or without osseular construction can be
done to restore bearing, Closure of perforation will also
‘heck repeated infection fom the external canal
B. ATTICOANTRAL TYPE
It involves postersuperior part of mide car cleft at,
strum, posterior tympanum and mastoid) and is asset
ted with cholesteatoma, which, because of ts bone ero.
ing properties, causes nk of serious completions. For
this reson, the disease is ako called atar dangerous
‘ype
Aetiology
Aetiology’ of atticoantral disease Is same a of cholestea-
toma and has been discussed erie eis seen in sclerotic
{aston and whether the later i the cause or eect Of
“sense not yet cleat
Pathology
Aticoatral discuss are associated with the following
pathologie processes
1. enouesrestowa,
2. Osteins ano GuANULATION Tissu, Otitis involves
Outer atc wall and postrosuperior margin of the m=
panic ing. A mass of granulation tissue surrounds the
Ara of osteitis and may even il the at, atm, poste
flor tympanum and mastod. A leshy re polyps maybe
Seen iting the meats.
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Assessment
1. EXAMINATION UNDER Micwoscore (Feu 11.10).
ds essential in every case and provides useful Informa
tion regarding presence of granulations, n-growth of
Squamous epithelium from the edges of portion, sta.
{us of osicular chain, tympanoscerosß and adhesions
[An car which appears ey may Show hidden discharge
under the microscope. Rarely, cholesteatoma may coe
Ist with a central perforation and can be seen under à
microscope
igure 11.10. Eamaton at ear under moe
2. Aumocan, It gives an assessment of degree of hear
Ing toss and its type. Usually the Tosi conductive but a
sensorineural element may De pesen,
3. CULTURE AND SexstrVi or En Discuaner.
els to select proper antibiotic ear drops
4. Masrom X.mavs/CT scaN TEMPORAL HONE. Mastoid
'S usualy slot but may be pneumatize with cloud:
ing far cells There so evidence of bone destruction
Presence of bone destruction 1 feature of aticoantral
disease.
Treatment
The aim isto control infection and eliminate cr di
charge and ata later tage to Core the heating los by
Surgical means
1. Avnar Totter, Remove al discharge and debris fom
the ear It can be done by dry mopping with absorbent
Soon uds suction sleranee under microscope ori
ation not force Singing) with tele normal saline
Far must be dried after ligation,
2. Eau Duors. Antibiotic car drops containing neomy:
in, polymyxin, chloromyeetin or gentamicin are used
‘The’ are combined saith serolds which have local ant
ntlammatory ec. To use ie drops, patient lis down.
sith thedseased car up, ante drop are insti and
en intermittent pressure applied on the trgus for an-
"boe solution to reach the middle car. This should be
done throc or four times day: Aid pH helps to eliminate
Pseudomonas infection, and gations with 1.8% ace
Rd ar useful.
Care should be taken as er drops are Hey to cause
‘maceration of canal sin, local alley, growth of fangs
orresstance of organisms. Some ear drops are potentially
3. SYStIMIC ANTIMOTICS. They are sel in cute ex
aceation of chronically infected car, otherwise role
fof systemic antibiotics In the treatment of CSOM Is
Tite
4. Pascaunons. Patients ae instructed to keep water
‘ut ofthe ear during bathing, swimming and har wash,
Rubber inserts an be use. Hard nose blowing can also
push ine Infection from nasopharynx to middle ea and
Should be avoided
5. TREATMENT oF CoNTRINUTORY CASES. Attention
Should be paid to teat concomitantly nected tons,
‘Mlenois, mailay antra and nasal alley
6. SURGICAL TREATMENT. Aural polyp or granulstions,
dí present, should be removed before local treatment
‘uth antibiotics wil faciitat car tllt and permit eat
{rops tobe used effectively. An aural polyp should never e
sedas may bearing fom the tapes, taal nerve or
horizontal canal and ths ead to facial parlyal or by
‘inthis,
7. RUCONSIRUCHIE SURGERY. Once car Is diy, min
opt with or without osseular construction can be
done to restore bearing, Closure of perforation will also
‘heck repeated infection fom the external canal
B. ATTICOANTRAL TYPE
It involves postersuperior part of mide car cleft at,
strum, posterior tympanum and mastoid) and is asset
ted with cholesteatoma, which, because of ts bone ero.
ing properties, causes nk of serious completions. For
this reson, the disease is ako called atar dangerous
‘ype
Aetiology
Aetiology’ of atticoantral disease Is same a of cholestea-
toma and has been discussed erie eis seen in sclerotic
{aston and whether the later i the cause or eect Of
“sense not yet cleat
Pathology
Aticoatral discuss are associated with the following
pathologie processes
1. enouesrestowa,
2. Osteins ano GuANULATION Tissu, Otitis involves
Outer atc wall and postrosuperior margin of the m=
panic ing. A mass of granulation tissue surrounds the
Ara of osteitis and may even il the at, atm, poste
flor tympanum and mastod. A leshy re polyps maybe
Seen iting the meats.
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3. OssicULAR Necosts It
‘ese, Destruction may be limited tothe long proces of
incus or may also involve stapes superstractre, handle
‘of malleus or the entire osscular chain. Therefore, hea
Inglos is always greater han in disease of tabotympante
type. Occasionally the cholesteatoma bridges the gap
std by the destroyed oncles and Hearing Tos is not
ppurent (cholesteatoma heer
4. CUOLISTEROL GIANVLOMA. tis mass of granulation
su with foreign body gan cells surrounding Ihe cho
lesterol estas isa action o long-standing retention
‘of secretions or haemorthage, and may or may not co.
is with cholesteatoma When presenti the my pa
‘hum, behind an intact drum, he latter appear lve
Bacteriology
Same as in tuborympanic type
Symptoms
1. Ear Discuancr. Usually scanty, but always fou
Selig ue to bone destruction. Discharge may be so
Samy that the patient may not even be aware of Rota
¿son of discharge rom an car which his Den ate
these cases might be scaled by crusted discharge, nam.
mon micos or polyp, coxe the fee ow of
‘charge, Pu, In he cases, may And ls way Intemaly
2. HEARING 1OSS. Hearings normal when ossicul
‘hain intact or when choleseatom, having destoyed
the esis, bridges the gap caused by dstoved esis
{chatte har). Hearing los le mostly conductive
but sensonncurl element may be added
3. Burn. It may occur from granulations oF the pol
Yi when cleaning the ear
Signs
1. PEnsORsrION. Iti either atic or posterosupeior mat
ginal type (igure 11.11). A Small ati perforation may
De missed duc to presence of a small amount of caste
charge. Sometimes, the area of poration is masked
y a small ganuloma.
2, Reaction Pocket. An invagination of tympanic
membrane Is cn inthe ati or posterosuperor aes oF
Par tensa. Degree of retraction and invagination vr
In can stages pocket ls shallow and self-cleaning but
Tater when pocket s deep, it accumulates eatin mass
and gets infected,
Stages oracion pokes. Thee ate four stages of ty
panic membrane retraction
(a) Stage Tympanic membrane retract but does not
(by Stage IL Tympanic membrane i reacted deep and
Contacts the inc middle ear mucosa Is no fect
(0 Stage I. Ako called mite cur ateects.Tympante
‘les. Middle eat space ls totally o partially obliterated
but mile car mucosa intact, Tympani membrane
mebooksi
»
Chapter 11 — Cholestetoma and Chronic Oi Meda
Figure 11.11.) te proton (8 Cae wh dobleperton
(OP ep ana pata nd ol mates an nie
ae wth enon le er ae wo).
«an bete from the promontory with suction tip 1
iso balloons up when NO fs used during anaesthe
Si. Tymponie membrane i thin because ls collage:
‘ous middle layer has been absorbed due to prolonged
Fetraction, In these cases long process of eus and
Sapes superstructure are absorbed. Placement of à
‘entation tube helps 10 restore the position of tym
panic membrane
Sage IV. Abo called ase ots medio, Tympanic
membrane & very thi and was the promontory and
sic. There 1 no middle ea space mucosa) nin
‘of the middle ar ls absent and tympanic membrane
gets adherent to the promontory. Retraction pockets
ne formed which may collet Berti ps nd Form
‘holesteatoma, Eroon of the long proces of incus
nd stapes superstructure ls common In such ss
“
3. CwotestearoMa, Pearly-hite fakes of chose»
ima can be sucked fiom the reaction pockets. Suction
free.com
‘ese, Destruction may be limited tothe long proces of
incus or may also involve stapes superstractre, handle
‘of malleus or the entire osscular chain. Therefore, hea
Inglos is always greater han in disease of tabotympante
type. Occasionally the cholesteatoma bridges the gap
std by the destroyed oncles and Hearing Tos is not
ppurent (cholesteatoma heer
4. CUOLISTEROL GIANVLOMA. tis mass of granulation
su with foreign body gan cells surrounding Ihe cho
lesterol estas isa action o long-standing retention
‘of secretions or haemorthage, and may or may not co.
is with cholesteatoma When presenti the my pa
‘hum, behind an intact drum, he latter appear lve
Bacteriology
Same as in tuborympanic type
Symptoms
1. Ear Discuancr. Usually scanty, but always fou
Selig ue to bone destruction. Discharge may be so
Samy that the patient may not even be aware of Rota
¿son of discharge rom an car which his Den ate
these cases might be scaled by crusted discharge, nam.
mon micos or polyp, coxe the fee ow of
‘charge, Pu, In he cases, may And ls way Intemaly
2. HEARING 1OSS. Hearings normal when ossicul
‘hain intact or when choleseatom, having destoyed
the esis, bridges the gap caused by dstoved esis
{chatte har). Hearing los le mostly conductive
but sensonncurl element may be added
3. Burn. It may occur from granulations oF the pol
Yi when cleaning the ear
Signs
1. PEnsORsrION. Iti either atic or posterosupeior mat
ginal type (igure 11.11). A Small ati perforation may
De missed duc to presence of a small amount of caste
charge. Sometimes, the area of poration is masked
y a small ganuloma.
2, Reaction Pocket. An invagination of tympanic
membrane Is cn inthe ati or posterosuperor aes oF
Par tensa. Degree of retraction and invagination vr
In can stages pocket ls shallow and self-cleaning but
Tater when pocket s deep, it accumulates eatin mass
and gets infected,
Stages oracion pokes. Thee ate four stages of ty
panic membrane retraction
(a) Stage Tympanic membrane retract but does not
(by Stage IL Tympanic membrane i reacted deep and
Contacts the inc middle ear mucosa Is no fect
(0 Stage I. Ako called mite cur ateects.Tympante
‘les. Middle eat space ls totally o partially obliterated
but mile car mucosa intact, Tympani membrane
mebooksi
»
Chapter 11 — Cholestetoma and Chronic Oi Meda
Figure 11.11.) te proton (8 Cae wh dobleperton
(OP ep ana pata nd ol mates an nie
ae wth enon le er ae wo).
«an bete from the promontory with suction tip 1
iso balloons up when NO fs used during anaesthe
Si. Tymponie membrane i thin because ls collage:
‘ous middle layer has been absorbed due to prolonged
Fetraction, In these cases long process of eus and
Sapes superstructure are absorbed. Placement of à
‘entation tube helps 10 restore the position of tym
panic membrane
Sage IV. Abo called ase ots medio, Tympanic
membrane & very thi and was the promontory and
sic. There 1 no middle ea space mucosa) nin
‘of the middle ar ls absent and tympanic membrane
gets adherent to the promontory. Retraction pockets
ne formed which may collet Berti ps nd Form
‘holesteatoma, Eroon of the long proces of incus
nd stapes superstructure ls common In such ss
“
3. CwotestearoMa, Pearly-hite fakes of chose»
ima can be sucked fiom the reaction pockets. Suction
free.com
80 SECTION! — Diseases of far
clearance and examination under operating microscope
forms an important part ofthe inal examination and
sessment of any type of CSOM.
Assessment
1. EXAMINATION UNDER Mickoscore, AU patients of
onic middle early disease should be examined un
Ser mieroscope (gut 119) Te may reveal presence
fof eholesteatoms, it site and extent, evidence of bone
‘estraction, granuloma, condition of esis and pockets
of dlscharg.
2. TUNING FORK Tests AND Auot They ate essen“
tl or preoperative assessment aná to confirm the dep
and typeof hearing loss
3. Xæw MASTO1DS/CT SCAN Teuromat Boy. They
indicate extent of bone destruction and degree of mastoid
Pneumatlaton. They ae useful o indicate à lowing
{ura or an anteposed sigmoid sinus when operation 1
being contemplated on a sckrotie mastoid, Choletes.
toma causes destruction inthe area of ati and antrum
{aa better sen in lateral view CT scan of temporal
bone gives more information and Is prcered to Arıy
A. CULTURE AND SENSI OF EAR DISCHARGE: Ithelps
cc proper antibite fr local or sistem use
Features indicating Complications in CSOM
1. PAIN, Pan is uncommon in uncomplicated CSOM. ts
presen I considered serous a 1 may indicate extra
‘ural, perinus or brain abscess. Sometimes, ii dueto
vs tema associated witha discharging es
2. VERTIGO. I indicates erosion of lateral semicircular
nal which may progres 10 labjintits or meningitis
Fistula test sould be performed In al ass.
3. PrUsISTENT HEADACHE. tis suggestive of a
al complication,
4. Fat Weak, indicates erosion of facil canal
5. A LSTLISS CHILD ResUSING TO TAKE Fes. and easily
going to slep (extadutal abs)
6: Fave, NALSEA AND Vowrrine intracranial infection)
7. URRITAMILIEY AND NECK RIGIDITY. (meningitis,
8. DarLomA. (Gradenig syndrome) ptosis
9. ATAXIA, (LABVRINIHITIS OR CEREBELLAR ABSCESS)
10. ANSCESS ROUND THE EAR. (mastoid)
itis not uncommon fora patient of CSOM,eeiing in
a farstung village, where medical faites ate poor, to go
{oa doctor forthe fist time, presenting with complica
tons then demands urgent attention and emergency
medical or surgical treatment
Treatment
1. Sumcteat.Itsthe mainstay of treatment Primary aim
in surgical treatment 1 to remove the disease and render
the cr safe, and Second i pioaty 1 preserve or econ:
Struct hearing bat never atthe cst ofthe primary am,
“wo types of surgical procedures are done to deal with
cholesteatoma:
(a) Canal wall down procedures. They leave the mas-
told cavity open into the external auditory canal
So that the dacased area is fly extelonized, The
Commonly performed operations for atticoantal
disease are atticotomy modifica radical mastold-
fectomy and rarely, the radical mastoidectomy (see
‘operative surgery).
(©) Canal mal up pas. Here disease I removed by
combined approach through the meatus and mastoid
ut retaining the posterior bony meatal wall intact,
thereby avoiding an open mastosd cavity e gives dy
‘ar and permit easy reconstruction of hearing mecha.
hsm. However, there Is danger of leaving some ch
Keteatoma behind, Incidence of residual or recurrent
‘holesteatoma in these ass is very high and there
for long-term follow-up is senta. Some surgeon's
ven advise routine reexplration in all cases after
‘S months o so. Canal wall up procedures are advised
‘nly in elected cases. In combined approach or ntact
‘anal wall mastldectomy, dise & removed both
permeatally, and through cortical mastldectomy and
posterior tympanotomy approach, in which à win-
Sov à created between the mastoid and mide ea
‘through the facial ress, to teach sinus tympani
en).
See Tab 11 forthe comparison of canal wall up and
canal wall down procedures
“Canal map procedure
Meats Normal appa
Dependence Doct no ure rue cing
Acer hae hat rece ret
Seca ok ge
‘dion ratico ato wear angie
eres second sy ter 6 months
IN mn Pate owed sing
‘Cana wall don procedure
ey open mens cmmunkating ith man
Dependence on dcr ing mu cy once
pce
So cn dt nic ma dy dt
biens tin ai ad due to ge meatus
“Démo oy wth Sometimes us ete
mebooksfree.com
clearance and examination under operating microscope
forms an important part ofthe inal examination and
sessment of any type of CSOM.
Assessment
1. EXAMINATION UNDER Mickoscore, AU patients of
onic middle early disease should be examined un
Ser mieroscope (gut 119) Te may reveal presence
fof eholesteatoms, it site and extent, evidence of bone
‘estraction, granuloma, condition of esis and pockets
of dlscharg.
2. TUNING FORK Tests AND Auot They ate essen“
tl or preoperative assessment aná to confirm the dep
and typeof hearing loss
3. Xæw MASTO1DS/CT SCAN Teuromat Boy. They
indicate extent of bone destruction and degree of mastoid
Pneumatlaton. They ae useful o indicate à lowing
{ura or an anteposed sigmoid sinus when operation 1
being contemplated on a sckrotie mastoid, Choletes.
toma causes destruction inthe area of ati and antrum
{aa better sen in lateral view CT scan of temporal
bone gives more information and Is prcered to Arıy
A. CULTURE AND SENSI OF EAR DISCHARGE: Ithelps
cc proper antibite fr local or sistem use
Features indicating Complications in CSOM
1. PAIN, Pan is uncommon in uncomplicated CSOM. ts
presen I considered serous a 1 may indicate extra
‘ural, perinus or brain abscess. Sometimes, ii dueto
vs tema associated witha discharging es
2. VERTIGO. I indicates erosion of lateral semicircular
nal which may progres 10 labjintits or meningitis
Fistula test sould be performed In al ass.
3. PrUsISTENT HEADACHE. tis suggestive of a
al complication,
4. Fat Weak, indicates erosion of facil canal
5. A LSTLISS CHILD ResUSING TO TAKE Fes. and easily
going to slep (extadutal abs)
6: Fave, NALSEA AND Vowrrine intracranial infection)
7. URRITAMILIEY AND NECK RIGIDITY. (meningitis,
8. DarLomA. (Gradenig syndrome) ptosis
9. ATAXIA, (LABVRINIHITIS OR CEREBELLAR ABSCESS)
10. ANSCESS ROUND THE EAR. (mastoid)
itis not uncommon fora patient of CSOM,eeiing in
a farstung village, where medical faites ate poor, to go
{oa doctor forthe fist time, presenting with complica
tons then demands urgent attention and emergency
medical or surgical treatment
Treatment
1. Sumcteat.Itsthe mainstay of treatment Primary aim
in surgical treatment 1 to remove the disease and render
the cr safe, and Second i pioaty 1 preserve or econ:
Struct hearing bat never atthe cst ofthe primary am,
“wo types of surgical procedures are done to deal with
cholesteatoma:
(a) Canal wall down procedures. They leave the mas-
told cavity open into the external auditory canal
So that the dacased area is fly extelonized, The
Commonly performed operations for atticoantal
disease are atticotomy modifica radical mastold-
fectomy and rarely, the radical mastoidectomy (see
‘operative surgery).
(©) Canal mal up pas. Here disease I removed by
combined approach through the meatus and mastoid
ut retaining the posterior bony meatal wall intact,
thereby avoiding an open mastosd cavity e gives dy
‘ar and permit easy reconstruction of hearing mecha.
hsm. However, there Is danger of leaving some ch
Keteatoma behind, Incidence of residual or recurrent
‘holesteatoma in these ass is very high and there
for long-term follow-up is senta. Some surgeon's
ven advise routine reexplration in all cases after
‘S months o so. Canal wall up procedures are advised
‘nly in elected cases. In combined approach or ntact
‘anal wall mastldectomy, dise & removed both
permeatally, and through cortical mastldectomy and
posterior tympanotomy approach, in which à win-
Sov à created between the mastoid and mide ea
‘through the facial ress, to teach sinus tympani
en).
See Tab 11 forthe comparison of canal wall up and
canal wall down procedures
“Canal map procedure
Meats Normal appa
Dependence Doct no ure rue cing
Acer hae hat rece ret
Seca ok ge
‘dion ratico ato wear angie
eres second sy ter 6 months
IN mn Pate owed sing
‘Cana wall don procedure
ey open mens cmmunkating ith man
Dependence on dcr ing mu cy once
pce
So cn dt nic ma dy dt
biens tin ai ad due to ge meatus
“Démo oy wth Sometimes us ete
mebooksfree.com
2. RICONSIRUCIIVE SURGERY. Hearing can be restored
by myringoplasty or tympanoplasty ft can be done at the
time of primary surgery or as second stage procedure.
3. CONSERVATIVE TREATMENT. I hasa limite role in the
‘management of eholstatoma bu canbe wid in selected
cases when choletestoma fs small and easly accesible
o suction clearance under operating microscope. Repeat
‘ed suction crane and periodic checkups ae senta
Tecan also be ted out in elderly patients above 65 and
‘those who are unfit for general anaesthesia or those refus
ing surgery. Polyps and ranulations can aso be surgical
removed y cup forceps or cauterized by chemical agents
Tike silver ite or tehloroaetc aid. Other measures
ke aura lt and dey ea precautions ar also essential
‘gr 1.12 summarizes the management of CSOM.
TUBERCULAR OTITIS MEDIA
AETIOLOGY
In most of the cases, infection is secondary to pulmonary
tuberculosis infection sache the middle car through
ustachian tube. Sometimes, It is Blood bome om
tubercular focus inthe lings, tonsils cervical or mesen
{erie mph nodes, Disease s mostly Seem in hire and
oung ats
PATHOLOGY
“The proces slow and insidious, Tubes appear
submucosa layers of middle ae if acest. The
ailes necrosis of ympanie membrane,
Multiple perforations may frm which coalesce 10
forma single lage perforation, Middle car and mastold
Chapter 11 — Chotestestoma and Chronic Otis Media 81
get led with pale granultions. Cais of bone and os-
Sices may occur leading to complications. Mastodits,
facial prays, postauriular fistula, osteomyelits with
formation of bony questa and profound Rearing loss
fe often seen in these ass,
CLINICAL FEATURES
Gly sent in ass of tubercular ots media, Discharge
IS often foulsmelling because of the underying bone
destruction:
2. Prnsoration. Multiple perforations two or three
fae seen in par tensa and om à laica! sige
3. HEARING Loss. There is severe heating loss, out of
proportion to symptoms. Mostly conductive, lt may
have sensorineural component duc to involvement of
aby
4. FACIAL PaRaLysts. Its à common complication and
may come unexpectedly. This may be the presenting fae
ture ina hid.
DIAGNOSIS
In the presence of secondary pyogenic infection, tu
berculae ons media may be Indstinguishable from
‘chronic suppurative ott media. Culture of car ischarge
csou
E
Mao O ran
Dites
Pen
Tepe ares
Stoic rima
. +
ren Me
men pas
sy
Figure 11.12. Management of tai prin meda (CSOM)
mebooksi
free.com
by myringoplasty or tympanoplasty ft can be done at the
time of primary surgery or as second stage procedure.
3. CONSERVATIVE TREATMENT. I hasa limite role in the
‘management of eholstatoma bu canbe wid in selected
cases when choletestoma fs small and easly accesible
o suction clearance under operating microscope. Repeat
‘ed suction crane and periodic checkups ae senta
Tecan also be ted out in elderly patients above 65 and
‘those who are unfit for general anaesthesia or those refus
ing surgery. Polyps and ranulations can aso be surgical
removed y cup forceps or cauterized by chemical agents
Tike silver ite or tehloroaetc aid. Other measures
ke aura lt and dey ea precautions ar also essential
‘gr 1.12 summarizes the management of CSOM.
TUBERCULAR OTITIS MEDIA
AETIOLOGY
In most of the cases, infection is secondary to pulmonary
tuberculosis infection sache the middle car through
ustachian tube. Sometimes, It is Blood bome om
tubercular focus inthe lings, tonsils cervical or mesen
{erie mph nodes, Disease s mostly Seem in hire and
oung ats
PATHOLOGY
“The proces slow and insidious, Tubes appear
submucosa layers of middle ae if acest. The
ailes necrosis of ympanie membrane,
Multiple perforations may frm which coalesce 10
forma single lage perforation, Middle car and mastold
Chapter 11 — Chotestestoma and Chronic Otis Media 81
get led with pale granultions. Cais of bone and os-
Sices may occur leading to complications. Mastodits,
facial prays, postauriular fistula, osteomyelits with
formation of bony questa and profound Rearing loss
fe often seen in these ass,
CLINICAL FEATURES
Gly sent in ass of tubercular ots media, Discharge
IS often foulsmelling because of the underying bone
destruction:
2. Prnsoration. Multiple perforations two or three
fae seen in par tensa and om à laica! sige
3. HEARING Loss. There is severe heating loss, out of
proportion to symptoms. Mostly conductive, lt may
have sensorineural component duc to involvement of
aby
4. FACIAL PaRaLysts. Its à common complication and
may come unexpectedly. This may be the presenting fae
ture ina hid.
DIAGNOSIS
In the presence of secondary pyogenic infection, tu
berculae ons media may be Indstinguishable from
‘chronic suppurative ott media. Culture of car ischarge
csou
E
Mao O ran
Dites
Pen
Tepe ares
Stoic rima
. +
ren Me
men pas
sy
Figure 11.12. Management of tai prin meda (CSOM)
mebooksi
free.com
82 SECTION! Diese of far
for tubercle Dali, histopathologicl examination of
{granulations and Xray chest, and other evidence oft
Berculoss in the body help 10 confim the diagnosis
Presently DNA probe and PCR (polymerase chain rea
tion) trom the dar discharge can give ely diagnosis ln
ray.
TREATMENT
1. SYSTEMIC ANTITUMERCULAR THERAPY. As being cr
tied for primary disease
2. Locas Taeammest. In the form of aura toilet and
‘onttl of secondary pyogenie infection.
3. Mastom SURGERY, I indicated for complications.
Healing i delayed in tuberculous cases. Wound break
down and fistula formation ae common, Reconstructive
surgery of idle ears deayed til anttubereular therapy
hasbeen complete.
SYPHILITIC OTITIS MEDIA
Is a rare condition. Spiechaetes each middle car
though eustachian tube when syphili sions are pre-
nose or nasopharynx fection may alo be
Blood.borne. Sensory end organs of the inner car and
thelr nerves are soon invaded by spirochates lading to
‘profound sensorineural hearing os, innitusand vertigo,
Bone necrons and sequesrum formation ae common
and they lead to oct var discharge, Secondary pyogenic
fection may occu, giving clinical picture very much
lke chronic suppurative o
Definite diagnos of split ts media can only be
made by specie treponemal antigen tests such a pone:
‘mal pallidum immobilzaon (10) test and urescent
{weponemal antibody absorption test (FTA-AB). DRL and
RPR reactive plasma ean tests are nonspecific but wet
10 monitor dise however fae postive tests may occur
Treatment consists of anisyphiite therapy with ate
tention to aural olle and control of secondary infection.
Surgery muy be required for removal of Sequeste.
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for tubercle Dali, histopathologicl examination of
{granulations and Xray chest, and other evidence oft
Berculoss in the body help 10 confim the diagnosis
Presently DNA probe and PCR (polymerase chain rea
tion) trom the dar discharge can give ely diagnosis ln
ray.
TREATMENT
1. SYSTEMIC ANTITUMERCULAR THERAPY. As being cr
tied for primary disease
2. Locas Taeammest. In the form of aura toilet and
‘onttl of secondary pyogenie infection.
3. Mastom SURGERY, I indicated for complications.
Healing i delayed in tuberculous cases. Wound break
down and fistula formation ae common, Reconstructive
surgery of idle ears deayed til anttubereular therapy
hasbeen complete.
SYPHILITIC OTITIS MEDIA
Is a rare condition. Spiechaetes each middle car
though eustachian tube when syphili sions are pre-
nose or nasopharynx fection may alo be
Blood.borne. Sensory end organs of the inner car and
thelr nerves are soon invaded by spirochates lading to
‘profound sensorineural hearing os, innitusand vertigo,
Bone necrons and sequesrum formation ae common
and they lead to oct var discharge, Secondary pyogenic
fection may occu, giving clinical picture very much
lke chronic suppurative o
Definite diagnos of split ts media can only be
made by specie treponemal antigen tests such a pone:
‘mal pallidum immobilzaon (10) test and urescent
{weponemal antibody absorption test (FTA-AB). DRL and
RPR reactive plasma ean tests are nonspecific but wet
10 monitor dise however fae postive tests may occur
Treatment consists of anisyphiite therapy with ate
tention to aural olle and control of secondary infection.
Surgery muy be required for removal of Sequeste.
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Chapter 12
Complications of Suppurative
Otitis Media
Though there is general decline in the incidence of
complications, they are sul teguently sen in India
The causes are poor sociosconomie conditions, ack of
education and aareness about healhcaro (middle car
charge i stil being considered merely a nuisance
rather than a potential dangerous condition), ad ack
of avalabilty of tained specialist in the farsung rra
ras where tansportation felis ae stl inadequate
FACTORS INFLUENCING DEVELOPMENT
OF COMPLICATIONS
1. AGE. Most fe complications ocur in the first decade
ie or in the elderly when the patients resistance low.
2. Poor Socorcovoune Grow. Several actos such as
‘vercomding poor health education and personal hygiene,
And limited access to heaıhcare play an important pr.
3. Vinvrance or Oncasısus. Many organises are de-
‘eloping resistance to antibiotics and acute infections are
‘ther not controlled or progress to subacute or chronic
‘outs media. suite dose, Jos eetive dra ois
ficient period of administration of antibiotic can cause
‘complications, Sheptecccus meunonde ype I (arler
{alle preumococes typeI) vry virulent due to pro-
‘duction of autolysin and preumolsin. Hemaphis nu
‘ase s developing resistance to lactam anibioties and
{hloramphenicol. Other estat stains ate Pseudomonas
engins and met resistant Saphir.
4. scene Comoras Host Patient suffering rom
DS uncontrolled diabetes, transplant patients rece
Immunosuppresive drugs and cancer patents reeving
‘chemotherapy are more pronto develop co
5. Prsronuep Paria. ton can easly ave beyond
the mide car cet proc pathways existe, des
‘cence of bony facial canal, previos car surgery, facture of
temporal bone, stapedetomy, penynph fis or congen
tal enlarged aqueduct of vestibule (sin Mondin abo
malty of nner ear or dehiscence in the or of middle eat.
6. CHoUESTEXTOMA. Osets or granulation tissue in
‘conte otis media destroy the bone and helps nee
tion to penetrate decper
In acute and chronic middle er infection disease pro:
cas is limited only to the mucoperosen ning of the
‘et but spreads into Ihe bony’ walls of the cl
beyond it, various complications can aise.
PATHWAYS OF SPREAD OF INFECTION
1. Dinscr Bove EROSION. In acute infections is the
process of hypetacmi decatlcation. In chronic infec
tion, I may beostts, erosion by chokstestoma or gran
als are connected with dural veins which in turn con.
oct with dura venous sinuses and supericial veins of
bra. Thus infection from the mastoid bone can cause
theombophiebits of venous sinuses and even costal
‘vin thrombosis This mode of spread is common in
cute infections
2. Paatonsan Paros.
la) Congenital dehiscenes, eg. in ony facial canal,
oor of mile car over the jugular bu,
(©) Patent sutures, e. petrosquamous suture
(e) Previous sll iactres. The acre tes hel only by
Abrous scar which permits infection
(0 Surgical defects, eg. stapdectomy, fenestration and
manoidectomy with exposure of dur,
(0 Ovatand round windows.
(9 infection trom labyrinth can travel along intemal
coste meatus,aqueducts ofthe vestibule and that
‘of the cochlea to the meninges.
CLASSIFICATION
Complications of otitis media ae clas ito two main
‘groups igure 12-1 (0):
A INTRATEMPORAL (WITHIN THE
‘CONFINES OF TEMPORAL BONE)
1. Mastoiitis
=
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Complications of Suppurative
Otitis Media
Though there is general decline in the incidence of
complications, they are sul teguently sen in India
The causes are poor sociosconomie conditions, ack of
education and aareness about healhcaro (middle car
charge i stil being considered merely a nuisance
rather than a potential dangerous condition), ad ack
of avalabilty of tained specialist in the farsung rra
ras where tansportation felis ae stl inadequate
FACTORS INFLUENCING DEVELOPMENT
OF COMPLICATIONS
1. AGE. Most fe complications ocur in the first decade
ie or in the elderly when the patients resistance low.
2. Poor Socorcovoune Grow. Several actos such as
‘vercomding poor health education and personal hygiene,
And limited access to heaıhcare play an important pr.
3. Vinvrance or Oncasısus. Many organises are de-
‘eloping resistance to antibiotics and acute infections are
‘ther not controlled or progress to subacute or chronic
‘outs media. suite dose, Jos eetive dra ois
ficient period of administration of antibiotic can cause
‘complications, Sheptecccus meunonde ype I (arler
{alle preumococes typeI) vry virulent due to pro-
‘duction of autolysin and preumolsin. Hemaphis nu
‘ase s developing resistance to lactam anibioties and
{hloramphenicol. Other estat stains ate Pseudomonas
engins and met resistant Saphir.
4. scene Comoras Host Patient suffering rom
DS uncontrolled diabetes, transplant patients rece
Immunosuppresive drugs and cancer patents reeving
‘chemotherapy are more pronto develop co
5. Prsronuep Paria. ton can easly ave beyond
the mide car cet proc pathways existe, des
‘cence of bony facial canal, previos car surgery, facture of
temporal bone, stapedetomy, penynph fis or congen
tal enlarged aqueduct of vestibule (sin Mondin abo
malty of nner ear or dehiscence in the or of middle eat.
6. CHoUESTEXTOMA. Osets or granulation tissue in
‘conte otis media destroy the bone and helps nee
tion to penetrate decper
In acute and chronic middle er infection disease pro:
cas is limited only to the mucoperosen ning of the
‘et but spreads into Ihe bony’ walls of the cl
beyond it, various complications can aise.
PATHWAYS OF SPREAD OF INFECTION
1. Dinscr Bove EROSION. In acute infections is the
process of hypetacmi decatlcation. In chronic infec
tion, I may beostts, erosion by chokstestoma or gran
als are connected with dural veins which in turn con.
oct with dura venous sinuses and supericial veins of
bra. Thus infection from the mastoid bone can cause
theombophiebits of venous sinuses and even costal
‘vin thrombosis This mode of spread is common in
cute infections
2. Paatonsan Paros.
la) Congenital dehiscenes, eg. in ony facial canal,
oor of mile car over the jugular bu,
(©) Patent sutures, e. petrosquamous suture
(e) Previous sll iactres. The acre tes hel only by
Abrous scar which permits infection
(0 Surgical defects, eg. stapdectomy, fenestration and
manoidectomy with exposure of dur,
(0 Ovatand round windows.
(9 infection trom labyrinth can travel along intemal
coste meatus,aqueducts ofthe vestibule and that
‘of the cochlea to the meninges.
CLASSIFICATION
Complications of otitis media ae clas ito two main
‘groups igure 12-1 (0):
A INTRATEMPORAL (WITHIN THE
‘CONFINES OF TEMPORAL BONE)
1. Mastoiitis
=
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B84 SECTION! — Diseases of far
Corn sacs
Figure 12.1, Complcaos où med.
LE spy Colonos Comptes.
B. INTRACRANIAL,
1. Extadural abscess
2 Subdural abscess
À Meningitis
3 Brain absess
$. Lateral sins thrombophlebitis
6, Otte hydrocephalus
‘SEQUELAE OF OTITIS MEDIA
‘Tey are the direct result of middle car infection and
should he drone rom complications. They include
Perortion of tym
Osseuar erosion
2
3, Aelctasis and adhesive otitis media
A
6
Tympanosclross
Cholesteatoma formation
‘Conductive hearing loss due 10 ossicular eresion or
fixation
2, Sensoineurl beating oss
8. Spocch impairment
9. Learning dab.
The lat two are secondary to los of ering
developmental phase ofthe inant or cil.
|. INTRATEMPORAL COMPLICATIONS
(OF OTITIS MEDIA
A. (D ACUTE MASTOIDITIS
Inflammation of mucosal lining of antrum and mastoid
ale call system ls an invariable accompaniment of acute
‘lis meca and forms par of i. The term “mastoid”
ls used when Infection spreads from the mucos, lining
the mastoid ar cells o mol bony walls of the mastoid
arc sistem
Aetiology
‘Acute mastitis usually accompanies o follows cute
Suppurative ottis media, Ihe determining factors be:
Ing high virulence of organisms or lowered resistance
fof the patient due to messes, exanthematous fevers,
poor nutrition or associated systeme disease such a
hades
"Acute mastoid i often seen in mastoids with well:
developed alr cll system. Children are affected more
Betathaemolyte streptococcus Is the most common caus-
ate organism though other organisms response for
cute tts media may also be seen. Very often, anaerobic
‘organisms ae also asocated with mastoliis and need
lactea therapy against the
Pathology
‘wo main pathologeal processes are responsible
1. Production of pus under tension.
2! Hypermemic dealeteation and osteoclastic resorption
ofbony walls
Extension of iflammatory proces to mucoperostea
ining a ir et system increases the amount of pus po:
duced due to large surface area Involved. Drainage of
{this pus, through a small perforation of tympani mem
brane andor eustachian te, cannot hep pace with he
amount being produced, Swollen mucosa o the antrum
and attic also impede the drainage system resulting in ac-
mation of pas under tension,
iyperaemia and engorgement of mucosa causes dsso-
ution of calcium from the bony walls ofthe mastoid ak
calls (hyperaemic decaliicaion)
Both these processes combine to cause destruction and
coalescence of mastoid ar ells, converting them into à
Se eo oy ed win ps omen of ms
Pus may break through mastoid cortex leading to sub
periosteal absces which may even Dust on surface led.
Ingo a discharging sul
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Corn sacs
Figure 12.1, Complcaos où med.
LE spy Colonos Comptes.
B. INTRACRANIAL,
1. Extadural abscess
2 Subdural abscess
À Meningitis
3 Brain absess
$. Lateral sins thrombophlebitis
6, Otte hydrocephalus
‘SEQUELAE OF OTITIS MEDIA
‘Tey are the direct result of middle car infection and
should he drone rom complications. They include
Perortion of tym
Osseuar erosion
2
3, Aelctasis and adhesive otitis media
A
6
Tympanosclross
Cholesteatoma formation
‘Conductive hearing loss due 10 ossicular eresion or
fixation
2, Sensoineurl beating oss
8. Spocch impairment
9. Learning dab.
The lat two are secondary to los of ering
developmental phase ofthe inant or cil.
|. INTRATEMPORAL COMPLICATIONS
(OF OTITIS MEDIA
A. (D ACUTE MASTOIDITIS
Inflammation of mucosal lining of antrum and mastoid
ale call system ls an invariable accompaniment of acute
‘lis meca and forms par of i. The term “mastoid”
ls used when Infection spreads from the mucos, lining
the mastoid ar cells o mol bony walls of the mastoid
arc sistem
Aetiology
‘Acute mastitis usually accompanies o follows cute
Suppurative ottis media, Ihe determining factors be:
Ing high virulence of organisms or lowered resistance
fof the patient due to messes, exanthematous fevers,
poor nutrition or associated systeme disease such a
hades
"Acute mastoid i often seen in mastoids with well:
developed alr cll system. Children are affected more
Betathaemolyte streptococcus Is the most common caus-
ate organism though other organisms response for
cute tts media may also be seen. Very often, anaerobic
‘organisms ae also asocated with mastoliis and need
lactea therapy against the
Pathology
‘wo main pathologeal processes are responsible
1. Production of pus under tension.
2! Hypermemic dealeteation and osteoclastic resorption
ofbony walls
Extension of iflammatory proces to mucoperostea
ining a ir et system increases the amount of pus po:
duced due to large surface area Involved. Drainage of
{this pus, through a small perforation of tympani mem
brane andor eustachian te, cannot hep pace with he
amount being produced, Swollen mucosa o the antrum
and attic also impede the drainage system resulting in ac-
mation of pas under tension,
iyperaemia and engorgement of mucosa causes dsso-
ution of calcium from the bony walls ofthe mastoid ak
calls (hyperaemic decaliicaion)
Both these processes combine to cause destruction and
coalescence of mastoid ar ells, converting them into à
Se eo oy ed win ps omen of ms
Pus may break through mastoid cortex leading to sub
periosteal absces which may even Dust on surface led.
Ingo a discharging sul
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Chapter 12 — Complications of Soppuratie Otis Media. 85
Clinical Features.
‘StarroMs. They ate similar 0 that of acute suppurative
‘otis media In a case of acute middle cr infection, It
Is the change in the character of these symptoms which
À Significant and a pointer to the development of acute
mastoid,
1. Pain hind theca, Pain 6 ssen in acute ots medía
Put i subsides with establishment of perforation or
treatment with antbitis. es the persistence of pal,
Increase In ts intensity or recurrence of pain, once It
ad subsided, These ae significant pointers of pan.
2. Fee tis the persistence or rcutenee of fever ln a case
fof acute ote medi, In spite of adequate antibiotic
3. Eardscarge In mastoid, lscharge becomes profuse
and inereses in paran, In some Cases dscharge
Symptoms would worsen. Any persistence of discharge
Beyond 3 weeks, In a ease of acute otitis medía, points
Sie
1. Mast tenders, This an important sign, Tender.
ss sei by pressure verte mide of mast
process at is Up, posterior Border or the rot of 2
‘may not be diagnostic of acute mastoid a een
‘ren in cases ofthe acute ofits media due to inflam
‘mation of maton ant ants) Tendernes should
always be compared with that ofthe healthy sie
2. Ear change, Macopuralent or purulent discharge, of
ten pulsatile house efec, may be seen comin
{through acenta perforation of pas tensa
3. Sang of posteasperio meatal wal LI det pels
‘itis of bony party wall ten the antrom and deeper
posteosuperor par of bony ana.
4 Penton of mpani menbran. Usually, asma perfo-
of tympanic membrane, Perforation may someti
Sppcaras3 nipplelke protrusion, Sometimes tympan-
le membrane intact but dul and opaque especial in
{hove who have received inadsquate antibiotes.
5. Suelingave e mst. Italy theres oedema of pe.
And pinna fs pushed fonvards and downwards, When
pus bursts through bony’ corte, a subperiosteal ue
{ant abscs formed (figure 122 400 12-3) which
may further burst on skin or form a st
‘Gener findings Patient appears and toxic with low
grade fever In children, fever high with a se In
Pulse rate
Investigations
1. Broo» CouNts show polymorphonuclea leucocytes,
3.X-Ry aston, CT scan temporal bone. There cloud
ing of calls due to collection of exudate in ther. Bony
putos between ae cells become indisnct, but ein
Plate Is sen asa tint outline. In later stages, a avy
may be een inthe maton,
4. Ean Swan. for culture
Differential Diagnosis
1. SUPPURSTION or MASTOID LYMPH N
fection may cause mastoa lymph mode 0
and sensitivity:
15. Scalp in
mebooksfree.com
Clinical Features.
‘StarroMs. They ate similar 0 that of acute suppurative
‘otis media In a case of acute middle cr infection, It
Is the change in the character of these symptoms which
À Significant and a pointer to the development of acute
mastoid,
1. Pain hind theca, Pain 6 ssen in acute ots medía
Put i subsides with establishment of perforation or
treatment with antbitis. es the persistence of pal,
Increase In ts intensity or recurrence of pain, once It
ad subsided, These ae significant pointers of pan.
2. Fee tis the persistence or rcutenee of fever ln a case
fof acute ote medi, In spite of adequate antibiotic
3. Eardscarge In mastoid, lscharge becomes profuse
and inereses in paran, In some Cases dscharge
Symptoms would worsen. Any persistence of discharge
Beyond 3 weeks, In a ease of acute otitis medía, points
Sie
1. Mast tenders, This an important sign, Tender.
ss sei by pressure verte mide of mast
process at is Up, posterior Border or the rot of 2
‘may not be diagnostic of acute mastoid a een
‘ren in cases ofthe acute ofits media due to inflam
‘mation of maton ant ants) Tendernes should
always be compared with that ofthe healthy sie
2. Ear change, Macopuralent or purulent discharge, of
ten pulsatile house efec, may be seen comin
{through acenta perforation of pas tensa
3. Sang of posteasperio meatal wal LI det pels
‘itis of bony party wall ten the antrom and deeper
posteosuperor par of bony ana.
4 Penton of mpani menbran. Usually, asma perfo-
of tympanic membrane, Perforation may someti
Sppcaras3 nipplelke protrusion, Sometimes tympan-
le membrane intact but dul and opaque especial in
{hove who have received inadsquate antibiotes.
5. Suelingave e mst. Italy theres oedema of pe.
And pinna fs pushed fonvards and downwards, When
pus bursts through bony’ corte, a subperiosteal ue
{ant abscs formed (figure 122 400 12-3) which
may further burst on skin or form a st
‘Gener findings Patient appears and toxic with low
grade fever In children, fever high with a se In
Pulse rate
Investigations
1. Broo» CouNts show polymorphonuclea leucocytes,
3.X-Ry aston, CT scan temporal bone. There cloud
ing of calls due to collection of exudate in ther. Bony
putos between ae cells become indisnct, but ein
Plate Is sen asa tint outline. In later stages, a avy
may be een inthe maton,
4. Ean Swan. for culture
Differential Diagnosis
1. SUPPURSTION or MASTOID LYMPH N
fection may cause mastoa lymph mode 0
and sensitivity:
15. Scalp in
mebooksfree.com
85 SECTION! — Diseases of far
thee suppurtion leading to abscess formation, but in
Such cases there is no history of preceding ots media,
ar discharge or deafness, Abscess usually Supera,
2. FumencuLosts or Mets. Its disent from
cute mastitis by
(a) Absence of preceding acute ot
(©) Painful movements of inna; pressure ove the tagus
or below the catlaginous port of meats causes ex
‘rutting pain
(© Swelling of meatus is confined 10
par only
(0 Discharge is never mucoid or mucopurulet. Mucoid
‘clement in discharge can only come irom the middle
«ar amd not from the extemal ear which s devoid of
mucussecrtin glands
(6) Enlargement of pe or postauricular Iymph modes.
{© Conductive heating los 1 usually mild and Is ducto
the action of meats,
(8) An absolutely normal looking tympa
‘excludes posibiityof acute mastoid
9 Xray mas wth clear alrcel system excudes
acute mastitis. Sometimes, fc arses when
“eco system appears hay due to superimposed Sot
tissue selig in eases OF Furuno
1 cartlginous
3. Inarcrto Stmerous Cost
Treatment
1. Hosertatazatiow oF te PARENT, Patient is hospital
st tot area done
2, Axrimones. Inthe absence of culture and sensitivity,
Start with amoxicilin or ampicilin. Specie animiero-
Dali started om the receipt of sens report. Since
anaerobic organisms are often present, Moramphenico
‘rmetronidaole 5 added
3. Mynincorowy. When pusisunder tension srllved
iy wide myrngotum (perales), E es
fof acute mastois respond to conservative treatment
‘eth nb alone or combined with myringotomy
4. CORTICAL MASTONDECTONN: sinds when there à
(a) Subperosteal abscess
(0) Sing of posterosuperior meatal wall.
(e) Poste reservoir sig, Le. meatus immediatly sls
‘sith pus afer it hasbeen mopped out.
(a) No change in condition of patent or i morsens in
spite of adequate medical treatment for 46.
(e) Matos, leading to complications, eg, facial pa-
ras yet intracranial complications, te
‘Aim of cortical mastoidectomy sto exenterat all he
mastoid ae els and remove any pockets of pus. Ade.
‘quate antibiotic treatment must be continue at east for
Sys following mastoldectomy:
Complications of Acute Mastoiditis
‘Subperiostcal abscess
Labyrinth
Facal paralysis
Petros
Sabu abscess
‘Meningitis
Lateral sinus thrombophebit
Gui hydrocephalous
ñ
Abscesses in Relation to Mastoid Infection
1. POSTALRICULAR AÑSCESS (Fix 12,3). This isthe
commonest abscess that forms over the mato, Pinna is
“placed forwards, outwards and downward. In infants
nd children, abscess forms over Ihe Mactwen' tangle
pus in these cases travels along the vascular channels of
mina ebro,
2. Zvcowaric AnscESS. It occurs due to infection of
ygomatie ae cals situated atthe posterior toot al 2y-
goma. Swelling appcas in front of and above the pinna
uo 124 Aand 8j. There i associated oedema OF the
"upper eyelid In these case, pus collect either superficial
for deep tothe temporal muscle
cots
Des
Peras
Figure 124. a Abscess in in oma (1) posure, (2) yopmat a 3 Bead tes.) Cal, postr an Br
mebooksfree.com
thee suppurtion leading to abscess formation, but in
Such cases there is no history of preceding ots media,
ar discharge or deafness, Abscess usually Supera,
2. FumencuLosts or Mets. Its disent from
cute mastitis by
(a) Absence of preceding acute ot
(©) Painful movements of inna; pressure ove the tagus
or below the catlaginous port of meats causes ex
‘rutting pain
(© Swelling of meatus is confined 10
par only
(0 Discharge is never mucoid or mucopurulet. Mucoid
‘clement in discharge can only come irom the middle
«ar amd not from the extemal ear which s devoid of
mucussecrtin glands
(6) Enlargement of pe or postauricular Iymph modes.
{© Conductive heating los 1 usually mild and Is ducto
the action of meats,
(8) An absolutely normal looking tympa
‘excludes posibiityof acute mastoid
9 Xray mas wth clear alrcel system excudes
acute mastitis. Sometimes, fc arses when
“eco system appears hay due to superimposed Sot
tissue selig in eases OF Furuno
1 cartlginous
3. Inarcrto Stmerous Cost
Treatment
1. Hosertatazatiow oF te PARENT, Patient is hospital
st tot area done
2, Axrimones. Inthe absence of culture and sensitivity,
Start with amoxicilin or ampicilin. Specie animiero-
Dali started om the receipt of sens report. Since
anaerobic organisms are often present, Moramphenico
‘rmetronidaole 5 added
3. Mynincorowy. When pusisunder tension srllved
iy wide myrngotum (perales), E es
fof acute mastois respond to conservative treatment
‘eth nb alone or combined with myringotomy
4. CORTICAL MASTONDECTONN: sinds when there à
(a) Subperosteal abscess
(0) Sing of posterosuperior meatal wall.
(e) Poste reservoir sig, Le. meatus immediatly sls
‘sith pus afer it hasbeen mopped out.
(a) No change in condition of patent or i morsens in
spite of adequate medical treatment for 46.
(e) Matos, leading to complications, eg, facial pa-
ras yet intracranial complications, te
‘Aim of cortical mastoidectomy sto exenterat all he
mastoid ae els and remove any pockets of pus. Ade.
‘quate antibiotic treatment must be continue at east for
Sys following mastoldectomy:
Complications of Acute Mastoiditis
‘Subperiostcal abscess
Labyrinth
Facal paralysis
Petros
Sabu abscess
‘Meningitis
Lateral sinus thrombophebit
Gui hydrocephalous
ñ
Abscesses in Relation to Mastoid Infection
1. POSTALRICULAR AÑSCESS (Fix 12,3). This isthe
commonest abscess that forms over the mato, Pinna is
“placed forwards, outwards and downward. In infants
nd children, abscess forms over Ihe Mactwen' tangle
pus in these cases travels along the vascular channels of
mina ebro,
2. Zvcowaric AnscESS. It occurs due to infection of
ygomatie ae cals situated atthe posterior toot al 2y-
goma. Swelling appcas in front of and above the pinna
uo 124 Aand 8j. There i associated oedema OF the
"upper eyelid In these case, pus collect either superficial
for deep tothe temporal muscle
cots
Des
Peras
Figure 124. a Abscess in in oma (1) posure, (2) yopmat a 3 Bead tes.) Cal, postr an Br
mebooksfree.com
Chapter 12 — Complications of Sopprate OW Media 87
Posterior vet LS
==
Der ns kenn abra hematin
ÉD EE DE
3. zon Anscess. It can occur following acute costes
‘ent mastoid when pus breaks throug the thin me
‘il side ofthe tip ofthe mastoid and presents asa sel:
ingin Ihe upper pat of neck. The abscess may 1) ie deep
to stemocleidomastold, pushing the muscle outwards,
{i follow the posterior belly of digastic and present as à
‘selling beten the tip of mastold an
be presen
the parapharyngeal space or)
roUd vessels (sue 12),
linia futures. Onset s sudden. There s pain, fever,
tender sig in the nc ad toto Patient gives
history of purulent otothoca
"A ezol abscess shouldbe diferentite rom:
ack down along the ca:
(a) acute upper jugular ymphadenitis
0) abscess ora mas in the lower par ofthe parotid land
(e) an infected branchial est
(8) parapharyngeal abscess
(e) Jaguar sein thrombosis.
computed tomography (CT) scan of the mastoid and
selling oF the neck may establish the digests
Treatment
(a) Coral. mastoldectomy for, coalescent mastoid
is with careful exploration f the tp fora Aistulous
‘pening into the sof issues of the neck
1) Drainage ofthe neck aces rough a separate inci
sion and puting a dran in the dependent port
16) Administration of intravenous antibiotics guide by
he culture and set report of he pus taken at
the time of surgery.
4. Mraraı ABSCESS (LUC ABSCESS) In tis case, pus
breaks through the bony wall between the antrum and
external osseous meatus. Swelling Is een in deep part of
bony meatus, Abscess may burst into the metas
5. BEHIND THE MastonD (Crea Anscıss). Abscess
À formed behind the mastoi more towards the oca
tal bone (compare postaurcuar mastoid abscess which
formsaner the mastoid). Some author consider abscess Of
the das tangle, which forme by tracking of pus
from the mastoid tip asthe Ciel’ abscess.
6. PARAPHARYNGEAL OR RETROPHARYNGEAL ARSCISS.
hs results from infection ofthe peritubal cells de
seutecomescent masto
A. (il) MASKED (LATENT) MASTOIDITIS
Its condition of sow destruction of mastoid ae cells
but without the acute signs and symptoms often seen in
acute masoldiis. There sno pan, no dischärge, no ever
And no mastoid swcling tut mantoldectomy may show
extensive destruction ofthe ar cells with granulation
Sue and dark gelatinous material Ang the mastoid eis
‘not surprising to find erosion of the tegmen tympani and
Sinus plate with an extradural or perisinus aces.
Aetiology
The condition often results rom inadequate antibiotic
therapy In terms of dose, frequency and duration of ad
min ration. Most often it results fom use of oral per
¿lin given in cases of acute otitis media when acute
Symptoms subside but smouldering infection continues
inthe mastoid
Clinical Features.
Patient i often a child, not entirely feling wel with
mil pin behind theca ut with persstent hearing os
“Tympanie membrane appears thick with los of ans.
lucene. sight tenderness may be elicited over the mas
told Audiometry shows conductive hearing loss of var
ble degre, Xray of mastold will eval clouding of lr
‘lls with loss of el outline,
Treatment
Conical mastoidetomy with fll doses of antbities is
the weatment of choice. This may cause tympanic ment.
‘rane to return to normal with improvement in hearing
PETROSITIS
Spread of infection from middle car and mastoid to the
etrou pat of temporal bone is called persis I may
Be roca with acute coslexcent mastldt, Intent
‘aston or chronic mide ar infections.
Pathology
Like mastoid, ptrous bone may be of tre types pr
‘mata wii le cells extending tothe petrous apex dp.
{oie containing only marrow spaces and sea. Feu
‘matization of perros apex actus in only 30% of cases
‘sith cells extending Kom the middle er oF mastoid to
the petrous apex. Usually two call tacts are recognized
1. Pestrosuperior tact which stats in the mastoid and
runs behind or above the bony labyrinth o the pe
{uous ape some cl even pus though the arch of
Superior semicircular canal t each the pex.
2. Amteroinfrior tract which stats at the hypotymp
m nea the eustachian terns around ne coches
to each the patrons apes
Infectve process uns along these ell acts and aches
the pettous apex Pathological process similar to that OF.
sent mastitis fring epidural aces at Ihe pets
Speximolving canal neve Vi and trigeminal ganglion.
mebooksfree.com
Posterior vet LS
==
Der ns kenn abra hematin
ÉD EE DE
3. zon Anscess. It can occur following acute costes
‘ent mastoid when pus breaks throug the thin me
‘il side ofthe tip ofthe mastoid and presents asa sel:
ingin Ihe upper pat of neck. The abscess may 1) ie deep
to stemocleidomastold, pushing the muscle outwards,
{i follow the posterior belly of digastic and present as à
‘selling beten the tip of mastold an
be presen
the parapharyngeal space or)
roUd vessels (sue 12),
linia futures. Onset s sudden. There s pain, fever,
tender sig in the nc ad toto Patient gives
history of purulent otothoca
"A ezol abscess shouldbe diferentite rom:
ack down along the ca:
(a) acute upper jugular ymphadenitis
0) abscess ora mas in the lower par ofthe parotid land
(e) an infected branchial est
(8) parapharyngeal abscess
(e) Jaguar sein thrombosis.
computed tomography (CT) scan of the mastoid and
selling oF the neck may establish the digests
Treatment
(a) Coral. mastoldectomy for, coalescent mastoid
is with careful exploration f the tp fora Aistulous
‘pening into the sof issues of the neck
1) Drainage ofthe neck aces rough a separate inci
sion and puting a dran in the dependent port
16) Administration of intravenous antibiotics guide by
he culture and set report of he pus taken at
the time of surgery.
4. Mraraı ABSCESS (LUC ABSCESS) In tis case, pus
breaks through the bony wall between the antrum and
external osseous meatus. Swelling Is een in deep part of
bony meatus, Abscess may burst into the metas
5. BEHIND THE MastonD (Crea Anscıss). Abscess
À formed behind the mastoi more towards the oca
tal bone (compare postaurcuar mastoid abscess which
formsaner the mastoid). Some author consider abscess Of
the das tangle, which forme by tracking of pus
from the mastoid tip asthe Ciel’ abscess.
6. PARAPHARYNGEAL OR RETROPHARYNGEAL ARSCISS.
hs results from infection ofthe peritubal cells de
seutecomescent masto
A. (il) MASKED (LATENT) MASTOIDITIS
Its condition of sow destruction of mastoid ae cells
but without the acute signs and symptoms often seen in
acute masoldiis. There sno pan, no dischärge, no ever
And no mastoid swcling tut mantoldectomy may show
extensive destruction ofthe ar cells with granulation
Sue and dark gelatinous material Ang the mastoid eis
‘not surprising to find erosion of the tegmen tympani and
Sinus plate with an extradural or perisinus aces.
Aetiology
The condition often results rom inadequate antibiotic
therapy In terms of dose, frequency and duration of ad
min ration. Most often it results fom use of oral per
¿lin given in cases of acute otitis media when acute
Symptoms subside but smouldering infection continues
inthe mastoid
Clinical Features.
Patient i often a child, not entirely feling wel with
mil pin behind theca ut with persstent hearing os
“Tympanie membrane appears thick with los of ans.
lucene. sight tenderness may be elicited over the mas
told Audiometry shows conductive hearing loss of var
ble degre, Xray of mastold will eval clouding of lr
‘lls with loss of el outline,
Treatment
Conical mastoidetomy with fll doses of antbities is
the weatment of choice. This may cause tympanic ment.
‘rane to return to normal with improvement in hearing
PETROSITIS
Spread of infection from middle car and mastoid to the
etrou pat of temporal bone is called persis I may
Be roca with acute coslexcent mastldt, Intent
‘aston or chronic mide ar infections.
Pathology
Like mastoid, ptrous bone may be of tre types pr
‘mata wii le cells extending tothe petrous apex dp.
{oie containing only marrow spaces and sea. Feu
‘matization of perros apex actus in only 30% of cases
‘sith cells extending Kom the middle er oF mastoid to
the petrous apex. Usually two call tacts are recognized
1. Pestrosuperior tact which stats in the mastoid and
runs behind or above the bony labyrinth o the pe
{uous ape some cl even pus though the arch of
Superior semicircular canal t each the pex.
2. Amteroinfrior tract which stats at the hypotymp
m nea the eustachian terns around ne coches
to each the patrons apes
Infectve process uns along these ell acts and aches
the pettous apex Pathological process similar to that OF.
sent mastitis fring epidural aces at Ihe pets
Speximolving canal neve Vi and trigeminal ganglion.
mebooksfree.com
BB SECTION! — Diseases of far
Clinical Features
Gradenigosyndrame the clasica presentation, and con-
Sts of tad of () externa rectus palsy (Rh nerve pal
(D decpseatel car or reroorbitl pain (VA nerve
Involvement) and (i) persistent car discharge. I une
‘common to se the ful tad these days,
Terasten ear discharge with or without deep-seated
pain in spite ofan adequate comica or modified radial
mastoldetomy als points to petrstis.
ever, headache, vomiting and sometimes neck ide
day may also be associated. Some patents may get aca
paralysis and recurrent vertigo due t involvement of fa
Diagnosis of petous aps requires both CT scan and
[ML CT scan of temporal bone wil show bony deals of
the petrou apex and the ae cells eile MRE lps to di
Forero ciple matrow containing apex tom the Bid
corpus
‘Treatment
Cortal, modified radical or radical mastoidectomy
te required fot already done. The fstulous tact
Should be found out, whic 1 then cueted and enlarged
to provide fee drainage. Tact of postrosupeior eels
Stats in the Trautmann ange rte at. Tac o an
terior cells situated ner the tympanic opening of eus.
tachan tube and pases above the cath artery, anterior
to the coche. In the ater ease, radical mastoidectomy
require
‘Stable Intavenous antibacterial therapy should pre
ce and follow surgical intervention. Most cases oF cute
Petostis can now be cued with antibacterial therapy
Bone. it should be given in nia high doses and con
{ined for 4. days, even alter complete disappearance of
symptoms.
C. FACIAL PARALYSIS.
Ik can oscuras a complication ofboth acute and chronic
otis mea
Acute Otitis Media
Facial nerve is normal well protect in ts bony canal
Sometimes the bony cal a dent athe nerve hes
inst under the mile car mucosa. iin thes css that
Antammatio of midde ar spreads 0 ep and perno
‘um easing faa paras. Fatal nerve function fly
cor Y cut tits meds controle wth systemic
notes Myringotomyor coca! mostodectony may
Sometimes be requis
Chronic Otitis Media
Facial paralysis In chronic ott media ether results from.
cholesteatoma or from penctrating granulation ussuc
holesteatoma destroys bony canal and then cause pres.
sure on the nerve, further alded by oedema or associated
Inflammatory process. Facial paralysis 1s insidicas but
Slowly progressive. Treatment urgent exploration of the
middle ear and mastod. Facial canal I inpected from
the geniculate ganglion to the sylomastold foramen, If
ration tse or cholesteatoma has entered the bony
Sana, the later is uncapped in the are of involvement
Granulation sue surrounding he ner i removed but
I cial invade the more sheath islet place
à segment of te nerve as been dope bythe paa
intone resection of neve ad grating ae Dette
toa scond sage when nfecon hs been contlled aná
Aros hs mature.
D. LABYRINTHITIS
Tere ate three types of labyrinths:
1. Cicumseribed labyrinths
2 Dine serous labyrinth
3 Dit suppurative eyes
Circumseribed Labyrinthitis (Fistula of
Labyrinth)
There Is thinning or erosion of bony capsule of abyinth,
«sai of the horizontal semer cana
1. Chronic suppurative outs media with cholesteatoma
Is ne most common case
2, Neoplasms of mid car, e. carcinoma or glomus tu-
2, Surgical or accidental trauma to labyrinth,
Guen. Featunes. À par of membranous Labyrinth
ls exposed and becomes sensitive 10 pressure changes
Patent complains of transient vertigo often induced by
protec ra ling he ar pen
Ris os by “fistula test” which c
in two ways
1. Pessue on tags, Sudden inward pressure s applied
‘om the tags. This increases sr pressure in the rca
‘aan stilts he labyrinth Patent will complain
‘Of vertigo. Nystagmus may aso be induced with quick
Component towards the car under tet
2, Sega's specu. When postive pressure is applied to
‘ar canal, patent complains of vertigo usually with
fystagmus, The quick component of nystagmus would
bx towards the affected car (ampullopetal ispace-
ment of cupula)
Ampalloetal flow of endolymph (as also ampullo-
‘petal lsplacement cupula) whether in rotation, clone
tu ts causes nystagmus to same ide
negative pressure is applied, again it would induce
vertigo and nystagmus but this time the quick com.
ponent of nystagmus would be directed tothe (oppo:
be pertormed
Se) healthy side due to ampullofugl displacement of
copula
TREATMENT. In chronic suppurative otitis media or
cholesteatoma, mastoid exploration Is often require to
Siminate the cause. Systemie antibiove therapy should
be stituted before and after operation to prevent spread
inicio ino the labyrinth
ffuse Serous Labyrinthitis
[es fuse itralabyrintie inflammation without pas
formation and ia reverse condition treated ea
mebooksfree.com
Clinical Features
Gradenigosyndrame the clasica presentation, and con-
Sts of tad of () externa rectus palsy (Rh nerve pal
(D decpseatel car or reroorbitl pain (VA nerve
Involvement) and (i) persistent car discharge. I une
‘common to se the ful tad these days,
Terasten ear discharge with or without deep-seated
pain in spite ofan adequate comica or modified radial
mastoldetomy als points to petrstis.
ever, headache, vomiting and sometimes neck ide
day may also be associated. Some patents may get aca
paralysis and recurrent vertigo due t involvement of fa
Diagnosis of petous aps requires both CT scan and
[ML CT scan of temporal bone wil show bony deals of
the petrou apex and the ae cells eile MRE lps to di
Forero ciple matrow containing apex tom the Bid
corpus
‘Treatment
Cortal, modified radical or radical mastoidectomy
te required fot already done. The fstulous tact
Should be found out, whic 1 then cueted and enlarged
to provide fee drainage. Tact of postrosupeior eels
Stats in the Trautmann ange rte at. Tac o an
terior cells situated ner the tympanic opening of eus.
tachan tube and pases above the cath artery, anterior
to the coche. In the ater ease, radical mastoidectomy
require
‘Stable Intavenous antibacterial therapy should pre
ce and follow surgical intervention. Most cases oF cute
Petostis can now be cued with antibacterial therapy
Bone. it should be given in nia high doses and con
{ined for 4. days, even alter complete disappearance of
symptoms.
C. FACIAL PARALYSIS.
Ik can oscuras a complication ofboth acute and chronic
otis mea
Acute Otitis Media
Facial nerve is normal well protect in ts bony canal
Sometimes the bony cal a dent athe nerve hes
inst under the mile car mucosa. iin thes css that
Antammatio of midde ar spreads 0 ep and perno
‘um easing faa paras. Fatal nerve function fly
cor Y cut tits meds controle wth systemic
notes Myringotomyor coca! mostodectony may
Sometimes be requis
Chronic Otitis Media
Facial paralysis In chronic ott media ether results from.
cholesteatoma or from penctrating granulation ussuc
holesteatoma destroys bony canal and then cause pres.
sure on the nerve, further alded by oedema or associated
Inflammatory process. Facial paralysis 1s insidicas but
Slowly progressive. Treatment urgent exploration of the
middle ear and mastod. Facial canal I inpected from
the geniculate ganglion to the sylomastold foramen, If
ration tse or cholesteatoma has entered the bony
Sana, the later is uncapped in the are of involvement
Granulation sue surrounding he ner i removed but
I cial invade the more sheath islet place
à segment of te nerve as been dope bythe paa
intone resection of neve ad grating ae Dette
toa scond sage when nfecon hs been contlled aná
Aros hs mature.
D. LABYRINTHITIS
Tere ate three types of labyrinths:
1. Cicumseribed labyrinths
2 Dine serous labyrinth
3 Dit suppurative eyes
Circumseribed Labyrinthitis (Fistula of
Labyrinth)
There Is thinning or erosion of bony capsule of abyinth,
«sai of the horizontal semer cana
1. Chronic suppurative outs media with cholesteatoma
Is ne most common case
2, Neoplasms of mid car, e. carcinoma or glomus tu-
2, Surgical or accidental trauma to labyrinth,
Guen. Featunes. À par of membranous Labyrinth
ls exposed and becomes sensitive 10 pressure changes
Patent complains of transient vertigo often induced by
protec ra ling he ar pen
Ris os by “fistula test” which c
in two ways
1. Pessue on tags, Sudden inward pressure s applied
‘om the tags. This increases sr pressure in the rca
‘aan stilts he labyrinth Patent will complain
‘Of vertigo. Nystagmus may aso be induced with quick
Component towards the car under tet
2, Sega's specu. When postive pressure is applied to
‘ar canal, patent complains of vertigo usually with
fystagmus, The quick component of nystagmus would
bx towards the affected car (ampullopetal ispace-
ment of cupula)
Ampalloetal flow of endolymph (as also ampullo-
‘petal lsplacement cupula) whether in rotation, clone
tu ts causes nystagmus to same ide
negative pressure is applied, again it would induce
vertigo and nystagmus but this time the quick com.
ponent of nystagmus would be directed tothe (oppo:
be pertormed
Se) healthy side due to ampullofugl displacement of
copula
TREATMENT. In chronic suppurative otitis media or
cholesteatoma, mastoid exploration Is often require to
Siminate the cause. Systemie antibiove therapy should
be stituted before and after operation to prevent spread
inicio ino the labyrinth
ffuse Serous Labyrinthitis
[es fuse itralabyrintie inflammation without pas
formation and ia reverse condition treated ea
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Chapter 12 — Complains of Soppurate Ou Media 89
Arnouoes
1. Most often it arises from pre-existing circumscribed
Habyrinthiis associated with chronic middle ea sup-
puration or cholesteatoma
2. In acute infections oF mle ea clef, inflammation
spreads though annular Igament or the round window.
Ifa follow sapedoctomy or fenesteation operation.
Clasica Fearuns. Mild cases complain of vetgo and
nausea but in severe cases, vero 1 worse with marked
ruses, vomiting and even spontaneousnystagmus. Quick
‘component of nytagmus towards the affected ca.
‘A the inflammation Is diffuse, cochlea I also affected
‘with some degree of sensorineural hearing loss
Serous Lynn, 4 not checked, may pass onto
suppurative labyrinths with total loss of vestibular and
‘cochlea function,
LUN
+ Malia!
1. Patent Is put to bed,
fected ear above
2. Amubacterl therapy is given in ful doses to con-
tro icon.
Labyrinthine sedatives, eg. prochlorperazine
{Stemeti or dimenhy dinate (Dramamine), ae 8.
‘en for symptomatic rele of vertigo.
Myringotomy is done if labyrinths has followed
acute outs media and the drum i bulging, Pus i
{Cultured for specific antibacterial therapy.
+ Suna Cortical mastectomy in acute mastoid)
or modi radical mastondectomy (in chronic middle
fa infection or cholesteatoma) wil often be required
to teat the source of infection. Medical treatment
Should always precede surgical intervention.
Diffuse Suppurative Labyrinthitis
This is diffuse pyogenic infection of the Labyrinth with
permanent os f vestibular and cochlea functions.
is head immobile with af
AgTioLocy. It usually follows serous labyrinths, pyo-
‘genic organisms entering through pathological or sr
Sa stl
‘Cuasicat Peares. There i severe vertigo with nausca
And vomiting due o acute vestibular flr. Spontane
‘us nystagmus wile observed with is quick component
towards the healthy sie, Patient is markedly tie. There
15 total 105 of hearing. Rele from vertigo Is sen ater
6 weeks dueto adaptation
“Tecra. Is same as for serous labyrinth, Rarely,
drainage ofthe abat i eguted ntralabyrimhine
Suppuration s acting as source of intracanlal complica
tions, eg. meningitis or bain abscess.
INTRACRANIAL COMPLICATIONS
OF OTITIS MEDIA
A. EXTRADURAL ABSCESS
leis collection of pus between and dur. e may
‘occur both in acute and chronic infections of middle ca
Pathology
In acute otitis media, bone over the dura is destroyed by
hyperaemic decalcficanon, while in chronic ots media
Its destroyed by cholesteatoma and in such a case the
pus comes to He ici in contact with dat, Spread of
{nection can also occur By venous thrombophlebitis: in
{this ase, Dane over the dur remains intact An ext.
{ural abscess may ein elation to dura of mile or pos.
rior cranial fosa or outside the dura of ater venous
ins (primas abscess) Te fected dura may be covered
‘with ganulations or appear unhealthy and dscloured
Clinical Features.
Most of the time extradural or peisinus abscesses are
asymptomatic and let, and are discovered accidental
ring cortical or model radial masoidectomy.
However, their presence I suspected when thee i
1. Pesstent headache on the side of os media
2: Severe pin in the ar.
3. General malaise with low:gead eve.
3. Pulse puren car discharge
$. Disappearance of headache with re low of pus from
theca pontancoss abies drainage
Diagnosis is made on conteastenhanced CT or MRL
Treatment
Roue TOM. Is often required to deal with the caus
tive dseave process, Extradural abscess Is evacuated by
emoving overlying Done til he limits of heathy dura
An reached, Cases where bony plate of tegmen tympant
Or sinus at Intact but theres suspicion ofan abscess,
the intact bony plates deliberately removed to evacuate
ny collection of pus,
2. Ax Axrimonte Coven. should be provided fora mini.
‘mum of § days and patent closely observed for any fur
ther complications such a sinus trombosis, meningitis
brain abscess,
B. SUBDURAL ABSCESS
"This is collection of pus between dura and aachno
Pathology
Infection spcads fom the ear by erosion of bone and
«dura or by thrombophlebitc process in which case inter
‘ening bone remains intact. us rapid spreads in ab
‘ural space and comes 1 le against the convex surface
‘of cerebral hemisphere causing pressure symptoms, With
time, the pus muy get loculated at various paces in sub.
‘ural space
Clinical Features.
‘Signs and symptoms of subdural abcess are due to (me:
ningeal entation, (i) thrombophlebitis of cortical veis
rer and (i) ised intracranial tension,
MENINGEAL IRRITATION. There Is headache, fever
loz “For more), malaise, increasing drowsines, neck
gy and postive Kernigs ga.
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Arnouoes
1. Most often it arises from pre-existing circumscribed
Habyrinthiis associated with chronic middle ea sup-
puration or cholesteatoma
2. In acute infections oF mle ea clef, inflammation
spreads though annular Igament or the round window.
Ifa follow sapedoctomy or fenesteation operation.
Clasica Fearuns. Mild cases complain of vetgo and
nausea but in severe cases, vero 1 worse with marked
ruses, vomiting and even spontaneousnystagmus. Quick
‘component of nytagmus towards the affected ca.
‘A the inflammation Is diffuse, cochlea I also affected
‘with some degree of sensorineural hearing loss
Serous Lynn, 4 not checked, may pass onto
suppurative labyrinths with total loss of vestibular and
‘cochlea function,
LUN
+ Malia!
1. Patent Is put to bed,
fected ear above
2. Amubacterl therapy is given in ful doses to con-
tro icon.
Labyrinthine sedatives, eg. prochlorperazine
{Stemeti or dimenhy dinate (Dramamine), ae 8.
‘en for symptomatic rele of vertigo.
Myringotomy is done if labyrinths has followed
acute outs media and the drum i bulging, Pus i
{Cultured for specific antibacterial therapy.
+ Suna Cortical mastectomy in acute mastoid)
or modi radical mastondectomy (in chronic middle
fa infection or cholesteatoma) wil often be required
to teat the source of infection. Medical treatment
Should always precede surgical intervention.
Diffuse Suppurative Labyrinthitis
This is diffuse pyogenic infection of the Labyrinth with
permanent os f vestibular and cochlea functions.
is head immobile with af
AgTioLocy. It usually follows serous labyrinths, pyo-
‘genic organisms entering through pathological or sr
Sa stl
‘Cuasicat Peares. There i severe vertigo with nausca
And vomiting due o acute vestibular flr. Spontane
‘us nystagmus wile observed with is quick component
towards the healthy sie, Patient is markedly tie. There
15 total 105 of hearing. Rele from vertigo Is sen ater
6 weeks dueto adaptation
“Tecra. Is same as for serous labyrinth, Rarely,
drainage ofthe abat i eguted ntralabyrimhine
Suppuration s acting as source of intracanlal complica
tions, eg. meningitis or bain abscess.
INTRACRANIAL COMPLICATIONS
OF OTITIS MEDIA
A. EXTRADURAL ABSCESS
leis collection of pus between and dur. e may
‘occur both in acute and chronic infections of middle ca
Pathology
In acute otitis media, bone over the dura is destroyed by
hyperaemic decalcficanon, while in chronic ots media
Its destroyed by cholesteatoma and in such a case the
pus comes to He ici in contact with dat, Spread of
{nection can also occur By venous thrombophlebitis: in
{this ase, Dane over the dur remains intact An ext.
{ural abscess may ein elation to dura of mile or pos.
rior cranial fosa or outside the dura of ater venous
ins (primas abscess) Te fected dura may be covered
‘with ganulations or appear unhealthy and dscloured
Clinical Features.
Most of the time extradural or peisinus abscesses are
asymptomatic and let, and are discovered accidental
ring cortical or model radial masoidectomy.
However, their presence I suspected when thee i
1. Pesstent headache on the side of os media
2: Severe pin in the ar.
3. General malaise with low:gead eve.
3. Pulse puren car discharge
$. Disappearance of headache with re low of pus from
theca pontancoss abies drainage
Diagnosis is made on conteastenhanced CT or MRL
Treatment
Roue TOM. Is often required to deal with the caus
tive dseave process, Extradural abscess Is evacuated by
emoving overlying Done til he limits of heathy dura
An reached, Cases where bony plate of tegmen tympant
Or sinus at Intact but theres suspicion ofan abscess,
the intact bony plates deliberately removed to evacuate
ny collection of pus,
2. Ax Axrimonte Coven. should be provided fora mini.
‘mum of § days and patent closely observed for any fur
ther complications such a sinus trombosis, meningitis
brain abscess,
B. SUBDURAL ABSCESS
"This is collection of pus between dura and aachno
Pathology
Infection spcads fom the ear by erosion of bone and
«dura or by thrombophlebitc process in which case inter
‘ening bone remains intact. us rapid spreads in ab
‘ural space and comes 1 le against the convex surface
‘of cerebral hemisphere causing pressure symptoms, With
time, the pus muy get loculated at various paces in sub.
‘ural space
Clinical Features.
‘Signs and symptoms of subdural abcess are due to (me:
ningeal entation, (i) thrombophlebitis of cortical veis
rer and (i) ised intracranial tension,
MENINGEAL IRRITATION. There Is headache, fever
loz “For more), malaise, increasing drowsines, neck
gy and postive Kernigs ga.
mebooksfree.com
9 SECTION! Diese of far
2. Conical Vexous TunoMpormtentrs. Veins over
the cerebral hemisphere undergo thrombophlebitis lead.
ing to aphasa, hemiplegia and hemianopka. There may
Be Jacksonlan type of epllep ts which may increase to
ve a picture of satus pps.
3. RulstD INTRACRAMAL TENSION. Ter is papillood:
‘ha, pss and diated pupil led nerve involvement,
And involvement of other ranlal nerves. CT scan or MRI
require for diagnosis,
‘Treatment
Lumbar puncture should not be done a it an cause hr
‘ition ofthe cerebellar tons Isa neurologieal emer
gency. A series of bute holes ora craniotomy is done to
{ran subdural empyema, Intavenous antbitis ae ad.
‘ministered to contol infection. Once infection is under
control attention Is paid to causative ear disease which
may require mastoidectom.
C. MENINGITIS.
Its inlammation of leptomeninges (pia and arachnoid)
usually with bacterial Invasion of CF in subarachnoid
Space, Its the most common intracranial complication
Sons media. <an occur in both acute and chronic
‘tts media. In infants and children, otogenic meningitis
sua follows acute ots media while adults 1 due
to chronic middle car infection,
Mode of Infection
Hood bone infection is commonin infants and children
in adults, follows chron ear disease, whieh
‘bone erosion or retrograde thrombophlebitis
ise, st may De associated Sith an extradural abscess OF
‘anulation tissue
‘in onethat of the patients with meningitis, another
ania complication may coexist.
Clinical Features
Symptoms and signs of meningitis are due o (D presence
‘of infection 1 rsd Intracranial tension and) me.
ingest and cereal tation, Their seventy il va
A the extent of disease
hls and igor.
2. Headache
3 Neck nity.
4. Photophobia and mental Italy.
5
%
perature (102-104 °F) often with
Nausea and vomiting sometimes profcctile
Drowsiness which may progres to deiium or coma,
‘Cranial nerve plses and hemiplegia
Examination wil show () neck egy, di) postive
Kern’ sign (extension of eg with thigh flexed on bdo:
men causing pain) (i) postive Brudinak sign exon
ft meck causes flexion of hip and knee) tendon rex
‘ae exaggerated intl but later become sgh or
‘Shsent and (0) ppilloedema (usually Seen in Lat stages).
Diagnosis
(CT or Mt with contrast wil help to make the diagnosis
Te may also rewal another associated intact Lesion,
Lumbar punctate and CSF examination establish the
dagnoss. CF turbid, ol counts ased and may even
‘each 1000/ml. with predominance of polymorphs: pro
fein Level raed, sugar i reduced and res re Uh
minis,
(CSF is always cultured o ind the causative organisms
and ther antibiotic sensi.
Treatment
MEDICAL, Medical treatment takes precedence over sur
soy
‘Antimicrobial therapy directed against aerobic and an-
aerobic organe 3 ur and sen
Sy of CSF wil further aldi te choice of antibiotic,
Corticosterids combined with antibio therapy
further helps to reduce neurological or audiologicl com.
pleations
Suncicat. Meningitis following acute otis media may
require myringotomy or cortical mastoldectomy. Menin-
fits following chronic tts media with cholesteatoma
Sil require radical or modied radial masoldeetumy:
Surgery ls undertaken as soon as general condition of
patient permits may be done urgent tere hasbeen
o satsactory response o medical treatment
D. OTOGENIC BRAIN ABSCESS
ty per cent of brain abscess in alts and tn
fe per cent in children ar otogen in origin. In adult,
Ass usually follows chronte suppurative ots mesa
‘vith cholestetoma, while in chkten, DI usual the
resul of acute atts medi, Cerebral abscess seen tw
frequently as cerebellar abscess.
Route of Infection
‘Creal abscess develops as a result of direct extension of
‘nid ar infection through the tegmen o by retrograde
{hombophlebits, in which case the tegmen will Dein.
tact Often associated with extradural absces,
Cerebelar abscess also devlops as a diret extension
tough the Trautmann tangle or by retrogead nom
bophlebits. This soften associated with extradural ab.
Sus, pedsinus absess,sgmotd sinus Homo
orne
Bacteriology
Both aerobic and anaerobic organisms are sen. Aero:
bic ones Include pyogenic staphylococe, Spaces
[pesmonive, Srpioccus huey, Paes aa,
Échec cll and Pseudomonas aeruginosa. Common
among the anaroble ones are the places and
actress Harps iflcnzae url sen,
Pathology
ain abscess develops through four stages
1. STAGE OF INVASION (INITIAL ENCEPMALITIS). It often
passes unnoticed as symptoms ate slight. Patient may
have headache, low gado ever, malas and drowsines.
2.$1nor oF LocauizaTion (LATENT Auscas). There ae
o symptoms during this stage. Nature wes lo localize
mebooksfree.com
2. Conical Vexous TunoMpormtentrs. Veins over
the cerebral hemisphere undergo thrombophlebitis lead.
ing to aphasa, hemiplegia and hemianopka. There may
Be Jacksonlan type of epllep ts which may increase to
ve a picture of satus pps.
3. RulstD INTRACRAMAL TENSION. Ter is papillood:
‘ha, pss and diated pupil led nerve involvement,
And involvement of other ranlal nerves. CT scan or MRI
require for diagnosis,
‘Treatment
Lumbar puncture should not be done a it an cause hr
‘ition ofthe cerebellar tons Isa neurologieal emer
gency. A series of bute holes ora craniotomy is done to
{ran subdural empyema, Intavenous antbitis ae ad.
‘ministered to contol infection. Once infection is under
control attention Is paid to causative ear disease which
may require mastoidectom.
C. MENINGITIS.
Its inlammation of leptomeninges (pia and arachnoid)
usually with bacterial Invasion of CF in subarachnoid
Space, Its the most common intracranial complication
Sons media. <an occur in both acute and chronic
‘tts media. In infants and children, otogenic meningitis
sua follows acute ots media while adults 1 due
to chronic middle car infection,
Mode of Infection
Hood bone infection is commonin infants and children
in adults, follows chron ear disease, whieh
‘bone erosion or retrograde thrombophlebitis
ise, st may De associated Sith an extradural abscess OF
‘anulation tissue
‘in onethat of the patients with meningitis, another
ania complication may coexist.
Clinical Features
Symptoms and signs of meningitis are due o (D presence
‘of infection 1 rsd Intracranial tension and) me.
ingest and cereal tation, Their seventy il va
A the extent of disease
hls and igor.
2. Headache
3 Neck nity.
4. Photophobia and mental Italy.
5
%
perature (102-104 °F) often with
Nausea and vomiting sometimes profcctile
Drowsiness which may progres to deiium or coma,
‘Cranial nerve plses and hemiplegia
Examination wil show () neck egy, di) postive
Kern’ sign (extension of eg with thigh flexed on bdo:
men causing pain) (i) postive Brudinak sign exon
ft meck causes flexion of hip and knee) tendon rex
‘ae exaggerated intl but later become sgh or
‘Shsent and (0) ppilloedema (usually Seen in Lat stages).
Diagnosis
(CT or Mt with contrast wil help to make the diagnosis
Te may also rewal another associated intact Lesion,
Lumbar punctate and CSF examination establish the
dagnoss. CF turbid, ol counts ased and may even
‘each 1000/ml. with predominance of polymorphs: pro
fein Level raed, sugar i reduced and res re Uh
minis,
(CSF is always cultured o ind the causative organisms
and ther antibiotic sensi.
Treatment
MEDICAL, Medical treatment takes precedence over sur
soy
‘Antimicrobial therapy directed against aerobic and an-
aerobic organe 3 ur and sen
Sy of CSF wil further aldi te choice of antibiotic,
Corticosterids combined with antibio therapy
further helps to reduce neurological or audiologicl com.
pleations
Suncicat. Meningitis following acute otis media may
require myringotomy or cortical mastoldectomy. Menin-
fits following chronic tts media with cholesteatoma
Sil require radical or modied radial masoldeetumy:
Surgery ls undertaken as soon as general condition of
patient permits may be done urgent tere hasbeen
o satsactory response o medical treatment
D. OTOGENIC BRAIN ABSCESS
ty per cent of brain abscess in alts and tn
fe per cent in children ar otogen in origin. In adult,
Ass usually follows chronte suppurative ots mesa
‘vith cholestetoma, while in chkten, DI usual the
resul of acute atts medi, Cerebral abscess seen tw
frequently as cerebellar abscess.
Route of Infection
‘Creal abscess develops as a result of direct extension of
‘nid ar infection through the tegmen o by retrograde
{hombophlebits, in which case the tegmen will Dein.
tact Often associated with extradural absces,
Cerebelar abscess also devlops as a diret extension
tough the Trautmann tangle or by retrogead nom
bophlebits. This soften associated with extradural ab.
Sus, pedsinus absess,sgmotd sinus Homo
orne
Bacteriology
Both aerobic and anaerobic organisms are sen. Aero:
bic ones Include pyogenic staphylococe, Spaces
[pesmonive, Srpioccus huey, Paes aa,
Échec cll and Pseudomonas aeruginosa. Common
among the anaroble ones are the places and
actress Harps iflcnzae url sen,
Pathology
ain abscess develops through four stages
1. STAGE OF INVASION (INITIAL ENCEPMALITIS). It often
passes unnoticed as symptoms ate slight. Patient may
have headache, low gado ever, malas and drowsines.
2.$1nor oF LocauizaTion (LATENT Auscas). There ae
o symptoms during this stage. Nature wes lo localize
mebooksfree.com
chapter 12
ee
3. STAGE OF EMARGEMENT (MAMIEST ABSCESS). Ab
‘cess begins to enlarge. A zone of edema appear ound
the abscess and ls responsible for aggravation of symp
toms Clinical features a this stage ate due to
{b) Disturbance of function in the cerebrum or cerbel
Tam, causing focal symptoms and signs
4. STAGE OF TERMINATION (RUPTURE OF ABSCESS) An
‘expanding abscs in the white matter of Bain ruptures
Into the ventricle or subarachnoid space resulting in fatal
Clinical Features.
Brain abscess often associat with other complica
tions, such a extradural abscess, prsinus aces, men
nic picture may be overlapping.
‘lineal features can be divided into
2, those due to area of brain affected. They are the loca:
ain features,
EN
(a) Hache, Often severe and gen
(0) Nason and vomiting. The later is usally projectile
(o) Level o clones. Lethargy, which progreses to
drowsiness, confusion, stupor and finally coma
(0 Papa et eye. ps, te
2-3 weeks. Appears early in crebellar abs
16) Stow pean anormal temperature
alias, worse in the
2, Locauizive Parents
(a) Temporal lobe abscess
(8 Nominal aphasia abscess involves dominant
hemisphere, ke left emsphere in rightshanded
persons, patent fils to tell the nam of om
mon objects such as ky, pen, et but can dem.
“onstrate thelr se,
(9 Hci erp, Ts due o pres
the le f lesion, slot Ian be elicited y con
{romtation ts by standing in font of he patent
miner, dr by perimetry. The defect usual in
the upper bat sometimes in the lower qundrants,
Spread of abscess, face Is involved frst followed
ternal capsule, involves the leg tt followed by
the am and the face
Epi Avenue psc
Untary smacking movements of lips and tongue
Generalize ts may occur
Complications of Soppurative Out Media 91
Figure 12.6. CT con showing lides car abcess
Pit hs and oot paty Wines
(D) Cerebellar abseess (gue: 2 0)
(i) Hache involves suboccpital region and may
(4) Spontmeous nystagmus is common and ie
(iy psa hypotonia and weakness.
(i) a ti Pt sages to the seo son
(9) Pastpointing and intention tenor can be elise
by finger nose test
(60) Dysdlatechokinesia, Rapid pronation and sup
‘movements on the sete side "
Investigations
2. SKULL XRAY. are useful to se midline shi, pineal
lan is Calico, and also reveals as inthe abace ca
fy. They have ben replaced by CT sea,
2. CT SCAN: the single most important means of Inves
tigation and haps to find the ste and size ofa abcess
{igure 12.7. Eso pveats asocated complications such
3. X. MASroIDS OR CF SCAN. of the temporal bone
4, Lowman Puncrune. Great care should be exercised
‘hile doing lumbar puncture because of the ak of con
ing, CSP wl show Some rise ln pressure, increase in pro
tein content but normal glucose eve. White cell count
mebooksfree.com
ee
3. STAGE OF EMARGEMENT (MAMIEST ABSCESS). Ab
‘cess begins to enlarge. A zone of edema appear ound
the abscess and ls responsible for aggravation of symp
toms Clinical features a this stage ate due to
{b) Disturbance of function in the cerebrum or cerbel
Tam, causing focal symptoms and signs
4. STAGE OF TERMINATION (RUPTURE OF ABSCESS) An
‘expanding abscs in the white matter of Bain ruptures
Into the ventricle or subarachnoid space resulting in fatal
Clinical Features.
Brain abscess often associat with other complica
tions, such a extradural abscess, prsinus aces, men
nic picture may be overlapping.
‘lineal features can be divided into
2, those due to area of brain affected. They are the loca:
ain features,
EN
(a) Hache, Often severe and gen
(0) Nason and vomiting. The later is usally projectile
(o) Level o clones. Lethargy, which progreses to
drowsiness, confusion, stupor and finally coma
(0 Papa et eye. ps, te
2-3 weeks. Appears early in crebellar abs
16) Stow pean anormal temperature
alias, worse in the
2, Locauizive Parents
(a) Temporal lobe abscess
(8 Nominal aphasia abscess involves dominant
hemisphere, ke left emsphere in rightshanded
persons, patent fils to tell the nam of om
mon objects such as ky, pen, et but can dem.
“onstrate thelr se,
(9 Hci erp, Ts due o pres
the le f lesion, slot Ian be elicited y con
{romtation ts by standing in font of he patent
miner, dr by perimetry. The defect usual in
the upper bat sometimes in the lower qundrants,
Spread of abscess, face Is involved frst followed
ternal capsule, involves the leg tt followed by
the am and the face
Epi Avenue psc
Untary smacking movements of lips and tongue
Generalize ts may occur
Complications of Soppurative Out Media 91
Figure 12.6. CT con showing lides car abcess
Pit hs and oot paty Wines
(D) Cerebellar abseess (gue: 2 0)
(i) Hache involves suboccpital region and may
(4) Spontmeous nystagmus is common and ie
(iy psa hypotonia and weakness.
(i) a ti Pt sages to the seo son
(9) Pastpointing and intention tenor can be elise
by finger nose test
(60) Dysdlatechokinesia, Rapid pronation and sup
‘movements on the sete side "
Investigations
2. SKULL XRAY. are useful to se midline shi, pineal
lan is Calico, and also reveals as inthe abace ca
fy. They have ben replaced by CT sea,
2. CT SCAN: the single most important means of Inves
tigation and haps to find the ste and size ofa abcess
{igure 12.7. Eso pveats asocated complications such
3. X. MASroIDS OR CF SCAN. of the temporal bone
4, Lowman Puncrune. Great care should be exercised
‘hile doing lumbar puncture because of the ak of con
ing, CSP wl show Some rise ln pressure, increase in pro
tein content but normal glucose eve. White cell count
mebooksfree.com
92 SECTION!
Diseases of far
Figure 127. CT scan agde gene exer aces,
meningitis. CSF contains polymorphs or lymphocytes de.
Pending on the acuteness of lesion,
Treatment
MEDICAL. High doses of antibiotics are given patentes
Ay. As the infection fs often mixed, antibiotics may be
<ombined: Cnloramphenicl and thin! generation exph
Slosporins are usually elective. Bacterides frags, an
‘obligate anactobe, offen seen ın brain abscess, responds
tamicin, may be required if infection suspected is pseu
‘domonas or prota, Culture of dixharge fom the car
may be hepful in the choke of antibiote
aised intaranial tension can be lowered by dexa:
metiasone, 4 mg Lv. 6 hourly or mannitol 20% In doses
LOS gg body weigh
clearance and use of topical ea drop.
leed: Options include (repeated xpration through
Sion ot te abcess and evacuation l pus. Te eee of
Surgical procedure Jh to the judgement of the new
tostngco abscess tested by aspiration, It should
ie followed by repeat CF or MB sans to se i dh
minis ze. An expanding abcess, or one ths dos
not decrease in size, may rele excision Pus recovered
trom the abscess shouldbe altar and ls snstity
covered. Penclin canbe insted Ino the abscess
ier aspiration,
Ororocic. Associated ear disease which caused the brain
Solved withthe antibiotics given forthe abscess. Chronic
‘tis media would require Taicl mastoidectomy to re
move the reversible diese and to exterior the int
Sara. Surgery of he ar is undertaken only after the ab:
Ss as been Controlled by antibiotics and neurosugeal
E LATERAL SINUS THROMBOPHLEBITIS
(SYN. SIGMOID SINUS THROMBOSIS)
Ie isan inflammation of inner wal of lateral venous sins
Aetiology
tis masked mastoltis or chronic suppuration of middle
‘ar and cholesteatoma
Pathology
The pathological process can be divided ito the follow
ing sages
{elation to cuter dura wall ofthe sins, Ovelying bony
‘ural plate may have been destryed by coalescent bone
‘osion or cholesteatoma, Sometimes, I remains intact
2. ExpOrmants AND MURAL THROMBUS FORMATION,
Immaton spread o inner wall ofthe venous snus
with deposition of thin, platelets and blood cols Leading
to thrombus formation within the lamen of Sins,
3. OMLITERATION OF SINUS LUMEN AND INTIASINOS
lumen completely Organisms may invade the thrombus
‘sing ntrasims abscess which may release Infected
‘molt nto the blood steam causing septic
4. Exression oF Tumostnes. Though central part of
‘trom breaks doren duc to intrasinus abscess, hom
ote process continues both proximally and distally
Prosimaly, it may spread to confluence of sinuses and
Lo superior sagital sinus or cavernous sinus, and distally
Into mastoid emissary’ Ven, 10 Jugular bulb or fugular
Bacteriology
In acute infections, hacmolyte streptococcus, pneumo-
‘occas or taphslococeys ate common. These da,
Jos of cases of thrombophlebitis ar seen in chronic
{nection with cholesteatmas, and the organisms found
re Baus proteus, Pseudomonas propane, Escherichia
Clinical Features
This ls due to septicaemia, often coinciding with release
ing one or more pes a day It is usually accompanied
by cl and got. Profuse sweating follows fl of tem
perature, lineal picture resembles malaria but Lack
Fur
in between the bouts of fever, patent Is alert with a
see of ling Patents a may ot
2, Mexpacat In early stage It may be due to perisnus
al pressure ses due to venous obsnuchion.
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Diseases of far
Figure 127. CT scan agde gene exer aces,
meningitis. CSF contains polymorphs or lymphocytes de.
Pending on the acuteness of lesion,
Treatment
MEDICAL. High doses of antibiotics are given patentes
Ay. As the infection fs often mixed, antibiotics may be
<ombined: Cnloramphenicl and thin! generation exph
Slosporins are usually elective. Bacterides frags, an
‘obligate anactobe, offen seen ın brain abscess, responds
tamicin, may be required if infection suspected is pseu
‘domonas or prota, Culture of dixharge fom the car
may be hepful in the choke of antibiote
aised intaranial tension can be lowered by dexa:
metiasone, 4 mg Lv. 6 hourly or mannitol 20% In doses
LOS gg body weigh
clearance and use of topical ea drop.
leed: Options include (repeated xpration through
Sion ot te abcess and evacuation l pus. Te eee of
Surgical procedure Jh to the judgement of the new
tostngco abscess tested by aspiration, It should
ie followed by repeat CF or MB sans to se i dh
minis ze. An expanding abcess, or one ths dos
not decrease in size, may rele excision Pus recovered
trom the abscess shouldbe altar and ls snstity
covered. Penclin canbe insted Ino the abscess
ier aspiration,
Ororocic. Associated ear disease which caused the brain
Solved withthe antibiotics given forthe abscess. Chronic
‘tis media would require Taicl mastoidectomy to re
move the reversible diese and to exterior the int
Sara. Surgery of he ar is undertaken only after the ab:
Ss as been Controlled by antibiotics and neurosugeal
E LATERAL SINUS THROMBOPHLEBITIS
(SYN. SIGMOID SINUS THROMBOSIS)
Ie isan inflammation of inner wal of lateral venous sins
Aetiology
tis masked mastoltis or chronic suppuration of middle
‘ar and cholesteatoma
Pathology
The pathological process can be divided ito the follow
ing sages
{elation to cuter dura wall ofthe sins, Ovelying bony
‘ural plate may have been destryed by coalescent bone
‘osion or cholesteatoma, Sometimes, I remains intact
2. ExpOrmants AND MURAL THROMBUS FORMATION,
Immaton spread o inner wall ofthe venous snus
with deposition of thin, platelets and blood cols Leading
to thrombus formation within the lamen of Sins,
3. OMLITERATION OF SINUS LUMEN AND INTIASINOS
lumen completely Organisms may invade the thrombus
‘sing ntrasims abscess which may release Infected
‘molt nto the blood steam causing septic
4. Exression oF Tumostnes. Though central part of
‘trom breaks doren duc to intrasinus abscess, hom
ote process continues both proximally and distally
Prosimaly, it may spread to confluence of sinuses and
Lo superior sagital sinus or cavernous sinus, and distally
Into mastoid emissary’ Ven, 10 Jugular bulb or fugular
Bacteriology
In acute infections, hacmolyte streptococcus, pneumo-
‘occas or taphslococeys ate common. These da,
Jos of cases of thrombophlebitis ar seen in chronic
{nection with cholesteatmas, and the organisms found
re Baus proteus, Pseudomonas propane, Escherichia
Clinical Features
This ls due to septicaemia, often coinciding with release
ing one or more pes a day It is usually accompanied
by cl and got. Profuse sweating follows fl of tem
perature, lineal picture resembles malaria but Lack
Fur
in between the bouts of fever, patent Is alert with a
see of ling Patents a may ot
2, Mexpacat In early stage It may be due to perisnus
al pressure ses due to venous obsnuchion.
mebooksfree.com
Chapter 12 — Complications of Sourate OU Media 93
3. PROGRESSIVE ANAEMIA AND BMACIATION
4. Gnutsincen’s St. This i due to thromboss of mas-
told emissary vein. Ocdema appear over the posterior
pur of mastoid
5. PAPILLonDIMA. Is presence depends on abstraction
19 venous return. Tes often sen when ight sins ic,
Is arger than le) is thombosed or when lo extends to
Superior Stat sinus, Fundos may show During o dise
matins, retinal haemorhage or diate veins. Fundas
‘changes may be absent when cllatral circulation is good
6. Tonty-AvER TEST. This is 10 recon CSF pressure by
manometer and tose the effect of manual compresion,
‘fone or both jugular vins.
‘Compression of vein on te thrombosed side produces
no effect while compression of vin on healthy sie pro
‘uc rapid ise in ESF pressure which will Be equal 10
bilateral compression of jugular veins
7. CROWK-BCK Test. Pressure on jugular vein of
‘Side produces engorgement of retinal veins cen y Op.
{halmoscopy) and supraobial veins. Engorgement of
‘eins subsides on release of preso,
8. Tex ALONG JUGULAR VEIN. This is cen when
thrombophlebitis extends along the jugular vein. There
may be associated enlargement and inflammation of fu
Ula chain of Iymph nodes and tónico
Investigations
1. Loop SMEAR. is done to rue out mala
2. Dioon CutrUm. Is done 0 find causative oraniss,
altre should be taken at the time of ll when organ:
Isms enter the blood stream. Repeated cultures may be
required 1 identify the organisms.
3. CSF EXauINaTION-CSE. is normal except for rise
pressure. ao helps to exclude meningitis
4. X-Ray MASTOIDS. may show clouding of air ls acute
maso) or destruction of bone (cholesteatoma)
5. IMAGING Srumts. Contastenhanced CT scan ca
Show sinus thromboss by typical det le. sa wlan
ula area with im enhancement and central low density
Ar I seen in posterior canal fossa on axial cuts. MR
imaging better delineates thrombus. “Delta sign” may
ako be seen on contrastenfanced MRI. MR venography
isusetul to ases progression or resolution of thrombus
46, CULTURE AND Sens
nV. of car swab,
‘Complications
1. Septiaemia and pyaemic abscesses in lung, bone,
joints or subcutaneous tissue
Meningitis and subdural abscess.
Cerebellar abscess,
Thrombosis of jugular bulb and jugular vein wi
snvolvement of IXth, Xth and Xith anal eves,
5. Cavernous sinus thrombosis. There would be chemo-
Sis proptoss, tation of eyeball and papllodema.
6. Otte hydrocephalus, when thrombus extends 10 sag
‘ins via conttuence of sinuses,
Treatment
1. Ivrmavenous ASTIRACTERIAL. THERA
anubiotic will depend on sensitivity of of
lerne of te patient. Antibiot can be changed af
{er culture and sensitivity report is valable. Antibiotics
Should be continued atlas for a week after the opera
tion, shih i invariably require
2, MASTOIDECFOMY AND EXPOSURE OF SINUS. A com
plete cortical or modified radical mastldectomy fs pee
formed, depending on whether sinus Ihrombosi has
‘complicated acute or chronic middle ear disease. Sinus
bony plate s removed to expose the dura and drain the
pedis abe
"An infected clot o intrasinus abscess may be present
and must be dened. In such eases, sinus dura lady
‘stoved or may appear unhealthy and discoloured with
‘ranulations on ts surface: Dura sinesed and the infect
fd lot and abscess drained. Before incon in the dura,
‘Sins Is poche, above and below, by inserting à pack be.
en ue bone and dura of sinus to control bleeding.
leathy re cot beyond the abscess at ether end of
sins should not be disturbed. Pack i removed 5.6 ys
Postoperatively and wound secondary clos.
3. LIGATION or INTERNAL JUGULAR VEIN. It is rely
required these days. I indicated when antibiotic and
Surgical treatment have fled to control embolic ph:
‘nomenon and rigors, or tendemess and swelling along
Juglar vein is spreading
4. ANTICOAGULANT Turm. 1 is rarly required and
{sed when Ihomboss Is extending o cavernous sinus
5. SUPPORTIVE TREATMENT. Repeated blood trnsfu-
sons may be required to combat anoemia and improve
Patient resistance.
FLOTITIC HYDROCEPHALUS
Its characterized by raised intracranial pressure with nor
smal CSF findings. seen in children and adolescents
‘sith acute or chronic mide car infections.
Mechanism
Lateral sinus thrombosis accompanying mide ar infec
tion causes obstruction to venous return. I thrombosis
extends to superior sagital sinus, wll iso impede the
function of sachnold vl to absorb CSF. Both thes ac
tors result in ra Inkracrnll tension,
Clinical Features.
Sourrons
1. Severe headache, sometimes intermittent, Is the pre
senting feature. may De accompanied by nausea and
vomiting
2. Diplopla due to paralysis of Vit cranial nerve.
3. luring of vision duc to ppilloedema or optic atrophy.
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3. PROGRESSIVE ANAEMIA AND BMACIATION
4. Gnutsincen’s St. This i due to thromboss of mas-
told emissary vein. Ocdema appear over the posterior
pur of mastoid
5. PAPILLonDIMA. Is presence depends on abstraction
19 venous return. Tes often sen when ight sins ic,
Is arger than le) is thombosed or when lo extends to
Superior Stat sinus, Fundos may show During o dise
matins, retinal haemorhage or diate veins. Fundas
‘changes may be absent when cllatral circulation is good
6. Tonty-AvER TEST. This is 10 recon CSF pressure by
manometer and tose the effect of manual compresion,
‘fone or both jugular vins.
‘Compression of vein on te thrombosed side produces
no effect while compression of vin on healthy sie pro
‘uc rapid ise in ESF pressure which will Be equal 10
bilateral compression of jugular veins
7. CROWK-BCK Test. Pressure on jugular vein of
‘Side produces engorgement of retinal veins cen y Op.
{halmoscopy) and supraobial veins. Engorgement of
‘eins subsides on release of preso,
8. Tex ALONG JUGULAR VEIN. This is cen when
thrombophlebitis extends along the jugular vein. There
may be associated enlargement and inflammation of fu
Ula chain of Iymph nodes and tónico
Investigations
1. Loop SMEAR. is done to rue out mala
2. Dioon CutrUm. Is done 0 find causative oraniss,
altre should be taken at the time of ll when organ:
Isms enter the blood stream. Repeated cultures may be
required 1 identify the organisms.
3. CSF EXauINaTION-CSE. is normal except for rise
pressure. ao helps to exclude meningitis
4. X-Ray MASTOIDS. may show clouding of air ls acute
maso) or destruction of bone (cholesteatoma)
5. IMAGING Srumts. Contastenhanced CT scan ca
Show sinus thromboss by typical det le. sa wlan
ula area with im enhancement and central low density
Ar I seen in posterior canal fossa on axial cuts. MR
imaging better delineates thrombus. “Delta sign” may
ako be seen on contrastenfanced MRI. MR venography
isusetul to ases progression or resolution of thrombus
46, CULTURE AND Sens
nV. of car swab,
‘Complications
1. Septiaemia and pyaemic abscesses in lung, bone,
joints or subcutaneous tissue
Meningitis and subdural abscess.
Cerebellar abscess,
Thrombosis of jugular bulb and jugular vein wi
snvolvement of IXth, Xth and Xith anal eves,
5. Cavernous sinus thrombosis. There would be chemo-
Sis proptoss, tation of eyeball and papllodema.
6. Otte hydrocephalus, when thrombus extends 10 sag
‘ins via conttuence of sinuses,
Treatment
1. Ivrmavenous ASTIRACTERIAL. THERA
anubiotic will depend on sensitivity of of
lerne of te patient. Antibiot can be changed af
{er culture and sensitivity report is valable. Antibiotics
Should be continued atlas for a week after the opera
tion, shih i invariably require
2, MASTOIDECFOMY AND EXPOSURE OF SINUS. A com
plete cortical or modified radical mastldectomy fs pee
formed, depending on whether sinus Ihrombosi has
‘complicated acute or chronic middle ear disease. Sinus
bony plate s removed to expose the dura and drain the
pedis abe
"An infected clot o intrasinus abscess may be present
and must be dened. In such eases, sinus dura lady
‘stoved or may appear unhealthy and discoloured with
‘ranulations on ts surface: Dura sinesed and the infect
fd lot and abscess drained. Before incon in the dura,
‘Sins Is poche, above and below, by inserting à pack be.
en ue bone and dura of sinus to control bleeding.
leathy re cot beyond the abscess at ether end of
sins should not be disturbed. Pack i removed 5.6 ys
Postoperatively and wound secondary clos.
3. LIGATION or INTERNAL JUGULAR VEIN. It is rely
required these days. I indicated when antibiotic and
Surgical treatment have fled to control embolic ph:
‘nomenon and rigors, or tendemess and swelling along
Juglar vein is spreading
4. ANTICOAGULANT Turm. 1 is rarly required and
{sed when Ihomboss Is extending o cavernous sinus
5. SUPPORTIVE TREATMENT. Repeated blood trnsfu-
sons may be required to combat anoemia and improve
Patient resistance.
FLOTITIC HYDROCEPHALUS
Its characterized by raised intracranial pressure with nor
smal CSF findings. seen in children and adolescents
‘sith acute or chronic mide car infections.
Mechanism
Lateral sinus thrombosis accompanying mide ar infec
tion causes obstruction to venous return. I thrombosis
extends to superior sagital sinus, wll iso impede the
function of sachnold vl to absorb CSF. Both thes ac
tors result in ra Inkracrnll tension,
Clinical Features.
Sourrons
1. Severe headache, sometimes intermittent, Is the pre
senting feature. may De accompanied by nausea and
vomiting
2. Diplopla due to paralysis of Vit cranial nerve.
3. luring of vision duc to ppilloedema or optic atrophy.
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94 SECTION! Diese of far
Sins
Y Papillocdems may be 546 dioptrs sometimes with
Patches of exudates and hacmorrhages.
2. Nystagmus due to als intracranial tension
3. Lumbar puncture. CSE pressure exceeds 300 mm HO
(normal 70-120 mm HO), Its otherwise normal in
sl, roten and Sugar content and bacteriology
Treatment
The aim sto reduce CSF pressure to prevent optic atrophy
and Blindness This achieved mediclly by accazoamide
nd corticosteroids an repeated lumbar puncture or place
‘ment of lumbar drin. Sometimes, drining CS into the
peritoneal cavity dumbopentonca shun) is necessary.
"Middle car infection may require antibiotic therapy
and mastoid exploration to deal with sinus thrombosis
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Sins
Y Papillocdems may be 546 dioptrs sometimes with
Patches of exudates and hacmorrhages.
2. Nystagmus due to als intracranial tension
3. Lumbar puncture. CSE pressure exceeds 300 mm HO
(normal 70-120 mm HO), Its otherwise normal in
sl, roten and Sugar content and bacteriology
Treatment
The aim sto reduce CSF pressure to prevent optic atrophy
and Blindness This achieved mediclly by accazoamide
nd corticosteroids an repeated lumbar puncture or place
‘ment of lumbar drin. Sometimes, drining CS into the
peritoneal cavity dumbopentonca shun) is necessary.
"Middle car infection may require antibiotic therapy
and mastoid exploration to deal with sinus thrombosis
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Chapter 13
Otosclerosis (Syn. Otospongiosis)
ANATOMY OF LABYRINTH
lt may be pertinent to review the anatomy of the aby
Hath and Introduce the terminology often used o de
serie It
1. Oi abyrinth, Aso called membranous lbysnth or
endolymphatic labyrinth Itconsstso walle, saul,
Sch, semi dcs, endolymphatic dt and
Ser led with endolynph,
2, Perioie labyrinth or perilymphatic labyrinth (or
space). I sure vinta ed
‘th perlymph, includes vestibule, saa tympani,
Sola til erymphatc space of semicircular a
fas and the petted, whieh surrounds the endo-
Emplea of oi bin
3, Otte capsule. T's the bony bye, has tree
2 Endscal. The inncemot Layer eines the bony
Hai.
Enon Deo om the carta and ter
Stes into bone. I this ayer hat some ands
ff Garage are ie noni hat ater give eto
toc
«Pte Covers the bony aby.
(Où capsule of the bony labyrinth estes from 14
centres, the stone appeas in the region of cochlea at
16 weeis and the last one appeas in the posterolateral
par of posterior semicitcular canal at 20th week
OTOSCLEROSIS
‘otosclerosis, more aptly called topongisi, ia primary
case of the bony labyrinth. In this, one or more foc.
of regularly lid spongy bone replace part of normally
‘Sense enchondra layer of Bony ote capsule. Most often,
Dtesleoti focus involves the stapes region leading 10
tapes ation and conductive deatness. However, may
involve certain other ares ofthe bony labyrinth where
may cause neurosensory los ro symptoms tall
AETIOLOGY
‘The exact cause of tesis not known; however, he
following facts have been documented
Anatomica ass Bony labyrinth made of enchondea
‘bone which i subject to lite change in if. But some
times, itis hard bone, there ate aes of Garage rests
sich due to certain onspeeie factors are activated to
Forma new spongy bone: One such ara s the fila ante
fenestra ing in front ofthe ova window —the site of
predilection fr stapedal typeof otospongios-
Heredity About So of otitis have positive a
Ay histor es are sporade. Genetic studies reveal that
Ai an autosomal dominant tit with incomplete pen:
{trance and a variable expressivity
ace White races are afete more than black Amer
cans. I is common in indians but rare among Chinese
and japanese.
‘ex. Females ae affect twice as often as mals but
Inia otosclerosis seems to predominate in male
“Age of ene. Hearing los usualy starts Between 20 and
30 para ol age and rare before 10 and after 0 years,
Eye o ner faces. Heating loss due to otosclerosis
may be initiated or made worse by pregnancy. Simi.
calme may increase during menopause, fer an ace
‘ent or a major operation.
The disease may be associated with osteagenss im
erfor with story of multiple features. The triad of
Symptoms of osteogenesis imperleca, otosclerosis and
ue cer called vun der Hove same. Lesions of tie
‘apse sen in osteogenesis impertcta ae histologically
Indsinguishable rom those of otosclerosis and both are
¿ue o genes encoding type | collagen,
Viral ft, Eecwon microscopic and immunohis
tochemical studies have shown RNA related to measles
‘ius Tex key that otosclerosis sa viral sense as has
een suggested for Paget's disease,
‘TYPES OF OTOSCLEROSIS
1. Stapeprat Oroscarnoss. Stapedil otosclerosis caus:
ng stapes fixation and conductive deafness the most
common variety. Here lion Stars just in front of the
‘val window in an arca called "sul ante fenestram
‘hiss the te of prediction (anor oc), Lesion may
Start behind the oval window (posteo fois), around
the margin ofthe stapes footplate (ruft, in ine
footplate but annular ligament being free (isa type.
Sometimes, may completely obliterate the oval window
niche (bee pe) igure 13.1 [9).
2. Cocmsar Oroseuross. Cochlar otoseroisin-
Volve region of round window or other reas in the oie
‘apse, and may cause sensorineural hearing los prob-
Sbly due to liberation of toxic materials into the Inner
ari,
3, MisroLocte OrosctsKosis. This type of otosclerosis
mains asympomat and causes nether conductive not
‘sensorineural hearing loss
9s
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Otosclerosis (Syn. Otospongiosis)
ANATOMY OF LABYRINTH
lt may be pertinent to review the anatomy of the aby
Hath and Introduce the terminology often used o de
serie It
1. Oi abyrinth, Aso called membranous lbysnth or
endolymphatic labyrinth Itconsstso walle, saul,
Sch, semi dcs, endolymphatic dt and
Ser led with endolynph,
2, Perioie labyrinth or perilymphatic labyrinth (or
space). I sure vinta ed
‘th perlymph, includes vestibule, saa tympani,
Sola til erymphatc space of semicircular a
fas and the petted, whieh surrounds the endo-
Emplea of oi bin
3, Otte capsule. T's the bony bye, has tree
2 Endscal. The inncemot Layer eines the bony
Hai.
Enon Deo om the carta and ter
Stes into bone. I this ayer hat some ands
ff Garage are ie noni hat ater give eto
toc
«Pte Covers the bony aby.
(Où capsule of the bony labyrinth estes from 14
centres, the stone appeas in the region of cochlea at
16 weeis and the last one appeas in the posterolateral
par of posterior semicitcular canal at 20th week
OTOSCLEROSIS
‘otosclerosis, more aptly called topongisi, ia primary
case of the bony labyrinth. In this, one or more foc.
of regularly lid spongy bone replace part of normally
‘Sense enchondra layer of Bony ote capsule. Most often,
Dtesleoti focus involves the stapes region leading 10
tapes ation and conductive deatness. However, may
involve certain other ares ofthe bony labyrinth where
may cause neurosensory los ro symptoms tall
AETIOLOGY
‘The exact cause of tesis not known; however, he
following facts have been documented
Anatomica ass Bony labyrinth made of enchondea
‘bone which i subject to lite change in if. But some
times, itis hard bone, there ate aes of Garage rests
sich due to certain onspeeie factors are activated to
Forma new spongy bone: One such ara s the fila ante
fenestra ing in front ofthe ova window —the site of
predilection fr stapedal typeof otospongios-
Heredity About So of otitis have positive a
Ay histor es are sporade. Genetic studies reveal that
Ai an autosomal dominant tit with incomplete pen:
{trance and a variable expressivity
ace White races are afete more than black Amer
cans. I is common in indians but rare among Chinese
and japanese.
‘ex. Females ae affect twice as often as mals but
Inia otosclerosis seems to predominate in male
“Age of ene. Hearing los usualy starts Between 20 and
30 para ol age and rare before 10 and after 0 years,
Eye o ner faces. Heating loss due to otosclerosis
may be initiated or made worse by pregnancy. Simi.
calme may increase during menopause, fer an ace
‘ent or a major operation.
The disease may be associated with osteagenss im
erfor with story of multiple features. The triad of
Symptoms of osteogenesis imperleca, otosclerosis and
ue cer called vun der Hove same. Lesions of tie
‘apse sen in osteogenesis impertcta ae histologically
Indsinguishable rom those of otosclerosis and both are
¿ue o genes encoding type | collagen,
Viral ft, Eecwon microscopic and immunohis
tochemical studies have shown RNA related to measles
‘ius Tex key that otosclerosis sa viral sense as has
een suggested for Paget's disease,
‘TYPES OF OTOSCLEROSIS
1. Stapeprat Oroscarnoss. Stapedil otosclerosis caus:
ng stapes fixation and conductive deafness the most
common variety. Here lion Stars just in front of the
‘val window in an arca called "sul ante fenestram
‘hiss the te of prediction (anor oc), Lesion may
Start behind the oval window (posteo fois), around
the margin ofthe stapes footplate (ruft, in ine
footplate but annular ligament being free (isa type.
Sometimes, may completely obliterate the oval window
niche (bee pe) igure 13.1 [9).
2. Cocmsar Oroseuross. Cochlar otoseroisin-
Volve region of round window or other reas in the oie
‘apse, and may cause sensorineural hearing los prob-
Sbly due to liberation of toxic materials into the Inner
ari,
3, MisroLocte OrosctsKosis. This type of otosclerosis
mains asympomat and causes nether conductive not
‘sensorineural hearing loss
9s
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96 SECTION! — Diseases of far
5
en
LS
otre
LG) Sent ly Ours and Management
PATHOLOGY
Gross toser lesion appears chaky white, greyish
Sr yellow. Sometimes tein colour du to nad
Si in which cs, ne OU focus ative
aná raid progresse
Menelao, spongy bone appcas in the normaly
eme enchondral Iyer te cape In imate e
fe esos, there ae numerous maso and vaclar
Spaces with plenty of table and ones and a
‘Stor cement ststance which tain be ne mans)
‘rth hacmatnplineein sin. Mature foc how tes
sea and ying of more bone and mote of ar
tance than cementum, and aimer
SYMPTOMS
1. HEARING Loss. This ls the presenting symptom and
usually stars in twenties. I is painless and progressive
‘eth Insidios onset, Ofen Is lateral conductive type.
2. Panactsts Witt An otoscertic patient eats et
{erin noisy than in quiet surroundings. This because à
normal person sil raise his voice in noisy surrounding.
3, Towsrrus. I is more commonly seen in cochlear oto:
Sclerosis and in active lesions
4. Vico, Its an uncommon symptom,
5. Sresen. Patient has monotonous, well-modulated
son speech
SIGNS
1. Tympanic membranes quite normal and mobile. Some
nes, à rsh hue may be seen on the promontory
though the tympanic membrane (Schwartz si). Ts
[indicative of ative fous with increas vascular
2, Eustachian tube function I normal
‘Types of supe oder. A) Arter focus. (1) Posteo oes (C) Cremer (D) But pe (ek pte
3. Tuning fork tts show negative Rinne (Le, BC > AC)
frst for 256 Ha ad then 512 He and stl ater, when
tapes ation is complete, or 2026 He. Weber test wll
be fatealzed to the ea with greater conductive los
Absolute bone conduction may be normal. I 5 de.
ras cochlear otosclerosis with serial os
Pure toneautiomeny shows los ale conduction, more
for lower fequencies
one conduction is normal. In some cass, there ls
a dip in bone conduction curve. diferent at ifr:
nt frequencies but maximum at 2000 Hz and is called
{Carnac ($ 4 at 500 Ha, 10 dB at 1000 Hz, 18 UB
02000 Hz and $ at 4000 Hz} (sre 132). Carhar’s
noch disappear after sucessful stapedectom
‘Mixed hearing los not uncommon in otosclerosis
‘Tere s loss in bone conduction with aicbone ap.
‘speech audiometry reveals. normal discrimination
seore except in those with cochlear involvement
125 20 00710 2% no exe
Pos
en
Esssessssso
Figure 122, Olin er. Note dp 2000 Hen bone
ion tan nt
mebooksfree.com
5
en
LS
otre
LG) Sent ly Ours and Management
PATHOLOGY
Gross toser lesion appears chaky white, greyish
Sr yellow. Sometimes tein colour du to nad
Si in which cs, ne OU focus ative
aná raid progresse
Menelao, spongy bone appcas in the normaly
eme enchondral Iyer te cape In imate e
fe esos, there ae numerous maso and vaclar
Spaces with plenty of table and ones and a
‘Stor cement ststance which tain be ne mans)
‘rth hacmatnplineein sin. Mature foc how tes
sea and ying of more bone and mote of ar
tance than cementum, and aimer
SYMPTOMS
1. HEARING Loss. This ls the presenting symptom and
usually stars in twenties. I is painless and progressive
‘eth Insidios onset, Ofen Is lateral conductive type.
2. Panactsts Witt An otoscertic patient eats et
{erin noisy than in quiet surroundings. This because à
normal person sil raise his voice in noisy surrounding.
3, Towsrrus. I is more commonly seen in cochlear oto:
Sclerosis and in active lesions
4. Vico, Its an uncommon symptom,
5. Sresen. Patient has monotonous, well-modulated
son speech
SIGNS
1. Tympanic membranes quite normal and mobile. Some
nes, à rsh hue may be seen on the promontory
though the tympanic membrane (Schwartz si). Ts
[indicative of ative fous with increas vascular
2, Eustachian tube function I normal
‘Types of supe oder. A) Arter focus. (1) Posteo oes (C) Cremer (D) But pe (ek pte
3. Tuning fork tts show negative Rinne (Le, BC > AC)
frst for 256 Ha ad then 512 He and stl ater, when
tapes ation is complete, or 2026 He. Weber test wll
be fatealzed to the ea with greater conductive los
Absolute bone conduction may be normal. I 5 de.
ras cochlear otosclerosis with serial os
Pure toneautiomeny shows los ale conduction, more
for lower fequencies
one conduction is normal. In some cass, there ls
a dip in bone conduction curve. diferent at ifr:
nt frequencies but maximum at 2000 Hz and is called
{Carnac ($ 4 at 500 Ha, 10 dB at 1000 Hz, 18 UB
02000 Hz and $ at 4000 Hz} (sre 132). Carhar’s
noch disappear after sucessful stapedectom
‘Mixed hearing los not uncommon in otosclerosis
‘Tere s loss in bone conduction with aicbone ap.
‘speech audiometry reveals. normal discrimination
seore except in those with cochlear involvement
125 20 00710 2% no exe
Pos
en
Esssessssso
Figure 122, Olin er. Note dp 2000 Hen bone
ion tan nt
mebooksfree.com
Figure 133. Deore serra spe.) Superman and
Med o en pin.
Tympanometry may be normal in cal cases but later
shows 3 curve of ossicular stiffness. Sapadlalselex be
‘ome absent when stapes I Id (se. 28).
DIFFERENTIAL DIAGNOSIS
Otosherosis shouldbe diferentated from other causes
of conductive deafness particularly serous otitis mea,
here ots medi, tympanoscerss, ti Baaton of
head of malleus, osicular discontinultyor congenital st
ps Raton,
‘TREATMENT
MEDICAL. There is no mesial treatment hat cures ot0-
ceros. Sodium Auoride has been ted to hasten the
mat of active focus and atest further cochlea 105,
‘but controversies exist and his treatment is not com:
mended general
‘Sumeteat Stapedctomystapalorany with a placement of
prosthesis is the treatment of choice Here the fixed to
Aleron stapes Is removed and a proshess Inserted be
en the incas and oval window (re 11.3). Poste.
Sis employed may bea teflon piston stainless sec piston,
platinum tehon or ttaniumtetion piston (ise LD.
In 90% of patent, there is good improvement in hearin
er stapetecto
inn
Figure 134. Supes prostheses 1) Teton piston. () Pin
{on ion Monta eon pion
chapter 13 — Otoxleross (yn, Otesporgioss) 97
SELECTION or PATIENIS JOR StArES SURGERY Hear
ing threshold for air conduction should be 30 JB or
‘worse. is this level when patent stats feeling socially
handicapped)
"Average ai-bone gap should be atleast 1B with
Rinne negative for 286 and 12 Hz.
‘pect discrimination score should be 6016 oF mor
Contraindications to Stapes Surgery
Y, ony bang or
2. Associated Meme disease, When there Is history of
vertigo with clinical evidence of Ménière discs in
an otoscerti patient, here are more chances of Sen
Sorineuralhearng os after tapedectom
3. Young children. Recurent eustachian tube dysfunc:
fon fs common in children. I can dspace the pros.
thesis o cause acute otitis media AKO the growth of
oleo focus ls faster in children lading to recio:
Sure of oval window.
4. Professional athletes, high constuction workers, di
vers and frequent ar taller tapes surgery has the
Tsk to cause postoperative vertigo and/or dizziness
and thus interfere with thelr profession: or frequent
Air pressure changes may damage the hearing or cause
“Those who work in noisy suroundings.Alterstapodec-
tomy, they would be more vulnerable to get sensor
neural hearing loss due o noise trauma.
6. Outs externa, tympanie membrane perforation and
exostsis ate relative contsindkation® tapedectomy
fan be done after they have been treated Ars for above
‘conditions. Similarly, stapedectomy Is avoided during
pregnancy.
‘The operation I preferably done under local anaesthesia,
Steps of Stapadectomy (igure 13.5)
Mental incision and elevation of the tympanomeatal
Map.
2. Exposure of stapes ate. This may require removal of
potteronuperior bony overhang ofthe canal.
3. Removal af tapes persa
4 Creation ofa hole inthe stapes footpate(tapedoto-
my) oF removal ofa part of footpate stapadectom)
5. Placement of prosthesis
$. Repositioning the tympanomeatal fap.
‘Complications of Stapedectomy
Y Tear of tympanomeatal ap and later perforation of
rmpanle membrane
2 Injury to chorda tympani wit taste disturbance par
cular i opposite horda was ear injured
3. eus distocton
3
5
a. Baly in postoperative period (intraoperative tau
ma, serous abyeinthiis tong prosihens>
bo Late due o perlymph fistula and benign paroxys-
mal postional vertigo
6 staan
>. velos
a. Short postes
bo Loose prosthesis
mebooksfree.com
Med o en pin.
Tympanometry may be normal in cal cases but later
shows 3 curve of ossicular stiffness. Sapadlalselex be
‘ome absent when stapes I Id (se. 28).
DIFFERENTIAL DIAGNOSIS
Otosherosis shouldbe diferentated from other causes
of conductive deafness particularly serous otitis mea,
here ots medi, tympanoscerss, ti Baaton of
head of malleus, osicular discontinultyor congenital st
ps Raton,
‘TREATMENT
MEDICAL. There is no mesial treatment hat cures ot0-
ceros. Sodium Auoride has been ted to hasten the
mat of active focus and atest further cochlea 105,
‘but controversies exist and his treatment is not com:
mended general
‘Sumeteat Stapedctomystapalorany with a placement of
prosthesis is the treatment of choice Here the fixed to
Aleron stapes Is removed and a proshess Inserted be
en the incas and oval window (re 11.3). Poste.
Sis employed may bea teflon piston stainless sec piston,
platinum tehon or ttaniumtetion piston (ise LD.
In 90% of patent, there is good improvement in hearin
er stapetecto
inn
Figure 134. Supes prostheses 1) Teton piston. () Pin
{on ion Monta eon pion
chapter 13 — Otoxleross (yn, Otesporgioss) 97
SELECTION or PATIENIS JOR StArES SURGERY Hear
ing threshold for air conduction should be 30 JB or
‘worse. is this level when patent stats feeling socially
handicapped)
"Average ai-bone gap should be atleast 1B with
Rinne negative for 286 and 12 Hz.
‘pect discrimination score should be 6016 oF mor
Contraindications to Stapes Surgery
Y, ony bang or
2. Associated Meme disease, When there Is history of
vertigo with clinical evidence of Ménière discs in
an otoscerti patient, here are more chances of Sen
Sorineuralhearng os after tapedectom
3. Young children. Recurent eustachian tube dysfunc:
fon fs common in children. I can dspace the pros.
thesis o cause acute otitis media AKO the growth of
oleo focus ls faster in children lading to recio:
Sure of oval window.
4. Professional athletes, high constuction workers, di
vers and frequent ar taller tapes surgery has the
Tsk to cause postoperative vertigo and/or dizziness
and thus interfere with thelr profession: or frequent
Air pressure changes may damage the hearing or cause
“Those who work in noisy suroundings.Alterstapodec-
tomy, they would be more vulnerable to get sensor
neural hearing loss due o noise trauma.
6. Outs externa, tympanie membrane perforation and
exostsis ate relative contsindkation® tapedectomy
fan be done after they have been treated Ars for above
‘conditions. Similarly, stapedectomy Is avoided during
pregnancy.
‘The operation I preferably done under local anaesthesia,
Steps of Stapadectomy (igure 13.5)
Mental incision and elevation of the tympanomeatal
Map.
2. Exposure of stapes ate. This may require removal of
potteronuperior bony overhang ofthe canal.
3. Removal af tapes persa
4 Creation ofa hole inthe stapes footpate(tapedoto-
my) oF removal ofa part of footpate stapadectom)
5. Placement of prosthesis
$. Repositioning the tympanomeatal fap.
‘Complications of Stapedectomy
Y Tear of tympanomeatal ap and later perforation of
rmpanle membrane
2 Injury to chorda tympani wit taste disturbance par
cular i opposite horda was ear injured
3. eus distocton
3
5
a. Baly in postoperative period (intraoperative tau
ma, serous abyeinthiis tong prosihens>
bo Late due o perlymph fistula and benign paroxys-
mal postional vertigo
6 staan
>. velos
a. Short postes
bo Loose prosthesis
mebooksfree.com
98 SECTION! — Discos of for
igure 13.5 Sips of aprecio eet
© Displacement ofp
& Incus erosión (ate
8 Sensorineural hearing los
a. Intraoperative tam
bh Labyeinniis
© Perl tul/granuloma
9, Dead et
thesis
‘wo per cent of patents undergoing this operation
may suffer sensorineural los, oi progressive high fe
uency loss is seen in longterm follow-up. One in 200
aly “dead” ca.
Patents may get
Stpes mobilization s no longer done these days as it
ives temporary result; realen being quite common.
eps’ fenestration operation i almost outdated non.
ere an alternative windows created in the lateral sem
iar anal 0 function forthe tra oval inde
the disadvantage of postoperative mastold cavity
a inherent heating loss of 25 dB which cannot
comtes.
Mann Arp. Patients who refus surgery or are unit for
surgery can use hearing ad. an efecuve alternative
mebooksfree.com
igure 13.5 Sips of aprecio eet
© Displacement ofp
& Incus erosión (ate
8 Sensorineural hearing los
a. Intraoperative tam
bh Labyeinniis
© Perl tul/granuloma
9, Dead et
thesis
‘wo per cent of patents undergoing this operation
may suffer sensorineural los, oi progressive high fe
uency loss is seen in longterm follow-up. One in 200
aly “dead” ca.
Patents may get
Stpes mobilization s no longer done these days as it
ives temporary result; realen being quite common.
eps’ fenestration operation i almost outdated non.
ere an alternative windows created in the lateral sem
iar anal 0 function forthe tra oval inde
the disadvantage of postoperative mastold cavity
a inherent heating loss of 25 dB which cannot
comtes.
Mann Arp. Patients who refus surgery or are unit for
surgery can use hearing ad. an efecuve alternative
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Chapter 14
Facial Nerve and Its Disorders
ANATOMY AND FUNCTIONS
‘OF FACIAL NERVE
Facial nerve suns from pons to parti, isa mined nerve
having motor and a sensory foot. The later Is also called
the nerve of Wriberg and caries secretomotor fibres to
the ermal gland and salivary’ glands, and brings bres
‘of taste and general sensation. Thus thete ate two eller
‘ent and to afferent pathways. Components ofthe cal
nerve inch
1. Special visceral efferent forms the motor soo and
supplies al the muscles derived Tom the second
branchial arch, Le al the muscles of facta expresion,
Aura muscles (now vestigial), sylohyoid posterior
belly of digastric and the tapes.
2. General visceral efferent supplies secretomoror fibres
Lo im, submandibular and sublingual glands and
the male secretory glands in the nasal mucosa and
the palate,
3. Special visceral afferent brings taste from the anterior
osado tongue via chorda tympar and soft and
"hard palate via grater superficial peros! nerve, Taste
‘Seared tothe nucleus of tracts solaris,
4. General somatic afferent brings general sensation
ftom the concha, posterosuperior prt of extemal «a
he mp membrane. These bres account
dar eruption in herpes zoster infection ofthe
fenlculate ganglion. I also rings proprioceptive sen:
tion fom the facil msc,
NUCLEUS OF FACIAL NERVE.
Motor nucleus ofthe nerve is situated in the pons. Ire
‘eves ire from the precenral gyrus. Upper part of the
nucleus which innervates forehead muscles receives res
From both the cerebral hemispheres, wile the lower par
of nucleus which supplies lower face gts only crosed
fibres om one hemisphere. The function of forehead
Is preserved in supranuclear lesions because of bilateral
Imereti. Fala mucleus also receive Abrc from the
thalamos by alternate routes and provides involuntary
contra to facial muscles, The emotional movements
Such as smling and crying are thus preserved in supra
eter palsies because ofthese es rom te thalamus
gure 1.
‘COURSE OF FACIAL NERVE
Motor fibres take origin from
the sensory root nee of Wish). Facial nerve leaves the
rainstem at pontomedallary junction,
posterior canal Tossa and en
catas A he fundus of tn meatus (atra most part ol
‘eats, he nerve enters ie bon 1acal anal, aves
the temporal bone and comes out of the stylomastold lo.
‘amen. Here roses the told process and divides into
terminal branches The couse ofthe nerve (Figure 142)
‘an thus be divided into thee parts.
1. INIRACRANIAL PARE. From pons to internal acoustic
seats (15-17 mm),
2. rares Part. From
{ts to stylomsstod foramen, il
er divided nt
(a), Metal segment (8-10 mm. Within Internal acoustic
(Labyrinth segment (4.0 mo. From fundas of min-
tus tothe geniculate ganglion where nerve takes à
turn posterior fomming a “gent.” The nerve in the
Lbyeinthine segment has the narrowest diameter
(0-61-0468 mm) and the bony canal in this segment
ls also the nareowest. Ths oedema or infammation
fan easily compress the nerve and cause paralysis
‘This s also the shortest segment of the nerve.
9 Tympani a horizontal segment (11.0 mm) From genie
lat ganglion to just above the pyramidal eminence
Teles above the oval window and below the lateral
semicircular canal
(9 Maso or vertical segment (13.9 mn). Brom the pyre
‘mid to stylomastosd foramen. Between the typ.
le and mastod segments I the second genu of the
3. EXTRACRANIAL PART. From stylomastoid foramen to
the termination of ts peripheral banches-
BRANCHES OF FACIAL NERVE
1. Gnzaren strennciat Perosat Nev tries from
geniculate ganglion and cartes secetomotor resto ae
mal gland and the glands of nasal mucosa and plate
2. Nenn To SIAPEDICS. tales at the level of second
‘nu and supplies the tps muscle
3. CHORDS Tyran tases from the middle o vertical
Segment, pases between the incus and neck of malleus,
and leaves the tympanic cavity Uvough petotympanic
sure, Tt caries secrtomotor Abres to submandibular
And sublingual glands and brings taste rom anterior wo
thirds of tongue
99
mebooksfree.com
Facial Nerve and Its Disorders
ANATOMY AND FUNCTIONS
‘OF FACIAL NERVE
Facial nerve suns from pons to parti, isa mined nerve
having motor and a sensory foot. The later Is also called
the nerve of Wriberg and caries secretomotor fibres to
the ermal gland and salivary’ glands, and brings bres
‘of taste and general sensation. Thus thete ate two eller
‘ent and to afferent pathways. Components ofthe cal
nerve inch
1. Special visceral efferent forms the motor soo and
supplies al the muscles derived Tom the second
branchial arch, Le al the muscles of facta expresion,
Aura muscles (now vestigial), sylohyoid posterior
belly of digastric and the tapes.
2. General visceral efferent supplies secretomoror fibres
Lo im, submandibular and sublingual glands and
the male secretory glands in the nasal mucosa and
the palate,
3. Special visceral afferent brings taste from the anterior
osado tongue via chorda tympar and soft and
"hard palate via grater superficial peros! nerve, Taste
‘Seared tothe nucleus of tracts solaris,
4. General somatic afferent brings general sensation
ftom the concha, posterosuperior prt of extemal «a
he mp membrane. These bres account
dar eruption in herpes zoster infection ofthe
fenlculate ganglion. I also rings proprioceptive sen:
tion fom the facil msc,
NUCLEUS OF FACIAL NERVE.
Motor nucleus ofthe nerve is situated in the pons. Ire
‘eves ire from the precenral gyrus. Upper part of the
nucleus which innervates forehead muscles receives res
From both the cerebral hemispheres, wile the lower par
of nucleus which supplies lower face gts only crosed
fibres om one hemisphere. The function of forehead
Is preserved in supranuclear lesions because of bilateral
Imereti. Fala mucleus also receive Abrc from the
thalamos by alternate routes and provides involuntary
contra to facial muscles, The emotional movements
Such as smling and crying are thus preserved in supra
eter palsies because ofthese es rom te thalamus
gure 1.
‘COURSE OF FACIAL NERVE
Motor fibres take origin from
the sensory root nee of Wish). Facial nerve leaves the
rainstem at pontomedallary junction,
posterior canal Tossa and en
catas A he fundus of tn meatus (atra most part ol
‘eats, he nerve enters ie bon 1acal anal, aves
the temporal bone and comes out of the stylomastold lo.
‘amen. Here roses the told process and divides into
terminal branches The couse ofthe nerve (Figure 142)
‘an thus be divided into thee parts.
1. INIRACRANIAL PARE. From pons to internal acoustic
seats (15-17 mm),
2. rares Part. From
{ts to stylomsstod foramen, il
er divided nt
(a), Metal segment (8-10 mm. Within Internal acoustic
(Labyrinth segment (4.0 mo. From fundas of min-
tus tothe geniculate ganglion where nerve takes à
turn posterior fomming a “gent.” The nerve in the
Lbyeinthine segment has the narrowest diameter
(0-61-0468 mm) and the bony canal in this segment
ls also the nareowest. Ths oedema or infammation
fan easily compress the nerve and cause paralysis
‘This s also the shortest segment of the nerve.
9 Tympani a horizontal segment (11.0 mm) From genie
lat ganglion to just above the pyramidal eminence
Teles above the oval window and below the lateral
semicircular canal
(9 Maso or vertical segment (13.9 mn). Brom the pyre
‘mid to stylomastosd foramen. Between the typ.
le and mastod segments I the second genu of the
3. EXTRACRANIAL PART. From stylomastoid foramen to
the termination of ts peripheral banches-
BRANCHES OF FACIAL NERVE
1. Gnzaren strennciat Perosat Nev tries from
geniculate ganglion and cartes secetomotor resto ae
mal gland and the glands of nasal mucosa and plate
2. Nenn To SIAPEDICS. tales at the level of second
‘nu and supplies the tps muscle
3. CHORDS Tyran tases from the middle o vertical
Segment, pases between the incus and neck of malleus,
and leaves the tympanic cavity Uvough petotympanic
sure, Tt caries secrtomotor Abres to submandibular
And sublingual glands and brings taste rom anterior wo
thirds of tongue
99
mebooksfree.com
100. sections —
Diseases of far
Figure 14: Fre scene Beinen adi Ou
ST nen pap Eta momen cate by
Inner memorizar
Figure 142. (N Counsel reve tempo ar coso
lo sets mes), yin Grp Cd mai
ema tna nan at
4. CONAMICATING Banc It joins auricular branch of
‘agus and supple the concha, rtrouncuar grove, pos
{err meatas ande outer surface of tympanic membrane,
5. Posrenson Aunicutan Nene. I supplis muscles of
Pinna, occipital bell of occiptofontal and communi-
‘ates with auricular branch of vagus.
6. MuscuLaR BRANCHES, To stylohyold and posterior
bly of ist
7. PuntrueRat. Bancs. The nerve trunk, after rose
Ing te aylod process, forms two disons, an upper
{emporofail and a lower cervcofacil, which further ie
vide into smaller branches. These are the temporal, 80.
‘mati buccal, mandibular and cervical and together orm
pes serna (goosedoot. They supply all the muscles of
facial expression,
‘BLOOD SUPPLY OF FACIAL NERVE
A is derived from four blood vessel: () Anterior infor
cercar arty supplies the nerve in cerchelopontine
ange: (brin are branch of anterioenteior
‘erchalar artery, which supplies the nerve in intemal
Suitry canal) pee perl artery, à ranch of
‘mide meningeal artery, which supplies geniculate gan:
Sion andthe adjacent region and I) amas ate,
branch of posterior aurkular artery, which supplies
‘stot and tyenpanie segment Al the arerie oem an
femal ples which lies in the epineurlum and feeds a
per intraneural Steal peu ise 1.
SURGICAL LANDMARKS OF FACIAL NERVE
For mide car and mastoid surgery
1. Processus cochlearformis. It demarcates the gencu-
lote ganglion which ls just anterior tot Tympanie
segment ofthe nerve tarts at this level
2, Oval window and horizontal canal. The aia nese
runs above the oval window (tapes) and below the
horizontal canal
3. Short proces of incas. Facil nerve ies medal tothe
nor proces of incu athe Level of adits.
4. Pyramid, Nerve runs behind the pyramid and the pos-
terior tympanic sulcus,
5, Tympanomastold suture. In vertical or mastoid seg
ment, nerve runs behind thi autre
6. Digastric ridge. The nerve eaves te mastoid atthe
anterior end of digastric idée.
or paid surgery (igure 14.4)
1. Cartilaginous pointer. The nerve les 1 cm deep and
Slightly anterior and inferior tothe pointer, Carla
fous pointer i a sharp triangular pce of catige of
the pina and points othe neve
2. Tympanomastold suture. Nerve les 6-8 mm deep to
4. Sold process. The nerve crosses lateral to toi
process
4. Posterior belly of digasti. If posterior belly of di
{asec muscle I race backwandı along its upper bor
‘er tots attachment tothe dipstie groove, nerve ls
found to ie between and the styled proces,
VARIATION AND ANOMALIES OF FACIAL.
[NERVE (FIGURE 14.5)
1. Bony dehiscence. This isthe most com
aby. Dehiscence (absence of bony cover) Occurs
‘most commonly in tympani segment over the oval
mebooksfree.com
Diseases of far
Figure 14: Fre scene Beinen adi Ou
ST nen pap Eta momen cate by
Inner memorizar
Figure 142. (N Counsel reve tempo ar coso
lo sets mes), yin Grp Cd mai
ema tna nan at
4. CONAMICATING Banc It joins auricular branch of
‘agus and supple the concha, rtrouncuar grove, pos
{err meatas ande outer surface of tympanic membrane,
5. Posrenson Aunicutan Nene. I supplis muscles of
Pinna, occipital bell of occiptofontal and communi-
‘ates with auricular branch of vagus.
6. MuscuLaR BRANCHES, To stylohyold and posterior
bly of ist
7. PuntrueRat. Bancs. The nerve trunk, after rose
Ing te aylod process, forms two disons, an upper
{emporofail and a lower cervcofacil, which further ie
vide into smaller branches. These are the temporal, 80.
‘mati buccal, mandibular and cervical and together orm
pes serna (goosedoot. They supply all the muscles of
facial expression,
‘BLOOD SUPPLY OF FACIAL NERVE
A is derived from four blood vessel: () Anterior infor
cercar arty supplies the nerve in cerchelopontine
ange: (brin are branch of anterioenteior
‘erchalar artery, which supplies the nerve in intemal
Suitry canal) pee perl artery, à ranch of
‘mide meningeal artery, which supplies geniculate gan:
Sion andthe adjacent region and I) amas ate,
branch of posterior aurkular artery, which supplies
‘stot and tyenpanie segment Al the arerie oem an
femal ples which lies in the epineurlum and feeds a
per intraneural Steal peu ise 1.
SURGICAL LANDMARKS OF FACIAL NERVE
For mide car and mastoid surgery
1. Processus cochlearformis. It demarcates the gencu-
lote ganglion which ls just anterior tot Tympanie
segment ofthe nerve tarts at this level
2, Oval window and horizontal canal. The aia nese
runs above the oval window (tapes) and below the
horizontal canal
3. Short proces of incas. Facil nerve ies medal tothe
nor proces of incu athe Level of adits.
4. Pyramid, Nerve runs behind the pyramid and the pos-
terior tympanic sulcus,
5, Tympanomastold suture. In vertical or mastoid seg
ment, nerve runs behind thi autre
6. Digastric ridge. The nerve eaves te mastoid atthe
anterior end of digastric idée.
or paid surgery (igure 14.4)
1. Cartilaginous pointer. The nerve les 1 cm deep and
Slightly anterior and inferior tothe pointer, Carla
fous pointer i a sharp triangular pce of catige of
the pina and points othe neve
2. Tympanomastold suture. Nerve les 6-8 mm deep to
4. Sold process. The nerve crosses lateral to toi
process
4. Posterior belly of digasti. If posterior belly of di
{asec muscle I race backwandı along its upper bor
‘er tots attachment tothe dipstie groove, nerve ls
found to ie between and the styled proces,
VARIATION AND ANOMALIES OF FACIAL.
[NERVE (FIGURE 14.5)
1. Bony dehiscence. This isthe most com
aby. Dehiscence (absence of bony cover) Occurs
‘most commonly in tympani segment over the oval
mebooksfree.com
Figure 143. too spy lol nee. (1) Cac an.
one nes contr ate.) itera oo cn
ayant ae) aia upon and nace a ap
Sipe petal () Mata seen: Sons nen: Th
‘aero and vera tens spy the nae ad et
Santa segment
cutee of
na
comas
6
Figure 144 Suc! nm of the fc none in pts
Chapter 14 — Facial Neve ands Disordes TO
window. I also occurs near the region of geniculate
ganglion or in the region of reteofaial mastoid cells.
A dehiscent nerve Is prone 10 injury at the time of
Surgery or gets easly involved in mastod and middle
cat infections
2, Prolapse of nerve. The dehiscent nerve may prolapse
over the stapes and make stapes sugery or osa
teconstruction difficult.
3, Hump. The nerve may make a hump posteriorly near
the horizontal canal making Wt vulnerable 10 injury
‘while exposing the antrum during mastoid surgery
4 Bifurcation and trfurcation, Ihe vertical part of
facial nerve divides ito two or thece branches, ed
occupying a separate canal and exiting though inde
‘it foramen
Tifurcation and enclosing the stapes. The newe
divides proximal to oval window. one part passing
above and the other Blow I and then reiting,
6. Between oval and round windows. Just before oval
‘window the nerve crosses the middle car passing be
een oval and ound windows,
Anomalies ofthe nerve are more common in congent
tat eas utmost care should be taken wie operating cas.
{sot mierona or other congenital conditions of the car.
STRUCTURE OF NERVE
From inside out, a nerve fire consists of axon, mye
sheath neurlemma and endoncwtu A group of nerve
‘bes enclosed in a sheath called pens 10 form a
sc and the faeces ae bound together y incr
I)
SEVERITY OF NERVE INJURY
Degree of nerve injury wil determine the regeneration of
nerveandis function, Earle neve injures were divided
1. Neuuprai a conduction block, where Now of ax0-
plasm through the axons was partial obstructed
2, xomsemess-infury to axons.
3. Neaotmesis—injury t nerve,
Sunderland classified nerve injuriesinto Ave degrees of
seven based on anatomical structure of the neve and
nis sation ive widely accept.
Partial block to flow of axoplasm; no morpholog-
«al changes are seen, Recovery of funtion Is complete
{nearaprai.
= Los of axons, but endoneural tubes remain intact
During recovery, axons il grow into Ihr respective
tubes, and the result s good axonotmes).
= Injury to endoncarum. During recovery, axons of
fone tube can grow into another, Sınkineis can occur
{neurotmests
= Injury to perincurium in ation o above, Scaring
‘ull impr generation of bres (partial tansecion)
injury to epineuum in addition to above (complete
nerve transection),
‘The fist tre degrcs ar cen in viral and inflamma:
tory sonders while our and ith are seen in surgical
accidental rauma tothe nerve or in neoplasns.
mebooksfree.com
one nes contr ate.) itera oo cn
ayant ae) aia upon and nace a ap
Sipe petal () Mata seen: Sons nen: Th
‘aero and vera tens spy the nae ad et
Santa segment
cutee of
na
comas
6
Figure 144 Suc! nm of the fc none in pts
Chapter 14 — Facial Neve ands Disordes TO
window. I also occurs near the region of geniculate
ganglion or in the region of reteofaial mastoid cells.
A dehiscent nerve Is prone 10 injury at the time of
Surgery or gets easly involved in mastod and middle
cat infections
2, Prolapse of nerve. The dehiscent nerve may prolapse
over the stapes and make stapes sugery or osa
teconstruction difficult.
3, Hump. The nerve may make a hump posteriorly near
the horizontal canal making Wt vulnerable 10 injury
‘while exposing the antrum during mastoid surgery
4 Bifurcation and trfurcation, Ihe vertical part of
facial nerve divides ito two or thece branches, ed
occupying a separate canal and exiting though inde
‘it foramen
Tifurcation and enclosing the stapes. The newe
divides proximal to oval window. one part passing
above and the other Blow I and then reiting,
6. Between oval and round windows. Just before oval
‘window the nerve crosses the middle car passing be
een oval and ound windows,
Anomalies ofthe nerve are more common in congent
tat eas utmost care should be taken wie operating cas.
{sot mierona or other congenital conditions of the car.
STRUCTURE OF NERVE
From inside out, a nerve fire consists of axon, mye
sheath neurlemma and endoncwtu A group of nerve
‘bes enclosed in a sheath called pens 10 form a
sc and the faeces ae bound together y incr
I)
SEVERITY OF NERVE INJURY
Degree of nerve injury wil determine the regeneration of
nerveandis function, Earle neve injures were divided
1. Neuuprai a conduction block, where Now of ax0-
plasm through the axons was partial obstructed
2, xomsemess-infury to axons.
3. Neaotmesis—injury t nerve,
Sunderland classified nerve injuriesinto Ave degrees of
seven based on anatomical structure of the neve and
nis sation ive widely accept.
Partial block to flow of axoplasm; no morpholog-
«al changes are seen, Recovery of funtion Is complete
{nearaprai.
= Los of axons, but endoneural tubes remain intact
During recovery, axons il grow into Ihr respective
tubes, and the result s good axonotmes).
= Injury to endoncarum. During recovery, axons of
fone tube can grow into another, Sınkineis can occur
{neurotmests
= Injury to perincurium in ation o above, Scaring
‘ull impr generation of bres (partial tansecion)
injury to epineuum in addition to above (complete
nerve transection),
‘The fist tre degrcs ar cen in viral and inflamma:
tory sonders while our and ith are seen in surgical
accidental rauma tothe nerve or in neoplasns.
mebooksfree.com
102 SECTIONI — Diseases ofr
Soe]
- EN!
A a ==
nee. (4 Nal (8) bon decena (O mp poner (or he seen
eng rou he oa von and (€) te nee pang eran the ul ad
pura sy Now var
9 Pormsunen
3)
Fr Er
AA
mebooksfree.com
Soe]
- EN!
A a ==
nee. (4 Nal (8) bon decena (O mp poner (or he seen
eng rou he oa von and (€) te nee pang eran the ul ad
pura sy Now var
9 Pormsunen
3)
Fr Er
AA
mebooksfree.com
ELECTRODIAGNOSTIC TESTS
“These test are ult iferentnte between neuraprania
nd degeneration ofthe nerve They also help to predict
prognosis and indicate time for Surgical decompresio:
ofthe neve
1. MINIMAL NERVE Exerramury Tisr, The newe Is
timated at steely increasing intensity il facil twitch
Is just noticeable. Ts is compared with the normal id.
“There sno difference between the normal and paralyzed
siden conduetion block In other injures, where degeer
tion esin, nerve exctabliy gradually lost. When the
‘ference betwen two sides exceed 3.5 m amp, the test
Is postive for degeneration. Degeneration of fibres cannot
e detected ales than 48-72 hols commencement,
2. Max SIMULATION Tit (MSI). This tests sin
Ine to the minimal nerve exctalty et ut instead of
measuring the threshold of stimulation, the current eel
‘which gives maximum facial movement fs determined
nd compared with the normal side, Response s ali
‘rade a equal, decreased or absent, Reduced or absent
response with maximal stimulation indices degeners:
tion and is followed by incomplete recovery.
3. ELLCTRONEURONOGRAPIY (ENOG). IC Is a sort of
‘evoked electrompography. The fa nerves tilted a
the sylomasto foramen and the compound muscle ac
ton potentials ae picked up by the surface electods. Su
pramaximal stimulation 1 used to obtain maximal acto
potential. The responses of action potential ofthe pat
Tze side ae compared with that of the normal side on
Similar stimulation and thus percentage of degeneatin
bres calculated Studis revel tat degeneration 01903
‘occurring in the fst 14 days indicates poor recovery of
function Faster rate of degeneration curing i ss a
14 days has a tl poorer prognoss. ENOG is most useful
etc 4 and21 days of the onset of complete paralysis
4. EUCROMOGRAPIY (EMG). Tis tts the motor
y of ail muses by diet Inserton of nee
Secre» usually in rca ocu and orto ars
miis an the recordings ar made ding est and vl
{itary contraction of mare
In a normal sing muscle, biphac or tiphase po-
tet ar sn vey 30.80 ms.
In dents mund, spontaneous involuntary ac
tim potas ale lin otis ae sen. Tay
Sppcar 14-21 day after denervation. With regeneration
athe nerve ati apart poten
replace Meilen potentiate. They appear 6-12 weeks
Por occ! evidence of fal function aná thus pr
ide the carie evidence rever.
‘Voluntary contraction causes moor share. Dia:
id or no sponsor) CONGO sen a
Dre
‘Becromyoqrphy Lust n planning animation
procedures, PRE of nomma o polyphase porel
Ser year of muy nats heine man aan
pie and tere tno esd for animation procure À
Ruin potentials are sen, indes Intact motor
cn plates ut mo erence of rnneraton and need or
tere substan: Becta sens Inde: atrophy of
mor end plates and need oracle tester procedure
ter han nerve sation
Chapter 14 — Facil Neve ands Diodes 103,
“Thus ENOG and ENG are complimentary and help to
prognostiate in eases of facial paralysis and in deciding
{the procedure for reanimation, Le. nerve substitution ver
us muscle transposition or sling operation,
CAUSES OF FACIAL PARALYSIS
The cause may be central or peripheral. The peripheral le
sion may involve the nerve fn Is intracranial, Itrstem-
poral or extratemporal pars Peripheral sions are more
Common and about to thinds of them are of fhe Ko.
Fate variety (D 11).
A. IDIOPATHIC
1. Bells Palsy
Sity to seventy-five per cent of facial paralysis is due to
B's palsy e deine as loan, periph facial pu
ras or paresis of acute onset oth sexes ate afeted with
2 Ponte amas
pacer
+ tania gto)
LEE ons
enga
intempo
Pape
pres
Mason ane
+ res
Gone apt tna
Mara ot ees
Serge Madectomy an saprdetomy
Bellen incest onporl bone
+ plans
‘gnc teste
ets tenpor one om acer of east,
bones, prose).
Pre
alga pot
1 Super pao
cena yin poi vegon
o ca y Cree),
ehe estas
Be
1 Poren ao
Mer randamatss,
codos (ers none)
Leo
Pi
Domini dene
mebooksfree.com
“These test are ult iferentnte between neuraprania
nd degeneration ofthe nerve They also help to predict
prognosis and indicate time for Surgical decompresio:
ofthe neve
1. MINIMAL NERVE Exerramury Tisr, The newe Is
timated at steely increasing intensity il facil twitch
Is just noticeable. Ts is compared with the normal id.
“There sno difference between the normal and paralyzed
siden conduetion block In other injures, where degeer
tion esin, nerve exctabliy gradually lost. When the
‘ference betwen two sides exceed 3.5 m amp, the test
Is postive for degeneration. Degeneration of fibres cannot
e detected ales than 48-72 hols commencement,
2. Max SIMULATION Tit (MSI). This tests sin
Ine to the minimal nerve exctalty et ut instead of
measuring the threshold of stimulation, the current eel
‘which gives maximum facial movement fs determined
nd compared with the normal side, Response s ali
‘rade a equal, decreased or absent, Reduced or absent
response with maximal stimulation indices degeners:
tion and is followed by incomplete recovery.
3. ELLCTRONEURONOGRAPIY (ENOG). IC Is a sort of
‘evoked electrompography. The fa nerves tilted a
the sylomasto foramen and the compound muscle ac
ton potentials ae picked up by the surface electods. Su
pramaximal stimulation 1 used to obtain maximal acto
potential. The responses of action potential ofthe pat
Tze side ae compared with that of the normal side on
Similar stimulation and thus percentage of degeneatin
bres calculated Studis revel tat degeneration 01903
‘occurring in the fst 14 days indicates poor recovery of
function Faster rate of degeneration curing i ss a
14 days has a tl poorer prognoss. ENOG is most useful
etc 4 and21 days of the onset of complete paralysis
4. EUCROMOGRAPIY (EMG). Tis tts the motor
y of ail muses by diet Inserton of nee
Secre» usually in rca ocu and orto ars
miis an the recordings ar made ding est and vl
{itary contraction of mare
In a normal sing muscle, biphac or tiphase po-
tet ar sn vey 30.80 ms.
In dents mund, spontaneous involuntary ac
tim potas ale lin otis ae sen. Tay
Sppcar 14-21 day after denervation. With regeneration
athe nerve ati apart poten
replace Meilen potentiate. They appear 6-12 weeks
Por occ! evidence of fal function aná thus pr
ide the carie evidence rever.
‘Voluntary contraction causes moor share. Dia:
id or no sponsor) CONGO sen a
Dre
‘Becromyoqrphy Lust n planning animation
procedures, PRE of nomma o polyphase porel
Ser year of muy nats heine man aan
pie and tere tno esd for animation procure À
Ruin potentials are sen, indes Intact motor
cn plates ut mo erence of rnneraton and need or
tere substan: Becta sens Inde: atrophy of
mor end plates and need oracle tester procedure
ter han nerve sation
Chapter 14 — Facil Neve ands Diodes 103,
“Thus ENOG and ENG are complimentary and help to
prognostiate in eases of facial paralysis and in deciding
{the procedure for reanimation, Le. nerve substitution ver
us muscle transposition or sling operation,
CAUSES OF FACIAL PARALYSIS
The cause may be central or peripheral. The peripheral le
sion may involve the nerve fn Is intracranial, Itrstem-
poral or extratemporal pars Peripheral sions are more
Common and about to thinds of them are of fhe Ko.
Fate variety (D 11).
A. IDIOPATHIC
1. Bells Palsy
Sity to seventy-five per cent of facial paralysis is due to
B's palsy e deine as loan, periph facial pu
ras or paresis of acute onset oth sexes ate afeted with
2 Ponte amas
pacer
+ tania gto)
LEE ons
enga
intempo
Pape
pres
Mason ane
+ res
Gone apt tna
Mara ot ees
Serge Madectomy an saprdetomy
Bellen incest onporl bone
+ plans
‘gnc teste
ets tenpor one om acer of east,
bones, prose).
Pre
alga pot
1 Super pao
cena yin poi vegon
o ca y Cree),
ehe estas
Be
1 Poren ao
Mer randamatss,
codos (ers none)
Leo
Pi
Domini dene
mebooksfree.com
104 SECTION! — Diseases of ar
qual frequency. Any age group may be affected though
Incidence ses with increasing age. A postive family his:
tory fs present in 6-8 of patients. Rsk of Bell palsy is
more in dobetis(angiopthy) and pregnant women ln
tention of ui)
1, Vita INHECHON. Most ofthe evidence supports the
ral atioogy due to herpes simplex, herpes zoster or the
Ftein-Bar Vins. Other cana eres may also be in
‘volved in Bell palsy which 1 thus considered part ol the
tou picture of polyneuropathy
2. VASCULAR ISCHAEMIA, It may be primary or second:
aay, Par ischacnia 5 induced by cold or emotional
Ses, Secondary chum the esto primary ce:
mia which causes increased capilar, permeability lead
{ng 10 exudation of Mud, oedema and compresion of
mic circulation ofthe nerve
5° Homer. The fallopian canal naro because of
retary predisposition and this males the nerve suscep
‘eto cary compression with the lightest osdema. Ten per
‘cent ofthe cases of Bll palsy havea post family history.
Automne Dinner. THymphocyte changes have
been observe
Canc Fearon (uns 147 vo 148 AB).
Srna ats niet de hs ye Oo
Berg die det gee am aloe
titan) Salts Gas hoe seo ma
Fae bat mente ey tow da fom de
eps) Pn say peo acompa
a mole
~ eg
Figure 14. ac pris e. Compare oem ie
(taped paralysis) or os of taste involvement of chor
da tympani. Paralysis may be complete or incomplete
pls is rcurret in 310% of patents
Dascosis. Diagnosis is always by exclusion.
other
‘known causes of perihera aia paralysis should be ex
clued. This requires careful
nd head
story, complete otoogical
nd neck examination, Xray studies, blood
tou count, peripherl smear, sedimentation
sugar and eto
‘Nerve excitability tests are done d
days and compared with the normal side to monitor
nerve degeneration.
Localling the site of lesion (topodiagnoss) helps in
‘stablishing he aetiology and as the ite of surgical de-
compression of neve, l that becomes necessary
uan
1 Reassurance
2: Relief of ear pain by analgesics
5. Care ofthe eye as outlined on p. 108. Eye must be pro
tected aginst exposure erat
4. Physiotherapy or massage ofthe facial muscles gives
Psychologen support to the patient. I has ot been
Shown to influence recovery. Active facial movements
fare encouraged when thete Is return o some move.
ment tothe facial muscles,
MEDICAL MANAGEMENT
+ Sois, Their ut has not been proved beyond
out in carefully controled studies. Prednsolone Is
the drug of choc patent reports shin 1 week,
the adult dose of prednisolone 1 mg/day divided
morning and evening doses for 3 days. Patients
seen om the filth day. If paralysis incomplee or
recovering doses tapered during the next S days. If
Paralysis remains complete, the same dose Is conti.
ted for another 10 das and thereafter tapered in next
$ days (otal of 20 days). Contradictions to use of
Steroids include pregnancy, diabetes, hypertension,
Peptic ue, pulmonary tuberculosis and glaucoma,
Serius have been found sel to prevent incidence
‘of skins, crocodile tears and to shorten the eco
‘ry time offical paralysis. Steroids an be combined
‘nth acyclovir for Herpes zoster tieus or Bel pals.
+ Ole dns. Vasodltor, vita, mast cl bons
antiistaminics have not been found wet
48, pr pt eh de: (MA. Ci
Sano ply Bas Py
mebooksfree.com
qual frequency. Any age group may be affected though
Incidence ses with increasing age. A postive family his:
tory fs present in 6-8 of patients. Rsk of Bell palsy is
more in dobetis(angiopthy) and pregnant women ln
tention of ui)
1, Vita INHECHON. Most ofthe evidence supports the
ral atioogy due to herpes simplex, herpes zoster or the
Ftein-Bar Vins. Other cana eres may also be in
‘volved in Bell palsy which 1 thus considered part ol the
tou picture of polyneuropathy
2. VASCULAR ISCHAEMIA, It may be primary or second:
aay, Par ischacnia 5 induced by cold or emotional
Ses, Secondary chum the esto primary ce:
mia which causes increased capilar, permeability lead
{ng 10 exudation of Mud, oedema and compresion of
mic circulation ofthe nerve
5° Homer. The fallopian canal naro because of
retary predisposition and this males the nerve suscep
‘eto cary compression with the lightest osdema. Ten per
‘cent ofthe cases of Bll palsy havea post family history.
Automne Dinner. THymphocyte changes have
been observe
Canc Fearon (uns 147 vo 148 AB).
Srna ats niet de hs ye Oo
Berg die det gee am aloe
titan) Salts Gas hoe seo ma
Fae bat mente ey tow da fom de
eps) Pn say peo acompa
a mole
~ eg
Figure 14. ac pris e. Compare oem ie
(taped paralysis) or os of taste involvement of chor
da tympani. Paralysis may be complete or incomplete
pls is rcurret in 310% of patents
Dascosis. Diagnosis is always by exclusion.
other
‘known causes of perihera aia paralysis should be ex
clued. This requires careful
nd head
story, complete otoogical
nd neck examination, Xray studies, blood
tou count, peripherl smear, sedimentation
sugar and eto
‘Nerve excitability tests are done d
days and compared with the normal side to monitor
nerve degeneration.
Localling the site of lesion (topodiagnoss) helps in
‘stablishing he aetiology and as the ite of surgical de-
compression of neve, l that becomes necessary
uan
1 Reassurance
2: Relief of ear pain by analgesics
5. Care ofthe eye as outlined on p. 108. Eye must be pro
tected aginst exposure erat
4. Physiotherapy or massage ofthe facial muscles gives
Psychologen support to the patient. I has ot been
Shown to influence recovery. Active facial movements
fare encouraged when thete Is return o some move.
ment tothe facial muscles,
MEDICAL MANAGEMENT
+ Sois, Their ut has not been proved beyond
out in carefully controled studies. Prednsolone Is
the drug of choc patent reports shin 1 week,
the adult dose of prednisolone 1 mg/day divided
morning and evening doses for 3 days. Patients
seen om the filth day. If paralysis incomplee or
recovering doses tapered during the next S days. If
Paralysis remains complete, the same dose Is conti.
ted for another 10 das and thereafter tapered in next
$ days (otal of 20 days). Contradictions to use of
Steroids include pregnancy, diabetes, hypertension,
Peptic ue, pulmonary tuberculosis and glaucoma,
Serius have been found sel to prevent incidence
‘of skins, crocodile tears and to shorten the eco
‘ry time offical paralysis. Steroids an be combined
‘nth acyclovir for Herpes zoster tieus or Bel pals.
+ Ole dns. Vasodltor, vita, mast cl bons
antiistaminics have not been found wet
48, pr pt eh de: (MA. Ci
Sano ply Bas Py
mebooksfree.com
Chapter 14 — Facil Neve ands Diodes 105.
SURGICAL TREATMENT. Nerve decompression relieves
pressure on the nerveHbres and thus improve he micro:
‘culation o the nerve. Vertical and tympanic segments
Of nerve ate decompresid. Some workers have suggested
total decompression including laby inline segment by
Postural and middle fossa approach
Procxosıs. Eight to ninety per cent ofthe patients
recover fully. Ten to Alten per cent recover incomplete
ly and may be Let with some stigmata of degeneration,
Recurrent fal patsy may not recover Fal. Prognosis
good in incomplete Bal palsy (95% complete recovery)
And in those where clinical recovery starts within 3 weeks
‘tenet (75% complete recover)
2. Melkersson Syndrome
Tes lso an idiopathic disorder consisting of a tia of
facial paralysis, swelling of lips and fissured tongue, o:
ral may be recurrent, Treatments the sme as fo Bell
pay
+ Recurrent facial palsy Recurent facial palsy I seen
in Bel palsy (3-10% cass), Melkenson syndrome,
¿labees sarcoidosis and tumours. Recurent palsy on
the same side may be cused by tumour in 30% of
Bilateral facial paralysis. Simultancous Bilateral fa
‘al paralysis may be seen in Gullaintare syndrome,
Sarcoidosis sche cell disease, acute leukaemia, bulbar
ply, leprosy and some other systemic disorders,
B. INFECTIONS
Herpes Zoster Oticus (Ramsay-Hunt
Syndrome)
“There fach paras alongwith vesicular rash in the
There
external auditory canal and pinma (ise 19)
may also be anaesthesia of face, giddiness and
Impoiment due to involvement of Vth and V
‘rentment sh same as for Bl aly
Infections af Mie Bar ee p89)
‘Malignant Onis Extra ee p. 55)
2 mn
pe 438 gra ti te
a toa emergent ae nt
Soe pr ni pr
Sere et en D nr
a bes
rar ta
C. TRAUMA
1. Fractures of Temporal Bone
Fractures of temporal bone may be longitudinal, tans:
vero or mixed (res 14.10 ad 14.19. Facial pay ts
con more often in transverse fractures (SO), Pal
Sir fs due to intraneural haematoma, compression by à
‘bony spiele or transection of nerve. In these cases it
À important to know whether paralysis was of imme
te or delayed onset. Delayed onset parayss treated
<onservatvey like Bel palsy while immediate onset a:
{abyss may require surgery in the form of decompres
sion, reanastomosis of cut ends or cable nerve graft
bic 112)
mebooksfree.com
SURGICAL TREATMENT. Nerve decompression relieves
pressure on the nerveHbres and thus improve he micro:
‘culation o the nerve. Vertical and tympanic segments
Of nerve ate decompresid. Some workers have suggested
total decompression including laby inline segment by
Postural and middle fossa approach
Procxosıs. Eight to ninety per cent ofthe patients
recover fully. Ten to Alten per cent recover incomplete
ly and may be Let with some stigmata of degeneration,
Recurrent fal patsy may not recover Fal. Prognosis
good in incomplete Bal palsy (95% complete recovery)
And in those where clinical recovery starts within 3 weeks
‘tenet (75% complete recover)
2. Melkersson Syndrome
Tes lso an idiopathic disorder consisting of a tia of
facial paralysis, swelling of lips and fissured tongue, o:
ral may be recurrent, Treatments the sme as fo Bell
pay
+ Recurrent facial palsy Recurent facial palsy I seen
in Bel palsy (3-10% cass), Melkenson syndrome,
¿labees sarcoidosis and tumours. Recurent palsy on
the same side may be cused by tumour in 30% of
Bilateral facial paralysis. Simultancous Bilateral fa
‘al paralysis may be seen in Gullaintare syndrome,
Sarcoidosis sche cell disease, acute leukaemia, bulbar
ply, leprosy and some other systemic disorders,
B. INFECTIONS
Herpes Zoster Oticus (Ramsay-Hunt
Syndrome)
“There fach paras alongwith vesicular rash in the
There
external auditory canal and pinma (ise 19)
may also be anaesthesia of face, giddiness and
Impoiment due to involvement of Vth and V
‘rentment sh same as for Bl aly
Infections af Mie Bar ee p89)
‘Malignant Onis Extra ee p. 55)
2 mn
pe 438 gra ti te
a toa emergent ae nt
Soe pr ni pr
Sere et en D nr
a bes
rar ta
C. TRAUMA
1. Fractures of Temporal Bone
Fractures of temporal bone may be longitudinal, tans:
vero or mixed (res 14.10 ad 14.19. Facial pay ts
con more often in transverse fractures (SO), Pal
Sir fs due to intraneural haematoma, compression by à
‘bony spiele or transection of nerve. In these cases it
À important to know whether paralysis was of imme
te or delayed onset. Delayed onset parayss treated
<onservatvey like Bel palsy while immediate onset a:
{abyss may require surgery in the form of decompres
sion, reanastomosis of cut ends or cable nerve graft
bic 112)
mebooksfree.com
106 SECTION! — Diseases of ar
Figure YA. Long act lv temp! one ot te, 8) Ca hang te at Ene.) Frau sn aig I
= Mor ommon m) Les commen 20%)
eo
2. Ear or Mastoid Surgen (©) Anatomia none of the course of ail ner
un possible sains and anomalies and U sug
Enemy tympanoplasty Tandmark, Cadaver disctions should be an impor
tant pat of he raining in car sur
(© Constant iigaion when ding to avo
Jury. Ue diamond bure when working nea
tention ipa tothe followings
mebooksfree.com
Figure YA. Long act lv temp! one ot te, 8) Ca hang te at Ene.) Frau sn aig I
= Mor ommon m) Les commen 20%)
eo
2. Ear or Mastoid Surgen (©) Anatomia none of the course of ail ner
un possible sains and anomalies and U sug
Enemy tympanoplasty Tandmark, Cadaver disctions should be an impor
tant pat of he raining in car sur
(© Constant iigaion when ding to avo
Jury. Ue diamond bure when working nea
tention ipa tothe followings
mebooksfree.com
(@) Gentle handling of the nerve when it is exposed,
avoiding any pressure of instruments on the neve
(0 Nottoremoveany ranulationsthat penetrate the nerve.
9. Using magniheation; never 10 work on facial neve
without an operating microscope
3. Parotid Surgery and Trauma to Face
Facial nerve may be injured in surgery of parotid tumours
‘or deliberately che in malignant tumours. Accidetal
Injuries inthe parotid segon can aso cause fal para
ss Application of obstetrical forceps may also result in
facial paralysis inthe neonate due to pressure on
tratemporl par of nerve
D. NEOPLASMS
1. Intratemporal Neoplasms
Carcinoma of external or middle car
Done, all result in facial paralysis. Facial nerve neuroma
‘occurs anywhere along the couse of nerve and produces
Pali of gradual or sudden onset Te tected by ex
ion and nerve grating. Migh-eslution CT scan and
Fadolintam nan MRIs very wel fr facial nerve
2. Tumours of Parotid
Facil paralysis with tumour ofthe parti almost always
Amplis malignancy (ee Tumours of salivary sland).
E. SYSTEMIC DISEASES AND FACIAL
PARALYSIS
Peripheral cial paralysis most of idiopathic variety bt
always needs exclusion of diabetes, hypothyroid, leu:
colons, pertes nodos, Wegeners gran:
1, eprosy sys and demyelinating disease
LOCALIZATION OF FACIAL LESION
A. CENTRAL FACIAL PARALYSIS.
Is caused by cerebrovascular accidents (haemonage,
thromboss or embolism, tumour or an abscess. I causes
Paralysis of only the lower half of face onthe conta
al side. Forchead movements are rtincd due to bila.
«ral Innervation of frontal muscle. Involuntary emo.
tonal movements and the tone of facial muscle real
retained,
PERIPHERAL FACIAL PARALYSIS.
All the muscles of the ac onthe involved sde ae para
Iyze Patient i unable to rove, ose the ee, purse the
PA ion at he vel of mtn dete by associated
paras of ith nerve.
‘Meson at rte pre anges dente y the pres
ence of vestibular and audtory defects and involvement
other canal nerves such as Vb, Eth, At and XI
Asis ebony canal, omiten acoustic meatus
to Sylomasold foramen, can De localiza by topo
Chapter 14 — Facil Neve ants Disorders 107
Tae res (ee)
Sexo …
A]
Figure 14.12. Topographic cazan of the it ee eons.
(A Sagem or dame non Sertometor rest
einander tte gente angen on era
Im en stated apron to arca gegen.
asap oun causes tape ande pee
Ein. ape ens cause hs of tate at preserve
‘ipa at ae. 0) cd a ceo
[Esc py toy and Scion acia Neve
A eso outside e temporal bone, the prota arca,
tes only the motor functions of nerve I may some.
times be incomplete as some branches ofthe nerve may
‘ot be involved in tumour ov trauma
TOPODIAGNOSTIC TESTS FOR LESIONS IN
INTRATEMPORAL PART (FIGURE 14.12 (9),
‘The following test ar useful in finding the site of lesion
in partys lower motor neuron
compares lacimation ofthe two
rook in the Lower for
‘ofeach eye and the amount of wetting o stp measur
diate lesion proximal to the
fe secretomotor Aes to aim
‘land leave atthe geniculate ganglion via greater super:
al potros nerve
2. StareDIAL REFLEX. Stapedal ele ls os in lesions
above te nerve to taped. Is tested by tympanomety
3. Taste Test. It can be measured by a drop of salt
ot sugar solution placed on one side of the protruded
Tongue, or by lecrogustomete: Impairment o ate in
dice lesion above the chords pan
4, SumasonneLan SALIVARY Flow Tr. I lo messe
{es function of chorda tympan. Polythene tubes are
passed into both Wharton ducts and drops of saliva
‘Counted during one minute period. Decreased sation
Shows injury above the chords.
mebooksfree.com
avoiding any pressure of instruments on the neve
(0 Nottoremoveany ranulationsthat penetrate the nerve.
9. Using magniheation; never 10 work on facial neve
without an operating microscope
3. Parotid Surgery and Trauma to Face
Facial nerve may be injured in surgery of parotid tumours
‘or deliberately che in malignant tumours. Accidetal
Injuries inthe parotid segon can aso cause fal para
ss Application of obstetrical forceps may also result in
facial paralysis inthe neonate due to pressure on
tratemporl par of nerve
D. NEOPLASMS
1. Intratemporal Neoplasms
Carcinoma of external or middle car
Done, all result in facial paralysis. Facial nerve neuroma
‘occurs anywhere along the couse of nerve and produces
Pali of gradual or sudden onset Te tected by ex
ion and nerve grating. Migh-eslution CT scan and
Fadolintam nan MRIs very wel fr facial nerve
2. Tumours of Parotid
Facil paralysis with tumour ofthe parti almost always
Amplis malignancy (ee Tumours of salivary sland).
E. SYSTEMIC DISEASES AND FACIAL
PARALYSIS
Peripheral cial paralysis most of idiopathic variety bt
always needs exclusion of diabetes, hypothyroid, leu:
colons, pertes nodos, Wegeners gran:
1, eprosy sys and demyelinating disease
LOCALIZATION OF FACIAL LESION
A. CENTRAL FACIAL PARALYSIS.
Is caused by cerebrovascular accidents (haemonage,
thromboss or embolism, tumour or an abscess. I causes
Paralysis of only the lower half of face onthe conta
al side. Forchead movements are rtincd due to bila.
«ral Innervation of frontal muscle. Involuntary emo.
tonal movements and the tone of facial muscle real
retained,
PERIPHERAL FACIAL PARALYSIS.
All the muscles of the ac onthe involved sde ae para
Iyze Patient i unable to rove, ose the ee, purse the
PA ion at he vel of mtn dete by associated
paras of ith nerve.
‘Meson at rte pre anges dente y the pres
ence of vestibular and audtory defects and involvement
other canal nerves such as Vb, Eth, At and XI
Asis ebony canal, omiten acoustic meatus
to Sylomasold foramen, can De localiza by topo
Chapter 14 — Facil Neve ants Disorders 107
Tae res (ee)
Sexo …
A]
Figure 14.12. Topographic cazan of the it ee eons.
(A Sagem or dame non Sertometor rest
einander tte gente angen on era
Im en stated apron to arca gegen.
asap oun causes tape ande pee
Ein. ape ens cause hs of tate at preserve
‘ipa at ae. 0) cd a ceo
[Esc py toy and Scion acia Neve
A eso outside e temporal bone, the prota arca,
tes only the motor functions of nerve I may some.
times be incomplete as some branches ofthe nerve may
‘ot be involved in tumour ov trauma
TOPODIAGNOSTIC TESTS FOR LESIONS IN
INTRATEMPORAL PART (FIGURE 14.12 (9),
‘The following test ar useful in finding the site of lesion
in partys lower motor neuron
compares lacimation ofthe two
rook in the Lower for
‘ofeach eye and the amount of wetting o stp measur
diate lesion proximal to the
fe secretomotor Aes to aim
‘land leave atthe geniculate ganglion via greater super:
al potros nerve
2. StareDIAL REFLEX. Stapedal ele ls os in lesions
above te nerve to taped. Is tested by tympanomety
3. Taste Test. It can be measured by a drop of salt
ot sugar solution placed on one side of the protruded
Tongue, or by lecrogustomete: Impairment o ate in
dice lesion above the chords pan
4, SumasonneLan SALIVARY Flow Tr. I lo messe
{es function of chorda tympan. Polythene tubes are
passed into both Wharton ducts and drops of saliva
‘Counted during one minute period. Decreased sation
Shows injury above the chords.
mebooksfree.com
108 SECTIONI — Diseases ofr
‘COMPLICATIONS FOLLOWING FACIAL
PARALYSIS.
Peripheral facial paralysis due to any cause may e
any ofthe following complications
tin
1. INOOUPLETE Recoveny, Facial asymmetry persists
By cannot be closed resulting in epiphora. A weak on
2. EXPOSURE KERATITIS. Eye cannot be closed, tar film
from the comes evaporates causing deynes, exposure
erat and come ulcer. This Is worse when teat pro
duction also affected. can be prevent by use of a
cal tar (meihyllulone drop) every 1-2 eye ont
ment and proper cover forthe eye at night
Temporary trsorhaphy may also be indicated Eye
closure can also be improved by using goldeveight im
Pant sutured to the tarsal plate deep 10 levator palpebeae
3. SYMKIMIS (Mass MovEMENT). When the patient
vists to close the eye come of mouth aso tithes or
‘ice versa. kis due cross inneration of res 4
4 Ties AND Srasus. They ar the result of faulty ee
‘ation of es. Involuntary movements ae sten on the
Siete side ofthe face
5. Conrmacrunts. They result fom oss of atrophicd
muscles or fixed contraction ofa group of muscles, They
lect movement of face but facial symmetry at et
good.
6. Crocon Teans (Gustarony Lacamaariov). There
is unilateral lacrimation with mastication This due to
faulty regeneration of parasympathetic bres which now
supply serial gland instead othe salivary glands I
fan be treated by section of greater Super petrosal
ere or fmpanicneortton
7. Fuav's Svwmon (Gustatony SWEMTING). Mer is
‘seating and shin of skin over the prota area during
mastication, It results from porotd surgery
8. PSYCHOLOGICAL AND SOCIAL PROBLEMS. Drooling
‘uring cating and drinking and impairment of speech
‘ase social problems.
HYPERKINETIC DISORDERS.
(OF FACIAL NERVE
They are characterized by involuntary twitching of facial
1. Mexaracını Spass. Ie characterized by repeated
controlable twitchings of cl muscles on one side
(igure 115} Ts of two types) essential o opi
Figure 14.12 Hen pm. Note the al mus and
lama ts uum Petre te doing pata oc an
"amo Many cas of heal spam are due ots
tion ofthe ners Bese of vascular loop the ee
Iopontin ange. Miroancular decompression tough
error fon craniotomy has met with high aces at
tive section ofthe branche offal neve the pt
by puncturing the faa nerve with net sym
tai toxin hasbeen used nthe fected mus.
te blocks the neuromuscular junction by preventing te
ike of acticin.
2. BLErmaKosPAsM. Titehings and spasms are limited
{6 orbicuars ocul muscles on both sides. The eyes ae
¿osed due to muscle spasms causing functional blind
ss. The causo fuera, but probably Hsin the basal
anglais treated by selective section o nerves supply
{ng muscles around the eye on both des.
Botulinum toxin Injected nto the perorital mus
les ies rele for 3-6 months. Injection an De repeated,
mecs
SURGERY OF FACIAL NERVE
1. DECOMPRESSION, The nerve may be compresed by
‘Sema hacmatoma or à facture bone in is Inratem
poral pat. The bony canal is exposed and uncappad. The
Sheath of nerve alo sit o eleve presure dueto sde:
ma or intrancural haematoma,
2. END-TO-END Anssrowosis, This Is done when the
fap between severed end ofthe nerves Is only a fee mil
metres It i stable procede or extratemporal part
‘of the nerve There should not be any tension inthe ap
Proximated ends.
mebooksfree.com
‘COMPLICATIONS FOLLOWING FACIAL
PARALYSIS.
Peripheral facial paralysis due to any cause may e
any ofthe following complications
tin
1. INOOUPLETE Recoveny, Facial asymmetry persists
By cannot be closed resulting in epiphora. A weak on
2. EXPOSURE KERATITIS. Eye cannot be closed, tar film
from the comes evaporates causing deynes, exposure
erat and come ulcer. This Is worse when teat pro
duction also affected. can be prevent by use of a
cal tar (meihyllulone drop) every 1-2 eye ont
ment and proper cover forthe eye at night
Temporary trsorhaphy may also be indicated Eye
closure can also be improved by using goldeveight im
Pant sutured to the tarsal plate deep 10 levator palpebeae
3. SYMKIMIS (Mass MovEMENT). When the patient
vists to close the eye come of mouth aso tithes or
‘ice versa. kis due cross inneration of res 4
4 Ties AND Srasus. They ar the result of faulty ee
‘ation of es. Involuntary movements ae sten on the
Siete side ofthe face
5. Conrmacrunts. They result fom oss of atrophicd
muscles or fixed contraction ofa group of muscles, They
lect movement of face but facial symmetry at et
good.
6. Crocon Teans (Gustarony Lacamaariov). There
is unilateral lacrimation with mastication This due to
faulty regeneration of parasympathetic bres which now
supply serial gland instead othe salivary glands I
fan be treated by section of greater Super petrosal
ere or fmpanicneortton
7. Fuav's Svwmon (Gustatony SWEMTING). Mer is
‘seating and shin of skin over the prota area during
mastication, It results from porotd surgery
8. PSYCHOLOGICAL AND SOCIAL PROBLEMS. Drooling
‘uring cating and drinking and impairment of speech
‘ase social problems.
HYPERKINETIC DISORDERS.
(OF FACIAL NERVE
They are characterized by involuntary twitching of facial
1. Mexaracını Spass. Ie characterized by repeated
controlable twitchings of cl muscles on one side
(igure 115} Ts of two types) essential o opi
Figure 14.12 Hen pm. Note the al mus and
lama ts uum Petre te doing pata oc an
"amo Many cas of heal spam are due ots
tion ofthe ners Bese of vascular loop the ee
Iopontin ange. Miroancular decompression tough
error fon craniotomy has met with high aces at
tive section ofthe branche offal neve the pt
by puncturing the faa nerve with net sym
tai toxin hasbeen used nthe fected mus.
te blocks the neuromuscular junction by preventing te
ike of acticin.
2. BLErmaKosPAsM. Titehings and spasms are limited
{6 orbicuars ocul muscles on both sides. The eyes ae
¿osed due to muscle spasms causing functional blind
ss. The causo fuera, but probably Hsin the basal
anglais treated by selective section o nerves supply
{ng muscles around the eye on both des.
Botulinum toxin Injected nto the perorital mus
les ies rele for 3-6 months. Injection an De repeated,
mecs
SURGERY OF FACIAL NERVE
1. DECOMPRESSION, The nerve may be compresed by
‘Sema hacmatoma or à facture bone in is Inratem
poral pat. The bony canal is exposed and uncappad. The
Sheath of nerve alo sit o eleve presure dueto sde:
ma or intrancural haematoma,
2. END-TO-END Anssrowosis, This Is done when the
fap between severed end ofthe nerves Is only a fee mil
metres It i stable procede or extratemporal part
‘of the nerve There should not be any tension inthe ap
Proximated ends.
mebooksfree.com
3. Nenn Gran (CanLE GRAF). When th
‘Severed ends cannot be dosed by endtovend anastomo-
sis, à mere grafts more suitable than extensive terut-
ing or mobilization of nerve. Nerve grat ls taken frm
greater auricular, lateral cutaneous nerve of thigh or the
Srl nerve In the bony Canal, the graft may not require
any string,
4. HypocLossM-FAciat, ANASFOMOSI Hypoglessal
nerves anastomoncd o the severed peipherl end of the
Facial nerveItimprovesthe muscle tone and permitssome
Chapter 14 — Facil Neve ants Diodes 1097
‘movements of facial muscles, ut at the expense of aro-
‘hy of tongue on that sige However, dia of tongue
‘ue to atrophy Is not so severe ad patent ast o the
‘ically im chewing and articulation lor fee weeks
5. PLASTIC PRoctDURES. They ar usd to improve cos
‘elle appearance when nerve galting Is not feasble or
has file, The procedures include facial slings, face Ut
‘operation or slings of masseter and temporal muscle
‘The later also gies some movement 0 face in addition
tosymmety.
mebooksfree.com
‘Severed ends cannot be dosed by endtovend anastomo-
sis, à mere grafts more suitable than extensive terut-
ing or mobilization of nerve. Nerve grat ls taken frm
greater auricular, lateral cutaneous nerve of thigh or the
Srl nerve In the bony Canal, the graft may not require
any string,
4. HypocLossM-FAciat, ANASFOMOSI Hypoglessal
nerves anastomoncd o the severed peipherl end of the
Facial nerveItimprovesthe muscle tone and permitssome
Chapter 14 — Facil Neve ants Diodes 1097
‘movements of facial muscles, ut at the expense of aro-
‘hy of tongue on that sige However, dia of tongue
‘ue to atrophy Is not so severe ad patent ast o the
‘ically im chewing and articulation lor fee weeks
5. PLASTIC PRoctDURES. They ar usd to improve cos
‘elle appearance when nerve galting Is not feasble or
has file, The procedures include facial slings, face Ut
‘operation or slings of masseter and temporal muscle
‘The later also gies some movement 0 face in addition
tosymmety.
mebooksfree.com
Page ot intentional blank
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Chapter 15
Méniere's Disease
Ménièes disease, ls calle endalmphate Ios, à
‘lsrder of the inner car where the endolymphatic ss
tem i disended with endolymph, I s characterized by
{vertigo sensorineural hearing loss, il) nits and
{i Surat fliese
PATHOLOGY
‘The main pathology ls distension of endolymphatic sys
tem, mainly affecting the cochlear duct (sala med)
And ie sccule, and to à ler extent the utile and
Semiclrular canals. The dilatation of cochlear duct Is
Such that it may completely fil the scala vestibul there
Is marked bulging of Resners membrane, which may
‘even hernite through the heictrema into the apio
pe of Scala tympani (iss 151). The distended sac-
ule may come to le against the Sapos footplate. The
ice and sacule may show outpovehings Into the
AETIOLOGY
“The main pathology in Meinl‘ disease is distension of
endolymphatic system due to increased volume of endo
Iymph. Tis can rest either kom increased producto
‘of endalymph oes faulty absorption or both, Normal
fendolymph Is secreted by sra vascular, Als the mem
ranous labyrinths an i absorbed through the endalym.
pati sac ep. 11 lr inner ear But).
"The exact cause of Meniere's disease not yet known,
Various theories have been postulated (Figure 152)
1. Dennis Ansoneriox sy Esporssrnaric Sac.
Normal, eadolymph 1 carried by the endolymphatic
‘duct tothe sac where tf absorbed. elective absorp
tion by the sa may be responsible for ad endolympl
pressure. Experimental obstruction of endolymphatic se
And ls dct aso produces hydrops. Schema o sc has
‘been observed in cases of Meniere's disease undergoing
ue indicating poor vascularty and thus poor ab.
Sorption by the sc. Distension of membranous aby
leads to rupture of Reise? membrane and thus ising
perl with endolymp, which s thought to bin
bout an attack of vertigo
2. VASOMOOR DISTURBANCE. There issympatheticover:
acti resulting in spasm of internal auditory artery and)
rs branches, thus interfering with the funcion of coch
cr or vestibular sensory neurocpthelum. This respon
sible for deafness and vertigo. Anoxaof capillaries of sia
"Vascular also causes increased permeability, with tans
‘ation of uid and increased reduction of endolymph
3. AULERGY. The offending alergen may be a foodstlt
oran inhalt. In these cases, mr ar acts asthe "shock
Organ“ producing excess of endotymph Nery SO of
patent with Minires disease have concomitant Ina.
sndfor food ales
Wis possible that Ménères disease ls multifactorial,
resulting the common end point of endolymphatic hy:
drops with classe presentation.
4, Sons AND Waren REtENTION. Excesive amounts
(ofl are retained leading to endolymphatic hydrops.
5. Hvromvmonisu. About 3% of caes of Minis
diese are due to hypothyroidism. Such cases bent
From thyroid replacement therapy.
6. AUTOIMMUNI AND VIRAL AETIOLOGIES have also been
Suggested on the bass of Experimental, laboratory and
al observations
CLINICAL FEATURES
Age and sex. Disease 1 commonIy sen in the age group of
38-60 years. Males ar affected more than females. Ust
lly disse is unilateral but the other car maybe afte
itera few yeas.
‘Cardinal symptoms of Ménières disease ae (1) episode
vertigo, (i) uctuating hearing os, i) Unnitus and (iv)
Sense 0 lines or pressure in the involve ae
1. Vero comes in attacks, Te onset Is sudden Po
Alen gets Kling of rotation of hielt or his enon
ment sometimes, there Is fing of 10 and fro or "up
And down” movement, Attacks come in sten, wi
"os of spontaneous remission lating for weeks, months
‘or ear Cal an attack accompanied by naunc and
‘vomiting with ataxia and nystagmus. Severe attacks may
e accompanie by other symptoms of vagal disturbances
Sch a abdominal cramps rrhoc, cold seat, pallor
and bradycardia. Usually, her sno warning symptom of
‘oncoming atack of vertigo but sometimes the patient
‘may fee sense o fllness in the ar, change in character
‘of tinnitus or discomfort in the ear wich era an attack.
Some cases of Meni’ disease show Talo meno.
Iris condition where loud sounds or nos product ve.
tigo and is due tothe distended Sacos ing gains the
tapes eotpate. This phenomenon abo sn when there
ar tree functioning windows in the ea, eg. fenesta
tion of horizontal ana inthe presence ofa mabe stapes,
2. Marino Loss. I usualy accompanies vertigo or may
recede it Hearing improves ater the attack and may be
mebooksfree.com
Méniere's Disease
Ménièes disease, ls calle endalmphate Ios, à
‘lsrder of the inner car where the endolymphatic ss
tem i disended with endolymph, I s characterized by
{vertigo sensorineural hearing loss, il) nits and
{i Surat fliese
PATHOLOGY
‘The main pathology ls distension of endolymphatic sys
tem, mainly affecting the cochlear duct (sala med)
And ie sccule, and to à ler extent the utile and
Semiclrular canals. The dilatation of cochlear duct Is
Such that it may completely fil the scala vestibul there
Is marked bulging of Resners membrane, which may
‘even hernite through the heictrema into the apio
pe of Scala tympani (iss 151). The distended sac-
ule may come to le against the Sapos footplate. The
ice and sacule may show outpovehings Into the
AETIOLOGY
“The main pathology in Meinl‘ disease is distension of
endolymphatic system due to increased volume of endo
Iymph. Tis can rest either kom increased producto
‘of endalymph oes faulty absorption or both, Normal
fendolymph Is secreted by sra vascular, Als the mem
ranous labyrinths an i absorbed through the endalym.
pati sac ep. 11 lr inner ear But).
"The exact cause of Meniere's disease not yet known,
Various theories have been postulated (Figure 152)
1. Dennis Ansoneriox sy Esporssrnaric Sac.
Normal, eadolymph 1 carried by the endolymphatic
‘duct tothe sac where tf absorbed. elective absorp
tion by the sa may be responsible for ad endolympl
pressure. Experimental obstruction of endolymphatic se
And ls dct aso produces hydrops. Schema o sc has
‘been observed in cases of Meniere's disease undergoing
ue indicating poor vascularty and thus poor ab.
Sorption by the sc. Distension of membranous aby
leads to rupture of Reise? membrane and thus ising
perl with endolymp, which s thought to bin
bout an attack of vertigo
2. VASOMOOR DISTURBANCE. There issympatheticover:
acti resulting in spasm of internal auditory artery and)
rs branches, thus interfering with the funcion of coch
cr or vestibular sensory neurocpthelum. This respon
sible for deafness and vertigo. Anoxaof capillaries of sia
"Vascular also causes increased permeability, with tans
‘ation of uid and increased reduction of endolymph
3. AULERGY. The offending alergen may be a foodstlt
oran inhalt. In these cases, mr ar acts asthe "shock
Organ“ producing excess of endotymph Nery SO of
patent with Minires disease have concomitant Ina.
sndfor food ales
Wis possible that Ménères disease ls multifactorial,
resulting the common end point of endolymphatic hy:
drops with classe presentation.
4, Sons AND Waren REtENTION. Excesive amounts
(ofl are retained leading to endolymphatic hydrops.
5. Hvromvmonisu. About 3% of caes of Minis
diese are due to hypothyroidism. Such cases bent
From thyroid replacement therapy.
6. AUTOIMMUNI AND VIRAL AETIOLOGIES have also been
Suggested on the bass of Experimental, laboratory and
al observations
CLINICAL FEATURES
Age and sex. Disease 1 commonIy sen in the age group of
38-60 years. Males ar affected more than females. Ust
lly disse is unilateral but the other car maybe afte
itera few yeas.
‘Cardinal symptoms of Ménières disease ae (1) episode
vertigo, (i) uctuating hearing os, i) Unnitus and (iv)
Sense 0 lines or pressure in the involve ae
1. Vero comes in attacks, Te onset Is sudden Po
Alen gets Kling of rotation of hielt or his enon
ment sometimes, there Is fing of 10 and fro or "up
And down” movement, Attacks come in sten, wi
"os of spontaneous remission lating for weeks, months
‘or ear Cal an attack accompanied by naunc and
‘vomiting with ataxia and nystagmus. Severe attacks may
e accompanie by other symptoms of vagal disturbances
Sch a abdominal cramps rrhoc, cold seat, pallor
and bradycardia. Usually, her sno warning symptom of
‘oncoming atack of vertigo but sometimes the patient
‘may fee sense o fllness in the ar, change in character
‘of tinnitus or discomfort in the ear wich era an attack.
Some cases of Meni’ disease show Talo meno.
Iris condition where loud sounds or nos product ve.
tigo and is due tothe distended Sacos ing gains the
tapes eotpate. This phenomenon abo sn when there
ar tree functioning windows in the ea, eg. fenesta
tion of horizontal ana inthe presence ofa mabe stapes,
2. Marino Loss. I usualy accompanies vertigo or may
recede it Hearing improves ater the attack and may be
mebooksfree.com
112 sections —
Diseases of far
Figure 15.1. (9) Nema cote ct (1) Coca dut dene wth end ung te Reiners ran int sala veia
o AE me
raring oes
meno |— init
[Sy
Tm
un
Stans ase. ur oe
Sho Endara
imposi)
Figure 15.2. Alí cos and spomataoay of Mies
‘Seas (eds op),
ing the periods of remission. This uctuating
ct of the disease,
‘Wath ccutent attacks, Improvement in heating during
emision may not be complete: some hearing los being
Added in every attack leading 0 slow and progressive de
{eriortion of hearing which permane
+ Distortion of sound. Some patients complain of distor.
fx hearing” A tone ofa particular Kequeney may ap.
fear normal none cara of higher pte in the other
Ending to plans Musi pets discordant.
+ Dune told suns, Paten of Ménères dsc
cannot tolerate amplification ofsound dueto erultment
[henomenon. They ae poor candidate for having al.
3. TINNITUS, It Is low: pitched roaring type and ls ag
rave during acute attacks, Sometimes, thas hiss
Ing character. I may persist during periods of remision,
Change in intensity and pitch of tinnitus may be the
warning symptom of attack
4. SENSE OF FULLNESS OR PRESSURE. Like other symp:
toms, also Nuctates. I may accompany or presede a
attack of vertigo.
5. Oren FESTURES. Patents of Ménièrés disease often
show signs of emotional upset due to apprehension of
{the repetition of attacks. alle, the emotional Srs was.
‘considered 10 be the eae of Mena’ dise,
EXAMINATION
1. Oroscory. No abnormality is seen in 4
membrane.
J tympanic
2, NYSIAGMUS. Iti seen only during acute attack, The
ick component of nystagmus is towards the una
3. Tuan Fons Tests. They indicate sensorineural ar
ingles Rinne tests positive absolute bone conduction is
reduced in the afta ea and Wee tra 10 Ihe
beter eae
INVESTIGATIONS.
1. PURA TONE AupiowETRY. Theres semsorincural hear
ingles nearly tages, lover frequencies are fete and
the curve is of sing type. When higher fequencies are
Involved cure becomes Hat ora falling types 15
me nan
® A
E
ii J
E
1
Figure 153. (3) Au in cry Mes dense Nate Her.
Bitar ndice end mor lo Regence tn
fave the das progres middle aná higher Fey a.
‘hed and sam becomes tora pe 6 0
mebooksfree.com
Diseases of far
Figure 15.1. (9) Nema cote ct (1) Coca dut dene wth end ung te Reiners ran int sala veia
o AE me
raring oes
meno |— init
[Sy
Tm
un
Stans ase. ur oe
Sho Endara
imposi)
Figure 15.2. Alí cos and spomataoay of Mies
‘Seas (eds op),
ing the periods of remission. This uctuating
ct of the disease,
‘Wath ccutent attacks, Improvement in heating during
emision may not be complete: some hearing los being
Added in every attack leading 0 slow and progressive de
{eriortion of hearing which permane
+ Distortion of sound. Some patients complain of distor.
fx hearing” A tone ofa particular Kequeney may ap.
fear normal none cara of higher pte in the other
Ending to plans Musi pets discordant.
+ Dune told suns, Paten of Ménères dsc
cannot tolerate amplification ofsound dueto erultment
[henomenon. They ae poor candidate for having al.
3. TINNITUS, It Is low: pitched roaring type and ls ag
rave during acute attacks, Sometimes, thas hiss
Ing character. I may persist during periods of remision,
Change in intensity and pitch of tinnitus may be the
warning symptom of attack
4. SENSE OF FULLNESS OR PRESSURE. Like other symp:
toms, also Nuctates. I may accompany or presede a
attack of vertigo.
5. Oren FESTURES. Patents of Ménièrés disease often
show signs of emotional upset due to apprehension of
{the repetition of attacks. alle, the emotional Srs was.
‘considered 10 be the eae of Mena’ dise,
EXAMINATION
1. Oroscory. No abnormality is seen in 4
membrane.
J tympanic
2, NYSIAGMUS. Iti seen only during acute attack, The
ick component of nystagmus is towards the una
3. Tuan Fons Tests. They indicate sensorineural ar
ingles Rinne tests positive absolute bone conduction is
reduced in the afta ea and Wee tra 10 Ihe
beter eae
INVESTIGATIONS.
1. PURA TONE AupiowETRY. Theres semsorincural hear
ingles nearly tages, lover frequencies are fete and
the curve is of sing type. When higher fequencies are
Involved cure becomes Hat ora falling types 15
me nan
® A
E
ii J
E
1
Figure 153. (3) Au in cry Mes dense Nate Her.
Bitar ndice end mor lo Regence tn
fave the das progres middle aná higher Fey a.
‘hed and sam becomes tora pe 6 0
mebooksfree.com
Chapter 15 — Ménitee’sDiease 113
re tne son Nowa Senotnesaleing os Serine Reng
cenar 961008 Pet ey por
Aiton pico Rent ‘ve Pla
Than ect 150 Less ds Rome 2568
parte Rom Smt om
pate dey ue 07) Vo ev
A trate stes pense som
2. Sra AuDIoMETRY. Discrimination score is usually
55-899 between the attacks but Userimination asi
much Impaled during and immediately following an at
tack
3. SPECIAL AUDIOMETAY ss. They indicate the
‘cochlear nature of disease and thus help to different.
te trom retrocochleas lesions, eg, acoustic neuroma
ble 15.D.
(2) Recmdient ets postive
19) SIS rt increment sent inde) tes. IS score is
iter than 70% in wo-thnds of the patents (normal
15%.
10 Tone decay ts. Normally, there
ET
dec of ess tha
A. ELECIROCOCHLEGGRAPAY: It shows changes diagnos:
cot Méntre disease. Normally rato of summating po:
tential (SP) to ation potential (AP) i 307%. In Ménibres
disease, SPA ratios eater than 30% Figure 15.2.
Sami
Den
Figure 15.4. Bcvocchieogaph. (A) Normal x. (ar with Me
re dea Vlogs peter (Scored win
alain pt Nom 730% a mo à
malito! even ave AV Mane eye or bent
5. Catomte TIS. I shows reduced response on the af
{ete sde in 7506 Of eases, Often, teves à Canal pac
‘esis on the afected sie (most common) but sometimes
there i ltcetional preponderance to healthy Side or a
‘combination of both canal paress on the affected side
And direction preponderante onthe opposite sie.
6. Giscnnon Test. Glycerol is a dehydrating agent
When given oral, it reduces endotymph pressure and
thus causes an improvement in esting
Patent is given glycerol (LS mL/kg) with an equal
amount of water and a Ile favouring agent or lemon
juice. Audiogram and speech discrimination scores are
recorded bere and 1-2 after ingestion of glycerol. An
Improvement of 10 dB in two or more adjacent octaves
‘or in of 10% in discrimination score makes the tot
postive. There ls also improvement in tines and in the
Sense of fullness in the ar The ss has a agnostic and
‘prognostic value. These days, glycerol tot is combined
Ni lectrocochleograph:
VARIANTS OF MENIERE’S DISEASE
1. Cocnusan Hypnors. Here, only the cochlear symp
ms and signs ot Meniere's disease ae presen. Vertigo Is
absent tis only after several yeas that vertigo will make
Its appearance Te is believed that in these cases, there Is
block atthe level of ducts reunins, thereby confining
the increased endolymph pressure to the coche only
Gare 189)
2. Vestimutan Hypnos Patient gts typical attacks of
“episodic vertigo while cochlear functions remain normal
iis only with time that y
>
ven are
Figure 15.5. ft membranous ye
mebooksfree.com
re tne son Nowa Senotnesaleing os Serine Reng
cenar 961008 Pet ey por
Aiton pico Rent ‘ve Pla
Than ect 150 Less ds Rome 2568
parte Rom Smt om
pate dey ue 07) Vo ev
A trate stes pense som
2. Sra AuDIoMETRY. Discrimination score is usually
55-899 between the attacks but Userimination asi
much Impaled during and immediately following an at
tack
3. SPECIAL AUDIOMETAY ss. They indicate the
‘cochlear nature of disease and thus help to different.
te trom retrocochleas lesions, eg, acoustic neuroma
ble 15.D.
(2) Recmdient ets postive
19) SIS rt increment sent inde) tes. IS score is
iter than 70% in wo-thnds of the patents (normal
15%.
10 Tone decay ts. Normally, there
ET
dec of ess tha
A. ELECIROCOCHLEGGRAPAY: It shows changes diagnos:
cot Méntre disease. Normally rato of summating po:
tential (SP) to ation potential (AP) i 307%. In Ménibres
disease, SPA ratios eater than 30% Figure 15.2.
Sami
Den
Figure 15.4. Bcvocchieogaph. (A) Normal x. (ar with Me
re dea Vlogs peter (Scored win
alain pt Nom 730% a mo à
malito! even ave AV Mane eye or bent
5. Catomte TIS. I shows reduced response on the af
{ete sde in 7506 Of eases, Often, teves à Canal pac
‘esis on the afected sie (most common) but sometimes
there i ltcetional preponderance to healthy Side or a
‘combination of both canal paress on the affected side
And direction preponderante onthe opposite sie.
6. Giscnnon Test. Glycerol is a dehydrating agent
When given oral, it reduces endotymph pressure and
thus causes an improvement in esting
Patent is given glycerol (LS mL/kg) with an equal
amount of water and a Ile favouring agent or lemon
juice. Audiogram and speech discrimination scores are
recorded bere and 1-2 after ingestion of glycerol. An
Improvement of 10 dB in two or more adjacent octaves
‘or in of 10% in discrimination score makes the tot
postive. There ls also improvement in tines and in the
Sense of fullness in the ar The ss has a agnostic and
‘prognostic value. These days, glycerol tot is combined
Ni lectrocochleograph:
VARIANTS OF MENIERE’S DISEASE
1. Cocnusan Hypnors. Here, only the cochlear symp
ms and signs ot Meniere's disease ae presen. Vertigo Is
absent tis only after several yeas that vertigo will make
Its appearance Te is believed that in these cases, there Is
block atthe level of ducts reunins, thereby confining
the increased endolymph pressure to the coche only
Gare 189)
2. Vestimutan Hypnos Patient gts typical attacks of
“episodic vertigo while cochlear functions remain normal
iis only with time that y
>
ven are
Figure 15.5. ft membranous ye
mebooksfree.com
114 SECTION! — Diseases of ar
ice wil develop. Many of the cases of vestibular ME-
lees disease ae labelled “recurrent vestbulopathy” as
endolymphatic hydrops could not be demonstrated In
the study of temporal one in such case
3. Dior ATTACKS (TOMARKIN'S OroLETINE CRIS). In
ths, there a sudden drop attack without loss of con.
Seiousness. There ino vertigo oF fluctuations in hearing
Joss Patent gets à tin of having been pushed to the
‘round or poleaxed. Is an uncommon maniestation
Sf Ménitres disease and occurs either In the early o ate
our of disease. Possible mechanism Is deformation of
the otolithec membrane of he utile or saute due to
‘changes in the endolymphatic pressure
4. LERMOYEZ SYNDROME, Here symptoms of Ménières
seas ae seen in reverse oder Fst thee progressive
‘eteriration of hearing followed by an attack Of vorige,
St which time te eating recovers
MÉNIERE'S DISEASE VS MENIERE’S
‘SYNDROME
Ménidres disease ls an idiopathic condition while Mé-
lees syndrome, though resembling Ménières disease
‘lintel (episodic vertigo, Nuctatin hearing los in
‘its and car fullness), resul om à variety’ f condi
tions such as trauma (head injury or ear surgery), vial
Infections dollowing measles or mumps) phils con:
genial o late acquit), Cogas syndrome otosclerosis
toimmune disorders. Its also called secondary ME.
DIAGNOSIS OF MENIERE’S DISEASE
Committee on Heating and Equilibrium ofthe American
Academy of Otolaryngology—Head and Neck Surgery
(AAOHNS) classed the diagnosis of Menke’ disease as
follows:
1. Certain. Definite Ménères disease confirmed by
Histopathology.
2. Definite, Two or more definitive spontaneous episodes
of vertigo lasting 20 min or longer
(a) Audiometacally documented hearing loss on at
feast one ocasion
or aural flies in the affected ea,
rer eases excluded.
(0) Audiomewicaliy doc
(©) Tinnitus or aura alles inthe treated car.
(0 Other causes exclude
4, Possible
(a) Fpisodic vertigo of Ménières type without docu:
stented hearing los (vestibular varian oF
(0) Sensorineual heating los, Muetuaing or fixe,
‘with disequilibrium but without dehnitive ep
des (cocher varian
(©) Other causes exclude
Stage Pure tone average in in previous months,
1 as
ES
STAGING OF MENIERE’S DISEASE
‘This can be done in certain and definite cases of Ménières
ise eis bad on the average of pure tone thresholds
310.8, 1, 2 and $ kl round 10 the nearest whole of
{the wostaudiogtam during period of 6 months before
treatment ee ble 12)
‘TREATMENT
A. GENERAL MEASURES
1. Reassurance. Patient ansety can be eelieved by reos
surance and by explaining the rue nature of disease. This
‘particulary important in acute attack,
2. Cessation of smoking. Nicotine causes vasospasm,
Smoking should be completely stopped. For some par
fens, this may be the only treatment necessary
3. Low salt dit. Patient should take sat re dict as far
3 ponte No extra sat should be permite Sal take
Should not exceed 1.520 py.
4. Avoid excesive intake of watt,
5. Avoid oxerindulgence in cote, tea and alcohol.
6. Avoid stress and bring a change in style. Mental
‘elation exercises and yoga are helpful todecrase stress,
7. Avoid activities requiring good body balance. As the
attack of Ménière disease fs abrupt, sometimes with no
‘warsing symptom, profesions such as Jing, underwater
“ving or working at great heights should be avoided
MANAGEMENT OF ACUTE ATTACK
Dring the acute attack, theres severe vertigo with nasa
and vomiting. Patient is apprehensive. Head movements
[provoke giddiness. TMercore treatment would consst of
1. Reassurance and psychological support tally worry
and anxiety
2, ed et ih ad supped on plows 1 preven
3. Intravenous fuids and clectrolyte administration
combat tel loss ducto vom
4, Vestibular sedatives to eleve vertigo, Mey should be
siministered intramuscularly or intavenously I vomit-
ing precludes orl administration. Drugs sel in acute
attack are dimenhydrinate Dramamine), promethazine
Acocate (Avomine) or prochlorperazine (eme.
mebooksfree.com
ice wil develop. Many of the cases of vestibular ME-
lees disease ae labelled “recurrent vestbulopathy” as
endolymphatic hydrops could not be demonstrated In
the study of temporal one in such case
3. Dior ATTACKS (TOMARKIN'S OroLETINE CRIS). In
ths, there a sudden drop attack without loss of con.
Seiousness. There ino vertigo oF fluctuations in hearing
Joss Patent gets à tin of having been pushed to the
‘round or poleaxed. Is an uncommon maniestation
Sf Ménitres disease and occurs either In the early o ate
our of disease. Possible mechanism Is deformation of
the otolithec membrane of he utile or saute due to
‘changes in the endolymphatic pressure
4. LERMOYEZ SYNDROME, Here symptoms of Ménières
seas ae seen in reverse oder Fst thee progressive
‘eteriration of hearing followed by an attack Of vorige,
St which time te eating recovers
MÉNIERE'S DISEASE VS MENIERE’S
‘SYNDROME
Ménidres disease ls an idiopathic condition while Mé-
lees syndrome, though resembling Ménières disease
‘lintel (episodic vertigo, Nuctatin hearing los in
‘its and car fullness), resul om à variety’ f condi
tions such as trauma (head injury or ear surgery), vial
Infections dollowing measles or mumps) phils con:
genial o late acquit), Cogas syndrome otosclerosis
toimmune disorders. Its also called secondary ME.
DIAGNOSIS OF MENIERE’S DISEASE
Committee on Heating and Equilibrium ofthe American
Academy of Otolaryngology—Head and Neck Surgery
(AAOHNS) classed the diagnosis of Menke’ disease as
follows:
1. Certain. Definite Ménères disease confirmed by
Histopathology.
2. Definite, Two or more definitive spontaneous episodes
of vertigo lasting 20 min or longer
(a) Audiometacally documented hearing loss on at
feast one ocasion
or aural flies in the affected ea,
rer eases excluded.
(0) Audiomewicaliy doc
(©) Tinnitus or aura alles inthe treated car.
(0 Other causes exclude
4, Possible
(a) Fpisodic vertigo of Ménières type without docu:
stented hearing los (vestibular varian oF
(0) Sensorineual heating los, Muetuaing or fixe,
‘with disequilibrium but without dehnitive ep
des (cocher varian
(©) Other causes exclude
Stage Pure tone average in in previous months,
1 as
ES
STAGING OF MENIERE’S DISEASE
‘This can be done in certain and definite cases of Ménières
ise eis bad on the average of pure tone thresholds
310.8, 1, 2 and $ kl round 10 the nearest whole of
{the wostaudiogtam during period of 6 months before
treatment ee ble 12)
‘TREATMENT
A. GENERAL MEASURES
1. Reassurance. Patient ansety can be eelieved by reos
surance and by explaining the rue nature of disease. This
‘particulary important in acute attack,
2. Cessation of smoking. Nicotine causes vasospasm,
Smoking should be completely stopped. For some par
fens, this may be the only treatment necessary
3. Low salt dit. Patient should take sat re dict as far
3 ponte No extra sat should be permite Sal take
Should not exceed 1.520 py.
4. Avoid excesive intake of watt,
5. Avoid oxerindulgence in cote, tea and alcohol.
6. Avoid stress and bring a change in style. Mental
‘elation exercises and yoga are helpful todecrase stress,
7. Avoid activities requiring good body balance. As the
attack of Ménière disease fs abrupt, sometimes with no
‘warsing symptom, profesions such as Jing, underwater
“ving or working at great heights should be avoided
MANAGEMENT OF ACUTE ATTACK
Dring the acute attack, theres severe vertigo with nasa
and vomiting. Patient is apprehensive. Head movements
[provoke giddiness. TMercore treatment would consst of
1. Reassurance and psychological support tally worry
and anxiety
2, ed et ih ad supped on plows 1 preven
3. Intravenous fuids and clectrolyte administration
combat tel loss ducto vom
4, Vestibular sedatives to eleve vertigo, Mey should be
siministered intramuscularly or intavenously I vomit-
ing precludes orl administration. Drugs sel in acute
attack are dimenhydrinate Dramamine), promethazine
Acocate (Avomine) or prochlorperazine (eme.
mebooksfree.com
Diazepam (Valium or Calmpose) 5-10 mg may be iv
en intravenously. It has a tranquilizing effect and slo
Suppresses the activity of medal vestibular nucleus
"some patients acute ¿tac can be stopped by aeo-
pine, 0-4 mg, given subcutaneously.
5, Vasodilators: Caragen (5% COs with 95% 03) is à
{ood cerebral vasodilator and ls inhalation improves
Esbyrimhine circulation.
C. MANAGEMENT OF CHRONIC PHASE
When patient presents after the acute attack, the trat
ment consist of
1. Vestibular sedatives, Prochlorperazine (Steet)
10 mg tic à day, orally or two months and the
reduced LOS mg ice a doy lor another month,
2. Vasodiltors. Betahistine (Verin) 8-16 mg, thrice
à day given only, also increases labyrinthine blood
Aw by releasing histamine nthe bod
Diuretics. Sometimes, diuretic furosemide, 40 mg
table, taken on alternate days wih potasum supple:
‘ment helps to contol fecurtent attacks, not Con.
troled by vasodilators or vestibular solatves. Th
de duren ¢hydrochloothiazide), 125 mg dally
Sin ho e used
4. Propantheline bromide (Probanthind), 15 mg, thrice
day, canbe given alone or in combination with vas.
‘dilator and quite efectve, However they are not
rer by many due tosie tcs
5, Elimination of allergen. Sometimes, fod or ina
ant llergen responsible for such aac I should be
{ound and eliminated or desenstzation done.
6: Hormones. Investigations should be directed o find
any endocinal disorder such as hypothyroidism, and
Appropriate replacement therapy” given, Control of
$s y change in eses important to even re
About 80% ofthe patients can be effectively managed
‘by medical therapy alone.
Intratympanic gentamicin therapy
(chemical abyrinthectomy)
tamicin is mainly vestibulotoic It has been used in
ly or bey into int he middle car Drug
nor through the round window and causes destruc
tion ofthe vestibuaelbysinth. Total control of vertigo
Sls has ben reported in 60-80% of patients with some
Fie from symptoms in others. Hearing os, sometimes
Severe and profound, has been reported in 4-30% of ps.
tens tae with this mode of trap.
Microwick
I is a small wick made of polyvinyl acetate and mes.
res 1 mm % 9 mm. is meant o deliver drags rom
‘exteral canal tothe inner ear and thus avoid repente
tratympanic injections. I requires a tympanostomy tube
{grommet to be meta Into the tympani membrane
Chapter 15 — MiniresDisee 115
and the wick is passed through it. When soaked with à
“rug the wick delves the drug to the round window to
‘beabsorbed into the inne ea. has Been used to deliver
steroids in sudden deafness and gentamicin 10 destroy
‘osibula ant in Meniere's disease
D. SURGICAL TREATMENT
Its used only when medical tentent fai
1. CONSERVATIVE PROCEDURES. They are used in cases
seo vertigo ts disabling but hearing i i sel and
‘needs to be preserved. Tey are:
(a) Decompression of ndlymphatie sc:
(0) Endohmphatc shunt operation. A abe is put, connect
ing endolymphatic sac with subarachnoid space, 10
drain excess endolymph
(9 Sacuatomy (FICS operation). Is puncturing the
‘Secule witha needle through stapes footpate À di.
tended saccul les cose to stapes footpate and can
be easly penetrated. Cody tack procedure consists
1 placin sans sel tack through the stapes
footplate: The tack would cause perodle decom
Sion o the sacule when e gets distended, Both these
‘operations were claimed to have shown good results
bt they could not be reproduce by others and thus
abandoned, Cochleosactulotumy I another similar
procedure in which, instead of Saco, cochlear duct
E punctured and drained into the peliymph (ti
penotie shunt. The procedure is performed va
Gand needle passed Hough te round window
[puncture cochlear duct.
ction of vestidor mont. The nerve is expose by ret
rosigmold or middle cranial fossa approach ands
scone con vers ut oes
“
(e) Umsoncdestucton of vestuario Cochlar
function Is preserved.
2. Desmmucrive Procemunes. They totally destiny
‘Cochlear and vestibular function and ae ths used ony
‘shen eochkar function is not serviceable,
+ Labyrinictony. Membranous labyrinth & completely
destroyed either by opening through the lateral emi
eur canal by tansmastod route or through the
‘oval window by attanscanal approach Tis gives let
From the attacks of vertigo.
3. Ieremerrrenr Low Presse Pest Tarma
Dausaert Device Tara (cum 15.0), Tes ob
Served that intermittent positive pressure delivered 10
Inner eat Aus brings ele rom the symptoms of Mé:
‘lees disease, Not only thers improvement in vertigo,
tinnitus and cr fais, but hearing may also improve.
Intermitent postive pressure waves can be delivered
‘hough an instrument called Meniet device which has
‘been approved by FDA. À prerequist for such a therapy
|S to perform a myringotomy and insert a ventilation
tule so thatthe device when couple tothe extemal car
anal can deliver pressure aves 10 the round window
‘membrane via the ventilation tube, Pressure waves Pass
mebooksfree.com
en intravenously. It has a tranquilizing effect and slo
Suppresses the activity of medal vestibular nucleus
"some patients acute ¿tac can be stopped by aeo-
pine, 0-4 mg, given subcutaneously.
5, Vasodilators: Caragen (5% COs with 95% 03) is à
{ood cerebral vasodilator and ls inhalation improves
Esbyrimhine circulation.
C. MANAGEMENT OF CHRONIC PHASE
When patient presents after the acute attack, the trat
ment consist of
1. Vestibular sedatives, Prochlorperazine (Steet)
10 mg tic à day, orally or two months and the
reduced LOS mg ice a doy lor another month,
2. Vasodiltors. Betahistine (Verin) 8-16 mg, thrice
à day given only, also increases labyrinthine blood
Aw by releasing histamine nthe bod
Diuretics. Sometimes, diuretic furosemide, 40 mg
table, taken on alternate days wih potasum supple:
‘ment helps to contol fecurtent attacks, not Con.
troled by vasodilators or vestibular solatves. Th
de duren ¢hydrochloothiazide), 125 mg dally
Sin ho e used
4. Propantheline bromide (Probanthind), 15 mg, thrice
day, canbe given alone or in combination with vas.
‘dilator and quite efectve, However they are not
rer by many due tosie tcs
5, Elimination of allergen. Sometimes, fod or ina
ant llergen responsible for such aac I should be
{ound and eliminated or desenstzation done.
6: Hormones. Investigations should be directed o find
any endocinal disorder such as hypothyroidism, and
Appropriate replacement therapy” given, Control of
$s y change in eses important to even re
About 80% ofthe patients can be effectively managed
‘by medical therapy alone.
Intratympanic gentamicin therapy
(chemical abyrinthectomy)
tamicin is mainly vestibulotoic It has been used in
ly or bey into int he middle car Drug
nor through the round window and causes destruc
tion ofthe vestibuaelbysinth. Total control of vertigo
Sls has ben reported in 60-80% of patients with some
Fie from symptoms in others. Hearing os, sometimes
Severe and profound, has been reported in 4-30% of ps.
tens tae with this mode of trap.
Microwick
I is a small wick made of polyvinyl acetate and mes.
res 1 mm % 9 mm. is meant o deliver drags rom
‘exteral canal tothe inner ear and thus avoid repente
tratympanic injections. I requires a tympanostomy tube
{grommet to be meta Into the tympani membrane
Chapter 15 — MiniresDisee 115
and the wick is passed through it. When soaked with à
“rug the wick delves the drug to the round window to
‘beabsorbed into the inne ea. has Been used to deliver
steroids in sudden deafness and gentamicin 10 destroy
‘osibula ant in Meniere's disease
D. SURGICAL TREATMENT
Its used only when medical tentent fai
1. CONSERVATIVE PROCEDURES. They are used in cases
seo vertigo ts disabling but hearing i i sel and
‘needs to be preserved. Tey are:
(a) Decompression of ndlymphatie sc:
(0) Endohmphatc shunt operation. A abe is put, connect
ing endolymphatic sac with subarachnoid space, 10
drain excess endolymph
(9 Sacuatomy (FICS operation). Is puncturing the
‘Secule witha needle through stapes footpate À di.
tended saccul les cose to stapes footpate and can
be easly penetrated. Cody tack procedure consists
1 placin sans sel tack through the stapes
footplate: The tack would cause perodle decom
Sion o the sacule when e gets distended, Both these
‘operations were claimed to have shown good results
bt they could not be reproduce by others and thus
abandoned, Cochleosactulotumy I another similar
procedure in which, instead of Saco, cochlear duct
E punctured and drained into the peliymph (ti
penotie shunt. The procedure is performed va
Gand needle passed Hough te round window
[puncture cochlear duct.
ction of vestidor mont. The nerve is expose by ret
rosigmold or middle cranial fossa approach ands
scone con vers ut oes
“
(e) Umsoncdestucton of vestuario Cochlar
function Is preserved.
2. Desmmucrive Procemunes. They totally destiny
‘Cochlear and vestibular function and ae ths used ony
‘shen eochkar function is not serviceable,
+ Labyrinictony. Membranous labyrinth & completely
destroyed either by opening through the lateral emi
eur canal by tansmastod route or through the
‘oval window by attanscanal approach Tis gives let
From the attacks of vertigo.
3. Ieremerrrenr Low Presse Pest Tarma
Dausaert Device Tara (cum 15.0), Tes ob
Served that intermittent positive pressure delivered 10
Inner eat Aus brings ele rom the symptoms of Mé:
‘lees disease, Not only thers improvement in vertigo,
tinnitus and cr fais, but hearing may also improve.
Intermitent postive pressure waves can be delivered
‘hough an instrument called Meniet device which has
‘been approved by FDA. À prerequist for such a therapy
|S to perform a myringotomy and insert a ventilation
tule so thatthe device when couple tothe extemal car
anal can deliver pressure aves 10 the round window
‘membrane via the ventilation tube, Pressure waves Pass
mebooksfree.com
116 SECTION — Diseases of Er
nymphs e
venetian tine Coeur mat
Figure 15.6. Mech teten Lou pee pue rap Pere ne ough venian tube (1) und éd men.
SE coito er con a compr ere mb dau meh on on and
‘through the perilymph and cause reduction in endo- Patient can selfadministr the treatment at home.
mph pressure by redistributing through varios com. may require a few months before complete emission
muniction chamns such asthe endolymphatic sac or of disease obtain. Meniet device therapy has been
Te blood veses (su. 15.0) Some believe they regulate recommended for patients who have faled medical ea:
secretion of endolymp by the sta vascular ‘ment and he surgical options ae being considered
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nymphs e
venetian tine Coeur mat
Figure 15.6. Mech teten Lou pee pue rap Pere ne ough venian tube (1) und éd men.
SE coito er con a compr ere mb dau meh on on and
‘through the perilymph and cause reduction in endo- Patient can selfadministr the treatment at home.
mph pressure by redistributing through varios com. may require a few months before complete emission
muniction chamns such asthe endolymphatic sac or of disease obtain. Meniet device therapy has been
Te blood veses (su. 15.0) Some believe they regulate recommended for patients who have faled medical ea:
secretion of endolymp by the sta vascular ‘ment and he surgical options ae being considered
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Chapter 16
Tumours of External Ear
‘fall the cases of car carcinoma, 55% occur onthe pinna,
10% the external canal and Sin the middle car.
Tumours ofthe external ear may arse fom the plnna
or external auditory canal (able 10.
‘TUMOURS OF AURICLE
BENIGN TUMOURS
1. Peawnicutanstves om sr; This results fom faulty
union of hilocks of the fist and second branchial ach
8 during the development of pinna. Preauricular sinus
presents a small opening in font of the ru a hele
has a branching trat lined by squamous epithelium
‘which when locked result ina retention cps. Patient
sully presents with à est which I infected: Surgery à
Indicated if there ls unsightly swelling or infection. Cyst
‘esis tact must De excise completely 10 avoid rece
2. Semacrous Cyst. Common sts postauricla sulcus
‘or below and behind the cr lobules Treatment is total
Surgical excision.
3. Dexwow Cyst. Usually presents as a rounded mass
‘ver the upper pat of mastold behind the pin.
4. Ketoup. often follows trauma such a piercing the ear
Iobule for omaments ora surgical incision (Agur 16.)
There 1a genetic susceptibility Mack races are more of
ten afected. Klo presents asa pedunculated tumour
= Pa
== .
Base “Ss
a —-
= Ein
er
Sn —
ne Es
ie ae
mess cet reams
acom
5. HARMANGIOMAS. They ae congenital tumours ft
cn in ehldhood. Other pars of ace and neck may aso
be involved. They are of two types:
(a) Capilay huemansioma. esa mass of calla szed
blood vessels and may present as “portan sae.”
does not egress spontaneous
Caverns haemangoma (lso calle stawberty tu
‘moun. const of endotheliklined spaces led
‘nth blood. I increases rapidly during dhe Hest year
but regreses thereafter and may completely disap
pearby the Aft year.
cua malormatin. See Figure 16 2A-C
©
©
6. PAPILOMA (WARD), I may presentas a tuted growth
‘flat grey plague and ouh to fee. Is al in ogi
Treatment surgical excsio or curetage with cauterza:
ion ofits base
7. Guranrous HORN. It Is a frm of papilloma sith
heaping up of keatin and presents as hom shaped tu
‘motu Tt soften seen at the im ot helix eed people
‘Treatment Is surgical excision
8. KERATOACANTIOMA. Its a benign tumour clinically
sembla a malignant one. It present 38a ais module
A a central rate. Ina e rows rapid but slowly
egress leaving Sar Treatment 5 excision ops)
Figure 16.1. Kd ling ring a solo a tg
17
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Tumours of External Ear
‘fall the cases of car carcinoma, 55% occur onthe pinna,
10% the external canal and Sin the middle car.
Tumours ofthe external ear may arse fom the plnna
or external auditory canal (able 10.
‘TUMOURS OF AURICLE
BENIGN TUMOURS
1. Peawnicutanstves om sr; This results fom faulty
union of hilocks of the fist and second branchial ach
8 during the development of pinna. Preauricular sinus
presents a small opening in font of the ru a hele
has a branching trat lined by squamous epithelium
‘which when locked result ina retention cps. Patient
sully presents with à est which I infected: Surgery à
Indicated if there ls unsightly swelling or infection. Cyst
‘esis tact must De excise completely 10 avoid rece
2. Semacrous Cyst. Common sts postauricla sulcus
‘or below and behind the cr lobules Treatment is total
Surgical excision.
3. Dexwow Cyst. Usually presents as a rounded mass
‘ver the upper pat of mastold behind the pin.
4. Ketoup. often follows trauma such a piercing the ear
Iobule for omaments ora surgical incision (Agur 16.)
There 1a genetic susceptibility Mack races are more of
ten afected. Klo presents asa pedunculated tumour
= Pa
== .
Base “Ss
a —-
= Ein
er
Sn —
ne Es
ie ae
mess cet reams
acom
5. HARMANGIOMAS. They ae congenital tumours ft
cn in ehldhood. Other pars of ace and neck may aso
be involved. They are of two types:
(a) Capilay huemansioma. esa mass of calla szed
blood vessels and may present as “portan sae.”
does not egress spontaneous
Caverns haemangoma (lso calle stawberty tu
‘moun. const of endotheliklined spaces led
‘nth blood. I increases rapidly during dhe Hest year
but regreses thereafter and may completely disap
pearby the Aft year.
cua malormatin. See Figure 16 2A-C
©
©
6. PAPILOMA (WARD), I may presentas a tuted growth
‘flat grey plague and ouh to fee. Is al in ogi
Treatment surgical excsio or curetage with cauterza:
ion ofits base
7. Guranrous HORN. It Is a frm of papilloma sith
heaping up of keatin and presents as hom shaped tu
‘motu Tt soften seen at the im ot helix eed people
‘Treatment Is surgical excision
8. KERATOACANTIOMA. Its a benign tumour clinically
sembla a malignant one. It present 38a ais module
A a central rate. Ina e rows rapid but slowly
egress leaving Sar Treatment 5 excision ops)
Figure 16.1. Kd ling ring a solo a tg
17
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SECTION! — Diseases of far
Figure 162. Venomphatiematormaton othe pra incl pen, 8) ing operado nd (the xd specimen,
Figure 163. Samson of pan.
9. NEUROTIBROMA. It presents nontende, firm sel
ing and may be associated with von Recklinghausen dí
ease. Treatment ls Surgical excision, I tumour occudes
‘ar canal or presents cosmetic problem.
MALIGNANT TUMOURS
1. SquaMous CULL CARCINOMA. The sit of prediction
Schal O Jn Tt may Present aa paies no.
le or an ulcer with red ever edges and indurated
thse, Metastases to regional lymph nodes occur very ate
Diseases more common in mats in thelr ites who had
‘Prolonged exposure to ret sunlight. Faircomplexioned
People are more prone
Treatment. Small sions with no nodal metastases
are exched locally with 1 cm of healthy rca around
IC Larger lesions 1 the pinma or those coming within
1 cm of external auditory canal and lesions with nodal
metastases may regule total amputation of the nna,
‘often with en bloc removal of parotid glandand cervical
Iymph nodes,
2. BASAL Cet CawetNowA The common sits ate the
nx and the tagus. tis more common in men beyond
SO year of age. presents as à nodule with central erst,
‘removal of which resul in bleeding, Ulcer asa ras ot
add edge. Leston often extends eircumfrentll
the shin but may penetrate deepe, involving carte or
bone: Lymph node metastases usualy do not occur
Tue, Super lesions, not involving care,
can be iradatal and cosmetic deformity avoided, Le
Sons involving cartilage may require surgical excion as
In cases of squamous el carino
3. MELANOMA. may occut anywhere over the auic.
is more common in men of ight complexion who are ex
pose to sun, Metastases ae seen in 16-5080 ofthe cases,
Treatment. Super melanom, es than 1 em in di
ameter, situated ver the heli, s managed by Wedge re
Section and primary cosut
Superficial melanoma, larger than 1 cm, infiltrative
mclamomas, melanoma of posterior auricular surface oF
‘oncha and all ecurent melanomas ae tested by rec
ton of pinna, ortidectomy and radial neck dissection,
‘TUMOURS OF EXTERNAL AUDITORY
CANAL
BENIGN TUMOURS
1. Osreow. it arises rom cancellous bone and presents
5 à singe, smooth, bony, hard, pedunculted tumour,
‘often rising fom the posterior wall of the osseous mea
tus, near its outer end ( ). Treatment 5 suglal
removal by fracturing through its price or removal with
2. Exostosts, They are multiple and bilateral often pre-
Seating as smooth, sessile, bony sweling in the deeper
Pan of the meatus near the tympanic membrane. They
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Figure 162. Venomphatiematormaton othe pra incl pen, 8) ing operado nd (the xd specimen,
Figure 163. Samson of pan.
9. NEUROTIBROMA. It presents nontende, firm sel
ing and may be associated with von Recklinghausen dí
ease. Treatment ls Surgical excision, I tumour occudes
‘ar canal or presents cosmetic problem.
MALIGNANT TUMOURS
1. SquaMous CULL CARCINOMA. The sit of prediction
Schal O Jn Tt may Present aa paies no.
le or an ulcer with red ever edges and indurated
thse, Metastases to regional lymph nodes occur very ate
Diseases more common in mats in thelr ites who had
‘Prolonged exposure to ret sunlight. Faircomplexioned
People are more prone
Treatment. Small sions with no nodal metastases
are exched locally with 1 cm of healthy rca around
IC Larger lesions 1 the pinma or those coming within
1 cm of external auditory canal and lesions with nodal
metastases may regule total amputation of the nna,
‘often with en bloc removal of parotid glandand cervical
Iymph nodes,
2. BASAL Cet CawetNowA The common sits ate the
nx and the tagus. tis more common in men beyond
SO year of age. presents as à nodule with central erst,
‘removal of which resul in bleeding, Ulcer asa ras ot
add edge. Leston often extends eircumfrentll
the shin but may penetrate deepe, involving carte or
bone: Lymph node metastases usualy do not occur
Tue, Super lesions, not involving care,
can be iradatal and cosmetic deformity avoided, Le
Sons involving cartilage may require surgical excion as
In cases of squamous el carino
3. MELANOMA. may occut anywhere over the auic.
is more common in men of ight complexion who are ex
pose to sun, Metastases ae seen in 16-5080 ofthe cases,
Treatment. Super melanom, es than 1 em in di
ameter, situated ver the heli, s managed by Wedge re
Section and primary cosut
Superficial melanoma, larger than 1 cm, infiltrative
mclamomas, melanoma of posterior auricular surface oF
‘oncha and all ecurent melanomas ae tested by rec
ton of pinna, ortidectomy and radial neck dissection,
‘TUMOURS OF EXTERNAL AUDITORY
CANAL
BENIGN TUMOURS
1. Osreow. it arises rom cancellous bone and presents
5 à singe, smooth, bony, hard, pedunculted tumour,
‘often rising fom the posterior wall of the osseous mea
tus, near its outer end ( ). Treatment 5 suglal
removal by fracturing through its price or removal with
2. Exostosts, They are multiple and bilateral often pre-
Seating as smooth, sessile, bony sweling in the deeper
Pan of the meatus near the tympanic membrane. They
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Flore, 164 ons ing fom the ner val Ht
aris rom compact bone, Exostosis soften seen in per
Sons expose 9 emt’ of cold water in the meats as
‘vers and swimmers Males ae afected three times more
than females
"Treatment, When small and asymptomati, no teat
ments necessary. Larger ones, which impair heating or
‘cause retention of wa and debs, may be removed wi
highspeed dil to store normal sized meatus Fxostoses
may extend deeply and le in lose ration tothe facial
herve. Therefore use of gouge and hammer should be
voided
3. CEMUMINONA. tis a tumour of modified sweat glands
hic secret rumen. I presents as a smooth, hrm,
Skin-covered polypoid swelling in outer pat of the mea
tus, generally attached 10 the posterior or Inferior Wal. I
‘obstruct the mest leading fo retention of war and de
ris Malignant type outnumber the benign by 2:1 ato.
Treatment, Tumour has à tendency to recut, there
fore wide surgical excision should be done and patient
Chapter 16 — Tumour of Extemal Ear 119
gli followed up. Some of the cruminomas are ma-
Iignant and i tere is any suspicion of malignancy on
Instology, postoperative radiotherapy should be given.
4, Senacrous ADENOMA. It arses fom sebaceous glands
of the meatus and presents as à smooth, skin-covered
Stelling in the outer menus. Treatment fs surgical exc
5. Parsons. Sila tothe one seen on the pin.
MALIGNANT TUMOURS
1. SQUAMOLS CELL CARCINOMA. Most often tis sce
ses of longstanding car discharge. I may ase primar.
from the meatus or be a secondary extension fom the
‘mide car carenoma,
Presenting symptoms are blood staining of hitherto
mucopurulent or purulent discharge and sever earache
"xamination may show an ulcerated arc in the me:
tus or a bleeding polypoid mass or geanulations. Facial
‘nerve may be paralyzcd because of fea extension of dis
fase though posterior meatal wal or Hs spread into the
middle car Regional Iymph nodes (presurcuar, posta:
Meu, ina-aurieular and upper deep cervical} may be
Involved,
“Treatment is en bloc wide surgical excision with post
operative radiation.
2. BASAL Ceux AND ADENOCANCINOMAS. They carey
aise from the meats. Clinical picture ss ar to that of
Squamous call variety. Diagnosis made only on Biopsy.
Treatment is wide surgical excision and postoperative a.
dition
3. Matsonayr CenUAANoMA, Malignant type twice as
‘sommon a benign
4. Matic MELANOMA, Rare tumour.
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aris rom compact bone, Exostosis soften seen in per
Sons expose 9 emt’ of cold water in the meats as
‘vers and swimmers Males ae afected three times more
than females
"Treatment, When small and asymptomati, no teat
ments necessary. Larger ones, which impair heating or
‘cause retention of wa and debs, may be removed wi
highspeed dil to store normal sized meatus Fxostoses
may extend deeply and le in lose ration tothe facial
herve. Therefore use of gouge and hammer should be
voided
3. CEMUMINONA. tis a tumour of modified sweat glands
hic secret rumen. I presents as a smooth, hrm,
Skin-covered polypoid swelling in outer pat of the mea
tus, generally attached 10 the posterior or Inferior Wal. I
‘obstruct the mest leading fo retention of war and de
ris Malignant type outnumber the benign by 2:1 ato.
Treatment, Tumour has à tendency to recut, there
fore wide surgical excision should be done and patient
Chapter 16 — Tumour of Extemal Ear 119
gli followed up. Some of the cruminomas are ma-
Iignant and i tere is any suspicion of malignancy on
Instology, postoperative radiotherapy should be given.
4, Senacrous ADENOMA. It arses fom sebaceous glands
of the meatus and presents as à smooth, skin-covered
Stelling in the outer menus. Treatment fs surgical exc
5. Parsons. Sila tothe one seen on the pin.
MALIGNANT TUMOURS
1. SQUAMOLS CELL CARCINOMA. Most often tis sce
ses of longstanding car discharge. I may ase primar.
from the meatus or be a secondary extension fom the
‘mide car carenoma,
Presenting symptoms are blood staining of hitherto
mucopurulent or purulent discharge and sever earache
"xamination may show an ulcerated arc in the me:
tus or a bleeding polypoid mass or geanulations. Facial
‘nerve may be paralyzcd because of fea extension of dis
fase though posterior meatal wal or Hs spread into the
middle car Regional Iymph nodes (presurcuar, posta:
Meu, ina-aurieular and upper deep cervical} may be
Involved,
“Treatment is en bloc wide surgical excision with post
operative radiation.
2. BASAL Ceux AND ADENOCANCINOMAS. They carey
aise from the meats. Clinical picture ss ar to that of
Squamous call variety. Diagnosis made only on Biopsy.
Treatment is wide surgical excision and postoperative a.
dition
3. Matsonayr CenUAANoMA, Malignant type twice as
‘sommon a benign
4. Matic MELANOMA, Rare tumour.
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Chapter 17
Tumours of Middle Ear and Mastoid
CLASSIFICATION
Tumours of mide ear and mastoid ca
1. Primary tumours
(a) Benign: Glomus tumoue
(0) Malignant Carcinoma, sarcoma
2. Secondary tumours
(a) From adjacent areas, eg nsoph
tana the prot
(0) Metastatic, e, Mom carcinoma of bronchus, brest,
ne ro, prostate and gastrointestinal tact,
be did into:
GLOMUS TUMOUR
1 is the most common benign neoplasm of middle ear
and Is So-named because ol song trom the glomus
bodies, The later resemble carotid body In structure and
ar found in he dome of jugar bulb or on the promo
tory along the course of tympanic branch of Ih cana
nerve Jacobson nerve). The tumour consists of paragan
‘ionic els derived from Ihe neural crest
AETIOLOGY AND PATHOLOGY
“The tumour often sen in the mide age (40-50 yeas),
Females ae fected Ave times more
is a benign, nonencapsuate but extremely vase:
Tar neoplasm. ts ate of growth is very slow and several
‘years may pas efore there say’ change fom the ni
Symptoms, Tumour i locally invasive
‘Microscopically It shows masses or sheets of epithelial
els whieh have large nucel and a granular cytoplasm,
Tier is abundance of thin-walled blood sinusoids ith
ho contractile muscle cost, accounting for profuse bled
Ing rom the tumour.
Tor purposes of diagnosis and treatment, two types are
cure
1. Gtows JUGULARe, They ars from the dome of jug
ar bulb, invade the hypotympanum and fugue €
men, causing neurologlal signs of TXth to XIE canta
herve Involvement. They may compres jugular vein or
invade ts lumen,
2. Guowes Truaranıcun. They aise from the promon:
tony of the mide ear and cause aural symptoms, some
times with fall paral
Spread of Glomus Tumour
1. Tumour may inal il the mide car and late per
forate through the tympanic membrane to presents
vascular pop.
2: may ade ay
3.1 may invade Juguar foramen and the base of sul
‘using IXth to lth eral mer pls
4. By spread through eustachian tube, I may present in
the nasopharyn.
5, Ie may spread Intracaniall tothe posterior and mid
dle canal osos
6: Metastatic spend to lungs and bones is ar, but seen
in 4% of ces. Metastatic Iymph nodo enlargement
+ peo
1 pyramid and the
CLINICAL FEATURES
In 90) o ases, symptoms peral to th car
1. Wey Tewoun 18 Ivrmarvanaste. facies symp:
{om are hearing loss and tnnltu. Hearing os 8 con.
‘dt and slowiy progressive. Tinnitus fs pulsar and
‘of sshing character, synchronous with pulse and can be
temporary stopped by aot pressure.
‘Otoscopy’shows a red reflex through Intact tympanic
wmbrane. “Rig sun“ appearance ise when tumour
es from the floor of mide eat. Sometimes, tympanic
‘membrane appears blush and may be bulging
“Pasa sgn” (Brown slg) is postive, Le. when car
canal pressure Is rise with Siegel speculum, tumour
pulsites vigorously and then Blanche; reverse happens
"a he release of pressure
2. WHEN TUMOUR PRESENTS AS À PoLYP. In addition
o hearing loss and natos, there i history of prose
bleeding from the ear ether spontaneously or on at
temps to ea
Dix or vertigo and facial paralysis may appar
Earache less common than in carcinoma ofthe external
And middle car, and helps to diferentiae them fom it
‘Otorthoes may occur due to secondary infection and
the condition may simulate chronic suppurative tits
média ith polyp.
Examination reveas a rd, vascular polyp filing the
meatus. It bleeds realy and protusely On manipulation
rat Bop
3. Cra NERVE PALSIES, This Isa Inte feature ap
‘esrng several years after aural symptoms. EX o Al
1
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Tumours of Middle Ear and Mastoid
CLASSIFICATION
Tumours of mide ear and mastoid ca
1. Primary tumours
(a) Benign: Glomus tumoue
(0) Malignant Carcinoma, sarcoma
2. Secondary tumours
(a) From adjacent areas, eg nsoph
tana the prot
(0) Metastatic, e, Mom carcinoma of bronchus, brest,
ne ro, prostate and gastrointestinal tact,
be did into:
GLOMUS TUMOUR
1 is the most common benign neoplasm of middle ear
and Is So-named because ol song trom the glomus
bodies, The later resemble carotid body In structure and
ar found in he dome of jugar bulb or on the promo
tory along the course of tympanic branch of Ih cana
nerve Jacobson nerve). The tumour consists of paragan
‘ionic els derived from Ihe neural crest
AETIOLOGY AND PATHOLOGY
“The tumour often sen in the mide age (40-50 yeas),
Females ae fected Ave times more
is a benign, nonencapsuate but extremely vase:
Tar neoplasm. ts ate of growth is very slow and several
‘years may pas efore there say’ change fom the ni
Symptoms, Tumour i locally invasive
‘Microscopically It shows masses or sheets of epithelial
els whieh have large nucel and a granular cytoplasm,
Tier is abundance of thin-walled blood sinusoids ith
ho contractile muscle cost, accounting for profuse bled
Ing rom the tumour.
Tor purposes of diagnosis and treatment, two types are
cure
1. Gtows JUGULARe, They ars from the dome of jug
ar bulb, invade the hypotympanum and fugue €
men, causing neurologlal signs of TXth to XIE canta
herve Involvement. They may compres jugular vein or
invade ts lumen,
2. Guowes Truaranıcun. They aise from the promon:
tony of the mide ear and cause aural symptoms, some
times with fall paral
Spread of Glomus Tumour
1. Tumour may inal il the mide car and late per
forate through the tympanic membrane to presents
vascular pop.
2: may ade ay
3.1 may invade Juguar foramen and the base of sul
‘using IXth to lth eral mer pls
4. By spread through eustachian tube, I may present in
the nasopharyn.
5, Ie may spread Intracaniall tothe posterior and mid
dle canal osos
6: Metastatic spend to lungs and bones is ar, but seen
in 4% of ces. Metastatic Iymph nodo enlargement
+ peo
1 pyramid and the
CLINICAL FEATURES
In 90) o ases, symptoms peral to th car
1. Wey Tewoun 18 Ivrmarvanaste. facies symp:
{om are hearing loss and tnnltu. Hearing os 8 con.
‘dt and slowiy progressive. Tinnitus fs pulsar and
‘of sshing character, synchronous with pulse and can be
temporary stopped by aot pressure.
‘Otoscopy’shows a red reflex through Intact tympanic
wmbrane. “Rig sun“ appearance ise when tumour
es from the floor of mide eat. Sometimes, tympanic
‘membrane appears blush and may be bulging
“Pasa sgn” (Brown slg) is postive, Le. when car
canal pressure Is rise with Siegel speculum, tumour
pulsites vigorously and then Blanche; reverse happens
"a he release of pressure
2. WHEN TUMOUR PRESENTS AS À PoLYP. In addition
o hearing loss and natos, there i history of prose
bleeding from the ear ether spontaneously or on at
temps to ea
Dix or vertigo and facial paralysis may appar
Earache less common than in carcinoma ofthe external
And middle car, and helps to diferentiae them fom it
‘Otorthoes may occur due to secondary infection and
the condition may simulate chronic suppurative tits
média ith polyp.
Examination reveas a rd, vascular polyp filing the
meatus. It bleeds realy and protusely On manipulation
rat Bop
3. Cra NERVE PALSIES, This Isa Inte feature ap
‘esrng several years after aural symptoms. EX o Al
1
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122 SECTIONI — senses ofr
‘ania nerves may be paralyzed. There s dysphagia and
Foaseness with unilateral paralysis of the soft palate
playa (X, X and vocal cord (X) with weakness of the
fraperts nd sternomastoid muscles (XD and atopy of
al or tongue (X,
Tumour may present asa mass over the mastold or in
the nasopharyne.
‘ns of intracranial involvement may also occu
4. Avie Baur. At al stages, auscultation with steih-
‘scope over the mastoid may reveal syto brut.
Some glomus tumours were atecholaminesand pro:
‘auc symptoms ke headache, sweating palpation, Ny-
pertension and ams, and requ furor investigations.
5. RULE OF 105. Remember that 10% ofthe tumours are
ala, 10% mulucentieoccurngin mor than one ste)
and upto 10% functional, Le hey Secret catecholamines.
DIAGNOSIS.
In addition to thorough history and physical examin
tion, the patient Is checked-up to find out the extent
fof tumour other associated glomus tumours and ser
levels of atecholamines or thelr breakdown products in
ine (anliyImandelic aid, metanephrine, ic). Inves
tigations include:
1. Courerep Towocraruy (CT) Scax HEAD. Using
‘bone window, 1 mım thin sections are ett helps to dis
{ingulsh glomus tympanicum from the glomus agulare
tumour by Identification of caroicofüguarspine which
A eroded in the latter. CT sean also help to diferent
ste it rom the aberant carotid artery, high ov dehiscent
Jugular but.
2. MRL It shows soft issu extent of tumour. Magnetic
resonance angiography and venography further help to
‘elineate invasion of jugular bulb and vein or compres
Som of the carotid arte
3. CT Hap AND MRI Comm, together provide an
Sollen preoperative guidance ln the differential dag
toss of pero apex lesions,
a. Four-Vesset ANGIOGKAMI I is necesa when CT
"head shows involvement of Juglar bulb, carotid artery or
Inradural extension. I also helps to delineate any other
lomas tumor (as they may be multiple), Bid the feed
Ing veses or embolization of tumout required.
5. BRAIN PERFUSION AND FLOW STUDIES. They ate nic-
say when tumour is pressing on internal carotid artery
Ifthe case nee surgery, brain person and adequacy of
omita internal caotidartery and cle of Wills ean
esse I needed, xenon blo flow and otope stu
‘es are done or precise blood Noy, and the rk of stoke
nd need for surgical replacement of internal aot artery
6. EMBOLIZATION, In large tumours, embolization of
{coding vessels 1-2 days before operation helps 10 seduce
‘ood los
7. Borsy. Preoperative biopsy of the tumour or digno.
SS 1 ever done, Clinic! and radiologie features ae very
haractorist to make dagnoss. Tumours very vascular
and bleeds profusely. There I ls Hood of injuring
ine high jugular bulb or aberrant internal tot artery I
lagnessIsmistaken,
‘TREATMENT
A consists of
1. Surgical removal
2: Radiation.
À Emol
À: Combination ofthe above techniques
Surgical approaches to glomus tumours
1. TRANSCANAL APPROACH, Suited for limited glomus
impanicum tumour where entire circumference of the
{tumour s visible, only tympanotomy wil suffice to gain
ces tothe tumor
2. Hyporvessic Arrnonct. Suited fr tumours limit
‘Sito promontory with extension to hypotympanum but
‘ot into the mastot. A superiorly based fympanom tal
fap ls rad by postauricalar approach. Bony inferior
tympanic ring is died away to ee the Tower Lit of
3. EXTINDED FACIAL RECESS Arrnoacı. Use for glo
‘us tympanicum extending into maso but not nto
the jugular bulb I extensive, modified radical operation
sons.
4. Mastom-Neck Arraoaeat, Use for glomus jugulare
tumours not extending 0 Internal carol artery, poste.
Hor ramal fossa or neck
$. InnearEwronat Fossa APPROACH OF FISH, Used for
large glomus gular tamous.
6. TRANSCONDYLAR APPROACH. Used for tumours
extending towards foramen magnum, Usually they are
recurrent glomus jugulare tumours I gives approach to
‘anlocerical Junction with Exposure of excita con
pie and jagulr uber.
Radiation weatment does not cure the tumour but
may reduce is vasculanty and ares ls growth. Radio
tion is tse for inoperable tumours, resida! tumours,
recurrences after surgery or for older individuals where
‘extensive shal base surgery ot indicated
Embolization used to reduce the vasculaity of
tumour before surgery or Is the sole treatment in the In-
‘operable patients who have recede radaion.
CARCINOMA OF MIDDLE EAR
AND MASTOID
Ati a rare condition, there being one case in 2,000 new
patients examined, ut iis Ihe commonest primary mi
{le ear malignancy.
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‘ania nerves may be paralyzed. There s dysphagia and
Foaseness with unilateral paralysis of the soft palate
playa (X, X and vocal cord (X) with weakness of the
fraperts nd sternomastoid muscles (XD and atopy of
al or tongue (X,
Tumour may present asa mass over the mastold or in
the nasopharyne.
‘ns of intracranial involvement may also occu
4. Avie Baur. At al stages, auscultation with steih-
‘scope over the mastoid may reveal syto brut.
Some glomus tumours were atecholaminesand pro:
‘auc symptoms ke headache, sweating palpation, Ny-
pertension and ams, and requ furor investigations.
5. RULE OF 105. Remember that 10% ofthe tumours are
ala, 10% mulucentieoccurngin mor than one ste)
and upto 10% functional, Le hey Secret catecholamines.
DIAGNOSIS.
In addition to thorough history and physical examin
tion, the patient Is checked-up to find out the extent
fof tumour other associated glomus tumours and ser
levels of atecholamines or thelr breakdown products in
ine (anliyImandelic aid, metanephrine, ic). Inves
tigations include:
1. Courerep Towocraruy (CT) Scax HEAD. Using
‘bone window, 1 mım thin sections are ett helps to dis
{ingulsh glomus tympanicum from the glomus agulare
tumour by Identification of caroicofüguarspine which
A eroded in the latter. CT sean also help to diferent
ste it rom the aberant carotid artery, high ov dehiscent
Jugular but.
2. MRL It shows soft issu extent of tumour. Magnetic
resonance angiography and venography further help to
‘elineate invasion of jugular bulb and vein or compres
Som of the carotid arte
3. CT Hap AND MRI Comm, together provide an
Sollen preoperative guidance ln the differential dag
toss of pero apex lesions,
a. Four-Vesset ANGIOGKAMI I is necesa when CT
"head shows involvement of Juglar bulb, carotid artery or
Inradural extension. I also helps to delineate any other
lomas tumor (as they may be multiple), Bid the feed
Ing veses or embolization of tumout required.
5. BRAIN PERFUSION AND FLOW STUDIES. They ate nic-
say when tumour is pressing on internal carotid artery
Ifthe case nee surgery, brain person and adequacy of
omita internal caotidartery and cle of Wills ean
esse I needed, xenon blo flow and otope stu
‘es are done or precise blood Noy, and the rk of stoke
nd need for surgical replacement of internal aot artery
6. EMBOLIZATION, In large tumours, embolization of
{coding vessels 1-2 days before operation helps 10 seduce
‘ood los
7. Borsy. Preoperative biopsy of the tumour or digno.
SS 1 ever done, Clinic! and radiologie features ae very
haractorist to make dagnoss. Tumours very vascular
and bleeds profusely. There I ls Hood of injuring
ine high jugular bulb or aberrant internal tot artery I
lagnessIsmistaken,
‘TREATMENT
A consists of
1. Surgical removal
2: Radiation.
À Emol
À: Combination ofthe above techniques
Surgical approaches to glomus tumours
1. TRANSCANAL APPROACH, Suited for limited glomus
impanicum tumour where entire circumference of the
{tumour s visible, only tympanotomy wil suffice to gain
ces tothe tumor
2. Hyporvessic Arrnonct. Suited fr tumours limit
‘Sito promontory with extension to hypotympanum but
‘ot into the mastot. A superiorly based fympanom tal
fap ls rad by postauricalar approach. Bony inferior
tympanic ring is died away to ee the Tower Lit of
3. EXTINDED FACIAL RECESS Arrnoacı. Use for glo
‘us tympanicum extending into maso but not nto
the jugular bulb I extensive, modified radical operation
sons.
4. Mastom-Neck Arraoaeat, Use for glomus jugulare
tumours not extending 0 Internal carol artery, poste.
Hor ramal fossa or neck
$. InnearEwronat Fossa APPROACH OF FISH, Used for
large glomus gular tamous.
6. TRANSCONDYLAR APPROACH. Used for tumours
extending towards foramen magnum, Usually they are
recurrent glomus jugulare tumours I gives approach to
‘anlocerical Junction with Exposure of excita con
pie and jagulr uber.
Radiation weatment does not cure the tumour but
may reduce is vasculanty and ares ls growth. Radio
tion is tse for inoperable tumours, resida! tumours,
recurrences after surgery or for older individuals where
‘extensive shal base surgery ot indicated
Embolization used to reduce the vasculaity of
tumour before surgery or Is the sole treatment in the In-
‘operable patients who have recede radaion.
CARCINOMA OF MIDDLE EAR
AND MASTOID
Ati a rare condition, there being one case in 2,000 new
patients examined, ut iis Ihe commonest primary mi
{le ear malignancy.
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AETIOLOGY
It ae age group of 40-60 years and i slighty more
common in female, Most caus (9%) have associated
longstanding car discharge. Chronic tation may be
the causative factor in such cates, Some cases ae son.
in radical mastoid cas. Primary carcinoma of mastoid
cells also sen in adv dal painters
PATHOLOGY
“Tumour may arise primarily from middle ear or be an ex:
tension of arcinoma of the deep meat, Squamous call
Variety iby far the most common, Adenocarcinoma may
‘ceasonally be sen; arses fom he glandular elements
‘oF mide ar
Sratan oF Tusoun. To begin with, carcinoma destroys
‘sles, facial cana, interna eat, jugular bulb, carotid ca
halo deep bony meatus and mastod. I may spread
Fous pyramid tomar ts apes. Duta susy resista
1 may spread to the parotid gland, temporomandibular
join intrtempora fossa and down the eustachian tube
to nasopharynx. Lymph node enlargement occurs at
(CLINICAL FEATURES
Patient often presents with ll
honte suppurative ofits medi.
Features in age group of 40-60 years may arouse suspicion
of maligna:
1. Chronic foutsmeling ascharge especially wh
2. Pain which is usually severe and comes a night
3. Facial ply.
4. Frable, haemorrhage granuations or polyp.
$. Appeatance of or increase in hearing los or vertigo.
blood
DIAGNOSIS
Definitive diagnosis is made only on biopsy. Extent of dis
‘ease i judged by clinical and radiological examination.
{CT scan and angiography are seul inthe assessment of
disease
TREATMENT
A combination o surgery and radiotherapy gives better
results. Surgery const OÙ radical mastoldectomy, sub
total or total pewosectomy depending on the extent of
Chapter 17 — Tumour of Mile Ear and Masoid 123
igure 17. A yen id hid with booms fhe ht
(m rand mato Hes dc pay onthe ame he
Radiotherapy alone is given as a palltive measure
‘when tumour involves cranial nerves (XA to IIH) OF
Spreads int the cranial eat othe nasopharyn.
SARCOMAS
+ RuanboxwosancoMs. Its 3 te tumour, mostly af
fing eden. It arses from the embryonie muscles
tise o the plrpotential mesenchyme. In cry tages,
I mimi cone suppurative ots mesa with ear i
Charge, polyp or granuatons Facial palsy occurs ely
(Hau 11) Diagnosis made only on biopsy rognoss
theteatment of hole Surgery s done in selected oa.
+ Orusx SARCOMAS. Ostcosarcoma, lymphoma, bros.
Soma and chondrosarcoma are rare. Dita metastases
re scen in the lungs or bone. Prog is poor
SECONDARY TUMOURS
Tumours of extemal auditory meatus, parotid gland or
nasophoryx may invade middle car cet eher theo
the preformed pathways oF bone erosion
Sometimes, temporal bone Me site of distant me
tastases in advanced case of carcinoma of the breast,
bronchus, prostate, kidney or gastrointestinal tat
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It ae age group of 40-60 years and i slighty more
common in female, Most caus (9%) have associated
longstanding car discharge. Chronic tation may be
the causative factor in such cates, Some cases ae son.
in radical mastoid cas. Primary carcinoma of mastoid
cells also sen in adv dal painters
PATHOLOGY
“Tumour may arise primarily from middle ear or be an ex:
tension of arcinoma of the deep meat, Squamous call
Variety iby far the most common, Adenocarcinoma may
‘ceasonally be sen; arses fom he glandular elements
‘oF mide ar
Sratan oF Tusoun. To begin with, carcinoma destroys
‘sles, facial cana, interna eat, jugular bulb, carotid ca
halo deep bony meatus and mastod. I may spread
Fous pyramid tomar ts apes. Duta susy resista
1 may spread to the parotid gland, temporomandibular
join intrtempora fossa and down the eustachian tube
to nasopharynx. Lymph node enlargement occurs at
(CLINICAL FEATURES
Patient often presents with ll
honte suppurative ofits medi.
Features in age group of 40-60 years may arouse suspicion
of maligna:
1. Chronic foutsmeling ascharge especially wh
2. Pain which is usually severe and comes a night
3. Facial ply.
4. Frable, haemorrhage granuations or polyp.
$. Appeatance of or increase in hearing los or vertigo.
blood
DIAGNOSIS
Definitive diagnosis is made only on biopsy. Extent of dis
‘ease i judged by clinical and radiological examination.
{CT scan and angiography are seul inthe assessment of
disease
TREATMENT
A combination o surgery and radiotherapy gives better
results. Surgery const OÙ radical mastoldectomy, sub
total or total pewosectomy depending on the extent of
Chapter 17 — Tumour of Mile Ear and Masoid 123
igure 17. A yen id hid with booms fhe ht
(m rand mato Hes dc pay onthe ame he
Radiotherapy alone is given as a palltive measure
‘when tumour involves cranial nerves (XA to IIH) OF
Spreads int the cranial eat othe nasopharyn.
SARCOMAS
+ RuanboxwosancoMs. Its 3 te tumour, mostly af
fing eden. It arses from the embryonie muscles
tise o the plrpotential mesenchyme. In cry tages,
I mimi cone suppurative ots mesa with ear i
Charge, polyp or granuatons Facial palsy occurs ely
(Hau 11) Diagnosis made only on biopsy rognoss
theteatment of hole Surgery s done in selected oa.
+ Orusx SARCOMAS. Ostcosarcoma, lymphoma, bros.
Soma and chondrosarcoma are rare. Dita metastases
re scen in the lungs or bone. Prog is poor
SECONDARY TUMOURS
Tumours of extemal auditory meatus, parotid gland or
nasophoryx may invade middle car cet eher theo
the preformed pathways oF bone erosion
Sometimes, temporal bone Me site of distant me
tastases in advanced case of carcinoma of the breast,
bronchus, prostate, kidney or gastrointestinal tat
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Chapter 18
Acoustic Neuroma
Acoustic neuroma is also known as vestibular schwumna-
‘ma neunlemmona or eg nerve tumour
INCIDENCE
Acoustic neuroma constitutes 80% ofall erbellopontine
gle tumours and 10% ofal the bran tumours,
PATHOLOGY
Its a benign, encapsulated, extremely sow. growing tu
mou ofthe Vllt nerve. Microscopkally consis of
longited spindle cals with rodshaped nuci ing
rows or palades. Bilateral tumours sre seen in patients
‘eth neurofibromatos
‘ORIGIN AND GROWTH OF TUMOUR
‘the estibuar, ut ar trom thecocheardvision of VI
eee within ie internal autor canal suse 1 DAS
‘expands, causes widening and erosion ofthe canal and
then appear in the ceebdlopontine ange. Here, t may
grow aerosaperiody to involve Vth nerve or inferior
do vole the Kt, Xul amd Ali cranial neves In late
Stages 1 cases displacement of bainstem, pressure on
seb and rabed Intracranial tension (Cua: 182)
Te growth of the tumours extremely don and the his:
Horymay extend over several Yeas
CLASSIFICATION
Depending on the size, the tumout is classified as:
1. Intacanaicular (when its confined to internal au
tory canal).
2, Smal size (up 10 1.8 em)
3. Medium sue (1-5-4 em)
4. Large se over cm)
CLINICAL FEATURES
1. Ace AND SEX. Tumour Is mostly sen In age group of
40-60 years. oth sexes ae equally affected
2. Cocuteovestanuan Surrous. They are the eal
‘st symptoms when tumour I sl intracanalicuar and
are caused by pressure om cochlear or vestibular nerve
‘bres or onthe Intemal auditor artery
Progressive unilateral senora bearing os, often
accompa by mis, the presenting spt In major
lity of cae. There is marked dificult in understanding
speech, out of proportion tothe pute tome hearing los
This feature character of acoustic neuroma, Some
Patients may ge sudden hearing loss.
Viseular Sjmptoms are lmbolance or unsteadinss.
‘True vertigo is seldom seen.
3. CRAMEAL Nenve BwvouvEMEN
‘There I educed corneal sensitivity, numbness or pr.
essa of face, Involvement of tls nerve indicate
that the tumour i roughly 28 em in diameter and
‘ccupies the cerebellopontine ange
Vi nore. Sensory Abres are affected ea. Ter 1
poses of posterior meatal wall (tzebergers
sien) loss of taste a este by lectrogustometos) and
Teducedlarimation on Schirmer test Motor fies are
more resistant and are affected late. Delayed Blin re
lex may be an ely manifestation,
Dah ad Xu nerves. Theres dysphagla and hoarseness
due o plata, pharyngeal and laryngeal paras
(ther canal nerves. XI and All, Hid, Ih and
Vit ar affected when tumour Is very large.
ave 1 be involve
4. Bauer Invonvaaaxt. There is alas, weak:
miss and numbness of the arms and legs with exagge.
ted tendon eles. They are seen when long motor and
Sensory tats are involved
5. CERUMELLAR INVOLVEMENT. Pressure symptoms on
‘rebel are scen in lage tumours. This 3 reveled
by fingernose te, knees! text, dysdiadochokinesa,
taxi git and inability to walk long straight ine with
den to fall to he ae side
6. RAISED INTRACRANIAL TENSION. This is also a late
tue. There is headache, nausea, vomiting, diplopia
¿ue to Vith nerve involvement and paplloedema with
blaring of vison
INVESTIGATIONS AND DIAGNOSIS
Attempts should be made to diagnose the tumour in ts
‘tologeal phase when ii sil tnracanaicaae. This
ds possible when all cases of unilateral sensorineural
hetring loss with tinnitus or imbalance are carefully
evaluated
1. AUDIOLOGIEAL Tests, See Ja 15. ordlflerence be
en cochlea and retrocochlcr sions,
125
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Acoustic Neuroma
Acoustic neuroma is also known as vestibular schwumna-
‘ma neunlemmona or eg nerve tumour
INCIDENCE
Acoustic neuroma constitutes 80% ofall erbellopontine
gle tumours and 10% ofal the bran tumours,
PATHOLOGY
Its a benign, encapsulated, extremely sow. growing tu
mou ofthe Vllt nerve. Microscopkally consis of
longited spindle cals with rodshaped nuci ing
rows or palades. Bilateral tumours sre seen in patients
‘eth neurofibromatos
‘ORIGIN AND GROWTH OF TUMOUR
‘the estibuar, ut ar trom thecocheardvision of VI
eee within ie internal autor canal suse 1 DAS
‘expands, causes widening and erosion ofthe canal and
then appear in the ceebdlopontine ange. Here, t may
grow aerosaperiody to involve Vth nerve or inferior
do vole the Kt, Xul amd Ali cranial neves In late
Stages 1 cases displacement of bainstem, pressure on
seb and rabed Intracranial tension (Cua: 182)
Te growth of the tumours extremely don and the his:
Horymay extend over several Yeas
CLASSIFICATION
Depending on the size, the tumout is classified as:
1. Intacanaicular (when its confined to internal au
tory canal).
2, Smal size (up 10 1.8 em)
3. Medium sue (1-5-4 em)
4. Large se over cm)
CLINICAL FEATURES
1. Ace AND SEX. Tumour Is mostly sen In age group of
40-60 years. oth sexes ae equally affected
2. Cocuteovestanuan Surrous. They are the eal
‘st symptoms when tumour I sl intracanalicuar and
are caused by pressure om cochlear or vestibular nerve
‘bres or onthe Intemal auditor artery
Progressive unilateral senora bearing os, often
accompa by mis, the presenting spt In major
lity of cae. There is marked dificult in understanding
speech, out of proportion tothe pute tome hearing los
This feature character of acoustic neuroma, Some
Patients may ge sudden hearing loss.
Viseular Sjmptoms are lmbolance or unsteadinss.
‘True vertigo is seldom seen.
3. CRAMEAL Nenve BwvouvEMEN
‘There I educed corneal sensitivity, numbness or pr.
essa of face, Involvement of tls nerve indicate
that the tumour i roughly 28 em in diameter and
‘ccupies the cerebellopontine ange
Vi nore. Sensory Abres are affected ea. Ter 1
poses of posterior meatal wall (tzebergers
sien) loss of taste a este by lectrogustometos) and
Teducedlarimation on Schirmer test Motor fies are
more resistant and are affected late. Delayed Blin re
lex may be an ely manifestation,
Dah ad Xu nerves. Theres dysphagla and hoarseness
due o plata, pharyngeal and laryngeal paras
(ther canal nerves. XI and All, Hid, Ih and
Vit ar affected when tumour Is very large.
ave 1 be involve
4. Bauer Invonvaaaxt. There is alas, weak:
miss and numbness of the arms and legs with exagge.
ted tendon eles. They are seen when long motor and
Sensory tats are involved
5. CERUMELLAR INVOLVEMENT. Pressure symptoms on
‘rebel are scen in lage tumours. This 3 reveled
by fingernose te, knees! text, dysdiadochokinesa,
taxi git and inability to walk long straight ine with
den to fall to he ae side
6. RAISED INTRACRANIAL TENSION. This is also a late
tue. There is headache, nausea, vomiting, diplopia
¿ue to Vith nerve involvement and paplloedema with
blaring of vison
INVESTIGATIONS AND DIAGNOSIS
Attempts should be made to diagnose the tumour in ts
‘tologeal phase when ii sil tnracanaicaae. This
ds possible when all cases of unilateral sensorineural
hetring loss with tinnitus or imbalance are carefully
evaluated
1. AUDIOLOGIEAL Tests, See Ja 15. ordlflerence be
en cochlea and retrocochlcr sions,
125
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126 SECTION! — Diseases of Ear
(a) Pure tone audiometry vil show sensorneura hs
Ing loss, more marked in high frequencies,
(D) Speech audiometry shows poor speech discrimina:
tom and ths is disproportionate o pure tone ha
Ingles. Rotover phenomenon, Le reduction ofa
‘mination score when loudness increased beyond
{particular imi most commonly observed.
(€) Recruitment phenomenon i absent.
(6) Short Increment Sensi Indo BIS test wil show
score of 0-20% in 70-90% of eases,
(e) Threshold tone decay test shows reirocochcar type
ofen.
2. Stareonat Ren Dicav Test. (ep. 27)
3. Vistinutan Tests Caloric test wil show diminished
ot absent response in 96% of patients. When tumour Is
Very small alor test may be normal,
4. NEUROLOGICAL Tests, Complete examination of
«ramal nerves, cerebellar functions, brainstem signs of
pyramidal and sensory tats should be done. Fundas i
examined forbluring o dise margins or papilloma,
egos vota rane
EEE
Cocinar german sra
ES rama a
ane gee eat)
gare 81. ec ad dt er oy cn
Een
$. Ramtotocica Tests
(a) Plate X as Wransrbita, Servers, Townes and sb.
‘mentovertcal views) ge postive ndings in BON of
patients. However small ntracanalcular tumours are
ot detected
Computed tomegraphy (CT) scan. A tumour that pro-
jects even OS cm into the posterior fosa can De de-
fected by a CT scan. I combined with intrathecal
a even te Intramcatl tumour canbe detected CT
Scam has replaced earlier methods of pneumoenccph-
Slogaphy and mye meatograpy.
(© ME wid gadalinitnconnast. I 8 superior to CT scan
and isthe old standar or diagnosis of acoustic neu
roma. ntacanalicular tumour, of even a few mil
mets can be easily diagnosed by this method
(@) Vseralansigapiy. This helpful to diferentiate
acoustic neuroma ftom other tumours of Cerco:
pontine ange when doubt exists.
©
6. EVOKED RIsPONSE AUDIOMETRY (MERA). Its very
‘ful in the diagnosis of rewocochlea lesions. In the
presence of VIII nerve tumour, dey of > 02 me In
fave bette tu ears gant (ep 28
7. CSF EXAMINATION, Protein level ls raise, Lumbar
puncte is usually avoided
Important vs for work-up of acoustic neuroma are
ven below:
+ Pure tone audiometry.
2 specch discrimination score.
Rotlover curve
2 Staph ex decay,
+ Evoked response audiometry.
2 Mi contest
Figure 18.2, Acute neroms aná sepas.) Iacanlclr (2) Tumoor xtecing ina cerontpontine ge (Tao presi,
NV (0) Voy ge mou resin on CNB XH, an ae and rd
mebooksfree.com
(a) Pure tone audiometry vil show sensorneura hs
Ing loss, more marked in high frequencies,
(D) Speech audiometry shows poor speech discrimina:
tom and ths is disproportionate o pure tone ha
Ingles. Rotover phenomenon, Le reduction ofa
‘mination score when loudness increased beyond
{particular imi most commonly observed.
(€) Recruitment phenomenon i absent.
(6) Short Increment Sensi Indo BIS test wil show
score of 0-20% in 70-90% of eases,
(e) Threshold tone decay test shows reirocochcar type
ofen.
2. Stareonat Ren Dicav Test. (ep. 27)
3. Vistinutan Tests Caloric test wil show diminished
ot absent response in 96% of patients. When tumour Is
Very small alor test may be normal,
4. NEUROLOGICAL Tests, Complete examination of
«ramal nerves, cerebellar functions, brainstem signs of
pyramidal and sensory tats should be done. Fundas i
examined forbluring o dise margins or papilloma,
egos vota rane
EEE
Cocinar german sra
ES rama a
ane gee eat)
gare 81. ec ad dt er oy cn
Een
$. Ramtotocica Tests
(a) Plate X as Wransrbita, Servers, Townes and sb.
‘mentovertcal views) ge postive ndings in BON of
patients. However small ntracanalcular tumours are
ot detected
Computed tomegraphy (CT) scan. A tumour that pro-
jects even OS cm into the posterior fosa can De de-
fected by a CT scan. I combined with intrathecal
a even te Intramcatl tumour canbe detected CT
Scam has replaced earlier methods of pneumoenccph-
Slogaphy and mye meatograpy.
(© ME wid gadalinitnconnast. I 8 superior to CT scan
and isthe old standar or diagnosis of acoustic neu
roma. ntacanalicular tumour, of even a few mil
mets can be easily diagnosed by this method
(@) Vseralansigapiy. This helpful to diferentiate
acoustic neuroma ftom other tumours of Cerco:
pontine ange when doubt exists.
©
6. EVOKED RIsPONSE AUDIOMETRY (MERA). Its very
‘ful in the diagnosis of rewocochlea lesions. In the
presence of VIII nerve tumour, dey of > 02 me In
fave bette tu ears gant (ep 28
7. CSF EXAMINATION, Protein level ls raise, Lumbar
puncte is usually avoided
Important vs for work-up of acoustic neuroma are
ven below:
+ Pure tone audiometry.
2 specch discrimination score.
Rotlover curve
2 Staph ex decay,
+ Evoked response audiometry.
2 Mi contest
Figure 18.2, Acute neroms aná sepas.) Iacanlclr (2) Tumoor xtecing ina cerontpontine ge (Tao presi,
NV (0) Voy ge mou resin on CNB XH, an ae and rd
mebooksfree.com
DIFFERENTIAL DIAGNOSIS
Acoustic neuroma should be diferentated from the
cocher pathoogy (ke. Ménieres disease) and other cr
Soon a nour € menciona, primary
‘cholesteatoma and arachnaidal gst Gabi 1.
‘TREATMENT
SURGERY
Surgcal removal ofthe rumour ithe treatment of choice.
Surgical approach will depend upon the size of tumour,
The various approach are
1. Middle cranial fosa approach,
2. Transabyeinthine approach
3. Suboceptal(etosigmold) approach,
44 Combined wanslabyrnthinesuboccpital approach
RADIOTHERAPY
Conventinalaiiotherapy by external beam has no role in
the treatment of acoustic neuroma due to lve tolerance
‘ofthe central nervous system 1 radiation,
Chapter 18 — Acoustic Newoma 127
einge
{peo (leet)
À Sor obec res 9. ENV IX
if or Gamme ae surge: 18 form of stereotac
tic radiotherapy where radiation energy Is converged on
the tumour, thus minimizing Ws eet on the surround.
Ing normal tse. This eases ares of the growth of the
tumour and also reduction in 4 sie. I can be used in
patents who else surgery or have containdeatons to
Surgery or in those witha residual tumour.
‘Kaif surgery Is done though linear accelerator and
gamma knife though a Cobalt 6D source.
(hier kn. Ie isan Improvement over the above It is
totaly rames and more accurate I ses realtime in
age guldance technology through computercontolled
robot
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Acoustic neuroma should be diferentated from the
cocher pathoogy (ke. Ménieres disease) and other cr
Soon a nour € menciona, primary
‘cholesteatoma and arachnaidal gst Gabi 1.
‘TREATMENT
SURGERY
Surgcal removal ofthe rumour ithe treatment of choice.
Surgical approach will depend upon the size of tumour,
The various approach are
1. Middle cranial fosa approach,
2. Transabyeinthine approach
3. Suboceptal(etosigmold) approach,
44 Combined wanslabyrnthinesuboccpital approach
RADIOTHERAPY
Conventinalaiiotherapy by external beam has no role in
the treatment of acoustic neuroma due to lve tolerance
‘ofthe central nervous system 1 radiation,
Chapter 18 — Acoustic Newoma 127
einge
{peo (leet)
À Sor obec res 9. ENV IX
if or Gamme ae surge: 18 form of stereotac
tic radiotherapy where radiation energy Is converged on
the tumour, thus minimizing Ws eet on the surround.
Ing normal tse. This eases ares of the growth of the
tumour and also reduction in 4 sie. I can be used in
patents who else surgery or have containdeatons to
Surgery or in those witha residual tumour.
‘Kaif surgery Is done though linear accelerator and
gamma knife though a Cobalt 6D source.
(hier kn. Ie isan Improvement over the above It is
totaly rames and more accurate I ses realtime in
age guldance technology through computercontolled
robot
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Page ot intentional blank
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Chapter 19
The Deaf Child
{Children with profound (>90 dos) or total deafness a
to develop spoveh and have often been termed! dente
‘or dean dumb. However, these children have no defect
In thet speech producing apparatus. The main efec Is
aimes They Have never head spocch and therefore do
‘not develo it, In lesser degrees of heating os, speech
cs develop but is defective. The period Lom bith to
‘Sears off etal forthe development of speech and
language, therefore, there 1 need for erly denuiication
and assessment of fearing loss and eatyreabatation in
‘nants and hen I was observed that children Whose
hearing loss was served and managed before 6 months
of age had higher scores of vocabulary, better expressive
and comprehensive language lb than those diagnose
And managed ater 6 months of age emphasing Ihe im-
portance of early dentlcation and ueatment.
AETIOLOGY
Hearing los in a chi may develop from causes before
bith (prenatal), during birth (perinatal) or thereafter
(postnatal.
A. PRENATAL CAUSES
‘They may peri to the infant or he mother
1: Nat FACIORS. An infant maybe born with inner ear
anomalies due 10 gente or nongenete causes Anoma:
lies may affect inner ear alone (nonsyndromic) or may
form par ot syndrome yom)
“Anomalies affecting the Inner car may invoive only
‘the membranous labyrinth or both the membranous and
bony labyrinths. They include:
(3) chit plas ts the most common innerearanom-
alse ony alpin normal Superior prt of mera
nous labyrinth (atice and semiccular ducts) slo
formal Dyspasa 1 en in che cochlea and scale;
hence so called eher pa. kind
as an autosomal recessive nonsymdromie tt
lamer pls. Ie aes only the bl tum of
‘membranous cochlea. Thus only high feyuencis are
Acid, Residual bering is preset in ow frequencies
and an beexploited by amplification with hearing aid.
Bing Seemann dpplai: There complete absence
‘of membranous Bla
(9 Mice pls, Theres complete absence of bony and
membranous ityrinth, ven the pros apex le ab-
Sent but external and middle ars may be complete
affected. No hearing ads o cochar implanta
fan be used,
©)
(e) Mani dysplasia. Onty basal cll is present or cochez
15 LS turns, There ls Incomplet partition between the
ic due 10 absence of osseous sprl lamina, Conde
unilateral or tlsteral, Ths dloraty may Be
sen in Pendred, Wardenburg, branchlooto-renä,
TreacherCollins and Wildenanck syndromes.
(9 Enlarge vestibular aqueduct. Vestibular aqui sen
larged (22 mm, eidolgmphatc Sac i also enlarged
and can be Seen on Ts MI cases early onset se
Sorineurl hearing loss which Is progressive. Vertigo
may be present, Prilymphati tla may occur
(Sonar cal malformations oth superior aná ltr
or only lateral sericea canal malformations may
‘peace Mey can be Mente on Imaging techs
2. Marenwat Acton
da) Infections during pregnancy.
db) Drags during pregnancy
(© Hatin to mother in the Fst trimestr
(a) Other factors
Syndromes commonly associated with hearing loss a
sien ta Table 11
(a) Ifcios during pregnancy nfceons which affc he
‘developing fetus ae toxoplasmoss, rubella, ytomey-
Slovirises, herpes type Land 2 and Syphlls Remem-
ber macmoni, TORCHES.
(©) Drags dun pray Sucptomycin, gentamicin, 0-
bramycin, smikacin, quinine or chloroquine, when.
ven to te pregnant mother, cross the placental bat
Fier and damage the cochlea. ‘thalidomide not only
fics ear Du also cause abnormalities of Hib,
Mean, face, lp and palate
(e) Ratton to mother ha the fist mese
(a) Other cos. Nurtional deficiency, diabetes, torae-
fais and thyroid deficieney. Matera alcoholism Is
so teratogenic to the developing aury system.
B. PERINATAL CAUSES,
They relate to causes during bth or in early neonatal
etd. Tey ae as follows,
1. Axoxta, I damages the cochlear nuck and causes
emoriag into the car, Placenta proc, prolongs
labour, cord round the neck and prolapsed cord can all
muse fetal anol
2. Prasarunrry AnD Low Burra Wat Bor before
cm or with bh weightless than 1500 3.31).
3. ur INJURIES. cg forceps delivery. They may cause
intracanial haemorrhage wih extravasation of blood
{nt the inner ear
The Deaf Child
{Children with profound (>90 dos) or total deafness a
to develop spoveh and have often been termed! dente
‘or dean dumb. However, these children have no defect
In thet speech producing apparatus. The main efec Is
aimes They Have never head spocch and therefore do
‘not develo it, In lesser degrees of heating os, speech
cs develop but is defective. The period Lom bith to
‘Sears off etal forthe development of speech and
language, therefore, there 1 need for erly denuiication
and assessment of fearing loss and eatyreabatation in
‘nants and hen I was observed that children Whose
hearing loss was served and managed before 6 months
of age had higher scores of vocabulary, better expressive
and comprehensive language lb than those diagnose
And managed ater 6 months of age emphasing Ihe im-
portance of early dentlcation and ueatment.
AETIOLOGY
Hearing los in a chi may develop from causes before
bith (prenatal), during birth (perinatal) or thereafter
(postnatal.
A. PRENATAL CAUSES
‘They may peri to the infant or he mother
1: Nat FACIORS. An infant maybe born with inner ear
anomalies due 10 gente or nongenete causes Anoma:
lies may affect inner ear alone (nonsyndromic) or may
form par ot syndrome yom)
“Anomalies affecting the Inner car may invoive only
‘the membranous labyrinth or both the membranous and
bony labyrinths. They include:
(3) chit plas ts the most common innerearanom-
alse ony alpin normal Superior prt of mera
nous labyrinth (atice and semiccular ducts) slo
formal Dyspasa 1 en in che cochlea and scale;
hence so called eher pa. kind
as an autosomal recessive nonsymdromie tt
lamer pls. Ie aes only the bl tum of
‘membranous cochlea. Thus only high feyuencis are
Acid, Residual bering is preset in ow frequencies
and an beexploited by amplification with hearing aid.
Bing Seemann dpplai: There complete absence
‘of membranous Bla
(9 Mice pls, Theres complete absence of bony and
membranous ityrinth, ven the pros apex le ab-
Sent but external and middle ars may be complete
affected. No hearing ads o cochar implanta
fan be used,
©)
(e) Mani dysplasia. Onty basal cll is present or cochez
15 LS turns, There ls Incomplet partition between the
ic due 10 absence of osseous sprl lamina, Conde
unilateral or tlsteral, Ths dloraty may Be
sen in Pendred, Wardenburg, branchlooto-renä,
TreacherCollins and Wildenanck syndromes.
(9 Enlarge vestibular aqueduct. Vestibular aqui sen
larged (22 mm, eidolgmphatc Sac i also enlarged
and can be Seen on Ts MI cases early onset se
Sorineurl hearing loss which Is progressive. Vertigo
may be present, Prilymphati tla may occur
(Sonar cal malformations oth superior aná ltr
or only lateral sericea canal malformations may
‘peace Mey can be Mente on Imaging techs
2. Marenwat Acton
da) Infections during pregnancy.
db) Drags during pregnancy
(© Hatin to mother in the Fst trimestr
(a) Other factors
Syndromes commonly associated with hearing loss a
sien ta Table 11
(a) Ifcios during pregnancy nfceons which affc he
‘developing fetus ae toxoplasmoss, rubella, ytomey-
Slovirises, herpes type Land 2 and Syphlls Remem-
ber macmoni, TORCHES.
(©) Drags dun pray Sucptomycin, gentamicin, 0-
bramycin, smikacin, quinine or chloroquine, when.
ven to te pregnant mother, cross the placental bat
Fier and damage the cochlea. ‘thalidomide not only
fics ear Du also cause abnormalities of Hib,
Mean, face, lp and palate
(e) Ratton to mother ha the fist mese
(a) Other cos. Nurtional deficiency, diabetes, torae-
fais and thyroid deficieney. Matera alcoholism Is
so teratogenic to the developing aury system.
B. PERINATAL CAUSES,
They relate to causes during bth or in early neonatal
etd. Tey ae as follows,
1. Axoxta, I damages the cochlear nuck and causes
emoriag into the car, Placenta proc, prolongs
labour, cord round the neck and prolapsed cord can all
muse fetal anol
2. Prasarunrry AnD Low Burra Wat Bor before
cm or with bh weightless than 1500 3.31).
3. ur INJURIES. cg forceps delivery. They may cause
intracanial haemorrhage wih extravasation of blood
{nt the inner ear
120. SECTION! — Diseases of Ear
“ype hewrng Onset Cangenal/
oe de
some Type otinhertance
Y. Mire nln bic Campe »
ne En
Count
2 Usersmaome son Deine a
2 Nonoinanes
2 frend Lange: © Ré copla sv congenital m
Ron oméame = Pompe QT mtenatin cc.
4 Pendedirome * Gate roto used Sa ange a
een,
+ Pate Gage test sows
et nan ing alone
betonten + Henn mua Para SL Dane Aer Xe
gong
+ Cone tony.
Trennen 3 Anmongoba pleat ue Cond Coge »
Sine + Cobos tirer
(rand + Hypopl of monde and maa
dd M ins mesa
+ et oie a es
7 come + fap opina Confer Cogent »
(cmc ‘Seren mes
paso pen
obesa
Manda program
1 Premature douse fan res
o + Sada Cente sup »
Same
9. ppt ‘Share su orme Congo m
Sie Fed cera vete
Spa bt
10. Wide gpl tome su Congo nes
some So
RTE
1. Bnchioctorns À ana dons Condor Campe »
aloe pi th prose “raed
Sond conor
12 she ciome > Seat Conde or SNL Deich ”
2 chat pie (een sequence)
{igi aaron
rein ost ars
13 Wonder? Open paca vt ty Conduce SNM One »
nee caro made
+ mes Sn)
1 Het (ss one
eve ico Son Conduce »
Sequence + sas los
Scheie
1 Often or Steer prom
15. atentar 2 Faciles Mined orconducine Campe dar sponcie un
Pré (do? Kowa ts roma Éd
Spa) erate + Pa ogi (Geen
edo à Homer nalen ‘wore
OM smatome) > bulbe dema
mebooksfree.com
“ype hewrng Onset Cangenal/
oe de
some Type otinhertance
Y. Mire nln bic Campe »
ne En
Count
2 Usersmaome son Deine a
2 Nonoinanes
2 frend Lange: © Ré copla sv congenital m
Ron oméame = Pompe QT mtenatin cc.
4 Pendedirome * Gate roto used Sa ange a
een,
+ Pate Gage test sows
et nan ing alone
betonten + Henn mua Para SL Dane Aer Xe
gong
+ Cone tony.
Trennen 3 Anmongoba pleat ue Cond Coge »
Sine + Cobos tirer
(rand + Hypopl of monde and maa
dd M ins mesa
+ et oie a es
7 come + fap opina Confer Cogent »
(cmc ‘Seren mes
paso pen
obesa
Manda program
1 Premature douse fan res
o + Sada Cente sup »
Same
9. ppt ‘Share su orme Congo m
Sie Fed cera vete
Spa bt
10. Wide gpl tome su Congo nes
some So
RTE
1. Bnchioctorns À ana dons Condor Campe »
aloe pi th prose “raed
Sond conor
12 she ciome > Seat Conde or SNL Deich ”
2 chat pie (een sequence)
{igi aaron
rein ost ars
13 Wonder? Open paca vt ty Conduce SNM One »
nee caro made
+ mes Sn)
1 Het (ss one
eve ico Son Conduce »
Sequence + sas los
Scheie
1 Often or Steer prom
15. atentar 2 Faciles Mined orconducine Campe dar sponcie un
Pré (do? Kowa ts roma Éd
Spa) erate + Pa ogi (Geen
edo à Homer nalen ‘wore
OM smatome) > bulbe dema
mebooksfree.com
saone tenues
16. Down yndome + Mec
en) Ne siennes
Sr,
Serena
1 High Inden fus out med
e sa
conducive
Chapter 19 — The Deal nid 131
protein,
ta
‘net Congenital
dors) pe of aertance
A rues not po, ce mate nar ee om à age IM Le roach a
eh net pe
al
Figure 1.1. Wardenburg ome Note wie foi, hetero
‘ram es a Sept in
-
gure 19.2. Neichroma il. Is showing fin cl
4. NeONAraL Jauxic. Blirubin level grater than
20 mah damages the cocher mic
5.Ntoxaraı MENINGITIS
6.surs
7. Tove SPENT IN NEONATAL ICU
8. OrO10XIC Das. used for neonatal meningitis or
septicaemia
C. POSTNATAL CAUSES,
1. Generic. Though deans is gent, t manifests later
An childhood or adult ite, Dean may occur alone 3 in
Fama presse serial defies or in ssocation
‘with certain syndrome, 69. Apor, KppelFll Hurley et
2. Nocevertc. They are essential same as in adults
And include:
(a) Vial infections (measles, mumps, varie
a) meningitis and encephalitis
0) Secretory otitis media
(© Ototoxt drugs
(9 Trauma, eg fractures of temporal bone, middle ear
surgery or perlymph Kak.
(0 Noise induced deafness
inten
EVALUATION OF A DEAF CHILD
FINDING THE CAUSE
"Tis may require detailed history of prenatal, perinatal or
postnatal causes, aly histor, phystal examination and
‘Certain investigations depending on the cause suspected
1. Suspicion of hearing las. Heating loss suspected i
(Othe child eps through loud noses unperturbed or
Faso state to loud sounds, lst develop pecch
aU 1-2 yeas. À puta heating ld may havea de:
fective speech and perform pool in choot and bel
Bold mentally retarded Tes essential hat al children
ts lo heating loss should be screened and alowed.
mebooksfree.com
16. Down yndome + Mec
en) Ne siennes
Sr,
Serena
1 High Inden fus out med
e sa
conducive
Chapter 19 — The Deal nid 131
protein,
ta
‘net Congenital
dors) pe of aertance
A rues not po, ce mate nar ee om à age IM Le roach a
eh net pe
al
Figure 1.1. Wardenburg ome Note wie foi, hetero
‘ram es a Sept in
-
gure 19.2. Neichroma il. Is showing fin cl
4. NeONAraL Jauxic. Blirubin level grater than
20 mah damages the cocher mic
5.Ntoxaraı MENINGITIS
6.surs
7. Tove SPENT IN NEONATAL ICU
8. OrO10XIC Das. used for neonatal meningitis or
septicaemia
C. POSTNATAL CAUSES,
1. Generic. Though deans is gent, t manifests later
An childhood or adult ite, Dean may occur alone 3 in
Fama presse serial defies or in ssocation
‘with certain syndrome, 69. Apor, KppelFll Hurley et
2. Nocevertc. They are essential same as in adults
And include:
(a) Vial infections (measles, mumps, varie
a) meningitis and encephalitis
0) Secretory otitis media
(© Ototoxt drugs
(9 Trauma, eg fractures of temporal bone, middle ear
surgery or perlymph Kak.
(0 Noise induced deafness
inten
EVALUATION OF A DEAF CHILD
FINDING THE CAUSE
"Tis may require detailed history of prenatal, perinatal or
postnatal causes, aly histor, phystal examination and
‘Certain investigations depending on the cause suspected
1. Suspicion of hearing las. Heating loss suspected i
(Othe child eps through loud noses unperturbed or
Faso state to loud sounds, lst develop pecch
aU 1-2 yeas. À puta heating ld may havea de:
fective speech and perform pool in choot and bel
Bold mentally retarded Tes essential hat al children
ts lo heating loss should be screened and alowed.
mebooksfree.com
132 SECTIONI — senses ofr
+ Neonat eng proces
"ae
on pone re
‘eter trato some
e
scouts (6-18 ment)
nd nas Oman yes)
artnet sy
Horda 57e)
Re
ee,
2. Risk factor for hearing loss in children (Recom
mendatons of Joint Commitee on Infant Hesring—
Updated 10 1004).
(a) Family history of hearing os.
(0) Prenatal infections TORCHES)
(e) Cramiotacal anomalies including those of pinna
andar canal.
(a) Birth weight es than 1500 86,1)
(e) Hypesbiiestinsemis requiring exchange tanshaion
(0) Ototexic medications Included but not limited
o aminogiycoides usc! in multiple course or in
‘combination with loop dures
(q Bacteria meningitis.
(Apgar score of 0-4 a 1 min or 0-6 at $ min
(i) Mechanical ventilation for days longer
{D Stigmata or other ndings associated with a
Syndrome known to include sensorineural and/or
<onducive eating los.
ASSESSMENT OF HEARING IN INFANTS
AND CHILDREN
Assessment of auditory function in neonates, fants and
‘deen demands spec technique, They ae grouped
Under the folowing heads 12192):
1. Scumwne ProceDumEs. They are employed to tes
heating in high-risk" Infants and are based on infant's
behavior response tothe sound signa. I snow ob:
served that 99% of len with one or more nk factors
have normal hearing. On the contary, SX of children
sith sensorineural hearing los had mo risk factor. Th
leads toa programme of universal neonatal screening for
y detection,
“wo Important tests are to study otoacoustic emissions
(ONES and auditory brainstem response (ABR).
(@) OAEs are generated at outer hair cells and can be
Picked up om the extemal eat as the energy pro
{ace by them travels in reverse ection from outer
hair cells — ossicles => tympanic membrane > €
anal where it plcked up. OAES ae absent if outer
middle ear effusion or canal debris due to meconium
‘wich may persist for 3-4 days. They ae normal even
‘shen VII nerves nonfunctional. Ths can be used
Inthe diagnosis of neuropathy of VIT nerve
(9) ARS re generate in response to sound Simulaspre-
Sented tothe car and peked up from the scalp. With
3 response of 30-35 dB ni, the infant who passes
the est and the bearings considered normal Infants
‘sho fal these test an followed up with repeat ets
us et, A igh-frequency marow band noise Is
presented for 2s tothe infant when hei im ight seep. A
oral hearing infant can De aroused ie when
Such stil are presented to him.
“altar response cradle 1 à screening device for new
oras, where aby is placed ina cradle and his behaviour
funk and limb movement, head jerk and respiration) In
response 1 autor stimulation re monitored by tans
Auen can sreen babies with moderate, severe or pro.
found hearing los.
2. LNAvIOUR OnSERVATION AUDIOMETRY. Auditory sige
‘al presented toa inant produces à change in behar
lou eg alerting, cessation of an activity, widening of
96 or facial grimacing. Moo’ ree sone of them and
ans of sudden movement of limbs and extension of
head in sesponse to sound of 80-50 dB. ocheopalperal
ref, the child responds by a blink 0 a Youd sound. In
sation wef, an Infant stops activity or stars eying in
response 10 à sound of 90 dB.
3. Disrmaction Teowwigurs. are used in children
627 monts old, The child at ts age turns is head to
locate une source of sound. In dis test the child sete
his mother lap, an assistant distracts the
tion white the examine produce sound fom be
ftom one ide t se the child wies 10 locate it Sounds.
sed are high frequency ate (8 Ka, low-frequency
um, whispered sound as 75, 5, 5, sylphone, warble
tones mao band noise (800-4000 Ho
4. Coxprmonine eats
(a) Visual winforcoment audiometry (VA Iisa condition
ing technique in which cl stained o Took for a
uit stimulus y turning his head. This behaviour
is reinforced by Hashing Hight or an animated toy
‘This test helps o determine the hearing threshold us
ing standard audiometric techniques. The auditor
stimulus is delivered by headphonesor bete til y
inset earphones which are accepted better and are
aso light welght. Tes Is well-suited between the de
‘elopmental age of 6 months 0 2 wars.
(©) Pay mama. The ch i conditioned to perform
an ct such a placing a mabletn a Box, puting ing,
Om à pos or putting a plastic Block in à bucket each
eas sud signal Bach corct performance
fof the acti enfored With praise, encouragement or
reward. ar specie tveshals can be determined by
Standard audiometic techniques This test can be used
in children with developmental age of 2-4 0r 8 yeas.
(6) Spc adam The childs aed 0 repeat the
ames of certain objects or 1 point them out on the
Pictures. The voice can be gradually lowered. In this
"vay, hearing evel and speech discrimination can be
mebooksfree.com
+ Neonat eng proces
"ae
on pone re
‘eter trato some
e
scouts (6-18 ment)
nd nas Oman yes)
artnet sy
Horda 57e)
Re
ee,
2. Risk factor for hearing loss in children (Recom
mendatons of Joint Commitee on Infant Hesring—
Updated 10 1004).
(a) Family history of hearing os.
(0) Prenatal infections TORCHES)
(e) Cramiotacal anomalies including those of pinna
andar canal.
(a) Birth weight es than 1500 86,1)
(e) Hypesbiiestinsemis requiring exchange tanshaion
(0) Ototexic medications Included but not limited
o aminogiycoides usc! in multiple course or in
‘combination with loop dures
(q Bacteria meningitis.
(Apgar score of 0-4 a 1 min or 0-6 at $ min
(i) Mechanical ventilation for days longer
{D Stigmata or other ndings associated with a
Syndrome known to include sensorineural and/or
<onducive eating los.
ASSESSMENT OF HEARING IN INFANTS
AND CHILDREN
Assessment of auditory function in neonates, fants and
‘deen demands spec technique, They ae grouped
Under the folowing heads 12192):
1. Scumwne ProceDumEs. They are employed to tes
heating in high-risk" Infants and are based on infant's
behavior response tothe sound signa. I snow ob:
served that 99% of len with one or more nk factors
have normal hearing. On the contary, SX of children
sith sensorineural hearing los had mo risk factor. Th
leads toa programme of universal neonatal screening for
y detection,
“wo Important tests are to study otoacoustic emissions
(ONES and auditory brainstem response (ABR).
(@) OAEs are generated at outer hair cells and can be
Picked up om the extemal eat as the energy pro
{ace by them travels in reverse ection from outer
hair cells — ossicles => tympanic membrane > €
anal where it plcked up. OAES ae absent if outer
middle ear effusion or canal debris due to meconium
‘wich may persist for 3-4 days. They ae normal even
‘shen VII nerves nonfunctional. Ths can be used
Inthe diagnosis of neuropathy of VIT nerve
(9) ARS re generate in response to sound Simulaspre-
Sented tothe car and peked up from the scalp. With
3 response of 30-35 dB ni, the infant who passes
the est and the bearings considered normal Infants
‘sho fal these test an followed up with repeat ets
us et, A igh-frequency marow band noise Is
presented for 2s tothe infant when hei im ight seep. A
oral hearing infant can De aroused ie when
Such stil are presented to him.
“altar response cradle 1 à screening device for new
oras, where aby is placed ina cradle and his behaviour
funk and limb movement, head jerk and respiration) In
response 1 autor stimulation re monitored by tans
Auen can sreen babies with moderate, severe or pro.
found hearing los.
2. LNAvIOUR OnSERVATION AUDIOMETRY. Auditory sige
‘al presented toa inant produces à change in behar
lou eg alerting, cessation of an activity, widening of
96 or facial grimacing. Moo’ ree sone of them and
ans of sudden movement of limbs and extension of
head in sesponse to sound of 80-50 dB. ocheopalperal
ref, the child responds by a blink 0 a Youd sound. In
sation wef, an Infant stops activity or stars eying in
response 10 à sound of 90 dB.
3. Disrmaction Teowwigurs. are used in children
627 monts old, The child at ts age turns is head to
locate une source of sound. In dis test the child sete
his mother lap, an assistant distracts the
tion white the examine produce sound fom be
ftom one ide t se the child wies 10 locate it Sounds.
sed are high frequency ate (8 Ka, low-frequency
um, whispered sound as 75, 5, 5, sylphone, warble
tones mao band noise (800-4000 Ho
4. Coxprmonine eats
(a) Visual winforcoment audiometry (VA Iisa condition
ing technique in which cl stained o Took for a
uit stimulus y turning his head. This behaviour
is reinforced by Hashing Hight or an animated toy
‘This test helps o determine the hearing threshold us
ing standard audiometric techniques. The auditor
stimulus is delivered by headphonesor bete til y
inset earphones which are accepted better and are
aso light welght. Tes Is well-suited between the de
‘elopmental age of 6 months 0 2 wars.
(©) Pay mama. The ch i conditioned to perform
an ct such a placing a mabletn a Box, puting ing,
Om à pos or putting a plastic Block in à bucket each
eas sud signal Bach corct performance
fof the acti enfored With praise, encouragement or
reward. ar specie tveshals can be determined by
Standard audiometic techniques This test can be used
in children with developmental age of 2-4 0r 8 yeas.
(6) Spc adam The childs aed 0 repeat the
ames of certain objects or 1 point them out on the
Pictures. The voice can be gradually lowered. In this
"vay, hearing evel and speech discrimination can be
mebooksfree.com
tested, The test an also be used to examine the cis
expresive ability when hei asked 1 name the 1095.
Ike horse, duck or objets ke cup, pate, et
5. Once rests
(a) Eve respons ando
(0 Eicamcachkguph À can measure auditory sen
St to within 20 dB. But it I an Invasive pr
“eure requiring placement of electrodes through
the tympanic membrane
(0) Autor rans response. I is mot a dret test
‘oF hearing but correlates highly wth the pure.
tone thresholds. Kdentible waveforms in ABR
are general present 10-20 dB above behavioural
resold. ABR provides an carspeci informa
ton as sound stimu can be presented to ca
‘a separately by headphones o ar nse. san
Objective test and can be done under sedition as
{heater has oo eect on ABR, ABR used both a
a screning test and a à definitive hearing ve
ment ts cen. In a screening est, response
{ora cick stimulus of ls than 40 dB all. or less
Is the tern of posing the test. To ind bearing
veshol an infant, ABR tracing obi est
tiger sound simulus and then gall lo
‘rd til wave V& just identifiable but repeatable
(b) Ovacoustic emission (se p. 29). Transient evoked
missions (TEOAES) ate ant in crs where hear
ing los exceeds 30 dB, Distortion product emissions
(DPOAES are absent when hearing loss exceeds SOB
Impodance audtameny. ‘Normally. stapedius muscle
contracts flex in response o a sound of 70-100 db
and this reflex can be record, Absence of acous
fc ner indicates middle car disorder, erocochle
hearing loss or severe to profound SNL. Used wit
behaviour audiometry, seoustic reflexes are useful
component to coss-check Absence o acoustic lex,
but à normal tympanomety with parental concer
for hearing loss suggest post of SNL of seve
to profound degree Absence ol acoustic rete but a
anormal tympanogsam generally indicates conduc
ve loss Since ABR and OAFs provide more Informa
fon, use of acoustic reflexes in assessment of peda
Fle esting has deine.
(OAES and ABR have been used both in screening pro-
grammes and in hearing evaluation in infantsand dre,
te ane
es =
pa 2
ans
ra Je —
ewer
Cpter 19 — The Deal Child 133
MANAGEMENT
Tes essential o now the degree and typeof hearing loss,
and other associated handicaps such as Blindness or men:
{ulretadation and whether Rearing os prit (e
{oe development of speech) or postngual,Aetiology of
‘nearing os remains obscure in about half the eases.
‘Ams of habitation of any hearing-impaired child are
‘development of speech and language, adjustment in soc
ety and seta employment ina vocation,
1. PARENTAL GUIDANCE. Iisa great emotional shock
{oe Parents to lesen that thei lds dea. They should
be dealt with sympathetically, o as to accept the child
y should be told of childs dsabilty and how to
a for Habitation of the dea demands à ot rom
patents: are and perodie replacement of heating aid,
Change of ur.moulds as child grows, follow-up vss for
revaluation, education at home and the selection of
2, HEARING AIDS. Most dea children have a small but
ul portion of residual hearing which can be exploited
by amplification of sound. Heating ads should be pre
scribed asealy as posse. necessary, binaural al, one
for each car, can be used. Hearing ads help to develop
ipeading as.
3. Conan IMPLANTS SEP. 138)
a. DivEtorueNT oF Srescn AND LANGUAGE, Communi
ation sa two way proces, depending on the receptive
Sd expressive sis. Recep
‘Visual auditory or tacle faculties while expression is
{through oral or writen spech or the manual Sign lan:
guage In the easing impaved, auditory acl s poor or
{orally absent (sun 19) Ths, for proper communica
tion, theres need ether to improve nearing through a
platon of the vidual hearing or cochleat implants:
And in the absence of the fs of developing the au:
‘tory faculty, one has to develop visual or tactile means
‘of communication
(a) Autor communication. This is the method used
bya normal person andthe est way of communi
tion Inthe det ea bed in those with moderate
to severe hearing loss or those who ate Postal
rose stale
ee, Singin or
Fe Fur
voto as ] ms
Conor, coronel.)
Figure 19.3. The acest esgumpies pero ich co be ul for cele and expresiva in communication
mebooksfree.com
expresive ability when hei asked 1 name the 1095.
Ike horse, duck or objets ke cup, pate, et
5. Once rests
(a) Eve respons ando
(0 Eicamcachkguph À can measure auditory sen
St to within 20 dB. But it I an Invasive pr
“eure requiring placement of electrodes through
the tympanic membrane
(0) Autor rans response. I is mot a dret test
‘oF hearing but correlates highly wth the pure.
tone thresholds. Kdentible waveforms in ABR
are general present 10-20 dB above behavioural
resold. ABR provides an carspeci informa
ton as sound stimu can be presented to ca
‘a separately by headphones o ar nse. san
Objective test and can be done under sedition as
{heater has oo eect on ABR, ABR used both a
a screning test and a à definitive hearing ve
ment ts cen. In a screening est, response
{ora cick stimulus of ls than 40 dB all. or less
Is the tern of posing the test. To ind bearing
veshol an infant, ABR tracing obi est
tiger sound simulus and then gall lo
‘rd til wave V& just identifiable but repeatable
(b) Ovacoustic emission (se p. 29). Transient evoked
missions (TEOAES) ate ant in crs where hear
ing los exceeds 30 dB, Distortion product emissions
(DPOAES are absent when hearing loss exceeds SOB
Impodance audtameny. ‘Normally. stapedius muscle
contracts flex in response o a sound of 70-100 db
and this reflex can be record, Absence of acous
fc ner indicates middle car disorder, erocochle
hearing loss or severe to profound SNL. Used wit
behaviour audiometry, seoustic reflexes are useful
component to coss-check Absence o acoustic lex,
but à normal tympanomety with parental concer
for hearing loss suggest post of SNL of seve
to profound degree Absence ol acoustic rete but a
anormal tympanogsam generally indicates conduc
ve loss Since ABR and OAFs provide more Informa
fon, use of acoustic reflexes in assessment of peda
Fle esting has deine.
(OAES and ABR have been used both in screening pro-
grammes and in hearing evaluation in infantsand dre,
te ane
es =
pa 2
ans
ra Je —
ewer
Cpter 19 — The Deal Child 133
MANAGEMENT
Tes essential o now the degree and typeof hearing loss,
and other associated handicaps such as Blindness or men:
{ulretadation and whether Rearing os prit (e
{oe development of speech) or postngual,Aetiology of
‘nearing os remains obscure in about half the eases.
‘Ams of habitation of any hearing-impaired child are
‘development of speech and language, adjustment in soc
ety and seta employment ina vocation,
1. PARENTAL GUIDANCE. Iisa great emotional shock
{oe Parents to lesen that thei lds dea. They should
be dealt with sympathetically, o as to accept the child
y should be told of childs dsabilty and how to
a for Habitation of the dea demands à ot rom
patents: are and perodie replacement of heating aid,
Change of ur.moulds as child grows, follow-up vss for
revaluation, education at home and the selection of
2, HEARING AIDS. Most dea children have a small but
ul portion of residual hearing which can be exploited
by amplification of sound. Heating ads should be pre
scribed asealy as posse. necessary, binaural al, one
for each car, can be used. Hearing ads help to develop
ipeading as.
3. Conan IMPLANTS SEP. 138)
a. DivEtorueNT oF Srescn AND LANGUAGE, Communi
ation sa two way proces, depending on the receptive
Sd expressive sis. Recep
‘Visual auditory or tacle faculties while expression is
{through oral or writen spech or the manual Sign lan:
guage In the easing impaved, auditory acl s poor or
{orally absent (sun 19) Ths, for proper communica
tion, theres need ether to improve nearing through a
platon of the vidual hearing or cochleat implants:
And in the absence of the fs of developing the au:
‘tory faculty, one has to develop visual or tactile means
‘of communication
(a) Autor communication. This is the method used
bya normal person andthe est way of communi
tion Inthe det ea bed in those with moderate
to severe hearing loss or those who ate Postal
rose stale
ee, Singin or
Fe Fur
voto as ] ms
Conor, coronel.)
Figure 19.3. The acest esgumpies pero ich co be ul for cele and expresiva in communication
mebooksfree.com
134 SECTIONI — senses ofr
‘eat Hearing ads are provides to augment auditory
reception. At the same me, taining f also imparted
Inspocch reading. Leto read movement of lips, face,
And natural gestures of hand and body. Expressive
SEL encouraged though oral speech
(©) Manual communication. À makes use of he sgn la
ge or fingeespellig edn but has the disadvan
tage that abstract ideas ae dificult to expres and
general publie does not understand
(6) Taal communication. uses all modalites o sensory
input, Le auditory visual, tactile and Kinacsthetc.
Such children are taught to develop orl speech, ip
reading and sign language, Al children th pen.
{ual severe 10 profound deafness, should undergo
training in this form of communication. Vice
id are useful fr these wh ae totaly eat and also
blind. These aids ave attached to the elds hand or
sternum and the vibrations o speech are perceived
‘through tactile sensation,
5. EDUCATION oF THE Dear. There ate residential and day
Schools forthe heating impair Some children with mod.
frat haringlosscan be megrate nt schools forthe mor
‘mat heaving chen with preferential eating in the cs.
Radio hearing als have revolutionizad education of
the dea. In this device, the microphone and tansmiter
fare worn by the teacher and the receiver and amplifier
by the child. With this system, the child can ear the
teacher’ voice bete, without being disturbed by ene
6. VOCATIONAL GUIDANE, The af ae since and good
‘workers Given the opportunity, commensurate wi their
oli iy can be usflly employed in several vocations
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‘eat Hearing ads are provides to augment auditory
reception. At the same me, taining f also imparted
Inspocch reading. Leto read movement of lips, face,
And natural gestures of hand and body. Expressive
SEL encouraged though oral speech
(©) Manual communication. À makes use of he sgn la
ge or fingeespellig edn but has the disadvan
tage that abstract ideas ae dificult to expres and
general publie does not understand
(6) Taal communication. uses all modalites o sensory
input, Le auditory visual, tactile and Kinacsthetc.
Such children are taught to develop orl speech, ip
reading and sign language, Al children th pen.
{ual severe 10 profound deafness, should undergo
training in this form of communication. Vice
id are useful fr these wh ae totaly eat and also
blind. These aids ave attached to the elds hand or
sternum and the vibrations o speech are perceived
‘through tactile sensation,
5. EDUCATION oF THE Dear. There ate residential and day
Schools forthe heating impair Some children with mod.
frat haringlosscan be megrate nt schools forthe mor
‘mat heaving chen with preferential eating in the cs.
Radio hearing als have revolutionizad education of
the dea. In this device, the microphone and tansmiter
fare worn by the teacher and the receiver and amplifier
by the child. With this system, the child can ear the
teacher’ voice bete, without being disturbed by ene
6. VOCATIONAL GUIDANE, The af ae since and good
‘workers Given the opportunity, commensurate wi their
oli iy can be usflly employed in several vocations
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Chapter 20
Rehabilitation of the Hearing Impaired
All easing impalied individuals need some sort of au
ral habitation for communication The various means
valable to them te
1. Instrumental devices
(a) Hearing ads
©) Conventional hearing ads
(i) Bone anchored hearing aids
(i) Implantable heating ald (brant soundbidge)
© implants
{Cochlear implants
i). Auditorybrtnstem implants
(© Asistve devices for the deat
2. Training
da) Speech (ip) reading
© Auditory training
(9) Speech conservation
1. INSTRUMENTAL DEVICES
A. HEARING AIDS.
Conventional Hearing Aids
A eating ad ia device to amplify sounds reaching the
‘an Essential, consist of three parts: 4) a microphone,
‘shich picks up sounds and converts them into elect
al impulses, (i) an amplifier, which magniis electrical
Impuls and (i) a rece, which convert electrical Im
pulses back to sound This ampli sound is then creed
{rough the earmould tothe tympanic membrane
“Tyres or Heanine Atos
‘Aik COXDLCTON HEARING AID In tis, the amplified
sound is wansmited va the car canal to the tympanic
‘BONE CONDUCTION HEARING AID. Instead ofa receiver,
It has a bone vibrator which snugly fits on the mastoid
nd direc stimulates the cochlea. This type of aid is
‘specially useful in persons with actively draining cas,
‘tts externa or atresia ofthe eat canal when eat insets
anno be wor
"Most ofthe ads ae lr conduction type. They can be
1. Bodywomtypes.Mostcommontype (sur 20.1A (8);
microphone and amplier along with the battery are
situated at he car el. This type Of aid allons high
(degree of amplification with minimal feedback. Ils
Useful in severly deat persons or calco with con:
genial dene
2. Bchind-ihecar (BTE) types. Here microphone, an
plier, recewer and Batey ae al in one unit whl
IS worn behind the ar. is coupled to the ear canal
With a tubing and an carmould. Rs useful for light
Yo menea as of hearing os party the igh
3. Specials types. ia modification ofthe "behind
hear” yp nd the une I housed Inthe arcuar
an of the paca frame. ul o sons ho
eed oth eye lasses for vison and a hearing a is
fot very popular now.
4. Inathesar (ITE) types. The ente hearing ad ds
housed in an camo which can be worn In
ist form
Configuration. They ae very popular because of
mee appeal
5. Canal types TC and CIC) Me hearing ai isso smal
thatthe entre aid can De worn in the car canal with:
ut projecting into the concha. or using this ad is
‘eared that theca canal shuld be age and vid,
And patient should have the dextenty 10 manipulate
the minute Sons inthe ai. is wet for md
to moderate cases of hearing los of high frequency
aa:
“wo types are avaible in the canal TC) and another
sui smaller and tise type, completely inthe anal
(cio.
2 hearing problem that cannot be helped by medical or
Surgical means isa candidate for hearing sk.
1. Sensorineural hearing loss, which interferes wth ay
today activites ofa person. Heating ad may not suit
allsuch persons because o the intolerable distortion of
Sound in some, particularly In those with rerutme
2, Deaf children should be ted with hearing ada car
ly as possible for development of speech and Teaming.
p severely del children, binaural ads (one foreach
ar and individually ted) are more useful Talning
In ip reading ls given simuttancousty
3. Conductive deafness. Most of such persons can be
Delp by Surgery but heaving aids prescribed when
surgery I refuse or not feasible o has lid
Farm a Heanine Ayo. While iting a bearing aid,
‘consideration Is given to:
1. Degree of hearing os
2. Configuration ot hearing los ype of feces af
fected.
3. Type of hearing los (conductive or sensorineural.
À Presence of recruitment,
5. Uncomfortable loudness Level.
© Age and dexteñt of patent
7. Condition of the outer and middle er
8. Cosmetic acceptance ofthe ald
ms
mebooksfree.com
Rehabilitation of the Hearing Impaired
All easing impalied individuals need some sort of au
ral habitation for communication The various means
valable to them te
1. Instrumental devices
(a) Hearing ads
©) Conventional hearing ads
(i) Bone anchored hearing aids
(i) Implantable heating ald (brant soundbidge)
© implants
{Cochlear implants
i). Auditorybrtnstem implants
(© Asistve devices for the deat
2. Training
da) Speech (ip) reading
© Auditory training
(9) Speech conservation
1. INSTRUMENTAL DEVICES
A. HEARING AIDS.
Conventional Hearing Aids
A eating ad ia device to amplify sounds reaching the
‘an Essential, consist of three parts: 4) a microphone,
‘shich picks up sounds and converts them into elect
al impulses, (i) an amplifier, which magniis electrical
Impuls and (i) a rece, which convert electrical Im
pulses back to sound This ampli sound is then creed
{rough the earmould tothe tympanic membrane
“Tyres or Heanine Atos
‘Aik COXDLCTON HEARING AID In tis, the amplified
sound is wansmited va the car canal to the tympanic
‘BONE CONDUCTION HEARING AID. Instead ofa receiver,
It has a bone vibrator which snugly fits on the mastoid
nd direc stimulates the cochlea. This type of aid is
‘specially useful in persons with actively draining cas,
‘tts externa or atresia ofthe eat canal when eat insets
anno be wor
"Most ofthe ads ae lr conduction type. They can be
1. Bodywomtypes.Mostcommontype (sur 20.1A (8);
microphone and amplier along with the battery are
situated at he car el. This type Of aid allons high
(degree of amplification with minimal feedback. Ils
Useful in severly deat persons or calco with con:
genial dene
2. Bchind-ihecar (BTE) types. Here microphone, an
plier, recewer and Batey ae al in one unit whl
IS worn behind the ar. is coupled to the ear canal
With a tubing and an carmould. Rs useful for light
Yo menea as of hearing os party the igh
3. Specials types. ia modification ofthe "behind
hear” yp nd the une I housed Inthe arcuar
an of the paca frame. ul o sons ho
eed oth eye lasses for vison and a hearing a is
fot very popular now.
4. Inathesar (ITE) types. The ente hearing ad ds
housed in an camo which can be worn In
ist form
Configuration. They ae very popular because of
mee appeal
5. Canal types TC and CIC) Me hearing ai isso smal
thatthe entre aid can De worn in the car canal with:
ut projecting into the concha. or using this ad is
‘eared that theca canal shuld be age and vid,
And patient should have the dextenty 10 manipulate
the minute Sons inthe ai. is wet for md
to moderate cases of hearing los of high frequency
aa:
“wo types are avaible in the canal TC) and another
sui smaller and tise type, completely inthe anal
(cio.
2 hearing problem that cannot be helped by medical or
Surgical means isa candidate for hearing sk.
1. Sensorineural hearing loss, which interferes wth ay
today activites ofa person. Heating ad may not suit
allsuch persons because o the intolerable distortion of
Sound in some, particularly In those with rerutme
2, Deaf children should be ted with hearing ada car
ly as possible for development of speech and Teaming.
p severely del children, binaural ads (one foreach
ar and individually ted) are more useful Talning
In ip reading ls given simuttancousty
3. Conductive deafness. Most of such persons can be
Delp by Surgery but heaving aids prescribed when
surgery I refuse or not feasible o has lid
Farm a Heanine Ayo. While iting a bearing aid,
‘consideration Is given to:
1. Degree of hearing os
2. Configuration ot hearing los ype of feces af
fected.
3. Type of hearing los (conductive or sensorineural.
À Presence of recruitment,
5. Uncomfortable loudness Level.
© Age and dexteñt of patent
7. Condition of the outer and middle er
8. Cosmetic acceptance ofthe ald
ms
mebooksfree.com
136 sections
Diseases of far
D
Figure 20.1. arcas pes lin ats (A) dom. (8) Behind ar pe (9 pride pe. (D) Idea pe
LD] Sen pay tng Ass
9. Type of earmold,
10, The type of hing, whether ts moncaur (one ad
‘only, binaural (one ald or each ea), inaural with
sut two receivers, one foreach
ral min of Sr yp.
CROS (ConTeALATERAL ROUTING or SIGNAL). In this
type, microphone is fitted on the side of the deat car and
‘he ou th ia up paso e eer plc
Severeiyimpied and helps in sound lcalizaton coming
from theside ofthe deat car. Now bone anchored hearing
ads (se ita) are being prefered for snglestded deat
ness amd have replaced the use of CROS als
Bone-anchored Hearing Aid (BAHA)
one-anchons! hearing ld sa type of earn ad which i
tse on the principe of bone conduction, ls prima
‘ited to people we have conductive hearing hs uniera
hearing os nd those with mixed hearing os who cannot
heise wear“ theca” or bx the ar ering a
"one anchored heating ads ase surgical implant
ed abutment to transmit sound by direct conduction
through bone tothe cochlea, bypassing the extra au
‘tory canal and middle ar iste 2)
S
Fer 202. hes whe und pers cd 10
AJA has three components () titanium ture
fanium abutment and Ui) sound processor (se 20)
The au ture Surgical mb in ıhe sal
one with abutment exposed outside the sin. The tan
tim fixture bonds with the surrounding ss ina process
‘alla osseintegutlon. The sound procsoris atached to
mebooksfree.com
Diseases of far
D
Figure 20.1. arcas pes lin ats (A) dom. (8) Behind ar pe (9 pride pe. (D) Idea pe
LD] Sen pay tng Ass
9. Type of earmold,
10, The type of hing, whether ts moncaur (one ad
‘only, binaural (one ald or each ea), inaural with
sut two receivers, one foreach
ral min of Sr yp.
CROS (ConTeALATERAL ROUTING or SIGNAL). In this
type, microphone is fitted on the side of the deat car and
‘he ou th ia up paso e eer plc
Severeiyimpied and helps in sound lcalizaton coming
from theside ofthe deat car. Now bone anchored hearing
ads (se ita) are being prefered for snglestded deat
ness amd have replaced the use of CROS als
Bone-anchored Hearing Aid (BAHA)
one-anchons! hearing ld sa type of earn ad which i
tse on the principe of bone conduction, ls prima
‘ited to people we have conductive hearing hs uniera
hearing os nd those with mixed hearing os who cannot
heise wear“ theca” or bx the ar ering a
"one anchored heating ads ase surgical implant
ed abutment to transmit sound by direct conduction
through bone tothe cochlea, bypassing the extra au
‘tory canal and middle ar iste 2)
S
Fer 202. hes whe und pers cd 10
AJA has three components () titanium ture
fanium abutment and Ui) sound processor (se 20)
The au ture Surgical mb in ıhe sal
one with abutment exposed outside the sin. The tan
tim fixture bonds with the surrounding ss ina process
‘alla osseintegutlon. The sound procsoris atached to
mebooksfree.com
sour
po
Figure 203. Bone cored es (BA.
the abutment once ossointegation Is complete which
sully takes 2-6 months after implantation, The BABA.
device tansmis Vibrations to the extenal abutment
‘whlch further vibrates the skull and cochlea,
'CXNDIDACY Pros, Bone-anchored hearing als can
be ued in
1. People who have chronic inflammation or infctio
fol the ar canal and cannot wea standard "inthe car
Sleconducton heating ais
2. Children with malformed or absent outer car and cor
‘canals asin micro or canal arena,
Single sed dentes (se Table 201).
nte pas, the contralateral routing of signal (CROS)
heating ad vas the only option available fr rehab
tion of patients with single-sided deafness. Poor perfor
mance and aesthetic considerations limited the use of
(CROS als. The BAHA device can now be implanted os
the side of the deat ca, and le transmis the sound by
means of bone conduction to the contralateral coche,
‘The BAHA i hae on the dest sie and colets sound
waves to transmi 0 healthy cochlea of the other side
‘Tis process eliminates the head shadow effet and al
lows for hearing from both sides ofthe head, The BAIA
substantially improves speech cognition in quiet and in
Role compared with the CROS ds.
Scene The surgery is typically performed ina sine
ge stage in adults. About 3 months are allowed for ose
‘integration before the sound processor canbe attached
A twostage procedure 1 recommended in children.
‘whom the ture space int the bone inthe rs stage
After about 6 months to allow for oseointeration, à
Secondstage operation is done to connect the abutment
hough the sin to the Atar.
‘Complications of BAHA are few and may include oc
«asonalfalre to osseointegrate the implant and local
Infections and nlammation atthe implant ste
Implantable Hearing Aids
Implantable middle ear heating als represent a new
category of hearing devices that work on a diet drive
principle. Ratner than delivering acoustic energy Into
the external autor canal (as with traditional hearing
ald systems), direct drive mide car implant systems use
mechanical vibrations delivered directly 10 the osu
‘hain, while leaving the car canal completely open.
Implantable middle ear devices are generally valable
in wo pes
Chapter 20 — Rehsbttation ofthe Hearing Impaired
137
Men second (A) eng i anna be un
En ere a eno
+ Con charge, at menait weinen.
en een a camion om cai
tearing
Typus eher ung conve
Sng ned neat o
1. Piezoelectic devices. Pezoelectre devices operat by
Pasing an electr current Into a piezoceramic cta,
“changes its volume and hereby’ produce a ví
signal This piezoet sucer in tum is
coupled to the ossicles and dives the ossicular chain
by Vibra
Examples of such devices ae Envoy, ml tr
ducer (MET or aso called etologiedevie), Ron and
total iterated cochlear ampli (FICA),
2. Hectromagnetic hearing. devices, lectiomagnetie
ring devices function y passing an dect cure
into col, which ceatesa magnetic us that deves an
Adjacent magnet. The small magnet fs tached! o one
the ossicles ofthe middlecarto convey vibrtions to
the coches,
An example of such a device she vibrant soundbridge
device previously knoven as the Symphonix devie; now
being manufactured by MED-EL).
‘Vinust Souspamnct Divice, The vibrant sound-
bridge's a semb-implantable device made of two compo
‘ens: an internal andan external, The era comport
{Scale wating ossicular posts (VORP) and is made
Lp of three parts: the receiver, floating mass transducer
{PAM and a Conductor ink between the two. FMT con
ect tothe incu (sure 20. and 20).
“The extemal component 5 called the audio proces
sor which i worm behind the ar. The audio processor
IMPLANTED paar
igure 20.4. Van sure mide crimp.
mebooksfree.com
po
Figure 203. Bone cored es (BA.
the abutment once ossointegation Is complete which
sully takes 2-6 months after implantation, The BABA.
device tansmis Vibrations to the extenal abutment
‘whlch further vibrates the skull and cochlea,
'CXNDIDACY Pros, Bone-anchored hearing als can
be ued in
1. People who have chronic inflammation or infctio
fol the ar canal and cannot wea standard "inthe car
Sleconducton heating ais
2. Children with malformed or absent outer car and cor
‘canals asin micro or canal arena,
Single sed dentes (se Table 201).
nte pas, the contralateral routing of signal (CROS)
heating ad vas the only option available fr rehab
tion of patients with single-sided deafness. Poor perfor
mance and aesthetic considerations limited the use of
(CROS als. The BAHA device can now be implanted os
the side of the deat ca, and le transmis the sound by
means of bone conduction to the contralateral coche,
‘The BAHA i hae on the dest sie and colets sound
waves to transmi 0 healthy cochlea of the other side
‘Tis process eliminates the head shadow effet and al
lows for hearing from both sides ofthe head, The BAIA
substantially improves speech cognition in quiet and in
Role compared with the CROS ds.
Scene The surgery is typically performed ina sine
ge stage in adults. About 3 months are allowed for ose
‘integration before the sound processor canbe attached
A twostage procedure 1 recommended in children.
‘whom the ture space int the bone inthe rs stage
After about 6 months to allow for oseointeration, à
Secondstage operation is done to connect the abutment
hough the sin to the Atar.
‘Complications of BAHA are few and may include oc
«asonalfalre to osseointegrate the implant and local
Infections and nlammation atthe implant ste
Implantable Hearing Aids
Implantable middle ear heating als represent a new
category of hearing devices that work on a diet drive
principle. Ratner than delivering acoustic energy Into
the external autor canal (as with traditional hearing
ald systems), direct drive mide car implant systems use
mechanical vibrations delivered directly 10 the osu
‘hain, while leaving the car canal completely open.
Implantable middle ear devices are generally valable
in wo pes
Chapter 20 — Rehsbttation ofthe Hearing Impaired
137
Men second (A) eng i anna be un
En ere a eno
+ Con charge, at menait weinen.
en een a camion om cai
tearing
Typus eher ung conve
Sng ned neat o
1. Piezoelectic devices. Pezoelectre devices operat by
Pasing an electr current Into a piezoceramic cta,
“changes its volume and hereby’ produce a ví
signal This piezoet sucer in tum is
coupled to the ossicles and dives the ossicular chain
by Vibra
Examples of such devices ae Envoy, ml tr
ducer (MET or aso called etologiedevie), Ron and
total iterated cochlear ampli (FICA),
2. Hectromagnetic hearing. devices, lectiomagnetie
ring devices function y passing an dect cure
into col, which ceatesa magnetic us that deves an
Adjacent magnet. The small magnet fs tached! o one
the ossicles ofthe middlecarto convey vibrtions to
the coches,
An example of such a device she vibrant soundbridge
device previously knoven as the Symphonix devie; now
being manufactured by MED-EL).
‘Vinust Souspamnct Divice, The vibrant sound-
bridge's a semb-implantable device made of two compo
‘ens: an internal andan external, The era comport
{Scale wating ossicular posts (VORP) and is made
Lp of three parts: the receiver, floating mass transducer
{PAM and a Conductor ink between the two. FMT con
ect tothe incu (sure 20. and 20).
“The extemal component 5 called the audio proces
sor which i worm behind the ar. The audio processor
IMPLANTED paar
igure 20.4. Van sure mide crimp.
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