HEENT

Professor: Ezekiel D Roger Rawana, M.D., MA, BA, AASc

New York State Licensed Physician & Surgeon
Internal Medicine, Board Certified, USA
Diplomate American Board of Internal Medicine
American College of Physicians
Ear, Nose, Mouth, and Throat Disorders
•Evaluation of Hearing Loss
•Tinnitus
•Otitis Media and Otitis Externa
•Cerumen Impaction
•Upper Respiratory Tract Disorders
•Epistaxis
•Oral Health
•Temporomandibular Disorder
 Evaluation of Hearing Loss
The two basic types of hearing loss are
conductive, which involves any cause that
limits external sound from reaching the inner ear, and
simple hearing loss,
to have ear pain,
and to have drainage.

sensorineural, which involves the

inner ear, cochlea, or auditory nerve.
trouble understanding speech, especially faint or high-
pitched voices.
tinnitus, dizziness, or true vertigo.
Other important historical items include onset and
progression; trauma, including noise and barotrauma;
surgery; and family history.
 Differential Diagnosis of Hearing Loss
Disease Notes
Conductive Hearing Loss
Otosclerosis Fixation of the stapes footplate
eventually causes a conductive hearing
loss. Affects both ears in most patients.
Stapedectomy or stapedotomy are the
standard treatments. A hearing aid may
also be helpful.
Disease Notes
Conductive Hearing Loss
Cholesteatoma A middle ear mass composed of
keratinized epithelial debris. Causes
ossicular disruption or may impede the
tympanic membrane’s capacity to
vibrate. Usually presents as a pearly
white mass. Any suspicion of
cholesteatoma (whitish, middle ear
mass; continually draining ear, over
weeks to months) should prompt an
otolaryngology consultation.
Disease
Conductive Hearing Loss
Tympanic membrane perforation
Notes
A large tympanic membrane perforation
prevents the tympanic membrane from
vibrating normally. Most tympanic
membrane perforations can be treated
surgically. Rule out cholesteatoma.
Disease Notes
Conductive Hearing Loss
Foreign body Foreign bodies may enter the
external auditory canal and
become impacted. Foreign bodies
should be removed by an
otolaryngologist.
Disease Notes
Conductive Hearing Loss
Cerumen impaction Cerumen may completely
obstruct the ear canal.
Sensorineural Hearing Loss
Noise-induced Chronic noise exposure or
sudden, short exposure to noise
blast can produce hearing loss.
Noise exposure produces
temporary threshold shifts, which
eventually become permanent.
Sensorineural Hearing Loss
Drug-induced History of ototoxic
medication use
(aminoglycosides, loop
diuretics, chemotherapeutic
agents)
Sensorineural Hearing Loss
Presbycusis Age-related hearing loss; typically
high-frequency hearing loss that
is symmetric with good speech
discrimination scores. Hearing
aids are the mainstay of therapy
for presbycusis.
Sensorineural Hearing Loss
Meniere disease Classically presents as a triad of
sensorineural hearing loss, tinnitus, and
vertigo, although all three are not
necessarily present.
Electronystagmography and
electrocochleography are important
tests in the diagnosis, although history
usually suggests the disorder.
 Sensorineural Hearing Loss
Vestibular schwannoma (acoustic Benign neoplasms that arise in
neuroma) the cerebellopontine angle,
usually causing sensorineural
hearing loss, tinnitus, and
sometimes vertigo. In advanced
cases, facial nerve function is
affected.
lists common causes of hearing loss.

A hearing evaluation can be performed by assessing the

patient’s ability to hear a whispered voice (2 feet from the
ear, with the examiner behind the patient and the
examiner’s finger occluding and simultaneously rubbing
the opposite external ear canal, the examiner whispers
three numbers/letters after exhalation).

Alternatively, an audioscope (a handheld combination

screening audiometer and otoscope) can be used.

The Weber and Rinne tests can help to distinguish

conductive from sensorineural hearing loss.
In the Weber test, a vibrating tuning fork is placed on the
forehead, the crown, or the nose.

If the sound is louder on the unaffected side,

sensorineural hearing loss is suggested; if the sound is
louder on the side with hearing loss, conductive hearing
loss is suggested.

The Rinne test is performed by touching the vibrating fork

to the mastoid tip of each ear (to assess bone conduction)
and then holding it over the external auditory canal (to
assess air conduction).
An abnormal Rinne test (hearing is better with bone
conduction) is consistent with conductive loss and is more
accurate than the Weber test in diagnosing conductive
hearing loss.

With normal hearing or sensorineural hearing loss,

hearing is better with air conduction.
A nonmobile tympanic membrane may indicate fluid or a
mass in the middle ear or retraction from negative middle
ear pressure.

If no obvious cause of hearing loss is found (such as

cerumen impaction or otitis media), the patient should
have formal audiologic testing.

Patients with hearing loss of unclear etiology should be

referred for otolaryngologic evaluation.

Asymmetric sensorineural hearing loss not clearly due to

Meniere disease should be evaluated with an MRI or CT
scan of the posterior fossa and internal auditory canal to
exclude acoustic neuroma and meningioma.
Sudden sensorineural hearing loss (SSNHL) is an alarming
problem that is defined as hearing loss occurring in 3 days
or less.

Patients often report immediate or rapid hearing loss or

loss of hearing upon awakening.

Ninety percent have unilateral hearing loss, and some

have tinnitus, ear fullness, and vertigo.

SSNHL constitutes a considerable diagnostic challenge

because it may be caused by many conditions, including
infection, neoplasm, trauma, autoimmune disease,
vascular events, and ototoxic drugs.
Immediate otolaryngologic referral is required.
Improvement occurs in about two thirds of patients. Oral
corticosteroids are usually given, although randomized
trials differ in their conclusions regarding efficacy.
Tinnitus
Tinnitus is an auditory perception of sound that is not
present in the external environment.

It affects up to 7% of the U.S. population, with incidence

increasing with age.

Tinnitus is usually minor and is noted only in quiet

environments, but for about 25% of patients it interferes
with daily life, sometimes to a significant degree.

Pulsatile tinnitus is often vascular in origin and may be due

to an arteriovenous fistula, arteriovenous malformation,
arterial aneurysm, tumor, or atherosclerotic disease.
Tinnitus that is clicking may be caused by myoclonus of the
palatal muscles or muscles of the middle ear and may be
an indication of neurologic disease, including multiple
sclerosis.
Table 49. Drugs that May Cause or Exacerbate Tinnitus
Aminoglycoside antibiotics
Antimalarial drugs (chloroquine, hydroxychloroquine)
Benzodiazepines
Carbamazepine
Loop diuretics
Quinidine
Salicylates
NSAIDs
Tricyclic antidepressants
 Otitis Media and Otitis
Externa
•Otitis Media

•Otitis Externa
Otitis Media
Otitis media is the most frequent bacterial infection in
children, but it is much less common in adults.

It is usually preceded by viral upper respiratory tract

infection.

The microbiology of otitis media in adults appears to be

similar to that of children:

Streptococcus pneumoniae: 21% to 63%;

Haemophilus influenzae: 11% to 26%;

Staphylococcus aureus: 3% to 12%;

Moraxella catarrhalis: 3%.

Thirty percent of bacterial cultures of middle ear effusions

are sterile.

Complications of otitis media include conductive hearing

loss from persistent middle ear effusion, tympanic
membrane perforation, mastoiditis, and, rarely, meningitis
or intracranial abscess.

To diagnose acute otitis media, there should be a history

of an acute onset, signs of middle ear effusion (using a
pneumatic otoscope to document lack of tympanic
membrane movement), and signs of middle ear
inflammation (erythema of the tympanic membrane).
Otitis Externa
Acute otitis externa is diffuse inflammation of the external
ear canal.

Factors that predispose to otitis externa are

regular cleaning of the ear canal with removal of cerumen,
which is an important barrier to moisture and infection;

debris from dermatologic conditions;

local trauma from attempts at self-cleaning, irrigation, and

hearing aids;

and increased exposure to water.

In the United States, nearly all external otitis is bacterial,
primarily Pseudomonas aeruginosa and Staphylococcus
aureus.

Polymicrobial infection occurs in about one third of cases.

Acute otitis externa usually has a rapid onset, typically

within 48 hours but sometimes up to 3 weeks.

Symptoms include otalgia, itching or fullness with or

without hearing loss, and pain intensified by jaw motion.
Signs include internal tenderness when the tragus or
pinna is pushed or pulled and diffuse ear canal edema
and erythema, with or without otorrhea.
Conditions that may mimic otitis externa are

an external canal furuncle;

inflammatory dermatologic conditions such as eczema and

seborrhea;

contact dermatitis of the ear and ear canal from ear drops,
earrings, or hearing aids;

and herpes zoster, which may cause the Ramsay Hunt

syndrome
Ramsay Hunt syndrome.
The triad of ipsilateral facial paralysis, ear pain, and
Herpes zoster vesicles in the auditory canal and auricle
define the Ramsay Hunt syndrome.