Clinical Otology

Balasubramanian Thiagarajan
Symtoms
• Deafness
• Discharge
• Tinnitus
• Pain
• Vertigo
Deafness

Onset

Sudden Gradual
Trigger
Sudden hearing loss (SN)

• Loss of atleast 30 dB in atleast three contiguous

frequencies over a period of less than 3 days.
• Viral causes
• Vascular causes
• Hearing loss is the only symptom
• High dose prednisolone may be useful
Sensorineural hearing loss (Sudden)

• Transverse fracture of pertrous bone

• Auto immune reaction following trauma / infection
• Inflammatory reaction (Viral infections)
• Vascular compromise
Conductive hearing loss - (Sudden)

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

• Fractures involving petrous bone

• Auto immune reaction to proteins released due to
traumatic injury
Gradual progressive hearing loss

• Inflammatory
• Degenerative
Fluctuating hearing loss

• Impacted cerumen
• Meniere's disease
• Perilymph fistula
Differentiating Conductive / SN loss

• Difficulty in comprehending spoken words

• Deafness associated with tinnitus
• Intolerance to loud sounds
• Tuning fork tests
Discharge

• Quantity
• Quality
• Duration of discharge
• Aggravating / releiving factors
Ear discharge - quality

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

• ASOM
• CSOM
• Otomycosis
• CSF otorrhoea
Tinnitus

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

• Otalgia
• Referred otalgia
 Ear pain 5,6,10th cranial nerves
C2 & C3

Tragal impated wax

tenderness
+ Referred otalgia

Tragal tenderness -
Tragal
tenderness +

Otalgia Otomcosis
Myringitis granulosa

Tragal tenderness +
Tragal tenderness -

AOM
Keratosis obturans
Tragal tenderness +

Furuncle
Vertigo

• Sensation of unsteadiness / rotation

• Diseases if inner ear cause vertigo
• Associated with tinnitus and hard of hearing
• Peripheral vertigo
Nystagmus
• Spontaneous / evoked
• Direction of nystagmus -
Right beating, left beating,
geotrophic, ageotrophic.
• Plane - Horizontal, rotatory
or vertical
• Intensity - (I, II and III
degree)
Spontaneous nystagmus

• Eye movements without congnitive, visual, vestibular

stimulus
• Commonly induced by vestibular imbalance
• Vestibular nystagmus is typically inhibited by visual
fixation
• It follows Alexander's law (nystagmus is greater in
the direction of fast phases)
Alexander's nystagmus grading

• I degree - Present only during gaze in the direction of

fast phase
• II degree - Present during straight gaze and also
increases in the direction of fast phase
• III degree - Present during all fields of gaze, but
greatest in the direction of fast phase
History should include

• Previous ear surgery

• Previous head injury
• Systemic diseases like diabetes / Hypertension
• Use of ototoxic drugs
• Noise exposure
• Family h/o deafness
• H/o atopy / allergy
Inspection of external ear

• Shape and size of pinna

• Presence of tags, preauricular sinus and pits
• Evidence of trauma to pinna
• Skin condition over pinna and external canal
• Presence of operative scar in post aural area and end
aural region
• Neoplastic lesions of pinna
• Discharge from external canal
Drug history / Occupation

• Drugs like gentamycin, Streptomycin, and Aspirin can

cause extensive damage to hair cells of cochlea
• Noise exposure can cause damage to outer hair cells
of cochlea
• May be reversible during early phases
Drug induced ototoxicity - Features

• Bilateral sensorineural hearing loss

• Bilaterally symmetrical hearing loss
• Onset time - ???
• Can occur even after a single large dose
• Vestibular injury - common (aminoglycosides)
• Positional nystagmus - a feature of vestibular injury
Aminoglycosides

• Cleared more slowly from inner ear fluids than

serum
• There exists a latency - deafness may occur even 2
months after cessation of the treatment
• Pts on potentially ototoxic aminoglycoside
medications should be monitored atleast for a
period of 6 months following cessation of the
offending drug.
Discharge

• Duration
• Quantity
• Quality
• Aggravating & releiving factors
Acute ear discharge - Causes

• ASOM - Blood tinged

• Otomycosis - Itchy ear, fungal mass seen
• CSF otorrhoea
Profuse ear discharge - Causes

• Chronic mastoiditis - Mastoid tenderness + May lead

to formation of subperiosteal abscess
• Mastoid reservoir - Mastoid tenderness on deep
palpation +
• Extradural abscess
Quality of ear discharge

• Mucoid - CSOM
• Mucopurulent - CSOM with mastoiditis
• Serous - asom
• Serosanguinous - ASOM, Otitis externa
• Watery - CSF
Tinnitus

• Subjective - perceived by the patient

• Objective - perceived by both the pt and examiner
Otalgia

• Pain in the ear

• Could be due to inflammatory pathology affecting
the ear
• Referred otalgia due to pathology elsewhere
Three finger test

• Index, middle and thumb are used.

• Index finger is applied over mastoid process -
tenderness indicates mastoiditis
• Middle finger is applied over well of the concha -
tenderness indicates inflammation in the mastoid
antrum area
• Thumb is used to apply pressure over mastoid
process. Tenderness indicates mastoid emissary vein
thrombophlebitis
Peripheral vertigo

• Is defined as sensation of unsteadiness / rotation

• Commonly caused by inner ear disorders
• Associated with tinnitus / ear block
Peripheral vertigo - Features

• It is fatigable
• It is positional
• Horizontal nystagmus
• Cerebellar signs absent
External ear
• Shape / size of pinna
• Tags / sinuses / pits
• Evidence of trauma to pinna
• Perichonditis
• Seroma
• Skin of pinna / external canal
• Discharge from external canal
• Evidence of previous surgery
• Neoplasm
External canal - Straightening

• Aural speculum
• Adults - Pinna is pulled
postero superiorly
• Infants - pinna is pulled
posteriorly and downwards
Ear drum

• Oval / pearly white in color

• Pars tensa
• Attic
• Cone of light
• Handle / lateral process of malleus
• Perforations
Cone of light

• Present in the antero

inferior quadrant
• Cone shaped
• Caused due to orientation
of middle fibrous layer
• Broken up in retracted ear
drums
• Broken up / lost when ear
drum bulges
Color of ear drum

• Pearly white - normal

• Red drum - Glomus jugulare, AOM
• Blue drum - SOM, Hemotympanum
• Pink drum - Flamingo sign
• Chalky drum - Tympanosclerosis
Retraction pocket features

• Prominent anterior and

posterior malleolar folds
• Apparent foreshortening of
handle of malleus
• Prominent lateral process of
Malleus
• Decreased / absent mobility
of ear drum
• Presence of pockets of
retraction
Siegel's speculum

• Convex lens
• Magnifies 2.5 times
• Mobility of ear drum
• To suck out secretions from
middle ear
• To apply ear drops by
displacement method
Tuning fork tests

• Three frequencies are used

• 256Hz, 512 Hz, 1024 Hz
• These frequencies fall within speech range
• Rinne, Weber and ABC
Prerequisites of a good tuning fork

• It should be made of good alloy

• Should vibrate for one full minute
• Should not produce overtones
Rinne test
• All three frequencies can be
used
• + Rinne (Air conduction
better than bone
conduction)
• -ve Rinne (Bone conduction
better than air conduction)
• False positive Rinne (occurs
in unilateral total hearing
loss due to opposite ear
hearing)
Weber test

• 512 Hz fork is used

• Lateralized to worse ear
• Useful in indentifying
conductive deafness
• Can identify even 5 dB
hearing difference between
two ears
ABC test

• Helps in identifying s/n loss

• Pts hearing is compared to that of the examiner
• It is not reduced in normal ears
Fistula test

• Performed by applying +ve - ve pressure to ear drum

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

• Oval / round window fistulae

• Post stapedectomy perilymph leak
• Horizontal canal fistula
• Meniere's disease
• Labyrinthitis
Hennebert's sign

• +v e fistula test in the presence of intact ear drum

• No evidence of middle ear disease
• Seen in syphilis and hyper mobile foot plate status
• Meniere's disease
Tullio phenomenon

• Sound induced vestibular symptoms - vertigo,

nystagmus, Oscillopsia and postural imbalance
• Seen in - Superior canal dehiscence, Meniere's
disease, vestibulo fibrosis, perilymph fistula, post
fenestration surgeries (i.e. stapedectomy)
Head shake test

• pts head is positioned with chin inclined down 30

degrees
• Head is rotated rapidly to one side.
• Normal response includes no nystagmus / few beats
of nystagmus
• In unilateral labyrinthine dysfunction - nystagmus is
present with slow phase directed towards the
direction of dysfunctional labyrinth
Thank You

Otolaryngology online
Published by drtbalu