3. Review of anatomy
• The ear has external, middle, and inner portions. The outer
ear is called the pinna and is made of ridged cartilage
covered by skin. Sound funnels through the pinna into the
external auditory canal, a short tube that ends at the
eardrum (tympanic membrane).
• Sound causes the vibration of eardrum and its tiny
attached bones in the middle portion of the ear, and the
vibrations are conducted to the nearby cochlea. The
spiral-shaped cochlea is part of the inner ear; it
transforms sound into nerve impulses that travel to the
brain.
4. Infections of the External Ear
• Otitis Externa is an infection of the external auditory
canal (EAC) that can be divided according to the time
course of the infection: acute, subacute, or
chronic
• Acute: less than 6 weeks of duration.
5. Types
• Chronic OE – This is the same as acute diffuse OE
but is of longer duration (>6 weeks)
• Eczematous (eczematoid) OE – This encompasses
various dermatologic conditions (eg, atopic dermatitis
, psoriasis, systemic lupus erythematosus, and
eczema) that may infect the EAC and cause OE
• Necrotizing (malignant) OE – This is an infection that
extends into the deeper tissues adjacent to the EAC; it
primarily occurs in adult patients who are
immunocompromised (eg, as a result of diabetes mellitus
or AIDS) and is rarely described in children; it may result
in cases of cellulitis and osteomyelitis
• Otomycosis - Infection of the ear canal secondary to
fungus species such as Candida or Aspergillus
6. Causes
• Swimming
• Constriction of the ear canal from bone growth (Surfer's ear)
• Saturation diver
• the use of objects such as cotton swabs or other small objects to clear the
ear canal
7. Pathophysiology
• OE is a superficial infection of the skin in the EAC. The
processes involved in the development of OE can be
divided into the following 4 categories:
• Obstruction (eg, cerumen buildup, surfer’s exostosis, or
a narrow or tortuous canal), resulting in water retention
• Absence of cerumen, which may occur as a result of
repeated water exposure or overcleaning the ear canal
• Trauma
• Alteration of the pH of the ear canal
8. • The two factors that are required for external otitis to
develop are (1) the presence of germs that can infect the
skin and (2) impairments in the integrity of the skin of the
ear canal that allow infection to occur
• atopic dermatitis , psoriasis
• otomycosis
9. Symptoms
• Drainage from the ear - yellow, yellow-green,
foul smelling, persistent
• Ear pain - felt deep inside the ear and may get worse
when moving head
• Hearing loss
• Itching of the ear or ear canal
• Fever
• Trouble swallowing
• Weakness in the face
• Voice loss
10. Diagnosis
• When the ear is inspected, the canal appears red and
swollen in well- developed cases.
• physical examination
• Otoscope :narrowing of the ear canal from inflammation
and the presence of drainage and debris.
• Culture of the drainage
11. Treatment
• Aural toilet
• Aural toilet must be performed and can be done most
conveniently by dry mopping. The ear is cleaned with a
gentle rotatory action. Once the cotton wool is soiled it is
replaced.
12. Dressings
If the otitis externa is severe, a length of 1 cm ribbon gauze,
impregnated with appropriate medication, should be
inserted gently into the meatus, and renewed daily until
the meatus has returned to normal
13. • The following medications are of value on the
dressing:
• 8% aluminium acetate;
• 10% ichthammol in glycerine;
• ointment of gramicidin, neomycin, nystatin and
triamcinolone
• (Tri-Adcortyl);
14. • other medication may be used as dictated by the
result of culture.
• If fungal otitis externa is present, dressings of 3%
amphotericin, miconazole
• or nystatin may be used.
Otitis media
• Inflamation of te middle ear. Types
Acute
suppurative
non suppurative
Chronic
suppurative
15. Acute Otitis Media
• Acute otitis media, i.e. acute inflammation of the middle-
ear cavity, is a common condition and is frequently
bilateral. It occurs most commonly in children and it is
important that it is managed with care to prevent
subsequent complications. It most commonly follows an
acute upper respiratory tract infection and may be viral or
bacterial.
Pathology
• Acute otitis media is an infection of the mucous membrane
of the whole of the middle-ear cleft Eustachian tube,
tympanic cavity, attic, mastoid antrum and air cells.
16. • The bacteria responsible for acute otitis media are:
Streptococcus pneumonia 35%, Haemophilus
influenzae 25%, Moraxella catarrhalis 15%. Group A
streptococci and Staphylococcus aureus may also be
responsible.
• The sequence of events in acute otitis media is
as follows:
• organisms invade the mucous membrane
causing inflammation, oedema, exudate and
later, pus;
• oedema closes the Eustachian tube, preventing
aeration and drainage;
17. • pressure from the pus rises, causing the drum to bulge;
• necrosis of the tympanic membrane results in
perforation;
• the ear continues to drain until the infection resolves
Causes
• Common cold
• Acute tonsillitis
• Influenza
• Coryza of measles, scarlet fever,
• whooping cough
18. Symptoms, signs
• Earache
• Deafness
It is conductive in nature and may be accompanied by
tinnitus
• Pyrexia
• Tenderness
There is usually some tenderness to pressure on the
mastoid antrum.
19. contd…….
• The tympanic membrane varies in appearance
• Loss of lustre and break-up of the light reflex.
• Redness and fullness of the drum;.
• Bulging, with loss of landmarks. Purple colour..
• Perforation with otorrhoea.
• Mucoid discharge
20. Treatment
• Antibiotics:, amoxycillin will be more effective.
Co-amoxiclav is useful in Moraxella infections.
• Analgesics
• Nasal vasoconstrictors
• Ear drops
• Myringotomy is necessary when bulging of the
tympanic membrane persists, despite adequate
antibiotic therapy
21. Chronic suppurative otitis media(CSOM)
• CSOM is a chronic inflammatory process involving the
middle ear cleft producing irreversible pathological
changes .
Causes
• Late treatment of acute otitis media.
• Inadequate or inappropriate antibiotic
therapy.
• Upper airway sepsis.
• Lowered resistance, e.g. malnutrition,
anaemia,immunological impairment.
• Particularly virulent infection, e.g. measles.
23. Types of CSOM
Mucosal disease with tympanic membrane perforation
(tubo- tympanic disease, relatively safe).
Bony:
cholesteatoma—dangerous (attico- antral disease).
• Tubo tympanic : this is a benign type of CSOM
confined only to the middle ear cleft.
• Attico antral: this involves the attic, antrum and the
posterior tympanum. It is characterized by bone
eroding cholesteatoma.
24. Mucosal infection
Symptoms
• Discharge- mucopurulant,non foul smelling
• Deafness
• Earache
• Signs:discharge, tympanic membrane
perforation,
• Tuning fork test:rinne-negative
• Weber-lateralised to one side
• ABC- normal
25. Investigations
• Culture and sensitivity
• Examination under microscope
• Pure toneaudiogram:mild conductive loss between 20 to
30dB
• X-ray of mastoid, PNS, neck lateral view
• Nasal endoscopy
Treatment of mucosal-type csom
• Removal of septic foci: tonsillectomy,adenoidectomy,
sinus wash
• Myringoplasty if hearing loss below 40dB
• Tympanoplasty:if above 40dB
26. Attico antral type – clinical
features
• Ear discharge: foul smelling scanty,, blood stained, no
relation with URTI
• Deafness:progressive conductive deafness
• Itching and pain in the ear
• Tinnitus and giddiness
•
27. Sign
• In Otoscopic examination: foul smelling discharge in
the ext. Auditory canal
• Granulation tissue in the meatus
• Attic or marginal perforation oftymanic membrane
• Cholesteatoma
• Mastoid tenderness
• Tuning fork test-Rinne negative, weber localised to
lateral side, ABC normal
29. Management
• Goal – to make the ear safe and dry
• To restore and improve hearing
• Surgical management
• Main line treatment.
• 1. canal wall down mastoidectomy:consists of radical
and modified radical mastoidectomy. These procedures
ensures safety and dry ear but functional improvement
may not be achieved.
30. • 2. Canal wall up mastoidectomy: or combined
approach tympanoplasty, where functional
improvement can be achieved but not the safety.
31. Medical management
• It is used only for patient who are unfit for surgery.
Topical antibiotic and steroid are used.
• In some cases 5- flurouracil used.
Complications-CSOM
• Brain abscess
• Lateral sinus thrombosis
• Otitic hydrocephalus
• Meningitis
• Mastoiditis
• Labyrynthitis
• Petrositis
• Cerebellar abscess
32. Difference between
TTD&AAD
TTD AAD
Parts involved Antero inferior Postero superior
Discharge Mucoid, profuse, non
foul smelling
Purulent, scanty,
foul
smelling
Perforation Central Marginal,
Involving attic
Polyp Usually pale Pink, fleshy
Granulation tissue Rare Common
Cholesteatoma Absent Common
Complications Rare Common
33. • Otosclerosis is a hereditary localised disease of the bone
characterised by alternating phases of bone resorption
and new bone formation. The mature
lamellar bone is removed by osteoclasis and replaced by
woven bone of greater thickness, cellularity and
vascularity
OTOSCLEROSIS
34. Pathophysiology
• The primary pathological change occurs in the bony
labyrinth with secondary effects upon middle ear and inner
ear function.The otosclerotic focus may be asymptomatic,
or if present in the area of foot plate of stapes it may give
rise to ankylosis of foot plate with resultant conductive
deafness.Otosclerotic foci may involve other portions of
labyrinth causing sensori neural hearing loss and
vestibular abnormalities.
Causative factors / etiology
• Many theories have been proposed to explain the
etiological factors of otosclerosis. They are:
1. Metabolic
2. Immune disorders
3. Vascular disease
35. • 4. Infection(Measles) currently accepted
5. Trauma : The petrous bone doesnot have regenerative
capacity.This is because of the fact that the enzymes
released during reparative phase are very toxic to the inner
ear hair cells.
• 6. Temporal bone abnormalities (congenital)
• Genetic factors predisposing to otosclerosis: The
tendency for otosclerosis to run in families has been
seen.
Otosclerosis is associated with osteogenesis imperfecta in
0.15 % of cases.This is known as Van der Hoeve
syndrome or Adair - Dighton syndrome.
36. Clinical features
• Deafness: Typically deafness in otosclerosis is bilateral
and gradually increasing in nature. In majority of cases
the deafness is conductive in nature.These patients may
hear better in noisy environment because the speaker
has a tendency to raise his voice because of excessive
ambient noise. This phenomenon a feature of
otosclerosis is known as Paracusis Willisii.
• Tinnitus: is a common symptom and occasionally could
be the only presenting feature. Mostly tinnitus indicates
sensorineural degeneration.Tinnitus may be unilateral or
bilateral. It is usually roaring in nature.
Vertigo:Transient attacks of vertigo is not uncommon
in patients with otoslerosis.These patients may even
have coexisting Meniere's disease
37. Clinical examination
The ear drum in these patients is normal (min
condition).Rarely during active phase of the disease the
increased vascularity of the promontory may be seen
through the ear drum.This sign is known as Flemingo's
flush sign or Schwartz's sign.This indicates
otospongiosis (active otosclerosis).
• Hearing assessment done using tuning forks.
Pure tone auditometry will show precisely the amount
and type of hearing loss. The presence of Carhart'snotch
is a classic audiometric feature in these patients.In
cochlear otosclerosis audiometry reveals sensorineural
hearing loss
38. • Impedence audiometry is an useful investigation to
diagnose otosclerosis.Middle ear compliance is often
reduced.When stapes is fixed stapedial reflex is absent.
The typical impedence curve is As curve.
Management
Medical:The aim of medical management is to convert an
active otosclerotic foci into an inactive or quiscent
foci.Fluride is the drug of choice
Surgical treatment
• Stapedectomy
• Hearing aids:These patients will benefit from the use of
hearing aids if surgery is not acceptable to the patient or
if it is risky.There is always a 1% risk of producing a
dead ear during surgery even in the best of hands.
39. Tympanic Membrane Perforation
• A tympanic membrane perforation is a condition where
your eardrum has a tear or hole in it.
Causes
Changes in ear pressure: Changes in ear pressure may
occur when travelling on an airplane, or if you are
involved in an explosion.
Underwater sports such as swimming or scuba diving
may also cause pressure changes in your ears
• Direct trauma to your eardrum
• Ear infection
• Head trauma
• Past ear surgery or procedure
40. signs and symptoms
• Clear, Mucoid (phlegm-like), thick and yellowish, or
bloody ear discharge.
• Hearing loss in involved ear.
• Pain in involved ear.
• Tinnitus (ringing or buzzing sound in your ear).
• Vertigo (dizziness).
Diagnosis
• History
• Otoscopic examination
41. Surgery
– Myringoplasty: This type of surgery uses a tissue graft to cover
torn eardrum. A tissue graft may be taken from own body, another
person, an animal, or is man-made. A procedure called a
mastoidectomy may also be done with a myringoplasty.
– Tympanoplasty: This surgery repairs torn eardrum and any
damage to inner ear. A tympanoplasty also helps prevent chronic ear
infections. The hole in eardrum will be covered with a tissue graft
42. Infections of the Inner Ear
• Labyrinthitis and Vestibular Neuritis
• Vestibular neuritis and labyrinthitis are disorders resulting
from an infection that inflames the inner ear or the nerves
connecting the inner ear to the brain. This inflammation
disrupts the transmission of sensory information from the
ear to the brain. Vertigo, dizziness, and difficulties with
balance, vision, or hearing may result.
43. signs and symptoms
• A prominent and debilitating symptom of labyrinthitis
is severe vertigo.
• (nystagmus)
• Nausea
• Anxiety
• general ill feeling.
44. Diagnosis
• No specific tests exist to diagnose vestibular neuritis or
labyrinthitis. Therefore, a process of elimination is often
necessary to diagnose the condition. Because the
symptoms of an inner ear virus often mimic other
medical problems, a thorough examination is necessary
to rule out other causes of dizziness, such as stroke,
head injury, cardiovascular disease, allergies, side effects
of prescription or nonprescription drugs (including
alcohol, tobacco, caffeine, and many illegal drugs),
neurological disorders, and anxiety
45. Treatment
• Vestibular rehabilitation therapy is a highly effective
way to substantially reduce or eliminate residual
dizziness from labyrinthitis. VRT works by causing the
brain to use already existing neural mechanisms for
adaptation, neuroplasticity, and compensation.
• Rehabilitation strategies most commonly used
are:
• Gaze stability exercises - moving the head from side
to side while fixated on a stationary object (aimed to
restore the Vestibulo-ocular reflex)
• Habituation exercises - movements designed to
provoke symptoms and subsequently reduce the
negative vestibular response upon repetition.
• Functional retraining - including postural control,
relaxation, and balance training
46. Ménière's disease
• Ménière's disease is a disorder of the inner ear that can
affect hearing and balance to a varying degree. It is
characterized by episodes of vertigo, low- pitched tinnitus,
and hearing loss. The hearing loss is fluctuating rather
than permanent, meaning that it comes and goes,
alternating between ears for some time, then becomes
permanent with no return to normal function.
Causes
• Ménière's disease is idiopathic, but it is believed to be linked
to endolymphatic hydrops, an excess of fluid in the inner ear.It
is thought that endolymphatic fluid bursts from its normal
channels in the ear and flows into other areas, causing damage.
This is called "hydrops."
• The symptoms may occur in the presence of a middle ear
infection, head trauma, or an upper respiratory tract infection,
• aspirin, smoking cigarettes, or drinking alcohol.
• excessive consumption of salt in some patients.
• herpes virus.
47. Symptoms
• Attacks of rotational vertigo
• Fluctuating, progressive, unilateral (in one ear) or
bilateral (in both ears) hearing loss
• Unilateral or bilateral tinnitus
• A sensation of fullness or pressure in one
or both ears
• Parasympathetic symptoms , These are typically
nausea, vomiting, and sweating which are typically
symptoms of vertigo, and not of Ménière's
• nystagmus,
• Migraine
48. Diagnosis
• Complaints and medical history.
• otolaryngological examination, audiometry, and
• Head MRI scan should be performed to exclude a
vestibular schwannoma or superior canal dehiscence
which would cause similar symptoms.
Management
• stopping to have coffee which contains caffeine &
stopping to have tea
• Recommended salt intake is often around one to two
grams per day. One source recommends taking two
grams of potassium or more daily
• Diuretics have traditionally been prescribed to facilitate
a Low sodium diet although there is no definite
supportive evidence.
49. • Both prescription and over-the-counter medicine can be
used to reduce nausea and vomiting during an episode.
Included are antihistamines such as meclozine or
dimenhydrinate, trimethobenzamide and other
antiemetics, betahistine, diazepam, or ginger root.
Surgery
• Non destructive surgeries include those which do
not actively remove any functionality, but rather aim
to improve the way the ear works
• Intratympanic steroid treatments involve injecting
steroids (commonly dexamethasone) into the
middle ear in order to reduce inflammation and alter
inner ear circulation.
50. • Surgery to decompress the endolymphatic sac has
shown to be effective for temporary relief from symptoms.
• Conversely, destructive surgeries are irreversible and
involve removing entire functionality of most, if not all, of
the affected ear. The inner ear itself can be surgically
removed via labyrinthectomy although hearing is always
completely lost in the affected ear with this operation
• Alternatively, a chemical labyrinthectomy, in which a
drug (such as gentamicin) that "kills" the vestibular
apparatus is injected into the middle ear can accomplish
the same results while retaining hearing.
51. • In more serious cases surgeons can cut the nerve to the
balance portion of the inner ear in a vestibular
neurectomy. Hearing is often mostly preserved, however
the surgery involves cutting open into the lining of the
brain, and a hospital stay of a few days for monitoring
would be required
• Physiotherapy
• In vestibular rehabilitation, physiotherapists use
interventions aimed at stabilizing gaze, reducing
dizziness and increasing postural balance within the
context of activities of daily living.
52. Hearing Loss
• Hereditary disorders - some types of deafness are
hereditary, which means parents pass on flawed genes
to their children. In most cases, hereditary deafness is
caused by malformations of the inner ear.
• Genetic disorders - genetic mutations may happen: for
example, at the moment of conception when the father’s
sperm joins with the mother’s egg. Some of the many
genetic disorders that can cause deafness include
osteogenesis imperfecta, Trisomy 13 S and multiple
lentigines syndrome.
53. • Prenatal exposure to disease - a baby will be born deaf
or with hearing problems if they are exposed to certain
diseases in utero, including rubella (German measles),
influenza and mumps. Other factors that are thought to
cause congenital deafness include exposure to methyl
mercury and drugs such as quinine.
• Noise - loud noises (such as gun shots, firecrackers,
explosions and rock concerts), particularly prolonged
exposure either in the workplace or recreationally,
can damage the delicate mechanisms inside the ear.
• Trauma - such as perforation of the eardrum, fractured
skull or changes in air pressure (barotrauma).
• Disease - certain diseases can cause deafness, including
meningitis, mumps, cytomegalovirus and chicken pox. A
severe case of jaundice is also known to cause deafness.
• Other causes - other causes of deafness include
Meniere’s disease and exposure to certain chemicals like
ototoxic drugs
54. Conductive hearing loss
• It is characterized by an obstruction to air conduction
that prevents the proper transmission of sound waves
through the external auditory canal and/or the middle
ear. It is marked by an almost equal loss of all
frequencies. The auricle (pinna), external acoustic canal,
tympanic membrane, or bones of the middle ear may
be dysfunctional.
55. Sensorineural hearing loss
Occurs when the sensory receptors of the inner ear are
dysfunctional. Sensorineural deafness is a lack of sound
perception caused by a defect in the cochlea and/or the
auditory division of the vestibulocochlear nerve. This type
of hearing loss is more common than conductive hearing
loss and is typically irreversible. It tends to be unevenly
distributed, with greater loss at higher frequencies.
Sensorineural hearing loss may result from congenital
malformation of the inner ear, intense noise, trauma, viral
infections, ototoxic drugs (e.g., cisplatin, salicylates, loop
diuretics), fractures of the temporal bone, meningitis,
ménière's disease, cochlear otosclerosis, aging (i.e.,
presbycusis), or genetic predisposition, either alone or in
combination with environmental factors. Many patients
with sensorineural hearing loss can be habilitated or
rehabilitated with the use of hearing aids.
56. Mixed hearing loss
• Have both conductive and sensory dysfunction. Mixed
hearing loss is due to disorders that can affect the middle
and inner ear simultaneously, such as otosclerosis
involving the ossicles and the cochlea, head trauma,
middle ear tumors, and some inner ear malformations.
Trauma resulting in temporal bone fractures may be
associated with conductive, sensorineural, and mixed
hearing loss
57. Degree of hearing loss
• Deaf/Deafness refers to a person who has a
profound hearing loss and uses sign language.
• Hard of hearing refers to a person with a hearing loss
who relies on residual hearing to communicate through
speaking and lip-reading.
• Hearing impaired is a general term used to describe any
deviation from normal hearing, whether permanent or
fluctuating, and ranging from mild hearing loss to
profound deafness.
• Residual hearing refers to the hearing that remains after
a person has experienced a hearing loss. It is suggested
that greater the hearing loss, the lesser the residual
hearing.
58. Assessment
• Hearing loss is confirmed using a battery of audiologic
tests, with the specific tests and measures selected
according to the age of the patient. However, in general,
comprehensive hearing assessment designed to confirm
hearing loss usually includes a hearing history,
physiological procedures, and behavioral procedures
59. Components of a Comprehensive Hearing Assessment and
Hearing History
• General concern about hearing and
communication
• Auditory behaviors (reacting to and recognizing
sounds)
• History of otological diseases and other risk factors for
hearing loss
61. Management
• Interventions for most infants and young children with
hearing loss are primarily focused on the following goals:
• Preventing or reducing the communication problems that
typically accompany early hearing loss.
• Improving the child's ability to hear.
• Facilitating family support and confidence in parenting a
child with a hearing loss.
62. A hearing aid is an electroacoustic device which is designed
to amplify sound for the wearer, usually with the aim of
making speech more intelligible, and to correct impaired
hearing as measured by audiometry. Ordinary small audio
amplifiers or other plain sound reinforcing systems cannot
be sold as "hearing aids".
63. Types
• There are many types of hearing aids (also known as
hearing instruments), which vary in size, power and
circuitry. Among the different sizes and models are:
– Body worn aids
– Behind the ear aids (BTE)
– "Mini" BTE (or "on-the-ear") aids
– Receiver in the canal/ear
(CRT/RIC/RITE)
– Earmolds
64. • In the ear aids (ITE)
• Invisible in canal hearing aids (IIC)
• Extended wear hearing aids
• Open-fit devices
• Personal, user, self, or consumer programmable
• Disposable hearing aids
65. • Bone anchored hearing aids (BAHA)
• Eyeglass aids
– Spectacle hearing aids
– Bone conduction spectacles
– Air conduction spectacles
Stetho-Hearing Aid
