Clinical Otology
Balasubramanian Thiagarajan
Symtoms
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Deafness
Discharge
Tinnitus
Pain
Vertigo
Deafness
Onset
Sudden
Trigger
Gradual
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)
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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
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Difficulty in comprehending spoken words
Deafness associated with tinnitus
Intolerance to loud sounds
Tuning fork tests
Discharge
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Quantity
Quality
Duration of discharge
Aggravating / releiving factors
Ear discharge - quality
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Mucoid - CSOM
Mucopurulent - CSOM with mastoiditis
Serous - ASOM
Serosanguinous - ASOM, Otitis externa, trauma
Watery - CSF otorrhoea
Ear discharge - causes
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ASOM
CSOM
Otomycosis
CSF otorrhoea
Tinnitus
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Wax
Active otosclerosis
Sensorineural hearing loss
Ototoxic drugs
Objective tinnitus - Patulous ET, Palatal myoclonus
Pain
• Otalgia
• Referred otalgia
Ear pain
Tragal
tenderness
+
5,6,10th cranial nerves
C2 & C3
impated wax
Referred otalgia
Tragal tenderness -
Tragal
tenderness +
Otalgia
Otomcosis
Myringitis granulosa
Tragal tenderness +
Tragal tenderness -
AOM
Keratosis obturans
Tragal tenderness +
Furuncle
Vertigo
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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
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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
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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
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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
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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
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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
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It is fatigable
It is positional
Horizontal nystagmus
Cerebellar signs absent
External ear
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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
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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
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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
incus
• Decreased / absent mobility
of ear drum
• Presence of pockets of
retraction
Siegel's speculum
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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
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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
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Oval / round window fistulae
Post stapedectomy perilymph leak
Horizontal canal fistula
Meniere's disease
Labyrinthitis
Hennebert's sign
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+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