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Sensoric disorders
EAR
1. EXTERNAL EAR
1.1.
INFLAMMANTIONS
A. Circumscribed inflamations
1. Impetigo is caused by staphylococcal or streptococcal infection under the superficial layer
of the skin. The disease is characterized by vesicles, which burst and dry up.
The patient doesn´t have too much discomfort, and the disease is treated by locally applied
antibiotics (for example Framykoin or Bactroban).
2. Folliculitis is the inflammation of hair follicles, usually caused by staphylococs. It looks
like the yelowish infiltration of the skin with the hair in the middle.
3. Furunculus is usually localised in the external auditory meatus, in the entrance to the
external auditory meatus and seldom on the auricle. The infection affects the hair follicle and
the sebaceous gland. The infection is mostly caused by staphylococs or by pseudomonas
pyocyanea. People working in the cement works, ironworks and sugar rafinery are more often
affected by this disease as well as patients with diabetes. The infection cause the necrosis of
the epithelium in the hair follicul and sebaceous gland, extends to surrounding tissues and
cause severe local inflammatory reaction. If the inflammation is deep seated, it can lead to
rising of the abscess, perichondritis and sometimes even the periostitis or osteomyelitis. The
perforation of the drum, extension to the parotid gland and extension to processus mastoideus
has been already described. The regional lymphadenitis is commonly found.
B. Bacterial diffuse otitis externa
1. Erysipelas - streptococcal infection spreading in the superficial lymphatic vessels,
localised often in the nasal cavity and the ear . The infection can get into the vessels through
small injuries (scratching, pricking). There is also rising of the vesicles in severe cases
(erysipelas vesiculosum or bulosum), besides the redness, which is in all cases.
Symptoms : fever (39 - 40°C), generalisied illness, chills and shivering.
Treatment : systemic antibiotics, local application of the liniments with topically active
antibiotics.
2. Perichondritis of the auricle is often result of the injury, sometimes it can rise from the
othematoma, furunculus or abscess.
Ethiology : pyogenous cocs or pseudomonas pyocyanea.
The inflammations are serous or purulent. The exsudation separate the perichondrium from
cartilage and so damage nutrition, so in the end it can lead to the necrosis of cartilage. The
inflammatory mass can burst outside through the skin and form, fistula.
Through this fistula the necrotic cartilage is eliminated with pus (purulent matter).
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C. Viral otitis externa
- Herpes simplex
- Herpes zoster
D. Alergic inflamations
They are caused by allergen, the substance to which is the skin sensitive. It can be chemical
substance (colors, metals, cement, flour dust), drugs (penicillin, streptomycin, iodine),
nutritions spread by the blood and causing the allergic inflammations in the region of the
external meatus of auricle (eggs, fruit, meat, metabolic products), pus containing bacterial
and mycotic toxins (in case of purulent otitis externa or otitis media). Eczema looks like
deep-red inflammatory swelling (eczema erytematosum), sometimes with vesicles or papuls
(eczema vesiculosum, eczema papulosum). Sometimes there are also crusts (eczema
crustosum) or scales (eczema squamosum).
Treatment include elimination of the allergen and local treatment (application of the
liniments).
1.2.
SPECIAL FORMS
1.2.1., 1.2.2.
Bacterial otitis
occurs in the circumscript [absces] and difuse form [phlegmona].
Differenties are in the appearence and in the course.
Differenties of therapeutic approach [treatment of circumscripte and diffuse inflammation].
Danger - development of perichondritis with consequent deformation.
External diffuse otitis as a frequent inflammation is caused by : ear wax, swimming pools.
Very paninfull disease.
Absces of external meatus: therapy - local (ointment, incision)
- general (antibiotic therapy)
1.2.3. Herpes zoster oticus
Dermatological – otoneurological disease.
Damage of external ear and VIIIth cranial nerve. Therefore are the symptoms
cochleovestibular.
Therapy - corticoids
- acyclovires
Danger : permanent disturbance of VIIIth cranial nerve, oligoneuritis (VIIth cranial nerve!).
1.2.4. Myringitis bulosa
Isolated para and post infections damage of ear drum.
Therapy: predominantly local and symptomatic.
Development of otitis!
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1.2.5. Otitis externa maligna
Expansive inflammatory disease – high mortality destruction of external meatus (osseous part,
mandibule, skull basis).
Diagnostic concribution of x ray examinations CT, NMR
Therapy: - antibiotics
- antimallarics
Surgery – only additional tool
1.2.5.1. Otomycosis
Very torpide disease by the changes of pH after middle ear surgery.
Therapy: local antimycotics
general antimycotics
1.2.5.2. Eczema
As a result of maceration of the skin by swimmers as a result of bacterial flow from middle
ear cavity – see 1.2.5.1.
1.2.6. Specific ear inflammations
TBC occurs predominantly on the ear drum (multiple perforations)
Specific changes on the bony chain (necrosis)
Therapy: tuberculostatics and local (surgery)
1.3.
TRAUMAS
Injuries of the external ear
-Trauma by mechanical violence
-Chemical burns
-Burns
-Frostbite
-Injury from radiation
-Injury
Traumas of the auricle-open injuries
-closed
Treatment: cleaning of the wound, surgical (suture), antibiotics, necrectomy. Amputation of
auricle rarely.
1.3.1. Othematoma
-closed blunt injury with dissection of the skin and perichondral layer from the cartilage
and the formation of a subperichondrial hematoma.
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Localisation-mostly fossa triangularis,sometimes the whole anterior part of the auricle.
In the beginning fluctuation,later,if a hematoma is not treated,connective tissue
organization,secondary deformity of the auricle(cauliflower ear).
Treatment:a wide incision,removing of necrotic tissues, operation sec.Herrman, compression,
antibiotic cover, important antisepsis
1.3.2. Injuries of meatus acusticus externus
-from different objects, possibility of superinfection-furunculus
-phlegmona
-erysipel
-iatrogenic injuries
-rupture of the meatus acusticus externus in fractures of the petrose bone and the base of the
skull
-possibility of liquorrhea
-syringitis or manipulation within the external auditory meatus must not be carried out
Complications: -superinfection
-meningitis
Treatment: sterile tampon, antibiotics local and general
1.3.3. Frostbite-congelatio auriculae
-more frequent than burn
general predisposition-disorder of general and local circulation
-exhaustion
-disturbances of nutrition
-intoxication
Degrees of disturbance.
Grade 1-congelatio erytematosa-cyanosis of the skin due to vascular spasm
Grade 2-congelatio bullosa-ischemia with formation of vesicles
Grade 3-congelatio escharotica-deep dressings,antibiotics,intravenous vasodilators,hot drinks
1.3.4. Perniosis
at the places earlier frostbitten,where was damage of the vessels
Treatment: local massage
Burns-combuscio auriculae
Grade 1-combuscio erytematosa
Grade 2-combuscio bullosa
Grade 3-combuscio escharotica
Grade 4-carbonisatio
Treatment:the same as burns of the skin
1.3.5. Damage from radiation
-sunshine,X-ray,Radium,Solux
Treatment:the same as burns
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1.3.6. Chemical burns-corrosio
-acids(coagulating necrosis)
eyes(colliquating necrosis),yperit,lewisit
Treatment:remove of toxic substance,neutralisation
1.4.
WAX AND FOREIGN BODIES
Wax is a yellowish-brown mass consisting of the secretion of the sebaceous and ceruminous
glands, desquamated epithelium, hair and particles of dirt.
Causes local:-narrowing of the external auditory meatus
-wrong cleaning
-inflammation of the external meatus
-growth of hair
general:-hypercholesterolemie
-diabetes
-nefritis, etc.
Symtoms:deafness,tinnitus,vertigo,feeling of pressure in the ear
Diagnosis:symtoms,otoscopy
Treatment:otomicroscopic suction,irrigation with water at 37 degrees C
contra-indication-perforation of the tympanic membrane and atrophy.Wax should
be softened by 3% hydrogen peroxide for 1-2 dayr and then cleaning.The hearing should be
tested after this procedure.
Corpora aliena
-anorganic
- organic
-mostly in childhood(marbles,beans,toys,beans,peas)
-adults(toothpicks,cottonQ-tips,garlic,grain,straw,insects)
Symtoms:feeling of pressure,pain in the ear,tinnitus,deafness,inflammation,vertigo
Treatment:careful removal with hook(no forceps!),in small children using general anesthesia
Complications:during removal-labyrintitis-meningitis-deafness
1.5.
TUMORS
1.5.1. Benign tumors
Benign tumors of the auricle are not very common. These include atheroma (it is in fact
retention cyst of sebaceous gland). It is usually sphere-shaped, localised most often in the
retroauriculary region. Other benign tumors are hemangioma, lymphangioma and fibroma.
Cicatricial keloids are commonly described at the Africans after the treating of injuries on
the auricle with cinders of the charcoal. In our conditions you can see most commonly the
cicatricial keloids on the auricle after the itroducing of the earrings. Their colour is dark red
and sometimes they can be as big as the pigeon egg. Meatal tumors include exostosis arising
from the ossification centers in the anulus tympanicus. They can be solitary or multiple
hemisphere-shaped tumors narrowing the external meatus. They can lead sometimes to the
complete obturation of the external meatus. Their development is very slow. The incidence is
higher at the swimmers.
Treatment: surgical removing under the control of operation microscope.
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1.5.2. Precancerous and Malignant tumors
Precancerous lesions – we can find on the auricle most commonly cornu cutaneum and senil
keratosis:
a) cornu cutaneum is a sharply limited warty growth of the epidermis without any cartilage
invasion. The colour is not different from the colour of the surrounding skin.
b) senile keratosis is a round yelowish-brown smooth mass covered with crusts. There is not
any cartilage invasion as well.
The treatment of both of them is surgical (excision).
Malignant tumors – they include basal cell carcinoma, squamous cell carcinoma and
malignant melanoma.
a) basal cell carcinoma manifests like a vaulty infiltration, often ulcerated, causing
destruction of cartilage and tissuses under the skin. Exulcerated basal cell carcinoma is
called ulcus rodens.
b) for squamous cell carcinoma is typical growth with infiltration of the surrounding
tissues, exulceration of tumor and the destruction of tissues infiltrated by tumor. About
20% of patients have regional lymph node metastases. About 50% of the squamous cell
carcinoma of the external ear is localised in external meatus.
c) melanoma is characterized by verrucous rapid growth and the darkbrown colour. The
tumor give rise to early metastases.
All the malignant tumors of the auricle are supposed to be treated by partial or total resection
of the auricle, sometimes with resection of the surrounding tissues. It is necessary to carry out
the revision or the resection en bloc of the affected cervical lymph nodes.
Especially in case of malignant melanoma the treatment has to be very radical.
Surgical treatment should be combined with radiotherapy.
1.6.
CONGENITAL ANOMALIES
Embryogenesis, clasification
… 5 min
1.6.1. Reconstructive operations
indication chart, correction of the auricle in case of bat ear, multiple stage operations – local
shifts, implantation of costal cartilage.
… 10 min.
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2.
THE MIDDLE AND INTERNAL EAR
2.1.
DISORDERS OF VENTILATION OF THE MIDDLE EAR
The middle ear cavity and pneumatic system are aerated by the Eustachian tube. The tube
serves to equalize the pressure and drainage between the middle ear and nasopharyngx. The
tube is closed, opened is actively by contraction of the tensor palati and levator palati
muscles/yawning and swalowing/. Disorders of ventilation and drainage are acute or
chronic.Otoscopy shows a retracted tympanic membrane,or occurs transudate in the middle
ear.There is e feeling of pressure and fullnes in the ear, pain, crascling noise on
swalowing,yawning and sneezing. Conductive hearing loss, Weber s test localizes the tone in
the diseased ear,tympanometry type C or B. Pathogenesis tube dysfunction due to following
factors:
chronic
inflammation,
allergy,hypertrophied
adenoids,tumor
of
the
nasopharyngx.Treatment and prognosis . removing adenoids,treatment allergy and
inflammations,progress to chronicity lead to adhesive process.
2.1.1. Acute tubal occluson (serotympanum)
Pathogeneseis:complication of the inflammation of the nasopharynx, nose and PNC,oedema
with closure of the Eustachian tube with bad ventilation and underpressure in the middle ear
cavity,heperaemia e vacuo,transsudation(hydrops e vacuo)
Symtoms-feeling of the pressure in the ear,deafness,pain,crackling nose on swallowing
Diagnosis-otoscopy:retracted tympanic membrane,injection of the handle of the malleus and
of the vessels of the tympanic membrane,an exudate or bubbles of air in the middle ear
-audiometry-light or middle conduction deafness
Differential diagnosis-to exclude acute otitis media
Treatment:degongescant nose drops,vasoconstrictors,antihistamines,therapy of
sinusitis,hypertrophied adenoids are removed later if necessary,insufflation of air
Course and prognosis:the symtoms usually resolve rapidly,but occasionally the disease
progresses to a chronic seromucinous otitis media
2.1.2. Cronic seromucinous otitis media
Pathogenesis: underpressure in the middle ear. Tubal incompetence, obstructive processes of
the nasopharynx, disorders of tubal kinetics, incompetence of the muscles in cleft palate,
barotrauma, infections. The primary cause can be adenoids, sinusitis, allergy or tumour.
Symtoms: feeling of pressure and fullness in the ear, often accompanying an infection of the
upper airway and considerable decrease in hearing, noises in the ear on yawning, swallowing,
sneezing. No pain.
Diagnosis: otoscopy-retracted tympanic membrane, discoloration of the tympanic membrane ,
fluid level or air bubbles
audiometry-conductive deafness for the entire frequency range of 40 to 50 dB
B impedance curve
X-ray-in Schueller´s view shows opacity of the cell system without bone changes
Differential diagnosis: hemotympanum, otitis media chronic with perforation, with
cholesteatoma
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Treatment: removing of primary cause-therapy of sinusitis, adenoidectomy or readenoidectomy, antiallergic treatment, mucolytics, antibiotics, alpha-chymotrypsin,
hyaluronidase, corticosteroids
surgical-paracentesis and drainage of the middle ear
Course and prognosis: in proportion of patients is progressive chronic course leading to
adhesive processes and tympanosclerosis
2.2.
MIDDLE AND MASTOIDAL EAR INFLAMATIONS
As a one of most frequent diseases in ENT (see 2.1.1. and 2.1.2.).
Prevalency in childern – in adults less frequent but course could be secions (conductive
hearing loss – permanent)
2.2.1. Otitis media acuta
2.2.2. Mastoiditis
As a complication of acute or subacute otitis – palpation ab planum mastoideum and
otoscopic finding as a most decisive indicators (i.e. depression of posterior – superior part of
external bony meatus)
Danger of further intracranial complications (sinus signoideus, facial nerve, invasion into
cranial cavity and labyrinth).
Surgery: exenteration of diseased and necrotised mastoidal cells.
2.2.3. Otitis media chronica
Predisposing factor – mostly in infants repeated acute otitis – not properly treated.
Intratympanic fibrosis, epitympanal adenoids, retractory pocket, atelectatic.
2.2.3.1. Otitis media chronica simplex
As relative simple form of chronic inflammation with good prognosis.
2.2.3.2. Otitis media chronica cholesteatosa
Conditions for a development of cholesteatoma – penetration of epidemius through tympanic
membrane (i.e. its upper part).
Agressive properties of cholesteatoma toward ossicular chain. Towards ossicus parts of
middle ear cavity. Possibility of penetration to – posterior scull base cavity pyramidal apel.
Diagnosis – local findings (CT, NMR)
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2.2.3.3. Otitis media chronica cum ostitide
mostly as a consequence of 2.2.3.2.
Surgery
2.3.
CONGENITAL CHOLESTEATOMA
2.4.
TYMPANOSCLEROSIS
as a consequence of not well treated middle ear information in childern.
Reconstructive surgery
2.5.
OTOGENIC INFECTIVE COMPLICATION
2.5.1. Labyrinthitis
1. circumscribed labyrinthitis
2. serous diffuse labyrinthitis
3. purulent diffuse labyrinthitis
1. Circumscribed labyrinthitis is an inflammation of circumscribed part of the labyrinth,
most often the lateral edge of the horizontal membranous semicircular canal. It is caused most
often by cholesteatoma. There is a penetration of toxins and bacterial invasion through fistula
into the horizontal semicircular canal. The patient has feeling of dizziness, nystagmus,
especially during any manipulation in the middle ear. The fistula test is positive .
Circumscribed labyrinthitis is an indication for surgical intervention. The fistula is cleaned
from the cholesteatoma and granulomatous matters and covered with fascia.
2. Serous labyrinthitis starts after the penetration of mitigated infection from the middle ear.
Most often is involved bacterial infection. There is not too much leukocytes inside the
labyrinth. Dizziness, nystagmus and loss of hearing are present.
The surgical intervention is needed. Paracentesis in case of acute otitis media, sometimes
antrotomy, combined with systemic antibiotics.
3. Purulent labyrinthitis usually folow up the acute mastoiditis or chronic otitis with
cholesteatoma. There is very strong infiltration of labyrinth by leukocytes and destruction of
membranous labyrinth. The disease can continue into cranial cavity and cause purulent
meningitis. Purulent labyrinthitis is characterized by heavy dizziness and spontaneous
nystagmus (the nystagmus beats toward the labyrinth without inflamation). There is also
very fast and irreversibil deafness in a few hours.
The surgical treatment is necessary- mastoidectomy or tympanomastoidectomy combined
with systemic antibiotics. Labyrinthectomy is not carried out now so much as before, because
of higher efficiency of the antibiotic therapy.
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2.5.2. Otogenic brain abscess
Otogenic brain abscess is caused by penetration of infection into the cranial cavity.
In the initial stage the increased intracranial pressure and vomiting are present. In the latent
stage diffuse headeache is present. As for manifest stage, the symptoms depends on
localisation of abscess. It can be for example amnestic aphasia, in case of localisation of
abscess in the left hemisphere. The diagnosis should be confirmed by CT scan. The
cooperation with neurosurgeon is needed during the treatment of brain abscess. The primary
focus is removed by mastoidectomy or radical mastoidectomy by an otologist before a
neurosurgical procedure to remove the abscess.
2.5.3. Otogenic sinus thrombosis
Thrombophlebitis of sigmoid sinus starts after the extending of the inflammation to the region
of sigmoid sinus. There is usually periphlebitis and a perisinus abscess before. Sepsis, a
spiking temperature chart and chills are usually present. The throbosis sometimes extends to
internal jugular vein. In such a case we can palpate rigid painfull cord on the neck. We can
find infection metastases to the lungs, kidneys and liver. In some more serious cases the
primary focus can give rise to an endocarditis. Surgical treatment is combined with systemic
antibiotics. The involved sinus is exposed and after the intersection of sinus, the thrombus is
removed. After that the ligature of the jugular vein is made.
2.5.4. Pachymeningitis externa
It´s present like a complication of acute otitis media. The inflammation is spreading toward
the dura matter of the middle or posterior cranial fossa. Dura starts to cover with
granulomatous mass and fibrin and granulomatous mass starts to produce pus. Collection of
pus in that space can form the extradural abscess. Perisinus abscess can rise if the collection
of pus is in the tissues surrounding sigmoid sinus. Dull pulsating pain in the retroauricular
region, irradiating to the top (parietal region) is usually present. The surgical treatment
(opening and drainage of abscess) is combined with systemic antibiotics.
2.6.
DISEASES OF THE CAPSULA OF LABYRINTH
chochlear or stapedial form of otosclerosis,CT findings,audiometry findings
2.6.1. Otosclerosis
stapedial form,audiometry findings,prosthetic solution,indicate system to surgical
treatment,types of operations,audiometry results,stapedotomy
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2.7.
MIDDLE AND INNER EAR INJURIES
Causes: traffic accidents, violence, shot injuries
Frequency - 3% of all injuries, in 45% connected with the fracture of the skull base
Symptomatology - bleeding, liquorrhea-nasal, ear, epipharyngeal
function of the facial nerve, heamotympanon, earrum perforation,
step-shaped fracture of the external auditory canal (otoscopy findings), event. presence of the
brain tissue in the ext. Auditory canal, hearing losts - conductive, sensorineural-its
quantification, vertigo, dizziness, nystagmus
2.7.1. Temporal Bone Fractures
Types - longitudinal, transversal, oblique - involvement of the middle and inner ear
according to the types
Symptomatology and differential diagnosis in between the types
Mechanism of injury
Diagnostics - imaging methods, local findings - otoscopic, neurologic audiometry,
vestibular
investigation,
neurology,
special
tests
Schirmer
test,
Gustometry, tympanometry, EMG
Treatment - conservative, surgical - indications and its priority
Course, prognosis, complications - early and late
2.7.2. Labyrinthine Commotion
Definition - normal morphology including imaging methods, function disoders of the inner
ear after the injury
Symptomatology: tinnitus, sensorineural hearing lost, vertigo
Pathogenesis: violence, resp. its effects on the labyrinthine membrane
Diagnostics: morphologic and function findings
Differential diagnosis: acutrauma, psychopathology according to the injury
Treatment, course, prognosis.
2.7.3. Direct (injuries of the Middle and Inner Ear)
Symptomatology: otoscopic, audiologic ev. vestibular findings and its differences in middle
and inner ear traumas
Pathogenesis: sharp particles in the external auditory canal-in childern cleaning of the
ear, professional injuries (hot metallic particles)
Diagnostic: otoscopic findings, imaging methods, audiovestibular findings
Treatment: conservative, surgical (types of the operations)
Course and prognosis
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2.7.4. Barotrauma
Causes: pressure changes (pressure chambers, aircrafts, diving)
Mechanism of injury - pressure - bleeding - transudation on the Middle ear event. membr.
foramen rotundum.
Treatment: conservative and surgical
2.7.5. Acoustic Trauma
2.7.5.1. Acute
Difference between explosion (pressure wave more than 1,5 ms) and gunshot (pressure wave
cca 1,5 ms)
Pathogenesis: mechanical component (pressure wave), metabolic component (changes in
microcirculation)
Diagnostics: otoscopic findings (explosion, gunshot) audiovestibular findings
Symptomatology: tinnitus, hypacusis, vertigo, pain (localisation and type)
Treatment, course and prognosis
2.7.5.2. Chronic
Symptomatology: pressure, hypacusis, tinnitus, fatigue
Pathogenesis: adaptation, metabolic changes leading to degeneration of the inner
and external hairy cells
Diagnostics: otoscopic finding,
intermitent or permanent hypacusis
audiovestibular
findings
(shape
of
the
curve)
Differential diagnosis: other types of hypacusis (hereditary, toxic, plurimetabolic
lesions)
Treatment, course and prognosis.
Literature:
Škeřík, Hybášek, Rems: Náhlé a neodkladné stavy v ORL, Avicenum 1985
Becker, Neumann, Pfaltz: Ear, nose and throat diseases Thieme 1994
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2.8.
TUMOURS OF THE MIDDLE AND INNER
EAR,N.VESTIBULOCOCHLEARIS
2.8.1. Benign tumours of the middle ear
The most frequent tumour hier is glomus tumour(chemodectomas,nonchromaffin
paraganglioma).It is a benign tumour,but in advanced stages it can cause intracranial
extension,death of the patient.More often in women.
2.8.2. Malignant tumours of the middle ear
They are rare,the most frequent of them is a squamous cell carcinoma.Mostly in women,age
of patients is 50-60 years.
Prognosis is poor.
2.8.3. Tumours of the inner ear
They are rare too,the most frequent is acoustic neuroma(schwannoma).
Symtoms:unilateral progressive deafness,tinnitus,paresis facial nerve.
Lesion is diagnosed by neurovestibular investigation(mainly BERA),CT,MRI.
Treatment:neurosurgery or otologic surgery
Literature:viz česká verze
2.9.
CONGENITAL ANOMALY
embryogenesis,CT findings
2.9.1. Combine anomalies of the middle and inner ear,prosthetic solutions,surgical
methods,indicate system to surgical treatment,results of treatment
2.10. COCHLEOVESTIBULAR DISORDERS
2.10.1. Toxic Damage
2.10.1.1.Aminoglycoside Antibiotics
The toxic concentrations in the inner ear retained for a longer period lead to irrevesible
damage to outer hair cels at higher conzentratitins,the inner hair cells, later the stria vascularis
and the ganglion cells. Streptomycin is mainly vestibulotoxic, Dihydrostreptomycin is
ototoxic. Neomycin and Kanamycin strongly ototoxic, Gentamycin is oto and vestibulotoxic.
The development damage depends on the dose, and its half-life,renal function and condition
of the stria vascularis and the resorptive cells in the inner ear. Diagnosis depends on
audiogram, vestibular tests and abnormal renal function.Treatment includes immediate
cessation of the aminoglycosides, intravenous infussion vasoaktive drugs, cortisone and
nootropics. Prognosis is poor.
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2.10.1.2. Ototoxic Occupational Damage
Exogenous ototoxins are in many industrial products. Tinnitus and hearing loss are
progressive, vertigo is associated with nausea. Carbon monoxide causes a peripheral cochlear
and central vestibular failure. Other substances cause degeneration of neurons, central nuclei
and pathways, on the first place of sensory cells. Arsenic compounds, Mercury salts, Lead
salts, Organic phosphate, Sulphur, Tetrachlorcarbon compounds, Benzol, Nitrobenzol and
Aniline caused toxic Damage to the hearing and balance apparatus.
2.10.2. Inflammatory Lesions of the Hearing and Balance Apparatus
2.10.2.1. Herpes Zoster Oticus
The disorder is due to a viral infection and may occur at any age. Symptoms: fever,erythema
and vesicles on the auricle and external meatus, regional lymhadenitis, otitis, peripheral facial
paralysis in 60 to 90 ˇ%, neuralgic pain, retrocochlear hearing loss and vertigo.
Diagnosis: otoscopy, audiometry, neurootology tests, viral serology.
Differential diagnosis: myringitis bullosa, idiopathic facial paralysis.
Treatment : antiviral agent, B vitamins. Prognosis poor for function.
2.10.2.2. Other Viral Infections
Influenza, measles, adenovirus, chicken pox, coxackie, mumps often causes symptoms
corresponding neuritis statoacustica. Infections with mumps virus is the most frequent cause
of unilateral deafness in young children. The vestibular part of the labyrinthis almost never
attacked by mumps. The viruses has particular affinity for the cochlea and spiral ganglion.
Prognosis is poor, irrevisible damage frequent.
2.10.2.3. Serous Labyrinthitis
This condition is a toxic or virally determined serous inflammations of the peri and
endolymphatic spaces with destruction cochlear and vestibullar sensory cells. Loss of function
is irreversible with total and reversible in cases with partial destruction sensory cells.
Symptoms: dizzines and deafness. Prognosis: Different clinical forms and courses of
labyrinthitis are possible.
2.10.3.
Menières Disease
This disease is caused by a disturbance of the quantitative relation between the volume of the
peri and endolymph. This cause is hydrops. Symptoms consists of attacks classic triad :
rotatory vertigo, deafness and tinnitus, usually unilateral. Typical attack begins acutely, the
hearing often returns to norma, tinnitus disappears.In the disease free intervals is a patient
without cochleovestibular failure, in the early phases of the disease. In the later stages is
persistent tinnitus, hearing loss, fullnes in the ear and frequent attacks of rotatory vertigo with
vomitus. Treatment during an attack consists of bed rest, antivertiginous and antiemetic drugs.
In the symptom free interval psychotropic and vasoaktive therapy. Betahistin is very usefull.
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In cases with poor hearing and marked tinnitus the treatment of choice is surgical technique
/neurectomy,endolymphatic sac drainage etc./
2.10.4.
Vestibular neuronitis
The disease /Acute vestibular paralysis/ may be caused by a disturbance of the
microcirculation due to an infection direct inflammatory damage to the vestibular organ, the
peripheral neurons or the higher primary centers. Symptoms: rotatory dizziness, nausea,
vomiting perissting for days and weeks. Hearing is normal. Treatment is mainly symptomatic.
Course and prognosis depend supon site, cause and age.
2.10.5.
Sudden Deafness
Initially symptoms are feeling of pressure in the ear followed by tinnitus and severe hearing
loss beginning within minutes. This disease is a medical emergency. Pathogenesis is largely
unexplained, probable the cause is a disorder of mikrocirculation or autoimmune or viral
disease. Audiogram shows usually unilateral sensorineural hearing loss. Differential diagnosis
must exclude acoustic neuroma, tubal occlusion, cerumen, herpes zoster oticus etc. Treatment
must be instituted within 24 hours by infused vasoactive drugs, corticoids or low molecular
weight Dextran. Spontaneus remission often occurs.
2.10.6.
Symptomatic Cochleovestibular Disorders
This term covers a group of symptoms of different origin /circulatory,traumatic,inflammatory
and degenerative/.
THE CERVICAL SYNDROME. Includes brief attacks of dizziness dictated by the position
and changes in position of the head.The cause is a lesion of the joints of the cervical spine and
of the muscles of the neck.
SYNDROME OF BENIGN PAROXYSMAL POSITIONAL NYSTAGMUS is a peripheral
lesion.Deposition of inorganic substances in the cupula of posterior semicircular canal
increases the sensitivity of the sensory end organ to linear as well as centrifugal acceleration.
In this situation the normal physiologic stimuli inducing a positional nystagmus and vertigo.
VERTEBROBASILAR INSUFFICIENCY causes central vestibular symptoms, irregular
provoked nystagmus, patology in optokinetic tests, drop attacks. The blood flows in the
wrong vertebral artery due to stenosis could be a cause. The result is transient, reversible
ischemia in the brainstem.
MULTIPLE SCLEROSIS is demyelinating disorders of the central nervous system with
spastic paralysis, dysdiadochokinesis, dissociated nystagmus, retrobulbar neuritis, irregular
positional nystagmus, abnormal caloric responses and optocinetic reflexes, vestibulospinal
reflexes and ataxia.
2.10.7.
Presbyacusis
This is a degenerative process in the inner ear and CNS. Include hearing loss on boths sides,
for the high tones initially and later for the middle frequencies. Loud sounds cause discomfort
due to positive recruitment. The hearing for speech is affected.Ahearing aid, lip reading
course are prescribed for treatment.
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2.10.8.
Central Deafness
The main symptom is the delayed development of speech in childrens age, due to the absence
of acoustic ability. Adults suffer from absence of acoustic ability to differentiate disturbances
of perception articulation. Directional hearing is lost.Causes may be cerebral and skull
trauma, encephalitis, pre, peri and postnatal damage to the CNS. Diagnosis can be made after
observation over a period time, EEG, CT, ERA audiometry and psychotechnical investigation.
Long term treatment includes acoustic exercises, articulation training and hearing aid.
Rhytmic music therapy and lip reading are usefull too.
2.11.
BASIS OF REHABILITATION OF DEAFNESS
2.11.1. The Cochlear Implant
Bilateral complete deafness is in selected cases children as well as adults indicated for a
cochlear implant. Implant consists of a directional microphone, which picks up speechsounds
and transmits them to a speech processor. This device encodes speech information, which is
transmitted through the intact skin by radio waves to a receiver stimulator implanted in the
mastoid bone. A multi electrode array implanted into basal turn of cochlea simulates normal
sound encoding by electrical stimulation of the remaining auditory nerve fibers in the inner
ear.
2.11.2. Hearing Aids
This devices are indicated if deafness cannot be relivied or improved by other means such as
surgery. A hearing aid comprises microphone, an amplifier and headphone drive by a battery.
The sound is conducted into the patient ear by tube and earpiece. A bone conduction aid can
be supplied in cases of chronic ear inflammation or congenital anomalies etc. This functional
prosthesis must be prescribed by specialist after pure tone audiometry and speech
audiometry. The choice of hearing aid: pocket apparatus, behind the ear and in the ear device
is determined by electroacoustic properties. These include amplification, frequency
characteritics, maximal output sound predsdure peak, automatic gain control or peak clipping.
This properties must correspond to the type of deafness and its site, middle or inner ear,
recruitment, the patient hearing dynamics and the shape of discrimination curve in speech
audiometry.
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SMELL
1.
OLFACTORY FUNCTION OF THE NOSE
The sense of smell and taste are stimulated by substances in liquids of the nose and mouth and
the sense of smell can stimulate or depress appetite.
Smell receptors responds to gaseous substances in inhaled air.Human olfactory organ of the
nose is relatively small-it is regio olfactoria in the ceiling of the nose and part of the septum.It
contains the bipolary nerve cells,which are to be regarded as the sensory cells.They continue
as fila olfactoria through lamina cribriformis and run to the primary of the olfactory center of
the olfactory bulb.
It is said,that there are about 30,000 different olfactory substances in the atmosphere,of
these,humans can perceive about l0,000 and are able to distinguish among 200.
1.1.
INVESTIGATION OF SMELL-OLFACTOMETRY
We can devide tests to the qualitative and quantitative methods
1.1.1. Qualitative tests
-Patient smells different substances and is asked to say which substance is it
We can distinguish 3 groups of substances:
a/substances which stimulate the olfactory nerve exclusively/vanilla/
b/substances that also stimulate the trigeminal nerve/acetic acid/
c/substances that also stimulate the sense of taste subserved by the glossopharyngeal nerve
1.1.2. Quantitative tests
Zwardemaker test,Elsberg test(they are not practise routinly)
ERO(evoked response olfactometry)
2.
OLFACTORY DISORDERS
2.1.
CAUSES:
2.1.1. Intranasal
a/ mechanical obstruction of the airway
b/ lesions of the olfactory receptors
2.1.2. Intranasal
a/ trauma
b/ infection
c/ tumour
d/ vascular
e/ systemic diseases
f/ congenital olfactory disorders
g/ hormonal olfactory disorders
h/ psychotic olfactory disorders
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2.2.
TYPES OF OLFACTORY DISORDERS
ANOSMIA-is complete loss of the ability to smell
HYPOSMIA-reduced ability to smell
PAROSMIA-the subjective impression does not correspond to the substance offered
CACOSMIA-all smells appear to be offensive
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TASTE
ANATOMY AND PHYSIOLOGY OF THE SENSORY
ORGAN FOR TASTE
1.
Gustometry-investigation of taste
Stimulus for sense of taste are substances in saliva or food,which are penetrating into the taste
buds-They are lying in the vallate papillae,foliate papillae and fungiform papillae on the
tongue and also on the hard pallate,the anterior faucial pillar,the tonsil,the posterior
pharyngeal wall and the buccal mucosa.The sensory nerve supply is provided peripherally by
two nerves in the particular:the anterior half of the tongue is supplied by ipsilateral chorda
tympani(by n.VII) and accompanying the lingual nerve from the Vth cranial nerve.The vagus
nerve has sensory contributions to the epiglottis,the laryngeal additus and the upper part of
the oesophagus.
The basic taste sensations are sweet,salty,sour and bitter.All other tastes are mixed sensations.
1.1.
INVESTIGATION OF TASTE-GUSTOMETRY
We are testing 4 basic taste perceptiones(glucose,sodium chloride,citric acid,quinine).
1.1.1. Electrogustometry
-electric current may also be used to stimulate the taste receptors(instead of the test solutions)
1.1.2. Objective gustometry
2.
DISTURBANCES OF TASTE
2.1.
CAUSES:
a/ congenital
b/ local lesions
c/ exogenous chemical toxins
d/ toxicity
e/ peripheral nerve lesions
f/ central taste disorders
g/ endocrine disorders
h/ others
2.2.
CLASSIFICATION OF THE DISORDERS OF TASTE
HYPOGEUSIA-reduced sensitivity
HYPEREGEUSIA-increased sensitivity
AGEUSIA-absence of the sense of taste
PARAGEUSIA-faulty taste
CACOGEUSIA-unpleasant taste
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