Ear, nose and throat

Chapter 4 Ear, nose and throat

SYMPTOMS OF EAR DISEASES

Pain in the ear (otalgia)

Pain in the ear may arise from the ear itself (usually unilateral) but may arise from other sources.

Discharging ear (otorrhoea)

The ear naturally discharges wax which is a mixture of skin debris and apocrine gland secretion.

Pathological discharge from the ear varies in nature from watery to foul-smelling or blood-stained. A most common cause of a bloodstained discharge is infection, but the rare instance of a squamous cell carcinoma may present with this.

Differential diagnosis: Otalgia

Pinna	Perichondritis, cellulitis
Pinna	Neoplasm (basal cell or squamous cell)
External canal	Furuncle, furunculosis
	Otitis externa
	Impacted wax
	Foreign body
	Herpes zoster (Ramsay Hunt syndrome)
	Neoplasm
Middle ear	Acute otitis media and its rare sequelae (mastoiditis, meningitis and cerebral abscess)
	Secretory otitis media (glue ear)
	Eustachian tube obstruction
	Barotraumas
	Neoplasm
Other sites	Teeth, tongue, pharynx (including tonsils and hypopharynx), sinuses, temporomandibular joint, cervical spine

Differential diagnosis: Discharging ear

Site	Diagnosis
External ear	Otitis externa – bacterial, fungal or secondary to middle-ear discharge
Middle ear	Acute suppurative otitis media, chronic suppurative otitis media, mastoid disease (rare), neoplasm (rare)
Inner ear	Fracture (cerebrospinal fluid leak)

Hearing loss (deafness)

Hearing loss is recognised as being either conductive or sensorineural.

CONDUCTIVE DEAFNESS

Conductive deafness is the term used to indicate that hearing is being impaired by a malfunction in the conduction and magnification of sound to the cochlea.

SENSORINEURAL DEAFNESS

The sensory part of the ear is the cochlea, but for full function the neural element is required. This comprises the auditory nerve and cerebral cortex.

Hearing loss in the elderly (presbyacusis) is mainly due to degeneration of the cochlea. The cochlea may be damaged during life in other ways. This may be by infection, vascular ischaemia, noise, drugs, surgery, or Ménière’s disease.

The red flag symptom to alert the clinician is unilateral deafness as this may indicate an acoustic neuroma of the VIIIth nerve. Early treatment of this space-occupying lesion lessens morbidity and mortality.

Differential diagnosis: Hearing loss

Age group	Causes	Type of loss
Infants	Congenital	Conductive or sensorineural
Infants	Secretory otitis media (glue ear)	Conductive
Young children	Congenital	Conductive or sensorineural
	Secretory otitis media (glue ear)	Conductive
	Postinfective (meningitis, viral)	Sensorineural
Adolescents	Congenital	Conductive or sensorineural
	Malingering	—
	Postinfective (meningitis, viral)	Sensorineural
	Acoustic trauma or drugs	Sensorineural
20–40 years	Postinfective (meningitis, viral)	Sensorineural
	Acoustic trauma or drugs	Sensorineural
	Otosclerosis	Conductive
	Acoustic neuroma	Sensorineural
	Ménière’s disease	Sensorineural
	Postoperative complications	Conductive or sensorineural
40–60 years	Acoustic trauma or drugs	Sensorineural
	Otosclerosis	Conductive
	Acoustic neuroma	Sensorineural
	Ménière’s disease	Sensorineural
	Postoperative complications	Conductive or sensorineural
60+ years	Presbyacusis	Sensorineural
	Acoustic trauma or drugs	Sensorineural
	Acoustic neuroma	Sensorineural
	Postoperative complications	Conductive or sensorineural

Tinnitus

Tinnitus is the symptom of noise in the ears. It is difficult to investigate because it is a subjective symptom. The sounds experienced are not complex auditory hallucinations as found in certain psychoses.

The most common cause of tinnitus is the onset of sensorineural deafness associated with degeneration of the cochlea. However, anything which interferes with the hearing mechanism (even wax) may produce tinnitus.

It is one of the triad of symptoms that are observed in Ménière’s disease, the others being vertigo and loss of hearing.

In present-day usage it is unusual to see tinnitus caused by drugs, but it may be seen in the treatment of rheumatic fever by high-dose aspirin and is a recognised side-effect of aminoglycosides. High doses of non-steroidal anti-inflammatory drugs may also induce tinnitus. This form of drug-induced tinnitus is usually reversible on stopping the medication.

Red flag box – urgent referrral: Unilateral deafness or tinnitus

A red flag sign is when the tinnitus is unilateral. As with unilateral deafness, an acoustic neuroma must be considered and investigated.

Vertigo (dizziness)

Vertigo is a symptom of imagined spinning or unsteadiness. Patients feel they or their surroundings are moving. This is true vertigo and is caused by inner-ear vestibular dysfunction. Vertigo arising from the vestibular mechanism is known as peripheral vertigo.

ACUTE LABYRINTHINE DYSFUNCTION

Acute labyrinthine dysfunction is the term used for severe episodic vertigo of sudden onset. Its cause includes diagnoses such as viral, idiopathic or vascular labyrinthitis. The disorder may last for days and may be prolonged in benign positional vertigo.

BENIGN POSITIONAL VERTIGO

Benign positional vertigo is recognised by the short-lasting onset of vertigo with movement of the head. It may be one of the sequelae of acute labyrinthine dysfunction. Other causes are trauma or idiopathic.

CENTRAL CAUSES OF VERTIGO

Other manifestations of giddiness arise from different sites. The vestibular (inner-ear) cause of vertigo is known as peripheral vertigo and that arising from other sites is termed central vertigo. Inputs from the eyes, proprioception, cerebellum, brainstem, cerebrum and reticular formation all have a function in balance.

Differential diagnosis: Central and peripheral vertigo

Diagnosis	Site
Acute labyrinthine dysfunction Benign positional vertigo Ménière’s disease Multiple sclerois Transient ischaemic attack (TIA) Vertebrobasilar ischaemia Head injury	Peripheral Peripheral Peripheral Central Central Central Central or peripheral

EXAMINATION OF THE EAR

The auroscope

Use the largest aural speculum that fits in the external canal comfortably.

External ear

PINNA

Minor congenital abnormalities

Bat ears is the term given to ears which do not lie flat against the head but protrude outwards. They occur in about 2% of the population and if surgical correction is proposed, this is best left until after 6 years of age.

Preauricular sinus is a defect in embryological development and usually occurs anterosuperiorly to the tragus.

Accessory auricles occur anterior to the tragus and are another embryonic fault.

Gross congenital deformities are rare and include anotia (complete absence of the pinna). The conditions can occur with normal or abnormal development of the middle and inner ear.

Skin changes

Eczema or psoriasis are common conditions which may involve the pinna and external canal. Like any skin condition, secondary infection is a possible complication and is more likely to occur in the external ear because of the accumulation of debris.

Cauliflower ears are the result of previous untreated traumatic haematoma of the pinna.

Chondrodermatitis nodularis helicis is a benign nodular condition usually of the helix of the ear. The aetiology is unknown but, as it occurs in later life, may be related to sun damage. It can only be differentiated from malignant conditions by biopsy.

Basal cell carcinomata and squamous cell carcinomata are tumours most commonly seen on the pinna and require appropriate surgical treatment.

EXTERNAL CANAL

The diameter of the canal is very variable and even in some adults may be very narrow. In a child the canal is straight and the tym panic membrane is easily seen. In adults the distal part of the canal, close to the tympanic membrane, narrows (the isthmus) in its final third and deflects downwards. This results in a recess inferiorly with an acute angle being formed between canal and tympanic membrane.

Chondromata arise from cartilage, which forms the outer one-third of the canal. They may vary in size from being quite small to obstructing the whole canal.

Water in the ears is a common trigger for otitis externa and it is important that the ears are fully cleaned if possible so that no water is trapped behind any remaining wax. The ears should be carefully dried after syringing.

OTITIS EXTERNA

Otitis externa is an infection of the external canal. Infections include furuncle or generalised furunculosis and otitis externa, bacterial or fungal. Otitis externa causes discharge, irritation and often pain.

FURUNCULOSIS

A single furuncle or generalised furunculosis of the external canal is usually painful and may be extremely so. Furuncles can be recognised as a small boil in the external canal.

MYRINGITIS BULLOSA

This is a manifestation of viral otitis externa where blisters are to be seen on the epithelial surface of the tympanic membrane.

The middle ear

TYMPANIC MEMBRANE (Fig. 4.1)

The whole circumference of the membrane should be visualised. In its normal state the membrane appears grey and shiny and through it the handle of the malleus is visible with its inferior pole (the umbo) pointing posteriorly. Inferior to the umbo, an arc of light reflects back to the observer. This arc is directed anteroinferiorly.

Fig. 4.1 Anatomy of normal tympanic membrane.

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Tags: Pocket Guide to Clinical Examination

Apr 20, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off

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