SHANZ – ENT 1.

03a INNER EAR (PART 1)

VERTIGO TINNITUS
• Subjective: feeling spinning • Auditory sensation
• Objective: feel room is spinning • NO electrical stimulus
• Cause: inner ear (peripheral) or brain (central) • Ringing sensation

Conductive Due to obstruction

Sensorineural due to NIHL
Central/Vascular due to HTN, aneurysm
Myogenic due to TMJ

MANAGEMENT
VERTIGO TINNITUS
DIAGNOSIS TREATMENT • TM rupture: repair
• Hearing test • BPPV: • White noise generator (WNG)
Pure tone audiometry: rule out acoustic EPLEY/particle repositioning maneuver o Simplest, fan/radio
neuroma (80% success) o wear earpiece
• VNG: Videonystagmography: SEMONT maneuver/ vestibular rehab exercise o neutralize hearing sensation
COWS: Cold, opposite, warm, same Less effective less comfy o high pitched sound → low tone
• MRI: neuroma • Meniere: ringing
• CT scan: brain injury (rule out central vertigo) Low salt diet, increase urine output o for sensorineural tinnitus
• FBS, cholesterol • MEDS (for dizziness, NOT cure for vertigo): • TCAD: Amitriptyline
• ECG Betathistine (H1 agonist) = acute attack • Anxiolytic: alprazolam
• Dix hallpike maneuver (nylen barany test) Cinnarizine (CCB) = maintenance • Circulatory stimulant: gingko biloba
For BPPV Cinnarizine + Dimenhydrinate (anti histamine)
Diazepam (vestibular suppressant)
Meclizine HCl = anticholinergic

TYPES OF VERTIGO
TYPES CENTRAL PERIPHERAL
Onset Gradual Sudden
Tinnitus, Hearing Loss --- +
NHS: Neighborhood signs + ---
Nystagmus Pure, vertical Mixed, horizontal
Multidirectional Undirectional
Suppress with fixation Suppress with fixation
Concerns the Neuro ENT

CAUSES OF VERTIGO
MENIERE’S DISEASE (LABYRINTHINE STORM) VESTIBULAR LABYRINTHIS VESTIBULAR VESTIBULAR
NEURITIS MIGRAINE
• Abnormal endolymph amount • Inflamm of vestibular & cochlear branches • vertigo • Migraine
• Low Na, high K • due to viral infection via ET • (-) hearing loss • +/- aura
• Triad: • due to bacterial infection (middle ear) • (-) tinnitus • spinning dizziness
o Unilateral low pitched tinnitus • (+) vertigo, (+) hearing loss, (+) tinnitus
o Episodic vertigo (2 eps = 20 min) • nausea, vomiting
o Episodic unilateral hearing loss
• Sudden and dramatic appearance
• TX: endolymph drainage, diuretic, steroid, surgery

ACOUSTIC NEUROMA BPPV VERTEBROBASILAR INSUFFICIENCY HEAD TRAUMA

SCHWANNOMA/
NEURILEMMOMA
• benign nerve tissue tumor
• CN 5,6,7
• 1 side gradual hearing loss
• 1 side tinnitus
• vertigo
• ipsilateral facial numbness
• Tx: surgery, observe ,RT
Benign paroxysmal positional vertigo NECK INJURY
• MOST COMMON FORM • Decreased blood supply from • nerve damage
• Dislodged particles from inner ear (utricle) vertebrobasilar arteries in neck • VBI
• motion sense + sudden head movement • insufficient perfusion to brain & inner ear • Temporal bone
• Canalithiasis (ear stone): most common • systemic dse: dyslipidemia, hyperChol, damage
cause of posterior BPPV atherosclerosis, diabetes
• Cupulolithiasis: lateral canal BPPV • BV narrowing
• Spontaneously disappear • neck trauma
 DISORDER OF HEARING IN INNER EAR ADVERSE EFFECT OF NOISE EXPOSURE
• largest group of hearing loss problem • loss of outer hair cells
• Patho: hair cell level • nerve degeneration in osseous lamina
• Inner hair cell = receive/ detect sound • biological changes in sensory cells
• Outer hair cell = amplifies sound (more sensitive) • physical hair cell dislodging
• SENSORINEURAL not conductive hearing loss • cochlear blood supply change
• DYSACUSIS: difficulty to process sound (More common); cochlear harmony distortion • altered stria vascularis
• HYPOACUSIS: Total hearing loss/ desensitization ot sound • rupture of reissner’s membrane
• Vestibular sx: disequilibrium/ vertigo • organ of corti detachment
• HALLMARK: • tinnitus
Hearing impairment • Anxiety, INC BP, illness incidence
Tinnitus

ENDOGENOUS CAUSE OF INNER EAR DISORDERS

HEREDITARY CHROMOSOMAL
• non syndromic: congenital, acquired • Missing chromosomes or extra genetic materials
• syndromic: pigment changes (most common) TRISOMY USHER SYNDROME WAARDENBURG SYNDROME
present at birth • extra 3rd chromosome • retinitis pigmentosa-dysacusis • distinct facial abnormalities
associated with: • most common: 21 • sensorineural HL • deafness at birth
• cleft palate, optic disorder, thyroid disorder, Down syndrome • Visual Impairment • hypopigmentation
heart disorder, MSK anomaly, intellectual • retinal discoloration
disability, balance disorder

EXOGENOUS/ ACQUIRED CAUSE OF INNER EAR DISORDERS

PRENATAL PERINATAL POST NATAL
• Rubella • Anoxia Bacterial Viral
• HIV • hyperBIL Otitis media Rubella (sudden HL)
• Syphillis • prematurity Bacterial meningitis (total deafness; Mumps (parotitis via fissures of Santorini)
• anoxia/hypoxia • high noise from infant’s incubator labyrinth full of necrotic tissue/pus) Mostly bilateral
• Rh • head trauma Syphilis
incompatibility delivery w/forceps
violent uterine contraction

NIHL OTOSCLEROSIS SUDDEN IDIOPATHIC SENSORINEURAL HEARING

• permanent cochlea damage (4kHz)
• Men > women
• Recreational audiology
• Hobbies, and gadgets
• Acute acoustic trauma: complete recovery
• Chronic NIHL: permanent impairment
Outcome:
• Temporary threshold shift (improve )
• Permanent threshold shift: irreversible
• Conductive hearing loss
• new bone growth
• affects oval/round window
• toxic metabolite deposit
• diseased bone (capsular sclerosis)
• Cochlear involvement: sensorineural HL
• Unilateral/ bilateral
• Flat audiometric config.
• Sclerosis of labyrinth
LOSS
• medical emergency (nerve not generating)
• Unilateral HL, instant
• autoimmune, ,viral, rupture, tumor, neuro
• Patho: internal auditory artery obstruction
• 30 dB drop in speech frequencies
• Dx: electrocochleography
• MRI (rule out skull base fracture)
TX: (golden: 3-7 days)
• steroid via trans tympanic injection
• Ear wick
• oral pentoxifylline

AUTOIMMUNE INNER EAR DISEASE OTOTOXICITY PRESBYCUSIS

• bilateral fluctuating and progressive SNHL • Cochlear (Outer hair cell) damage • 35 dB HL due to aging
• (+) Tinnitus • due to prolonged medication • men early 60 (greater HL > 1000 Hz)
• (+) aural fulness • Tx: stop meds • women late 60 (greater HL <1000 Hz)
• (+) vertigo • TM: thickening
• TX: Anti inflammatory and steroid • Ossicular chain: arthritis
• Cochlear window: sclerosis
• DIFFICULTY IN SPEECH RECOGNITION
• PHONEMIC REGRESSION
• Strial & organ of corti degeneration

MEDICATIONS CAUSING OTOTOXICITY

COCHLEOTOXIC
• high frequency HL
• Kanamycin, neomycin, amikacin
QUININE
• All frequency HL
• (+) Tinnitus
• (+) disequilibrium
• for malaria and nighttime leg cram
VESTIBULOTOXIC OTHERS
• Vestibular apparatus • all frequency HL
• Streptomycin, Gentamycin • Aspirin, nicotine, loop diuretic, alcohol
 BAROTRAUMA
• profound conductive HL
• +/- fistula or perilymph leak
High Na, Low K; similar to CSF and serum
• round window rupture
• annulus of oval window rupture
• sudden middle ear pressure change
• diving or violent sneezing
• Surgery, reversible
HEAD TRAUMA
• injury to temporal bone
• notch of 3000Hz to 6000 Hz during hearing test
• damage to TM & middle ear
• severe HL: cochlear rupture or contusion
• organ of corti: flat or destroyed
• Oval window membrane rupture
types of trauma:
• longitudinal (most common) – similar to acoustic trauma
• Transverse – complete loss of auditory and vestibular function