ENT CORE CONDITIONS

Special Senses: EAR, NOSE + THROAT

Anatomy
Outer ear/externa – pinna + external auditory canal
 Pinna gathers sound waves and localise sound
 Dependant on sound frequency
 External auditory canal transmits sound to
tympanic membrane
 Outer third = cartilageous – skin, hair follicles
 Inner third = bony – thin skin over periosteum is very
sensitive
 Infection = otitis externa

Middle ear/media – ossicles + air

 Medial to tympanic membrane
 Not visualised by otoscopy
 Auditory ossicles = malleus, incus, stapes
 Communicates with nasopharynx via eustachian tube
 ET equalises pressure in middle ear with outside
world, opens by yawning or swallowing
 hence swallowing when taking off in aeroplane
prevents pain in ear, causes ear to pop
 Infection = otitis media

Tympanic membrane
• = eardrum
• boundary between external + middle ear
• 3 layers: outer squamous epithelium, middle fibrous, inner respiratory epithelium
• handle of malleus visible on otoscopy  anteriorly
• sound waves cause vibration of tympanic membrane  transmitted to cochlear via
ossicles

Inner ear – cochlea + vestibular apparatus

 fluid-filled membranous sac within bony chamber
 cochlea = organ of hearing: sound waves  fluid
motion  electrical impulses
 3 outer hair cells: 1 inner hair cell in Organ of Corti
 outer hair cells receive efferent input from brain =
sharper quality of sound
 inner hair cell fires action potential to brain –
allows us to hear
 apex of cochlea  lower pitch sounds
 base of cochlea  higher pitch sounds
ENT CORE CONDITIONS

Hearing, Deafness and Tinnitus

 10 million people in UK have a hearing impairment (1 in 6)

 Deafness has significant impact of psychosocial wellbeing  social communication
 Can cause problems with social interactions, work + academic performance
 Important to identify children with hearing loss early
 considerable decline in school work
 contributes to social isolation if unsupported
 auditory map is imprinted in brain from <5 years old
 if auditory map doesn’t imprint in early years, later interventions can’t help child
understand + associate sounds

 CONDUCTIVE DEAFNESS
- disease of external or middle ear
- prevents sound wave from reaching
cochlear
- ear wax, osteomata, congenital
absence of external auditory canal
- fluid in middle ear following upper
respiratory tract infection
- dislocation or erosion of ossicles

 SENSORINEURAL DEAFNESS
- damage of cochlea, cochlear nerve or
central auditory pathway in brain
- PRESBYCUSIS = death of outer hair
cells in older age
- causing progressive, irreversible hearing loss
- requires hearing aid
- loss of hair cells can be accelerated by chronic excessive noise exposure  e.g. loud
concerts, loud machinery at job
- congenital causes: inherited or due to underlying syndrome
- neoplasm – acoustic neuroma = benign tumour on vestibulocochlear nerve
- drugs – vancomycin/gentamycin (aminoglycoside antibiotics) + cisplatin
(chemotherapy agents)

 audiogram measures hearing level in decibels (y axis) + frequency in hertz (x axis)

 bedside tests using short tuning fork:
 Weber test – tuning fork placed in centre of forehead and patient is asked in which
ear the sound can be heard
ENT CORE CONDITIONS
Fork will lateralise to WORSE ear in CONDUCTIVE deafness
Fork will lateralise to BETTER ear in SENSORINEURAL deafness

 Rinne test – tuning fork placed at mastoid process vs. external meatus and patient
is asked at which location is sound loudest

Normal = Air conduction is louder than bone conduction

Abnormal = Bone conduction is louder  suggests conductive impairment

 Tinnitus = ringing in the ears with no external stimulation

 1 in 200 patients – severe enough to affect quality of life
 Can be idiopathic or due to underlying sensorineural hearing loss
 Vascular malformations, arteriovenous fistulas (Ix: contrast head + neck CT), acoustic
neuromas (Ix: MRI), stroke, multiple sclerosis, aspirin
 Treat underlying cause if known, masking devices, cognitive behavioural therapy

The Discharging Ear

 Common symptoms of ear problems:

- Deafness / Hearing loss
- Otalgia – pain
- Otorrhea – discharge (pus, blood)
- Dizziness
- Tinnitus
- Pruritis – itchy ear
- Facial palsy
 Otitis externa

3. Vertigo.
4. Facial Palsy.
5. Facial Pain.
6. Acute and chronic rhinosinusitis.
7. Nose bleed (epistaxis).
8. Acute throat infections.
9. Salivary gland disorders.
10. A lump or swelling in the neck.
11. Suspected head & neck cancer

- Air in middle ear allows eardrum to vibrate freely

- Eustachian tube – function is to equalise pressure in middle war with outside world,
opens by swallowing + yawning
- Middle ear infections by infection travelling up tube from nose can cause pressure
changes
- Cochlear housed in the temporal bone  located in close proximity to temporal lobe
of the brain + cerebellum, important when considering complications
- Malleus is the only earbone you can see when looking in an ear
- Maleus, incus, stapes  front to back
ENT CORE CONDITIONS
- Eardrum (translucent) is split into pars tensa (divided into 4 quadrants) + pars
flaccida  used to describe location of lesion

Ear-related symptoms:
Otolgia, discharge, swelling, tinnitus, deafness, dizziness, itchiness (implies dermatitis/
eczema), facial weakness/palsy

Otitis media = hearing loss – fluid in middle ear affecting vibration of eardrum
Common causative agent of otitis externa is staphylococcus aureus + pseudomonas
aeruginosa (found in water = swimming pool)  treat with antibiotic eardrops (contain
ototoxic agents, damage hair cells = aminoglycosides gentamycin – only agents that are
effective against pseudomonas + staph aureus, safe if inner is intact

If otitis externa spread onto pinna – oral antibiotics + come back in 2 days, then refer to
ENT if not resolved + contain eardrops

Acute otitis media – disease of childhood, associated with upper resp tract infection
travels up through eustachian tube
Can be viral – treat symptomatically for 2 days
Eardrum can perforate

Chronic otitis media – antibiotic eardrops (topical + local reduces , keep ear dry, use ear
plug + cap when swimming for protection
Perforated eardrum – still has some hearing, only have surgery to repair it at an earlier
age (myringoplasty)

Acute mastoiditis – happens in <5 age group

Intact bulging drum, pain + swelling behind ear = EMERGENCY, need admitting, IV
antibiotics, myringotomy (create hole in ear drum to allow pus to drain), drain mastoid
abscess
Watch for complications, raised intracranial pressure (headache, blurred vision
(papillodema), nausea, vomiting, loss of consciousness, floppy child)  intracranial
abscess in temporal lobe or cerebellum – hence require urgent treatment

Cholesteatoma – several years ongoing, smelly otorrhoea, hearing loss

Necrotising otitis externa = EMERGENCY

Otalgia – pain keeping them awake at night, deep boaring pain RED FLAG
Facial palsy – RED FLAG
Diabetes – immunocompromised – RED FLAG
Ddx – squamous cell carcinoma

Admit, Requires IV antibiotics, swab culture

CN 7, 9, 10, 11 – most dangerous is swallowing difficulty, can’t protect their glottis = higher
chance of aspiration pneumonia