1.

04 Problems of Inner Ear 1 ENT

Dr. Kenneth Calavera LE 1
24 August 2020 (Mon) TRANS 4

● Vertiginous
OUTLINE
○ Spinning
I. Describing Balance Problems 1 Review Questions 6 ● Fainting spells
II. Vertigo 1 Summary 8 ○ Described as almost losing consciousness (2021)
A. Common Causes Appendix 11 ● Disequilibrium
B. Diagnosis ○ Sense of imbalance
C. Vertigo Medications ● Lightheadedness
D. Vertigo Treatment ○ Feeling as though your head is weightless (2021)
III. Disorders of Hearing in II. VERTIGO
the Inner Ear 3
IV. Causes of Inner Ear ● False sensation of spinning
Disorders 4 ● Describes an illusion of movement
A. Endogenous Causes ○ The movement is not real ☜
B. Etiology According
Categories of Vertigo
to Patient Age at Onset
C. Exogenous/ ● Subjective vertigo
Acquired Causes ○ When you feel as if you are spinning
V. Tinnitus 6 ● Objective vertigo
○ When you feel as if the room/environment is spinning
LEGEND Causes of Vertigo
Important Recording Book/Article Previous Trans ● Central
☜ ☊ (Author (ed), pp.) (Year & Section)
○ Arises from problems in the brain or the central nervous
system
WORD BANK ● Peripheral
○ Arises from problems in the inner ear
Word/Abbreviation Meaning Table 1. Differences between the two types of vertigo
HL Hearing Loss Peripheral Vertigo Central Vertigo
BPPV Benign Paroxysmal Positional Vertigo Onset Usually sudden Gradual
AIED Autoimmune Inner Ear Disease Worsened by head
Head Position No change
movement
Lecture Objectives
Intensity Severe Mild
At the end of the lecture, the student should be able to:
1. Understand the clinical presentation of the diseases found Tinnitus, hearing loss,
Present Absent
within the inner ear nausea, vomiting
2. Distinguish inner ear problems and their symptoms Neurologic symptoms Absent Present
3. Enlist appropriate diagnostic modalities for inner ear
conditions Combined horizontal
Nystagmus Purely vertical not
4. Become knowledgeable in the basics of management and and torsional,
(most suppressed with
treatment suppressed with
important/defining fixation,
5. Recognize when to refer the patient fixation,
multidirectional,
characteristic☜) unidirectional, long
I. DESCRIBING BALANCE PROBLEMS no latency
latency
Neighborhood Signs
(2021)

(Diplopia, cortical Absent Present

blindness,
dysarthria)
Concerns the
following ENT department Neuro department
department (2021)

A. COMMON CAUSES OF VERTIGO

1. Benign Paroxysmal Positional Vertigo (BPPV)

Figure 1. Optical illusion. Staring blankly at the middle of the image gives the illusion
that the circles are rotating either forward or backward, slowly or quickly. There are
different interpretations of this illusion, just as there are different ways to describe
balance problems.
● Aka Canalithiasis/Cupulolithiasis
● Most common form of vertigo
● Due to the dislodgement of ear particles (otoconia or otoliths
[CaCO3 crystals]) from the semicircular canals (utricle) (2021)
● Characterized by the sensation of motion initiated by sudden
head movements or movement of the head in a certain direction

TRANS (14) Bravante, Cabujat, Caraig (2022A) CORE Asuncion, Baguilat (2022A)
Cachola Baguilat 1 of 11
1.04 Problems of Inner Ear 1
● Rarely serious and very much treatable
5. Vertebro-Basilar Insufficiency (VBI)
2. Vestibulocochlear Nerve (CN VIII) Inflammation ● Decreased blood flow to the base of the brain
● Caused by a viral infection (herpes virus, flu virus, poxvirus) ● Possible causes:
● Vestibular Labyrinthitis ○ Bleeding into the back of the brain
○ Inflammation of both branches of CNVIII (vestibular and ○ Arteriosclerosis
cochlear branches)
6. Head trauma and neck injury
○ Symptoms: sudden onset of vertigo, nausea, vomiting, hearing
loss, and episodes of tinnitus 7. Migraine
● Vestibular Neuritis
● Vestibular migraine
○ Swelling of nerve connecting the inner ear to the brain
○ Migraine associated with dizziness
○ No tinnitus, no hearing loss
○ Usually caused by muscle spasms

CONCEPT CHECKPOINT:
1. What is the most common form of vertigo?
2. This is the most important factor in differentiating central and
peripheral vertigo.
3. T/F Central vertigo is worsened by head movement.

ANSWERS:
1. Benign Paroxysmal Positional Vertigo (BPPV)
2. Nystagmus
3. FASLE. Peripheral vertigo is worsened by head movement. There is no effect of
the change of head position in central vertigo.

B. DIAGNOSIS

Important Points in History Taking

Figure 2. Normal ear, vestibular neuritis, and labyrinthitis.
3. Meniere’s Disease/Labyrinthine Storm
● Caused by abnormal amounts of endolymph in the inner ear
● TRIAD of symptoms ☜
○ Episodic vertigo (2 episodes lasting 20 minutes)
○ Unilateral low pitched tinnitus
○ Episodic Unilateral Hearing loss (both high and low
frequencies with normal to mild degree)
● Treatment (2021)
○ Decrease production or drain excess endolymph
○ Diuretics, anti-vertigo medicine or steroids
○ Middle-ear injections
○ Surgery of the endolymphatic sac, vestibular nerves or the
labyrinth
4. Acoustic Neuroma/Schwannoma/Neurilemmoma
● Non-malignant tumor of the nerve tissue
● Symptoms:
○ One sided gradual hearing loss
○ One sided tinnitus
○ Vertigo
○ Facial numbness
● Treatment (2021)
○ Observation, surgery or radiotherapy
● Duration of symptoms and whether they are constant or they
come and go
○ If it’s peripheral, you can be sure it is vertigo if the duration will
be very short ☜
● Does the imbalance occur when moving or changing positions?
● Is it associated with ringing in the ears or hearing loss?
● Has there been any recent head trauma?
● Any symptoms such as nausea, vomiting, or profuse sweating?
● Any neurological symptoms such as weakness, visual
disturbances, altered level of consciousness, difficulty walking,
abnormal eye movements, or difficulty speaking?
○ If you have neurologic symptoms, you can consider the vertigo
to be central in origin ☜
Investigation
● Hearing test
● VNG (Videonystagmography)
○ “Cold Opposite side, Warm Same side” (COWS)
● Imaging studies
○ MRI for neuromas
○ CT scan if a brain injury is suspected to be the cause of the
vertigo
● Blood test to check blood sugar/cholesterol levels
● An electrocardiogram (ECG) to assess the heart rhythm may also
be helpful
● Most important tests that you can perform:
○ Complete history and PE
○ DIX-HALLPIKE MANEUVER (Nylen-Barany Test)
■ For diagnosing BPPV (95% of the time, this is the vertigo
being described by your patient) ☜
Figure 3. Dix-Hallpike Maneuver for Eliciting Nystagmus and Vertigo as a Result of
Posterior Canal BPPV.

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1.04 Problems of Inner Ear 1
● Dix-Hallpike Maneuver (2021):
○ Position the patient on an examination table such that when
placed supine, their head extends over the edge of the table.
■ Make sure to protect the head and the neck portion of the
patient.
○ Inform the patient not to close their eyes. While supporting the
patient, lower the head and turn it 45 degrees to one side.
○ Observe the eyes carefully for 30 seconds for HORIZONTAL
and TORSIONAL nystagmus.
○ If no abnormal eye movements are seen, the patient is returned
to the upright position.
○ The maneuver is repeated with the head in the opposite
direction, and with the head extended supine.
C. VERTIGO MEDICATIONS
● Supportive medications can be given. These only dampen the
sensation of dizziness and do not cure the vertigo. (2021)
● Commonly prescribed medications for vertigo: (2021)
○ Vestibular Suppressants (antihistamines, anticholinergics,
benzodiazepines)
○ Betahistine (histamine H1-antagonist) for acute attacks and
Cinnarizine (piperazine/ Ca channel blocker) for maintenance
○ Meclizine hydrochloride (antihistamine with central
anticholinergic property)
○ Cinnarizine + Dimenhydrinate (antihistamine/ Ca channel
blocker + antihistamine/anticholinergic)
○ Diazepam, Lorazem (benzodiazepines)
D. VERTIGO TREATMENT
● Choice of treatment will depend on the diagnosis
● Identify and eliminate the underlying cause
○ Bacterial infections of the middle ear require antibiotics
○ Meniere’s disease: in addition to symptomatic treatment,
patients might be placed on a low-salt diet, and may require
medication used to increase urine output
● In addition to the drugs used for benign paroxysmal positional
vertigo, several physical maneuvers can be used to treat the
condition
● Physical Maneuvers for BPPV: (2021)
○ Particle repositioning maneuver (EPLEY Maneuver)
■ Eliminates BPPV in > 80% of cases
○ Vestibular rehabilitation exercises (SEMONT Maneuver)
■ Less effective, less comfortable
Figure 4. EPLEY Maneuver (2021 ) See Appendix for a larger version.
● EPLEY Maneuver: (2021)
○ (A) Turn the patient’s head to the right. Ask them to sit straight
and look at a nonmoving object for 15 seconds.
■ The inset shows the location of the debris near the ampulla
of the posterior canal. The diagram of the head in each inset
shows the orientation from which the labyrinth is viewed.
○ (B) Lower the patient into the supine position with the head
extended below the level of the gurney (until here is the
Dix-Hallpike position).
■ The debris falls toward the common crus as the head is
moved backward. Observe for nystagmus.
○ (C) Move the head approximately 180 degrees to the left while
keeping the neck extended with the head below the level of the
gurney.
■ When moving the head 180 degrees to the left, do it in two
increments of 90 degrees, with a 15 second interval. Stop
only when nystagmus is observed.
■ Debris enters the common crus as the head is turned toward
the contralateral side.
○ (D) Rotate the patient’s head to the left by having them roll onto
their left side until their head faces down.
■ Debris begins to enter the vestibule.
○ (E) Bring the patient back to the upright position.
■ Debris collects in the vestibule.
Figure 5. SEMONT Maneuver (2021).
● SEMONT Maneuver: (2021)
○ (1) Ask the patient to stare at a non-moving object.
○ (2) Quickly move the patient into the position that provokes the
vertigo and have them remain in that position, with the head
hanging and the nose pointed upward, for 15 seconds.
○ (3) Rapidly turn the patient to the opposite side and have them
remain in that position, with the nose pointed downward, for 15
seconds.
○ Ask the patient to sit up slowly.
NEED-TO-KNOW:
● Nystagmus
○ Most important characteristic for differentiating peripheral and
central vertigo
○ Peripheral vertigo: combined horizontal and torsional
nystagmus
○ Central vertigo: purely vertical nystagmus
● Meniere’s Disease/Labyrinthine Storm
○ TRIAD of symptoms
■ Episodic vertigo (2 episodes lasting 20 minutes)
■ Unilateral low pitched tinnitus
■ Episodic Unilateral Hearing loss (both high and low
frequencies with normal to mild degree)
● If vertigo is peripheral in origin, duration will be very short.
● If it’s central in origin, patient will manifest neurologic symptoms.
● DIX-HALLPIKE MANEUVER (Nylen-Barany Test)
○ Important test for diagnosing BPPV
III. DISORDERS OF HEARING IN THE INNER EAR
● Constitutes the largest group of hearing loss problems
● Pathology is at the level of the hair cells, which can lead to:
○ Dysacusis: results from difficulty processing sound due to a
combination of frequency and harmonic distortion in the cochlea
○ Auditory Dysaesthesia: pain/discomfort due to sound; more
common
○ Hypoacusis: partial loss of hearing or loss of sensitivity to sound
○ Note: Disorders of hearing in the inner ear result to
sensorineural and not conductive hearing loss (2021)
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NICE-TO-KNOW: (2021) 3. What are the clinical hallmarks of inner ear hearing disorders?
● Inner hair cells: receive or detect sound
● Outer hair cells: amplify sound, more sensitive to hearing, ANSWERS:
1. FALSE. Hereditary Sensorineural HL is the most common cause.
weaker and more prone to having problems Trisomy 21 is the most common Chromosomal Disorder.
2. Disorders of the inner ear result in sensorineural hearing loss.
● Hearing loss is not the only symptom resulting from cochlear 3. Hearing impairment, tinnitus, and vestibular symptoms.
damage. Clinical hallmarks of inner ear hearing disorders include:
○ Hearing impairment B. ETIOLOGY ACCORDING TO PATIENT’S AGE AT ONSET
○ Tinnitus Prenatal causes
○ Vestibular symptoms (disequilibrium and vertigo)
● Rubella
■ Since vestibular and cochlear are intertwined with each
● Human Immunodeficiency Virus (HIV)
other, hearing loss would also entail problems in your
● Syphilis
balance
● Anoxia/Hypoxia
IV. CAUSES OF INNER EAR DISORDERS ● Rh (rhesus) Factor/Rh incompatibility
A. ENDOGENOUS CAUSES Perinatal Causes
● Anoxia when the baby’s cord tangles around its neck during
1. Hereditary Sensorineural Hearing Loss (HL) (2021)
delivery (2021)
● Frequent cause of cochlear hearing loss ● Hyperbilirubinemia
● Approximately 1/3 of all cases of sensorineural hearing loss have a ● Prematurity
genetic cause or a contributing genetic cause ○ Low birth weight (<1500 grams = 3.5 pounds)
● May have a dominant, recessive, sex-linked, or mitochondrial ● High noise levels from infants’ incubators
mode of inheritance ● Head trauma
● Non-Syndromic ○ Violent uterine contractions
○ Congenital: usually autosomal recessive ○ Use of forceps in delivery (most common) due to clamping of
○ Acquired (or later-onset form): more common than congenital; temporal and frontal bone (2021)
tend to be autosomal-dominant
● Syndromic Postnatal Causes (Infectious Process)
○ Usually present at birth ● Bacterial
○ Multiple organ system involvement ○ Otitis media
○ Conglomeration of different findings and symptoms pertaining ■ Bacterial toxins in the middle ear enter the inner ear through
to one disease (e.g. combination of HL and eye changes, or HL the oval or round window
and pigment changes) ○ Bacterial meningitis
○ Common syndromes directly associated with hearing loss of the ■ Inflammation of the meninges
inner ear: ■ May cause total deafness when the labyrinth is full of
■ Skull and facial deformities necrotic tissue or pus
● Cleft palate in addition to HL ○ Syphilis
■ Changes in eye color ■ Also seen in prenatal or acquired cases (2019A)
● Usher syndrome ● Viral (produce bilateral hearing loss) (2021)
○ Aka Retinitis Pigmentosa - Dysacusis Syndrome ○ Measles (rubeola)
○ Sensorineural hearing loss, discoloration of retina and ■ Cause sudden hearing loss
visual impairment ○ Mumps (parotitis)
■ Changes in hair and skin pigmentation ■ Inflammation of the parotid (salivary) gland located on either
● Waardenburg Syndrome side (which is close to the vestibulocochlear system)
○ Deafness present at birth ■ The virus enters through the Fissures of Santorini up to the
○ Distinctive facial abnormalities inner ear, causing hearing loss
○ Hypopigmentation of hair, skin, and iris (partial ■ Most virus-produced hearing loss are bilateral
albinism), aka white forelock ● Note: Usually starts as a Conductive Hearing Loss in the middle
○ Thyroid disease ear then patient develops Mixed Hearing Loss (Sensorineural
○ Heart disorders component is added) (2021)
○ Musculoskeletal anomalies
C. EXOGENOUS/ACQUIRED CAUSES
○ Mental retardation
○ Balance disorders 1. Ototoxicity
○ Other sensory and motor deficits ● Cochlear damage resulting from prolonged use of medications
2. Chromosomal Disorders ● Some medications are known to be toxic to the cochlea
● Chromosomes are missing, or extra genetic material is found (particularly the outer hair cells) and some to the vestibular
● Trisomy apparatus (2021)
○ An extra third chromosome is present (e.g. Trisomy 21/Down’s ● In most cases, the effect will be on the high frequency range
Syndrome is the most common) (2021) ● Kidney disease might prevent medications from being excreted
○ E.g. Down Syndrome, Usher Syndrome and Waardenburg thereby raising their levels in the blood, resulting in ototoxicity.
Syndrome ● Ototoxic effects are generally symmetrical/bilateral (unless
substance is applied or exists locally), may be reversible or
CONCEPT CHECKPOINT: irreversible, and may be caused by endogenous or exogenous
1. The most frequent cause of cochlear hearing loss is Trisomy agents (2021)
21. ● Treatment: Hold/Discontinue the medications (if the patient does
2. Disorders of hearing in the inner ear result in what kind of not have kidney disease (2021)
hearing loss?

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Table 2. Metabolites/ Medications Causing Cochlear Hearing Loss ● Permanent threshold shift (PTS): Relates to irreversible hearing
Description impairment after chronic noise exposure
Type
● Higher incidence in men (Due to job and leisure activities)
● Increasing incidence in young age groups (use of gadgets,
● Medications affecting cochlea
e-gaming, phones, musical instruments, firecrackers, stereo
● Medications causing hearing loss
systems, and toy guns) (2021)
(frequently accompanied by tinnitus and a
○ Recent journal before older age group only are affected but now
degree of hearing loss that is similar on
it doesn’t pick any age ☊
both sides) (2021)
Cochleotoxic ● Other noise-hazards: jet engines (140 dB), drop forges, pneumatic
● High frequency hearing loss (mild to
hammers, subways, loud music, and computers
profound)
● “Recreational Audiology”
○ A field that studies the activities of professionals involved in
i.e. Amikacin, Neomycin, Sisomycin,
finding hearing loss caused by hobbies and recommending
Dihydrostreptomycin, and Kanamycin
appropriate precautionary steps
● Medications affecting the vestibular ○ Hobbies such as sports associated with motorboats,
apparatus snowmobiles, motorbikes, race cars, gun use; professional
Vestibulotoxic musicians and aerobics instructors; use of music players
i.e. Streptomycin, Tobramycin, and (joggers or those working out with gym equipment)
Gentamicin ● ADVERSE EFFECTS OF NOISE EXPOSURE
○ Loss of outer hair cells and their supporting structures in the
Quinine - drug used to treat malaria and
basal turn
nighttime leg cramps; known to cause hearing
○ Physiologic dislodging of hair cells
loss in all frequencies including tinnitus and
○ Nerve (CNVIII ) degeneration in the osseous lamina
dysequilibrium
○ Biological changes in the sensory cells
OTHERS Aspirin (salicylates), loop diuretics ○ Changes in cochlear blood supply
(Furosemide), nicotine, and alcohol ○ Alterations in the function of stria vascularis
○ Rupture of Reissner’s membrane
Cytotoxic drugs (Cisplatin, Carboplatin,
○ Detachment of Organ of Corti from the basal membrane
Vinca Alkaloids) - cause HL (all frequencies)
when taken in large amounts and over ○ Tinnitus - ringing sensation ☊
prolonged periods of time ○ Other effects
■ Increased anxiety levels
Immediate plan of action/treatment: DISCONTINUATION OF THE ■ Loss of ability to concentrate
DRUG ■ Increased blood pressure levels
■ Higher marital dispute rates
2. Otosclerosis
■ Greater incidence of illness
● A disease of the bony labyrinth (main culprit ☊) that causes a ■ Lack of sleep
conductive HL
5. Idiopathic Sudden Sensorineural Hearing Loss
● Caused by toxic metabolite deposits from diseased bone
(capsular sclerosis) ● Idiopathic means sudden ☊
● If it involves the cochlea, a sensorineural hearing loss or mixed ● Hearing loss often unilateral that may develop over the course of
(conductive and sensorineural) HL will result a few days or occur seemingly instantaneously
● The bone growth affects either the oval window or round window ● Abrupt - many patients claim that they wake up from sleep to find
● Could be unilateral or bilateral that their hearing has changed
● Audiometric configuration is generally flat (hearing test will be ● 30 dB drop in 3 consecutive speech frequencies (in pure tone
more or less flat already ☊) audiometry/hearing test)
● Speech recognition (pure tone audiometry) is not severely affected ● Can occur at any age; most frequent in adults
● Suggested etiologies: (idiopathic)
3. Barotrauma ○ Autoimmune disease
● Sudden changes in middle ear pressure (as in diving or violent ○ Viral infection (if respiratory infection has preceded the HL)
sneezing, high altitude events) usually cause a conductive HL ○ Rupture of the basement membrane
● May cause a rupture of round window or of the annulus of the oval ○ Vascular disorders
window ○ Tumors
○ Fistula (perilymph leak) can result ○ Other neurological/psychosomatic disorders
○ May produce mild to profound inner ear hearing loss ● Internal Auditory Artery - considered the main culprit (☊) since it
● Can be surgically repaired and may reverse a permanent is the only blood supply of the stria vascularis with no collateral
fluctuating cochlear HL and or vertigo tributaries
○ If obstruction occurs in this artery, total unilateral hearing loss
4. Noise- induced hearing loss might occur
● Hearing loss from intense noise may result from ○ Should always be treated as a medical emergency
○ Acute Acoustic Trauma - 140dB in less than 1.5 ms; brief (consultation and treatment would be adamant ☊)
exposure to high-level sounds with subsequent partial or ■ The sooner the therapy following the onset of symptoms, the
complete hearing recovery better the prognosis for complete recovery.
○ Chronic Acoustic Trauma- work/recreational socioacussis; ● Diagnosis:
repeated exposure to high-level sounds, with permanent ○ Blood tests
hearing impairment ○ Magnetic Resonance Imaging
● Temporary threshold shift (TTS): Wherein hearing thresholds ○ Neurological testing
improve after an initial impairment following noise ○ Electrocochleography

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● Aim of treatment is towards improving the microcirculation and ○ Sometimes HL occurs without fracture (cochlear contusion)
oxygenation ○ Oval window membrane may rupture
○ Oral Steroids (tapering dose) /administration of steroids to the ○ Oval window fistula with perilymph may leak into middle ear
inner ear through trans-tympanic injections ○ Px may present with: otitis media, meningitis
○ Oral pentoxifylline (vascular enhancer )/hyperbaric O2 ● 3 Types of Trauma/Fractures: (2021)
● Sometimes, hearing recovery is complete, and symptoms ○ Longitudinal fracture
disappear spontaneously ■ More common
○ Miraculously it can disappear on its own. Supportively, we can ■ Fracture that uncommonly extends through the labyrinth
treat it with the aim of improving microcirculation. ☊ ● produces hearing loss similar to acoustic trauma (ie.
● For others, symptoms persist in the form of severe or total limited to the high frequencies and worse at 4kHz) (2021)
unilateral HL. ■ Caused by blunt trauma to the temporoparietal area ☊
■ Less likely to cause injury to CN VII
6. Hydrops
○ Transverse fracture
● Normal inner ear: endolymph is maintained at a constant volume ■ Less common
and contains specific concentrations of Chloride, Sodium, ■ Fracture line runs through cochlea
Potassium, and other electrolytes which allow the structures to ■ Caused by blows on frontal and occipital aspects ☊
function normally ■ Sensorineural Hearing Loss: severe to profound w/
○ Abnormal levels would result in hydrops ☊ associated CN VII injury ☜
● Other causes: head blow, infection, degeneration of inner ear, ● Most probably patient will have HL + facial nerve injury ☊
allergy or a tumor ○ Mixed Type
● Trauma, surgery, syphilis, hypothyroidism, and low blood
sugar 9. Presbycusis
● Most of the time cause is undetermined ● No contributing factors to hearing loss except age
● Endolymphatic Hydrops ○ Hearing loss of around 35 dB due to aging
○ Over-secretion or under absorption of endolymph ○ Men: expected at early 60s
○ As fluid pressure builds up in the cochlear duct, the pressure on ○ Women: expected at late 60s
the hair cells produces tinnitus and hearing loss ● Characteristic: difficulty in speech recognition
○ If pressure builds up sufficiently, the vestibular apparatus ● Popular theory: decreased hair cells activity is the cause of
becomes overstimulated and evokes vertigo age-related HL
● Treatment ● Phonemic regression ☜
○ Limit fluid intake and retention using diuretic drugs ○ Defined as a decrease in the intelligibility of speech due to
(if oversecretion) aging (Medical Dictionary)
○ Sedatives, tranquilizers, and vestibular suppressants ○ How to address patients: speak slowly rather than loudly for
○ Ear wicks placed through the middle ear to reduce symptoms of them to understand better
vertigo ● Produces alterations in many areas of the auditory system:
○ Multimemory hearing aids to address fluctuating hearing loss Tympanic membrane, ossicular chain, cochlear windows
● Surgery ● Other findings:
○ Decompressing the endolymphatic sac or draining the ○ Strial degeneration
excessive endolymph by inserting a shunt into spaces in the ○ Organ of corti degeneration
skull, so fluid can be excreted along with cerebrospinal fluid.
(more aggressive) CONCEPT CHECKPOINT:
1. Example of cochleotoxic drug
7. Autoimmune Inner Ear DIsease (AIED)
2. True/ False. Acute acoustic trauma is 140dB in less than 1.5 ms
● Inflammatory condition that occurs when the immune system 3. Only blood supply of the stria vascularis with no collateral
causes the body to attack its own tissues as it fails to distinguish tributaries
them from bacteria, viruses, or cells from other organisms
ANSWERS:
● Specifically attacks the inner ear 1. Aminoglycosides (Kanamycin, Neomycin, Amikacin)
● Results in bilateral fluctuating and progressive sensorineural 2. True
hearing loss 3. Internal auditory artery

● May occur over several months

V. TINNITUS
● Other symptoms include tinnitus, aural fullness, and vertigo
● Prevalence is low ● Auditory sensation in the absence of an electrical stimulus
● Some bilateral symptoms of Meniere’s disease may be due to ○ False sensation, non-existent ☊
AIED
● Treatment: Causes
○ Steroids via a wick for absorption into inner ear through Table 3. Causes of Tinnitus
the round window Mechanism Description
8. Head Trauma Due to obstruction such as:
● When head injury results in hearing loss, the audiogram is quite Conductive ● Impacted cerumen (earwax)
similar to acoustic trauma ● Foreign body
● Notch range: 3,000Hz - 6,000Hz Noise-induced hearing loss;
● Damage to tympanic membrane and middle ear mechanism: Sensorineural
May be idiopathic
○ Inner ear structures: may be torn, stretched, or deteriorated
from the oxygen loss due to hemorrhage Due to high blood pressure or aneurysms
Central
○ Hair cells: may be lost (patient senses pulsations)
○ Organ of corti: may be flattened or destroyed

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Perceived as rushing, humming, or weakness, numbness, paresthesia, or headache. The
Vascular vertigo is persistent and not precipitated by rolling over
beating sound
in bed. She had no prior similar episodes. The most
Clicking sound likely diagnosis is:
Causes: ☊ a. Meniere’s disease
● Eustachian tube dysfunction b. Transient ischemic attack
Myogenic
● Palatal myoclonus c. Otolithiasis
● Temporomandibular joint spasm d. Vestibular neuronitis
● Muscle induced (2021) 3. The endolymph is rich in what electrolyte?
a. Sodium
Treatment b. Magnesium
● White noise generation (WGN) c. Chloride
○ Rationale: tinnitus is usually heard before sleeping and when d. Potassium
the environment is very quiet ☊ 4. Gold standard for diagnosis of BPPV?
○ Solution: sleep next to an open fan or radio ☊ a. Toynbee Maneuver
■ It will try to counteract the high pitch sound (tinnitus) by b. Epley Maneuver
producing low pitched ringing sensation (2021) c. Half-Somersault Maneuver
○ Usually used in sensorineural tinnitus (2021) d. Dix – Hallpike Maneuver
● Tricyclic antidepressants (Amitriptyline), Anxiolytics (Alprazolam) 5. Meniere’s disease is an inner disease caused by
○ To calm patients down (2021) excessive endolymph in the inner ear. The triad of
● Circulatory stimulants symptoms of Meniere’s disease are the following
○ Ginkgo biloba - memory enhancing herbal drug, increases the EXCEPT:
circulation and oxygen supply of affected are in the ear (2021) a. Episodic unilateral hearing loss
Note: Tinnitus is hard to treat because it is hard to pinpoint the main b. Unilateral tinnitus
c. Episodic vomiting
cause. ☊
d. Episodic vertigo
○ If conductive: remover obstruction (2021) Answers: (1) a, (2) d, (3)d, (4)d, (5)c
○ If rupture of tympanic membrane: repair TM (2021)
2020 Feedback (same lecturer, [74-85])
NEED-TO-KNOW:
1. Which are more susceptible to ototoxins?
● Longitudinal fracture vs Transverse fracture
a. Inner Hair Cells
○ Longitudinal fracture
b. Outer Hair Cells
■ More common
c. Stria Vascularis
■ Less likely to cause injury to CN VII
d. Tectorial Membrane
○ Transverse fracture
2. The inner ear structure known also as the pars inferior?
■ Less common
a. Bony labyrinth
■ Fracture line runs through cochlea
b. Cochlea and saccule
■ Sensorineural Hearing Loss: severe to profound w/
c. Cochlea and utricle
associated CN VII injury
d. Utricle and semicircular canals
● Most probably patient will have HL + facial nerve injury
3. Labyrinthine infection with no active invasion of the
labyrinth by the infecting organism?
CONCEPT CHECKPOINT:
a. Autoimmune infection of the labyrinth
1. T/F. Only the individual complaining of tinnitus can hear the
b. Serous labyrinthitis
ringing sound.
c. Vestibular labyrinthitis
2. This is the simplest solution/treatment for tinnitus.
d. Vestibular neuritis
3. An example of a circulatory stimulant which increases the
4. Symptoms of Vestibular Schwannoma?
circulation and oxygen supply in the affected area of the ear.
a. Bilateral tinnitus, low frequency SNHL, vertigo
ANSWERS:
b. Involves CN IV, V, VI, VII
1. True. It is a false sensation c. Unilateral tinnitus, high frequency SNHL, headache
2. White Noise Generator d. Unilateral tinnitus, high frequency SNHL, vertigo
3. Ginkgo biloba
5. What is the cranial nerve not involved in Acoustic
Neuroma?
IV. REFERENCES a. CN III
Calavera, K. (2020). Problems of the Inner Ear 1 [lecture powerpoint]. b. CN V
2021 lecture transcription. c. CN VI
phonemic regression. (n.d.) Farlex Partner Medical Dictionary. (2012). d. CN VII
Retrieved from 6. Violent spinning vertigo is a classic symptom of?
https://medical-dictionary.thefreedictionary.com/phonemic+regression
a. Central vertigo
REVIEW QUESTIONS b. Mastoidectomy
c. Peripheral vertigo
2022 Canvas Quiz Feedback
d. Vertiginous migraine
1. What is the function of the outer hair cells? 7. The diuretic drug that can cause sensorineural hearing
a. Amplification of sound loss?
b. Minimize sound a. Acetazolamide
c. Dispersion of sound b. Furosemide
d. Detection of sound c. Hydrochlorothiazide
2. A 35 year old woman presents with a 2 day history of d. Spironolactone
isolated vertigo. There is no hearing loss, tinnitus,

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8. A viral disease which affects the cochlea and causes a. Central vertigo
profound sensorineural hearing loss? b. Objective vertigo
a. CMV infection c. Peripheral vertigo
b. Maternal rubella d. Subjective vertigo
c. Measles 11. Type of fluid that flows through the scala tympani?
d. Rubeola a. Endolymph
9. Defined as hearing loss due to aging? b. Perilymph
a. Myringosclerosis c. Sodium rich fluid
b. Presbycusis d. Potassium rich fluid
c. Presbylaryngis Answers: (1) b, (2)b, (3)b, (4)d, (5)a, (6)c, (7)b, (8)a, (9)b,10(b), 11(b)
d. Tympanosclerosis
10. The perception that your environment is moving is
known as?

SUMMARY

Table 1. Differences between the two types of vertigo

Peripheral Vertigo Central Vertigo
Onset Usually sudden Gradual
Head Position Worsened by head movement No change
Intensity Severe Mild
Tinnitus, hearing loss,
Present Absent
nausea, vomiting
Neurologic symptoms Absent Present

Nystagmus Combined horizontal and torsional,

Purely vertical not suppressed with fixation,
suppressed with fixation, unidirectional,
(most important/defining characteristic☜) multidirectional, no latency
long latency
Neighborhood Signs (2021)
Absent Present
(Diplopia, cortical blindness, dysarthria)
Concerns the following department (2021) ENT department Neuro department

NOTE: If vertigo is peripheral in origin, duration will be very short.

Table 2. Summary table for the causes of Vertigo
Causes of Vertigo
Pathophysiology Symptom/s Treatment/s

Benign Paroxysmal Dislodgement of ear particles Sensation of motion upon sudden In addition to drugs used for
Positional Vertigo (BPPV) (otoconia or otoliths [CaCO3 head movement BPPV, several physical
crystals]) from the semicircular maneuvers can be used to treat
canals (utricle) the condition

Physical Maneuvers for BPPV:

Particle repositioning maneuver

(EPLEY Maneuver): eliminates
BPPV in > 80% of cases

Vestibular rehabilitation
exercises (SEMONT Maneuver):
less effective, less comfortable

Vestibulocochlear Nerve Viral infection (Herpes virus,flu Vestibular Labyrinthitis:

Inflammation (VCNI) virus, poxvirus) Inflammation of both branches of
CN VIII
Symptoms: sudden vertigo,
nausea, vomiting, hearing loss,
episodic tinnitus

Vestibular Neuritis:
Swelling of nerve connecting
innear to the brain,
NO tinnitus
NO hearing loss

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Meniere's Disease/ Abnormal amount of endolymph in Triad: Decrease production or drain
Labyrinthine Storm inner ear Episodic vertigo endolymph
Unilateral tinnitus Diuretics/Steroids/Anti-vertigo
Unilateral hearing loss Middle ear injections
Surgery
Acoustic Neuroma/ Non malignant tumor of the nerve Unilateral gradual hearing loss Observe
Schwannoma/ tissue Unilateral tinnitus Surgery
Neurilemmoma Vertigo Radiotherapy
Facial numbness
Vestibulobasilar Insufficiency Decreased blood flow to the base
of the brain
(e.g. of causes: bleeding at the
back of brain, arteriosclerosis)
Head Trauma and Neck Injury

Migraine Associated with dizziness

Usually due to muscle spasms

Table 3. Summary Table for the Causes of Inner Ear Disorders

Causes of Inner Ear Disorders
Pathophysiology/ Definition Symptom/s Treatment/s

Endogenous
Hereditary Sensorineural Frequent cause of cochlear Syndromic:
Hearing Loss hearing loss Common syndromes directly
associated with hearing loss of the
Non-Syndromic
inner ear:
(Congenital and Acquired)
Skull and facial deformities
Syndromic Changes in eye color (Usher
(Usually present at birth, syndrome)
characterized by multiple organ Changes in hair and skin
system involvement associated pigmentation (Waardenburg
with hearing loss) Syndrome)
Thyroid disease
Heart disorders
Musculoskeletal anomalies
Mental retardation
Balance disorders
Other sensory and motor deficits

Chromosomal Disorders Chromosomes are missing, or Trisomy: an extra third

extra genetic material is found chromosome is present
Trisomy 21 (Down’s Syndrome)
is most common

Prenatal Causes Rubella

Human Immunodeficiency Virus (HIV)
Syphilis
Anoxia/Hypoxia
Rh (rhesus) Factor/incompatibility
Perinatal Causes Anoxia
Hyperbilirubinemia
Prematurity
High noise levels from infant’s incubators
Head trauma
Postnatal Causes Bacterial
Otitis media
Bacterial meningitis
Syphilis

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Viral (produce bilateral hearing loss)

Exogenous/ Acquired
Ototoxicity Cochlear damage resulting from
prolonged use of medications
Some medications are known to
be toxic to the cochlea
(particularly the outer hair cells)
Kidney disease might prevent
medications from being
excreted thereby raising their
levels in the blood, resulting in
ototoxicity
Otosclerosis Caused by toxic metabolite
deposits from diseased bone
(capsular sclerosis)
Measles (rubeola)
Mumps (parotitis)
Ototoxic effects are generally Treatment: Hold/Discontinue the
symmetrical/bilateral (unless medications (if the patient does
substance is applied or exists not have kidney disease
locally), may be reversible or
irreversible, and may be caused
by endogenous or exogenous
agents
Hear hearing loss will be more or
less flat already
a sensorineural hearing loss or
mixed (conductive and
sensorineural) hearing loss will
result

Barotrauma Sudden changes in middle ear
pressure
Noise Induced Hearing Loss Acute Acoustic Trauma - 140dB in
less than 1.5 ms
Chronic noise-induced hearing
loss
Idiopathic Sudden Abrupt, many patients claim that
Sensorineural Hearing Loss they wake up from sleep to find
that their hearing has changed
30 dB drop in 3 consecutive
speech frequencies
Cause a conductive hearing loss Surgically repaired
May produce mild to profound
hearing loss
Temporary threshold shift
(TTS): Wherein hearing thresholds
improve after an initial impairment
following noise
Permanent threshold shift
(PTS): Relates to irreversible
hearing impairment after chronic
noise exposure
Hearing loss often unilateral that Oral Steroids (tapering dose)
may develop over the course of a /administration of steroids to the
few days or occur seemingly inner ear through trans-tympanic
instantaneously injections
Oral pentoxifylline (vascular
enhancer )/hyperbaric O2

Hydrops Caused by head blow, infection,
degeneration of inner ear, allergy
or a tumor Trauma, syphilis,
hypothyroidism, and low blood
sugar
Most of the time cause is
undetermined
Endolymphatic Hydrops Limit fluid intake and retention
tinnitus and hearing loss using diuretic drugs (if
oversecretion)
If pressure builds it evokes vertigo Sedatives, tranquilizers, and
vestibular suppressants
Ear wicks placed through the
middle ear to reduce symptoms of
vertigo
Multi Memory hearing aids to
address fluctuating hearing loss

Surgery
Decompressing the
endolymphatic sac

Autoimmune Inner Ear Inflammatory condition that occurs Results in bilateral fluctuating and Steroids via a wick for absorption
Diseases when the immune system causes progressive sensorineural hearing into inner ear through the round
the body to attack its own tissues loss window

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1.04 Problems of Inner Ear 1

AIED specifically attacks the inner

ear
Head Trauma 3 Types of Fractures:
1. Longitudinal - more common, less likely to cause injury to CN VII
2. Transverse - less common, with CN VII injury, causes severe to profound sensorineural hearing
loss
3. Mixed
Presbycusis Hearing loss due to aging (men at early 60s, women at late 60s)
Characteristic: difficulty in speech recognition
Phonemic regression - address by speaking slowly not loudly

APPENDIX

Figure 4. EPLEY Maneuver (2021)

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