UNIT: ENT

CODE:DCM223
CLINICAL MEDICINE CLASS 2021
LECTURER: Mr.WELDON KORIR
LECTURE 2.
Diseases of the Middle Ear
Congenital Anomalies of the Middle Ear
Introduction
• Congenital anomalies of the middle ear refer to structural or
developmental abnormalities present from birth that affect the
components of the middle ear, including the tympanic membrane
(eardrum), ossicles (bones of the middle ear), and the Eustachian tube.
These anomalies can lead to hearing impairment and other related
issues. Here are some common congenital anomalies of the middle
ear:
Common Congenital Anomalies
list of common anomalies, including:
1. Aural Atresia
2. Microtia
3. Ossicular Malformations
4. Congenital Cholesteatoma
5. Inner Ear Anomalies
6. Patulous Eustachian Tube
7. Eustachian Tube Dysfunction
8. Facial Nerve Anomalies
9. Enlarged Vestibular Aqueduct
1.Aural Atresia
Aural atresia involves the absence or closure of the ear canal (external
auditory meatus). This condition can affect one or both ears and is
usually associated with underdeveloped or absent middle ear
structures.
2.Microtia
Microtia is a congenital deformity where the external ear (pinna) is
underdeveloped or malformed. It can range from a small, abnormal ear
to a complete absence of the ear
3.Ossicular Malformations:
Ossicular Discontinuity: Disruption or abnormal formation of the ossicular
chain (malleus, incus, stapes) that can lead to conductive hearing loss.
Ossicular Fixation: Abnormal fusion or immobility of the ossicles, affecting
sound transmission.
4.Congenital Cholesteatoma:
A non-cancerous growth of skin cells in the middle ear and mastoid
region. It may cause erosion of the ossicles and other middle ear
structures.
5.Inner Ear Anomalies:
Abnormalities in the cochlea and vestibular apparatus, such as
incomplete or absent cochlear structures, leading to sensorineural
hearing loss.
6.Patulous Eustachian Tube:
The Eustachian tube remains abnormally open, causing issues with
pressure regulation and possible hearing problems.
7.Eustachian Tube Dysfunction:
Anomalies in the structure or function of the Eustachian tube can
result in recurrent ear infections and hearing issues.
8.Facial Nerve Anomalies:
Abnormalities in the course or structure of the facial nerve within the
middle ear can be associated with hearing loss and facial nerve
dysfunction.
9.Enlarged Vestibular Aqueduct:
An abnormally large vestibular aqueduct, which is associated with
hearing loss, particularly sensorineural hearing loss.
Management of congenital anomalies of the middle ear
involves a multidisciplinary approach, including paediatric
otolaryngologists, audiologists, speech therapists, and sometimes
plastic or reconstructive surgeons.
Treatment may include surgical intervention to reconstruct or repair
affected structures, hearing aids, cochlear implants, and ongoing
audiological and developmental support for the affected individual.
TRAUMATIC LESIONS.
1.Otitic Barotrauma"
Trauma to the middle ear caused by acute atmospheric pressure
changes that may result in tympanic membrane rupture."
Mechanism
"Pressure Change Mechanism"
During descent in an airplane or diving, if Eustachian tube is
obstructed, unequal pressure in middle ear occurs leading to effusion.
Rapid descent can cause tympanic membrane rupture.
Predisposing Factors
"Factors Leading to Eustachian Tube Obstruction"
• Inflammation (rhinitis or sinusitis)
• Allergic rhinosinusitis
• Adenoid hypertrophy
Clinical Picture
Symptoms:
Severe ear pain and sense of ear fullness
Deafness, tinnitus
Congested retracted drum
Fluid or hemorrhage in middle ear in severe cases
Tympanic membrane rupture and bleeding per ear in severe cases
Treatment –
1.Prophylactic
"Preventive Measures" Recommendations:
Avoid flying with nasal obstruction
Stay awake and perform swallowing or chewing action during airplane
descent
Use nasal decongestant drops
2. Therapeutic
"Management and Therapeutic Actions" Recommendations:
Chew gum while on flight to help equalize pressure
Proper management to treat ruptured tympanic membrane
2. Traumatic Ossicular Disruption
Aetiology
Causes of Traumatic Ossicular Disruption
Causes:
Head trauma
Foreign body
Ear surgery
Pathology
"Pathological Changes"
Description:
Disruption of incudo-stapedial joint or incudo-malleolar joint revealed by CT
or MRI.
Dislocation of stapes causing perilymph fistula.
Symptoms
"Common Symptoms"
Deafness and tinnitus
Vertigo due to perilymph fistula
Signs
"Clinical Signs"
Otoscopy: Intact or ruptured tympanic membrane
Tuning Fork Test: Conductive hearing loss
Investigations
Pure tone audiometry: Conductive hearing loss or mixed with SNHL
(due to inner ear injury)
Tympanometry
Treatment
Middle ear exploration
Ossiculoplasty
Temporal Bone Fractures:
Aetiology
Causes:
Head injury due to car accidents or fall from height.
Types
Types of Temporal Bone Fractures
Longitudinal fractures (80%): Fracture line passes along the longitudinal axis.
Clinical Picture
Clinical picture of longitudinal fractures:
Bleeding from ear and may be cerebrospinal otorrhoea if tympanic membrane is
ruptured.
Lacerations in the skin of the external ear canal.
Ruptured or intact tympanic membrane.
Tuning fork test reveals conductive hearing loss due to rupture of the tympanic
membrane.
 Investigations
Investigations:
CT scan of the temporal bone.
Treatment
Treatment options:
Conservative:
Same as for ruptured tympanic membrane.
Vestibular sedatives for vertigo.
Surgical:
Myringoplasty or ossiculoplasty.
OTITIS MEDIA
Definition:
Acute (less than two weeks) or chronic (more than two weeks).
Acute Suppurative Otitis Media (ASOM) in Adults
Definition:
Acute inflammation of the mucosal lining of the middle ear cleft.
Incidence:
Common in infants and children.
Causative Organisms:
Beta hemolytic streptococci, streptococcus pneumonia, Haemophilus
influenza, Staphylococcus aureus, and moraxella catarrhalis.
Causative Organisms and Routes of Infection
Causative Organisms:
Viral infection secondary to bacterial invasion.
Routes of Infection:
Through the Eustachian tube (E.T.) from nasopharynx, adenoids, postnasal drip,
etc.
Through drum perforation during activities like bathing, swimming, and ear wash.
Pathology
Edema and obstruction of Eustachian tube lead to negative pressure and
tympanic membrane retraction.
Edematous middle ear mucosa causes exudation and accumulation of
purulent secretions, resulting in tympanic membrane bulging, necrosis,
and perforation.
Clinical Picture and Resolution
Symptoms before and after perforation: severe ear pain, fever, hearing
loss, tinnitus.
Otoscopy findings and Tuning Fork test results for both pre and post-
perforation phases.
Resolution outcomes: complete resolution, incomplete resolution with
complications.

Fate of Acute Suppurative Otitis Media

Complete resolution: healed perforation, normal drum position, and
hearing.
Incomplete resolution with residual discharge or deafness.
Treatment
Systemic treatment: I.V. antibiotics, analgesics, rest, and fluids.
Local treatment:
Before perforation: decongestant nasal drops, anesthetic ear drops,
myringotomy.
After perforation: suction of discharge, antibiotic ear drops, decongestant
nasal drops, myringotomy.
Prognosis
AOM is self-limiting in 80% of cases.
Antibiotics lead to rapid relief of symptoms in nearly all patients.
Complications
Possible complications: cranial nerve palsy.
Extracranial complications: tympanic membrane issues, middle ear
effusion, mastoiditis, facial nerve paralysis.
Intracranial complications: meningitis, abscesses, sinus thrombosis.
Acute Otitis Media in Children
Acute otitis media (AOM) is an inflammation of the middle ear,
primarily affecting children.
Incidence
Common in children, especially under the age of 5.
Pathophysiology
Eustachian tube anatomy in children:
Wider
Shorter
More horizontal
Factors contributing to AOM:
Adenoid enlargement in infants
Frequent upper respiratory infections
Lower immune resistance in children
Clinical Presentation
Symptoms may include:
Fever
Vomiting and diarrhoea (can be mistaken for gastroenteritis)
Crying, restlessness, difficulty sleeping
Pulling at the affected ear
Otoscopy Findings
A diffusely congested tympanic membrane
Treatment
Treatment approach is similar to that of adults
Chronic Non-Suppurative Otitis Media (CNSOM)
Accumulation of non-suppurative effusion in the middle ear.
Etiology
1.Prolonged eustachian tube obstruction:
Adenoids
Nasopharyngeal tumor
Rhinitis
Sinusitis
Radiotherapy
Cleft palate
2.Unresolved ASOM:
Inadequate antibiotics
Inadequate tubal drainage
3.Viral infection
4.Allergy
Symptoms
Hearing loss, tinnitus, and ear discomfort.
Bubbling sound in the ear (may occur).
May be asymptomatic.
Signs
1.Tympanic membrane:
Retracted, colored amber yellow or dull grey
Restricted mobility
Fluid level (biconcave hairline)
Air bubbles
2.Tuning fork tests: Conductive deafness
Investigations
X-ray nasopharynx lateral view
Treatment
Medical treatment initially for 3 months
If unsuccessful, recommend surgery
Chronic Suppurative Otitis Media (CSOM)
Clinical Presentation
Patient complains of:
Profuse, odorless, mucopurulent scanty ear discharge
Hearing loss (conductive or mixed)
Otoscopy reveals:
Perforated ear drum on pars tensa
Complications
Rare but may include:
Injury of facial nerve
Injury of lateral sinus leading to bleeding
Injury of inner ear
Injury of the dura
Treatment
Recommend surgery: Mastoidectomy
Mastoidectomy Complications
1.Injury of facial nerve
2.Injury of lateral sinus leads to bleeding
3.Injury of inner ear
4.Injury of the dura

Tympanoplasty Operation
Aim
Eradication of pathology in the middle ear cleft (granulations, polyps,
and diseased cells)
Complications of Suppurative Otitis Media
1.Cranial complications (bony skull):
Mastoiditis
Petrositis
Otitic labyrinthitis
Otitic facial paralysis
2.Intra-cranial complications (inside the intra cranial cavity):
Extra-dural abscess
Sub-dural empyema
Lateral sinus thrombosis or thrombo-phlebitis
Meningitis
Brain abscess (Temporal lobe or Cerebellum)
Otitic hydrocephalus
3.Extra-cranial complications (in the soft tissues of the head and neck):
Otitis externa
Retropharyngeal abscess
 Mastoiditis
Extension of infection from mucoperiosteal lining to bony septa and
cortex of mastoid process in suppurative otitis media
Can manifest as acute or chronic
Acute Mastoiditis
Acute mastoiditis is a bacterial infection and inflammation of the
mastoid air cells, a part of the temporal bone behind the ear
Common complication of suppurative otitis media
Etiology
Bacterial Infection:
Often follows untreated or inadequately treated acute otitis media (AOM).
Commonly caused by Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis.
Epidemiology
Age Group:
More common in children than adults.
Peak incidence in children aged 2-5 years.
Prevalence:
Varies by region and healthcare practices.
Pathophysiology
Infection Spread:
Begins in the middle ear (AOM).
Infection progresses to mastoid air cells due to inadequate drainage or treatment.
Inflammation:
Inflammatory response in mastoid cells leads to swelling and accumulation of pus.
symptoms:
Increasing ear pain
Increasing or recurring fever
Increasing and persistent ear discharge
Post-auricular swelling
Signs
Purulent, profuse ear discharge (positive reservoir sign)
Tenderness on mastoid antrum
Sagging of external auditory meatus due to edema
Congested tympanic membrane (perforated or bulging)
Fluctuant abscess may form
Tuning fork test: Conductive hearing loss
 Complications
1.Local Complications:
Abscess formation
Facial nerve palsy
Labyrinthitis
Meningitis
2.Systemic Complications:
Septicemia
Differential Diagnosis
Acute Otitis Media (AOM):
Distinguishing based on clinical and otoscopic findings.
Post-auricular Lymphadenitis:
Swelling may mimic mastoiditis.
 Investigations
CT Scan-To assess the extent of disease and plan surgical
intervention.
Culture and sensitivity test of ear discharge
Treatment
i. I.V Antibiotics:
Broad-spectrum antibiotics (able to bypass brain barrier)
ii. Symptomatic Management:
Analgesics, antipyretics, anti-inflammatory agents
iii. Nasal Decongestants:
Local & systemic to improve Eustachian tube function
Surgery Indications - Mastoidectomy
1.Acute Mastoiditis with:
1. Mastoid abscess
2. Mastoid fistula
2.As a step in other more extensive surgeries
Prognosis
With Prompt Treatment:
Generally good prognosis.
Early treatment reduces complications.
Prevention
Prompt Treatment of AOM:
Timely management to prevent progression to mastoiditis.
Address risk factors promptly.
CHRONIC MASTOIDITIS.
Chronic inflammation and infection of mastoid air cells in the
temporal bone, often following acute mastoiditis.
Aetiology
Usually arises from inadequately treated or untreated acute
mastoiditis.
Pathophysiology
Chronic inflammatory changes persist within mastoid air cells.
Ongoing infection and inflammation lead to tissue destruction and
bone resorption.
 Clinical Features
1.Symptoms:
Chronic, foul-smelling ear discharge
Hearing loss
Ear discomfort or pain
Headache
2.Signs:
Perforated or retracted tympanic membrane
Granulation tissue in the ear
Mastoid tenderness
 Complications
1.Local Complications:
Spread to adjacent structures (e.g., inner ear)
Labyrinthitis
Facial nerve palsy
Mastoid abscess
2.Systemic Complications:
Septicemia (rare but serious)

Differential Diagnosis
Chronic otitis media with effusion
Cholesteatoma
Squamous cell carcinoma of the temporal bone
 Investigations
CT Scan:
To assess the extent of disease and plan surgical intervention.
Audiological Testing:
To evaluate hearing loss.
Management
1.Medical Treatment:
Antibiotics (based on culture and sensitivity)
Ear cleaning and care
2.Surgical Treatment:
Mastoidectomy to remove infected tissue and reconstruct the ear structures
 Prognosis
Prognosis varies based on the extent of disease and response to
treatment.
Early and appropriate treatment can improve outcomes.
Prevention
Prompt and appropriate treatment of acute otitis media to prevent
progression to chronic mastoiditis.
 Petrositis
Inflammation of the petrous air cells.
A patient complains of ear discharge after surgery (Mastoidectomy)

Clinical Picture
Presentation - Gradenigo's Triad:
Persistent otorrhea.
Orbital pain due to trigeminal nerve irritation.
Squint and double vision (diplopia) from 6th nerve paralysis
Investigations
Diagnostic Tool:
CT scan

Treatment
1.Antibiotics:
Targeting the causative bacteria.
2.Surgery:
Intervention may be necessary for severe cases.
Tumors of the Middle Ear
Introduction
Tumours in the middle ear can be either benign or malignant.
1.Benign Tumours
Glomus Tumours:
Common in the middle ear.
Subtypes: a. Glomus tympanicum b. Glomus jugulare
Histologically similar to glomus jugulare body.
Characterized by vascularity, tendency to bleed, and reddish tint behind tympanic
membrane.
May cause pulsatile tinnitus and slow, gradual growth.
Classic triad: localized tenderness, severe paroxysmal pain, sensitivity to cold
 Diagnosis of Glomus Tumours
Clinical presentation and physical examination are crucial.
• Key Signs:
Vascularity resulting in a reddish tint behind tympanic membrane.
Pulsatile tinnitus.
Slow, gradual growth of the tumour.

Diagnostic Tools
High Clinical Suspicion:
Essential for diagnosis.
Magnetic Resonance Imaging (MRI):
Helpful in confirming the diagnosis.
Treatment for Glomus Tumours
Surgery:
Primary mode of treatment.
Complete excision of the tumour.
2.Malignant Tumours
Squamous Cell Carcinoma:
A malignant tumour type.
Treatment for Malignant Tumours
Approach:
Wide local excision
Chemotherapy
Prognosis
Prognosis varies based on the type and stage of the tumour.
Early detection and intervention can improve outcomes.
Prevention
Regular ear examinations and prompt medical attention for any ear
symptoms or abnormalities.
Some diseases of the Inner Ear and 8th Nerve
1. Presbyacusis
Age-related sensorineural hearing loss.
Common in elderly individuals
Etiology
Primary Causes:
Degeneration of inner ear structures over time.
Loss of hair cells and cochlear neurons.
Contributing Factors:
Prolonged exposure to loud noises throughout life.
Genetic predisposition
Pathophysiology
Gradual loss of:
Hair cells in the cochlea.
Cochlear neurons.
Reduction in:
Ability to hear high-frequency sounds.
Clinical Features
Symptoms:
Gradual hearing loss, particularly high-pitched sounds.
Difficulty understanding speech, especially in noisy environments.
Signs:
Audiogram showing a high-frequency sensorineural hearing loss.
Diagnosis
Audiometric Evaluation:
Pure-tone audiometry to assess hearing thresholds.
Speech Discrimination Tests:
Evaluate ability to understand speech.
Management
1.Hearing Aids:
Amplify sound to compensate for hearing loss.
2.Cochlear Implants:
For severe cases where hearing aids are ineffective.
3.Communication Strategies:
Lip reading, sign language, and speech therapy.
Prognosis
1.Progression:
Typically gradual and irreversible.
2.Adaptation:
Hearing aids and communication strategies can improve quality of life.
 Meniere's Disease
Paroxysmal attacks of vertigo, tinnitus, and perceptive deafness
Causes of Meniere's Disease
Hypoabsorption of endolymph theory
Local disturbance of salt and water mechanisms theory
Note: Cause not clearly understood, various theories proposed
Symptoms of Meniere's Disease
Vertigo: sudden, severe, and recurrent
Tinnitus and its relation to vertigo
Hearing loss: sensory type
Aural fullness: sense of pressure in both ears
 Diagnosis of Meniere's Disease
Importance of patient history
Normal ear drum examination
Audiological evaluation: unilateral mild low tone loss in early stages,
affecting all tones in late stages
Diagnostic role of Electrocochleography
Medical Treatment
Diet: salt restriction
Medications:
Dramamine and cinnarizine
Vasodilators like betahistine
Diuretics for salt and water retention
Corticosteroids for autoimmunity and allergy
Minor tranquilizers
 Surgical Treatment
Indications for surgery (when medical treatment fails)
Mention that various surgical options exist (e.g., endolymphatic sac
decompression)
Diet and Lifestyle Modifications
Details about salt restriction and its role in managing symptoms
Other lifestyle modifications to manage the disease
Management and Coping Strategies
Overview of how individuals can manage Meniere's disease on a day-
to-day basis
Coping strategies for dealing with vertigo attacks and associated
symptoms
Prognosis
Information on the long-term outlook for individuals with Meniere's
disease
Mention that early intervention and management can improve quality
of life
 Bell's palsy (Idiopathic facial paralysis)
Definition:
Acute, unilateral lower motor neuron facial nerve paralysis affecting
the entire side of the face.
Pathology of Bell’s palsy
 Edema compression on the nerve causes ischemia
Etiology
Theories on the etiology: viral infection of the facial nerve or
immunological response to viral infection
Implicated viruses: HSV-1, HSV-2, human herpes virus, VZV,
Influenza B, adenovirus, Coxsackie virus, and EBV
Possible preceding upper respiratory tract viral infection
 Demographics
Age group affected: typically young and middle-aged individuals (15-
45 years)
No gender preference mentioned
Clinical Presentation
Complete paralysis or asymmetry of one side of the face
Specific areas affected: frontal region, loss of taste, dry eye, pain,
increased sensitivity to noise (hyperacusis)
Absence of systemic, neurological, or otological symptoms
 Investigation
Bell's palsy as a diagnosis of exclusion
Emphasis on not needing additional investigations
Prognosis
Recovery in two-thirds of patients within 3 months
No recovery usually occurs after 6 months of initial presentation
Treatment Approaches
Steroids (prednisolone): Dosage and duration
Antiviral (acyclovir): Dosage and duration
Eye protection: Wet sterile napkin, artificial tears
Physiotherapy
Complications
possible complications (e.g., facial contractures, synkinesis)
Otosclerosis
This the Formation of new vascularized spongy bone, replacing the
normal compact labyrinth
Common complaint: Progressive hearing loss in both ears
Aetiology
Aetiology of Otosclerosis:
Not clearly known
Possible causes:
 Genetic
 Developmental Theory (focus replaces cartilaginous cells of the otic capsule)
 Aggravated by pregnancy
Incidence
Incidence of Otosclerosis:
Commoner in females
Age of onset: 20-40 years
Family history positive in 50% of cases
Commonest cause of bilateral Conductive Hearing Loss (CHL) in adults
Symptoms
Symptoms of Otosclerosis:
Bilateral and progressive hearing loss
Tinnitus
Paracusis Willshii: Better hearing in noisy areas than quiet areas

Signs
Signs of Otosclerosis:
Tympanic membrane: Normal in shape and mobility
Differential Diagnosis
Differential Diagnosis of Otosclerosis:
Ossicular fixation due to congenital or inflammatory causes
Otitis media with effusion
Middle ear atelectasis
Adhesive otitis media
Tympanosclerosis
Ossicular disconnection
Investigations
Investigations for Otosclerosis:
Pure tone audiometry (PTA)
Tympanometry
Medical Management
Medications:
Sodium fluoride: May slow down progression of the disease
Bisphosphonates: Some studies suggest potential benefit

Surgical Options
Key surgical options:
Stapedectomy
Stapedotomy
Stapes mobilization
Symptomatology of Ear Diseases Summary
Common Ear Disease Symptoms
1.Tinnitus
2.Hearing loss
3.Otorrhea (Ear discharge)
4.Vertigo
5.Earache (Otalgia)
Deafness
Definition:
Diminution of hearing
Types of Deafness:
Conductive Hearing Loss (CHL)
Sensorineural Hearing Loss (SNHL)
Mixed Hearing Loss
Functional (psychogenic or malingering)
Causes of Conductive Hearing Loss
Causes related to the External Canal:
Wax accumulation
Congenital atresia
Foreign body impaction
Otitis externa, furuncle, or fungus mass
Tumors
Causes of Conductive Hearing Loss (contd.)
Causes related to the Middle Ear:
Congenital anomalies
Drum issues (perforations, adhesion, bullous myringitis, Tympanosclerosis)
Acute and chronic Serous Otitis Media (SOM), Non-SOM
Trauma
Tumors (e.g., Glomus, carcinoma)
Causes of Sensorineural Hearing Loss
Causes related to Cochlea or 8th Nerve:
Abnormalities in the cochlea
Abnormalities in the 8th nerve
Causes of Mixed Hearing Loss
Combination of conductive and sensorineural deafness
Usually starts as conductive deafness and progresses
Factors Affecting Hearing During Pregnancy
TORCHES (Toxoplasma, Rubella, CMV, Herpes, Syphilis) affecting
the mother during the first 3 months of pregnancy
Intake of ototoxic drugs by the mother (e.g., Quinine, gentamicin - to
be avoided in pregnancy)
The Hearing Process
hearing process:
Outer ear collects sound waves
Transmission to the ear drum
Vibration of the ear drum
Transmission of sound waves into the middle ear
Ossicles transmitting waves to the cochlea fluid
Cochlea changes sound into electrical energy
Electrical energy transmitted to the brain, interpreted as sound