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S2 E069 Inner Ear and Hearing Loss

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Acoustic Neuroma (Vestibular Schwannoma)

  • Slow growing benign tumor of the vestibulocochlear nerve, CN VIII
  • Occurs in males and females equally
  • Most often found in those between the ages of 50 and 60.
  • The are the most common intracranial tumor

Clinical Presentation

  • Sudden onset of unilateral hearing loss that is then slowly progressive
  • Episodic or continuous vertigo
  • Tinnitus
  • Headache
  •  

Labs, Studies and Physical Exam Findings

  • Demonstration of unilateral sensorineural hearing deficit
  • Diagnosis is confirmed with an MRI with contrast

Treatment

  • Observation with annual MRI
  • Surgical excision
  • Radiotherapy

Barotrauma

  • Trauma to the eardrum secondary to pressure difference between the inside and the outside of the eardrum
  • Sudden changes in pressure
    • Airplane flights
    • Scuba diving

Clinical Presentation

  • Unilateral or bilateral pain
  • Feeling of pressure in ears
  • Dizziness

Labs, Studies and Physical Exam Findings

  • Clinical diagnosis
  • May clinically look like an otitis media

Treatment

  • Prevention by opening the eustachian tube
    • Autoinflation – forcefully exhale while the mouth is closed and holding the nostrils
    • Chew gum
    • Yawn
    • Swollowing – suck on hard candy
    • Decongestants if sinus congestion

Dysfunction of the Eustachian Tubes – Narrowed tubes

Clinical Presentation

  • Fullness in the ears
  • Decreased hearing
  • Popping or crackling with yawning or swallowing

Labs, Studies and Physical Exam Findings

  • Retraction of the tympanic membrane
  • Decreased tympanic membrane motility with pneumatic otoscope

Treatment

  • Decongestants
    • pseudoephedrine orally
    • oxymetazoline spray
  • Intranasal steroids
  • Surgical insertion of a tympanostomy tube

Dysfunction of the Eustachian Tubes – Overly Patent Tubes

Clinical Presentation

  • Mild hearing impairment
  • Exaggerated ability to hear yourself breathe and speak
  • Feels better during a URI

Labs, Studies and Physical Exam Findings

  • Clinical diagnosis

Treatment

  • Do not take decongestants
  • Surgical narrowing of the tube

Labyrinthitis

Inflammation of the inner ear

Causes/Predisposing Factors

  • Upper respiratory infection
  • Allergies
  • Fatigue
  • Alcohol consumption
  • Smoking
  • Stress
  • Drugs

Clinical Presentation

  • Acute onset of vertigo
  • Involuntary eye movements
  • Unilateral hearing loss
  • Nausea and vomiting
  • Tinnitus

Labs, Studies and Physical Exam Findings

  • History and physical

Treatment

  • Diazepam for the acute vertigo
  • Streriods
  • Antihistamines

Vertigo

  • An inappropriate sensation of movement

Causes

  • Benign paroxysmal positional vertigo
  • Meniere’s disease
  • Labyrithitis
  • Drugs
    • Antibitocs
    • Analgesics
    • Hypnotics
    • etc

Clinical Presentation

  • Sensation of moving or spinning while not moving
  • Nausea and vomiting

Labs, Studies and Physical Exam Findings

  • Usually a clinical diagnosis
  • MRI may be helpful for a further workup
  • Complete audiologic evaluation

Treatment

  • Control triggers
    • Diet
    • Stress
    • Fatigue
    • Bright light
  • Diazepam for acute vertigo
  • Antihistamines
  • Compazine or Zofran for nausea

Benign Paroxysmal Positional Vertigo

  • Sesnsation of spinning or moving
  • Typically lasts less than 60 seconds
  • Believed to be caused by displacement of small calcium carbonate crystals in the inner ear

Clinical Presentation

  • Episodes of veritgo

Labs, Studies and Physical Exam Findings

  • Dix-Hallpike maneuver

Treament

  • Canilith repositioning maneuvers

Meniere Disease

  • May be caused by inflammation and excess fluid production in the inner ear

Clinical Presentation

  • Episodic vertigo lasting 1-6 hours
  • Low frequency hearing loss
  • Tinnitus
  • Unilateral ear pressure

Labs, Studies and Physical Exam Findings

  • History and physical
  • MRI to rule out other diagnosis

Treatment

  • benzodiazepines for acute vertigo
  • Antihistamines
  • Low salt diet
  • Diuretics
  • Intratympanic steroid injection
  • Labyrinthectomy or ablation

Tinnitus

A high pitched ringing in the ears

Clinical Presentation

  • There is a high pitched ringing in my ears driving me nuts!
  • I can hear my heartbeat in my ears
    • This is pulsatile tinnitus usually caused by conductive hearing loss
  • I hear a clicking in my ears

Labs, Studies and Physical Exam Findings

  • Think about getting an MRI

Treatment

  • Prevention!!
    • Avoid excessive noise
    • Ototoxicity of some medications
  • Masking the sound with music
  • Stimulation of the auditory system

Mastoiditis

Causes

  • Secondary to otitis media

Clinical Presentation

  • Redness and swelling behind the ear
  • High fever
  • Ear pain
  • Drainage from the ear
  • Loss of hearing

Labs, Studies and Physical Exam Findings

  • Typically a clinical diagnosis
  • CT may give more information

Treatment

  • Prevention!! Treat the ear infection with antibiotics
  • IV antibiotics – Cephalosporins
  • Surgery
    • myringotomy (whole to drain the middle ear)
    • removal of the mastoid may be necessary

Hearing Impairment

  • Conductive – The problem is with conducting sound waves through the structures of the ear
  • Sensory – This is a problem with the inner ear and usually is related to loss of hair cells
  • Neural hearing loss – The problem is with damage to the vestibulocochlear nerve, CN VIII. This is the least common form of hearing loss.

Most Common Causes

  • Conductive loss
    • Cerumen impaction
    • Osteosclerosis
  • Sensory loss
    • Age related hearing loss due to loss of the hair cells
    • Head trauma
    • Significant noise exposure
  • Neural loss
    • Acoustic neuroma
    • Multiple sclerosis

Clinical Presentation

  • People keep telling me I can’t hear

Labs, Studies and Physical Exam Findings

  • Weber test – Tuning fork placed against the forehead equidistant from both ears. A patient without hearing loss will hear the tuning fork equally in both ears.
  • Rinne test – Place the tuning fork on the mastoid process and then remove it and place it next to the ear. Normal hearing or a positive test will be louder with air conduction rather than bone conduction
    • Conductive
      • Weber test – Patient will report the sound louder in the affected ear.
      • Rinne test – The sound will be louder on the mastoid with bone conduction than when near the ear. This is referred to as a negative Rinne’s test
    • Sensorineural
      • Weber test – Louder in unaffected ear
      • Rinne test – The sound will be louder off the mastoid with air conduction. This is referred to as a positive Rinne’s test
  • Formal hearing test by an audiologist

Treatment

  • Prevention
    • Avoid excessive noise
    • Quit smoking
    • Don’t put things like q-tips in your ears
  • Conductive hearing loss is the most treatable form of hearing loss
    • Removal of cerumen
  • Hearing Aid
  • Cochlear implant

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