Ear Disorders

1. Ear Disorders

2. Outline of z session
• Anatomy & physiology overview of Z ear
• Common ear emergencies
– Acute Otitis Externa(EOA)
– Acute Otitis media(AOM)
– -Auricular hematoma
– -Foreign body in the ear
– -Ear drum perforation
– -Hearing loss

3. Main Components of the Hearing Mechanism:
• Outer Ear
• Middle Ear
• Inner Ear
• Central Auditory Nervous System
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The three major parts of ear

5. THE EXTERNAL EAR
• The external ear, includes the auricle (pinna) and the external auditory
canal.
• The external ear is separated from the middle ear by a disk like structure
called the tympanic membrane (eardrum).
• Auricle (Pinna)
• Collects sound
• Localization
• Amplifies sound

6. Structures of the Outer Ear
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7. THE EXTERNAL EAR
• External Auditory Canal:
– Approx. 1 inch in length
– “S” shaped
– Lined with cerumen glands
– Outer 1/3 surrounded by cartilage
– Inner 2/3’s surrounded by mastoid bone
• Mastoid Process
– Bony ridge behind the auricle
– Provides support to the external ear and posterior
wall of the middle ear cavity
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8. THE MIDDLE EAR
• The middle ear, an air-filled cavity, includes the tympanic membrane
laterally and the otic capsule medially.
• The middle ear is connected by the eustachian tube to the nasopharynx.
• The tube serves as a drainage channel for normal and abnormal
secretions of the middle ear and equalizes pressure in the middle ear
with that of the atmosphere.

9. THE MIDDLE EAR
• Tympanic Membrane
– also referred to as the eardrum
– separates the middle ear from the external
auditory canal;
– protects the middle ear
– conducts sound vibrations from the external
canal to the ossicles.
– Thin membrane
– Forms boundary b/n outer and middle ear
– Vibrates in response to sound
– Changes acoustical energy into mechanical
energy

10. THE MIDDLE EAR
• The Ossicles:
– Two small fenestrae (i.e., oval and round windows).
A. Malleus
B. Incus
C. Stapes
– Smallest bones in the body
– Acts as a lever system
– Footplate of stapes enters oval window of the cochlea
• Stapedius Muscle
– Connects stapes to wall of middle ear
– Contracts in response to loud sounds (called the Acoustic Reflex)
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11. The Ossicles:

12. THE MIDDLE EAR
• Eustachian Tube (“The Equalizer”)
– Lined with mucous membrane
– Connects middle ear to nasopharynx
– “Equalizes” air pressure
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13. THE INNER EAR
• The organs for hearing (cochlea) and balance
(semicircular canals),
• CN VII (facial nerve)
• CN VIII (vestibulocochlear nerve)
• Organ of corti
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• Cochlea
– Snail shaped organ with a series of fluid-filled tunnels
– Converts mechanical energy to electrical energy

14. THE INNER EAR
• Organ Of Corti:
–The end organ of hearing
–Contains stereocilia and hair cells.
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15. THE INNER EAR
• Hair Cells:
– Frequency specific
• High pitches= base of cochlea
• Low pitches= apex of cochlea
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16. THE INNER EAR
• Vestibular System
– Consists of three semi-circular canals
– Shares fluid with the cochlea
– Controls balance
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17. THE INNER EAR
• Central Auditory System
– VIIIth Cranial nerve or “Auditory Nerve” (vestibulocochleal nerve)
• Carries signals from cochlea to brain
• Auditory Cortex
– Temporal lobe of the brain where sound is perceived and
analyzed
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18. How Sound Travels Through The Ear...
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1. Acoustic energy, in the form of sound waves, is channeled into the ear canal by the
pinna
2. Sound waves hit the tympanic membrane and cause it to vibrate, like a drum,
changing it into mechanical energy
3. The malleus, which is attached to the tympanic membrane, starts the ossicles into
motion
4. The stapes moves in and out of the oval window of the cochlea creating a fluid
motion
5. The fluid movement causes membranes in the Organ of Corti to shear against the hair
cells
6. This creates an electrical signal which is sent up the Auditory Nerve to the brain
The brain interprets it as sound!

19. FUNCTION OF THE EARS
• Hearing
• SOUND CONDUCTION AND TRANSMISSION
• Balance and Equilibrium
• Hearing is conducted over two pathways: air and bone.
• Sounds transmitted by air conduction travel over the air-filled external and middle ear through
vibration of the tympanic membrane and ossicles.
• Sounds transmitted by bone conduction travel directly through bone to the inner ear, bypassing
the tympanic membrane and ossicles.
• Normally, air conduction is the more efficient pathway.
• However, defects in the tympanic membrane or interruption of the ossicular chain disrupt normal
air conduction, which Results in a conductive hearing loss.

20. Assessment
• Inspection & palpation of the external ear
• Otoscopic examination
• EVALUATION OF AUDITORY ACUITY
– Whisper Test
– Weber Test
– Rinne Test

22. Whisper Test
• To exclude one ear from the testing, the examiner covers the untested
ear with the palm of the hand.
• Then the examiner whispers softly from a distance of 1 or 2 feet from the
unoccluded ear and out of the patient’s sight.
• The pt with normal acuity can correctly repeat what was whispered.

23. Weber Test
• uses bone conduction to test lateralization of sound.
• A stem of vibrating tuning fork is placed on the pt’s head or forehead.
• the sound is heard:
– equally in both ears – normal hearing.
– better in the affected ear – conductive hearing loss.
– lateralizes to the better-hearing ear – sensorineural hearing loss.

24. Rinne Test
• is method of shifting the stem of a vibrating tuning fork b/n two positions:
– 2 inches from the opening of the ear canal – for air conduction and
– against the mastoid bone – for bone conduction
• useful for distinguishing b/n conductive and sensorineural hearing losses.
• Normally, sound heard by air conduction is audible longer than sound heard
by bone conduction.
• With a conductive hearing loss
– bone-conducted sound is heard as long as or longer than air-conducted sound.
• with a sensorineural hearing loss,
– air-conducted sound is audible longer than bone-conducted sound.

26. Hearing Loss
• Conductive hearing loss –
– from an external ear disorder, such as:
• impacted cerumen, or
• a middle ear disorder, such as
– otitis media or
– otosclerosis
• A sensorineural hearing loss –Involves damage to:
– the cochlea or
– vestibulocochlear nerve
• Mixed hearing loss and functional (psychogenic) hearing loss also may
occur.

27. Clinical Manifestations
• Early manifestations of hearing impairment and loss may include:
– tinnitus,
– increasing inability to hear in groups, and
– a need to turn up the volume of the television.
• Hearing impairment can also trigger changes in attitude, the ability to
communicate, the awareness of surroundings, and even the ability to
protect oneself, affecting the person’s quality of life.

28. Risk factors for hearing loss
• Family hx of sensorineural impairment
• Congenital malformations of the ear
• Use of ototoxic medications (e.g., gentamicin, loop diuretics)
• Recurrent ear infections
• Bacterial meningitis
• Chronic exposure to loud noises
• Perforation of the tympanic membrane

29. Prevention
• Many env’tal factors have an adverse effect on the auditory system and,
with time, result in permanent sensorineural hearing loss.
• The most common is noise.
• There are no medications that protect against noise-induced hearing
loss; hearing loss is permanent b/c the hair cells in the organ of Corti are
destroyed.
• Ear protection against noise is the most effective preventive measure
available.

30. 1. PERFORATED EARDRUM
• results from a rupture of the tympanic membrane.
• may cause hearing loss.
• Causes
– Trauma is the usual cause
• insertion of a sharp object
– deliberate or accidental
– e.g., a hair pin
• a sudden excessive change in pressure from:
– Explosion- loud noise
– a blow to the head,
– Flying with a severe cold due to changes in air pressure and blocked eustachian tubes resulting
from the cold.
– Diving
• surgery
– Infection – Otitis media
– Foreign body

31. 1. PERFORATED EARDRUM….
• Risk factors for perforated TM
– The eardrum can become damaged by a direct injury.
– It is possible to perforate the eardrum:
• with a cotton-tipped swab or another foreign object
• by hitting the ear with an open hand
• after a skull fracture
• after a loud explosion or other loud noise
• Presentation
– sudden onset of a severe earache and bleeding from the ear, usually the
first Symptoms.
– The pt may also report Mild hearing loss, tinnitus, and vertigo.
– signs of hearing loss such as the patient turning his unaffected ear toward
you when you speak.

32. 1. PERFORATED EARDRUM ….
• Diagnostic tests
– An otoscopic examination confirms the Dx
– Audiometric testing
– X-rays of the temporal lobe and skull
• used to determine an associated fracture, especially when a bad fall caused
the perforation.
– Culture of the drainage can identify a causative organism, if
infection caused the rupture.

33. 1. PERFORATED EARDRUM ……
• Management
– usually may heal spontaneously in a few weeks or may take up to a few months.
– If any crust remains on the tympanic membrane after 2 wks, an ear specialist removes it under
magnification to see whether healing is complete.
– Some perforations require intervention.
– If necessary, Tx includes:
• local and systemic Antibiotics therapy and
• analgesics for pain
– Surgical closure – a myringoplasty or tympanoplasty
• for a large perforation with uncontrolled bleeding
• to approximate the ruptured edges.
• may take the form of a paper patch to promote healing
– wearing an ear plug –
• If severe ruptures
• to prevent water contact with the ear drum
• Complications
– Infection – mastoiditis and meningitis
– Permanent hearing loss; if the injury is not treated.

34. External Ear Injuries
• Associated Clinical Features
– may be open or closed.
– Blunt – may cause a hematoma (otohematoma) of the pinna
which, if untreated, may result in cartilage necrosis and chronic
scarring or further cartilage formation and permanent deformity
("cauliflower ear")
– Open injuries include
• lacerations (with and without cartilage exposure) and
• avulsions

35. 4. Auricular Hematoma
• Ch’zed by
– swelling,
– discoloration,
– ecchymosis, and
– flocculence.
• Immediate incision and drainage or
aspiration is indicated, followed by an ear
compression dressing.

36. 4. Auricular Hematoma
• collection of blood b/n the cartilage and its perichondrium.
• a mass of usually clotted blood that occurs in a tissue, organ or body space as
a result of a broken blood vessel, in this case, on the auricle.
• is a Cxn results from direct trauma to the anterior auricle and is a common
facial injury in wrestlers.
• prevents proper oxygenation of the cartilage, resulting in necrosis and a
cauliflower ear.

37. 4. Auricular Hematoma
Normal Auricle
Auricular Injury

38. 4. Auricular Hematoma
• Causes
– Auricular hematomas can occur due to blunt trauma to the auricle; commonly among
athletes such as football players or wrestlers.
– The underlying pathophysiology of the hematoma is due to the separation of the
perichondrial tissue from the cartilage in the ear.
– This causes tearing of the blood vessels in the tissue.
 Diagnosis
 History
 Visual Inspection
 Report of pain
 Complications:
 reaccumulation of the hematoma
 the risk of infection – perichondritis
 Cauliflower ear
 disfiguring cauliflower ear or
cartilage necrosis
 Management
 Incision and drainage or Needle aspiration
 compressive dressing
 antibiotics that cover common skin flora for 7-10 days.

39. 4. Auricular Hematoma
• Management
– Incision and drainage or Needle aspiration
– compressive dressing
– antibiotics that cover common skin flora for 7-10 days.
Needle aspiration, incision and drainage
compressive dressing

40. Cauliflower Ear
• Repeated trauma to the pinna or
undrained hematomas can result in
cartilage necrosis and subsequent
deforming scar formation.

41. Avulsed Ear
• This ear injury, sustained in a fight, resulted when the
pinna was bitten off.
• Plastic repair is needed.
• The avulsed part was wrapped in sterile gauze soaked
with saline and placed in a sterile container on ice.
• Differential Diagnosis
– These injuries are normally self-evident.
– Pinna hematomas and contusions can sometimes be
difficult to distinguish, but flocculence is the hallmark
of the hematoma.

42. Avulsed Ear
• ED Treatment and Disposition
– Laceration should carefully examined for cartilage
involvement; if this is present,
• copious irrigation,
• Closure - primary closure of the overlying skin using small
number absorbable stitch
• compressive dressing, and
• postrepair oral antibiotics covering skin flora are indicated.
– In case of avulsion injuries;
• the avulsed part should be cleansed, wrapped in saline-
moistened gauze, placed in a sterile container, then placed
on ice to await reimplantation by ENT specialist.
– Complex lacerations or avulsions normally require ENT or
plastic surgery referral.
– refer to ENT or plastic surgery with in 24 hrs.

43. THANK YOU!!