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99 Cards in this Set
- Front
- Back
What is a "phase lead"?
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Eye velocity is greater than head velocity
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When is it normal to have a phase lead?
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at low frequencies
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What does an abnormal phase lead at low frequency suggest?
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Peripheral lesion
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What does an abnormal phase lead at all frequencies suggest?
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Central lesion
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What is "phase lag"?
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Head velocity is greater than eye velocity
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What does occulomotor testing evaluate?
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Eye movement in the absence of vestibular stimulation
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Three components to occulomotor testing?
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1. Saccades 2. Smooth pursuit 3. Optikokinetic nystagmus
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What is posturography?
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Evaluates: 1. Balance 2. Visual, proprioceptive and vestibular signal processing
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What are the 6 testing conditions for posturography?
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1. eyes open, support stable, visual field fixed 2. eyes closed, support stable, visual field fixed 3. eyes open, support stable, visual field sway referenced 4. eyes open, support tilted, visual field fixed 5. eyes closed, support tilted, visual field fixed 6. eyes open, support tilted, visual field sway referenced
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What does ENG (electronystagmography) incorporate?
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Nystagmus VOR/HSCC Oculomotor testing
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What degree of hearing loss seen in external ear atresia?
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40-65 dB air-bone gap
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Which precedes first? Microtia repair or atresia repair?
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Microtia repair - preserve soft tissue and provide a thin envelope free of scar to receive cartilage framework
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What three syndromes is Atresia associated with?
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1. Treacher-Collins Syndrome 2. Goldenhar syndrome 3. Hemifacial microsomia
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What is atresia?
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Atresia is absence or underdevelopment of the ear canal and middle ear structures.
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What are two non-surgical options for atresia?
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BAHA Early amplification for bilateral disease
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9 Jahrsdoerfer criteria:
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1. Stapes - 2 2. Oval window open 3. Round window open 4. Middle ear space 5. Pneumatized mastoid 6. Normal CNVII 7. Malleus and incus (minus 1) 8. Incus and stapes 9. External ear 5 or less - poor 6 - marginal 7 - fair 8 - good 9 - very good 10 - excellent
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What percentage of aural atresia patients are candidates for surgery?
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0.5
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For Microtia what are the common demographics?
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Right > Left Unilateral > Bilateral (4:1) Males > Females (2.5:1)
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What is one classification scheme for microtia?
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Type I - mild deformity (lop ear, cup ear) Type II - all structures present, but this is a tissue deficiency Type III - classic microtia - few recognizable landmarks - lobule present often and anteriorly displaced
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Best time to reconstruct ear microtia?
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Between 6 and 10
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At what age does ear reach 85% of adult size?
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5
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4 steps of reconstruction for microtia?
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1. Auricular reconstruction 2. Lobule transposition 3. Ear elevation/formation of postauricular crease 4. Tragal and concha bowl reconstruction
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Treatment for ear frostbite?
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Rapidly rewarm what saline soaked gauze (38-42 degrees) No not debride - wait several weeks for demarcation Treat with topical antibiotics, ointment and analgesics
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What are the most common bacterial and fungal organisms seen with otitis externa?
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Bacterial: - Staphylococcus aureus - Pseudomonas aeruginosa Fungal: - Aspergillus niger
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Treatment for bacterial otitis externa (4)
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1. neomycin 2. polymyxin 3. ciprofloxacin 4. ofloxacin +/- steroids
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Treatment for otomycosis (6)
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1. Merthiolate (thimerosal) 2. Acetic Acid 3. Isopropyl alcohol 4. Gentian Violet 5. Nystatin 6. Azole
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What is MOE? Who gets it?
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Malignant otitis externa Diabetic and immunocompromised patients
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What bacteria is most likely the source for MOE
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Pseudomonas aeruginosa
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How does infection spread to the skull base with MOE?
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Fissures of Santorini
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How is MOE diagnosed radiographically? Followed radiographically?
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Diagnosed: Technetium 99 Followed: Gallium CT can confirm osteomyelitis, but 30-50% of trabecular bone of the mastoid must be destroyed before obviously positive
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Treatment of MOE?
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Antipseudomonal antibiotics for 3-4 months and surgical debridement
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What are exostoses?
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Broad-based bony lesions (multiple) of EAC secondary to cold water exposure
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What do you operate on exostoses?
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CHL or cerumen impaction
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What is an osteoma?
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Benign pedunculated bony neoplasm of the anterior EAC
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What do you operate on an osteoma?
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CHL or cerumen impaction
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4 nerve sources of referred otalgia?
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1. CN V - oral cavity, mandible, TMJ, palate preauricular region 2. CN VII - EAC, post auricular region 3. CN IX - tonsil, tongue base, nasopharynx, eustachian tube, pharynx (via Jacobson nerve) 4. CN X - hypopharynx, larynx, trachea (via Arnold nerve)
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What is Jacobson's Nerve?
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Also called tympanic nerve (branch of IX) It arises from the petrous ganglion, and ascends to the tympanic cavity through the fossula petrosa/tympanic canaliculus, on the under surface of the petrous portion of the temporal bone on the ridge which separates the carotid canal from the jugular fossa. In the tympanic cavity it divides into branches which form the tympanic plexus and are contained in grooves upon the surface of the promontory
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What is Arnold's Nerve?
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Arises from the jugular ganglion, and is joined soon after its origin by a filament from the petrous ganglion of the glossopharyngeal; it passes behind the internal jugular vein, and enters the mastoid canaliculus on the lateral wall of the jugular fossa. Traversing the substance of the temporal bone, it crosses the facial canal about 4 mm. above the stylomastoid foramen, and here it gives off an ascending branch which joins the facial nerve. The nerve reaches the surface by passing through the tympanomastoid fissure between the mastoid process and the tympanic part of the temporal bone, and divides into two branches: 1. Joins the posterior auricular nerve. 2. Skin of the back of the auricula and to the posterior part of the external acoustic meatus.
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Components of Jacobson's nerve
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1. Sensory fibers supply the middle ear. 2. Parasympathetic secretory fibers serve the parotid gland. The secretory fibers enter the otic ganglion. 3. Sympathetic fibers (for the large deep petrosal nerve) through communication with the carotid plexus
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Where is the most common source for a CSF otorrhea?
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Mastoid tegmen secondary to meningoencephalocele
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What % seal spontaneously? Why?
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90% Middle fossa close fast - rich arachnoid mesh leads to fibrosis Posterior fossa leaks close more slowly - little arachnoid
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What are the indications for repair of a CSF otorrhea?
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1. Persistent leak for >2 weeks despite bed rest with head elevation 2. Recurrent meningitis 3. Brain or meningeal herniation 4. Penetration of brain by bony spicule
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Two types of cholesteotoma?
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Congenital and Acquired
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How does a congenital cholesteotoma usual appear?
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"pearl" in middle ear space
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Where does a congenital cholesteotoma develop from?
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Embryonic rest of epithelium in anterior-superior quadrant
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Where does an acquired cholesteotoma usually develop from?
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Retraction pocket of pars flaccida into Prussack space (between pars flaccida and malleus neck)
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What is the most common location for a cholesteotoma?
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Around long process of incus and stapes suprastructure
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What are common areas for residual disease following surgery for a cholesteotoma?
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1. Sinus tympani 2. Facial recess 3. Anterior epitympanum
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What is the most common complication of a cholesteotoma?
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Erosion of horizontal semicircular canal
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What test should you perform if you suspect semicircular canal fistula?
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Fistula test
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What is a positive fistula test?
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Hennebert sign Positive pressure causes ampulopetal stimulation of the horizontal SCC with horizontal nystagmus to the ipsilateral side With negative pressure nystagmus reverses
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Which is the most commonly eroded ossicle?
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long process of the incus
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Which is the most commonly injured portion of the facial nerve during surgery?
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Tympanic portion of the facial nerve - confusing anatomy and frequent nerve dehiscence
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How do you treat an oval or round window fistula?
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Patched with fascia and packed
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What are some complications of cholesteotoma? (besides horizontal SCC fistula)
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1. extradural or perisinus abscess 2. serous or suppurative labyrinthitis 3. Meningitis secondary to tegmen erosion 4. Epidural, subdural or parenchymal absces 5. Sigmoid sinus thrombosis, phlebitis 6. Subperiosteal abscess, Bezold abscess due to erosion of mastoid cortex 7. Recurrence
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What are the treatment options for cholesteotoma?
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Canal wall down mastoidectomy Canal wall up mastoidectomy
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What are the indications for a canal wall down mastoidectomy?
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1. Only hearing ear 2. Contracted mastoid 3. Labyrinthine fistula 4. EAC erosion
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What are the reasons for a persistently draining mastoid cavity?
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1. Inadequate meatoplasty 2. Dependent tip cell 3. High facial ridge 4. Exposed eustachian tube
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When don't you remove all the cholesteotoma matrix?
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1. matrix is adherent to dura 2. matrix is adherent to superior semicircular canal 3. matrix is adherent to FN 4. matrix extends into mesotympanum covering the footplate
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Which muscle opens the eustachian tube?
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Tensor Veli Palatini
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What is the Teunissen classification system for ossicular abnormalities?
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Class I - congenital stapes fixation Class II - stapes ankylosis with ossicular abnormality Class III - ossicular abnormality with mobile foot plate, ossicular discontinuity, or epitympanic fixation Class IV - aplasia or dysplasia of round or oval window +/- crossing facial nerve or persistent stapedial artery
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What are the most common bacteria that cause acute otitis media?
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Streptococcus pneumoniae (40%) Haemophilus influenzae (30%) Moraxella catarrhalis (20%)
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First line antibiotic for acute otitis media?
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amoxicillin
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Define recurrent acute otitis media?
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>3 episodes in 6 months or >4 episodes in 1 year
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Define chronic otitis media with effusion?
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(OME) - serous middle ear effusion for at least 3 months
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What is chronic suppurative otitis media?
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infected otorrhea through TM perf or typanostomy tubes
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Organisms that cause chronic suppurative otitis media?
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Pseudomonas aeruginosa Staphylococcus aureus Proteus
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Treatment for chronic suppurative otitis media?
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Antipseudomonal penicillin Cephalosporin Ear gtts and quinolone (adults)
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Risk factors for acute otitis media?
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day care tobacco smoke upper respiratory infection lack of breast feeding genetics immunodeficiency birth defects (cleft palate, etc)
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Most common cause of vertigo in children?
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Otitis Media
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What are five complications of otitis media?
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1. Otorrhea 2. Mastoiditis (subperiosteal abscess, Bezold abscess) 3. Petrous apicitis 4. Facial nerve paralysis 5. Intracranial complications (meningitis, cerebral abscess, sigmoid sinus thrombosis)
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What is a Bezold abscess?
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Abscess in digastric groove of SCM
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Most common complication of otitis media?
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mastoiditis
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What is Gradenigo syndrome?
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otorrhea, retro-orbital pain, lateral rectus palsy
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Why do you get a VI palsy with petrous apicitis
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Irritation to VI within Dorello canal
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Common bacterial agents associated with meningitis as a complication from otitis media?
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S. pneumoniae H. influenzae
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Clinical findings with sigmoid sinus thrombosis
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1. Picket fence fevers 2. Cannonball chest infiltrates on CXR 3. Edema and tenderness over mastoid cortex (thrombosis of mastoid emissary vein)
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What is Griesinger sign?
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Edema and tenderness over mastoid cortex (thrombosis of mastoid emissary vein)
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What is the likely diagnosis of a patent with Jacksonian epilepsy, hemiplegia and otitis media?
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subdural abscess
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Chance of having residual middle ear effusion after treatment of ottis media?
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70% @ 2 weeks 40% @ 4 weeks 20% @ 2 months 10% @ 3 months
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Most common cause of conductive hearing loss in people 15 to 50?
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Otosclerosis
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Prevalence of otosclerosis?
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Caucasian>Asian>African American Female>Male (2:1)
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What elevated antibody is seen in perilymph in otosclerosis
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anti-measles virus IgG
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Genetic inheritance of otosclerosis?
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Autosomal dominant with 40% penetrance
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What conditions hasten the appearance of otosclerosis?
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Pregnancy and menopause
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How often is otosclerosis seen bilaterally?
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0.85
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Where does disease begin with otosclerosis?
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Region anterior to oval window niche (fissula ante fenestrum)
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What are the "Blue Mantles of Manasse"?
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Finger-like projections of blue otosclerotic bone around normal vasculature
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What is Schwartze sign?
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pinkish hue over promontory and oval window niche (thickened mucosa)
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Results of acoustic reflex testing in patients with otosclerosis:
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Early - increased compliance at beginning and end of stimulus Late - decreased or absent
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What do you see on audiometry in patients with otosclerosis?
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Air-bone gap (not usually greater than 50 dB) with Carhart notch
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What can you see on CT in patients with otosclerosis?
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"double ring" "halo sign"
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Treatment of otosclerosis?
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1. Consider hearing aid first 2. Stapedectomy (30-40 db air-bone gap) 3. Amplification if CHL >45 dB and has high frequency sensorineural hearing loss (think cochlear otosclerosis)
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What findings should make you think of cochlear otosclerosis?
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CHL >45 dB and has high frequency sensorineural hearing loss
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Sudden decrease in hearing following an initial good result from stapedectomy?
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Incus erosion PLF - most common cause of cochlear hearing loss following surgery
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What causes delayed FN paralysis 5-7 days after stapedectomy? Treatment?
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Consider vial infection Treat with steroids, antivirals
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What pathology should you consider if a patient has delayed vertigo following stapedectomy?
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PLF Labyrinthitis Prosthesis that is too long
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What are the features of tuberculosis in the middle ear?
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1, Grey TM with small perforations 2. Mucoid, clear drainage 3. Incus resorption, denuded malleus head 4. SNHL
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What are 4 vascular anomalies found in the middle ear?
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1. Dehiscent carotid - pulsatile mass in anteroinferior quadrant 2. High-riding jugular bulb - bluish mass in posterointerior quadrant 3. Persistent stapedial artery 4. Glomus tympanicum
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