ENT update on common ear problems The Spire Hospital Leeds ENT update on common ear problems seen in primary care, including hearing loss The Leeds Teaching Hospitals NHS Trust Gerard Kelly MD MEd FRCS(Ed) FRCS(ORL-HNS) ENT surgeon 20th April 2017

aims get an overview of audiology relevant to primary care improve our knowledge common ear pathologies

objectives define a hearing loss with reference to pure tone thresholds identify symbols on an audiogram diagnose otitis externa and chronic otitis media from a picture or scenario list pros and cons of treatment for AOM list symptoms of a ear condition plan treatment for COM and otitis externa list referral criteria for asymmetric hearing losses

Ear 6 symptoms otorrhoea otalgia itch hearing tinnitus balance

what is normal, what is poor hearing? otology and audiology what is normal, what is poor hearing?

otology and audiology what is normal, what is poor hearing? pure tone average (dB) 0-20 normal 20-40 mild 40-70 moderate 70-95 severe 95+ profound British society of audiology, 2011

otology and audiology Browning, Clinical otology & audiology

audiology Browning, Clinical otology & audiology

otology and audiology Swan 1984

otology and audiology Swan 1984

an audiogram

description?

description? right high tone sensorineural hearing loss

asymmetric audiograms what is the threshold to refer?

asymmetric audiograms non ear symptoms trigeminal, facial or lower cranial nerve symptoms should have a scan 10% will have significant abnormality needs MR scan Cheng TM, Cascino TL, Onofrio BM. Comprehensive study of diagnosis and treatment of trigeminal neuralgia secondary to tumors. Neurology (1993);43(11):2298-302.

normal audiograms vertigo in isolation is rare sign of acoustic neuroma in a series of 1,358 patients none had acoustic neuromas no MR scan Gandolfi MM, Reilly KR, Galatioto J, Judson RB, Kim AH. Cost-effective analysis of unilateral vestibular weakness investigation. Otol Neurotol (2015);36(2):277-81.

sudden unilateral loss MR scans show abnormality in 10% case CPA angle lesion, vascular lesion or MS needs MR scan Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. (2012);146(3 Suppl):S1-35.

unilateral tinnitus unilateral tonal tinnitus with symmetric hearing represents less than 1% of all acoustic neuromas (and they tend to be smaller than average if present) no MR scan Chatrath P1, Frosh A, Gore A, Nouraei R, Harcourt J. Identification of predictors and development of a screening protocol for cerebello-pontine lesions in patients presenting with audio-vestibular dysfunction. Clin Otolaryngol (2008);33(2):102-7.

asymmetric audiograms Unilateral sensorineural hearing loss (all thresholds <=25dB on good side) Intra-aural asymmetry at two neighbouring frequencies of at least 15dB. Asymmetric sensorineural hearing loss (not all thresholds <=25dB on good side) Intra-aural asymmetry at two neighbouring frequencies of at least 20dB.

asymmetric audiograms 1 normal ear, 2 frequencies, difference of 15dB no normal ear, 2 frequencies, difference of 20dB

1 normal ear, 2 frequencies, difference of 15dB no normal ear, 2 frequencies, difference of 20dB so, here, no normal ear, 2 frequencies, R 30 & 45dB at 4 & 8kHz L 45 dB & 60dB, so 15dB difference, so no referral, no MR scan

1 normal ear, 2 frequencies, difference of 15dB no normal ear, 2 frequencies, difference of 20dB so, here, R normal ear, 2 frequencies, R 20 & 15dB at 4 & 8kHz L 40 dB & 25dB, so 20dB difference but only at one frequency (4kHz), so no referral, no MR scan

1 normal ear, 2 frequencies, difference of 15dB no normal ear, 2 frequencies, difference of 20dB so, here, R normal ear, 2 frequencies, R 20 & 20dB at 4 & 8kHz L 35 dB & 35dB, so 15dB difference at two frequencies (4 & 8kHz), so referral and MR scan

1 normal ear, 2 frequencies, difference of 15dB no normal ear, 2 frequencies, difference of 20dB so, here, no normal ear, 2 frequencies, R 30 & 45dB at 4 & 8kHz L 50 dB & 65dB, so 20dB difference at 2 frequencies (4&8kHz), so referral and MR scan

Large perforation hearing level?

Damaged middle ears % perf Mean air bone gap (dB) 0-15 10 16-64 20 0-15 10 16-64 20 65-100 30 Loss not related to the site of the perforation Austin 1976

Acute otitis media treatment?

Antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia

acute otitis media and antibiotics

Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days.

Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain.

Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics.

Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears.

Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears. For most other children with mild disease, an expectant observational approach seems justified. We have no data on populations with higher risks of complications.

Case

Case 4 year old boy hearing loss performing poorly at school recurrent otalgia

Hearing testing

Management nothing otovent grommets (referral)

Case

64 year old woman presents 2 day history of hearing loss in the right ear

64 year old woman presents 2 day history of hearing loss in the right ear what do you ask? ear symptoms, vascular risks

sudden sensorineural loss definition at least 30dB hearing loss over 3 contiguous frequencies a period of a few hours to 3 days

sudden sensorineural loss incidence 5 – 20 per 100 000 people per year 1 in 10 000 people per year 0.01% people per year

sudden sensorineural loss typical patient 40 – 50 years M=F 30% have balance symptoms

sudden sensorineural loss aetiology?

sudden sensorineural loss Infection Bacterial postmeningitis, bacterial labyrinthitis, syphilis Viral mumps, cytomegalovirus Inflammation Autoimmune Cogan’s syndrome, systemic lupus erythematosus Multiple sclerosis Trauma Temporal bone fracture Acoustic trauma Perilymph fistula Tumor CPA tumour Temporal bone metastasis Carcinomatosis meningitis Toxins Aminoglycosides Aspirin Vascular Thromboembolism Macroglobulinemia, sickle cell disease, post-CABG, vasculitides

stroke and SSNHL Stroke. 2008 Oct;39(10):2744-8. Epub 2008 Jun 26. Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study. Lin HC, Chao PZ and Lee HC CONCLUSIONS: Our findings suggest that SSNHL can be an early warning sign of impending stroke. We suggest that SSNHL patients should undergo a comprehensive hematologic and neurological examination to help clinicians identify those potentially at risk for stroke developing in the near future.

sudden SNHL Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study. Lin HC, Chao PZ and Lee HC Treatment? most would treat as for a sudden idiopathic facial nerve paralysis (Bell’s palsy) with steroids eg 40mg prednisolone