1. Disorders of the Outer and Middle ear

2. Disorders of the Outer ear
Auricle/Pinna - malformations may be congenital or due to surgery/accident
Does not result in any significant hearing loss
Microtia
Anotia
Cosmetic surgery - otoplasty or pinnaplasty.
Different Otoscopy images
Microtia-smalling of the pinna
Anotia- no pinna

3. Disorders of the External Auditory Meatus
Atresia - Lack of canalization
can be congenital (Ex., Treacher Collins syndrome) or be due to trauma
Stenosis - Narrowing of the canal
Collapsing External Auditory Canals - seen usually in elderly clients when you place head phones for testing - Caution!

4. Disorders of the External Auditory Meatus
Foreign bodies in the canal.
All of the above conditions may result in a __________ hearing loss
Maggots in the ear canal!!!

5. Disorders of the External Auditory Meatus
External Otitis -
an infection that occurs in the skin of the external auditory Meatus
If fungal - Otomycosis
Usually caused by overuse of ear drops.
Furunculosis - infection of hair follicles (very painful!).
External otitis of any kind may lead to inflammation of the tympanic membrane
Myringitis
Swimmers ears
Myringo refers to the TM.

6. Disorders of the External Auditory Meatus
May result in a conductive hearing loss although it is hard to test these patients due to tenderness of the auricle.
Treated with systematic antibiotics and irrigating the ear canal regularly.
Growths in the Ext. Ear
includes tumors (benign or malignant) & bony growths.
Ear wax/Cerumen
Treat with cerumenolytic to soften the wax.

7. Disorders of the External Auditory Meatus
Perforations of the tympanic membrane
Could be due to trauma - usually recovery is good
Middle ear infection - TM usually recovers once the primary infection is treated.
Surgical repair of TM - Myringoplasty
Earlier muscle fascia was used to graft the TM

8. Disorders of the Middle ear
A) Otitis Media - Any infection of the mucous-membrane lining of the middle ear cleft.
Seen in 70% of children before 2 yrs of age
Predisposing factors:
Poorly functioning Eustachian tubes
Barotrauma (ex., sky diving)
Abnormal action of the cilia of the mucous membranes.

9. Disorders of the Middle ear
Anatomical deformities of the middle ear
Decreased immune functioning (ex, AIDS)
Cigarette smoke or other fumes
Infection usually starts at opening of Eustachian tube in nasopharynx.
Spreads up the tube. Tube becomes swollen and shut. Infection spreads to middle ear space.
Results in negative pressure in middle ear which can be recorded in a tympanogram.

10. Disorders of the Middle ear
Most common type of Otitis Media (OM) is Suppurative OM - results in accumulation of pus and blood in middle ear cavity.
Can be chronic or acute
Audiometric findings:
Conductive Hg loss - flat configuration- bone thresholds are normal
Word recognition = excellent.
Tympanogram = flat
Static compliance lower than normal values with normal Ear canal volume

11. Disorders of the Middle ear
Other complications of OM include
1) Facial Palsy
Facial nerve may be exposed due to OM & damage leads to paralysis of one side of face
Bells Palsy - usually spontaneously resolves.
2) Mastoiditis
Infection of the mastoid air cells.
3) Meningitis
Infection of meninges
Bells palsy- paralasis of face because of facial nerve.
Meningitis-infection of covering of the brain.

12. Disorders of the Middle ear
SURGICAL INTERVENTION
Myringotomy: insertion of PE tubes into the TM.
Mastoidectomy: scrape the mastoid bone to free it of infection.
Tympanoplasty: OM can cause ossicles to erode.
Tympanoplasty attempts to attach intact structures together. (e.g. attach malleus to stapes, in absence of incus).
A cholesteatoma is a benign growth of skin in an abnormal location such as the middle ear or petrous apex.
Mastoidectomy
Myringotomy

13. Disorders of the Middle ear
B) Eustachian tube dysfunction
Patulous Eustachian Tube - chronically open Eustachian tube
Results in autophony - “head in the barrel”
May not be identified in normal tympanometry - if suspected, perform tympanometry when the client is oral/ nasal breathing - you can notice the change in middle pressure for every breathing cycle.

14. Disorders of the Middle ear
C) OTOSCLEROSIS
70% of cases = hereditary.
Origin = bony labyrinth of inner ear. Usually not recognized clinically until it effects the middle ear.
Progressive in nature. Varying age of onset in mid-childhood to late middle adulthood.
Most common in white women (more during pregnancy or menopause).

15. Disorders of the Middle ear
Growth of spongy bone. Growths occur throughout middle ear, but often are on stapes footplate, which immobilizes it, causing a conductive hearing loss.
As disease progresses, might develop to a mixed hg loss.
Audiometric :
Low frequency air bone gap. slightly reduced bone scores, with a notch at 2000 Hz because of immobility of stapes in the oval window -Carharts notch.
Tympanogram - reduced Static Admittance.

16. Disorders of the Middle ear
Treatment: Surgical
Stapedectomy: removal of the stapes. Replacement with a prosthetic device.
If progressed and leads to a SN hearing loss, hearing aids may be an option.

17. Disorders of the Middle ear
Other disorders include - Tumors, disarticulation of ossicles, cancer, trauma.

18. Disorders of the Inner Ear

19. Introduction Constitutes the majority of hearing losses.
Mostly due to pathology at the level of the hair cells.
Abnormalities of the cochlea, unlike a conductive pathology, not only results in a reduced hearing sensitivity but may also result in difficulty understanding speech.

20. Causes of Inner Ear Disorders
Can be of endogenous (internal factors) or exogenous (external factors) in origin.
Prenatal causes
Hereditary causes - may be seen isolated or along with other abnormalities (syndromes)
Environmental causes - trauma, viral infections such as rubella, AIDS and CMV (especially the first trimester)

21. Causes of Inner Ear Disorders
Perinatal Causes
Anoxia
Premature birth (<3.5 pounds) is often associated with different kinds of abnormalities
Trauma during forced delivery or ‘forceps’ delivery

22. Causes of Inner Ear Disorders
Postnatal causes
Complications of otitis media
Meningitis
Viral infections such as measles, mumps, chicken pox etc
Bacterial infections such as syphilis (may be prenatal or acquired)
Infections of the labyrinth - Labyrinthitis
May involve both cochlear & vestibular organs.

23. Causes of Inner Ear Disorders
Toxic causes
Ototoxicity
Prolonged use of drugs, especially antibiotics.
May be cochleotoxic (such as kanamycin, neomycin, viomycin) or vestibulotoxic (streptomycin, gentamycin).
Should be avoided but if absolutely necessary, dosage should be monitored with follow-up audiometry.

24. Causes of Inner Ear Disorders
Usually the hearing loss starts at the high frequencies.
ASHA (1994) published guidelines for monitoring patients who receive ototoxic drugs
Timely identification of at-risk patients.
Pretreatment counseling & baseline audiometric measures.
Periodic evaluations to document progression of hearing loss.

25. Causes of Inner Ear Disorders
Otosclerosis
Progression of the disease may affect the oval or round window.
May be following surgery! (Iatrogenic nature)
Barotrauma
Severe, sudden changes in middle ear pressure may cause a rupture of the round or a tearing of the annulus of the oval window.
Results in a fistula & drainage of the inner ear fluids.
Sergical hearing loss is called iatrogenic “doctor caused”

26. Causes of Inner Ear Disorders
Noise Induced Hearing Loss (NIHL)
Temporary and Permanent threshold shift
Some factors aggravate the degree of loss (ex, aspirin)
Men are affected more.
Acoustic trauma - NIHL from impulsive sounds, such as explosions.
Typical bilateral audigram configuration with a notch in the range of Hz.

27. Hair cell loss seen in NIHL

28. Hair cell loss seen in NIHL

29. NIHL Occupation noise is a major cause for NIHL
Occupational Safety and Health (OSHA) (1983) has recommended a scale on which the time that worker may be safely exposed to intense sounds is decreased as the intensity of the noise is increased.
Damage risk criteria
85 dBA: 8 hrs
90 dBA: 4 hrs & every five dB increase, half the permitted time.
105 dBA: 30 mins

30. NIHL
The actual amount of hearing loss due to noise exposure depends on other factors such as genetics, disease, aging, life style off work etc.
One of the initial symptoms of NIHL (& in fact of many cochlear pathologies) is tinnitus.
Noise has also been shown to other adverse affects such as increased anxiety levels, loss of ability to concentrate, and loss of sleep.

31. Sudden Idiopathic Sensori-neural hearing loss
Refers to a hg loss, usually unilateral, that may develop over the course of a few days or occur seemingly instantaneously.
The etiology may be either viral or vascular (vasospasm).
A viral origin is suspected if recent respiratory infections were present.
If treated immediately, may be reversible.
Can be reversible if caught in time.

32. Méniére Disease Another cause of sudden unilateral hg loss.
Characterized by sudden attacks of vertigo, tinnitus, vomiting, and unilateral hearing loss.
Onset of symtoms is usually a description of fullness in one ear, followed by a low frequency roaring tinnitus, difficulty in speech recognition, violent spells of vertigo with vomiting.
The hearing loss is usually fluctuating and progressive in nature.

33. Méniére Disease Is believed to be caused due to endolymphatic hydrops
The over secretion or under absorption of endolymph.
Anxiety and allergic factors have been considered as causes.
Is more often seen in males and rarely affects children.
Méniére disease may be extremely handicapping because of the paroxysmal attacks of vertigo.

34. Méniére Disease Dilated membranous labyrinth Normal membranous
in Meniere's disease
Normal membranous
labyrinth

35. Méniére Disease
Treatment - limit fluid retention through diuretic drugs and the decrease in sodium intake in the diet.
Surgical approaches often aim at decompressing the endolymphatic sac or draining the excessive endolymph by inserting a shunt into the skull to relieve the pressure.
In extreme cases, the entire labyrinth may be surgically destroyed or auditory nerve sectioned to alleviate the vertigo and tinnitus.

36. Head Trauma
Due to head injury - The audiogram is quite similar to those due to acoustic trauma with notch in the Hz range.
Depending upon the magnitude of the injury, the tympanic membrane, middle ear structures, inner ear structures may be affected by varied extents.
The resulting loss may be severe to profound.

37. Presbycusis Hg loss due to advancing age.
The lesions are not restricted to only the cochlea but produces alteration in nearly all the auditory structures.
Usually begins at the early 60’s for males and late 60’s for females.
It is even believed that the hearing mechanism starts slowly deteriorating from birth!
App 25% in the age range 45-64yrs & 40% above 65 have some degree of hg loss.

38. Presbycusis

39. Presbycusis
Common audiological symptom - difficulty in speech recognition.
Performance improves with reduced rate of speech.
Management - Hearing aids.