– History –
- CC: most likely will present as hearing loss:
- Site: uni\bi-lateral? Alternates?
- Onset: first time? When? What were you doing (after loud noise)? Gradual\sudden? Continuous\intermittent? Getting better\worse?
- Duration: how long does each episode last? How frequent?
- Relieving\aggravating factors:
- Characteristics: background noises? Quiet settings? Speech discrimination?
- Severity: Interfering w\ ADL?
- Associated sx:
- Constitutional: fever, fatigue, wt loss, loss of appetite, night sweats, chills?
- Ear: ear pain, discharge, tinnitus, ringing, popping sensation?
- Inner ear: vertigo, dizziness, balance problems, N\V?
- Eye: eye pain, blurred\double vision, lacrimation?
- Nose: obstruction\breathing difficulty, stuffed nose, snoring, epistaxis, discharge, loss of smell?
- Sinusitis: headache, facial pain\numbness, pressure, recent flu\ear infection?
- Throat: difficulty swallowing, speech problems, loss of taste?
- If peds: any delay in development (speech, motor), infections during pregnancy, neonatal (sepsis, seizures, jaundice), head trauma?
- Chronic ds (HTN, DM, DLP)
- Neurological (meningitis, MS)
- Autoimmune ds
- Medications: abx, aspirin, diuretics, chemo
- Surgery (Ear procedures\interventions; wax removal), hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation (pilot, work in “loud noises” -> motorbikes, airports, factories), marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx
- Diet, exercise
- “Ear-specific activities”; Diving? Swimming? Excessive use of Q-tips\headphones?
– Ear Physical Exam –
- WIPE, blah blah 🙂
- “Take vital signs”
- Proper position and exposure of both ears
- General inspection of the pt and surroundings
- Mention that you should do a full head and neck exam, but for now, you’ll focus on the ears
1. External Inspection
- Pinna (auricle): shape, anomalies, deformities
- Pre-auricular: pits, sinuses, fistula, bony outgrowths
- Post-auricular: scars, redness
- Symmetry, swellings
- Discharge, wax
3. Rinne and Weber test: using 512 Hz tuning fork
- Check the pic at the end for interpretation of the results
4. Otoscope: “start with the good ear”:
- Tell the pt that they might feel some discomfort, but they should let you know if the feel any pain!
- Test the light, use the largest speculum that will comfortably fit, hold it like a pen
- Pull the pinna upwards and outwards to straighten the auditory canal
- As you’re going into the canal, comment on:
- Foreign bodies
- Tympanic membrane; inspect all four quadrants and comment on:
- Light reflex
- Mobility: by using a pneumatic otoscope (mention only)
- “Normal translucent pale tympanic membrane, in neutral position; not bulging nor retracted, no signs of (drainage, perforation, scarring, cholesteatoma), with intact light reflex”
5. To complete:
- Full exam of: head and neck, ENT, eyes (nystagmus), CN (esp facial nerve), and LN
– Differential Diagnosis –
- External ear: impacted cerumen, foreign body, otitis externa, osteoma, exostosis
- Middle ear: AOM, OME, TM perforation, ossicular fixation\discontinuity, otosclerosis, cholesteatomas
- Congenital: hereditary (non-\syndrome associated), intrauterine infections, teratogens
- Acquired: presbycusis (aging), noise-induced, sudden SNHL, ototoxicity, Meniere’s, vestibular schwannoma\acoustic neuroma, infections (meningitis, labyrinthitis), temporal bone trauma
- Sudden SNHL is defined as: happens in < 3 days, in 3 consecutives frequencies, drop in > 30 dp
– Investigations –
- Imaging: head CT, MRI
– Management –
- Conservative -> medical -> surgical
- Sudden SNHL: steroids