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Management of middle ear disease
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ENT for GPs: the ear
Kevin Green
Consultant OtolaryngologistManchester Royal Infirmary
Hope Hospital
Topics
• Hearing loss• Dizziness• Ear infections
Hearing loss
• Congenital / acquired• Unilateral / bilateral
• Sensorineural• Conductive• Mixed
History
• Duration- acute / chronic• Communication difficulties encountered
• Associated symptoms- vertigo, tinnitus, ear pain, ear discharge
History
• Drug history- particularly antibiotics• Noise exposure• Head injury / trauma to ear• Previous medical history• Family history• Previous ear problems • Previous ear surgery
Examination
• Earssigns of acute / chronic otitis mediaglue earwaxforeign body
history dependent
Investigation
• Pure tone audiogram
• Whisper tests• Role of tuning forks
Referral?
• GPSI
• ENT
• Audiology / audiological physician
Management
• conservative• hearing aid• medical• surgical- including implantable devices
Dependent on cause
Dizziness
• affects at least 20% of population at some stage
• 75% of cases do not require further investigation
• history is crucial
10 key dizziness questions
1. Does the room spin? types of dizziness-vertigopresyncopedysequilibriumlightheadedness
10 key dizziness questions
1. Is the spinning horizontal or vertical?
2. Is it better with eyes open or closed?
3. How long does the vertigo last?
10 key dizziness questions
1. Is there a positional trigger?
2. Are deafness and tinnitus associated?
3. Are there any other symptoms?
10 key dizziness questions
1. Has there been a recent viral illness?
2. Is there a history of migraine?
3. Is there an associated aura?
Examination
• Examine the ears• Assess nystagmus• Examine cranial nerves• Assess cerebellar function
Dix-Hallpike test
Epley Manouvre
Investigations
• Pure tone audiogram
• Blood tests- only if indicated by history and examination
• Imaging?
Management
• Reassurance and explanation• Vestibular rehabilitation• Psychological support
• Specific treatment if diagnosis clear
Management
• BPPV• Acute vestibular failure / labyrinthitis /
vestibular neuronitis• Vestibular migraine
Ear infections
• Acute otitis media• Chronic otitis media
Management
• History• Examination
• Medical • Surgical
Acute otitis media 1
Acute otitis media 2
Acute otitis media 3
Chronic otitis media
• perforation• retraction pocket• cholesteatoma
• no such thing as ‘safe’ and ‘unsafe’ disease
Complications of otitis media
• Hearing loss• Vertigo• Facial palsy
• Meningitis• Brain abscess• Hydrocephalous
Perforation
Cholesteatoma
Retraction
Ear infections- which to always refer?
• Persistent infections / otalgia• Suspected cholesteatoma• With any complications of otitis media
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10