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EAR : 

EAR Ear is the organ that detects sound. It is not only acts as a receiver for sound, but also plays a major role in the sense of balance and body position. Therefore, the ear is part of the auditory system.




EXTERNAL EAR The external ear consists – Pinna and, External auditory canal or Meatus The pinna is cartilaginous and is covered with pericondrium and skin, forming the helix and antihelix. The external auditory canal has an outer cartilaginous and an inner bony component. The skin overlying the external auditory meatus contains modified sebaceous glands, which produce wax (cerumen). Cerumen helps to protect the tympanic membrane.


MIDDLE EAR Air filled chamber in the temporal bone is called middle ear. The middle ear consists - Tympanic membrane or Eardrum, Auditory ossicles – Malleus, Incus and, Stapes. Tympanic cavity and, Eustachian tube. The opaque or semitranslucent eardrum is tympanic membrane. It permits visualization of the middle ear and separates the external ear from the middle ear. The pars tensa, the lower part of the eardrum, is formed from an outer layer of skin, a middle layer of fibrous tissue and an inner layer of middle ear mucosa. It is attached to the annulus, a fibrous ring that stabilizes the drum to surrounding bone. The pars flacida, the upper part of the eardrum. Auditory ossicles are small connecting bones that transmit sound across the middle ear from the tympanic membrane to the cochlea. The bony cartilaginous passage way between nasopharynx and middle ear is called eustachian tube. It’s function is to equalizes the pressure


INNER EAR The inner ear has two portion – cochlea and, semicircular canal. The spiral organ of hearing is called cochlea. It helps to converts sound energy into digital nerve impulses that are transmitted by cochlear (eighth cranial) nerve to brainstem and hence to the auditory cortex. The organ of corti lie within the cochlea which contains hair cells that detect frequency – specific sound energy. The semicircular canal maintain equilibrium and perform vestibular function.




SYMPTOM OF EAR DISEASE OTALGIA Otalgia is defined as earache or ear pain. It is of two types:- a) Primary otalgia= Pain that originates within the ear. b) Referred otalgia= Pain that originates outside the ear. Typical source of primary otalgia are:- a) External ear pain – Mechanical such as foreign bodies such as hairs, insects etc. Iinfective such as staphylococcus, pseudomonas etc. b) Middle ear pain – Mechanical such as Barotrauma, Eustachian tube obstruction leading to Acute Otitis Media Infective such as Mastoiditis . Ear pain can be referred pain in 5 main ways:- => Trigeminal nerve (cranial nerve V). Rarely, trigeminal neuralgia can cause otalgia. => Facial nerve (cranial nerve VII). This can come from the teeth, the temporomandibular joint or the parotid gland. => Glossopharyngeal nerve (cranial nerve IX). This comes from the oropharynx and can be due to pharyngitis or tonsilitis or to carcinoma of the posterior 3rd of the tongue. => Vagus nerve (cranial nerve X). This comes from the laryngopharynx or oesophagus. => 2nd and 3rd cervical vertebrae. This ear pain is therefore postural.

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CONTD………… 2. OTORRHOEA Otorrhoea is defined as discharge from the ear and may originate from the ear canal or middle ear. It is often associated with hearing loss. A profuse mucoid discharge with pulsation suggests a tympanic membrane perforation. Persistent discharge suggests chronic otitis media. Cholesteatoma usually begins with tympanic membrane retraction and blockage of desquamated skin from the drum and external meatus. The infection may spread outside the temporal bone, even causing meningitis or intracranial abscess, cranial trauma followed by bleeding and leakage of cerebrospinal fluid suggests fracture of the base of the skull.

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CONTD………… 3. HEARING LOSS Hearing loss is the total or partial inability to hear sound in one or both ears. Classification :- a) Conductive deafness, b) sensorineural deafness # sensory deafness and, # nervous deafness c) Mixed deafness, d) congenital deafness and, e) acquired deafness Degree of hearing loss- based on WHO:- Mlid HL(<40 DB) Middle HL(41-55 DB) Middle severe HL(56-70 DB) Severe(71-90 DB) Profound HL(>90 DB)

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CONTD……… CONDUCTIVE HEARING LOSS Pathogen- infection, trauma, EAC obstruction( foreign body, cerumen, tumour) Location- deformation of auricle(3 DB) Stenosis and austrsia of EAC(45-60 DB) Dysfunction of eustachian tube(60 DB) Diagnosis-tuning fork:- Rinne test= negative Wiber test= lesion side sensorineural test= prolongation PTA:- Bone threshold is normal Air threshold is 25-60 DB Image study Intervention- Surgery and, Hearing aid. SENSORINEURAL HEARING LOSS Defination- Damage of hair cell, stria vacular, spinal ganglion neuron, auditory nerve and central auditory system. Pathogen- Congenital hearing loss:- hereditary hearing loss and, non-hereditary hearing loss. Acquired hearing loss:- virus or bacteria induced hearing loss, drug induced hearing loss, trauma induced hearing loss, noise induced hearing loss etc. Intervention- medical therapy, hypobaroxygen, hearing aid, auditory speech training.

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CONTD…………. 4. TINNITUS Tinnitus is a ringing sound or noise in the ear in the absence of an appropriate auditory stimulus. Types- Subjective, which can only be heard by the patient, Objective, which can even be heard by the examiner with the use of a stethoscope. Causes- loud noise exposure Meniere’s syndrome Otosclerosis Aneurysm Brain tumour etc. Treatment- It is usually improves with time, but in most cases there is no specific treatment. - Hearing aids - Masking devices

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CONTD………. 5.VERTIGO Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary. Patients frequently have difficulty describing symptom. The symptoms are due to a dysfunction of vestibular system in the inner ear. Symptom- Nausea, Vomiting and, Difficulty in standing and walking. Causes- Benign paroxysmal positional vertigo, Vestibular migraine, Meniere’s disease, Vestibular neuritis and, Ethanol consumption. Treatment- Anticholinergics and, Antihistamines etc.


HISTORY TAKING Ask about 5 main symptoms of ear such as otalgia, otorrhoea, hearing loss, tnnitus and vertigo. Previous ear surgery Head injury Systemic disease( e.g stroke, multiple sclerosis, cardiovascular disease) Otoxic drugs history (antibiotics, diuretics, cytotoxics) Occupational history such as exposure to noise at work or recreation (shooting) Family history of deafness History of atopy and allergy in children


CLINICAL EXAMINATION EXTERNAL EAR First inspect the pinna and the surrounding skin. Congenital abnormalities may be associated with skin tags, abnormal cartilaginous fragments and sinuses. Also look for any lymphadenopathy and protrusion. Look for surgical scars. A hot, tender, posturnal, swelling, pushing the pinna forward, suggests mastoid infection. Then inspect the external auditory canal using a handheld otoscope for cerumen color lesions discharge or foreign bodies.


OTOSCOPIC EXAMINATION HOW THE TEST PERFORMED? The health care provider may dim the lights in the room. A young child will be asked to lie on his or her back with the head turned to the side, or the child’s head may rest against an adult’s chest. Older children and adults may sit with the head titled toward the shoulder opposite the ear being examined. The health care provider will gently pull up, back or forward on the ear to straighten the ear canal. The, the tip of the otoscope will placed gently into your ear. A light beam shines through the otoscope into the ear canal. The health care provider will carefully move the scope in different directions to see the inside of the ear and eardrum. Sometimes, this view may be blocked by earwax. The otoscope may have a plastic bulb on it, which delivers a timy puff of air into the outer ear canal when pressed. This is done to see how the eardrum moves. Decreased movement can mean that there is fluid in the middle ear. HOW THE TEST WILL FELL? If there is an ear infection, there may be some discomfort or pain. The health care provider will stop the test if the pain gets worse. NORMAL RESULT Everyone’s ear canal differs in size, shape and color. Normally, the canal is skin colored and has small hairs.yellowish brown earwax may be present. The eardrum is a light grey color or shiny pearly-white. Light should reflect off the eardrum surface.


TYMPANIC MEMBRANE Firstly inspect the tympanic membrane for landmarks, color and perforation. The normal color is gray or shinny pearly-white, translucent, with no bulging or retraction.consistency is smooth and landmarks is cone shaped while light reflection of the otoscope. Short process, malleus and umbo are clearly visible. The most common abnormality is :- Tympanosclerosis, which consist of white chalky patches in the drum caused by hyaline degeneration of fibrous layer due to previous infection. Prolonged negative middle ear pressure may cause the drum to become thinned and atelectatic, either diffusely or with a retaction pocket. Eustachian tube dysfunction or otitis media may cause a middle ear effusion. Otitis media occurs in the area between the eardrum(end of the outer ear) and the inner ear, includding a duct known as eustachian tube. Sign and Symptom=pressure build up behind the eardrum, frequently causing pain. In severe cases, the tympanic membrane may rupture, allowing the pus in the ear space to drain into the ear canal. Diagnosis= otoscope and tympanometer Treatment= pain management by using antibiotics such as azithromycin, amoxicillin etc.

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CONTD………… 4. CHOLESTEATOMA Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and mastoid process. Symptom - hearing loss,mucopurulent discharge, dizziness, vertigo, balance disruption, earache, headache, tinnitus. Causes=tear or retraction of the ear drum. may grows from birth behind the eardrum. cholesteatoma may arise from the pars flaccida region of eardrum. Treatment= Surgery, mastoidectomy. 5.MENIERE’S DISEASE Meniere’s disease is a disorder of inner ear that can affect hearing and balance to a varying degree. It is characterized by episode of vertigo and tinnitus and hearing loss, usually in one ear. It is caused by lymphatic channel dialation, affecting the drainage of endolymph. Diagnosis= careful history and physical examination such as audiometery, otolaryngological examination and MRI. Treatment= vestibular training, environmental and dietary changes, salt restriction and, sedative, diuretic can be used.


BASIC TEST OF HEARING TUNING FORK TEST A tuning fork is an acoustic resonator in the form of a two prolonged fork with prongs (tines) formed from a U- shaped bar of elastic metal (usually steel). It resonates at a specific constant pitch when an vibrating by striking it against a surface or with an object, and emits a pure musical tone after wating a moment to allow some high overtones to die out. A) WEBER TEST Weber’s tuning fork is a method of screening auditory acuity. It is especially useful in determining whether a hearing loss is in one ear is conductive or sensorineural loss. The test is performed by placing the stem of a vibrating tuning fork in the center of the person’s forehead, or the midline vertex. The loudness of sound is equal in both ears if hearing is normal or if there is equal in both ears if hearing is normal or if there is a symmetric hearing loss. If the person has a sensorineural loss in one ear, the unaffected ear percieves the sound as louder. When conductive hearing loss is present in one ear, the sound is perceived as louder in that ear because it does not hear ordinary background noise conducted through the air and recieves only vibrations by bone conduction.

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CONTD………… B) RINNE TEST Rinne test is used to compares perception of sounds as transmitted by air or by bone conduction through the mastoid. It is performed by placing a vibrating tuning fork (512HZ) intially on the mastoid process until sound is no longer heard, the fork is then immediately placed just outside the ear. Normally, the sound is audible at the ear. Air conduction uses the apparatus of the ear to amplify and direct the sound whereas bone conduction by passes some of these and allows the sound to be transmitted directly to the inner ear albeit at a reduced volume or via the bones of the skull to the opposite ear. In normal ear, air conduction is better than bone conduction i.e. positive rinne. In conductive hearing loss, bone conduction is better than air i.e. negative rinne. In sensorineural hearing loss, bone conduction and air conduction are both equally depreciated i.e. positive rinne. In sensorineural hearing loss patients there may be a false negative rinne i.e. negative rinne.

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CONTD……… 2. ROMBERG TEST Romberg test is a test used by docters in a neurological examination and also as a test of drunken driving. The patient stands with feet together, and maintains balance with eyes open. The eyes are then closed. A loss of balance with eyes closed is positive, abnormal response. 3.WHISPER TEST a) Stand 1-2 feet behind client so they can not read your lips. b) Instruct client to place one finger on tragus of left ear to obscure sound. c) Whispher word with 2 distinct syllables towards client’s right ear. d) Ask client to repeat word back. e) Repeat test for left ear. f) Client should correctly repeat 2 syllable word.

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