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Advanced Hearing andBalance
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Evaluation inOtitis Media
Rafaelda CostaMonsanto, LeandroGuenade Castro,
MatheusSaito, JoséCarlosConventoJunior,
andNormade OliveiraPenido
44
Introduction
Otitis media, dened as the presence of middle ear inammation or infection, is a highly burdening disease [1]. The
high burden of otitis media is aggravated by its high
worldwide incidence: acute otitis media (AOM) affects
~709 million people yearly, and it was estimated that over
31 million new cases of chronic otitis media (COM) are
diagnosed worldwide [1, 2]. The World Health
Organization (WHO) estimated that complications of otitis media are responsible for 28,000 deaths every year.
These complications include (but are not limited to) intratemporal (acute mastoiditis, labyrinthitis, labyrinthine stula and petrous apicitis, for example) and intracranial
complications (sigmoid sinus thrombosis, intracranial
abscess, and meningitis) [2].
The association of otitis media and inner ear lesions has
been extensively studied in the past 4 decades. Adam
Politzer, in 1894, was the rst to hypothesize that patients
with otitis media might be at risk of developing hearing
loss [3]. Many experimental studies then dedicated to
understanding the pathophysiological mechanisms
involved with auditory sequela secondary to otitis media.
R. da CostaMonsanto (*)
Department of Otolaryngology, Head & Neck Surgery, Banco de
Olhos de Sorocaba Hospital, Sorocaba, SP, Brazil
Department of Otolaryngology, Head & Neck Surgery,
Universidade Federal de São Paulo/Escola Paulista de Medicina
(UNIFESP/EPM), São Paulo, SP, Brazil
Department of Otolaryngology, Head & Neck Surgery, University
of Minnesota, Minneapolis, MN, USA
e-mail: rdacosta@umn.edu
L. G. de Castro · M. Saito · J. C. C. Junior
Department of Otolaryngology, Head & Neck Surgery, Banco de
Olhos de Sorocaba Hospital, Sorocaba, SP, Brazil
N. de OliveiraPenido
Department of Otolaryngology, Head & Neck Surgery,
Universidade Federal de São Paulo/Escola Paulista de Medicina
(UNIFESP/EPM), São Paulo, SP, Brazil
However, it was only in 1972 that Paparella etal. [4] published a pioneer translational study corroborating the presence of sensorineural hearing loss, also demonstrating its
otopathological correlates. The authors showed high-frequency hearing loss in patients with COM, which correlated otopathologically with loss of cochlear hair cells in
the basal turn of the cochlea. These ndings were later corroborated by many experimental and clinical studies. More
recently, the WHO [5] demonstrated that otitis media is the
third leading cause of hearing impairment, and Cordeiro
etal. [6] revealed that a single episode of uncomplicated
AOM may result in permanent hearing loss. Tinnitus is
also a frequent complaint in patients with otitis media: a
cohort study of 30 years including over 2000 participants
revealed that children who had recurrent AOM or chronic
otitis media with effusion (OME) had worse hearing and a
higher prevalence of tinnitus in adulthood as compared
with controls [7].
Based on the observations of cochlear/auditory sequela of
otitis media, the presence of an associated peripheral vestibular lesion was also hypothesized. As vestibular problems
are not major complaints of most patients with otitis media,
this hypothesis has not been explored in depth [8] Many
authors associated dizziness or vertigo in otitis media patients
with the presence of perilymphatic stula, variation in the
middle ear pressure, or other associated clinical problems
(such as metabolic diseases and benign paroxysmal postural
vertigo) Nonetheless, clinical and experimental evidence
demonstrated that otitis media can independently result in
vestibular damage [9]. Histopathological studies in human
temporal bones demonstrated loss of vestibular hair cells in
the saccular and utricular macula of temporal bones with
COM [10]. A cohort study showed that adults with a history
of recurrent AOM or COM in childhood had a much higher
prevalence of self-reported dizziness as compared with ones
without a history of otitis media [11]. Thus, it seems that
although the vestibular sequela of otitis media may be less
burdening than auditory symptoms, these should be assessed
to allow prevention and assertive treatment as required [12].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. V. Goycoolea et al. (eds.), Textbook of Otitis Media, https://doi.org/10.1007/978-3-031-40949-3_44
465
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R. da CostaMonsanto et al.
However, assessing vestibular function in patients with otitis
media is challenging: the results of several vestibular function tests (such as caloric test, and Vestibular Evoked
Myogenic Potential—VEMPs) are negatively inuenced by
the presence of the middle ear abnormalities (tympanic
membrane perforation, brosis, effusion, and cholesteatoma)
and the presence of conductive hearing loss [8]. Therefore, it
is arguable whether the ndings demonstrate the presence of
vestibular deciency or are the result of these technical artifacts. Other vestibular tests that are not inuenced by these
limitations (e.g., rotatory chair, video-head impulse test, and
posturography) are expensive and unavailable in some locations [10].
The inner ear sequelae of otitis media may result in varying degrees of hearing and vestibular problems. The highfrequency hearing loss, which is commonly observed in
patients with otitis media, may result in deterioration in
music perception, sound localization and speech perception
problems (especially in noisy environments), and tinnitus
[6]. The hearing loss associated with unaddressed otitis
media also results in language and development delays and
may lead over time to academic underachievement, higher
rates of unemployment, lower salary, and even increase the
risks of neurodegenerative diseases, including Alzheimer
and dementia [13, 14]. The impact of vestibular impairment
secondary to otitis media has been less explored in the literature; however, children with otitis media are reported as
“clumsy” and tend to fall more often than controls.
Additionally, the development of gross and ne motor skills
is delayed, and the posturography results are much worse in
children with otitis media [15]. In adults, COM leads to a
high prevalence of vestibular symptoms (40-60%), abnormal
caloric and cervical vestibular-evoked myogenical potentials
(cVEMP) tests, lower limit of stability and increased sway in
posturographic evaluation [12].
In this chapter, we will explore in detail the auditory and
vestibular function tests that are available in the clinical
practice to evaluate patients with otitis media.
Anamnesis andPhysical Examination
Anamnesis
The most frequent symptoms of acute otitis media (AOM)
are otalgia and fever, followed by the presence of otorrhea.
Adequate treatment results in resolution of the infection
without any further complications. Potential sequelae of
AOM include chronic perforation of the tympanic membrane, hearing loss, tinnitus, and vestibular symptoms. The
presence of a chronic eardrum perforation is a frequent cause
of recurrent otorrhea and middle ear infections, requiring
surgical treatment over time. AOM may also result in intracranial and intratemporal complications such as mastoiditis,
labyrinthitis, petrositis, meningitis, cerebellar abscess, and
sigmoid sinus thrombosis. In AOM patients presenting with
severe vestibular symptoms, diplopia, facial paralysis, severe
headache, high fever, lethargy, vomiting, or neck stiffness
should be thoroughly investigated for the presence of intratemporal or intracranial complications (Fig.44.1).
Otitis media with effusion (OME) results from the presence of middle ear uid for more than 3 months. The accumulation of middle ear effusion may occur for several
reasons, the most frequent being Eustachian tube dysfunction. OME has a peak incidence in children, as the Eustachian
tube in this population is shorter, more horizontal, and has a
smaller lumen as compared with adults– it was observed that
virtually 100% of preschool children will experience at least
one transitory episode of OME [16]. As in most cases, the
middle ear effusion is sterile, the presence of symptoms
related with an acute infection are infrequent in
OME. However, the accumulation of uid may result in
increased susceptibility for developing AOM through the
course of the disease. Adults with OME frequently present
with aural fullness, and less frequently with tinnitus and vestibular symptoms. In children, the symptoms may be less
specic than in adults. Most frequently, OME is suspected in
children with difculties in speech and reading, delayed
Fig. 44.1 Magnetic resonance imaging of a 23-year-old female patient
with acute otitis media (AOM) who presented with a severe hearing loss
in the left ear and vertigo. In hear physical examination, otoscopy
revealed the presence of intense erythema and bulging of the left ear.
Clinical vestibular examination revealed the presence of left-beating
nystagmus, and Romberg test revealed a tendency fall to her left side.
T1- weighted MRI with contrast showed intense enhancement of the
cochlea (yellow arrow), suggesting acute labyrinthitis.
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response to auditory input, limited vocabulary, and disturbances in attention. It was observed that the most frequent
symptoms reported by the caregivers of children with OME
are otalgia (76%), sleep disruption (64%), behavioral problems (49%), speech or hearing impairment (33-62%), and
disequilibrium (15%) [16].
Chronic otitis media (COM), dened as the presence of
chronic (>3 months) inammation of the middle ear, may
result in a myriad of clinical symptoms. Several authors
have attempted to categorize COM to facilitate development
of pathology-oriented diagnosis and treatment algorithms.
Most frequently, studies report COM as either (1) nonsuppurative COM, dened as cases with a chronic perforation
of the tympanic membrane secondary to otitis media with
infrequent otorrhea; (2) chronic suppurative otitis media
(CSOM), encompassing cases with frequent or intractable
otorrhea; and (3) COM with cholesteatoma, dened as cases
presenting with cholesteatoma identied in the middle ear
or mastoid [17]. Paparella [18], also introduced the concept
of “silent otitis media,”, comprising patients who have tissue abnormalities in the middle ear cleft and mastoid (such
Fig. 44.2 A 13-year-old with
chronic otitis media presented
with a retroauricular edema in
the left ear (a), associated
with a profound hearing loss
in the left ear and intense
disequilibrium. Computed
tomography (CT) revealed
soft tissue lling the middle
ear and mastoid, with an
associated erosion of the left
semicircular canal (white
arrow, b) and a large opening
of the mastoid with the
posterior cranial fossa (black
arrow, d). Contrast-enhanced
CT revealed a subperiosteal
and cranial abscess (c)
a
as brosis, cholesterol granuloma, ossicular chain erosion,
granulation tissue, or cholesteatoma) behind an intact eardrum. Considering the numerous potential sites of middle
ear lesion secondary to otitis media, the clinical presentation of COM may signicantly vary among patients. The
most frequent clinical symptom described by patients with
COM is hearing loss, affecting over 95% of the patients
[12]. Other frequent symptoms are tinnitus, otorrhea, otalgia, dizziness, or vertigo. Less frequently, COM may result
in deafness and facial nerve paralysis. COM also associates
with intracranial and intratemporal complications, being
more frequent (80%) than AOM-associated (20%) complications [19]. de Oliveira Penido etal. [2] estimated the incidence of intracranial complications of COM at 0.8%.
Therefore, symptoms that may indicate an intracranial complication (such as the onset of profound hearing loss, severe
vestibular symptoms, facial or abducens nerve paralysis,
and other neurological symptoms) should be thoroughly
investigated (Fig.44.2).
Although vestibular symptoms are less frequent com-
plaints as compared with hearing impairment in otitis media,
b
c
d
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it has been demonstrated that over 50% of patients with
AOM and COM report symptoms that are attributable to vestibular dysfunction [12]. Therefore, it is critical that the presence and characteristic of these symptoms are objectively
assessed through structured anamnesis. Most patients with
COM refer to the vestibular symptoms as disequilibrium,
which is frequently triggered or worsened by the presence of
otorrhea. In patients with AOM or COM exacerbations,
patients may present vertigo and nystagmus, suggesting an
acute vestibular lesion and the presence of labyrinthine stula, especially in cases of cholesteatomatous COM
(Fig.44.2). In children, assessing vestibular symptoms can
be challenging, as these are rarely reported by the patients
and may not be perceived by the caregivers [20]. Children
with OME or COM are more prone to falling and have
delayed ne and gross motor development as compared with
children without otitis media.
Physical Examination
The physical examination is critical to the diagnosis of otitis
media. A precise diagnosis allows for timely and adequate
treatment, in addition to prevention of sequelae and complications. The hearing evaluation in patients with otitis media
initiates with an adequate otoscopy. As otitis media may
result in hearing loss through a variety of pathophysiological
mechanisms, these must be carefully examined to increase
the chances of an adequate diagnosis and indicate potential
treatment and prevention strategies.
The tympanic membrane (TM) should be examined thoroughly. The TM is abnormal in virtually 100% of patients
with otitis media. However, the presence of a near-normal
tympanic membrane may not indicate the absence of an
underlying disease: patients with Eustachian tube dysfunction and chronic middle ear inammation may present with
only mild opacity and retraction of the eardrum. In these
cases, the physician must also consider the clinical symptoms in the equation, in addition to audiometric results and
imaging tests (when required). The otoscopy may indicate
the type of otitis media and the adequate treatment. AOM is
suspected in patients with erythema and bulging of the TM,
in association with the presence of clinical symptoms such as
otalgia, fever and/or otorrhea. In patients with aural fulness
and hearing loss presenting with chronic (>3 months) retrotympanic middle ear effusion, in association with bulging or
retraction of the tympanic membrane, must be screened for
otitis media with effusion or silent otitis media. Pneumatic
otoscopy is an important adjuvant in the diagnosis of OME
in children, as a recent clinical practice guideline from the
AAO [16] has demonstrated its efcacy in comparison to
other diagnostic tools.
Cases presenting with a chronic tympanic membrane perforation with persistent or intractable suppuration are indicative of CSOM. Cholesteatoma can be in the otoscopic
examination, and it may associate with the ndings of middle ear inammation and erosion of the scutum and ossicular
chain. The absence of a TM perforation does not exclude the
possibility of COM: Paparella etal. [18, 21] have demonstrated, through histological temporal bone and clinical studies, the presence of tissue changes that indicate chronic otitis
media (brosis, granulation tissue, bone erosion, cholesterol
granuloma, and cholesteatoma) in patients with an intact
membrane. Also, the otoscopy may indicate potential abnormalities resulting in conductive hearing loss and indicate
potential strategies for hearing restoration. The extension of
the bony erosion and ossicular chain abnormalities secondary to otitis media may indicate the need for ossicular reconstruction or the use of prosthesis to allow optimal hearing
restoration in cases where otologic surgery is warranted.
A thorough neurotologic examination is critical to evaluate potential vestibular impairment secondary to otitis media.
Although many tools and devices are available in the clinical
practice to evaluate vestibular function, the presence of conductive hearing loss and the middle ear abnormalities that are
frequent in otitis media has a negative impact in some of
these tests (such as caloric tests and VEMPs). Thus, the vestibular evaluation should be performed with tests that are not
inuenced signicatively by the presence of these abnormalities. In this regard, clinical vestibular tests are essential to
the diagnosis of vestibular impairment in patients with otitis
media, as they may indicate the presence of vestibular dysfunction with minimal inuence of the middle ear status.
Among the tests used are the static (Romberg test) and
dynamic (gait and Fukuda stepping tests) equilibrium tests,
cerebellar function tests (index-index, index-nose, and diadochokinesis), assessment of the presence of nystagmus
(spontaneous with and without visual xation), head impulse
and head-shaking tests, muscular tone and strength, examination of cranial nerves, and positional tests (Dix-Hallpike
and head roll). In cases of noncomplicated AOM, OME, and
COM, the clinical vestibular function tests frequently yield
normal results; in some cases, patients may present mild
instability in the Romberg test or lateral shifts in the Fukuda
stepping test. In cases of more severe AOM and CSOM,
some patients may present spontaneous nystagmus and an
abnormal head impulse test in the side of the affected ear.
The presence of spontaneous nystagmus and an abnormal
head impulse test, in association with severe vestibular
symptoms (including vertigo or postural instability) may
indicate an increased risk of labyrinthitis, labyrinths stula,
an intracranial complication. Thus, these patients should be
monitored closely to allow timely treatment if an intracranial
complication is detected.
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Hearing Evaluation
The gold-standard test to assess hearing in patients with otitis media is the pure-tone audiometry and speech tests. The
tuning fork tests can be used to evaluate the type of hearing
loss in the affected ears, being are especially useful in cases
where an inner ear complication is suspected or in cases
where a pure-tone audiometry is not readily available. Otitis
media result in hearing loss in virtually 100% of the cases,
with the most frequent type of hearing decit being conductive, present in almost all forms of otitis media. However, it
has been extensively demonstrated that some patients with
otitis media develop sensorineural hearing loss, being most
frequent in patients with CSOM.
Tonal Audiometry
The pure-tone audiometry is the most frequently used test for
evaluating hearing thresholds, and it could be tested through
air and bone conduction. Hearing thresholds are dened, as
per the “American National Standards Institute” (2004) as
“the minimum effective sound pressure level of an acoustic
signal producing an auditory sensation in a specied fraction
of the trials. The most accepted classication of the severity
of hearing loss is: (1) mild (thresholds ranging from 26 to
40 dBHL); (2) moderate (41–55 dBHL); (3) moderately
severe (56–70dBHL); severe (71–90dBHL); and profound
(thresholds exceeding 90dBHL).
Pure-Tone Air-Conduction Testing
The air-conduction testing measures the function of the
external, middle, and inner ears. The pure tones are tested in
the frequencies of 250–8000 Hz, in octave spacings.
Although the pure-tone air conduction testing is potentially
the most valuable hearing test, it does not provide specic
information regarding the etiology of the auditory pathology
when used in isolation. Thus, in the event of the airconduction testing reveals thresholds exceeding 25 (adults)
or 15 (children) dBHL, the test must be complemented by
the bone-conduction testing.
Pure-Tone Bone-Conduction Testing
The bone-conducted stimulus reaches the cochlea directly,
without going through the external and middle ears, through
the skull bones, as the signal of a pure tone is presented to the
patient through a bone vibrator that is placed on the mastoid
to obtain hearing thresholds. Thus, the bone-conduction
audiometry is remarkably useful in patients with a suspected
conductive or mixed hearing loss. When the bone-and airconduction audiometry is performed in association, a difference between the measured thresholds exceed 10 dBHL
indicates the presence of a conductive hearing loss, which
may or may not associate with a sensorineural hearing loss.
Speech Testing
Speech testing (“vocal audiometry”) aims to assess the ability to perceive and recognize speech. A basic audiometric
evaluation should routinely include speech testing. Among
the tests used are the speech detection thresholds (SDT),
speech reception thresholds (SRT), and speech discrimination scores. Both the SDT and SRT can be obtained using
either air- or bone-conduction.
– Speech detective threshold (SDT): Measures the lowest
sound intensity that the patient can detect the presence of
50% of the speech signals that are presented through the
headphone. This test does not evaluate the recognition of
speech, but the sound intensity that the patient acknowl-
edges that he is listening to the speech signal. The SDT
usually coincides with the pure-tone average, which is the
average of the thresholds obtained with the pure-tone
audiometry in the frequencies of 500, 1000, and 2000Hz.
– Speech reception threshold (SRT): Corresponds to the
lowest intensity that the patient can repeat 50% of the
speech material. The SRT is usually 8–9 dB higher than
the SDT.
– Speech discrimination: Determination of the speech dis-
crimination is a more complex task as it evaluates the lis-
tener’s ability to recognize speech. In conjunction with
the pure-tone audiometry, it can help determine the dif-
ferential diagnosis of hearing loss, provide information
regarding the ability to communicate effectively, provide
information regarding central auditory function, and pro-
vide insights about effectiveness of certain hearing reha-
bilitation strategies. The most frequent test used to
evaluate discrimination is to present monosyllabic words
in an open-set format. Patients with a pure conductive
hearing loss frequently achieve optimal speech discrimi-
nation scores when the test is conducted using an ade-
quate sound intensity. In patients with sensorineural
hearing loss, the results may vary signicantly among
patients: patients with loss of sensorial cochlear cells fre-
quently have lower discrimination scores as compared
with nondiseased peers. In patients with lesions affecting
the vestibulocochlear nerve, central auditory pathway, or
even the auditory cortex, the discrimination scores are
even lower, and this phenomenon can be seen even in
patients with a normal or mild-to-moderate hearing loss
in the pure-tone audiometry. In patients with otitis media,
it has been demonstrated that their neural apparatus is fre-
quently spared from the lesion secondary to the middle-
ear inammation. Therefore, even in patients with more
severe degrees of mixed hearing loss, the discrimination
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scores are within normal range or mildly abnormal.
However, cases who had suffered an otitis media-related
inner ear complication may present with very low discrimination scores.
Extended High-Frequency Audiometry
The extended high-frequency audiometry is performed in an
acoustic booth using earphones that are calibrated to emit
sounds at frequencies ranging from 8000 to 16,000 Hz.
Theoretically, the extended high-frequency audiometry
might constitute an ideal exam to evaluate initial hearing loss
secondary to otitis media, as it has been demonstrated that
the hook of the cochlea, which is adjacent to the round window membrane, is the primary lesion site secondary to otitis
media [22]. However, the extended high-frequency audiometry is not yet validated for clinical use, as there are no normality values dened for these frequencies, and a wide
variation in their results is seen in the normal population [6].
Despite these limitations, some authors dedicated to testing potential hearing losses affecting the extended high frequencies in patients with otitis media. Kasemodel etal. [22]
revealed that patients with acute otitis media present with
sensorineural hearing loss affecting the extended high frequencies in the rst seven days from the onset of the disease.
Cordeiro etal. [6] further revealed that a single episode of
acute otitis media causes a signicant and permanent elevation of hearing thresholds in the extended high frequencies
(8–16 kHz) as compared with the non-diseased contralateral
side.
Acoustic Immittance
The acoustic immittance aims to perform an objective measurement of the functional integrity of the tympanic- ossicular
ensemble. The screening test named “acoustic immittance”
test was based on the phenomena of “acoustic admittance,”
which is the amount of energy owing through a system, and
“acoustic impedance,”, which is an opposition to the ow of
sound energy. Measuring the acoustic immittance allows for
identication and classication of peripheral (middle ear)
and central auditory disorders. The most frequently used
tests to evaluate acoustic immittance are the tympanometry
and stapedial reex measures.
Tympanometry
The tympanometry test was developed based on the observation that in cases where the middle ear and eustachian tube
are normal, the best complacency of the tympanic membrane/ossicular chain system will occur when the pressure
within the external auditory canal tends to equal the atmospheric pressure. Thus, in this test, an air-tight sealed probe
is inserted into the ear canal, and it provides both positive
and negative pressures onto the eardrum. Then, the probe
measures the amount of acoustic energy reected from the
eardrum, providing information regarding transmission
characteristics of the middle ear.
The result obtained with the tympanometry test is a direct
estimate of the magnitude of the reected acoustic energy. In
a normal ear, the acoustic admittance is maximal when the
pressure in the external auditory canal is equal to the atmospheric pressure. In cases presenting with an abnormal middle ear pressure, Eustachian tube dysfunction, ossicular
chain abnormalities, or presence of middle ear effusion, the
acoustic impedance increases, and the admittance decreases.
To provide a more visual and intelligible demonstration of
the results, Jerger [23] classied the potential results in a
graphic representation. The types of tympanograms were
classied as follows:
– Type A: Indicates a normal middle-ear pressure, in cases
where the peak is at 0daPa. There are two sub-categories
of A-type curves: As, which indicates a pressure peak at 0
that is reduced in amplitude, suggestive of ossicular chain
xation; and Ad, which indicates an unusually high-
pressure peak at 0, suggesting ossicular chain
discontinuity.
– Type B: Constitutes a “at line” tympanogram, which
indicates no point of maximum compliance. It indicates a
mass-pressure effect behind the eardrum, which is seen in
cases of serous or mucoid otitis media, space-occupying
lesions of the middle ear (such as cholesteatoma or
tumors), or a perforation of the tympanic membrane with
a sealed Eustachian tube.
– Type C: Is graphically represented by the peak of compli-
ance located in a negative pressure area, suggestive of the
presence of negative middle ear pressure. It is frequently
seen in early stages of otitis media without a signicant
amount of effusion.
The tympanometry is extremely useful in cases of otitis
media with effusion and silent otitis media, as it reveals the
presence of middle ear effusion and negative pressure in the
middle ear, as well as the presence of tissue abnormalities in
the middle ear. In cases of acute otitis media, as the tympanometry is not essential as a diagnostic tool, it is not recommended as it could result in worsening of the otalgia and
discomfort of the patient. In patients with chronic otitis
media presenting with a tympanic membrane perforation, the
tympanometry offers a very limited benet, being used in
selected cases to evaluate the function of the Eustachian
tube.
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Stapedial Reexes
The stapedial reex is a protective mechanism dedicated to
lower the sound intensity in cases of exposure to loud sounds.
When the reex pathway is activated, the stapedius muscle in
both ears’ contracts, stiffening the ossicular chain, resulting
in a change in immittance. This pathway is composed of the
cochlea, the VIII nerve, the ventral cochlear nucleus, the
superior olive complex, the facial motor nucleus, and the
facial nerve motor branch. Stapedial reexes are useful in the
differential diagnosis of hearing loss as they suggest the
location of the injury.
Although testing the stapedial reexes is useful for a complete audiologic diagnosis, it offers limited benets in cases
of otitis media. The test of the stapedial reex is negatively
inuenced by the presence of middle ear disorders, as they
prevent the tympanic membrane from showing a change in
compliance when the stapedial muscle is contracted.
Therefore, both ipsilateral and contralateral reexes are
bilaterally absent when the patient has a conductive hearing
loss in the tested ear.
Otoacoustic Emissions
The active motility of outer hair cells serves as an amplier
of the displacement of the cochlear partition, which results in
sound waves (termed “cochlear echoes”) that are detectable
at low intensities. These emissions may be detected spontaneously, or with a higher intensity following a sound stimulus, which is the “evoked otoacoustic emission”. As
spontaneous emissions may be absent in some patients, the
evoked otoacoustic emissions are consistently detected in
patients who have intact cochlear and middle ear apparatus.
The evoked emissions can be tested using a transient, brief
stimulus (such as a click or a brief tone burst (transient
evoked otoacoustic emissions—TEOE) or using pure-tones
separated by a specic frequency difference (distortionproduct otoacoustic emissions—DPOE).
Testing the otoacoustic emissions is critical for an adequate audiological diagnosis in the present days. However, it
offers very limited benets when applied to patients with otitis media, as the presence of middle ear effusion, ossicular
chain erosion or xation, middle-ear tissue pathology, and
tympanic membrane abnormalities do not allow for adequate
detection of the otoacoustic emissions.
they are represented graphically as “waves” as the impulses
are transmitted through central auditory pathway landmarks.
The ABR might be recorded using standard or disposable
surface electrodes positioned on the forehead or at the vertex, on the medial surface of the ipsilateral or contralateral
earlobe; the ground electrode is placed on the center of the
forehead.
A normal ABR is comprised of 5–7 peaks that occur
within a time frame of less than 10ms; however, only the rst
5 peaks are considered within the test. The waves are elicited
as they are captured in central auditory landmarks: wave I is
originated at the level of the distal cochlear nerve, and the
wave V at the level of lateral lemniscus in the midbrain. In a
normal person, the latency of the waves I, III, and V (which
are the most consistently identied waves) is consistent and
can be used for evaluating normality of the electrical conduction of the stimuli. Abnormal values might occur when there
is presence of middle ear pathology interfering with the conduction of the sound wave (occasion where the latency of the
wave I is prolonged, but the interpeak interval between waves
I–III–V are normal), or when a neural abnormality is present
(resulting in complete absence of ABR waves, increased
interpeak intervals and/or latency between waves I–III–V, or
absence of one or more waves). It is also possible to evaluate
the hearing thresholds at the tested frequencies, being considered as hearing thresholds the minimum sound intensity
where the wave V is still detected in the ABR.
Considering patients with otitis media, the ABR is
extremely useful to evaluate and diagnose children with otitis media with effusion or chronic otitis media who cannot
perform the audiogram adequately. In these cases, the ABR
can provide an adequate differential diagnosis between the
presence of other potential causes of hearing loss (cochlear
and central) from a pure conductive decit caused by middle
ear pathology. It can also indicate the best hearing rehabilitation strategy in cases presenting with a more intense hearing
loss, being extremely useful in cases where a cochlear
implant may be indicated. In older patients with otitis media,
the ABR might be used only in selected cases, as the puretone audiometry is frequently sufcient to provide optimal
evaluation of hearing.
Vestibular Function Tests
Caloric Tests
Auditory Brainstem Responses
The auditory brainstem response (ABR) represents the electric activity of the distal portion of the auditory pathway. The
electrical impulses are recorded with surface electrodes, and
Caloric tests have been widely used in the study of vestibular
function. However, the use of the caloric tests in patients
with otitis media has not been extensively used for several
reasons. First, the initially proposed caloric tests using water
stimulation was not adequate to patients with otitis media, as
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