Книга_4440_Библиотеки_им_академика_М_И_Перельмана

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Table 3.18 Differential diagnosis of vertigo: based on duration of episode/duration of vertigo with the presence or absence of hearing loss

Duration of episode of vertigo Hearing loss absent Hearing loss present Seconds BPPV Perilymph stula, cholesteatoma Minutes Vertebral or basilar artery

insufciency Hours Vestibulopathy Meniere’s disease Days Vestibular neuronitis Labyrinthitis Weeks CNS lesion, Lyme disease Autoimmune disease, psychogenic

Table 3.19 Features of mild, moderate and severe vertigo

Mild Moderate Severe Occurs occasionally for a brief time

and goes away on its own, nausea present but vomiting absent

Nystagmus present in fast component

Causes—central, peripheral Causes—peripheral Causes—peripheral

Table 3.20 Causes of sudden and gradual onset vertigo

Sudden Gradual/insidious Vertigo develops all of sudden Vertigo develops slowly BPPV, low blood pressure, dehydration, Meniere’s

disease, labyrinthitis, vestibular neuronitis, TIA

Requires patient to lie down and lie

still (no head motion) to stop the

feeling of movement, nausea

present, vomiting +/−

Nystagmus present in fast

component and resting stage

Vestibular schwannoma

3 History andExamination ofEar

Feeling of movement is continuous even when lying down. Both nausea and vomiting present

Nystagmus present in all directions

Table 3.21 Difference between congenital and acquired vertigo

Feature Acquired Congenital Form Pure sinusoidal Variable Different in two eyes Frequent Rare Direction Omnidirectional—vertical circular,

elliptical OKN reversal Never Frequent Oscillopsia Frequent Mild

• Non-progressive—The severity of vertigo is constant for long period as termed as non-progressive vertigo. It is caused by BPPV.

• Aggravating/Exacerbating fac- tors—Provoking factors and circumstances around the onset of vertigo may prove useful in narrowing the differential diagnosis to a peripheral vestibular condition.

– No trigger—vestibular neuritis. – Walking—bilateral vestibulopathy.

Horizontal uniplanar

– Lateral head turning—vestibular

paroxysmia, rotational vertebral artery occlusion syndrome, compression of the VIIIth nerve due to cerebellopontine angle mass, carotid sinus syndrome.

– Head positioning (turning over in

bed, bending over at the waist and then straightening up, or hyperextending the neck)— BPPV, acute labyrinthitis and CP angle tumour.

3.1 Symptoms/History/Chief Complaints ofEar Diseases

– Sneezing, coughing, pressing, loud

sounds of a certain frequency—as Tullio’s phenomenon—perilymph stula.

– Certain social situations—phobic

postural vertigo.

– Recent viral upper respiratory

infection—acute vestibular neuronitis or acute labyrinthitis.

– Change in ear pressure, head

trauma, excessive straining, loud noise—perilymphatic stula.

• Associated symptoms— Audiological symptoms such as hearing loss, pain, nausea, vomiting, or neurological symptoms can help differentiate the cause of vertigo. Most causes of vertigo with hearing loss are peripheral, the main exception

Table 3.22 Diagnosis of vertigo with different associated symptoms

Associated symptoms with vertigo Probable diagnosis Aural fullness, ear or mastoid pain, facial weakness,

headache, hearing loss, focal neurological weakness, imbalance (severe)

Mastoid or ear pain (pain accompanying vertigo) Acute middle ear disease, otitis media, herpes zoster

Imbalance Acute vestibular neuronitis Tinnitus Acute labyrinthitis Aural fullness, tinnitus, hearing loss Meniere’s disease Hearing loss Perilymphatic stula, cholesteatoma, AICA ischaemia Neurological symptoms such as weakness, dysarthria,

vision or hearing changes, paraesthesia, altered level of consciousness, ataxia, or other changes in sensory and motor function

Vertigo often is associated with nausea or vomiting Acute vestibular neuronitis, severe episodes of

Symptoms related to the migraine, including a typical headache (often throbbing, unilateral, sometimes preceded by an aura), nausea, vomiting, photophobia and phonophobia

Acoustic neuroma

oticus, invasive disease of the temporal bone

Central cause of vertigo such as cerebrovascular disease, neoplasm, or multiple sclerosis

Meniere’s disease, BPPV Migrainous vertigo

being a cerebrovascular event involving the internal auditory artery or anterior inferior cerebellar artery (Table3.22).

Differential diagnosis of vertigo

with hearing loss (Table 3.23)

Differential diagnosis of vertigo

with audiological symptoms (Table

3.24)

Differential diagnosis of vertigo with additional brainstem/cerebellar symptoms (Table 3.25)

Differential diagnosis of vertigo with headache (Table 3.26)

• Oscillopsia—It is an illusionary movement of the surrounding presented as jumping, jittery, wobbly or shimmering vision with vertigo or blurred vision (Tables 3.27 and 3.28).

Table 3.23 Differential diagnosis of vertigo associated with hearing loss

Characteristics of hearing loss with vertigo Diagnosis Progressive, unilateral, SNHL Acoustic neuroma Progressive/non-progressive, U/L, COHL Cholesteatoma Acute onset hearing loss Ramsay Hunt’s syndrome Episodic, uctuating, SNHL Meniere’s disease Progressive U/L Perilymphatic stula Sudden onset U/L TIA or stroke involving AICA

3 History andExamination ofEar

Table 3.24 Differential diagnosis of vertigo with audiological symptoms

Meniere’s disease Perilymph stula or superior canal dehiscence

syndrome Vestibular paroxysmia Cerebellopontine angle tumour Cogan’s syndrome or other inner ear autoimmune

diseases Ear/head trauma Pontomedullary brainstem infarct Pontomedullary MS plaque Labyrinthine infarct (anterior inferior cerebellar artery,

labyrinthine artery) Hyperviscosity syndrome Neurolabyrinthitis Herpes zoster oticus Cholesteatoma Inner ear malformation Vestibular atelectasis Otosclerosis Vestibular epilepsy

Table 3.25 D/D of vertigo with cerebellar symptoms

Basilar/vestibular migraine Intoxication Craniocervical malformations (e.g. Arnold-Chiari

malformation) Lacunar or territorial infarcts Haemorrhages (e.g. cavernoma) Inammation (e.g. MS plaque) Brainstem encephalitis Head trauma Tumours of the cerebellopontine angle, brainstem or

cerebellum Familial episodic ataxia type 2 Creutzfeldt-Jakob disease

Table 3.26 Differential diagnosis of vertigo with headache

Migraine without aura (‘motion sickness’) Basilar/vestibular migraine Brainstem/cerebellar ischaemia Vertebrobasilar dissection Infratentorial haemorrhage Inner/middle ear infection Head trauma (especially transverse temporal bone

fracture) Infratentorial tumour Herpes zoster oticus

Table 3.27 Differential diagnosis of oscillopsia without head movement

Spontaneous vestibular nystagmus (e.g. in vestibular neuritis)

Congenital nystagmus (depending on direction of gaze)

Downbeat nystagmus Upbeat nystagmus Acquired pendular nystagmus Periodic alternating nystagmus Opsoclonus Ocular utter Vestibular paroxysmia Myokymia of the superior oblique muscle (monocular) Paroxysmal ‘ocular tilt reaction’ Spasmus nutans (infants) Voluntary nystagmus

Table 3.28 D/D of oscillopsia with head movement

Bilateral vestibulopathy Disorders of the ocular motor system (peripheral or

central) Vestibular paroxysmia (only in part) Benign paroxysmal positioning vertigo Central positional/positioning vertigo Vestibulocerebellar ataxia Perilymph stulas Superior canal dehiscence syndrome Post-traumatic otolith vertigo ‘Rotational vertebral artery occlusion syndrome’ Intoxication (e.g. anticonvulsants, alcohol)

Differential diagnosis of oscillop-

sia without head movements

Differential diagnosis of oscillop-

sia during head movements (Table

3.28)

(d) Tinnitus—It is a perception of ringing,

buzzing, humming noise in ear without persisting objects. The phantom noise may vary in pitch from a low roar to a high squeal, unilateral or bilateral and continuous or episodic. In some cases, the sound can be so loud to interfere with ability to concentrate or hear external sound (Table3.29).

3.1 Symptoms/History/Chief Complaints ofEar Diseases

Table 3.29 Various types of tinnitus

Type of tinnitus Denition Causes Subjective tinnitus This is the most common type of tinnitus

only heard by patient

Sensory tinnitus It is a side effect of an impaired auditory

system

Somatic tinnitus It is generated by muscle spasm in ear or

neck and by other mechanical force

Objective tinnitus It is rare type of tinnitus which can be

heard by observer, usually with stethoscope

Table 3.30 D/D of pulsatile and non-pulsatile tinnitus

Pulsatile (It is caused by blood vessel disorder) Non-pulsatile

Subjective Subjective

High blood pressure, turbulent blood ow (kinking of neck artery or vein)

Objective Objective (pulsatile uttering tinnitus)

Arterial: aberrant internal carotid artery, carotid atherosclerosis, persistent stapedial artery, arteriovenous malformations, aneurysm, carotid artery dissection, vascular compression of cranial nerve eight, vascular tumours (glomus) Venous: jugular bulb abnormalities (high-riding, dehiscence, diverticulum), idiopathic intracranial hypertension, idiopathic pulsatile tinnitus (venous hum)

Presbyacusis, hair cell damage with age, noise-related tinnitus, wax, otosclerosis, TMJ disorder, atherosclerosis, thyroid disorder, drug-induced, hyperlipidaemia, vitamin B12 def

Presbyacusis

Head and neck injury, multiple sclerosis, spasm of ear muscle

Vascular lesion of carotid artery or jugular vein, arterior venous (AV) malformation, patulous Eustachian tube, palatomyoclonus, idiopathic stapedial muscle spam

U/L—idiopathic, noise-induced, intracranial tumour, muscle spasm in ear and neck, acoustic neuroma, injury to head and neck B/L—Meniere’s disease, Eustachian tube dysfunction (ETD), presbyacusis, drug-induced

Palatal myoclonus, stapedial muscle spasm, patulous ET, TM joint dysfunction, FB in ear

• Type of tinnitus

• Nature of tinnitus (Table 3.30)

• Type of sound—The sound heard by patient may be ringing, hissing, roaring, crickets, screeching, sirens, whooshing, static, pulsing, ocean waves, buzzing, clicking, dial tones and even music. It can be pulsatile or non-pulsatile.

• Pitch of sound

– Low-pitched rumbling pattern sug-

gests Meniere’s disease.

– High-pitched pattern suggests sen-

sorineural hearing loss (presbyacusis).

• Duration

– Acute—retraction of TM, AOM,

wax, otitis externa.

– Chronic more or less than

3 months—Meniere’s disease, presbyacusis.

• Mode of onset – Sudden—ASOM, trauma,

barotrauma.

– Gradual—presbyacusis, noise

trauma, acoustic neuroma.

• Severity of tinnitus—The severity of

tinnitus varies from an occasional awareness of a noise in one or both ears, to an unbearable sound that may drive some persons to contemplate suicide.

– Mild—Tinnitus does not interfere

with hearing and normal daily activity—ETD, otitis externa.

3 History andExamination ofEar

– Moderate—Tinnitus interferes

with day-to-day activity in quiet environment or at night.

– Severe—Tinnitus interferes with

day-to-day activity even in normal environment.

• Progression of tinnitus – Progressive—The severity of ver-

tigo increases with time— presbyacusis, otosclerosis, Meniere’s disease.

– Non-progressive—The vertigo

remains same over long period of time—retracted TM, vestibular schwannoma, AV malformation, turbulent blood ow due to kinking of blood vessels, TM joint disorder, drug-induced, noise-induced.

• Side—It can be either unilateral or

bilateral (Table3.31).

• Episodic or continuous—Tinnitus

can be either continuous or episodic (Table3.32).

• Associated history or symptoms – H/o drug intake like

Antibiotics—vancomycin, neomycin, polymyxin B, erythromycin Chemotherapeutic agent— methotrexate, cisplatin, etc. Diuretics—furosemide, ethacrynic acid, bumetanide, etc. Antimalarial drug—quinine Aspirin Antidepressants

– H/o risk factors such as

Exposure to loud noise—construction workers, musician, soldiers Age—old age Sex—male>female Smoking—higher risk Cardiovascular problem like hypertension, atherosclerosis

– Associated symptoms like fatigue,

stress, sleep problems, trouble concentrating, memory problems, depression, anxiety, irritability, vertigo, ear discharge, hearing loss, heaviness in the ear, etc. (Table3.33).

Table 3.31 Causes of U/L and B/L tinnitus

Unilateral Bilateral Head and neck injury, acoustic neuroma, vascular

neoplasm, turbulent blood ow (kinking or narrowing of neck artery or vein), AV malformation

Table 3.32 D/D of episodic and continuous vertigo

Continuous Episodic Presbyacusis, drug-induced, noise-induced,

hypertension, drug-induced, noise-induced, AV malformation, vascular neoplasm, head and neck injury

Table 3.33 Differential diagnosis of tinnitus with associated symptoms

Associated symptoms with tinnitus Diagnosis Tinnitus+progressive hearing loss+old age Presbyacusis U/L SNHL+tinnitus+vertigo Acoustic neuroma Episodic tinnitus+hearing loss+episodic vertigo Meniere’s disease Tinnitus alleviates by lying down with head in

dependent position Tinnitus+ear discharge CSOM

Meniere’s disease, TMJ disorder, Eustachian tube disorder, atherosclerosis, hypertension, ETD, druginduced, noise-induced

Meniere’s disease, TM joint dysfunction

Patulous Eustachian tube

3.1 Symptoms/History/Chief Complaints ofEar Diseases

(e) Earache (otalgia)—It is dened as pain

localized in ear. Two separate and distinct types of otalgia exist. The rst one, pain that originates in ear, is called primary otalgia, and the second one, pain that originates outside the ear but feels in the ear, is called referred otalgia (Table3.34).

• Types of otalgia

• Causes of pain – Causes of primary otalgia (Table

3.35)

– Causes of referred otalgia (Table

3.36)

Table 3.34 Difference between primary and referred otalgia

Primary otalgia (pain originates in ear) Referred otalgia (pain originates outside ear) Middle ear—acute otitis media, otitic barotrauma,

bullous myringitis, haemotympanum, carcinoma

External auditory canal and pinna—acute otitis externa, impacted wax, furunculosis, otomycosis, infected preauricular sinus, haematoma, perichondritis, frost bite, sunburn, laceration, bite, keratosis obturans

Inner ear—noise, barotrauma Laryngeal pathology—laryngeal carcinoma,

Mastoid—mastoiditis, trauma, subperiosteal abscess Dental pathology—impacted least molar, dental caries,

Tonsillar pathology—acute tonsillitis, peritonsillar abscess, Eagle’s syndrome (stylalgia) and glossopharyngeal nerve

Pharyngeal pathology—tumour of pharynx, glossopharyngeal nerve, pharyngeal branch of glossopharyngeal nerve (Jacobson’s nerve), glossopharyngeal neuralgia

hypopharyngeal carcinoma—auricular branch of vagus nerve (Arnold nerve)

periodontal infection, ill-tting denture, TM joint dysfunction

• Type of pain – Nociceptive pain—This is as a

result of tissue injury.

– Inammatory pain—This is due to

inammation.

– Neuropathic pain—This is due to

nerve irritation.

– Functional pain—pain without

obvious origin.

• Side of pain—Right or left side should

be noted.

• Site of pain (Table3.37)

• Nature of pain (Table3.38)

Table 3.35 Diagnosis making in primary otalgia

History Examination D/D Pain starts while scuba diving,

ying in an airplane Heaviness in ear Retracted drum ETD H/o swimming, ear cleaning Tragal tenderness Otitis externa H/o upper respiratory tract infection

(URI) present Retroauricular pain in patient of DM

or immunocompromised state Pain develops before lesion (rashes),

hearing loss; vertigo may be present Recurrent swelling of pinna and

hearing loss Localized pain Mass/growth/cyst present Tumour or infected cyst Pain in ear Bullae present over TM Bullous myringitis Otalgia, arthralgia, hearing loss, oral

ulcer, otorrhoea, myalgia, rhinorrhoea

TM may show haemotympanum Barotrauma

Inamed TM Acute otitis media

Granulation in EAC, lower cranial nerves (9, 10, 11, 12th) neuropathies

Vesicular rashes on pinna and EAC Facial nerve palsy may be present or absent

Earlobe is spared; other cartilage may be involved

COM or SOM (antineutrophilic cytoplasmic antibody present)

Malignant otitis externa

Ramsay Hunt syndrome (herpes zoster oticus)

Relapsing polychondritis

Wegener granulomatosis

Table 3.36 Diagnosis making in referred otalgia

History Examination Differential diagnosis Difculty in chewing Tenderness over TM joint movement Temporomandibular joint syndrome Throat pain Tonsillar hypertrophy Pharyngitis, tonsillitis Dental pain and caries Swelling or caries teeth Dental disease Neck pain Tenderness over neck Cervical spine arthritis Dysphagia Growth over tonsil Carcinoma tonsil Change of voice Growth over larynx Carcinoma larynx

3 History andExamination ofEar

Table 3.37 Differential diagnosis according to the site of pain

Site of pain Differential diagnosis Preauricular Preauricular abscess, preauricular

lymphadenitis, parotitis, TM joint dysfunction

Auricular Perichondritis, haematoma, abscess,

AOE, wax, AOM Otomycosis, haemotympanum, SOM, retracted TM

Postauricular Postaural abscess, lymphadenitis,

fracture temporal bone

Table 3.38 Differential diagnosis according to the nature of pain

Dull Oedematous otitis externa, secretary

otitis media, wax Sharp Furunculosis, otic barotrauma Throbbing ASOM, malignant otitis externa

• Duration—The duration can be either more than 3 months or less than 3 months termed chronic and acute accordingly (Table3.39).

• Mode of onset of pain—The pain can be either sudden or gradual in onset (Table3.40).

• Severity of pain—The severity of pain may be mild, moderate or severe (Table3.41).

• Aggravating or relieving factors

– Pain relieved with discharge—

ASOM

– Pain increased with swallowing—

AOM

– Pain increased on yawning or

chewing—furunculosis of anterior wall of EAC

• Association with discharge—Otalgia can be associated with discharge; types and timing of association helps in making diagnosis (Table3.42).

• Other associated symptoms – Oropharyngeal symptoms that

may suggest a head and neck cancer are dysphagia, dysphonia, odynophagia, haemoptysis, weight loss, smoking history

– Audiological symptoms—pro-

gressive or sudden onset hearing loss, tinnitus, vertigo, discharge, swelling

– Eye symptoms (loss of vision,

black spots) – Pain on chewing, trismus – H/o immunosuppression or diabe-

tes mellitus which may allow an

infection to rapidly progress

(f) Injury/trauma—The ear can be injured

(traumatized) in a number of different ways. The more common types of injuries are a slap to the ear, a cotton swab injury, a severe blow to the head from falling off a bicycle or height, motor vehicle accident, etc. These types of injuries can range from minor to severe.

• Symptoms of trauma/injury to ear – Bleeding

Active bleeding +/− Site of bleeding—It can be from external ear or middle ear. Severity of bleeding—mild, moderate or severe

– Deformity—present or absent

Minor deformity—partial loss of pinna, stenosis of EAC Major deformity—complete loss of pinna, atresia of EAC

– Watery discharge—It suggests

CSF otorrhoea.

– Hearing loss—The degree/severity

of hearing loss is noted.

3.1 Symptoms/History/Chief Complaints ofEar Diseases

Table 3.39 Differential diagnosis according to the duration of pain

Acute < than 3months Chronic > than 3months External ear Perichondritis, acute otitis externa, otomycosis Malignancy Middle ear ASOM, bullous myringitis, trauma to TM Retracted TM, adhesive otitis media Inner ear Labyrinthitis, noise-induced Noise-induced

Table 3.40 Differential diagnosis of otalgia according to onset

Sudden onset Gradual onset External ear Furunculosis, otic barotrauma, trauma Otitis externa secondary to CSOM,

malignancy, malignant otitis externa Middle ear Acute otitis media Serous otitis media Inner ear Barotrauma, acoustic trauma Acoustic trauma

Table 3.41 Differential diagnosis of otalgia according to severity

Mild Moderate Severe

External ear FB in ear, trauma, eczema

in EAC

Middle ear SOM, retraction of TM Secretary otitis media,

Inner ear Barotrauma

Otomycosis, wax Otitis externa, malignant otitis

externa, furunculosis, Ramsay Hunt syndrome, abscess in EAC, keratosis obturans

Bullous myringitis, acute otitis haemotympanum, traumatic perforation

Labyrinthitis

media

Petrositis

Table 3.42 D/D of association of pain with discharge

Types of association Denition Cause Pain followed by discharge Pain develops rst, then discharge ASOM, furunculosis Pain following discharge Discharge develops rst, then pain Otomycosis, acute otitis externa Pain persists with discharge Both develop together and persist Otomycosis, Luc’s abscess

Table 3.43 Differential diagnosis trauma to ear

Mode of injury Symptoms Diagnosis/ndings Slap to the ear, cotton swab injury,

falling off bicycle, barotrauma, acoustic trauma

Vehicle accident, falling from height Watery discharge from ear CSF otorrhoea Road trafc accident (RTA), falling

from height, barotrauma RTA, fall from height Facial paralysis, vertigo Fracture temporal bone

– Facial paresis—Either it is com-

plete or partial, immediate onset or late onset.

• Associated symptoms—hearing loss, associated injury, vertigo, neurological decit, facial injury.

Hearing loss, blocked ear, dizziness, tinnitus bleeding from ear

Blocked ear, tinnitus, hearing loss Haemotympanum

Perforation of TM, dislocation of incudostapedial joint, laceration in EAC

• Mode of injury—The mode of injury to ear is different in different individuals and presents with different symptoms (Table3.43).

• Type of injury

– Burn (thermal injury and electrical

injury)

3 History andExamination ofEar

– Blunt Trauma—Slap on ear, falls,

car accidents, head trauma, sports injuries, or ghts may perforate the TM or dislocate the ossicles or damage the inner ear. Wrestlers, boxers, and athletes may have subperichondrial haematoma of pinna due to repeated forceful hits to the pinna (cauliower ear).

– Sharp injury/trauma—It ranges

from simple laceration to amputation of pinna.

– Fire arm injury—Firearm that pro-

duces the sound of more than 130dB may cause acoustic trauma.

– Barotrauma (trauma due to pres-

sure change)—it happens in scuba diving, ying in an airplane, driving at high altitudes, shock waves.

– Acoustic trauma (injury due to

sound/noise exposure)—It is dened as injury to ear due to exposure to loud sound. It may be either due to single exposure to very loud sound or due to longterm exposure to signicant decibel sound. In this, patient rst begins to have difculty hearing high-frequency sounds, then lower frequency sound. Acoustic trauma may cause a buzzing or ringing type of tinnitus. H/o exposure to loud sound for long period such as industrial equipment, frequently attending music concert, gun range.

• Time/duration of injury—It should be noted because it is important in medicolegal cases.

• Site of injury—It should be noted because it is important in medicolegal cases.

(g) Facial palsy or paresis—This is one of

common symptoms of ear diseases, temporal bone trauma, facial nerve infection. The facial paralysis can be presented as:

• Presentation/history of facial nerve paralysis

– Common complaints/symptoms of

facial palsy

Dropping of one side of face Difculty closing eye Watery or dry eye Difculty in smiling or expressionless face Dribbling of corner of mouth Sensitivity to high pitch sound Possible altered taste

– Other symptoms are altered taste,

phonophobia, postauricular pain, lacrimal dysfunction, otalgia, facial paraesthesia, hyperacusis, cold sore

– Associated symptoms are pain,

discharge, fever, blisters, etc.

• Duration – Acute—If duration is less than

3 months, and causes are AOM, trauma, Bell’s palsy, Ramsay Hunt syndrome.

– Chronic—If duration is more than

3 months, and causes are CSOM, H/o trauma, facial nerve tumour, Bell’s palsy.

• Mode of onset – Sudden onset—Rapid onset of

mild weakness or total paralysis of face on one side or both sides, occurring within hours to days, e.g. Bell’s palsy, trauma (transection of nerve or bony fragment impinges on nerve).

– Gradual/insidious onset—Slow

onset of mild weakness or total paralysis of face on one side or both sides over a period of weeks or months, e.g. facial nerve schwannoma, cholesteatoma, trauma (oedema of nerve).

• Degree of facial palsy – Partial—Partial facial paralysis is

suggestive of partial obstruction of transmission of impulse due to neurotmesis, axonotmesis and presents with slight weakness of facial movement. This is also

3.1 Symptoms/History/Chief Complaints ofEar Diseases

termed as facial paresis and caused by CSOM, ASOM, Bell’s palsy, Ramsay Hunt syndrome, acoustic neuroma.

– Complete—Complete facial paral-

ysis presents with no movement of face due to complete cessation of transmission of impulse through nerve. This is caused by complete transection of nerve by either trauma, cholesteatoma or carcinoma ear.

• Side—The facial paralysis can be either unilateral or bilateral (Table3.44).

• Associated symptoms and h/o

– Postauricular pain—Ramsay Hunt

syndrome

– Ear discharge—CSOM, ASOM,

trauma

– Bleeding from ear—trauma, gran-

ulation with CSOM – Pregnancy—Bell’s palsy – Hearing loss, vertigo—vestibular

schwannoma – Mass in EAC—carcinoma of

mastoid – H/o risk factors like diabetes, preg-

nancy, age (>60years), high blood

pressure.

(h) Bleeding from ear

• Site of bleeding—The bleeding can be from preauricular, auricular or postauricular (Table3.45).

• Duration

– Acute/short—trauma, bleeding

disorder, decreased platelet count, infection

– Chronic/long mass/growth, bleed-

ing disorder, granulation, cholesteatoma

• Mode of onset

– Sudden—trauma, infection,

tumour, haemangioma, glomus tympanicum

– Insidious—infection, bleeding dis-

order, granulation

• Amount of bleeding

– Mild/small—infection, carcinoma,

granulation – Moderate—haemangioma, trauma – Severe/large—bleeding disorder,

thrombocytopenia, glomus

tympanicum

• Associated symptoms/h/o trauma— present/absent, h/o bleeding from other sites, previous history of bleeding, h/o bleeding disorder, hearing loss, pain, vertigo, facial palsy, mass or growth.

Table 3.44 Differential diagnosis of facial nerve palsy

Unilateral facial palsy Bilateral facial palsy Bell’s palsy, traumatic facial palsy, infectious,

cholesteatoma, tumour, surgical, acoustic neuroma, malignancy, parotid tumour

Table 3.45 Differential diagnosis of bleeding from ear

Preauricular Auricular (external ear, ME, inner ear) Postauricular Haemangioma,

trauma

Causes of external ear—haemangioma, trauma to EAC, FB in external ear, carcinoma ear, head trauma, Iatrogenic Causes of ME—myringitis bullosa, trauma to TM, FB in ME, granulation, head trauma, glomus tympanicum, glomus jugulare Causes of inner ear—barotrauma

Moebius syndrome, GB syndrome, sarcoidosis, myotonic dystrophy, skull trauma, infectious mononucleosis, CMV, acute porphyria, botulism, Lyme disease, Bell’s herpes simplex

Haemangioma, trauma, laceration

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