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170 Disorders of the Auditory System
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B
Figure 4–10. continued
Audiologic Recommendations
and Management
Due to the bacterial meningitis, which
was diagnosed 1 week following the
accident (see discussion in the following
medical section), it was recommended
that the patient be closely monitored
audiologically. Both the patient and his
parents were counseled to alert audiology
immediately should any changes in hearing be noted. It was also recommended
that a trial fitting with a contralateral
routing of signal (CROS) hearing aid be
considered.
Medical Recommendations
and Management
The patient remained stable until approximately 1 week following the accident. At
which time, the patient’s recovery became
complicated by a cerebrospinal fluid leak
and bacterial meningitis. Due to these
complications, the patient was taken to
the operating room by otolaryngology
and neurosurgery for a left total facial
nerve decompression and left transmastoid and transcranial repair of the temporal bone. In addition, repair of a dural
defect and placement of a lumbar drain
was required. These procedures were
completed without complication.
The patient was eventually discharged from the hospital. Prior to his
discharge, his parents were counseled
regarding the fact that it was unlikely
their son would regain any hearing function in his left ear and left facial nerve
function would be monitored for possible
recovery of or improvement. Postoperatively, the patient has demonstrated no
significant audiologic changes. To date,
the patient continues to have left-sided
facial paralysis and no residual hearing in
the left ear. Hearing sensitivity and facial
nerve function for the right side continues
to be normal.
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171
C
Figure 4–10. continued
172 Disorders of the Auditory System
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otheR disoRdeRs
affecting the outeR
and
middle eaRs
External Otitis
External otitis is an infection of the ear
canal and/or the pinna that is often
noticed in the summer months and is
commonly caused by swimming in water
with high counts of bacteria. It is typically caused by a bacterial invasion into
the external ear canal. The most common
bacteria is Pseudomonas. External otitis can
also be related to fungal infections, but
these are relatively rare. In viewing the
ear canal, mucopurulent matter is usually
observed along with redness and swelling of the tissue involved. The patient will
complain of severe discomfort, especially
when the pinna is moved. Audiologically,
there is seldom much of an effect on hearing unless swelling closes the ear canal.
Treatment of the patient includes cleaning
of the affected area and topical application
of antibacterial agents. These antibacterial agents are sometimes combined with
corticosteroids, which may provide better
treatment than antibacterial applications
alone (Castillo & Roland, 2007).
block the ear canal. The presence of exostoses in the ear canal may make it difficult to visualize the tympanic membrane.
If large enough to close off the ear canal,
these growths can cause conductive hearing loss. The ear canal, especially if cerumen is present, can be blocked by pushing
cerumen against the exostoses when ear
inserts are used. Therefore, care must be
exercised when using ear insert receivers
with patients with exostoses. Management of these patients usually involves
surgical removal of the exostoses (Zender,
Marzo, & Leonetti, 2007).
Osteomas are also bony growths and
are often confused with exostoses. These,
however, are usually singular in number
and are located more laterally in the canal.
They are a true neoplasm that is a mix of
bone and fibrous tissue, and they tend
to occur more often in children than in
adults. Audiologically, the same concerns
exist for osteomas as those mentioned for
exostoses. Osteomas occasionally can be
removed in the otolaryngologist’s office,
but often a brief general anesthetic is
required (Zender et al., 2007).
Tympanic Membrane
Perforation
Exostoses and Osteomas
Exostoses are bony growths occurring in
the medial (bony) portion of the ear canal
(see Appendix 4H). These multiple bony
growths seem to be related to cold water
exposure and are often seen in swimmers.
This is often a bilateral condition. Exostoses become bothersome only when they
trap debris in the ear canal or become so
large that they impinge on the eardrum or
Castillo and Roland (2007) provide a
review of tympanic membrane perforations from which we draw information.
These perforations generally are related
to trauma (blasts, penetrating injuries,
head trauma, etc.) or infections, such as
otitis media. Most tympanic membrane
perforations will heal spontaneously
unless they are large or are related to
ongoing or recurring infections. They can
occur in either the pars flaccida or pars
tensa. However, if they occur in the pars
4. Outer and Middle Ear Disorders 173
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flaccida, concern about cholesteatomas
would be in order.
Long-standing perforations also herald concern over possible cholesteatomas.
Small perforations generally do not yield
hearing loss; however, large tympanic
membrane perforations can result in up
to 50 dB of hearing loss, although in most
cases, the hearing loss is much less severe.
Increased volume measures during tympanometric testing are indications of tympanic membrane perforations unless the
patient has a PE tube in place. Careful otoscopic exams should always be completed
to determine if a tympanic membrane
perforation is present. Care must also be
taken during audiologic and vestibular
(caloric) exams whenever a perforation
is noted so that the tympanic membrane
perforation is not further disturbed or
contaminated. Treatment for tympanic
membrane perforations that do not spontaneously heal is otologic surgical repair
(see Appendix 4I for an example of a tympanic membrane perforation).
Tympanosclerosis
Tympanosclerosis is a condition in which
white calcified plaques of connective tissue occur at and around the circumference
of the tympanic membrane and/or the
head of the malleus (Castillo & Roland,
2007) (see Appendix 4J for an example of
tympanosclerosis). When these plaques
are only on the tympanic membrane,
the condition is called myringosclerosis, which is more common than tympanosclerosis. Both conditions are often
associated with chronic otitis media and
inflammatory processes of the middle ear.
Myringosclerosis seldom yields a measurable hearing loss; however, tympanoscle-
rosis can result in a hearing loss especially
if it involves the ossicular chain. In cases
with measurable hearing loss, the hearing
loss will be a conductive hearing loss and
the tympanograms will typically reveal
slightly reduced compliance (Castillo &
Roland, 2007).
Ossicular Chain Discontinuity
Multiple terms have been used to describe
conditions affecting the ossicular chain
where the normal articulation of the middle ear bones is absent or disrupted (e.g.,
ossicular chain discontinuity, ossicular
chain disarticulation, ossicular chain dislocation). Although this topic has been
discussed to some extent in the section of
this chapter that deals with temporal bone
trauma, it is important to highlight that
there are other etiologies that can result in
this middle ear disorder. Ossicular chain
discontinuity can be a result of various
types of congenital abnormalities, necrosis (secondary to chronic infections), and
surgical interventions, as well as trauma
(Castillo & Roland, 2007). The hearing
loss noted in cases of ossicular chain discontinuity typically is a conductive hearing loss; however, in some cases of head
injury, the associated trauma may cause
a subluxation of the ossicular chain with
injury to the cochlea, which results in a
mixed hearing loss (Castillo & Roland,
2007). Audiology plays a key role in the
diagnosis of ossicular chain discontinuity
in that near to maximum conductive loss
is often observed in patients with ossicular chain discontinuity. In addition, their
tympanograms show hypercompliance,
but no crossed acoustic reflexes even if
hearing sensitivity is good in the acoustically stimulated ear. If the ossicular chain
174 Disorders of the Auditory System
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is subluxed or fibrous tissue has formed to
keep the chain somewhat intact, the hearing may be relatively good with tympanograms showing either normal or reduced
compliance, and acoustic reflexes may
be measured in some cases; however, if
reflexes are noted, they are typically elevated (Jerger & Jerger, 1981). Treatment
of ossicular chain discontinuity is otologic surgery to repair the dislocation or
disarticulation of the ossicular chain and
to resolve the conductive hearing loss
that has resulted from the disarticulated
ossicular chain. This surgical procedure
involved is called ossiculoplasty (i.e.,
repair of the ossicular chain) and is quite
successful with closure of the air-bone gap
to within 10 dB slightly less than 75% of
the time (Castillo & Roland, 2007).
summaRy
This chapter provided a brief overview of
select conditions that affect the external
and/or middle ears. Diseases of these portions of the auditory system are diverse in
etiology and can have profound effects on
auditory function. Appropriate management of these diseases requires a combination of thorough history and physical
examination, careful audiologic testing,
and often appropriate diagnostic imaging.
A clear understanding of these conditions
and the implementation of appropriate
management procedures (whether audiological or medical) can lead to improved
auditory function and quality of life for
those patients who present with external
and/or middle ear disorders.
Acknowledgments. The authors grate-
fully acknowledge the contributions of
Matthew Bush, MD, PhD, Associate Professor, Department of OtolaryngologyHead and Neck Surgery, University of
Kentucky, to this chapter.
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