Книга_4540_Библиотеки_им_академика_М_И_Перельмана

Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

26 Мб

Скачать

☆

<<< < Предыдущая 8 9 10 11 12 13 14 15 16 17 18 1920 / 4720 21 22 23 24 25 26 27 28 29 30 31 32 > Следующая >>>

178

CHAP TER6 Theear

Common presentations

• Abnormal sounds (tinnitus)

• Dizziness

• Fullness/ discharge

• Injuries

• Itching

• Loss of hearing/ deafness

• Pain (otalgia)

• Swellings.

Common problems and theircauses

Abnormal sounds (tinnitus)

Common

• Wax impaction

• Glueear

• Infections (otitismedia)

• Perfor ated eardrum

• Noise induced

• Presbycusis

• TMJ disorders

• Ototoxicdrugs

• Many patients have underlying depression and anxiety.

Uncommon

• Insects

• Otosclerosis

• Ménière’s disease

• Trau m a

• Acoustic neuroma

• AVMs and venoushums

• Glomus jugulare and carotid body tumours

• Patulous Eustachian tube and palatal myoclonus.

Dizziness

Common

• Otological causes:

•

Benign paroxysmal positional vertigo

•

Ménière’s disease

•

Iatrogenic (middle ear/ mastoid surgery)

•

Impac tedwax

•

Ear infection (otitismedia)

• Systemic causes:

•

Migraine

•

Medications.

COMMON PROBLEMS AND THEIRCAUSES

Uncommon

• Otological causes:

•

Cerebellopontine angle tumours

•

Perilymphatic stulas

•

Trauma (tempor al bone fracture)

•

Vestibular neuronitis/ labyrinthitis

•

Oto syphilis

• Systemic causes:

•

Metabolic disorders (hypo/ hyperthyroidism, diabetes)

•

Vascular cause (vertebrobasilar insuciency, Eagle syndrome)

• Neurological disorders (stroke, seizures, Parkinsonism).

Fullness/ discharge

Common

• Chronic suppurative otitis media (mucoid)

• Furunculosis or local abscess (purulent)

• Trauma (bloody/ CSF)

• Eczema (watery)

• Acute otitis media (bloody)

• Eustachian tube dysfunction

• Wax.

Uncommon

• Nasopharyngeal malignancy (bloody)

• Cholesteatoma (foul smelling)

• Ménière's disease.

Injuries

Common

• Blunt/ bruising

• Lacerations.

Uncommon

• Bites (animal/ human)

• Avulsions/ tears

• Barotrauma.

179

Itching

Common

• Otitis externa

• Contact dermatitis.

Uncommon

• Cholesteatoma.

180

CHAP TER6 Theear

Loss ofhearing/ deafness

Common

• Acute otitismedia

• Acoustic trauma/ trauma

• Eustachian tube dysfunction

• Wax impaction

• Presbycusis

• Idiopathic.

Uncommon

• Autoimmune, Ménière’s,MS

• Infections (herpes, mumps, cytomegalovirus, toxoplasmosis,

syphilis)

• Foreignbody

• Otosclerosis

• Drugs

• Metabolic (diabetes/ thyroid)

• Tumour.

Pain (otalgia)

Common

• Acute otitis externa

• Otitis media with eusion

• Referredpain

• Furuncles (infected hair follicles)

• Perichondritis.

Uncommon

• Malignant otitis externa

• Barotrauma

• Herpeszoster

• Tumours

• Mastoiditis.

Referredpain

• Tonsillitis and upper respiratory tract disease

• Eustachian tube dysfunction

• Dental pathology

• Disorders of theTMJ

• Parotid disease

• The oropharynx

• The lar ynx and pharyn x

• Cervical spondylosis

• Malignancy of any of the above- listed (par ticularly the tonguebase).

USEF UL QU ESTI ONS AND WHAT TO LOOKFOR

Swellings

Common

• Pinna haematoma (trauma)

• Perichondritis of thepinna.

Uncommon

• Seroma/ pseudocyst of thepinna

• Erysipelas

• Gout

• Sebaceouscyst

• Herpes zoster.

Useful questions and what tolookfor

Abnormal sounds (tinnitus)

Askabout

• Character of tinnitus:unilateral or bilateral, high- pitched or low-

pitched (roaring, buzzing), pulsatile, clicking

• Progression and frequency

• Severity:eect on sleep, dailylife

• Histor y oftr auma

• Medications

• Underlying anxiety and depression.

Lookfor

• Look for retrotympanicmasses

• Audiblebruits

• TMJ dysfunction

• Similar work- up as evaluating hearingloss.

181

Dizziness

Askabout

• Describe dizziness:rotatory vertigo (‘spinning’, ‘whirling’, or

‘turning’ of patient or surroundings), disequilibrium (‘o- balance’), lightheadedness (sense of impending faint), physiological dizziness (motion sickness)

• Duration:seconds to minutes (benign paroxysmal positional

vertigo (BPPV), arrhythmia), hours (Ménière’s, migraine), days (vestibular neuritis, labyrinthitis), or constant (central)

• Associated symptoms:hearing loss, aural fullness, tinnitus,

sympathetic response (nausea, vomiting), central symptoms (numbness, weakness, diplopia, blurred vision)

182

CHAP TER6 Theear

• Contributing factors:medications (antihypertensives, ototoxic

medications, sedatives); medical history (hypertension, cardiac arrhythmias, diabetes, vascular disease, otological disease, neurological disease, migraines).

Lookfor

• General exam:(pulse, BP:standing and lying, carotid bruit s), with

focus on neurological, cardiovascular, and peripheral vascular disorders

• Otoscopy:otitis media, glue ear, cholestatoma

• Neurological exam:for cranial nerve palsies, vestibulospinal

reexes (e.g. Romberg’s test, gait, past pointing test), later alizing signs (e.g. weakness, paraesthesia)

• Eye movements:check pursuit and for nystagmus

• Specic tests:Dix– Hallpike, head- shake, stula test, caloric testing,

tuning fork, and audiometry.

Fullness/ discharge

Askabout

• Tinnitus

• Hearing disturbance

• Autophony (abnor mal hearing of one's own voice and respiratory

sounds)

• Nasal obstruction

• Otalgia

• Otorrhoea

• Rhinorrhoea

• Sore throat.

Lookfor

• Otoscopy for signs of infection, wax, discharge,etc.

• Examine the throat/ nasopharynx for disease

• Nasal endoscopy

• Ask patient to perform the Valsalva manoeuvre.

Injuries

Askabout

• When it occurred?

• Mechanism ofinjury

• Loss of consciousness/ neck,etc.

• Hearingloss

• Dizziness.

Lookfor

• Other injuries

• Facial nerve weakness

• Hearing loss (tuning forks if stable)

• Nystagmus

USEF UL QU ESTI ONS AND WHAT TO LOOKFOR

• Other neurological decits and cranial nerve palsies

• CSFleak

• Haemotympanum

• External auditory canal lacerations

• Battle’s sisgn (ecchymosis over the mastoid process).

Itching

Askabout

• Dischar ge from theear

• Tenderness orpain

• Cough

• Fever andchills

• Headache

• Runnynose

• Sneezing

• Sore throat.

Lookfor

• Crusting or akingskin

• Redness, warmth, or swelling.

Loss ofhearing/ deafness

Askabout

• Onset and duration, constant vs intermittent, progression,

unilateral or bilater al, high or low tone loss, decreased speech intelligibility

• Contributing factors:recent infection; loud noise exposure

• Recent tr auma:barotrauma, head injury; exacerbating factors for

tinnitus (sleep, exercise, caeine, alcohol)

• Previous otological surgery, infections

• Medications

• Systemic:history of autoimmune disease, hyper tension, diabetes,

vascular disorders, neurological disease (stroke), depression

• Family history of deafness

• Associated symptoms:aural fullness, fever s, ver tigo, tinnitus,

otalgia, otorrhoea, other neurological complaints.

Lookfor

• Malformations, auricular pits, scars, oedema, mastoid tenderness,

tragal tenderness

• Otoscopy (wax, lesions, masses) and tympanic membrane (colour,

thick ness, presence of uid, perforations)

• Pneumatic otoscopy:test mobilit y of tympanic membrane with

positive and negative pressure

• Fistula test:positive pressure causes nyst agmus which rever ses

with negative pressure (perilymph stula and labyrinthitis)

• Neurological and vestibular exam,bruits

• Tuning forktests.

183

184

CHAP TER6 Theear

Pain (otalgia)

Askabout

• Duration of symptoms

• Discharge

• RecentURTI

• Hearingloss

• Degree of pain and radiation (malignant otitis externa pain is often

severe, post- auricular pain suggests mastoiditis)

• Previous episodes and treatment todate

• Previous ear surger y

• PMH (diabetes or other immune compromise)

• Injury to the mandible (fractured condyle).

Lookfor

• Swelling

• Discharge

• Furuncles

• Signs ofinjur y

• CN VII weakness

• Systemicupset

• Tenderness over the mastoid prominence

• Otoscopy (bulging of the external auditory canal/ tympanic

membrane may appear red, per forated, and discharging).

Swellings

Askabout

• Any known aetiological factors

• Histor y oftr auma

• Any preceding otalgia (perichondritis can arise following otitis

externa and trauma)

• Predisposing factors (e.g. immune compromise)

• Any painful (pseudocyst can present as a painless swelling).

Lookfor

• Conrm presence

• Discharge

• Otoscopy:inspection of ear drum and middle ear (otitis media,

glue ear, cholesteatoma).

EX AMIN ATION OF THEEAR

Examination oftheear

Applied anatomy

Externalear

This comprises of pinna, external auditory meatus (EAM), external auditory canal, and tympanic membrane (ear dr um). The skin on the outer part of the E AM is self- cleansing and contains hair follicles and waxproducing ceruminous glands. These are absent on the inner part. Ears are normally self- cleansing and use of cotton buds should be discouraged. If wax is dislodged into the deeper part of the canal it cannot be removed by this natural process.

Middleear

This is an air- cont aining space allowing sound transfer to the cochlea. It contains three ossicles (malleus, incus, and stapes), two muscles (tensor tympani and st apedius), and part of the facial nerve (chorda tympani branch). Equalization of pressures occurs via the Eustachian tube. The mastoid air cells communicate with the middle ear space. This is closely related to the brain (middle cranial fossa), jugular bulb (posteriorly), and labyrinth (medially). Infections in middle ear are potentially very serious as they can extend into surrounding structures.

Innerear

This comprises the cochlea, vestibule, and semicircular canals. The ‘membranous’ par t is lled by endolymph and is surrounded by the bony labyr inth, which is lled with perilymph. The cochlea contains the organ of hear ing (organ of Corti). The vestibule and semicircular canals are involved in balance.

Nerve supply totheear

The ear is innervated by the V, IX, and X cranial nerves, and by the posterior roots of C2 and C3. Because of this, pathology at sites of similar

nerve distribution (TMJ, dental, oropharyngeal, laryngeal, and hypopharyngeal) can present with otalgia (referredpain).

Examination oftheear

Inspect the external ear r st. Remove any discharge or wax. Look for obvious signs of abnormality:

• Size and shape of thepinna

• Extra cartilage tags/ pre- auricular sinuses orpits

• Signs oftrauma

• Skin lesions, e.g. neoplasia

• Skin condition of the pinna and externalcanal

• Infection/ inammation of the external ear canal, with discharge.

Then palpate for mastoid tenderness, tragal tenderness, and lymphadenopathy. Use an otoscope (auroscope) to inspect the exter nal auditory canal and tympanic membrane. Gr asp the pinna and gently pull it up and backwards. This helps str aighten the canal for inspection (in infants, pull the pinna posteriorly). Note the condition of the canal skin and the

185

186

CHAP TER6 Theear

presence of wax, foreign tissue, or discharge. Inspect the tympanic membrane for signs of injury, perforation, or discharge. The mobility of the eardrum can be evaluated using a pneumatic speculum, which attaches to the otoscope. Check facial nerve function.

Special manoeuvres include the following:

Dix– Hallpike manoeuvre

This is a positional test for BPPV. The patient sits upright with the legs extended. Their head is rotated by approximately 45 degrees. The clinician then helps the patient to quickly lie down backwards with the head held in approximately 20 degrees of extension. The patient’s eyes are obser ved for nystagmus. If rot ational nystagmus occurs then the test is considered positive for benign positional vertigo.

Head- shake nystagmus

Move the head in the horizont al plane for 20– 30 seconds, then suddenly stop and evaluate for nystagmus.

Fistula test and pneumatic otoscopy

Positive pressure causes nystagmus which reverses with negative pressure (perilymph stula and labyrinthitis). Test mobility of tympanic membrane with pressure changes.

Tuning forktests

Rinnetest

Use a 512 Hz tuning fork to compare air conduction (AC) and bone conduction (BC). Strike the tuning fork then place it within 1cm of the EAM (AC) and then immediately place on the mastoid(BC).

Normal hearing

AC should be greater than BC and so the patient should be able to hear the tuning fork next to the pinna after they can no longer hear it when held against the mastoid.

Abnormal hearing

• If they are not able to hear the tuning fork after the mastoid, it means

that BC is greater than AC. Something is inhibiting the passage of

sound from the ear canal, through the middle ear apparatus and into

the cochlea (i.e. there is a conductive hearingloss).

• In sensorineural hearing loss both BC and AC are equally diminished.

Patients with sensorineur al hearing loss can usually hear better on

the mastoid process than air, but indicate the sound has stopped

much earlier than conductive loss patients.

Webertest

Strike the tuning fork and place it in the centre of the forehead. The perceived sound should normally be heard centrally.

Remember that nasophar yngeal pathology can present with unilateral ear symptoms. Always look at the throat and nasopharynx, especially in adults presenting with unilateral glue ear — this can be a presenting symptom of a nasopharyngeal tumour.

INVESTIGATIONS

Investigations

Laborator ytests

• FBC may show a raised WCC (neutrophils).

• Electrolytes:ototoxicity

• Glucose:screen for diabetes (associated with hearingloss)

• Coagulation and immunological prole:coagulopathies can be

associated with hearing disorders

• ESR

• Treponemal studies:Lyme titres/ TPHA/ VDRL/ FTA- ABS depending

on where youwor k

• Lipid prole:atherosclerotic disease can be associated with sudden

senorineural hearingloss

• Fluid analysis (beta- 2 tr ansferr in in suspected CSF leakage)

• Microbiology for any discharge.

Plainlms

Mastoid X- rays:will show opacity of the air cells. These and other special views of the temporal bone (Schuller’s, Stenvere’s, Towne’s views) have now largely been replaced by CT andMRI.

CT/ MRI oftemporalbones

These look for potential complications of suppurative ear disease, cho lesteatoma, mastoiditis, temporal bone fracture, congenital disorder or neoplasm (especially acoustic neuroma).

MRI is often required for suspected cerebellopontine angle tumours,

acoustic neuromas, meningiomas, and petrous apex lesions.

Audiometrictests

Audiometr y tests are carr ied out in soundproofed rooms using precision equipment. Tests may be subjective (pure tone audiograms, speech audiometry), or objective (impedance audiometry, evoked response audiometry).

These tests are essential to dene auditory function and to quantify

the thresholds of AC/ BC hearing for both ears. It distinguishes conductive loss from sensorineural hearing loss; cochlear ver sus neural dysfunction, and malingering (pseudohypacusis).

Dierent audiologicaltests:

• Pure tone audiometr y:tests threshold of AC andBC.

• Tympanometry:check s middle ear pressure and impedance (indirect

measure of Eustachian tube function).

• Auditory brainstem response (ABR):recording of the activity of the

eighth ner ve and central auditor y pathway response to an auditor y signal.

• Otoacoustic emissions (OAEs):tests objective sounds in external

auditory canal emitted from outer hair cells (cochlearecho).

• AB R and OAE are objective tests and do not need the patient’s

cooperation and hence used identify malingerers and for medicolegal purposes.

187

<<< < Предыдущая 8 9 10 11 12 13 14 15 16 17 18 1920 / 4720 21 22 23 24 25 26 27 28 29 30 31 32 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202627 Мб0Книга_4533_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202627 Мб0Книга_4534_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_4537_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_4538_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_4539_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_4541_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_4544_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_4545_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202625 Мб0Книга_4547_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202625 Мб0Книга_4548_Библиотеки_им_академика_М_И_Перельмана.pdf