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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3998_Библиотеки_им_академика_М_И_Перельмана
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Adult ear disease 97
ADULT EAR DISEASE
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What is the important nding on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.9 –
Ear discharge
A 25-year-old man presents with progressive hearing loss of 3 years and recently an intermittent, but
scanty, smelly discharge.
CASE 2.10 –
Progressive hearing loss
A woman aged 53 years presents with a 12-month history of a progressive, left-sided, sensorineural
hearing loss with occasional tinnitus.
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98 Ear, nose and throat (ENT)
OSCE Counselling cases
OSCE COUNSELLING CASE 2.9 –
What advice would you give to the
patient who is having a mastoid
exploration?
OSCE COUNSELLING CASE 2.10 –
A patient with a unilateral acoustic
neuroma wants to know the risk of
developing one on the other side.
What is your advice to the patient?
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Adult ear disease 99
Key concepts
Unilateral discharge with mucus means that there is a tympanic membrane perforation.
Unilateral discharge which smells foul suggests a cholesteatoma.
Always examine the eardrum.
A unilateral sensorineural hearing loss needs MRI to exclude an acoustic neuroma.
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100 Ear, nose and throat (ENT)
Answers
Clinical cases
CASE 2.9 –
Ear discharge
A1: What is the likely differential diagnosis?
The differential diagnosis includes otitis externa, or chronic middle-ear disease (chronic otitis media),
either a perforation or a cholesteatoma. A carcinoma is very rare.
A2: What additional features in the history would you like to elicit?
Ask about any hearing loss, pain, discharge, dizziness and tinnitus for each ear. Ask about the
relationships between the symptoms. If a patient has a progressive hearing loss together with an
intermittent scanty discharge, but no pain, it suggests a chronic middle-ear problem. If there is pain
the patient may have had either an acute middle-ear infection (acute otitis media) or otitis externa. If
the discharge is profuse and mucoid, it comes from the middle ear, so the eardrum must be perforated.
(There are mucus glands in the middle ear, but not in the external ear.) Middle-ear disease may produce
vertigo but the dizzy patient is considered later and you are referred to Cases 2.13 and 2.14.
A3: What is the important nding on examination?
The external ear canal and drum should be inspected. Start with the better ear and then proceed to
the diseased side. Note whether there is any wax or debris in the external canal. This requires removal
because the eardrum must be inspected fully. Do not syringe a discharging ear as this may transmit
infection medially. The history in this case suggests chronic middle-ear disease with cholesteatoma.
Cholesteatoma is the presence of squamous epithelium in the middle ear. This is thought to arise as a
repercussion of ear infections. It can erode into middle-ear structures (ossicles, labyrinth, facial nerve)
and may give rise to intracranial complications; this is why it is important to diagnose the condition.
Brown/white smelly discharge is seen in the attic and also sometimes in the posterior part of the
eardrum.
A4: What investigations would be most helpful and why?
This patient should have a pure-tone audiogram. High-resolution computed tomography (HRCT)
of the temporal bone is performed and can demonstrate the extent of disease and the presence of
complications – erosion of the semicircular canals, facial canals or tegmen tympani.
A5: What are the treatment options?
If a cholesteatoma is present, mastoid surgery is required to remove the disease and prevent intracranial
or intratemporal complications. If the patient has an infected perforation, this is initially treated with
antibiotic eardrops and a tympanoplasty (repair of eardrum with or without ossicle reconstruction) can
be considered.
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Adult ear disease 101
CASE 2.10 –
Progressive hearing loss
A1: What is the likely differential diagnosis?
Typically a unilateral, progressive, sensorineural hearing loss has no identiable cause, an acoustic
neuroma must be excluded (i.e. a tumour of the eighth nerve, which usually arises in the internal
acoustic meatus and can extend into the intracranial cavity by the brain stem). Occasionally, a unilateral
sensorineural hearing loss may arise from a viral infection or ischaemia, particularly in older patients.
A2: What additional features in the history would you like to elicit?
Ask about any hearing loss, pain, discharge, dizziness and tinnitus for each ear. Large acoustic neuromas
can cause facial nerve, trigeminal nerve and bulbar nerve dysfunction.
A3: What is the important nding on examination?
The external ear canal and drum should be inspected. Start with the better ear and then proceed to
the diseased side. Note whether there is any wax or debris in the external canal. This requires removal
because the eardrum must be inspected fully. A patient with a sensorineural hearing loss with no other
obvious cause has a normal eardrum. Tuning fork tests would demonstrate a Weber lateralizing to the
better hearing ear in a sensorineural hearing loss.
Cranial nerves should be examined and an assessment of balance function undertaken – heal-toe
gait. Patients with presbycusis typically have otoscopically normal ears.
A4: What investigations would be most helpful and why?
The patient should have an audiogram to determine whether the loss is conductive or sensorineural.
If sensorineural is conrmed, then an MRI scan is arranged to exclude a cerebellopontine angle lesion,
typically an acoustic neuroma, causing the loss.
A5: What are the treatment options?
The majority of patients investigated for unilateral or asymmetric sensorineural hearing loss have no
underlying cause found. Approximately 1.5 per cent have an acoustic neuroma causing their symptoms;
this is a benign tumour of Schwann cells of, usually, the vestibular nerve. Two-thirds of acoustic neuromas
do not grow in the long term. The primary management strategy for <2-cm tumours is conservative with
a wait-and-rescan policy. The patient is scanned at increasing intervals to conrm it is static. If the tumour
grows then it can be treated with stereotactic radiosurgery or surgical excision.
Rehabilitation of the patient’s hearing can be performed with a conventional hearing aid, or bone-
anchored hearing aid.
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102 Ear, nose and throat (ENT)
OSCE Counselling cases
OSCE COUNSELLING CASE 2.9 –
What advice would you give to the
patient who is having a mastoid
exploration?
The aims of mastoid surgery are twofold, to prevent potential intracranial and intratemporal
complications of a cholesteatoma (these are thankfully rare and occur in 4 per cent per decade the
disease is present), and to improve symptoms – chiey discharge and malodour, but also potential
hearing loss although hearing may be worse after surgery. There is a very small risk to the facial nerve
while undertaking middle-ear surgery, although the chance of damage is similar to the chance of
disease-related facial palsy if no surgery is undertaken. The disease may require some form of follow-up
for life if a mastoid cavity is created during surgery. Surgery often removes the self-cleansing external
ear skin and so wax and debris accumulate.
OSCE COUNSELLING CASE 2.10 –
A patient with a unilateral acoustic
neuroma wants to know the risk of
developing one on the other side.
What is your advice to the patient?
Unless a patient has neurobromatosis type 2, the risk of developing bilateral acoustic neuroma is
incredibly rare. It is possible to hear with one ear perfectly satisfactorily. Problems may occur in localizing
sound and discrimination in a noisy environment.
REVISION PANEL
A discharging ear is always pathological; the clinician should examine the ear thoroughly to
determine the cause.
Copious mucoid discharge is from a middle-ear infection with a perforated tympanic membrane.
Scanty discharge is due to a cholesteatoma or otitis externa – the diagnosis is made on
examination.
A unilateral sensorineural hearing loss is typically idiopathic; however, it may be caused by an
acoustic neuroma.
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Adult bilateral deafness 103
ADULT BILATERAL DEAFNESS
Questions
Clinical cases
For the clinical case scenario given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What is the important nding on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.11 –
Adult with bilateral deafness
A 66-year-old man comes to the department with decreased hearing over the previous 7 years and both
ears are the same.
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104 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.11 –
A patient wants to use a hearing aid
but feels that it will exacerbate the
condition. What is your advice?
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Adult bilateral deafness 105
Key concepts
Presbycusis (age-related hearing loss) may require a hearing aid.
Hearing aids work if the patient requests them.
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106 Ear, nose and throat (ENT)
Answers
Clinical cases
CASE 2.11 –
Adult with bilateral deafness
A1: What is the likely differential diagnosis?
Presbycusis
A2: What additional features in the history would you like to elicit?
Ask about any hearing loss, pain, discharge, dizziness and tinnitus for each ear. Ask about risk factors
for hearing loss/ear disease:
Ear operations – may have iatrogenic cause of hearing loss
Ear infections – can cause conductive or sensorineural hearing loss, or represent chronic otitis media
Noise exposure – occupational history
Head injuries – ask an occupational history
Systemic diseases such as diabetes mellitus and cardiovascular atheroma may exacerbate the ageing
changes
Previous/current use of ototoxic medications
Family history of hearing loss
Ask whether the patient wants a hearing aid – relatives often want the device rather than the patient.
This is a recipe for failure.
A3: What is the important nding on examination?
Patients with presbycusis typically have otoscopically normal ears.
A4: What investigations would be most helpful and why?
Assess the degree of hearing loss in both the low and the high frequencies. The high-frequency
component is the element associated with articulation. Patients will often say that they hear what
people say but they cannot understand.
A5: What are the treatment options?
Most patients who have a moderate hearing loss or greater require a hearing aid but the patient has
to accept this before it is worth prescribing one. If a patient is in two minds one should be tried for a
period and returned if it is unsatisfactory. Further audiometric assessment may be undertaken after a
year if a patient is unhappy with the hearing aid.
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