1. Otalgia, Temporal bone fracture, C.S.F. otorrhea, Ototoxicity
Dr. Vishal Sharma

2. Otalgia

3. Etiology of Primary Otalgia
Pinna
Laceration & bite
Hematoma
Otitis externa
Perichondritis
Infected pre-auricular sinus
Frostbite, sunburn
Neoplasm
External auditory canal
Impacted wax
Foreign body
Keratosis obturans
Otitis externa
Herpes zoster oticus
Exostoses
Neoplasm

4. Middle Ear
Bullous myringitis
Acute otitis media
Secretory otitis media
Traumatic perforation
Hemotympanum
Otitic barotrauma
Neoplasm
Mastoid
Mastoiditis
Mastoid abscess
Granulomas
Neoplasm
Inner ear
Acoustic trauma
Meniere’s disease
Vestibular schwannoma

5. Etiology of referred otalgia

7. A. Via trigeminal nerve
Teeth: infection, impacted 3rd molar, malocclusion
Oral cavity: infection, ulcer, malignancy, Ludwig’s angina, sialadenitis, salivary calculus
Temporo-mandibular joint: arthritis, dysfunction
Nose & PNS: impacted DNS, sinusitis, neoplasm
Nasopharynx: infection, post- adenoidectomy, adenoiditis, tumor
Trigeminal neuralgia

8. B. Via glossopharyngeal nerve
Tonsil: tonsillitis, peritonsillar abscess, post tonsillectomy, neoplasm
Oropharynx: infection, ulcer, retropharyngeal + parapharyngeal abscess, trauma, neoplasm
Eagle’s syndrome (stylalgia)
Glossopharyngeal neuralgia

9. C. Via facial nerve: Herpes zoster oticus, vestibular schwannoma D
C. Via facial nerve: Herpes zoster oticus, vestibular schwannoma D. Via vagus nerve: Larynx + hypopharynx: neoplasm, infection, tuberculosis, trauma, foreign body E. Via second & third cervical nerves: Herpes zoster, cervical spondylosis & arthritis

10. Temporal bone fracture

11. Introduction 30% of head trauma cases result in skull fracture
Temporal bone # comprises 15-25% of all skull #
Classification of temporal bone fracture:
Longitudinal (80%)
Transverse (20%)
Recent view: > 90% are mixed or oblique fractures especially in severe trauma

13. Longitudinal fracture
80% of all temporal bone fractures
Caused by lateral blows over temporal bone
Fracture line parallels long axis of petrous pyramid
Starts in pars squamosa, extends through postero-superior bony external canal, continues across roof of middle ear space (anterior to labyrinth), ends antero-medially in middle cranial fossa in close proximity to foramen lacerum & ovale

14. Longitudinal fracture

15. Clinical features Bleeding into ear canal from skin & TM laceration
External auditory canal fracture, hemotympanum
Conductive deafness: due to ossicular disruption
Facial nerve paralysis (20%): late onset, involves tympanic segment, usually temporary
CSF otorhinorrhea: common, usually temporary
Sensori-neural hearing loss & vertigo are rare

16. Transverse fracture 20% of all temporal bone fractures
Caused by frontal or occipital blows
Fracture line at 900 to long axis of petrous pyramid
Starts in middle cranial fossa (close to foramen lacerum), crosses petrous pyramid transversely & ends at foramen magnum. May extend through internal auditory canal & injure nerves directly.

17. Transverse fracture

18. Clinical features Profound sensori-neural hearing loss
Severe ablative vertigo
Third degree nystagmus present with fast component beating away from fracture site
Facial nerve paralysis (50%): early onset, permanent
Intensity of vertigo + nystagmus es after 7-10 days, continues to decrease steadily until compensation finally occurs after 3-6 months

19. Examination for temporal #
Complete neurologic + ENT examination
Otoscopy: EAC & TM lacerations, fracture lines
Siegalization: for presence of fistula
Eyes for nystagmus (direction + degree)
Tuning fork tests: type of hearing loss
Battle sign (ecchymosis of postauricular skin)
Raccoon sign (ecchymosis of periorbital area)
Kernig’s & Brudzinski’s test: for meningitis

20. 20%, temporary, delayed onset 50%, permanent, early onset
Features
Longitudinal
Transverse
Incidence
80%
20%
Trauma site
Temporal or parietal
Frontal / occipital
CSF leak
Otorrhea
Oto-rhinorrhea
Hemotympanum
Occasional
Common
EAC lacerations
TM perforation
Otorrhagia
Hearing loss
Conductive
Sensori-neural
Facial palsy
20%, temporary, delayed onset
50%, permanent, early onset
Vertigo + nystagmus
Common, severe

21. CT scan axial cut
Transverse
Longitudinal

22. Treatment of facial nerve palsy
A. Delayed onset & incomplete facial paralysis: oral Prednisolone for 2 weeks + observation
B. Immediate onset or complete paralysis  Nerve stimulation done b/w days 3 to 7 of trauma:
no loss of stimulability occurs: observation
loss of stimulability within 1 week or >90% degeneration on ENOG within 2 wks: surgical exploration

23. C.S.F. otorrhea

24. Introduction
Abnormal communication between subarachnoid space & tympano-mastoid space leading to discharge of cerebrospinal fluid through external auditory canal or via Eustachian tube into nasopharynx

25. Etiology A. Acquired (more common)
Operative trauma: mastoidectomy, stapedectomy, vestibular schwannoma excision, skull base surgery
Accidental trauma
Non-traumatic: infection, neoplasm
B. Spontaneous
Bony defect theory
Arachnoid villi granulation theory

26. Congenital defect theory: SNHL present
enlarged petrosal facial nerve canal
patent Hyrtl’s fissure (congenital fusion plane found b/w otic capsule & jugular bulb)
wide vestibular aqueduct (Mondini’s dysplasia)
annular ring of stapes footplate
Dehiscent tegmen plate
Arachnoid villi granulation theory: SNHL absent
Enlargement of arachnoid villi due to congenital entrapments / large pressure variations

27. Wide facial nerve canal

28. Patent Hyrtl fissure

29. Wide vestibular aqueduct

30. Arachnoid villi granulations

31. Clinical features H/o surgery / accidental trauma
Clear watery discharge from ear or nose: appears during straining or leaning forward (Dandy maneuver); salty taste
Unilateral hearing loss:
Sensori-neural: abnormality of inner ear
Conductive: leak elsewhere in temporal bone
Unexplained episode of meningitis

32. Investigations
Confirmatory test for CSF: glucose level > 30 mg/dL; presence of beta 2 transferrin
High-resolution CT scan with contrast
Abnormality of otic capsule: Mondini deformity
Wide vestibular & cochlear aqueducts
Tegmen plate defect
Localization of leak with intrathecal Iohexol
Presence & location of pneumocephalus

33. Medical treatment 1. Compressive dressing + bed rest (head elevation)
2. Prophylactic antibiotics indicated in:
post-traumatic CSF leakage
immuno-suppressed patient
obvious soilage of central nervous system
postoperative & spontaneous leaks (controversial)

34. 3. Medications to decrease production of CSF
a. Diuretics ( Frusemide, hydrochlorothiazide)
b. Carbonic anhydrase inhibitors (Acetazolamide)
4. Steroids (to reduce inflammation)
Hydrocortisone, dexamethasone
5. Continuous lumbar CSF drainage
Allows natural healing

35. Surgical treatment
Primary closure with multi-layer technique using cartilage + muscle + fascia + fat + bone wax
Approaches: Trans-canal, Trans-mastoid, Middle cranial fossa, Combined (middle fossa + trans-mastoid). Combined approach for large defect (>2cm), multiple defects, or defects that extend anteriorly.
Refractory cases: obliteration + closure of EAC

36. Ototoxicity

37. Definition
Tendency of certain therapeutic agents & other chemical substances to cause functional impairment + cellular degeneration of tissues of inner ear (especially end organs) & neurons of cochlear + vestibular division of the eighth cranial nerve (Hawkins, 1976)

38. American Speech-Language-Hearing Association definition
Pure tone audiometry:
20db or greater decrease in pure-tone threshold at one frequency
10db or greater decrease at 2 adjacent frequencies
Otoacoustic Emissions or BERA:
loss of response at 3 consecutive test frequencies where responses were previously obtained 

39. Classification of ototoxic agents

40. 1. Acetyl salicylic acid (Aspirin) 2
1. Acetyl salicylic acid (Aspirin) 2. Anti-malarial: quinine, chloroquine 3. Loop diuretic: ethacrynic acid, furosemide, bumetanide 4. Antibiotic: aminoglycoside, macrolide 5. Anti-neoplastic: cisplatin, bleomycin, 5-fluorouracil 6. Beta blocker: propranolol, atenolol, metoprolol 7. Anti-convulsant: phenytoin, carbamazepine 8. Topical: betadine, alcohol, chloramphenicol, ciprofloxacin 9. Miscellaneous: desferrioxamine, bromocriptine, imipramine

41. Clinical features
Hearing loss: B/L, symmetrical, high frequency, sensori-neural; temporary / permanent; may not manifest until several weeks or months after completion of ototoxic agent therapy.
Tinnitus
Vestibular toxicity: positional nystagmus, oscillopsia & dysequilibrium

42. Mechanisms of ototoxicity
Direct hair cell damage: outer hair cells affected first. Begins at basal turn of cochlea (high-frequency sloping SNHL) & proceeds toward apex (involvement of lower frequencies too)
Direct vestibular injury
Direct damage to stria vascularis
Metabolic (non-morphologic) damage

43. Acetyl salicylic acid Tinnitus: main symptom
Hearing loss: sensori-neural, reversible (within 72 hours of withdrawal), flat curve on audiogram
Etiology: multi-factorial due to metabolic rather than morphological damage to cochlea

44. Aminoglycosides Ototoxicity first with Streptomycin (1944)
Streptomycin, Gentamicin, Netilmicin: primarily vestibulotoxic; destroy type 1 hair cells of crista ampullaris
Kanamycin, Amikacin, Neomycin: primarily cochleo-toxic; damage outer hair cells at basal turn of cochlea
Tobramycin: vestibulotoxic + cochleo-toxic

45. Aminoglycoside clearance
Aminoglycosides cleared more slowly from inner ear fluids than from serum  latency exists to ototoxic affects of aminoglycoside  progression of hearing loss or onset of hearing loss after cessation of aminoglycoside treatment + prolonged susceptibility to noise-induced hearing loss

46. Macrolides Drugs: Erythromycin, Azithromycin, Clindamycin, Vancomycin
Cause reversible ototoxicity
Onset generally within 3 days of starting treatment
Speech frequencies affected rather than higher frequencies

47. Loop diuretics Drugs: ethacrynic acid, furosemide, bumetanide
Mechanism: changes in ionic gradients between perilymph & endolymph causing edema + damage of stria vascularis
Ototoxicity dose dependent, self limited & reversible

48. Anti-neoplastic agents
Drugs: cisplatin, carboplatin, bleomycin, 5-fluorouracil
Mechanism: Multi-factorial, partially mediated by free-radical production. Damage stria vascularis + outer hair cells at basal turn of cochlea.
Hearing loss bilateral, sensori-neural, progressive & irreversible

49. Quinine Oto-topical agent:
Toxicity produces tinnitus, hearing loss, vertigo, headache, nausea & vision loss
Hearing loss usually sensori-neural & reversible
Characteristic notch often present at 4000 Hz
Oto-topical agent:
Rare
Only possible if mastoid cavity is open or
tympanic membrane perforated

50. Brock’s grading of ototoxicity
Grade 0: threshold < 40 dB HL at all frequencies
Grade 1: threshold > 40 dB at 8000 Hz
Grade 2: threshold > 40 dB at Hz
Grade 3: threshold > 40 dB at Hz
Grade 4: threshold > at 40 dB at Hz

51. High Risk Patients Larger doses of ototoxic agent
Higher blood levels of ototoxic agent
Longer duration of therapy with ototoxic agent
Receiving other ototoxic or nephrotoxic agent
Elderly patients
Renal insufficiency
Preexisting hearing problems
Family history of ototoxicity

52. Management No therapy available to reverse ototoxic damage.
Awareness of ototoxic agents & drug monitoring during treatment. Prompt reporting of tinnitus, hearing loss, oscillopsia & vertigo.
Alternative therapy for high-risk patients.
Avoid noisy environments for 6 months after treatment completion. Avoid co-prescription of ototoxic agents.
Amplification with hearing aid or cochlear implant.

53. Ototoxicity prevention drugs
α-tocopherol (vitamin E derivative)
D-methionine (amino acid)
Desferrioxamine (iron chelator)
N-acetyl-cysteine (antioxidant)
Caspase & Calpain inhibitors (prevent apoptosis)
Gene therapy

54. Thank You