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

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Presentation on theme: "Otalgia, Temporal bone fracture, C.S.F. otorrhea, Ototoxicity Dr. Vishal Sharma."— Presentation transcript:

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

6

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. 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: 1.Longitudinal (80%) 2.Transverse (20%) Recent view: > 90% are mixed or oblique fractures especially in severe trauma

12

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 90 0 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 FeaturesLongitudinalTransverse Incidence 80%20% Trauma site Temporal or parietalFrontal / occipital CSF leak OtorrheaOto-rhinorrhea Hemotympanum Occasional Common EAC lacerations CommonOccasional TM perforation CommonOccasional Otorrhagia CommonOccasional Hearing lossConductiveSensori-neural Facial palsy20%, temporary, delayed onset 50%, permanent, early onset Vertigo + nystagmusOccasionalCommon, severe

21 CT scan axial cut Longitudinal Transverse

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. 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 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


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