1. ENT update on common ear problems
The Spire Hospital Leeds
ENT update on common ear problems
seen in primary care, including hearing loss
The Leeds Teaching
Hospitals NHS Trust
Gerard Kelly MD MEd FRCS(Ed) FRCS(ORL-HNS)
ENT surgeon
20th April 2017

2. aims get an overview of audiology relevant to primary care
improve our knowledge common ear pathologies

3. objectives
define a hearing loss with reference to pure tone thresholds
identify symbols on an audiogram
diagnose otitis externa and chronic otitis media from a picture or scenario
list pros and cons of treatment for AOM
list symptoms of a ear condition
plan treatment for COM and otitis externa
list referral criteria for asymmetric hearing losses

4. Ear
6 symptoms
otorrhoea
otalgia
itch
hearing
tinnitus
balance

5. what is normal, what is poor hearing?
otology and audiology
what is normal, what is poor hearing?

6. otology and audiology what is normal, what is poor hearing?
pure tone average (dB)
0-20 normal
20-40 mild
40-70 moderate
70-95 severe
95+ profound
British society of audiology, 2011

12. otology and audiology
Browning, Clinical otology & audiology

13. audiology
Browning, Clinical otology & audiology

16. otology and audiology
Swan 1984

17. otology and audiology
Swan 1984

18. an audiogram

20. description?

21. description?
right high tone sensorineural hearing loss

22. asymmetric audiograms
what is the threshold to refer?

23. asymmetric audiograms
non ear symptoms
trigeminal, facial or lower cranial nerve symptoms
should have a scan
10% will have significant abnormality
needs MR scan
Cheng TM, Cascino TL, Onofrio BM. Comprehensive study of diagnosis and treatment of trigeminal neuralgia secondary to tumors. Neurology (1993);43(11):

24. normal audiograms vertigo
in isolation is rare sign of acoustic neuroma
in a series of 1,358 patients none had acoustic neuromas
no MR scan
Gandolfi MM, Reilly KR, Galatioto J, Judson RB, Kim AH. Cost-effective analysis of unilateral vestibular weakness investigation. Otol Neurotol (2015);36(2):

25. sudden unilateral loss
MR scans show abnormality in 10% case
CPA angle lesion, vascular lesion or MS
needs MR scan
Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. (2012);146(3 Suppl):S1-35.

26. unilateral tinnitus
unilateral tonal tinnitus with symmetric hearing represents less than 1% of all acoustic neuromas (and they tend to be smaller than average if present)
no MR scan
Chatrath P1, Frosh A, Gore A, Nouraei R, Harcourt J. Identification of predictors and development of a screening protocol for cerebello-pontine lesions in patients presenting with audio-vestibular dysfunction. Clin Otolaryngol (2008);33(2):102-7.

27. asymmetric audiograms
Unilateral sensorineural hearing loss (all thresholds <=25dB on good side)
Intra-aural asymmetry at two neighbouring frequencies of at least 15dB.
Asymmetric sensorineural hearing loss (not all thresholds <=25dB on good side)
Intra-aural asymmetry at two neighbouring frequencies of at least 20dB.

28. asymmetric audiograms
1 normal ear, 2 frequencies, difference of 15dB
no normal ear, 2 frequencies, difference of 20dB

29. 1 normal ear, 2 frequencies, difference of 15dB
no normal ear, 2 frequencies, difference of 20dB
so, here, no normal ear, 2 frequencies, R 30 & 45dB at 4 & 8kHz
L 45 dB & 60dB, so 15dB difference, so no referral, no MR scan

30. 1 normal ear, 2 frequencies, difference of 15dB
no normal ear, 2 frequencies, difference of 20dB
so, here, R normal ear, 2 frequencies, R 20 & 15dB at 4 & 8kHz
L 40 dB & 25dB, so 20dB difference but only at one frequency (4kHz), so no referral, no MR scan

31. 1 normal ear, 2 frequencies, difference of 15dB
no normal ear, 2 frequencies, difference of 20dB
so, here, R normal ear, 2 frequencies, R 20 & 20dB at 4 & 8kHz
L 35 dB & 35dB, so 15dB difference at two frequencies (4 & 8kHz), so referral and MR scan

32. 1 normal ear, 2 frequencies, difference of 15dB
no normal ear, 2 frequencies, difference of 20dB
so, here, no normal ear, 2 frequencies, R 30 & 45dB at 4 & 8kHz
L 50 dB & 65dB, so 20dB difference at 2 frequencies (4&8kHz), so referral and MR scan

33. Large perforation
hearing level?

34. Damaged middle ears % perf Mean air bone gap (dB) 0-15 10 16-64 20
Loss not related to the site of the perforation
Austin 1976

35. Acute otitis media
treatment?

36. Antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia

37. acute otitis media and antibiotics

38. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days.

39. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain.

40. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics.

41. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears.

42. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears. For most other children with mild disease, an expectant observational approach seems justified. We have no data on populations with higher risks of complications.

43. Case

44. Case 4 year old boy hearing loss performing poorly at school
recurrent otalgia

45. Hearing testing

46. Management
nothing
otovent
grommets (referral)

47. Case

48. 64 year old woman presents
2 day history of hearing loss in the right ear

49. 64 year old woman presents
2 day history of hearing loss in the right ear
what do you ask?
ear symptoms, vascular risks

51. sudden sensorineural loss
definition
at least 30dB hearing loss
over 3 contiguous frequencies
a period of a few hours to 3 days

52. sudden sensorineural loss
incidence
5 – 20 per people per year
1 in people per year
0.01% people per year

53. sudden sensorineural loss
typical patient
40 – 50 years
M=F
30% have balance symptoms

54. sudden sensorineural loss
aetiology?

55. sudden sensorineural loss
Infection
Bacterial postmeningitis, bacterial
labyrinthitis, syphilis
Viral mumps, cytomegalovirus
Inflammation
Autoimmune
Cogan’s syndrome, systemic lupus erythematosus
Multiple sclerosis
Trauma
Temporal bone fracture
Acoustic trauma
Perilymph fistula
Tumor
CPA tumour
Temporal bone metastasis
Carcinomatosis meningitis
Toxins
Aminoglycosides
Aspirin
Vascular
Thromboembolism
Macroglobulinemia, sickle cell disease, post-CABG, vasculitides

56. stroke and SSNHL
Stroke Oct;39(10): Epub 2008 Jun 26.
Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study. Lin HC, Chao PZ and Lee HC
CONCLUSIONS: Our findings suggest that SSNHL can be an early warning sign of impending stroke. We suggest that SSNHL patients should undergo a comprehensive hematologic and neurological examination to help clinicians identify those potentially at risk for stroke developing in the near future.

57. sudden SNHL
Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study. Lin HC, Chao PZ and Lee HC
Treatment?
most would treat as for a sudden idiopathic facial nerve paralysis (Bell’s palsy) with steroids eg 40mg prednisolone