1. What is developing here? Can you identify the 3 stages?2 3 1

2. What is the difference between these two images and how would you tell this difference on examination?

3. What is this called and when would you use it?

4. What is this instrument and what is it for?

5. Ear Examination Externals Orientation Cysts/ pits Mastoid
Helix/ skin – remember cutaneous diseases.. Solar keratoses/chondrodermatitis N H/ infection/BCC/ SCC
Orientation
Age differences and directions
Oedema and tighter canals/ hour-glass shape
Holding the ear

6. Ear Examination Auroscope Canal Optics – head movement
Handling - angles
Speculum
Insufflation (Siegel)
Canal
Eczema/ psoriasis
Ot externa + debris + cleaning (remember pseudomonas and fungi)
Wax clearing
Furunculosis
F/B

7. Ear Examination T/M Landmarks Pars tensa and pars flaccida CSOM
Acute ot. Media
Sequele of CSOM
Insufflation

8. Doctor for Sonja Sonja (4 years) is down for duty surgery again.
Last time was 3 weeks ago with some left ear discharge treated with Otomize
7 weeks ago she had a heavy URTI and sore ears.

9. Sonja’s Mother/ Father
This is the third time you have had to bring in Sonja (4 years) since Christmas with one of her sore ears. There was even some slight discharge last time. This time it started suddenly in the middle of the night on the right side, and was awful with her screaming. She has had a cold for 24 hours.
If only the doctor would give you antibiotics this would stop happening
If asked, you think Sonja is a bit more naughty and withdrawn at the moment – in trouble in school and ignores you a lot of the time
Examination reveals a pink right drum and some radial vessels across the drum on the left

10. E/T Dysfunction Chronic serous otitis media
Resolution
Negative middle ear pressure
Acute perforation
Acute serous otitis media
Acute otitis media
Chronic serous
otitis media
Atelectatic drum segment
in pars tensa
Attic retraction pocket
Chronic Perforation
Cholesteatoma
Aural Polyp

11. Serous otitis – light reflex
Early otitis media in serous otitis

12. Serous otitis

13. Otitis Media

14. E/T dysfunction resolution

15. Sequele of CSOM
Chronic perforation
Retraction Pocket

16. Cholesteatoma

17. The hallmark is a recurrent ear discharge
The hallmark is a recurrent ear discharge. Granulation tissue and a discharge (through a marginal perforation of the ear drum) may be seen on examination.
O/E, the most common sign of a cholesteatoma is drainage and granulation tissue in the ear canal and middle ear unresponsive to a/b. A tympanic membrane perforation is present in more than 90% of cases
NB – always eventually see the attic, or refer, if there is a recurrent dx
Cholesteatoma

18. CCG Policy on Grommets Patient eligibility criteria:
The patient's local NHS commissioning organisation will only fund surgical treatment for children from age three to 12 years if the patient meets the following criteria:
Children with on-going glue ear over a period of three months, with a hearing level in the better ear of 25–30 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz; or
Children with on-going glue ear over a period of three months with a hearing loss less than 25–30 dBHL, where the hearing loss is impacting on a child's development.
. Children who have undergone insertion of grommets for glue ear should be followed up and their hearing should be re-assessed.
The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. 

19. Sarah (43yrs) with a past history of mild asthma has come back from Turkey and has booked to see you this morning. You notice she saw the OOH 3 days ago with a discharging left ear and has been diagnosed with otitis externa and is on flucloxacillin from them. The note from reception says she is in pain.
What differentials come to mind immediately?   What do you think about her current treatment? What you going to do now?   What advice might you also give about the future?   Anything else?

21. Otitis externa Inflammation of ear canal What to do? Protection
Allergic and infective
Exacerbating factors
Discomfort – might be bad – but..
+/- discharge
What to do?
Look (be careful when you pull!)
If mucky – clean and then look
MC&S – not first time?
Analgesia, Spray/drops for 3 days after better
Protection
OTC 2% acetic acid for frequent recurrence?
throat-mouth/earache-ear-pain/ear- infection-otitis-externa#nav-7

23. Acute Vertigo : Epidaemiology
There is a wide variability in reported prevalence (3.1% % one-year prevalence of diseases causing vestibular dysfunction )
Incidence increases with age.
Vestibular neuritis : peak age of onset of years. Incidence is about 3.5 cases per 100,000[2].
Viral labyrinthitis is the most common form of labyrinthitis. Usually year-olds. It is most common in the fourth decade with women outnumbering men by about 2:1.

24. Vertigo: Differentials
BPPV
Serous labyrinthitis:
Viral Labarynthitis/ V Neuronitis
Is associated with acute or chronic middle ear disease and is an uncommon complication of otitis media.
Vestibular migraine
Vestibular migraine is thought to be the most common cause of recurrent spontaneous vertigo attacks. In the general population the lifetime prevalence is about 1% and one-year prevalence 0.9%.
Perilymph fistula (FISTULA SIGN)
TIA/ Stroke, especially posterior inferior cerebellar artery (PICA) syndrome..
Vertigo lasts from 5 minutes to 72 hours.
Multiple sclerosis.
Meningitis.
Vertigo can precede, accompany or occur after the headache but there will be one or more migraine features with at least 50% of episodes.
Subarachnoid haemorrhage.
Tumours.
Vertebral artery dissection.
Hearing is only mildly and transiently affected.
Drug-induced vertigo, hearing loss, or both.
During an attack patients may develop either central or peripheral vestibular dysfunction.
Carbon monoxide poisoning.
Autoimmune inner ear disease.
Ramsay Hunt syndrome
Wernicke’s encephalopathy
Menieres

25. Vertigo
Relatively common symptom, most cases are self-limiting, serious pathology is rare, drugs of little use and potentially harmful.  
Otalgia/ discharge/ deafness/ tinnitus
Examination
Is it rotational at all? ( If not, then = unsteadiness/ Dysequillibrium )
Nystagmus (?ataxic)
Head Impulse test
Cover test
Exactly how long did it last?
Cerebellar signs(‘DANISH’)
What provokes it / when does it tend to occur?
Ear exam – attic (Rinne + Weber)
BP / CVS
Associated headache / Earache
Cranial Nerves
Proprioception
Trauma
Dix-Hallpike test
Medication?
Cerebellar Signs
Dysdiadochokinesis & Dysmetria (finger overshoot) Ataxia (unsteadiness of gait towards side of lesion) Nystagmus Intention tremor Slurred speech Hypotonia

27. Seconds / minutes Minutes Hours Days Duration Vestibular Cause
Diagnosis
Features
Seconds / minutes
Over stimulation
BPPV
Onset immediate or few seconds ; fatigues
Minutes
CPV / migraine/ hyperventilation/ cholesteatoma (= fistula) / caloric
Onset after a few seconds/minutes. Does not fatigue
Hours
Depression of function
Hydrops (menieres) 43/ prevalence/ Vestibular hydrops
Assoc. acute deafness +/- tinnitus, chronic low-tone deafness.
Days
Destruction or failure
Viral labyrinthitis /vestibular neuronitis
/CVA/ /Ramsay-Hunt /Demyelination / Acoustic neuroma
Basal skull fracture / CPA tumour
Full neuro. exam .
Refer immediately if sensorineural deafness. Most common are first two – recovery 2 weeks with BPPV following. Get patient up.

28. Acute Vertigo Rx
Most cases of vertigo are caused by peripheral vestibular disorders such as vestibular neuronitis, benign paroxysmal positional vertigo (BPPV), vestibular migraine, and Ménière’s disease. Initial treatment varies, depending on the most likely underlying cause: •Vestibular neuronitis / Viral Labarynthitis - Prochlorperazine or antihistamines - only use for 3 days (ongoing use suppresses vestibular compensation and slows recovery) •BPPV - Epley manoeuvre is the treatment of choice •Meniere’s disease - if suspected patients should be referred to ENT for further management. (low tone loss, triad of sx with feeling of fullness) •Vestibular migraine - evidence for treatment is limited; triptans and antiemetics can be considered but this is based on expert opinion

29. Vertigo
BPPV
has a variable course – lasts months usually and recurs from time to time esp. with fatigue /stress/ other infections esp. when affecting the ear.
Epley’s manoeuvre is helpful for some patients and can be taught or performed after the Dix-Hallpike test.
Viral Labarynthitis/ Vestibular Neuronitis
After failure of the labyrinth the cerebellum switches off it’s vestibular nucleus later the nucleus develops new synapses with contralateral vestibular system (twin- engined plane with engine failure can still fly). Seems to occur in autumn and spring clusters.

30. Unsteadiness
Decompensation / failure of one or more parts of a balance system previously in equilibrium
Age?
Onset and pattern?
Duration?
Associations and causation?
Medications?
Causes
Drug side effects – don’t forget alcohol
Cardiovascular – postural/ arrhythmia/ ischaemia/ carotid sinus hypersensitivity( >70 yrs)
Cerebrovascular disease
Proprioceptive – OA/ B12 and other neuropathies/ demyelination/ etc
Motor impairment – OA/ Parkinson’s / hypothyroidism etc.
Visual impairment
Examination
As above + cardiovascular check including sitting / standing BP (?carotiid sinus massage)
Fuller Neuro
Visual acuity
Intercurrent infection

31. Chronic Vertigo
Betahsitine only indicated for Menieres. Other drugs not indicated.
Otherwise Rehabilitation is best:
Can be done on line
Here is an example

32. Hazel / Harry Thomas (patient ) a
43 yrs, married. School Teacher.
Non-smoker. No PMH of note or head injury.
Saw nurse last week for cough and URTI – no rx needed.
Awoke this morning and could not get out of bed – dizzy ++. Had to crawl on hands and knees to bathroom. Vomited. Back in bed now and feel awful – still very dizzy and worse when moving at all.
You are frightened and agitated phoning for an urgent home visit or advice about calling an ambulance as you know that this could be a stroke and time is critical..

33. Hazel / Harry Thomas (Dr ) a
43 yrs, married. School Teacher.
Non-smoker. No PMH of note
Saw nurse last week for cough and URTI – no rx needed.
You are duty doctor and reception have asked to put Hazel’s/ Harry’s phone call through because of patient insistence and distress

34. Hazel / Harry Thomas (patient ) b
You may relent after careful listening and calm questions and agree to come up to the surgery – if not insist on a home visit. It is now some 2 hours later and your dizziness is already slightly better.
It is true rotational vertigo. You have no deafness though slight pain in the ear canal, but no other symptoms of any import. You are vomiting and very dizzy and need help on and off from husband/ wife to walk slowly.
Examination shows a normal TM’s and canals, Normal cranials, speech, coordination, no tremor, normal BP, pulse, rhythm and temperature. Rinne and Weber testing normal. Obvious horizontal nystagmus – fast phase to left and worse on looking to left. Head impulse test is abnormal to the left only.

35. Hazel / Harry Thomas (doctor) b
You will be seeing the patient and need to consider the story carefully and also what examination you need to offer.
What are doctor anxieties and patient anxieties?
What consultation style will help both of you?

36. Audiograms x - left, air conduction o - right, air conduction
> or ] - left, bone conduction
< or [ - right, bone conduction

38. Presbyacusis Noise-induced impairment

39. Conductive loss