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Thursday, October 16, 2014

Ear Disorders



Barotrauma of the Ear
Unequal air pressure on both sides of the eardrum can damage the middle ear. This is called barotrauma. It is also called barotitis media or aerotitis media.
The middle ear is separated from the ear canal by the eardrum. The Eustachian tube connects the middle ear with the back of the nose and allows outside air to enter the middle ear. This helps maintain equal pressure on both sides of the eardrum. Sometimes, the outside air pressure may change suddenly. For example, during deep-sea diving or when an airplane is ascending or descending, the outside air pressure may change suddenly.
The Eustachian tube has to work to help equalize the pressure in the middle ear. However, if it is partly or completely blocked, air cannot move in and out of the middle ear. A blocked Eustachian tube may occur due to scarring, tumor, infection, cold, or an allergy. This causes pressure on the eardrum and it may lead to bruising, rupturing or bleeding of the eardrum.
In some cases, the entrance from the middle ear into the inner ear (referred to as the oval window) can rupture causing fluid to leak into the middle ear from the inner ear. If an individual experiences vertigo or hearing loss during deep-sea diving or while an airplane is descending, it may suggest that fluid leakage is occurring. If the same symptoms are experienced by an individual while an airplane is ascending, it means that an air bubble has formed in the inner ear.
Prevention and Treatment
Sudden changes in pressure cause fullness and pain in the ear. The discomfort can be relieved through several methods for equalizing the middle ear pressure.
If there is decrease in outside air pressure, for example due to an airplane ascending, the individual should open his or her mouth and try breathing through it. Chewing gum or swallowing may also help. These measures open the Eustachian tube and the air can leave the middle ear.
If there is an increase in the outside air pressure, for example when the airplane is descending or when an individual goes deep-sea diving, the individual should close his or her nose by pinching it, keep the mouth closed and blow gently through the nose. This maneuver forces the air to move through the blocked Eustachian tube.
An infection or allergy which affects the nose and throat can cause problems for an individual while flying or diving. A decongestant, such as phenylephrine nasal spray or drops, can help relieve congestion and open up the Eustachian tube. This can help equalize pressure and reduce discomfort while flying. An individual should avoid diving until the infection or allergy is controlled. 


Benign Paroxysmal Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) is a disorder in which changes in the head position lead to short episodes of vertigo. Changes in head position that stimulate the posterior semi-circular canal of the inner ear cause these vertigo episodes. Vertigo is a false sensation that makes the individual feel that they or their surroundings are moving or spinning. Nausea and vomiting are also part of these episodes. The eyes of the individual may also move abnormally.
Diagnosis is usually based on the symptoms and the conditions in which they occur. A physical examination is also used for diagnosis. The disorder can be cured by performing the Epley maneuver once or twice.
Causes
Most vertigo episodes are triggered in two situations: when the individual wakes up in the morning and turns his or her head over on the pillow, or when he or she tips the head to reach a high shelf. Both these situations involve a change in head position and usually trigger an episode of vertigo.  

There are three semi-circular canals in the inner ear and these help with balance: anterior, horizontal and posterior. Unlike the other two, the location of the posterior canal makes it the best canal to receive any loose particles during the night due to gravity.
Otoconia or calcium particles are embedded in the utricle and saccule of the inner ear. When these particles are displaced and move into another part of the inner ear, mostly posterior semicircular canal, it causes BPPV.
These calcium particles basically collect in the posterior canal and form a chalky sludge and then a mass. When the individual changes head position, this mass exaggerates the movement of fluid in the posterior canal. This over-stimulates the nerve receptors (hair cells) present in the canal. The result is that it makes the brain feel that the head is moving differently or faster than it actually is.
The calcium particles can get displaced from the utricle and saccule as people get older. Other conditions that may cause displacement of the particles are the following:
·         Ear infections
·         Ear surgery
·         Head injury
·         Ear injury
·         Prolonged bed rest
·         Blockage of an artery going to the inner ear
Symptoms

Although vertigo is quite scary for most people, it is usually quite harmless. It also disappears by its own. A person may move his head while rolling over in bed or while bending to pick something. This change in head position may cause an episode of vertigo. The episode may last for a few seconds to a few minutes. It may be experienced many times over a course of a few days and then subside by its own.
Nausea, vomiting and nystagmus may accompany vertigo. Nystagmus is involuntary movement of the eyes from one side to the other with a slower drift back to the original position. Tinnitus or hearing loss is not found in people with BPPV.
Diagnosis
The symptoms and the conditions in which they occur are used by doctors to make a diagnosis. Doctors usually use a maneuver called Dix-Hallpike to stimulate the posterior semi-circular inner ear canal and trigger an episode of vertigo and nystagmus.
In this maneuver, the person is made to sit on the examining table and turn his head 45 degrees to the right. With his head turned this way, the person is then asked to lie down backward. In this position, the person’s head hangs over the table by about 20 degrees. In individuals with BPPV, there is a delay between 5-30 seconds before the vertigo and nystagmus occur. Symptoms may last 10-30 seconds.
If the gaze is fixated on a single location, nystagmus may be shortened or it may disappear. This is why the person going through the maneuver is made to wear Frenzel lenses. These lenses make visual fixation impossible and the individual is not able to fix his gaze on a single object.
When the maneuver is repeated, habituation may occur. This means that the intensity of the vertigo and nystagmus decreases every time the maneuver is repeated.
The above-mentioned conditions may not be met in individuals with a brain disorder, such as multiple sclerosis or stroke. In such patients, the maneuver is able to trigger symptoms immediately. The episode of vertigo continues for as long as the head is held in this position. When the maneuver is repeated, habituation does not occur either.  
Treatment
Simply moving the calcium particles out of the posterior semi-circular canal and into a part where they won’t cause any symptoms is enough to treat BPPV. To do this, the canalith repositioning maneuver or Epley maneuver is used. This is a somersault-like maneuver of the head which cures vertigo in about 90% of the people. If the vertigo is not cured, the maneuver can be repeated. Another 5% will benefit by repeating it. People can learn to do this maneuver and use it at home whenever vertigo happens. In some people the vertigo may recur at a later time. In such cases, the same maneuver can help again.
Surgery is rarely needed for BPPV. Sometimes, the horizontal canal in the inner ear may also be affected and cause vertigo. People can relieve these symptoms by rolling over like a log in this case.

Eardrum Perforation
Overview
The word “perforation” means hole and eardrum perforation means that there is a hole in the eardrum of the individual. These perforations usually occur due to infection in the middle ear. Sudden ear pain, bleeding from the ear, loss of hearing, and noise in the ear are some signs of a perforated eardrum.
A doctor uses a device called otoscope to see the perforation. An eardrum perforation usually heals by its own. However, sometimes surgical repair may be required.
Causes
Otitis media or infection in the middle ear is the most common cause of perforation in the eardrum. Sudden increase or decrease in pressure can also cause a hole in the eardrum. An increase in pressure can occur due to an explosion, diving underwater, or a slap. The pressure may decrease while flying in an airplane.
Objects placed in the ear (such as a cotton swab for cleaning the ear) or entering the ear accidentally (such as twig or pencil entering the ear) may also puncture the eardrum. If the object penetrates the eardrum, it may also fracture or dislocate the ossicles. The ossicles are small bones that connect the inner ear to the eardrum. Broken pieces of the ossicles or objects may penetrate the inner ear.
Barotrauma or severe imbalance of pressure due to a blocked Eustachian tube may also cause perforation in the eardrum. The Eustachian tube connects the middle ear to the back of the nose.
Symptoms
Symptoms of eardrum perforation may include the following:
·         Sudden severe pain
·         Bleeding from the ear
·         Loss of hearing
·         Tinnitus or noise in the ear
·         Vertigo due to damage to the inner ear
·         Pus oozing out from the ear in about 24-48 hours, especially if water or a foreign object has entered the middle ear
Diagnosis
A perforated eardrum is diagnosed with the help of a device called otoscope. Format hearing tests may also be recommended.
Treatment

The patient is asked to keep the ear dry. If the ear is infected, an antibiotic may be given by mouth. Ear drops may be prescribed for infected injuries. No further treatment is usually required and the eardrum heals by its own.
However, if it does not heal within 2 months, a surgical procedure called tympanoplasty may be recommended to repair the eardrum.
If there is severe injury and it is accompanied by loss of hearing and/or severe vertigo, immediate surgery may be recommended. It is important to repair the perforation since it can cause chronic otitis media, that is, chronic infection in the middle ear.
Persistent conductive hearing loss after perforation of the eardrum suggests that there is disruption or fixation in the ossicles. This may require surgical repair. If the injury causes sensorineural hearing loss or vertigo for more than a few hours, it means the inner ear is injured or damaged.

Herpes Zoster Oticus
When the ganglia (clusters of nerve cells) controlling 7th and 8th cranial nerves are infected by the herpes zoster virus, the condition is called herpes zoster oticus. The 7th cranial nerve controls facial movement, whereas the 8th cranial nerve controls hearing and balance.
Causes
Varicella-zoster virus is the virus that causes chicken pox. The virus lies inactive in the nerve roots. When this virus is reactivated, it travels down the nerve fibers to the skin. The reactivated virus creates painful sores on the skin. The cause of reactivation is not known. However, most experts believe that it may be reactivated when the immune system is weakened, for example, when the person has a life-threatening disease, such as cancer or AIDS, or when the person is taking certain drugs.
Reactivation of the varicella-zoster virus causes herpes zoster infection.  When the virus infects the 7th and 8th cranial nerves, it leads to herpes zoster oticus. These two nerves are responsible for controlling hearing, balances and facial muscles.
Symptoms
Following are the symptoms of herpes zoster oticus:
·         Severe ear pain
·         Temporary or permanent facial paralysis, which is quite similar to Bell Palsy
·         Vertigo or a false sensation that you or your surroundings are spinning or moving
·         Temporary or permanent hearing loss, which may resolve completely or partially
·         Fluid-filled blisters called vesicles that occur on the pinna (outside of the ear) and inside the ear canal
Although rare, some people may experience headaches, stiff neck or confusion. The virus may sometimes affect other cranial nerves as well.
Diagnosis and Treatment
A doctor will conduct a physical examination. Although medications are given to relieve the symptoms, not much is known about how much these drugs actually help. Doctors may prescribe corticosteroids such as prednisone to block inflammation. Anti-viral drugs such as acyclovir or valacyclovir can help reduce the duration of the infection. The doctor may prescribe Diazepam to reduce episodes of vertigo. For pain, oral opiods are prescribed. If the individual has complete paralysis of the face, a surgical procedure may be required to relieve pressure on the facial nerve.


Mastoiditis
Mastoid is the prominent bone behind the ear. Infection in this bone is referred to as mastoiditis. It usually occurs when acute otitis media is left untreated or is not properly treated, resulting in the infection spreading from the middle ear to the mastoid process.
Symptoms
Symptoms of mastoiditis may develop from a few days to a few weeks after the occurrence of acute otitis media. The infection spreads to the mastoid process and begins to destroy the inner part, which may result in the following symptoms:
·         Collection of pus forms in the bone, called abscess
·         Redness, swelling, tenderness in the skin covering the mastoid process
·         External ear is pushed sideways and down
·         Fever
·         Persistent and throbbing pain around and within the ear,
·         Creamy and heavy discharge from the ear
·         Hearing loss which becomes progressively worse
Diagnosis
A computer tomography (CT) is used to diagnose mastoiditis. In case of mastoiditis, a CT will reveal that the air cells in the mastoid process are filled with fluid. Air cells are spaces in the bone that are filled with air. These spaces tend to enlarge as the mastoiditis continues to get worse.
Complications
If mastoiditis is left untreated or is not properly treated, it can cause complications that may include the following:
·         Deafness
·         Sepsis or blood poisoning
·         Meningitis or infection of the tissues that cover the brain
·         Brain abscess
If ignored, mastoiditis may even cause death.
Treatment
Intravenous antibiotics are the usual treatment for mastoiditis. The doctor usually takes a sample of the ear discharge to help identify the organism causing the infection. This will help the physician to determine which antibiotics will be appropriate for killing the bacteria present in the ear discharge.
Once the person begins to recover, antibiotics may be given by mouth. These are continued for a minimum of 2 weeks. If an abscess is found on the bone, a mastoidectomy or surgical drainage is required.

Infectious Myringitis
When the eardrum is infected by a bacteria or virus it is called infectious myringitis. The condition can be caused due to a variety of bacteria and viruses. One of the most common causes of myringitis is a bacterium called Mycoplasma.
Symptoms
Symptoms of myringitis include the following:
·         Inflamed eardrum
·         Fluid-filled blisters or vesicles on the surface of the eardrum
·         Sudden pain which lasts for 24-48 hours
·         Loss of hearing
Blisters are also found in otitis media or infection of the middle ear. However, in that case the middle ear does not have any fluid or pus.
Diagnosis and Treatment
Myringitis is diagnosed by a doctor after looking at the eardrum with a device called otoscope. It is not always possible to say whether the infection has been caused by bacteria or by a virus. This is why doctors usually treat myringitis with antibiotics and analgesics.
A small blade may also be used to rupture the blisters and to relieve pain. 


Meniere Disease
Overview
Disabling vertigo accompanied by fluctuating hearing loss especially in the lower frequencies, and noise in the ear or tinnitus are typical signs of Meniere disease. The individual in this case goes through sudden and recurrent attacks of severe vertigo, nausea and vomiting which stop the individual from performing his or her normal activities.
Doctors may recommend hearing tests and magnetic resonance imaging (MRI) for diagnosing this condition. The frequency and severity of attacks may be reduced by eating a low-salt diet and taking a diuretic. Doctors may prescribe meclizine or lorazepam to relieve vertigo.
Causes
A pouch-like structure in the ear called endolymphatic sac contains the inner ear fluid. A consistent amount of this fluid is maintained in the ear by continuous secretion and reabsorption. However, sometimes there may be an increase in the production of the fluid or decrease in its reabsorption. This results in an imbalance of the inner ear fluid. Meniere disease is caused due to this imbalance in the inner ear fluid.
Symptoms
Following are the main symptoms of Meniere disease:
·         Sudden, acute and unprovoked attacks of severe, disabling vertigo (sense that the objects around you are moving or spinning), nausea and vomiting which last for 1-6 hours; although rare these may also last up to 24 hours
·         A feeling of fullness or pressure in the affected ear before and during the attack
·         Fluctuating hearing which worsens over the years
·         Ringing or noise in the ear (tinnitus), which may be intermittent or constant; the noise may be worse before, during, or after an attack
·         Loss of hearing and tinnitus affect only one ear
·         Loss of hearing is worse at lower frequencies
Ringing in the ear and loss of hearing may precede the first attack of vertigo by months or even years in one form of Meniere disease. Once the attacks of vertigo begin, the individual’s hearing may improve.
Diagnosis and Treatment
Typical symptoms of severe vertigo, tinnitus and hearing loss in one ear are usually enough for a doctor to suspect Meniere disease. He or she may recommend hearing tests and magnetic resonance imaging (MRI) to ascertain the cause of the symptoms.
In most people, the frequency of vertigo attacks can be lowered by taking the following steps:
·         Taking a low-salt diet
·         Avoiding caffeine and alcohol
·         Taking diuretics, such as hydrochlorothiazide or acetazolamide, that increase the frequency of urine
Treatment usually does not stop progressive hearing loss. Most people will experience moderate to severe hearing loss in one ear within 10-15 years of the first attack.
A doctor may prescribe oral medications, such as meclizine or lorazepam for vertigo attacks. Pills or suppositories containing prochlorperazine can help relieve nausea and vomiting. Since these medications do not prevent attacks, these should not be taken on a regular basis. The medications should only be taken when an acute attack occurs. Doctors may also prescribe oral corticosteroids such as prednisone or intravenous corticosteroids such as dexamethasone behind the ear to relieve the symptoms.
There are several procedures available for individuals who have frequent and severely disabling attacks of vertigo despite medications. While some procedures aim at reducing fluid pressure in the ear, others may aim at destroying the balance function of the inner ear.
Endolymphatic sac decompression is the least damaging of these procedures. It involves exposing the bone that lies over the endolymphatic sac. A thin sheet of flexible plastic material is then placed in the inner ear. The procedure is quite safe since it rarely damages the hearing of the individual. It rarely affects the balance of people.
In some cases, endolymphatic sac decompression may fail. In such cases, the doctor will need to destroy the balance function of the inner ear. This is done by injecting a solution of gentamicin into the inner ear, right through the eardrum of the affected ear. Gentamicin destroys the balance function of the inner ear and then proceeds towards damaging the hearing in the ear. Hearing damage may be reduced if the gentamicin is injected only once and a gap of several weeks is given before giving the next injection.
Some people may continue experiencing severe attacks of vertigo despite having these procedures. Surgery is recommended for such patients. Surgery usually involves cutting the vestibular nerve permanently. This destroys the balance of the inner ear, but keeps the hearing intact in the affected ear. In about 95% of the cases, this surgery is effective in controlling vertigo attacks.
The surgery is usually performed when symptoms do not lessen after undergoing endolymphatic sac decompression. People who do not want to experience another vertigo attack may also want to go for this surgery.
If the hearing has deteriorated in the affected ear and vertigo is severe and disabling, labyrinthectomy may be recommended. Labyrinthectomy is a procedure that involves drilling away the semi-circular canals.
The surgical procedures offer relief in vertigo. However, the hearing loss that accompanies Meniere disease cannot be helped by these procedures.

Otitis Media (Acute)
Acute otitis media is caused due to an infection in the middle ear. This infection can be bacterial or viral in nature and usually occurs as a result of the common cold or respiratory allergies. While symptoms and treatment of acute otitis media are similar in both adults and children, the condition is more common in children than in adults.
Symptoms
Following are the symptoms of acute otitis media:
·         Pain in the infected ear
·         Red, bulging eardrum
Treatment
Otitis media usually gets better by its own without treatment. However, it is difficult for any doctor to say which individual will get better without medications. Therefore, most doctors treat people affected with otitis media with antibiotics, such as amoxicillin. Others may wait for about 72 hours to see if the symptoms lessen. These doctors only prescribe antibiotics if the symptoms are severe or if they do not lessen even after 3 days.
Since pain relief is important, doctors may prescribe acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs). Decongestants containing phenylephrine may be prescribed for adults, but they are not given to children. People with allergies will benefit from antihistamines. However, those with colds may not get relief with antihistamines.
Painful ear and bulging eardrum accompanied by fever may require myringotomy. In this procedure, the doctor makes an opening in the eardrum so that the fluid accumulated in the middle ear can drain out. This opening does not cause hearing loss and heals by its own without treatment.
Tympanostomy tubes may be required for people who have repeated episodes of acute otitis media. Tympanostomy tubes are drainage tubes that are placed in eardrums to allow the fluid to drain out from the middle ear.


Otitis Media (Secretory)
Overview
Accumulation of fluid in the middle ear is referred to as secretory otitis media. When acute otitis media does not resolve or when allergies block the eustachian tubes, secretory otitis media may occur. A sense of fullness and temporary hearing loss in the affected ear are common symptoms of secretory otitis media. The condition is diagnosed using tympanometry. An opening may be made in the eardrum to allow the fluid to drain out.
Causes
Also known as serous otitis media, the condition develops when acute otitis media has not completely cleared. It may also occur when the tube connecting the middle ear and the back of the nose (eustachian tube) gets blocked. Blockage may occur in the eustachian tube due to allergies.
The condition may occur in people of all ages. However, it is more common in children.
The eustachian tube opens during swallowing and equalizes the pressure in the middle ear 3-4 times a minute. When oxygen is absorbed from the middle ear into the bloodstream, a blocked eustachian tube causes a decrease in pressure in the middle ear. A decrease in pressure causes fluid to accumulate in the middle ear. This makes it difficult for the eardrum to move.
Symptoms
The fluid accumulating in the middle ear may contain bacteria. However, symptoms of an active infection, such as redness, pain and pus, are rarely seen.
Following are the common symptoms of secretory otitis media:
·         Sense of fullness in the affected ear
·         Popping or crackling sound while swallowing
·         Some loss of hearing
Diagnosis and Treatment
The ear is examined and a tympanometry is used to determine the presence of fluid in the middle ear.
Decongestants, such as phenylephrine and ephedrine are prescribed. Nasal congestion can be reduced in people with allergies through antihistamines. Antibiotics are not useful for the treatment of secretory otitis media.
Forcing air past the blockage in the eustachian tube can help increase the pressure in the middle ear. An individual can do this by pinching his or her nose shut, keeping the mouth closed, and blowing out gently through the nose.
Symptoms that do not subside even after 3 months may require myringotomy. In this procedure, the doctor makes an opening through the eardrum so that the fluid can drain out from the middle ear.
Tympanostomy tube can also be inserted into the opening of the eardrum so that the fluid can drain out and air can enter the middle ear.


Vestibular Neuronitis
In vestibular neuronitis, the patient experiences a sudden severe attack of vertigo. The sensation of vertigo makes the individual feel that they or their surroundings are moving or spinning. The attack occurs due to inflammation of the nerve that travels to the semi-circular canals. The semi-circular canals are part of the vestibular system and help control balance.
People with vestibular neuronitis usually have a single attack of vertigo that lasts for several days. However, additional milder attacks may be experienced for several weeks after that. Probably caused by a virus, the first vertigo attack is the most severe. Vertigo may be accompanied by nausea and vomiting which may last for 7-10 days. It may be accompanied by nystagmus, which is rapid jerking movement of the eyes from one side to the other with a slower drift back to the original position.
Subsequent attacks of vertigo are usually less severe and also shorter. These attacks usually occur when the head is in a particular position. Vestibular neuronitis usually does not affect hearing.
Diagnosis
Hearing tests and nystagmus tests may be recommended. The doctor may also recommend magnetic resonance imaging (MRI) of the head to rule out disorders such as a brain tumor.
Treatment
Treatment aims at relieving symptoms caused by the vertigo. Medications such as meclizine, lorazepam, or scopolamine may be prescribed. Since prolonged use of these drugs may increase the duration of the symptoms and prevent the brain from compensating for vestibular loss, the drugs should be taken only on a temporary basis.
Pills and suppositories containing prochlorperazine may be used to relieve nausea and vomiting. If the vomiting does not stop for a long time, the doctor may recommend giving fluids and electrolytes intravenously. The vertigo usually subsides over the course of only a few days. However, dizziness may continue for several weeks. The individual is encouraged to stay active during this period by doctors.

 
Otitis Media (Chronic)
Overview
A persistent infection of the middle ear is referred to as chronic otitis media. The condition is usually caused by a cholesteatoma or perforated eardrum that hasn’t healed. Chronic otitis media may flare up after an ear infection. Water entering the middle ear may also cause a flare-up. Persistent discharge of foul-smelling pus is the main symptom of this condition. A doctor may clean the ear canal and prescribe eardrops.
Causes
Dysfunction of the eustachian tube is the most common cause of chronic otitis media. However, a perforated eardrum which has not healed after trauma or acute infection of the middle ear may also cause this condition. Cholesteatoma or a non-cancerous growth of the white skin-like material may also occur. An eardrum perforation may not exhibit any symptoms. However, a bacterial infection may occur, and cause a flare-up of chronic otitis media. An infection of the nose and throat or water entering the middle ear during bathing or swimming may also cause chronic otitis media to flare-up.
Symptoms and Complications
Discharge of pus, possibly with a foul smell, from the ear is the main symptom of a flare-up. There is usually no pain. If the flare-ups occur repeatedly, they may lead to the formation of polyps. These polyps are protruding growths that can extend from the middle ear, pass through the perforated portion of the eardrum, and enter the ear canal.
If the infection is persistent, it may destroy the ossicles. Small bones present in the middle ear connecting the inner ear to the eardrum are called ossicles. These small bones are responsible for conducting sounds from the outer ear to the inner ear. Damage to the ossicles can cause conductive hearing loss.
Chronic otitis media may also lead to other serious complications. These include the following:
·         Inflammation of the inner ear
·         Facial paralysis
·         Brain infections
·         Cholesteatoma in the middle ear
A cholesteatoma in the middle ear that damages the bones increases the chances of other serious complications. Presence of pus or skin-like material in a hole or pocket in the eardrum with fluid oozing out is usually taken as a sign of chronic otitis media by the doctor.
Treatment
 A doctor treats a flare-up of chronic otitis media by cleaning the ear canal and middle ear. This is done with the help of suction and dry cotton wipes. The doctor will then prescribe antibiotic ear drops or a solution that contains acetic acid with hydrocortisone. If perforation is present, the individual should prevent water from entering the ear.
Tympanoplasty can be used to repair the eardrum. If the ossicles are damaged, these can be repaired during the same procedure. If a cholesteatoma is present, it must be removed surgically or it may result in serious complications.