Important Clinical Findings In The Tympanic Membrane and Middle Ear

“Chalk” patches. White areas of tympanosclerosis are common findings on examination of the ear drum. They are of little significance in themselves, and the hearing is often normal.

A past history of otorrhea in childhood or grommet insertion is usual. Chalk patches do occur with no
apparent past otitis media. Extensive tympanosclerosis with a rigid drum is a sequela of past otitis media, and the ossicles, too, may be fixed or noncontinuous.

Scarring of the drum. A gossamer-thin membrane can be seen to close this previously well-defined central perforation (arrow).

At first sight with the auriscope, a central perforation would appear to be the diagnosis; more careful
examination with a pneumatic otoscope will show that this thin membrane moves and seals the defect, giving reassurance that the drum is intact.

Scarring of the drum with retraction onto the round window, promontory, and incus is also evidence of past otitis media.

It is sometimes difficult to be sure whether this type of drum is intact; a thin layer of epithelium indrawn onto the middle-ear structures may seal the middle ear, and examination with the operating
microscope may be necessary to be certain of an intact drum.

Scarred tympanic membrane. A scarred tympanic membrane in which the drum has become atelectatic and indrawn onto the long process of the incus and promontory.

A retracted tympanic membrane which is thin and indrawn onto the long process of the incus (a), head of the stapes (b), promontary (c), and round window (d).

The stapedius tendon is also seen in this panoramic view obtained with a fiberoptic endoscope.

Bullous Myringitis - Clinical presentation & Management

Bullous myringitis is a direct inflammation and infection of the tympanic membrane secondary to a viral or bacterial agent. Vesicles or bullae filled with blood or serosanguinous fluid on an erythematous tympanic membrane are the hallmarks. Frequently, a concomitant otitis media with effusion is noted.
Typical pathogens are the same as seen in Acute otitis media.

Clinical Presentation: The onset of bullous myringitis is preceded by an upper respiratory tract infection and is heralded by sudden onset of severe ear pain, scant serosanguinous drainage from the ear canal, and frequently some degree of hearing loss.
Otoscopy reveals bullae on either the inner or outer surface of the tympanic membrane.

Bullous Myringitis. A large fluid-filled bulla is seen distorting the surface of the tympanic membrane.

Patients presenting with fever, hearing loss, and purulent drainage are more likely to have concomitant infections, such as Otitis media and otitis externa .

Management: Differentiation between viral and bacterial etiologies for tympanic membrane bullae is not necessary. Although most episodes resolve spontaneously, many physicians prescribe antibiotics. Warm compresses, topical or strong analgesics, and oral decongestants provide symptomatic relief. Referral is not necessary in most cases unless rupture of the bullae is required for pain relief.

The External Ear - Different Conditions With Pictures

Eczematous Otitis Externa.
Eczema of the meatus and pinna (see picture below) may be associated with eczema elsewhere, particularly in the scalp, or it may be an isolated condition affecting only one ear.
Itching is the main symptom, with scanty discharge.

The eczematous type of otitis externa usually settles with the use of a topical corticosteroid and antibiotic drop. Cleaning of the meatus may also be necessary, either with cotton wool on a probe, or
suction and the Zeiss microscope. Otitis externa tends to recur.

A Furuncle In the Meatus
A furuncle in the meatus is the other common type of otitis externa. It is characterized by pain; pain on movement of the pinna or on inserting the auriscope is diagnostic of a furuncle.

Diabetes mellitus must be excluded with recurrent furuncles.

Some Common Deformities of the Pinna (The External Ear)

The pinna is formed from the coalescence of six tubercles, and development abnormalities are common. Also deformities could be seen later on in life following trauma or infection.
Some of the common deformities are shown here with brief description.

1. Duplication of the lobule: It is of of little clinical importance, other than cosmetic worry mostly in females.

2. Hillocks (or accessory lobules): These are commonly found anterior to the tragus, and are excised for cosmetic reasons. A small nodule of cartilage may be found underlying these hillocks.

3. Darwin’s tubercle: A deformity of the pinna of phylogenetic interest. It is homologous to the tip of the mammalian ear and may be sufficiently prominent to justify surgical excision.
Although Darwin’s name is used for this tubercle, Woolmer gave the first description.

4. Microtia: Absence of the pinna or gross deformity is often associated with meatal atresia and ossicular abnormalities. Faulty development of the 1st and 2nd branchial arches results in aural

deformities which may be associated with hypoplasia of the maxilla and mandible, and eyelid deformities

Introduction to Laryngeal cancer

The most common form of laryngeal cancer is squamous cell carcinoma (95%); rare forms include adenocarcinoma, sarcoma, and others. Such cancer may be intrinsic or extrinsic.
An intrinsic tumor is on the true vocal cord and tends not to spread because underlying connective tissues lack lymph nodes. An extrinsic tumor is on some other part of the larynx and tends to spread early.

Gender and Age
Laryngeal cancer is nine times more common in males than in females; most victims are between ages 50 and 65.

Causes
With laryngeal cancer, major predisposing factors include

• smoking and alcoholism; 
• minor factors include chronic inhalation of noxious fumes and familial tendency.

Classification
Laryngeal cancer is classified according to its location:

• supraglottis (false vocal cords)
• glottis (true vocal cords)
• subglottis (downward extension from the vocal cords [rare]).

Signs and symptoms
With intrinsic laryngeal cancer, the dominant and earliest indication is hoarseness that persists longer than 3 weeks; with extrinsic cancer, it’s a lump in the throat or pain or burning in the throat when drinking citrus juice or hot liquid. Later signs and symptoms of metastasis include dysphagia, dyspnea, cough, enlarged cervical lymph nodes, and pain radiating to the ear.

Brief Summary of Otosclerosis

Definition: The most common cause of conductive deafness, otosclerosis is the slow formation of spongy bone in the otic capsule, particularly at the oval window. 

Incidence: It occurs in at least 10% of the population in the United States. It commonly affects both ears and is seen in many females between the ages of 15 and 30.

Causes
Otosclerosis appears to result from a genetic factor transmitted as an autosomal dominant trait; many patients report family histories of hearing loss (excluding presbycusis). Pregnancy may trigger the onset of this condition.

Signs and symptoms
Spongy bone in the otic capsule immobilizes the footplate of the normally mobile stapes, disrupting the conduction of vibrations from the tympanic membrane to the cochlea. This causes progressive unilateral hearing loss, which may advance to bilateral deafness. Other symptoms include tinnitus and paracusis of Willis (hearing conversation better in a noisy environment than in a quiet one).

Chondrodermatitis nodularis helicis

Chondrodermatitis nodularis helicis (CNH) is a common and benign condition characterised by the development of a painful nodule on the ear.

Causes: It is thought to be caused by factors such as persistent pressure on the ear (e.g. secondary to sleep, headsets), trauma or cold. CNH is more common in men and with increasing age.

Clinical Presentation: The classic presentation of chondrodermatitis nodularis chronica helicis (CNH) is a middle-aged to elderly man with a spontaneously appearing painful nodule on the helix or antihelix. The nodule usually enlarges rapidly to its maximum size and remains stable. Onset may be precipitated by pressure, trauma, or cold. When asked, the patient usually admits to sleeping on the affected side.

On Examination: Nodules are firm, tender, well demarcated, and round to oval with a raised, rolled edge and central ulcer or crust. Removal of the crust often reveals a small channel. Color is similar to that of the surrounding skin, although a thin rim of erythema may be noted.

External Ear Injuries - Brief Description With Pictures.

Injuries to the external ear may be open or closed.

• Blunt external ear trauma may cause a hematoma (otohematoma) of the pinna, which, if untreated, may result in cartilage necrosis and chronic scarring or further cartilage formation and permanent deformity (“cauliflower ear”). 
• Open injuries include lacerations (with and without cartilage exposure) and avulsions

Pinna Hematoma. A hematoma has developed, characterized by swelling, discoloration, ecchymosis, and flocculence.  Immediate incision and drainage or aspiration is indicated, followed by an ear compression dressing.

Management: Pinna hematomas must undergo incision and drainage or large needle aspiration using sterile technique, followed by a pressure dressing to prevent reaccumulation of the hematoma.

This procedure may need to be repeated several times; hence, after Emergency department drainage, the patient is treated with antistaphylococcal antibiotics and referred to ENT or plastic surgery for follow- up in 24 hours. Lacerations must be carefully examined for cartilage involvement; if this is present, copious irrigation, closure, and postrepair oral antibiotics covering skin flora are indicated.

A 35 Year Old Patient With Progressive Hearing Loss

A 35-year-old presents with unilateral hearing loss that has been gradual but progressive over the last 6 months. Otoscopy reveals a Cholesteatoma.

Appropriate treatment of the above condition consists of
A) Prolonged antibiotics for up to 4 weeks
B) Decongestant and antihistamine administration
C) Corticosteroid treatment for 2 weeks
D) Hearing aid amplification
E) Tympanomastoidectomy

Answer:

A 5 Year Old Girl Presents With A Mass In Her Neck

A 5 year old girl with a mass in her neck is brought to the clinic for an evaluation.

Her mother says that this mass appeared 6 months ago and is increasing in size. There is no pain or discomfort. On examination , the mass is is the midline, inferior to the hyoid bone. Laboratory test reveal normal thyroid panel. Surgery was recommended after a CT scan is performed.

What is the most likely diagnosis?

A, Dermoid cyst
B. Ectopic thyroid gland
C. Lipoma
D. Thyroglossal duct cyst
E. Branchial cleft cyst.

Answer And Discussion:

Ludwig’s angina

Which of the following best describes Ludwig’s angina?

A) Substernal chest pain that radiates to the right arm.
B) An infection involving the sublingual and submaxillary space.
C) Abdominal pain secondary to an enlarging AAA.
D) A tonsillar infection that leads to chronic abscess formation.
E) Ischemic pain related to insufficient blood flow to an extremity.

Answer and Discussion
The answer is B. ( An infection involving the sublingual and submaxillary space.)

Ludwig’s angina usually develops from a periodontal or dental infection and is one of the most common neck space infections.

The condition is usually a rapidly developing, bilateral cellulitis that affects the sublingual and submaxillary space, without involvement of the lymph nodes or formation of abscesses.
The infection usually rapidly arises from the second and third mandibular molars as a result of poor dental hygiene, tooth extraction, or trauma.

Symptoms include:

Cauliflower Ear.

Medical students are examining a patient in the medical ward admitted with the diagnosis of pneumonia. While doing a general physical examination a deformity is observed in his ear. The patient mentions that he got it after a trauma few years ago.

This deformity is known as Cauliflower Ear.

Case discussion:

Cauliflower Ear: It refers to a deformity of the ear that is caused by a blunt trauma or an injury to the ear. Initially there is bruising and swelling due to subperichondral hematoma. If the swelling is not drained or repeted trauma occurs, this leads to a deformity known as Cauliflower ear.
It is often seen in boxers, wrestlers and rugby players.

A 32 Year Old Man Presents With Unilateral Nasal Obstruction - A Case Of Nasal Polyp

A 32-year-old man complains of unilateral nasal obstruction for the past several months of gradual onset. On examination of the nose, a nasal polyp is found.

Case Discussion

Nasal Polyp:
Introduction: Nasal polyps are benign lesions arising from the mucosa of the nasal passages including the paranasal sinuses. They are most commonly semitransparent.

Epidemiology: Prevalence of 1% to 4% of adults; 0.1% of children of all races and classes.
• The male-to-female ratio in adults is approximately 2:1.
• Peak age of onset is 20 to 40 years old; rare in children younger than 10 years old.

Associations: Associated with the following conditions:
~ Nonallergic and allergic rhinitis and rhinosinusitis.
~ Asthma—In 20% to 50% of patients with polyps.
~ Cystic fibrosis.
~ Aspirin intolerance—In 8% to 26% of patients with polyps.
~ Alcohol intolerance—In 50% of patients with polyps

A 27 Year Old Male Presenting with Nasal Discharge, Congestion and Headache

A 27 year old male presents to his doctor with symptoms of nasal discharge. nasal congestion and headache which all started about a week ago. He mentions being in a healthy state before these symptoms started and has no significant past history except getting frequent upper respiratory infections which usually resolve on conservative management. He took acetaminophen but is still not getting better.

Case Discussion:

Introduction To Upper Respiratory Infections:

• URIs are among the leading cause of lost of time from work and school.
• It is difficult to distinguish URIs caused by virus or bacteria since the signs and symptoms are almost the same. 
• Non specific URIs also known as "the common cold" have no prominent localizing features and usually present with nasal discharge, nasal congestion, cough and sore throat. In more severe cases patients may suffer from hoarseness, fever, malaise and body ache. 
• The average duration of symptoms is about 1 week. 

Etiology of URIs: A wide variety of viruses e.g rhinoviruses, coronaviruses, parainfluenza, influenza virus and adenoviruses can cause non specific URIs. Secondary bacterial infections may complicate a few cases and may lead to prolonged course of disease with more severity of symptoms like purulent nasal and throat discharge. 

Treatment: Symptom based treatment like decongestants, antipyretics and anti inflammatory drugs are all that is required along with conservative measures like warm fluids, saline water gargles, etc.

Sinus Infections: Infection and inflammation of the sinuses known as Sinusitis is a common reason for visits to primary care physicians. it most commonly involves the maxillary sinus, followed by the ethmoid, frontal and sphenoidal sinus. 

Acute Sinusitis:

A 3 Year Old Girl With A Foreign Body In The Ear

A 3-year-old girl is brought by her parents to an urgent care facility after a day of crying, irritability, scant otorrhea, and frequent pulling of her right ear.
Otoscopy reveals an erythematous, swollen external auditory canal (EAC) where a bead is wedged (Picture shown below). The patient was referred to an otolaryngologist and the bead is removed
using an operating microscope for visualization.

Case Discussion:
Foreign Body In The Ear:

Introduction: Ear Foreign Bodiess are commonly seen in children ages 1 to 6 years. Most common FBs in children include:
~ Inanimate objects such as beads , cotton tips, paper, toy parts, crayons , eraser tips, food, or organic matter, including sand, sticks, and stones as well as sometimes insects.

Pathogenesis: Pathogenesis includes some of the key elements of otitis externa :

Enlarged Adenoids On Lateral Pharyngeal X Ray

This lateral pharyngeal X ray was done for a 5 year old child who was brought to a pediatrician with the complaints of snoring, recurrent respiratory infections and chronic suppurative otitis media and peculiar facies.

What Is the most likely Diagnosis?

Lateral pharyngeal X-ray reveals obliteration of nasopharyngeal air column and adenoidal hypertrophy. All these features along with this X-ray are very much suggestive of enlarged adenoids in this child. Digital palpation or indirect visualization by pharyngeal mirror in older children helps in the diagnosis of this condition.

Case Discussion: