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Author: admin, 14.11.2013
There are a number of practical ways teachers can assist students with hearing loss in the classroom. The Care for Kids’ Ears campaign is part of the Australian Government’s commitment to improving eye and ear health services for Indigenous Australians for better education and employment outcomes. One of the important benefits of an endoscope compared to the microscope is the wide-field view of the middle ear afforded by the location of the light source at the tip of the endoscope and the availability of angled lenses. In many cases of pediatric ears even with small ear canals, a large incision or cut behind the ear can be avoided during tympanoplasty or cholesteatoma surgery.
The image below was taken using 3mm 0 degree, 14cm long endoscope placed through the left ear external auditory canal.
The modern era of otoendoscopy was pioneered by Dennis Poe MD and endoscopic ear surgery (EES) has been the focus of Muaaz Tarabichi MD at the American Hospital in Dubai for over 20 years.
At the Massachusetts Eye and Ear Infirmary both pediatric and adult otologists perform endoscopic ear surgery in hundreds of children and adults with routine and complex middle ear disease. BOTH microscopic and endoscopic ear surgery are complementary approaches that are used alone or together to ensure that our patients in Boston receive the best possible surgical outcomes.
Our active program on EES at MEEI and Harvard Medical School is committed to 1) determining the clinical and radiologic indications for EES in children and adults, 2) understanding the surgical and audiologic outcomes following EES, 3) improving instrumentation for EES, 4) developing novel teaching tools to enhance the educational experience of residents, fellows, and surgeons in practice when learning EES, and 5) offering Harvard CME courses on endoscopic ear dissection.
Middle ear procedures that employ a rigid endoscope for visualization may reduce the need to drill for enhanced exposure to the operative field. The image below was taken using a 0 degree endoscope following the elevation of the tympanomeatal flap, revealing the left middle ear, the three ossicles (malleus or hammer, incus or anvil, and stapes or stirrup), the cochlea, the round window, and the facial nerve. The clinical indications for this powerful technique are currently evolving in the literature and the use of rigid endoscopes to perform ear surgery (rather than just to visualize the middle ear) is increasing and primed to expand as refined instrumentation and operative approaches become available. The preoperative audiogram showed a conductive hearing loss in both ears, worse in the left ear. The right ear was found to have an otitis media with serous effusion and this was addressed with a myringotomy and tympanostomy tube placement in the office. Computed tomography (CT) scans of the left ear temporal bone revealed a soft tissue process involving Prussak's space and the epitympanum (attic). The left ear axial CT scan below shows a soft tissue density of the epitympanum abutting the ossicular heads of the malleus and incus. The left ear coronal CT scan below shows a soft tissue density filling Prussak's space and extending into the attic. This patient elected to undergo a left ear transcanal endoscopic ear surgery (TEES or EES) with resection of an attic cholesteatoma.
The incus and malleus head were removed in order to successfully resect the retraction pocket and cholesteatoma.
OTITIS MEDIA Otitis media (OM) may be defined as inflammation of the middle ear due to any cause. OTITIS MEDIA -- DIAGNOSIS Children with acute otitis media frequently present with sudden onset of fever, ear pain, and fussiness. OTITIS MEDIA -- COMPLICATIONS Complications of acute otitis media were common in the pre- antibiotic era. HEARING LOSS Conductive hearing loss Cerumen impactions Swelling of the external auditory canal Tympanic membrane perforation Middle ear fluid Ossicular chain abnormalities Sensorineural hearing loss Injury to hair cells in the cochlea or neural elements innervating the hair cells.
HEARING LOSS -- AUDIOMETRY Hearing threshold levels are determined between 250 and 8000 Hertz (Hz) for pure tones and measured in decibels (dB). HEARING LOSS -- AUDIOMETRY A conductive hearing loss in the left ear due to otitis media with effusion. HEARING LOSS -- AUDIOMETRY This audiogram suggests noise exposure that may be encountered occasionally in younger individuals who have been exposed to hazardous or “toxic” noise. HEARING LOSS -- TYMPANOGRAM Tympanometry is commonly used to evaluate the tympanic membrane (TM) and middle ear status. Three tympanograms demonstrating change in compliance of the middle ear (vertical axis) with changes in ear canal pressure. OTITIS EXTERNA Otitis externa (OE) is an inflammation or infection of the external auditory canal (EAC), the auricle, or both This condition can be found in all age groups.
OTITIS EXTERNA -- CONSIDERATIONS Ramsay Hunt syndrome, more accurately known as herpes zoster oticus, is caused by varicella-zoster virus (VZV) infection. OTITIS EXTERNA -- TREATMENT Commonly used topical eardrops are acetic acid drops (which decrease pH), antibacterial drops, and antifungal preparations.

DIZZINESS Patients frequently present with a complaint of “dizziness,” including symptoms such as disequilibrium, syncope, lightheadedness, ataxia, and vertigo. DIZZINESS – VESTIBULAR TESTING Vestibular testing can be performed to help determine whether the problem exists within the vestibular (balance) portion of the inner ear. DIZZINESS – VESTIBULAR TESTING There are four main parts to ENG testing Calibration test, which measures rapid eye movements Tracking test, which evaluates the ability of the eyes to track a moving target Positional test, which measures responses due to head movements Caloric test, which measures responses to warm and cold water introduced to the ear canal.
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) One of the most common causes of vertigo is benign paroxysmal positional vertigo (BPPV). BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) BPPV can usually be successfully treated with a canolith reposition maneuver (Epley or Semont maneuver) in the office setting. Bedside maneuver for the treatment of a patient with benign paroxysmal positional vertigo (BPPV) affecting the right posterior semicircular canal. LABRYNTHITIS -- TREATMENT Treatment is symptomatic Vestibular suppressant medications (meclizine) Antiemetics Short, tapering course of oral steroids It may take several weeks for symptoms to completely resolve Residual vestibulopathy that persists for months or even years is not uncommon, and is best managed with vestibular rehabilitation.
Children with hearing loss often have to work extra hard to hear correctly, which can make them tired and distracted. To find out more visit the Australian Hearing website, call 131 797 to be connected to your nearest Australian Hearing Centre or contact the Australian Hearing Head Office on (02) 9412 6800.
The panoramic view of the tympanic membrane (eardrum) provides the surgeon with a high definition view of the entire ear using a transcanal approach. In contrast, the traditional otologic operating microscopes typically require larger portals (e.g.
1: 55 year old woman who presented with progressive left ear (aural) fullness and hearing loss.
An attic retraction pocket is defined by the black arrows collecting keratinaceous debris, and represents a small cholesteatoma. The blue line represents sound detection in the left ear and the red line represents sound detection in the right ear. There is also erosion of the lateral wall of the epitympanum (or attic), a finding often seen in middle ear cholesteatoma. The tympanic membrane (eardrum) was reconstructed with a small perichondrium and cartilage graft taken from the conchal bowl.
Due to: persistent noise exposure, age-related (presbycusis), genetic factors, and infectious or postinflammatory processes.
The 0-dB level is “normalized” to young, healthy adults and doesn’t mean there is absence of detectable sound. Note that bone conduction thresholds are normal in both ears, but air conduction on the left is 30 dB poorer than that measured on the right. Note that low-tone thresholds are relatively normal, with a drop in thresholds at higher frequencies.
This test assesses the mobility of the TM and its response to pressure changes in the external auditory canal. Type A is normal, with the greatest compliance at the point where the pressure in the ear canal is equal to that of atmospheric pressure (peak is at 0).
If the condition does not respond to treatment as expected, an otolaryngologist should evaluate the patient. It is characterized by facial nerve paralysis and sensorineural hearing loss, with bullous myringitis and a vesicular eruption of the concha of the pinna and the external auditory canal (EAC). True vertigo (an illusion of motion) is primarily associated with the balance organs of the inner ear. BPPV is caused by sediment, such as calcium carbonate crystals, that have become free floating within the inner ear. Dislodged otoliths repositioned into the vestibule is about 80 percent effective in eliminating symptoms of BPPV. The presumed position of the debris within the labyrinth during the maneuver is shown in panels A–D. It is thought to be caused by inflammation, secondary to a viral infection, of the vestibular portion of the eighth cranial nerve or of the inner ear balance organs (vestibular labyrinth). For Aboriginal and Torres Strait Islander children, these issues are amplified further by the fact English may not be their first language. There are two common variants: (1) acute otitis media (AOM) and (2) otitis media with effusion (OME).

There is decreased movement of the eardrum on pneumatic otoscopy (insufflation of air into the ear canal). Mastoiditis -- Patients with acute mastoiditis present with fever, ear pain, and a protruding auricle. Some patients hear 0 dB, but reaching the threshold of hearing usually requires louder test signals. This is a consequence of the normal aging process and may vary widely from patient to patient. Type B demonstrates very poor compliance at any frequency, suggestive of a tympanic membrane (TM) immobilized by fluid in the middle ear or a TM perforation (no peak).
Skull base osteomyelitis occurs most often in patients who are diabetic or immunocompromised.
Rotatory chair testing is the “gold standard” for diagnosing bilateral vestibular weakness.
Turning the head quickly or into a certain position, causes this free- floating material to move the endolymph in the inner ear, stimulating the vestibular division of the eighth cranial nerve. Ears Otitis media Hearing loss Otitis externa Vertigo Nose Sinusitis Allergic rhinitis Epistaxis Throat Strep. Common bacteria that cause acute OM in children are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
Meningitis With increasing antibiotic resistance, especially Streptococcus pneumoniae, these complications may again become more common.
Type C represents a tympanogram in which the compliance of the membrane is greatest at a point where the pressure in the canal is 200 mm of water below that of atmospheric pressure (peak shifted to the left).
The patient is slowly spun in a rotating chair and dizzinessis is measured with optokinetic testing and a fixation test.
The Dix-Hallpike test is performed with the patient’s head rotated 45? toward the right ear, and the neck slightly extended with the chin pointed slightly upward. The patient will usually awaken with room-spinning vertigo that will gradually become less intense over 24–48 hours. In healthy children older than two years of age who present with less severe symptoms, observation for 48 hours may be considered. This suggests inefficient eustachian tube function with persistent negative pressure in the middle ear. The diagnosis is strongly suggested by a history of diabetes mellitus, severe otalgia, cranial neuropathies, and characteristic EAC findings. Moving platform posturography is a method of quantifying balance, but should not be used alone to diagnose vestibular disorders. Medical therapy with vestibular suppressants is ineffective because the episodes of vertigo are so fleeting, and should be discouraged.
During the audiogram, independent thresholds are determined for each ear for both air conduction (conductive hearing) and bone conduction (sensorineural hearing).
It is most useful in quantifying balance improvement (or worsening) following treatment for a particular problem, and can help identify the functional dizzy patient.
Once the vertigo and the nystagmus provoked by the Dix-Hallpike test cease, the patient’s head is rotated about the rostral-caudal body axis until the left ear is down (panel B).
ECOG is not really a test of the vestibular system, but is a useful test of hearing in the evaluation of Meniere’s disease. The test is a variant of brainstem audio-evoked response and, if possible, should be performed during active Meniere’s attacks.
With the head kept turned toward the left shoulder, the patient is rought into the seated position (panel D). Once the patient is upright, the head is tilted so that the chin is pointed slightly downward.

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