Download Management of Ear, Hearing and Balance Disorders: Fact, Fiction

 Management of Ear, Hearing and Balance Disorders: Fact, Fiction, and Future George W. Hicks, M,D. 7440 N. Shadeland Avenue, Suite 150 Indianapolis, IN 46250 904 N. Samuel Moore Parkway Mooresville, IN 46158 (317) 842‐4901 (800) 818‐EARS (3277) I.
Introduction
ADA "18x18 Initiative," Phoenix, Az 2012 II.
BasicEarAnatomy
Bony labyrinth, contents, cochlear, vestibular 1 III.
PathologiesoftheEar,Hearing,andBalance
A.
HearingLoss:"Theearlistens;thebrainhears."
1.
Epidemiology
2.
3.
Types
a)
conductive
b)
cochlear
c)
retrocochlear(neural)
d)
mixed
Etiology
a)
aging
b)
infection
c)
noise
d)
headtumors
e)
genetics
f)
metabolicsyndromes
4.
Warningsignsrequiringpromptintervention
5.
History
6.
Medical/PhysicalExamination:vitalsigns,ausculatation,head&neck,tuning
forks,audiometrics
7.
Treatment:medical,surgical,rehabilitative
"What about earwax?" 8.
Future:implantablehearingaids,moleculartherapy,hybridcochlearimplant
2 B.
Tinnitus(FromtheLatin‐"tojingle")
1.
Definition
2.
Epidemiology
3.
Types
a)
subjective:85%SNHL,15%other
b)
objective(vascular,myoclonus)
4.
Etiology
a)
Aging
b)
Infection
c)
Noise(acoustic,chronic)
d)
Headtumors
e)
Endolymphatichydrops
5.
Pathophysiology:outerhaircells,striavascularis,endocochlearpotential,central
auditorypathways
6.
Concerns:lifestyle,diversity,gravity,difficulty
7.
Mechanism
8.
Modulatingfactors
9.
History:TinnitusHearingIndex,TinnitusQuestionnaire(subjective)
3 10.
Medical/PhysicalExamination:audiometrics,symmetry
11.
Treatment:nocure,variablecontrol,imaging(MRI,PET),goaloftreatment
a)
Reassurance/explanation‐‐avoid"There'snocure....livewithit!"
b)
Audiological
c)
Psychological
d)
Surgery
e)
Future:directauditorystimulationofauditorycortex,repetitive
transmagneticstimulation,tinnitusretrainingtherapy
4 C.
Vestibulopathies
1.
Introduction:Thefirststepofthepractitioneristodeterminewhetherthe
problemissensory,integrative,ormotor.
2.
AnatomyandPhysiology
3.
History:Thisiswhereonebegins.Itisthesingle,mostimportantelementofa
diagnosticevaluation
4.
Medical/PhysicalExamination:spontaneousandgazenystagmus,pursuitand
saccades,VOR,positionalandpositioning,cerebellum,posture/gaitanalysis,Ten
MinuteDizzyExamination,tuningforks(SuperiorSemicircularCanalDehiscence),
pneumaticotoscopy,Snellenchart
5.
LaboratoryTesting
a)
Guidedbyhistoryandexamination
b)
Testoptions:AHR,VNG,VEMP,RotationalChair,CDP,ECoG,audiometrics,
imagingstudies,bloodtests(serologic)
6.
WorkingDiagnoses:peripheral,central,both
7.
Treatment:dietary,medical,surgical,rehabilitation
8.
"MillionDollarClues"
9.
Vertigosyndromes:peripheralvs.central
10.
SummaryofVestibulopathies
5 D.
FacialNerveDisorders
1.
Anatomy:longcoursewithintemporalbone;motor/sensory
2.
Bell'sPalsy:acuteonset,60‐70%noknownetiology;incidence15‐40/100,000
3.
Riskfactors:diabetes,pregnancy(3xincidence),immuno‐deficiencies(HIV)
4.
Differentialdiagnosis
5.
Treatment:immediatemedicalreferraltootologist("Allthatpalsiesisnot
Bell's")
E.
AcousticNeuroma
1.
Definition:nonmalignanttumoroftheeighthcranialnerve
2.
Symptoms:variable‐‐SNHL,gradual/sudden,tinnitus,balanceproblems,facial
weakness,changeintaste,headaches,clumsiness,confusion
3.
Audiometry:assymetry,disproportionallypoorSDS,"rollover,"reflexes(ABR,
VNG,VEMP)
4.
Imaging:MRIwithcontrast
5.
IV.
Summary
Treatment:observation,surgery,radiationtherapy(SRS,FRS)
6 Red Flags-Warning of Ear Disease
Indications for Medical Referral to an Otologist.
1. Hearing loss with a positive history of familial hearing loss, TB, syphilis, HIV, Meniere’s
disease, autoimmune disorder, otosclerosis, von Recklinghausen’s neurofibromatosis,
Paget’s disease of bone, head trauma related to onset.
2. History of pain, active drainage, or bleeding from an ear.
3. Sudden onset or rapidly progressive hearing loss--(URGENT ATTENTION!)
4. Acute, chronic, or recurrent episodes of dizziness.
5. Evidence of congenital or traumatic deformity of the ear.
6. Visualization of blood, pus, cerumen plug, or foreign body in the ear canal.
7. Conductive hearing loss or abnormal tympanogram.
8. Unilateral or asymmetric hearing loss; or bilateral hearing loss > 80 dB.
9. Unilateral or pulsatile tinnitus.
10. Unilateral or asymmetrically poor speech discrimination scores.
11. Facial Nerve Paralysis--(URGENT ATTENTION!)
These red flags do not include all indications for a medical referral and are not intended to
replace clinical judgment in determining the need for consultation with an otologist.
Adapted from a policy statement from the American Academy of Otolaryngolgy--Head and Neck
Surgery.
George W. Hicks, M.D. (317) 842‐4901 (800) 818‐EARS (3277) 7