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1. Which are the three most common organisms causing acute sinusitis ?
2. What are Ducts of Rivinus ?
3. Whartons duct?
4. What is the most probable diagnosis when the findings are as follows : erythematous aryepiglottic folds, grey granulation tissue in the interarytenoid region and posterior
thirds of vocal cords, ulcers in the posterior thirds of vocal cords ?
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7. What is your first diagnosis is an elderly male who comes with progressively worsening stridor of 3 months duration ?
8. A 3 yr old boy comes with the complaint of foul smelling sero sanguinous discharge from one nostril. What is your first diagnosis ?
9. In which condition is steeple sign seen ?
10. Expand Gd-DTPA.
Labels
just4fun (2)
MCQs (8)
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ANSWERS
5. Andy Gump deformity .This anatomic defect results from resection of the anterior mandibular arch without adequate reconstruction.
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These plaques consist of heaped-up areas of necrotic epithelial debris or actual colonies of C.
albicans on the esophageal mucosa; the esophagus per se has an irregular or shaggy appearance .
20. Moure incision. The incision is started from the inner extremity of the eyebrow, descending along the lateral wall of the nose over the naso labial fold. It is curved up to the
alar margin. The classic Moure's incision should not extend into the vestibule of the nose. The advantage of this incision is that it can be extended above and below to
facilitate better exposure of midface, anterior skull base and orbit. The incision heals with minimal scarring.
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21. 30 C and 44 C
22. Vestibular or Posterior column
23. Also known as Winkler's disease . Chondrodermatitis nodularis chronicis helicis is an painful, inflammatory nodule of the external ear. nonwhites have been noted
occasionally to have lesions in areas other than the helix, such as the antihelix or antitragus. The lesions are believed by several researchers to relate to trauma or sun
damage. The nodules are more commonly reported on the right ear, which is believed to be the preferred resting side during sleep.
24. TB lymphadenitis.Cervical lymphadenopathy is also termed scrofula, meaning glandular swelling in Latin. The nodes coalesce, break down and perforate the deep fascia,
resulting in the characteristic collar-stud abscess, which this case resembles.
25. Diffuse esophageal spasm.
26. Darwin's tubercle is a congenital ear condition which often presents as a thickening on the helix at the junction of the upper and middle thirds.However Darwin himself
named it the Woolnerian tip, after Thomas Woolner, a British sculptor who had depicted it in one of his sculptures and had first theorised that it was an atavistic feature.
Type 2
Type 3
Type 4
Type 5
29.
30.
Ludwigs angina
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Fistula test or Perilymphatic fistula test : The fistula test is performed by applying positive and negative pressure to the intact eardrum using a pneumatic
otoscope or by pressing tragus.
Used to detect Perilymph fistula.
Positive
Result(indicates
Perilymphatic Fistula)
Negative
Result(Normal)
No changes noted.
No changes noted.
The type of nystagmus seen can be deducted from the picture below.
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Perilymphatic fistula:
A perilymph fistula (PLF) is an abnormal opening between the air-filled middle ear and the fluid-filled inner ear. It may occur due to a defect in one of three locations:
Oval Window (most common site)
Stapedectomy surgery (for otosclerosis)
Head trauma or barotrauma (pressure injury)
Acoustic trauma
Round window Barotrauma -- SCUBA diving, airplane pressurization
Congenital malformations (such as Mondini dysplasia)
Otic capsule-Another possible location for a fistula is in the bone of the ear (the otic capsule). This is a rare condition where the bone between the ear and brain area is missing or
thin, causing symptoms very similar to that of a round or oval window fistula. Problems in the otic capsule that may cause a perilymph fistula include:
Superior canal dehiscence syndrome (anterior SCC)
Cholesteatoma
Fenestration -Another type of bony fistula can occur after a surgical procedure called fenestration previously done for otosclerosis;
Temporal bone fracture
Micro-fissure
The most common type of otic capsule fistula is located just above the superior semicircular canal and is called the superior canal dehiscence syndrome.
Congenital syphilis
(here stapes footplate is hypermobile, so even
small pressure changes in ear, cause excessive
movement of stapes footplate & excessive
stimulation of utricular macule)
HENNEBERT'S SIGN:
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It is a false positive fistula test i.e, when there is no evidence of middle ear disease causing fistula of horizontal semicircular canal.
It is seen in 25% cases of meniere's disease or congenital syphilis.
Hennebert sign- pressure induced nystagmus &
Hennebert symptom- pressure induced dizziness.
Tullios phenomenon:
Sound-induced vestibular symptoms such as vertigo, nystagmus, oscillopsia, and postural imbalance .
Tullio's phenomenon is seen mainly in:
Superior canal dehiscence,
Meniere's syndrome,
vestibulofibrosis.
other causes of perilymph fistula,
post fenestration surgery(for otosclerosis).
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The vulnerability of the optic nerve with or without the presence of an Onodi cell is further compounded by the thin lamina papyracea in the posterior ethmoid area .
This anatomic variation is found in 8-14% of cases according to studies using CT in association with recent developments in endoscopic sinus surgery.
The presence of Onodi cells increases the chance that the optic nerve and/or carotid artery would be exposed (or nearly exposed) in the pneumatized cell.
The optic nerve, and more rarely, the internal carotid artery, may be exposed within or lie immediately adjacent to such an air cell.
During endoscopic sinus surgery attempts to localise the sphenoidal sinus via instrumentation through the posterior most ethmoidal air cells can lead to
optic nerve, and even, internal carotid artery, injury.
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AQUINO'S SIGN is the blanching of the tympanic mass with gentle pressure on the carotid artery.Seen in Glomus tumors .
BATTLE SIGN- Bruising behind ear at mastoid region, due to petrous temporal bone fracture (middle fossa #)
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BRYCE SIGN - If combined laryngocele & external laryngocele is presenting as a neck mass, compression will cause a hissing sound as the air escapes from it into the
larynx. This test is fraught with danger in cases of combined laryngoceles because air from the external component may get forced into the internal component causing acute
airway obstruction.
DELTA SIGN
Lateral sinus thrombosis on CT or MRI with contrast shows an empty triangle appearance of the thrombosed sinus surrounded by contrast enhanced dura{since contrast may
flow around the clot to outline the periphery of the sinus}. It is also called as empty triangle sign.
DODDS SIGN/CRESCENT SIGN- X-ray finding-Crescent of air between the mass and posterior pharyngeal wall. positive in AC ployp Negative in Angiofibroma
FURSTENBERG'S SIGN-Positive in Encephaloceles.Owing to the intracranial connection, there is pulsation and expansion of the mass with crying, straining, or compression of
the jugular vein (Furstenberg test).This is used to differentiate Nasal Encephaloceles from other congenital midline nasal masses like Nasal Gliomas.
GRIESINGER'S SIGN-Erythema and oedema posterior to the mastoid process resulting from septic thrombosis of the mastoid emissary vein. seen in lateral sinus thrombosis
HALO SIGN/ HANDKERCHIEF SIGN - A finding in CSF rhinorrhea when CSF is mixed with Blood.
In patients with head trauma, a mixture of blood and CSF may make the diagnosis difficult.
CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign.
CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo.
Blood alone does not produce a ring.
The best ring is obtained with a 50: 50 mix of blood and CSF.
More importantly, they found that the presence of a ring was not exclusive for CSF.
Blood mixed with tap water, saline, and rhinorrhea fluid also produced a ring.
The halo sign does occur, but clearly does not clinch the diagnosis.
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HITSELBERGERS SIGN - In Acoustic neuroma- loss of sensation in the postero-superior part of external auditory meatus supplied by Arnolds nerve( branch of Vagus nerve to
ear )
HOLMAN MILLER SIGN, ANTRAL SIGNThe anterior bowing of the posterior wall of the antrum seen on lateral skull film .Pathognomic for juvenile nasopharyngeal angiofibroma.
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MILIANS EAR SIGN- Erysipelas can spread to pinna(cuticular affection), where as cellulitis cannot.
Cellulitis and erysipelas manifest as areas of skin erythema, edema and warmth in the absence of underlying suppurative foci.
They differ in that erysipelas involves the upper dermis and superficial lymphatics, whereas cellulitis involves the deeper dermis and subcutaneous fat.
As a result, erysipelas has more distinctive anatomic features than cellulitis; erysipelas lesions are raised above the level of surrounding skin, and there is a clear line of
demarcation between involved and uninvolved tissue.
Classic descriptions of erysipelas note "butterfly" involvement of the face.
Involvement of the ear (Milian's ear sign) is a distinguishing feature for erysipelas since this region does not contain deeper dermis tissue.
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Paul Dudley White's winking ear lobe sign-Movement of the ear lobe coincident with the pulse suggests tricuspid insufficiency.
PHELPS SIGN - loss of crest of bone (as seen in CT-scan) between carotid canal and jugular canal in glomus jugulare.
RAT TAIL SIGN /Bird-beak sign-Sign in barium swallow of achalasia. The oesophagus is dilated, and contrast material passes slowly into the stomach as the sphincter
opens intermittently. The distal oesophagus has a narrow segment and the image resembles a bird's beak.
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This is in contrast to the rat's tail appearance of carcinoma of oesophagus.Barium swallow shows characteristic rat tail appearance with irregular mucosa margins in
carcinoma esophagus.
RISING SUN SIGN
There is red vascular hue seen behind the intact tympanic membrane. it is seen in glomus tumour, high jugular bulb and aberant carotid artery in the floor of middle ear.
RACCOON SIGN-Indicate subgaleal hemorrhage,and not necessarly base of skull .
SCHWARTZ SIGN
It is also called flamingo flush sign. it is seen because of increased vascularity in submucous layer of promontory in active phase of otosclerosis(otospongiosis).
STEEPLE SIGN- X-ray finding in Acute laryngotracheobronchitis (CROUP).The steeple sign is produced by the presence of edema in the trachea, which results in elevation of
the tracheal mucosa and loss of the normal shouldering (lateral convexities) of the air column.
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STANKIEWICKS SIGN - indicate orbital injury during FESS. fat protrude in to nasal cavity on compression of eye ball from outside .
TEAR DROP SIGN
Seen in Orbital floor fracture. It is defined as tear drop shaped opacification seen hanging from the roof of the maxillary sinus on water's view. The floor of the orbit is the most
common portion of the orbit to sustain fracture. A classic radiographic finding in blow-out fractures is the presence of a polypoid mass (the tear-drop) protruding from the floor of the
orbit into the maxillary antrum The tear-drop represents the herniated orbital contents, periorbital fat and inferior rectus muscle.
THUMB SIGN
It is a thumb like impression (due to enlarged epiglottis) seen on X-ray lateral view neck in patients with acute epiglottitis.Direct visualization of the epiglottis by laryngoscope, if
attempted, reveals a beefy red, edematous epiglottis.
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TRAGUS SIGN
In acute otitis externa there is marked tenderness when tragus is pressed against the pinna.
TEA POT SIGN is seen in CSF rhinorrhoea.This could be related to the relationship of the sphenoid ostium to the sinus floor. The sphenoid ostium lies at an appreciable distance
anterosupe-rior from the sinus floor. An increase in the CSF rhinorrhea therefore occurs in a case of sphenoid sinus leak when the patient bends forward as an increasing amount of
CSF gains access to the ostium "teapot" sign.
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Delphian node
Labels: ENT
A midline prelaryngeal (cricotyhroid) lymph node.
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Assessment of Hearing
Labels: ENT
In this post we will deal with the techniques followed to assess auditory function
we should be able to know theses 4 things after doing the tests:
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Not significant
0-25dB(adults)
0-15dB(children)
Mild
26-40dB
Moderate
41-55dB
Moderately severe
56-70dB
Severe
71-90dB
Profound
total
site of lesion
cause
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These 3 tests are non-specific & they don't indicate the type of deafness.they only give a rough idea about the hearing loss.
Finger friction test
Watch test
Speech test
Rinne test:
method:To perform this test, a 512Hz vibrating tuning fork is placed on the mastoid bone and then moved next to the external ear. The patient indicates at which of the two sites
the sound is louder.
principle:Sound transmitted through an external ear traverses the middle ear and is perceived by the cochlea (inner ear). Sound can
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be transmitted directly to the cochlea, skipping the external and middle ear, by placing the vibrating tuning fork on the mastoid bone
directly behind the ear. This is the basis for the Rinne hearing test.
Rinne
normal
conductive
deafness
SN deafness
AC>BC
(Rinne +)
BC>AC
(Rinne -)
AC>BC
note:
rinne (-)ve
256Hz fork
512Hz fork
1024Hz fork
minimum
air-bone gap
15dB
30dB
45dB
Weber test:
method:Place the tuning fork in the center of the forehead and the physician asks the patient where he or she hears it.
principle:
The occlusion effect is responsible for this phenomenon. Sound conducted through bone causes the
cochlea, the ossicular chain, and the air in the external auditory canal to vibrate. Some lower frequency
sound, as produced by the 512 Hz tuning fork, escapes from the canal. When the ear is occluded, these
frequencies cannot escape and the sound seems to become louder.
it is the occlusion effect, rather than elimination of environmental sound, that is responsible for the improved bone conduction
threshold when occluding a normal ear.
Middle ear effusion and ossicular chain disruptions cause a "mass loaded" middle ear, with lowering of the inherent resonant frequency.
Ossicular chain fixation causes a phase shift in the sound wave. Both cause preferential transmission of lower frequencies to the
cochlea
Weber
normal
conductive
deafness
SN deafness
not lateralised
lateralised to
poorer ear
lateralised to
better ear
note:lateralisation of sound in Weber test with a tuning fork of 512Hz implies either
conductive loss of 15-20dB in ipsilateral ear (or)
sensorineural deafness in contralateral ear
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patients bone conduction compared to that of examiner(presuming that examiner has normal hearing)by keeping on mastoid.
External auditory meatus of both patient & examiner is occluded by pressing tragus inwards ,this is to prevent external ambient noise entering through air
conduction route.
normal
ABC test
conductive
deafness
SN deafness
reduced
Schwabach test:
method:same as ABC test,but meatus is not occluded.
Schwabach
normal
conductive
deafness
SN deafness
equal
lengthened in reduced
patient(due to
absence of
external
ambient noise
the patient
hears it for
longer time)
Bing test::
determine whether closing of ear canal results in occlusion effect.
The Bing test can simulate unilateral (one-sided) conductive hearing loss results by placing a finger in one ear while performing the Weber test.
method:tuning fork placed on mastoid while examiner alternately closes & opens ear canal by pressing tragus inwards.
principle:same principle as Weber test(occlusion effect)
Bing test
normal
conductive
deafness
SN deafness
louder(when
occluded)
no effect
(bing negative)
louder
Gelle's test:
method:A vibrating tuning fork is applied over the mastoid process; if it is heard, the air in the external auditory canal is compressed, by means of a Siegle's
speculum.
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stapes
SN deafness
fixation(otosclerosis)
decreased in
intensity after
increasing
pressure
Audiometric tests:
Pure tone audiometry:
used to measure the auditory threshold of an individual
pure tone-a single frequency sound is used while testing ,audiometer-an electronic device which produces pure tones.
Audiometer: There are two types of audiometers widely used. They are:
1. Those that require a subjective response on the part of the patient and
2. Those that require no subjective response from the patient.
Examples include:
1. Pure tone audiometer is the classic example of the first type
2. Impedence audiometer / BERA (Brainstem Auditory Evoked Responses audiometer) are examples of the second type.
The frequencies generated are 125, 250, 500,750, 1000, 1500, 2000, 3000, 4000, 6000 and 8000 Hz.
Intensity is the level of sound power measured in decibels; loudness is the perceptual correlate of intensity.
Frequency is cycles per unit of time. Pitch is the perceptual correlate of frequency. Frequency is measured in hertz, which are cycles per second.
Usually frequencies of 250-8000 Hz are used in testing because this range represents most of the speech spectrum, although the human ear can detect
frequencies from 20-20,000 Hz.
The hearing level (HL) is quantified relative to "normal" hearing in decibels (dB), with higher numbers of dB indicating worse hearing. The dB score is not really percent
loss, but neverthless 100 dB hearing loss is nearly equivalent to complete deafness for that particular frequency. A score of 0 is normal. It is possible to have scores
less than 0, which indicate better than average hearing.
note:In a normal PTA audiogram we see that both AC(air conduction) & BC(bone conduction) are at the same 0dB level.But we know that AC is better than BC.So you
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note:In a normal PTA audiogram we see that both AC(air conduction) & BC(bone conduction) are at the same 0dB level.But we know that AC is better than BC.So you
may get a doubt how come they are same here.Actually In a clinic a calibrated audiometer is used to present the correct intensity for each tone such that 'normal
hearing' registers as 0 dB HL (audiometric zero) .This is done for the ease of reading the audiogram report.& standardisation
0 dB Hearing Level at 1000 Hz = 7 dB SPL
Pure tone air conduction testing:
This is a measurement of air conduction thresholds of audibility.
Pure tone air conduction threshold is tested using head phones:
method:
note:when establishing threshold ,2 choices are ascending & descending way to change intensity.
ascending(Hughson - Westlake ascending technique)- begins with stimuli that are below patient's threshold & intensity is
increased until patient responds.
descending- stimuli presented first are above patient's threshold & intensity is decreased until the patient no longer
responds.
but both have drawbacks=
in descending technique the patient might continue to respond to stimuli ,when he no longer perceives (false +
response)
in ascending technique the patient may fail to respond even when stimuli are audible.(false - response)
Modified Hughson - Westlake technique :this procedure uses an ascending technique to determine threshold .but each threshold search is preceeded by a
descending familiarization trial.
ex:"Up 5-down 10" method of threshold estimation
1. The better ear is tested first in order to determine the need for masking.
2. Start with a 1000 Hz tone at a level above the threshold to allow easy identification of the tone. This tone is selected because it is an important speech frequency, and
the patient is less apt to mistake the frequency. To ensure the subject is familiar with the task, present a tone of 1000 Hz that is clearly audible (e.g. at 40 dB
HL for a normally hearing subject or approximately 30 dB above the estimated threshold for a subject with a hearing impairment,)
3. If the patient is suspected to be having a profound hearing loss then the testing should be started with 250Hz frequency. This is because of the fact that the individuals with
profound hearing loss often have testable hearing only in the low frequency range.
4. Next, test 2000, 4000, 8000, 500 and 250 Hz in that order
5. As the threshold levels are being reached, a check should be made for the existance of abnormal tone decay. This is done by sustaining the tone for several seconds longer
than usual. If the index finger drops before the tone is discontinued, abnormal tone decay should be suspected.
6. "Up 5-down 10" method =The starting intensity of the test tone is reduced in 10 dB steps following each positive response, until a hearing threshold level is reached at
which the subject fails to respond. Then, the tone is raised by 5 dB, if the subject hears this increment, the tone is reduced by 10 dB; if the tone is not heard then ti is raised
by another 5 dB increment. This 5 dB increment is always used if the preceding tone is not heard, and a 10 dB decrement is always used when the sound is heard. The
threshold is defined as the faintest tone that can be heard 50% or more of the time, and is established after several threshold crossings.
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Testing of the second ear should begin with the last frequency used to test the first ear. There is no need to start again with a 1000 Hz tone because if one side of the
heard has learned the listening task, the other side knows it as well. The test is terminated after all desired frequencies have been examined.
Masking
Masking presents a constant noise to the nontest ear to prevent crossover from the test ear. The purpose of masking is to prevent the nontest ear from detecting
the signal (line busy), so only the test ear can respond.
When a signal is presented to the test ear, the signal may also travel through the head and reach the cochlea on the other side. However the intensity of the signal from
the test to the nontest ear can be reduced by the mass of the head. This signal reduction is called interaural attenuation.(transcranial transmission loss)
For bone conduction, the interaural attenuation may be as low as 0 dB because the bones of the skull are very efficient at transmitting sound. Thus, any
suspected difference in bone conduction between the test and nontest ears requires masking. (ie,Masking is done in all Bone conduction studies)
Crossover occurs when sound presented to the test ear travels across the head to the nontest ear. This occurs at approximately 40 dB for circumaural earphones
across all frequencies.Interaural attenuation for air conduction can range between 40 and 80 dB. Masking should be used if the difference in air conduction in
one ear and bone conduction in the other ear is 40 dB or greater.(ie,masking required when there is difference b/w the 2 ears of minimum 40dB in air conduction
threshold )
When the difference in the thresholds of the two ears is greater than the transcranial transmission loss, cross-hearing may occur and the apparent threshold of the
worse ear is in fact a shadow of the better ear.
Narrow band masking noise is used
Audiograms:
red indicates right ear
blue indicates left ear.
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Audiogram depicting a mild rising conductive hearing loss in the left ear:
Speech audiometry:
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note:P ure tone av erage( P T A) =av erage of pure tone thres hold of 3 s eparate f requencies ( 500 ,1000 ,2000H z) as meas ured by pure tone audiometry .
here patient doesn't repeat words ,just a measure of patient's ability to understand speech.
here Phonetically balanced words(PB) used=single syllable words=pin,bus
phonetically balanced means that the distribution of phonetic elements in list of words approximates the distribution found in everyday conversations.
list of 50 words given & then the number of correctly heard words multiplied by 2 to get score.
done at supra-threshold level i.e, at 30-40dB above SRT.
in normal people & those with conductive deafness have a high score of 90-100%.
90-100%
75-90%
slight difficulty
60-75%
moderate difficulty
50-60%
poor discrimination
<50%
very poor
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defined as the decay of the speech discrimination score (greater than 20% change) with increased stimulus intensity,
When present, this finding is indicative of a retrocochlear lesion
When the ear with a damaged nervous system is stimulated with a very loud sound, the nerves may be unable to handle the increased signal load. Consider this
analogy. If you injured your arm, you might be able to lift a small weight, but would be unable to lift a heavy weight. Similarly, the damaged VIII nerve may be able to
transmit a conversational level speech signal, but tire out when faced with the demand of sending strong, sustained messages.
Impedence audiometry:::Acoustic immittance.Immittance is a term derived from the terms for two inversely related processes for assessing middle ear function, impedance
and admittance. Impedance is the resistance to the flow of acoustic energy. Admittance is the ease of which acoustic energy can flow. A middle ear with low impedence (high
admittance) more readily accepts acoustic energy, whereas a middle ear with high impedence (low admittance) tends to reflect energy consists of 1. tympanometry
2. acoustic reflex measurements
The primary purpose of impedence audiometry is to determine the status of the tympanic membrane and the middle ear.
The secondary purpose of this investigation is to evaluate the acoustic reflex pathway which include the 7th and 8th cranial nerves and the brain stem.
principle:
when a sound strikes tympanic membrane ,some of the sound energy is absorbed while rest is reflected.A stiffer membrane would reflect more sound energy than a
compliant (loose) one.
so by changing the pressure in a sealed external ear canal & then measuring the reflected sound energy ,we measure the compliance or stiffness of tympano-ossicular
system & thus find the healthy or diseased status of middle ear.
The maximum compliance occurs when the pressure of the external auditory canal and the middle ear becomes equal.
Only at this pressure maximal acoustic transmission occur through the middle ear & minimum sound energy is reflected back.
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Tympanograms:
A tympanogram is a graphic representation of the relationship of external auditory canal air pressure to impedance
Pressure in the external auditory canal is varied from -200 daPa(decaPascal=mmH2O) through +200daPa while monitoring impedance
The Jerger system is the most commonly used classification system for tympanograms
Type A. The peak compliance occurs at or near atmospheric pressure indicating normal pressure in the middle ear. There are three subgroups. Compliance peak is 150 to +100 daPa
A - normal shape reflects a normal mechanism .immittance is 0.2-2.5 millimhos(unit of conductance)
AD - A deep curve with a tall peak indicates an abnormally compliant middle ear, as seen in ossicular dislocation or erosion, or loss of elastic fibers in
the tympanic membrane. immittance is less than 0.2 mmhos
AS - A shallow curve indicates a stiff system, as in otosclerosis. immittance is more than 2.5 mmhos
Type B - No sharp peak, with little or no variation in impedance over a wide range, usually secondary to non-compressible fluid in the middle ear (otitis media), tympanic
membrane perforation or obstructing cerumen.
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This Type B curve must always be interpreted in conjunction with the ear canal volume. Average ear canal volume in children ranges between 0.42 - 0.97 ml,
while in adults it ranges between 0.63 - 1.46 ml.
1. Type B curve with normal ear canal volume suggests otitis media.
2. Type B curve with small canal volume suggests that the ear canal could be occluded by the presence of wax, or the probe of the impedance
audiometer has not been properly placed.
3. Type B curve with large canal volume suggests that there could be perforation of the ear drum. (so middle ear volume is added up to volume of
ear canal)
Type C - Peak compliance is significantly below zero, indicating negative pressure (sub-atmospheric) in the middle ear space. This finding is often indicative
eustachian tube dysfunction. compliance peak is less than -150 daPa
note:
Testing for the presence of absence of perilymph fistula:
Testing implies presence or absence of a fistula (ie, an abnormal opening in the inner ear labyrinthine system).
This can be indirectly assessed by the presence of intense giddiness along with nystagmus when the external canal pressure in increased by increasing the probe
pressure. This sign is also known as the Hennebert's sign. This sign is manifested only in the presence of perilymph fistula.
Testing function of eustachian tube:
A negative or positive air pressure is created (-200 to +200) in middle ear & person is asked to swallow 5 times in 20 sec.
the ability to equate the pressure indicates normal tubal function.
also used to test patency of grommet placed in tympanic membrane in cases of serous otitis media.
Physical volume of ear canal:(Equivalent ear canal volume)Includes the volume between
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probe tip(of impedence audiometer) & tympanic membrane ,if tympanic membrane is intact. (or)
volume of ear canal & middle ear space if tympanic membrane is perforated.
method:
it is derived from acoustic admittance of volume of air medial to probe.
Under reference conditions ,a given volume of air has a known acoustic admittance, which can be used to calculate the equivalent volume of air.
eg;when a 226Hz probe tone is used ,1cubic cm of air has admittance of 1acoustic mmho under standard atmospheric conditions.
so, if admittance of air b/w probe & tympanic membrane is 1.5 acoustic mmho ,then equivalent volume is 1.5 cubic cm.
Average ear canal volumes for children are 0.42-0.97 mL. Average adult volumes are 0.63-1.46 mL.
Used in case of Type B tympanograms(flat) to know the cause:
Type B curve with normal ear canal volume suggests otitis media.
Type B curve with small canal volume suggests that the ear canal could be occluded by the
presence of wax, or the probe of the impedance audiometer has not been properly placed.
Type B curve with large canal volume suggests that there could be perforation of the ear drum.
(so middle ear volume is added up to volume of ear canal)
Static compliance:
Measure of middle ear mobility.
it is measures in equivalent volume in cc's, based on 2 volume measurements.
C1= made with tympanic membrane in position of poor compliance with +200 mmH2O in external canal.
C2= made with tympanic membrane at max compliance
C1-C2= Static compliance, which cancels out the compliance due to column of air in external canal.the remainder is compliance due to middle ear mechanisms.
static compliance is low when value is less than 0.28cc & high when more than 2.5cc
its major contribution is to differentiate b/w fixed middle ear & middle ear discontinuity.
Acoustic reflex:
principle:
Contraction of the stapedius muscle occurs with loud sounds, producing a measurable change in compliance.
When the stapedius muscle contracts in response to a loud sound, that contraction changes the middle ear immittance. This change in immittance can be detected as
a deflection in the recording.
A significant change in middle ear immittance immediately after the stimulus is considered an acoustic reflex.
A stapedial muscle contraction in response to an intense signal occurs bilaterally in normal ears with either unilateral or bilateral stimulation. This reaction occurs
because the stapedial reflex pathway has both ipsilateral and contralateral projections
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the immittance change caused by stapedius muscle contraction is measured in the ear containing the probe tip --this is PROBE EAR.
the ear receiving the stimulus to activate the reflex is --STIMULUS EAR.
either ear can be stimulus ear --i.e, the stimulus can even originate from the probe tip as well as from the ear phone on the opposite ear.
Absent reflex means even 125dB of sound doesn't elicit contralateral reflex.
Elevated reflex : the patient's threshold is compared to respective 90th percentiles that apply to his hearing threshold for the frequencies tested.If ART falls
above the 90th percentile it is considered elevated.
Ipsilateral or uncrossed acoustic reflex: here the stimulus is presented to the probe ear ,which is the same ear in which immitance change is measured.
Contralateral or crossed acoustic reflex: here the reflex is measured in the ear with probe tip ,but stimulus is given to opposite ear.
"right contralateral acoustic reflex" means stimulus is in right ear & probe in left ear.
"left contralateral acoustic reflex" means stimulus is in left ear & probe in right ear.
Probe ear principle:acoustic reflexes are usually absent when there is conductive pathology in probe ear.
stimulus ear principle: a conductive disorder in the stimulus ear reduces the stimulus level reaching the
cochlea by the amount of air-bone gap,As a result ART is elevated by the amount of air-bone gap.
2 basic acoustic reflex tests:
1. acoustic reflex threshold(ART)--lowest stimulus which produces reflex
2. acoustic reflex decay--measure of how long reflex lasts when stimulus is kept for a period of time
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ART:
Acoustic reflex thresholds generally are determined in response to stimuli of 500, 1000, 2000, and 4000 Hz. For screening purposes, or for a general check of the
pathway's integrity, usually test at 1000 Hz.
Range of ART :loud sound 70-100dB above threshold of hearing of that particular ear is used
The greater the hearing loss, the higher the acoustic reflex threshold for conductive hearing loss.
For sensorineural hearing loss, acoustic reflex thresholds may be within the normal range, particularly for mild-to-moderate hearing losses with
recruitment.
Absent(means even 125dB of sound doesn't elicit contralateral reflex) in:
1. Reflexes usually are absent or cannot be recorded if the patient has type B tympanograms; therefore, acoustic reflexes generally are not tested in these ears.
For example,
if the ear canal is occluded with cerumen, a type B tympanogram with low volume will be recorded. In this case, acoustic reflexes cannot be measured because middle
ear immittance is not being measured. (Cerumen blocks the signal.)
For a type B tympanogram with normal volume (as in otitis media) no pressure peak for immittance is obtained. The pressure between the ear canal and middle ear are
not equilibrated, and acoustic reflexes cannot be recorded.
For a type B tympanogram with high volume (as in the presence of patent pressure equalization tubes or perforated tympanic membranes), an open exchange of air
occurs between the ear canal and middle ear; thus, any contraction of the stapedius muscle cannot be measured.
2. In the presence of severe-to-profound sensorineural hearing loss in the stimulated ear, acoustic reflexes may be absent secondary to insufficient stimulation.
3. Similarly, a conductive component may attenuate the signal intensity, preventing sufficient stimulation in the stimulated ear or precluding a clear response in the recording
ear.
Typical patterns for the interpretation of acoustic reflex abnormalities are as follows:
With unilateral conductive deafness:
In the given image ,right contralateral reflex absent or elevated (due to probe principle)
but left ear ipsilateral absent (due to both probe ear & stimulus ear principles)
So in ipsilateral both principles are operative (ie,stimulus is attenuated due to conductive disorder & even immitance
change cannot be measured due to conductive disorder)
Due to this double effect ipsilateral acoustic reflex are so sensitive to conductive disorder.
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it is measure of how long the response lasts if stimulus is kept on for a period of time.
The acoustic reflex decay test is used to assess the integrity of CN VIII. Using a stimulus of either 500 or 1000 Hz, a
contralateral continuous tone is presented for 10 seconds at a stimulus level 10 dB above the acoustic reflex
threshold for that stimulus frequency in that ear. This suprathreshold acoustic reflex then is recorded over the 10-second stimulation period. If the amplitude of the
recorded deflection on the screen decreases by 50% or more within 10 seconds, the test is considered positive.
In some cases of muscular or neuromuscular disorder, tone decay results also may be positive secondary to muscle fatigue.
along with ART (absent or elevated),acoustic reflex decay is used to detect retro-cochlear disorder
useful in:
test hearing in infants & young children - since it is objective test
find malingers- a person who feigns total deafness & doesn't give any response on PTA ,but shows +ve stapedial reflex is malingerer.
detect cochlear pathology - presence of stapedial reflex at lower intensities like 40 -60 dB than usual 70dB indicates recruitment & thus cochlear type hearing loss
lesions of facial nerve- absence of reflex when hearing is normal indicates lesion of facial nerve proximal to nerve to stapedius.
lesion of VIIIth nerve- Acoustic reflex decay test
lesion in brain stem:ipsilateral reflex present but contralateral absent indicates lesion is in crossed pathways in brain.
one frequency at a time(fixed frequency Bekesy audiometry):one frequency for a given period of time.
test frequency changes from low to high.(sweep frequency Bekesy audiometry):test tone increases smoothly from 100 to 10,000Hz at rate of 1 octave/sec
Each Bekesy audiogram is obtained twice
once with a continuous tone (CONTINUOUS TRACING)
other with a tone that pulses on & off 2.5 times/sec(PULSED TRACING)
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seen in
(C) &(P)
tracings
overlap
II
III
illustration
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IV
(C) falls
retrocochlear lesion
below (P)
at
frequencies
up to
1000Hz by
more than
25dB but
not to
audiometer
limits.
(C) above
(P)
We will discuss about the "special tests for hearing assessment" in the next post.
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