MindMap Gallery Otolaryngology, Head and Neck Surgery--Otology 001
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Otolaryngology, Head and Neck Surgery--Otology 001
Chapter 1 General Introduction to Otology
Section 1 Applied Anatomy of the Ear
1. External ear
Auricle, external acoustic meatus
2. Middle ear
(1) Tympanic cavity
1. Six walls
Lateral wall: bone tympanic membrane
Tympanic membrane: an inwardly concave, oval, translucent membranous structure; most of its edges are embedded in the tympanic groove, called the pars tensa, and the upper tympanic membrane is directly attached to the temporal squamous area, called the pars tensa. It is the pars flaccida; there is a triangular reflective area from the umbilicus of the tympanic membrane forward to the edge of the tympanic membrane, called the cone of light.
∎ Medial wall/labyrinth wall: vestibular window/oval window, cochlear window/
round window
Anterior wall/carotid artery wall: There is the opening of the tensor tympani semicanal and the opening of the Eustachian tube (slightly inferior)
Posterior wall/mastoid wall
Superior wall/tegmen tympanum
Inferior wall/jugular vein wall
2. Contents
Ossicles: malleus, incus, stapes
Tympanic muscles: tensor tympani muscle (innervated by the mandibular branch of the trigeminal nerve), stapedius muscle (innervated by the stapedius muscle branch of the facial nerve)
(2) Eustachian tube (pharyngotympanic tube)
Functions: ① Adjust the tympanic air pressure to maintain a balance between the pressure inside and outside the tympanic membrane; ② Remove tympanic secretions; ③ Prevent pharyngeal fluid from entering the tympanic cavity; ④ Sound blocking and silencing effects
(3) Tympanic antrum
The air-containing cavity above and behind the tympanum is the hub where the tympanum and mastoid air cells communicate.
(4) Mastoid process
It is not yet developed at birth and usually develops from the sinus tympanum to the mastoid after the age of 2 years.
3. Inner ear/labyrinth
(1) Bone labyrinth
Vestibule, osseous semicircular canals, cochlea
(2) Membranous labyrinth
Utricle and macula utriculi, saccule and macula sacculi, membranous semicircular canals and crista ampullaris
Section 2 Symptomology of the ear
Earache (otalgia), otorrhea (otorrhea), deafness (deafness), tinnitus (tinnitus), vertigo (vertigo)
Section 3 Ear Examination Method
1. Auditory function test method
(1) Overview of auditory sensation
1. The sound frequency that the human ear can hear is between 20 and 20,000 Hz. Those with <20 Hz are called infrasound, and those with >20,000 Hz are called ultrasound.
2. Physiological functions of the ear
(1) Outer ear: collects sound waves, locates and resonates
(2) Middle ear: conducted sound waves, amplification/supercharging effect (22 times, Δ=30dB)
(3) Inner ear: energy conversion (hearing, balance sense)
3. Hearing examination
(1) Subjective listening: tuning fork test, pure tone audiometer examination, speech audiometry
(2) Objective observation and listening: acoustic impedance detection, otoacoustic emission detection, auditory evoked potential detection
(2) Tuning fork test (key content)
1. Rinne test (RT): The purpose is to compare the length of air conduction and bone conduction in the subject's ear; test the bone conduction hearing first. Once the subject's ear cannot hear the sound of the tuning fork, immediately test the ipsilateral air conduction hearing. If you can hear again at this time, it means air conduction (AC) > bone conduction (BC) (in terms of conduction time), and the test is called positive; if you cannot hear, you should knock the tuning fork again and measure the air conduction hearing first. Listen again in time, and immediately measure the bone conduction hearing in the same ear. If you can hear again at this time, it means bone conduction > air conduction, and the test is said to be negative.
2. Weber test (WT): The purpose is to compare the bone conduction hearing of the subject's two ears; after knocking the tuning fork, place it at any point on the craniofacial midline, and ask the subject to identify which side the tuning fork sound is deflected to.
3.Schwabach test (ST): The purpose is to compare the bone conduction hearing of the subject and normal people; first try the bone conduction hearing of the normal person. When the person can no longer hear the sound of the tuning fork, quickly move the tuning fork to the sinus area of the ear of the subject. Then use the same method to test the test ear first, and then move to the normal person; if the bone conduction of the test ear is extended, the test is positive.
4.Gellle Test (GT):
The purpose is to check whether the stapes is mobile; it is positive when it is mobile
(3) Pure tone audiometer examination method
1. Application: Understand the hearing sensitivity of the subject's ear, estimate the degree of hearing damage, and initially determine the type of deafness and the location of the lesion
2. Pure tone hearing threshold test
Hearing threshold: the minimum sound intensity value that can cause hearing in a certain ear; that is, given a certain number of sound signals under specified conditions, the subject can respond to 50% of the sounds at a level that is barely audible.
Analysis of pure tone hearing threshold diagram
Conductive deafness: bone conduction is normal/near normal, air conduction hearing threshold is increased; air-bone conduction difference exists, generally <60dB; air conduction curve is flat or low-frequency hearing loss is severe and rising.
Sensorineural hearing loss: The air-bone conduction curve decreases in consistency, and the air-bone conduction is poor; generally high-frequency hearing loss is severe (gradual/steep decrease)
Mixed deafness: Air-bone conduction curves all decrease, but there is a certain air-bone conduction difference
3. Pure tone suprathreshold function test: It has certain reference value in identifying cochlear deafness and neurological deafness.
Loudness recruitment: In cochlear disease, further increase in sound intensity at a certain intensity value can cause abnormal increase in loudness.
Pathological auditory adaptation (auditory adaptation): In neurological deafness, auditory fatigue is more obvious, and the degree/speed of auditory adaptation exceeds the normal range.
(4) Acoustic immittance measurement
1. Tympanometry: The curve is A-shaped in people with normal middle ear function; Type As is more common when the activity of the middle ear sound transmission system is obviously limited, such as otosclerosis, fixed ossicles, and obvious thickening of the tympanic membrane; Type Ad is more common when the ossicles are When the activity of the middle ear sound transmission system is significantly increased, such as chain interruption, tympanic membrane atrophy, healing perforation, abnormal opening of the Eustachian tube, etc.; Type B is more common in patients with tympanic effusion and obvious middle ear adhesions; Type C is more common in patients with Eustachian tube dysfunction, negative tympanic pressure
2. Acoustic stapedius reflex
Principle: It refers to the reflex contraction of the stapedius muscle that can be induced when exposed to external sound/other types of stimulation.
Applications: ① Estimating hearing sensitivity; ② Differentiating conductive deafness and sensorineural deafness; ③ Determining loudness revitalization and pathological auditory adaptation; ④ Identifying non-organic deafness; ⑤ Provide information for retrocochlear auditory pathway and brainstem diseases Diagnostic reference; ⑥ Make localization diagnosis and prognosis prediction for some peripheral facial paralysis; ⑦ Make auxiliary diagnosis and efficacy evaluation for myasthenia gravis
(5) Otoacoustic emission detection method
1. Otoacoustic emissions (OAEs): refers to the sound energy originating from the cochlea and can be recorded in the external auditory canal; including spontaneous otoacoustic emissions (SOAEs) and induced otoacoustic emissions (EOAEs)
2. Application: ① Hearing screening of infants and young children; ② Early quantitative diagnosis of cochlear deafness; ③ Differential diagnosis of cochlear deafness and retrochlear deafness; ④ Analysis of retrocochlear auditory pathway lesions
(6) Auditory evoked potentials (AEP) detection method
1. Electrocochleograph (ECochG): differential diagnosis of various types of deafness on the auditory nerve and its peripheral auditory conduction pathways; objective evaluation of treatment effects
2. Auditory brainstem response audiometry (ABR): ① Determine high-frequency hearing threshold; ② Newborn hearing screening; ③ Differentiate organic deafness and functional deafness; ④ Diagnose cerebellopontine angle space-occupying Lesions; ⑤ Diagnosis, localization, and curative effect selection of various central nervous system diseases
2. Vestibular function test method
(1) Balance and coordination function check
1. Static balance examination: Romberg test, static posturography
2. Dynamic balance examination: star-shaped footprint walking test, dynamic posture tracing method
3. Limb test: finger passing test, writing test
4. Coordination function test: finger-nose test, heel-knee-shin test, rapid rotation test
(2) Eye movement examination
1. Spontaneous nystagmus examination method
The slow phase is caused by vestibular stimulation, and the fast phase is caused by central corrective movement; the slow phase is toward the side with lower vestibular excitability, and the fast phase is toward the side with higher vestibular excitability; usually in the direction pointed by the fast phase as nystagmus direction
The degree of nystagmus
Ⅰ degree: nystagmus induced in the direction of fast phase
Second degree: nystagmus induced in fast phase direction and forward gaze
Ⅲ degree: nystagmus induced in fast phase, forward gaze and slow phase
2. Opto-oculomotor system examination methods: saccade test, smooth tracking test, optokinetic nystagmus examination, gaze nystagmus examination
3. Vestibular eye function test: Check the function of the semicircular canals
Hot and cold stimulation test: Inject cold, warm water or air into the external auditory canal to induce vestibular response
Rotation test
4.Others
Fistula sign: place the air-inflating otoscope in the external auditory canal without leaving a gap, alternately add and reduce pressure into the external auditory canal, and observe the subject's eye movements and autonomic nervous system symptoms at the same time, and ask whether there is any dizziness; when the bony labyrinth When fistulas are formed due to various pathologies, eye deviation/nystagmus with dizziness will occur (positive)
Tulio phenomenon: strong sound stimulation can cause dizziness/vertigo; seen in perilymph fistula and superior semicircular canal cleft syndrome
Chapter 2 Ear Trauma
1. Injury of tympanic membrane
[Clinical manifestations]
symptom
Sudden earache, ear canal bleeding, ear fullness, hearing loss, tinnitus; dizziness and nausea may occur when combined with inner ear damage
examine
Otoscope: Multiple slit-like perforations of the tympanic membrane, with blood stains/scabs on the edge of the perforation/in the ear canal; clear water-like fluid may flow out when the temporal bone fracture is accompanied by cerebrospinal fluid leakage
Hearing Test: Conductive/Mixed Hearing Loss
[Treatment] Prevent and treat infection and keep the ear canal clean and dry (if there is no secondary infection, it is forbidden to instill any ear drops locally); small perforations can generally heal on their own, while larger perforations or those that do not heal can be treated surgically
2. Fracture of temporal bone
[Classification] Longitudinal fracture (the most common; the fracture line is parallel to the long axis of the temporal bone), transverse fracture, mixed fracture
[Clinical manifestations]
systemic symptoms
Such as headache, coma, shock after trauma
local symptoms
Bleeding: blood can overflow through the external auditory canal, nose, and pharynx. Cerebrospinal fluid leakage: otorrhea and rhinorrhea.
Hearing loss and tinnitus: longitudinal fracture → damage to the middle ear → conductive hearing loss, low-frequency tinnitus; transverse fracture → damage to the inner ear → sensorineural hearing loss, high-frequency tinnitus
Dizziness: transverse fracture → damage to inner ear
Facial paralysis: transverse fracture → damage to the intracranial segment of the facial nerve to the internal auditory canal → poor prognosis and difficult recovery
[Treatment] To prevent and treat infection, packing in the external auditory canal is generally prohibited; first treat systemic symptoms, and then deal with otological conditions
Chapter 3 Diseases of the External Ear
1. Furuncle of external acoustic meatus
[Cause] Pathogenic bacteria: most of them are Staphylococcus aureus
[Clinical manifestations]
symptom
Severe pain (when the boil is on the front wall, it can be aggravated by chewing/talking), pus discharge from the external auditory canal (mixed with blood, but no mucus → different from otitis media), swollen and painful lymph nodes in front/back of the ear; in severe cases, it may General discomfort and elevated body temperature
examine
There is localized redness and swelling in the cartilage of the external auditory canal, and there may be a white pus head in the center; there will be a fluctuating feeling after maturity; the pus will be very thick after discharge.
There is traction pain in the auricle and tenderness in the tragus; the postauricular groove disappears and the auricle stands up (the furuncle on the posterior wall of the external auditory canal spreads to the back of the ear)
Blood routine: WBC↑
【treat】
topical treatment
Early stage: Ichthyostatin, detumescence ointment; local physical therapy
Progressive stage: Immature boils are contraindicated for incision; if there is a white purulent head at the tip, it can be gently punctured and the purulent head is pressed out; if there is obvious fluctuation, incision and drainage can be performed (the incision should be parallel to the longitudinal axis of the external auditory canal); the boil has ulcerated on its own. Hydrogen oxygen can be used in case of rupture
Rinse with water and place for drainage
systemic treatment
Oral antibiotics are required in severe cases
2. Otitis externa/"tropical ear"
[Cause] Pathogenic bacteria: Hemolytic Streptococcus and Staphylococcus aureus are more common in temperate areas; Pseudomonas aeruginosa is more common in tropical areas
[Clinical manifestations]
symptom
Acute diffuse otitis externa: early burning sensation in the ear, followed by ear swelling and pain that gradually intensifies, and discharge from the external auditory canal (from thin to thick)
Chronic otitis externa: ear itching and discomfort, with a small amount of secretions coming out from time to time; it can be acutely exacerbated
examine
Acute diffuse otitis externa: tragus tenderness, auricle pulling pain; diffuse congestion, edema, and secretions in the external auditory canal
Chronic otitis externa: The skin of the external auditory canal is often thickened and scabs are attached (the skin appears to be bleeding after being avulsed); there may be a small amount of viscous secretions in the external auditory canal, or white bean dregs-like secretions accumulated deep in the external auditory canal.
【treat】
①Clean the external auditory canal, keep the area dry, and ensure smooth drainage;
②Choose sensitive antibiotics;
③Local treatment: Ichthyostatin, swelling ointment;
④Analgesics and sedatives can be given when the earache is severe;
⑤Chronic otitis externa needs to keep the area clean and use acidified and dry drugs. Antibiotics and hormones can be used in combination.
3. External auditory canal cerumen embolism (impacted cerumen)
[Clinical manifestations]
symptom
Incomplete obstruction: mostly asymptomatic, may have local itching
Complete obstruction: ear fullness, hearing loss, pulsatile tinnitus (which can be consistent with the pulse), dizziness, earache (especially when the mandibular joint moves, after water intrusion, and when accompanied by infection)
examine
Otoscope: There is a brown-black mass in the external auditory canal, which is hard, and there may be no gap between the external auditory canal wall and the external auditory canal wall.
Hearing test: polyconductive hearing loss
[Treatment] Remove the cerumen: ① cerumen hook; ② flush the external auditory canal (usually 3~5% sodium bicarbonate solution)
4. Foreign bodies in external acoustic meatus
[Clinical manifestations]
symptom
Foreign bodies that do not change shape when exposed to water: may be asymptomatic
Foreign bodies that change shape when exposed to water can quickly cause ear swelling, pain, and infection.
Live insects: unbearable itching, pain, reflex coughing, and even ringing in the ears
examine
Otoscope: can often detect foreign bodies
[Treatment] It must be removed, but the methods are different; for example, if there are motile insects, you can use non-irritating oil to drip into the external auditory canal to make it stick and then remove it; for bean foreign bodies, do not use local drops of water, otherwise it will be difficult to remove after swelling.