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Middle ear diseases are usually seen in the changes of the tympanic membrane, or through the transparent tympanic membrane. The commonest conditions are shown here. Bullous MyringitisHistory: Examination:
Information: Bullous myringitis is considered by many primarily a viral inflammation of the tympanic membrane that accompanies colds and influenza. It usually does not cause injury to the middle ear or the ossicles. Signs and symptoms include otalgia, blockage, fullness, severe pain with movement of the eardrum, hemorrhagic (herpetic) blebs on lateral surface of the tympanic membrane and adjacent canal. The tympanic membrane may have a purplish hue. Raised water blisters may develop on the tympanic membrane. However, David Fairbanks,M.D. in Antimicrobial Therapy in Otolaryngology - Head and Neck Surgery defines acute bullous myringitis in the absence of prior TM perforation or cholesteotoma as a varient of acute otitis media. It is caused by the same organisms (Streptococcus pneumoniae, Hemophilus influenzae,and Moraxella catarrhalis) and treated with the same agents. Acute otitis mediaHistory: Examination:
Information: Acute otitis media is the rapid onset of an inflammatory process in the mucosa of the middle ear space associated with local or systemic signs. The infection results in a bulging tympanic membrane, swelling, and redness due to a bacteria or virus that has migrated from the nasopharynx, through the Eustachian tube, to the middle ear. The Eustachian tube becomes increasingly blocked by inflammation and fluid accumulates under pressure. Without treatment, this bacterial infection progresses through four stages.
Complications may include acute mastoiditis, petrositis, labyrinthitis, facial nerve paralysis, conductive/sensorineural hearing loss, and lateral sinus thrombosis. Complications beyond the tympanic membrane and mastoid air cells include a subperiosteal mastoid abscess, an extradural abscess, a brain abscess, leptomeningitis, and sigmoid sinus thrombophlebitis. The bone in acute coalescent mastoiditis is soft due to decalcification and osteoclasis, yet still living. New bone can form when the pus under pressure is relieved. Chronic otitis media exists when there is a permanent perforation in the tympanic membrane with or without a permanent change in the middle ear. The extent of mucopurulent inflammation in the middle ear is variable. Signs and symptoms include ossicular bone loss, perforation, retraction, opacities, and granulation tissue including polyps. The tympanic membrane perforation may allow an ingrowth of squamous epithelium. Although drainage may be more or less continuous, active infection is marked by hyperemic, thickened mucosa with mucopurulent discharge. Serous Otitis Acute and ChronicHistory: Examination: Information: Serous otitis media (SOM) - acute is an ear condition due to the accumulation of a thin, watery transudate in the middle ear. Eustachian tube dysfunction is the primary cause. Respiratory infections and allergies are predisposing factors. Serous otitis is commonly found in
children younger than six years of age with a history of otitis media. Patients with an early first episode of otitis, low birth weight, bottle feeding, and daycare in their history are more prone to this disease as well. In adults, barotrauma from flying or scuba diving can cause serous otitis. Serous otitis media - chronic is the long term accumulation of non-purulent middle ear fluid behind the eardrum. Serous otitis lasting longer then three months, affects up to 5-10% of children. SOM is common in those
with syndromic conditions, such asTreacher-Collins and Trisomy 21 and abnormalities such as cleft palate and immotile cilia syndrome. TympanosclerosisHistory: Examination:
Information: Tympanosclerosis is collagen in the pars tensa of the tympanic membrane typically found in patients with a previous history of recurrent otitis media. Tympanosclerosis appears as smooth, white, slightly raised areas of dense tissue. It usually occurs in the area of a healed perforation or extruded tube after recovery from otitis media. Hearing loss is not usually noted unless a major portion of the TM is involved. Tympanosclerosis is usually asymptomatic. In rare cases tympanosclerosis may involve the ossicles and cause fixation with a resultant conductive hearing loss. Aural PolypHistory: Examination: Information: An aural polyp is granulation tissue with a stalk that extends from the middle ear through a perforation in the tympanic membrane. It is usually associated with a cholesteatoma or a retained ventilation tube. In suppurative otitis media a polyp is a sign of consolidation and chronicity. This chronic process is difficult to heal without surgery. Polyps may occur singly or in multiples and are quite variable in size. They may occlude the ear canal and protrude from the meatus. The consistency may vary from very soft to firm. They may appear erythematous or pale. There are two types of polyps: mucous membrane and granulation. Both are inflammatory in origin, consisting of a mixture of polymorphonuclear leukocytes, plasma cells, mast cells, giant cells and fibroblasts containing numerous new blood vessels. Mucous membrane polyps originate from folds in the mucous membrane that protrude and are covered by the same epithelial layer as the middle ear. Granulation polyps are not usually covered by epithelium and often signify a cholesteatoma. Granulation polyps may also occur adjacent to a tympanostomy tube. Retraction PocketHistory: Examination:
Information: A retraction pocket occurs when an area of the tympanic membrane is pulled into the middle ear space by chronic negative pressure. A superior retraction pocket occurs when the pars flaccida is retracted into the attic. A posterior retraction pocket occurs when the posterior part of the TM is retracted possibly draping over the incus and stapes. The pocket is caused by Eustachian tube dysfunction creating a negative pressure in the middle ear cavity. The physical orientation of the pocket in the tympanic membrane often prevents the epithelium from sloughing properly,allowing keratin debris to accumulate, forming a cholesteatoma. Adhesive OtitisHistory: This is a 75 year old female who complains of severe hearing loss in her left ear. She has a life long history of recurrent ear infections and several operations to repair her ear drum (tympanoplasties). Examination: Notice the severe retraction of the tympanic membrane. It has moved so far medially that ii lies on the inner wall of the middle ear space. Any ossicles present are highly visible because the TM drapes around them. The midportion of the middle ear bony wall - the promontory - appears white.
Information: Adhesive otitis is the end stage of serous otitis. It develops over an extended period of time in the presence of chronic serous otitis media. Atrophy of the tympanic membrane occurs causing it to drape over and adhere to the incus and stapes, obliterating the middle ear space. CholesteatomaHistory: This is a 40 year old male who had a history of many infections as a child. His only complaint now is left ear hearing loss and fullness. He has had no ear surgery. Examination: The cholesteotoma is seen filling the entire middle ear space. It can be seen through the transparent TM and makes it appear white. The landmarks of the TM can be seen, but there is a slight bulging The second picture shows a cholesteotoma that has formed in a perforation or retraction pocket through the TM and is growing outward from the ear drum. The patient has a history of chronic otitis media; the cholesteatoma presents as the whitish area at the 12 o'clock position. This is a common area to find a cholesteatoma that develops from a superior retraction pocket. When the outer squamous debris is suctioned away, the resultant perforation or retraction pocket with retained debris is seen in the middle ear space. Information: A cholesteatoma is a keratin accumulation in concentric onion-like layers containing crystals of cholesterol. It is caused by squamous epithelium growing in an enclosed space. The expanding mass of desquamated epitheliium destroys surrounding bone. Cholesteatomas may develop in retractions of the tympanic membrane or from squamous metaplasia in the middle ear due to longstanding infection. The characteristic feature is the presence of white keratin debris in the middle ear. A cholesteotoma typically causes erosion of the ossicles and may damage the semicircular canals and facial nerve, resulting in hearing loss, dizziness and facial paralysis Cholesteatomas require surgery, usually a mastoidectomy and possible reconstruction of the ossicular chain. BarotraumaHistory: Examination: Information:The Eustachian tube is normally closed. It opens with positive pressure in the nasopharynx or by palatal muscle contraction. It acts as a flutter valve and remains closed unless it is opened voluntarily or by reflex. While climbing in an airplane, the external pressure decreases, causing the volume of the air in the middle ear to expand. This relative increase in middle ear pressure will passively open the Eustachian tube, relieving the pressure difference. During descent, middle ear volume decreases, creating a relatively negative middle ear pressure. This pressure opposes the opening of the Eustachian tube and can lead to an irreversible negative pressure, resulting in pain, dizziness, TM rupture, middle ear hemorrhage (hemotympanum) or effusion and hearing loss. The hemotympanum seen above gives a purple color to the TM. The middle ear space is filled with blood that usually resolves spontaneously. Tympanometry would show a "flat" tympanogram. Decongestants may be prescribed to aid in the resolution. | Home | Unit One | Unit Two | Unit Three | Unit Four | Unit Five | Unit Six | Unit Seven | Unit Eight | References | Site administrator: Barbara Heywood MD. Which part of the ear does the tympanic membrane separate quizlet?The outer ear is separated from the middle ear by the tympanic membrane (the eardrum). The structure in the cochlea of the inner ear made up of the basilar membrane, the auditory hair cells, and the tectorial membrane.
When assessing the tympanic membrane where would the nurse expect to see a cone of light?*The cone of light can be used to orientate; it is located in the 5 o'clock position when viewing a normal right tympanic membrane and in the 7 o'clock position for a normal left tympanic membrane.
Which part of the ear would be affected in a patient with impaired hearing impaired balance?The inner ear is composed of two parts: the cochlea for hearing and the vestibular system for balance. The vestibular system is made up of a network of looped tubes, three in each ear, called the semicircular canals.
Which cranial nerve would be damaged in a patient who has a hearing impairment?The eighth cranial nerve (vestibulocochlear nerve) may also be inflamed. The inflammation of these causes a feeling of spinning (vertigo), hearing loss, and other symptoms. In most people, these symptoms go away over time.
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