ผศ.พญ.ส ว ชา อ ศราด ส ยก ล แก วศ ร
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1 Common Disorders of Hearing and Balance ผศ.พญ.ส ว ชา อ ศราด ส ยก ล แก วศ ร หน วยโสตประสาท ภาคว ชาโสต ศอ นาส กว ทยา คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม กระบวนว ชา พ.วพ.306 (330306): ระบบประสาท 2 26 พฤศจ กายน 2557
2 ว ตถ ประสงค เพ อให น กศ กษาสามารถ 1. ม ความร ความเข าใจเก ยวก บพยาธ สภาพและพยาธ กาเน ด ของโรคท พบบ อยในระบบการได ย นและการทรงต ว 2. อธ บายพยาธ สร รว ทยาของโรคท พบบ อยในระบบการได ย น และการทรงต ว 3. อธ บายสาเหต และหล กการว น จฉ ยโรคท พบบ อยในระบบการ ได ย นและการทรงต ว 2
3 เน อหา Overview of anatomy of the hearing and balance system Common Hearing and Balance Disorders of the External ear/ Middle ear/ Inner ear Pathology/ Pathogenesis/ Pathophysiology/ Etiology/ Principle for diagnosis ระด บของความผ ดปกต ของการได ย นและความสามารถในการฟ ง 3
4 Anatomy of the hearing and balance system
5 Ear: 3 parts 5
6 Pinna (auricle) 6
7 Middle ear 7
8 Inner ear Balance peripheral vestibular system Hearing peripheral auditory system 8
9 Peripheral auditory system: cochlea Organ of Corti 9 %20Organ%20of%20Corti.htm
10 Organ of Corti 10
11 Peripheral vestibular system 5 sensory organs 3 semicircular canals utricle, saccule 11
12 Angular acceleration 3 Semicircular canals 12
13 Ampulla Cupula Crista ampullaris Hair cells 13 _of_hearing.htm
14 Linear acceleration Utricle: แนวด ง Saccule: แนวราบ Otolithic membrane Calcium carbonate Hair cells Utricle & Saccule 14
15 Cochlear nerve Cochlear nuclei Auditory cortex Central auditory system 15
16 Vestibular nerve Vestibular nuclei Cerebellum Cerebral cortex Central vestibular system 16
17 Common Hearing and Balance Disorders External ear Middle ear Inner ear Pathology Pathogenesis/ Pathophysiology Etiology Principle for diagnosis
18 Common Hearing and Balance Disorders External ear Middle ear Conductive hearing loss (CHL) Otalgia Otorrhea Inner ear Sensorineural hearing loss (SNHL) Vertigo Tinnitus
19 Common Hearing and Balance Disorders External ear
20 Common diseases of the external ear Pre-auricular sinus/ cyst ข ห อ ดต น ส งแปลกปลอมในช องห ช องห ต บ ห ช นนอกอ กเสบ การต ดเช อง สว ดบร เวณห 20
21 Pathology: ร เป ดเล ก ๆ หน าห ใต ต อ crus of helix Pre-auricular sinus/ cyst 21
22 Pre-auricular sinus/ cyst Pathogenesis/ Pathophysiology: hillock of His ท 1-3 มาจาก branchial arch ท 1 -> tragus, crus of helix และ helix hillock of His ท 4-6 มาจาก branchial arch ท 2 -> crura of antihelix, antihelix และ antitragus 22
23 Pre-auricular sinus/ cyst Pathogenesis/ Pathophysiology: epithelium ระหว าง hillock of His ท 1 และ 2 ไม สลายไป 23
24 Pre-auricular sinus/ cyst Etiology: congenital Principle for diagnosis: Preauricular pit Epithelium debris Recurrent infection 24
25 Impacted cerumen Pathology: 25
26 Impacted cerumen Pathogenesis/ Pathophysiology: Ceruminous gland Epithelial migration 0.07 mm/day Aging: dry, decreased migration Etiology: แคะห Principle for diagnosis: CHL, ear wax, otalgia after swimming 26
27 Pathology: Foreign body in the ear canal 27
28 Foreign body in the ear canal Etiology: ใส เอง อ บ ต เหต Principle for diagnosis: Foreign body CHL, Otalgia, Otorrhea 28
29 Ear canal stenosis Pathology: 29
30 Ear canal stenosis Etiology: Congenital (congenital aural atresia) Pathogenesis/ Pathophysiology: Failure of development of Branchial arch ท 1, 2, hillocks of His Canalization (ectodermal branchial groove) Principle for diagnosis: atresia, CHL, facial paralysis 30
31 Ear canal stenosis Etiology: Acquired trauma (temporal bone fracture) Principle for diagnosis: Bloody/ CSF otorrhea, CHL, facial paralysis 31
32 Temporal bone fracture Left complete facial paralysis ได ร บอน ญาตจากผ ป วยให ใช ภาพถ ายนาเสนอในทางว ชาการแล ว 32
33 Temporal bone fracture Pathogenesis/ Pathophysiology: fracture, bone chip Facial nerve 33
34 Ear canal stenosis Etiology: Acquired otitis externa; ป นห บ อย ๆ Pathogenesis/ Pathophysiology: Chronic inflammatory stage Thick skin 34
35 Otitis externa Pathology: 35
36 Otitis externa Pathogenesis/ Pathophysiology: Apopilosebaceous unit (hair follicles, sebaceous glands, ceruminous glands) Self-cleansing mechanism skin/cerumen protective barrier แคะห น าเข าห โรคผ วหน งท เก ดในช องห แพ ยาหยอดห 36
37 Otitis externa 3 stages: 1. preinflammatory: stratum corneum swelling, obstruction of apopilosebaceous unit 2. acute inflammatory: disruption of epithelium, ear canal swelling, otalgia, otorrhea 3. chronic inflammatory: eczematization, lichenification, superficial ulceration, itching 37
38 Otitis externa Etiology: Bacteria Fungus Acute otitis externa Principle for diagnosis: Otalgia, otorrhea, CHL Bullous myringitis Otomycosis 38 content/uploads/2013/03/acute-otitis-media.jpg
39 Herpes zoster oticus Pathology: Group of vesicles in sensory dermatome Pathogenesis/ Pathophysiology: Reactivation of virus in sensory ganglion Immunocompromised host Etiology: Herpes (varicella) zoster virus 39
40 Ramsey Hunt syndrome Principle for diagnosis: vesicles in the head and neck area & facial paralysis 40
41 Common Hearing and Balance Disorders Middle ear
42 Common diseases of the middle ear ห ช นกลางอ กเสบ ห นป นเกาะฐานกระด กโกลน การบาดเจ บจากแรงด นต อห 42
43 Otitis media Pathology: Inflammation of the middle ear & mastoid Acute otitis media Otitis media With effusion Chronic otitis media 43
44 Otitis media Pathogenesis/ Pathophysiology: Eustachian tube dysfunction: Pressure/ reflux/ drainage Anatomical obstruction: mucosal swelling, nasopharyngeal mass Functional obstruction: cleft palate, cartilage stiffness 44
45 Otitis media Etiology: bacteria AOM: - Streptococcus pneumonia - Haemophilus influenzae - Moraxella catarrhalis COM: - Proteus spp. - Pseudomonas aeruginosa - Staphylococcus spp. 45
46 Otitis media Principle for diagnosis: Otoscopy Otalgia CHL Otorrhea CHL Vertigo/ complications CHL Otorrhea 46
47 Otosclerosis Pathology: replacement of otic capsule with densed mineralized bone (otospongiosis) Pathogenesis/ Pathophysiology: osteoblastic & osteoclastic activity at stapes footplate Etiology: unknown, autosomal dominant Principle for diagnosis: CHL, Schawartze sign 47
48 Otitic barotrauma Pathology: different pressure between middle ear & environment -> swelling of middle ear mucosa, mucous gland secretion, tear of vessels Etiology: air travel, diving Principle for diagnosis: CHL, otalgia 48
49 Otitic barotrauma Pathogenesis/ Pathophysiology: Boyle s law
50 Common Hearing and Balance Disorders Inner ear
51 Common diseases of the inner ear ห นป นในห ช นในหล ด โรคน าในห ไม เท าก น ประสาทห เส อมเฉ ยบพล นแบบไม ทราบสาเหต ห ช นในอ กเสบ เส นประสาททรงต วอ กเสบ ยาท เป นพ ษต อห การส ญเส ยการได ย นจากเส ยงด ง ห ต งเหต ส งอาย 51
52 Benign paroxysmal positional vertigo Most common cause of vertigo Pathology: floating of calcium carbonate crystal (otolith) in semicircular canal (canalithiasis), *posterior canal* Pathogenesis/ Pathophysiology: Head movement -> canalith movement -> endolymph flow -> stimulation canalith 52
53 Benign paroxysmal positional vertigo Etiology: unknown, minor head trauma, common cold Principle for diagnosis: brief episodes of vertigo while changing positions *Dix-Hallpike test: vertigo & nystagmus 53
54 Benign paroxysmal positional vertigo Dix-Hallpike test: head turn 45 o, downward 30 o Test the right posterior semicircular canal: turn right ได ร บอน ญาตจากผ ป วยให ใช ภาพถ ายนาเสนอในทางว ชาการแล ว 54
55 Benign paroxysmal positional vertigo Dix-Hallpike test: positive; right ear Rotatory upbeating nystagmus downward to the right ear ได ร บอน ญาตจากผ ป วยให ใช ภาพถ ายนาเสนอในทางว ชาการแล ว 55
56 Ménière's disease; 2 nd most common cause of vertigo Idiopathic endolymphatic hydrops Pathology: Hydrops of the endolymph Etiology: idopathic 56
57 Ménière's disease; Pathogenesis/ Pathophysiology: **Rupture of membranous labyrinth -> mixing of endolymph & periplymph -> acute inactivation of nerve cells -> auditory & vestibular neuronal outflow -> ATTACK! Principle for diagnosis: triad of vertigo, SNHL, tinnitus 57
58 Idiopathic sudden sensorineural hearing loss Pathology: nonspecific Pathogenesis/ Pathophysiology: hypothesis 1) viral infection 2) cochlear ischemia, perilymphatic oxygen 3) intracochlear membrane rupture 4) autoimmune inner ear disease 5) CNS anomalies Etiology: idiopathic Principle for diagnosis: Sudden loss of hearing < 3 days audiogram: PTA > 30 dbhl, 3 frequencies 58
59 Labyrinthitis Pathology: depended on causes of infection Scala tympani filled with a mixture of acute inflammatory cells, bacteria, and a granular eosinophilic precipitate Pathogenesis/ Pathophysiology: Suppurative labyrinthitis From middle ear: via round window, fistula From CSF: via internal acoustic canal, cochlear modiolus, cochlear duct 59
60 Labyrinthitis Etiology: 1. Bacteria: Otitis media Meningitis: Streptococcus pneumonia, Haemophilus influenzae, Neiseria meningitides, Streptococcus suis 2. Virus: herpes simplex type I, herpes zoster, cytomegalovirus 3. spirochete: syphilis 4. mycobacterium Principle for diagnosis: SNHL, vertigo, specific symptoms 60
61 Vestibular neuritis Vestibular neuronitis Pathology: degeneration in scarpa ganglion, chronic inflammation Pathogenesis/ Pathophysiology: hypofunction Etiology:? reactivation of latent herpes simplex virus type I in vestibular ganglion Principle for diagnosis: vertigo (days), no hearing loss, common cold 61
62 Ototoxicity Pathology: depended on group cochlear hair cells; base -> apex, Outer hair cells sensitive > inner hair cells Pathogenesis/ Pathophysiology: blood-labyrinth barrier Severity: multiple groups, high dose, extreme age Principle for diagnosis: SNHL, vertigo, tinnitus 62
63 Noise-induced hearing loss ความด งของเส ยงในส งแวดล อม ป จจ ยท ม ผลกระทบต อการได ย น ความด ง ความถ ล กษณะเส ยง ระยะเวลาส มผ สเส ยง สภาพห 63
64 Noise-induced hearing loss ชน ดและแหล งกาเน ดเส ยง 1. เส ยงด งสม าเสมอ (Steady state Noise): เคร องจ กร เคร องทอผ า 2. เส ยงด งค อยสล บไปมา (Fluctuation): เล อยไฟฟ า หวอ 3. เส ยงท ด งเป นระยะ (Intermittent Noise): การจราจร เคร องบ น 4. เส ยงกระแทก (Impulse Noise or Impact Noise): ป น ประท ด 64 ไพฑ รย น กสอน อ นตรายจากเส ยงด ง ใน: พ ช ต ส ทธ ไตรย, สายสวาท ไชยเศรษฐ, ส ว ชา อ ศราด ส ยก ล, บรรณาธ การ. ตาราห คอ จม ก สาหร บเวชปฏ บ ต ท วไป ภาคว ชาโสต ศอ นาส กว ทยา ค ณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม. Trick think; หน า
65 Pathology: Noise-induced hearing loss เส ยงด งสม าเสมอ (Steady state Noise): เคร องจ กร เคร องทอผ า Damage organ of Corti: 1 st = OHCs: fused sterocilia 65
66 Noise-induced hearing loss 2 nd = IHCs, supporting cells; 3 rd = Entire organ of Corti Swelling auditory nerve ending, degeneration of synapse in cochlear nucleus 66
67 Noise-induced hearing loss Pathology: เส ยงกระแทก (Impulse Noise or Impact Noise): ป น ประท ด Rupture of membrane in organ of Corti Mixing of endolymph & perilymph Tympanic membrane rupture 67
68 Noise-induced hearing loss Pathogenesis/ Pathophysiology: Acoustic reflex: > 90 db contracted of stapedius muscle Not function if noise < 1 seconds, > 140 decibels Principle for diagnosis: SNHL 3-6 khz), tinnitus 68
69 Presbycusis Age-related hearing loss Pathology: sensory cells & supporting cells in organ of Corti, spiral ganglion cells atrophy of stria vascularis, basilar membrane stiffness Pathogenesis/ Pathophysiology: multifactorial Etiology: older, vascular disease, ototoxic, noise, smoking Principle for diagnosis: bilateral SNHL, > year-old 69
70 ระด บของความผ ดปกต ของการได ย น และความสามารถในการฟ ง
71 ระด บของความผ ดปกต ของการได ย น และความสามารถในการฟ ง ระด บของการได ย น ห ปกต (normal hearing) ห ต งน อย (mild hearing loss) ห ต งปานกลาง (moderate hearing loss) ห ต งมาก (moderately severe hearing loss) Hearing threshold ความสามารถในการฟ ง (pure tone average) -10 ถ ง 25 เดซ เบล ไม ลาบากในการร บฟ งคาพ ด เดซ เบล ไม ได ย นเส ยงพ ดเบา ๆ เดซ เบล พอจะเข าใจในระด บความด งปกต ระยะ 3-5 ฟ ต เดซ เบล ต องพ ดด วยเส ยงด ง ๆ จ งจะเข าใจ แต จะม ความ ลาบากในการฟ งเม ออย ท ม เส ยงจอแจ ห ต งอย างร นแรง เดซ เบล อาจจะได ย นเส ยงตะโกน ในระยะ 1 ฟ ต (severe hearing loss) แต ไม เข าใจ ห หนวก (deafness) > 90 เดซ เบล เส ยงตะโกนก ไม ได ย น 71
72 ห ปกต (Normal limits) -10 ถ ง 25 db ไม ลาบากในการร บฟ งเส ยงพ ด ห ต งน อย (Mild hearing loss) db ไม ได ย นเส ยงพ ดเบาๆ ระด บของการได ย น วาสนา วะส นนท การฟ นฟ สมรรถภาพการได ย น ใน: พ ช ต ส ทธ ไตรย, สายสวาท ไชยเศรษฐ, ส ว ชา อ ศราด ส ยก ล, บรรณาธ การ. ตาราห คอ จม ก สาหร บเวชปฏ บ ต ท วไป ภาคว ชาโสต ศอ นาส กว ทยา คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม. Trick think; หน า
73 ระด บของการได ย น ห ต งปานกลาง (Moderate hearing loss) db ** พ ดด วยความด งปกต แล วไม ได ย น ห ต งมาก (Moderately severe hearing loss) db ต องพ ดด วยเส ยงด งๆ จ งจะเข าใจ และเม ออย ท ม เส ยงจอแจ จะม ความลาบากในการฟ ง วาสนา วะส นนท การฟ นฟ สมรรถภาพการได ย น ใน: พ ช ต ส ทธ ไตรย, สายสวาท ไชยเศรษฐ, ส ว ชา อ ศราด ส ยก ล, บรรณาธ การ. ตาราห คอ จม ก สาหร บเวชปฏ บ ต ท วไป ภาคว ชาโสต ศอ นาส กว ทยา คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม. Trick think; หน า
74 ระด บของการได ย น ห ต งอย างร นแรง (Severe hearing loss) db ตะโกนหร อใช เคร องขยายเส ยง จ งจะได ย น แต ย งได ย นไม ช ดด วย ห หนวก (Deafness) > 90 db ตะโกนหร อขยาย เส ยงพ ดแล ว ก ย งไม ได ย น ไม เข าใจ วาสนา วะส นนท การฟ นฟ สมรรถภาพการได ย น ใน: พ ช ต ส ทธ ไตรย, สายสวาท ไชยเศรษฐ, ส ว ชา อ ศราด ส ยก ล, บรรณาธ การ. ตาราห คอ จม ก สาหร บเวชปฏ บ ต ท วไป ภาคว ชาโสต ศอ นาส กว ทยา คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม. Trick think; หน า
75 Suggested resources 75
76 Suggested resources 2. Physiology of hearing: phiz/classes_stud/en/nurse/bacchaour%20of%20sciences%2 0in%20nurses/ADN/18_Physiology_of_hearing.htm 3. Ear anatomy: 76
77
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