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

Transcription

1 Management of Ear, Hearing and Balance Disorders: Fact, Fiction, and Future George W. Hicks, M,D N. Shadeland Avenue, Suite 150 Indianapolis, IN N. Samuel Moore Parkway Mooresville, IN (317) (800) 818 EARS (3277) I. Introduction ADA "18x18 Initiative," Phoenix, Az 2012 II. Basic Ear Anatomy Bony labyrinth, contents, cochlear, vestibular 1

2 III. Pathologies of the Ear, Hearing, and Balance A. Hearing Loss: "The ear listens; the brain hears." 1. Epidemiology 2. Types a) conductive b) cochlear c) retrocochlear (neural) d) mixed 3. Etiology a) aging b) infection c) noise d) head tumors e) genetics f) metabolic syndromes 4. Warning signs requiring prompt intervention 5. History 6. Medical/Physical Examination: vital signs, ausculatation, head & neck, tuning forks, audiometrics 7. Treatment : medical, surgical, rehabilitative "What about earwax?" 8. Future: implantable hearing aids, molecular therapy, hybrid cochlear implant 2

3 B. Tinnitus (From the Latin "to jingle") 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) Head tumors e) Endolymphatic hydrops 5. Pathophysiology: outer hair cells, stria vascularis, endocochlear potential, central auditory pathways 6. Concerns: life style, diversity, gravity, difficulty 7. Mechanism 8. Modulating factors 9. History: Tinnitus Hearing Index, Tinnitus Questionnaire (subjective) 3

4 10. Medical/Physical Examination: audiometrics, symmetry 11. Treatment: no cure, variable control, imaging (MRI, PET), goal of treatment a) Reassurance/explanation avoid "There's no cure... live with it!" b) Audiological c) Psychological d) Surgery e) Future: direct auditory stimulation of auditory cortex, repetitive transmagnetic stimulation, tinnitus retraining therapy 4

5 C. Vestibulopathies 1. Introduction: The first step of the practitioner is to determine whether the problem is sensory, integrative, or motor. 2. Anatomy and Physiology 3. History: This is where one begins. It is the single, most important element of a diagnostic evaluation 4. Medical/Physical Examination: spontaneous and gaze nystagmus, pursuit and saccades, VOR, positional and positioning, cerebellum, posture/gait analysis, Ten Minute Dizzy Examination, tuning forks (Superior Semicircular Canal Dehiscence), pneumatic otoscopy, Snellen chart 5. Laboratory Testing a) Guided by history and examination b) Test options: AHR, VNG, VEMP, Rotational Chair, CDP, ECoG, audiometrics, imaging studies, blood tests (serologic) 6. Working Diagnoses: peripheral, central, both 7. Treatment: dietary, medical, surgical, rehabilitation 8. "Million Dollar Clues" 9. Vertigo syndromes: peripheral vs. central 10. Summary of Vestibulopathies 5

6 D. Facial Nerve Disorders 1. Anatomy: long course within temporal bone; motor/sensory 2. Bell's Palsy: acute onset, 60 70% no known etiology; incidence 15 40/100, Risk factors: diabetes, pregnancy (3x incidence), immuno deficiencies (HIV) 4. Differential diagnosis 5. Treatment: immediate medical referral to otologist ("All that palsies is not Bell's") E. Acoustic Neuroma 1. Definition: nonmalignant tumor of the eighth cranial nerve 2. Symptoms: variable SNHL, gradual/sudden, tinnitus, balance problems, facial weakness, change in taste, headaches, clumsiness, confusion 3. Audiometry: assymetry, disproportionally poor SDS, "rollover," reflexes (ABR, VNG, VEMP) 4. Imaging: MRI with contrast 5. Treatment: observation, surgery, radiation therapy (SRS, FRS) IV. Summary 6

7 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) (800) 818 EARS (3277) 7