Ear Disorders

Disorders of the labyrinth

Benign Paroxysmal Positional Vertigo

This is a condition which causes movement-dependent vertigo.

It is seen more in elderly patients.

Symptoms come on suddenly when head position is altered.

It is not difficult to treat, but the symptoms do tend to recur after a few years.

Symptoms

Vertigo worsened by head movement, e.g., turning in bed

Each episode lasts less than 30 seconds and can make the patient feel sick/extremely dizzy

Key tests

A positive Dix-Hallpike manoeuvre – this reproduces vertigo and nystagmus is seen in the affected side

Management

Recovery is normally spontaneous but may take several weeks.

If persistent, the Epley manoeuvre allows particles in the semicircular canals to be relocated back into the utricle, so they do not stimulate the cupula triggering vertigo

Vestibular rehabilitation exercises can be used

If severe, patients can be given anti-emetics, e.g., prochlorperazine

Viral Labyrinthitis

This is the most common form of labyrinthitis, a disorder characterised by inflammation of the membranous lining of the bony labyrinth of the inner ear.

It affects the vestibular and cochlear organs, causing vertigo and hearing symptoms.

Unlike BPPV, it has a distinct acute onset.

Symptoms

These often present with a history of an upper respiratory tract infection (URTI)

Acute onset vertigo (dizziness/nausea/vomiting), made worse by movement

Deafness and tinnitus

Unidirectional horizontal nystagmus towards unaffected side

Key tests

Bedside tests to confirm vestibular and cochlear dysfunction

Abnormal head impulse test (showing impaired vestibulo-ocular reflex)

Otoscopy may show inflammation, suggesting an infectious cause

Management

Most cases are self-limiting and resolve naturally

Can give a short course of prochlorperazine if dizziness is disabling

Vestibular Neuronitis

This is an infection of the vestibular nerve that gives vertigo-like symptoms.

Since only the vestibular nerve is involved, there is no hearing impairment.

It is associated with a history of an URTI (cough, sore throat, fever).

Symptoms

Signs of recent URTI (cough, sore throat, fever)

Acute onset recurrent vertigo attacks (dizziness/nausea) lasting hours/days

Horizontal nystagmus but no hearing loss

Management

Usually self-limiting, but offer symptomatic relief

Cinnarizine/prochlorperazine can be used to alleviate dizziness and nausea/vomiting 

Disorders of the ear

Presbycusis

This is a condition that gives sensorineural hearing loss, usually in the elderly and is caused by the natural ageing and degeneration of the auditory system over time.

There is no known cause, but it is related to genes, stress, noise and arteriosclerosis.

Symptoms

It affects high-frequency noises first, giving problems over a prolonged period

Speech becomes more difficult to understand (asking people to repeat themselves)

Hard to hear the TV (so patients increase the volume on TV and phone)

Problems understanding things in noisy situations

Key tests

Audiometry shows bilateral sensorineural hearing loss

Management

Hearing aids

Meniere’s Disease

A disorder which is due to an increase in fluid within the endolymph system of the inner ear, resulting in high pressure, leading to problems with hearing and balance.

For many patients, the symptoms do eventually resolve but they may develop some irreversible hearing loss.

Symptoms

Start with acute attacks in one ear, but then over time both ears become involved

Recurrent vertigo attacks with tinnitus/hearing loss lasting minutes to a few hours

Eventually the hearing loss and tinnitus may become constant

Feeling of aural fullness/pressure

Autonomic system symptoms (nystagmus, nausea, sweating, balance problems)

Key tests

Involves referral to ENT for audiometry and further tests

Management

To alleviate nausea/vomiting, medications including cyclizine or prochlorperazine

For prophylaxis, betahistine to reduce the frequency and severity of attacks 

Cholesteatoma

This is a condition caused by a benign growth of squamous cells that exist in the middle ear behind the eardrum.

This can grow over time, leading to local destruction of nerves.

It can be a birth defect but is mostly caused by repeated middle ear infections.

It is mostly seen in teenagers, with higher risk if you are born with a cleft palate. 

Symptoms

Conductive hearing loss

Foul smelling discharge from ear

Invasion symptoms – vertigo, facial nerve palsy

Key tests

Otoscopy shows keratinizing epithelium in upper part of ear drum

Management

ENT referral for assessment, may require surgical removal

Infections of the ear

Otitis Externa

This refers to inflammation of the external ear, which occurs usually due to a bacterial infection by Staphylococcus aureus.

It can also be due to dermatological conditions which affect the ear (eczema).

Symptoms

Pain localised to the external ear, but hearing loss/tinnitus is rare

Key tests

Otoscopy shows reddened lesions on the external ear

Management

Antibiotics. e.g., flucloxacillin (topical if localised, oral if severe/spreading)

If unresolved, consider contact dermatitis and take swab inside the ear canal

Otitis Media

This is an infection of the middle ear, which is usually seen in children, often due to eustachian tube dysfunction.

It usually occurs with a history of an URTI (S. pnemoniae) causing a fever and cough.

Children can develop a glue ear (otitis media with effusion), leading to conductive hearing loss and secondary problems like speech and language delay.

Symptoms

Earache, fever, irritability, can cause tympanic membrane perforation

Management

1st line is 5–7 day course of amoxicillin (but strict antibiotic guidelines, only give if:)

Systemically unwell or high risk of complications

Younger than 2 years with bilateral otitis media

Otorrhea (discharge after ear drum perforation)

If symptoms do not improve after 3 days (use back-up prescription)