Otology/Neurotology Questions

March 22nd, 2023

A 6-year-old is brought to clinic for repeat evaluation of hearing loss. Which of the following characteristics would be most suggestive of congenital stapes fixation?
 
A.  The patient has a recent history of multiple ear infections
B.  There is conductive hearing loss that has worsened since the prior visit
C.  Otoscopy reveals a perforated tympanic membrane
D.  All of the above
E.  None of the above

  • Answer: E (none of the above)

    Explanation: Congenital stapes fixation is the most common congenital ossicular anomaly, and it can be described by fixation between the peripheral lamina of the stapes and the annular ligament. This causes nonprogressive conductive hearing loss that is usually bilateral in the setting of a normal tympanic membrane. While congenital ossicular anomalies are rare, they are a clinically relevant cause of hearing loss in the absence of trauma or infections. In pediatrics, congenital stapes fixation can be differentiated from juvenile otosclerosis, which instead presents with progressive conductive hearing loss.

    Reference:

    Park HY, Han DH, Lee JB, Han NS, Choung YH, Park K. Congenital stapes anomalies with normal eardrum. Clin Exp Otorhinolaryngol. 2009;2(1):33-38. doi:10.3342/ceo.2009.2.1.33 Article Link

January 25th, 2023

A 43-year-old woman is seen in the clinic for 3 days of left-sided hearing loss. She had a productive cough and stuffy nose one week ago while on vacation in Hawaii. She states she had stabbing pain in her left ear during plane descent on her return flight and that the flight attendant’s pre-landing announcements sounded muffled. She also noticed blood on the tissue she used to rub her ear canal during landing. All symptoms have resolved except her unilateral hearing loss. What is the next step in management?

A. Tympanoplasty

B. Irrigation of the external auditory canal

C. Oral antibiotics + steroids

D. Topical antibiotics

E. Reassurance

  • Correct answer: E (Reassurance)

    Explanation: This patient most likely suffered barotraumatic tympanic membrane rupture, which typically heals spontaneously within a few weeks. Her recent rhinogenic infection predisposes her to this condition as any condition that restricts eustachian tube function may prevent equalization of the pressure between the middle ear and the external environment, increasing risk of ear barotrauma during rapid shifts in barometric pressure. This is a clinical diagnosis and any hearing loss that accompanies tympanic membrane perforation is usually transient, although patients should seek reevaluation if ear symptoms persist or worsen. Workup should include an otoscopic exam looking for hemotympanum and/or ruptured tympanic membrane, hearing tests, and tympanometry. Management is conservative with active follow-up. Surgery (A), such as tympanoplasty or myringotomy, is indicated when conservative management is unsuccessful or when rupture of tympanic membrane is large or complicated by perilymphatic fistula formation. Irrigation of the external auditory canal (B) may be used to treat cerumen impaction, but would not be indicated in this scenario. Antibiotics (C&D) are indicated only when there is a rupture of the tympanic membrane and contamination of the middle ear.

    References:
    Basu A. Middle ear pain and trauma during air travel. BMJ Clin Evid. 2007 Sep 1;2007:0501. PMID: 19450303; PMCID: PMC2943805. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943805/

    Mirza S, Richardson H. Otic barotrauma from air travel. J Laryngol Otol. 2005 May;119(5):366-70. doi: 10.1258/0022215053945723. PMID: 15949100. https://pubmed.ncbi.nlm.nih.gov/15949100/

October 12th, 2022

A three-year-old is brought into the clinic for evaluation. The following is seen on her otoscopy exam. She has no history of otitis media or previous otologic procedures.

Which of the following is most likely to be true in this patient’s case?

A. Surgical intervention is not indicated because the cause of this patient’s presentation is not infectious and can be treated medically.

B. The likely etiology of this patient’s presentation involves perforation of the eardrum.

C. This finding likely arose from trapped squamous epithelium during embryogenesis.

D. If left untreated, this patient is most likely to develop sensorineural, rather than conductive, hearing loss.

  • Quiz Answer: C

    Explanation: This patient presents with a congenital cholesteatoma, which appears as a white mass that forms prior to birth behind an intact eardrum and with no history of otitis media, previous otologic procedures, or perforation of the eardrum. They are thought to develop during embryogenesis. This is in comparison to an acquired cholesteatoma, which develops either as a retraction pocket in which desquamated keratin epithelium accumulates behind an apparently intact eardrum, or secondary to epithelial migration into the middle ear through a perforated eardrum [B], which is in turn caused by infection, trauma, or iatrogenesis.