Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Common Otologic Symptoms H. Bryan Neel III & Thomas J. McDonald To cite this article: H. Bryan Neel III & Thomas J. McDonald (1975) Common Otologic Symptoms, Postgraduate Medicine, 57:6, 59-63, DOI: 10.1080/00325481.1975.11714044 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714044
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 20 August 2017, At: 14:14
co sder • What is the most valuable part of the evaluation of patients with common or routine otologie complaints? • What is the most common cause of conductive hearing loss in adults?
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
• What does the character of a discharge from the ear help elucidate?
H. BRYAN NEEL Ill, MD THOMASJ.McDONALD,MD Maya Clinic and Maya Foundation Rochester, Minnesota
Common Otologie Symptoms Eliciting a thorough history is the first step in the diagnosis of disorders of the ear, and it must be done in an orderly, complete manner. It is helpful to think of the ear as a unit consisting of the external auditory canal, middle ear, and inner ear. The middle ear consists of the auditory tube, tympanic cavity, and tympanic membrane, along with the mastoid air-cell system. The inner ear consists of the cochlea and the eighth cranial nerve and its central connections. In obtaining the history, it is important not only to concentrate on the ear but also to inquire about allergies, medications, operations, systemic illness, family his tory, occupation, and travel. Hearing Loss
Hearing Joss is of two general types: conductive and sensorineural. A patient may have bath types, which is called mixed loss. Conductive hearing loss occurs when conduction of sound through the external auditory canal, tympanic membrane, middle ear space, or ossicular chain is impaired. Sensorineural lasses result
Vol. 57 • No. 6 • May 1975 • POSTGAADUATE MEDICINE
from injury to the cochlea, cochlear nerve, or acoustic branch of the eighth cranial nerve anywhere along its course from the cochlea to its connections within the brain stem. Foreign bodies within the canal, cerumen impaction, tumors, otitis externa which produces swelling of the soft tissues, and partial or complete atresia of the external auditory canal may impair passage of sound through the external auditory canal. If the soft tissues of the canal are particularly resilient, the audiogram may show a conductive hearing Joss in the high tones, which should lead the examiner to suspect canal collapse; tuning fork tests will indicate normal hearing. Tympanic membrane perforation is a cornmon cause of conductive hearing loss, and the degree of hearing loss depends primarily on the size of the perforation. Extensive thickening, retraction, or scarring of the tympanic membrane also may produce conductive hearing loss. In children, the most common cause of conductive hearing loss is serous otitis media, which in sorne instances is secondary to hypertrophy of
59
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
the lymphoid (adenoid) tissue in the nasapharynx and around the eustachian tubes. Allergy, hypothyroidism, hypogammaglobulinemia, tumors of the nasopharynx, irradiation, and palatal muscle dysfunction associated with an obvious or submucous cleft palate are other etiologie factors. The palate must be palpated if the diagnosis of submucous cleft palate is to be made. A bifid uvula often accompanies submucous cleft palate.
bilateral, symmetric high-tone loss, which eventually affiicts everyone because of the aging process. A similar hearing loss can occur after trauma, such as noise exposure, an explosion, or a blow to the head. A few patients who have sensorineural hearing loss have correctable or partially correctable problems, such as those with cerebellopontine angle neoplasm, endolymphatic hydrops (Meniere's disease), congenital syphilis, Cogan's syndrome, relapsing polychon-
Unilateral sensorineural hearing loss that is subjectively not striking but objectively obvious on an audiogram should lead one to suspect the presence of multiple sclerosis. Disease within the middle ear may interfere with the mobility of the ossicular chain. The most common cause of conductive hearing loss in adults is otosclerosis, which produces fixation of the stapes foot plate. Occasionally, otosclerosis may induce a purely sensorineural hearing loss in the form of the controversial entity, cochlear otosclerosis. Fixation of the ossicular joints because of tympanosclerosis occasionally occurs after repeated middle ear infections. The large white plaques within the tympanic membrane and the immobility of the malleus on examination are elues to the presence of this entity. Fixation of the ossicular chain also can occur congenitally. A single virulent beta hemolytic streptococcal infection may dissolve the long process of the incus, thereby interrupting the ossicular chain and leading to conductive hearing loss; more commonly, recurrent infections (often secondary to cholesteatoma) lead to destruction of the ossicular chain. Hearing may be normal, and the only clue to an extensive cholesteatoma may be a small perforation in the pars flaccida, often hidden beneath a crust. In contrast to conductive hearing !osses, most sensorineural hearing !osses are uncorrectable. Sensorineural hearing loss is most commonly a
60
dritis, Wegener's granulomatosis, temporal arteritis, adult myxedema, and toxicity due to aspirin, quinine, or isoniazid. Therefore, sensorineural hearing impairment may be a manifestation of a serious systemic illness. In endolymphatic hydrops and related diseases, the hearing may fluctuate and the first indications of an acoustic neuroma or cerebellopontine angle problem may be a hydrops-like syndrome. The most common cause of unilateral sensorineural hearing loss in childhood is mumps. The loss is usually total and uncorrectable. Meningoencephalitic infections can involve the auditory nerve and the labyrinth and lead to profound sensorineural hearing loss. Unilateral sensorineural hearing loss that is subjectively not striking but objectively obvious on an audiogram should lead one to suspect the presence of multiple sclerosis. The degree of hearing loss varies from slight to severe, sornetimes waxes and wanes, and is apparently due to plaques involving the central auditory connections. Sudden idiopathie hearing loss is generally attributed to vascular insufficiency or viral infection, but such loss is the first indication of acoustic neuroma in about 10% of patients with confirmed acoustic neuromas.
POSTGRADUATE MEDICINE
o
May 1975
o
Vol. 57
o
No. 6
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
Figure 1. Diagram of pathways from various sensory distributions accounting for referred pain in the ear. Adapted with permission from Kern EB: Referred pain ta the ear. Minn Med
55:896-898, 1972.
Pain The cause of pain ansmg within the ear (primary ear pain) usually can be found on physical examination. Pain is commonly associated with acute suppurative otitis media and is seen sometimes in the early stages of acute serous otitis media. Persistence of pain or recurrence after acute suppurative otitis generally indicates that pus is accumulating under pressure in the mastoid cells and that complications are about to develop. Inadequate treatment may lead to various meningeal complications, labyrinthitis, petrositis, or facial paralysis. Although pain is an uncommon symptom in the usual case of chronic middle ear disease, it is serious and may mean that the disease has caused ·exposure of the dura or sigmoid sinus wall and that localized pachymeningitis, a perisinus abscess, or a brain abscess is present. Pain is almost always associated with primary or metastatic tumor of the temporal bane. The external auditory canal must be examined for
Vol. 57 • No. 6 • May 1975 • POSTGRAOUATE MEDICINE
small masses that may be smooth and have intact overlying skin. If palpation of such a lesion elicits extreme pain, the presence of a cy lindroma should be suspected. Otalgia may be referred from disorders distant from the ear. The sensory distribution accounting for referred pain in the ear consists of the fifth cranial nerve (trigeminal nerve, mandibular division), seventh cranial nerve (facial nerve), ninth cranial nerve (glossopharyngeal nerve), tenth cranial nerve (vagus nerve), and second and third cervical nerves (figure 1). Common sources of referred pain are the oral cavity (teeth, tangue, tonsils), temporomandibular joint, nasopharynx, and perilaryngeal regions, including the trachea, thyroid, and pharynx. Ear Noise
Tinnitus is a common ear symptom that may be subjective (intrinsic) or objective (extrinsic). Bilateral subjective tinnirus is commonly associated with presbycusis and acoustic trauma.
61
H. BRYAN NEEL Ill Dr. Neel is a consultant, department of otorhinolaryngology, Maya Clinic and Maya Foundation, Rochester, Minnesota.
eliminates the symptoms temporarily, presumably by causing enough swelling of the tissues surrounding the eustachian tube to reduce the patency. This dysfunction is seen in patients who have had recent profound weight loss, are pregnant and have endocrine dysfunction, or are taking hormones (eg, oral contraceptives).
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
Discharge From the Ear
Unilateral tinnitus may be the first symptom associated with an acoustic neuroma or a lesion of the cerebellopontine angle. Low-pitched roaring tinnitus preceding an episode of vertigo accompanied by pressure or fullness in the ear and fluctuating hearing typically occurs with endolymphatic hydrops. The typical symptoms of hydrops can occur with congenital syphilis, spontaneous oval- or round-window perilymph fistulas, and various systemic maladies. Objective tinnitus is due to vascular bruits from glomus tumors, aneurysms, arteriovenous malformations, referred heart sounds, clicking jaw, and nasopharyngeal sounds. Muscle spasms from palatal myoclonus cause an annoying snap or click in the ear. Palatal myoclonus is a neurologie disorder that produces rhythmic contractions of the muscles of the soft palate. The eustachian tube is opened with each contraction. The diagnosis is made by observing contractions of the soft palate that are synchronous with a click heard through an auscultation tube. The cause is not known, and there is no effective treatment. The examiner should stress that normal eustachian tube function can produce a feeling of "popping" or "clearing," especially with changes in altitude; patients often need to be reassured about this. In another form of eustachian tube dysfunction, called abnormal patency of the eustachian tube, patients complain of autophony (a booming quality of the ir own voice) and of hearing a swishing sound on respiration. Recumbency
62
The character of the discharge helps elucidate the nature of the pathologie process. Discharge from the soft tissues alone is generally watery or mucoid and inoffensive, but when disease extends into the bone, the discharge becomes thick, yellow or green, and foui smelling. Therefore, foul-smelling, discolored discharge is often indicative of cholesteatoma, and small, white, shiny flakes seen in the discharge are pathognomonic of cholesteatoma. Chronic oticis media with cholesteatoma can be capricious, and the discharge from a small perforation in the pars flaccida may be scanty, consisting chiefly of flakes of epithelium. Foul-smelling, purulent drainage occurs not only with cholesteatomas but also with osteomyelitis and tumors. Intermittent mucoid discharge during colds is seen in patients with chronic inactive otitis media and tympanic membrane perforations. Infection from the nasopharynx probably extends by way of the open eustachian tube to the middle ear and leads to the discharge. When the infection subsides, the drainage diminishes, although it seldom ceases entirely, and the patient may report that he sees a small amount of mucoid discharge on the pillow on awakening in the morning. Thin, cloudy drainage without pain is suggestive of tuberculosis, particularly if multiple perforations are noted in the tympanic membrane. Clear, watery drainage dribbling intermittently or continuously from the ear or clown the throat from the orifice of the eustachian tube in the nasopharynx may represent cerebrospinal fluid leakage after head trauma or it may occur spontaneously through congenital dehiscences in the bone surrounding the ear. Blood-
PDSTGRADUATE MEDICINE • May 1975 • Vol. 57 • No. 6
tinged or bloody drainage from the ear also can occur after head injuries and temporal bone trauma but is more commonly due to serous otitis media or its rarer forms (idiopathie hemotympanum and chronic serous mastoiditis), primary and meiastatic malignant tumors, and sometimes granulomatous diseases.
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
Vertigo
Because dizziness is ubiquirous, helping the patient to clarify his complaint referable to balance is important. Helpful questions in this regard are "What do you mean by dizziness?" and "Does your imbalance last seconds, minutes, or hours?" True vertigo is a sensation of motion and disorientation, and it is usually associated with other otologie symptoms such as nausea and vomiting. Ir indicates primary labyrinthine disease. It is to be distinguished from a floating sensation, light-headedness, faintness, and blackours. Disturbed balance, or dysequilibrium, may be mild and vague and, like unilateral tinnitus, may be the earliest symptom of an acoustic neuroma or other lesions of the cerebellopontine angle. The character of the vertigo is another important consideration. Most patients who cornplain of constant dizziness, especially when there are no objective signs such as nystagmus or ataxia, have a functional problem. Patients who have clusters of episodes of disturbed balance or vertigo, with long remissions and often with other vague symptoms, may have multiple sclerosis. Clusters of violent episodes of whirling vertigo with nausea and vomiting lasting severa!
minutes to severa! hours occur in patients with endolymphatic hydrops. Certain symptoms associated with dizziness are suggestive of neurologie disease. Examples are visual disturbances, paresthesias of the face or extremities, weakness or clumsiness of the extremities, confusion and other aberrations of consciousness, dysphagia, and dysarthria. An attempt must be made to find the cause of the vertigo. Often a history can be elicited of recent viral infection; excessive use of tobacco or alcohol; drug abuse; use of oral contraceptives; serious underlying metabolic, endocrine, or vascular disease; or head injuries thar produce labyrinthine concussion. Conclusions
Eliciting a reliable history is probably the most important part of the overall assessment of the patient with ear symptoms, but it is only the first step in diagnosis. An otorhinolaryngologic examination, often including audiometrie and vestibular testing, is required. When the diagnosis is less obvious, a complete general medical examination may be necessary, including neurologie and ophthalmologic examinarions, roentgenograms of the skull and petrous bones, and an electronystagmogram. The results of these tests may indicate the need for further, more specialized testing. Address reprint requests to Thomas J. McDonald, MD, Department of Otorhinolaryngology, Maya Clinic, Rochester, MN 55901. For ReadySource on ENT, see page 162. Overall self-test on ENT begins on page 154.
~_IO_n______________~ Disease within the middle ear causes a. Conductive hearing loss b. Sensorineural deafness c. Dizziness d. Both band c
Vol. 57 • No. 6 • May 1975 • POSTGRADUATE MEDICINE
a
63
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Common Otologic Symptoms H. Bryan Neel III & Thomas J. McDonald To cite this article: H. Bryan Neel III & Thomas J. McDonald (1975) Common Otologic Symptoms, Postgraduate Medicine, 57:6, 59-63, DOI: 10.1080/00325481.1975.11714044 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714044
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 20 August 2017, At: 14:14
co sder • What is the most valuable part of the evaluation of patients with common or routine otologie complaints? • What is the most common cause of conductive hearing loss in adults?
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
• What does the character of a discharge from the ear help elucidate?
H. BRYAN NEEL Ill, MD THOMASJ.McDONALD,MD Maya Clinic and Maya Foundation Rochester, Minnesota
Common Otologie Symptoms Eliciting a thorough history is the first step in the diagnosis of disorders of the ear, and it must be done in an orderly, complete manner. It is helpful to think of the ear as a unit consisting of the external auditory canal, middle ear, and inner ear. The middle ear consists of the auditory tube, tympanic cavity, and tympanic membrane, along with the mastoid air-cell system. The inner ear consists of the cochlea and the eighth cranial nerve and its central connections. In obtaining the history, it is important not only to concentrate on the ear but also to inquire about allergies, medications, operations, systemic illness, family his tory, occupation, and travel. Hearing Loss
Hearing Joss is of two general types: conductive and sensorineural. A patient may have bath types, which is called mixed loss. Conductive hearing loss occurs when conduction of sound through the external auditory canal, tympanic membrane, middle ear space, or ossicular chain is impaired. Sensorineural lasses result
Vol. 57 • No. 6 • May 1975 • POSTGAADUATE MEDICINE
from injury to the cochlea, cochlear nerve, or acoustic branch of the eighth cranial nerve anywhere along its course from the cochlea to its connections within the brain stem. Foreign bodies within the canal, cerumen impaction, tumors, otitis externa which produces swelling of the soft tissues, and partial or complete atresia of the external auditory canal may impair passage of sound through the external auditory canal. If the soft tissues of the canal are particularly resilient, the audiogram may show a conductive hearing Joss in the high tones, which should lead the examiner to suspect canal collapse; tuning fork tests will indicate normal hearing. Tympanic membrane perforation is a cornmon cause of conductive hearing loss, and the degree of hearing loss depends primarily on the size of the perforation. Extensive thickening, retraction, or scarring of the tympanic membrane also may produce conductive hearing loss. In children, the most common cause of conductive hearing loss is serous otitis media, which in sorne instances is secondary to hypertrophy of
59
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
the lymphoid (adenoid) tissue in the nasapharynx and around the eustachian tubes. Allergy, hypothyroidism, hypogammaglobulinemia, tumors of the nasopharynx, irradiation, and palatal muscle dysfunction associated with an obvious or submucous cleft palate are other etiologie factors. The palate must be palpated if the diagnosis of submucous cleft palate is to be made. A bifid uvula often accompanies submucous cleft palate.
bilateral, symmetric high-tone loss, which eventually affiicts everyone because of the aging process. A similar hearing loss can occur after trauma, such as noise exposure, an explosion, or a blow to the head. A few patients who have sensorineural hearing loss have correctable or partially correctable problems, such as those with cerebellopontine angle neoplasm, endolymphatic hydrops (Meniere's disease), congenital syphilis, Cogan's syndrome, relapsing polychon-
Unilateral sensorineural hearing loss that is subjectively not striking but objectively obvious on an audiogram should lead one to suspect the presence of multiple sclerosis. Disease within the middle ear may interfere with the mobility of the ossicular chain. The most common cause of conductive hearing loss in adults is otosclerosis, which produces fixation of the stapes foot plate. Occasionally, otosclerosis may induce a purely sensorineural hearing loss in the form of the controversial entity, cochlear otosclerosis. Fixation of the ossicular joints because of tympanosclerosis occasionally occurs after repeated middle ear infections. The large white plaques within the tympanic membrane and the immobility of the malleus on examination are elues to the presence of this entity. Fixation of the ossicular chain also can occur congenitally. A single virulent beta hemolytic streptococcal infection may dissolve the long process of the incus, thereby interrupting the ossicular chain and leading to conductive hearing loss; more commonly, recurrent infections (often secondary to cholesteatoma) lead to destruction of the ossicular chain. Hearing may be normal, and the only clue to an extensive cholesteatoma may be a small perforation in the pars flaccida, often hidden beneath a crust. In contrast to conductive hearing !osses, most sensorineural hearing !osses are uncorrectable. Sensorineural hearing loss is most commonly a
60
dritis, Wegener's granulomatosis, temporal arteritis, adult myxedema, and toxicity due to aspirin, quinine, or isoniazid. Therefore, sensorineural hearing impairment may be a manifestation of a serious systemic illness. In endolymphatic hydrops and related diseases, the hearing may fluctuate and the first indications of an acoustic neuroma or cerebellopontine angle problem may be a hydrops-like syndrome. The most common cause of unilateral sensorineural hearing loss in childhood is mumps. The loss is usually total and uncorrectable. Meningoencephalitic infections can involve the auditory nerve and the labyrinth and lead to profound sensorineural hearing loss. Unilateral sensorineural hearing loss that is subjectively not striking but objectively obvious on an audiogram should lead one to suspect the presence of multiple sclerosis. The degree of hearing loss varies from slight to severe, sornetimes waxes and wanes, and is apparently due to plaques involving the central auditory connections. Sudden idiopathie hearing loss is generally attributed to vascular insufficiency or viral infection, but such loss is the first indication of acoustic neuroma in about 10% of patients with confirmed acoustic neuromas.
POSTGRADUATE MEDICINE
o
May 1975
o
Vol. 57
o
No. 6
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
Figure 1. Diagram of pathways from various sensory distributions accounting for referred pain in the ear. Adapted with permission from Kern EB: Referred pain ta the ear. Minn Med
55:896-898, 1972.
Pain The cause of pain ansmg within the ear (primary ear pain) usually can be found on physical examination. Pain is commonly associated with acute suppurative otitis media and is seen sometimes in the early stages of acute serous otitis media. Persistence of pain or recurrence after acute suppurative otitis generally indicates that pus is accumulating under pressure in the mastoid cells and that complications are about to develop. Inadequate treatment may lead to various meningeal complications, labyrinthitis, petrositis, or facial paralysis. Although pain is an uncommon symptom in the usual case of chronic middle ear disease, it is serious and may mean that the disease has caused ·exposure of the dura or sigmoid sinus wall and that localized pachymeningitis, a perisinus abscess, or a brain abscess is present. Pain is almost always associated with primary or metastatic tumor of the temporal bane. The external auditory canal must be examined for
Vol. 57 • No. 6 • May 1975 • POSTGRAOUATE MEDICINE
small masses that may be smooth and have intact overlying skin. If palpation of such a lesion elicits extreme pain, the presence of a cy lindroma should be suspected. Otalgia may be referred from disorders distant from the ear. The sensory distribution accounting for referred pain in the ear consists of the fifth cranial nerve (trigeminal nerve, mandibular division), seventh cranial nerve (facial nerve), ninth cranial nerve (glossopharyngeal nerve), tenth cranial nerve (vagus nerve), and second and third cervical nerves (figure 1). Common sources of referred pain are the oral cavity (teeth, tangue, tonsils), temporomandibular joint, nasopharynx, and perilaryngeal regions, including the trachea, thyroid, and pharynx. Ear Noise
Tinnitus is a common ear symptom that may be subjective (intrinsic) or objective (extrinsic). Bilateral subjective tinnirus is commonly associated with presbycusis and acoustic trauma.
61
H. BRYAN NEEL Ill Dr. Neel is a consultant, department of otorhinolaryngology, Maya Clinic and Maya Foundation, Rochester, Minnesota.
eliminates the symptoms temporarily, presumably by causing enough swelling of the tissues surrounding the eustachian tube to reduce the patency. This dysfunction is seen in patients who have had recent profound weight loss, are pregnant and have endocrine dysfunction, or are taking hormones (eg, oral contraceptives).
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
Discharge From the Ear
Unilateral tinnitus may be the first symptom associated with an acoustic neuroma or a lesion of the cerebellopontine angle. Low-pitched roaring tinnitus preceding an episode of vertigo accompanied by pressure or fullness in the ear and fluctuating hearing typically occurs with endolymphatic hydrops. The typical symptoms of hydrops can occur with congenital syphilis, spontaneous oval- or round-window perilymph fistulas, and various systemic maladies. Objective tinnitus is due to vascular bruits from glomus tumors, aneurysms, arteriovenous malformations, referred heart sounds, clicking jaw, and nasopharyngeal sounds. Muscle spasms from palatal myoclonus cause an annoying snap or click in the ear. Palatal myoclonus is a neurologie disorder that produces rhythmic contractions of the muscles of the soft palate. The eustachian tube is opened with each contraction. The diagnosis is made by observing contractions of the soft palate that are synchronous with a click heard through an auscultation tube. The cause is not known, and there is no effective treatment. The examiner should stress that normal eustachian tube function can produce a feeling of "popping" or "clearing," especially with changes in altitude; patients often need to be reassured about this. In another form of eustachian tube dysfunction, called abnormal patency of the eustachian tube, patients complain of autophony (a booming quality of the ir own voice) and of hearing a swishing sound on respiration. Recumbency
62
The character of the discharge helps elucidate the nature of the pathologie process. Discharge from the soft tissues alone is generally watery or mucoid and inoffensive, but when disease extends into the bone, the discharge becomes thick, yellow or green, and foui smelling. Therefore, foul-smelling, discolored discharge is often indicative of cholesteatoma, and small, white, shiny flakes seen in the discharge are pathognomonic of cholesteatoma. Chronic oticis media with cholesteatoma can be capricious, and the discharge from a small perforation in the pars flaccida may be scanty, consisting chiefly of flakes of epithelium. Foul-smelling, purulent drainage occurs not only with cholesteatomas but also with osteomyelitis and tumors. Intermittent mucoid discharge during colds is seen in patients with chronic inactive otitis media and tympanic membrane perforations. Infection from the nasopharynx probably extends by way of the open eustachian tube to the middle ear and leads to the discharge. When the infection subsides, the drainage diminishes, although it seldom ceases entirely, and the patient may report that he sees a small amount of mucoid discharge on the pillow on awakening in the morning. Thin, cloudy drainage without pain is suggestive of tuberculosis, particularly if multiple perforations are noted in the tympanic membrane. Clear, watery drainage dribbling intermittently or continuously from the ear or clown the throat from the orifice of the eustachian tube in the nasopharynx may represent cerebrospinal fluid leakage after head trauma or it may occur spontaneously through congenital dehiscences in the bone surrounding the ear. Blood-
PDSTGRADUATE MEDICINE • May 1975 • Vol. 57 • No. 6
tinged or bloody drainage from the ear also can occur after head injuries and temporal bone trauma but is more commonly due to serous otitis media or its rarer forms (idiopathie hemotympanum and chronic serous mastoiditis), primary and meiastatic malignant tumors, and sometimes granulomatous diseases.
Downloaded by [Australian Catholic University] at 14:14 20 August 2017
Vertigo
Because dizziness is ubiquirous, helping the patient to clarify his complaint referable to balance is important. Helpful questions in this regard are "What do you mean by dizziness?" and "Does your imbalance last seconds, minutes, or hours?" True vertigo is a sensation of motion and disorientation, and it is usually associated with other otologie symptoms such as nausea and vomiting. Ir indicates primary labyrinthine disease. It is to be distinguished from a floating sensation, light-headedness, faintness, and blackours. Disturbed balance, or dysequilibrium, may be mild and vague and, like unilateral tinnitus, may be the earliest symptom of an acoustic neuroma or other lesions of the cerebellopontine angle. The character of the vertigo is another important consideration. Most patients who cornplain of constant dizziness, especially when there are no objective signs such as nystagmus or ataxia, have a functional problem. Patients who have clusters of episodes of disturbed balance or vertigo, with long remissions and often with other vague symptoms, may have multiple sclerosis. Clusters of violent episodes of whirling vertigo with nausea and vomiting lasting severa!
minutes to severa! hours occur in patients with endolymphatic hydrops. Certain symptoms associated with dizziness are suggestive of neurologie disease. Examples are visual disturbances, paresthesias of the face or extremities, weakness or clumsiness of the extremities, confusion and other aberrations of consciousness, dysphagia, and dysarthria. An attempt must be made to find the cause of the vertigo. Often a history can be elicited of recent viral infection; excessive use of tobacco or alcohol; drug abuse; use of oral contraceptives; serious underlying metabolic, endocrine, or vascular disease; or head injuries thar produce labyrinthine concussion. Conclusions
Eliciting a reliable history is probably the most important part of the overall assessment of the patient with ear symptoms, but it is only the first step in diagnosis. An otorhinolaryngologic examination, often including audiometrie and vestibular testing, is required. When the diagnosis is less obvious, a complete general medical examination may be necessary, including neurologie and ophthalmologic examinarions, roentgenograms of the skull and petrous bones, and an electronystagmogram. The results of these tests may indicate the need for further, more specialized testing. Address reprint requests to Thomas J. McDonald, MD, Department of Otorhinolaryngology, Maya Clinic, Rochester, MN 55901. For ReadySource on ENT, see page 162. Overall self-test on ENT begins on page 154.
~_IO_n______________~ Disease within the middle ear causes a. Conductive hearing loss b. Sensorineural deafness c. Dizziness d. Both band c
Vol. 57 • No. 6 • May 1975 • POSTGRADUATE MEDICINE
a
63
