16. Ear, Nose, and Throat

“How great was the humiliation when one who stood beside me heard the distant sound of a shepherd’s pipe, and I heard nothing; or heard the shepherd singing, and I heard nothing. Such experiences brought me to the verge of despair; but little more and I should have put an end to my life. Art, art alone deterred me.”

Ludwig van Beethoven on slowly losing his hearing. (By the age of 46 he was completely deaf, possibly due to a mixture of nerve deafness and a degree of otosclerotic bony deafness)

16.1 Causes of Hearing Loss

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Causes of conductive hearing loss

Causes of sensorineural hearing lossa

Outer ear

Middle ear

Inner eara

  • Cerumen (ear wax) impaction

  • Bony lesions in ear canal (e.g., osteoma)

  • Infection and debris

  • Atresia of ear canal

  • Otosclerosis, or damage to middle ear ossicles

  • Middle ear infection or fluid

  • Cholesteatoma

  • Tympanic membrane (TM) perforation or retraction

  • Meniere’s disease

  • Labyrinthitis

  • Cochleotoxicityb

  • Acoustic neuroma (eighth cranial nerve tumor)

  • Other neural lesions

aTinnitus (ringing in ears) is common in patients with sensorineural hearing loss, but can also occur with middle ear issues.

bDrugs that are cochleotoxic (ototoxic)

  • Quinine, chloroquine (antimalarials), quinidine (antiarrhythmic)

    1 Overdose with these drugs can lead to cinchonism (tinnitus, hearing loss, blurred vision, confusion, nausea, vomiting, etc.).

  • Aspirin

  • Aminoglycosides

  • Cisplatin

  • Loop diuretics

16.2 Bedside Test for Hearing Loss

Rinne test

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After vibrating the tuning fork, put it on the bone as pictured. After patient stops hearing the sound, then place the tuning fork in front of ear.

  • If patient still hears the tuning fork, then air conduction (AC) is better than bone conduction (BC), which is normal, since air conducts sound better than bone.

  • If BC (bone conduction) is better, it means that there is an abnormality in the conductive portion of the ear.

In sensorineural hearing loss, both AC and BC are decreased equally, thus AC > BC.

Weber test

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To remember how the Weber test is done, picture W in the center of the head.

After vibrating the tuning fork, it is placed right in the center of the top of the head (between the two ears), as pictured.

  • To understand what happens in the Weber test with conductive hearing loss, we must understand the principle of external interference.

Example of external interference—we may be able to hear water drops in a silent cave where there is no other sound interference, but we may not be able to hear the whole fountain in a city center where there are a lot of ambient sounds interfering with your hearing.

In the affected ear with conductive hearing loss, external interference from conducted sound waves from air is absent or reduced, so the sound conducted through the bone is better heard in the affected ear.

  • In unilateral sensorineural hearing loss, as both BC and AC are affected in an abnormal ear, the sound will be heard more in the normal ear (lateralizes to the normal ear).

In a nutshell

Rinne test

Weber test



No lateralization

Conductive hearing loss

BC > AC in the affected ear

Lateralizes to affected ear

Sensorineural hearing loss

AC > BC in all ears

Lateralizes to normal ear

16.3 Presbycusis

Background: Progressive bilateral hearing loss that occurs primarily with age due to degeneration of inner ear sensory structures. This is the MCC of hearing loss.

Presentation: Hearing loss that is more pronounced in noisy environments.

2When I am talking to my mother on the phone, I always make sure that she is in a very quiet environment (e.g., TV is not on).

Workup: Audiometry will reveal hearing function more preserved at high frequencies.

Management: Hearing aids and if severe, cochlear implant.

16.4 Otitis Externa

16.4.1 Uncomplicated otitis externa

Background: Infection of external ear canal is commonly due to Pseudomonas (MCC), Staphylococcus epidermidis or Staphylococcus aureus.

Presentation: Ear pain and discharge. Patients may have mild low-grade fever, but there are usually no other systemic symptoms.

Physical exam findings: Tenderness while pulling the ear. External ear canal will appear edematous and red. Otosocopy will reveal normal tympanic membrane.

Management: Topical antiseptic or antibiotic (e.g., ciprofloxacin) ± topical steroids (for significant itching or inflammation).

16.4.2 Malignant (Necrotizing) Otitis Externa

Background: Think of this when patient with otitis externa has any of the following features:

  • Persistent foul-smelling discharge not responsive to general measures.

  • Granulation tissue in external canal.

  • Severe pain out of proportion to exam findings.

  • Systemic symptoms (e.g., high-grade fever).

Microbiological cause: Same as in uncomplicated otitis externa.

Risk factor: Occurs particularly in patients who have underlying immunosuppression (e.g., HIV, uncontrolled diabetes, active malignancy).

Workup: NSIDx is computed tomography (CT) scan (presence of bony erosions distinguishes this from severe otitis externa).

Rx: Systemic antibiotics that should cover Pseudomonas (e.g., oral or IV ciprofloxacin depending upon severity).

16.5 Middle Ear Issues


Presentation (all middle-ear issues can present with conductive hearing loss)

Otoscopic findingsa


Acute otitis media b

  • Pus drainage from ear

  • Fever

  • Pain in the earc

  • No tenderness when the pinna

  • pulledd

Red (erythematous) ± bulging TM (tympanic membrane)

  • Use oral amoxicillin.

  • If symptoms persist after

  • days or if hx of recent antibiotic usage, then give amoxicillin + clavulanate.

Bullous myringitis

Painful vesicles in TM (tympanic membrane) + red (erythematous) TM ± bulging TM

Rx is the same as above, as the causative organism is similar to acute otitis media.

  • Additional causes include Mycoplasma pneumoniae, viral (e.g., influenza, herpes zoster), etc.

Serous otitis media (a.k.a. otitis media with effusion) This might be a complication of eustachian tube dysfunction or sequelae of acute otitis media.

  • Painless hearing loss

  • No signs of active infection

  • Dull hypomobile TM (tympanic membrane) ± airfluid level in tympanic cavity

  • Best diagnostic test is tympanometry, which uses a probe to detect reflected sound waves. Stiff middle ear or TM reflects more sound.

  • Conservative expectant management in uncomplicated cases.

  • Tympanostomy is indicated for persistent symptomatic effusion (> 12 wk) or in whom air travel cannot be deferred.

Chronic otitis media MC causes are Pseudomonas and S. aureus.

Recurrent or persistent ear discharge (major differentiating factor from acute otitis media is hx of > 6 weeks)

Calcific patches + perforation

  • In uncomplicated cases, use ear irrigation with topical antibiotics (e.g., ciprofloxacin).

  • In complicated cases (e.g., with mastoiditis, systemic symptoms), do CT scan and give systemic antibiotics. Surgery might also be needed.

Cholesteatoma (keratinized desquamated epithelial collection, with inflammatory and infectious component that can spread and destroy bones) May be primary (due to chronic eustachian tube dysfunction) or secondary (due to acquired TM perforation)

Presents similarly to chronic otitis media, but otoscopic findings are different

Debris, granulation tissue, and inflammatory polyps

NSIM is CT to determine the extent of disease.

Rx: surgical removal/ debridement.

Eustachian tube dysfunction Look for hx of recent upper respiratory tract symptoms which can cause eustachian tube inflammation and edema. If persistent, look for secondary causes such as:

  • Obstructive tumors

  • Obstructive lymph nodes

  • (e.g., in HIV or lymphoma)

  • Nasal polyps

Fullness and pain in ear, worsened by chewing food. Audible pop might also be heard when the tube opens intermittently.

Retracted TM

Treat underlying cause.

Nasal decongestants, hydration.

aFor all middle ear issues the best initial test is pneumatic otoscopy. Decreased mobility on air insufflation is the most sensitive finding and can be present in all the following conditions.

bRemember the MC bacterial cause of bronchitis and sinusitis; they are also the ones that commonly cause otitis media—they are St reptococcus pneumoniae, Hae mophilus influenzae, and Mo raxella catarrhalis.

cAfter TM ruptures, patients may feel less pain as the pressure inside the middle ear cavity is released.

dAbsence of external ear tenderness is the major differentiating factor in between uncomplicated otitis media and otitis externa. Both can have pus coming out of ear.

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Dec 11, 2021 | Posted by in OTOLARYNGOLOGY | Comments Off on 16. Ear, Nose, and Throat
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