• must examine opposite ear and nose (check for multiple objects)
• need cooperation and immobilization
• might need brief anesthesia in young kids
• put pressure behind object to remove
• small soft objects (that do not occlude canal): use syringe irrigation
  • if water used dry out with ethanol
  • do not use water if cuts present
• Organic material: use curet or blunt hook 
• get audiogram 1st if object near TM

• no gross contamination or infection of middle ear→ Medication not necessary
• Lacerations of ear canal or TM→ Keep ear dry for healing
  • no water should enter canal
  • cotton balls coated with petroleum jelly

Bleeding of any object in ear canal

• suspect it is a mucosal polyp form the middle ear
  • occurs with chronic middle ear infections
• Do not try to remove
• CONSULT otolaryngology

• mineral oil
• 3% hydrogen peroxide
• Cerumenex
• Debrox
• Cesylate: fastest
• use for 5-10 minutes
• us epithelium disrupted use antibiotics

• Neomycin, polymyxin B, hydorcortisone (Cortisporin Otic), Antibacterial and anti inflammatory solution for otic use
• 4-5 gtt instilled to affected ear qid

• perception of abnormal ear or head noises
• persistent:often (not always) indicates sensory hearing loss 
• Intermittent: short periods of mild, high pitched are common in normal hearing persons
• can be objective or subjective

• most important: avoidance of exposure to excessive noise, ototoxic agents and other factors that can damage chochlea 
• mask with other sounds (music or amp normal sounds in a hearing aid)
• TCAs (amitryptyline) or alprazolam (Xanax) have been used to reduce severity

• described as listening to one's own heart beat
• often due to conductive hearing loss, but may be due to something more serious:
• vascular abnormality (glomus tumor, venous sinus stenosis, aneurysm...)
• magnetic resonance angiography and venography used to establish dx

• may result for middle ear muscle spasm
• sometimes associated with palatal myoclonus
• rapid series of popping noises and fluttering feeling in the ear

• head 45 degrees to right
• patient in supine position, head off table lower than body by 30 degrees
• vertigo within 30 seconds
• nystagmus rotational or torsional

• continuous 
• dizzy when standing or walking
• improves when seated or supine

• lightheadedness
• due to lack of bloodflow to brain
• cardiovascular not neurological problem

• symptom of disease in the vestibular system
• can be central or peripheral

• Includes the labyrinth, 3 semicircular canals, and otoliths

• petrous portion of temporal bone
• a system of fluid passages in the inner ear
• includes both the cochlea (part of the auditory system) and the vestibular system (provides the sense of balance)

• region of the inner ear where the semicircular canals converge
• works with the visual system to keep objects in focus when the head is moving 
• Joint and muscle receptors also help maintain balance

• part of the vestibular system of the inner ear
• sense head rotation

• utricle & saccule
• sense head position relative to gravity

• external inspection for signs of mastoiditis, cellulitis, or prior ear surgery
• inspect ear canal for otitis externa, otorrhea (discharge) or vesicles
• inspect TM and middle ear for perforation, cholesteatoma, middle ear effusion (fluid) or acute otitis media

• inspect ocular range of motion and pupillary response
• funduscopic exam to assess for papilledema 
• observe for nystagmus (Dix-hallpike test if tolerable)
• if visual changes suggested, consult opthalmologist

• optic disc swelling
• Causes: Tumor, bleeding, abscess

• complete cranial nerve exam
• assess for balance using the Romberg test and tandem gait
• assess cerebellar fxn by performing finger-to-nose and heel-to-shin tests

• neurological test used to exam balance
• pt holds arms out directly in front of them
• If a peripheral problem exists: pt will sway when eyes are closed, but not when opened
• If a central problem exists: pt will sway when eyes are closed or open

• used to rule out acoustic neuroma, stroke, brain abscess or epidural hematoma
• MRI without contrast 1st to detect blood
• then with contrast to detect labyrinthitis (cochlea, vestubule, and semicircular canals will be enhanced on T1) Rarely done though. Contrast also used to detect acoustic neuroma etc.

Prochlorperazine (Compazine)

PO: 10mg q6h

IV: 2.5-10 mg slow push q6h

PR: 25mg q12h

• for control of vertigo associated with diseases affecting the vestibular system
• recommended dose: 25-100 mg daily, in divided doses (depending on clinical response)

• acute symptoms of vertigo, nausea and vomiting: resolve after several days to weeks
• Hearing loss: more variable (all to absolutely no hearing may be resolved)
  • Suppurative (bacterial): permanent and profound hearing loss
  • viral: usually less profound
  • permanent in 10-20% of children with meningitis and 6% of those with herpes zoster oticus
• Dysequilibrium &/or positional vertigo: may be long-term

seen in all patients with acute vertigo

• subsides with vertigo
• unidirectionsl
• fast component beats in same direction 
• often horizontal

• persists longer than vertigo
• multi directional
• fast component changes with direction of gaze
• vertical or rotary almost always central

• determines presence of vestibular dysfunction
• establish whether uni or bilateral dysfunction
• distinguish central from peripheral dysfunction

homonymous hemianopsia

homonymous (hemifield defect on same side of both eyes)

ex: nasal 1/2 field of left eye and temporal 1/2 field of right eye

• Tumor is on opposite side as visual field loss

• feeds the back of the brain
• must be imaged with MRI 

• vertigo is cardinal symptom in many of the posterior circulation stroke syndromes
• consider with persistent vertigo and vascular risk factors (elderly)
• prominent gait ataxia
• + finger to nose test
• Worse finding: CEREBELLAR Hemorrhage

• CNS needs adequate sensory input regarding position of head and body in space
• CNS must properly process sensory input
• an appropriate motor response must then be generated
• Deficits in any of these result in disequilibrium / imbalance

1. vision
2. vestibular
3. proprioception (joints/muscle)
4. hearing

• produces worst disequilibrium
• diplopia, corneal and retinal disease: asymmetry of visual input

•  acute peripheral vestibulopathy
• Meniere's
• vestibulotoxic drugs (anticonvulsants, benzos)
• neoplasms of posterior fossa (acoustic neuromas)

• peripheral neuropathy
• proprioceptive loss in lower extremities
• diabetes, spinal cord disease

• contributes to disorientation in disequilibrium

Elements in motor system

1. Pyramidal system
2. extrapyramidal system
3. cerebellum

• Gross motor movements (innervation from top of brain to muscles)
• Abnormalities:
  • degenerative frontal lobe dysfunction
  • gait apraxia
  • hydrocephalus
  • frontal lobe neoplasms
• All interfere with normal motor fxn

Extrapyramidal system

• involved in fine motor movement
• affected by:
  • Parkinson's 
  • psych drugs

• primary and alcoholic degenerative syndromes
• neoplasms
• infarcts 
• demyelination
• disequilibrium syndrome

• bony fusion of stapes, reduces motion of ossicles → hearing loss
• treatable with surgery

• mechanical stress on structures of inner ear produce temporary injury
• if prolonged: permanent injury and increasing hearing loss
• structures damaged: hair cells in organ of Corti: attached to basilar membrane in cochlea

• Temporary threshold shift
• usually improves over 24-72 hrs
• repeated or persistent noise exposures: irreversible hearing loss

aminoglycosides and ototoxicity

• produce SNHL that start with high freq, then progresses to a flat moderately severe loss across all freq
• drugs [ ] in endo and perilymph and damage hair cells
• ototoxicity does not correlate well with serum drug levels
• Total dose < 2mg, duration < 10 days = low rate of hearing damage
• kidney eliminated so be careful in kidney failure

• when conductive hearing loss occurs with sensorineural hearing loss
• may follow injury to structures of external, middle and inner ears
• infection may produce nerve injury, inflammation, tympanosclerosis
• congenital disorders: may involve structures and nerves

• can be heard when examiner places a stethoscope (with bell removed) in patients external auditory canal, or when bell is placed around ear or neck
• blowing sound with inspiration and expiration from abnormally patent (patulous) eustachian tubes
• follows rapid weight loss, or during a debilitating illness

• sound in ears heard only by pt
• may be produced by lesions or conditions in the external ear canal, CN 8, brainstem or cerebral cortex
• described as: "buzzing, ringing, whistling, hissing, insect sounds or motor sounds"

• If, bilateral and high pitched, can be from:
  • chronic noise exposure
  • presbycusis
  • ototoxic chemicals or durgs
• Unilateral:
  • Vestibular schwannoma (acoustic neuroma)
• low pitched:
• Meniere's, otosclerosis

can be due to:

• Salicylates (aspirin)
• Indomethacin (NSAID)
• Quinidine (lupus, malaria)
• Propranolol (beta blocker)
• Levodopa (Parkinsons)
• Carbamezapine (Seizure)
• Aminophylline (bronchial asthma)
• Caffeine

• common in all age groups
• one of largest categories of illness in pediatrics
• can be viral, bacterial or fungal
• can involve: external ear, TM, mastoid cavities, labyrinth and temporal bone

• auditory meatus: skin lined cul de sac
• lined by thin stratified squamous epithelium
• lateral 1/3 cartilage
• medial 2/3s bonny: skin over this area is thin, susceptible to trauma
• pathogens enter here form minor abrasions to the skin: extremely pain sensitive area

• warm and humid
• exfoliate skin: great growth medium for bacteria and fungi
• contains cerumen
• hair prevents entry of foreign bodies, but too much prevents migration of cerumen (can lead to impaction)

• produced by pilosebaseous glands
• protective b/c acidic and it is hydrophobic
• contains lysozymes that inhibit bacterial growth
• too much or little perdisposes to otitis externa

• normal external auditory canal should be self cleaning
• If not: remove cerumen with irrigation, suction, mechanical removal, cerumenolytics

• If TM not perforated: Topical mix of neomycin and bacitracin or polymyxin with hydrocortisone
• small portion of pts have a sensitivity to neomycin, which can be ototoxic. If sxs persist 1-2 weeks post application switch to another med (Vasocidin, Cetapred, domeboro, chloroamphenicol otic solution acetic acid and burrows solution)
• If TM perforated or unsure: give oral Antibiotic

3-4 gtt, 3-4 x per day

pt lies on side with treated ear up for 2-5 minutes

Penicillinase-resistant penicillin

dicloxacillin orally or oxacillin or cephalosporins IV

• Lethal: necrotizing otitis externa (malignant otitis extern)
• soft tissue infection
• usually affects elderly, diabetic or immunocompromised pts
• typically: pseudomonas alone or with other organisms

malignant otitis exteran

• may begin mildly, course progresses relentlessly if untreated
• invades and destroys contiguous soft structures (auricle, scalp, parotid gland)
• further extends to: structures of middle and inner ear
• eventually to brain
• Facial nerve paralysis may be early sign

• oxygen is absorbed from the air in the middle ear space
• results in a negative partial pressure, which causes an inflammatory response
• a sterile transudate is produced in the middle ear, which can become 2° infected

• objective test where mobility of TM is assessed by means of a signal reflected from it
• pressure against TM is continuously changed
• Typanograms:
  • Type A: normal
  • Type B: flat, middle ear effusion
  • Type C: retracted, negative middle ear pressure
• portable models available
• probe placed in external ear canal
• sound stimulus transmits acoustic energy 
• vacuum pump introduces + and - pressures into the canal