Small vade mecum of the affections of the ear

By seriniti , on 26 March 2022 - 17 minutes to read
Petite vademecum des affections de l'oreille

 

Vast program to take again a known expression. The affections of the ear are indeed numerous and we will be satisfied here to quote the most important or the most awkward of them in the absence, sometimes, of the most frequent.

Tinnitus

Noises. Not my voice, nor my laughter, but unbearable sounds, parasites, buzzing, snoring, screams, stunts, falls, motors. – Géraldine Maillet, Tinnitus

Like whistles of vapors in each ear. – Céline, Journey to the End of the Night.

These are permanent parasitic noises, often very badly experienced and which can sometimes make our daily life unbearable. Tinnitus can take all forms, from the high-pitched whistle to the classic low-pitched buzzing. But tinnitus can also take infinitely more complex forms, going so far as to say for some patients that they perceive voices in their head.

Its etiology, apart from all kinds of sound aggressions, is often poorly known and, as a consequence, treatments are not very effective, especially if they are delayed. Let us therefore insist on prevention, which is as simple as it is difficult in today’s world, which is based on a lifelong prevention of sound aggression.

>> Tinnitus, what is it ? >> read full article here

Cerumen, ear wax

Produced by glands located outside the ear canal, earwax is a mixture of secretions from the sebaceous glands and sweat glands. It has a triple function:

A cleaning role

The earwax is naturally transported by the microcilia towards the outside of the ear, thus evacuating the dirt deposited in the auditory canal. Schematically, the cells formed in the center of the tympanic membrane slowly migrate towards the umbilicus of the tympanic membrane to the walls of the ear canal and then, more rapidly, towards the entrance of the canal. As it is pushed outward, the earwax carries with it dust, dirt and particles that could accumulate in the ear canal. The movements of the jaw facilitate this process.

A lubricating role

The purpose of lubrication is to prevent the skin of the ear canal from drying out and causing itching. The lubricating properties of earwax come from the lipid content of the sebum produced by the sebaceous glands. These lipids can include cholesterol, squalene and many fatty acids and long chain alcohols.

Antibacterial function

The antibacterial and antifungal properties of earwax are due to the presence of saturated fatty acids and lysozyme, which make earwax an acidic medium. Cerumen has a protective function against certain types of bacteria (Haemophilus influenzae, Staphylococcus aureus and variants of Escherichia coli). The growth of fungi is also significantly reduced by its presence.

Everyone secretes earwax, but the nature of the earwax varies from person to person. The difference in the type of earwax in humans varies by a single nucleotide pair in the C11 gene. This mutation, in addition to affecting earwax, would also reduce sweating. Although earwax plugs cannot be considered a disease, they can contaminate life when they are large and obstructive, causing hearing loss and even otitis externa or media if the water, after a bath, presses on the eardrum, putting a layer of water between the eardrum and the earwax plug, which is an almost inevitable source of infection.

The cotton swab is a great source of obstructive earwax: inserting a cotton swab into the ear canal is equivalent to compacting the earwax, as one would do with gunpowder in the barrel of a gun. Fortunately, cotton swabs will be banned from 2020, which will reduce environmental pollution linked to single-use plastics, but also eardrum perforations by inserting them into the ear canals.

>> Wax in all its states >> read full article here

 


Cholesteatoma

Cholesteatoma is a misplaced skin in the middle ear. – Gray, 1964

Cholesteatoma has been known for 150 years and is the subject of countless studies and publications. New research techniques have improved our knowledge of the subject. Cholesteatoma is a benign tumor that develops in the middle ear. It is a proliferative epithelium that progressively accumulates in a posterior-superior invagination pocket of the tympanum (tubal dysfunction) which will progressively become infected, achieving by enzymatic lysis and inflammation a bone destruction extending fromone to another. The invagination pocket, during its growth, will eventually rupture invading the mastoid cavities.

Various causes :

  • A chronic dysfunction of eustachian tube,
  • Tympanoplasty,
  • Tympanic perforation,
  • A congenital cause.

The mastic white aspect of the tumor makes the diagnosis characteristic. Its sanction is surgical. The risk of recurrence is not negligible

>> Cholesteatoma >> read full article here

 


Crystals

What is it ?

The inner ear is the seat of hearing and balance.
The vestibular (balance) system is made up of sensory zones composed of cells with cilia at the top, which are immersed in a gel. This gel is studded with calcium crystals called otoconia or otoliths (ear stones). Any movement of the head moves the cilia under the weight of these crystals, which makes it possible to know at any time the position of the head in space. An excess of crystals, held captive in this gel, will exert an excessive pressure on these cilia. A movement of the head then triggers a positional vertigo (BPPV: benign paroxysmal vertigo right or left)

The specific treatment remains the liberatory maneuver.

Schematically, one shakes the branches of a tree which bend under the excess of fruits. The fall of a part of them repositions the branches. The release maneuver does the same thing. Too many crystals escape from the “sticky” gel (the cause of this condition) when the head is mobilized. The eyelashes then return to their normal position… at least until the next attack, which will occur when the otoconia are again in excess. The frequency of this condition explains why it is so well known.

>> Vertigo, did you say vertigo ? >> read the full article here

Acoustic neuroma

More precisely called schwannoma of the vestibular nerve, it is a benign tumor developed at the expense of the cells of the sheath of the vestibular nerve (nerve of balance), the sheath of schwann.

Formerly exceptional, ENT specialists of my generation diagnose a few dozen of them during a career. To date, the responsibility of the microwaves of the cell phone has not been formally proven, but the diagnostic means have made a leap forward in 35 years.

The symptoms can be limited to a simple unilateral deafness of variable importance, or even a vertigo (it is the vestibular cells which are concerned) or more serious attacks if the tumor is important (which has disappeared nowadays). Surgery remains the most radical indication but the low evolution or the age can make prefer a treatment by gamma rays (gammaknife).

Otitis

Otitis is an inflammation of the ear. Whatever its form, otitis only affects the outer and/or middle ear: there is no infection of the inner ear.

External otitis

It is an inflammation of the external ear which includes exclusively the external auditory canal excluding the eardrum and, by extension, the auricle. The clinic is made of ear pain with, in extreme cases, a quasi closure of the canal (eczema stage). If it extends to the pinna, eczematous lesions of the pinna are found. At this stage of eczema, the pain is stabbing, insomniac and the ear canal, very oedematous, is oozing (like all eczema). One of the most frequent causes remains the inopportune scraping of the ear by cotton swabs or more frequently the stuffing of the conduit after baths if water stagnates in the conduit, all the more so as the water will be hot in summer.

Otitis media

Otitis media affects the eardrum and sometimes the eardrum case. If it is an acute otitis media, the pain is sharp and the lesions can go from the simple congestion of the eardrum to the purulent collection of the case requiring sometimes a drainage by paracentesis (incision of the abscess) to relieve the patient (often a child). The cause remains mostly an inflammation or an infection of the ear spreading through the Eustachian tube, generally during purulent rhinopharyngitis of the child. However, otitis media can be painless, resulting only in a decrease in hearing. Otoscopy reveals a frosted, dull eardrum, where the reliefs of the eardrum are modified (light cone). Sometimes the eardrum takes on an amber appearance. It is usually a seromucous otitis, frequent in children and consecutive to a chronic dysfunction of the Eustachian tubes (search for large adenoid vegetations causing snoring and rhinopharyngitis which will often require their removal). In case of school delay or delay in reading acquisition, this sero-mucous otitis may also require the installation of trans-tympanic aerators which will eliminate this retro tympanic glue and will durably ventilate the case in order to avoid a recurrence when the aerator is spontaneously eliminated.

>> Otitis in all its forms >> read the full article here

 


Otorrhagia

Otorrhagia is the outflow of blood through the ear canal.

Let’s put aside at once the more or less severe ear trauma ranging from a road accident with fracture of the rock in serious cases and joint tear of the eardrum causing this otorrhagia – but the diagnosis is obvious here – to the classic slap on the auricle which can be accompanied by an immediate drop in hearing and blood outflow (or not) signalling a perforation of the eardrum which will be able to heal spontaneously if the tear is discreet.

In most cases, however, this otorrhagia seems spontaneous and painless, especially in adults. In fact, it is almost never spontaneous and sometimes follows the usual ear cleaning with a cotton swab (because otherwise it is dirty…) and is a sign of a frequent wound of the ear canal. But if this frequent lesion is benign and will not be renewed if one stops prying. The trauma can be more consequent with traumatic perforation of the eardrum (an immediate hearing loss associated with a sharp pain must make it fear). This tear may require a tympanic graft if it does not heal.

A very characteristic otorrhagia can affect the young child. The child wakes up in the middle of the night, cries, suffers and the ear bleeds spontaneously, which obviously frightens the terrified parents who rush to the emergency room. What is it? In the vast majority of cases, it is a phlyctenular myringitis, i.e. serous vesicles that form on the external membrane of the eardrum and break through in the middle of the night, triggering this instantaneous pain, but the child, calmed down, goes back to sleep afterwards. The cause is usually viral and accompanies a rhinopharyngitis. The prognosis is excellent.

>> Otorrhagia : ear bleeding >> read the full article here

 


Otosclerosis

This is a blockage of the ossicular chain, more particularly of the stapes, which no longer vibrate in front of the oval window, no longer transmitting the acoustic vibrations.

The latter is in fact blocked by a progressive constitution of bone (sclerosis) blocking all movement. It is accompanied by a conductive deafness, as we shall see, which can therefore be operated on. The auditory curve is quite characteristic and shows a deafness predominantly in the low frequencies. This condition is usually familial.

The operation will consist of making an opening in the stapes plate (stapedotomy) to introduce a piston whose base is inserted in the terminal part of the anvil. In more severe cases, it will be a stapedectomy with interposition of a venous graft on which the piston is articulated.

Deafness

This is of course a decrease in hearing capacity that must be differentiated from cognitive comprehension capacity that affects the auditory area of the brain during a cerebral vascular accident, for example, or another cerebral disorder and that cannot be treated with an aid. We distinguish schematically two types of deafness:

Conductive hearing loss

Conductive hearing loss affects the transmission organ, i.e. the eardrum and/or the ossicles. This type of hearing loss can be corrected surgically and cannot be fitted with a hearing aid (except in the case of a serious medical condition or if the patient refuses to undergo a minor operation).

Sensorineural hearing loss (inner ear)

Sensorineural hearing loss affects the hearing cells or the auditory nerve. When the cells are affected, a hearing aid may be offered.

Sensorineural hearing losses can be acquired or familial and can be of any stage of intensity. Profound deafness, which affects very young children, poses the problem of language acquisition. It is necessary to perceive sounds and sentences around us to form words. However, this obvious fact sometimes escapes the average person and if we find ourselves in front of a profoundly deaf adult, even with a hearing aid, we are surprised by his or her difficulty in articulating, giving his or her sentences something unfinished… How can you pronounce correctly if you do not hear yourself or very badly ? But one must be careful not to equate profound deafness with an intellectually retarded individual. Do we need to recall the lives of men (or women) like Beethoven, Thomas Edison, Graham Bell, Goya or in our sphere a Ferdinand Berthier, founder of the Society of the Deaf and Dumb of Paris, to whom Victor Hugo will write these magnificent sentences:

What does the deafness of the ear matter when the mind hears? The only deafness, the real deafness, the incurable deafness, is that of the intelligence..

Sound trauma

There are two causes, sometimes intertwined, in sound trauma.

The violent noise of course is the most constant traumatism of the internal ear. Any lesion is irreversible and the inner ear accompanies us throughout our lives. Let’s protect it from all kinds of sound aggressions! A revealing sign: tinnitus after a concert..

Notes
A study conducted by Gary Housley of the University of New South Wales and his fellow researchers from the University of Auckland and the University of California explained why we lose our hearing for a few hours or days after exposure to excessive noise: it could be a defense mechanism of the body against long-term hearing damage. The study revealed a physiological adaptation mechanism that allows the cochlea to function normally when exposed to excessive noise. The cochlea releases a molecule called ATP (adenosine triphosphate), the level of which increases after exposure to noise and thus causes a temporary reduction in hearing sensitivity. However, the researchers warn that this defense mechanism cannot protect against continuous exposure to high-frequency noise.

Another study, conducted by the research team of Dr. Seidman, an otolaryngologist at Henry Ford Hospital (Michigan), highlights the protective properties of resveratrol, a molecule known for its antioxidant and anti-inflammatory properties, present in black grapes and red wine, on hearing. According to this study, resveratrol has the ability to reduce the expression of the COX-2 protein and the formation of reactive oxygen derivatives (DRO), two phenomena observed after intense exposure to noise. In summary, black grapes and red wine should be consumed regularly, especially before exposure to continuous aggressive noise.

Pressure trauma is very similar to noise trauma. What does it mean? A sudden compression of the air in the ear canal can create pressure trauma… A slap on the pinna is a great example. The sound of the slap that propagates can already create a sound trauma, to which is added the mini blast, with the possible consequence of a tympanic tear! It is far from being rare and we see it every year. A politician had his moment of glory by slapping (on the cheek) a kid who had tried to pick his pocket… Sure, but aim right or abstain! The use of firearms can produce this double lesion: pressure and sound. Close to these lesions, those that one can meet in sea and in diving. One cannot go down, whether in scuba or in apnea, without balancing the tube by maneuvers, the least traumatic of which is the Frenzel. This maneuver is essential if we want to avoid the inevitable consequence of a lack of equilibration: barotrauma of the ear. Without balancing, the pressure of the water on the ear canal will cause an increasingly sharp pain as the descent proceeds, created by the pressure of the water on the eardrum with, in extreme cases, its tearing with an irruption of water in the ear cavity which can create intense dizziness causing loss of spatial orientation with sometimes dramatic consequences.

>> Noise and auditory risks >> read the full article here

>> Articles related to scuba diving >> consult this section

Vertigo

In medicine, it remains the most overused word in the French language. Not a day goes by without four or five “vertigoes” being referred by the doctor, who is at a loss when faced with a bastardized symptomatology that sometimes resembles nothing!

A medical definition should perhaps be recalled. A vertigo is defined as an erroneous sensation of displacement of objects (often rotatory movements) in relation to the subject. It can also be a question of sensations of drunkenness, instabilities felt by the patient, impressions of pitching or tendency to leave sideways with the walk. These dizzinesses can be accompanied by nausea, even vomiting according to the importance of the symptoms. Other auditory signs may be associated: sensation of blocked ear, joint decrease in hearing, tinnitus. The positional notion, i.e. the triggering of the symptomatology during the movement of the head is quite evocative of an oto-rhino history.

They constitute about 5% of consultations with general practitioners who often refer their patients affected by such discomfort to us. However, the causes of vertigo are numerous and often escape our specialty.

The vertigo that are the responsibility of the ENT specialty:

Meniere’s vertigo.

Rare. It is a question of great vertigo, which can last several hours, or even more, associated at least in the later crises with a progressive loss of hearing. Permanent treatment and treatment of the crisis are necessary.

Benign paroxysmal positional vertigo (BPPV).

See the point on crystals.

Vestibular neuritis.

Vestibular neuritis: It is a great vertigo, violent, brutal, lasting. The patient can no longer stand up in extreme cases, remaining immobilized in his bed. The cause is essentially viral. It is the attack of the vestibular nerve (nerve of balance) of the internal ear with lesions which can be definitive. Our cerebellum (control and final regulation center) will progressively “take over” the affected sensory organ totally or partially, but this will take time.

A neuroma of the auditory nerve.

See Auditory nerve neuroma.

Certain medications

Certain medications, especially antibiotics, are rarely used nowadays.

A vascular accident affecting the inner ear.

A vascular accident affecting the inner ear, but there, the “vascular” terrain of the patient or/and the risk factors orient quickly. They will concern more the cardiologists than the Oto-Rhinos.

Anemia, a fall of the tension in upright position (orthostatic hypotension) are also responsible for discomfort (uneasiness), more than for vertigo when the patient stands, often without moving, symptomatology worsened with heat (venous vasodilatation and bad venous return).

But a good part of “dizziness” do not look like anything on the symptomatic level and invade our consultations..

The clinical examination, especially for these cases, must be flawless and one can willingly be helped by complementary examinations, because, if very often these vertigoes that look like nothing… are nothing at all, coming from stress or being triggered by particular psychological profiles, only the clinical explorations can formally attest it.

 

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