Lecture 1 Audiology 05/03/2021

Arthur Yanez and Mirko Vicinanza

Audiology – 01
05/03/2021 Prof. Gian Gaetano Ferri

Exams will be written both in person and online. There will be 10 multiple choice questions (6 is the
threshold for passing) and the content of the slides are enough for studying.

Deafness
Deafness
Epidemiology

• Deafness can affect people in every age, from

newborns to the elderly.
• However, the degenerative sequelae of hearing
usually start at 65-70 years of age, and with the
increase in life expectancy we have been observing
(look at the graph) this topic is becoming more
important.

• One in three people over the age of 60 have

hearing loss, but also younger people have hearing
loss in a good percentage, especially because of the
increasing use of earphones to listen to music and so
Figure 1: Life expectancy worldwide
this situation is coming more frequent over the years.

The WHO estimated a few years ago that in all the

world there are 360 million people with deafness or
hearing impairment, and this represents about 5.3 %
of all the population, most of them concentrated in
developing countries.

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Lecture 1 Audiology 05/03/2021

Anatomy

• Outer ear
• Middle ear
• Inner ear

The ear combines an outer ear, a middle ear,

and an inner ear. So, there are three different
paths outer, middle, and inner.

Tympanic membrane
Definition and structure
It is intact, slightly concave outwards, pearly-gray, bright
and transparent, elliptical, with a vertical diameter of 9-
10 mm and horizontal diameter of 8-9 mm
It consists of three parts:
• Outer SKIN layer: a skin that continues the skin
of the external auditory canal center is very
important.
• Middle FIBROUS layer: (only in pars tensa) with
radiate, circular, transverse, and parabolic fibers.
It is very important because it y6y6gives Figure 2 This is an autoscopic view of our tympanic membrane
also called eardrum. It is the most important structure that we see
elasticity and resistance to TM. when you use the otoscope.
• Inner MUCOSAL layer

We can divide the tympanic membrane in four parts by

drawing 2 imaginary/theoretical lines from the point
where the hammer/malleus touches the membrane. The
4 quadrants are:
• Antero-superior (AS)
• Antero-inferior (AI)
• Posterior-superior (PS)
• Posterior-inferior (PI)
This is useful especially when we must describe, for
example, a perforation of the tympanic membrane, we
can say in the report that the patient has a small hole in
the anterior inferior quadrant.

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Other points of observation of the tympanic
membrane:

• Pars tensa: represent most of the

tympanic membrane, and it has three
layers.
• Pars flaccida: which has only the skin the
mucosa layers.
• Anulus: connective tissue that fixes the
tympanic membrane to the bone to the
surrounding bone of the external auditory
canal.

• Malleolar prominence: also called

the short process of the malleus.
• Handle of the malleus: divides left
tympanic membrane and right tympanic
membrane.
• Umbus: that is a final part of the
malleus. In the picture the light reflection is
the light of the otoscope projected to the
tympanic membrane also called Politzer
light triangle. When you see this Politzer
light it means that probably the tympanic
membrane is in perfect conditions.

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Middle ear
The middle ear is compresses of three parts: Mastoid Cavity
• Eustachian tube: very important in almost all the
phlogistic pathology of the middle ear. It connects
the nose/rhinopharynx with the middle ear.
• Middle ear cavity: where you find the ossicles,
malleus, incus, and stapes (smallest bone in our
body).
• Mastoid: located posteriorly, made of hard bone
tissue, full of cells that are usually empty.
The roof of the middle ear cavity (tegmen tympani) is
adjacent to the middle skull base, and this explains why a
patient can get meningitis from a simple otitis media (ear
infection).

Figure 3 Middle ear

Eustachian tube

Inner ear
Labyrinth structure inside the petrous part of the temporal bone, divided into anterior and posterior part:

• Anterior part: represented by the cochlea that is

important for the auditory function.
• Posterior part: there are the vestibular structures
that are the three semicircular canals (the lateral, the
superior, and the posterior one), important for the
vestibular function.

Figure 4 Labyrinth structure

Then we have the analogous membranous labyrinths

that have the same shape.

Figure 5 Membranous labyrinths

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Organ of Corti
The organ of Corti is in the cochlea and
is composed of:
• Basilar membrane: where are
located the outer and inner hair cells.
• Outer hair cells: have 3 rows,
numerically more important than
inner hair cells. Predominant efferent
innervation, so they are important for
regulatory and inhibitory activity.
• Inner hair cells: only 1 row, but
functionally are more important than
outer hair cells. Predominant afferent
innervation.
In the organ of Corti 2 liquids are very important, the endolymph and the perilymph:
• Perilymph: similar to extracellular liquid, rich of sodium and low quantity of potassium;
• Endolymph: rich in potassium and poor in sodium.

Functions of the inner ear:

• It participates in the transmission of mechanical energy (labyrinthine liquids and membranous
structures).
• It transforms the mechanical energy into an electrical signal (organ of Corti).

Basilar membrane: tonotopic organization

The basilar membrane, where the hair cells are located is not the
same along the cochlea. It changes in the apical part, the
intermediate part and in the lower part. When listening to sounds,
different sounds stimulate different parts of the cochlea, meaning
that sounds of a given frequency cause a circumscribed area of the
basilar membrane to oscillate.
• A low frequency tone stimulates the upper part;
• A high tone stimulates the basal part.
There is a selective cellular stimulation by frequency.

• A young person's human ear can hear frequency sounds between

20 and 20.000 Hz, and sensitivity is maximum for central
frequencies.
• For intensity up to 50-60 dB, oscillatory stimulation evokes the
contraction of the outer hair cells, which are the only ones in
contact with the tectorial membrane.
Figure 6: tonotopic organization of the • This contraction allows the contact of the tectorial membrane with
basilar membrane
the inner hear cells that are responsible of the signal transduction.
• Instead, inner hair cells are directly stimulated by sounds over 60
db.

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Innervation
• Fibers start at:
o From the organ of Corti start the fibers of the
cochlear nerve;
o From the posterior part of the semicircular canals
start the fibers of the vestibular nerve;
• Central acoustic pathways:
o Then the fibers go up the central acoustic pathway
reaching the Brodmann auditory area located in
the temporal lobe (area 43).
o The tonotopic organization that started at the
organ of Corti continues until reaching the
Brodmann area.

Physiology
The sound wave is conveyed into the outer ear (in some animals the muscles capable of orienting the
auricle are very developed).
The middle ear is an impedance coupler:
• It promotes the wave propagation sound from the air, which has a low impedance, to labyrinthine
liquids, which have a much higher impedance (x 3740).
• Its function is to transmit energy in the optimal way, dispersing the
smallest amount possible (in the form of energy reflected).
To have the best functional result from the tympanic-ossicular system, the air
pressure inside the middle ear should be in balance with the external pressure,
which is regulated by the EUSTACHIAN TUBE.

To reduce the loss of energy that are 2 advantageous situations in the middle
ear: Figure 7 Ossicular chain
• Tympanic membrane area and oval window area ratio, which is 22/1.
• The ossicular chain (malleus, incus, and stapes) is a second-degree leverage.

Summary:
1. We hear a sound,
2. There is a perilymphatic wave in the vestibular ramp that causes the oscillation of the basilar
membrane and organ of Corti. Again, depending on the frequency of the sound different parts of
the cochlea oscillate (acute sounds cause oscillation in the lower part while low frequency sounds
stimulate the upper part of the cochlea).
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3. Then, in the organ of Corti the deflection of the hairs of the inner and outer hair cells triggers
mechano-electric transduction and the beginning of the path of the electrical impulse along the
cochlear nerve.
4. The path of the electrical impulse continues from the cochlear nerve along the central acoustic
pathways until it ends at the level of the auditory cortex located in the temporal lobe (Brodmann
area). The tonotopic distribution is always maintained.

Hearing loss
Definition
• The reduction in hearing capacity resulting from alterations in one or more structures of the
auditory apparatus.
• Hearing loss may be of different entity, from partial hearing loss up to anacusis/cophosis (both
terms mean complete hearing loss).
• Hearing loss may be unilateral or bilateral.
• The type of hearing loss depends on the part of the affected auditory system and this has
significant therapeutic and prognostic implications.

Diagnosis
The DIAGNOSIS of HEARING LOSS can be obtained through:
• OTOSCOPY: observations of the external auditory canal and of part of the tympanic-ossicular
system with optic instruments. Sometimes it is enough, for example if the patient has an acute
otitis media, but in most of the cases otoscopy is not enough and we need to perform an
audiometric examination.
• AUDIOMETRY: recording (in a soundproof booth) of the minimum audibility threshold for some
pure tones, representative of the human auditory field, both by air (headset) and by bone
(vibrator); this threshold is immediately comparable with that of normal hearing people.
• OTHER INSTRUMENTAL EXAMINATIONS: Tympanometry, Auditory Evoked Potentials, etc.

When we see a patient affected by hearing loss the first thing to do is to collect an accurate ANAMNESIS:
• Causal events (trauma or infection)
• Timing (sudden, progressive, etc.)
• Familiarity (because there are genetic causes in which some parents some relatives could have
hearing loss too)
• Associated symptoms (tinnitus, vertigo, etc.)
• Other diseases (syndromes)
• Prenatal, perinatal, postnatal events (when examining a child affected by possible deafness we
must search for possible prenatal, perinatal, or postnatal events that could have caused deafness)
• Drugs (especially in elderly people even drugs assumed for a very long period could sometimes
provoke a sensorineural hearing loss)

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Otoscopy
After an accurate analysis, the first thing we do is to perform otoscopy: it means we want to look inside the
ear.
What can we see?
• External auditory canal
• Tympanic membrane
• If there is a perforation sometimes, we can see also something inside the middle ear
It allows us to:
• Exclude diseases of the outer ear
• Exclude diseases of the middle ear (by looking at the tympanic membrane)
• Hemotympanum (sometimes can be seen after a traumatic events)
• IMPORTANT: It is generally normal in sensorineural hearing loss
Instruments (we can perform the exam in different ways):
• Using our Clar and the ear speculum (1)
• Using a 2 batteries otoscope (2)
• Using otoscopy (3)
Now let us further explore these methods.

1. Ear speculum otoscopy

• Direct, natural, and complete vision, TRI-DIMENSIONAL, with sense of depth, of the external
auditory canal (EAC) and of the tympanic membrane.
• It allows the introduction of instruments we use to clean the external auditory canal, for example
to remove ear wax or to perform a biopsy.
• It is used to clean the external auditory canal, and cleaning is very important and necessary if we
want to see completely the tympanic membrane.

Figure 10 Otoscopy instrument for Figure 9 Clar headlight for ear

Figure 8 Ear speculum otoscopy ear speculum otoscopy speculum otoscopy

2. Otoscope
• Very simple to use.
• Enlarged vision (3-4x), but TWO-DIMENSIONAL, of external auditory canal and tympanic
membrane.
• Difficult introduction and use of small instruments into the external auditory canal by removing
the lens of the otoscope.

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• Cannot be used to remove ear wax because either you use the otoscope to see inside the external
auditory canal or insert an instrument to clean. For cleaning we need the Clar headlight and the
speculum.

Figure 12 Otoscope use Figure 12 Two batteries (AA type)

otoscope

3. Otoscopy
• It allows a very enlarged vision (6-20x), adjustable, TWO-DIMENSIONAL, of external auditory canal
and tympanic membrane.
• It is possible to record pictures and videos in the PC, but you cannot introduce tools to clean the
external auditory canal (it must be done previously).
• It is used for example for medical legal reasons if you are not sure of a very tiny perforation.

Figure 14 Otoscopy using "otoscopy"

4. Otoscopy by binocular operating microscope

• In the operating room you can also use otoscopy. It is very important to
diagnostic and therapeutic procedures.
▪ You can enlarge and adjust the image; it allows the STEREOSCOPIC VISION
(with good depth) and the use of tools with both hands.

Figure 13 Binocular
Otoscopy advantages x disadvantages: operating microscope

• Advantages: rapid, repeatable, not very invasive, cheap, and have good
sensibility
• Disadvantages: subjective, and not very specific. The doctor needs to have experience and be able
to recognize correctly the otoscopic landmarks.
How do improve diagnostic accuracy?
• CHECK every time the LIGHTNESS of the otoscope (sometimes we just need to change the
batteries).
• CLEAN completely the external auditory canal (secretion and earwax make it harder to see).

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Important observations:
• The otoscopic maneuvers must be performed with caution, after cleaning the external auditory
canal, in order not to harm the patient, causing for example tinnitus.
• The external auditory canal is not straight it is a bit arched, so you need to backward tract the
auricle to see completely the tympanic membrane.
• In the case of infants, the movement is bottom and forward.

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Weber Test
When is it useful?
• When a patient comes to your office suffering from a
sudden hearing loss (which is an audiology emergency)
sometimes it can happen that you cannot immediately
perform an audiometric exam, for example if the patient
comes in a Friday afternoon, audiometric technicians are
usually at home.
• It can be used to distinguish if the patient has a simple
conductive hearing loss or a sensorineural hearing loss,
which have different treatments. Figure 15 Weber test
How is it performed?
• It is performed using a u-shaped tuning fork that have different morphologies because they
represent different frequencies.
• You strike the tuning fork against a firm but elastic object and then you place it vibrating on the
vertex of the patient’s head. Then the patient tells us where do they listen to the vibration? If in the
middle, the right part, or the left part.
o In case of sensorineural hearing loss, the sound will be lateralized/heard in the normal ear.
o In case of conductive hearing loss, the vibration will be heard in the worse ear.

Audiometry
• Performed using a soundproof booth.
• The patient stays inside the box and the technician sits outside.
• By means of audiometry we will have a correct information of
the hearing loss of each patient, and we will record different
kind of audiometric charts.

Hearing facts to remember

• HEARING is the first of the 5 senses to develop in the fetus and
allow contact with the world.
• ACOUSTIC PERCEPTION:
o It is innate, precocious, and automatic.
o It is the sense through which you can hear sounds and
noises.
• PERCEPTION OF VERBAL LANGUAGE:
o Based on language-specific hearing experiences, it is
Late and composite.
o It is the platform on which man builds interpersonal Figure 16 Soundproof booth for Audiometry
communication through the words. test
o Children learn to speak not because they go to school,
but because they can listen, if they cannot listen, they cannot speak.
• SOUNDS are pressure waves, generated by a sound source and transmitted in an elastic medium
with a sine pattern.
o There are simple sounds, complex sounds, and noises.
o 2 characteristics thar are important about sounds are loudness and frequency:
o Loudness
▪ Subjective perception of volume or intensity.
▪ Calculated using decibel (dB).
▪ We can perceive only sounds between the lowest threshold and the pain threshold
for that kind of sound.
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o Frequency
▪ Subjection perception of pitch.
▪ Calculates using cycle/sec or Hertz (Hz).
▪ We can perceive only sounds between 20 (lowest pitch) and 20.000Hz (highest
pitch).
▪ Other animals can hear infra and ultrasounds, unlike humans.
• The dB (decibel)
o dB HL (hearing level): referred to the audiometric threshold of normal people. Normally
used in clinical practice
o dB SPL (sound pressure level): referred to an absolute value of acoustic pressure

Pure-tone audiometry
What do we do in the soundproof booth?
We record the MINIMUM AUDIBLE THRESHOLD for a series of PURE TONES representative of the human
auditory field. The AUDIOMETER sends sounds at varying intensity values MONOAURALLY in two ways:
• Through a headset (AIR CONDUCTION).
• Bone vibrator to the mastoid (BONE CONDUCTION).
Why do we need to perform it in 2 ways?
We must identify the kind of hearing loss to find the site of onset and of origin of hearing loss that could
be at the:
• External canal in the middle ear
• In the inner ear
When we send the sounds through a headset,
the air conduction, we stimulate all the hearing
path, from the outer ear, through the middle
ear, the cochlea, and the acoustic nerve.
When we send sounds through the vibrator
located over the mastoid, we study only the
bone conduction that BYPASSES the outer ear
and the middle ear and DIRECTLY STIMULATES
the cochlea and the acoustic nerve.

Pure-tone audiogram
In the audiometry exam we record a pure-tone audiogram.
• In abscissa (x-axis) there are the pure
tones: we usually start from 1000 hertz
then we continue with higher frequencies
and then we come back to the lower
frequencies.
• In ordinate (y-axis) there are the loudness
values in dB that range from 0 to 120. In
case no answers are recorded even at 120
dB there is a situation of anacusis or
cophosis.
Our goals are:
• First to quantify the hearing loss Figure 17 Pure-tone audiogram
• Then to classify the type of hearing loss
o To classify the type of hearing loss we need to compare the answers to the questions
recorded by AIR and BONE conduction, that are recorded separately in the audiogram.
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This is an example of normal hearing in pure

tone audiometry.
If you do not have a computer that draws
the answers you can do it by hand, using a
red pen, a blue, or a black pen.
The right responses are marked in red the
left responses are in blue or black.
As you can see for all the frequencies, from
the lower to the higher one, the patient had
excellent responses in the range 0 20 dB,
which is a normal bilateral hearing.
These are the symbols that we use in
audiometry.
In case of masking, you must mask the
better ear if there is a significant difference
Figure 18 Example of a normal pure-tone audiogram
between right and left, the symbols change
as here represented.

Hearing loss classification (very important to remember)

• CONDUCTIVE HEARING LOSS: normal bone conduction; outer and middle ear diseases.
• SENSORINEURAL HEARING LOSS: bone conduction = air conduction; cochlear and/or acoustic
nerve diseases.
• MIXED HEARING LOSS: both bone and air conduction are affected, but the bone conduction is
better than air conduction; conductive + sensorineural hearing loss.

Figure 19 Typical example of conductive hearing loss

audiogram. You can see that the bone conduction is normal
(the > signs on the x axis). This means that the inner ear
and the acoustic nerve are ok. Looking at lower part of the
graph (with the connected circles) we observe a lower
threshold conduction, which is pathologic and represents
conductive hearing loss.

Conductive hearing loss

Can be cause by outer ear pathologies and by middle ear pathologies:
• Outer ear pathologies: EAC malformations, foreign bodies, acute otitis externa, ear wax,
otomycosis, neoplasms.
• Middle ear pathologies: acute and chronic otitis media, TM perforation, ossicular chain
malformations, neoplasms.
Hearing loss is generally slight or mild in magnitude, without distortion phenomena and is often
correctable with medical or surgical therapy.

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Outer ear diseases

Acute otitis externa
Definition
• Acute inflammation of the external auditory canal (EAC)
favored by favored by traumatism, dermatosis, moisture and
contact with non-sterile liquids (swimming pools, sea). It is
more common during the summer period, when people go to
swimming pools, and to the sea.

Etiology
• Usually bacterial (Pseudomonas Aeruginosa, Streptococcus Figure 20 Acute otitis externa. Sometimes
we cannot see the tympanic membrane
Haemolyticus, Proteus, and Staphylococcus aureus) because of the hyperemia and edema of the
• It is possible a mycotic over-infection. walls of the EAC.

Symptoms
• Very intense and spontaneous ear
PAIN, that can also be evoked by
tragus pressure.
Tragal pressure is pressure that is
applied to the cartilage at the front, or
anterior aspect of the ear canal (called
the tragus), closing the canal and
increasing pressure on the tympanic
membrane (ear drum).
• Aural fullness, especially if the Figure 21 Acute otitis externa: in these 2 cases we can see the TM, but there are
secretions and hyperemia of the EAC
EAC is stenotized.
• Conductive hearing loss.
Therapy
• Ear drops (steroid + quinolones)
• Oral antibiotics
• Oral analgesics
In case of previous TM perforation, it is better not to perform ear wash with borosalicylic solution. Avoid
aminoglycosides ear drops (quinolone ear drops are preferred are mentioned above because they are not
associated with ototoxicity).
In case of a very stenotized EAC, it is preferred to introduce a long strip of gauze impregnated with
steroid and antibiotic ointment to be removed within 24-48 hours. Once removed you can start
introducing ear drops. If we start with ear drops, since the canal is very stenotized the ear drops will
probably come out of the ear canal.
Differential diagnosis
• Applying tragus pressure is an important examination to do to distinguish pain from AOE to other
problems, even before doing otoscopy. If the patient does not feel pain under it the problem is
probably not related to AOE.
• Malignant otitis externa: if AOE is not cured by adequate therapy you should suspect malignant
otitis externa (see below more info about this disease). In these cases, we try to treat the patient
but there is no improvement (we still see secretions for example).

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Malignant otitis externa
Etiology
• Generally caused by Pseudomonas Aeruginosa and favored by diabetes; it has an osteolytic
pattern and can extend to the skull base, even contralateral: its natural course is lethal.
• You must suspect this disease especially in elderly people affected by diabetes in case an acute
otitis externa is not going to recover after adequate therapy.
Differential diagnosis
• Acute otitis externa, as seen above.
• EAC carcinoma: in this case we need to distinguish by doing a biopsy.
Diagnosis
• Physical examination: otorrhea, pain, granulations on the floor of the EAC. Fever is not constant.
• Labs: Increase in Erythrocyte sedimentation rate (ESR) always
• Imaging: CT, PET, Technetium Tc-99 scan.

Therapy
• Antibiotic therapy (quinolones or third generation cephalosporins)
• This therapy can last for a long time, ranging from weeks to months.
o We do it until ESR comes back to normal ranges and negative Gallium citrate Ga-67 scan is
recorded.
o Due to the long duration periodically check liver and kidney function!

Herpes Zoster Oticus (aka Ramsay-Hunt Syndrome)

Etiology
• Reactivation of varicella-zoster virus that probably is inside the geniculate ganglion (middle ear).
• Reactivation happens due to unknown reasons.
Diagnosis
Physical examination:
• Fluid-filled blisters in the concha of the auricle (in this area we find
the sensory branches of the VII CN, the facial CN)
• Hearing loss, tinnitus, vertigo (due to involvement of the VIII CN,
the vestibulocochlear)
• Facial nerve palsy
• Intense pain
• Sometimes dysgeusia ed odynophagia (because of blisters on the
soft palate)
Therapy
• Antiviral drugs (start within 72 hours to stop viral replication)
• Antiviral ointment on the blisters
• Steroids are useful if taken after 5 days (Recent studies: Coulson,
2011) Figure 22 Herpes Zoster Oticus

Prognosis
• In general, it is worse than in Bell’s Palsy.
• Importance of therapy timing.

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Carcinoma
• Rare pathology, generally a squamous cell carcinoma
Differential diagnosis
• With malignant otitis externa, as seen above.
Clinical presentation
• Initially asymptomatic, but it can suffer an over infection.
• In progression it tends to invade the middle ear and metastasize
to locoregional lymph nodes
Diagnosis
• Biopsy + CT scan
• Possibly an MRI to study the extension of the lesion, to stage the
tumor.
Therapy Figure 23 Carcinoma of the external
• Surgery possibly followed by radiotherapy. auditory canal / auricle

Ear eczema
Definition
• Dermatitis (inflammation), often bilateral, of the skin of the EAC.
Etiology
• Allergies: food, inhalants or contact with scented lotions, soaps,
perfumes, hair dyes, earrings, etc.
• Possible bacterial over infection (also caused by scratching).
Symptoms
• Dry, scaly skin around and inside the ear canal; redness and
swelling; itchiness; clear discharge from the ear.
Diagnosis
• Physical examination
• In case of recurrent or chronic episodes it is important to try to
determine, when possible, the existence of an allergic pathology to
inhalants, various substances, foods, through specific tests (Prick Figure 24 Ear eczema
test, Patch test, RAST and tests for food intolerances).
Therapy
• Topical steroids are usually enough.
• Sometimes we can use oral steroids and antihistamines.
• In recurrent cases it is important to eliminate the allergen.
• Therapy-resistant cases or diagnostic doubt (Psoriasis??).
• Sometimes a dermatologist/allergist consultation could be useful.

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Otomycosis
Etiology
• Aspergilli (niger, fumigatus, flavus, etc.)
Predisposing Factors
• Humidity, heat, topical antibiotics, dermatitis, chronic
otorrhea, poor local hygiene
• Usually in the summer period, as acute otitis externa.
Symptoms
• There is no pain.
• Intense, unilateral itching
• Possible simultaneous acute otitis externa, and in these cases
the patient will feel pain.
Therapy Figure 25 Otomycosis: notice that the color
of the secretion is different.
• Topical antimycotics (they should not be used in case of TM
perforation).
• Ear wash with H2O2 can also be added.

Earwax
Definition
• Very frequent.
• It is not a real disease, but it can be very annoying.
Etiology
• It comes from a significant wax production by the ceruminous
glands of the EAC, easily associated to self-cleansing
Figure 26 Otomycosis
maneuvers.
Symptoms
• Aural fullness
• Conductive hearing loss
• Sometimes tinnitus and vertigo
Therapy
• Softeners cerumenolytics
• Ear wash (ENT specialist)
Prevention
• Finger and water at the morning is enough, especially because
earwax tends to leave naturally.
Figure 27 Earwax
• No cotton swabs!

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Exostosis
Definition
• Bone thickening of the EAC walls, usually bilateral.
• Found by accident mostly in divers and swimmers (or people
that spent too much time in water).
Differential diagnosis
• D.D. with an osteoma, which is a little and unilateral bone
tumor.
Figure 28 Exostosis
Treatment
• They rarely cause conductive hearing loss and need surgical planning (occasional feedback).

Atresia Auris
Definition
• Malformation of the outer ear resulting from an abnormal development of the first and second
gill arcs and of the first gill groove.
• Generally unilateral, its prevalence is 1:10.000 cases.
• Frequently associated to malformations of the middle ear.
Diagnosis
• Physical examination: aesthetic anomaly, mild conductive hearing loss
Therapy
• Hearing aids: useful when the hearing loss is more severe, which is not so common.
• Surgical procedure: only in some cases, especially when hearing loss is severe. It is done with
aesthetic and/or functional purposes.
• In unilateral cases therapeutic abstention may be advisable.

Middle ear diseases

Important: The EUSTACHIAN TUBE has a central role in middle ear diseases. From its malfunctioning
originates practically all the phlogistic pathology of the middle ear.

Diagnostic considerations for middle ear diseases

In many cases anatomic changes correspond to functional
alterations. We said before we can do OTOSCOPY and
functional studies, such as AUDIOMETRY. In some cases,
another test is useful, the IMPEDANCE TESTING.

Figure 29 Tympanometry: 3 way device.

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Impedance testing
There are 2 types: tympanometry and stapedial reflex.

Tympanometry
• Objective examination
• The patient does not have an active role (as in
audiometry), but a passive role, the person just must sit
still without swallowing.
• We introduce a probe in the external ear canal. This is a
3-way device:
o Pressure gauge for pressure variation within the
external ear canal
o Probe tone generator
o Reflected energy deflector
• We then record a tympanogram, which can be:
o Tympanogram type A (peak in the middle): it is
a normal/healthy tympanogram. Figure 30 Tympanogram type A: Normal tympanogram.
o Tympanogram type B (flat): means there is a The compliance peak is in the middle. It means there is
thick fluid inside the middle ear. a normal situation in the tympanic membrane, the
Eustachian tube and the ossicular chain.
o Tympanogram type C (peak is in the low-
pressure values): means there is probably a
Eustachian tube dysfunction/stenosis.
o “M-shape” tympanogram: typical of ossicular discontinuity. Found when there is
dislocation of the prothesis after stapedoplasty (therapeutic operation used for the
otosclerosis treatment).
o There is a last case without a specific name (see figure 30): it is found when there are scar
irregularities of the tympanic membrane, but it has no clinical implications.

Figure 31: "M-shape" tympanogram to the left and tympanogram

found when there are scar irregularities of the TM.

Figure 32: Abnormal tympanograms, types B

and C.

Stapedial reflex
• Reflex with an afferent branch (VIII cranial nerve) and an efferent branch (VII c.n.), which end
close to the stapedius muscle (it the smallest skeletal muscles in the body and it stabilizes the
smallest bone in the human body, the stapes).
• It protects us from very loud sounds because there is a sort of block of the action of the stapes
that is very close to the inner ear.
• It gives information about the conductive system and the cochlea.
• It is useful in the diagnosis of otosclerosis (when it is absent) and in facial palsy (topodiagnosis and
prognostic value).

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Lecture 1 Audiology 05/03/2021
Acute otitis media
Definition
• Infection of the middle ear space.
• Simultaneous rhinitis is very common.
Etiology
• It results from the propagation of an infectious
rhinopharyngeal phlogosis. Look for a rhinitis in the
clinical history.
• “infernal trio” (Haemophilus Influenzae, Streptococcus
Pneumoniae, Moraxella Catarralis)
• It is more frequent in children because in children the
Eustachian tube is larger, shorter (18 vs 35mm) and less
angulated (10° vs 45°). These characteristics deem
children more susceptible to infections of the ear since
pathogens can travel with more ease from the nose to the Figure 33 Eustachian tube in children vs adults. The
ear. differences in morphology are responsible for
children having more commonly acute otitis media.

Course of the disease

Figure 34: This is the common course of the disease

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Lecture 1 Audiology 05/03/2021
Symptoms
• Pain (pulsatile) is the main symptom.
• Aural fullness
• Conductive hearing loss
• Sometimes purulent otorrhea
• In case of TM perforation, the patient does not feel
pain.
• Symptoms of rhinitis
• Fever
Diagnosis
• Otoscopy (figure 34) and anamnesis
Therapy
• Oral antibiotics for at least 6-8 days
(amoxicillin/clavulanic acid, cephalosporins) in most
cases. Figure 35 Typical otoscopy of acute otitis media.
Hyperemic tympanic membrane and budging
• NSAIDs or paracetamol in case of fever or pain. because of the fluid inside the middle ear.
• Ear drops (antibiotic + anesthetic if intact TM), mainly in
children with strong ear pain.
• Nasal decongestants (due to the concomitant rhinitis)
o Nasal washes with saline irrigations
o Antibiotic nasal drops
• Mucolytics
Complications (rare)
• Sensorineural hearing loss (steroids and myringotomy).
• Mastoiditis (children).
• Facial palsy.
• Sphenoid sinus thrombophlebitis.
• Propagation of the infection to the inner ear, meninges, and brain.
• For these cases treatment changes:
o Parenteral antibiotic therapy is mandatory and sometimes surgery.

The professor stops the lecture here. He still needs to cover chronic phlogistic
pathology which will be done next lesson.

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Lecture 1 Audiology 05/03/2021
Q & A:
Question:
Concerning malignant otitis, you mentioned that we should suspect malignant when we have a
patient that has acute otitis externa but does not respond (the professor interrupts the question and
starts answering)
Answer:
Yes, in fact because exactly it is the typical situation that the patient comes to me, I find a
presumed external otitis media, I prescribe ear drops then I suggest for the patient to come back
after one week or 10 days, then the patient finds another medical doctor. The pathology is still
present, maybe the doctor changes the kind of ear drops, he gives another kind of antibiotics, and
again the patient comes back. At the third or fourth visit finally someone thinks about this kind of
pathology, you suspect it when you have an elderly patient affected by diabetes that has this
situation that does not recover in the normal period, is it ok?
Question:
But if the patient has a controlled diabetes, does it change something for the patient?
Answer:
It does not change; it does not matter if diabetes is compensated or not.

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