Published on 22/03/2015 by admin
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Chapter 628 General Considerations and Evaluation
Joseph Haddad, Jr.
Diseases of the ear and temporal bone commonly manifest with one or more of eight clinical signs and symptoms.
Otalgia usually is associated with inflammation of the external or middle ear, but it can represent pain referred from involvement of the teeth, temporomandibular joint, or pharynx. In young infants, pulling or rubbing the ear along with general irritability or poor sleep, especially when associated with fever, may be the only signs of ear pain. Ear pulling alone is not diagnostic of ear pathology.
Purulent otorrhea is a sign of otitis externa, otitis media with perforation of the tympanic membrane (TM), drainage from the middle ear through a patent tympanostomy tube, or, rarely, drainage from a first branchial cleft sinus. Bloody drainage may be associated with acute or chronic inflammation (often with granulation tissue and/or an ear tube), trauma, neoplasm, foreign body, or blood dyscrasia. Clear drainage suggests a perforation of the TM with a serous middle-ear effusion or, rarely, a cerebrospinal fluid leak draining through defects (congenital or traumatic) in the external auditory canal or from the middle ear.
Hearing loss results either from disease of the external or middle ear (conductive hearing loss) or from pathology in the inner ear, retrocochlear structures, or central auditory pathways (sensorineural hearing loss). The most common cause of hearing loss in children is otitis media (OM).
Swelling around the ear most commonly is a result of inflammation (e.g., external otitis, perichondritis, mastoiditis), trauma (e.g., hematoma), benign cystic masses, or neoplasm.
Vertigo is a specific type of dizziness that is defined as any illusion or sensation of motion. Dizziness is less specific than vertigo and refers to a sensation of altered orientation in space. Vertigo is an uncommon complaint in children; the child or parent might not volunteer information about balance unless asked specifically. The most common cause of dizziness in young children is eustachian tube–middle-ear disease, but true vertigo also may be caused by labyrinthitis, perilymphatic fistula between the inner and middle ear due to trauma or a congenital inner ear defect, cholesteatoma in the mastoid or middle ear, vestibular neuronitis, benign paroxysmal vertigo, Ménière disease, or disease of the central nervous system. Older children might describe a feeling of the room spinning or turning; younger children might express the dysequilibrium only by falling, stumbling, or clumsiness.
Nystagmus may be unidirectional, horizontal, or jerk nystagmus. It is vestibular in origin and usually is associated with vertigo.
Tinnitus rarely is described spontaneously by children, but it is common, especially in patients with eustachian tube–middle-ear disease or sensorineural hearing loss (SNHL). Children can describe tinnitus if asked directly about it, including laterality and the quality of the sound.
The facial nerve may be dehiscent in its course through the middle ear in as many as 50% of patients. Infection with local inflammation, most commonly in acute OM, can lead to a temporary paralysis of the facial nerve. It also can result from Lyme disease, cholesteatoma, Bell palsy, Ramsay Hunt syndrome (herpes zoster oticus), fracture, neoplasm, or infection of the temporal bone. Congenital facial paralysis can result from birth trauma or congenital abnormality of the 7th nerve or from a syndrome such as Möbius or CHARGE (coloboma, heart defects, atresia choanae, retarded growth, genital hypoplasia, and ear anomalies), or it may be associated with other cranial nerve abnormalities and craniofacial anomalies.
Complete examination with special attention to the head and neck can reveal a condition that can predispose to or be associated with ear disease in children. The facial appearance and the character of speech can give clues to an abnormality of the ear or hearing. Many craniofacial anomalies, such as cleft palate, mandibulofacial dysostosis (Treacher Collins syndrome), and trisomy 21 (Down syndrome) are associated with disorders of the ear and eustachian tube. Mouth breathing and hyponasality can indicate intranasal or postnasal obstruction. Hypernasality
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