Dr. Abdulrahman Hagr MBBS FRCS(c) Assistant Professor King ... · Dr. Abdulrahman Hagr MBBS FRCS(c)...
Transcript of Dr. Abdulrahman Hagr MBBS FRCS(c) Assistant Professor King ... · Dr. Abdulrahman Hagr MBBS FRCS(c)...
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Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor KingAssistant Professor King Saud University Saud University
Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base SurgeonOtologist, Neurotologist & Skull Base Surgeon
King Abdulaziz HospitalKing Abdulaziz Hospitalhttp://http://faculty.ksu.edu.sa/drhagrfaculty.ksu.edu.sa/drhagr
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Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor KingAssistant Professor King Saud University Saud University
Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base SurgeonOtologist, Neurotologist & Skull Base Surgeon
King Abdulaziz HospitalKing Abdulaziz Hospital
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Hearing• Introduction
• CHL otosclerosis
• SNHL – congental, trauma, infection, noise,
ototxic, presbycusis, acoustic neuroma
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H2O O2
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)الماء والاآسجين ( السمع والبصر
)وتعيها أذن واعية (قال تعالى
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والسمع الكريم القرآن القرآن معجزة سمعية •
مرة٨٨ مرة وذآر البصر بمعنى الرؤية ١٨٥ذآر السمع •
: -يقدم السمع فيها–مرة )٣٨( السمع و البصر معا لفظي•
٧٨: المؤمنون ) و هو الذي أنشأ لكم السمع والأبصار و الأفئدة (–
. ٣٦: الإسراء )مسؤلا إن السمع و البصر و الفؤاد آل أولئك آان عنه ( –
آيات يقدم في اغلبها الصمم٨ذآر الصمم مع العمى في •
)صم بكم عمي فهم لا يرجعون (–
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السمع والبصرأول حاسة •
الجنين يسمع في الشهر الخامس من الحمل –يبصر جيدا بعد الولادة بعشرة اسابيع –
آخر حاسة •إذا وضع الميت في قبره وانصرف الناس عنه إنه ليسمع قرع (قال صلى االله عليه وسلم
) نعالهم وهم عنه مدبرون أقوى حاسة •
يفقد البصر قبل السمع في النوم والتخدير والاغماء –تخترق الجدار –
أوسع احساسا •) درجة عمودية ١٤٥ درجة أفقية و ١٨٠البصر ( درجة ٣٦٠–
أآثر حماية •عمق الاذن الداخلية وفي العظم الصخري –منطقتين في المخ –
أآثر تأثيرا •فقد الكلام –فقد التواصل والتعلم –
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How common is hearing loss
• Overall about 1 in 10• 1 in 3 adults 65 - 75• 1 in 2 older than 75• 1-2% school age children• 4% children under 5
Common and Important
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Signs of Hearing Loss
• Talking louder than necessary• Turning up volume on the TV or radio• Complaints that other people “mumble”• Confusion of similar sounding words نخلة / نحلة• Inappropriate responses in conversation• Ringing or buzzing in the ears• Lip Reading
– Watching a speaker’s face intently– Difficulty “hearing” someone behind – Having difficulty on the telephone
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Effects• Don’t enjoy conversations – too much work• People think you are an idiot• Scared to try new contacts• Scared to take new jobs• Limits your world
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Hearing Loss –contracts your world
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Hearing Loss• limit activities• Isolation• Depression• Anxiety• Insecurity " إذا آانوا ثلاثة فلا يتناجى اثنان دون الثالث " • strain relationships • Increases psychosocial difficulties
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Deafness & Recruitment
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Outer Ear
Middle Ear
Inner Ear
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Conductive Defects
• Wax & foreign bodies• Otitis externa• Ear drum Scarring; perforation• Otitis media (ASOM)
– Acute suppurative– Otitis media with effusion (OME)– Chronic otitis media (CSOM)
• Otosclerosis• Ossicular chain disruption
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Wax
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Microtia
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Microtiaصمعاء = الأصمعي
الثمــليصـوت صــفير الـبلبـلي هيج قـــلبي
المـــــــاء والزهر معا مــــع زهر لحظ المقلي و أنت يا ســـــــــيد لي وســــــيدي ومولي لي
الى
انا الأديب الألمــعي من حي ارض الموصلي
ليالأدبونظمت قطــــعا زخرفت يعجز عنها
أقول في مطلعــــــــــها صوت صفير البلبلي
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Atresia= رتق
الشيء المرتوق أي المسدود والملتئم:الرتق )ففتقناهما انتا رتقا أو لم ير الذين آفروا أن السموات والأرض آ (
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AOE
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Racoon eyes sign
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Battle’s sign
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Case Case LEFT EAR (AS)
250 500 1000 2000 4000 8000
100
0
10
20
30
40
50
60
70
80
90
110
1
1
NR IPSI & CONTRA
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Drum Retraction (Adhesive OM)
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MEE
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Tympanosclerosis
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Otosclerosis
• 10% otosclerotic lesions (10% symptomatic)
• Females: Male 2: 1• Middle-age• Worse during pregnancy • Stapedectomy
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Sensorineuralhearing loss
SNHL
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SNHL• Congenital• Trauma• Infection• Noise• Ototoxic• Presbycusis• Acoustic neuroma
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Congenital hearing loss• Deafness affects 0.2%• SNHL attributed to
– 50% genetic factors– 20-25% environmental– 25-30% sporadic
• Genetic– 75% AR– 20% to AD– 5 % X-linked
• Over 400 syndromes
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Noise induce SNHL• Boilermaker's deafness
• one of the most common occupationally induced disabilities
• Tinnitus – commonly accompanied NISNHL
– warning sign
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9898• 90 db for 8 hours
• 95 db for 4 hours
• 100 db for 2 hours
• 105 db for 1 hours
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OtotoxicityOtotoxicity
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MedicationsMedications• Antibiotics• Diuretics• Antineoplastics• Antiinflammatories• Antimalarial agents• Ototopic agents• Others
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Higher risk Higher risk 1. Renal failure (Elevated peak and trough levels)2. Liver failure3. Immunocompromise4. Collagen-vascular disorders5. Advanced age (> 65 years)6. Prior ototoxicity7. Concurrent use of known ototoxic agents8. Preexisting HL or Vestibular9. Bacteremia (fever )10. Treatment course longer than 14 days11. + ve FHx of AG ototoxicity
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Presbycusis
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Presbycusis = Deafness + Tinnitus + Recruitment
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Overview of Hearing Loss
• #1 Handicapping disorder
• 60% of Americans > 65 HL
• 90% of > 75 Y have HL
• HL + degenerative processes of aging.
• ½ Vestibular symptoms
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Problems With Diagnosis
• Shame or embarrassment.
• HA social stigma
• Embarrassment prevents 15 million elderly
people from getting help.
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Hearing Aids
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HistoryHistory• 1550 by Girolamo
Cardano when he saw that sound could be transmitted through the teeth
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السماعات وتطورها
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Hearing Aids
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Cochlear implant
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) ١٨٢٧-١٧٤٥(الكساندرو فولتا
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Bone Anchored Hearing AidsB.A.H.A
Dr. Abdulrahman Hagr MBBS FRCS(c)
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Direct bone Conduction
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Auditory brainstem implant
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Auditory brainstem implant A.B.I.
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Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor KingAssistant Professor King Saud University Saud University
Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base SurgeonOtologist, Neurotologist & Skull Base Surgeon
King Abdulaziz HospitalKing Abdulaziz Hospital
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VertigoVertigo• Mechanism of Balance• Causes
– Meniere’s– Vestibular neuronitis– BPPV
• Investigations
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Why have a VOR?
1. Stabilize retina in space – fast!
On headmovement
2. Posture Control
Do finger test
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Types of Spatial Movement
• Rotational – 3 degrees of freedom
• Translational – 3 degrees of freedom
Semicircular Canals
Otolith Organs
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Basic Mechanism of Detection of Rotation
• INERTIA• Detects head acceleration – but encodes
head velocity (i.e. integrator)
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Velocity Profile vs Signal
VelocityAccn Deaccn
Nerve Firing
Decays with constant velocity
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Canals are Paired
AC
PC
AC
PC
HC HC
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Push-Pull SystemFiring Rate
0
100s/s
Right HC
Left HC
Differential is Driving VOR
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Balance – more than just vestibular
Balance
Visual
Proprioception
VestibularBrain &Cerebellum
Muscle toneJoints
Efferent pathways(SC, nerves)
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An Otologists Approach to Dizziness….
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What is Dizziness?Illusion of movement of self or environment• Exact description important: Not accept
“dizziness” - too vague– True spinning? -comparator– Lightheadedness?– Unsteadiness?– Fainting, passing out
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Prime Clue #1Significance of True Spinning
• Almost all true spinning is vestibular• All vestibular is not true spinning
True Spinning
Vestibular etiology
To and fro rocking
lightheadedness ataxia
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Central ?peripheral
• Neurologic symptoms– New severe headache – LOC
• Type of nystagmus• Risk factors• No improvement within 48 hours
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Vestibular Vertigo
Spinningsensation
A t a x i a
nystagmus
nausea &vomiting
worseon headmovement
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Common Clinical Diseases
• Meniere’s Disease
• Benign Paroxysmal Positional Vertigo (BPPV)
• Vestibular neuritis
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Prime Clue #2Duration of Dizziness
Otologic: Prime causes– Seconds to minutes: BPPV – Minutes to hours: Meniere’s, Recurrent
Vestibulopathy, Migraine Associated Vertigo– Days: Vestibular Neuronitis, Sudden
Sensorineural Hearing Loss with Vertigo (Labyrinthitis)
– Constant, no improvement: Never vestibular
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All you need to know
Vestibular Neuronitis
Labyrinthitis(SSHL with vertigo)
Hours-Days
RV, MAVMeniere’sDisease
Minutes-Hours
BPPVSeconds-Minutes
Without Hearing Loss
With Hearing Loss
VERTIGO
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Can be More Than One Type
• More than one type?
– E.g. Vestibular Neuronitis followed by BPPV
• 1st episode vs. most recent episode
• How often, how long, how changing
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Worrisome Features
• Diplopia, Dysarthria, Dysphagia, Difficulty moving one side/limb, paraesthesia one side/limb
• Bowel or bladder disturbance• True loss of consciousness• Prominent arrhythmia
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Benign Paroxysmal Positional Vertigo BPPV
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Etiology• not identifiable. • closed head injury followed `(surgery )• infections (15% vestibular neuronitis)• prolonged bed rest.• Ménière's disease • recurrent vestibulopathy• migraine
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BPPV: Pathophysiology
Canalithiasis TheoryDegenerative debris from
utricle (otoconia) floating freely in the
endolymph
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? posterior canal
hangs down like the water trap in a drain pipe, allowing the crystals to settle in the bottom of the canal.
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History.• severe vertigo
• associated with change in head position. – rolling over or getting into bed
– assuming a supine position.
– arising from a bending position
– looking up to take an object off a shelf
– tilting the head back to shave
• suddenly and last in the order of seconds,
• bouts of vertigo remissions
• Chronic balance problems
• worse on awakening in the morning
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BPPV: Clinical Approach
• history is virtually pathognomonic
• Only type of vertigo
– Multiple times per day
– brief episodes
– Unaccompanied by auditory complaints
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Dix-Hallpike Maneuver
Hagr 6 D1. Delay seconds latency
2. Downward (Geotropic)
3. Duration <1 minute
4. Directional change5. Dizziness (Subjective)
6. Disappear fatigable
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D/D• Postural hypotension
– anti-hypertensive drugs
– CV problems
• Fistula
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Epley Maneuver
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Menieres Disease• Recurrent attacks of vertigo lasting hours• Associated tinnitus, hearing loss pressure
buzzzz
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Pathology• Decreased endolymphatic reabsorption• Progressive hydrops• membranous ruptures • Spillage of large amounts of neurotoxic
endolymph into the perilymphaticcompartment
• healing of the membranes• Distortion and atrophy of sensory and
neural structures
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Cause of Meniere’sOverproduction or retention of endolymph• Unknown• Autoimmune etiology• Ischemia • Mumps• Syphilis• Hypothyroidism• Head trauma• Previous infection• Hormonal Pregnant females are more prone
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Endolymphatic hydrops is most consistently found in the pars inferior (cochlea and saccule)
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Menieres - Course
• Early – Predominant Vertigo – Deafness– Normal hearing between
• Later – Hearing loss stops fluctuating – Progressively worse (50db)
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Diagnosis• Hx • PE: unilateral weakness• PTA: LF-SNHL• R/O other Dx
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Treatments• Education• To treat the acute attacks • To prevent further attacks • To improve hearing • Vestibular rehabilitation • F/U.. bilateral Meniere's disease
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Acute attacks• prevent falls • head should be restricted • Anticholinergics• Antihistamines • Phenothiazine• Benzodiazepines
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MedicalTREATMENT
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SxTREATMENT
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Vestibular neuritis• abrupt onset
• single, severe and prolonged vertigo
• Not hearing loss or severe vertigo
• NO neurologic signs or symptoms
• nystagmus
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Vestibular neuritis
• 50% Infectious illness precede VN• Spontaneous recovery occurs over weeks to
months• Symptomatic Treatment
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Ototoxicity• Usually aminoglycosides• Complain of oscillopscia• Video
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Investigations • Audiology
– PTA– ENG– Posturography– Rotation chair
• Radiology– CT Scan – MRI
• Blood Test– CBC, TFT, FT-Abs
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Secretory Otitis Media (Glue Ear)
• 3 Y• Recurrent OM• Hearing Loss
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Fracture Base of Skull
• MVA• Left earache• Hearing loss
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Otosclerosis vs Tympanosclerosis
• 33 y• No hearing loss• Ear exam
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Cochlear implant
• What is this?
• Which type of hearing loss?
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15 years old girl
• What is this?
• Which type of hearing loss?
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آرسي بحث الاعاقة السمعية
وزراعة السماعات ) رشـــــد (
rchd.ksu.edu.sahttp://
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