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Physician Assistant Exam: Conditions of the Ear

There are several conditions that affect the ear and the Physician Assistant Exam will expect you to be familiar with the basics. These conditions include everything from vertigo to problems with earwax.

Vertigo

If you’ve ever had vertigo, you know how debilitating the sensation of the room spinning can be. Vertigo can occur by itself, or it can accompany other symptoms, such as decreased hearing or even tinnitus.

Benign positional vertigo

Benign paroxysmal positional vertigo is the most common form of positional vertigo and is probably the most common disorder involving vertigo. It’s an affliction of the inner ear. In the most common clinical scenario, when the patient changes the position of the head, he or she feels that the room is spinning. The person may experience significant nausea as well.

The diagnosis is confirmed by the Dix-Hallpike test. Treatment involves a maneuver such as the Epley maneuver to help retrain the inner ear.

Experts attribute benign paroxysmal positional vertigo to the buildup of calcium within the posterior semicircular canals of the inner ear. The utricular sac actually contains crystals. The role of the semicircular canals is the detection of rapid changes in head movement, and with the buildup of calcium crystals, the patient may feel the sensation of being on a merry-go-round.

Ménière’s disease

Ménière’s disease usually affects one ear and can cause dizziness, vertigo, tinnitus, or decreased hearing in the affected ear. It’s caused by an increased amount of fluid in the inner ear. The build-up of this extra fluid in the inner ear is referred to as endolymphatic duct obstruction.

There’s no gold standard for diagnosing of Ménière’s disease — the diagnosis is made by ruling out other potential causes of vertigo. Unfortunately, there’s no cure. Treatment is supportive. Low-sodium diets are advocated. Meclizine is recommended to help with the vertigo. Perhaps 20 to 30 percent of patients go on to develop bilateral disease.

Schwannomas

Schwannomas are rare, slow-growing brain tumors that can affect cranial nerve VIII. Symptoms can include hearing loss and balance problems. You also see vertigo and tinnitus with these tumors. They’re diagnosed with brain imaging, usually a CT scan or MRI of the brain with intravenous contrast. Options for treatment are often surgical, but radiation can be used as well.

Labrynthitis

Labrynthitis can cause vertigo. A classic presentation is a person who had a cold or sore throat a week or so ago that has resolved but who several days later presents with significant vertigo. These symptoms can sometimes persist for months. The gold standard treatment is vestibular rehabilitation therapy, usually in an outpatient unit.

Tinnitus

The most common type of tinnitus is subjective, in which the person doesn’t have any objective hearing problems but complains of a buzzing noise. The treatment for tinnitus depends on its cause. For some causes, the use of a low masking sound may help.

Mastoiditis

Mastoiditis is an inflammation of the mastoid bone. It’s usually the result of an untreated middle ear infection or bad middle ear infections that persist despite treatment. Symptoms can include fever and pain in the mastoid area. You may see swelling and redness. In the setting of an acute otitis media, there may be purulent ear drainage.

The treatment involves antibiotics as well as consideration of surgery if the person remains symptomatic despite aggressive antibiotic treatment. Imaging studies of the head, including an MRI, are often done.

Ear trauma

A foreign body in the ear is a pretty common condition. Toys and other things may be shoved in the ear, or insects can fly into it. Symptoms depend on the object as well as on how deep it is in the ear canal and how long it’s been there. The deeper it is, the higher the risk of perforating the tympanic membrane.

If the person tries to take the object out, that can cause further irritation. If the tympanic membrane isn’t perforated, a medical professional looks in the ear and tries to remove the object. The doc or PA may even try irrigation. Sometimes the person has to see an ENT for the removal.

Barotrauma is injury of the ear due to sudden changes in pressure. The changes in pressure can be enough to cause damage to the ear — typically decompression sickness. The most common area to be affected by changes in pressure is the middle ear. Symptoms can include hearing and balance problems.

Wax

The body makes many odd substances, and cerumen — ear wax — leads the list. Excessive cerumen may impede the passage of sound in the ear canal, causing conductive hearing loss. An article in the Journal of the American Academy of Audiology says cerumen is the cause of 60 to 80 percent of hearing aid faults.

Treatment of excessive ear wax is with carbamide peroxide, and the patient can use the ear drops at home. If that doesn’t work, a medical professional tries syringing and should inspect the ear canal afterward. The gold-standard treatment is an ear pick or curette used by a medical professional, which guarantees physical removal of the wax.

Hearing loss

Different medical conditions can contribute to hearing loss. The two kinds of hearing loss are conduction hearing loss and sensorineural hearing loss. Conduction hearing loss most commonly refers to problems with sound being transmitted from the outer ear to the middle ear. Causes include ear wax buildup, a foreign body in the ear, or a narrowing of the ear canal.

Sensorineural hearing loss occurs farther in. The problem is with the hair cells in the organ of Corti and/or with the nerves in the inner ear. Cranial nerve XIII can be affected, and sometimes the brain function is affected, too. Medications that cause ototoxicity can cause sensorineural deafness. Other causes include schwannomas and Ménière’s disease.

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