EAR DISORDERS

Review of anatomy
The ear has external, middle, and inner
portions. The outer ear is called the pinna and
is made of ridged cartilage covered by skin.
Sound funnels through the pinna into the
external auditory canal, a short tube that
ends at the eardrum (tympanic membrane).
Sound causes the vibration of eardrum and
its tiny attached bones in the middle portion
of the ear, and the vibrations are conducted
to the nearby cochlea. The spiral-shaped
cochlea is part of the inner ear; it transforms
sound into nerve impulses that travel to the
brain.
 Infections of the External
Ear
Otitis Externa is an infection of the
external auditory canal (EAC) that
can be divided according to the time
course of the infection: acute,
subacute, or chronic
Acute: less than 6 weeks of
duration.
 Types
Chronic OE This is the same as acute diffuse OE
but is of longer duration (>6 weeks)
Eczematous (eczematoid) OE This encompasses
various dermatologic conditions (eg, atopic dermatitis
, psoriasis, systemic lupus erythematosus, and
eczema) that may infect the EAC and cause OE
Necrotizing (malignant) OE This is an infection
that extends into the deeper tissues adjacent to the
EAC; it primarily occurs in adult patients who are
immunocompromised (eg, as a result of diabetes
mellitus or AIDS) and is rarely described in children; it
may result in cases of cellulitis and osteomyelitis
Otomycosis - Infection of the ear canal secondary to
fungus species such as Candida or Aspergillus
 Causes
Swimming
Constriction of the ear canal from
bone growth (Surfer's ear)
Saturation diver
the use of objects such as cotton
swabs or other small objects to clear
the ear canal
 Pathophysiology
OE is a superficial infection of the skin in
the EAC. The processes involved in the
development of OE can be divided into the
following 4 categories:
Obstruction (eg, cerumen build-up, surfers
exostosis, or a narrow or tortuous canal),
resulting in water retention
Absence of cerumen, which may occur as a
result of repeated water exposure or
overcleaning the ear canal
Trauma
Alteration of the pH of the ear canal
 The two factors that are required for
external otitis to develop are (1) the
presence of germs that can infect the
skin and (2) impairments in the
integrity of the skin of the ear canal
that allow infection to occur
atopic dermatitis , psoriasis
otomycosis
 Symptoms
Drainage from the ear - yellow, yellow-green,
foul smelling, persistent
Ear pain - felt deep inside the ear and may get
worse when moving head
Hearing loss
Itching of the ear or ear canal
Fever
Trouble swallowing
Weakness in the face
Voice loss
 Diagnosis

When the ear is inspected, the canal

appears red and swollen in well-
developed cases.
physical examination
Otoscope :narrowing of the ear canal
from inflammation and the presence
of drainage and debris.
Culture of the drainage
 Treatment
Aural toilet
Aural toilet must be performed and
can be done most conveniently by
dry mopping. The ear is cleaned with
a gentle rotatory action. Once the
cotton wool is soiled it is replaced.
 Dressings
If the otitis externa is severe, a length
of 1 cm ribbon gauze, impregnated
with appropriate medication, should
be inserted gently into the meatus,
and renewed daily until the meatus
has returned to normal
 medication may be used as dictated
by the result of culture.
If fungal otitis externa is present,
dressings of 3% amphotericin,
miconazole
or nystatin may be used.
 Otitis media
Inflamation of the middle ear.
Types
Acute
suppurative
non suppurative
Chronic
suppurative
 Acute Otitis Media
Acute otitis media, i.e. acute inflammation
of the middle-ear cavity, is a common
condition and is frequently bilateral. It
occurs most commonly in children and it is
important that it is managed with care to
prevent subsequent complications. It most
commonly follows an acute upper
respiratory tract infection and may be viral
or bacterial.
 Pathology
Acute otitis media is an infection of
the mucous membrane of the whole
of the middle-ear cleft Eustachian
tube, tympanic cavity, attic, mastoid
antrum and air cells.
 The bacteria responsible for acute
otitis media are: Streptococcus
pneumonia 35%, Haemophilus
influenzae 25%, Moraxella
catarrhalis 15%. Group A
streptococci and Staphylococcus
aureus may also be responsible.
.
 The sequence of events in acute
otitis media is as follows:
organisms invade the mucous
membrane causing inflammation,
oedema, exudate and later, pus;
oedema closes the Eustachian tube,
preventing aeration and drainage;
 pressure from the pus rises, causing
the drum to bulge;
necrosis of the tympanic membrane
results in perforation;
the ear continues to drain until the
infection resolves
 Causes
Common cold
Acute tonsillitis
Influenza
Coryza of measles, scarlet fever,
whooping cough
 Symptoms, signs
Earache
Deafness
It is conductive in nature and may be
accompanied by tinnitus
Pyrexia
Tenderness
There is usually some tenderness to
pressure on the mastoid antrum.
 contd.
The tympanic membrane varies in
appearance
Loss of lustre and break-up of the
light reflex.
Redness and fullness of the drum;.
Bulging, with loss of landmarks.
Purple colour..
Perforation with otorrhoea.
Mucoid discharge
 Treatment
Antibiotics:, amoxycillin will be
more effective.
Co-amoxiclav is useful in Moraxella
infections.
 Analgesics
Nasal vasoconstrictors
Ear drops
Myringotomy is necessary when
bulging of the tympanic membrane
persists, despite adequate antibiotic
therapy
 Chronic suppurative otitis
media(CSOM)
CSOM is a chronic inflammatory
process involving the middle ear cleft
producing irreversible pathological
changes .
 causes
Late treatment of acute otitis media.
Inadequate or inappropriate
antibiotic therapy.
Upper airway sepsis.
Lowered resistance, e.g.
malnutrition, anemia, immunological
impairment.
Particularly virulent infection, e.g.
measles.
 Classification
It is of two types.
Tubotympanic(safe)

Attico
antral(dangerous)
 Types of CSOM
Mucosal disease with tympanic
membrane perforation (tubo-
tympanic disease, relatively safe).

Bony:
cholesteatomadangerous (attico-
antral disease).
 Tubo tympanic : this is a benign type
of CSOM confined only to the middle
ear cleft.

Attico antral: this involves the attic,

antrum and the posterior tympanum.
It is characterized by bone eroding
cholesteatoma.
 Mucosal infection
Symptoms
Discharge- mucopurulant, non-foul
smelling
Deafness
Earache
 Signs: discharge, tympanic
membrane perforation,
Tuning fork test: rinne-negative
Weber-lateralised to one side
ABC- normal
 Investigations

Culture and sensitivity

Examination under microscope
Pure toneaudiogram:mild conductive
loss between 20 to 30dB
X-ray of mastoid, PNS, neck lateral
view
Nasal endoscopy
 Treatment of mucosal-type
csom
Removal of septic foci:
tonsillectomy,adenoidectomy, sinus
wash
Myringoplasty if hearing loss below
40dB
Tympanoplasty:if above 40dB
 Attico antral type clinical
features
Ear discharge: foul smelling scanty,,
blood stained, no relation with URTI
Deafness:progressive conductive
deafness
Itching and pain in the ear
Tinnitus and giddiness

 Sign

In Otoscopic examination: foul smelling

discharge in the ext. Auditory canal
Granulation tissue in the meatus
Attic or marginal perforation oftymanic
membrane
Cholesteatoma
Mastoid tenderness
Tuning fork test-Rinne negative, weber
localised to lateral side, ABC normal
 Investigations

Examination under microscope

Culture and sensitivity
Rigid oto-endoscopy
Audiogram(PTA)
Imaging- X-ray mastoid,CT scan,MRI
scan
 Management
Goal to make the ear safe and dry
To restore and improve hearing
Surgical management
Main line treatment.
1. canal wall down
mastoidectomy:consists of radical
and modified radical mastoidectomy.
These procedures ensures safety and
dry ear but functional improvement
may not be achieved.
 2. Canal wall up mastoidectomy:
or combined approach
tympanoplasty, where functional
improvement can be achieved but
not the safety.
 Medical management
It is used only for patient who are
unfit for surgery. Topical antibiotic
and steroid are used.
In some cases 5- flurouracil used.
 Complications-CSOM
Brain abscess
Lateral sinus thrombosis
Otitic hydrocephalus
Meningitis
Mastoiditis
Labyrynthitis
Petrositis
Cerebellar abscess
 Otosclerosis is a hereditary localised
disease of the bone characterised by
alternating phases of bone resorption
and new bone formation. The
mature lamellar bone is removed by
osteoclasis and replaced by woven
bone of greater thickness, cellularity
and vascularity
 Pathophysiology
The primary pathological change occurs in
the bony labyrinth with secondary effects
upon middle ear and inner ear
function. The otosclerotic focus may be
asymptomatic, or if present in the area of
foot plate of stapes it may give rise to
ankylosis of foot plate with resultant
conductive deafness. Otosclerotic foci may
involve other portions of labyrinth causing
sensori neural hearing loss and vestibular
abnormalities.
 Causative factors /
etiology
Many theories have been proposed to
explain the etiological factors of
otosclerosis. They are:
1. Metabolic
2. Immune disorders
3. Vascular disease
 4. Infection (Measles) currently
accepted
5. Trauma : The petrous bone doesnot have
regenerative capacity. This is because of the fact
that the enzymes released during reparative
phase are very toxic to the inner ear hair cells.
6. Temporal bone abnormalities
(congenital)
 Genetic factors predisposing to
otosclerosis: The tendency for
otosclerosis to run in families has
been seen.
Otosclerosis is associated with
osteogenesis imperfecta in 0.15 %
of cases. This is known as Van der
Hoeve syndrome or Adair -
Dighton syndrome.
 Clinical features
Deafness: Typically deafness in
otosclerosis is bilateral and gradually
increasing in nature. In majority of
cases the deafness is conductive in
nature. These patients may hear
better in noisy environment because
the speaker has a tendency to raise
his voice because of excessive
ambient noise. This phenomenon a
feature of otosclerosis is known as
Paracusis Willisii.
 Tinnitus: is a common symptom and
occasionally could be the only presenting
feature. Mostly tinnitus indicates
sensorineural degeneration. Tinnitus may
be unilateral or bilateral. It is usually
roaring in nature.

Vertigo: Transient attacks of vertigo is

not uncommon in patients with
otoslerosis. . These patients may even
have coexisting Meniere's disease.
 Clinical examination
The ear drum in these patients is
normal (mint condition). Rarely
during active phase of the disease
the increased vascularity of the
promontory may be seen through
the ear drum. This sign is known as
Flemingo's flush sign or
Schwartz's sign. This indicates
otospongiosis (active otosclerosis).
 Hearing assessment done using
tuning forks.
Pure tone auditometry will show
precisely the amount and type of
hearing loss. The presence of
Carhart's notch is a classic
audiometric feature in these
patients. In cochlear otosclerosis
audiometry reveals sensorineural
hearing loss
 Impedence audiometry is an
useful investigation to diagnose
otosclerosis. Middle ear compliance
is often reduced. When stapes is
fixed stapedial reflex is absent. The
typical impedence curve is As curve.
 Management
Medical: The aim of medical
management is to convert an active
otosclerotic foci into an inactive or
quiscent foci.
 Surgical treatment:
Stapedectomy
Hearing aids: These patients will
benefit from the use of hearing aids
if surgery is not acceptable to the
patient or if it is risky. There is
always a 1% risk of producing a
dead ear during surgery even in the
best of hands.
 Tympanic Membrane
Perforation
A tympanic membrane perforation is
a condition where your eardrum has
a tear or hole in it.
 Causes
Changes in ear pressure: Changes
in ear pressure may occur when
travelling on an airplane, or if you
are involved in an explosion.
Underwater sports such as swimming
or scuba diving may also cause
pressure changes in your ears.
 Direct trauma to your eardrum
Ear infection
Head trauma
Past ear surgery or procedure
 Signs and Symptoms
Clear, Mucoid (phlegm-like), thick
and yellowish, or bloody ear
discharge.
Hearing loss in involved ear.
Pain in involved ear.
Tinnitus (ringing or buzzing sound in
your ear).
Vertigo (dizziness).
 Diagnosis
History
Otoscopic examination
 Surgery
Myringoplasty: This type of surgery uses a
tissue graft to cover torn eardrum. A tissue
graft may be taken from own body, another
person, an animal, or is man-made. A
procedure called a mastoidectomy may also be
done with a myringoplasty.
Tympanoplasty: This surgery repairs torn
eardrum and any damage to inner ear. A
tympanoplasty also helps prevent chronic ear
infections. The hole in eardrum will be covered
with a tissue graft
 Infections of the Inner Ear
Labyrinthitis and Vestibular
Neuritis
Vestibular neuritis and labyrinthitis are
disorders resulting from an infection that
inflames the inner ear or the nerves
connecting the inner ear to the brain. This
inflammation disrupts the transmission of
sensory information from the ear to the
brain. Vertigo, dizziness, and difficulties
with balance, vision, or hearing may
result.
 Signs and Symptoms
A prominent and debilitating
symptom of labyrinthitis is severe
vertigo.
(nystagmus)
Nausea
Anxiety
general ill feeling.
 Diagnosis
No specific tests exist to diagnose vestibular
neuritis or labyrinthitis. Therefore, a process
of elimination is often necessary to diagnose
the condition. Because the symptoms of an
inner ear virus often mimic other medical
problems, a thorough examination is
necessary to rule out other causes of
dizziness, such as stroke, head injury,
cardiovascular disease, allergies, side effects
of prescription or nonprescription drugs
(including alcohol, tobacco, caffeine, and
many illegal drugs), neurological disorders,
and anxiety
 Treatment
Vestibular rehabilitation therapy
is a highly effective way to
substantially reduce or eliminate
residual dizziness from labyrinthitis.
VRT works by causing the brain to
use already existing neural
mechanisms for adaptation,
neuroplasticity, and compensation.
Rehabilitation strategies most
commonly used are:
Gaze stability exercises - moving the head
from side to side while fixated on a stationary
object (aimed to restore the Vestibulo-ocular
reflex)
Habituation exercises - movements
designed to provoke symptoms and
subsequently reduce the negative vestibular
response upon repetition.
Functional retraining - including postural
control, relaxation, and balance training.
 Mnire's disease
Mnire's disease is a disorder of the
inner ear that can affect hearing and
balance to a varying degree. It is
characterized by episodes of vertigo, low-
pitched tinnitus, and hearing loss. The
hearing loss is fluctuating rather than
permanent, meaning that it comes and
goes, alternating between ears for some
time, then becomes permanent with no
return to normal function.
 Causes
Mnire's disease is idiopathic, but it is
believed to be linked to endolymphatic hydrops,
an excess of fluid in the inner ear.It is thought
that endolymphatic fluid bursts from its normal
channels in the ear and flows into other areas,
causing damage. This is called "hydrops."
The symptoms may occur in the presence of a
middle ear infection, head trauma, or an upper
respiratory tract infection,
aspirin, smoking cigarettes, or drinking alcohol.
excessive consumption of salt in some patients.
herpes virus.
 Symptoms
Attacks of rotational vertigo
Fluctuating, progressive, unilateral
(in one ear) or bilateral (in both
ears) hearing loss
Unilateral or bilateral tinnitus
A sensation of fullness or
pressure in one or both ears
 Parasympathetic symptoms ,
These are typically nausea, vomiting,
and sweating which are typically
symptoms of vertigo, and not of
Mnire's
nystagmus,
Migraine
 Diagnosis
Complaints and medical history.
otolaryngological examination,
audiometry, and
head MRI scan should be performed
to exclude a vestibular schwannoma
or superior canal dehiscence which
would cause similar symptoms.
 Management

stopping to have coffee which contains

caffeine & stopping to have tea
Recommended salt intake is often around
one to two grams per day. One source
recommends taking two grams of
potassium or more daily
Diuretics have traditionally been
prescribed to facilitate a Low sodium diet
although there is no definite supportive
evidence.
 Both prescription and over-the-counter
medicine can be used to reduce nausea
and vomiting during an episode. Included
are antihistamines such as meclozine or
dimenhydrinate, trimethobenzamide and
other antiemetics, betahistine, diazepam,
or ginger root.
 Surgery
Non destructive surgeries include
those which do not actively remove any
functionality, but rather aim to improve
the way the ear works
Intratympanic steroid treatments
involve injecting steroids
(commonly dexamethasone) into the
middle ear in order to reduce
inflammation and alter inner ear
circulation.
 Surgery to decompress the endolymphatic sac has
shown to be effective for temporary relief from symptoms.
Conversely, destructive surgeries are irreversible and
involve removing entire functionality of most, if not all, of
the affected ear. The inner ear itself can be surgically
removed via labyrinthectomy although hearing is always
completely lost in the affected ear with this operation
Alternatively, a chemical labyrinthectomy, in which a
drug (such as gentamicin) that "kills" the vestibular
apparatus is injected into the middle ear can accomplish
the same results while retaining hearing.
 In more serious cases surgeons can cut the nerve
to the balance portion of the inner ear in a
vestibular neurectomy. Hearing is often mostly
preserved, however the surgery involves cutting
open into the lining of the brain, and a hospital
stay of a few days for monitoring would be
required
Physiotherapy
In vestibular rehabilitation, physiotherapists use
interventions aimed at stabilizing gaze, reducing
dizziness and increasing postural balance within
the context of activities of daily living.
 Hearing Loss
Hereditary disorders - some types of
deafness are hereditary, which means
parents pass on flawed genes to their
children. In most cases, hereditary deafness
is caused by malformations of the inner ear.
Genetic disorders - genetic mutations
may happen: for example, at the moment of
conception when the fathers sperm joins with
the mothers egg. Some of the many genetic
disorders that can cause deafness include
osteogenesis imperfecta, Trisomy 13 S and
multiple lentigines syndrome.
 Prenatal exposure to disease - a baby will be
born deaf or with hearing problems if they are
exposed to certain diseases in utero, including
rubella (German measles), influenza and mumps.
Other factors that are thought to cause
congenital deafness include exposure to methyl
mercury and drugs such as quinine.
Noise - loud noises (such as gun shots,
firecrackers, explosions and rock concerts),
particularly prolonged exposure either in the
workplace or recreationally, can damage the
delicate mechanisms inside the ear.
 Trauma - such as perforation of the
eardrum, fractured skull or changes in air
pressure (barotrauma).
Disease - certain diseases can cause
deafness, including meningitis, mumps,
cytomegalovirus and chicken pox. A severe
case of jaundice is also known to cause
deafness.
Other causes - other causes of deafness
include Menieres disease and exposure to
certain chemicals like ototoxic drugs
 Conductive hearing loss
It is characterized by an obstruction
to air conduction that prevents the
proper transmission of sound waves
through the external auditory canal
and/or the middle ear. It is marked
by an almost equal loss of all
frequencies. The auricle (pinna),
external acoustic canal, tympanic
membrane, or bones of the middle
ear may be dysfunctional.
 Sensorineural hearing loss
Occurs when the sensory receptors of the inner ear
are dysfunctional. Sensorineural deafness is a
lack of sound perception caused by a defect in
the cochlea and/or the auditory division of the
vestibulocochlear nerve. This type of hearing loss
is more common than conductive hearing loss
and is typically irreversible. It tends to be
unevenly distributed, with greater loss at higher
frequencies.
 Sensorineural hearing loss may result from
congenital malformation of the inner ear,
intense noise, trauma, viral infections,
ototoxic drugs (e.g., cisplatin, salicylates,
loop diuretics), fractures of the temporal
bone, meningitis, mnire's disease, cochlear
otosclerosis, aging (i.e., presbycusis), or
genetic predisposition, either alone or in
combination with environmental factors.
Many patients with sensorineural hearing loss
can be habilitated or rehabilitated with the
use of hearing aids.
 Mixed hearing loss
Have both conductive and sensory
dysfunction. Mixed hearing loss is due to
disorders that can affect the middle and
inner ear simultaneously, such as
otosclerosis involving the ossicles and the
cochlea, head trauma, middle ear tumors,
and some inner ear malformations.
Trauma resulting in temporal bone
fractures may be associated with
conductive, sensorineural, and mixed
hearing loss
 Degree of hearing loss
Deaf/Deafness refers to a person who has a
profound hearing loss and uses sign language.
Hard of hearing refers to a person with a hearing
loss who relies on residual hearing to communicate
through speaking and lip-reading.
Hearing impaired is a general term used to describe
any deviation from normal hearing, whether
permanent or fluctuating, and ranging from mild
hearing loss to profound deafness.
Residual hearing refers to the hearing that remains
after a person has experienced a hearing loss. It is
suggested that greater the hearing loss, the lesser the
residual hearing.
 Assessment
Hearing loss is confirmed using a
battery of audiologic tests, with the
specific tests and measures selected
according to the age of the patient.
However, in general, comprehensive
hearing assessment designed to
confirm hearing loss usually includes
a hearing history, physiological
procedures, and behavioral
procedures
 Components of a Comprehensive Hearing
Assessment and Hearing History

General concern about hearing and

communication

Auditory behaviors (reacting to and

recognizing sounds)

History of otological diseases and other

risk factors for hearing loss
 Physiological procedures or acoustic
admittance measurements
Otoacoustic emissions (OAE)
Auditory brainstem response (ABR)
Middle ear muscle reflexes
Tympanometry
Behavioral audiometry testing
Behavioral Observation
Audiometry (BOA
 Visual Reinforcement Audiometry
(VRA)
Conditioned Play Audiometry
(CPA)
Speech Audiometry
 Management
Interventions for most infants and young
children with hearing loss are primarily
focused on the following goals:
Preventing or reducing the communication
problems that typically accompany early
hearing loss.
Improving the child's ability to hear.
Facilitating family support and confidence
in parenting a child with a hearing loss.
 Communication approach options for
young children with hearing loss
range from sign language alone to
auditory/verbal (spoken language) or
various combination approaches.
Parents also must choose a means
for improving their child's access to
sound.

 Hearing aid
A hearing aid is an electroacoustic
device which is designed to amplify
sound for the wearer, usually with
the aim of making speech more
intelligible, and to correct impaired
hearing as measured by audiometry.
Ordinary small audio amplifiers or
other plain sound reinforcing
systems cannot be sold as "hearing
aids".
 Types
There are many types of hearing aids (also
known as hearing instruments), which vary in
size, power and circuitry. Among the different
sizes and models are:
Body worn aids
Behind the ear aids (BTE)
"Mini" BTE (or "on-the-ear") aids
Receiver in the canal/ear
(CRT/RIC/RITE)
Earmolds
 In the ear aids (ITE)
Invisible in canal hearing aids
(IIC)
Extended wear hearing aids
Open-fit devices
Personal, user, self, or consumer
programmable
Disposable hearing aids
 Bone anchored hearing aids
(BAHA)
Eyeglass aids
Spectacle hearing aids
Bone conduction spectacles
Air conduction spectacles
Stetho-Hearing Aid
Bone anchored hearing
aids (BAHA)
Eyeglass aids
 Other assistive devices include FM systems and
tactile aids. Some children with severe to
profound hearing loss who have demonstrated
little benefit from conventional hearing aids may
receive a cochlear implant, an electronic device
that is surgically placed in the inner ear.
A cochlear implant (CI) is a surgically
implanted electronic device that provides a sense
of sound to a person who is profoundly deaf or
severely hard of hearing. Cochlear implants are
often called bionic ears.
 Parts of the cochlear
implant
The implant is surgically placed under the
skin behind the ear. The basic parts of the
device include:
External:
one or more microphones which picks up
sound from the environment
a speech processor which selectively filters
sound to prioritize audible speech, splits the
sound into channels and sends the electrical
sound signals through a thin cable to the
transmitter,
 a transmitter, which is a coil held in position by a magnet
placed behind the external ear, and transmits power and
the processed sound signals across the skin to the internal
device by electromagnetic induction,
Internal:
The internal part of a cochlear implant (model Cochlear
Freedom 24 RE)
a receiver and stimulator secured in bone beneath the
skin, which converts the signals into electric impulses and
sends them through an internal cable to electrodes,
an array of up to 22 electrodes wound through the
cochlea, which send the impulses to the nerves in the scala
tympani and then directly to the brain through the auditory
nerve system.
 Aural rehabilitation
Refers to the services and procedures needed to
facilitate adequate receptive and expressive
communication in individuals with hearing
impairments [American Speech-Language-
Hearing Association (ASHA), 1984]. It is also
called auditory or audiologic rehabilitation. Aural
rehabilitation is typically an integral component
used in the overall management of individuals
with hearing loss and is often an interdisciplinary
endeavor involving physicians, audiologists, and
speech-language pathologists. For school-age
children, therapy may also be coordinated with
the school system.
 Services involved in the provision of aural
rehabilitation include
Identification and evaluation of sensory
capabilities, including the extent of impairment
and the fitting of auditory aids.
Interpretation of the audiological findings, plus
counseling and referral.
Development and provision of an intervention
program for communicative disorders in order to
facilitate expressive and receptive
communication.
Re-evaluation of the patient's status.
Evaluation and modification of the intervention
program.