LECTURE 14 Disorders of Hearing and Balance

Revise the anatomy of the inner ear, the vestibular cochlea nerve and its CNS projections.
Learn about diseases of the outer and middle ear.
Learn about disorders of the inner ear that affect hearing and balance.
Understand that CNS lesions rarely cause hearing loss.
Understand that dizziness is an imprecise term that may mean lightheadedness (as if about to feint)
or imbalance of one sort or another and recognise some of the common causes - low blood
pressure, disease of the vestibular apparatus, brain stem or cerebellar disease.

A. Ear structure//
Out ear:
Pinna collects and focuses sounds to external auditory meatus
External auditory meatus ends at the tympanic membrane (eardrum)
Damage to outer ear or middle ear or eustachian tube = CHL
(Conductive Hearing Loss)
Middle ear (tympanic cavity):
An air-filled chamber that connects with nasopharynx via eustachian
tube
Eustachian tube drains fluid to equalise pressure
Converts sounds waves into mechanical energy
Has ossicles knowns as malleus, incus, stapes
Malleus attaches to eardrum inner surface, and transmits vibrations to
incus
Incus transmits to stapes
Stapes foorplate attaches to oval window of inner ear
Outer and middle ear are part of conducting hearing system
Inner ear is part of perceiving hearing system
Inner ear
Contains convoluted fluid-filled chambers known as membranous labyrinth that enclosed
within the bony labyrinth with a thin layer of perilymph between
them
Auditory portion = cochlea
Vestibular portion (balance) = otolith organs (utricle and saccule)
and 3 semicircular canals

B. Impedance matching//
Middle ear amplifies sound to create enough force to overcome the
inertia of the inner ear fluid
Damping:
o Muscle = tensor tympani anchors malleus, and is innervated
by CN V
o Muscle = stapedius anchors stapes, and is innervated by CN
VII
 o When these 2 muscles contract, the ossicular chain (ossicles lever system) becomes
more rigid, and sound transmission becomes attenuated

C. Cochlea//
Contains three fluid-filled chambers knowns as scala vestibuli, scala media, scala tympani
o Scala vestibule and tympani = upper and lower chambers filled with perilymph
o Scala media = middle chamber. Separated from scala vestibuli
by Reissner membrane and from scala tympani by basilar
membrane.
Scala media is filled with endolymph; a fluid rich in
K+ produced by stria vascularis (specialised
epithelium)
Scala media contains organ of Corti which is the
auditory sensory organ

//Auditory Transduction
Sounds enters oval window
Stapes pushes perilymph down scala vestibuli
Passes through helicotrema at the apex, then goes down scala tympani to the cochlear base
where it encounters the round window beneath the oval window, then travels backward
towards apex
Round window is important to let stapes push perilympth by vibrating back and forth
Sound never enters the scala media, but the scala media vibrates entirely
Scala media has the organ of Corti
o Has hair cells that is covered by the tectorial membrane
o When the basilar membrane vibrates, the stereocilia on the hair cells are bent against
the tectorial membrane which triggers hair cells to fire
o https://www.youtube.com/watch?v=PeTriGTENoc
More details, check Lippincotts Physiology Page 105-109

//Balance
Vestibular system:
Has Otolith organs = utricle and saccule
Utricle detects linear acceleration
Saccule detects vertical acceleration
Has 3 Semicircular canals (anterior, posterior, lateral) that detect angular head rotation
At base of canals is a swelling (ampulla) contains a ridge (crista ampullaris) covered with
sensory hair cells, each bearing a kinocilium and stereocilia.

//Vestibulocochlear nerve
Divides into cochlear nerve and vestibular nerve
Cochlear nerve projects to organs of Corti
Vestibular nerve projects to utricle, saccule and the 3 ampullas of the semicircular canals

//Diseases of outer and middle ear

External ear:
o Congenital: Atresia
o Trauma: Foreign body
o Inflammatory:
Bacterial: Furunclosis/ Otitis Externa
 Fungal: Otomycosis
Viral
o Tumors
o Impacted Wax
** Otitis Extrna
Non-infective:
o Allergic (Eczema)
Acute: severe itching, marked oedema, redness and watery discharge
Chronic: mainly itching
o Dermatits: contact, seborrhhoeic
o Other: Psoriasis
Infective:
o Bacterial:
Localised (Furuncle)
Localised acute suppurative inflammation of a hair follicle
Organism = Staphylococcus aureus
PDF (predisposing factors): Skin laceration, diabetes
CP (Clinical Presentation): severe pain, hearing loss (if block),
tenderness, red swelling, discharge
Diffuse
Acute = Diffuse acute suppurative inflammation of EAC
Organism = S. Aureus, pseudomonas aeruginosa
CP: severe pain, hearing loss, purulent discharge (pus), diffuse
swelling, and oedema of EAC
Chronic = Less severe symptoms and signs
o Fungal (Otomycosis)
Organism = Aspergillus niger, Asp. Flavus or candida albicans
PDF: Hot humid conditions, prolonged use of antibiotics
CP: itching, pain and hearing loss, skin of EAC inflamed and fungal mass
(hyphae and spores)
o Viral
Herpes simplex: vesicles, occurs with common cold
Herpes Zoster Oticus (Ramsay Hunt Syndrome)
Pain, and vesicles on auricle and EAC
Facial paralysis
SNHL (inner ear) and vertigo
o Tumours:
Benign tumours
Bony: exostosis
Glands: ceuminoma
Malignant: SCC (Squamous Cell Carcinoma commonest)
Earache, bloody discharge, facial weakness, hearing loss
Middle ear:
o Congenital: Anomalies of the osccicles
o Trauma
Tympanic membrane perforation = hearing loss,
pain, bleeding
Haemotympanum (blood in middle ear cavity) =
hearing loss
Barotrauma (trauma due to pressure)
 o Inflammation:
Acute Otitis Media
Chronic Otitis Media
Suppurative
(CSOM)
Non Suppurative
(OME)
o Tumours
** Otitis Media
Acute Otitis Media (AOM)
o Acute suppurative inflammation of the middle ear cleft
o Aetiology:
Viral infection: Adeno, Rhino virus
Bacterial: Staph aureus, Strept. Pneumoniae, H. Influenza
o Stages of AOM
Stage of Eustachian tube obstruction
Invasion of lining of ET and oedema > Obstruction > Absorption of
air> negative pressure
Hearing loss, retracted tympanic membrane
Stages of congestion (Hyperaemia)
Inflammation extends to the mucous membrane lining of middle ear
> exudation of serous fluid > tympanic membrane hypermia> more
exudation> tympanic membrane bulge
Hearing loss, pain, red TM
Stages of suppuration
Suppuration in middle ear > temperature rise> throbbing pain
Fever, headache, malaise, hearing loss, bulging tympanic membrane
Stages of perforation
Increase middle ear pressure > pressure necrosis of tympanic
membrane > perforation
Symptoms of inflammation disappear, discharge, hearing loss, no
pain
Chronic Suppurative Otitis Media
o Failure of complete resolution: TM perforation, discharge and conductive hearing
loss
Cholesteatoma
o Sac like structure lined with Keratinizing Squamous epithelium
o Migration of epithelium vs retraction pocket
o Bone destruction (pressure necrosis) and hearing loss
Chronic Non-suppurative Otitis Media (OME)
o ET obstruction due to enlarged adenoids > negative pressure >
transudation (bubble/fluid inside middle ear)
o Hearing loss, bubbles behind tympanic membrane

Inner Ear
o Sensorineural Hearing Loss + Vertigo
o Menieres diseases (endolymphatic hydrops)
Disorder of the endolymphatic system characterised by distension of
membranous labyrinth due to increased volume of endolymph
Recurrent attacks of tetrad:
 Vertigo
Tinnitus
SNHL
Ear presuure
One of commonest causes of vertigo
o Congenital inner ear disorders
Aplasia or hypoplasia = SNHL since birth
o Trauma
Acoustic trauma
Damage to the cochlea due to exposure of loud sounds
Very brief + very loud (gunfire)
Prolonged exposure + loud sound (industrial)
Temporal bone fracture
SNHL
Vertigo
o Inner ear inflammation (Labyrinthitis)
Vertigo + SNHL
OM, measles, mumps or meningitis
o Degenerative
Presbycusis: degeneration of cochlear end organ
Bilateral SNHL
Commonest cause of SNHL in adults
o Ototoxicity
Degeneration of inner ear due to drungs
Aminoglycosides (gentamicin), diuretics (furosemide), cytotoxic drugs,
quinines, salicylate
Bilateral SNHL + vertigo

Disorders of Vestibulocochlear Nerve

o Vestibular Neuronitis
Inflammation of vestibular nerve probably viral infection
Sudden severe vertigo that last for days, no HL
o Neoplastic = Vestibular schwannoma (Acoustic neuroma)
Benign tumour arising from the sheath of VII nerve
Vertigo + HL

o Central vertigo (diseases of brain)

Strokes esp. cerebellum
Tumours
Encephalitis