Chapter 8

Ear, Nose, and Throat Surgery

1 What is the most common cause of lower motor neuron facial nerve paralysis? What are the classic symptoms?

The most common cause is Bell palsy. Look for sudden unilateral onset, usually after an upper respiratory infection (URI). The cause is thought to be a reactivation of latent herpes simplex 1 infection in most cases. Patients may have hyperacusis, in which everything sounds loud because the stapedius muscle in the ear is paralyzed. In severe cases, patients may be unable to close the affected eye; if so, use drops to keep the eye moist. Most cases resolve spontaneously in about 1 month, although some have permanent sequelae. Oral prednisone and antiviral treatment for herpes (e.g., valacyclovir, acyclovir) may improve outcomes and lessen duration of symptoms.

2 What are the other causes of lower motor neuron facial nerve paralysis?

 Herpes infection (Ramsay Hunt syndrome), which commonly involves the eighth nerve. Look for vesicles on the pinna and inside the ear; encephalitis or meningitis may be present.

 Lyme disease (one of the most common causes of bilateral facial nerve palsy)

 Stroke

 Middle ear or mastoid infection

 Meningitis

 Temporal bone fracture (look for Battle sign and/or bleeding from the ear)

 Tumor, classically an acoustic schwannoma (i.e., neuroma) of the cerebellopontine angle (Fig. 8-1)

Order a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the head if the cause is not apparent or if the history or physical exam raises suspicion—especially in the presence of additional neurologic signs.

3 What are the common causes of hearing loss?

The most common cause is aging (presbyacusis); prescribe a hearing aid, if needed. The history may suggest other causes:

 Prolonged or intense exposure to loud noise (e.g., work-related).

 Congenital TORCH infection (toxoplasmosis, others, rubella, cytomegalovirus, herpes virus).

 Ménière disease (accompanied by severe vertigo, tinnitus, nausea and vomiting; treat acute episodes with benzodiazepines, anticholinergics [scopolamine], and antihistamines [meclizine or dimenhydrinate]; diuretics are often used for ongoing treatment; surgery may be used for refractory cases).

 Drugs (e.g., aminoglycosides, aspirin, quinine, loop diuretics, cisplatin).

 Tumor (classically acoustic neuroma).

 Labyrinthitis (may be viral or follow or extend from meningitis or otitis media).

 Miscellaneous causes (diabetes, hypothyroidism, multiple sclerosis, sarcoidosis, pseudotumor cerebri).

4 What is the usual cause of sudden deafness?

Sudden sensorineural hearing loss (SSNHL) involves acute unexplained hearing loss that is usually unilateral and occurs over hours (usually less than 72 hours). More than 90% of patients with SSNHL report tinnitus. Most cases are idiopathic but have been postulated to be caused by viral causes, microvascular events, or autoimmune causes. Physical examination is unremarkable. MRI is indicated to rule out etiologies such as acoustic neuroma, multiple sclerosis, or vascular insufficiency. Glucocorticoids (administered orally or by intratympanic injection) are considered first line therapy; antiviral agents are sometimes used, although there is not much evidence to support their use. Two thirds of patients recover, although the resolution is often not complete. Among those who recover, hearing usually returns within 2 weeks.

5 What is the most common cause of acquired hearing loss in children?

Bacterial meningitis. All children should receive formal hearing testing after a bout of meningitis.

6 What are the common causes of vertigo?

Vertigo can result from the same eighth cranial nerve lesions that cause hearing loss (Ménière disease, tumor, infection, multiple sclerosis). Another common cause is benign positional (paroxysmal) vertigo, which is induced by certain head positions, may be accompanied by nystagmus, and is not associated with hearing loss. This condition often resolves spontaneously; no treatment is required. Epley maneuver, or modified Epley maneuvers, may help with resolution of symptoms.

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