Chapter 70 / Otolaryngology: Head and Neck Surgery 595

What are the signs/symptoms	Otorrhea and hearing loss
of chronic otitis media?
OTOSCLEROSIS
What is it?	Genetic disease characterized by abnormal
	spongy and sclerotic bone formation in
	the temporal bone around the footplate
	of the stapes, thus preventing its normal
	movement
What is the inheritance	Autosomal dominant with incomplete
pattern?	one-third penetrance
What are the symptoms?	Painless, progressive hearing loss (may be
	unilateral or bilateral), tinnitus
What is the usual age of	Second through fourth decade
onset?
How is the diagnosis made?	Normal TM with conductive hearing loss
	and no middle-ear effusion (though may
	be mixed or even sensorineural if bone of
	cochlea is affected)
What is Schwartze’s sign?	Erythema around the stapes from
	hypervascularity of new bone formation
What is the treatment?	Frequently surgical (stapedectomy with
	placement of prosthesis), hearing aids, or
	observation; sodium fluoride may be used
	if a sensorineural component is present
	or for preoperative stabilization

MISCELLANEOUS

FACIAL NERVE PARALYSIS

How is the defect localized? Supranuclear—paralysis of lower face only, forehead muscles are spared because of bilateral corticobulbar supply

Intratemporal bone—paralysis of upper and lower face, decreased tearing, altered taste, absent stapedius reflex

Distal to stylomastoid foramen—paralysis of facial muscles only

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What are the causes?	Bell’s palsy
	Trauma
	Cholesteatoma
	Tumor (carcinoma, glomus jugulare)
	Herpes zoster inflammation of geniculate
	ganglion (Ramsay-Hunt syndrome)
	Peripheral lesions are usually parotid
	gland tumors
What is the most common	Lyme disease (Borrelia burgdorferi)
cause of bilateral facial
nerve palsy?
BELL’S PALSY
What is it?	Sudden onset, unilateral facial weakness
	or paralysis in absence of CNS, ear, or
	cerebellopontine angle disease (i.e., no
	identifiable cause)
What is the clinical course?	Acute onset, with greatest muscle
	weakness reached within 3 weeks
What is the incidence?	Most common cause of unilateral facial
	weakness/paralysis
What is the pathogenesis?	Unknown; most widely accepted hypothesis
	is viral etiology (herpes virus); ischemic and
	immunologic factors are also implicated
What is the common	URI
preceding event?
What are the signs/	Pathology is related to swelling of the
symptoms?	facial nerve; may present with total facial
	paralysis, altered lacrimation, increased
	tearing on affected side, change in taste if
	region above chorda tympani is affected,
	dry mouth, and hyperacusis
What is the treatment?	Usually none is required, as most cases
	resolve spontaneously in 1 month;
	protect eye with drops and tape closed
	as needed; most otolaryngologists
	advocate steroids and acyclovir
	Surgical decompression of CN VII is
	indicated if paralysis progresses or
	tests indicate deterioration

Chapter 70 / Otolaryngology: Head and Neck Surgery 597
What is the prognosis?	Overall, 90% of patients recover
	completely; if paralysis is incomplete,
	95% to 100% will recover without
	sequelae
SENSORINEURAL HEARING LOSS
What is it?	Hearing loss from a lesion occurring in
	the cochlea or acoustic nerve, rather than
	the external or middle ear
What are the symptoms?	Distortion of hearing, impaired speech
	discrimination, tinnitus
What are the signs?	Air conduction is better than bone
	conduction (positive Rinne test), Weber

lateralizes to the side without the defect; audiogram most commonly shows greatest loss in high-frequency tones

What is the Weber vs. Rinne test?

Weber: tuning fork on middle of head (lateral louder either ipsilateral conductive loss or contralateral sensorineural)

Rinne: tuning fork on mastoid and then next to ear (conductive loss louder on mastoid)

What are the causes?	Aging (presbycusis)—leading cause
	Acoustic injury from sudden or
	prolonged exposure to loud noises
	Perilymph fistula
	Congenital (TORCHES: maternal
	TOxoplasmosis, Rubella, CMV,
	HErpes, and Syphilis)
	Ménière’s disease
	Drug/toxin-induced
	Acoustic neuroma
	Pseudotumor cerebri
	CNS disease
	Endocrine disorders
	Sarcoidosis
What is the most common	Meningitis (bacterial)
cause in children?

598 Section III / Subspecialty Surgery
What is the treatment?	Treatment of underlying cause, hearing
	aids, lip reading, cochlear implant
VERTIGO
What is it?	Sensation of head/body movement, or
	movement of surroundings (usually
	rotational)
What is the cause?	Asymmetric neuronal activity between
	right and left vestibular systems
What is the history of	Severe vertigo, nausea, vomiting, always
peripheral vertigo?	accompanied by horizontal or rotatory
	nystagmus (fast component almost always
	to side opposite disease), other evidence
	of inner ear disease (tinnitus, hearing loss)

What are the risk factors for peripheral vertigo?

What is the history of central vertigo?

Frequently associated with a previously operated ear, a chronic draining ear, barotrauma, or head trauma

Found in brainstem or cerebellum: insidious onset, less intense and more subtle sensation of vertigo; occasionally, vertical nystagmus

What are the steps in diagnostic evaluation?

Depends on probability of central versus peripheral; careful neurologic and otologic examinations are required

May need FTA/VDRL (syphilis), temporal bone scans/CT scan/MRI, ENG, position testing, audiometric testing

What is the most common	Benign Paroxysmal Positional Vertigo
etiology?	(BPPV); history of brief spells of severe
	vertigo with specific head positions
What is the differential	Central: vertebral basilar insufficiency
diagnosis?	(often in older patients with DJD of
	spine), Wallenberg syndrome, MS,
	epilepsy, migraine
	Peripheral: BPPV, motion sickness,
	syphilis, Ménière’s disease, vestibular
	neuronitis, labyrinthitis, acoustic
	neuroma, syphilis, perilymph fistula

Chapter 70 / Otolaryngology: Head and Neck Surgery 599
What is Tullio’s	Induction of vertigo by loud noises;
phenomenon?	classically, result of otosyphilis
MÉNIÈRE’S DISEASE
What is it?	Disorder of the membranous labyrinth,
	causing fluctuating sensorineural hearing
	loss, episodic vertigo, nystagmus, tinnitus,
	and aural fullness, N/V
What is the classic triad?	Hearing loss, Tinnitus, Vertigo (H, T, V)
What is the	Obscure, but most experts believe
pathophysiology?	excessive production/defective resorption
	of endolymph
What is the medical	Salt restriction, diuretics (thiazides),
treatment?	antinausea agents; occasionally diazepam
	is added; 80% of patients respond to
	medical management, antihistamines
What are the indications for	Surgery is offered to those who fail medical
surgery?	treatment or who have incapacitating
	vertigo (60%–80% effective)
What are the surgical	1. Shunt from membranous labyrinth to
options?	subarachnoid space
	2. Vestibular neurectomy
	3. Severe cases with hearing loss:
	labyrinthectomy
GLOMUS TUMORS
What are they?	Benign, slow-growing tumors arising in
	glomus bodies found in the adventitial
	layer of blood vessels; often associated
	with cranial nerves IX and X in the middle
	ear
What is the usual location?	Middle ear, jugular bulb, course of CN
	IX to XII
How common are they?	Most common benign tumor of the
	temporal bone