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HeadNeckPA

ENT Pic of the Day, 4-3-11

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The picture below (albeit not a great one) is from the middle ear of a 67 yr-old male with a complicted past medical history including CAD, HTN and uncontrolled type II DM that is further complicated by diabetic neuropathy, prior amputation of the left forefoot and ongoing hyperbaric therapy for a chronic right heel ulcer. His medication list is extensive as one might imagine.

 

He presents to you with a one day history of severe ear pain and associated hearing loss on the same side. You look in the ear and see the image below.......audiogram reveals a 30 dB air-bone gap on the affected side in the setting of high frequency sensori-neural loss .

 

What are your thoughts? What treatment would you suggest?

 

hemotympanum2.jpg

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audiogram reveals a 30 dB air-bone gap on the affected side in the setting of high frequency sensori-neural loss .

 

 

 

can you expound on what this means clincally? (I don't do testing in primary care)

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High frequency SNHL is essentially consistent with age-related hearing loss or presbycusis.....

 

The air-bone gap in this setting is basically indicative of a conductive hearing loss......so this patient has a mixed hearing loss.

 

Assume the SNHL is age related. What you want to focus on then is a history of abrupt onset of pain in conjunction with a conductive loss. Weber test lateralizes to this affected side........now with the picture shown, what do you think may be the source/ cause of these symptoms

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Ok, so maybe this one was a little tough. The kicker here is to pick up on the hyperbaric treatments for his diabetic leg wounds.

 

This patient has suffered from barotrauma secondary to the hyperbaric chamber. He now has blood in the middle ear space, or hemotympanum (reddish hue in bottom right of picture). Anytime you have fluid behind the TM you have a conductive hearing loss to some degree, as in this case.

 

The patient's history of high frequency sensorineural loss is attributed to his age and has nothing to do with the barotrauma.

 

On to the next case............

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Barotitis Media, I would say observe, rarely requires a myringotomy.

 

Incorrect.....this patient requires multiple treatments in the hyperbaric chamber. Standard of care is myringotomy with placement of a tube. In select cases of barotrauma ( ie single flight ) you may be able to observe but not in this case. This patient can not return to the chamber without a tube.

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Incorrect.....this patient requires multiple treatments in the hyperbaric chamber. Standard of care is myringotomy with placement of a tube. In select cases of barotrauma ( ie single flight ) you may be able to observe but not in this case. This patient can not return to the chamber without a tube.

 

I see your point. I was making the assumption that their hyperbaric txs were done.

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As a former submariner and diver, this would be a TEED III Barotrauma, "squeeze"

 

What amazes me is that the chamber operator allowed this to happen.. The pain as he progressed thru stage I and II woulda been substantive.. And the chamber companion or outside dive master shoulda slowed the descent down, or stopped it until he could equalize. The in chamber operator coulda given nasal or eustacian osteum decongestant / vasoconstrictor spraying.. These squeezes rarely occur in appropriately managed pressure. ( I am assuming the PT was conscious and not so sedated as to be insensate.. Even so , to be sedated to the point of not responding to this pain would pretty much preclude pressure at all.)

 

Just my 2 cents.

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Interestingly, I had a case today with this exact same diagnosis. 54 y/o female c/ o right sided hearing loss x 3 days. On Sunday she went to get certified in scuba making her first dive in a rock quarry here in NC. On exam, there was an obvious hemotympanum on the right, and a distorted, obscured drum on the left. I called the ENT on call, and she will be seen tomorrow at 1 PM.

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Interestingly, I had a case today with this exact same diagnosis. 54 y/o female c/ o right sided hearing loss x 3 days. On Sunday she went to get certified in scuba making her first dive in a rock quarry here in NC. On exam, there was an obvious hemotympanum on the right, and a distorted, obscured drum on the left. I called the ENT on call, and she will be seen tomorrow at 1 PM.

 

The big difference here is the treatment! If the person plans to continue diving, then they absolutely can not have a tube placed. there have been cases of divers drowning because water went down the tube and caused severe vertigo resulting in disorientation and subsequent death......if this person had a hemotympanum from a single dive I would say their days of diving are numbered........

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If I see her back soon, will keep you posted on the outcome. I do know she planned a vacation in May to the Caribbean expressly for diving. My feelings were she was not going to be able to make this trip, but left it up to ENT to discuss that with her.

 

What about a simple myringotomy without tube placement for treatment?

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That should be okay, with no diving until normal Tympanogram and ability to clear with valsalva. If she cannot clear than she should be restricted to 1 ATM pressure( 33 feet) or less, if allowed to dive at all.

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If I see her back soon, will keep you posted on the outcome. I do know she planned a vacation in May to the Caribbean expressly for diving. My feelings were she was not going to be able to make this trip, but left it up to ENT to discuss that with her.

 

What about a simple myringotomy without tube placement for treatment?

 

It's reasonable to do a myringotomy and aspiration with the understanding that their may not be any diving in May. I would also be sure to have this in writing and ensure follow-up to protect yourself. Most myringotomies heal extremely fast, but on occasion the patient can have a persistant perf. ETD in patients who dive can be a real challenge.

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