Vestibular provocation nystagmus in the presence of vertigo, and more rarely

spontaneous nystagmus, possibly reduced sensitivity to caloric stimulation

Differential Diagnosis

Acute acoustic trauma in which vestibular symptoms are absent

Posttraumatic psychogenic hearing loss in which the findings are inconsistent

and vestibular symptoms absent

Treatment. It includes intravenous low-molecular-weight dextran infusion,

provided that there is no general contraindication, e.g., hypertension or

allergy. Antivertiginous drugs are given for dizziness.

Course and prognosis. The disease usually settles rapidly in young patients and

those with normal circulation. Otherwise, the symptoms, especially those of loss

of cochlear function, only resolve incompletely. Irreversible vestibular defects

are compensated centrally. Cochleovestibular symptoms, especially dizziness,

often progress in elderly patients.

Direct injures to the middle and internal ear

Symptoms. Injury of the tympanic membrane is accompanied by momentary pain,

slight bleeding from the ear, and modest deafness.

In middle ear injuries, there is profuse bleeding, pain and deafness, a

pulsating sound in the ear, and occasionally facial paralysis.

In inner ear injuries, there is immediate tinnitus, deafness, dizziness, nausea,

and vomiting.

Pathogenesis. Damage to the tympanic membrane and the middle and internal ear

may be caused by introduction of pointed objects such as matchsticks,

toothpicks, knitting needles, hairpins, and twigs into the ear, by careless

removal of foreign bodies, by occupational injuries (hot cinders, welding

sparks), by acid burns, or by gunshot wounds.

Diagnosis. Otoscopic findings include a tympanic membrane perforation with

jagged, frayed, blood-streaked, and occasionally inrolled edges. Blood is found

in the external auditory meatus mixed with perilymph in injuries to the inner

ear. Conductive deafness is found in middle ear injuries, sensorineural

deafness, or mixed deafness if the inner ear is involved, and in severe lesions

there is complete deafness and spontaneous nystagmus to the sound side. An

immediate total peripheral facial nerve paralysis is found in fractures

involving the bony tympanic segment of the facial nerve canal.

A bullet may be localized by radiographs in Schueller's or Stenver's view or by

tomograms.

Treatment. In simple tympanic membrane rupture, the fragments of the membrane

are repositioned and splinted aseptically under the operating microscope.

Systemic prophylactic antibiotics are given.

Warning: Unsterile instruments should not be used in the ear, and the ear should

not be syringed.

Combined injuries of the tympanic membrane, middle ear, and inner ear are

subjected to immediate exploration of the middle ear cavity and labyrinthine

capsule under the operating microscope (tympanoplasty). A perilymph leak, e.g.

from the round window, is stopped by closing the labyrinthine fistula.

Prophylactic antibiotics are given. A simultaneous facial nerve paralysis is

treated by decompression of the facial nerve.

Course and prognosis. Simple injuries of the tympanic membrane and middle ear

usually heal smoothly and without functional deficit if they are treated in the

correct manner by an otologist. Involvement of the labyrinth is usually followed

by irreversible cochleovestibular failure. The prognosis for the facial

paralysis is very good if continuity of the nerve has been preserved.

Barotrauma

Symptoms. They include acute pain, pulsating noise in the ear, deafness, and

occasionally vertigo and disturbance of balance.

Pathogenesis. Sudden changes in air pressure, producing an absolute or relative

reduction of pressure in the middle ear, cause bleeding into the middle ear

mucosa and into the tympanic membrane, and on occasion even rupture of the

tympanic membrane and of the round window membrane. This may occur after rapid

decompression or recompression from a low- or high-pressure chamber, a rapid

dive from a great height in a nonpressurized aircraft, or after surfacing too

quickly from deepsea diving.

The disease is caused by a sudden closure of the tube which is compressed by the

rapid rise of atmospheric pressure or by the associated increase of tissue

pressure. After about 2 h of closure of the tube, the Valsalva maneuver and

politzerization are ineffective since mucosal edema and serous-hemorrhagic

exudate of the middle ear cavity have occurred due to the reduced pressure in

the middle ear. This disorder is called aero- or barotitis.

Diagnosis. This is made from the history, from the otoscopic findings which show

retraction of the tympanic membrane, occasionally subepithelial hemorrhage in

the pars tensa, transudate behind the tympanic membrane, or a hemotympanum, and

from the finding of conductive deafness.

Treatment. It includes decongestant nose drops, catheterization of the tube,

possibly paracentesis, analgesics, and oral anti-inflammatory agents.

Prophylaxis is important by avoiding flying and diving during inflammation of

the nasopharynx, nose, and paranasal sinuses. Anatomic deformities in the nose

and nasopharynx obstructing nasal respiration and favoring the development of