Common Ear Problems

Chronic ETD Complications?

Vestibular symptoms Facial palsy Intracranial complications

Ear wax impaction causes and sx?

Wax is produced in the outer half of the ear canal and migrates outwards along with the canal skin. Instrumentation can cause impaction Wax impaction can cause hearing loss, pain, tinnitus, vertigo, or chronic cough but not usually with discharge. Sudden expansion after getting water in can cause sudden deafness or pain, but needs careful exclusion of other pathology behind the obstruction e.g. infection

Cholesteatoma otoscopic view?

a pearly white mass usually in the pars tensa +/- discharge and sometimes erosion of the bone. A perforation is usually present, but is not always visible due to overlying keratin. Granulation tissue or polyps may be seen due to chronic inflammation and sometimes retraction pockets are present. A crust adherent to the tympanic membrane is indicative of a cholesteatoma

What is Cholesteotoma?

a three dimensional epidermoid structure exhibiting independent growth, replacing middle ear mucosa, resorbing underlying bone, and tending to recur after removal

Where are safe perforation locations?

a) In the anterior region or b) In the inferior region c) And not involving the eardrum margin

Where are unsafe perforation locations?

a) In the attic or b) In the posterior region. These are often linear rather than oval c) Or involve the eardrum margin

Peak prevalence of otitis media?

between ages of 6 months and 3 years MOST common dx in children

Acute serous otitis media sx?

feeling of pressure or fullness in the ears, often accompanied by hearing loss and crackling or popping while swallowing

What is Acute Serous Otitis Media?

fluid is present in the middle ear for an extended period in the absence of signs and symptoms of infection. In general, acute effusions are self-limited; most resolve in 2-4 weeks or 3 months

What is Auricular Cellulitis?

infection of the skin overlying the external ear

Acute otitis media risk factors?

o Passive smoker o Male o Family history of otitis media. o In day care o On formula feed

Very common ddx for ear pain?

otitis media cerumen impaction

Cholesteotoma treatment?

surgical marsupialization of the sac or its complete removal. This may require the creation of a "mastoid bowl" in which the ear canal and mastoid are joined into a large common cavity that must be periodically cleaned Treatment depends on whether condition is associated with a cholesteatoma With cholesteatoma: Refer to otolaryngologist for surgical treatment Without cholesteatoma: Resolve infection with antibiotics and irrigation, then mastoidectomy can be avoided

auricular cellulitis presentation?

tenderness, erythema, swelling, and warmth of the external ear, particularly the lobule without apparent involvement of the ear canal or inner structures.

Management of Auricular Cellulitis?

warm compresses oral antibiotics -cephalexin (Keflex) or dicloxacillin

When to refer to Otolaryngologist for Ear Wax?

′ Known tympanic membrane perforation ′ Previous ear surgery (needs micro suction) ′ Only hearing ear ′ Syringing/irrigation fails ′ Causing pain or vertigo ′ Hearing loss persists after wax removal

Chronic Otitis Media s/s?

′ Recurrent ear discharge ′ Hearing loss, painless ′ Perforation of the TM - central ′ Presence of cholesteatoma ′ Marginal, Attic perforation ′ Offensive discharge, bleeding, granulations

Two stages of otitis externa?

1. Acute inflammatory stage Bacterial infection occurs; patient experiences pain in the affected ear As infection becomes more severe, pain and swelling in the external auditory canal increase 2. Chronic inflammatory stage Characterized by marked thickening of skin of the external auditory canal Examination reveals flakes of dry, scaly skin in the canal; often, the lumen of the canal is significantly narrowed

Otitis Externa presentation?

1. Pain (often severe) 2. Pruritus 3. Hearing loss 4. Fullness, a "plugged" sensation Pain when pressure is placed on the tragus is strongly suggestive of otitis externa. Inflammation and swelling of the pinna itself is indicative of a more severe infection and an otolaryngology consultation is indicated.

Ear wax impaction management?

Cotton tip applicators ( Q-tips) ARE NOT your friend If symptomatic- topical medication. Sodium bicarbonate drops might be better if disintegrating wax, but can cause dryness of the canal and/ or irritation Lubrication- olive oil, mineral oil Syringing- Half warm water / half hydrogen peroxide - irrigating slowly while pointing tip of syringe superiorly in the canal Avoid- if organic material (i.e. vegetables, this can swell and occlude the ear)

Furunculosis Treatment?

Drain fluctuant areas and apply topical antibiotics. Systemic antibiotics are only necessary if cellulitis or systemic symptoms are noted Treatment typically consists of an oral anti-staphylococcal penicillin (e.g., dicloxacillin or cephalexin)

Chronic Serous Otitis Media (otitis media with effusion) features?

Effusion is present for at least 3 months characterized by persistent or recurrent purulent otorrhea in the setting of TM perforation. Usually, there is also some degree of conductive hearing loss

Causes of chronic serous otitis media?

Eustachian tube dysfunction Allergies Abnormalities of the adenoids, sinuses, or nasopharynx may be responsible

Herpes Zoster Oticus (Ramsay Hunt Syndrome) severe presentation?

Facial nerve paralysis, (Bell's Palsy) or hearing loss, balance disorders

chronic serous otitis media presentation?

Feeling of fullness in the ear and hearing loss without pain. PE similar to those for acute serous otitis media

Healing phase of acute otitis media?

Healing phase, lasts 2-4 weeks, tympanic membrane and middle ear normalize

chronic serous otitis media ddx?

Hemotympanum and CSF leak associated with significant bilateral hearing loss

Otitis Externa features?

Infection of the auditory canal= Swimmer's ear Usually unilateral Gradual onset Risk factors- trauma, water, immunosuppression, eczema

What is Perichondritis and Chondritis?

Infection of the perichondrium of the auricular cartilage, typically follows local trauma (e.g., piercings, burns, or lacerations). Occasionally, when the infection spreads down to the cartilage of the pinna itself, patients may develop chondritis.

Etiology of inner ear pain?

Inner ear problems are located at the tympanic membrane or deep to it and include acute otitis media (OM)—the single most common cause of ear pain Injuries to the tympanic membrane, which can occur from barotrauma or from direct trauma to the ear, can also cause ear pain

Rare ddx for ear pain?

Mastoiditis Ear tumors (eosinophyllic granulomas, rhabdosarcomas)

Middle phase acute otitis media?

Middle phase, lasts 3-8 days, purulent effusion often discharges spontaneously; fever and pain subside With bacterial infection, the TM can also be erythematous, bulging, or retracted and occasionally can perforate spontaneously

How to pull the pinna when conducting and ENT exam?

Newborn: The canal may be partly straightened by pulling the pinna backwards and upwards during examination In infants pull the pinna more horizontally backwards as the shape of the ear canal is different Adults: Pull the pinna gently upward, outwards and backwards to extend the ear canal

Acute Serous Otitis Media cause?

Often precedes or follows an episode of acute suppurative otitis media. May also be associated with conditions that cause eustachian tube dysfunction

What do you see with early phase acute otitis media?

On otoscopy, tympanic membrane shows hyperemia, opacification, loss of landmarks. Mastoid tenderness is common Fluid in the middle ear is typically demonstrated or confirmed with pneumatic otoscopy Early phase, lasts 1-2 days, characterized by fever; severe, pulsating pain; hearing loss.

Common ddx for ear pain?

Otitis externa Referred pain from throat/ temporal bone

What will you see on otoscopic exam of acute otitis media?

Otitis media with purulent material seen behind the tympanic membrane

Etiology of outer ear pain?

Outer ear problems are located external to the tympanic membrane and include otitis externa, ear canal foreign bodies, earwax, and mastoiditis

Most common pathogens for Perichondritis and Chondritis?

P. aeruginosa and S. aureus

Otitis Externa common pathogens?

P. aeruginosa and S. aureus the most common pathogens.

Herpes Zoster Oticus (Ramsay Hunt Syndrome) presentation?

Pain out of proportion to the physical findings may be due to herpes zoster oticus, especially when vesicles appear in the ear canal or concha Painful herpetic lesions on auricle and in external auditory canal. could just be referred pain because of the rich nerve supply of the ear

Otitis externa pathogenesis?

Particularly common during summer months Caused by breakdown of protective barrier normally formed by skin and cerumen

Perichondritis and Chondritis presentation?

Patients often present with a diffusely swollen and exquisitely tender pinna The infection may closely resemble auricular cellulitis, with erythema, swelling, and extreme tenderness of the pinna, although the lobule is less often involved in perichondritis.

External Ear anatomy and what to check for?

Pinna- shape, color, position, tenderness swelling or hematoma Mastoid- erythema, swelling, tenderness or pain to palpation

Perichondritis and Chondritis Treatment?

REFERRAL. Administer intravenous antibiotics Antipseudomonal- pipercillin, nafcillin (Nallpen) & ciprofloxacin (Cipro)-

Acute otitis media referral?

Refer adult patients with acute serous otitis media unilateral and outside the setting of an upper respiratory tract infection Rule out obstruction of the eustachian tube by a nasopharyngeal mass

Cholesteotoma management?

Referral Otolaryngologist

Clinicians should consider and exclude the following 4 serious diagnoses in any patient with ear pain?

Referred pain from malignancy necrotizing (malignant) external otitis temporal arteritis mastoiditis

What to look for in Malignant Otitis Externa?

Risk factors; Diabetes, Elderly Signs & Symptoms- Otalgia, (Severe, deep-seated otalgia, frequently out of proportion to findings on examination ), ottorhea, hoarseness, puffiness, trismus, failure to respond to drops, granulation, CN palsies

Furunculosis usual pathogen?

S. aureus is the usual pathogen

Pathogens for auricular cellulitis?

S.Aureus, streptococci

Safe vs Unsafe Perforations

Safe perforations ′ may allow infection to enter the middle ear ′ conductive deafness Unsafe perforations ′ Represents as a retraction of the tympanic membrane. ′ Essentially a part of the drum becomes sucked inwards and may gradually enlarge. ′ When the retraction becomes extensive, keratinous debris builds up in the retraction and may become infected and an acquired cholesteatoma develops

What is Malignant Otitis Externa?

Severe infection due to Pseudomonas aeruginosa & anaerobes causing osteomyelitis of the skull base Risk factors in elderly life-threatening Facial nerve palsy- 50% of patients, CN IX to CN XII may also be involved Tx: referral treat against pseudamonas, Cipro

Causes of Acute Otitis Media?

Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis group A streptococci Acute otitis media results when pathogens from the nasopharynx are introduced into the inflammatory fluid collected in the middle ear (e.g., by nose blowing during a URI) Pathogenic proliferation in this space leads to the development of the typical signs and symptoms of acute middle-ear infection.

Internal Ear anatomy and what to check for?

The Canal- skin, spores, foreign body, discharge, debris, or wax Tympanic membrane- look anteriorly. Posteriorly, superiorly and inferiorly of malleus

What to check the TM for?

The Canal- skin, spores, foreign body, discharge, debris, or wax Tympanic membrane- look anteriorly. Posteriorly, superiorly and inferiorly of malleus Color- opaque, white, red, patches & translucency Retraction- landmarks behind TM are more visible Perforation- safe vs unsafe Discharge- mucopurulent Fluid behind the drum- meniscus, color, bubbles Any red bits- glomus tumor, granulations or blood? White- chlesteotoma

What does the diagnosis of acute otitis media require?

The diagnosis of acute otitis media requires the demonstration of fluid in the middle ear (with tympanic membrane [TM] immobility). Otitis media (OM) may be defined as inflammation of the middle ear due to any cause. It is the second most common disease diagnosed in young children.

Innervation of the ear?

The ear is innervated by different neural pathways (7th,9th,10th CN) The conchae and external canal primary sensory from somatic fibers of the facial nerve (7th cranial nerve) Parts of external auditory canal also receives innervation from the auricular branch of vagus (Arnold's nerve) which contains nerve fibers from 7th, 9th and 10th nerves The middle ear receives its neural innervation through branches of the glossopharyngeal nerve (9th CN) -This nerve also innervates throat and tongue = common for throat pain to be referred to the middle ear

Cholestetoma MCC?

The most common cause is prolonged eustachian tube dysfunction, with inward migration of the upper flaccid portion of the tympanic membrane this creates a squamous epithelium-lined sac, which—when its neck becomes obstructed—may fill with desquamated keratin and become chronically infected

Safe Interior Perforation

This is more likely to be as a result of chronic middle ear infection

Herpes Zoster Oticus (Ramsay Hunt Syndrome) Treatment?

Treatment: Bell's palsy can progress to a severe, complete facial nerve paralysis Prednisone 60 mg/d PO tapered over 3 wk Valacyclovir (Valtrex)1000 mg PO q8h x 7 d Analgesics- ( Ibuprofen, Narcotics) Referral to an otolaryngologist is warranted for these patients

Treatment of Acute Serous Otitis Media?

Address causes of eustachian tube dysfunction and eradicate causative organism o Antihistamines: For patients with allergic rhinitis o Decongestants: For patients with viral rhinosinusitis o Antibiotics: Warranted to ensure sterilization of the effusion

What is Herpes Zoster Oticus (Ramsay Hunt Syndrome)?

Caused by infection of the cranial nerve ganglia, most likely by the virus that causes chicken pox.

Cholesteatoma pathophys?

Cholesteatomas typically erode bone, with early penetration of the mastoid and destruction of the ossicular chain Over time they may erode into the inner ear, involve the facial nerve, and on rare occasions spread intracranially

Chronic ETD PE?

Chronic ETD may reveal retraction pockets or collapsed middle ear disease with erosion of incus/stapedius. Difficulty auto-inflating the ear drum Generally, the fluid clears spontaneously over a period of several weeks

What is Eustachian Tube Dysfunction?

Chronic blockage of the Eustachian tube The eustachian tube becomes congested and swollen so that it may temporarily close; this prevents air flow behind the ear drum and causes ear pressure, pain or popping just as you experience with altitude change when travelling on an airplane or an elevator. Generally clears on its own

What is Furunculosis?

Circumscribed swellings, which may be single or multiple, are noted in the cartilaginous portion of the external auditory canal Acute localized otitis externa (furunculosis) can develop in the outer third of the ear canal, where skin overlies cartilage and hair follicles are numerous

Acute Otitis Media features?

Common in children Unwell/pyrexia, otalgia/discharge there may be tenderness over the mastoid discharge in meatus loss of outline of drum and landmarks TM: red, bulging, oedematous or perforation Mostly viral but can be Streptococcus/Haemophilus

How should you confirm the diagnosis of acute serous otitis media?

Confirmed using tympanometry or pneumo-otoscopy. A flat configuration will be seen on tympanometry, and tympanic membrane hypomobility will be seen on pneumo-otoscopy

Management of Chronic Serous Otitis Media?

Consider use of decongestants and antihistamines May also consider Short course oral corticosteroids (eg, prednisone, 40 mg daily orally for 7 days)

What are the common variants of acute otitis media?

(1) acute otitis media (AOM) and (2) otitis media with effusion (OME).

Otitis Externa treatment?

Acedic otic topical antibiotics Neomycin/polymixin B ear drops Oxyfloxin ear drops Usually corticosteroids are added to decrease canal edema Treats -Pseudomonas Systemic antimicrobial agents typically are reserved for severe disease or infections in immunocompromised hosts WARNING- Aminoglycosides, neomycin should be avoided if TM ruptured or not visualized= OTOTOXIC

MCC of ear pain?

Acute otitis media (OM)

Ear Pain Alarm symptoms

1. Weight loss/Referred pain: from a malignancy usually has been present for some time. In a series of patients with referred pain, the time between onset of ear pain and tumor diagnosis ranged from 4 to 21 months, with a mean of 7.5 months These patients are typically older mean age at diagnosis was 55.8 years 2. Persistent Ear Discharge: Necrotizing (malignant) external otitis is a rare condition in which external otitis progresses to invade the temporal bone and adjacent structures -Exclusively due to infection with Pseudomonas aeruginosa -Occurs in immunocompromised patients, especially older diabetic patients 3. Jaw Claudication: Consider temporal arteritis when a patient over the age of 50 reports acute or subacute onset of headache, pain in the temporal area, or scalp tenderness 4. Mastoiditis generally occurs in children when OM spreads to the mastoid air cells behind the ear. A typical presentation is fever with postauricular swelling, tenderness, and erythema

Eustachian Tube Dysfunction otoscopic view

A severely retracted eardrum. Margins are very clear as is the malleus and it looks very sunken.

When should you avoid ototoxic drugs?

Aminoglycosides, neomycin should be avoided if TM ruptured or not visualized

When to do surgery for otitis media?

Antibiotic therapy or myringotomy with insertion of tympanostomy tubes typically is reserved for patients in whom bilateral effusion (1) has persisted for at least 3 months and (2) is associated with significant bilateral hearing loss.

Management & Treatment of Otitis Media?

Antibiotic therapy- FIRST LINE THERAPY Amoxicillin (80-100 mg/kg) in divided doses Amoxicillin-clavulanic acid, cefuroxime, or trimethoprim-sulfamethoxazole may also be used

Unsafe Attic Perforation

Any defect or apparent perforation in the attic must be considered unsafe and should be referred for ENT assessment. This crust in the attic represents a large underlying cholesteatoma sac. Note the bulging eardrum too

Where should you always check on otoscopy exam?

Attic area