Earache
malignant otitis externa
an invasive infection of the external auditory canal and skull base, which typically occurs in elderly patients with diabetes mellitus. Increasing reports of malignant external otitis in patients infected with the human immunodeficiency virus (HIV) implicate a compromised immune system as a predisposing factor in this disease.
evaluate CN VII
anterior two thirds of tongue and sensation to external ear sweet and salty
Inspect external ear
battle sign eczema, seborrheic dermatitis,psoriasis- redness/scaliness of the skin that can extend into the external ear canal pain in opening of the ear canal and inflamed skin may be suggestive of bacterial infection fungal and yeast infections appear as white or dark patches furuncles or lesions secondary to trauma or irritation appear as localized areas of tenderness or swelling. hot,swollen, erythematous ear and surrounding skin indicate cellulitis redness/painful swelling over the mastoid process is a sign of infection in the mastoid air cells.
cholesteatoma
collection of skin cells and cholesterol in a sac within the middle ear cyst-like mass behind the ear drum can be caused by chronic otitis media can grow to cause necrosis of ossicles can be life threatening if left untreated bc it will continue to erode away medially to impinge on intracranial structures -can also occur congenitally -commonly located in pars flaccida area in superior anterior quadrant of TM
Other organ system
diabetes- predisposes adults to malignant otitis externa (cellulitis involving ear and surrounding tissue). Also at increased risk for OM, mastoiditis, osteomyelitis of skull base immunosuppression- tx for cancer, HIV, AIDs increased risk for malignant otitis externa hx of seborrheic dermatitis or psoriasis- increase of debris in external canal and thickening of epidermis, overproduction of sebum. cleft palate- functional obstruction of eustachian tubes
Hearing Loss
difficulty in hearing- can indicate blockage of ear canal by cerumen or foreing body, inflammation of middle or inner ear, or a neoplasm. Most frequent cause is conductive hearing loss cause by blockage of the external canal usually by cerumen. hearing loss in children- chronic otitis media w/effusion causes a conductive hearing loss in children. May be caused by negative middle ear pressure, the presence of an effusion in the middle ear or structural damage to the TM or ossicles. dizziness, ringing in ear-hearing loss associated w/dizziness,vertigo or tinnitus may indicate serious inner ear condition such as acoustic neruoma or meniere disease. Abnormal middle ear ventilation and middle ear effusion are the most common causes of balance disturbance in children. They are caused by aeration in the middle ear cavity as effusion clears.
History of trauma or injury
ear trauma- perforation of eardrum can be caused by blunt or penetrating trauma. Blunt trauma= slap to the ear or barotrauma. Penetrating trauma= self induced qtips, sharp objects to remove cerumen head trauma- direct injury to the inner ear by fx of the petrous temporal bone, located at base of skull also destroys the inner ear cerumen impaction- accumulation can cause hearing loss, tinnitus, pressure sensation, vertigo and infection. Self cleaning practices can produce trauma to the canal and cerumen-softening solutions can cause chemical irritation to the canal tissue. foreign body- feathers, beads, insects can produce ear pain and inflammation. children often self-insert objects into the ear canal. insect bites- can lead to acute pain and tenderness of external canal and may develop into a secondary infection loud noise- exposure to high-pitched and loud noise for a prolonged period of time destroys cochlear hair cells. Exposure to noisy work environments, to the operation of heavy machinery and to loud music increases the risk of injury and eventual hearing loss.
Referred pain in adults
earache is more often from external ear conditions or from referred pain from other head and neck structures. -50% of referred pain is caused by dental problems -other causes include TMJ disorder, parotitis, pharyngitis, cervical, mouth or facial disorder -most serious (but less common) is nasopharyngeal cancer (more common in patients of Asian descent)
examine related body systems
head, neck conjunctiva, mucosa/patency of nose, percussion and palpation of frontal and maxillary sinuses for tenderness, inspection of posterior pharynx for lympedema, color, presence of exudate inspect condition of oral mucosa, teeth and gums palpation of cervicofacial lymph nodes (esp preauricular and post auricular)
mastoiditis
infection of the soft tissue surrounding the air spaces in the mastoid bone and is connected to middle ear space. -occurs w/bacterial otitis media and is assoc w/fever more advanced mastoiditis is manifested by swelling, erythema and tenderness over the mastoid bone. swelling can displace the auricle swelling can extend to the facial nerve causing paralysis or to the labryinth or CSF causing meningitis or brain abscess advanced mastoiditis requires immediate referral and surgical management
myringitis
inflammation of the tympanic membrane red, inflamed ear drum w/o effusion
Presence of pain
location- otitis externa described as tenderness around the outer ear or opening to the ear canal that worsens with manipulation of the pinna. mastoiditis is often associated with severe pain or tenderness over hte mastoid bone. if pain is bilateral, suspect otitis externa. Referred pain or pain of AOM is usually unilateral. quality- pain of AOM is often described as a deep pain or blockage of the ear. Serous otitis is often painless or may be described as a bubbling, popping or stuffy sensation in the ear. Otitis externa involves a tenderness of the outer ear or ear canal that can be accompanied by itching. cerumen impaction creates a milder pain or vague discomfort of stuffed ears quantity and severity of pain- pain of AOM is severe enough to interfere with sleep and may be suddenly relieved if the TM perforates. Chronic ear pain that is unresponsive to treatment may indicate a tumor onset, timing and duration of pain- TMJ pain is often describe as severe pain lasting a few minutes and recurring 3-4x/day. sometimes associated with HA. worse in the morning bc nighttime teeth grinding. nocturnal onset of otalgia from a developing infection is caused by increased vascular pressure in the reclined position which causes the TM to bulge and stimulate pain sensation
inspect ear canal
observe for patency condition of skin in canal presence of cerumen vesicles? discharge/drainage- color, consistency, odor cheesy, green-blue, gray- otitis externa
palpate external ears
palpate for tenderness in mastoiditis- pinna is displaced forward and swelling may be present behind the ear. palpation of mastoid process elicits severe tenderness otitis externa- associated w/pain on manipulation of pinna and tragus. referred pain- structures appear normal although palpation over TMJ may elicit tenderness and movement of the jaw may create a clicking sound. preauricular nodes may be enlarged in AOM and otitis externa. Post auricular swelling may indicate extension of infection into the mastoid cavity.
evaluate CN IX
posterior one third of tongue external ear bitter and sour
perforation of tympanic membrane
rupture of the tympanic membrane or eardrum. May be due to middle ear trauma such as a severe infection, direct injury from a sharp object, barotrauma from an explosion, etc. The rupture makes a direct opening into the middle ear and risk for infection is high and infection can cause severe pain.
Environmental Risks
smoke exposure- 2-3x risk of otitis media. leads to functional eustachian tube obstruction and decreases protective ciliary action day care- increased incidence rate of otitis media bc of exposure to organisms bottle propping-swallowing while lying down allos NP fluid to enter middle ear swimming- repeated or prolonged immersion in water results in loss of protective cerumen and chronic irritation along with maceration from excessive moisture in the canal airplane travelers/divers- barotrauma is a cause of acute serous otitis r/t pressure changes from flying or scuba diving. often aggravated by recent URI or nasal congestion. swallowing, chewing, or blowing out the nose with the mouth and nose occluded can relieve symptoms
evaluate CN V
trigeminal nerve observe jaw and facial muscle movement for symmetry and strength by palpating over the masseter muscle and ask the patient to clench their teeth. Assess intactness of sensation to pain and light touch using a sharp/dull stimulus over the three branches of CNV.
chronic otitis media
usually a condition in adults who have a chronic infection that may destroy the ossicles and spread to the mastoid, labyrinth, and intracranial structures causing hearing loss and ear discharge secondary to a perforated non-healing TM.
Acute otitis media (AOM)
usually associated with an upper respiratory infection and is most commonly seen in young children (younger than six) any inflammation of the middle ear and encompasses a variety of clinical conditions. associated w/ear pain and a bulging, red eardrum. severe enough to interfere w/sleep and may be suddenly relieved if eardrum perforates swelling of preauricular node sometimes seen in children
presence of itching and drainage
usually indicates an infection or inflammation of the external canal. itching- can be precursor to herpes zoster of trigeminal nerve (CN V), which can cause paroxysmal pain of the face and jaw, and hyperalgesia to minimal stimulation such as tooth brushing, cold air or grimacing. Itching may also be related to allergic rhinitis, which patients describe as a deep itching in the ears. prodrome for herpes zoster=itching burning, tingling before vesicular eruption. CNVII (facial nerve) also involved in ear pain. drainage- may be present after the TM ruptures from increased middle ear pressure, as exudate from otitis externa or malignant otitis externa. may be exudate secondary to mastoiditis. cholesteatoma. a perforation of the TM and associated foul-smelling discharge may occur.
test hearing acuity
whisper, rinne, weber tests
otitis externa
Infection of the outer ear (ear canal) more common in adults than in children and often presents as bilateral pain that worsens with manipulation of the pinna "stuffed ear" occasionally conductive hearing loss occurs discharges and itches that occur 1-2 days after swimming affected canal may be swollen shut enlarged preauricular and postauricular nodes
Pneumatic Otoscopy
Insufflation insensitive test for otitis media if poor technique fails to create a seal
Inspect tympanic membrane
Normal- shiny, pearly gray or light pink and free of lesions mild diffuse redness= crying/coughing mild vascularity is normal- esp on handle of malleus localized redness=inflammation scarring/effusion- can cause whitening and opacification of TM -Deep pink or red may indicate inflammation (otitis media) -Blue indicates an accumulation of blood -Bulging of the membrane may indicate fluid or pus behind the membrane (otitis media) -Sunken membrane may indicate dehydration -Note the cone of light which is a reflection of the otoscope light- Located at 5 o clock in the right ear and 7 o clock in the left ear
Behaviors in Children
Otitis media is most common childhood disorder. Young infants exhibit nonspecific signs of irritability, poor feeding, congestion and fever. Older infants and young toddlers are irritable and may pull on the painful ear or bang their head on the affected side. Older children will report earache
bullous myringitis
Small vesicles containing blood on the drum; accompany mucoplasma pneumonia and virus infections extremely painful caused by bacterial otitis media
Acute infection
Age- occurence of AOM decreases significantly after the age of 6 fever- fever is present in 60% of children with AOM. In infants younger than 2 months, fever w/AOM is uncommon. URI- occurs when the mm of the nasopharynx and/or sinuses become infected and organisms are forced up the lumen of the eustachian tube. Inflammation of the mucosa or enlarged adenoids obstruct the eustachian tube opening so that the air in the middle ear is absorbed and replaced by mucus. This mucus creates a mechanical obstruction and can serve as a medium for bacterial growth. Previous infections- Infants younger than 3 mos who have their first AOM run a high risk of recurrence. Up to 71% of children younger than 3 have had at least one episode, and 33% have had an average of three episodes. Chronic otitis media can result in anatomical changes to the TM and middle ear ossicles. This may predispose the patient to further infection. Family hx- having a sibling or a parent with chronic otitis media makes it twice as likely for the illness to develop in the child. Presence of chronic OM may also be related to child-care practices like bottle propping or environmental exposures such as second-hand cigarette smoke.
Otitis media with effusion (OME)
By definition, painless TM may be injected and immobile either bulging or retracted An amber-yellow drum suggests serum in middle ear that transudates to relieve negative pressure from the blocked eustachian tube. you may note an air/fluid level with fine black dividing line or air bubbles visible behind drum. Symptoms are feeling of fullness, transient hearing loss, popping sound with swallowing. Also called serous otitis media (glue ear), secretory otitis, nonsuppurative otitis associated recent URI is a common finding in adults
