Approach to Ear Problems By Stacey Singer-Leshinsky R-PAC

Approach to Ear Problems

By Stacey Singer-Leshinsky R-

PAC

Includes:

Disease of the external earDisease of the middle earDisease of the inner ear

Normal TM

External Auditory CanalOtitis Externa

Defenses include cerumen which acidifies the canal and suppresses bacterial growth.

External Auditory CanalOtitis Externa

Cerumen prevents water from remaining in canal and causing maceration. Etiology: Pseudomonas aeruginosa and staphylococcus aureus, strep

External Auditory CanalOtitis Externa

Risk factors for Otitis Externa include:

Swimming, perspiration, high humidity, insertion of foreign objects, Eczema, psoriasis, seborrheic dermatitis

External Auditory CanalOtitis Externa-Clinical manifestations

Otalgia/otorrheaFeverPain Canal edematous and obscured with debris, discharge, blood, or inflammation Lymphadenopathy

External Auditory CanalOtitis Externa-

Complications malignant otitis externa caused by pseudomonas

Differential diagnosis basal cell carcinomasquamous cell carcinoma

External Auditory CanalOtitis Externa-Management

Topical antibacterial drops such as Neomycin otic, polymyxin, Quinolone otic Otic steroid drops containing polymyxin-neomycin and a topical corticosteroid. Analgesics

External Auditory CanalOtitis Externa-Management

Discuss patient education issues such as:

Swimmer prophylaxis contains acid and alcohol

External Auditory CanalChronic Otitis Externa

Duration of infection greater than four weeks, or greater than 4 episodes a yearRisks: inadequate treatment of otitis externa, persistent trauma, inflammation or malignant otitis externa. Etiology: Bacterial,fungal or dermatologic such as candida or Aspergillus, pseudomonas or psoriasis

External Auditory Canal Chronic Otitis Externa

Purulent dischargeDry or scaly. Pruritus Conductive hearing lossDiagnosis:

External Auditory CanalChronic otitis externa-Management

Cover fungi with clotrimazole(Lotrimin) Systemic antifungal include ketoconazoleCortisporin Wick with few drops of Domeboro’s astringent Differential diagnosis to include basal cell or squamous cell carcinoma, Foreign bodies, otitis media

External Auditory CanalMalignant Otitis Externa

Inflammation and damage of the bones and cartilage of the base of the skull Occurs primarily in immunocompromised Most common etiology is pseudomonas aeruginosa.

External Auditory CanalMalignant Otitis Externa

Otorrhea: yellow green, foul smelling. Granulation tissue in external auditory canalTrismusFeverFacial and cranial nerve palsies

External Auditory CanalMalignant Otitis Externa

Diagnosis: Culture of ear secretions and pathological examination of granulation tissue, CTComplications include sepsis, cranial nerve palsies, meningitis, brain abscess, osteomyelitis of the temporal bone and skullDifferential diagnosis to include basal cell or squamous cell carcinoma

External Auditory CanalMalignant Otitis Externa

Need IV antibiotics Might need surgical debridement. If treatment interrupted rate of recurrence is 100%

External Auditory CanalCerumen Impaction

Cerumen is produced by apocrine and sebaceous glands in external ear canal. Often caused by attempts to clean the ear, or water in canal Cerumen is pushed down

Cerumen ImpactionClinical Manifestations

Hearing loss Stuffed or full feeling to earPain if cerumen touches TM

External Auditory CanalCerumen Impaction

Be sure TM is intact prior to lavageIrrigate ear with one part peroxide, and one part water Debrox and Cerumenex drops Ear irrigation and manual cerumen removal

External Auditory CanalForeign body

Can include toys, beads, nails, vegetables or insects.Damage depends on amount of time object has been in ear.

External Auditory CanalForeign body-Clinical Manifestations

Might present with purulent dischargePainBleedingHearing loss

External Auditory CanalForeign body

Complications include internal injury Differential diagnosis to include cholesteatoma, cerumen impaction, otitis externa

External Auditory CanalForeign body- Management

Irrigation is best provided the TM is not perforatedDestroy insect with lidocaine or mineral oil. Irrigate and suction liquid. For inanimate objects suction or use alligator forceps.

Tympanic MembraneBullous Myringitis

Vesicles develop on the TM second to viral infections or bacterial infection Usually associated with middle-ear infection May extend into canal.

Tympanic MembraneBullous Myringitis- Clinical Manifestations

Sudden onset of severe pain No fever usuallyNo hearing impairmentBloody otorrhea possible Inflammation to TM Multiple reddened inflamed blebs possibly blood filled

Tympanic Membrane Bullous Myringitis

Differential diagnosis to include squamous or basal cell carcinoma, acute otitis mediaComplications

Tympanic Membrane Bullous Myringitis-Management

AntibioticsIf pain is severe, rupture the vesicles with a myringotomy knife Analgesics

Tympanic MembranePerforated TM

Etiology is direct trauma, infection, pressure build up Bacteria can travel into middle ear and lead to secondary infection

Tympanic MembranePerforated TM- Clinical Manifestations

Sudden severe painHearing loss Drainage Otoscope exam reveals puncture in TM, might be able to see bones of middle earPurulent otorrhea may begin in 24-48 hours post perforation

Tympanic MembranePerforated TM

Differential diagnosis to include acute and chronic otitis mediaComplications include secondary infection into inner ear

Tympanic MembranePerforated TM-Management

Antibiotics to prevent infection or treat existing infection Surgical repair

Middle EarAcute Otitis Media

Viral respiratory infections cause inflammation of ETWhen ET is blocked, fluid collects in the middle ear.

Middle EarAcute Otitis Media

Common in fall, winter or spring ET in child is shorter and more horizontal in infants/children. Bacterial Etiology : S.pneumoniae, H.influenzae, and M.Catarrhalis. Risks include URI,smoking at home, allergies, cleft palate, adenoid hypertrophy, bottle feeding, barotrauma

Middle EarAcute Otitis Media

Otalgia. Conductive hearing lossURI symptomsVomiting, diarrhea FeverTM bulging and erythematous with decreased or poor light reflex. Decreased TM mobility on pneumatic insufflation

Middle EarAcute Otitis Media -Diagnosis

Tympanometry Differential diagnosis to include TM perforation, Tympanosclerosis, recurrent AOM, mastoiditis

Middle EarAcute Otitis Media -Management

Analgesics/ AntipyreticsAuralgan Antibiotics Trimethoprim-sulfamethoxazole or AzithromycinDecongestants: Avoid antihistamines

Middle EarAcute Otitis Media –Patient Education

Myringotomy in patients with hearing loss, poor response to therapy or intractable painDiscuss patient education issues including breast feeding, no smoking in homes, pneumococcal vaccine

Middle EarAcute Otitis Media -Complications

TM perforation/ TympanosclerosisRecurrent AOM or chronic OMPersistent middle ear effusionMastoiditisBacteremia

Middle EarAcute Otitis Media -Recurrent OM

Three episodes of AOM in 6 months or 4 episodes in 12 months Diagnosis Prevent by antibiotic prophylaxis, pneumovax, tympanostomy tubes, adenoidectomy

Middle EarOtitis Media with EffusionFluid accumulation behind TM in middle ear Build up of negative pressure and fluid in eustachian tube Common in children because of anatomy, cleft palate, allergies, barotrauma.

Middle EarOtitis Media with Effusion

Hearing loss Fullness, pressure TM neutral or retracted. Gray or pink. Landmarks visible or dull. Decreased TM mobility

Middle EarOtitis Media with EffusionDiagnosis

Tympanometry- most accurate, Audiometry- Differentials to include: Acute Otitis Media, malignant tumors to nasal cavity, cystic fibrosis

Middle EarOtitis Media with Effusion Management

Decongestants/Oral steroidsAntibioticsMyringotomy with or without tubes AdenoidectomyComplications:

Middle EarChronic Otitis Media

Recurrent or persistent otitis media due to dysfunctional eustachian tube Risks: allergies, multiple infections, ear trauma, swelling to adenoids. Bacteria: P aeruginosa, proteus species, Staphylococcus aureus, and mixed anaerobic infections.

Middle EarChronic Otitis Media

Causes long term damage to middle ear due to infection and inflammation including

Severe retraction of TM due to prolonged negative pressureScaring or erosion of small conducting bones of middle ear and inner ear Erosion of mastoid Thickening of mucous secretions in ETCholesteatoma Persistent OME

Middle EarChronic Otitis Media

Ear pain Fullness to earsPurulent discharge Hearing loss Dullness, redness or air bubbles behind TM

Middle EarChronic Otitis Media

Diagnosis: clinical, audiometry, tympanometry, CT, MRIDifferential diagnosis to include AOM, cholesteatomaComplications include bony destruction or sclerosis of mastoid air cells, facial paralysis, sensineural hearing loss, vertigo

Middle EarChronic Otitis Media-Management

Antibiotics , steroids, placement of tubes. Myringotomy Surgical tympanoplasty, mastoidectomy

Cholesteatoma

Epithelial cyst consists of desquamating layers of scaly or keratinized skin. Erosion of ossicles common. As more material is shed, the cyst expands eroding surrounding tissue.Two types: congenital and acquired.

Acquired due to tear in ear drum, infection

Cholesteatoma

Perforation of TM filled with cheesy white squamous debrisPossible conductive hearing loss Drainage Differential Diagnosis: squamous cell carcinoma

Cholesteatoma-Management

Large or complicated cholesteatomas require surgical excisionComplications include erosion of bone and promote further infection leading to meningitis, brain abscess, paralysis of facial nerve.

Barotrauma

Physical damage to body tissue due to difference in pressure between an air space inside or beside body and surrounding gas. Ear barotrauma:

Barotrauma

Etiology is a change in atmospheric pressure. Negative pressure in the middle ear causes Eustachian tube to collapse.Since air can not pass back through the ET, hearing loss and discomfort developRisk factors Differential diagnosis should include serous, acute or chronic otitis media, bullous myringitis

Barotrauma

Hearing lossOtalgia

Barotrauma-Management

Auto inflation by yawning, swallowing or chewing gum to facilitate opening of ET to equalize air pressure in middle earDecongestants Myringotomy Patient education to include valsalva maneuver.

Mastoid

Portion of temporal bone posterior to the ear. Mastoid air cells connect with the middle earFluid in the middle ear can lead to fluid in the mastoid

Mastoiditis

Middle ear inflammation spreads to mastoid air cells resulting in infection and destruction of the mastoid bone. Etiology: Streptococcus pneumoniae, Haemophilus influenzae, streptococcus pyogenes, and other bacteria

Mastoiditis

PainBulging erythematous TMErythema, tenderness, edema over mastoid areaPostauricular fluctuance

Mastoiditis-Diagnosis/differentials

Diagnosis: CT show bony destruction or drainable mastoid abscessTympanocentesis to culture middle ear fluid.( S. pneumoniae, H. influenzae, M. catarrhalis)\Culture of fluid

Differential diagnosis to include otitis media, Cellulitis, scalp infection with inflammation of posterior auricular nodes

MastoiditisComplications

Destruction of mastoid boneSpread to brain leading to brain abscess or epidural abscess

Mastoiditis-Management

Treat with antibiotics Patients with severe or prolonged May need to surgically remove a portion of the bone

Labyrinthitis

Viral infection Vestibular neural input disrupted to the cerebral cortex and brain stem Vertigo due to inflammation and infection of labyrinthNeurological exam normalCan also follow allergy, cholesteatoma, or ingestion of drugs toxic to inner ear

Labyrinthitis

Nausea/vomitingVertigo with head or body movements lasts about 1 minNystagmus(rotary away from affected ear)Loss of balance

Labyrinthitis-History and PE

Diagnosis: Audiologic testing, CT and MRI Differentiate other causes of dizziness by CT, MRIDifferential diagnosis to include acoustic neuroma, vertigo, cholesteatoma, meniere’s disease

Labyrinthitis-Management

Steroids Sedatives Antivert Tigan Patient reassurance that symptoms usually last 7-10 days with subsequent episodes up to 18 months.Complications include spread of infection

Meniere’s Syndrome

Imbalance in secretion and absorption of endolymph fluid that causes buildup of fluid in cochlea. Swelling leads to hair cell damage

Meniere’s Syndrome

Episodic vertigo for 24-48 hours Sensorineural hearing loss TinnitusFullness/pressure in earsN/V/dizziness

Meniere’s Syndrome

Diagnosis: Audiologic testing, CT Valium, tigan, antivertHCTZ Low sodium dietLabyrinthectomy if hearing already lost

Vertigo

Motion perceived when no motion, or exaggerated motion perceived in response to body movementCauses- Irritation to labyrinth CNS Brainstem or temporal lobe 8th cranial nerve dysfunction (acoustic

neuroma) Labyrinthitis, Meniere’s disease

Vertigo

N/VIn peripheral lesions nystagmus can be horizontal or rotationalCentral lesions nystagmus is bi-directional or verticalEvaluation

Vertigo

Differential diagnosis to include Diabletes mellitus, hypothyroidism, drugs such as alcohol, barbituates, salicylates, hyperventilation, cardiac originManagement: Meclizine, Promethazine, Scopolamine

Tinnitus

Perception of abnormal ear noises Can be ringing, hissing Constant, intermittent, unilateral, or bilateralCan originate in outer, middle or inner ear

Tinnitus- Causes

Etiology can include damage to inner ear or cochlea, middle ear infection, medication such as Aspirin, stimulants such as nicotine, and caffeine, noise induced, hypertension, presbycusis

Tinnitus-Treatment

Some drugs such as antihistamines and CCB ENT referral- AntidepressantsSurgical intervention-

Example 1

A 22 year old swimmer complains of pain when moving her ear. She also has noticed a bump in front of her ear. She has noticed difficulty in hearing. On otoscopic exam you visualize this. What is the complication associated with this? What is the treatmentWhat are some patient education tips on this?

Example 2

A Diabetic patient is complaining of severe ear pain and otorrhea. On physical exam you note this. What is your differential diangosis? For what condition is this a complication?What is the etiology and treatment for this?

Example 3

This is a 44 year old female who complains of increasing hearing loss, and believes she is going deaf.What is the treatment of this?

Example 4

This patient recently had a viral infection. She now complains of a sudden onset of constant severe ear pain since yesterday. You see this on physical exam. What is this?How is this treated?

Example 5

This patient was SCUBA diving and had a non controlled ascent. He complains of tinnitus and severe ear pain since this incident. He thinks he has an ear infection. What is this?How is this treated? What are some complications of this?

Example 6

A 2 year old presents to your clinic crying tugging her ear. Mother states child has a bad cold for a few days. On otoscopic exam you note this. What is your differential diagnosis?What are some etiologies of this? What is the treatment for this? What is the name of the vaccine which tries to prevent this?

Example 7

A child with a history of allergies complains of hearing loss to her right ear. She has no fever. Otoscopic exam reveals this.What is this?What is the management of this? What is the treatment if child is not responsive to therapy?

Example 8

This 4 year old was not treated for AOM. Now the child has a fluctuant mass behind his ear. He also has a high fever. What is the diagnosis?How would this be treated?What diagnostics are necessary?

Example 9

A 35 year old female complains of vertigo with head movement. She also notices she is falling to the right side for the past 7 days. This is due to a viral infection.What is this?What is the pathophysiology of this?What is the management of this?

Example 10

This patient has episodes of dizziness lasting up to 2 days. She also notices difficulty hearing low frequency notes to her left ear. In addition her left ear feels stuffy. She also hears a ringing in that ear. What is the differential diagnosis?How is this managed?