Is it more important to know Is it more important to know what kind of what kind of diseasedisease a person a person

has?has?

Or what kind of Or what kind of personperson has the has the dis-ease??dis-ease??

EAR PAINEAR PAIN

Does Patient have a fever?

Yes-Suspect infection!

No- Suspect Physical Blockage

Or Trauma

http://familydoctor.org/online/famdocen/home/tools/symptom/507.html

Infection: Ruling In/OutInfection: Ruling In/Out

Acute Otitis MediaAcute Otitis Media Chronic Supperative Otitis MediaChronic Supperative Otitis Media Otitis ExternaOtitis Externa MastoiditisMastoiditis Other Conditions to be aware of:Other Conditions to be aware of:

CholesteatomaCholesteatoma ErysipelasErysipelas PerichondritisPerichondritis CarcinomaCarcinoma

Acute Otitis MediaAcute Otitis Media

Normal Tympanic Membrane Acute Otitis Media

Acute Otitis MediaAcute Otitis Media Middle Ear InfectionMiddle Ear Infection Acute otitis media (AOM) is most often purely viral and self-limited, Acute otitis media (AOM) is most often purely viral and self-limited,

as is its usual accompanying viral URI (upper respiratory infection).as is its usual accompanying viral URI (upper respiratory infection). If it progresses to Acute bacterial otitis media, can invade mastoidsIf it progresses to Acute bacterial otitis media, can invade mastoids

Streptococcus pneumoniaeStreptococcus pneumoniae, nontypable , nontypable Haemophilus influenzaeHaemophilus influenzae Patient Presentation:Patient Presentation:

classic "earache", pain that is severe and continuous classic "earache", pain that is severe and continuous and is often accompanied by fever of 102 °F or moreand is often accompanied by fever of 102 °F or more

Bullous Myringitis, eardrum perforationBullous Myringitis, eardrum perforation

Acute Bacterial Otitis MediaAcute Bacterial Otitis Media

1st phase1st phase - exudative inflammation lasting 1-2 days, - exudative inflammation lasting 1-2 days, fever, rigors, meningism (occasionally in children), fever, rigors, meningism (occasionally in children), severe pain (worse at night), muffled noise in ear, severe pain (worse at night), muffled noise in ear, deafness, sensitive mastoid process.deafness, sensitive mastoid process.

2nd phase2nd phase - resistance and demarcation lasting 3-8 - resistance and demarcation lasting 3-8 days. Pus and middle ear exudate discharge days. Pus and middle ear exudate discharge spontaneously and afterwards pain and fever begin to spontaneously and afterwards pain and fever begin to decrease. This phase can be shortened with topical decrease. This phase can be shortened with topical therapy.therapy.

3rd phase3rd phase - healing phase lasting 2-4 weeks. Aural - healing phase lasting 2-4 weeks. Aural discharge dries up and hearing becomes normal.discharge dries up and hearing becomes normal.

Chronic Supperative Otitis MediaChronic Supperative Otitis Media

involves a perforation involves a perforation (hole) in the tympanic (hole) in the tympanic membrane and active membrane and active bacterial infection within bacterial infection within the middle ear space for the middle ear space for several weeks or more. several weeks or more. There may be enough There may be enough pus that it drains to the pus that it drains to the outside of the ear outside of the ear (otorrhea)(otorrhea)

Hearing impairment Hearing impairment typically accompaniestypically accompanies

Otitis ExternaOtitis Externa ““Swimmer’s Ear”Swimmer’s Ear”

Swimming frequentlySwimming frequently Polluted waterPolluted water Water trapped in ear after showeringWater trapped in ear after showering Humid climateHumid climate

Patient Presentation:Patient Presentation: the canal appears red and swollen in the canal appears red and swollen in

well-developed cases of acute external well-developed cases of acute external otitis. The ear canal may also appear otitis. The ear canal may also appear eczemaeczema-like, with scaly shedding of -like, with scaly shedding of skin. Touching or moving the outer ear skin. Touching or moving the outer ear increases the pain, and this maneuvre increases the pain, and this maneuvre on physical exam is very important in on physical exam is very important in establishing the clinical diagnosis. It establishing the clinical diagnosis. It may be difficult for the physician to see may be difficult for the physician to see the the eardrumeardrum with an with an otoscopeotoscope at the at the initial examination because of initial examination because of narrowing of the ear canal from narrowing of the ear canal from inflammation and the presence of inflammation and the presence of drainage and debrisdrainage and debris

MastoiditisMastoiditis

Typically can occur as a result of infection spread from Typically can occur as a result of infection spread from the middle earthe middle ear

Some common Some common symptomssymptoms and and signssigns of mastoiditis of mastoiditis include include painpain, tenderness, and swelling in the mastoid , tenderness, and swelling in the mastoid region. There may be ear pain (region. There may be ear pain (otalgiaotalgia), and the ear or ), and the ear or mastoid region may be red (erythematous). Fever or mastoid region may be red (erythematous). Fever or

headaches may also be present.headaches may also be present.

CholesteatomaCholesteatoma

CholesteatomaCholesteatoma is a is a destructive and destructive and expanding growth expanding growth consisting of keratinizing consisting of keratinizing squamoussquamous epithelium epithelium in in the middle ear and/or the middle ear and/or mastoid processmastoid process.. May May also contain cholesterol also contain cholesterol crystals.crystals.

Congenital or Congenital or acquired (Eardrum acquired (Eardrum retraction). retraction).

CholesteatomaCholesteatoma

Produces enzymes which can erode bone. Produces enzymes which can erode bone. If ear ossicles are eroded, may result in nerve If ear ossicles are eroded, may result in nerve

deterioration, deterioration, deafnessdeafness, imbalance and , imbalance and vertigovertigo. .

Can erode the skull resulting in brain abcess, Can erode the skull resulting in brain abcess, mastoiditismastoiditis

Can affect the Can affect the facial nervefacial nerve causing causing weakness weakness

ErysipelasErysipelas Typically on extremities and face, Typically on extremities and face,

including skin of earincluding skin of ear Dermatological infection caused Dermatological infection caused

by by Streptococcus PyogenesStreptococcus Pyogenes Patient Presentation:Patient Presentation:

high high feversfevers, , shakingshaking, , chillschills, , fatiguefatigue, , headachesheadaches, , vomitingvomiting, and , and general illness within 48 hours of general illness within 48 hours of the initial infection. The the initial infection. The erythematous skin lesion enlarges erythematous skin lesion enlarges rapidly and has a sharply rapidly and has a sharply demarcated raised edge. It demarcated raised edge. It appears as a red, swollen, warm, appears as a red, swollen, warm, painful rash.painful rash.

PerichondritisPerichondritis Inflammation of the tissue surrounding Inflammation of the tissue surrounding

the ear cartilage. The inflammation can the ear cartilage. The inflammation can result from such things as trauma, result from such things as trauma, burns, piercings and chronic ear burns, piercings and chronic ear infections. Prompt treatment is needed infections. Prompt treatment is needed to prevent deformity of the ears. to prevent deformity of the ears.

DX: based on the person's DX: based on the person's medical medical historyhistory and by looking at the ear. If and by looking at the ear. If there is a there is a history of trauma to the earhistory of trauma to the ear and the ear is and the ear is red red and veryand very tender tender, , then perichondritis is diagnosed. There then perichondritis is diagnosed. There may be a may be a change in the normal shapechange in the normal shape of the ear.of the ear.

Patient presentation: Patient presentation: Ear redness, pain, swelling, fluid Ear redness, pain, swelling, fluid

seeping from earseeping from ear

CarcinomaCarcinoma

Basal Cell Carcinoma Basal Cell Carcinoma (not often associated with (not often associated with Mets)Mets)

Squamous Cell Squamous Cell Carcinoma (suspect Carcinoma (suspect Mets)Mets)

Patient may present with:Patient may present with: Red plaque or ulcer that Red plaque or ulcer that

won’t healwon’t heal

Skin Lesion can be Skin Lesion can be painful painful in/around earin/around ear

Basal Cell Carcinoma

Physical Blockage/Trauma:Physical Blockage/Trauma:Ruling In/OutRuling In/Out

Patient HISTORY!!! Remember, 90%!Patient HISTORY!!! Remember, 90%! PHYSICAL TRAUMA (Ruptured Eardrum)PHYSICAL TRAUMA (Ruptured Eardrum) CERUMINOSISCERUMINOSIS SEROUS OTITISSEROUS OTITIS BAROTRAUMABAROTRAUMA EUSTACIAN TUBE PROBLEMSEUSTACIAN TUBE PROBLEMS SEBACEOUS CYSTSEBACEOUS CYST KELOIDKELOID

RUPTURED EARDRUMRUPTURED EARDRUM

PerforationPerforation Tympanosclerosis (scarring)Tympanosclerosis (scarring) Retraction (due to ET dysfunction)Retraction (due to ET dysfunction)

Generally, Tympanic membrane problems are Generally, Tympanic membrane problems are NOT associated with dizziness and rupture is NOT associated with dizziness and rupture is almost always more likely as the result of almost always more likely as the result of infection rather than mechanical traumainfection rather than mechanical trauma

CERUMINOSIS CERUMINOSIS vsvs SEROUS OTITIS SEROUS OTITIS

CeruminosisCeruminosis Earwax buildup in the external auditory canal, can be due to overproduction of Earwax buildup in the external auditory canal, can be due to overproduction of

cerumen or impaction of earwax with an object such as a Q-tip.cerumen or impaction of earwax with an object such as a Q-tip.

Serous OtitisSerous Otitis collection of fluid that occurs within the middle ear space as a result of the collection of fluid that occurs within the middle ear space as a result of the

negative pressure produced by altered Eustachian tube function. This can occur negative pressure produced by altered Eustachian tube function. This can occur purely from a viral URI, with no pain or bacterial infection, or it can precede purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media. Fluid in the middle ear sometimes and/or follow acute bacterial otitis media. Fluid in the middle ear sometimes causes conductive hearing impairment, but only when it interferes with the causes conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves.normal vibration of the eardrum by sound waves.

In children: associated with feeding while lying down and early entry into In children: associated with feeding while lying down and early entry into group child care, while parental smoking, too short a period of group child care, while parental smoking, too short a period of breastfeeding and greater amounts of time spent in group child care breastfeeding and greater amounts of time spent in group child care may increase the duration of OME in the first two years of life.may increase the duration of OME in the first two years of life.

EUSTACHIAN TUBEEUSTACHIAN TUBE The Eustachian tube connects the middle ear space to the back of the nose.The Eustachian tube connects the middle ear space to the back of the nose.

Normally, the Eustachian tube is closed. The Eustachian tube can become blocked from common Normally, the Eustachian tube is closed. The Eustachian tube can become blocked from common colds or allergies. Partial or complete blockage of the Eustachian tube can cause sensations of colds or allergies. Partial or complete blockage of the Eustachian tube can cause sensations of popping, clicking, and ear fullness. popping, clicking, and ear fullness.

EUSTACHIAN TUBE PROBLEMSEUSTACHIAN TUBE PROBLEMS

BAROTRAUMABAROTRAUMA- “Airplane Ear”- “Airplane Ear”

-A rapid change in altitude and thus air pressure is equalized across the -A rapid change in altitude and thus air pressure is equalized across the eardrum by a normally functioning Eustachian tube. A healthy tube opens frequently eardrum by a normally functioning Eustachian tube. A healthy tube opens frequently and widely enough to equalize these changes in air pressure. With altitude changes and widely enough to equalize these changes in air pressure. With altitude changes during the descent of an airplane, air pressure increases as the plane lowers. The air during the descent of an airplane, air pressure increases as the plane lowers. The air pressure change pushes the eardrum inward (retraction). Persons with Eustachian pressure change pushes the eardrum inward (retraction). Persons with Eustachian tube blockage can develop fullness of the ear, dulled hearing, and possibly pain when tube blockage can develop fullness of the ear, dulled hearing, and possibly pain when

this occurs.this occurs.

- Trip to the mountains, Scuba Diving, Sky Diving, Swimming to the - Trip to the mountains, Scuba Diving, Sky Diving, Swimming to the bottom of a pool/lakebottom of a pool/lake

- Elevators- Elevators- i.e., Has patient recently taken a new job on a high floor in a tall building ?- i.e., Has patient recently taken a new job on a high floor in a tall building ?

Sebaceous CystSebaceous Cyst

Can containCan contain Fibrous tissues/fluidsFibrous tissues/fluids Fatty, keratinous substance Fatty, keratinous substance

that resembles that resembles cottage cheesecottage cheese, in which , in which case the cyst may be case the cyst may be called "keratin cyst" This called "keratin cyst" This material has a material has a characteristic "cheesy" or characteristic "cheesy" or

"foot odor" smell."foot odor" smell. viscous, serosanguineous viscous, serosanguineous

fluid (containing fluid (containing purulentpurulent

and bloody material)and bloody material)

KeloidKeloid

Firm, rubbery lesions Firm, rubbery lesions or shiny, fibrous or shiny, fibrous nodulesnodules, usually if on , usually if on ear, due to a ear, due to a piercingpiercing, , scratch, or pimple.scratch, or pimple.

Secondary OtalgiaSecondary Otalgia

Tic Douloureux (Trigeminal Neuralgia)Tic Douloureux (Trigeminal Neuralgia)

Referral from dysfunction of joints at Referral from dysfunction of joints at C2/C3C2/C3

TMJ DysfunctionTMJ Dysfunction

Case #1Case #1

You live in an arid climate. Male, 7 years old, 56 lbs. You live in an arid climate. Male, 7 years old, 56 lbs. Presents in late November to your office with chief Presents in late November to your office with chief complaint of L ear pain, tells his mom he hears “buzzing” complaint of L ear pain, tells his mom he hears “buzzing” in his L ear, and she discovered dried blood and pus in his L ear, and she discovered dried blood and pus draining from the affected ear after he came in from draining from the affected ear after he came in from playing in the woods near their home one afternoon.playing in the woods near their home one afternoon.

Mother then mentions that he had Strep throat a little Mother then mentions that he had Strep throat a little over a month ago. She also suddenly recalls that he has over a month ago. She also suddenly recalls that he has complained of L ear pain recently, maybe last week she complained of L ear pain recently, maybe last week she

thinks.thinks.

What do you think so far???What do you think so far???

Bread & ButterBread & Butter

Slight fever of 99.9 Slight fever of 99.9 °F. Vitals WNL.°F. Vitals WNL. Otoscopy reveals no evidence of foreign Otoscopy reveals no evidence of foreign

objects and a perforation in the L eardrumobjects and a perforation in the L eardrum (-) Rinne Test, AC<BC, indicative of (-) Rinne Test, AC<BC, indicative of

conductive hearing loss in L earconductive hearing loss in L ear Weber’s Test lateralizes on L (affected) Weber’s Test lateralizes on L (affected)

side, also indicative of conductive hearing side, also indicative of conductive hearing loss in L ear.loss in L ear.

DifferentialsDifferentials

Foreign body (insect, stick, etc.)Foreign body (insect, stick, etc.) Acute Bacterial Otitis MediaAcute Bacterial Otitis Media Otitis ExternaOtitis Externa Chronic Supperative Otitis Media w/ Chronic Supperative Otitis Media w/

Perforated eardrumPerforated eardrum

Case #2Case #2

Female, 22, 120 lbs. Vitals WNLFemale, 22, 120 lbs. Vitals WNL Presents to your office with R face Presents to your office with R face

paralysis, it was like that when she woke paralysis, it was like that when she woke up this morning. She is a little panicky.up this morning. She is a little panicky.

Also she has pain in the R ear, swollen Also she has pain in the R ear, swollen tongue, dry mouth, and eruption of a tongue, dry mouth, and eruption of a erythematous vesicular rash in the R ear erythematous vesicular rash in the R ear canal canal

Slight fever, flu-like symptoms. Slight fever, flu-like symptoms.

What do you think so far???What do you think so far???

Bread & ButterBread & Butter

She reports that she is in Nursing school She reports that she is in Nursing school and she is extremely stressed out because and she is extremely stressed out because of final exams.of final exams.

She is currently taking birth control She is currently taking birth control medication.medication.

She reports having chickenpox at age 5 She reports having chickenpox at age 5 and then Shingles at age 19. and then Shingles at age 19.

Differentials:Differentials:

Erysipelas Erysipelas StrokeStroke Tic DouloureuxTic Douloureux Lyme DiseaseLyme Disease Bell’s PalsyBell’s Palsy Ramsey Hunt Syndrome (Herpes zoster Ramsey Hunt Syndrome (Herpes zoster

oticus)oticus)