Approach to Ear Problems

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Approach to
Ear Problems
By
Stacey Singer-Leshinsky R-PAC
Includes:
Disease of the external ear
Disease of the middle ear
Disease of the inner ear
Normal TM
External Auditory Canal
Otitis Externa
Defenses include
cerumen which
acidifies the canal and
suppresses bacterial
growth.
External Auditory Canal
Otitis Externa
Cerumen prevents water from
remaining in canal and causing
maceration.
Etiology: Pseudomonas aeruginosa and
staphylococcus aureus, strep
External Auditory Canal
Otitis Externa
Risk factors for Otitis Externa
include:
Swimming, perspiration, high humidity,
insertion of foreign objects,
Eczema, psoriasis, seborrheic dermatitis
External Auditory Canal
Otitis Externa-Clinical manifestations
Otalgia/otorrhea
Fever
Pain
Canal edematous and
obscured with debris,
discharge, blood, or
inflammation
Lymphadenopathy
External Auditory Canal
Otitis ExternaComplications
malignant otitis externa caused by
pseudomonas
Differential diagnosis
basal cell carcinoma
squamous cell carcinoma
External Auditory Canal
Otitis 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 Canal
Otitis Externa-Management
Discuss patient education issues such
as:
Swimmer prophylaxis contains acid and
alcohol
External Auditory Canal
Chronic Otitis Externa
Duration of infection greater than four
weeks, or greater than 4 episodes a year
Risks: 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 discharge
Dry or scaly.
Pruritus
Conductive hearing loss
Diagnosis:
External Auditory Canal
Chronic otitis externa-Management
Cover fungi with clotrimazole(Lotrimin)
Systemic antifungal include ketoconazole
Cortisporin
Wick with few drops of Domeboro’s
astringent
Differential diagnosis to include basal cell
or squamous cell carcinoma, Foreign bodies,
otitis media
External Auditory Canal
Malignant 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 Canal
Malignant Otitis Externa
Otorrhea: yellow
green, foul smelling.
Granulation tissue in
external auditory canal
Trismus
Fever
Facial and cranial
nerve palsies
External Auditory Canal
Malignant Otitis Externa
Diagnosis: Culture of ear secretions and
pathological examination of granulation
tissue, CT
Complications include sepsis, cranial nerve
palsies, meningitis, brain abscess,
osteomyelitis of the temporal bone and
skull
Differential diagnosis to include basal cell
or squamous cell carcinoma
External Auditory Canal
Malignant Otitis Externa
Need IV antibiotics
Might need surgical debridement.
If treatment interrupted rate of
recurrence is 100%
External Auditory Canal
Cerumen 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 Impaction
Clinical Manifestations
Hearing loss
Stuffed or full
feeling to ear
Pain if cerumen
touches TM
External Auditory Canal
Cerumen Impaction
Be sure TM is intact prior to lavage
Irrigate ear with one part peroxide,
and one part water
Debrox and Cerumenex drops
Ear irrigation and manual cerumen
removal
External Auditory Canal
Foreign body
Can include toys, beads, nails,
vegetables or insects.
Damage depends on amount of time
object has been in ear.
External Auditory Canal
Foreign body-Clinical Manifestations
Might present with
purulent discharge
Pain
Bleeding
Hearing loss
External Auditory Canal
Foreign body
Complications include internal injury
Differential diagnosis to include
cholesteatoma, cerumen impaction,
otitis externa
External Auditory Canal
Foreign body- Management
Irrigation is best provided the TM is
not perforated
Destroy insect with lidocaine or
mineral oil.
Irrigate and suction liquid.
For inanimate objects suction or use
alligator forceps.
Tympanic Membrane
Bullous Myringitis
Vesicles develop on the TM second to
viral infections or bacterial infection
Usually associated with middle-ear
infection
May extend into canal.
Tympanic Membrane
Bullous Myringitis- Clinical Manifestations
Sudden onset of
severe pain
No fever usually
No hearing impairment
Bloody 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 media
Complications
Tympanic Membrane
Bullous Myringitis-Management
Antibiotics
If pain is severe, rupture the vesicles
with a myringotomy knife
Analgesics
Tympanic Membrane
Perforated TM
Etiology is direct trauma, infection,
pressure build up
Bacteria can travel into middle ear
and lead to secondary infection
Tympanic Membrane
Perforated TM- Clinical
Manifestations
Sudden severe pain
Hearing loss
Drainage
Otoscope exam reveals
puncture in TM, might be able
to see bones of middle ear
Purulent otorrhea may begin in
24-48 hours post perforation
Tympanic Membrane
Perforated TM
Differential diagnosis to include
acute and chronic otitis media
Complications include secondary
infection into inner ear
Tympanic Membrane
Perforated TM-Management
Antibiotics to prevent infection or
treat existing infection
Surgical repair
Middle Ear
Acute Otitis Media
Viral respiratory
infections cause
inflammation of ET
When ET is
blocked, fluid
collects in the
middle ear.
Middle Ear
Acute 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 Ear
Acute Otitis Media
Otalgia.
Conductive hearing loss
URI symptoms
Vomiting, diarrhea
Fever
TM bulging and erythematous
with decreased or poor light
reflex.
Decreased TM mobility on
pneumatic insufflation
Middle Ear
Acute Otitis Media -Diagnosis
Tympanometry
Differential diagnosis to include TM
perforation, Tympanosclerosis,
recurrent AOM, mastoiditis
Middle Ear
Acute Otitis Media -Management
Analgesics/ Antipyretics
Auralgan
Antibiotics
Trimethoprim-sulfamethoxazole
or Azithromycin
Decongestants:
Avoid antihistamines
Middle Ear
Acute Otitis Media –Patient Education
Myringotomy in patients with
hearing loss, poor response to
therapy or intractable pain
Discuss patient education
issues including breast
feeding, no smoking in homes,
pneumococcal vaccine
Middle Ear
Acute Otitis Media -Complications
TM perforation/ Tympanosclerosis
Recurrent AOM or chronic OM
Persistent middle ear effusion
Mastoiditis
Bacteremia
Middle Ear
Acute 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 Ear
Otitis Media with Effusion
Fluid 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 Ear
Otitis Media with Effusion
Hearing loss
Fullness, pressure
TM neutral or
retracted. Gray or pink.
Landmarks visible or
dull.
Decreased TM mobility
Middle Ear
Otitis Media with Effusion
Diagnosis
Tympanometry- most accurate,
AudiometryDifferentials to include: Acute Otitis
Media, malignant tumors to nasal
cavity, cystic fibrosis
Middle Ear
Otitis Media with Effusion
Management
Decongestants/Oral steroids
Antibiotics
Myringotomy with or without tubes
Adenoidectomy
Complications:
Middle Ear
Chronic 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 Ear
Chronic Otitis Media
Causes long term damage to middle ear due
to infection and inflammation including
Severe retraction of TM due to prolonged
negative pressure
Scaring or erosion of small conducting bones of
middle ear and inner ear
Erosion of mastoid
Thickening of mucous secretions in ET
Cholesteatoma
Persistent OME
Middle Ear
Chronic Otitis Media
Ear pain
Fullness to ears
Purulent discharge
Hearing loss
Dullness, redness
or air bubbles
behind TM
Middle Ear
Chronic Otitis Media
Diagnosis: clinical, audiometry,
tympanometry, CT, MRI
Differential diagnosis to include
AOM, cholesteatoma
Complications include bony
destruction or sclerosis of mastoid
air cells, facial paralysis, sensineural
hearing loss, vertigo
Middle Ear
Chronic 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 debris
Possible conductive
hearing loss
Drainage
Differential Diagnosis:
squamous cell
carcinoma
Cholesteatoma-Management
Large or complicated cholesteatomas
require surgical excision
Complications 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 develop
Risk factors
Differential diagnosis should include
serous, acute or chronic otitis media,
bullous myringitis
Barotrauma
Hearing loss
Otalgia
Barotrauma-Management
Auto inflation by yawning, swallowing
or chewing gum to facilitate opening
of ET to equalize air pressure in
middle ear
Decongestants
Myringotomy
Patient education to include valsalva
maneuver.
Mastoid
Portion of temporal bone posterior to
the ear.
Mastoid air cells connect with the
middle ear
Fluid 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
Pain
Bulging
erythematous TM
Erythema,
tenderness,
edema over
mastoid area
Postauricular
fluctuance
MastoiditisDiagnosis/differentials
Diagnosis:
CT show bony destruction or drainable mastoid
abscess
Tympanocentesis 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
Mastoiditis
Complications
Destruction of mastoid bone
Spread 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 labyrinth
Neurological exam normal
Can also follow allergy, cholesteatoma, or
ingestion of drugs toxic to inner ear
Labyrinthitis
Nausea/vomiting
Vertigo with head or
body movements lasts
about 1 min
Nystagmus(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, MRI
Differential 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
Tinnitus
Fullness/pressure in
ears
N/V/dizziness
Meniere’s Syndrome
Diagnosis: Audiologic testing, CT
Valium, tigan, antivert
HCTZ
Low sodium diet
Labyrinthectomy if hearing already
lost
Vertigo
Motion perceived when no motion, or
exaggerated motion perceived in
response to body movement
Causes




Irritation to labyrinth
CNS
Brainstem or temporal lobe
8th cranial nerve dysfunction (acoustic neuroma)
Labyrinthitis, Meniere’s disease
Vertigo
N/V
In peripheral lesions nystagmus can
be horizontal or rotational
Central lesions nystagmus is bidirectional or vertical
Evaluation
Vertigo
Differential diagnosis to include
Diabletes mellitus, hypothyroidism,
drugs such as alcohol, barbituates,
salicylates, hyperventilation, cardiac
origin
Management: Meclizine,
Promethazine, Scopolamine
Tinnitus
Perception of abnormal ear noises
Can be ringing, hissing
Constant, intermittent, unilateral, or
bilateral
Can 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 referralAntidepressants
Surgical 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 treatment
What 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?
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