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?