2. Ear Assessment Glue Ear Flashcards
What structures should be assessed during an Ear Examination?
Pinna
Mastoid (process of the temporal bone)
Canal
The Tympanic Membrane
What assessments/tests should be carried out as part of an ear examination?
Free Speech Hearing Assessment
Tuning Fork Test
Facial Nerve Exam
Post Nasal Space
What should be looked for in or around the pinna?
Discharge Swelling. Erythema. Deformity. Scars. Symmetry
Draw and label the parts of tympanic membrane
Malleus Handle of Malleus Pars Flaccida Chorda Tympani Long process of the incus Umbo Annulus Fibrosis Pars Tensa Cone of Light
What is acute otitis media?
Inflammation of the middle ear
In whom is acute otitis media common?
Children
Is otitis media unilateral or bilateral?
Can be both
What condition can precede acute otitis media?
URTI
What are the causes of acute otitis media?
Bacterial
Viral
What are the most common bacterial causes of acute otitis media?
Streptococcus Pneumoniae (35%) Haemophilus Influenzae (25%) Maraxella Catarhalis (15%) Group A Strep or Staph Aureus
Describe the inflammatory steps in Otitis Media
Organisms invade mucous membrance
Oedema closes off the eustachian tube
Pressure from the pus rises, bulging the drum
Local necrosis of the Tympanic Membrane perforation
Spontaneous drainage from the ear until the infection resolves.
What are the clinical features of acute otitis media?
Rapid Onset of Severe ear pain. \+/- Irritability, Anorexia, Vomitting, Tenderness of the Mastoid, Hearing loss. Temperature. (Fever, AKA pyrexia) Bulging TM. (Stages) Perforation of TM with accompanying purulent discharge Otorrhoea Often settles in 48 hours.
Describe the inflammatory steps in Otitis Media
Organisms invade mucous membrance
Oedema closes off the eustachian tube
Pressure from the pus rises, bulging the drum
Local necrosis of the Tympanic Membrane perforation
Spontaneous drainage from the ear until the infection resolves.
Describe the change in appearance of the Tympanic membrane as the inflammation progresses in acute suppurative otitis media?
Grey, with lack of luster Radial injection of small drum vessels. Redness and fullness of drum Bulging of drum, loss of landmarks Desquamation perforation.
What is the Early Tx for Acute Otits Media?
A/B’s not always needed but if are oral penicillin (I.V. If necessary)
(Oxford says Amoxcillian +/- clavulanate for ≤7 days = 1st line adult, UCD say only in s )
Co-ammoxiclav in Moraxella
Analgesics, Nasal Vasoconstrictors (ephedrine drops)
Swab if discharge present for culture+sensitivity.
What is the Late Tx for Acute Otits Media?
Late stage = Bulging Drum, failure to resolve with persistence of severe symptoms.
Hospital Admission for I.V. Antibiotics
Followed by Surgical Myringotomy with insertion of grommet.
Specimen Culture+Sensitivity
If discharge persists after acute phase passed. Specimen for culture+stain to inform use of targeted antibiotic or eardrops (A/B and/or steroids)
What are the potential complications of Acute Otitis Media?
Mastoiditis Meningitis Extra-dural Abcess Sub-Dural Abcess Brain Abcess Lateral Sinus Thrombosis Facial Paralysis Gradenigo's Syndrome Citelli's Abscess Bezold's Abcess
What should be suspected in recurrent acute suppurative otitis media?
IgA deficiency of Hypogammaglobulinaemia
What Tx is indicated in the case of a child with recurrent attacks of acute suppurative otitis media, what might these attacks be associated with?
Insertion of a grommet.
The attacks in a child may be associated for example with teething
How is success in treatment of acute otitis media defined?
- Symptoms have resolved
- Ear drum has returned to normal
- Hearing is normal
What Ddx might be considered if Acute Otitis Media fails to resolve?
Residual source of infection within the Nose, sinus or adenoid.
Ineffective choice of antibiotic
A low grade mastoid infection “masked mastoiditis”
What is chronic suppurative otitis media (C.S.O.M)?
Inflammation+middle ear fluid which develops from A.S.O.M, which fails to resolve. (ASOM of several months duration (oxford).
What are the types of chronic suppurative otitis media? Identify those that are safe and unsafe.
- Tubotympanic (aka mucosal) Type = Safe
2. Atticoantral (aka bony) Type = Unsafe
What are the predisposing factors for C.S.O.M?
Late treatment for ACOM
Inadequate/Inappropriate Antibiotic Tx
Persistent Upper Respiratory Sepsis
Lowered resistance, malnutrition, immunological defect etc.
Particularly virulent infection e.g. Measles.
What are the clinical features of mucosal (tubotympanic) C.S.O.M?
- Perforation present, usually central with well defined rim.
- Recurrent infection occurs with otorrhoea, frequently triggered by upper respiratory sepsis via the Eustachian Tube.
- There may be periods of quiescence, where the only symptoms is hearing loss, which becomes progressive over years.
- The perforation may spontaneously heal. This is less likely with larger perforations, which are likely to remain permanent.
Little pain
What is the Tx for mucosal (tubotympanic) COSM?
Swab for Culture+Sensitivity Antibiotic Treatment as Indicated Topical ear antibiotics ±steroids. Admission for aural toilet and I.V AB Surgery = Myringoplasty
What are the clinical features of bony type (atticoantral) COSM?
- Perforation located postero-marginally, poster-superiorly or into the attic part of the ear through the pars flaccida (schrapnells membrane).
- Granulations occur from areas of osteitis, these are bright red and bleed on contact.
- Aural Polyps form from granulation tissue, appearing as cherry like growths at the external ear canal opening.
- Cholesteatoma
Little pain
What is cholesteatoma?
Cholesteatoma or ‘active squamous chronic otitis media’ is a misnomer.
Rare 1:10,000, Peak 5-15yrs
Neither a cholesterol, nor a tumour. It is the progressive local invasion (and destruction) of the middle ear and mastoid by retracted tympanic membrane.
It is associated with perforation at the mouth of the membrane and the production of squamous debris within its depths as well as osteolytic activity at its periphery.
Attic choleseatoma (involvement of the pas tensa or flaccida) indicates serious disease.
Potentially lethal complications if untreated.
What are the symptoms indicate impending CNS complications due to cholesteatoma?
Foul discharge ± Deafness
Headache/Pain
Facial Paralysis
Vertigo
What is the Tx for bony (atticoantral) type COSM?
Safe Dry Ear by removal of disease a priority, hearing secondary.
Early Cases: Aural toilet may enable the abortion of small area of localised osteitis, as well as halt progression. Microscopic debridement may allow evacuation of small pocket of early cholesteatoma development in order to stabalise condition.
Following Failure of Period of Conservative Treatment: Major surgical intervention if failed or progression continued.
What are the major surgical interventions for the treatment of unsafe COSM?
Atticotomy
Combined Approach Tympanoplasty
Modified Radical Mastoidectomy
What are the main complications of Middle Ear Disease
Infratemporal and intracranial extension
What are the main complications of an infratemporal extension of ACOM/COSM?
Acute Mastoiditis
Labyrinthitis
Facial Nerve Paralysis
Petrositis (Gradenigo’s Syndrome)
What are the main complications of an intracranial extension of ACOM/COSM?
Meningitis Extradural Abscess Subdural Abscess Brain Abscess Lateral Sinus Thrombosis
List the grades of central perforation of the tympanic membrane?
Dry (permanently)
Intermittent Discharge
Constant Discharge
Constant Discharge with Complication
What information should be collected as part of the Hx for a central perforation of TM?
Duration of Symptoms Discharge (character, smell, periodicity) Previous middle ear disease/surgery Hearing on the contralateral ear Other relevant disease.