29. Ear Infection + Pathology

Question 1

What are 4 common symptoms of otologic pathologies

Answer 1

Pain
Drainage
Tinnitis (high/low frequencies)
Vertigo (room is spinning, not feeling dizzy)

Question 2

Outer Ear
Define and explain tx for:
Microtia/Aural Atresia
Cerumen Impaction
Bacterial Acute Otitis Externa (what are the two most common pathogens)
Foreign Body
Ear Canal Osteoma + Exostosis
Acquired EAC Stenosis

Answer 2

Microtia: underdeveloped ear, conductive hearing loss (tx rebuild ear surgically with rib cartilage, osseointegrated implant for hearing (via bone conduction))
Cerumen Impaction: earwax causes conductive hearing loss, tx with irrigation/peroxide
Bacterial AOE = swimmers ear, (#1 Pseudomonas, #2 Staph spp.), tx: clean canal (otowick - expands when wet to open EAC), topical Abx/steroid ear drops (ciprofloxacin/dexamethasone), pain mgmt
Foreign body: remove with special equipment
Osteoma - pedunculated/singular (surgery if obstructive)
Exostosis - broad-based/multiple, assoc with cold water exposure (surgery if obstructive)
Acquired EAC stenosis: usually after infection, may need surgery to reopen

Question 3

TM Perforation

Causes, CP, Tx

Answer 3

Cause: extruded ear tube, traumatic perforation, underlying eustachian tube dysfx (too much negative pressure)
CP: conductive hearing loss
Tx: tympanoplasty to protect middle ear/improve healing

Question 4

Eustachian Tube Dysfx:
what tympanogram would you expect?
what would you notice about the TM?
what is the middle ear pathology of conductive hearing loss (4 diseases)?

Answer 4

Type B (blunted) or Type C (left shift - negative pressure)
TM retraction - retraction pockets interfere with TM vibration and cause conductive hearing loss (type of eustachian tube dysfx)
1. AOM
2. Cholesteatoma
3. Middle Ear Mass
4. Otosclerosis

Question 5

Acute Otitis Media vs. Serous Otitis Media (Chronic Otitis Media with Effusion)
what are they? causes of both - specific bugs? sx? tx?

Answer 5

AOM: purulence behind TM due to pathogens entering middle ear from nasopharynx via Eustachian tubes (s. pneumo, H. flu, M. Catarrhalis); sx of fever, otalgia, irritability, conductive hearing loss, tx: oral ABx (Amoxicillin - a PCN)

COM: resolved purulent OM, serous/amber fluid may persist, due to eustachian tube dysfx, conductive hearing loss, tx: tympanostomy tubes - equalize pressure, drain ear, restores hearing, improves future treatment of AOMs (drops down ear hole), use when recurrent OMs (3 in 6 mo., 5 in 1 year) or persistent effusions (>3mo)

Question 6

What are the 6 complications of AOM? how to tx?

Answer 6

1. Facial Nerve Palsy
2. Abducens Palsy
3. Coalescent Mastoiditis w/ Subperiosteal Abscess
4. Intercranial complications (epidural/subdural/brain abscess)
5. Meningitis
6. Sinus Thrombosis (compress sigmoid sinus)

Tx: tympanostomy tubes!

Question 7

Causes and tx of ossicular discontinuity/fixation

Answer 7

Cause: congenital fixation/malformation, erosion from retracted TM, traumatic disarticulation (q-tip or car accident), otosclerosis
Tx: reconnect bone, replace bone, insert new prosthesis

Question 8

Otosclerosis: what is it? CP, genetics, tympanogram, tx

Answer 8

progressive scarring/fixation of cochlea/cochlea-stapes junction
CP: progressive conductive hearing loss, absent stapedius reflex
Genetic: AD, variable penetrance, caucasian F>M
Tympanogram: normal (the bone behind TM is problem)
Tx: hearing aid, surgery (stapedectomy w/ prosthesis)

Question 9

Cholesteatoma

What is it, types - causes for each type, tx

Answer 9

Epithelial (skin) cyst in middle ear, may extend to mastoid
1. Congenital - epithelial cells trapped behind TM during embryogenesis - presents like AOM (white bulging eardrum) - REQUIRES surgical excision, good prognosis
2. Acquired - chronic eustachian tube dysfx - retraction pockets form, grow to epithelial cysts - exten into mastoid or down eustachian tubes
Inflammatory rxn/cyst enzymes cause bony erosion of ossicles (conductive hearing loss) or otic capsule, tegmen, facial nerve (SEVERE) - tx: surgical mastoidectomy

Tx: surgical resection of EVERY CYST CELL to prevent recurrence (tricky, requires multiple surgeries)

Question 10

Congenital Sensorineural hearing loss

Etiologies, Risk Factors, Workup, Tx

Answer 10

Etiologies: infectious (TORCH), genetic, cochlear malformations
Risk factors: ICU stay/intubation at birth, blood transfusions, family hx, perinatal infections
Workup: CMV testing (MOST COMMON CAUSE), genetic testing (GJB2 - MOST COMMON DEFECT - inner ear ion channel), imaging for cochlear malformation
Tx: Cochlear implant - take advantage of speech language learning window (dx at 6 mo, tx at 1 year, learn language by 3 years)

Question 11

Sudden Hearing Loss

Causes, sx, etiology, tx, other considerations

Answer 11

Causes: viral, vascular, ototoxic meds, trauma
Sx: vertigo, clogged ear but normal on exam, tinnitus
Etiology - inflammation
TX: steriods (prednisone 20 mg TID + ENT followup)

If asymmetric - consider a tumor - Acoustic Neuroma (vestibular schwannoma) - tx: observation, microsurgery, gamma knife to stop growth

Question 12

Meniere's Disease
who gets it
sx
cause
tx

Answer 12

Adults 40+ years
Episodic vertigo, fluctuating hearing loss, aural pressure, tinnitus, negative MRI (no tumor)
Cause: endolymphatic hydrops (too much endolymph)
Tx: low Na diet, diuretics, surgery (nerve section, labyrinthectomy, endolymphatic sac drillout)