Chapter 89: Ear

Question 1

Anatomy of the Ear

Answer 1

External ear​
Auricle or pinna​
External auditory canal (EAC)​

Middle ear​
Malleus, incus, stapes​

Inner ear​
Semicircular canals, cochlea​

Question 2

Acute Otitis Media

Answer 2

Inflammation of and fluid in the middle ear​

Otalgia: Ear pain​

Children may tug or hold affected ear​

May be bacterial, viral, or both​

Usually starts as viral infection of the nasopharynx​

Diagnosis (must have all three of the following):​
Acute onset of signs and symptoms​
Middle-ear effusion​, bulging TM with limited mobility ​
Middle-ear inflammation​

Affect 75% of kids by age 3 and 95% of kids by age 12

Question 3

Standard Treatment ​of Acute Otitis Media​

Answer 3

Requires pain medication​

Some should receive antibiotics when clearly indicated​. immediate AB therapy is only marginally superior to observation. Obs is s/sx management for 48-72 hrs –if pain persist or worsens, start AB

80% of cases resolve spontaneously without antibiotics​

Question 4

tx of AOM

Answer 4

Acute otitis media (AOM)​
High-dose amoxicillin​
Varys from 5-10 day course

Antibiotic-resistant otitis media​ -s/s for 2-3 days despite AB therapy + RF: daycare, younger than age 2, AB use in the last 1-3m, winter and spring seasons
High-dose amoxicillin-clavulanate

PCN allergy –depends on allergy, if not severe (type II) might so cephalosporin. If the allergy is severe type 1 allergy rash or anaphylaxis, avoid cephalo, use azithromycin ​instead.

Pain management with Tylenol or ibuprofen.

Severe can bring on codeine in patients over 5 years. Can see topical anesthetic drops like procaine or lidocaine drops.

​

Question 5

prevention of acute OM

Answer 5

Breastfeeding for at least 6 months​

Avoiding child care centers when respiratory infections are prevalent​

Eliminating exposure to tobacco smoke​

Reducing pacifier use in the second 6 months of life​

Avoiding supine bottle feeding​

Vaccination for and treatment of influenza​

Vaccination against Streptococcus pneumoniae​

Question 6

Recurrent Otitis Media

Answer 6

Acute otitis media that occurs 3 or more times within 6 months, or 4 or more times within 12 months​

Short-term antibacterial therapy​

Prophylactic antibacterial therapy​

Prevention and treatment of influenza​

Tympanostomy tubes​

Question 7

Otitis Media with Effusion

Answer 7

Often seen after AOM episode. Can occur with resp tract infections ​

Fluid in middle ear without local or systemic illness​

May cause mild hearing loss but no pain​

Antibiotics have minimal effect—do not use​

Question 8

Otitis Externa

Answer 8

Acute otitis externa (OE) (“swimmer’s ear”)​

Bacterial infection of the EAC​
Abrasion and excessive moisture​
Pseudomonas aeruginosa and staph areus

Present wit itching, rapid onset ear pain, ear fullness, tenderness, swelling, redness, purulent discharge

Most infections improve in 3 days and resolve in 10 days​

Question 9

OE topical tx

Answer 9

2% solution of acetic acid + alcohol as ear drops​
Unlike many otic preparations, fluoroquinolones and fluoroquinolone/corticosteroid combinations are safe for patients who have perforated tympanic membranes​

Ciprofloxacin plus hydrocortisone [Cipro HC], ciprofloxacin plus dexamethasone [Ciprodex], and ofloxacin alone [Floxin Otic] ​

Question 10

OE oral tx

Answer 10

Adults: Ciprofloxacin​

Children: Cephalexin [Keflex]

Oral fluoroquinolones can cause tendon rupture in younger patients; they should not be given to patients younger than 18 years​

only indicated if infections go to pinna

need pain management

Question 11

prevention of OE

Answer 11

Do not put anything in the ear, including swabs​

Dry the ear (with towel and tipping of the head) after swimming and showering​

Do not remove earwax​

Do not use earplugs except when swimming

Question 12

Necrotizing Otitis Externa

Answer 12

Rare but potentially fatal complication of acute OE ​

High-risk groups: Older adults with diabetes, immunocompromised patients​

Bacteria in EAC invade mastoid or temporal bone​
Infection can spread to skull base, cranial nerves, and dura mater, causing meningitis and lateral sinus thrombosis​

Treatment: Antipseudomonal drugs​
Ear drops and/or IV form​
Oral ciprofloxacin ​

Referral to specialist

Question 13

Fungal Otitis Externa (Otomycosis)

Answer 13

10% of OE caused by fungi, not bacteria​

Two most common pathogens:​
Aspergillus: 80% to 90%​
Candida​

Intense pruritus and erythema with or without pain or hearing loss​

Managed with thorough cleansing and acidifying drops​

1% clotrimazole used if acidifying drops are not effective​ -2/day for 7 days

Acetic acid solution 3-4x/day for 7 days