Clin Med - Ear Flashcards
1
Q
What bacteria cause acute otitis media
A
S. pneumonia
H. Influenza
Moraxella catarrhalis
2
Q
non bacterial causes of acute otitis media
A
- ETD
- Viral URI (negative pressure pulls nasopharyngeal fluid into middle ear)
3
Q
Risk factors for AOM (8)
A
- Craniofacial abnormalities
- Nasal allergies
- Recurrent URI
- Daycare attendance
- Smoking
- Immunologic disorders
- Reflux
- Adenoid hypertrophy
4
Q
S/S AOM (11)
A
- Abrupt onset
- Typically in URI onset
- Otalgia (tugging, rubbing, irritability, sleep disruption, decreased appetite
- Fever
- Aural fullness
- Tinnitus
- Hearing loss
- Fluid/Pus behind TM
- Bulging TM, loss of TM landmarks
- Hyperemic/thickened TM
- Purulent drainage in EAC not related to OE
5
Q
AOM vs. OE painful to pull pinna
A
YES in OE
NO in AOM
6
Q
non abx treatment of AOM
A
- tylenol or acetaminophen
- warm compress
- NO topical numbing drops
7
Q
When use Abx in AOM
A
- Severe in >6 mo
- non-severe unilateral 6-23 mo
- do not use prophylactically
- *Ok to not use if have a f/u plan with parents
8
Q
Abx for AOM
A
- flow chart full details
- Amoxicillin if simple
- Augmentin ES if purulent conjunctivitis or abx in 30 days
- Augmentin ES if hx AOM unresponsive to amox.
9
Q
AOM monitoring parameters
A
- 3 weeks still have fluid then f/u 1 month
- still fluid after 3 weeks and 1 month, refer to ENT
10
Q
Mastoiditis Def
A
- Middle ear infection spreads to mastoid resulting in osteitis of the mastoid air cells
- May develop into purulent infection and breakdown of the bony septa and coalescence of air cells
11
Q
SS Mastoiditis
A
- Sick individuals
- Mastoid tenderness
- Concurrent AOM
- Edema over the mastoid
- Fever
- Adenopathy
- Protrusion of pinna
12
Q
Workup Mastoiditis
A
- Physical exam
- CT temporal bone reveals coalescence or loss of mastoid air cells, presence of fluid
13
Q
Mastoiditis treatment
A
- IV abx
- Tube placement
- Possible mastoid ectomy if recalcitrant
14
Q
Cerumen impaction S/S
A
- ear discomfort
- aural fullness
- itching
- hearing loss
15
Q
Cerumen impaction treatment
A
- Irrigation
- Curette with direct visualization
- OTC ear wax softening kits or mineral oil
- NO ear candling
16
Q
When refer for cerumen impaction
A
- can’t get out in office
- unsure about TM status
- prior sx
- prior radiation
17
Q
When should not irrigate ear
A
- if have tubes
- known perforation
- previous otologic
- previous sx
- head radiation hx
18
Q
Keratosis Obliterans
- definition
- danger
A
“canal cholesteatoma”
- Accumulation of cerumen and epithelial debris puts pressure on EAC skin
- Causes erosion, bony exposure, bone remodeling
19
Q
Keratosis Obliterans
- frequent location
A
junction of bone and cartilage in EA
20
Q
Keratosis Obliterans
- S/S
A
- Pain
- Chronically draining ear
21
Q
Keratosis obliterans
treatment
A
- Routine debridement
- Mineral oil drops to soften wax
22
Q
Exostosis
- def,
- cause
A
- bony outcropping distally in the EAC
- benign
- usually from cold water exposure
23
Q
Exostosis
- s/s
A
- Hearing loss if traps wax and obstructs canal
- Can cause otitis externa
24
Q
Exostosis treatment
A
possible surgical removal
25
Auricular hematoma
- def
- cause
"Cauliflower ear"
- Compression or sheering trauma to pinna
- Hematoma between perichondrium and cartilage
- Remodeling of cart. over time to form classic appearance
(cart. gets blood supply from perichon.)
26
Auricular hematoma
| tx
- Drain
- Bolster dressing (dental roll under helix)
- Through and through suture, remove 2 wks
+/- abx
27
Perichondritis
| def
infection of auricular cartilage
28
Perichondritis
| caused by what orgs
- Pseduomonas aeruginosa
- S. aureus
- Strep
29
Perichondritis
- cause (5)
- risk if untreated
- Undertreated OE,
- cellulitis
- trauma
- exposed cartilage
- Risk: cauliflower ear d/t cartilage remodeling
30
Perichondritis tx
Treat aggressively w/ fluoroquinolones
31
Microtia/Atresia
| def
Congenital malformation of the pinna, often involving the canal and middle ear; can have associated CHL
- small ear
32
Microtia/Atresia
| Grades
- Grade I: small appearing ear, most normal features present
- Grade II: helix not fully developed, lobule absent, minimal cartilage present
- Grade III: disorganized tissue, nubbin, typically no canal
33
Anotia
no external ear features
34
SS microtia/atresia
Usually associated conductive or mixed hearing loss d/t ossicular malformation
35
Treatment for microtia/atresia
- Reconstructive surgery w/ plastic surgeon for external appearance, and otologist for ossicular reconstruction and canaloplasty
- Hearing can be rehabilitated w/ hearing aids or osseointegrated bone conduction devices
36
Foreign body in ear treatment
- If alive, drown it w/ normal saline, mineral oil, lidocaine after verifying TM status
- Do not remove unless it’s simple to extract
37
Acute otitis externa (AOE)
| organisms (4)
- Pseudomonas aeruginosa
- staph aurea
- polymicrobial
gram negative pathogens
- 10% of the time can be fungal – aspergillis
38
AOE definition
Diffuse inflammation of the external ear canal which may involve the pinna or the TM. Cellulitis of the ear canal skin and dermis.
39
malignant AOE
not a malignancy but potentially life threatening infection of the EAC, usually in elderly diabetics or immunocompromised individuals from previous OE that did not respond to tx
40
SS AOE
- Significant pain w/ manipulation of the pinna and tragus. Pain will often appear out of proportion to exam. AOM will not have this sign
- Purulent drainage.
41
TX AOE 1st step
1st: clean out ear canal - can irrigate w/ 1:1 dilution of hydrogen peroxide
42
AOE and oral abx
not recommended (board) - UNLESS pt is immunocompromised or infection is severe and extends beyond ear canal
43
mild AOE treatment
acetic acid/hydrocortisone - 7 days
44
Moderate AOE treatment
- topical fluoroquinolone: Cipro HC, Ciprodex, or cortisporin otic (contains neomycin)
- 7 days
45
Severe AOE not beyond EAC treatment
same topical tx as moderate – 7-14 days plus wick placement
46
Severe AOE beyond EAC treatment
same topical tx as moderate, wick tx,
| AND oral fluoroquinolones 7-10 days
47
Monitoring parameters AOE
- adherence
| - response to therapy for infection and pain control
48
Eustachian tube dysfunction
| risk factors
- Craniofacial abnormality (syndromes, cleft palate, VPI)
- infancy
- allergies
- URI
- adenoid hypertrophy
- smoking
49
Eustachian tube dysfunction
- purpose of ET
- what does dysfunction cause
- to maintain neutral pressure in the middle ear to keep the TM suspended in normal anatomic position
- dysfunction is the root cause of most middle ear pathologies
50
Acoustic neuroma def
mild intermittent balance complaints
51
Acoustic neuroma ss
- One-sided hearing loss - ringing in the ear
52
Acoustic neuroma diagnostic test
MRI
53
Meniere disease
| s/s
- Recurrent, spontaneous spells of vertigo.
| - Accompanied by: hearing loss, tinnitus, aural fullness
54
Meniere disease meds
- vestibular suppressants
- Anti-nausea meds
- Low salt diet
- Diuretics
-
55
Meniere disease interventions
- Endolymphatic sac decompression
- Labyrinthectomy
- Vestibular nerve section
56
Tinnitus causes
- Ototxicity
- Middle Ear
- Pathology
57
Tinnitus s/s
ringing in ears
58
Tinnitus tx
no definitive treatment
- counseling
- meds for depression
59
Vestibular Neuritis
| def
Acute vestibular crisis with gradual improvement
| - rare
60
Vestibular neuritis
| - cause
virus attacks vestibular nerve
61
Vestibular neuritis S/S
- vertigo lasting up to 72 hours
- Vertigo may fluctuate during this period
- no auditory sx
- Vertigo while motionless
- Failure to return rapidly to normal
62
Vestibular neuritis treatment
-high dose steroids
63
Vestibular neuritis
| outcome
- complete recovery expected
| - mild position or motion-provoked vertigo may persist
64
Viral Endolymphatic Labyrinthitis
| def
acute vestibular crisis
65
Viral Endolymphatic Labyrinthitis s/s
- Hx similar to vestibular neuritis (sudden onset long lasting vertigo)
- WITH sudden sensorineural hearing loss
66
Viral Endolymphatic Labyrinthitis outcome
hearing loss may recover or persist
67
Benign Paroxysmal Positional Vertigo (BPPV) cause
Otolith displacement, free within posterior canal not in utricle or saccule
68
Benign Paroxysmal Positional Vertigo (BPPV) S/S
- short episodes of vertigo
- provoked by position (lie down, roll over, look up)
- nystamus as long as rocks are in semicircular canal
69
Benign Paroxysmal Positional Vertigo (BPPV) dx test
Hallpike maneuver
70
Benign Paroxysmal Positional Vertigo (BPPV) treatment
Epley's maneuver
71
how to induce nystagmus
Cold or hot water
72
Nystagmus induction with water, temp rule
COWS
- cold slow phase to opposite side ear
- warm slow phase to the same side ear
73
Two very common GI s/s with vestibular issue
nausea and vomiting
hardwired to nausea center in brain
74
6 ss of vestibular loss
- tonic vestibular imbalance
- nystagmus
- nausea
- vertigo
- fixation suppression
- skew deviation
75
What is the most important way to dx cause of vertigo?
H & P!!!
- ROS
- PMH
- MEDICATIONS
- "define dizziness"
76
What happens when control MA that is associated with vertigo?
usually controls dizziness and vertigo!
77
4 H&P tests when dealing with dizzy/vertigo
- neurologic exam
- Gait
- Romberg (stand straight and close eyes)
- Fukuda stepping tests (Romberg with steps in place)
78
What specialist can usually really improve balance and vestibular problems?
Physical therapy - train the body to adapt and compensate
79
What type of disorder is often associated with vertigo?
psych disorders! if treat psych, often vertigo is gone
80
how does facial nerve exit the skull?
stylomastoid foramen
81
definition of vertigo
- illusion of movement
| - asymmetric involvement of vestibular pathway, peripheral or central
82
Three inputs to balance
1. visual
2. proprioception
3. vestibular system
83
If pt complains of dizzy AND has nystagmus, what should have high suspicion of?
inner ear problem
84
How does the horizontal semicircular canal attach ?
to the vestibule alone
| - has non-ampulated and ampulated ends
85
How do the posterior and superior semicircular canals attach?
share a common joining point - the common crus
86
what is the number one sign of an ear emergency?
one sided sudden hearing loss
| - can be conductive or neural
87
how would you first treat sudden, one sided hearing loss?
high dose prednisone taper
| - probably from a virus
88
When is tinnitus a worry
- fluctuating
- pulsatile
- asymmetric
89
What CN go through internal auditor canal
5, 7, 9, 10
90
what CN go across middle ear promontory
9, 10
91
how tell difference between vestibular neuritis and viral labyrinthitis
viral labyrinthitis has hearing loss
92
OM w/ effusion
non infected fluid w/i the middle ear space
93
Cause of OM w/ effusion
result of ETD causing transudative collection of fluid or remnant, sterile fluid from treated AOM
94
sx of OM w/ effusion
Clear to amber to mucoid colored fluid, a/f meniscus, decreased mobility of TM, patients c/o decreased hearing, aural fullness, pressure, dizziness, off balance, otalgia
95
tx of OM w/ effusion
Majority of OME will resolve w/in 3 months (90%) regardless of tx
- Nasal steroids, antihistamines, mucolytic agents, abx have not been shown to resolve effusions any faster! (However, if they have underlying allergic rhinitis treat accordingly)
- If persist after 3 mo, consider placement of PET
96
Cause of TM changes
- Atrophy d/t pushing ear drum out w/ ear infection and pulling it in w/ resolve infection over and over
- Tympanosclerosis results from inflammation of the layers of the drum usually during infection and calcium deposition w/ the layers making the drum stiff and rock hard
97
causes of TM peforation
- R/t chronic ETD, AOM, multiple PET's, tympanosclerosis, TM atrophy
- Sometimes r/t trauma (ie. Slap injury/pressure concussion, slag injury, direct puncture)
98
TM perf classifications
Classified as central or marginal
- Marginal extends to annulus, more susceptible to cholesteatoma formation
- Central are away from annulus
99
Sx of TM changes
Usually doesn't contribute to hearing loss
- Process can extend to ossicles resulting in CHL
- Atrophy, thinning of the drum, causes the drum to be hypercompliant (floppy)
- Can predispose to retraction of the TM and subsequent cholesteatoma formation
- Can lead to perf w/ infection or tube placement
100
Sx of TM perf
Location, size of perf will determine amount of hearing loss
- Ant/Inf: <10%, low likelihood of hearing loss
- Post/Sup: >25%, increased likelihood of HL
101
Tx of TM perf
Not all perfs need to be repaired but all perfs need to be evaluated by an ENT
102
Barotrauma causes
Ambient pressure changes (flying, driving) causes a pressure differential in the middle ear and mastoid
103
Sx of barotraums
Otalgia, ETD, middle ear hemorrhage, TM perf
- Auricular pain & fullness/hearing loss that persists after the eitologic event
- Inner ear decompression sickness (Caisson disease, "The Bends")- rapid ascension while diving causes nitrogen to form small gas emboli, which can enter cerebral circulation leading to blindness, deafness, paralysis, or death)
104
Cholesteatoma
"Skin in the wrong place"
| -Accumulation of keratinizing stratified epithelium within the middle ear or temporal bone
105
cause of congenital cholesteatoma
occurs from embryonic epithelial tissue within the temporal bone
106
cause of aquired cholesteatoma
forms in a retraction pocket as squamous epithelium begins to collect and becomes trapped. Can form after healing of a TM perf, or an invasion of the middle ear by epithelium that fails to respect the borders of the perf, or temporal-bone fx, bad head injury
107
Sx of cholesteatoma
Painless otorrhea (brown/yellow discharge w/ strong odor), conductive hearing loss, "pearly white" mass in middle ear space or within a retraction pocket, or a combo of squamous debris and wax
108
How does a congenital cholesteatoma generally present?
as white mass in the anterosuperior middle ear behind an intact drum
109
Complications of cholesteatoma
-Ossicular erosion with subsequent CHL. Tegmen, labyrinth or facial nerve dehiscence
110
Tx of cholesteatoma
surgical excision of debris/cholesteatoma
111
glomus tumor
Slow growing, benign tumor of the chemoreceptive cells along the parasympathetic nerves in the skull, base, neck and chest (paraganglimoa, chemodectoma)
- Most commonly benign tumor of the temporal bone
- Locally destructive
112
4 types of glomus tumors
1. Carotid body (most common)
2. Glomus tympanicum (arise from the promontory along Jaconson's nerve, back wall of middle ear)
3. Glomus jugulare (arise from the area of the jugular formane, floor of the middle ear)
4. Glomus vagale
113
sx of glomus tumor
Pulsatile tinnitus, red mass in the middle ear space, aural fullness, conductive hearing loss, crainal nerve palsies, otalgia, ear drainage
114
tx of glomus tumor
Surgical excision or XRT (gamma knife)
