ear Flashcards
inflame of the middle ear, usually assoc w buildup of fluid and related to viral/bacterial infx
acute otitis media
fluid in middle ear wout infx
otitis media w effusion
drainage from middle ear for at least 2w usually assoc tympanic membrane perf
chronic supperative otitis media
what systems are involved with otitis media
nares, eustation tube, mastoid air cells
path of acute otitis media
- inflam response obstructs gustation tube causing neg pressure/accum of secretions
- vir/bac enter middle ear via aspiration/reflux
- organisms mult=supprative infx
bacterial organisms of otitis media
strep pneumo*
h flu
m cat
viral organisms of otitis media
rsv, rhinovirus, coronavirus, influenza
path of ome
chronic inflame response to residual bacterial componetns
allergic rhinitis, myringotomy
rf for otitis media
daycare, bottles, smoking, male, fam hx
presentation aom and ome
aom- earache, +/- fever, +/- uri symp, dec hearing
ome- asymp, dec hearing
pt presents with earache and fever. upon further exam so inflamed tm
otitis media
proper dx ome
pneumatic otoscopy, typanometry
GS= myringotomy
syndromes of aom
otitis conjunctivitis
bullous myringitis
combination of otitis media and purulent conjunctivitis caused by H flu and seen in pt
otitis conjunctivitis
inflammation of TM w bullae, painful caused by same organism as AOM
bullous myringitis
what does it mean if pt has otalgia then pain suddenly goes away and followed by purulent discharge
aom w perforation of tm
when will you see purulent drainage from the ear
aom w tm rupture
otitis externa
causes of perforation
excess fluid and pressure
extreme pressure changes
trauma
pt presents w bloody drainage, pain, and tinnitis
perforation of tm
what 3 findings are needed to call it aom
bulging tm, middle ear effusion, inflammation
tx aom pain relief
motrin/tylenol
topical benzocaine/antipyrine (auralgan) >2yo= numb
tx aom kids
abx
tx aim kids 6m-2y
abx if dx certain (bulging,effusion,inflam)
tx aom >2y
dx certain- abx amoxil
if tx aom in kid with analgesics and no abx what do you do
48-72hr then reexamine
abx of choice tx peds for aom
amoxicillin
10d if severe
5-7d >6y
abx of choice tx peds for aim w resistance to amoxicillin
high dose augmentin
abx choice tx peds for aom w pcn allergy
mild 3rd gen- cefdinir, cefpodoxime, cefuroxime
anaphylaxis- azithryomycin or clarithromycin
what is recommended for kids unable to take oral abx for tx aom
ceftriaxone 50mg/kg
tx aom adults
1st line amoxicillin may use augmenting if severe pain/fever mild allergy-cefdinir, cefuroxime anaphylaxis- zithromax maybe bactrim
tx peds and adults aom w perforation
peds- oral abx
adults- oral and otic abx
tx otitis media w effusion in adults
resolve spont but attempt to correct gustation tube dysfunction- antihistamines, decongestants, nasal steroids
tx otitis media w effusin in kids
watchful waiting, sympt past 3 months= chromic refer to ent
when are tympanostomy tubes in kids indicated
> 3 confirmed cases aom in 6m
>4 confirmed cases aom in 12 m
pt presents w ear pain, postauricular tenderness, erythma, swelling and displacement of auricle
mastoiditis
primary rf for mastoiditis
aom
bacteria causes mastoiditis
strep pneumo, strep pyogene, staph aureus
complications of mastoiditis
facial nerve palsy subperiosteal abscess hearing loss labryrinthitis (tinnitis, vertigo, n/v, nystagmus) osteomyelitis bezold abscess
when should you get ct w iv contrast for mastoiditis
extracranial complications (mass/abscess)
intracranial complications (neuro deficits)
severe illness/toxic appearance
aom not responding to abx
should cx be obtained for mastoiditis? if so when
blood if >102.2 temp
fluid strongly considered
tympanocentesis or myrinotomy
already drainage from ear
tx mastoiditis
ent for aspiration/drainage/mastoidectomy
admit + iv abx (vanco)
may need to add gram neg coverage
another name for otitis externa
swimmers ear
inflammation or infx of external auditory canal
otitis externa
origins/causes of otitis externa
infx
allergic
dermatologic
what ages does otitis externa most commonly occur
5-14
path of otitis externa
breakdown skin-cerumen barrier leads to inflam and edema of skin that causes pruritus and obstruction
the inflam changes alter cerumen prod and creates environment for breeding organisms
rf otitis externa
swimming/excess moisture
trauma to canal
devices- hearing aids, earphones
allergic contact dermatitis-shampoos,earrings
dermatologic issues-psoriasis, atopic dermatitis
prior radiation to ear area
bacteria that causes otitis externa
usually gram pos- staph aureus, staph epidermidis
**pseudomonas
candidal- check sugar
pt presents with pain when move tragus, pruritus, and hearing loss
otitis externa
on otoscopy exam what will otitis externa look like
canal erythematous, edematous
debris yellow, brown, white, gray
tm might be erythematous
no signs aom or tm rupture
complication of OE
malignant external otitis (necrotizing external otits)
- severe, potentially fatal
- elder diabetics and immunocompromised
- spreads from skin to bone to marrow of skull
pt presents with pain out of proportion, granulation tissue at bony cartilaginous junction of ear canal floor, and erythema
malignant external otitis
tx malignant external otitis
admit and consult ENT
IV cipro 1st line consider levofloxacin
control bs
tx otitis externa
- clean debris- remove cerum/ debris
- topical abx- fluoroquinolones (ofloxacin, cipro), polymyxin B/neomycin mix, aminoglycosides (tobramycin, gentamycin)
- antiseptics- bacterial static agent
- glucocorticoids to dec swelling
- wick placement for severe/bad
when should you tx OE w systemic abx and what are they
severe infx and immunocomp
cipro or ofloxacin
in tx oe with amino glycosides-tobramycin and gentamycin what can se be
ototoxicity
iatrogenic hearing loss, balance dysfunction
follow up OE and when to refer
improve by 36-48hr
refer not better 48-72hr
anatomy of eustation tube
runs from anterior wall of middle ear cavity and opens into nasopharynx
3 functions of eustation tube
- equalization of pressure across tm
- protecting middle ear from infx/ reflux of nasopharyngeal contents
- clearance of middle ear secretions
all mediated by opening/closing eustation tube
-yawning opens=pop
3 pathologic process of eustation tube
- pressure dysregulation
- impaired protective function
- diminished clearance
path of pressure dysregulation of eustation tube
failure to open and allow adequate ventilation leading to mucosal inflam and obstructed nose
functional obstruction w pressure dysregulation of eustation tube
neg pressures make opening of tube difficult
ex barometric pressure changes, airplanes
path of impaired protective function of eustation tube
reflux of nasophar pathogens, allergy inducing proteins, and gastric secretions into tube
what causes impaired protective function of eustation tube
- congenital
- short/floppy tubes (craniofacial anomalies)
- abn pos pressure nasopharynx (blowing nose, crying)
- loss immune protection in tube due to secretions
- loss mucosal protection from gastric enzymes
path of impaired clearance of eustation tube
- inability to clear viscous material/pathogens from middle ear
- loss of mucociliary function due to bacterial toxins, viruses, smoking, allergic ds, inflam
pt presents w ear pain/fullness, tinnitus and popping sounds
eustation tube dysfx
what will otoscopy exam look like for ETD
- dull bluish gray/ yellow tm (fluid behind)
- bony structures behind tm distorted
- retracted tm
- nasal mucosal swelling/inflam/polyps
tx ETD
- tx underlying issue is key: rhino sinusitis, allergic rhinitis, laryngopharyngeal reflux
- decong: pseudoephedrine/phenylephrine
when should refer for ETD
- severe ear complaints
- no improvement
- cholestetomma, recurrent aom, tm rupture
abnormal growth of squamous epithelium in middle ear and mastoid
cholesteatoma
what 2 ways can cholesteatoma lead to hearing loss
- destroy ossicles
- obstructs ET orifice leading to effusion
predisposing factors of cholesteatoma
- hx recurrent aom/middle ear effusions
- older age tympanostomy tube placement
- cleft palate
- craniofacial abn
- turner syndrome
- down syndrome
- fam hx of chronic middle ear ds/cholesteatoma
path of congenital cholesteatoma
squamous cysts arise from epithelium of middle ear, fail to dissipate, dev into cholesteatoma
path of acquired cholesteatoma
- arise form retraction pocket of TM
- invaginations of TM that form in pts w chronic ETD, neg middle ear pressure, and focal collapse of tm
- retraction poclet pulled into middle ear space creating pouch that collects desquamating cells and forms cholesteatoma
complications fo cholesteatoma
late stage can destroy bone and lead to deafness and paralysis of facial nerve
secondary infx- pseudomonas, proteus
where is acquired cholesteatoma found
posterosuperior quadrant tm
where is congenital cholesteatoma found
anterosuperior quadrant of tm
pt presents with white mass behind intact tm and focal granulation on surface of tm
cholesteatoma
tx cholesteatoma
refer and surgery
complete excision (tympanoplasty) and reconstruction of ossicles
exteriorization forming a skin lined cavity
what is acoustic neuroma known as and why
vestibular schwannomas- schwan cell derived tumors that commonly arise from vestibular portion of 8th cranial nerve
avg age 50
path of acoustic neuroma
genetically linked assoc w neurofibromatosis type 2- gene located on chromosome 22
rf of acoustic neuroma
exposure to loud noise
childhood exposure low dose radiation head/neck
hx parathyroid adema
pt presents with hearing loss and tinnitus, unsteadiness while walking, and taste disturbance
acoustic neuroma
cochlear nerve- hearing loss/tinnitus
vestibular nerve- unsteadiness
facial nerve- taste disturbance
pt presents with tinnitus, feel like tilting, and hypesthesea
acoustic neuroma
cochlear- tinnitus
vestibular- tilting
trigeminal- hypesthesea
pt presents hearing loss, facial numbness, facial paresis
acoustic neuroma
cochlear-hearing loss
trigeminal-numbness
facial- paresis
cochlear nerve invol of acoustic neuroma
hearing loss and tinnitus
vestibular nerve invol of acoustic neuroma
unsteadiness while walking, feeling of tilting or veering
trigeminal nerve invol of acoustic neuroma
facial numbness, hypesthesea, pain
facial nerve involve of acoustic neuroma
facial paresis, taste disturbance
tumor progression in acoustic neuroma is a sign of
cerebellar or brainstem compression
best initial test for dx acoustic neuroma
audiometry
tx options of acoustic neuroma
surgery- good long term control
radiation- sterotactic radiosurgery/radiotherapy and proton beam therapy
observation- slow growing, MRI every 6-12m
pt presents with episodic vertigo, sensorineural hearing loss, and tinnitus (age 20-40)
meniere ds
path of meniere ds
endolymphatic hydrops cause distortion and distention of membrane/endolymph portions of labyrinthine system
not sure why excess fluid builds up
how does episodic vertigo present in meniere ds
- rotatory spinning or rocking sensation
- +/- N/V
- persists for 20m to 24h
- disequilibrium sensation
how does hearing loss present in meniere ds
sensorineural fluctuating affect lower frequencies progressive over time permanent 8-10y
how does tinnitus present in meniere ds
low pitch sound
auditory distortion
definitive dx of meniere ds
postmortem
guideline to dx meniere
2 separate episodes vertigo lasting at least 20m
audiometric confirmation of sensorineural hearing loss
tinnitus / perception aural fullness
what diagnostic studies should be performed w meniere ds
audiometry- normal in mid freq, low/high loss
vestibular testing
labs- rpr rule out syphilis
imaging- mdi rule out cns lesions
vestibular evoked myogenic potential (VEMP)- detect hydrops
lifestyle adjustments w menieres
salt restriction
caffeine/nicotine/alcohol restriction
antihistamine tx menieres
meclizine (antivert)
dimenhydrinate (dramamine)
anticholinergic tx menieres
scopolamine
antiemetic tx menieres
promethazine (phenergan)
prochlorperazine (compagine)
benzo tx menieres
lorazepam (ativan)
types rehab menieres
hearing aids
vestibular rehab- exercises max balance
what improves fluid exchange in inner ear for menieres
pos pressure pulse generator (meniett)
perception of sound in absence of an external source within 1 or both eyes, within or around head or as outside distant noise
tinnitus- buzzing, ringing, hissing
vascular disorders that can cause tinnitus
believed to be secondary to atherosclerotic narrowing of vessels
- arterial bruits
- av shunts (av fistula)
- paranganglioma: near carotid bifurcation
- venous hum: htn , inc ICP
path of neuralgic disorders causing tinnitus
spasm of muscles in middle ear- pulsatile tinnitus- related to cn V/VII (MS)
ETD path causing tinnitus
vents too much causes ocean sound; mc after sudden weight loss and improves when lie down
causes of tinnitus from auditory system
ototoxic meds
presbycusis-hearling loss w age
otosclerosis-bony overgrowth of stapes
acoustic neuroma- tumor compressing cochlear nerve
behavioral therapies for tinnitus
tinnitus retraining- suppress auditory neural connections
biofeedback/stress reduction- relaxation tech control autonomic functions
cognitive behaviroal- altering psychological response to tinnitus
meds to tx tinnitus
prostaglandin analogue- misoprostol (limited benefit)
intratympanic dexamethasone
illusion of movement, transient sensation of spinning and can be assoc with gait, N/V, nystagmus
vertigo
vertigo is either 2 things in origin
central- cps issue
peripheral- vestibular system issure
peripheral vestibular vertigo can sense 2 motions
semicircular canal- angular motion “spinning”
otolith organs- linear motion
path of vertigo w 1 ear
dysfunction of 1 of vestibular labyrinths sends different messages to brain which doesn’t match with visual data
vestibular labyrinth dysfn=peripheral vertigo
path of vertigo w both ears
sending appropriate msg to brain along w eyes so when brain malfunctions/misinterprets data causes vertigo
brain misinterpretation= central vertigo
vestibular labyrinth dysfunction = ? vertigo
peripheral
brain misinterpretation= ? vertigo
central
mc vertigo caused by Ca debris within posterior semicircular canal
benign paroxysmal positional vertigo (BPPV)
spinning sensation brought on when turning in bed or tilting head backward to look up
BPPV- peripheral
dx BPPV
horizontal/vertical/torsional nystagmus
dix hallpike maneuver/epley maneuver
rapid onset severe, persistent vertigo, N/V, and gait
vestibular neuritis (labyrinthitis)- peripheral
acute vertigo, +/- hearing loss, facial paralysis, ear pain and vesicles in auditory canal
herpes zoster oticus “ramsay hunt syndrome”
peripheral
steroids/acyclovir
vertigo, n/v, gait w traumatic peripheral vestibular injury following direct concussion
labyrinthine concussion
hemotympanum/hearing loss noted
weeks- months
types of central vertigo
migrainous
brainstem ischemia
cerebellar infarct/bleed- sudden,intense, limb ataxia
MS-lesions near vestibular nuclei
recurrent vertigo lasting under 1 min
bppv
single episode vertigo lasting several min to hrs
migraine or transient ischemia
recurrent episodes w meniere ds can last how long
hrs
prolonges and severe episodes vertigo
vestibular neuritis
presentation of nystagmus w peripheral vertigo
horizontal, fast and away from affected side
presentation nystagmus w central vertigo
can have any trajectory
gait presentation w vertigo
unilateral/peripheral lean/fall to affected side
cerebellar stroke-unable to walk without falling
dx testing vertigo
acute setting- ct scan, mri/mra
ent referral- electronystagmography and video nystagmography, vestibular evoked myogenic potentials (vemp), audiometry
acute sump relief vertigo
iv fluids
antiemetics- zofran, reglan, phenergan
antihist- antivert, dramamine, benadryl
benzos- valium, ativan
vestibular neuritis (labyrinthitis) vertigo tx
oral steroidsantiemetics- zofran, reglan, phenergan antihist- antivert, dramamine, benadryl benzos- valium, ativan anticholinergics- scopolamine vestibular rehab
blunt trauma to outer ear
auricular hematoma
path of auricular hematoma
blood accumulates in subperichondrial space creating barrier and cuts off blood supply to cartilage leading to necrosis and maybe infx
another name for auricular hematoma
cauliflower ear
tx auricular hematoma
needle drainage
I&D
