Ear Flashcards
What is otitis media? Classification?
Inflammation of the middle ear
- Acute suppurative - viral/bacterial infection –> pain and tenderness
- Chronic suppurative - persistent drainage –> conductive hearing loss, not painful
- Serous/secretory - non-suppurative fluid accumulation (eustachian tube dysfunction) –> hearing loss
Who gets otitis media? Aetiology?
Common condition - children aged 3-6 years
Usually follows URTI (viral or bacterial)
- Viruses = RSV, parainfluenza, rhinovirus, enterovirus
- Bacteria = Strep, H.influenzae, Moraxella, group A staph/strep
Signs and symptoms of otitis media?
Symptoms
- Ear pain (throbbing and severe)
- Pyrexia
- Ear rubbing in kids
- Otorrhoea (blood stained à thick and yellow)
Signs
- Conductive deafness/tinnitus
- Tympanic membrane = dull, ↓light reflex, red, ↓mobile, bulging –> perforation
- Tenderness in mastoid antrum
Complications of otitis media?
Rare - intracranial/extracranial
- Persistent middle ear effusion
- Contiguous/ haematogenous spread to other structures (mastoid, inner ear, temporal bones, meninges, brain)
- Spread of infection –> facial palsy, brain/dural abscesses, endocarditis
Management of otitis media?
Reassurance
- 80% recover in around 3 days without abx.
- No evidence for decongestants, or ear drops if intact eardrum
Analgeisa
- Paracetamol/ibuprofen (+ fluids)
Antibiotics
- No prescribing, delayed prescribing (if persisting for >4 days), or immediate prescribing.
- Amoxicillin or erythromycin
Indications for offering immediate abx in otitis media?
- Patient is systemically very unwell
- Signs/symptoms suggestive of serious illness/complications (pneumonia, mastoiditis, peritonsillar abscess etc)
- If at high risk of complications because of co-morbidities (heart/lung/renal/liver disease, CF, prem babies)
- Older than 65 with acute cough and 2 or more of: hospitalised in previous year, type 1/2 DM, CCF, current steroid use.
What is otitis externa and how does it occur?
- Inflammation of skin lining the external auditory meatus. Often called “swimmer’s ear”.
- Sac-like structure is prone to collection of water –> gets moist and dampened –> lovely environment for bacterial and fungal growth à infection.
- Removing or breaching the natural oil barrier in the meatus (trauma) allows bacteria to penetrate into the skin of the canal
Causes of otitis externa?
- Infective - bacteria, fungi
- Allergy - eczema, contact allergy
- Iatrogenic - frequent ear syringing
RFs
- Moisture – swimming, bathing, perspiration, high humidity
- Foreign objects – cotton buds, finger nails, hearing aids
- Trauma – vigorous cleaning
- Chronic skin diseases – eczema, psoriasis
Signs and Symptoms of Otitis Externa?
Symptoms
- No discharge (no mucous secreting glands in external ear)
- Pain – only if secondary bacterial infection occurs
- Hearing loss - mild
Signs
- Meatal tenderness – often marked, especially on movement of pinna
- Narrowed, oedematous meatus
- Meatal debris
Complication of otitis externa?
Malignant otitis externa
- Otitis externa which has spread to cause osteomyelitis of the skull base
- Due to pseudomonas and anaerobes causing a mound of tissue in the external canal
- Facial nerve palsy occurs in 50% of cases
- Mostly immunocompromised patients – elderly diabetics.
Investigations in otitis externa?
- Swab any discharge for culture
- Investigate for diabetes if patient over 50
Management of otitis externa?
Advice
- Don’t poke ear; use olive oil for wax removal or irritation; don’t rub ears when drying after washing/swimming (drain by tilting head to side)
Eardrops
- Containing antibiotic and anti-inflammatory (Gentisone-HC contains gentamicin and hydrocortisone à appropriate for most bacteria)
Oral Abx
- May occasionally be prescribed with topical treatment (fluclox, or ciprofloxacin if pseudomonas suspected).
What does cerumen (ear wax) contain?
- Complex mixture of lipids produced by sebaceous glands of EAM as means of protecting epithelial lining of the tract.
- Made of epithelial cells, hair and secretions of external ear.
Risk factors for impacted earwax?
Old age, learning disability, use of cotton swabs in ears, hearing aids, earplugs
Management of impacted ear wax?
Softening
- Use olive oil for at least 1 week before attempting syringing
Removal
- Irrigation (syringing) – contraindicated if perforated ear drum, recent otitis externa/media, or if only hearing ear.
- Removing wax manually – curette, forceps, suction.
Advice
- Never put cotton swabs or other objects in ear canal!
Types of deafness?
- Conductive = lesions in outer or middle ear
- Sensorineural = lesions in inner ear or auditory nerve
- Mixed = conductive/sensorineural both involved
Causes of conductive deafness?
- Wax/foreign body
- Eustachian tube dysfunction
- Otitis media/externa
- Otosclerosis
- Paget’s disease
- Barotrauma
Acquired causes of sensorineural deafness? (think surgical seive)
- Infective – rubella, syphilis, CMV, HSV, meningitis, mumps
- Trauma – chronic noise exposure, petrous temporal bone fracture, surgery
- Autoimmune
- Metabolic – diabetes, hypothyroidism, Paget’s disease
- Neoplastic – acoustic neuroma
- Degenerative
- Toxic – drugs (aminoglycosides, loop diuretics, cytotoxics)
- Meniere’s disease
Rinne’s and Weber’s interpretation?
Weber’s conductive
- Sound heard better in deaf ear (ipsilateral) because it’s only receiving input from bone and not air –> innear ear (functioning) picks up noise and middle ear doesn’t pick up ambient noise from room.
Weber’s sensorineural
- Sound heard better in good ear (contralateral) because affected ear not picking up input from bone.
Investigations in deafness?
Simple voice tests, tuning fork tests
Audiometry
- Pure tone = measurement of indivual’s hearing sensitivity for calibrated pure tone
Screening (children)
4 categories of dizziness?
- Vertigo - hallucination of movement about the patient, or of the patient with respect to the environment
- Presyncope - feeling of impending faint, caused by reduced total cerebral perfusion
- Disequilibrium - feeling of unsteadiness or imbalance when standing
- Light-headedness - “wooziness”
What is labyrinthitis? Symptoms?
- Commonest cause of acute vertigo; associated with sweating, nausea, vomiting, pallor and occasional diarrhoea.
- Presumed to be of viral origin in most cases – in elderly it may be due to an ischaemic event.
Nystagmus – towards the side contralateral to the lesion
Profound sensorineural deafness (sometimes)
Investigations in labyrinthitis?
Romberg’s test, provocation tests (Hallpike test)
Differentials for dizziness?
Peripheral vertigo - BPPV, Meniere’s, vestibular neuronitis, cholesteatoma
Central vertigo – acoustic neuroma, MS, head injury,
Drugs – gentamicine, diuretics, co-trimoxazole, metronidazole
Management of labyrinthitis?
Anti-emetic – prochlorperazine, promethazine, cyclizine
Vestibular sedatives – cinnarizine, betahistine
Vestibular Neuronitis/Acute Vestibular Failure?
- Acute inflammation of the vestibular nerve
- Sustained non-positional vertigo in previously healthy young or middle age adult
- Nystagmus/unsteady gait; N+V; no tinnitus/hearing loss/neurological signs
Méniére’s disease?
Vertigo with…
- Prostration (weakness)
- Nausea/vomiting
- Feeling of fullness in ear
- Unilateral or bilateral tinnitus
- Sensorineural deafness
BPPV?
Displacement of otoconia in semi-circular canals. Brief episodes of vertigo/nausea on moving the head.
No persistent vertigo, no speech, visual, motor or sensory problems, no tinnitus, headache, ataxia, facial numbness or dysphagia, no vertical nystagmus.
HALLPIKE TEST. Fixed by Epley manoeuvres.
What is cholesteatoma?
- Active squamous otitis media
- Serious rare complications (meningitis/cerebral abscess).
- Locally destructive around and beyond pars flaccida.
Presentation of cholesteatoma? Management?
- Peak age: 5-15 years.
- Foul discharge +/- deafness; headache, pain, facial paralysis and vertigo indicate impending CNS complications
Management
- Mastoid surgery needed to make a safe dry ear by removing disease.
