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QM Loco GP > Ear > Flashcards

Ear Flashcards

1
Q

What are the main areas of the ear that can have pathology?

A
  • Outer ear: auricle, pinna, ear canal
    ▫Inflammation/infection → otitis externa
  • Outer ear, middle ear: separated by tympanic membrane (eardrum); normally no air passage/fluids between two compartments
    ▫Perforated eardrum → communication through tympanic membrane
  • Middle ear: tiny chamber; contains functional ear bones (malleus, incus, stapes)
    ▫Inflammatory middle ear disease →otitis media
  • Eustachian tube: connects middle ear to nasopharynx
    ▫Failure to open/close, remove secretions → Eustachian tube dysfunction
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2
Q

Causes of Eustachian tube dysfunction?

A

Failure to EQUALIZE/dilatory dysfunction
▪Functional: inflammation (viral infection—e.g. common cold, allergy) → Eustachian tube swelling, secretion accumulation →Eustachian tube mechanical blockage →equalization failure
▪Anatomical: regional mass pressure (e.g. tumour) or previous trauma scar/medical procedure

PATULOUS dysfunction (chronic patency)
▪Weight-loss (> 6 lbs/2.7 kg) → tissue atrophy (e.g. chronic illness)
▪Chronic allergy/gastric-content reflux →mucosal atrophy
▪Chronic gum-chewing → repeated muscle-facilitated Eustachian tube opening
▪Short, floppy Eustachian tubes (in children) → provide little resistance against middle-ear refl ux during ↑ positive pressure on nasopharyngeal end of tube (e.g. crying/nose blowing)

CILIARY dyskinesia
▪Acquired: toxins → ciliary damage, paralysis → mucociliary elevator failure ▫Cilia can’t flick back and forth (e.g. cigarette smoke)
▪Congenital: cystic fibrosis → very thick secretions not adequately cleared

COMPLICATIONS can be:
Conductive hearing loss, otitis media, tympanic membrane perforation, cholesteatoma

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3
Q

Signs and symptoms of Eustachian tube dysfunction?

A

▪Affected ear is clogged, muffled
▪Ear pain
▪Autophony (hearing one’s own voice, breathing)
▫Encountered primarily in patulous dysfunction
▪If inner ear affected → balance problems

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4
Q

Diagnostics and Imaging in Eustachian tube dysfunction?

A

CT scan / MRI
▪Contrast in persistent effusion cases
▫Neoplasm may cause Eustachian tube obstruction

Nasal endoscopy
▪Inflammation, secretion, allergic manifestation signs
▫Eustachian tube opening quality (assessed through yawn, swallowing maneuvers)

Otoscopic ear examination ▪Normal tympanic membrane appears shiny, translucent
▪Examine for abnormality (e.g. retraction, effusion, perforation)
▫Dull bluish-gray/yellowish coloration denotes effusion behind membrane; reddish coloration, engorged vessels signal inflammation
▪Pneumatic examination
▫Fluid-filled ear minimizes tympanic membrane excursion with insufflation

Others:
▪Hearing tests for conductive hearing loss
▫Weber test: sound lateralized to affected ear
▫Rinne test: BC > AC

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5
Q

Treatment for Eustachian tube dysfucntion?

A

MEDICATIONS
▪Dilatory dysfunction
▫Upper respiratory tract inflammation (viral infection, allergy)
→ short intranasal/systemic decongestant, corticosteroid course

▪Patulous dysfunction
▫Avoid decongestants and corticosteroids

SURGERY
▪Dilatory dysfunction
▫Tympanostomy tubes: hollow tubes inserted into eardrum → create direct opening between middle, outer ear → allow easy pressure equilibration, accumulated debris drainage

OTHER INTERVENTIONS
▪Patulous dysfunction
▫Hydration, nasal saline drops/irrigation

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6
Q

What is otitis externa and what causes it?

A

▪Outer ear canal irritation
▪AKA “swimmer’s ear”

CAUSES
▪Outer ear canal microbial infection (primary cause):

▫Bacterial (90%): Pseudomonas aeruginosa, Pseudomonas vulgaris, E. coli, S. aureus
▫Fungal: Candida albicans, Aspergillus niger

▪Dermatological conditions
▫Allergic contact dermatitis, psoriasis, atopic dermatitis

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7
Q

Risk factors for otitis external?

A

▪Frequent swimming
▪Mechanical cleaning/irritation (cotton swabs/scratching)
▪Ear canal occlusion (hearing aid, headphone)
▪Diabetes

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8
Q

Signs and Symptoms of otitis external?

A

▪Acute (< six weeks)

  1. Pinna traction → aggravated pain
  2. Otorrea: sticky yellow discharge)
  3. Swelling, purulent debris → external canal obstruction → conductive hearing loss, +/- aural fullness
  4. Posterior auricular lymphadenopathy
  5. Complicated otitis externa: periauricular soft tissue erythema, swelling

▪Chronic (> three months)
▫External ear canal pruritus; epidermis atrophy, scaling; otorrhea; normal tympanic membrane

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9
Q

Treatment of otitis media?

A

MEDICATIONS
▪General
▫Burow’s solution: topical drops application (buffered aluminum sulfate, acetic acid mixture)

▪Bacterial
▫Antipseudomonal otic drops/topical steroid drops/combination
▫3% acetic acid solution → acidify ear canal (bacteriostatic acidic pH)
▫Systemic antibiotics (lymphadenopathy/cellulitis)

▪Fungal
▫Topical antifungal preparation (e.g. gentian violet, boric acid)

▪Chronic otitis externa (pruritus without obvious infection)
▫Corticosteroid otic drops alone

OTHER INTERVENTIONS
▪General
▫Clean ear under magnification →irrigation, suction, dry-swabbing
▪Fungal
▫Debridement
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10
Q

Name the types of otitis media?

A

Acute otitis media

Otitis media with effusion (glue ear)

Chronic otitis media

  • benign
  • chronic serous otitis media
  • chronic supportive otitis media (CSOM)
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11
Q

What happens in acute otitis media?

And symptoms?

A

Acute otitis media

▪Acute middle ear compartment infection (< three weeks)
or
▪Acute infection/allergies
→ nasopharyngeal mucous membrane inflammation → Eustachian tube dysfunction → secretion reflux/aspiration from nasopharynx to middle ear (normally sterile) → infection

SYMPTOMS
▫Otalgia, fever, conductive hearing loss (triad)
▫Children: ear pulling, crying, poor sleep, irritability
▫Crying → small blood vessel distension on tympanic membrane → mimics otitis media redness (confounds diagnosis)

OTOSCOPY

  • Tympanic membrane ↓ mobility
  • hyperemia
  • bulging membrane (pus behind tympanic membrane), landmark loss (malleus handle, long process not visible)
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12
Q

What happens in otitis media with effusion (glue ear)?
And symptoms?

And otoscopy?

A

Otitis media with effusion

▪Fluid presence in middle ear, with/without infection signs

▪Eustachian tube dysfunction → trapped fixed gas volume in middle ear →surrounding tissue slowly absorbs gas → ↓middle-ear pressure
▫Sufficient ↓ middle-ear pressure →surrounding tissue fluid drawn into middle ear cavity → middle-ear effusion (transudate)

▪Most common pediatric hearing loss cause

SYMPTOMS
▪Otitis media with effusion
▫Ear fullness, conductive hearing loss +/- tinnitus, no pain/fever

OTOSCOPY

  • Amber/dull grey tympanic membrane discoloration
  • meniscus fluid level ↑ ↓, air bubbles behind tympanic membrane
  • air insufflation → immobile tympanic membrane
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13
Q

What happens in chronic supperative otitis media?
And symptoms?

And otoscopy?

A

Acute otitis media complication → chronic suppurative otitis media

▪Perforated tympanic membrane with persistent drainage (> 6–12 weeks)

▪Acute otitis media → prolonged inflammatory response → middle ear mucosal oedema; tympanic membrane ulceration, perforation → chronic middle ear, mastoid cavity inflammation →persistent discharge from middle ear through perforated tympanic membrane

▪Persistent infection/ inflammation →granulation tissue → polyps within middle-ear space → inflammation, ulceration, infection, granulation tissue formation cycle → eventual surrounding bony structure destruction

SYMPTOMS
▪Chronic suppurative otitis media
▫Perforated tympanic membrane; otorrhea; hearing loss; no pain/discomfort; fever, vertigo, pain →danger signs (possible complications)

OTOSCOPY
▫Perforated tympanic membrane:
- otorrhea
- visible granulation tissue (medial canal/middle-ear space)
- middle ear mucosa (through perforation) may be edematous, polypoid, pale, erythematous

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14
Q

Causes of otitis media?

A

▪Bacteria

  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis
  • group A streptococcus
  • S. aureus
▪Virus
- Respiratory syncytial virus
- influenza
- parainfluenza
- adenovirus)
▫Often viral/bacterial coinfection
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15
Q

Risk factors for otitis media?

A

▪Smoke, air-pollution exposure
▪Immunosuppression
▪Pacifier use; daycare
▪Down syndrome
▪Recent upper-respiratory tract viral infection
▪Craniofacial malformation (cleft lip/palate, microcephaly)
▪Cystic fibrosis

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16
Q

Treatment of each type of otitis media?

A

MEDS
▪Acute otitis media
▫Analgesics
▫Systemic antibiotics if severe/persistent (> three days)

▪Otitis media with effusion
▫Avoid antihistamines, decongestants →secretions thicken

▪Chronic suppurative otitis media
▫Corticosteroid drops → ↓ granulation tissue
▫Antibiotics (topical/drops)
▫Granulation tissue control: granulation tissue prevents affected-site topical medication penetration

SURGERY
▪Acute otitis media
- Frequent recurrence: tympanostomy tubes

▪Otitis media with effusion
- Severe cases: tympanostomy tubes, myringotomy (tiny eardrum incision) +/- ventilating-tube insertion

OTHER
▪Otitis media with effusion
- Watchful waiting: 90% of children clear fluid in three months without intervention
- Minor cases: may resolve spontaneously; manual autoinflation (manually pinch nasal passage, close back of pharynx → forceful diaphragm contraction)

▪Chronic suppurative otitis media
- Mechanical/irrigative debris clearing:aural toilet (mechanical removal of mucoid exudates, desquamated epithelium, associated debris prior to medication administration); aural irrigation (50% acetic acid/sterile water ear-rinse solution)

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17
Q

Causes of a perforated ear drum?

A

▪Otitis media
▪Trauma
▪Explosive/percussive force, exceptionally loud noise
▪Iatrogenic, sudden pressure ↑ ↓ (with blocked Eustachian tubes)

COMPLICATIONS
▪Chronic infection → permanent hearing loss

18
Q

Signs and symptoms of a perforated eardrum?

A 
▫Hearing loss
▫Tinnitus
▫Ear-ache (infection association)
▫Otorrhea
▫Nausea/vomiting
19
Q

Treatment for a perforated eardrum?

A

MEDS
▪Avoid otic drops containing gentamicin, neomycin sulfate, tobramycin
- Ototoxicity → permanent hearing loss
▪Otorrhea control
- Topical: fluoroquinolone otic drops
- Systemic: antibiotics covering respiratory flora

SURGERY
▪Tympanoplasty: surgical repair

OTHER
▪Watchful waiting
- Perforations may heal in weeks/months

20
Q

What is the anatomy of the pinna? Name the landmarks.

A 
Lobule
Antitragus
Cavum conchae
Tragus
Crus of helix
Helix
Fossa triangularis bordered by the crura of anti helix
Antihelix
21
Q

What conditions can affect the pinna?

A

Perichondritis: inflammation of perichondrium from trauma, eg piercings

Cauliflower ear: (haematoma under the perichondrium –> fibroses), decompress acutely haematoma to prevent formation

CDNH: Chondrodermatitis nodularis helicis - painful raised bump on helix of ear, not infective, excise

TUMOURS
Basal cell carcinoma, squamous cell carcinoma, malignant melanoma

Skin conditions

22
Q

What is the innervation of the ear canal?

A

Sup: VII
Ant: V
Inf: X
Post: C3

23
Q

When you visualise the ear drum what can you see?

A 
Umbo - malleus - lateral process or malleus 
pars flacida 
chorda tympani nerve
long process of incus
annulus fibrosis
pars tensa
cone of light
24
Q

What is the course of the facial nerve?

A

internal acoustic meatus, geniculate nucleus, greater petrosal nerve
nerve to stapedius, chorda tympani,
stylomastoid foramen

25
Q

What are the main ear symptoms to ask about?

A 
Hearing impairment
Otorrhoea
Otalgia
Itching
Vertigo
Tinnitus
Examining ear:
Inspection
Otoscopy (do worse ear first in children)
Microscopy
Tuning forks
Also: facial nerve and post nasal space
26
Q

What investigations can you do for the ears?

A 
Hearing tests
Swabs
Balance tests
CT
MRI
27
Q

What are some ear conditions?

A 
Otitis externa
Wax
Foreign bodies
Acute otitis media
Chronic otitis media
Glue ear
Ear trauma
Hearing loss
Vertigo
28
Q

Tell me about wax?

A

Produced in the outer third of the canal only
Skin cells then migrate out of the ear canal and move wax with them.

Wax deeper in the canal has been pushed there or it isn’t wax.

Squalene, lanosterol and cholesterol

  • wet (dominant) caucasians and afro-caribbeans
  • dry (recessive) asians and native Americans

Function:
clean, lubricate, antibacterial. anti fungal,

Problems:
pain, infection, hearing loss, unable to visualise ear drum

29
Q

Key points on Otitis External?

A

Sx: pain, itching, discharge, hearing impairment

Signs: pain on pinna movement, swelling, erythema, debris in canal, eczema

Infective: bacterial, fungal, viral vs
Reactive: eczema, psoriasis

Health has Diphtheroids, Staph epidermidis
Otitis externa has Pseudomonas, Coliforms, proteus, Staph aureus

30
Q

What is furunculosis?

A

a type of OE
Staph infection of the hair follicles
Hx of pain in ear, pain moving jaw, deafness then discharge
Tender red EAM with single or multiple furuncles, pain over tragus and lymphadenopathy

31
Q

What is Otomycosis?

A

OE
Primary fungal infection or secondary to prolonged antibiotics
C. albicans, Aspergillus niger

Sometimes can see spores in EAM and can be mixed bacterial too.
May require prolonged toilet

32
Q

Management of OE dermatitis, eczema, psoriasis?

A

eg scaling reaction on pinna EAC with supra added infection
RX:
clear debris
steroid based drops and topical hydrocortisone to pinna
+ antibiotic drops is swab grows organism

33
Q

What bacteria likely cause Acute Otitis Media?

A

Strep pneumo
H. influenza
Moraxella catarrhalis

34
Q

Sx of AOM?

Treatment?

A

fever and associated URTI
otalgia (pain, rubbing, screaming)
otorrhoea
bulging TM, injected TM, perforation or mucupus

Paracetamol, oral Abx (amoxycillin, erythromycin), myringotomy

35
Q

What is glue ear?

A

Otitis media with effusion (fluid in the middle ear but not purulent) OME
“serous otitis media with effusion”

Common in children 2-6yrs, Eustachian tube dysfunction, adenoid hypertrophy, infection / allergy, cleft palate, downs. mucociliary disorders.

Unilateral in adult think about nasopharyngeal tumour

Effusion can persist after infection, may not be painful but big cause of hearing loss in children

Observe for 3months, usually resolves. May need grommets or hearing aids.

36
Q 
Tell me about Chronic Otitis Media?
Sx
Types
Rx
Complications
A

COM can be infectious or inflammatory and has a perforated tympanic membrane.

Sx - hearing loss, pyorrhoea, fullness, pain.

Types:

  • Benign (or inactive); dry perf without active infection
  • Chronic Serous Otitis Media; perf with continuous serous drainage
  • Chronic Suppurative Otitis Media; persistent purulent drainage through perf

Rx
topical / systemic Abx, aural cleaning, myringoplasty, cortical mastoidectomy.

Complications:
Low pressure gives retraction pocket, squamous epithelium build up, cannot escape, gives a cholesteatoma. (more common in attico-antral perfs, ie not central ones)

37
Q

What is cholesteatoma?

A

Misnomer (neither cholesterol or a tumour)

From epithelial cells unable to migrate out of a retraction pocket. Lytic enzymes.

Foul smelling discharge.

Nasty complications: meningitis, cerebral abscess, hearing loss, mastoiditis, facial nerve dysfunction.

38
Q

What are the complication from Otitis Media?

A

Extracranial:

  • ossicular erosione and middle ear scarring
  • tympanosclerosis
  • facial nerve palsy
  • labyrinthitis
  • petrositis

Intracranial:

  • meningitis
  • intracranial abscess
  • lateral sinus thrombosis
  • otitic hydrocephalus
39
Q

Causes of conductive hearing loss?

A

Congenital
Aquired:
- ear canal: wax, otitis externa, foreign body
- middle ear: fluid/effusion, infection, chronic otitis, ossicular abnormalities, scarring, otosclerosis, TM perf, exostosis

40
Q

Causes of sensineural hearing loss (SNHL)?

A

CONGENITAL:

  • Hereditary, alone or syndromic
  • Intra-uterine disease:
    1. infections: rubella, CMV, toxoplasmosis
    2. ototoxic drugs
    3. metabolic: maternal diabetes
    4. perinatal disease: hypoxia, prematurity

ACQUIRED

  • trauma; head injury
  • inflammatory; otitis media, meningitis, mumps
  • ototoxicity; ahminoglycosides, cytotoxics
  • neoplasm; acoustic neuroma
  • idiopathic; menieres, sudden hearing loss
  • iatrogenic; surgery
41
Q

Salient points in a hearing loss history?

A
  • one or both ears?
  • onset; gradual or sudden?
  • duration
  • associated Sx (pain, discharge, tinnitus, vertigo)
  • degree of disability (work affected, socially affected)
42
Q

Treatment of Sudden SNHL?

A

Medical Emergency

  • corticosteroids
  • antiviral agents
  • admit?

Inject ear

  • corticosteroids
  • silverstein wick

QM Loco GP (3 decks)

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