Ear Canal Pathology Flashcards
Foreign bodies in the EAC are a frequently encountered problem and include
beads
insects
food
pebbles
small batteries
how to remove foreign bodies
hook or suction
with/without local anesthesia
what can PT complain about with insects in the canal
itching or tickling sensation or patients report that they can hear something “moving”
Small alkaline batteries that can cause ____ in canal
chemical burns
should you remove insects
NO
you may leave behind parts of it that will cause a reaction for the PT, refer them out to get remove
what is ear canal stenosis
When the ear canal fails to completely develop during the 7th month in utero, the result is a very narrow ear canal
how to fix stenosis
canalplasty - widening the canal
what can stenosis lead to
difficulty in examining the EAC
collection of wax and debris in EAC
possible CHL
what is congenital aural atresia
Failure of canalization of the EAC can result in aural atresia
is atresia bilateral and in females
no one sided and more common in males
Congenital Aural Atresia is often associated with
microtia & middle ear anomalies
peanut ear is an example of
microtia
Often sporadic, it may occur in association with a known syndrome including
Treacher-Collins, Trisomy 22, Crouzon’s syndrome, and hemifacial microsomia
trisomy 21 is usually associated with
stenotic ear canals
can establish cochlear function in children with unilateral and bilateral atresia
bone conducted ABR
why do you want to do bone conducted ABR?
establish cochlear function because changes the treatment plan knowing the cochlear fxn
Aural atresia occurs after inner ear development, therefore, most patients (› 80%) have _____ cochlear function but have a maximum_____ (~ 60 dB HL)
normal, CHL
Repair of ___ should take place after repair of a ____
aural atresia, coexisting microtia
when does surgical repair of aural atresia take place
around 6-8 yrs old because aural is close to full size by then
FDA has approved that children with bilateral or unilateral atresia can be fit with a surgically implanted bone-anchored hearing aid (BAHA) after _____
5 years of age
Children < 5 years can be fit a
bone-conducted hearing aid/BAHA coupled to a soft or hard headband
CI vs BAHA
CI stimulates auditory nerve
BAHA sends signal in nonfunctioning middle ear and sending it to the functioning inner ear
which populations are more adapt to having collapsing ear canals
children - cartilage not fully developed
adults - cartilage is deteriorating
what are collapsing ear canals
Ear canal walls can collapse when standard supraaural headphones are placed over the ears
an occluded ear canal can cause as much as a
50 dB HL hearing loss
what happens if you test for HL and close off the ear canal?
exaggerate their HL
result in mixed HL if they already had a HL
how can you figure out you have a collapsed ear canal
if they can converse with you and the thresholds dont match
high frequency conductive hl (abg)
unmasked bc will show huge ABG that you think has a snhl
audio findings in collapsing canals
Normal tympanogram
A “conductive” hearing loss, present only at or worse in the higher frequencies with supraaural headphones
Threshold improves when the headphone(s) are elevated slightly from the ear canal
Rarely, patients may complain that they cannot hear as well with headphones as without
best ways to manage collapsing ear canals
Use of insert phones (best option)
Placement of immittance probe tips in the ear canal
Use of stock ear mold(s) to keep the canal open
Pull the pinna upwards and backwards when placing the headphones
If suspecting collapsing canal, hold the headphone, if possible, against the ear rather than fixing it in place with the headband
what is epithelial migration
Cerumen and dead skin are carried out of the external auditory canal by an unusual lateral migratory property of the squamous epithelium (skin) lining the ear canal
why does cerumen get drier with age
reduced number and activity of ceruminous and sebaceous glands
why is impaction more common in males
due to thicker and coarser hairs found at the lateral end of the EAC
what are examples of what can lead to impaction
Narrow canals, over-zealous use of cotton coated tips, and a hearing aid/earmold can all impede the normal flow of cerumen to the periphery
if there is complete impaction what should you do
you do not know how far back it goes, do not try to remove it but refer for a medical cerumen management with a physician
what happens besides safety if you test with ceumen impaction?
a fake conductive loss or mixed loss
what are audiologic findings you would see with cerumen impaction
sensation of obstruction
on otoscopy, cerumen blocking the ear canal; ™ structures are not visualized
tympanogram volume </= .2ml
mild CHL
otalgia
vertigo/dizziness
coughing (Arnold’s nerve, branch of X nerve in EAC)
what level hl can you have with cerumen impaction
can have up to 30dB HL with impacted cerumen
otoscopy is not 100% accurate for everything we see
what else could be done to determine cerumen impaction
if the tymp shows volume of .2 ml you have a complete obstruction
flat tymp
if it is greater than .2, there is some opening and you may be ok to do a hearing test
what is management of the cerumen impaction
removal by medical personnel
Cerumen softening by cerumenolytic agents like olive oil, Murine, and Debrox prior to removal
what are inflammatory polyps
abnormal tissue growth
what is inflammatory polyps typically seen with
chronic otitis media with or without choesteatoma
what is a cholesteatoma
sudo tumors, eat into anything that gets in their way, can present as a polyp or have them associated with it
what can cause inflammatory polyps
Foreign bodies in the EAC or TM such as retained PE tubes, canal cholesteatoma, and benign or malignant tumors
how are inflammatory polyps treated
usually not painful
respond to topical therapy and steroid antibiotic drops
what happens if inflammatory polyp doesn’t heal with medication
biopsy
the single most common condition to affect the EAC
otitis externa
what is otitis externa
inflammatory condition of the skin lining the EAC
otitis externa aka
swimmers ear
what are the causes of OE
acute, chronic, diffuse (whole eac), or localized (part of eac)
describe acute diffuse otitis externa
severe, sudden onset in whole eac
bacterial infection
can be caused by local trauma (q tips)
frequent swimming
spontaneously
what are the audiologic findings with ADOE
severe pain
usually CHL (superimposed)
whitish, watery otorrhea
acute swelling (severe enough to close EAC)
why is there pain associated with ADOE
swelling because there is fluid (edema) and causes pain because there is not a lot of room in the canal between the skin and cartilage/bone and the pressure there is what you are feeling
What are the two forms of ADOE
furuncle (abscess)
bullous myringitis
treatment for ADOE
Analgesics for pain
Topical antibiotics and steroids
Removal of infected debris by physician
describe furuncle (abscess) form of ADOE
staphylococcus aureus infection of a hair follicle in the EAC
Extremely tender and painful, but self-remitting in a few days
Symptomatic treatment for pain if needed
describe bullous myringitis form of ADOE
Localized viral (e.g., influenza or herpes zoster) or bacterial infection (e.g., Strep. pneumoniae) of TM and deep EAC
Results in blood blisters of various sizes
Extremely painful but again self-remitting in a few days
treatment for bullous myringitis
Symptomatic for pain
Cleaning of debris in the EAC by a physician
most common cause is seborrhic dermatitis believed to be caused by a yeast-like organism
chronic otitis externa
describe chronic OE
generalized condition of EAC
skin appears red & scaly & lack of cerumen
itchy (rather than pain)
watery discharge
prone to frequent acute flare ups
treatment for chronic OE
topical steroids
what are complications of chronic OE
Stenosis of the EAC due to inflammation
Formation of a false membrane across the EAC that may obscure the TM and result in a conductive hearing loss
fungal infection
otomycosis
occurs spontaneously or a result of frequent use of topical antibiotics, in which case it may be secondary to chronic otitis externa
otomycosis
describe otomycosis
range from blue-black, green, yellow, to white
produces debris in EAC
PT complain of HL or wetness in ear
what can happen if otomycosis is untreated
can destroy sections of EAC
mastoid bone
can cause meningitis & death
treatment for otomycosis
Topical anti-fungal medication
Removal of debris from the EAC by a physician
what is the difference bw chronic and recurring?
recurrent - can come and go and come and go
chronic - continuously occurring
dermatitis
any inflammation in the skin
how does otomycosis cause meningitis?
starts in eac, can eat structures and cause mastitis and can go into the middle ear, the brain is above the bony plate in the middle ear and if it eats through the plate into the brain it reaches the meninges and causes this
Historically called malignant otitis externa
necrotizing external otitis (NEO)
Otitis externa can be a much more aggressive infection in the immunocompromised patient, such as
Poorly controlled diabetic patients (most common)
HIV and AIDs patients
NEO can involve
temporal bone and skull base and then it is essentially osteomyelitis - skull-base osteomyelitis
describe neo
episode begins as an acute otitis externa but because the host is immunocompromised, the infection spreads beyond soft tissue of the ear canal to the underlying temporal bone
chronic infection ensues with granulation and inflammatory tissue forming in the EAC replacing a significant portion of the bony EAC, which then mimics a malignant disease
why does uncontrolled diabetes cause immunocompromised?
affects multi systems so it will also attach your immune system
Intratemporal and intracranial complications with NEO occur through involvement of neurovascular pathways, including
Inferior extension of the disease into the mastoid portion of the temporal bone can produce facial weakness/paralysis
Medial extension into the petrous apex can affect CNs V & VI
Inferior-medial extension can involve the jugular foramen and cranial nerves IX, X, & XI resulting in
what is inferior extension of the disease
astoid portion of the temporal bone can produce facial weakness/paralysis
what is the medial extension of NEO
into the petrous apex can affect CNs V & VI
what is the inferior-medial extension of NEO
can involve the jugular foramen and cranial nerves IX, X, & XI resulting in hoarseness, dysphonia, and aspiration
Extension of NEO into the dura lining the temporal bone can result in
Vascular complications – e.g., sigmoid sinus thrombosis
Intracranial complications – e.g., otic hydrocephalus & meningitis
what is aspiration pneumonia
liquids or food particles go into the lungs
blood clot
thrombosis
what is otic hydrocephalus
caused by a problem at the ears, excessive fluid caused from an external ear canal infection
how do you diagnose NEO
Biopsy of granulation tissue in the EAC to rule out malignant disease and obtain cultures for bacterial and fungal organisms
CT scan and MRI to evaluate temporal bone, skull base, & soft tissue
waht should be suspected in immunocompromized PT with ear pain
necrotizing external otitis
what is the treatment of NEO
Parental and topical antibiotics (resolves the condition in ~ 80% of patients) but may require meds for up to 6 months
Treatment of underlying immunocompromising condition
Common benign neoplasms are
exostosis & osteomas
Bony growth and the most common benign tumor of the EAC
exostosis
what is exostosis caused by
localized hyperplasia (abnormal cell increase) usually due to irritation or may be idiopathic
Single or multiple growths
what is common to see in exostosis PT’s
bilateral but usually starts as a unilateral growth
Common in individuals with prolonged exposure to cold water
If large, may lead to a conductive hearing loss by obstructing EAC
symptoms of exostosis (at a later stage)
pain/discomfort, tinnitus & associated OE
what isthe treatment for exostosis
antibiotics analgesics & surgical excision of growth
types of benign neoplasms
exostosis & osteoma
what is an osteoma
true benign bony tumor
Less common and more laterally based than exostosis
what is the difference bw osteomas & exostosis
exostosis are irregular and multiple, osteomas are smooth and usually singular
symptoms of osteomas
similar to exostosis
treatment for osteomas
cause obstruction faster so will need surgical excision
if you have infection need antibiotcs
if pain, pain meds etc.
rare; with an incidence of 1 to 6 per 1,000,000
malignancies of the temporal bone
25% of all temporal bone malignant tumors are
malignancies of EAC
most common malignant temporal bone (neoplasm) in adults
squamous cell carcinoma
rare form of adenocarcinoma found usually in head & neck
adenoid cystic carcinoma
most common malignant neoplasm in children
sarcoma
tumors of the temporal bone have varied presentation. Explain some ways it does
pain, drainage, and hearing loss, mimicking chronic otitis externa and delaying diagnosis
All patients presenting with non-healing granulation tissue in the EAC should be
biopsied
tumors are usually red due to
high vasculature
what is osteoradionecrosis (ORN)
rare and most serious complication arising from radiation of the base of skull bones due to cancer, but idiopathic variants do occur
caused by radiation to the outer ear area (more for skull based cancers)
can ORN occur years after original radiation?
yes
ORN in EAC can be
localized or diffuse
describe a localized EAC ORN
happens because EAC is portal of radiation like nasopharyngeal carcinoma
describe diffuse EAC
more common in high dose radiation to the temporal bone
why does radiated bone become susceptible to infection and healing compromised?
becaues you are killing off the tissue
what bone is most commonly affected in ORN
mandible (jaw)
to get radiation to the cancer in the back of the nose, they send the radiation into
the ear
what are signs and symptoms of ORN
Ear fullness
Otalgia
Foul odor
Hearing loss (can be conductive or SNHL)
Discharge including bloody otorrhea
Tinnitus
what will microscopy show with ORN
Debris in EAC and occasionally granulation tissue
Single or multiple areas of exposed devascularized bone that is yellowish in color and soft
Persistent granulation tissue in the area should be biopsied
what is the treatment for localized ORN
less aggressive condition
in office debridement
topical antiobiotics
treatment for diffuse ORN
more lethal condition
necrotic temporal bone at risk for intratemporal and intracranial neurovascular complications
surgical debridement
I/V antibiotics
what is the differential diagnosis for ORN
chronic otitis media
A 70-year-old man presents with a history of right-sided hearing loss, otalgia, and blockage
how many biopsies did it take to find his cancer
FOUR
3 showed benign
what is the ICD 10 code for diseases of the ear and mastoid process
H60-H95 (overall code)
would down syndrome use H61.319 acquired stenosis of EAC
NO becuase they were born with it
