Ear Conditions Flashcards
How does the position of the eustachian tube in Child differ in Adult?
- Adults the tube is relatively vertical, wide, rigid and secretions that pass into it from nasal passages drain easily
- Young children - tube is more horizontal, narrow, less rigid, shorter
- More likely for tube to be blocked by secretions, collapse and block air from reaching middle area
- Virus or bacteria can move up the eustachian tube of infants
What is the purpose of the eustachian tube? (2)
- Eustachian tube drains fluid from ear to middle of throat
- equalize air pressure
- Pressure difference causes pain, bruising, rupture of ear drum
How to administer ear drops for children under age of 3 vs over 3?
- Ear drops under the age of 3, pull outer flap of ear downward and backward to straighten the ear canal
- Over 3, gently pull the outer flap of the affected ear upward and backward to strengthen the ear canal so you can open up the ear canal
Assessing Ear Conditions
Name 5 common otic symptoms
- ear pain (otalgia)
- ear drainage (otorrhea)
- hearing loss
- tinnitus
- vertigo
Assessing Ear Conditions
Describe otalgia (1)
- Associated with inflammation of the external or middle ear
- May be referred pain from a dental, joint, or sinus
issue
Assessing Ear Conditions
Describe otorrhea
- where does it originate?
- characteristics?
Could originate from the outer ear or the middle ear.
- From scratch in outer ear
- Clear drainage could be from tympanostomy tubes or a CSF leak.
- Bloody drainage could be due to trauma, neoplasm, or foreign body.
Assessing Ear Conditions
Hearing Loss
- name 2 types
- Conductive – when sound cannot access the middle ear
(e.g., impacted wax, trapped water, otitis media, URTI,
tumors, or foreign objects) - Sensorineural – involving the inner ear / cochlea,
auditory nerve, or a central nerve lesion
Assessing Ear Conditions
Describe Tinnitus (1)
- perception of a buzzing or whistling sound without
any external stimulus
Assessing Ear Conditions
Describe Vertigo (1)
- A type of dizziness defined as the sensation of motion
where there is none
Assessing Ear Conditions
What is drug-induced ototoxicity? (1)
- ototoxicity may result in hearing loss, tinnitus, vertigo
- may be reversible (dose-dependent) or irreversible after even a single dose
- patients presenting with symptoms of ototoxicity should be asked about new drugs or drug changes
Assessing Ear Conditions
What are examples of drug types that can cause ototoxicity (8)
- ASA - tinnitus, recovers
- Quinine - high freq sensorineural loss, reversible
- Chemotherapy (cisplatin) - sensorineural, tinnitus, permanent
- Loop diuretics (furosemide) - hearing loss, tinnitus, transient
- Macrolide antibiotics (azithromycin) - sensorineural, tinnitus, reversible
- Tetracycline antibiotics (minocycline) - vestibular symptoms, self-limiting
- Aminoglycoside antibiotics (tobramycin) - cochlear and vestibular, irreversible
- Phosphodiesterase type-5 inhibitors (sildenafil) - sudden loss with tinnitus/dizziness, reversible 1/3 of cases
anticoagulants can cause excessive bleeding if ear is injured
Assessing Ear Conditions
What are the red flags? (11)
- tympanostomy tubes
- history or recent ear surgery
- perforated tympanic membrane
- drainage of pus or blood
- recent air travel, scuba diving
- congenital or anatomic abnormalities
- pt that are immunocompromised and are at risk of infections - may spread systematically
- symptoms of tinnitus, vertigo, dizziness
- symptoms consistent with otitis media
- refer if child
- acute ear pain, esp associated with
- foreign body
- ear drainage
- hearing loss
- impacted ear wax - use judgement
Assessing Ear Conditions
What are Tympanostomy Tubes?
why are they needed?
- tiny cylinders made of plastic or metal surgically inserted into eardrum
- creates airway that ventilates middle ear and prevents accumulation of fluids behind eardrum
- For children with consistent fluid buildup behind the eardrum
- Frequent ear infections
- Most fall out within 6-9 months and the hole heals itself, some need to be surgical closed
Otitis Externa
What is otitis externa?
definition and location?
often caused by _______
- Blanket term for various causes and presentations
- Aka swimmer’s ear
- Often caused by infections
- Conditions in ear canal are warm, moist, dark promote bacterial and fungal growth
- Is defined as
- An inflammation of external auditory canal and may involve pinna or tympanic membrane
Otitis Externa
signs and symptoms? (4)
- pain, discharge, itching, tenderness
Otitis Externa
What are the types of otitis externa (5)
- acute diffuse
- acute localized
- chronic3
- eczematous
- necrotizing (malignant)
Otitis Externa
Acute Localized Otitis Externa (Furunculosis)
describe (1)
manage (2)
- an infected hair follicle (boil) usually due to S. aureus
- pain subsides when boil bursts
- manage:
- incision and drainage by HCP
- topical antibiotic therapy with mupirocin or fusidic acid
Otitis Externa
Chronic Otitis Externa
describe (2)
manage (1)
- a thickening of the ear canal skin secondary to low grade infection/inflammation, allergic contact dermatitis
- cause pruritis, dry, flaky skin
- manage
- topical corticosteroid with/without topical antibiotic
Otitis Externa
Eczematous Otitis Externa
describe (1)
manage (3)
- may be due to a variety of skin conditions with similar lesions occurring elsewhere in the body
- manage
- address underlying condition (psoriasis)
- avoid offending agents if applicable (dye, hair pdt, ear plugs)
- treat w/ topical steroid or topical calcineurin inhibitor
Otitis Externa
Necrotizing (malignant) otitis externa
describe (1)
manage (2)
- an infection that extends to mastoid or temporal bone in immunocomp pts
- urgent referral
- manage
- systemic antibiotics (can be IV)
Otitis Externa
Acute diffuse otitis externa common cause (1) and some risk factors (3)
Most common etiology is bacterial infection
Pseudomonas aruginosa (20-60%)
Staphylococcus aureus (10-70%)
Polymicrobial (30%)
Other risk factors include the following:
Too much or too little cerumen, moisture which raises
pH, trauma leading to inoculation of organisms,
dermatologic disorders, hearing aids, or a narrow /
hairy ear canal
Otitis Externa
Acute diffuse otitis externa
symptoms (5)
most common for ages?
- Acute onset of pain (otalgia within 48 hours)
- Tenderness is worse with manipulation of the ear or actions such as chewing. - Itching (prutitis)
- Sense of fullness
- Discharge (otorrhea)
- Possible hearing loss
- Very commonly unilateral (90%)
- 70% with itching, pain, sense of fullness
Common in children aged 7-12
Incidence declines after age 50
May have presence of contributing
factors such as history of swimming or trauma.
Otitis Externa
What are the goals of therapy (3)?
- eliminate pathogenic microorganism
- control pain, any fever, and otorrhea
- restore canal to normal health prevent recurrence
Otitis Externa
Non-pharm
what are 2 ways for non-pharm treatment?
- adequate, frequent cleansing to ensure topical therapies make contact with ear canal
- ear wicks
Otitis Externa
Non-pharm
how do ear wicks work?
- Ear wicks help facilitate delivery of topical medications
- Antibiotic drops are placed on the external end of the wick to carried into canal
- Wick should fall out with less edema
Otitis Externa
pharm treatment
Name 4 types of drugs or substances that can be used
- acidifying agents
- antibiotics
- analgesics
- corticosteroids
Otitis Externa
pharm treatment
acidifying agents
- example
- MOA
- AE (2)
- acetic acid 2%
- broad spectrum antibacterial agent
- restores acidity in ear canal, not commercially available
- dilute white vinegar w/ water 1:1
- AE: irritation, ototoxicity
- ear drops have low pH
- don’t use without intact tympanic membrane or tubes
Otitis Externa
pharm treatment
antibiotics
- example (2)
- MOA (1)
- AE (1)
- gramicidin/polymixin B drops (OTC)
- against G+/G- organisms
- AE: ototoxic
- Moxifloxacin, ofloxacin, tobramycin drops (Rx) - tobra ototoxic if tympanic membrane rupture or use >1 week
Otitis Externa
pharm treatment
analgesics
- example (2)
- MOA (1)
- AE (3)
- topical: antipyrine/benzocaine drops (OTC)
- suggest oral analgesics instead
- addition of these agents may dilute other agents
- very painful, acetaminophen, ibuprofen
- AE: burning, itching, hypersensitivity, mask signs of worsening condition
Otitis Externa
pharm treatment
corticosteroids
- example (1)
- MOA (1)
- dexamethasone drops (Rx)
- reduce inflamm and edema
- can combine w/ acidifying agents or antibiotics
Otitis Externa
pharm treatment
What 2 types of OTC Products can be recommended?
Antibiotics
- Polysporin Ear Drops, generics like Optimyxin drops
Analgesics: Auralgan, homeopathic options like similaan earache relief
- not recommended generally
- lack of improvement on day 14 = treatment failure
Otitis Externa
Prevention (5)
- Dry the external ear canal well after swimming or bathing
Use a hair-dryer on the low setting
Instil acidifying or alcohol drops to help restore normal pH and evaporate excess moisture
e.g., Auro-Dri Ear Water®, which contains 95% isopropyl alcohol
and 5% glycerin - Avoid overzealous cleansing or scratching
- Avoid the use of Q-tips in inner ear
- Avoid water sports during treatment
- May use bathing caps or ear plugs, but there is limited evidence and the latter may also promote infection.
Otitis Externa
Monitoring
- symptom improvement time
- full resolution time
F/U
- time?
- symptoms should improve 48-72 hours
- full resolution in 7-10 days
- refer if symptoms worse or not improved
- F/U 3-5 days after
Impacted Earwax
What is ear wax made of? (4)
Function? (3)
Earwax (a.k.a. cerumen) is a mixture of secretions produced by the ear canal. It is normally moved through the ear canal and expelled by cilia, chewing, and talking.
-Composition:
Cerumen and sebum from associated glands
Exfoliated epithelium
Sweat
Foreign substances (e.g., dirt, hairspray, shampoo)
- Function:
Is water repellent
Is bacteriostatic
Lubricates and protects the ear
Impacted Earwax
pathophys (3) risk factors (name a few)
Accumulation and impaction may occur due to:
Overproduction
Failure of epithelial migration
Diseases leading to canal obstruction (e.g., bony growths)
Specific risk factors include the following:
Use of Q-Tips®, Inadequate hygiene, Excess hair in the ear canal, History of previous impaction, Abnormally narrowed ear canals, Use of hearing aids (can cause earwax accumulation), Older age (ceruminous gland atrophy, drier cerumen, which is
more difficult to expel from the ear)
Impacted Earwax
Symptoms (6)
which 3 to refer depending on severity?
- Sensation of fullness or pressure
- General discomfort
- Itchiness
- Vertigo*
- Tinnitus*
- Hearing loss*
Impacted Earwax
Complications (3)
- Prevents visualization of the external auditory canal and tympanic membrane
- Infection due to impairment of the ear’s natural cleaning mechanism
- chronic cough
Impacted Earwax
Goals of Therapy (5)
- Relieve symptoms
- Avoid damage to external auditory canal
- Prevent infection
- Prevent recurrence
- Allow visualization
Impacted Earwax
Non-pharm (1)
describe
Syringing (Irrigation)
- There are special ear “bulbs”
- May or may not suggest various ear drops to soften earwax prior to syringing (e.g., olive oil)
- Contraindicated if the tympanic membrane is or has been perforated (tubes)
No ear candles
Impacted Earwax
pharm: water-based cerumenolytics
name 3
- Water, normal saline, sodium bicarbonate 10- 15%, or hydrogen peroxide 3%
- Chlorbutol 5% (Cerumol®)
- Docusate sodium 10mg/mL (Colace®)
Impacted Earwax
pharm: water-based cerumenolytics
1. Water, normal saline, sodium bicarbonate 10- 15%, or hydrogen peroxide 3%
Describe + procedure
Loosens or dissolves the wax plug
Fill the ear canal with product, leave for
15-20 minutes, then remove wax by
syringing
Impacted Earwax
pharm: water-based cerumenolytics
2. Chlorbutol 5% (Cerumol®)
Describe + procedure (how much and how many times a day)
- Instil 5 drops into the ear canal followed by a moist cotton ball. Keep in ear for at least 1 hour or overnight.
- Repeat BID to TID for 3 days or until symptom
improvement. - Use with caution in those with peanut allergy!
Impacted Earwax
pharm: water-based cerumenolytics
3. Docusate sodium 10mg/mL (Colace®)
Describe + procedure (how much)
Use oral product (stool softener)
- Put 1mL in the ear canal, leave for 10- 15 minutes, then remove by syringing.
Impacted Earwax
pharm: oil-based cerumenolytics
name 3
Describe + procedure (how much and how many times a day)
- olive, mineral, almond oil
- Lubricates the ear canal
- Does not disintegrate the wax
- Generally not irritating
- Instill 4-6 drops BID for up to 4 days, or
- Instill 3 drops HS for 3-4 nights
Impacted Earwax
pharm: other cerumenolytics
name 1
Describe + procedure (how much and how many times a day)
- Carbamide peroxide 6.5% ((Murine®)
- Instill 5-10 drops in the ear canal, then leave for several minutes. Wax may then be removed by gently flushing with warm water. Use BID up to 4 days.
Impacted Earwax
Prevention
- self-cleaning
- cleanse external with washcloth
- oil hydrogen peroxide, glycerin, sodium bicarbonate may prevent impaction twice weekly to once daily
Impacted Earwax
Monitoring
- when is there symptom relief?
- AE (1)
F/U
- when should you refer?
Effectiveness: Symptom relief should occur as soon as the wax is expelled.
- Swelling of the wax upon product installation may initially worsen hearing loss or the sense of fullness.
Adverse effects: Irritation of the external canal.
Symptoms should resolve in 3-4 days; if no relief after 5-7 days refer
Otitis media
why is it common for kids
what is the ratio b/w viral and bacterial?
- 75% have 1+ ear infection before school
- high rate of viral infections
- shorter horizontal eustachian tube
- rate drops significantly after 5 years of age
- After 6 months, more susceptible lose protection from antibodies from mother
- 1/3 viral, 2/3 bacterial (S. pneumoniae, influenza, Moraxella
Otitis media
Risk Factors (7)
- Younger age
- Daycare attendance or overcrowded household
- Orofacial abnormalities
- Pacifier use
- Short duration of breastfeeding
- Prolonged bottle feeding while lying down
- Cigarette smoke exposure
usually self limiting - most recover 3 days
Otitis media
management
when to watch and wait (3)
when to start antibiotics (6)
- Non-specific symptoms (even otalgia) cannot be used to diagnose AOM- must have ear exam
- Use analgesic/antipyretics for pain and fever if needed
- If no middle ear effusion, consider viral etiology and reassess in 48 h
When to watch and wait:
- Mild otalgia (able to sleep)
- Fever < 39 degrees
- < 48 h illness
When to start antibiotics:
- < 6 mos
- Bilateral AOM
- Mod-severe or prolonged (> 48 h) otalgia
- Fever > 39 degrees
- Perforated eardrum
- If no improvement in 48 h
Barotrauma
describe, caused by (2)?
pathophysiology
Risk factors (3)
- cannot equalize pressure gradient b/w middle ear and atmosphere
- air travel, underwater diving
- Eustachian tube closes which results in painful pressure change in the middle ear and extravasation of fluid and blood into the middle ear space
- tympanic membrane may rupture
- anatomical conditions, URTI, edema in eustachian tube from allergies
Barotrauma
Symptoms (2)
Manage (3)
- Sensation of ear blockage followed by ear pain, tinnitus, vertigo and transient conductive hearing loss; clear or bloody otorrhea
- vertigo when diving
Manage:
- analgesics
- oral/topical decongestants
- Valsalva maneuver or Toynbee maneuver
Barotrauma
Monitor + F/U
when to refer?
Refer if symptoms of barotrauma > 24 hours, or if bloody fluid drains from the ear indicating ruptured tympanic membrane
Barotrauma
Prevention
- yawn, swallow, move jaw, be awake, breast or bottle feed child during descent
- use oral decongestants in appropriate
- 120 mg pseudoephedrine 30 minutes prior to flight for
short flights, for long flights take 30-60 minutes prior to decent and 30 mins before diving
