Ear Disease Flashcards
What is otitis externa?
inflammation of the skin of the ear canal
What bacteria can cause otitis externa?
Pseudomonas (most common)
Staph aureus
Otitis externa can be caused by a fungal infection. TRUE/FALSE
true
What are the symptoms of otitis externa?
discharge
itch
pain
tragal tenderness
What are the causes of otitis externa?
excess canal moisture (most common)
trauma (e.g. from fingernails in itchy conditions like eczema)
high humidity
absence of wax (e.g. from self-cleaning)
narrow ear canal
hearing aids
dermatitis
What are the clinical features of mild otitis externa?
scaly skin with some erythema
normal diameter of external auditory canal
What is the treatment for mild otitis externa?
clean external auditory canal
hydrocortisone cream to pinna
EarCalm spray
How do you clean the external auditory canal?
syringing or irrigation to remove debris provided tympanic membrane is intact
What is EarCalm and what does it do?
2% acetic acid
acts as an antifungal and antibacterial
What are the clinical features of moderate otitis externa?
painful ear
narrowed external auditory canal with malodourous creamy discharge
What is the management of moderate otitis externa?
swab
clean external auditory canal
prescribe topical antibiotics +/- steroid drops (if inflamed)
What are the clinical features of severe otitis externa?
external auditory canal occluded
What is the management of severe otitis externa?
ENT referral
When should you suspect malignant/necrotising otitis externa? (life threatening)
persistent unilateral otitis externa in diabetics, immunosuppressed or the elderly
otitis externa that is resistant to treatment
What is acute otitis media?
middle ear inflammation
In what age group is acute otitis media most common?
children
What is acute otitis media associated with?
glue ear
upper respiratory tract infections
What is the clinical presentation of acute otitis media?
rapid onset of pain and fever \+/- irritability anorexia vomiting
When does acute otitis media often occur?
after a viral upper respiratory tract infection
What are the common organisms that cause acute otitis media?
Pneumococcus
Haemophilus
Moraxella
What causes the pain in acute otitis media?
bulging of tympanic membrane - pain relieved if TM bursts
What causes purulent discharge in acute otitis media?
tympanic membrane bursting
What is the management of acute otitis media?
usually resolves in 24hrs without antibiotics
analgesia
When should antibiotics be considered in acute otitis media?
systemically unwell immunocompromised no improvement in >4days <3 months old perforation/discharge <2 years old with bilateral OM
What antibiotics are given in acute otitis media?
amoxicillin
erythromycin if penicillin allergic
What is otitis media with effusion/glue ear?
effusion present after regression of symptoms of acute otitis media
In what age group is otitis media with effusion/glue ear most common in?
children
What is the most common cause of hearing loss in young children?
otitis media with effusion/glue ear
What causes otitis media with effusion/glue ear in children?
eustachian tube dysfunction or obstruction
What causes otitis media with effusion/glue ear in adults?
rhinosinusitis
nasopharyngeal carcinoma
nasopharyngeal lymphoma
What are the symptoms of otitis media with effusion/glue ear in children?
poor listening poor speech language delay inattention poor behaviour ear infections upper respiratory tract infections balance problems poor progress at school
What are the signs of otitis media with effusion/glue ear?
conductive hearing loss with tuning fork tests flat tympanogram retracted TM reduced TM mobility altered TM colour visible middle ear fluid or bubbles
What is the management of otitis media with effusion/glue ear?
active observation for 3 months (50% will resolve spontaneously)
after 3 months consider insertion of grommet
What does a grommet do?
ventilates middle ear
What are the side effects of a grommet?
increased risk of infection discharge early extrusion retention persistent perforation swimming and bathing issues
What can cause perforation of the tympanic membrane?
acute otitis media
trauma (e.g. head injury or cotton bud)
What is the management of perforation of the tympanic membrane?
usually heals spontaneously within 6-8 weeks - if kept infection free (avoid water)
myringoplasty if doesn’t heal by itself
What is cholesteatoma?
presence of keratin within the middle ear - erodes surrounding bone
What are the clinical features of cholesteatoma?
foul discharge \+/- conductive hearing loss headache pain facial paralysis vertigo
What is the peak age for cholesteatoma?
5-15 years
What is the management of cholesteatoma?
surgical excision and reconstruction - mastoid surgery
What are the complications of acute otitis media and cholesteatoma?
medially - sensorineural hearing loss, tinnitus, vertigo, facial palsy
superiorly - brain abscess, meningitis
posteriorly - venous sinus thrombosis
What is otosclerosis?
fixation of the stapes footplate due to new bone being formed around it
What are the symptoms of otosclerosis?
gradual onset conductive hearing loss
+/-
tinnitus
mild vertigo
What is conductive hearing loss?
impaired sound transmission via the external canal and middle ear ossicles to the foot of the stapes
What age is the normal onset for otosclerosis?
late teens to 20s
Otosclerosis is more common in women. TRUE/FALSE
true
What makes otosclerosis progress more rapidly?
pregnancy
How is otosclerosis inherited?
autosomal dominant with incomplete penetrance (can skip generations- may not have positive family history)
What is the treatment for otosclerosis?
hearing aid
correction by stapedectomy
What is sensorineural hearing loss?
results from defects to the oval window in the cochlea (sensory), cochlear nerve (neural) or (rarely) more central pathways
What is presbycusis?
gradual, age-related, bilateral, high frequency sensorineural hearing loss
What is the treatment for presbycusis?
hearing aids
What are the symptoms of noise induced hearing loss?
bilateral sensorineural hearing loss
+/- tinnitus
What is the aetiology of noise induced hearing loss?
acoustic trauma (one time exposure to intense sound e.g. explosion) occupational (continuous exposure to loud sounds)
What is seen on audiology of someone with noise induced hearing loss?
dip at 4kHz
What is the management of noise induced hearing loss?
prevention
hearing aids
What drugs can cause sensorineural hearing loss?
gentamicin and other aminoglycosides
chemotherapeutic drugs (e.g. Cisplatin, Vincristine)
overdose of aspirin or NSAIDs
furosemide
What is vestibular schwannoma/acoustic neuroma?
benign tumour arising in the internal acoustic meatus within the temporal bone
What are the symptoms of vestibular schwannoma/acoustic neuroma?
progressive ipsilateral tinnitus +/- sensorineural hearing loss (compression of cochlear nerve)
may also feel dizzy and have facial numbness (trigeminal compression above the tumour
What cranial nerves are at risk in vestibular schwannoma/acoustic neuroma?
V - trigeminal - absent corneal reflex
VI - abducens
VII - facial - facial palsy
VIII - hearing loss, vertigo, tinnitus
How is vestibular schwannoma diagnosed?
MRI scan
What is the treatment for vestibular schwannoma/acoustic neuroma?
hearing aids
surgery
What is seen on otoscopy of cholesteatoma?
“attic crust” - seen in uppermost part of the ear drum
What is the Rinne’s test?
tuning fork placed over the mastoid process until the sound is no longer heard - followed by repositioning just over the external acoustic meatus air conduction (AC) is normally better than bone conduction (BC) if BC> AC = conductive deafness
What is Weber’s test?
tuning fork is placed in the middle of the forehead equidistant from the patient’s ears
the patient is then asked which side is loudest
unilateral sensorineural deafness sound is localised to the unaffected side
unilateral conductive deafness sound is localised to the affected side
What is acoustic neuroma/vestibular schwannoma associated with?
Neurofibromatosis type II
What is Neurofibromatosis type 2?
Benign tumours growing along nerves
What are the symptoms of neurofibromatosis type II?
Ear problems - progressive sensorineural hearing loss, tinnitus, balance problems
Cataracts
Skin problems- cafe au lait spots (also NF1), skin plaques
Peripheral neuropathy- pins and needles, numbness in feet, burning pain, muscle weakness
Neurological- headaches, vomiting, seizures, vision disturbances
Back pain
What may improve tinnitus?
Background noise
What are some of the risk factors for otitis media with effusion/glue ear?
immunodeficiency household smoking allergy day care bottle feeding
What are the most common fungal causes of acute otitis externa?
aspergillus niger
candida albicans
What is myringitis?
form of acute otitis media in which vesicles develop on the tympanic membrane
What can cause myringitis?
Ramsay Hunt syndrome
myringitis bullosa
What is Ramsay Hunt syndrome?
herpes zoster infection of the facial nerve (CN VII)
In what age group is Ramsay Hunt syndrome common?
the elderly
What are the symptoms of Ramsay Hunt syndrome?
severe otalgia precedes CN VII palsy (+/- CN VIII, IX, V, VI in order of frequency)
vesicles appear around the ear and tympanic membrane (+/- soft palate, tongue)
+/-
vertigo
tinnitus
sensorineural hearing loss
What is the treatment for Ramsay Hunt syndrome?
acyclovir
prednisolone
What is malignant/necrotising otitis externa?
extension of otitis externa into the bone surrounding the ear canal - mastoid and temporal bones
fatal without treatment
osteomyelitis will progressively involve the skull and meninges
What are the symptoms of malignant/necrotising otitis externa?
otalgia and headache more severe than clinical signs would suggest
What are the signs of malignant/necrotising otitis externa?
granulation tissue at bone-cartilage junction of the ear canal
exposed bone in the ear canal
facial nerve palsy - drooping face on side of lesion
What are the investigations for necrotising/malignant otitis externa?
plasma viscosity and CRP - demonstrate an inflammatory response
CT scan
biopsy
culture
What bacteria usually cause malignant/necrotising otitis externa?
Pseudomonas aeruginosa - most common
Proteus
Klebsiella
What causes chronic otitis media?
Pseudomonas aeruginosa
Staph aureus
fungal
What is the pathogenesis of cholesteatoma?
chronic otitis media - perforated tympanic membrane - - abnormally situated squamous epithelium - high cell turnover and abundant keratin production - inflammation
What should be considered if there is bilateral vestibular schwannoma/acoustic neuroma in a young person?
NF 2
What is the gross appearance of vestibular schwannoma/acoustic neuroma?
circumscribed (confined) tan/white/yellow mass
What is classed as normal on an audiogram?
anything above the 20dB line
What does a audiogram of sensorineural hearing loss show?
both air and bone conduction are impaired - below 20dB line
What does an audiogram of conductive hearing loss show?
only air conduction is impaired - below 20dB line
What does an audiogram of mixed hearing loss show?
both air and bone conduction are impaired - below 20dB line
air conduction normally worse than bone
What is otalgia in the absence of any ear signs a red flag for?
head and neck malignancy
What drugs can cause tinnitus?
aspirin
aminoglycosides
loop diuretics
quinine
What are the clinical features of mastoiditis?
severe otalgia - classically behind ear
may have a history of recurrent otitis media
fever
systemically unwell
swelling, erythema and tenderness over the mastoid process
the external ear may protrude forwards
ear discharge may be present if the eardrum has perforated
Why is mastoiditis a medical emergency?
risk of meningitis
other complications - cranial nerve palsies, hearing loss, osteomyelitis, carotid artery spasm
What causes acute mastoiditis?
acute otitis media spreading out from the middle ear
What causes chronic mastoiditis?
cholesteatoma - part of the spectrum of otitis media
What is the treatment of malignant/necrotising otitis externa?
IV antibiotics that cover pseudomonal infections e.g. ciprofloxacin
What is the management of mastoiditis?
urgent referral to ENT for admission
In a child with persistent glue ear and symptoms reoccur despite grommet insertion what should be the next step?
repeat grommet insertion
consider adenoidectomy
In patients with chronic or recurrent ear discharge what is the most impart part of the tympanic membrane to visualise on otoscopy?
attic - looking for cholesteatoma
