Ear Disorders 2

Question 1

Traumatic Auricular Hematoma

etiology and S/Sx

Answer 1

Symptoms: Pain, paresthesia, and ecchymosis, Swelling

Etiology
Vessel rupture after blunt trauma which causes blood and serum accumulation between the perichondrium and cartilage. They are relatively common injuries in contact sports such as wrestling and boxing.

Misc
If the mechanism of trauma is large, such as a motor vehicle accident, the practitioner must rule out temporal bone trauma as well as assessing the patient for other injuries.

Question 2

Traumatic Auricular Hematoma

PE

Answer 2

Exam
evaluation of the external ear
evaluation of the tympanic membrane with an otoscope
evaluation for any coexistent lacerations or trauma of the head and neck
evaluate for facial nerve weakness as the facial nerve passes through the ear and can be damaged when there is trauma to the ear

Physical exam findings consistent with auricular hematoma include contour irregularity of ear with swelling and fluctuant area overlying the ear’s cartilaginous portions

Question 3

Traumatic Auricular Hematoma

Dx

Answer 3

Diagnostic Studies
Ultrasound can be used to rule out an auricular abscess.
If significant trauma has occurred, there is concern for a foreign body or an abscess or it is determined that it is important to evaluate middle or inner ear structures, CT or MRI can be ordered.
CT and MRI should not be used routinely to evaluated auricular hematomas.

Question 4

Traumatic Auricular Hematoma

Tx

Answer 4

Treatment
must be drained to prevent significant cosmetic deformity (cauliflower ear) or canal blockage resulting from dissolution of supporting cartilage.

Question 5

External Auditory Canal Neoplasm

Etiology

Answer 5

Etiology
Squamous carcinoma is the most frequent neoplasm in the external auditory canal (EAC), about four times more common than basal carcinomas
These tumors have been associated with chronic suppurative otitis media and exposure to chemicals, though the most important factor may be previous radiotherapy (radiation) for nasopharyngeal cancer
Most squamous cell carcinomas (SCC) of the temporal bone occur in the fifth and sixth decades of life

Question 6

External Auditory Canal Neoplasm

Sx

Answer 6

Symptoms
Otorrhea (ear drainage) is the primary symptom, and otalgia, hearing loss, and bleeding may be frequent as well
Diagnosis is usually delayed because symptoms are quite similar to other benign otologic conditions such as chronic suppurative otitis media

Question 7

External Auditory Canal Neoplasm

PE and Dx

Answer 7

Exam
Obvious abnormality of tissue in the canal
Facial nerve paralysis and lymph node involvement are associated with decreased survival rates

Diagnostic Studies
Biopsy
CT or MRI

Question 8

External Auditory Canal Neoplasm

Tx

Answer 8

Treatment
Treated with either a lateral (LTBR) or an extended temporal bone resection (total or subtotal)
Parotidectomy is performed in patients with suspected clinical or radiological invasion
Radiotherapy is used often
When tumor is not fully removed surgically, survival rates drop significantly

Misc
Don’t forget about the auricle- usually from basal cell and not squamous

Question 9

Otitis Externa

Etiology

Answer 9

Etiology
There is often a history of recent water exposure (ie, swimmer’s ear) or mechanical trauma (eg, scratching, cotton applicators).
External otitis is usually caused by gram-negative rods (eg,Pseudomonas, Proteus) or fungi (eg,Aspergillus), which grow in the presence of excessive moisture.

Question 10

Otitis Externa

S/Sx

Answer 10

Symptoms
Painful erythema and edema of the ear canal skin
Purulent exudate
Frequently accompanied by pruritus

Question 11

Otisis Externa

Exam and Dx
When is CT necessary

Answer 11

Exam
erythema and edema of the ear canal skin
often with a purulent exudate
Manipulation of the auricle elicits pain
Because the lateral surface of the tympanic membrane is ear canal skin, it is often erythematous
TM moves normally with pneumatic otoscopy
When the canal skin is very edematous, it may be impossible to visualize the tympanic membrane

Diagnostic Studies
CT only necessary with malignant OE

Question 12

Otitis Externa

Tx

Answer 12

Treatment
In cases of moisture in the ear (eg, swimmer’s ear), acidification with a drying agent (ie, a 50/50 mixture of isopropylalcohol/white vinegar) is often helpful
When infected, an otic antibiotic solution or suspension of an aminoglycoside (eg,neomycin/polymyxin B) or fluoroquinolone (eg,ciprofloxacin), with or without a corticosteroid (eg,hydrocortisone), is used
Purulent debris filling the ear canal should be gently removed to permit entry of the topical medication. Might need to place a wick.
Oral fluoroquinolones (eg,ciprofloxacin, 500 mg twice daily for 1 week) are used for cellulitis
Any case of persistent otitis externa in an immunocompromised or diabetic individual must be referred for specialty evaluation.

Question 13

malignant Otitis Externa

Misc
Diabetic/immune compromised
Dx Tx

Answer 13

Misc
In diabetic or immunocompromised patients, osteomyelitis of the skull base (“malignant external otitis”) may occur
Malignant external otitis typically presents with persistent foul aural discharge, granulations in the ear canal, deep otalgia, and in advanced cases, progressive palsies of cranial nerves VI, VII, IX, X, XI, or XII.

Diagnosis is confirmed by the demonstration of osseous erosion on CT scanning.

Antipseudomonal antibiotic administration, often for several months. Although intravenous therapy is often required initially (eg,ciprofloxacin200–400 mg every 12 hours), selected patients may be graduated to oralciprofloxacin(500–1000 mg twice daily).

Surgical debridement of infected bone is reserved for cases of deterioration despite medical therapy.

Question 14

Eustachian Tube Dysfunction

Etiology & S/Sx

Answer 14

Viral upper respiratory tract infections and allergy that cause inflammation of the tube

Symptoms
The pain ofETDis usually modest, often described by a patient as discomfort or fullness.
Fluctuating hearing
Discomfort with barometric pressure change
When the tube is only partially blocked, swallowing or yawning may elicit a popping or crackling sound

Question 15

Eustachian Tube Dysfunction

Exam and Dx

Answer 15

Exam
Examination may reveal retraction of the tympanic membrane
Decreased mobility on pneumatic otoscopy

Diagnostic Studies
Tympanometry

Question 16

Eustachian Tube Dysfunction

Tx

Answer 16

Treatment
systemic and intranasal decongestants (eg, pseudoephedrine, 60 mg orally every 4–6 hours;oxymetazoline, 0.05% spray every 8–12 hours)
autoinflation by forced exhalation against closed nostrils may hasten relief but should not be done with nasal infxn (can cause otitis media)
Allergic patients may also benefit from intranasal corticosteroids (eg,beclomethasonedipropionate, two sprays in each nostril twice daily for 2–6 weeks)
Balloon dilation of the eustachian tube is a newer treatment being used in some centers; however, which patients benefit and how long results last are still being elucidated.

Misc
ProlongedETDwith resultant negative middle ear pressure may cause a transudation of fluid. This condition, AKA serous otitis media, is common in children because theireustachiantubesare narrower and more horizontal in orientation

Question 17

Serous Otitis Media AKA otitis media with effusion (SOM or OME)

etiology, length of time, common causes (general)

Answer 17

Etiology
fluid is present in the middle ear for an extended period in the absence of signs and symptoms of infection
occurs because of Eustachian tube blockage; negative pressure causes serous (transudative) fluid to build up

Typically self-limited; most resolve in 2–4 weeks. In some cases, however (in particular after an episode of acute otitis media), effusions can persist for months

Common causes: upper respiratory tract infection, with barotrauma, or with chronic allergic rhinitis

Question 18

Serous Otitis Media AKA otitis media with effusion (SOM or OME)

Sx

Answer 18

Symptoms
impaired hearing and “crackling“
Sometimes will have pain because of ETD Serous Otitis Media AKA otitis media with effusion (SOM or OME)

Question 19

Serous Otitis Media

PE & Dx

Answer 19

Exam
The tympanic membrane is dull and hypomobile, occasionally accompanied by air bubbles in the middle ear and conductive hearing loss

Diagnostic Studies
tympanometry

Question 20

Serous Otitis Media

Tx

Answer 20

Treatment
USUALLY resolves without ABX
Antibiotic therapy or myringotomy (small incision into the TM) with insertion of tympanostomy tubes typically is reserved for patients in whom bilateral effusion (1) has persisted for at least 3 months and (2) is associated with significant bilateral hearing loss.

Question 21

Cholesteatoma

S/Sx 3

Answer 21

Symptoms
Conductive hearing loss secondary to ossicular erosion is common
chronically draining ear that fails to respond to appropriate antibiotic therapy

Question 22

Cholesteatoma

etiology

Answer 22

Etiology
a benign tumor composed of stratified squamous epithelium in the middle ear or mastoid; slowly growing lesion that destroys bone and normal ear tissue

Causes: traumatic immigration and invasion of squamous epithelium through a retraction pocket of the tympanic membrane, implantation of squamous epithelia in the middle ear through a perforation or surgery, and metaplasia following chronic infection and irritation

Question 23

Cholesteatoma

PE and Dx

Answer 23

Exam
often a perforation of the tympanic membrane filled with cheesy white squamous debris or granulation tissue is seen
presence of an aural polyp obscuring the tympanic membrane is also highly suggestive of an underlying cholesteatoma.

Diagnostic Studies
Bony destruction visualized on computerized tomography (CT) of the temporal bone is highly suggestive of cholesteatoma

Question 24

Cholesteatoma

Tx, fix

Answer 24

Treatment
Surgery is required to remove this destructive process and reconstruct the ossicles

Question 25

# Foreign bodies Sx

Answer 25

Symptoms Hearing loss Drainage Feelings of pain or fullness Admitted by patient

Question 26

# Foreign Bodies PE and Dx

Answer 26

Exam Drainage Erythema Swelling of canal …a foreign body! Diagnostic Studies Not usually needed MRI might be contraindicated if FB is metal Misc **Living insects are best immobilized before removal by filling the ear canal with lidocaine.** Aqueous irrigation should not be performed for organic foreign bodies (eg, beans, insects), because water may cause them to swell.

Question 27

# Foreign Bodies Tx

Answer 27

Treatment Firm materials may be removed with a loop or a hook, taking care not to displace the object medially toward the tympanic membrane; microscopic guidance is helpful. Sometimes suction works. Don’t be a hero. Refer to ENT if you can’t get it. DO NO HARM! It might damage the TM if you push it in rather than pull it out.

Question 28

# Cerumen Impaction Sx

Answer 28

Symptoms Unilateral hearing loss and tinnitus Might even be able to see it with naked eye

Question 29

# Cerumen Impaction PE and Dx

Answer 29

Exam Visibility of cerumen Diagnostic Studies None needed for wax but tympanometry can be useful if you are worried about what else might be happening to the TM that you cannot see

Question 30

# Cerumen Impaction Tx

Answer 30

Treatment It may be relieved by the patient using **detergent ear drops (eg, 3% hydrogen peroxide; 6.5% carbamide peroxide) and irrigation** clinician using mechanical removal, suction, or irrigation Irrigation is performed with water at *body temperature - The stream should never be directed at the TM. Irrigation should be performed only when the tympanic membrane is known to be intact. Use of jet irrigators (eg, WaterPik) should be avoided since they may result in tympanic membrane perforations

Question 31

# Perforated Tympanic Membrane Sx

Answer 31

Symptoms Sudden decrease in pain, followed by the onset of otorrhea Conductive hearing loss can occur

Question 32

# Perforated Tympanic Membrane PE and Dx

Answer 32

Exam Otoscopy Usually obvious hole in TM Drainage in canal Diagnostic Studies Tympanometry (only if rupture site is difficult to see)

Question 33

# Perforated Tympanic Membrane Tx

Answer 33

Treatment While small perforations often heal spontaneously, larger defects usually require surgical intervention. Tympanoplasty is highly effective (>90%) (repair of tympanic membrane perforations.)   Tympanic membrane perforations due to chronic otitis media or trauma can be repaired with an outpatient tympanoplasty Misc When the tympanic membrane is perforated, use of potentially ototoxic ear drops (eg, neomycin, gentamicin) is best if avoided

Question 34

# Mastoiditis Sx and PE

Answer 34

Symptoms postauricular pain and erythema accompanied by a spiking fever swelling of the mastoid process along with displacement of the pinna, usually in conjunction with the typical signs and symptoms of acute middle-ear infection

Question 35

# Mastoiditis etiology and Dx

Answer 35

Etiology usually evolves following several weeks of inadequately treated acute otitis media the mastoid air cells connect with the middle ear and can fill with fluid Purulent fluid produces pressure that may result in erosion of the surrounding bone and formation of abscess-like cavities Diagnostic Studies CT scan reveals coalescence of the mastoid air cells due to destruction of their bony septa

Question 36

# Mastoiditis Tx

Answer 36

Treatment Initial treatment consists of intravenous antibiotics (eg, cefazolin 0.5–1.5 g every 6–8 hours) directed against the most common offending organisms (S pneumoniae, H influenzae, and S pyogenes), and myringotomy (incision of TM) for culture and drainage Failure of medical therapy indicates the need for surgical drainage (mastoidectomy) Misc Purulent fluid should be cultured whenever possible to help guide antimicrobial therapy.

Question 37

# Barotrauma Sx and PE

Answer 37

Symptoms Pain Hearing loss Possibly will have blood in canal Exam the TM may be bruised or even ruptured as it is pushed inward Negative pressure in the middle ear results in engorgement of blood vessels in the surrounding mucous membranes and leads to effusion or bleeding, which can be associated with a conductive hearing loss.

Question 38

# Barotrauma general and Dx

Answer 38

Etiology Persons with poor eustachian tube function (eg, congenital narrowness or acquired mucosal edema) may be unable to equalize the barometric stress exerted on the middle ear by air travel, rapid altitudinal change, or underwater diving and this will then cause damage to the tissue Typically middle ear involvement and less likely inner ear Diving tends to cause more trauma that flying severely negative pressures in the tympanum may result in hemorrhage (hemotympanum) or in perilymphatic fistula. In the latter, the oval or round window ruptures, resulting in sensory hearing loss and acute vertigo Diagnostic Studies Nothing performed regularly Physical exam is typically all you need

Question 39

# Barotrauma Tx and misc

Answer 39

Treatment Avoidance of trauma with swallowing, yawning, and autoinflating frequently during descent from high altitude. Oral **decongestants** (eg, pseudoephedrine, 60–120 mg) should be taken several hours before anticipated arrival time so that they will be maximally effective during descent. Topical decongestants such as 1% phenylephrine nasal spray should be administered 1 hour before arrival. Myringotomy and ventilation tubes for severe or chronic cases when related to descent Misc Tympanic membrane perforation is an absolute contraindication to diving, as the patient will experience an unbalanced thermal stimulus to the semicircular canals and may experience vertigo, disorientation, and even emesis.