Ear Disorders I Flashcards by Raquel Ross

An elderly male presents with unilateral hearing loss for one day. He denies URI symptoms, fever, ear pain, or ear drainage. PE reveals normal balance, negative Romberg, and evidence of conductive hearing loss in the affected ear. What is the most likely diagnosis?

Cerumen impaction!

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What is the protective secretion of the external auditory canal called?

cerumen

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How should we clean our ears?

cleanse the external opening with a washcloth over the finger – do not put anything into the ear canal, including cotton swabs!

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How are most cases of cerumen impaction caused?

self-induced

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What are three things a PE would reveal in a patient with cerumen impaction?

fullness, hearing loss, and pain

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What are four ways to treat cerumen impaction?

detergent ear drops like Debrox
mechanical removal
irrigation
referral

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What are three things to remember when using irrigation to treat cerumen impaction?

Use body-temperature water.
Perform ONLY when the TM is known to be intact!
Make sure to dry the ear canal after irrigation to reduce the likelihood of otitis externa.

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When should you refer a cerumen impaction case to an ENT?

if impaction is frequently recurrent or not responding, OR if there is a history of chronic otitis externa/media or TM perforation

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Do foreign bodies in the ear occur more frequently in children or adults?

children

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How do you remove firm materials vs. organic foreign bodies (like beans and insects) from the ear?

Firm materials can be removed with a loop, hook, or irrigation – but organic materials should not be irrigated because they can swell! Living insects should be immobilized with lidocaine before removal.

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What are five symptoms of otitis externa?

otalgia, pruritis (itching), hearing loss, fullness, purulent discharge

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Patients with otitis externa often have a history of…

recent water exposure or mechanical trauma

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Otitis externa is an infection of what?

ear canal skin

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What organisms usually cause otitis externa?

Gram-negative rods like Pseudomonas or Proteus, or fungi like Aspergillus (likely to grow in moist environments)

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What are four risk factors for otitis externa?

warmer, high humidity climates
increased water exposure, like swimming
debris from dermatologic conditions like psoriasis
trauma

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What kinds of trauma can cause otitis externa?

use of hearing aids or ear plugs, or even abrasions from cleaning the ear canal (cerumen removal can promote growth of microbes!)

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What are some physical exams findings in a patient with otitis externa?

erythema and edema of the ear canal skin
purulent exudate
tenderness with manipulation of the auricle

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What is the tug test?

pain on manipulation of the auricle, found in otitis externa

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What would the TM be like in a physical exam for otitis media? Would it be immobile?

may be erythematous but will move normally with pneumatic otoscopy, may not be visible due to edema of the canal

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differential diagnoses in otitis externa (5 things)

middle ear disease
contact dermatitis of ear canal
squamous cell carcinoma of external canal
radiation therapy
herpes simplex virus (rare, called Ramsay Hunt Syndrome or herpes zoster oticus)

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What is the most common neoplasm of the ear canal?

squamous cell carcinoma – can mimic a chronic infection

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What medications are used to treat otitis externa?

Treat for 7-10 days with topical aminoglycoside or fluoroquinolone antibiotic with or without corticosteroids (otic suspension). Drying agents to keep the canal dry can also be used.

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What is Ramsay Hunt Syndrome?

Herpes simplex virus causing rare vesicles on the outer ear; also called herpes zoster oticus…in the differential for otitis externa

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What patient education would you provide for a patient with otitis externa?

Avoid any additional moisture or scratching, and remove debris.

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When would you use a wick in a patient with otitis externa?

if swelling is significant

How would we treat severe otitis media with cellulitis or recalcitrant (uncooperative) cases?

oral antibiotics

When do we refer otitis media to an ENT?

when it is persistent or when the patient has diabetes or is immunocompromised

What are six ways that swimmers and other people can prevent otitis externa?

1. Avoid water accumulation in the ear canal. 2. Use ear plugs when swimming. 3. Use a hair dryer to dry ear canal after swimming. 4. Use acidifying drops before and after exposure. 5. STOP removing cerumen! 6. Avoid trauma to the ear canal.

In order to prevent otitis externa, we should make sure to treat any ___ conditions.

dermatologic

What is the most serious complication of otitis externa?

can turn maligant -- osteomyelitis of the skull base!

What patients are most at risk for maligant otitis externa?

diabetes patients or those who are immunocompromised

How does malignant otitis externa present?

foul smelling discharge, granulations in ear canal, deep otalgia, and cranial nerve palsies

How is malignant otitis externa diagnosed?

Do a CT and look for osseous erosion.

How is malignant otitis externa treated?

IV antibiotics and surgery

Why does contact dermatitis sometimes occur with otitis externa?

delayed hypersensitivity reaction to one or more components of the topical antimicrobials

What does contact dermatitis in the ear canal look like?

pruritis, edema, inflammation of skin in canal

What topical antimicrobial is usually the culprit for contact dermatitis in the ear canal?

neomycin

How is contact dermatitis in the ear canal treated?

topical steroids -- and stop the agent

What is acute otitis media?

bacterial infection of middle ear

Acute otitis media is usually precipitated by what? How does this occur?

URI! Eustachian tubes get obstructed, and then fluid and mucus accumulates and becomes secondarily infected

What are three reasons for poor Eustachian tube drainage in acute otitis media?

age (tubes straighter in kids) inflammation and edema congenital malformation

Acute otitis media is most common in what age?

4-24 months

presentation of acute otitis media

otalgia, URI symptoms, fever, pressure, pain, loss of hearing

Is acute otitis media most often caused by viruses or bacteria?

bacteria

What are the three most common organisms that cause acute otitis media?

Strept. pneumoniae Moraxellla catarrhalis Haemophilus influenzae

Recurrent cases of otitis media are often associated with what two variables?

allergies or second hand smoke exposure

In acute otitis media, what does the TM look like?

bulging and erythematous

Bullae in the TM are associated with what infection?

Mycoplasma!

Acute otitis media can be associated with a __ TM.

ruptured

A ruptured TM would show what symptoms?

DECREASED pain and otorrhea (discharge)

How do we treat acute otitis media?

first line antibiotics (amoxicillin, erythromycin/sulfonamide) for ten days

What antibiotics would you give a patient with otitis media if they were allergic to penicillin?

erythromycin or clarithromycin

Inadequate treatment of OM can lead to...

mastoiditis

symptoms of mastoiditis

spiking fever, postauricular pain, erythema

How is mastoiditis treated?

IV antibiotics or mastoidectomy!

If medications fail in a patient with OM, what surgeries would you have to consider?

tympanostomy, myringotomy

acute otitis media vs. otitis media with effusion

acute OM = red, bulging TM | OM with effusion = TM retracted with yellowish hue

What three organisms cause CHRONIC otitis media?

Pseudomonas aeruginosa Proteus Staph aureus

How would a patient with chronic OM present?

chronic otorrhea with or without otalgia

What would the PE of a patient with chronic OM look like?

perforated TM usually present, conductive hearing loss

How is chronic OM treated?

removal of infected debris, use of ear plugs, topical antibiotic drops, oral ciprofloxacin, surgery for TM repair

The Eustachian tube connects the middle ear to the ___.

nasopharynx

What does the Eustachian tube do for the middle ear?

provides ventilation and drainage for the middle ear

When it the Eustachian tube closed and open?

It is normally closed by opens when swallowing or yawning.

In Eustachian tube dysfunction, air becomes trapped in the ___ and causes ___ pressure.

middle ear; negative pressure

What is the etiology in Eustachian tube dysfunction?

edema of tube lining, caused by viral URI or allergies

presentation of Eustachian tube dysfunction (4 things)

ear fullness, fluctuating hearing, pain with pressure change, popping/cracking sensation

How is Eustachian tube dysfunction treated (4 ways)?

decongestants, topical or systemic; autoinflation, desensitization therapy if allergies, intranasal corticosteroids

How would a topical medication be given for Eustachian tube dysfunction?

intranasally!

What do we tell patients Eustachian tube dysfunction to avoid?

avoid air travel, altitude changes, underwater diving during symptoms

Eustachian tube dysfunction increases the risk for what?

serous otitis media

What is another term for serous otitis media?

otitis media with effusion

What happens in serous otitis media/otitis media with effusion?

Eustachian tube stays blocked for a period of time; negative pressure causes transudation of fluid in the middle ear.

Why is serous otitis media more common in kids?

Their Eustachian tubes are more narrow and more horizontal.

When does serous otitis media occur in adults?

after URI, with barotrauma, with chronic allergies

What three things would a PE reveal in a patient with serous otitis media?

TM is dull and hypomobile, bubbles visible, conductive hearing loss

4 ways to treat serous otitis media

decongestants, oral corticosteroids, oral antibiotics, ventilating tubes as last resort

How do you treat small vs. large TM ruptures?

Small ones generally go away on their own. Large ones may require tympanoplasty.

What should patients avoid when they have an open TM rupture?

letting water in ear

What ear drops would we want to AVOID in a patient with a TM rupture?

ototoxic drops like aminoglycoside antibiotics

What are the three types of acute/gradual hearing loss?

conductive, sensory, or neural

Where does the term "sensorineural" come from?

Sensory and neural hearing loss are hard to differentiate, hence this term!

Hearing loss involves dysfunction of the __ or ___ ear.

external or middle ear

Conductive hearing loss involves impairment of transmission of sound along ____, across the ____, and through the ____.

Impairment of transmission of sound along external auditory canal, across the ossicles, and through oval window

Is conductive hearing loss usually permanent or temporary?

temporary

What are four things that could cause conductive hearing loss?

obstruction, mass effect, stiffness effect, discontinuity

What are the causes of conductive hearing loss in adults? What are the two most common?

most common = cerumen impaction, Eustachian tube dysfunction chronic otitis media/externa, trauma, otosclerosis

Can conductive hearing loss be treated?

Yes, medically or surgically, based on cause!

two causes of sensorineural hearing loss

sensory deterioration of cochlea OR neural dysfunction of CN VIII/brain

conductive vs. sensorineural hearing loss

conductive affects the middle or external ear and involves impaired sound transmission; sensorineural affects the inner ear and involves the nerves or mechanics of hearing

What are four etiologies of SENSORY hearing loss?

systemic disease, head trauma, excessive noise exposure, presbyacusis (age and genetics are factors)

What are three etiologies of NEURAL hearing loss?

acoustic neuroma, MS, auditory neuropathy

How do we treat sensorineural hearing loss?

Medical and surgical treatments are not usually effective. But this can be stabilized or prevented.

SUDDEN sensory hearing loss is sometimes treated with...

corticosteroids

Who does the formal evaluation of hearing?

audiology

What are three ways to estimate a patient's hearing?

1. Weber test 2. Rinne test 3. whisper test

What would a Weber test show with conductive hearing loss? Sensorineural hearing loss?

``` Conductive = sound lateralizes to bad ear Sensorineural = sound lateralizes to good ear ```

What would a Rinne test show with conductive hearing loss? Sensorineural hearing loss?

``` Conductive = BC > AC Sensorineural = AC > BC ```

__ is the preferred diagnostic test for central lesions in cases of hearing loss.

MRI

T/F. ALL patients with hearing loss should be referred to audiology.

False! MOST patients, especially those with new onset hearing issues where there is no obvious cause (except those with obvious causes like cerumen impaction or otitis media)

Idiopathic sudden sensorineural hearing loss can be treated with ___ if caught early.

corticosteroids

What patients should we always refer to audiology even if they don't complain of symptoms?

anyone who has been exposed to excessive noise, anyone 65 years and older

What is the most common cause of unilateral hearing loss?

Cerumen impaction is most common cause of unilateral hearing loss, and most common in the elderly

``` A 14 year old boy presents with a history of “swimmer’s ear” which was treated by another provider 3 days earlier with Cortisporin Otic suspension. He now presents with increased erythema and crusting around the outer ear canal and a weeping, vesicular area that extends below the tragus. His pain has increased. What is the most likely diagnosis? A. Pseudomonas otitis externa B. Otitis media C. Neomycin allergy D. Malignant otitis externa ```

C. Neomycin allergy

Up to __% of the population has a sensitivity to neomycin.

15%

If a patient is allergic to cortisporin otic suspension, what is the cause of the allergy and what should we do?

The patient probably has a sensitivity to the neomycin; change to Ciprofloxacin or Floxin