Ear Infections Flashcards
What are the risk factors for otitis externa?
Frequent water contact (swimmers) Humid environments Ear polyps Foreign bodies Narrow ear canal Ear eczema or psoriasis Local trauma (hearing aids, cotton buds) Immunocompromised + DM (+increased risk of complications)
What are the common bacterial causes of otitis externa?
Staph aureus
Proteus
Pseudomonas aeruginosa
What are the fungal causes of otitis externa?
Aspergillus niger
Candida albicans
What are the clinical features of otitis externa?
Ear pain Purulent discharge Itchiness Ear fullness Less commonly: hearing loss + tinnitus Swollen, erythematous ear canal Swollen pinna, tender tragus
How is otitis externa diagnosed and which investigations can be done?
Diagnosed clinically
Swab discharge if not resolving or fungal cause suspected
High resolution CT if complications
How is otitis externa managed?
Topical aural toilet
Antibiotic drops (gentamicin or ciprofloxacin) - only if complicated e.g. signs of cellulitis
Topical clotrimazole
What is malignant otitis externa?
Life threatening complication
–> extension of OE into temporal and mastoid bone
What are the clinical features of malignant otitis externa?
Severe pain + headaches
Granulation tissue/exposed bone in the canal
Facial palsy
How is malignant otitis externa investigated and managed?
Urgent high resolution CT + biopsy for culture
–> urgent debridement + IV antibiotics
What causes acute otitis media (AOM)?
Nasopharyngeal bacteria/virus –> middle ear via Eustachian tube
Bacteria: H. influenzae, S. pneumoniae, S. pyogenes, M. catarrhalis
Viruses: RSV, rhinovirus, enterovirus
What are the risk factors for AOM?
Age (peak 6-15 months) Boys Passive smoking Bottle feeding Craniofacial abnormalities Nursery/day care
What are the clinical features of AOM?
Preceded by URTI
Pain, malaise, fever + coryzal symptoms lasting a few days
In young children: ear tugging, irritability, loss of appetite, vomiting
May be conductive hearing loss
Purulent discharge if TM bursts (pain improves)
What might be seen on examination in AOM?
Otoscopy: - erythematous bulging TM - injected TM - may be rupture + discharge Cervical lymphadenopathy
Function of which nerve needs to be checked in AOM?
Facial nerve
What is the management for AOM?
Analgesia (ibuprofen) and anti-pyretic (paracetamol)
- majority self limiting in 1 - 3 days
Oral antibiotics if no improvement in a few days or:
- systemically unwell
- known risk factor for complications
- discharge (take swabs first)
Which antibiotics are used for AOM?
First line: amoxicillin 5 days
Second line: clarithromycin
When should you consider admission for AOM?
- child < 3 months with temperature > 38
- child 3-6 months with temperature > 39
- evidence of complications
What are the intratemporal complications of AOM?
- tympanosclerosis (white patch on ear drum due to scarring)
- hearing loss
- TM perforation
- mastoiditis
- labyrinthitis
- CN VII palsy
What are the intracranial complication of AOM?
- meningitis
- intracranial abscess
- lateral sinus thrombosis
- cavernous sinus thrombosis
- subdural empyema
Why does mastoiditis occur and what is the pathology?
Middle ear + mastoid are one cavity –> always a degree of mastoiditis with AOM
If inflammation in air cells progresses to necrosis + subperiosteal abscess –> very concerning
What does mastitis look like?
Boggy, erythematous swelling behind ear, can push pinna forward if not treated
How is mastoiditis managed?
Admit for IV antibiotics
CT if no improvement in 24 hours
Mastoidectomy if no improvement with antibiotics (high risk of intracranial spread)
What is otitis media with effusion (OME)?
Middle ear effusion without signs of infections (glue ear)
Why is OME more common in young children?
Immature shape of Eustachian tube
What should be considered if new onset unilateral OME in an adult?
Red flag for malignancy blocking Eustachian tube
What are the risk factors for OME?
Bottle fed Passive smoking Atopy CF or primary ciliary dyskinesia Craniofacial disorders e.g. Down's, cleft palate
What are the clinical features of OME?
Conductive hearing loss (may be unilateral or bilateral)
–> may present as behaviour problems or poor speech development
Sensation of pressure +/- popping or clicking noises
What would be seen on otoscopy in OME?
Dull TM +/- fluid level line
Light reflex will be lost
May see bubble behind TM
Which investigations should be done for OME?
Pure tone audiometry –> conductive hearing loss
Tympanometry
In adults –> full ENT exam + flexible nasoendoscopy
What would tympanometry show in OME?
Flat trace due to reduced membrane compliance
–> type B curve
How is OME managed?
Active surveillance for 3 months (most resolve)
If no improvement:
- non-surgical: hearing aid while waiting for resolution
- surgical: myringotomy + ventilation tube (grommet) insertion
What are the indications for grommet insertion?
> 3 months of bilateral OME + hearing in better ear < 25-30 dBHL
How long does a grommet last and what are the complications?
Usually fall out after about 9 months
Complications:
- tympanosclerosis (scar)
- TM rupture
Which surgical procedure can be done for recurrent OME?
Adenoidectomy
How are types of chronic otitis media categorised?
Mucosal: TM perforation in presence of recurrent/persistent ear infection
Squamous: gross retraction of TM with formation of keratin collection
Active: infection present
Inactive
What is an inactive mucosal chronic otitis media?
Dry perforation
What is an inactive squamous chronic otitis media?
Retraction pocket
Potential to become active with retained debris (keratin)
What is an active mucosal chronic otitis media?
Wet perforation with inflamed middle ear + discharge
What is an active squamous chronic otitis media?
Cholesteatoma
What are the clinical features of mucosal COM?
Hearing loss
Chronic discharge
May develop secondary otitis externa
Often history of recurrent AOM, previous ear surgery or trauma
How is mucosal COM managed?
Aural toiletting + topical steroid/antibiotic cream (if active)
Most TM perforations heal, but large holes may require surgery
What are the surgical options for a large TM perforation in COM?
Myringoplasty –> closure of perforated pars tensa using a patch of autologous graft (cartilage or fascia)
Tympanoplasty –> a myringoplasty with reconstruction of the ossicular chain
What is a cholesteatoma?
Accumulation of benign keratinised squamous cells in middle ear
Secrete enzymes which can be locally destructive
How does a cholestatoma form?
Usually ET dysfunction/otitis media
–> retraction of pars flaccida causing a pocket to form in attic of middle ear
–> cell debris builds up –> cholesteatoma
Debris can become infected –> chronic discharge
What are the clinical features of cholesteatoma?
Conductive hearing loss on background of chronic otitis media
Persistent discharge despite antibiotics
What is seen on otoscopy in cholesteatoma?
Pay particular attention to superior TM (attic)
- deep retraction pocket with keratinous debris within it -“pearly mass”
- may be granulations + bony erosion
- discharge if secondary infection
Which investigations need to be done for a cholesteatoma?
Pure tone audiometry
CT of temporal bone
How is cholesteatoma managed?
Surgery –> removal of entire cholesteatoma or it will recur
- mastoid cavity drilled to allow access to middle ear
- once removed, any destructed ossicles can be reconstructed (ossiculoplasty) + TM replaced with graf
