Ear Infections Flashcards by Megan Rose

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)

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What are the common bacterial causes of otitis externa?

Staph aureus
Proteus
Pseudomonas aeruginosa

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What are the fungal causes of otitis externa?

Aspergillus niger

Candida albicans

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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

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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

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How is otitis externa managed?

Topical aural toilet
Antibiotic drops (gentamicin or ciprofloxacin) - only if complicated e.g. signs of cellulitis
Topical clotrimazole

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What is malignant otitis externa?

Life threatening complication

–> extension of OE into temporal and mastoid bone

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What are the clinical features of malignant otitis externa?

Severe pain + headaches
Granulation tissue/exposed bone in the canal
Facial palsy

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How is malignant otitis externa investigated and managed?

Urgent high resolution CT + biopsy for culture

–> urgent debridement + IV antibiotics

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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

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What are the risk factors for AOM?

Age (peak 6-15 months)
Boys
Passive smoking
Bottle feeding 
Craniofacial abnormalities
Nursery/day care

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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)

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What might be seen on examination in AOM?

Otoscopy:
- erythematous bulging TM
- injected TM
- may be rupture + discharge
Cervical lymphadenopathy

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Function of which nerve needs to be checked in AOM?

Facial nerve

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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)

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Which antibiotics are used for AOM?

First line: amoxicillin 5 days

Second line: clarithromycin

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When should you consider admission for AOM?

child < 3 months with temperature > 38
child 3-6 months with temperature > 39
evidence of complications

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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

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What are the intracranial complication of AOM?

meningitis
intracranial abscess
lateral sinus thrombosis
cavernous sinus thrombosis
subdural empyema

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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