Ear - Otalgia (earache) Flashcards
Otitis Externa, Acute Otitis Media, Acute Mastoiditis, Malignant otitis externa, Referred Otalgia
1
Q
What is Otitis Externa?
A
Inflammation of the outer ear canal
2
Q
What is the aetiology of Otitis Externa in adults?
A
Otitis Externa in adults is almost always infective but may also be inflammatory (eg, response to shampoo or ear drops)
3
Q
What are the bacterial causes of Otitis Externa?
A
(1) Staphylococcus aureus
(2) Proteus species
(3) Pseudomonas aeruginosa
4
Q
What are the clinical features of Otitis Externa?
A
(1) Redness and swelling of the ear canal
(2) Itching, especially in the early stages
(3) Pain and discomfort
(4) Discharge or increased ear wax
(5) Blocked tympanic membrane (affecting hearing)
(6) If the tympanic membrane ruptures, the discharge could be from otitis media rather than otitis externa.
4
Q
What are the fungal causes of Otitis Externa?
A
(1) Aspergillus niger
(commonly associated with swimming)
(2) Candida albicans
5
Q
What are common triggers for Otitis Externa?
A
(1) “Swimmer’s ear” caused by Aspergillus niger
(2) Water exposure
(3) Use of cotton buds
(4) Skin conditions
6
Q
What is the first-line management for Otitis Externa?
A
(1) Topical aural toilet (cleaning the ear)
(2) For moderate cases, use ciprofloxacin + hydrocortisone ear drops
7
Q
Why should fungal infections be considered in patients with recurrent Otitis Externa?
A
Fungal infections should be considered in patients who have had multiple courses of antibiotics, as antibiotics kill protective “friendly bacteria,” making the ear canal more prone to fungal overgrowth, similar to how oral antibiotics can cause thrush
7
Q
What is the treatment for fungal Otitis Externa?
A
Topical clotrimazole ear drops
8
Q
What is the treatment for bacterial Otitis Externa?
A
Gentamicin ear drops
9
Q
What is the treatment of moderate otitis externa?
A
aural toilet and combined antibiotic/steroid drops (Gentamix)
10
Q
Otitis Externa is defined as chronic when it has been present for which length of time?
A
3 months
11
Q
What is Acute Otitis Media?
A
Inflammation of the middle ear, often with fluid
11
Q
Who is most affected by Acute Otitis Media?
A
Infants + children
12
Q
How does the infection spread in acute otitis media?
A
Through the Eustachian tube from the throat
13
Q
What are the symptoms of acute otitis media?
A
Ear pain, fever, irritability, possible hearing loss
14
Q
What are the signs of acute otitis media?
A
Inflamed ear, bulging tympanic membrane, fluid in middle ear
15
Q
How can we distinguish Otitis Media from Otitis Externa?
A
Otitis Media affects the tympanic membrane, not the ear canal
16
Q
A 6-month old girl is brought in to see the General Practice by her mother, who is concerned because she is highly irritable, has stopped feeding properly and is crying all the time. She was born at term, has no significant past medical history and her immunisations are up to date. On examination, there is a boggy mass behind the right pinna which causes the auricle to protrude forwards and upwards. On otoscopy, there is profuse discharge and the tympanic membrane is perforated. Temperature is 39.
What is the most likely important diagnosis?
A
This baby has acute mastoiditis as a complication of otitis media
16
Q
What complications can arise In acute otitis media?
A
(1) Hearing loss
(2) Mastoiditis = mass behind ear
(3) Brain abscess
(4) Meningitis
(5) Vertigo
(6) Facial palsy
17
Q
What is Acute Mastoiditis?
A
A complication of acute otitis media involving infection of the mastoid air cells
18
Q
What is the aetiology of Acute Mastoiditis?
A
(1) It typically results from middle ear infections (otitis media) spreading to the mastoid air cells
(2) often caused by bacteria like Streptococcus pneumoniae and Haemophilus influenzae
19
Q
Why are the mastoid air cells prone to infection?
A
The mastoid air cells are porous, making them a suitable site for pathogen replication
20
Q
What are the clinical features of Acute Mastoiditis?
A
Pain, tenderness, and MAJOR swelling behind the ear
21
How is Acute Mastoiditis treated?
(1) IV antibiotics are used
(2) Surgical drainage may be necessary
22
A 4-year-old boy is brought by his parents to the GP practice because they are concerned that there is discharge from his right ear. For the last two days, he has been irritable and tugging on the outside of his ear.
He has just recovered from a recent upper respiratory tract infection (URTI). He is afebrile and alert and active. On otoscopy, there is a perforated tympanic membrane on the right.
What is the most appropriate management?
Prescribe amoxicillin
= patient has acute otitis media
23
What are the complications of Acute Mastoiditis?
Infection can spread to the mastoid process, middle cranial fossa, and brain
= causing meningitis
24
When should admission be considered for a child with Acute Otitis Media (AOM)?
Admission should be considered for =
(1) Children under 3 months with a temperature of 38°C or more
(2) Children with suspected acute complications such as meningitis, mastoiditis, or facial nerve palsy.
(3) Children who are severely systemically unwel
25
When should immediate antibiotics be given to a child with Acute Otitis Media?
(1) The child is systemically unwell.
(2) The child is at high risk of complications (eg, immunocompromised)
(3) The child has otorrhoea or is aged under 2 years with bilateral AOM
26
What is the first-line antibiotic for treating Acute Otitis Media in children?
Amoxicillin for 5-7 days is typically given as the first-line treatment
27
A 12-month-old boy is brought into A&E following a referral by his GP. His parents report they have been unable to settle him for the past 3 days. He has been off his feeds and their home infrared thermometer recorded his temperature at 38.8 degrees this morning.
His mother noticed he has been tugging at his left ear at night and he has vomited twice today. He has never suffered from anything like this before. On further questioning, his parents admit they are heavy smokers.
What should be the next immediate step in his management whilst he's here?
Examination of the tympanic membrane
28
What should be done if symptoms of Acute Otitis Media do not improve after 2-3 days of antibiotics?
co-amoxiclav may be considered.
29
A 4-year-old boy is brought to the GP by his mother complaining of constant pulling of the right ear, fever, poor feeding and restlessness for the past 4 days. It was preceded by a viral upper respiratory-tract infection, which resolved spontaneously without treatment. His father is a chronic smoker.
Otoscopy reveals a bulged and erythematous tympanic membrane
Given the clinical history, what is the most likely diagnosis?
Acute otitis media
30
A 5-year-old boy presents to the general practice with a 2-day history of right ear pain, fever and irritability. He is recovering from a cold but has no other significant medical history. On examination, the right tympanic membrane was erythematous and bulging
What is the most likely diagnosis?
acute Otitis media
31
A 23-month-old boy is brought to the general practice by his mother with a one-day history of fever. His mother reports noticing him rubbing his ears over the past four days. He has no past medical history except for a recent viral upper respiratory tract infection. His temperature is measured at 37.3 degrees Celsius.
On examination, he looks clinically well and stable. Otorrhoea is noted bilaterally and there is no evidence of rash, and both Kernig’s and Brudzinski’s signs are negative.
Based on the most likely diagnosis, what is the best management plan for this patient? and why
Offer amoxicillin
(1) The patient is younger than 2 years old, hence a 5-7 day course of amoxicillin
(2) since the symptoms started 4 days ago
(3) NICE guidance on waiting/offering a backup prescription suggests waiting to see if symptoms resolve within 3 days
32
What is malignant otitis externa?
Invasive infection of the mastoid and temporal bones
33
What is the most common causative organism in malignant otitis externa?
Pseudomonas aeruginosa
34
Name two major risk factors for malignant otitis externa
Diabetes and head/neck radiotherapy
35
What symptom is disproportionately severe compared to clinical signs in malignant otitis externa?
Severe ear pain disproportionate to clinical signs - eg, mild signs
36
What nerve is commonly affected, causing palsy in malignant otitis externa?
Facial nerve
37
What are the main treatments in malignant otitis externa?
(1) Immunosuppression correction
(2) Ear canal cleaning
(3) Long-term systemic antibiotics
(4) Surgery if needed
38
What is the most common cause of referred ear pain?
Temporomandibular joint (TMJ) disorders
39
Name three mandibular pathologies that can cause referred ear pain
(1) Dental abscess
(2) Dental caries
(3) Impacted molars
40
How can stress contribute to referred ear pain?
Tooth grinding (bruxism) affecting the TMJ
41
Name two salivary gland conditions causing referred otalgia
(1) Infection (mumps, bacterial)
(2) Salivary stones
42
What viral infection affecting CN VII can cause referred otalgia?
Geniculate herpes (Ramsay Hunt syndrome)
= facial nerve
43
Name two nasal pathologies that can cause referred otalgia
(1) Sinus infections (sphenoid/ethmoidal)
(2) Foreign bodies
44
What throat conditions can cause ear pain via CN IX?
(1) Tonsillitis
(2) Quinsy
(3) Post-tonsillectomy pain
= Glossopharyngeal nerve
45
What malignancy is associated with CN IX referred otalgia?
Carcinoma at the base of the tongue or tonsil
= Glossopharyngeal nerve
45
Name two cancers associated with CN X referred otalgia
Laryngeal carcinoma and post-cricoid carcinoma
= Vagus nerve
45
What type of foreign body can cause referred otalgia via CN X?
Fishbone in the piriform fossa
= Vagus nerve
46
Which nerve is affected in cervical neuritis causing ear pain?
Greater auricular nerve (C2/3)
47
What cervical condition linked to C3 can cause referred ear pain?
Cervical spondylosis
48
What cranial nerves experience otalgia?
1. CN V (Trigeminal nerve)
2. CN VII (Facial nerve)
3. CN IX (Glossopharyngeal nerve)
4. CN X (Vagus nerve)
48
Otalgia meaning
ear pain
49
What are all the cranial nerves in order?
CN I – Olfactory
CN II – Optic
CN III – Oculomotor
CN IV – Trochlear
CN V – Trigeminal
CN VI – Abducens
CN VII – Facial
CN VIII – Vestibulocochlear
CN IX – Glossopharyngeal
CN X – Vagus
CN XI – Accessory
CN XII – Hypoglossal
50
Which cranial nerve is responsible for smell and taste?
CN I (Olfactory nerve)
51
Which cranial nerves control eye movement?
CN III (Oculomotor)
CN IV (Trochlear)
CN VI (Abducens)
52
Which cranial nerve is responsible for vision?
CN II (Optic nerve)
53
Which cranial nerve controls the facial expression and taste from the anterior 2/3 of the tongue?
CN VII (Facial nerve)
54
Which cranial nerve provides facial sensation and controls mastication?
CN V (Trigeminal nerve)
55
Which cranial nerve is responsible for hearing and balance?
CN VIII (Vestibulocochlear nerve)
56
Which cranial nerve provides taste sensation from the posterior 1/3 of the tongue and is involved in the gag reflex?
CN IX (Glossopharyngeal nerve)
56
Which cranial nerve is responsible for sensory and motor functions, including parasympathetic control?
CN X (Vagus nerve)
57
Which cranial nerve controls cervical musculature?
CN XI (Accessory nerve)
58
Which cranial nerve provides motor innervation to the tongue?
CN XII (Hypoglossal nerve)
59
A 5-year-old boy presents with his mother to the GP surgery with a 5-day history of right-sided otalgia and reduced hearing. On examination, he has a temperature of 38.5ºC and a heart rate of 120 bpm. There is swelling around his right ear and the ear appears to be displaced anteriorly. The canal seems normal however the tympanic membrane is red and bulging.
What is the most appropriate next step in management?
Ear swelling and displacement
= acute mastoiditis
Therefore refer him
60
A 5-year-old girl presents to the emergency department with fever and lethargy over the past five days associated with poor oral intake. She has no prior medical history of note.
On examination, the child appears distressed. The external ear is displaced anteriorly, and there is marked tenderness to palpation behind the ear. Otoscopy reveals a bulging tympanic membrane and middle ear effusion. Her heart rate is 132 bpm, respiratory rate 27/min, BP 90/60 mmHg, and temperature 38.5ºC.
Given the most likely diagnosis, what is the most appropriate treatment?
IV antibiotics
61
When would urgent surgical drainage be the first line for mastoiditis?
1. Neck stiffness
2. Photophobia
3. Altered mental state
62
A 76-year-old man was seen by one of your colleagues one month previously complaining of right ear otalgia and discharge. He was diagnosed with otitis externa and started on antibiotic ear drops. He was next seen by an out-of-hours doctor one week ago who prescribed further antibiotic drops and tramadol. He has come to see you reporting that his symptoms are no better and the pain is becoming unbearable.
He has a past medical history of type-2 diabetes mellitus and hypertension. His regular medicines are metformin, gliclazide, ramipril and atorvastatin. He has no drug allergies. He has never smoked and rarely drinks alcohol.
On examination, there is debris in the right ear canal but the tympanic membrane remains visible. There was no erythema of the pinna or mastoid swelling. Examination of the cranial nerves is normal.
What is the most appropriate course of action?
Non-resolving otitis externa with worsening pain should be referred urgently to ENT
63
'Otalgia, fever, protruding ear and post-auricular tenderness' suggests what?
mastoiditis
= Arrange same-day hospital admission
64
A 24-year-old patient attends their general practitioner with an earache. They complain of being unable to hear clearly and have had difficulty sleeping due to the pain. They noticed feeling hot at home and recorded a temperature of 38ºC. On examination, the tympanic membrane appears to be bulging and opacified.
What is the most likely causative organism of this presentation?
Haemophilus influenzae
65
A 32-year-old female is referred urgently to the ear, nose and throat (ENT) specialists with a 1-month history of severe, unrelenting otalgia, associated with temporal headaches and purulent otorrhoea. She has a past medical history of type one diabetes mellitus and has no allergies. Examination identifies an erythematous external auditory canal and periauricular soft tissue on the left side which is exquisitely tender.
What is the most appropriate antibiotic management for this patient?
Otitis externa in diabetics
= treat with ciprofloxacin to cover Pseudomonas
66
An 8-year-old boy presents to the emergency department with a 3-day history of right-sided otalgia and otorrhoea. On further questioning, his father believes he has a middle ear infection as he has suffered from these in the past.
On examination, he is pyrexial and tender behind his right ear. His right ear appears more prominent than his left ear. An otoscopy of the affected ear reveals an erythematous tympanic membrane with a visible tear and purulent discharge.
Given the likely diagnosis, what is the usual first-line management?
IV antibiotics
= Patient has Mastoiditis
67
A 6-year-old boy is brought to the GP by his mother after he experienced 3 days of left ear pain. Initially, he was pulling at his ear and has been crying, however, he has been managing to eat and drink as normal, and this morning he woke up to find blood-stained discharge on his pillow but his pain has now resolved.
His observations are normal except for a temperature of 37.5ºC.
What is the most appropriate next step in his management?
Just perforation so Prescribe oral amoxicillin now
68
A 23-year-old male swimmer presents to his GP with left ear pain, discharge, and mild hearing loss for the past two days. Otoscopy reveals a swollen external auditory meatus and a normal appearance of the tympanic membrane.
What is the first-line treatment for his condition?
Topical ciprofloxacin + dexamethasone
= Topical antibiotics with or without steroid are first line treatment in otitis externa
69
A 35-year-old woman presents to her GP with recurrent episodes of otitis externa despite numerous courses of antibiotics. She reports intense itching and a muffled sensation in her ear. On examination, there is erythema, oedema, and a white, curd-like discharge in the external auditory canal. The patient denies recent swimming or trauma to the ear. The rest of the physical examination is unremarkable.
What is the most likely cause of this patient's presentation?
Recurrent otitis externa following numerous antibiotic treatment should raise suspicion of Candida infection
70
A 24-year-old man books into your emergency duty clinic. He was seen by one of your colleagues four days previously and diagnosed with right-sided otitis externa and started on antibiotic ear drops. He reports that despite these the pain is getting worse. For the last 24 hours, he has been unable to apply the drops due to swelling of the canal.
On examination, the right external auditory canal is swollen completely shut and you are unable to see any further. The examination is otherwise unremarkable. Observations are within the normal range.
What is the most appropriate management?
Poor response to topical antibiotics should be referred to ENT
71
A 23-year-old woman presents one week after being prescribed a combined antibiotic and steroid spray for otitis externa. There has been no improvement in her symptoms and the erythema seems to have extended to the ear itself. What is the most appropriate treatment?
The spreading erythema is an indication of oral antibiotics. Flucloxacillin is first-line
72
You see a 22-year-old woman with 3 days history of severe right-sided ear pain, watery discharge and muffled hearing. The ear also feels very itchy.
On examination, the tympanic membrane appears intact, but the external auditory canal looks red, swollen and inflamed with purulent debris and wax. Pulling out the pinna causes the patient extreme pain. The mastoid process appears normal and is not tender to palpation. Conductive hearing loss is diagnosed using Rinne's and Weber's tests.
What is the 1st line treatment for this patient?
Topical antibiotic + a topical steroid for 1-2 weeks
73
You see a 3-year-old boy as a follow-up appointment. Two weeks ago he presented with left-sided otalgia associated with a purulent discharge. You prescribed amoxicillin and arranged to see him today. His mum reports that he is much better and says she has managed to keep the ear dry.
On examination of the left side a perforation of the tympanic membrane is noted. What is the most appropriate action?
Advise to keep ear dry and see in a further 4 weeks' time
= If there is still a perforation when the boy is reviewed in 4 weeks time (i.e. 6 weeks since the perforation occurred) then ENT referral should be considered
Should resolve on its own in 6-8 weeks
74
A 33-year-old male presents to ENT having been referred by his GP. He perforated his tympanic membrane 6 months ago and it has failed to heal spontaneously over this time.
What is the most appropriate next step in management?
Myringoplasty
75
A 27-year-old male presents to the GP with intense left-sided ear pain which he has had for 24 hours. On examination, you see that the left ear is protruding forward, with a tender, boggy mass behind the ear. The tympanic membrane is bulging and erythematous. He is tachycardic and his temperature is 37.9 ºC.
Urgent treatment of this condition is necessary to prevent which complication?
Meningitis
76
Jamie is a 13-year-old girl who presents to her general practitioner complaining of right ear pain over the last three days, with slightly worse hearing over this time. She also complained of fluid leaking from her ear this morning. Jamie's past medical history includes recurrent otitis media as a child (approximately two episodes per year until the age of 5) and had grommets inserted once at age 4.
On examination, Jamie's blood pressure is 120/80mmHg, heart rate 85/min and temperature 37.4ºC. On otoscopy, the right external auditory canal appears swollen and erythematous. The tympanic membrane is slightly erythematous with no effusion present. There is no pain on mastoid palpation, however, when the GP pulls on the right tragus there is significant tenderness.
What is the most likely diagnosis?
Otitis externa
= pain on palpation of the tragus, itching, discharge and hearing loss
77
A 74-year-old man presents with an 8-week history of right-sided otalgia. This is associated with a sore throat and odynophagia. He smokes 20 cigarettes every day and is known to be a heavy drinker. On examination of the ear, there are no abnormalities noted.
What is the most likely cause of the otalgia?
Referred pain from nasopharyngeal carcinoma
78
A 12-year-old girl is brought into her general practice by her mother. She is complaining of hearing loss in her left ear following using a cotton bud to clean her ear
She appears well and is afebrile. On examination, the acoustic canal is clean and no exudate or erythema is present. The tympanic membrane cannot be seen on otoscopy
What is the most appropriate management for this patient?
Avoid water, and review in 6 weeks
= This patient has potentially ruptured her tympanic membrane
79
An anxious mother has brought her 18-month-old son into your practice as he has been crying for the last 2 days with a fever of 38 degrees according to a temperature colour strip she has used at home. He seems playful in the clinic but repeatedly tugs at his left ear. On examination with an otoscope you see erythema of the tympanic membrane, which is bulging, and behind it is an effusion
What is the correct management for this patient and why?
The boy has otitis media
Antibiotics are only considered for children under two years if they have
1. bilateral otitis media and fever
2. or systemic infection
3. or symptoms >3 days
Therefore plan is
= Analgesia and observe for 48 hours and if symptoms worsen, consider antibiotics
80
Summary of otitis externa treatment
1. Ear cleaning (by a clinician) to remove debris
Topical drops:
1. Bacterial: antibiotic + steroid drops (e.g. ciprofloxacin + dexamethasone)
2. Fungal: antifungal drops
(e.g. clotrimazole).
3. paracetamol or ibuprofen.
4. Avoid water in the ear
5. Ear wick: if the canal is very swollen (helps deliver drops deeper).
81
If a patient with acute otitis media (AOM) is started on antibiotics (e.g. amoxicillin for 5 days) but symptoms do not improve after 2–3 days. What should you do?
Symptoms don't improve in 5 days, this is when you reassess and consider second-line antibiotics.
You don’t wait until the full 5 days are over if they’re not improving. Most people start to improve within 48–72 hours on antibiotics, so therefore switch to co-amoxiclav or refer to ENT
