Ear, otitis media and otitis externa

Question 1

risk factors for otitis externa

Answer 1

water exposure

trauma (cotton swabs, ear candling)

foreign material (hearing aid, headphones)

dermatological conditions - eczema and contact dermatitis

Question 2

microbiology of otitis externa

Answer 2

pseudomonas aeruginosa

staphlococcus aureus

Question 3

clinical manifestations of otitis externa

Answer 3

otalgia,

pruritis,

discharge,

hearing loss pain with auricle manipulation ear

canal erythema,

edema,

debris

tympanic membrane is spared (clear, not inflamed, no middle ear fluid)

Question 4

treatment of otitis externa

Answer 4

topical antibiotic (fluoroquinolone + topical glucorticoid treatment) consider wick placement to facilitate medication delivery

Question 5

initial treatment of otitis externa

Answer 5

clean the ear canal to remove cerumen and other debris and NSAIDS for pain control.

Can use otoscope and wire loop to gently remove debris and cerumen. Then irrigating canal with 1:1 dilution of 3% hydrogen peroxide is effective in pts with intact tympanic membranes.

Question 6

Mild Otitis externa symptoms are

Answer 6

pruritis with minimal canal edema

Question 7

how to treat mild otitis externa treatment:

Answer 7

acidifying agent (acetic acid) to inhibit bacterial growth in ear canal and topical steroids to decrease inflammation.

Question 8

moderate otitis externa symptoms are

Answer 8

pain, pruritis, partial canal occlusion

Question 9

treatment of moderate to severe otitis externa

Answer 9

OE requires combined topical antibiotics- quinolones, polymyxin B, neomycin) antiseptics and steroids (with possible wick placement If does not improve in 3 days, needs culture of her ear canal or referral to ENT. Both ofloxacin and ciprofloxacin cover pseudomonas very well.

Question 10

severe otitis externa symptoms are

Answer 10

severe (intense pain canal occlusion, fever)

Question 11

when do we give oral antibiotics for otitis externa infections?

Answer 11

immunocompromised pts and infection in deeper tissue beyond the ear canal.

for simple uncomplicated otitis externa, oral abx don’t really help

Question 12

When to refer to ENT or otolaryngologist?

Answer 12

those at risk for malignant otitis externa infection (with infection to skull base)

Question 13

right ear pain with discharge. See ulceration with exudation in the right ear canal and pain with mild pinna movement. What to do next?

Answer 13

biopsy the lesion. Could be due to malignant otitis externa or squamous cell carcinoma and need to rule out SCC

Question 14

malignant otitis externa is:

Answer 14

invasive pseudomonal infection with uncontrolled DM2

can cause severe pain, purulent discharge and unresponsive to topical antimicrobial therapy.

Can see osteomyelitis of skull and cause cranial nerve palsies as worse case scenario

Question 15

malignant otitis externa treatment

Answer 15

responds to oral fluoroquinolone therapy and IV third generation cephalosporins (with or without aminoglycoside)

Question 16

what is seen on labs with suspected malignant otitis externa

Answer 16

elevated to high ESR but squamous cell cancer can also have mildly elevated ESR so biopsy needs to be done.

Question 17

acute otitis media is caused by

Answer 17

Eustachian tube blockage which causes fluid accumulation in middle ear with subsequent bacterial growth.

Caused by

Strep pneumo,

non typeable H influenzae

Moraxella catarrhalis

Question 18

What is the presentation of acute otitis media?

Answer 18

allergic rhiniits or URI precedes the onset of severe ear pain and hearing loss, . Fever can be present.

Question 19

what is seen on physical exam with acute otitis media?

Answer 19

Otoscopic exam: redness, opacification, airfluid level, bulging of tympanic membrane and pneumatic otoscope whould have poor moveability of tympanic membrane

Tuning fork would show conductive hearing loss

Question 20

1st line treatment for acute otitis media?

Answer 20

amoxicillin and if doesn’t improve in 48-72 hrs then should be rechecked for new area of infection or inadequate treatment

If antibiotic fails, then start augmentin or amoxicillin clavulanate to cover beta lactamase producing H influenzae

If allergic to penicillin can use cefuroxime (2nd or 3rd gen cephalosporins).

Can use macrolide (azithromycin) too.

Question 21

when to get CT scan of head for acute otitis media?

Answer 21

posterior ear pain, fever, headache despite getting treated with antibiotics. This would be concerning for extension of infection.

when there’s concern for mastoiditis, brain abscess, and lateral sinus thrombosis (MRI needed)

Question 22

when to get myringotomy?

Answer 22

only for chornic unresolved otitis media with effusion or mastoiditis.

Question 23

when to get a nasopharnygoscopy?

Answer 23

when there’s >2 recurrent otitis media infections and concerned for possible eustachian tube or nasopharyngeal obstruction by malignancy

two recurrent otitis media infections : >2 episodes in 6 months

Question 24

ear pain in one hear after URI

conductive hearing loss

otoscopic with erythema, opacification and bulging and airfluid level of tympanic membrane

Answer 24

acute otitis media

tx with amoxicillin and if doesn’t improve in 48-72 hrs then start augmentin.

Question 25

Eustachian tube dysfunction

Answer 25

ear discomfort and auditory symptoms in acute upper respiratory infection.

Eustachian tube connects the airfilled middle ear to the nasopharynx and equalizes pressure across the tympanic membrane.

IF there’s functional obstruction (viral URI, allergic rhinitis) then or structural blockage by tumor, there can be muffled hearing, crackling, popping sounds or feeling of pain with pressure and accumulation of middle ear effusion.

Persistent obstruction can predispose or increase risk for acute otitis media.

Question 26

Treat acute eustachian tube dysfunction with

Answer 26

By treating the underlying cause

If URI, give nasal decongestants

If allergic rhinitis, give glucocorticoid nasal sprays and antihistamines.

Question 27

eustachian tube dysfunction physical exam:

Answer 27

otoscopic may reveal erythematous, retracted tympanic membrane or effusion and see conductive hearing loss on testing with at tuning fork.

Tx is based off treating underlying disorder.

Question 28

When to get a CT head for someone with eustachian tube dysfunction?

when to get nasal endoscopy?

Answer 28

if there’s unilateral symptoms for more than 3 months to rule out nasopharygneal neoplasm

Get nasal endoscopy if cases don’t respond to decongestants or for recurrent cases.

Question 29

unilateral ear fullness, popping sounds and decreasing hearing with a URI.

Answer 29

eustachian tube dysfunction

Question 30

complication of acute otitis media?

Answer 30

perforation of tympanic membrane

• can occur with unilateral ear pain (otalgia) decreased hearing, and fever

Can see opaque or erythematous TM with bulging and poor mobility. There can be subsequent perforation of TM and lead to purulent otorrhea and relief of ear pain

Question 31

how to treat perforation of the tympanic membrane from acute otitis media?

Answer 31

treat with combination of oral and topical antibiotics and prevention of water entry into ear canal

It heals completely.

No topical acetic acid (only for external otitis) because it can damage the area further

Question 32

acute otitis media with bone involvement requires treatment with

Answer 32

reconstructive surgery - only if there’s refractory mastoiditis