EAR PAIN

Question 1

What is otalgia?

Answer 1

Ear pain

Question 2

What are the 2 types of otalgia?

Answer 2

Primary otalgia - coming directly from ear
Secondary otalgia - referred pain from somewhere outside the ear

Question 3

What are causes of primary otalgia?

Answer 3

Acute otitis media - most common cause in children <2
Otitis externa
Necrotising otitis externa
Eustachian tube dysfunction
FB
Trauma
Impacted ear wax
Otalgic neoplasms

Question 4

What are causes of secondary otalgia?

Answer 4

Dental inflammation or infection
TMJ disorders
Trigeminal neuralgia
Head and neck cancer
Temporal arteritis

Question 5

What is otitis externa?

Answer 5

Diffuse inflammation of the skin and subdermis of the auditory canal which may also involve the pinna or tympanic membrane

Question 6

What is otitis externa commonly known as?

Answer 6

Swimmers ear
Tropical ear

Question 7

What is acute and what is chronic otitis externa?

Answer 7

Acute - <6 weeks duration
Chronic - >3 months

Question 8

What typically causes acute otitis externa?

Answer 8

Bacterial infection with staph aureus or pseudomonas aeruginosa

Question 9

What typically causes chronic otitis externa?

Answer 9

Fungal infection e.g. Candida albicans or aspergillus species

Question 10

What is malignant otitis externa?

Answer 10

Aka necrotising otitis externa
A potentially life-threatening progressive infection of the external ear canal which may spread to cause osteomyelitis of the temporal bone and adjacent structures

Question 11

What commonly causes malignant otitis externa?

Answer 11

Pseudomonas aeruginosa

Question 12

Risk factors for acute otitis externa?

Answer 12

Skin conditions e.g. eczema, psoriasis and seb derm
Acute otitis media
Contact dermatitis e.g. shampoos
Trauma to ear canal e.g. from cleaning
FB in ear
Water exposure
Ear canal obstruction e.g. debris or excess wax production

Question 13

Risk factors for chronic otitis externa?

Answer 13

Skin conditions e.g. eczema, psoriasis
Uncontrolled DM or other causes of immunocompromise
Contact dermatitis e.g. shampoo, nickel earrings
Fungal infections after topical antibiotics or corticosteroid use

Question 14

What can cause malignant otitis externa?

Answer 14

Uncontrolled diabetes or other cases of immunocompromise
Older age
Radiotherapy to head, ear or neck which may damage the ear
Previous ear surgery or ear irrigation

Question 15

Possible complications of otitis externa?

Answer 15

Chronic otitis externa
Regional spread of infection e.g. cellulitis
Fibrosis and stenosis of ear canal or fibrosis of TM -> conductive hearing loss
Myringitis and perforation of TM
Malignant otitis externa

Question 16

Prognosis of malignant otitis externa

Answer 16

Life threatening
Temporal bone osteomyelitis is associated with a mortality rate of 10-21%

Question 17

How does acute otitis externa present?

Answer 17

Rapid onset within 48 hours of:
Itchy ear canal
Ear pain and tenderness of tragus or pinna with possible jaw pain
Ear discharge
Hearing loss due to ear canal occlusion - less common

In young children - crying, poor feeding, restlessness at night, cough, rhinorrhoea, rubbing of ear

Question 18

Signs of acute otitis externa?

Answer 18

Tenderness of the tragus and/or pinna.
The ear canal is red and oedematous, and there may be debris and ear discharge contributing to swelling and canal occlusion.
Tympanic membrane erythema (may be difficult to visualize if the ear canal is narrowed or filled with debris).
Cellulitis of the pinna and adjacent skin.

Conductive hearing loss (less common).
Tender regional lymphadenitis (less common).

Question 19

Symptoms and signs of chronic otitis externa?

Answer 19

Constant itch in the ear.
Mild discomfort or pain (rare).

Lack of ear wax in the external ear canal.
Dry scaly skin in the ear canal, which varies in thickness but often results in at least partial canal stenosis; or red, moist skin in the ear canal.
Fluffy, cotton-like debris, hyphae, or dots of black debris may be seen in the ear canal if there is fungal infection.
Conductive hearing loss.

Question 20

Symptoms of malignant otitis externa?

Answer 20

Unremitting disproportionate ear pain, headache, purulent otorrhoea, fever, or malaise.
Vertigo.
Profound conductive hearing loss.
Ipsilateral facial nerve palsy

Question 21

Signs of malignant otitis externa?

Answer 21

Systemically unwell, high fever.
Granulation tissue seen on the floor of the ear canal and at the bone-cartilage junction; exposed bone in the ear canal.
Ipsilateral facial nerve palsy.

Question 22

Management of otitis externa?

Answer 22

topical antibiotic or a combined topical antibiotic with a steroid
if the tympanic membrane is perforated aminoglycosides are traditionally not used
if there is canal debris then consider removal
if the canal is extensively swollen then an ear wick is sometimes inserted

Question 23

What % of cases of maligannt otitis externa are in diabetics?

Answer 23

90%

Question 24

How is maligannt otitis externa diagnosed?

Answer 24

CT scan is typically done

Question 25

How is maligannt otitis externa treated?

Answer 25

non-resolving otitis externa with worsening pain should be referred urgently to ENT
IV antibiotics that cover pseudomonal infections

Question 26

How does acute otitis media present?

Answer 26

Recent viral URTI symptoms
Otalgia
Fever
Hearing loss
Ear discharge if TM perforates

Question 27

What usually causes acute otitis media?

Answer 27

Viral URTI precede and disturb the normal nasopharyngeal microbiome allowing bacteria to infect the middle ear via the Eustachian tube
Strep pneumoniae
H influenza
Moraxella catarrhalis

Question 28

Otoscopy findings in acute otitis media?

Answer 28

bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope