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CLIN MED > Ear Pain > Flashcards

Ear Pain Flashcards

1
Q

Innervation of the Ear (6)

A

5th (trigeminal), 7th (facial), 9th(glossopharyngeal), 10th (Vagus)CN

1st, 2nd, 3rd cervical nerves

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2
Q

sections of the ear - common infections for each

A

Outer - otitis externa, skin conditions : eczema, BCC, furuncles

Medial (from typmanic membrane to proximal end of the eustachian tube) : boney case , otitis media

Inner ear : thin stratefied squamous tissue
cartilagenous tissue

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3
Q

what are semicircular canals?

A

propriocepters - help orient the body in space

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4
Q

What is special about eustachian tube in children?

A

It’s more horizontal - more prone to AOM : children typically outgrow this by age 7

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5
Q

Primary causes of otalgia

A

Ear pain:

Otitis externa
Otitis media
Impacted cerumen
Foreign body
Barotrauma ( pressure)
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6
Q

Secondary causes of otaligia

A

Ear pain but problem doesn’t originate in the ear

if you don’t see anything, you may need to search for other things

Carious teeth
TMJ disorder
Cervical spine pain
Cervical lymphadenitis
Tonsillitis
Parotitis
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7
Q

Supprative definition

A

acute.

ie) supprative ear pain

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8
Q

Timing of ear issues

A

Infection tends to be continous and progressive ( bacterial)

intermittant more likely to be MSK related ie - TMJ

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9
Q

location of ear issues

anterior to tragus
pinna
vague

A

anterior to tragus - TMJ

manipulation of pinna ( otitis external)

vague - secondary issue

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10
Q

Fever with earache

A

URTI, bacterial infection

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11
Q

Runny nose and earache

A

viral or allergic

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12
Q

itching and earache

A

fungal, herpes zoster, allergic

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13
Q

aural fullness, hearing loss, dizziness and earache

A

primary otalgic cause ie) OM, OW, foreign body, trauma

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14
Q

Elevating risk factors for earache (8)

A 
Daycare
Smoke exposure
Swimming
Airplane travel
Immunocompromisation, eg. diabetes mellitus, HIV
Tooth infections
Recent trauma
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15
Q

What consists of a full ear exam?

A

Pinna, post-auricular region
External ear canal
Tympanic membrane
Hearing tests

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16
Q

What consists of a full neck and head exam?

A

Pinna, post-auricular region
External ear canal
Tympanic membrane
Hearing tests

PLUS 
Nasal cavity
Oral cavity and pharynx
Neck, anterior and posterior
TMJ
(looking for secondary causes of ear pain)
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17
Q

What are possible things to see on the external ear - don’t forget the back!

questions to ask

A

tophi associated with gout : accumulation of uric acid

discharge : ass. with perforated tympanic membrane, blood, clear may be CSF

red , scaly lesions : psoriasis, herpes zoster, atopic dermatitis

Fununcles, acne, etc.

is it itchy?painful? been there for long?

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18
Q

What are the characteristics of cerumen?

A

glandular secretions + sloughed epithelial cells
Acidic pH; self-cleaning; protective against pathogens

can be golden or dark when oxidized

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19
Q

Cerumen impaction

types?
prevalence
what does it do? (10)

A

Complete or partial

very prevalent esp in elderly and kids

Can cause symptoms:
Hearing loss, tinnitus, vertigo, aural fullness, itching, otalgia, discharge, odour, cough
AND

Interferes with inspection of tympanic membrane

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20
Q

Why would impacted cerumen or other ear disorder cause a cough?

A

because the nerve that passes by is irritated - may trigger a nerve to elicit a cough reflex.

5th (trigeminal), 7th (facial), 9th(glossopharyngeal), 10th (Vagus)CN
1st, 2nd, 3rd cervical nerves

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21
Q

A very common problem for 4 year old children in regards to ear pain

A

foreign body

also AOM very common

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22
Q

Otitis Externa

where?
types? (general)

A

Infection of auricle and/or external ear canal

Acute : (unilateral)

a) Diffuse: swimmers ear - bacterial
b) focal: folliculitis -
lateral ear canal
gram neg organisms : s. aureus

chronic : longer thana week
more likely bilateral
predisposing conditions such as allergices, psoriasis etc.

necrotizing - rare : medical emergency
spread of infection to skull base - jugular foramen and brain

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23
Q

Acute otits externa

A

Acute : (unilateral)

a) Diffuse: swimmers ear - bacterial
b) focal: folliculitis -
lateral ear canal
gram neg organisms : s. aureus

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24
Q

Chronic otistis externa

A

chronic : longer than a week
more likely bilateral
predisposing conditions such as allergices, psoriasis etc.

can be something like fungal on top of bacterial etc.

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25
Q

Necrotizing Otitis Externa (OE)

what?
who is at risk?
typical presentation?
organism?

A

necrotizing - rare : medical emergency
spread of infection to skull base - jugular foramen and brain

Greater risk with immunocompromisation, especially DM (diabetes mellitus - 90% of cases)

Persistent purulent otorrhea, facial nerve palsy,

Typically due to Pseudomonas aeruginosa

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26
Q

what is otorrhea?

A

dischrage from the ear

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27
Q

Which condition may cause facial nerve palsy and possibly ear pain

A

Necrotizing otitis externa

red flag - emergent

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28
Q

Diffuse acute otitis externa

presentation? (6)
organism?

A
  1. Rapid onset of unilateral ear canal inflammation
  2. Pain, itching, fullness, hearing loss
  3. ++Pain on manipulation of tragus/pinna
  4. Diffuse edema, erythema, +/- discharge or debris
  5. Erythema of tympanic membrane with normal mobility
  6. Regional lymphadenitis or cellulitis

98% bacterial
Pseudomonas aeruginosa, Staphylococcus aureus

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29
Q

Diffuse acute otitis externa general ( 1 sentence)

A

titis externa (OE) is an inflammation or infection of the external auditory canal (EAC), the auricle, or both

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30
Q

Diffuse acute otitis externa

associated with?
who?

A

Associated with exposure to moisture or trauma

Highest incidence in 7-12 year olds, more common in summer months

can affect anyone

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31
Q

Diagnostic considerations for AOE (3)

A
  1. rapid onset (48 hrs) AND
  2. Symptoms of ear canal inflammation
    a) otaligia
    b) itching
    c) fullness
    d) with or without hearing loss or jaw pain

AND
3. signs of ear canal inflammation : tenderness of tragus, pinna or both OR diffuse ear canal edema

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32
Q

If I have a furuncle in my ear canal ( external) what do I have?

A

A. Otitis Externa

due to a bacterial infection ( usually) s, aureus

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33
Q

If my ear canal is edematous but not eryathemaous what might i have?

A

Acute Otitis Externa

may not be able to see redness due to debris

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34
Q

Parts of the tympannic membrane

and hour on clock on right ear (10)

A 
Pars Flaccida (12-1)
Anterior fold (1)
Short process of malleus (2)
manubrium of malleus (2)
cone of light ( 5 or 7 on left ear)
Pars tensa (membrane) 
Annulus ( around the whole thing)

umbo ( middle)
Incus ( 11)
Posterior fold ( 11)

35
Q

how to describe a healthy tympannic membrane ?

A

pearly grey

36
Q

Acute Otitis Medica (AOM)

clinical presentation

A

Fluid in the middle ear
local or systemic illness evidence

otaligiam fever, or hearing loss
pain is aching or pulsating

abnormal TM : red yellow or cloudy, bulging, reduced mobility to negative pressure or in general

37
Q

AOM tympannic membrane

colour
shape
mobility
other

A

Opaque, red, yellow, or cloudy

bulging

reduced mobility
may respond to positive pressure with pneumatic otoscopy

effusion present

38
Q

Why can’t you see the cone of light in AOM?

A

B/c the TM is bulging and it does not reflect the light in the same way

39
Q

I have severe pain, very red and very swollen TM, I may have pus - what do I have?

A

AOM

may be bacterial - should be treated with Abx

40
Q

When does AOM show up?

dangerous/risk?

A

Kids 3 years of age

secondary to an URTI

80% self limiting
severe symptoms that don’t get better in 24-48 hours should be treated by Abx

41
Q

Most significant LRs for AOM (3)

A

Bulging tympannic membrane

cloudy tympannic membrane

impaired mobility of TM

42
Q

A child is rubbing their ear in your office. what could they have? what are we less concerned about?

A

They could have AOM, or they could be teething

less concerned about OE - because touching would really hurt them but can’t toally rule out

43
Q

A 6 month old comes in they have been vomitting and very irritable . Mom reports child puuling at ear.

no previous ear infections

what are the possible DDxs?

why vomitting?

A

AOM

check tympannic membrane to confirm

with a red/cloudy/bulging, immobile tympanic membrane

OE, teething, meningitis, etc.

vomitting may be due to pain

44
Q

AOM sequelae and complications

A
  1. Perforated TM
  2. Hearing loss ( usually temporary)
  3. facial nerve paralysis (generally self limiting)
  4. Supprative ( uncommon)
    mastoiditis
    meningitis, brain abscess, thrombophlebitis, labyrinthitis
45
Q

Supprative complications with AOM

presentation and TX

A

uncommon
serious

Mastoiditis (1.2-6.0/100,000)
Post-auricular swelling, mastoid tenderness, obliteration of postauricular fold
Meningitis, brain abscess, thrombophlebitis, labyrinthitis

person appears very sick and this is agood indication for antibiotics

46
Q

Mastoiditis

A

rare -
Post-auricular swelling, mastoid tenderness, obliteration of postauricular fold

need Abx

mastoid process mushy and soft

47
Q

when do we find Retracted TM?

A

typically in OME

48
Q

Otits Media with Effusion ( OME)

what is it?
presentation? (7)

A

Glue-like” fluid in the middle ear (viscous mucin)

without evidence of acute infection due to chronic inflammatory response

  1. Cloudy tympanic membrane,
  2. visible effusion (air-fluid level, bubbles),
  3. decreased TM mobility
  4. TM may be retracted
  5. Discomfort, fullness, 6. hearing loss (and
  6. academic/ behavioural difficulties)
49
Q

When do we commonly see OME?

A

Precedes a nd follows AOM
After 2 weeks = 75%
After 1 month = 50%
After 3 months = 10-25%

50
Q

How does the TM look in Otits Media with Effusion? (5)

A
  1. Translucent
  2. grey or pink
  3. neutral of retracted
  4. reduced mobility but may respond to negative pressure on PO
  5. effusion present
51
Q

(5) Main OME pathogenesis

A 
Inflammatory cytokines 
(from environment, genetic polymorphism, biofilm, ET dysfunction, refluc)
  1. Mucin upregulation
  2. Viscous fluid in ME
  3. Impaired mucous clearance
  4. OME
52
Q

Why would reflux be a risk factor for OME?

A

Gi - acid into the oropharynx and middle ear and irritating the mucosa

53
Q

How does cilliary dysfunction affect OME?

cause?

A

It creates impaired mucous clearnace

Second hand smoke - risk factor

beat mucous to clear it.
They are columnar shaped.
with smoking there is dysfunction which can cause dyplastic changes and turn into squamous cells so they have deceased ability to clear mucous

54
Q

Main AOM pathogenesis (3)

A
  1. Viral URTI
  2. Ascending bacterial or viral infection via the eustachian tube
  3. AOM
55
Q

Why is the TM retracted in OME?

A

eustachian tube is not opening and closing like it is supposed to
its job is to regulate pressure

negative pressure accumulates if it’s closed

this creates a vacuum in the moddle ear

when it does open, it pulls pus from the nasopharynx into the middle ear

56
Q

Factors that influence a chronic Otitis Media (4)

A

1.Anatomic/ physiologic dysfunction

  • Immunosuppression
  • Cleft palate
2. Environmental factors ( can't change) 
Environmental factors
	Day care
	Smoke exposure
	Household income
	Season of birth
	Lack of breastfeeding
	Lower socioeconomic status
3. Host factors
Familial predisposition
Male
Caucasian
Age
Premature birth
Pacifier use
  1. Allergy
    - atopy
57
Q

Otitis media and hearing loss

types that cause hearing loss?

consequences?

A

Both AOM and OME can cause hearing loss

OME most common cause of hearing loss in children in developed world

Can impact language development, academic success, behaviour

If early, persistent and/or bilateral, may have negative impacts …

58
Q

Trauma to the TM

How?

feeling?

how long does it take to heal?

risks?

A

Perforation of the tympanic membrane due to:
Direct blow, blast injury, barotrauma, direct trauma to the TM (eg. foreign object)

Fullness, +/- tinnitus, +/- hearing loss, can feel better if it was ruptured due to AOM

commonly heals in a month

risks : continuous ruptures could cause scar tissue and permanent hearing loss

59
Q

Common Secondary Otalgia causes (4)

A

1 .Sinusitis (maxillary, ethmoid)
5th cranial nerve

  1. Dental or oral inflammation
  2. TMJ disorders
    65% experience otalgia
    Intrinsic joint disease or spasm of muscles
  3. Pharyngeal, laryngeal, supraglottic inflammation
    9th, 10th cranial nerves
60
Q

Insufflation

whats normal? abnormal?
how to test?

A

describes mobility of the TM

test via pneumotic otoscopy

positive pressure pushing TM in

neg pressure pulling TM out

Normal : moves in response to pressure

Abnormal : decreased movement

fluid/effusion likely

61
Q

T or F

OM is usually due to eustachian tube dysfunction?

A

true

62
Q

T or F

streptococcus pneumoniae, Haemophilus influenzae,
and Staph. aureus are the most common organisms isolated from middle ear fluid.
=

A

False :

streptococcus pneumoniae, Haemophilus influenzae,Moraxella catarrhalis

63
Q

T or F

Otitis media with effusion is defined as middle ear effusion with the presence of acute symptoms.

A

false

absence

64
Q

T or F
Antibiotics, decongestants, or nasal steroids hasten the
clearance of middle ear fluid and are recommended.

A

false

do not help

65
Q

T or F

AOM usually follows an URTI?

A

True

66
Q

Diagnosis criteria for AOM

AAP

A

Bulging TM

and
otorrhea (not cuased by OE)

or onset of ear pain or erythema

67
Q

What is the best treatment for a self limiting AOM infection?

A

viral

watchful waiting - inform caregiver about potential red flags (gets worse in 24-48 hours) , stiff neck ( meningitis) , high fever and to go to ER

Analgesics for pain management ( ibuprofen recommended)

68
Q

What is the best treatment for a bacterial AOM infection?

how do you know?

A

Severe signs or symptoms
temperature of 39C (fever)
bilateral under 2 years

69
Q

when are kids eligable for tympanostomy tubes?

risks?

A 
After recurrent (3+ in 6 mos) of AOM
bilateral

risk for long term tympanic membrane abnormalities and redued hearing

70
Q

T or F

The American Pediatrics Association recommends probiotics in infants to reduce the incidence of infections during the first year of life?

A

true! <3

71
Q

whats the biggest clue for AOM? (3)

A

bulging TM
cloudy membrane
immobile TM

72
Q

which 5 symptoms are less helpful in diagnosing AOM yet still may be present?

A

fever - many other diseases
redness ( slightly more helpful)

otalgia
otorrhea
irritability

73
Q

True or False

by age 1 year, 60% of all children have had at least 1 AOM? by 3 years, 80% of kids?

A

True

74
Q

What is a must for AOM diagnosis?

A

Effusion

75
Q

Common and non-specific signs of AOM

A 
fever
ear pain
ear pulling
irritability
cough
rhinitis
vomitting ( in smaller children)
76
Q

How to examine the tympannic membrane 6

A

evaluate the position, colour, landmarks, degree of tranluccency and mobility

77
Q

What size speclum do you use for otoscopy?

A

largest ear canal will accomodate so view is not limited

78
Q

Barotrauma

history physical findings
diagnostic studies

A

history of flying or diving
sensation of fullness
history of recent nasal conjestion

Retraction of bulging TM
perforation of TM
fluid in Canal
otaligia

tympanogram

79
Q

Trauma to the ear

history physical findings
diagnostic studies

A

histroy of blunt or penetrating trauma

perforated TM

radiograph/CT dictated by injury

80
Q

Cervical lymphadenitis

history physical findings
diagnostic studies

A

history of cervical lymph node swelling
pain in ear

enlarged, tender cervical lymph nodes
early onset AOM in children
common cause of referred ear pain

throat culture if indicated (assoc. with strep throat)
Monospot in adolescents if indicated

81
Q

Referred pain from Cervical nerves 2 and 3

why?

history physical findings
diagnostic studies

A

innervate skin and muscles of the neck, and ear
ear exam will be normal

Pan in skin and muscles of neck and ear canal

dermatome evaluation for cervical nerve involvement

no diagnostic studies

82
Q

Referred pain from CN

which ones?

A

CN 5, 7, 9, 10 (trigeminal, facial, glossopharyngeal, and vagus)

histroy depending on the CN involved

Test functions of CN 5,7,9,10 - ear exam is normal

Radiograph or CT if indicated

83
Q

TMJ disorder

what?

history (5)

physical findings (5)

A

Common cause of referred ear pain

more common in adults
50% dental problems
discomfort to severe pain
unilateral
pain worse in the morning (after waking up)
pe : NORMAL ear findings exam
jaw click
abnormal CN funcyion
malocclusion ( misalignment of the teeth)
bruxism (teeth grinding)
84
Q

Cholesteatoma

what is it?

history?

pE findings?

what to do?

A

cyst formation in the middle ear or mastoid. occurs from chronic negative middle ear presssure

History : hearing loss, perforated TM

pearly white lesion on or behind TM

immediate referral - live threatening if untreated b/c it will erode away medially to impinge intracranial structures

CLIN MED (5 decks)

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