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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
Necrotizing Otitis Externa (OE) what? who is at risk? typical presentation? organism?
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
26
what is otorrhea?
dischrage from the ear
27
Which condition may cause facial nerve palsy and possibly ear pain
Necrotizing otitis externa red flag - emergent
28
Diffuse acute otitis externa presentation? (6) organism?
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
29
Diffuse acute otitis externa general ( 1 sentence)
titis externa (OE) is an inflammation or infection of the external auditory canal (EAC), the auricle, or both
30
Diffuse acute otitis externa associated with? who?
Associated with exposure to moisture or trauma Highest incidence in 7-12 year olds, more common in summer months can affect anyone
31
Diagnostic considerations for AOE (3)
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
32
If I have a furuncle in my ear canal ( external) what do I have?
A. Otitis Externa due to a bacterial infection ( usually) s, aureus
33
If my ear canal is edematous but not eryathemaous what might i have?
Acute Otitis Externa may not be able to see redness due to debris
34
Parts of the tympannic membrane and hour on clock on right ear (10)
``` 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
how to describe a healthy tympannic membrane ?
pearly grey
36
Acute Otitis Medica (AOM) clinical presentation
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
AOM tympannic membrane colour shape mobility other
Opaque, red, yellow, or cloudy bulging reduced mobility may respond to positive pressure with pneumatic otoscopy effusion present
38
Why can't you see the cone of light in AOM?
B/c the TM is bulging and it does not reflect the light in the same way
39
I have severe pain, very red and very swollen TM, I may have pus - what do I have?
AOM may be bacterial - should be treated with Abx
40
When does AOM show up? dangerous/risk?
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
Most significant LRs for AOM (3)
Bulging tympannic membrane cloudy tympannic membrane impaired mobility of TM
42
A child is rubbing their ear in your office. what could they have? what are we less concerned about?
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
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?
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
AOM sequelae and complications
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
Supprative complications with AOM presentation and TX
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
Mastoiditis
rare - Post-auricular swelling, mastoid tenderness, obliteration of postauricular fold need Abx mastoid process mushy and soft
47
when do we find Retracted TM?
typically in OME
48
Otits Media with Effusion ( OME) what is it? presentation? (7)
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 7. academic/ behavioural difficulties)
49
When do we commonly see OME?
Precedes a nd follows AOM After 2 weeks = 75% After 1 month = 50% After 3 months = 10-25%
50
How does the TM look in Otits Media with Effusion? (5)
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
(5) Main OME pathogenesis
``` Inflammatory cytokines (from environment, genetic polymorphism, biofilm, ET dysfunction, refluc) ``` 2. Mucin upregulation 3. Viscous fluid in ME 4. Impaired mucous clearance 5. OME
52
Why would reflux be a risk factor for OME?
Gi - acid into the oropharynx and middle ear and irritating the mucosa
53
How does cilliary dysfunction affect OME? cause?
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
Main AOM pathogenesis (3)
1. Viral URTI 2. Ascending bacterial or viral infection via the eustachian tube 3. AOM
55
Why is the TM retracted in OME?
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
Factors that influence a chronic Otitis Media (4)
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 ``` 4. Allergy - atopy
57
Otitis media and hearing loss types that cause hearing loss? consequences?
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
Trauma to the TM How? feeling? how long does it take to heal? risks?
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
Common Secondary Otalgia causes (4)
1 .Sinusitis (maxillary, ethmoid) 5th cranial nerve 2. Dental or oral inflammation 3. TMJ disorders 65% experience otalgia Intrinsic joint disease or spasm of muscles 4. Pharyngeal, laryngeal, supraglottic inflammation 9th, 10th cranial nerves
60
Insufflation whats normal? abnormal? how to test?
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
T or F OM is usually due to eustachian tube dysfunction?
true
62
T or F streptococcus pneumoniae, Haemophilus influenzae, and Staph. aureus are the most common organisms isolated from middle ear fluid. =
False : | streptococcus pneumoniae, Haemophilus influenzae,Moraxella catarrhalis
63
T or F Otitis media with effusion is defined as middle ear effusion with the presence of acute symptoms.
false absence
64
T or F Antibiotics, decongestants, or nasal steroids hasten the clearance of middle ear fluid and are recommended.
false do not help
65
T or F AOM usually follows an URTI?
True
66
Diagnosis criteria for AOM AAP
Bulging TM and otorrhea (not cuased by OE) or onset of ear pain or erythema
67
What is the best treatment for a self limiting AOM infection?
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
What is the best treatment for a bacterial AOM infection? how do you know?
Severe signs or symptoms temperature of 39C (fever) bilateral under 2 years
69
when are kids eligable for tympanostomy tubes? risks?
``` After recurrent (3+ in 6 mos) of AOM bilateral ``` risk for long term tympanic membrane abnormalities and redued hearing
70
T or F The American Pediatrics Association recommends probiotics in infants to reduce the incidence of infections during the first year of life?
true! <3
71
whats the biggest clue for AOM? (3)
bulging TM cloudy membrane immobile TM
72
which 5 symptoms are less helpful in diagnosing AOM yet still may be present?
fever - many other diseases redness ( slightly more helpful) otalgia otorrhea irritability
73
True or False by age 1 year, 60% of all children have had at least 1 AOM? by 3 years, 80% of kids?
True
74
What is a must for AOM diagnosis?
Effusion
75
Common and non-specific signs of AOM
``` fever ear pain ear pulling irritability cough rhinitis vomitting ( in smaller children) ```
76
How to examine the tympannic membrane 6
evaluate the position, colour, landmarks, degree of tranluccency and mobility
77
What size speclum do you use for otoscopy?
largest ear canal will accomodate so view is not limited
78
Barotrauma history physical findings diagnostic studies
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
Trauma to the ear history physical findings diagnostic studies
histroy of blunt or penetrating trauma perforated TM radiograph/CT dictated by injury
80
Cervical lymphadenitis history physical findings diagnostic studies
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
Referred pain from Cervical nerves 2 and 3 why? history physical findings diagnostic studies
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
Referred pain from CN which ones?
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
TMJ disorder what? history (5) physical findings (5)
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
Cholesteatoma what is it? history? pE findings? what to do?
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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