Ear pain Flashcards
What is the most common cause of ear pain in kids?
AOM
Other DDx Otitis externa FB Dental caries or abscess Pharyngitis Cervical lymphadenitis
What are the diagnostic criteria for AOM?
1) Recent, usually abrupt onset of signs and symptoms of middle ear infection (pain, irritability, fever, otorrhea)
2) Presence of middle ear effusion
3) Signs of middle ear inflammation (ear pain, bulging or redness of TM with impaired motility)
Other signs of AOM:
- Hearing loss
- Vertigo
- Tinnitus
- Postauricular swelling
- Facial paralysis
- Conjunctivitis
What bug causes otitis-conjunctivitis syndrome?
H. flu
What are the most common bacterial pathogens that cause AOM?
Strep pneumonia
Nontypable H flu
Moraxella catarrhalis
Occasionally:
- Strep pyogenes
- Staph Aureus
- Mycoplasma
- Gram neg bacilli
Describe the management of AOM
If patient < 6 months - TREAT
If > 6 months can:
- Watch and wait for 1st 48h of Sx
- Manage with analgesia - usually q6h Advil and Tylenol as breakthrough
- If Sx > 48-72h or no relief from above - Tx with Abx
1st line: Amoxicillin 40-60 mg/kg/day div TID
OR 80-90 mg/kg/day div BID
2nd line: Amox-Clav
5 days for > 2 years
10 days for < 2 years
If Type 1 penicillin allergy - Azithromycin, Clarithro, Septra
If not Type 1 penicillin allergy - Cefuroxime, Clinda
If noncompliant or not tolerating PO:
Ceftriaxone 50mg/kg IV x 1
Can get a second dose in 48h
What is otitis media with effusion?
Collection of fluid in the middle ear without signs and symptoms of acute infection
Bulging TM, limited or absent motility with pneumatic otoscopy, A/F level behind the TM, or otorrhea
Tx - Abx x 10 days with anti-Beta-lactamase activity
No resolution - refer to ENT for tubes
What bugs has vaccines reduced the incidence of in terms of AOM?
Strep pneumo (pneumococcal conjugate) Influenza (influenza vaccine)
How many months of prophylaxis is needed to prevent AOM?
9 months to prevent a single episode of AOM
Not practical - not recommended
Indications for tubes
Associated hearing loss
Risk of developmental loss or failure to progress
Name the complications of AOM
Perforation of the TM Cholesteatoma Adhesive OM Tympanosclerosis Mastoiditis Petrositis Labrynthitis Meningitis Facial paralysis Suppurative complications of the brain
What is bullous myringitis?
Infection of the TM with intensely painful bulla formation on the surface
Dx by otoscopy
Pathogen - usually viral or Strep pneumoniae
Same Tx as regular AOM
What is otitis externa?
Inflammatory process affecting the external auditory canal
Often present with pain after a few days of external pruritis
Common in the summer
Pain when pushing on the tragus or traction of the pinna or moving the jaw from side to side
What are the RF for otitis externa?
Summer months
Pool exposure
Obstructive cerumen
Long tortuous canal
Loss of acidic environment due to inadequate cerumen lavage
Exposure to an alkaline substance
Interruption of the epithelial lining due to trauma or dermatitis
What are the most caustive organisms for otitis externa?
Pseudomonas
Staph
Strep
Proteus with pseudomonas
Treatment for otitis externa
Avoidance of swimming
Pain control
Ear drops from steroid/Abx combo - Ciprodex
If severe edema of the canal - can place a wick
If severe infection - may need PO Abx
What is malignant otitis externa?
Severe form of otitis externa that is not responsive to conventional therapy
Caused by Pseudomonas
Involves the bone and marrow of the skull base - causing osteomyelitis
Complications: chondritis, facial paralysis, stenosis of the canal and permanent hearing loss
More common in diabetes mellitus or immunocompromised patients
Need CT or nuclear imaging to help Dx
Tx - IV Abx and removal of granulation tissue
What is bruising to the internal surface of the pinna or hemotympanum concerning for?
Child abuse
Only results from direct blow to the ear
What types of infection can result from ear piercing, bugs and Tx
Cellulitis or perichondritis
Bugs: Staph and Pseudomonas
Tx - remove the piercing, I&D abscess, IV antibiotics if cartilage is infected
What are the features of mastoiditis
Fever Ear pain Red swollen ear Protruding from the side of the head Erythematous and tender posterior auricular area Must have erythematous TM
Can be confused with otitis externa - TM would be normal in this case
CT can help confirm Dx
What is petrositis?
Infection of the petrous part of the temporal bone
What is the triad for Gradenigo syndrome?
Deep facial pain
Otitis media
Ipsilateral abducens nerve paralysis (CN6) - cannot perform lateral gaze
How is mastoiditis treated?
Admit
IV Abx - cover Staph, Strep, H influenza
(Cefotaxime, Clindamycin, Vancomycin)
Complicated infection or abscess may need mastoidectomy
What are the potential complications of mastoiditis?
Intratemporal OR Intracranial
INTRATEMPORAL
Facial paralysis
Labyrinthitis
Petrositis
INTRACRANIAL
Meningitis
Lateral sinus thrombosis
Epidural, subdural or brain abscess
Methods for removing a FB from the external canal
Alligator forceps Curettes Right-angle hooks Baron suction devices Elephant ear irrigation with warm water Dermabond on stick Fogerty catheter
What is the most worrisome FB in the external canal?
Hearing aid battery
Call ENT
How to settle down an insect in the ear?
Pour immersion oil, mineral oil, 1% or 2% lidocaine or viscous lidocaine in the ear
This will paralyze the bug and relieve the pain
Then remove the bug with a curette or flushing after
What is middle ear barotrauma?
Injury to the TM from a sudden change in pressure due to diving, flying or blast injuries
Can cause severe ear pain
TM appears swollen and blue
Refer to ENT if patient has dizziness or hearing loss - worry about a perilymphatic fistula
Name causes of non-otogenic otalgia
Otalgia can be referred pain from distant sites secondary to inflammatory processes, tumors or trauma
Dental issues (from CN 5,6,9,10 and cervical nerves C2/C3) These nerves supply the nasal sinus area, oral cavity and teeth, oropharynx, hypopharynx, larynx, and upper esophagus
TMJ Joint dysfunction
Can also be psychogenic
Name the nerve that carries the sensation of non-otogenic otalgia
CN5
- Disturbances in the oral cavity including stomatitis, gingivitis, lymphadenitis, parotiditis, trauma, tongue infections, dental conditions (eruption, impaction, trauma, caries, infection, abscess)
CN6
- Bell’s palsy, herpes zoster, tumors
CN9
- Tonsillitis, retropharyngeal abscess, adenotonsillectomy, nasopharyngeal or oropharyngeal tumors
CN10
- lesions of the base of the tongue, trachea, larynx, and esophagus
- GERD
UPPER CERVICAL NERVES (C2/C3)
- Cspine injuries, arthritis, disc disease
What is Ramsay-Hunt Syndrome?
Herpes zoster otitis OR Viral polycranial neuropathy affecting the ear
What are the Sx of Ramsay-Hunt Syndrome?
Severe otalgia Facial palsy Vesicles on the pinna, external auditory canal, and TM All CN can be affected Hearing loss Vertigo N/V Dizziness
How do you Tx Ramsay-Hunt Syndrome?
Acyclovir PO
Systemic steroids
Analgesia
How to confirm that TMJ dysfunction is the cause of referred otalgia
Carefully palpate the TMJ externally by placing the fingers just anterior to the tragus and having the patient open and close the mouth
Positive test - patient reports otalgia during attempted occlusion
Pain can be caused by nerve irritation, muscle spasm, or degenerative changes in the joint
RF
- clenching teeth
- bruxism
- gum chewing
- malocclusion
Tx
- heat therapy
- soft diet
- analgesia
- physiotherapy
- oclusal splints
- rarely surgery
