Ear presentations

Question 1

What are the key points of a focused ear history?

Answer 1

Preceding events, onset and progression
Unilateral /bilateral

Key symptoms: hearing loss, tinnitus, vertigo/balance, pain, discharge, speech/language in children

Specific past medical history: acoustic trauma, family history, previous surgery, Diabetes, immunocompromising conditions
Treatment history: ototoxics, OTC drops, prescribed meds, self treatment (cotton buds, ears ringing/washing)

Question 2

Name some ototoxics

Answer 2

-Aminoglycoside antibiotics
Eg. Gentamycin
-Other antibiotics
Eg. Clindamycin, erythromycin, ciprofloxacin
-Diuretics (loop)
Eg. Furosemide, bumetanide
-Cytotoxcis
Eg. Carboplatin, cisplatin, methotrexate
-NSAID’s
Eg. Aspirin
-Antimalarials
Eg. Chloroquine, quinine

Question 3

What is acute otitis media?

Answer 3

Infection involving the middle ear space, common after a respiratory tractinfection

Presentation:
Otalgia, decreased hearing
Babies – hold/rub their ear, crying, poor feeding, irritability

Examination: bulging, discoloured (red, yellow, cloudy) tympanic membrane

Question 4

What is the management for otitis media?

Answer 4

Paracetamol/ibuprofen for pain + fever, most do not need abx instead reassure usually lasts 3 days (but can last up to 1 week) and safety net to seek help if symptoms worsen rapidly or they become systemically unwell

Abx indicated for:
1) systemically unwell,
2) high risk complications,
3) signs of a more serious illness
Consider abx in:
1) otorrhoea,
2) <2 yo with bilateral infection

1st line: 5-7 PO amox (if pen allergic clarithromycin/erythromycin).
2nd line: PO co-amox if worsening symptoms

Question 5

When do you admit somebody with acute otitis media?

Answer 5

Admit immediately:
-Severe systemic infection
-Acute complications – meningitis, mastoiditis, FN palsy
-Children <3 months with a temp of >38 degrees

Consider admitting: Children 3-6 months with a temp of >39 degrees

Question 6

What is otitis externa?

Answer 6

Inflammation of the external ear canal, usually bacterial
- pseudomonasaeruginosa or staph aureus

Risk factors: swimming (swimmers ear), diabetes, immunocompromised

Presentation: rapid onset ear pain + tenderness (increased by jaw movement), itching, aural fulness, hearing loss

Examination: tenderness over pinna, erythematous swollen ear canal, otorrhea

Necrotising/malignant otitis externa in those with diabetes – ENT referral

Question 7

What is the management for otitis externa?

Answer 7

1. Self care: clean + dry ear (avoid swimming, ear plugs when showering)
2. OTC acetic acid spray max 7 days
3. Analgesia
4. Abx?
   a. Consider a topical abx ciprofloxacin) +/- steroid for 7-14 days – otomize spray
   b. PO abx in severe/resistant cases/spread beyond external ear canal ordiabetic/immunocompromised – 1st line is ciprofloxacin

Question 8

What is Cholesteatoma?

Answer 8

Collection of keratinizing squamous epithelium and keratin in the middle ear
Presentation: persistent foul smelling discharge from the ear, conductive hearing loss

Examination: ear discharge, crust/keratin in the upper part of the tympanic membrane

Requires referral to ENT as expansion can destroy local structures

Question 9

Why does it matter whether hearing loss is unilateral or bilateral?

Answer 9

Actual hearing loss is usually bilateral

Question 10

What is Otitis media with effusion (glue ear)?

Answer 10

Not an infection, but can proceed one
- Fluid collects in the middle ear causing conductive hearing loss and discharge
- more common in children
- If prolonged, it can lead to communication issues and membrane damage

Symptoms: hearing loss (conductive), aural pressure with popping sounds, speech/language issues

Examination: dull tympanic membrane with loss of light reflex, bubbles

Question 11

What is the management for otitis media with effusion?

Answer 11

Management: Active surveillance – 50% resolve within 3 months

No resolution in 3 months ?myringotomy and grommet insertion

Unilateral OME in an adult? Secondary to blockage of eustachian tube (cancer)

Question 12

What is a Vestibular schwannoma (acoustic neuroma)?

Answer 12

A rare tumours of the vestibulocochlear (8th) nerve ,arising from the Schwann cells

Symptoms arise from compression of nerves: unilateral sensorineural deafness (90%), vertigo, tinnitus, facial numbness/weakness, headache

Managed through radiation/surgery or active observation if little growth

Question 13

What is Sudden sensorineural hearing loss?

Answer 13

-Medical emergency-

Unclear aetiology
Symptoms: unilateral hearing loss (within 3 days), otalgia, tinnitus, balance disturbance

Examination: typically no abnormalities

Investigations: audiometry, MRI IAM (exclude vestibular schwannoma)

Urgent ENT discussion, short course high dose steroids (+ PPI)

Question 14

What are some red flags ear related symptoms?

Answer 14

-Systemically unwell
-Persistent symptoms
-Persistent discharge + hearing loss
-Sudden onset hearing loss
-Unilateral otitis media with effusion in adult

Question 15

How do you perform an ear examination?

Answer 15

1. Inspect the outer ear for deformity, skin changes and deformity
2. Palpate the pinna and lymph nodes
3. Look for discharge, foreign bodies, and skin changes
4. Look inside using an otoscope