Ear Symptoms Flashcards
Focused history for ear related pain
Preceding events, onset + progression
Unilateral/bilateral
Key Sx - hearing loss, tinnitus, vertigo/balance, pain, discharge, speech/language in children
Specific PMH - acoustic trauma, FH, previous surgery, DM, immunocompromising conditions
Treatment history: ototoxics, OTC drops, prescribed meds, self treatment (cotton buds, ear syringing/washing)
Ototoxics
Aminoglycoside ABs
Cancer chemotherapy
Temporary damage - aspirin, quinine, loop diuretics
Normal ear drum
Acute otitis media
Acute otitis media (AOM) refers to inflammation of the middle ear with effusion and clinical features of a middle ear infection.
Persistent and recurrent acute otitis media
Persistent AOM: patients with a single episode of AOM who re-present with persistent or worsening symptoms.
Recurrent AOM: three or more distinct episodes of AOM in the past six months, or four or more in the past twelve months, one of which was in the last six months.
Aetiology of acute otitis media
Examination in acute otitis media
Bulging, discoloured tympanic membrane
How do we diagnose acute otitis media?
Otoscope
Symptoms of otitis media in neonates
Irritability
Difficulty feeding
Fever
Symptoms of otitis media in young children
Holding or tugging ear
Irritability
Fever
Symptoms of otitis media in older children/adults
Otalgia (Ear pain)
Hearing loss
Fever
Otoscopy
Otoscopy is key to identifying signs of AOM. It allows for visualisation of the tympanic membrane, behind which the middle ear lies. The normal tympanic membrane has a slight translucency with a colour sometimes described as pearly-grey. The malleus (the first of the three bones of the middle ear) is clearly visible.
Acute otitis media - changes seen in otoscopy
Red, yellow or cloudy tympanic membrane
Bulging tympanic membrane or perforated membrane
Air-fluid level behind the tympanic membrane
General advice in acute otitis media
Generally self-limiting, usually 3days to 1 week
Give analgesia and antipyretics
Safety netting advice - systemically unwell/symptoms worsening - antibiotics may be necessary
Delayed/backup prescription advise in acute otitis media
When giving a delayed or backup prescription advise using if symptoms don’t improve after 3 days or if they worsen (rapidly or significantly).
Antibiotic - first-line in otitis media
Where antibiotics are indicated, amoxicillin tends to be preferred first-line (in absence of penicillin allergies) as a 5-7 day course, with alternatives including clarithromycin and erythromycin. Co-amoxiclav (combination of amoxicillin and clavulanic acid) is used second line (again in the absence of penicillin allergies) in treatment-resistant cases.
Persistent acute otitis media
Patients with persisting (or worsening) symptoms should be reviewed. Repeat a complete history and re-examine. Consider other potential causes of similar symptoms such as otitis media with effusion (‘glue ear’). In general, management follows the outline described above.
Some patients may develop chronic suppurative otitis media (CSOM) as a complication of their AOM. Those with persistent symptoms of AOM should be referred to ENT, particularly if lasting longer than 6 weeks or there is persistent hearing loss.
Recurrent acute otitis media
ENT referral for specialist management should be considered for those with recurrent AOM. This is especially important if there is a craniofacial abnormality, an adult patient, or debilitating/complicated AOM.
If nasopharyngeal cancer is suspected an urgent referral to ENT is required. In particular, NICE CKS advises high suspicion if:
Persistent symptoms and signs of otitis media with effusion in between episodes (for example, conductive hearing loss) due to obstruction of the eustachian tube orifice.
Persistent cervical lymphadenopathy (usually in the upper levels of the neck).
Epistaxis and nasal obstruction.
Complications of acute otitis media
Persistent AOM
Recurrent AOM
Perforation of tympanic membrane
Hearing loss
Cholesteatoma
A cholesteatoma is an abnormal sac of keratinizing squamous epithelium and accumulation of keratin within the middle ear or mastoid air cell spaces.
Persistent foul smelling discharge, conductive hearing loss
Ear discharge on exam in the upper part of the tympanic membrane
ENT referral necessary
Otitis media with effusion (glue ear)
On exam, dull tympanic membrane with loss of light reflex, bubbles may be seen
Glue ear tends to affect children under the age of seven, most commonly between the ages of two and five. Some children develop glue ear after a cold, so it can be more common during the winter months. It’s also more common in boys than girls.
Adults with unilateral glue ear - red flag
Otitis media with effusion (glue ear) - management
Active surveillance - 50% resolve within 3 months
No resolution. Myringotomy and grommet insertion
Vestibular Schwannoma
Rare tumour
Benign
8th cranial nerve
Myringotomy - what is this procedure?
A myringotomy is a procedure to create a hole in the ear drum to allow fluid that is trapped in the middle ear to drain out. The fluid may be blood, pus and/or water. In many cases, a small tube is inserted into the hole in the ear drum to help maintain drainage.
Sudden sensorineural hearing loss
Medical emergency
Unclear aetiology
Symptoms 0 unilateral hearing loss, otalgia, tinnitus, balance disturbance
Exam - typically nothing shown
Investigations, audiometer, MRI/IAM - exclude vestibular schwannoma
Urgent ENT - high dose short course steroids
Ear exam
External inspection (pinna, pre-auricular region, mastoid)
Palpate around the ear
Otoscopy - better ear first, gently retract pinna, right hand for R ear
Assess - external auditory canal, ear wax, erythema, discharge
Tympanic membrane - colour, shape, light reflex, perforation, scarring
