EENT #5 (Ears) Flashcards
What are some risk factors for otitis externa?
- Water immersion (swimmer’s ear)
- Local mechanical trauma (use of Q tips)
- Age 7-12 years
- Aberrant ear wax (too much or too little)
MC bacterial etiology of otitis externa?
Pseudomonas aeruginosa
Other causes of otitis externa
- Staph A
- Staph Epidermidis
- GABHS
- Aspergillus
Symptoms of otitis externa
- Ear pain
- Pruritus in ear canal (may have recent activity of swimming)
- Auricular discharge
- Ear pressure/fullness
- Hearing loss
- Pain on traction of canal or tragus
- Purulent auricular discharge
How do you diagnose otitis externa?
Otoscopy: edema of external auditory canal with erythema, debris, and discharge
How do you manage otitis externa?
- Protect ear against moisture (isopropyl alcohol and acetic acid)
- Removal of debris or cerumen
- Topical ABX: Ciprofloxacin-Dexamethasone, Ofloxacin
- -Aminoglycoside combination: Neomycin/Polymyxin B/Hydrocortisone
Why would you NOT use aminoglycosides for topical antibiotics for otitis externa if TM perforation is suspected?
They are ototoxic
What is malignant (necrotizing) otitis externa?
Invasive infection of external auditory canal and skull base
–Complication of acute otitis externa
MC etiology of malignant otitis externa
Pseudomonas Aeruginosa
Risk factors for malignant otitis externa
- Immunocompromised (Elderly diabetics MC)
- High dose glucocorticoid therapy
- Chemotherapy
- Advanced HIV
Symptoms of malignant otitis externa
- Severe auricular pain
- Otorrhea
- Cranial nerve palsies (CNVII)
- May radiate to TMJ pain with chewing
- Severe auricular pain with movement of tragus or ear canal
How do you initially diagnose malignant otitis externa?
- Otoscopy: edema or external auditory canal, discharge, erythema
- -Granulation tissue at bony cartilaginous junction of ear canal floor
- -Frank necrosis of the ear canal skin
What are the diagnostics that A) confirm malignant otitis externa and B) is the definitive diagnostic?
Confirm: CT or MRI
Biopsy is definitive and most accurate
How do you manage malignant otitis externa?
-Admission + IV ABX (IV Ciprofloxacin is first line)
Mastoiditis, an infection of ____________, is largely a disease of ________
Mastoid air cells of the temporal bone
Childhood (especially under 2 years old)
Symptoms of mastoiditis
- Usually a complication of acute otitis media
- -Otalgia, Fever, bulging and erythematous TM
- -Mastoid (post auricular) tenderness, edema, erythema
- -Protrusion of auricle
- -Narrowed auditory canal
What is the first-line diagnostic test for mastoiditis?
CT Scan with contrast
How do you manage a patient with mastoiditis?
- IV ABX + middle ear or mastoid drainage (myringotomy) with or without tympanovstomy tube placement
- Tympanocentesis can be performed to get cultures
IV Vanco + Ceftazidime, Cefepime, or Piperacillin-Tazobactam
What ABX are best used for mastoiditis?
-IV Vanco + Ceftazidime or Cefepime or Piperacillin-Tazobactam
If the mastoiditis is refractory or complicated, what treatment should be done?
Mastoidectomy
What is chronic otitis media?
Recurrent or persistent infection of the middle ear and/or mastoid cell system in the presence of TM perforation > 6 weeks
MC etiology of chronic otitis media
Pseudomonas Aeruginosa
True or False: Chronic otitis media can become worse after a URI or after water enters the ear?
True
Symptoms of chronic otitis media
- Perforated TM membrane + persistent or recurrent purulent otorrhea (painless)
- Conductive hearing loss
- Ear fullness
How do you manage a patient with chronic otitis media?
- removal of infected debris + Topical ABX drops (Cipro or Ofloxacin)
- Avoid water, moisture, and topical aminoglycosides if TM rupture
Risk factors for Acute otitis media
Age 6-18 months Day Care pacifier or bottle use Second hand smoke Not being breastfed
4 MC organisms seen in acute otitis media
A…SMH
Strep Pneumoniae (MC)
H. Influenzae
M. Catarrhalis
Group A Strep
What is the pathophysiology of acute otitis media (AOM)
Most commonly preceded by viral URI
Leading to blockage of Eustachian tube
Symptoms of AOM
- Fever
- Otalgia
- Ear tugging in infants
- Conductive hearing loss
However, if the TM ruptures, what symptoms would you expect?
-Rapid relief of pain + Otorrhea (usually heals in 1-2 days)
What is seen on physical exam of a patient with AOM?
- Bulging and erythematous TM with effusion
- Loss of landmarks
- Decreased TM mobility (MOST SENSITIVE FINDING)
Although AOM is a clinical diagnosis, what can be done?
Tympanocentesis for culture is definitive
Management for AOM
- Children over 2 receive ABX
- -Amoxicillin is first line
- -Second line: Amoxicillin-Clavulanic acid, Cefuroxime, Cefdinir, Cefpodoxime
If the child has a PCN allergy, what medications are options for AOM
Azithromycin, Clarithromycin, Erythromycin-Sulfisoxazole, Trimethoprim-Sulfamethoxazole
If the AOM is severe or recurrent, what should be done?
Myringotomy (surgical drainage) with tympanostomy tube insertion
In children with recurrent otitis media, they may need _________ and _______
Iron deficiency workup and CT scan
What is serous otitis media with effusion?
Middle ear fluid + no signs or symptoms of acute inflammation (no fever, no pain, no erythema, no bulging of TM)
What is seen on otoscopy of a patient with serous otitis media with effusion?
Effusion with TM that is retracted or flat
Management for serous otitis media with effusion
Observation in most cases (spontaneously resolves)
Symptoms of eustachian tube dysfunction
- ear fullness or pressure
- popping of the ears
- underwater feeling
- tinnitus
- conductive hearing loss that fluctuates
Management for eustachian tube dysfunction
- Treat underlying cause is the mainstay of treatment
- Autoinsufflation (swallowing, yawning, blowing against slightly pinched nostril)
- Decongestants for congestive symptoms
What is barotrauma?
Damage to TM can occur with sudden pressure changes (flying, diving, hyperbaric oxygen, decompression)
Symptoms of barotrauma
-Ear pain, fullness, hearing loss that persists after etiologic event
What is seen on physical exam of a patient that has undergone barotrauma?
May have bloody auricular discharge if traumatic
TM visualization may reveal petechiae or rupture
How do you manage a patient with barotrauma?
- Avoidance is best treatment (do not fly with a cold)
- Autoinsufflation: yawning, swallowing, chewing gum
cerumen impaction may lead to _______ and _____
Conductive hearing loss and ear fullness
Conductive hearing loss pattern with cerumen impaction
Lateralization to affected ear on Weber testing
-Bone conduction > air conduction
What is used to soften the cerumen?
Hydrogen Peroxide or Carbamide Peroxide
If softening the cerumen doesn’t work what other treatment can be done for cerumen impaction?
-Aural toilet: irrigation, curette removal of cerumen, suction
MCC of sensorineural hearing loss
Presbycusis (normal gradual aging hearing loss)
MCC of conductive hearing loss
Cerumen impaction
A weber hearing test is assessed with a tuning fork placed at the top of the head. Normal results are no lateralization. What occurs with conductive hearing loss? With sensorineural hearing loss?
Conductive: lateralizes to affected ear
Sensorineural: lateralizes to normal ear
A Rinne hearing test is assessed with a tuning fork placed on the mastoid by the ear. Normal results are air conduction > bone conduction. However, what occurs in conductive hearing loss? In sensorineural hearing loss?
Conductive: BC > AC (negative)
Sensorineural: Normal AC > BC
