ENT I: Outer Ear Disorders Flashcards
Pt 1 of the first ppt
What is pneumatic otoscopy used for?
Pneumatic insufflation used to evaluate TM mobility is described as normal, absent, decreased, or increased
Give an example of a condition that can decrease TM mobility
Effusion
1) Define cerumen impaction
2) What is it a common cause of?
3) Who is it most common in?
1) Accumulation of cerumen (aka, ear wax) causing bothersome symptoms and/or preventing needed assessment of ear canal
2) Common condition & common cause of hearing impairment
3) 1 in 10 children, 1 in 20 adults, 1 in 3 older adults
Define cerumen
Naturally occurring from epithelial cells in the external auditory canal (EAC)
What is the cause of cerumen impaction?
Disrupted/dysfunctional migratory pattern of epithelium
Give 6 examples of things that can cause disrupted/ dysfunctional migratory pattern of epithelium
1) Canal disease
2) Canal narrowing
3) Aging
4) Foreign objects
5) Inappropriate removal attempts
6) Overproduction
1) True or false: cerumen accumulation is usually asymptomatic
2) What are some symptoms of impaction?
3) How do you dx cerumen impaction?
4) What are two indications for removal?
5) When is removal not recommended?
1) True
2) Hearing loss, ear fullness, earache, itchiness, reflex cough, dizziness, and/or tinnitus
3) otoscopic exam (otoscopy)
4) Symptomatic patients & patients unable to express
symptoms
5) Not recommended for asymptomatic patients
What is the most common ENT procedure?
Cerumen removal
List potential removal methods for cerumen
1) Cerumenolytic agents
2) Irrigation
3) Manual
1) What patients are Cerumenolytic agents appropriate for to remove cerumen?
2) Where can it be done and for how long?
3) What are some examples of these agents?
4) What may you need to follow up with?
1) Patients without h/o ear infections, TM perforation, or otologic surgery
2) In clinic or at home (no more than 3-5 days)
3) Water, saline, mineral oil, hydrogen peroxide, docusate sodium, carbamide peroxide (Debrox; OTC drops)
4) Irrigation
1) Can irrigation be done alone?
2) What are the two tools used for irrigation?
3) What are some potential irrigants?
4) What is recommended for immunocompromised pts?
1) Yes; alone or with pre-treatment
2) Large catheter-tipped syringe or mechanical jet irrigator
3) Warm (body temp) irrigant: tap water, saline, or water + hydrogen peroxide
4) Post-irrigation acidification
1) What does manual cerumen removal require?
2) What are some examples of different manual tools?
3) What is not an appropriate removal method?
1) Requires adequate visualization
2) Curettes, spoons, forceps, cotton-tipped applicators, suction
3) Ear candling (aka, ear coning or thermal auricular therapy)
List potential complications for each of the 3 methods of cerumen removal
1) Cerumenolytics: allergic reactions, otitis externa, earache, transient hearing loss, dizziness
2) Irrigation: water retention, TM perforation, hearing loss, tinnitus, pain, vertigo
3) Manual: ear pain, bleeding, laceration, TM perforation
What should you recommend patients with h/o recurring symptomatic cerumen impaction (>1/year despite removal) and otherwise normal ears do?
1) Cotton ball dipped in mineral oil in EAC x 10-20 min. once weekly
2) Routine cleaning q6-12 mos. by health professional
3) No chronic use of cotton swabs or cerumenolytics
List 3 criteria for referral to otolaryngologist (seldom necessary
1) Hx of chronic cerumen impaction, perforated TM, or ear surgery
2) Purulence or necrotic tissue in ear canal
3) Persistence of otologic complaints after cerumen removal
1) What is Otitis Externa (aka “Swimmer’s ear”)?
2) How common is it? When does it most commonly occur?
3) What are 3 things that can induce it?
4) What is the most common cause?
1) Inflammation of EAC
2) ~10% lifetime occurrence; childhood predominant; more likely to occur in summer
3) Infectious, allergic, & dermatologic disease
4) Acute bacterial infection
1) What are the 3 most common bacteria to cause otitis externa?
2) What two fungi commonly cause otitis externa?
1) Pseudomonas aeruginosa, S. epidermidis, & S. aureus
2) Aspergillus, Candida
List 6 risk factors for otitis externa
1) Water/swimming
2) Mechanical trauma
3) Allergic contact dermatitis
4) Dermatologic conditions
5) Devices (hearing aids, ear buds, diving caps)
6) Prior radiation therapy
List 4 symptoms of otitis externa
Otalgia, pruritis, otorrhea, hearing loss
What 6 Hx questions should you ask for otitis externa?
1) Known TM perforations
2) Previous ear infections
3) Prior ear surgery or radiation
4) Recent ear instrumentation
5) Use of devices in ear canal
6) Water exposure
List the 5 signs of otitis externa during a PE
1) Erythema or signs of trauma to auricle or tragus
2) Tenderness with tragal pressure or auricle manipulation
3) Canal edema, canal erythema
4) May have purulent exudate (discharge), periauricular cellulitis, or TM erythema
5) Mobile TM with pneumatic insufflation
With otitis externa:
1) If air-fluid level in TM, what should you suspect?
2) What should you suspect if the TM is perforated?
1) Middle ear effusion from underlying otitis media
2) Middle ear conditions
Describe the 3 levels of severity of otitis externa based on H&P
1) Mild: minor discomfort, pruritis, minimal canal edema
2) Moderate: intermediate pain, pruritis, +/- partial canal occlusion
3) Severe: intense pain, complete canal occlusion; +/- fever, preauricular erythema, regional lymphadenopathy
1) How do you Dx otitis externa?
2) What is a typical presentation?
3) When should cultures be taken?
1) Clinical (based on H&P)
2) Rapid onset (~within 48 hrs in previous 3 wks)
3) Severe, recurrent, chronic, immunosuppressed, infections after ear surgery, no response to initial therapy
What are the 3 main components of treatment of otitis externa?
1) Cleaning EAC (aural toilet)
2) Treating inflammation & infection
3) Pain control (NSAIDs or acetaminophen)
What is a mainstay of otitis externa treatment? Describe how it’s used in mild and moderate cases
Topical therapy:
1) Mild: Topical acidifying agent + glucocorticoid (i.e., acetic acid + hydrocortisone TID-QID) x 7 days
2) Moderate: Topical antibiotic + glucocorticoid (i.e., Cipro HC BID, Cortisporin TID-QID) x 7 days
(tl;dr use drops)
1) How should you treat severe otitis externa?
2) What should you do for some patients?
1) Topical antibiotic + glucocorticoid (i.e., Cipro HC, Cortisporin)
2) Add wick placement & systemic antibiotics (if evidence of deep tissue infection)
What systemic antibiotics are used on wicks for less severe otitis externa patients? What about more severe?
1) Less severe: PO levofloxacin 500 mg daily x 7d
2) More severe: IV vancomycin + IV cefepime
1) What should you obtain for severe OE?
2) What should you do for immunocompromised OE pts?
1) Cultures of ear drainage
2) Same preferred antibiotics as with severe disease
1) What should you do regarding otitis externa follow-up?
2) What two things should you counsel the pt on?
1) Depends on severity & resolution; consider culture & ENT referral if no response
2) Protect ear while recovering & ear hygiene
1) How should a pt protect their ear when healing from otitis externa?
2) What should you tell them about ear hygiene?
1) Cotton ball while bathing
Refrain from water sports x 7-10 days
No hearing aids or earbuds until pain & discharge subside
2) EAC is self-cleaning; don’t insert fingers, towels, cotton swabs, or other foreign objects
-Drying EAC: hair dryer, fan, isopropyl alcohol/white vinegar
List 2 complications of otitis externa
Periauricular cellulitis & malignant external otitis (next)
1) What is Malignant (Necrotizing) External Otitis?
2) Who is it most common in?
3) What is the #1 cause?
1) Invasive infection of EAC & skull base (osteomyelitis)
2) Diabetics over age 60, HIV, immunocompromised
3) Pseudomonas aeruginosa is #1 cause
Malignant (Necrotizing) External Otitis:
1) What are its symptoms?
2) What should be cultured or biopsied?
3) What tests should be done?
4) What is treatment based on?
1) Deep otalgia (nocturnal), persistent & foul otorrhea, EAC granulation
2) Cultures of drainage & biopsy of granulation tissue
3) CT and/or MRI; bone scan
4) Severity (4 wks-6 months of PO or IV antibiotics)
1) Who are foreign bodies in the EAC most common in?
2) What ear is it most common in?
3) List some common FBs
1) Most common in children aged 6 & younger
2) More common in right ear (predominant handedness)
3) Beads, pebbles, tissue paper, small toys, popcorn kernels, & insects
What 3 groups of kids are foreign bodies in the EAC more common in?
1) Irritating conditions of the ear (i.e., cerumen impaction, otitis externa, otitis media)
2) Pica
3) ADHD
What are 5 common presentations of foreign bodies in EAC?
1) Caregiver concern (witnessed placement or seeing FB in EAC)
2) Incidental finding during routine otoscopy
3) Decreased hearing or ear pain
4) Purulent or bloody ear drainage (rare)
5) Chronic cough or hiccups (rare)
1) How are foreign bodies in the EAC examined?
2) How is it Dxd?
1) Otoscopy (also evaluate other ear & nostrils)
2) Visualization on otoscopy
1) What foreign bodies require urgent removal?
2) Which require removal within a few days?
3) Which should be referred to an otolaryngologist?
1) Button batteries, live insects, penetrating FBs
2) Glass or other sharp FB, spherical or other FB wedged in medial EAC, & FB against TM
3) All of the above
1) What non-specialists can remove FBs in the EAC?
2) What is important to do during removal?
1) Emergency department or primary care office
2) Ensure adequate restraint
What are some commonly available instruments to remove foreign bodies from EAC?
1) Irrigation setup
2) Headlight
3) Otoscope
4) Alligator or Bayonet forceps
5) Plastic or metal cerumen curette
1) Who is irrigation of ear for FB removal contraindicated in?
2) How is it done?
3) What solution is used?
1) T-tubes, perforated TM, vegetable matter, button batteries
2) 20-50 mL syringe of irrigation solution at body temp (tap water, sterile water or NS) via plastic butterfly needle tubing or 14-16 g plastic IV catheter
3) Mineral oil or 1% lidocaine
What are the two main techniques for FB removal?
1) Irrigation
2) Instrumentation under direct visualization
