ENT - Otorrhoea Flashcards
What does otorrhoea (discharing ear) often indicate?
Infection or inflammation of the
middle ear (otitis media) or outer ear (otitis externa)
What symptoms commonly present with Otorrhoea?
- Ear pain (otalgia)
- Hearing loss
- Tinnitus
- Sometimes vestibular disturbance
What are the common features of otitis externa?
Features:
- Ear pain (otalgia)
- Otorrhoea (ear discharge)
- Itch
- Occasional pre / post auricular lymph node swelling
On otoscope:
- Erythema
- Swollen (ear canal is narrower than normal)
- Tender
What are the common causes otitis externa?
-
Infection:
- bacterial (staph. aureus, pseudomonas aeruginosa)
- fungal (aspergillus niger - commonest ear fungal infection)
- rarer than bacterial
- symptoms = more itching than otalgia, otorrohea is rare
- Seborrhoeic dermatitis (skin inflammation in areas of sebaceous glands)
- Contact dermatitis (allergic and irritant)
How is otitis externa managed?
1st line:
- SWAB FIRST!!
-
topical Abx OR combined topical Abx + corticosteroid
- e.g. Sofradex (framycetin, dexamethasone and gramicidin)
- some believe if tympanic membrane is perforated aminoglycosides (e.g. gentamicin, streptomycin, neomycin) are to be avoided due to otoxticity concerns
- keep ear dry
- remove excessive canal debris
- ear wick (cylindrical sponge) - if canal is swollen extensively, aids administration of ear drops
- oral analgesia - otitis externa can be very painful
2nd line:
- oral Abx:
- flucloxacillin - if no penicillin allergy
- clarithromycin - if penicillin allergy
- ciprofloxacin - if pseudomonas suspected
- consider antifungal agent
- consider contact dermatitis 2ndary to neomycin
Name 3 risk factors for developing otitis externa?
- Allowing water to enter ear
- Instrumentation of the ear canal e.g. cotton buds
- Skin conditions i.e. eczema or psoriasis
What is perichondritis?
Inflammation of the perichondrium (layer of connective tissue surrounding cartilage) - commonly used to refer to auricular perichondritis
- Infection of the pinna
- Often due to trauma, surgical wound or spread from local infections
- Left untreated –> can cause pinna necrosis + deformity
What is malignant otitis externa?
Rare form of otitis externa seen in immunocompromised patients. Infection begins in soft tissue of external auditory meatus –> progresses to bony ear canal –> progresses to temporal bone osteomyelitis
- 90% cases found in diabetics
- Pseudomonas aeruginosa = commonest organism
- Diagnosis = CT scan
- Management:
- 6 weeks IV Abx that cover pseudomonal infections e.g. ciprofloxacin
- Regular clinical assessment + bloods (CRP / ESR) and MR of skull base
Symptoms:
- ear pain (otalgia) - severe, unrelenting, deep
- purulent otorrhea
- temporal headaches
- possible facial nerve (CN VII) dysfunction
- other CN may be involved
- can cause sensorineural deafness
What are the possible complications of otitis externa?
- Facial cellulitis
- Otomycosis (fungal ear infection - often in immunosuppresed or after topical Abx)
- Canal stenosis w/ hearing loss
- Malignant otitis externa (w/ osteomyelitits of temporal bone)
- Sensorineural deafness
What questions might you want to cover in a ear discharge history?
SOCRATES each symptom:
- Which ear?
- Duration of discharge?
- Character of discharge; thick, watery, offensive?
- What precipitated it?
- Other symptoms:
- Ear pain (otalgia)?
- Hearing loss (and how does this affect the patient)?
- Balance issues?
- Tinnitus?
- What treatment have they had so far and has it responded?
- What hobbies or sports are they involved in and do they get water in the ear e.g. swimming?
- Have they had any surgery to the affected ear?
- Do they have any other significant medical problems e.g. allergic chronic rhinosinusitis, asthma, diabetes?
What are the 2 issues in this ear drum image?
- Inferior perforation of pars tensa
- Anterior tympanosclerosis (white calcium deposits caused by healing from previous ear infections)
Name 3 causes of tympanic membrane rupture?
- Recurrent infections
- Trauma e.g. barotrauma or foreign body
- Iatrogenic e.g. ear surgery
Name the 4 most common organisms involved in chronic otitis media?
- Pseudomonas aeruginosa
- Staph. aureus
- Streptococcus
- Anaerobic bacteria ie peptostreptococcus
How is acute otitis media managed?
Generally, alike other self-limiting infections a no Abx / delayed Abx prescribing approach is suggested (policy for respiratory tract infections)
Prescribe Abx immediately IF:
- Symptoms lasting > 4 days / not improving
- Systemically unwell but not requiring admission
- Immunocompromised
- High risk of complications 2ndary to significant heart, lung, kidney, liver, or neuromuscular disease
- Children < 2 yrs old with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
How long should an episode of acute otitis media last?
~ 4 days
What are the management options for a perforated tympanic membrane?
-
No treatment (majority of cases) - membrane will heal in ~6-8 weeks
- Don’t get ear wet!!
-
Combined topical Abx + corticosteroid (7-10 days) - if associated with active infection:
- Sofradex (framycetin, dexamethasone and gramicidin)
- Gentisone H/C (gentamicin and hydrocortisone)
- Otomise (dexamethasone, neomycin and acetic acid)
- Ciprofloxacin drops (covers pseudomonas)
- Myringoplasty (ear drum repair) - freshen edges of perforation + place graft underneath as scaffold for membrane to grow
What is a Cholesteatoma?
Cholesteatoma = non-cancerous growth of squamous epithelium that is ‘trapped’, often in a deep retraction of tympanic membrane
- Involves accumulation of keratin within the retraction (normally skin cells migrate out of the ear canal as they are refreshed - but the retraction causes build up –> kertain cyst)
- Epidemiology:
- commonest age = 10-20 yrs
- cleft palate = 100 fold risk
-
Features:
- Otorrhoea - foul-smelling, non-resolving discharge, resistant to Abx
- Hearing loss
- Can have tinnitus
- Depending on local invasion: dizziness (erosion of semicircular canal), facial nerve palsy (weakness, altered taste), deafness (erosion of ossicles)
- Not likely painful
-
Otoscopy:
- ‘attic crust’ - keratin cyst in the uppermost tympanic membrane w/ or wo/ perforation
-
Management:
- Refer to ENT for surgical removal
What can cause a Cholesteotoma?
- Otitis media - commonly precipitates cholesteotoma
- Eustachian tube dysfunction - can promote invagination of tympanic membrane, due to chronic -ve pressure in middle ear
- Otological surgery (iatrogenic)
- Trauma (barotrauma)
What is a Glomus jugulare?
A vascular tumour that presents as a ‘red mass’ behind an intact tympanic membrane
- Pt may complain of ‘pulsatile tinnitus’
What measures should be taken in a patient presenting with a cholesteotoma?
-
Pure tone audiogram
- Determines degree of hearing loss
- Enables pre / post surgery hearing assessment (see if hearing was improved or if surgery caused deafness)
- Topical Abx + steroid - helps if infection is present
-
Close inspection + cleaning under microscope
- pars flaccida (also called the attic) is often ignored and only the pars tensa is inspected, missing pathology in the attic area
What is the definitive treatment for a cholesteatoma?
Mastoidectomy
- Involves opening the mastoid air cells, removing the cholesteatoma from the middle ear
- Reconstruction of ossicles + tympanic membrane
Name some of the complications of any major middle ear surgery?
- Infection
- Bleeding
- No improvement in hearing
- Complete loss of hearing, called a dead ear (if the inner ear is damaged)
- Tinnitus
- Vertigo
- Facial nerve palsy
- Altered taste (chorda tympani nerve damage)
- Recurrence of disease needing revision surgery
Describe the following types of otitis media.
- Acute otitis media (AOM)
- Recurrent acute otitis media (RAOM)
- Chronic otitis media (COM)
- Otitis media with effusion
-
Acute otitis media (AOM)
- acute inflammation of middle ear with systemic upset (AOM is often precipitated by a URTI)
- otolgia, fever, cough, nasal discharge
-
Recurrent acute otitis media (RAOM)
- > 4 episodes of AOM in a 6-month period
-
Chronic otitis media (COM)
- inflammation of middle ear for > 3-months. There are 2 types:
-
Mucosal COM - inner cells of tympanic membrane
- Active - wet perforation (i.e. with middle ear infection)
- Inactive - dry perforation
-
Squamous COM - outer cells of tympanic membrane
- Active - cholesteatoma
- Inactive - shallow self-cleaning retraction of membrane
-
Mucosal COM - inner cells of tympanic membrane
- inflammation of middle ear for > 3-months. There are 2 types:
-
Otitis media with effusion
- inflammation (not infection) of middle ear + effusion –> conductive hearing loss
What are the intra-temporal and extra-temporal complications of COM?
Intra-temporal complications:
- Vertigo - inflammation spreads to vestibular apparatus
- Hearing loss - COM can cause either conductive (dmg to ossicles / tympanic membrane) or sensorineural (cochlea inflammation) hearing loss
- Acute otitis externa - discharge causing skin irritation
- Facial weakness - erosion of thin bony canal exposes CN VII
Extra-temporal complications:
- Meningitis - erosion through tegmen (roof of middle ear) to expose the dura
- Subdural abscess - same as above, infection spreads from extradural to subdural
- Temporal lobe abscess
- Sigmoid sinus thrombosis
What does this image show?
Active squamous chronic otitis media
- There is a deep retraction in the pars flaccida with accumulation keratin around it
- Pars tensa looks normal
What does this image show?
Inactive mucosal chronic otitis media
- There is an inactive (no pus) subtotal perforation of the right ear
What does this image show?
Active mucosal chronic otitis media
- There is a large central perforation with mucopurulent secretions present in the middle ear
