External and Middle Ear - Exam 4 Flashcards
What is the medical term for “swimmers ear”? What organism is MC?
Acute otitis externa (AOE)- diffuse
pseudomonas- MC
_____ is infection of a hair follicle. What organism is MC?
furunculosis
Staph Aureus
_____ is infection of the external ear with a fungal species
otomycosis
Chronic otitis externa
Healthy ear canal skin has an ____ pH. What is the job of the cerumen?
acidic
Serves as a water-repellent coating for the skin of the canal and provides antimicrobial properties
Itching
Severe pain
Conductive hearing loss
Feeling of fullness or pressure
Purulent discharge
Pain with palpation of tragus or traction of auricle (classic sign)
Swollen, red canal
Moist debris in canal
TM difficult to visualize
What am I?
What is the highlighted sign?
What is the tx?
Acute Otitis Externa - Diffuse
Pain with palpation of tragus or traction of auricle (classic sign)
tx:
-clean ear canal to remove debris
-**topical abx: ofloxacin, cipro, neomycin, Polymyxin B
- pain relief
-ear wick
What is an ear wick? When is it used?
drop a few abx drops onto wick and place in ear. Helps distribute medicine and keep medicine in canal
Expands as its moistened
Acute Otitis Externa - Diffuse
Severe diffuse acute otitis externa is commonly seen in what pt population? **What is the tx?
Immunocompromised, elderly, DM
Cipro 500mg BID for 1 week only for severe cases/ immunocompromised
Acute Otitis Externa - Furunculosis is commonly found in the ____ of the canal. What is is caused by? What organism? What is the tx?
Usually lateral ⅓ of canal
Infection of hair follicle
Staph aureus
tx: **Oral Dicloxacillin or Cephalexin (Keflex)
I&D if needed
Chronic Otitis Externa - Otomycosis is a ____ infection of the ear canal. What are the 2 MC organisms?
fungal infection
Aspergillosis and Candidiasis
Ear itching: deep seated itching
discomfort
discharge
foreign body sensation in ear
less severe edema
May resemble mold growing on spoiled food
soft, white, sebaceous-like material that may fill ear canal
What am I?
What is the highlighted symptom?
what is the tx?
Otomycosis
deep seated itching
tx:
-clean canal
-Cotrimazole 1% solution BID 10-14 days
Seborrheic Dermatitis
Psoriasis
Contact Dermatitis
Canal is red, scaly and dry
What am I?
what is the tx?
Chronic Otitis Externa - Non-infective
Topical Hydrocortisone cream/otic drops
Potentially life-threatening
Infections spreads from skin to bone and marrow spaces of the skull base
Elderly patients with Diabetes Mellitus
Immunocompromised patients
severe, deep seated otalgia out of proportion to exam findings
progressive
purulent otorrhea, very foul-smelling
temporal HA
Granulation tissue at the bony cartilaginous junction of the ear canal floor
What am I?
What is the MC organism?
What are the 2 highlighted s/s?
Chronic Otitis Externa - Malignant/Necrotizing
Pseudomonas M/C
Severe, deep seated otalgia out of proportion to examination findings
Granulation tissue at the bony cartilaginous junction of the ear canal floor
What are complications of Chronic Otitis Externa - Malignant/Necrotizing? What is the highlighted one?
Spread to base of skull - osteomyelitis
Spread to meninges and brain
CN involvement - cranial nerve palsy
Thrombosis of sigmoid sinus
High mortality rate
How do you dx Chronic Otitis Externa - Malignant/Necrotizing? what is the tx? How long do you need to continue tx?
CT: to determine the extent of dz
tx: IV and oral abx
1st line: IV Ciprofloxacin 200-400mg BID, tx until clinical improvement then can change to oral cipro 500-1000mg BID
Treat until gallium (nuclear) scan is clear of inflammation (generally 6-8 weeks)
What is another name for Chronic Otitis Externa - Herpes Zoster Oticus? What does it present like? What is the tx?
Ramsay Hunt Syndrome
Unilateral facial nerve (CN VII) palsy, severe otalgia, vesicular eruption on the face. May have altered taste and tongue lesions. (Cannot close eye)
Prednisone and Famciclovir (Famvir) or Valacyclovir (Valtrex)
Where is cerumen produced?
outer portion of ear canal
Ear pain
Fullness
conductive hearing loss
What am I?
What is the tx?
cerumen impaction
irrigation with water
mechanical removal with ear curette
3% hydrogen peroxide
OTC Debrox
What are CI for cerumen impaction?
Presence or history of perforated TM
Previous pain on irrigation
Previous surgery of the middle ear or mastoidectomy
Uncooperative patient
Very hard cerumen
What are some foreign body removal techniques for the ear?
irrigation : avoid if object could expand when wet
alligator forceps
if its an insect need to immobilize with lidocaine first
What is an auricle hematoma? What is a result from? ____ will result if left untreated?
Collection of blood under the perichondria
Results from direct trauma to the anterior auricle
“Cauliflower ear” or “Wrestler’s Ear” as a result of untreated
What is the tx for auricle hematoma?
needs to be within 7 days
Lidocaine 1%: auricle block
I&D
Irrigate pocket with NS
Compression dressing
Leave on for 7 days
Re-examine for recurrence every 24 hours for several days
Avoid NSAIDS
Antibiotic prophylaxis +/-
For an auricular laceration, when are abx indicated? Need to also consider giving _____
Contaminated wound
Bite injuries
Signs of inflammation
tetanus vaccine
Auricular Laceration _____ is preferred. Why? What is the technique?
primary closure
Failure to cover exposed cartilage increases risk of infection
Anesthesia
Debridement
Copious Irrigation
Suture
Packing
Xeroform strips into ear crevices
Petrolatum occlusive dressing
Compression dressing
Recheck 24 hours
Sutures out in 4 - 5 days
Describe the correct way to numb an ear?
2 punctures with a needle
1 at the top of the ear, aim down towards the tragus, injection solution as you are pulling out, rotate the needle 45 degrees without pulling out and aim for the auricle. Repeat at the base of the ear lobe
What 3 nerves are you aiming to block when performing a auricular block?
auriculotemproal nerve
lesser occipital nerve
greater auricular nerve
When would you want to refer to plastic surgery for a auricular laceration?
Large skin avulsions (5 mm or >)
Severe crush injuries
Complete or near complete avulsion
Auricular hematoma
Large cartilage defect (> 5 mm)
Wounds that require removal of > 5 mm tissue
Involvement of auditory canal
Tissue devitalization
______ is a swollen, erythematous, hot external ear lobule usually due from a minor trauma, insect bite, or ear piercing. What is the tx? What is the tx for severe?
Auricular Cellulitis
Choose 1:
Cephalexin
Trimethoprim-Sulfamethoxazole (MRSA)
Clindamycin (MRSA)
and
warm compresses
NSAIDs for pain
severe: IV Vanc
if pt is tachycardic, erythema is rapidly progressing, continues to grow even once on oral abx, fever over 100.5
auricular cellulitis is called by ____ and ______
Staph aureus and Streptococci
______ Infection of the perichondrium of the auricular cartilage. What is usually due to ? What causes the ear deformity? What can it rapidly progress to?
Perichondritis
local trauma, surgery or burns. Lobe is NOT involved
Interruption to blood supply of cartilage causes ear deformity
Rapidly progress to produce necrosis of cartilage
What are the MC organisms that cause perichondritis? What is the tx?
Pseudomonas and Staph aureus M/C
oral or IV Cipro
I&D
What is this? What color would you describe it?
normal TM
pearly gray color
What is it called when their is fluid in the middle ear? acute infection of the middle ear fluid?
middle ear effusion or serous otitis media (middle ear fluid that is NOT infected)
acute otitis media
______ is an acute, suppurative, infectious process marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the inner ear space.
Acute Otitis Media
What is the most frequent dx in sick children and is the MC reason for abx use? ____ can reduce the occurence
acute otitis media
pneumococcal vaccine
What are some risk factors for acute otitis media?
age between 6 - 24 months
Family History
Daycare
Lack of breastfeeding
Tobacco use
Seasonal
Altered host defenses and underlying disease
Pacifier use
_____ generally precedes acute otitis media. Usually a result of _____. What is the pathogenesis?
URI
Eustachian tube dysfunction
Impaired function of the Eustachian tube, results in the retention and suppuration of retained secretions. Dysfunction induces a negative pressure in the middle ear space. Negative pressure followed by accumulation of secretions produced by the middle ear mucosa. Viruses and bacteria that colonize the upper respiratory tract enter the middle ear
What are the 3 MC organisms that cause AOM?
strep pneu
H. Influ: think bilateral OM
M. Catarrhalis: 10% of cases
_____ cause of OM is more common in older children and has more local complications
____ is the cause of OM in infants younger than 2 weeks
Group A strep
Group B Strep
_____ cause of OM leads to acute otorrhea in children with tympanostomy tubes
Staphlococcus
____ is the cause of AOM in first months of life
____ is the cause of chronic and suppurative OM
E. coli
Pseudomonas
ear pain (not always but common)
Cough, congestion, Fever, irritability, headache, anorexia, N/V/D, ear tugging, and some decreased hearing
bulging of TM
poor mobility of TM
erythema of TM
TM is opaque
What am I?
What are the 2 highlighted s/s?
Acute otitis media
**bulging of TM: Distinguishes AOM from otitis media with effusion
**mobility of TM
What is the tx for mild/moderate AOM? What if the pt has exposure to abx within 30 days or treatment failure after 72 hours?
Amoxicillin 875mg BID
Cefdinir is another option for PCN NOT anaphylaxis
Amoxicillin plus Clavulanate 875mg (Augmentin ES or XR) PO in divided doses BID,
Cefdinir (Omnicef) 300mg BID
what is the all the tx options for AOM, include first line, not severe PCN allergy and severe PCN allergy.
first line: amoxicillin
NOT severe PCN: Cefdinir
severe PCN: zithromax or doxy
What is considered severe AOM? What is another common dz to see along side AOM? What is the tx?
Significant hearing loss, severe pain, fever > 102⁰F, immunocompromised, under 6 months of age and or marked TM erythema
bacterial conjunctivitis (Likely H. Influenza)
tx: augmentin or ceftriazone
What do you give for severe AOM if the pt has been exposed to abx within 30 days or recent treatment failure?
Ceftriaxone (Rocephin), OR
Clindamycin, OR
Consider tympanocentesis
When prescribing pharmacotherapy, how do you decide how long to initiate therapy for?
10 days for patients <6 years old and /or patients with severe disease, TM perforation or recurrent AOM
5 - 7 days (with consideration of observation only in previously healthy individuals with mild disease) for patients ≥6 years old
need to re-evaluate in 48-72 hours if no improvment
When do you need to refer out for AOM? What is the tx?
3 or > AOM within 6 months OR
4 or > AOM within 12 months OR
Unresponsive to pharmacological treatment regime
Tympanostomy Tubes
What are some complications of AOM?
Hearing loss
Balance and motor problems
TM perforation
Tympanosclerosis
Chronic suppurative OM
Cholesteatoma
Ossicular fixation
Extension of suppurative process to adjacent structures
Mastoiditis
Intracranial complications
Meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis
What are some preventions for AOM? What is the major one?
-breastfeeding: IgA is secreted through breastmilk
- upright for bottle feeding
-Avoid passive smoke exposure
-Limit exposure to groups of children
-Careful hand washing
-Avoid pacifier use >10 months old
**-IMMUNIZATIONS!!!!!
______ is associated with AOM with bullae present on the TM. What is the tx?
Bullous Myringitis: more painful
tx: same as AOM (amoxicillin but may need to cover for atypicals: azithromycin)
_____ is an AOM complications that results in rupture accompanied by sudden decrease in pain, followed by otorrhea. What is the tx?
Tympanic Membrane Rupture
audiogram now and repeat in 3 months
same abx: amoxicillin, augmentin, cefdinir
can add low ototoxic topical abx: ofloxacin, ciprodex
earplugs when swimming and bathing
Should resolve on its own but tympanoplasty if no resolution
_____ is a scar on the TM
Tympanosclerosis
______ is the presence of perforation of the TM with chronic purulent drainage from the middle ear for >6 weeks. What is another name for it? Is it painful? What is the tx?
Chronic suppurative OM
“otorrhea”
pain is NOT common
Refer to otolaryngologist
What bacteria are common for CHRONIC otitis media? What is the tx? What is the definitive management?
Pseudomonas, Proteus, S aureus, and mixed anaerobic infections
Topical and oral Abx:
-topical: Ofloxacin or Cipro with dexamethasone for exacerbations
-Oral: Ciprofloxacin 500 mg BID X 1-6 weeks
-remove debris and use earplugs
sx: TM repair
______ Abnormal growth of squamous epithelium in middle ear and mastoid.
May enlarge to surround and destroy the ossicles. What is it due to? What is the MC cause?
Cholesteatoma
Due to chronic negative pressure in the middle ear
Prolonged eustachian tube dysfunction
Deep retraction pockets
White mass behind the TM
Focal granulation at the TM periphery
Can become chronically infected
Ear drainage for >2 weeks despite treatment
Hearing loss - conduction - due to ossicular erosion
What am I?
What is the tx?
Cholesteatoma
tx: surgery
Surgical marsupialization or removal
_____ occurs after several weeks of untreated or inadequately treated OM. ____ air cells connect with middle ear. Pus filling the air cells.
Erosion of the surrounding bone. Formation of abscess-like cavities
Mastoiditis
Mastoid
Pain, erythema and swelling over _____ process with proptosis of ear
Fever
S/Sx of AOM
What am I?
What organisms?
How do you dx?
Mastoid process
mastoiditis
S. pneumoniae, H. flu, S. pyogenes, S. aureus, pseudomonas
CT scan
What is the tx for mastoiditis?
IV antibiotics 7-10 days
Empiric until culture results available
Ceftriaxane (Rocephin) 1g QD
Cefazolin (Ancef) - 0.5 - 1.5 g Q6 - 8 hr
Followed by oral antibiotics
Amoxicillin/Clavulanate acid
Cefdnir
Myringotomy: surgical drainage of TM to allow drainage of middle ear fluid
Surgery if failure of conservative treatment: mastoidectomy and debridement of infected and necrotic bone
What is the function of the Eustachian Tube? When is it normally open? What is dysfunction of the eustachian tube? What are 3 common causes? what is the MC?
Provides ventilation and drainage for the middle ear
Normally opens only during yawning or swallowing
Dysfunction - air trapped in middle ear becomes absorbed and negative pressure results
Viral URI- MC
Allergies
Edema of the tubal lining
Fullness in ear
Mild to moderate hearing impairment
Partially blocked tube
swallowing or yawning creates popping or crackling sound
Retraction of TM
decreased TM mobility
What am I?
What commonly happened before these s/s appeared?
What is the tx?
Auditory “Eustachian” Tube Dysfunction
Lasts days to weeks following a viral infection
oral or intranasal decongestants
Auto-inflation by forced exhalation against closed nostrils
intranasal steroids
Avoid air travel and altitude change, underwater diving
_____ unable to equalize the barometric stress on middle ear during air travel, rapid altitude change, or underwater diving. ____ is air filled.
Barotrauma
Middle Ear Space
What are some prevention strategies for barotrauma? Treatment?
Do not dive with conditions that can lead to ET dysfunction: viral URI
Swallow, yawn, and auto inflate often during descent
Systemic decongestants several hours before arrival
Topical decongestants 1 hour before arrival
No diving with URI or allergies
No diving with TM perforation
______
oral decongestants
attempt autoinflation
myringotomy (ear tube)
Which is worse in terms of potential barotrauma, diving or flying? With barotrauma, is it common to see _____ and ______
underwater diving is worse than flying
Hemotympanum
Perilymphatic fistula
_____ and ____ are bony overgrowths of the ear canals d/t benign tumors. Skin-covered mounds in medial ear. What is the cause? What is the tx?
Exostoses and Osteomas
Acquired from repeated exposure to cold water
sx
What is the MC neoplasia of the ear canal? Why is it dangerous?
Squamous cell carcinoma
Tumor tends to invade lymphatic of cranial base. Requires wide surgical resection and radiation therapy
______ tumor originate from ceruminous glands and are more indolent
Adenomatous
