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(C) CM 1B: ID/EENT > Lecture 7: Middle and Outer Ear > Flashcards

Lecture 7: Middle and Outer Ear Flashcards

1
Q

What part of the external ear canal contains hair follicles, sebaceous glands, and ceruminous glands?

A

Outer one-third.

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2
Q

What are the 4 types of otitis externa?

A
  • Acute otitis externa (Swimmer’s ear and Localized)
  • Chronic otitis externa (Otomycosis and non-infective)
  • Malignant/necrotizing otitis externa
  • Herpes zoster oticus or ramsey-hunt syndrome
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3
Q

What is the MC of diffuse acute otitis externa or swimmer’s ear?

A

Pseudomonas

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4
Q

What is the MC of localized acute otitis externa or furunculosis?

Infection of a hair follicle

A

Staph aureus.

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5
Q

Where is acute otitis externa - diffuse?

A

Ear canal

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6
Q

What can generally cause Swimmer’s ear?

A
  • Swimming
  • Bacterial infections (Pseudomonas #1)
  • Overcleaning of ear
  • Warm, moist environments (summer)
  • Trauma
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7
Q

Why does swimming cause swimmer’s ear?

A
  1. The outer ear canal has an acidic pH.
  2. Long-term exposure to water makes it prone to maceration.
  3. Water can wash off the protective cerumen.
  4. Bacterial infections or macerations can occur more easily.
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8
Q

What clinical symptoms are typical of swimmer’s ear?

A
  • Itching
  • Severe pain
  • Conductive hearing loss
  • Sense of fullness/pressure
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9
Q

What clinical signs are typical of swimmer’s ear?

A
  • Otorrhea
  • Pain upon tragus palpation or auricle traction. (CLASSIC)
  • Swollen, red canal
  • Moist debris in canal
  • TM difficult to visualize
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10
Q

How do you diagnose swimmer’s ear?

A

Clinical presentation.

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11
Q

How do you treat swimmer’s ear?

A
  • Clean out ear via hypertonic saline.
  • Topical ABX (cipro, ofloxacin, cortisporin)
  • Pain relief
  • Ear wick
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12
Q

What is an ear wick?

A

A cotton thingie that expands when moistened. Helps distribute abx and protect ear canal, esp in children.

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13
Q

What is the first-line abx for severe/immunocompromised swimmer’s ear?

A

Cipro 500mg BID x 1 week

Covers pseudomonas

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14
Q

What is the first-line tx for furunculosis?

A

Oral dicloxacillin or cephalexin

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15
Q

What are the 2 MC organisms for otomycosis/chronic otitis externa?

A
  • Aspergillosis
  • Candidiasis
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16
Q

What risk factors tend to contribute to otomycosis?

A
  • Previous abx in ear
  • Hot/humid
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17
Q

How does otomycosis typically present?

A
  • Mild pain
  • Deep-seated itching (concerning)
  • Discomfort
  • Discharge
  • Looks like mold growing on food
  • Soft-white
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18
Q

How do you treat otomycosis?

A
  1. Clean ear canal
  2. Clotrimazole solution 1% BID for 10-14 days
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19
Q

What 3 skin conditions can result in non-infective chronic otitis externa?

A
  • Seborrheic Dermatitis
  • Psoriasis
  • Contact dermatitis
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20
Q

How does non-infective chronic otitis externa look like?

A

Red, scaly, and dry skin

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21
Q

How do you treat non-infective chronic otitis externa?

A

Topical/otic drop hydrocortisone.

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22
Q

What is the MC organism for malignant or necrotizing otitis externa?

A

Pseudomonas

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23
Q

What populations are MC at risk for necrotizing otitis externa?

A
  • Elderly pts with DM
  • Immunocompromised pts
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24
Q

Why is necrotizing otitis externa concerning?

A

Can spread to the bone and then skull.
AKA osteomyelitis

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25
Q

What clinical findings would suggest that a patient has necrotizing otitis externa?

A
  • Severe, deep seated otalgia disproportionate to exam findings.
  • Purulent otorrhea
  • Temporal HA
  • Not responding to otic drops!
  • Granulation tissue at the bony cartilaginous junction of the ear canal floor (HALLMARK SIGN)
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26
Q

How do we determine the extent of necrotizing chronic otitis externa?

A
  • CT scan (osseous erosion extent)
  • Biopsy of granulation tissue
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27
Q

How do we treat necrotizing chronic otitis externa?

A
  • Aggressive glycemic control (DM pts)
  • IV Cipro 200-400mg BID (FIRST-LINE)
  • Oral Cipro 500-1000mg BID (once IV is done)
  • Surgical debridement (if severe and refractory)
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28
Q

When can we stop oral cipro for necrotizing chronic otitis externa?

A

Gallium (nuclear) scan shows no more inflammation!

Check at 6-8 weeks.

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29
Q

What is herpes zoster oticus?

A

An infection of the geniculate ganglion, AKA the sensory ganglion of the facial nerve.

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30
Q

What are the S/S of Ramsey-hunt syndrome/Herpes Zoster oticus?

A
  • Unilateral facial palsy
  • Severe otalgia
  • Vesicular eruption on face

Difficult to distinguish from Bell’s if a rash is not present initially.

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31
Q

What is the treatment for Herpes Zoster oticus?

A

Prednisone + Famciclovir/Valacyclovir

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32
Q

Clinical

A parent brings her 11 year old son into the clinic with the chief complaint of ear pain. The child states it started yesterday evening. It is tender to the touch. He states he has been swimming for the past several days. On PE, you notice pain on palpation of tragus and significant purulent drainage. What is your diagnosis and treatment for this patient?
a. Otitis externa and ear drops
b. Otitis media and oral antibiotics
c. Otitis externa and oral antibiotics

A

A. Otitis Externa and ear drops.

Swimmer’s ear + hallmark sign.

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33
Q

Clinical

What is the MC cause of Otitis externa furunculosis?
a. Staph Aureus
b. Pseudomonas
c. Strep. Pneumonia

A

A. Staph Aureus

B is swimmer’s ear.

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34
Q

Clinical

Which of the following should you suspect if you have acute otitis externa that is not responding to treatment?
a. Herpes zoster oticus
b. Otitis Externa Furunculosis
c. Malignant Necrotizing OE

A

C. Malignant Necrotizing OE

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35
Q

What are the functions of cerumen?

A
  • Self-cleaning ear
  • Antimicrobial
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36
Q

What usually causes cerumen impaction?

A

Overcleaning your ear canal.

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37
Q

How does cerumen impaction typically present?

A
  • Ear pain/fullness
  • Decreased conductive hearing
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38
Q

When is removal of cerumen impaction indicated?

A
  • Examining TM
  • OE
  • Hearing loss workup
  • Ear canal pathology
  • Patient Request
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39
Q

When should cerumen impaction treatment NOT be performed?

A
  • Perforated TM (or Hx of)
  • Pain on previous irrigation
  • Previous mastoidectomy or middle ear surgery
  • Uncooperative patient or hard cerumen.
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40
Q

What are the techniques to remove ear wax?

A
  • Body temp water irrigation
  • Mechanical removal via curette
  • Microsuction
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41
Q

What can you recommend to a patient for at home cerumen impaction removal?

A
  • 3% h2o2
  • Detergent ear drops
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42
Q

How do I remove a bug from an ear? Mechanical object?

A
  • Lidocaine for a bug first before alligator forceps use.
  • Mechanical object just needs the forceps. Can also irrigate if not organic and non-expandable uipon water.
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43
Q

Review

Which of the following is not an indication for cerumen impaction removal?
a. Patient request
b. Hearing loss evaluation
c. Difficulty examining TM
d. All of the above are indications

A

D. All of the above.

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44
Q

What is an auricle hematoma? Presentation?

A

Collection of blood under the perichondria.
Usually caused by direct trauma to anterior auricle.

Presents like a big swollen ear, often pale as well.

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45
Q

What does an untreated auricle hematoma become?

A

Cauliflower ear/Wrestler’s ear

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46
Q

What are the treatment goals for an auricular hematoma?

A
  • Evacuate the perichondrial blood
  • Prevent the blood from reaccumulating
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47
Q

How do you treat an auricle hematoma?

A
  • 7 days of onset to prevent cosmetic damage.
  • Lidocaine 1% (4 locations, stick twice)
  • I&D
  • NS Irrigation
  • Compression Dressing for 7 days (check daily)
  • ABX prophylaxis (maybe)

AVOID NSAIDS

48
Q

What nerves must be blocked for a complete auricle block?

A
  • Lesser occipital nerve
  • Greater auricular nerve
  • Auriculotemporal nerve
49
Q

What are the treatment goals for an auricular laceration?

A
  • Cover exposed cartilage
  • Minimize wound hematoma
50
Q

What do we need to check for a patient that presents with auricular laceration?

A
  • TM, external auditory canal
  • Facial Nerve
  • Basilar skull fracture (Raccoon eyes)
  • Hearing deficits
51
Q

What might prompt us to use ABX for an auricular laceration?

A
  • Signs of inflammation
  • Bite wound
  • Contamination of wound
52
Q

What is the preferred procedure for auricular laceration?

A

Primary closure with interrupted sutures

53
Q

What are the MC organisms for auricular cellulitis?

A
  • Staph Aureus
  • Streptococci
54
Q

What is the treatment of choice for auricular cellulitis?

A

Oral ABX:
* Cephalexin
* Bactrim (MRSA)
* Clinda

55
Q

When would IV vanco be used for auricular cellulitis?

A
  • Tachycardia
  • Rapidly progressing erythema
  • Unresponsive to oral ABX
  • Fever > 100.5
56
Q

What is perichondritis?

A

Infection of the perichondrium of the auricle, usually resulting in a deformity of the upper ear.

57
Q

What are the MC organisms that cause perichondritis?

A
  • Pseudomonas
  • Staph Aureus

Local trauma or burn usually precedes

58
Q

What is the treatment of choice for perichondritis?

A

Oral or IV cipro within 5 days of onset.

59
Q

Does serous otitis media imply infection?

Serous otitis media is also called OM with effusion.

A

No!
Can precede or follow OM.

60
Q

Picture of normal TMs.

A
61
Q

2nd picture of TMs

A
62
Q

Define acute otitis media.

A
  • Acute, suppurative, infectious process
  • Infected middle ear fluid
  • Inflammation of inner ear mucosa
63
Q

How common is AOM?

A

MC reason for childhood ABX use.

64
Q

Why are children < 2y most susceptible to AOM?

A

Horizontal eustachian tubes.

65
Q

What generally precedes an AOM infection?

A
  • URI (MC)
  • Eustachian tube dysfunction
  • Negative pressure followed by accumulation of secretions
  • Viruses and bacteria from the upper respiratory tract
66
Q

What PE findings on otoscopic exam might suggest AOM?

A
  • Bulging TM (Whitish discoloration)
  • Marked erythema
  • Increased air fluid levels
67
Q

What are the 3 MCC of AOM?

A
  1. Strep Pneumo (MC)
  2. H flu
  3. M Cat
68
Q

What is the MCC of an infant < 2 weeks developing AOM?

A

Group B Streptococcus

69
Q

What might suggest a child has AOM?

A
  • Otalgia seen by pulling of the ear constantly.
  • Hearing loss
70
Q

What clinical finding suggest AOM over OM with effusion?

A

Bulging of the TM

71
Q

What findings suggest otitis media with effusion on otoscopy?

A
  • TM suppurative opacity
  • Decreased/absent TM mobility
  • Otorrhea
72
Q

What is the initial treatment for uncomplicated mild-mod AOM?

A

Amoxicillin

73
Q

If a patient has recent abx use or failure to treatment to amoxicillin for AOM, what should we use instead?

A

Augmentin or cefdinir

74
Q

If a patient is allergic to PCNs, what are some other treatment options for AOM?

A
  1. Cephalosporins (Cefdinir/ceftriaxone)
  2. Zithromax/Doxy (if anaphylaxis)
75
Q

What qualifies as severe AOM?

A
  • Significant hearing loss
  • Severe pain
  • Fever > 102F
  • Immunocompromised
  • Under 6mo of age
  • Marked TM erythema
76
Q

How do you treat severe AOM or AOM w/ associated bacterial conjunctivitis?

A

Augmentin or rocephin

77
Q

How do you treat severe AOM w/ recent abx exposure or recent tx failure?

A
  • Rocephin
  • Clinda
  • Tympanocentesis

10 days for children, 5-7 normal.

78
Q

What is a temporary treatment option for AOM that does not respond well to pharmacologics? Indication?

A
  • Tympanostomy tubes
  • 3 or more AOM in 6 mo
  • 4 or more AOM in 12 mo

Fall out on their own.

79
Q

What are some complications of AOM?

A
  • Tympanosclerosis
  • Cholesteatoma
  • Ossicular fixation
  • Mastoiditis
80
Q

What patient education should be given to prevent AOM, esp in infants?

A
  • Breastfeeding
  • Avoid laying down to feed
  • Avoid passive smoke
  • Avoid pacifier use < 10mo
  • IMMUNIZATIONS
81
Q

What is bullous myringitis?

A

Complication of AOM, presenting with bullae on TM.

82
Q

How do you treat bullous myringitis?

A
  • Same as AOM
  • May need to cover for atypicals (mycoplasma-zithromax)
83
Q

What might suggest TM rupture?

A
  • Sudden decrease in otalgia
  • Otorrhea
84
Q

What are some treatment options for TM rupture?

A
  • Oral ABX, same as AOM.
  • Otic drops
  • Earplugs

Should resolve on its own. If not, tympanoplasty.

85
Q

What should be documented when describing a TM rupture?

A
  • Location (clock)
  • Size
  • Any signs of infection
86
Q

What is tympanosclerosis?

A

Scar on the TM.

87
Q

What is chronic suppurative OM?

A
  • Otorrhea
  • Complication of recurrent OM
  • Perforated TM with drainage > 6 weeks
  • Usually painless
88
Q

What ear condition tends to worsen post URI or swimming?

A

Otorrhea/chronic suppurative OM

89
Q

What are the MCC bacteria for Chronic OM?

A
  • Pseudomonas
  • Proteus
  • Staph Aureus
90
Q

What is the treatment for chronic OM?

A
  • Topical ofloxacin/cipro with dexamethasone for exacerbations
  • Oral Cipro
  • Surgery is most definitive. (Uses temporalis muscle fascia)
91
Q

What is a cholesteatoma?

A

Abnormal growth of squamous epithelium in middle ear or mastoid

92
Q

What are the concerns with cholesteatoma?

A
  • Destroying auditory ossicles
93
Q

What is the MCC of a cholesteatoma?

A

Prolonged eustachian tube dysfunction

94
Q

What are the clinical findings associated with a cholesteatoma?

A
  • Deep retraction pockets
  • White mass behind TM
  • Focal granulation at TM periphery
  • Ear drainage > 2 weeks despite tx
  • Conductive hearing loss
95
Q

What is the treatment for a cholesteatoma?

A

Surgery (debridement)

96
Q

When does mastoiditis typically occur?

A

Weeks after improperly treated OM.

97
Q

What is mastoiditis?

A

Pus filling mastoid air cells, leading to bone erosion and cavity formation

98
Q

What clinical findings are associated with mastoiditis?

A
  • Pain, erythema, and swelling over mastoid with proptosis of ear.
  • Fever
  • S/Sx of AOM
99
Q

How do you diagnose mastoiditis?

A

CT scan

100
Q

What is the treatment protocol for mastoiditis?

A
  1. IV ABX 7-10 days (empiric, rocephin or ancef)
  2. Oral ABX (augmentin/cefdinir)
  3. Myringotomy
  4. Failure: mastoidectomy and debridement
101
Q

What is the MCC of OM?

A

Strep Pneumo

102
Q

What is first line treatment for a patient with mild to moderate OM with no allergies?

A

Amoxicillin

103
Q

What is the imaging modality of choice to diagnose mastoiditis?

A

CT Scan

104
Q

What is the MCC of eustachian tube dysfunction?

A

Viral URI

105
Q

What is the eustachian tube for?

A

Draining middle ear, open only during yawning or swallowing

106
Q

What are the S/S associated with eustachian tube dysfunction?

A
  • Aural fullness
  • Mild-mod hearing impairment
  • Partially blocked tube creates crackling/popping sound upon yawning.
  • Decreased TM mobility on tympanogram
107
Q

What is the treatment protocol for eustachian tube dysfunction?

A
  1. Systemic/IN decongestants
  2. Autoinflation maneuver (Breathe out against closed nostrils)
  3. If dt allergies (IN OTC steroids)
  4. Avoid air travel and diving
108
Q

When is barotrauma most likely to occur?

A
  • Plane DESCENT
  • Deep sea diving (most severe)
109
Q

What is the treatment for barotrauma?

A
  • Decongestants
  • Myringotomy (if more severe)
110
Q

What are some complications of barotrauma?

A
  • Hemotympanum
  • Perilymphatic fistula
111
Q

What are exostoses/osteomas?

A

Bony overgrowths of the ear canal.

112
Q

What usually causes multiple exostoses?

A

Repeated exposure to cold water. Need Surgery.

113
Q

What is the MCC of neoplasia of the ear canal?

A

Squamous cell carcinoma.

114
Q

A mom brings her 13 month old child into the office for fussiness. She states it has been going on for the past 2 days. The mom also reports the patient has had cough and cold symptoms for 6 days that is slightly worsening. Her child has a fever of 100.4, congestion, cough, and is tugging at her ear. On PE, you notice an erythematous and bulging tympanic membrane with purulent fluid. What is your diagnosis and first line treatment?

A

Mild-mod AOM.
Amoxicillin is DOC if no allergy.

115
Q

What is the MC cause of Eustachian Tube Dysfunction?
a. Viral URI
b. Pneumonia
c. Conjunctivitis
d. Nasal decongestants

A

A. Viral URI

116
Q

What is the treatment for mild to moderate Otitis Media with a mild hypersensitivity reaction (rash) to penicillins?
a. Amoxicillin
b. Amoxicillin-Clavulanic Acid
c. Cefdinir (Omnicef)
d. Azithromycin

A

C. Cefdinir

Zithromax if anaphylaxis

(C) CM 1B: ID/EENT (27 decks)

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