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EENT Exam 2 > Middle and External Ear > Flashcards

Middle and External Ear Flashcards

1
Q

Auricular Hematoma epidemiology

A

● Direct trauma to the auricle
○ Shearing forces

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2
Q

Auricular Hematoma pathophysiology

A

● Accumulation of blood between the
cartilage and the skin
● Compromises blood flow to the
cartilage
○ Irregular cartilage formation
○ “Cauliflower Ear”

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3
Q

Treatment for Auricular Hematoma

A

● Ice
● Moderate compression
● Aspiration
● I & D – within 1 week (ENT)

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4
Q

Auricular Hematoma complications

A

● Infections
● Deformity
● Conductive hearing loss

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5
Q

Otitis Externa epidemiology

A

● Inflammatory and infectious process of the EAC
● 10% lifetime risk
● 35% of cases ages 5-14 years old
● More common in the summer months
● Water sports and humidity
○ “Swimmer’s ear”

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6
Q

Otitis Externa comorbidities

A

● Hearing aid/obstructive devices
● Trauma
● Dermatological condition (eczema, psoriasis)
● Diabetes
● Immunocompromised

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7
Q

Otitis Externa pathophysiology

A

● Inflammation due to heat, humidity, maceration, the absence of
cerumen, and an alkaline pH
● Results in edema and bacterial overgrowth
● Bacterial (most common)
○ Pseudomonas species 38-41%
○ Staphylococcus epidermidis (9%)
○ Staphylococcus aureus (8%)
○ Streptococci/gram negative rods
● Fungal (otomycosis) 2-10%
○ Aspergillus
○ Candida (hearing aids)
● Eczematoid

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8
Q

Otitis Externa treatment

A

● Mild (w/o discharge): Acetic acid w/ or w/ hydrocortisone
● Moderate: Topical antibiotics (typically fluoroquinolones)
■ Ciprofloxacin and ofloxacin (BID x 7-10 days)
■ Polymyxin B, neomycin, chloramphenicol,
gentamicin, and tobramycin
● Severe
○ Topical abx with addition of PO abx
■ Amox/clavulanate (BID x 7-10 days)
○ Possible ENT debridement

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9
Q

Otitis Externa treatment if fungal

A

Fungal (Otomycosis) – KOH positive on fungal culture
○ Acidify the canal and administering antifungal agents
■ Drops BID/TID x 10 days – Clotrimazole, nystatin (otic drops or powder), ketoconazole, cresylate otic drops – >80% effective
■ CSF powder
Eczematoid
○ Emollients (mineral oil)
○ Topical steroids
○ Possible ENT debridement

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10
Q

What does an Ear Wick do?

A

Allows liquid medication to delivered deeper in to the canal
■ Left in place for 2-3 days, or until it falls out as swelling decreases

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11
Q

Malignant Otitis Externa (MOE)

A

Complication of otitis externa
○ Necrotizing Otitis Externa (NOE)
90% Pseudomonas Aeruginosa
● DM, elderly, or immunosuppressed
patients with intense otalgia, otorrhea,
hearing loss, fullness, and pruritus.
○ Temporal bone pain → osteomyelitis

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12
Q

How does Malignant Otitis Externa occur?

A

Starts as OE → granulation tissue at the bony-cartilaginous junction
○ Progresses to osteomyelitis of the temporal bone may result in
neuropathies of CN V and VII
○ Can progress to meningitis, sepsis, and death

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13
Q

Malignant Otitis Externa (MOE) Treatment

A

Hospital admission for IV abx
○ Aminoglycosides, antipseudomonal beta-lactams
○ Blood sugar and immunosuppression control

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14
Q

Exostosis and Osteoma

A

● Firm broad-based bony lesions of the EAC (typically multiple lesions)
● Reactive bone formation associated with repetitive cold water or wind
exposure (periostitis)
○ Surfer’s Ear

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15
Q

Osteoma

A

● Benign neoplastic growth of the EAC (typically pedunculated lesions)
● Arise near the bony-cartilaginous junction of the EAC
● Fibrovascular core surrounded by bone
○ Unknown etiology
○ Rare

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16
Q

Exostosis and Osteoma Exam

A

● Narrowing of the canals
● Pedunculated bony mass

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17
Q

Exostosis and Osteoma Diagnosis

A

● High-resolution CT scan of the temporal bone

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18
Q

Exostosis and Osteoma Treatment

A

● Management of cerumen and otitis externa
● ENT referral for surgical management if indicated
○ Hearing loss

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19
Q

Prevention of Exostosis and Osteoma

A

Silicone earplugs to those frequently in cold water

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20
Q

Laceration of the Canal epidemiology

A

Direct trauma
○ Digital
○ Q-tip
○ Bobby pin
○ Car keys/Pen Caps
○ Foreign objects

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21
Q

Laceration of the Canal complications

A

With prolonged bleeding may need cautery
○ Silver nitrate sticks
○ Aluminum chloride topical (DrySol)

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22
Q

Cerumen Function

A

● Cleans and protects the EAC and TM
● Emollient
● Creates a difficult environment for bacteria and fungi to thrive

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23
Q

Cerumen Impaction presentation

A

● Hearing loss
● Earcaches
● Ear Fullness
● Itching
● Dizziness
● Tinnitus
● History of Q-tip, hearing aid, or earbud use

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24
Q

Cerumen Impaction Treatment

A

● Indication for removal — symptomatic
● Minimal cerumen without evidence of tympanic perforation
○ Mineral oil and hydrogen peroxide
○ OTC ear wax removal kits

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25
Q

Ear Foreign Bodies common items

A

○ Beads, pebbles, popcorn kernels, tissue paper, cotton, small toys
○ Insects
○ Batteries – liquefactive necrosis, low voltage injury, pressure necrosis

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26
Q

Ear Foreign Bodies presentation

A

● Asymptomatic – delayed diagnosis
● Fidgeting with ear
● Pain
● Pruritus
● Conductive hearing loss
● Bleeding, odor or discharge

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27
Q

Bullous Myringitis

A

Inflammation/infection of the tympanic membrane
● Streptococcus pneumoniae, viral
infection such as influenza or RSV

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28
Q

Bullous Myringitis Presentation

A

● Other URI symptoms
● Acute onset of ear pain
● Sensation of heaviness
● Hearing changes
● Mild discharge

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29
Q

Bullous Myringitis Exam

A

● Otoscopic examination
○ TM is red and deformed, light
reflex is shortened or disappears
completely
○ Bullae or blebs
○ TM appears to be weeping
● Audiogram often WNL
● Tympanometry reveals an intact TM
with no negative pressure and good
movement

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30
Q

Bullous Myringitis Treatment

A

● Amoxicillin (peds 80-90 mg/kg/day)
○ PCN allergy – Clarithromycin 500 mg
BID x 10-14 days
● May need ENT for microscopic debridement/drainage of
bullae
● Reevaluate after treatment – hearing test/audiogram

31
Q

Tympanic Membrane Perforation presentation

A

● Audible whistling sounds/tinnitus
● Discharge from the ear
○ Otalgia resolves following discharge
● Decreased hearing
● Ear fullness
● Vertigo/balance issues

32
Q

Tympanic Membrane Perforation Treatment

A

● Observation
○ Most heal spontaneously (3-4 wks)
▪ Monomeric membrane
○ Dry ear precautions
○ Abx drop (Ofloxacin 3-5 gtt 2-3 x daily for 5 days)
▪ NO STEROID DROPS
● Refer to ENT for surgical management if suspected damage to the ossicles or perforation persists > 3 weeks

33
Q

Tympanosclerosis

A

Scarring of the TM
○ a.k.a. myringosclerosis
● Occurs after TM injury

34
Q

Tympanometry

A

Tympanometry is helpful to determine the mobility of the tympanic membrane and the presence of effusion or perforation.

35
Q

Tympanogram readings (A-F)

A

● A – Decreased motility of TM
(typically fluid in behind the TM)
● B – Cerumen/ poor seal
● C – Perforation
● D – Not reliable
● E – Retracted TM
● F – Bulging TM

36
Q

Serous Otitis Media

A

otitis media with effusion (OME)
● Collection of non-infected fluid in the middle ear space
○ Nearly always follows AOM
■ Infection resolves, effusion persists

37
Q

Serous Otitis Media presentation

A

● Asymptomatic (i.e., painless)
● Hearing loss post AOM
○ Ear feels “full” or “plugged” following an episode of AOM

38
Q

Serous Otitis Media Exam

A

● Air-fluid levels, dull or yellowish TM
● Decreased tympanic mobility
○ Tympanometry – Type B
● Conductive hearing loss

39
Q

Serous Otitis Media Treatment

A

● Observation (may take 1-3 months to resolve)
○ Nasal decongestant and/or steroid spray
○ Autoinsufflation – equalize ear, “pop” open eustachian tube
● Oral steroids
● Refer to ENT

40
Q

Serous Otitis Media Complications

A

● Children with otitis media with effusion
are at risk for speech, language, and/or
learning delays
● Promptly evaluate hearing, speech,
language, and determine need for
intervention

41
Q

Acute Otitis Media

A

● Transudation of neutrophils, serum, and inflammatory mediators into the middle ear space
● Most common condition resulting in
medical therapy for children younger
than 5 years
● 70% of all children experience one or
more attacks of AOM before age 2

42
Q

Majority of AOM episodes are triggered by an ____

A

upper respiratory infection (URI)

43
Q

Common AOM pathogens

A

● RSV
● Streptococcus pneumoniae
● Haemophilus influenzae

44
Q

Acute Otitis Media

A

● Irritability
● Feeding difficulties
● Fever
● Otalgia and/or tugging at the ears
● Decreased hearing

45
Q

Acute Otitis Media Exam

A

TM
○ Inflammation
○ Purulent middle ear effusion
○ Poor tympanic mobility with
pneumatic otoscopy
○ May bulge in the posterior
quadrants
○ Scalded appearance
● Tympanometry may confirm effusion

46
Q

Acute Otitis Media Treatment

A

○ High dose Amoxicillin (Peds dose: 80-90 mg/kg/day)
○ Children less than 6 months of age should be treated immediately
with an abx
○ > 6 months old with severe signs or symptoms (moderate or severe
otalgia or otalgia for 48 hours or longer or temperature 39°C or
higher) and for non-severe, bilateral AOM in children aged 6-23
months

47
Q

Acute Otitis Media Complications

A

● Tympanic perforation
● Persistent infection
● Persistent effusion (OME)
● Tympanosclerosis
● Hearing loss
● Lasting more than 3 weeks may
result in mastoiditis
Refer to ENT if complications arise

48
Q

referred otalgia – “The 5 T’s”

A

○ Teeth
○ Tongue
○ TMJ
○ Tonsils
○ Throat

49
Q

Recurrent Otitis Media is defined as

A

3 episodes within 6 months or 4
or more episodes within 1 year

50
Q

Chronic Suppurative Otitis Media

A

● Perforated tympanic membrane with
persistent drainage from the middle ear
● Cycle of inflammation, ulceration, infection, and granulation tissue formation may continue, eventually destroying the surrounding bony margins

51
Q

Chronic Suppurative Otitis Media symptoms

A

● Ear drainage for some time (2-6 weeks)
● Typically, no pain or discomfort
● History of recurrent acute otitis media, traumatic perforation
● Hearing loss

52
Q
A
52
Q

Chronic Suppurative Otitis Media exam

A

● EAC is not typically tender
● Granulation tissue may be seen in the medial canal or middle ear space
● Middle ear mucosa visualized through the perforation, may be edematous or even polypoid

53
Q

Chronic Suppurative Otitis Media Labs

A

● Labs typically not indicated
● Hearing test
● High-resolution CT scan of the temporal bone
Referral to ENT
● Antibiotics (topical quinolones), microscopic debridements, surgery

54
Q

Mastoiditis

A

● Complication of AOM
○ The infection spreads beyond the
mucosa of the middle ear
○ Streptococcus pneumoniae ~ 25%
● Osteitis within the mastoid air-cells
● Possible subperiosteal abscess

55
Q

5 Stages of Mastoiditis Development

A

○ Hyperemia of the mucosal lining of the mastoid air cells
○ Transudation and exudation of fluid and/or pus within the cells
○ Necrosis of bone by loss of vascularity of the septa
○ Cell wall loss with coalescence into abscess cavities
○ Extension of the inflammatory process to contiguous areas

56
Q

Mastoiditis presentation

A

● Lethargy/Malaise (96%)
● Abnormal appearing TM (82%)
● Postauricular erythema/tenderness/swelling/protrusion (80%)
● Ear pain (67%)
● Otorrhea (50%)
● Persistent fever despite treatment (76%)
● AOM >3 weeks
● Hearing loss
● Children < 2 years of age

57
Q

Mastoiditis exam

A

● Tenderness and inflammation over the
mastoid process (periostitis)
● Subperiosteal abscess displaces the
auricle laterally (seen on last slide)
● Otoscopic exam
○ Otitis media
○ Swelling of external auditory canal
○ Otorrhea (+/-)

58
Q

Mastoiditis labs/imaging

A

○ CBC w/diff (left shift)
○ ESR and/or CRP (elevated)
● Possible audiometry
● Imaging
○ High resolution CT scan of the
temporal bone

59
Q

Treatment of Osteitis

A

● Acute mastoiditis without osteitis
○ 2-week course of broad-spectrum oral antibiotics
○ Possible tympanocentesis
● Acute mastoiditis with osteitis/periostitis
○ Broad spectrum antibiotics (likely IV – requires hospital admission)
○ Refer to ENT

60
Q

Eustachian Tube Dysfunction

A

Eustachian tube is blocked or does not open properly

61
Q

When the Eustachian tube does
not function properly, ____
____ occurs behind the TM

A

negative pressure

62
Q

Eustachian Tube Dysfunction risk factors

A

● Family history
● Children under age 6: Eustachian tubes shorter and run horizontally

63
Q

Eustachian Tube Dysfunction symptoms

A

● Muffled hearing
● Otalgia
● Ear fullness
● Difficulty “popping” the ears
● Tinnitus
● Dizziness/Balance disturbance

64
Q

Eustachian Tube Dysfunction ear exam

A

○ May appear relatively normal if
mild-moderate
○ Dull appearing TM
○ Decreased light reflex
○ Retraction pocket

65
Q

Eustachian Tube Dysfunction treatment

A

● Nasal decongestant spray
○ Oxymetazoline (Afrin)
■ Rebound congestion (rhinitis medicamentosa)

66
Q

When an ENT referral is needed with Eustachian Tube Dysfunction

A

○ Recurrent unilateral in an adult –
nasopharyngoscopy
○ Myringotomy and/or tube placement

67
Q

Eustachian Tube Dysfunction Complications

A

● Decreased hearing
● Otitis Media (OM)
● Cholesteatoma

68
Q

Cholesteatoma

A

Presence of squamous epithelium in the middle ear or mastoid
- Erode and destroy the ossicles and other
structures within the temporal bone
- May cause meningitis or brain abscess if left untreated

69
Q

How is Cholesteatoma acquired?

A

● Acquired Primary
○ Chronic rectration of the TM – secondary
to eustachian tube dysfunction
● Acquired Secondary
○ Squamous epithelial migration from a
TM perforation (CSOM) or surgery

70
Q

Cholesteatoma symptoms

A

● Recurrent or persistent
purulent otorrhea
● Hearing loss
● Tinnitus
● Unresponsive to Abx therapy

71
Q

Cholesteatoma Exam

A

● Retracted pars (primary)
● Matrix of squamous
epithelium and often keratin
debris (may or may not be
visible)
● Purulent otorrhea
● TM perforation (secondary)

72
Q

Cholesteatoma Imaging

A

○ In patients whose TM is opaque, further studies, such as imaging, may be required
○ High resolution CT scan of the temporal bone
▪ MRIs are finding a place

EENT Exam 2 (5 decks)

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