Middle and External Ear Flashcards
Auricular Hematoma epidemiology
● Direct trauma to the auricle
○ Shearing forces
Auricular Hematoma pathophysiology
● Accumulation of blood between the
cartilage and the skin
● Compromises blood flow to the
cartilage
○ Irregular cartilage formation
○ “Cauliflower Ear”
Treatment for Auricular Hematoma
● Ice
● Moderate compression
● Aspiration
● I & D – within 1 week (ENT)
Auricular Hematoma complications
● Infections
● Deformity
● Conductive hearing loss
Otitis Externa epidemiology
● 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”
Otitis Externa comorbidities
● Hearing aid/obstructive devices
● Trauma
● Dermatological condition (eczema, psoriasis)
● Diabetes
● Immunocompromised
Otitis Externa pathophysiology
● 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
Otitis Externa treatment
● 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
Otitis Externa treatment if fungal
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
What does an Ear Wick do?
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
Malignant Otitis Externa (MOE)
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
How does Malignant Otitis Externa occur?
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
Malignant Otitis Externa (MOE) Treatment
Hospital admission for IV abx
○ Aminoglycosides, antipseudomonal beta-lactams
○ Blood sugar and immunosuppression control
Exostosis and Osteoma
● 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
Osteoma
● 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
Exostosis and Osteoma Exam
● Narrowing of the canals
● Pedunculated bony mass
Exostosis and Osteoma Diagnosis
● High-resolution CT scan of the temporal bone
Exostosis and Osteoma Treatment
● Management of cerumen and otitis externa
● ENT referral for surgical management if indicated
○ Hearing loss
Prevention of Exostosis and Osteoma
Silicone earplugs to those frequently in cold water
Laceration of the Canal epidemiology
Direct trauma
○ Digital
○ Q-tip
○ Bobby pin
○ Car keys/Pen Caps
○ Foreign objects
Laceration of the Canal complications
With prolonged bleeding may need cautery
○ Silver nitrate sticks
○ Aluminum chloride topical (DrySol)
Cerumen Function
● Cleans and protects the EAC and TM
● Emollient
● Creates a difficult environment for bacteria and fungi to thrive
Cerumen Impaction presentation
● Hearing loss
● Earcaches
● Ear Fullness
● Itching
● Dizziness
● Tinnitus
● History of Q-tip, hearing aid, or earbud use
Cerumen Impaction Treatment
● Indication for removal — symptomatic
● Minimal cerumen without evidence of tympanic perforation
○ Mineral oil and hydrogen peroxide
○ OTC ear wax removal kits
Ear Foreign Bodies common items
○ Beads, pebbles, popcorn kernels, tissue paper, cotton, small toys
○ Insects
○ Batteries – liquefactive necrosis, low voltage injury, pressure necrosis
Ear Foreign Bodies presentation
● Asymptomatic – delayed diagnosis
● Fidgeting with ear
● Pain
● Pruritus
● Conductive hearing loss
● Bleeding, odor or discharge
Bullous Myringitis
Inflammation/infection of the tympanic membrane
● Streptococcus pneumoniae, viral
infection such as influenza or RSV
Bullous Myringitis Presentation
● Other URI symptoms
● Acute onset of ear pain
● Sensation of heaviness
● Hearing changes
● Mild discharge
Bullous Myringitis Exam
● 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
Bullous Myringitis Treatment
● 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
Tympanic Membrane Perforation presentation
● Audible whistling sounds/tinnitus
● Discharge from the ear
○ Otalgia resolves following discharge
● Decreased hearing
● Ear fullness
● Vertigo/balance issues
Tympanic Membrane Perforation Treatment
● 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
Tympanosclerosis
Scarring of the TM
○ a.k.a. myringosclerosis
● Occurs after TM injury
Tympanometry
Tympanometry is helpful to determine the mobility of the tympanic membrane and the presence of effusion or perforation.
Tympanogram readings (A-F)
● 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
Serous Otitis Media
otitis media with effusion (OME)
● Collection of non-infected fluid in the middle ear space
○ Nearly always follows AOM
■ Infection resolves, effusion persists
Serous Otitis Media presentation
● Asymptomatic (i.e., painless)
● Hearing loss post AOM
○ Ear feels “full” or “plugged” following an episode of AOM
Serous Otitis Media Exam
● Air-fluid levels, dull or yellowish TM
● Decreased tympanic mobility
○ Tympanometry – Type B
● Conductive hearing loss
Serous Otitis Media Treatment
● 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
Serous Otitis Media Complications
● 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
Acute Otitis Media
● 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
Majority of AOM episodes are triggered by an ____
upper respiratory infection (URI)
Common AOM pathogens
● RSV
● Streptococcus pneumoniae
● Haemophilus influenzae
Acute Otitis Media
● Irritability
● Feeding difficulties
● Fever
● Otalgia and/or tugging at the ears
● Decreased hearing
Acute Otitis Media Exam
TM
○ Inflammation
○ Purulent middle ear effusion
○ Poor tympanic mobility with
pneumatic otoscopy
○ May bulge in the posterior
quadrants
○ Scalded appearance
● Tympanometry may confirm effusion
Acute Otitis Media Treatment
○ 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
Acute Otitis Media Complications
● 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
referred otalgia – “The 5 T’s”
○ Teeth
○ Tongue
○ TMJ
○ Tonsils
○ Throat
Recurrent Otitis Media is defined as
3 episodes within 6 months or 4
or more episodes within 1 year
Chronic Suppurative Otitis Media
● 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
Chronic Suppurative Otitis Media symptoms
● Ear drainage for some time (2-6 weeks)
● Typically, no pain or discomfort
● History of recurrent acute otitis media, traumatic perforation
● Hearing loss
Chronic Suppurative Otitis Media exam
● 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
Chronic Suppurative Otitis Media Labs
● Labs typically not indicated
● Hearing test
● High-resolution CT scan of the temporal bone
Referral to ENT
● Antibiotics (topical quinolones), microscopic debridements, surgery
Mastoiditis
● 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
5 Stages of Mastoiditis Development
○ 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
Mastoiditis presentation
● 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
Mastoiditis exam
● 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 (+/-)
Mastoiditis labs/imaging
○ CBC w/diff (left shift)
○ ESR and/or CRP (elevated)
● Possible audiometry
● Imaging
○ High resolution CT scan of the
temporal bone
Treatment of Osteitis
● 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
Eustachian Tube Dysfunction
Eustachian tube is blocked or does not open properly
When the Eustachian tube does
not function properly, ____
____ occurs behind the TM
negative pressure
Eustachian Tube Dysfunction risk factors
● Family history
● Children under age 6: Eustachian tubes shorter and run horizontally
Eustachian Tube Dysfunction symptoms
● Muffled hearing
● Otalgia
● Ear fullness
● Difficulty “popping” the ears
● Tinnitus
● Dizziness/Balance disturbance
Eustachian Tube Dysfunction ear exam
○ May appear relatively normal if
mild-moderate
○ Dull appearing TM
○ Decreased light reflex
○ Retraction pocket
Eustachian Tube Dysfunction treatment
● Nasal decongestant spray
○ Oxymetazoline (Afrin)
■ Rebound congestion (rhinitis medicamentosa)
When an ENT referral is needed with Eustachian Tube Dysfunction
○ Recurrent unilateral in an adult –
nasopharyngoscopy
○ Myringotomy and/or tube placement
Eustachian Tube Dysfunction Complications
● Decreased hearing
● Otitis Media (OM)
● Cholesteatoma
Cholesteatoma
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
How is Cholesteatoma acquired?
● Acquired Primary
○ Chronic rectration of the TM – secondary
to eustachian tube dysfunction
● Acquired Secondary
○ Squamous epithelial migration from a
TM perforation (CSOM) or surgery
Cholesteatoma symptoms
● Recurrent or persistent
purulent otorrhea
● Hearing loss
● Tinnitus
● Unresponsive to Abx therapy
Cholesteatoma Exam
● Retracted pars (primary)
● Matrix of squamous
epithelium and often keratin
debris (may or may not be
visible)
● Purulent otorrhea
● TM perforation (secondary)
Cholesteatoma Imaging
○ 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
