Middle and Outer Ear Conditions

Question 1

• External Ear Conditions

Answer 1

• Otitis Externa
  
  • Otomyxosis
  • Contact dermatitis
  • Chronic Suppurative otitis media
  • Carcinoma of the ear canal
  • Psoriasis

Question 2

• Middle Ear Conditions

Answer 2

• Acute Otitis Media
  
  • Glue ear or Otitis Media with effusion
  • Chronic Otitis Media
    • Benign
    • Serous
    • Suppurative

Question 3

Define Otitis externa

Answer 3

Acute otitis externa (AOE) is a form of cellulitis that involves the skin and subdermis of the external auditory canal, with acute inflammation and variable oedema. It is colloquially called swimmer’s ear.

Question 4

Otitis externa Epidemiology

Answer 4

AOE has a lifetime incidence of 10%, with a yearly incidence of 0.4%. The peak age group is at 7 to 12 yo with a decline in those > 50 yo. It is associated with:

• Swimming
• Mechanical ear cleaning
• Devices like head phones or hearing aids.

Question 5

Otitis externa Pathogenesis

Answer 5

AOE is due to bacterial infection in 90% of cases with Pseudomenas aeruginosa and Staph. aureus the common pathogens.

Question 6

Otitis externa Clinical Presentation

Answer 6

• Pain - This pain is aggravated by the movement of the auricle (traction of pinna or pressure over tragus).
  
  • Pruritus
  • Discharge or otorrhea - Sticky yellow purulent discharge.
  • Hearing loss
  • Post-articular lymphadenopathy

Question 7

Otitis externa Investigations

Answer 7

Otoscopy

The canal is edematous and erythematous. There is cerumen (wax) in the canal and a normal tympanic membrane (the mark of solely existing externa).

Question 8

Otitis externa severity classification

Answer 8

Mild:

• Minimum oedema;
• minor pain
• pruritus.

Moderate:

• Canal partially occluded;
• pain
• pruritus

Severe:

• Occlusion,
• periauricular erythema,
• LN,
• fever;
• intense pain.

Question 9

Management of Acute diffuse otitis externa

Answer 9

Keep the ear canal as dry

• Don’t syringe with water
• Debris removed by dry aural toilet by a health professional either
• mechanical suction under direct vision
• or dry mopping with cotton wool on a thin carrier (not cotton bud).

This is typically followed by:
- Topical Corticosteroids
— Dexamethasone
- Antibiotic Combination Drops
— Dexamethasone 0.05%
— Framycetin 0.5% (aminoglycaside similar to neomycin)
—
Acute localised is usually a furuncle, folliculitis or a boil, associated with a hair follicle and is commonly due to Staph aureus, systemic antibiotics are usually curative.
Systemic antibiotics Di/flucloxacillin 500mg Gramicidin 0.005% (against gram-positive)

Question 10

Management of Acute localised otitis externa

Answer 10

Acute localised is usually a furuncle, folliculitis or a boil, associated with a hair follicle and is commonly due to Staph aureus, systemic antibiotics are usually curative.
Systemic antibiotics Di/flucloxacillin 500mg

Question 11

Management of Recurrent otitis externa

Answer 11

Keeping the ear canals free of water is the mainstay.

• Water exclusion with ear plugs during swimming or showering.

Question 12

Define Otomyxosis

Answer 12

• A fungal infection that can be a primary infection or secondary to antibiotic therapy for bacterial external otitis.

Question 13

Signs of external canal contact dermatitis

Answer 13

• Look out for patients with persistent edema and erythema of the external canal and auricle.

Question 14

Signs of Carcinoma of the ear canal

Answer 14

• A rare disease characterised by mild pain and bloody otorrhea

Question 15

Define Otitis Media

Answer 15

A spectrum of illness with middle ear fluid and inflammation of the mucosa that lines the middle ear space

Question 16

Define acute otitis media

Answer 16

• An acute illness with middle ear fluid and inflammation of the mucosa that lines the middle ear space. The infection is often caused by obstruction of the Eustachian tube (Eustachian tube dysfunction), often due to viral URTI. This results in fluid retention and suppuration (formation of pus) of retained secretions.

Question 17

Define Glue ear or Otitis media with effusion (OME)

Answer 17

• The persistence of middle ear effusion for more than 3 months. Fluid collects in the middle ear space due to negative pressure produced by Eustachian tube dysfunction. The child may have behavioural problems as a result of undetected hearing loss or dull aching otalgia. Over weeks and months, middle ear fluid becomes thick and glue-like causing hearing loss

Question 18

Define Chronic otitis media (COM)

Answer 18

• An ear with tympanic membrane perforation in the setting of recurrent or chronic ear infections.
  
  • Benign: unassociated with active infection
  • Serous: continuous serous (straw-coloured) drainage
  • Suppurative: persistent purulent drainage

Question 19

Epidemiology of otitis media

Answer 19

More than 80% of children experience at least one episode before the age of 2 years with a peak incidence between 6 and 18 months. Children with anatomical abnormalities (cleft palate, cleft uvula) encounter more AOM than their healthy peers.

Question 20

Otitis media aetiology

Answer 20

A result of

• Viral URTI causing Eustachian tube dysfunction
• Rarer bacterial causes are
• • Strep pneumoniae
  • Haem influenzae
  • Moraxella catarrhalis.

Question 21

Otitis media Clinical Presentation

Answer 21

• Pain

* Conductive hearing loss

Question 22

Otitis media Investigations

Answer 22

Otoscopy

• white, bulging tympanic membrane can be seen
• marked erythema along the handle of the malleus
• an air-fluid level in the anterosuperior portion of the tympanic membrane.

Question 23

Otitis media diagnosis

Answer 23

• A history of acute onset of symptoms and signs
  
  • Demonstrable middle air effusion characterised by:
    • Bulging of the tympanic membrane
    • Limited or absent movement
    • Air-fluid level behind the tympanic membrane
    • Perforation with otorrhoea
  • Signs and symptoms of middle ear inflammation, characterised by redness of the tympanic membrane

Question 24

Otitis media management

Answer 24

• Non-pharmacological - Mainstay of treatment
  * Unblock Eustachian tube

     * Steam
     * Blowing up balloons
     * Chewing gum
  
  * Analgesia for otalgia
     * Ibuprofen  * Pharmacological
  * Antibiotics
     * < 2 years or systemic features
        * Amoxycillin

Question 25

Glue ear management

Answer 25

The traditional treatment is ventilation tube (grommet) insertion through the tympanic membrane, which restores hearing in the short term acting as the Eustachian tube. Bacterial infection is only one of many factors that contribute to this condition. Children may benefit from a 10 to 30-day course of amoxycillin.
Indications for referral to an ENT specialist are;

• Effusion for >3 months with educational handicap and/or audiometry showing bilateral hearing loss
• Structural damage to tympanic membrane (significant retraction or cholesteatoma)

Question 26

Chronic Suppurative Otitis Media management

Answer 26

• Aural toilet is very important.

If aural discharge is from a recent perforation (6 weeks) or persisted >6 weeks

• corticosteroid and antibiotic drops:
• – Dexamethasone + Framycetin + Gramicidin