middle ear Flashcards
eustacian tube links?
pharynx to the middle ear
Eustacian tube fx?
Equalize pressure
Mucus drainage
Children are at higher risk of eustacian tube issues due to?
1- Shorter ET
2- Horizontal ET
3- Immature floppy elastic cartilage
4- Larger adenoids
Eustacian tube reaches adult length by what age?
Age 6
ETD (eustacian tube dysfx) S/S to dx?
Aural Fullness
Fluctuating hearing
Discomfort with barometric pressure changes
ETD is at risk of developing?
Otitis media with effusion (OME) AKA - Serous Otitis Media (SOM)
How to assess TM integrity and eustachian tube patency
Valsalva maneuver
Difference between - DILATORY DYSFUNCTION (common) vs PATULOUS DYSFUNCTION (uncommon)?
Dilatory dysfx = stuck closed - cannot dilate
Patulous dyfx = stuck open
Dilatory dysfx can be due to?
Any cause of inflam -Infection – usually viral MC OR -Allergies MC Pressure dysreg (altitudes) Anatomic/congenital ABNL -Downs, Turners
MC cause of ETD?
Allergies
Patulous dyfx can be due to?
Overly patent - hear my body fx - rare/benign
wgt loss as little as 6lbs
Scarring
Atrophy from neuromuscular d/o
Dilatory dysfx S/S
HL, TM retraction/effusion
Patulous dyfx S/S
– autophony, (TM appears normal without HL), movement of TM with inspiration and expiration
Dilatory dysfx TXT
Decongestants for URI AH and/or nasal steroids for allergic rhinitis Smoking cessation Behavioral mod/PPI – acid reflux Frequent valsalva
Patulous dyfx TXT
Mild - ressure and educate, hydrate, NS spray
Sev - Surgery maybe (cartilage graft)
Serous Otitis Media AKA
Otitis Media with Effusion (OME)
SOM patho
ETD dilatory - blocked prolonged time >
Negative pressure middle ear pressure > transudation
SOM S/S
Middle ear fluid w/ut inflam/infection
Viscous bubbles
Conductive HL
Reduced TM mobility
PEDs get SOM due to?
narrow/horizontal ET
Adults may have h/o w/ SOM?
URI
CHronic seasonal allergies
barotrauma
Best way to Dx SOM?
Tympanometry
Adults w/ persistent (>3mo) unilateral SOM req?
R/O nasopharyngeal carcinoma w/ NP endoscopy
SOM TXT?
HL mild > Observe 3mo
Freq valsalva
Rx - if URI/allergic rhinitis (po) CCS, AH, Abx +-
Failure of TXT >
Pressure equalization tube placement
Adenoidectomy (relives nasal obstruct)
Endoscopic orifice widening
TM PE Tubes complications
PE tubes allow water to enter middle ear = recurrent infections.
TM PE tube surgery expectations?
In place 6-18mo > naturally fall out.
TM heals on its own.
AOM essentials of Dx
1 S/S - Otalgia often w/ URI
Erythema,
hypomobile TM
PE Tubes indications
Severe/recurrent AOM
SOM >3mo or >30dB HL
Chronic retraction of TM (ETD)
Surgery/rad/cranial involvement of middle ear
AOM is a sequeala of?
ETD
MC illnesses affecting children?
URI and OM
RFs of getting AOM?
Pacifer/bottle feed
Daycare
2nd hand smoke
What will protect infants from getting AOM?
Breastfeeding
AOM presents PEDs/Adults
Peds- Fever, irritable, crys, ear drainage, altered sleep
Adults - Fever, sudden otalgia onset in affected ear, Mastoid TTP, aural pressure, HL
Dx PE findings *
Decreased TM mobility, bulging TM w/out TM, erythema
Pneumatic otoscopy
MC bacteria of AOM
S. pneumoniae
H. influenza
S. pyogenes = (GABHS)
AOM TXT
Abx, antipyretics/analgesics (Ibuprofen, APAP)
AOM observe for TXT when?
> 2yo
Healthy and mild illness (<102.2 fever)
Able to F/U if worsens
AOM Abx indications for PEDs?
<2yo
no improvement in 48-72h of observation
more severe S/S
AOM 1st line Abx? Resistant?
Amoxicillin
-Amox-clav
AOM #1 S/S? needs what?
Otalgia - (po) analgesic
SNAP is an AOM concept for?
Safety-net approach to Abx prescription
- Prescribe Abx however educate pt/parent to only use Abx if no improvement after 2d
PEDs SE of taking amoxicillin?
Itchy maculopapular rash >72h of initiation (adults too)
- not an allergy/CI to future amoxicillin
Ensure not MONO
X-imm - persistent - recurrent AOM infection req?
Tympanocentesis for Cx
Severe otalgia/complications (mastoiditis/meningitis) req?
Myringotomy
Recurrent AOM def?
≥ 3 distinct episodes of AOM within 6 months, OR
≥ 4 episodes within 12 months
Recurrent AOM TXT in young children?
PE Tubes
COM essentials of Dx *
Chronic otorrhea +- otalgia
TM perf w/ conductive HL (ossicular chain destroyed)
COM is a sequela of?
Recurrent AOM
COM time frame to call it as such?
2w to 3mo
COM is defined as?
Chronic infection of middle ear/astoid that results in Chronic otorrhea thru perforated TM
COM bacteria?
Different from AOM
- P aeruginosa
- Proteus species
- S aureus
- anaerobic bacteria
Hallmark COM S/S?
Purulent D/C thats continuous or intermittent that increases w/ URI or water exposure
Is pain common w/ COM?
No - uncommon (+- exacerbations)
TXT of COM?
Remove debris Earplugs for water (top) Abx drops (ofloxacin, cipro, dexamethasone) (po) cipro Surgical TM repair Mastoidectomy
Complications of otitis media?
Perf TM Cholesteatoma Masoiditis Facial paralysis CNS inf (otogenic meningitis)
TM perf occurs w/ otitis media due to?
Purulence draing down path of least resistance
TM perf TXT
Combo (po)/(top) Abx
- Otic - cirpo or ofloxacin for contaminated ear canals
(po) Abx if infection is present
PVT water into ear
TM perf CI rx
Aminoglycosides
Alcohol
Polymyxin/neomycin
TM perf heals spontaneously if
<25% involvement
Refer TM perf when?
Persists >6w
Chronic perf occurs when/patho?
All 3 layers perf >
If Squamous layer and cuboidal layer meet >
Fibrous layer stop growing
Chronic perf TXT?
Tympanoplasty
Cholesteatoma is?
Epidermal inclusion cyst behind tympanic membrane
Cholesteatoma is due to?
Prolong ETD dysfx/Chronic NEG middle ear pressure
Draws upper flaccid portion of TM in (pars flaccida) >
Creastes squam epi lined sac fill with keratin >
Chroniclly infected
Cholesteatoma presents as?
TM retraction
Perf w/ keratin debris/granulation
SOC for Cholesteatoma?
CT
Cholesteatoma TXT?
Surgical excise - (recurrence common due to inability to remove entire lesion)
ETD dysfx still remains > PE tubes PVT NEG pressure
Mastoiditis evolves from?
Inadq TXT of AOM/COM
Mastoiditis presents as?
Fever, posterior ortalgia and/or erythema over mastoid
Edema of the pinna or displacement of auricle
Protruding auricle & loss of postauricular crease
Mastoiditis mgmt?
CT > Positive > Refer
Mastoiditis CT findings?
coalescence of the mastoid air cells due to destruction of their bony septa
Mastoiditis TXT
IV ABX (cefazolin)
Mastoiditis offending organisms
S pneumoniae,
H influenzae,
S pyogenes
Mastoiditis Abx TXT fails reflex?
Myringotomy for culture and drainage
Mastoidectomy
What is definitive TXT of mastoiditis?
Mastoidectomy - surgical drainage is definitive treatment
Petrous apicitis AKA?
Petrositis
Petrous apicitis is?
Rare AOM complication - infection spreads w/in temporal bone of the petrous apex
Petrous apicitis classic triad presentation?
(Gradenigo syndrome):
- Retro-orbital pain
- AOM (foul smelling discharge)
- CN VI palsy (abducens) lateral rectus/eye abduction)
Petrous apicitis Dx?
Gradenigo syndrome triad +
Rad - bony destructivion of petrous apex
Petrous apicitis TXT?
prolonged Abx based on Cx and surgical drainage
Facial palsy ass/w AOM - notes? Patho/TXT/prognosis
Inflam of CN VII in middle ear
TXT: myringotomy for drainage and Cx, + IV Abx
Good prognosis
Facial palsy ass/w COM - notes?
Evolves slowly - due chronic CN VII pressure by cholesteatoma
TXT: surgical correction of cholesteatoma
Less favorable prognosis than AOM
MC intracranial complication of ear infections? TXT?
Otogenic meningitis - myringotomy
Tympanosclerosis is
Formation of hyaline deposits and calcification in the TM
What causes Tympanosclerosis plaques?
Injuries to the eardrum, PET and chronic disease in the middle ear
Tympanosclerosis evolve to what S/S?
Deposits cause CHL due to decrease mobility of TM and immobilization of ossicular chain.
Tympanosclerosis Dx
Pneumatic otoscopy - decreased/absent mobility
Otosclerosis is
ABNL bony growth on footplate of stapes that results in HL (max 60dB) > impedence of sound through ossicular chain
Otosclerosis max HL?
60dB
Otosclerosis presents as?
Slow progressive unilateral or bilateral CHL
Onset in early life (3rd-4th decade)
Dx of Otosclerosis req to R/O other causes of CHL w/?
CT/MRI
Weber/Rinne
Tympanometry
Otosclerosis TXT? Mild/sev
Unilateral and mild CHL - Observation
NL cochlear Fx + speech discrimination - Amplification
Sev- Surgery: stapes prosthesis (stapedectomy)
Barotrauma is? due to?
If equalization does not occur > TM will retract from negative pressure > -Air travel -Diving -Blast injuries
Barotrauma PE findings?
TM retraction, hemotympanum, +/- perforation
Barotrauma Dx?
Clinical
Barotrauma PVT?
Avoidance - Swallow, Yawn, Valsalva, chew gum
Rx - Pseudoephedrine/Oxymetazoline - prior to descent
Ventilating tubes if freq flier
Barotrauma TXT?
Most resolve spon
TXT if ETD
- analgesics
-Abx PRN
When to refer Barotrauma to ENT?
Severe otalgia, HL, Vertigo, >4-5d persistence, Blast injury
When/how to TXT Barotrauma?
Ossicular disruption or perilymphatic fistula
- Myringotomy (Also PVT)
Impact injury or explosive acoustic trauma can cause?
TM perforation
Hemotympanum
Disruption of ossicular chain
TM perf - notes
Heal spon usually
LRG perf may req tympanoplasty
Hemotympanum can occur due to?
Blunt trauma
Extreme barotrauma
Hemotympanum TXT?
None - heals spon over several weeks
> 30dB CHL >3mo may indicate?
Disruption of ossicular chain
Disruption of ossicular chain TXT?
Middle ear exploration w/ reconstruction of ossicular chain and TM repair
Mgmt for TM?
Signs of inf > Abx
HL
Refer ENT/Audiology PRN
Mgmt for TM w/out comorbids/HL?
Observe
Avoid water in ears (No swimming)
F/U 2-3mo
Primary middle ear tumors type?
Glomus tumor
Glomus tumors patho
arise i middle ear or in jugular bulb with upward erosion into hypotympanum
Glomus tumors present as?
Pulsatile tinnitus and CHL
LRG tumors > CN neuropathies
Glomus tumors PE
Vascular mass may be visible behind intact TM
Glomus tumors TXT?
requires surgery, radiotherapy, or both
Pulsatile tinnitus finding always reqs?
magnetic resonance angiography and venography to rule out a vascular mass
Earache w/ pain out of proportion?
Herpes zoster oticus, esp. when vesicles in EAC or auricle
Earache w/ Persistent pain and discharge?
Osteomyelitis of the skull base or cancer
Non-otologic causes of earche
TMJ dysfx (chewing - bruxism or malocclusion)
CN V, VII, IX, X and upper cervical nerve issues
Glossopharyngeal neuralgia
Inf/neoplasma of oropharynx, hypopharynx, and larynx
Repeated episodes of severe lancinating otalgia (pain in the back of the throat and in the ear) indicate?
Glossopharyngeal neuralgia
Glossopharyngeal neuralgia mgmt after TXT failures?
Microvascular decompression of CN IX is required
TMJ dysfx mgmt?
Soft diet, heat to masticatory muscles, massage, NSAIDs, and dental referral
Persistent earache reqs?
refer to R/O cancer of upper aerodigestive tract