Middle Ear Flashcards
Causes of otitis media with effusion
Impaired eustachian tube function causing poor aeration of the middle ear.
Low-grade viral or bacterial infection.
Persistent local inflammatory reaction.
Adenoidal infection or hypertrophy.
what is Ramsay hunt syndrome
ndition where reactivation of pre-existing Varicella Zoster virus occurs in the geniculate ganglion.
features of Ramsay hunt syndrome
vesicles on the tympanic membrane. cause pain in the ear, facial paralysis taste loss dry eyes tinnitus vertigo hearing loss.
management for Ramsay hunt syndrome
oral acyclovir and corticosteroids
treatment for idiopathic sudden-onset sensorineural hearing loss
high-dose oral corticosteroids; ENT UK’s guideline recommends: oral prednisolone 1mg/kg/day (maximum 60mg/day) for 7 days and then tapered over the next week.
where does nasopharynx drain into
posterior triangle
what drains into anterior triangle
larynx, buccal mucosa, and tonsillar fossa
nasopharyngeal carcinoma features
epistaxis, headaches, lymph node metastasis or unilateral hearing loss.
define otitis media with effusions OME
- fluid is present in the middle ear with an intact tympanic membrane and is related to eustachian tube dysfunction.
- More common in children
- If it occurs in adults – BE AWARE OF POST NASAL SPACE TUMOURS AS IT CAN CAUSE EUSTACHIAN TUBE DYSFUNCTION
Causes of OME
- Uncertain
- Persistence of OME
o Impaired eustachian tube function causing poor aeration of the middle ear.
o Low-grade viral or bacterial infection.
o Persistent local inflammatory reaction.
o Adenoidal infection or hypertrophy
Risk factors for OME
- MORE COMMON IN THESE CHILDREN
- Primary ciliary dyskinesia
- Allergic rhinitis
Younger child (usually under seven years old)
Male
Multiple runny noses or upper respiratory tract infections
Bottle fed
Parents smoke
Craniofacial abnormalities eg in Down’s Syndrome or patients with cleft palate
Mucociliary abnormalities eg cystic fibrosis
tonsillitits
clinical features of OME
- Conductive hearing loss
o Ass. With speech delay and problems at school - Mild intermittent ear pain with fullness or ‘popping’ may occur
- PERSISTENT FOUL SMELLING DISCHARGE REQUIRES URGENT REFERRAL
- Ask about fluctuations in hearing, lack of concentration, listening skills, speech, balance problems
- Dysequilibrium
• Middle ear effusion on otoscopy
OME examination features
- Abnormal colour of drum – yellow, amber or blue
- Loss of light reflex or a more diffuse light reflex
- Opacification of eardrum
- Air bubbles or an air/fluid level
- Retracted concave or indrawn drum – LESS FREQUENTLY, FULLNESS OR BULGING
investigations for OME
Tympanogram
- Flat (Type B) Tracing with normal canal volume
- Ability of eardrum to react to sound
Pure tone audiogram - Conductive hearing loss
- Visual response – under 2.5 years
- Above 4 conventional audiogram
CHILDREN WITH DOWN’S SYNDROME OR CLEFT PALATE – ASSESSED EVERY 3-6 MONTHS
Treatment for OME
1) conservative – most cases settle within 3 months
o 2 hearing tests
Pure tone audiometry – 3 moths apart with tympanometry
2) Hearing aid – bilateral otits media WHERE SURGER IS CONTRADICTED
o Autoinflation - where you blow thru a balloon 2/3 times a day – ventilating the middle ear and equilibrating pressure and allowing drainage of fluid
o Older children Valsalva manoeuvre
3) Surgery - for prolonged hearing loss causing significant problems
o Grommets (ventilation tubes)
o o +/- Adenoidectomy
- myringiotomy - drain fluid
when to refer to secondary care OME
- 61 dB or greater – requires urgent referral within 2 weeks toe xclude sensorineural deafness
- 2 occasions significant hearing loss
- TM is abnormal
- Persistent foul smelling discharge – cholesteatoma
- Down’s syndroms or cleft palate
complciations of OME
- conductive hearing loss
- educational, developmental, behavioural and social difficulties
- chronic damage to the tympanic membrane
differential diagnosis OME
EAR DISCOMFORT - AOM o Pain, systemic upset - Mastoiditis - Otitis externa – more common in swimmers and adults o Pain or itching - Referred oain - Otitic barotrauma – scuba diving HEARING LOSS - Foreign body in the ear canal - Impacted earwax - Perforated TM - Sensorineural hearing loss
differential diagnosis of OME
EAR DISCOMFORT - AOM o Pain, systemic upset - Mastoiditis - Otitis externa – more common in swimmers and adults o Pain or itching - Referred oain - Otitic barotrauma – scuba diving HEARING LOSS - Foreign body in the ear canal - Impacted earwax - Perforated TM - Sensorineural hearing loss
red flags for OME
Acute otitis media (AOM) with signs of a complication
Unilateral otitis media with effusion in an adult - an urgent outpatient appointment is appropriate
possible pathophysiology of OME
Eustachian tube dysfunction, leading to difficulty in ventilating/equalising the pressure in the middle ear
Chronic inflammatory changes to the middle ear mucosa
why should one be wary if an adult has OME
Nasopharyngeal cancers can present when they occlude the Eustachian tube outflow in the post-nasal space. It is important to perform nasendoscopy in adults with OME to help exclude malignancy.
Nasopharyngeal tumours are relatively more common in southern Chinese populations. This seems to be due to a combination of genetics, EBV infection and diet.
define cholesteatoma
a non-cancerous growth of keratinised stratified squamous epithelium that is ‘trapped’ within the skull base causing local destruction
common age for cholesteatoma
10-20 years
what increases the risk of cholesteatoma
cleft palate
features of cholesteatoma
foul-smelling, non-resolving discharge hearing loss vertigo facial nerve palsy cerebellopontine angle syndrome
otoscopy of cholesteatoma
‘attic crust’ - seen in the uppermost part of the ear drum
- ear discharge
- deep retraction pocket
- crust or keratine upper part of the TM
- TM may be perforated
management of cholesteatoma
patients are referred to ENT for consideration of surgical removal
mastoidectomy
canal up - high recurrence
canal down - low recurrence, loads of wax
risk factors for cholesteatoma
- Male
- 20-40 years
- Middle ear disease
- Eustachian tube dysfunction
- Ontological surgery or traumatic blast to ear
- Congenital abnormalities and genetic syndromes – cleft palate, down’s or turner
- Family history
- Use of bisphosphonates
emergency referral for cholesteatoma
- Facial nerve palsy or vertigo
- Other neuro symptoms
complications for cholesteatoma
- Recurrent ear infections
- Conductive hearing loss
- Labyrinthine fistula
MORE EXTENSIVE - Facial palsy
- Vertigo
- Sensorineural hearing loss
- Meningitis or intracranial abscess
- Mastoiditis
DD for cholesteatoma
- OME
- Otitis externa
- Tympanosclerosis
- Osteonecrosis of the external auditory canal
- Benign necrotising otits externa
- Myringitis
when to presribe ABx for otitis media
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge in the canal
what type of Ab to give in otitis midea
5–day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.
characteristics of acute mastoiditis
severe pain and protrusion of the ear forwards, with a tender, boggy and often reddened mass behind the ear.
complications of acute mastoiditis
intracranial spread cranial nerve palsies hearing loss osteomyelitis carotid artery spasm.
what is bell’s palsy
Bell’s palsy is an acute, unilateral facial nerve weakness or paralysis of rapid onset (less than 72 hours) and unknown cause
causes of bell’s palsy
UNKNOWN
- Inflammation and oedema of the facial nerve
- HSV, varicella zoster and autoimmunity
bell’s palsy common in who
- 15-45
- Diabetes, immunocompromise, obesity, hypertension or URT
- Pregnant
complications of bell’s palsy
- Eye injury, corneal ulceration, vision – INABILITY TO CLOSE EYELID
- Facial pain and paraesteisa
- Dry mouth – loss of parasympathetic
- Synkinesis abnormal facial muscle contraction
- Psych impact of facial disfigurement
The factors that suggest a poor prognosis from a facial palsy include:
- Complete palsy
- No signs of recovery within 3 weeks
- Age >60yrs
- Associated pain
- Ramsay Hunt syndrome
- Associated hypertension, diabetes mellitus, or pregnancy
diagnosis of bell’s palsy
- Rapid onset (less than 72 hours)
- Facial muscle weakness unilateral
- Ear and postauricular region pain on the affected side
- Difficulty chewing, dry mouth and change in taste
- Incomplete eye closure, dry eye (in 30%), eye pain, or excessive tearing -CHEMOSIS/ CONJUNCTIVITIS
- Numbness or tingling of the cheek and/or mouth.
- Speech articulation problems, drooling.
- Hyperacusis (in less than 5%).
management of bell’s palsy
- Full recovery within 3-4 months
- EYE LUBRICATED – day and night – Viscotears QDS and Lacrilube at night REVIEWED BY OPTHAM
- Tape eyelid down
- Wear sunglasses
- Swimming and dusty environments should be avoided
- Use straw or liquid if eating is affected
Bell’s - WITHIN 72 HOURS OF THE ONSET OF SYMPTOMS CONSIDER PREDNISOLONE - 50MG DAILY FOR 10 DAYS
- OR 60MG DAILY FOR FIVE DAYS
round opacity with mixed density in sinus
fungal ball
complications of acute otitis media
Persistent otitis media with effusion.
Recurrence of infection.
Hearing loss (usually conductive and temporary).
Tympanic membrane perforation.
Labyrinthitis.
Rarely, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.
downs syndrome features
dental abnormalities
slanting eyes
abnormal ears
auricular haematoma Tx
incision drainage
