Otalgia Flashcards
What is otalgia?
Earache
What are some causes of otalgia arising from the pinna and ear canal?
- Otitis externa
- Malignant otitis externa
- Infection (E.g. folliculitis, cellulitis, perichondritis, candida, Herpes-zoster, HSV)
- Sebaceous cyst
- Squamous cell carcinoma of ear canal
- Trauma with cleaning techniques
What is otitis external?
Inflammation of the outer ear canal
What are some causes of otitis external?
Infection (Most common)
Inflammation in response to shampoo or ear drops
What are some bacterial causes of otitis external?
Staph. aureus
Proteus spp.
Pseudomonas aeruginosa
What are some fungal causes of otitis external?
Aspergillus niger
Candida albicans
What are some common triggers of otitis external?
Water exposure
Cotton buds
Skin conditions
What are some symptoms of otitis externa?
- Redness and swelling
- Possibly itchy (In early stages)
- Otalgia
- Discharge or increased wax
- Possible hearing loss if blocked by swelling or secretions
What condition is shown?
Otitis externa
What management options are available in otitis external?
General advice
Topical aural toilet
Antimicrobials if unresponsive
Systemic antibiotics if severe (E.g. cellulitis)
What topical antimicrobial is used in bacterial otitis media?
Gentamicin
What topical antimicrobial is used in fungal otitis media?
Clotrimazole
What are some pieces of general advice given to patients with otitis externa?
- Keep water out of the ear
- Avoid traumatising with e.g. cotton buds
- Keep hearing aids out as much as possible
What management option is there for eczematous otitis externa?
Steroid with no antibiotic (Antibiotic may cause local sensitivity)
How are antibiotics applied in cases where the external ear canal is very oedematous and swollen?
A wick or dressing may be used to carry the drops past the swollen skin
What are the most common tumours found within the ear canal?
SCCs and BCCs of the pinna or ear canal
What are some other tumours found within the ear?
- Ceruminous adenoma
- Ceruminous adenocarcinoma
- Meningioma
- Middle ear adenoma
- Aggressive papillary tumour
- Vestibular schwannoma (Acoustic neuroma)
How will SCCs of the ear present?
- Firm, red nodules and sores on skin of the ear
- Discomfort in the affected ear
- Hearing problems
- Tinnitus
- Vertigo
What are some causes of otalgia arising from the tympanic membrane?
- Barotrauma
- Myringitis (Ramsay Hunt syndrome, Myringitis bullosa)
- Inflammation secondary to otitis media
What are some causes of otalgia arising from the middle ear?
- Cholesteatoma
- Otitis media
- Otitis media with effusion (OME)
- Malignant otitis
What is malignant otitis externa?
Invasive infection of the bone surrounding the ear canal (i.e. the mastoid and temporal bones)
What is the most common cause of malignant otitis externa?
Pseudomonas aeruginosa
What are some risk factors for developing malignant otitis externa?
Diabetes
Radiotherapy to the head and neck
What are some symptoms of malignant otitis externa?
Pain and headache, more severe than clinical signs would suggest
What are some signs of malignant otitis externa?
- Granulation tissue at bone-cartilage junction of ear canal
- Exposed bone in the ear canal
- Facial nerve palsy
What are some investigations required in malignant otitis externa?
- Plasma viscosity/CRP
- Radiological imaging
- Biopsy and culture to demonstrate extent of the osteitis and its cause
What will happen in malignant otitis externa without treatment?
Osteomyelitis will progressively involve the skull and meninges, leading to death
What are some treatment options used in malignant otitis externa?
- Correction of immunosuppression (when possible)
- Local treatment of the auditory canal (e.g. cleaning and debridement, topical antibiotics)
- Long-term systemic antibiotic therapy
- Surgery in selected patients
What is a cholesteatoma?
Growth consisting of keratinising squamous epithelium in the middle ear and/or mastoid process; non-cancerous but destructive and expanding
What are the causes of acquired cholesteatoma?
Chronic otitis media
Perforated tympanic membrane
What causes congenital cholesteatoma?
Proliferation of the embryonic crest
What is a risk factor for cholesteatoma?
History of frequent ear surgery
Describe the pathophysiology of a cholesteatoma
- Keratin becomes trapped and builds, usually in areas of retraction (Sucking in) of the tympanic membrane
- As this mass expands, it erodes into surrounding bone, tissue, nerves and into the inner ear
What are the 2 forms of cholesteatoma?
Macro-cholesteatoma
Micro-cholesteatoma
What are the features of a macro-cholesteatoma?
Pearly white mass in the middle ear
What are the features of a micro-cholesteatoma?
Squamous epithelium with abundant keratin production, which is associated with inflammation
How does cholesteatoma in the early stages present?
- Asymptomatic
- Unilateral discharge (Often foul smelling)
- Conductive hearing loss
- Tinnitus
What are some rarer symptoms of progressive cholesteatoma?
- Vertigo
- Sensorineural hearing loss
- Facial nerve palsy
- Meningitis
- Intracranial abscess
- Venous sinus thrombosis
What will be seen on otoscopy in cholesteatoma?
Visible retraction of the tympanic membrane, showing a defect full of cheesy, white material
What is shown?
Cholesteatoma
How is a cholesteatoma managed?
Usually requires mastoid surgery to remove the sac of debris and reconstruction
What is acute otitis media?
Inflammation of the middle ear accompanied by the symptoms and signs of acute inflammation with/without an accumulation of fluid
Who is most at risk of acute otitis media and why?
Predominantly disease of infants and children, because they have a smaller eustachian tube, so infection is more likely to extend up
What causes otitis media?
Often viral infection ascending the Eustachian tube from the throat, with bacterial secondary infection
What are the most common causative bacteria of acute otitis media?
H. influenzae
Strep. pneumoniae
Strep. pyogenes
What are the most common causative organisms of chronic otitis media?
Pseudomonas aeruginosa
Staph. aureus
Fungal
What are some symptoms of acute otitis media?
- Ear pain
- Fever
- Irritability
- May have hearing loss
What are some signs of acute otitis media?
- Ear appears inflamed
- Middle ear effusion may be present
- Opaque tympanic membrane
- Bulging typanic membrane may be present
- Mobility of tympanic membrane may be impaired
What is shown?
Acute otitis media (Bulging, red, inflamed)
What investigations are used in acute otitis media?
Otoscopy
Swab of pus if eardrum perforates
How is acute otitis media managed?
- 80% resolve in 4 days without antibiotics
- Amoxicillin/erythromycin if indicated
What are some possible complications of acute otitis media?
- Sensorineural hearing loss
- Tinnutus
- Acute mastoiditis
- Brain abscess/meningitis
- Vertigo
- Facial palsy
- Brain abscess/meningitis
- Venous sinus thrombosis
What is otitis media with effusion (OME) also known as?
Glue ear or serous otitis media (SOM)
What is OME?
Inflammation of the middle ear accompanied by accumulation of fluid without the symptoms and signs of acute inflammation
Who is most at risk of OME?
Children aged 2-8
What causes OME?
Eustachian tube dysfunction or obstruction with infection of the middle ear
What are the most common organisms in OME?
Strep. pneumonae
H. infuenzae
Moraxella catarrhalis
What are some risk factors for developing OME?
- Day care
- Older siblings
- Smoking household
- Recurrent URTI
- Craniofacial/genetic abnormalities
- Prematurity
- Immunodeficiency
What are some possible causes of OME in adults?
- Rhinosinusitis
- Nasopharyngeal carcinoma or lymphoma
What are some symptoms of OME?
- Asymptomatic
- Hearing loss leading to:
- Poor school performance
- Behavioural problems
- Speech and language delay
- Poor balance
- No otalgia
What are some signs of OME?
- Middle ear effusion - visible fluid/bubbles
- Altered TM colour
- TM retraction
- Impaired tympanic membrane mobility
What is shown?
Otitis media with effusion (OME)
What investigations are required in OME?
Otoscopy
Rinnes and Weber’s tests
Audiometry and tympanometry possibly in adults
What will Rinnes and Weber’s tests show in OME?
Conductive hearing loss
How is OME managed normally?
- ‘Watchful waiting’ and explain to parent - generally a transient condition, 90% resolved after 3 months
- Review at 3 months - otoscopy, hearing assessment if relevent
When should a child with OME be referred to surgery?
- Persistent (over 3 months) bilateral OME
- CHL >25dB
- Speech/language problems
- Developmental/behavioural problems
What is the surgical management of a child under 3 with OME if required?
Grommets
What is the 1st intervention surgical management of a child over 3 with OME if required?
Grommets
What is the 2nd intervention surgical management of a child over 3 with OME if required?
Grommets and adenoidectomy
What is a grommet?
A vent placed in the eardrum which allows fluid drainage
What is shown?
Grommet for the treatment of OME
What are some complications of grommets?
- Infection/discharge
- Early extruction
- Retention
- Persistent perforation
- Swimming/bathing issues
What management option can be used to help reduce speech and language delay alongside treatment?
Hearing aids
What is involved in tympanometry?
What are some pathologies that can cause referred otalgia?
- Trigeminal nerve pathology
- Facial nerve pathology
- Glossopharyngeal nerve pathology
- Vagus nerve pathology
- TMJ pathology
- Acute mastoiditis
What branch of the trigeminal nerve most commonly causes referred otalgia?
V3
What structures are supplied by CN V3?
Anterior 2/3rds tongue
Inferior oral cavity
Palate
Lower teeth
Mandible
Salivary glands
What other trigeminal nerve branch often causes referred otalgia?
Auriculofacial nerve - Joins with lingual nerve, buccal nerve and inferior alveolar branch, joining at the trigeminal ganglion
What are some CN V3 pathologies that can cause referred otalgia?
Teeth
TMJ
Tongue
Salivary gland (E.g. Infection, stones)
What structures are supplied by the facial nerve?
Sphenoid sinus
Nasal mucosa
Posterior ethmoid sinus
Soft plate
What are some pathologies of the facial nerve that can cause referred otalgia?
- Genticulate herpes (Ramsay Hunt syndrome)
- Sphenoid or ethmoidal pathology
- Nasal pathology
What is supplied by the glossopharyngeal nerve?
Posterior 1/3rd of tongue
Inferior nasopharynx
Pharyngeal space
Retropharyngeal space
Tonsillar fossa/pillars
Why can the facial nerve cause referred pain?
The vision nerve and greater petrosal nerve of CN VII join with the posterior auricular nerve at the gesticulate ganglion
Why can the facial nerve cause referred otalgia?
Auriculofacial nerve is also a branch of CN V which joins with lingual nerve, buccal nerve and inferior alveolar branch, joining at the trigeminal ganglion
Why can the glossopharyngeal nerve cause referred otalgia?
Pharyngeal, lingual and tonsillar branches of IX join with tympanic nerve and tympanic plexus of IX at the superior glossopharyngeal ganglion, causing referred pain
What are some glossopharyngeal pathologies that can cause referred otalgia?
Tonsillitis
Carcinoma of the tongue
Glossopharyngeal neuralgia
What structures are supplied by the vagus nerve?
Supraglottic larynx
Laryngeal and lingual surfaces of epiglottis
Lower pharynx
Why can the vagus nerve cause referred otalgia?
Internal laryngeal ranch of superior laryngeal nerve and pharyngeal branch of CN X joins with tympanic nerve and plexus and auricular nerve at the superior vagal ganglion, causing referred pain
What are some vagus nerve pathologies that can cause referred otalgia?
Foreign bodies in piriform fossa (Fishbones)
Carcinoma of piriform fossa
Laryngeal carcinoma
Sepsis
What is acute mastoiditis?
Complication of acute otitis media involving infection of the mastoid air cells
How can otitis media spread to the mastoid air cells?
Via the mastoid aditus in the tympanic cavity
What are the most common bacterial causes of acute mastoiditis?
Strep. pneumoniae
H. influenzae
Why is the mastoid susceptible to bacterial growth?
The mastoid air cells are a suitable site for pathogenicreplication due to their porous nature
How will acute mastoiditis present?
Pain, tenderness and swelling behind the ear
What is shown?
Acute mastoiditis
What investigations are required in acute mastoiditis?
Imaging (CT, MRI)
What is the management of acute mastoiditis?
IV antibiotics and some cases may require surgical drainage
What is a possible complication of acute mastoiditis?
The mastoid process itself can get infected, and this can spread to themiddle cranial fossa, and into the brain, causingmeningitis
