Otalgia

Question 1

What are the causes of otalgia?

Answer 1

Otitis externa/media
Furunculosis
Malignant/necrotising otitis externa
Barotrauma
TMJ dysfunction
Referred pain

Question 2

What are the causes of otitis externa?

Answer 2

Excess canal moisture (most common)
Trauma
High humidity
Absence of wax (from self-cleaning)
Narrow ear canal
Hearing aids

Question 3

What are the most common organisms causing otitis externa?

Answer 3

Pseudomonas (main organism)

Staph aureus

Question 4

What is the main differential for otitis externa?

Answer 4

Contact dermatitis

Question 5

What are some of the symptoms of otitis externa?

Answer 5

Discharge
Itch
Pain
Tragal tenderness

Question 6

What are the symptoms and signs of mild otitis externa?

Answer 6

Scaly skin
Some erythema
Normal diameter of external auditory canal

Question 7

What is the treatment for mild otitis externa?

Answer 7

Clean the external auditory canal
Keep ears water-free
Hydrocortisone cream to pinna/acetic acid spray

Question 8

What is the function of acetic acid spray?

Answer 8

Has antibacterial and antifungal properties

Question 9

What are the signs/symptoms of moderate otitis externa?

Answer 9

Painful ear
Narrowed ear canal
Smelly creamy discharge

Question 10

What is the treatment for moderate otitis externa?

Answer 10

Swab for microscopy
Clean the canal
Topical antibiotics +/- steroid drops for up to 7 days

Question 11

Which topical antibiotics are contraindicated in patients with a perforated TM/grommets and why?

Answer 11

Aminoglycosides

Ototoxicity

Question 12

Why should ear drops not be used for more than 7 days? How is this treated?

Answer 12

Troublesome fungal infections

Treated with clotrimazole

Question 13

What is the treatment for pinna cellulitis?

Answer 13

Immediate antibiotics and refer

Question 14

What are the signs/symptoms of severe otitis externa?

Answer 14

Complete occlusion of the external auditory canal

Question 15

What is the treatment for severe external otitis externa?

Answer 15

Insertion of an ear wick (may require ENT referral)

After a few days the ear canal should open up enough for ear cleaning

Question 16

What should you be wary of when treating otitis externa?

Answer 16

Persistent unilateral otitis externa in diabetics/immunosuppressed/elderly - at increased risk of malignant/necrotising otitis externa
Resistant to treatment - can be a sign of malignancy like SCC - do a biopsy

Question 17

What is furnuculosis?

Answer 17

Very painful staphylococcal abscess arising in a hair follicle within the ear canal

Question 18

What is the treatment for furunculosis?

Answer 18

Consider lancing

if there is pinna cellulitis start antibiotics (e.g. flucloxacillin)

Question 19

What is a predisposing factor to furunculosis?

Answer 19

Diabetes

Question 20

What is malignant/necrotising otitis externa?

Answer 20

An aggressive life-threatening infection of the external ear that can lead to temporal bone destruction and base-of-skull osteomyelitis

Question 21

What is the biggest risk factor for malignant otitis externa?

Answer 21

90% of patients with this have diabetes

Question 22

What are the most common organisms causing malignant otitis externa?

Answer 22

Pseudomonas aerginosa
(Though Proteus and Klebsiella can also cause this)

Question 23

What is the treatment for for malignant otitis externa?

Answer 23

Surgical debridement
Systemic antibiotics
Specific immunoglobulins

Question 24

What is barotrauma?

Answer 24

The pressure in the middle ear is not equalised due to occlusion of the Eustachian tube causing damage

Question 25

In what situations is barotrauma most likely to occur?

Answer 25

Descent in an aircraft | Diving

Question 26

What are the symptoms of barotrauma?

Answer 26

Initially severe pain as the drum becomes indrawn | Secondary effusion may occur as transudate/haemotympanum

Question 27

How can barotrauma be prevented?

Answer 27

Not flying with an URTI Decongestants into nose Repeated yawns/swallows/jaw movements

Question 28

What is the treatment for barotrauma?

Answer 28

Supportive if simple Effusions usually clear spontaneoulsy Most perforations heal

Question 29

What causes TMJ dysfunction?

Answer 29

Teeth grinding Joint derangement Stress (may become a chronic pain syndrome)

Question 30

What are the symptoms of TMJ dysfunction?

Answer 30

Earache Facial pain Joint clicking/popping

Question 31

What are the signs of TMJ dysfunction?

Answer 31

Joint tenderness exacerbated by lateral movements of the open jaw Trigger points in the pterygoids

Question 32

What is the treatment for TMJ dysfunction?

Answer 32

Most self-resolve Reassure and explain Simple analgesia

Question 33

What is the specialist treatment for TMJ dysfunction?

Answer 33

Dental occlusion therapy Physiotherapy CBT Surgery (rarely needed)

Question 34

What is the function of cleaning the external auditory canal when treating otitis externa?

Answer 34

Facilitates the application and effectiveness of topical treatments

Question 35

What are the options for cleaning the ear canal?

Answer 35

Gentle syringing/irrigation Dry mopping Microsuction

Question 36

Referred pain to the ear can arise from disease processes in the areas of the sensory nerves supplying the ear. Describe the different nerves that can be affected and how.

Answer 36

CN V (auriculotemporal nerve branch) - dental disease & TMJ dysfunction CN VII (geniculate ganglion) - geniculate herpes (Ramsay Hunt Syndrome) CN IX - glossopharyngeal neuralgia (rare cause of otalgia) - from talking/swallowing CN IX & X - tympanic branch of glossopharyngeal and auricular branch of vagus - tongue, larynx, throat - cancer, tonsillitis, tonsillectomy, quinsy C2, C3 - great auricular nerve - soft tissue injury in neck, cervical spondylosis/arthritis