Otalgia, Ear discharge, Hearing loss Flashcards
What is otitis externa
Inflammation of the outer ear canal
Aka swimmer’s ear
Causes of otitis externa
Bacterial infections (S aureus, Proteus spp, pseudomonas aeruginosa)
Fungal infections (aspergillus, candida)
Triggers (water, cotton buds, skin conditions)
What are the bacterial causes of otitis externa
S aureus
Proteus spp.
Pseudomonas aeruginosa
What are the fungal causes of otitis externa
Aspergillus
Candida
Common causative pathogens of otitis externa
Pseudomonas
S aureus
What are the common triggers of otitis externa
Water
Cotton buds
Soap, shampoo
Skin conditions - eczema, seborrheic dermatitis, psoriasis
Symptoms of otitis externa
Redness, swelling of outer ear canal
May be itchy
May become sore and painful
May have discharge
Hearing loss if canal is blocked by discharge / swelling
Management of mild otitis externa
Topical acetic acid
Keep ear dry
Management for severe otitis externa
Topical antibiotics or anti fungal +/- steroids drops if more severe
Which topical antibiotic drop to use for bacterial cause of severe otitis externa
Topical gentamicin
Add steroids if cellulitis develops
Which topical anti fungal drop is used for fungal causes of severe otitis externa
Topical clotrimazole
Add steroids if cellulitis develops
management of otitis externa caused by eczema
Topical steroid drops
Avoid topical antibiotics because it can cause local sensitivity
Management of otitis externa when there is significant swelling
Use pope wick to apply topical antibiotics - pope wick ensures that the antibiotic ear drops are in constant contact with the inflamed ear canal
When is oral antibiotics indicated in otitis externa
Cellulitis beyond ear canal
Very significant swelling hence Wick cannot be inserted
Immunocompromised
Diabetics
What is acute otitis media
Inflammation of the middle ear due to infection
Who does acute otitis media commonly affect
Infants and children after viral URTI
How does a viral URTI cause acute otitis media
The infection travels up to the ear via Eustachian tube
Why are children more susceptible to acute otitis media after viral URTI
Children’s Eustachian tube is shorter and less angled, making it easier for pathogens to enter the middle ear cavity
Children have immature immune system
Causes of acute otitis media
Bacterial
Viral
Bacterial causes of acute otitis media
Strep pneumoniae (most common)
H. influenza
Viral causes of acute otitis media
RSV
Rhinovirus
Adenovirus
Influenza virus
Symptoms of otitis media in children
Fever
Irritability
Difficulty feeding
Holding / tugging ear
Symptoms of otitis media in adults
Fever
Otalgia
Hearing loss
Clinical signs of otitis media
Middle ear effusion
Feeling of aural fullness -> discharge and relief of pain when tympanic membrane perforates
Diffuse erythema
May have Bulging of tympanic membrane
Investigations for acute otitis media
Clinical
Swab if tympanic membrane perforates
Management of acute otitis media
Admit any children under 3 months with a temperature of 38 or more
Paracetamol, ibuprofen
Most resolve without antibiotics
Delayed antibiotic prescribing strategy - if symptoms don’t improve after 4 days
Immediate antibiotic prescription to children who are unwell but do not need admission / perforated TM
When should you admit a patient with acute otitis media
Children under 3 months with a temperature of >38
Children with suspected complications of acute otitis media
When are antibiotics used in otitis media
Delayed - if symptoms do not improve after 3-4 days
Immediate
When is immediate antibiotic prescription indicated for otitis media
Symptoms not improving after 4 days
Unwell but does not need admission
Immunocompromised
Children under 2 with bilateral AOM
Otitis media with perforation
Complications of acute otitis media
Facial palsy
Mastoiditis
Petrositis
Labrynthitis
Vertigo
Brain abscess
Meningitis
Sigmoid sinus thrombosis
What is mastoiditis
When the infection (otitis media) spreads into the mastoid air spaces of temporal bone
Why can otitis media cause mastoiditis
Because infection can spread to mastoid air cells via aditus to mastoid antrum (an opening at posterior wall of middle ear cavity)
Signs of mastoiditis
Erythematous Swelling behind the ear, pushing the auricle outwards and forwards
Investigations for mastoiditis
CT
MRI
Management of mastoiditis
IV antibiotics
Surgical drainage
Mastoiditis secondary to otitis media can further lead to
Meningitis
What is petrositis
When the infection spreads into the apex of petrous temporal bone
Petrositis secondary to otitis media can develop into a serious syndrome. What is the clinical triad of this syndrome
Gradenigo syndrome
Otitis media + Facial pain + Diplopia (due to abducens nerve (CN VI) palsy
Why can otitis media cause petrositis
Due to petrous part of temporal bone being the roof of middle ear cavity
Clinical signs of meningitis
High fever
Non-blanching rash
Photophobia
Neck stiffness
Headache
Vomiting
What is labrynthitis
Inflammation of the semicircular canals in inner ear cavity
Symptoms of labrynthitis
Vertigo
Nausea
Imbalance
Vomiting
What is sigmoid sinus thrombosis
When infection from the adjacent mastoid spreads into the venous wall and forms a thrombus
Symptoms of sigmoid sinus thrombosis
Swinging pyrexia
Meningitis
Sepsis
What is malignant otitis externa
Invasive infection of the bone surrounding the outer ear canal - mastoid and temporal bones
Most common cause of malignant otitis externa
Pseudomonas aeruginosa
Risk factors for malignant otitis externa
Diabetes
Radiotherapy to head and neck
Symptoms and signs of malignant otitis externa
Severe pain, headache
Pain on chewing
Facial nerve palsy - weakness in muscles of face
Exposed bone in ear canal
Granulation tissue in external canal
What does granulation tissue in malignant otitis externa look like
red/purple fleshy tissue
Usually on the floor of ear canal
Investigations for malignant otitis externa
Bloods - CRP, plasma viscosity
Imaging
Biopsy and culture
Management of malignant otitis externa
Refer to ENT
Topical ciprofloxacin
Describe the sensory innervation of the auricle
Auriculotemporal branch of trigeminal CN V3
- medial superior part of concha
Greater auricular nerves C2 C3
- Lateral and anterior surface of helix
Lesser auricular nerves C2 C3
- Posterior surface of helix
Facial nerve
- small parts of concha
Describe the sensory innervation of the external ear canal
Auriculotemporal branch of trigeminal nerve
- superior and anterior
Auricular branch of vagus nerve
- inferior and posterior
Describe the sensory innervation of the external surface of tympanic membrane
Auricular branch of vagus CN X
- posteroinferior of tympanic membrane
Facial nerve
-posterosuperior of tympanic membrane
Auriculotemporal branch of CN V3
- anterior of tympanic membrane
Describe the sensory innervation of the internal surface of tympanic membrane
Tympanic branch of glossopharyngeal nerve
Describe the sensory innervation of the middle ear cavity
Tympanic branch of Glossopharyngeal nerve CN XI
Nerves that causes referred otalgia
Trigeminal CN V3 (auriculotemporal)
Vagus CN X
Sensory branch of Facial nerve CN VII
Glossopharyngeal CN IX
Spinal nerves C2 C3
Glossopharyngeal nerve provides general sensory innervation to
Middle ear cavity
Internal surface of tympanic membrane
Eustachian tube
Oropharynx
Nasopharynx
Posterior 1/3 of tongue
What pathologies can cause referred otalgia due to glossopharyngeal nerve
Tonsillitis
Post-tonsillectomy
Pharyngitis
Carcinoma at posterior 1/3 of tongue
Mandibular division of trigeminal nerve CN V3 provides general sensory innervation to
External ear canal and area above concha
External surface of tympanic membrane
Lower lip
Chin
Anterior 2/3 of tongue
Lower molar, incisor, canine teeth and gingiva
Parotid gland
Which nerve provides special sensory innervation to the tongue
Anterior 2/3 - lingual nerve (branch of facial nerve)
Posterior 1/3 - glossopharyngeal (provides both general sensory and special sensory)
What pathologies can cause referred otalgia due to auriculotemporal trigeminal nerve CN V3
Dental abscess
Dental caries
Infection / piercing of anterior 2/3 of tongue
Infection of salivary glands
Facial nerve gives sensory innervation to
External ear
External surface of tympanic membrane
Ethmoid sinus
Maxillary sinus
Nasal mucosa
Pathologies that can cause referred otalgia due to facial nerve
Sinusitis
Nasal pathology - foreign Bodies
Vagus nerve provides sensory innervation to
Laryngopharynx and larynx
External ear and surface of TM
Pathologies that causes referred otalgia due to vagus nerve
Foreign bodies in piriform fossa
Carcinoma of piriform fossa
Carcinoma of larynx
Piriform abscess
What is chronic otitis media
A group of conditions that causes inflammation of the middle ear cavity for 3 months or more
Conditions consisted in chronic otitis media
Benign chronic otitis media
Chronic secretory otits media (glue ear)
Chronic suppurative otitis media
What is benign chronic otitis media
Dry tympanic membrane perforation without chronic infection
What is chronic secretory otitis media (glue ear)
Inflammation of the middle ear + accumulation of fluid without symptoms and signs of acute inflammation (often asymptomatic)
What is chronic suppurative otitis media
Persistent purulent drainage through the perforated tympanic membrane
Complications of chronic otitis media
Hearing loss
Perforation
Cholesteatoma
Mastoiditis
Meningitis
Labrynthitis
What is cholesteatoma
Growth of keratinising squamous epithelium cells in middle ear that can erode into mastoid air cells
Cholesteatoma commonly occurs in
young patients 5-15 years old
Cholesteatoma can be acquired or congenital. What are the causes of each
Acquired - due to chronic otitis media or perforated tympanic membrane
Congenital - proliferation of fragment embryonic tissue that has been retained
Histology of cholesteatoma will show
Squamous epithelium with a lot of keratin production
Inflammatory infiltrates
Symptoms of cholesteatoma
May be asymptomatic
Foul smelling discharge
Headache
Otalgia
Conductive hearing loss
otoscope findings for cholesteatoma
Otoscopy
- visible retraction before development of cholesteatoma
- defect in tympanic membrane full of cheesy white material at the top
Management for cholesteatoma
Mastoid surgery
Complication of mastoidectomy
Facial nerve palsy
Complications of cholesteatoma
Facial nerve palsy
Vertigo
Meningitis
Intracranial abscess
Sigmoid sinus thrombosis
Risk factors for otitis media with effusion (glue ear)
Day care
Older siblings
Smoking household
Recurrent URTI
Craniofacial abnormalities (Down syndrome)
Prematurity
Immunodeficiency
Otitis media with effusion most commonly occurs in
Children 2-8 years old , but can occur at any age
Cause of otitis media with effusion
Eustachian tube dysfunction - fluid builds up due to blocked Eustachian tube unable to drain it from middle ear cavity to the nasal cavity
Cause of otitis media with effusion in adults
Rhinosinusitis
Nasopharyngeal carcinoma or lymphoma (causes Eustachian tube dysfunction)
How does nasopharyngeal carcinoma cause Eustachian tube dysfunction
Block / narrow the Eustachian tube
Otitis media with effusion is often preceded by
Recurrent URTI
Recurrent otitis media
Frequent nasal obstruction
Is otitis media with effusion an infection
No, it is not but it can be a consequence of an infection
Symptoms of otitis media with effusion in children
Often asymptomatic
No otalgia
Hearing loss can lead to poor school performance, behavioural problems, speech delay, impact on balance
Hearing loss in children can have a huge impact on them. What are the consequence of hearing loss in children
Poor school performance
Delayed speech development
Behavioural problems
Poor balance
Investigations for otitis media with effusion
Otoscopy
Tuning fork tets
Audiometry
Tympanometry
What would otoscope show in a patient with otitis media with effusion
Visible fluid / bubbles = effusion
Retraction of tympanic membrane - due to Eustachian tube dysfunction causing decreased pressure in ear
Altered tympanic membrane color
Reduced mobility of tympanic membrane
What does tympanometry measure
How well the tympanic membrane moves
What pattern would tympanometry show in a patient with otitis media with effusion
Flat tracing = stiff tympanic membrane
What pattern would audiometry show for otitis media with effusion
Conductive hearing loss
What is conductive hearing loss
Hearing loss due to obstruction of sound waves at any point in the outer ear and foot plate of stapes in the middle ear
What pattern does conductive hearing loss cause on audiometry
Difference between bone conduction and air conduction at least 10db
Bone conduction > air conduction
Management of otitis media with effusion
Generally self limiting - resolves after 3 months
Review at 3 months (otoscope, hearing assessment)
Refer Down syndrome patients w OME to ENT
Surgery if indicated
When is surgery indicated for otitis media with effusion
Persistent glue ear (over 3 months)
Conductive hearing loss > 25dB
Speech / language problems
Developmental / behavioural problems
Surgical management for Otitis media with effusion
Grommets
Grommets + adenoidectomy
Complications of grommets
Infection
Early extraction
Retention
Persistent perforation
Causes of conductive hearing loss
Otitis media with effusion
Ear wax
Perforation of tympanic membrane
Chronic suppurative otitis media
Ear infections
Otosclerosis
Cholesteatoma
What is otosclerosis
Hereditary disorder in which new bony deposits occur within the stapes footplate and the cochlear
Otosclerosis causes a distinct pattern on audiometry. What is the pattern
Conductive hearing loss pattern
+ Carhart’s notch at 2000Hz - an apparent loss of bone conduction at 2000Hz
Risk factors of otosclerosis
Female
Pregnancy
Family history
Why is otosclerosis more common in females
Linked to high oestrogen level
Effect of pregnancy on otosclerosis
Can be triggered / deteriorate rapidly during pregnancy
Symptoms of otosclerosis
Gradual hearing loss
Investigations for otosclerosis
Audiometry - conductive hearing loss pattern + Carhart’s notch at 2000Hz
Management for otosclerosis
Hearing aids
Stapedectomy
Perforated tympanic membrane is most commonly seen in
Young patients with acute otitis media
Causes of perforated tympanic membrane
Otitis media
Sudden negative pressure - scuba diving
Insertion of foreign objects
Acoustic trauma - exposure to loud noises
Trauma
Symptoms of perforated tympanic membrane
Sudden severe pain
Followed by bleeding, hearing loss, tinnitus
Investigations for perforated tympanic membrane
Otoscope
Audiometry
Perforated tympanic membrane causes what pattern on audiometry
Conductive hearing loss
Management of perforated tympanic membrane
Usually self limiting
Surgery if patient is symptomatic with recurrent discharge
What is sensorineural hearing loss
Hearing loss due to malfunction / disease within the cochlea or auditory nerve (inner ear)
What is the auditory nerve that is usually affected in sensorineural hearing loss
Vestibulocochlear nerve CN VIII
Function of vestibulocochlear nerve
Transmit sound information from the cochlea to the brain
Balance and equilibrium
Causes of sensorineural hearing loss
Presbycusis
Noise-induced hearing loss
Congenital infections
Kernicterus (brain damage due to hyperbilirubinaemia)
Meningitis
Drugs
Vasculopathy
What are the congenital infections that can cause sensorineural hearing loss
Rubella
CMV
What are the drugs that cause sensorineural hearing loss
Gentamicin - aminoglycosides
Overdose NSAID
Cisplatin (chemo)
Vincristine (chemo)
What vasculopathy can cause sensorineural hearing loss
Stroke
TIA
What is the pattern shown on audiometry for sensorineural hearing loss
Significant hearing loss
No difference in bone / air conduction
Most common cause of sensorineural hearing loss
Presbycusis
What is presbycusis
Degenerative disorder of cochlea
how does presbycusis cause sensorineural hearing loss
Loss of outer hair cells
Loss of ganglion cells
Atrophy of stria vascularis
What is stria vascularis
Region in cochlea for blood supply, production of endolymph and maintenance of ion composition
Describe how do we hear sounds
- Sound waves causes vibration of tympanic membrane
- The vibrations are transferred through the ossicles in middle ear
- Then to the footplate of stapes which vibrates in oval window of cochlea
- This causes vibration and movement of perilymph
- The movement of perilymph causes vibration in the cochlear duct which activates the organ of corti
- organ of corti converts that mechanical stimuli into neural stimuli (action potentials) -> cochlear nerve -> vestibulocochlear nerve
- Vibrations are dampened at round window
Describe the anatomical course of vestibulocochlear nerve
Exit the cranium via internal acoustic meatus then splits into 2 parts -> cochlear and vestibular nerves
The vestibular nerve innervates the vestibular system
The cochlear nerve innervates the cochlea
Function of vestibulocochlear nerve
Hearing
Balance (because it innervates the vestibular system)
Describe how do we coordinate balance
Utricle and saccule detect linear movement change of the head
3 semicircular canals detect rotational movements of the head
As your head moves, the endolymph fluid in the vestibular system moves and triggers the hair cells in ampulla -> trigger APs to vestibular nerve -> vestibulocochlear nerve back to brain
what are the 3 semicircular canals
Horizontal
Superior
Posterior
Movement detected by each semicircular canal
Horizontal - head rotation in transverse plane ; head from side to side
Superior - head rotation in sagittal plane ; nodding head
Posterior - head rotation in coronal plane ; moves head to touch shoulder / doing a cartwheel
What is vestibulo-ocular reflex
Reflex that allows images to be stabilised when the head is turning by moving eyes in the opposite direction
Vestibulo-ocular reflex is regulated by
Vestibular system - vestibular nerve, semicircular canals and otoliths (utricle and saccule)
Where is the perilymph of cochlea located at
Scala vestibuli
Scala tympani
How does the organ of corti detect stimuli
Receptor hair cells at the basilar membrane of cochlear duct
Another name for cochlear duct
scala media
Presentation of presbycusis
Gradual hearing loss
Features on audiometry for presbycusis
- sensorineural hearing loss
- higher frequencies affected the most
Management for presbycusis
High-frequency specific hearing aid
Causes of noise induced hearing loss
Damage to the cochlea due to
- Shooting without ear protectors
- Industrial noise
Features on audiometry for noise induced hearing loss
Sensorineural hearing loss
Dip at 4000Hz
What is vestibular schwannoma
Benign tumour of vestibulocochlear nerve CN VIII nerve sheath that arises in internal auditory meatus
What structures pass through the internal auditory meatus
Vestibulocochlear nerve
Facial nerve
Labyrinthine artery and vein
What is labyrinthine artery
Branch of artery from the circle of Willis
Causes of vestibulocochlear schwannoma
Extensive exposure to excessively loud noise
Neurofibromatosis type 2
Clinical presentation of vestibulocochlear schwannoma
Gradual unilateral hearing loss
Imbalance
Facial nerve palsy
Investigations for vestibulocochlear schwannoma
Audiometry - sensorineural
MRI
Management for vestibulocochlear schwannoma
Surgery
Small lesions may be monitored in 6 months interval
Most common tumour of the ear
Squamous cell carcinoma
