Otalgia, otitis externa and otitis media Flashcards
What are the causes of otalgia associated with the external ear?
- Wax impaction
- Otitis externa
- Malignant otitis externa
- Furuncle (infection of hair follicle)
- Malignancy of external canal
Other than the external and middle ear, where else can otalgia originate from?
- Disorders of the temporomandibular joint
- Periauricular lymphadenopathy
- Referred pain from any of the nerves with sensory input to the ear
What are the nerves that have a sensory input to the ear and therefore can cause referred pain?
- Vestibulo-cochlear - Ramsay Hunt syndrome
- Facial nerve - Bell’s palsy
- Glossopharyngeal nerve - Tonsilitis, especially quinsy, glossopharyngeal neuralgia
- Trigeminal nerve - dental pain, nasal and paranasal sinus malignancy
- Vagus nerve - laryngeal, pharyngeal and oesophageal pathology
- Cervical plexus - C2, C3 root lesions
What is otitis externa?
Inflammation of the external ear canal skin
What are the most common causes of otitis externa?
General causes:
- General skin conditions eg eczema, psoriasis
- Generalised skin infections eg impetigo
- Neurodermaitis
Local causes:
- Trauma eg from a cotton bud or a dirty finger nail
- Local infection:
- Bacterial: pseudomonas aeruginosa, staphylococcus aureus
- Fungal: Candida, Aspergillus
- Viral
- Middle ear discharge
What are the organisms most commonly responsible for infective otitis externa?
Bacteria:
- Staphylococcus aureus
- Pseudomonas aeruginosa
Fungi:
- Candida
- Aspergillus
What are the symptoms of infective otitis externa?
- Ear pain (otalgia)
- Itching
- Discharge (otorrhoea)
- Hearing loss (from blockage)
On examination of someone with infective otitis externa, what might you see?
- The auricle and specifically the tragus is tender on movement
- The external aucostic meatus may be swollen and full of debris
- In fungal infections, hyphae and spores may be seen
How do we manage someone with an itchy, otalgic ear which otoscopy suggests is due to infective otitis externa?
- Swab the ear for cultures
- Mechanical cleaning with microsuction
- Patient told to keep the ear dry
- Analgesia
- First line for mild case (mild discomfort and pruritus) is acetic acid
- If more moderate/severe (pain, deafness, discharge) topical combination of antibiotic and corticosteroid - in the form of ear drops
- If gross cellulitis oral antibiotic
What is the other name for malignant otitis externa?
Necrotizing otitis externa
What is necrotizing (malignant) otitis externa?
A potentially life threatening condition where there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal
Who is most often affected by necrotizing (malignant) otitis externa?
- Elderly patients
- Diabetic patients
- Immunocompromised
What is the organisms most commonly responsible for necrotizing otitis externa?
Pseudomonas aeruginosa
What are the clinical features of malignant (necrotizing) otitis externa?
- Deep seated otalgia
- Resistant to usual treatment
- Facial soft tissue swelling
- Spreading osteomyelitis may produce cranial nerve palsies (facial, vagus, hypoglossal)
- Fever
- Malaise
- Loss of diabetic control
What are the complications of necrotizing (malignant) otitis externa?
Without aggressive treatment may lead to meningitis, encephalitis and death
How would you manage someone with necrotizing (malignant) otitis externa?
High dose intravenous antibiotics and sometimes surgical debridement
What is otitis media?
Inflammation of the middle ear
What are the three types of otitis media?
- Acute otitis media (ASOM)
- Otitis media with effusion (OME) - Glue ear
- Chronic suppurative otitis media (CSOM)
What is the difference between acute suppurative otitis media (ASOM) and otitis media with effusion (OME)?
- Acute suppurative otitis media is an ongoing viral or bacterial infection of the middle ear.
- Otitis media with effusion is often preceded by ASOM, however typically there is no ongoing infection, but rather just the fluid left behind. This will be causing hearing loss and some mild discomfort.
What are the three ways that microorganisms may colonise the middle ear?
- Via the Eustachian tube
- Via a perforation in the tympanic membrane
- Via haematogenous spread (very rare)
What are the bacteria commonly responsible for acute otitis media?
- Streptococcus pneumoniae
- Haemophilus influenzea
- Moraxella catarrhalis
Which group of patients are most commonly affected by acute suppurative otitis media?
Children
What are the typical clinical features of acute otitis media?
- Otalgia
- Otorrhoea
- Hearing loss
- Pyrexia
- Systemic upset
Recent upper respiratory tract infection
What is the natural course of uncomplicated acute otitis media?
Untreated ASOM usually leads to ischaemia of part of the tympanic membrane and a perforation results, leading to discharge and eventual resolution of symptoms.
Treatment of otitis media
Advice if perforation
- Most require no specific treatment
- Simple analgesia
- Give antibiotics (such as amoxicillin) if:
- under 2 years old
- bilateral
- severe or recurrent
- no resolution after 3 days
- symptoms of local complications (facial weakness, dizziness)
- perforation
- If perforation keep ear dry until it is healed
What are some of the complications of acute otitis media?
- Residual perforation
- Otitis media with effusion (glue ear)
- Mastoiditis
Mastoiditis management
- Admit
- IV antibiotics
- +/- CT scan or surgery
What proportion of children will have had a bout of otitis media with effusion by their 4th birthday?
80%
Why are children so susceptible to otitis media with effusion?
Pathophysiology of the disorder?
Because of the angle and length of their Eustachian tubes. Also the adenoids make them more susceptible to effusion.
Porr ventilation of the middle ear cavity, which leads to a sterile and often thick and sticky effusion.
What are the clinical features of otitis media with effusion?
- Main symptom is conductive hearing loss
- Mild discomfort
- Blocked nasal airway
On examination:
- Middle ear effusion
- Dull grey tympanic membrane
- Retracted ear drum
How would you investigate someone with the signs and symptoms of otitis media with effusion and what results would you expect?
- Normally no investigations necessary
- A pure tone audiogram would reveal a conductive hearing loss
- A tympanogram will show a flattened trace
How would you initially manage a patient with otitis media with effusion?
Active observation for several months. Self-limiting illness and 90% of children will have complete resolution within a year. You review periodically for 3 months.
What are the surgical options that an ENT specialist may advise for a child with otitis media with effusion?
- Insertion of grommets
- Adenoidectomy
How long do grommets stay in the ear?
They fall out naturally as part of the desquamative processes of the ear drum, within 6-12 months
What should parents of children with grommets be advised?
- How long will it take for hearing to return to normal?
- Should the child go back to school?
- Should they immerse the child’s head in soapy water?
- Can the child go swimming?
- Can the child fly?
- Hearing will return immediately and may initially feel like everything is too loud
- Normal school activities should be encouraged
- Avoid immersing child’s head in soapy water
- Not a contraindication to swimming - although advise against diving to any significant depth (due to pressure)
- Not a contraindication to flying
Aetiology of chronic suppurative otitis media
Repeated or prolonged bouts of acute otitis media, often in childhood, can cause damage to the tympanic membrane and a non-healing perforation may result.
Symptoms of chronic suppurative otitis media
- Hearing loss
- Otorrhoea
- Intermittent
- Mucoid/mucopurulent
Treatment of chronic suppurative otitis media
Regular aural toilet, combination antibiotic and steroid ear drops and keeping the ear dry will help to settle active infection.
Myringoplasty (surgical repair of the ear drum), if successful, will prevent reinfection.
What is a cholesteatoma?
A cyst or sac of keratinising squamous epithelium and most commonly occurs in the attic or epitympanic part of the ear.
Symptoms and signs of cholesteatoma
- Foul smelling discharge
- Conductive hearing loss
- Attic retraction filled with squamous debris
Complications of cholesteatoma
Cholesteatoma is able to erode bone and therefore can damage any of the important structures in or around the middle ear and mastoid, for example:
- the ossicles, leading to a conductive deafness
- the facial nerve, leading to facial palsy
- the labyrinth, leading to vertigo
- erosion of the tegmen (roof of the middle ear) leading to intracranial sepsis
