Otitis media and externa Flashcards
1
Q
What are 2 ways to categorise otitis externa?
A
- Acute (<3 weeks) or chronic (>3 months)
- Diffuse vs localised vs malignant
2
Q
What is acute otitis externa?
A
lasts <3 weeks
3
Q
What is chronic otitis externa?
A
lasts >3 months
4
Q
What is diffuse otitis externa?
A
Widespread inflammation of the skin and subdermis of the external ear canal
5
Q
What is localised otitis externa?
A
Infection of a hair follicle that can progress ot become a boil in the ear canal
6
Q
What is malignant otitis externa?
A
spread of otitis externa into th ebone surrounding the ear canal (mastoid and temporal bones) - can be fatal
7
Q
In which patient group is malignant otitis externa more common?
A
More common in elderly diabetics
8
Q
At what age does incidence of otitis externa peak?
A
Age 7-12
9
Q
What are 4 signs of otitis externa?
A
- ear canal or external ear, or both, red swollen, or eczematous with shedding of the scaly skin
- swelling in ear canal typical of an early presentation of localised otitis externa; later, swelling has white or yellow centre filled with pus. ocasionally progresses and swelling eventually completely occludes ear canal
- discharge (serous or purulent) may be present in ear canal
- inflamed eardrum, which may be difficult to visualise if ear canal narrowed or filled with debris
10
Q
What is the most common cause of otitis externa and the 2 organisms which can cause it?
A
Most commonly caused by bacterial infection
- pseudomonas aeruginosa
- staphylococcus aureus
11
Q
What are 3 possible precipitating factors for otitis externa?
A
- Ear trauma
- Excessive moisture
- Dermatitis
12
Q
What are 3 possible complications of otitis externa?
A
- Abscess
- Inflammation of tympanic membrane
- Malignant otitis
13
Q
What are 2 risk factors for otitis externa?
A
- Diabetes
- Radiotherapy to head and neck
14
Q
What are 8 aspects of the management of otitis externa?
A
- Assess severity of symptoms e.g. pain, itch, hearing loss, discharge
- Managing aggravating or precipitating factors e.g. diabetes mellitus, dermatitis, ear trauma
- Offering paracetamol or ibuprofen for symptomatic relief (plus codeine for severe pain)
- Treating infection usually with topical preparation
- Considering need for investgiations such as ear swab - rarely useful, but may be necessary if persistent or recurrent
- Providing appropriate self-care advice to aid recovery and reduce risk of recurrence - keep ears clean and dry, avoid use of cotton buds, treat generalised skin conditions such as eczema
- May need specialist advice
- Refer to secondary care if needed
15
Q
What are 3 reasons why you might need specialist advice in cases of otitis externa?
A
- If symptoms persist
- Contact sensitivity suspected
- Ear canal occluded
16
Q
What are 5 reasons why referral to secondary care may be needed in cases of otitis externa?
A
- extensive cellulitis
- extreme pain or discomfort
- considerable discharge
- extensive swelling of auditory canal
- sufficient earwax or debris to obstruct application of topical medication
17
Q
What are 3 cases when follow up of otitis externa may be necessary?
A
- severe otitis externa
- chronic otitis externa
- diabetes mellitus or compromised immunity
18
Q
What are 2 elements of the management of localised otitis externa?
A
- Advise people to apply local heat using warm flannel - may be sufficient as folliculitis usually mild and self-limiting
- Consider incision and drainage if pus causing severe pain and swelling - usually required referral but small pustule near entrance to ear canal may be drained by incising with surgical needle
19
Q
What is the management of malignant otitis externa?
A
Urgent admission
20
Q
What are 8 symptoms of otitis externa?
A
- Itch
- severe ear pain, disproportionate to size of lesion
- pain made worse when tragus or pinna moved, or when otoscope inserted
- tenderness on moving jaw
- tender regional lymphadenitis (less common)
- sudden relief of pain if furuncle in localised otitis externa bursts (rare)
- loss of hearing if sufficient swelling to occlude ear canal (rare)
21
Q
What are 3 signs and 3 symptoms of chronic otitis externa?
A
Signs:
- lack of earwax in external ear canal
- dry hypertrophic skin, which varies in thickness but often results in at least partial canal stenosis
- pain on manipulation of external ear canal and auricle
Symptoms:
- constant itch in ear
- mild discomfort
- pain, if present, is usually mild
22
Q
What are 3 signs and 3 symptoms of malignant otitis?
A
Signs:
- granulation tissue at bone-cartilage junction of ear canal; exposed bone in ear canal
- facial nerve palsy (drooping face on side of lesion)
- tempearture over 39 degrees C
symptoms
- pain and headache, more severe than clinical signs would suggest
- vertigo
- profound hearing loss
23
Q
What are 10 differentials for otitis externa?
A
- Acute otitis media (externa could be secondary to otorrhoea from this, esp if children with grommets)
- Foreign body
- Impacted wax
- Cholesteatoma
- Mastoiditis - if very unwell, high tempearture, mastoid tenderness or swelling
- Malignant otitis
- Neoplasm
- Ramsay Hunt syndrome - herpes zoster affecting facial nerve, assoc/w facial paralysis and loss of taste
- Barotrauma - divers, recent flight, blow to ear
- Skin conditions e.g. seborrhoeic dermatitis, atopic dermatitis, dermatophytosis etc.
24
Q
What are 3 times when localised otitis externa may need treatment with oral antibiotics?
A
- furunculosis or cellulitis spreads beyond ear canal to the pinna, neck or face
- systemic signs of infection, such as fever
- person has medical condition associated with increase risk of severe infection e.g. diabetes, immunosuppressed
25
If an oral antibiotic is required for localised otitis externa, what should be used?
7 day course of flucloxacillin, 250-500mg qds or clarithromycin if penicillin allergy
26
When are 2 times you might follow up a patient with localised otitis externa?
1. oral antibiotic has been prescribed
2. person has underlying medical conditiosn such as diabetes mellitus or immunocompromised
27
What are 3 things that should make you consider referral of a patient with localised otitis externa to secondary care?
1. relief of pain and swelling requires incision and drainage of the furuncle and resources and skills not available in primary care
2. inadequate response to oral antibiotic treatment
3. if cellulitis spreading outside auditory canal
28
What are 7 things to do in the assessment of someone with caute otitis externa?
1. Take clinical history - onset and nature of symptoms
2. Ask about severity of symptoms - pain or tenderness on moving ear (tragus or pinna) or jaw
3. Severity of inflammation
4. Examine ear canal, tympanic membrane (perforation?), aurical and cervical nodes
5. Examine surrounding tissue for derm conditions
6. Identify potential causes
7. Consider need for investigations - ?swab or ?tympanometry if available to see if membrane intact
29
What are 9 potential causes for otitis externa to try and identify?
1. Radiotherapy to ear, neck and head
2. Previous ear surgery, such as tympanostomy
3. Previous topical treatments for otitis externa or otitis media
4. Atopic, allergic, or irritant dermatitis
5. Dermatoses
6. Trauma to ear canal from cleaning, scratching or instrumentation
7. Use of hearing aid or ear plugs
8. Exposure to water or humid climate
9. Diabetes, immunosuppression, older age
30
What are 5 situations to consider taking an ear swab in otitis externa?
1. treament fails
2. otitis externa recurrent or chronic
3. topical treatment can't be delivered effectively e.g. ear canal occluded due to swelling or debris
4. infection has spread beyond external auditory canal
5. condition severe enough to require oral antibiotics
31
How should a swab be taken for diffuse otitis externa?
take swab from medial aspect of ear canal under visualisation to reduce contamination
32
What are 6 ways to manage someone with acute, diffuse otitis externa?
1. Manage any aggravating or precipitating factors
2. Consider cleaning external auditory ear canal if earwax or debris ostructs application of topical medication - may need ENT referral
3. Prescribe or recommend analgesic - pct or ibf
4. Consider topical antibiotic with/without corticosteroid for minimum 7 days, bit if sx persist continue up to max of 14 days
5. Ear wick if extensive swelling - may require ENT referral
6. Oral abx rarely indicated - consider specialist advice if thought to be required
7. Provide self-care advice to aid recovery and reduce risk of future infection
33
What topical antibiotic ± corticosteroid can be used for diffuse otitis externa? 4 examples + 1 non-abx
* Aminoglycoside: gentamicin 0.3% drops
* Non-aminoglycoside: chloramphenicol 5% drops
* Quinolone with corticosteroid: ciprofloaxin + dexamethasone (Cilodex)
* Aminoglycoside with steroid: Neomycin + betamethasone: Betnesol-N
* Also topical acetic acid 2% spray for mild cases
etc.
34
How long should a topical antibiotic ± steroid be prescribed for diffuse otitis externa?
minimum of 7 days, but if symptoms persist continue using until resolve, up to maximum of 14 days
35
What is an ear wick?
PIece of gauze soaked in treatment drops and pushed gently into ear canal between swollen walls. Used for if ear canal very swollen and blocked
36
What are 3 situations when oral antibiotics may be considered to treat diffuse otitis externa?
1. cellulitis extending beyond external ear canal
2. when ear canal occluded by swelling and debris and wick can't be inserted
3. people with diabetes or compromised immunity, and severe infection or high risk of severe infection e.g. with Pseudomonas aeruginosa
37
If an oral antibiotic is to be prescribed under primary care for dffuse otitis externa, what should be prescribed?
7 day course of flucloxacillin or clarithromycin if allergy
38
What are 3 options for ways to clean external auditory canal in acute diffuse otitis externa?
1. Syringing or irrigation
2. Dry swabbing - gently mop out secretions
3. Microsuction - irrigation and swabbing ineffective or inappropriate. usually requires secondary care referral
39
What are 4 pieces of self-care advice to give in acute diffuse otitis externa?
1. Avoid damage to external ear canal: if earwax a problem get it removed professionally, don't use cotton buds etc.
2. Keep ears clean and dry - use ear plugs/cap when swimmin, hair dryer after washing, keep shampoo away
3. Ensure skin conditions well controlled - avoid ear plugs/ hearing aids/ earrings if allergic, use alternatives e.g. hypoallergenic hearing aids
4. consider using acidying ear drops or spray (e.g. EarCalm) before swimming, after swimming and at bedtime. can get OTC
40
What are 4 reasons you would refer a patient with acute diffuse otitis externa?
* malignant otitis suspected:
1. unremitting pain, ototrrhoea, fever, malaise
2. granulation tissue at bone-cartilage junction of ear canal, or exposed bone in ear canal
3. facial nerve paralysed (drooping on one side)
4. tempearture over 39
41
What are 4 cases when you would seek specialist advice for acute diffuse otitis externa?
1. symptoms have not improved despite treatment, treatment failure unexplained
2. cellulitis is extensive
3. pain or discomfort is extreme
4. considerable amount of discharge, extensive swelling of auditory canal, microsuction or ear wick insertion required
42
What are 4 times you would consider follow up in a patient with acute diffuse otitis externa?
1. severe and accompanying cellulitis which has spread outside auditory canal
2. diabetes mellitus
3. immunocompromised
4. wax accumulation or narrow ear canals
43
What are 6 ways to manage treatment failure in people with acute diffuse otitis externa?
1. Review diagnosis, exclude and manage other conditions
2. Check compliance with medication/ self-care advice
3. Assess factors that would impede delivery of topical meds to area: discharge, swelling. irrigation, microsuction → referral, ear wick →referral
4. If contact dermatitis due to neomycin/ other aminoglycoside suspected: switch to a preparation without, referral to derm for patch testing
5. Prescribe 7 day course of oral antibiotic e.g. flucloxacillin or clarithromycin. If signs of systemic infection or spreading outside ear canal
6. If have tried these: ear swab, specialist advice
44
What are 3 types of otitis media?
1. Acute otitis media
2. Otitis media with effusion
3. Chronic suppurative otitis media
45
What defines acute otitis media?
Presence of inflammation in middle ear, associated with effusion, and accompanied by rapid onset of symptoms and signs of ear infection
46
What can cause acute otitis media?
Both viruses and infection
47
Which age group is most commonly affected by acute otitis media? What are 4 factors that make them even more susceptible?
Children 0-4
1. subject to passive smoking
2. attend daycare/nursery
3. formula-fed
4. craniofacial abnormalaties such as cleft palate)
48
What are 8 complications of acute otitis media?
1. Recurrence of infection
2. Hearing loss
3. Tympanic membrane perforation
4. Mastoiditis
5. Meningitis
6. Intracranial abscess
7. Sinus thrombosis
8. Facial nerve paralysis
49
What are 8 possible symptoms of acute otitis media in children?
1. Earache
2. Hold or rub ear
3. Fever
4. Crying
5. Poor feeding
6. Restlessness
7. Cough
8. Rhinorrhoea
50
What is the typical finding on otoscopy in acute otitis media? 3 aspects
1. Tympanic membrane is distinctly red, yellow or cloudy
2. Moderate to severe bulging of tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane (indicates middle ear effusion)
3. Perforation of tympanic membrane and/or discharge in external auditory canal
51
What is the usual management of acute otitis media?
* manage pain and fever with ibuprofen
* many won't need antibiotic treat - usually resolves spontaneously within a few days
52
What are 3 situations when you would use antibiotics to treat acute otitis media?
1. People who are systemically very unwell
2. People who might have symptoms and signs of a more serious illness or condition
3. People who have high risk of complications
53
If antibiotics are used to treat acute otitis media which ones / what course would you go for?
5-7 day course of amoxicillin recommended first line. Clarithromycin or erythromycin if allergy
54
What are 3 groups of people who should be admitted to hospital for immediate specialist assessment if they have AOM?
1. People with severe systemic infection
2. People with suspected complications of AOM, such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, facial nerve paralysis
3. Children younger than 3 months with temperature 38 or more
55
What are 3 key elements of management of **perisistent** acute otitis media?
1. Reassessing person
2. Considering need for paediatric or ENT referral or admission, depending on clinical situation
3. Considering first-line antibiotic (if not already prescribed) or second-line if initial was ineffective
56
What are 4 ways to prevent recurrent AOM in children?
1. Avoid exposure to passive smoking
2. Avoid use of dummies
3. Avoid flat, supine feeding
4. Ensuring have had compelte course of pneumococcal vaccinations
57
What is a key piece of advice to give to adults to avoid recurrent acute otitis media?
Avoid smoking and/or passive smoking
58
What are 3 reasons why it could be difficult to diagnose acute otitis media in children \<6 months?
1. May be coexisting systemic illness, such as bronchiolitis or bacteraemia
2. Symptoms likely to be non-specific
3. Tympanic membrane may not be visible - often lies in an oblique position and ear canal small and tends to collapse
59
What are 5 differentials for acute otitis media?
1. Otitis media with effusion (glue ear) - fluid in middle ear without symptoms or signs of acute infection
2. Chronic suppurative otitis media - persistent inflammaiton and perforation of tympanic membrane with draining discharge for \>2 weeks
3. Myringitis - erythema and injection of tympanic membrane visible on otoscopy but no other features of otitis media
4. Otitis externa - can also cause ear ache
5. Other causes of ear pain: eastachian tube dysfunction, mastoiditis, malignancy, referred pain
60
How long should you advise patients is the usual course of acute otitis media?
about 3 days, can be up to 1 week
61
Is there evidence to support the use of decongestants or antihistamines for the management of symptoms in acute otitis media?
No
62
In acute otitis media, what are the 2 key things to do for patients who do not require admission to hospital but are systemically very unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications?
1. Offer immediate antibiotics
2. Advise to seek medical advice if symptoms worsen rapidly or significantly or they become systemically very unwell
63
What are 2 groups of people with otitis media who are more likely to benefit from antibiotics?
1. Those with otorrhoea
2. Those aged less than 2 years with bilateral infection
64
What are 2 groups of people with acute otitis media in whom you may consider follow up?
1. people with persisting symptoms despite antibiotic treatment
2. people with recurrent symptoms - 3 or more separate episodes in the previous 6 months, or four or more in previous 12 months
65
What are the benefits and drawbacks of prescribing antibiotics in acute otitis media?
Acute complications such as mastoiditis are rare with or without antibiotics, and they make little difference to symptoms or development of common complications
66
What are 3 ways to consider prescribing antibiotics in acute otitis media?
1. **Immediate prescription**
2. **Back-up prescription:** addvise re not being needed immediatly, use if symptoms don't start to improve within 3 days or worsen significantly or rapidly at any time
3. **No antibiotic prescription:** safety netting if if rapidly worsen or don't improve within 3 days etc.
67
What it otitis media with effusion?
Characterised by a collection of fluid within the middle ear space without signs of acute inflammation
68
Over what time frame does otitis media with effusion usually resolve and what can it lead to otherwise?
Several weeks or months; may be more persistent and, if bilateral, may lead to developmental problems
69
In what age of chidren is otitis media with effusion most common?
2-5 years
70
In what time of year does otitis media with effusion most commonly present?
Winter months
71
What is thought to be the cause of otitis media with effusion? What are 4 things that cause its persistence?
OVer 50% of cases thought to follow episode of acute OM, especially in children under 3 years of age
Persistence of OME may be caused by one or more of the following:
* impaired eustachian tube function causing poor aeration of middle ear
* low-grade viral or bacterial infection
* persistent local inflammatory reaction
* adenoidal infection or hypertrophy
72
What are 5 groups of children in whom otitis media with effusion is more common?
1. Clef palate
2. Down's ysndrome
3. Cystic fibrosis
4. Primary ciliary dyskinesia
5. Allergic rhinitis
73
What are 3 environmental factors that can increase the chance of a child developing otitis media with effusion?
1. Low socioeconomic group
2. Parental smoking
3. Frequent upper-respiratory infections
74
What are 3 complications of otitis media with effusion?
1. Conductive hearing loss
2. Speech and language development, and communications skills difficulties
3. Chronic damage to the tympanic membrane
75
What are 7 steps towards the diagnosis of otitis media with effusion?
1. Suspected hearing loss
2. Clinical history
3. Examine ears
4. Consider need for wider examination of respiratory system including nose and throat
5. Excluding alternative diagnoses e.g. acute OM, foreign body, impacted wax, balance disorders
6. Confirm diagnosis with tympanometry
7. Assessing hearing loss with audiometry
76
For what period of time is active observation the appropriate management for otitis media with effusion?
6-12 weeks
77
If signs and symptoms of otitis media with effusion persist beyond 6-12 weeks what should be done?
Refer for hearing test or to ENT specialist if direct referral for audiometry not available
78
What is chronic suppurative otitis media?
Chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear dishcarges (otorrhoea) through a tympanic perforation
79
What is assumed to be the cause of chronic suppurative otitis media?
Complication of acute otitis media
80
What is thought to be the cut off between acute otitis media and chronic suppurative otitis media?
WHO: AOM is CSOM after 2 weeks of discharge
Some experts suggest more than 6 weeks of discharge is the cut off
81
What are 5 complications of chronic suppurative otitis media?
1. Can cause problems with language development in children
2. Can spread extracranially causing facial paralysis or
3. mastoiditis
4. Can spread intracrnially causing meningitis or
5. cerebral abscess
82
What are 4 symptoms that support a diagnosis of chronic suppurative otitis media?
1. Ear discharge (for more than 2 weeks) without pain or fever
2. History of AOM (ear pain, fever, irritability), history of ear trauma, previous glue ear and grommet insertion
3. Painless ear examination (unlike AOM or acute otitis externa) with evidence of tympanic membrane perforation
4. Possible hearing loss
83
What are 3 things that the assessment of suspect chronic suppurative otitis media should include?
1. Checking for postauricular swelling (tenderness), facial paralysis, vertigo and signs or symptoms of intracranial infection (requiring admission)
2. Asking about hearing loss and, if appropriate, the effect of CSOM on daily activities (e.g. school or work) and language development
3. Excluding alternative causes: otitis externa, foreign body, impacted ear wax, neoplasm
84
When should admission be arranged in chronic suppurative otitis media? 4 key signs
If signs of infection beyond ear e.g. postauricular swelling or tenderness, headache, facial paralysis, vertigo
85
What is the management if chronic suppurative otitis media is suspected? 4 things
1. Referral to ENT
2. **Don't** swab ears
3. **Don't** initiate treatment
4. Reassure hearing loss will eventually return when perforation heals but hearing test may be carried out in secondary care
