Otology - otalgia and otitis externa Flashcards
What do we call ear pain?
Otalgia
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 and external auditory meatus (ear canal)
What are the causes of otitis externa?
Infection (bacterial and fungal)
Seborrhoeic dermatitis
Contact dermatitis
Caused by..
Moisture (swimming, surfing, daily hair wash),
Trauma (eg fingernails, cottonbuds), absence of wax, hearing aid, DM etc…
What are the organisms most commonly responsible for infective otitis externa?
Bacteria:
Staphylococcus aureus
Pseudomonas aeruginosa
Fungi:
Candida
Aspergillus
What are the risk factors for developing infective otitis externa?
Swimming
Scratching with dirty fingernail
Canal exostoses (bone growth into canal due to prolonged exposure to cold water - surfer’s ear)
What are the symptoms of infective otitis externa?
Ear pain (otalgia)
Otorrhoea/discharge (watery, thick in acute, blood in chronic)
Itching
Discharge
Hearing loss (from blockage)
On otoscopy of someone with infective otitis externa, what might you see?
Erythema
Inflammation and oedema
Discharge
Fungal spores may be seen (pigmented if Aspergillus)
Tympanic membrane may be ruptured
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 micro suction + aural toilet (regular cleaning)
Analgesia
First line for mild case (mild discomfort and pruritus) is acetic acid.
Moderate/severe (pain, deafness, discharge) topical combination of antibiotic and corticosteroid - in the form of ear drops.
If really severe oral antibiotic
Patient told to keep ear dry
What antibiotic/steroid combination ear drops are classically given to those who present with signs and symptoms of more severe infective otitis externa?
Gentamicin/hydrocortisone
Neomycin/betamethasone
Both of these antibiotics are aminoglycosides
Givem 7-14 daus
What are the contraindications for using topical aminoglycosides such as gentamicin or neomycin in the treatment of infective otitis externa?
Perforation of tympanic membrane
If contact dermatitis is suspected - they can cause this
What oral antibiotics should be used in someone with severe spreading infective otitis externa?
First line - Flucloxacillin
What oral antibiotics should be used in someone with severe spreading infective otitis externa who is allergic to penicillin and therefore cannot have the first line which is flucloxacillin?
Erythromycin
If they do not tolerate this then clarithromycin
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. Can lead to temporal bone destruction and base of skull osteomyelitis.
Who is most often affected by necrotizing (malignant) otitis externa?
Elderly diabetic patients, or those who are immunocompromised
What is the organisms most commonly responsible for necrotizing otitis externa?
Pseudomonas aeruginosa in 90%
What are the clinical features of malignant (necrotizing) otitis externa?
Deep seated otalgia
Resistant to usual treatment
Facial soft tissue swelling
Suppuration - copious otorrhoea
Oedema
Florid granulation tissue
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
What investigations might you do for someone in whom you suspected necrotizing (malignant) otitis externa?
Blood sugars
Cultures
FBC, CRP, U&Es
Ear swabs
High resolution CT - rule out encephalitis
Technetium bone scan - rule out osteomyelitis
HIV test in younger or immunocompromised patient
How would you manage someone with necrotizing (malignant) otitis externa?
Admission to hospital
IV and topical antibiotics for up to 6 weeks - ciprofloxacin (although there is evolving resistance)
Control of blood sugars
Daily microsuction of ear canal
Analgesia
Failure to respond to these measures:
May require surgical debridement
What is an external ear furuncle?
Infection or blockage of a hair follicle of cartilaginous portion of the ear
How do you manage a external ear furuncle?
Treatment involves incision of the furuncle under local anaesthetic following which pain and oedema should settle quickly
Describe a mild otitis externa
Scaly skin, some erythema
Describe a moderate otitis externa
Painful ear, narrowed ear canal and creamy discharge
Describe a severe otitis externa
Ear canal occluded
