Otorrhoea

Question 1

Acute Otitis Externa

Answer 1

Can be diffuse or localised as a furuncle (recurrent furunculosis should raise suspicion of diabetes).

Hearing is only impaired if meatus becomes blocked by swelling / disharge, discharge is usually thick and scanty, pinna tender to move

Question 2

Treatment of Otitis Externa

Answer 2

Systemic antibiotics only if there are palpable lymph nodes / fever
Insertion of wicks / aural tampons to reduce meatal swelling - drops may then be used (aluminium acetate / topical antibiotics plus steroid)
Analgesic and heat to relieve pain
Keep the ear dry

Question 3

Malignant / Necrotizing Otitis Externa

Answer 3

Osteomyelitis - bony ear canal and underlying bone

Most common in early diabetics. Any patient with diabetes / immunocompromised who has otitis externa should be assumed to have osteomyelitis of the temporal bone if their symptoms do not settle within 2 weeks.

Continue oral antibiotics. IV antibiotics for at least 6 weeks (swab before). Regular monitoring.

Question 4

Perichondritis

Answer 4

Inflammation of cartilage - the pinna

Known complication of otitis externa, can also occur following trauma.

If left untreated it can result in necrosis of the pinna cartilage - ‘Cauliflower ear’.

Other complications - facial cellulitis, osteomycosis, canal stenosis with hearing loss

Question 5

Acute Otitis Media

Answer 5

Acute inflammation of the inner ear - deep-seated pain, impaired hearing with a systemic upset.

Most common in children and rare in adults. May present with discharge if tympanic membrane ruptures - causes relief of pain,

Secondary to eustachian tube dysfunction

Question 6

Diagnosis of Acute Otitis Media

Answer 6

Inspection of tympanic membrane

Only i the whole drum can be certified as normal and there is no conductive hearing loss can otitis media confidently be excluded.

Question 7

Antibiotics for Otitis Media

Answer 7

Amoxicillin / Clarithromycin

Symptoms lasting more than 4 days / not improving
Systemically unwell
Immunocompromised / high risk of complications
Younger than 2 years with bilateral otitis media
With perforation and / or discharge in the ear canal.

Question 8

Chronic Otitis Media (3 months)

Answer 8

Usually presents with conductive deafness and discharge without pain.

Mucosal:
Active - perforated TM which then allows infection to develop in the middle ear.
Inactive - dry perforation

Squamous:
Active - cholesteatoma formation
Inactive - shallow self-cleaning retracted tympanic membrane

Question 9

Cholesteatoma

Answer 9

Destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and / or mastoid process

With = perforation of the pars flaccida, impaired hearing loss and foul-smelling discharge. Radical mastoidectomy. 
Without = perforation of the pars tensa, intermittent discharge (non-offensive).

Question 10

Medical Management of Chronic Otitis Media

Answer 10

Microsuction and inspection of the ear under microscope
Topical antibiotics and steroid drops for 7-10 days if there is active infection.
Strict water precautions

Question 11

Surgical management of COM

Answer 11

Myringoplasty - repair the ear drum. Placing a graft underneath the perforation.

Hearing defects may if necessary be helped by a hearing aid, or by reconstructing the drum and the ossicular chain (tympanoplasty)

Mastoidectomy - opening the mastoid air cells, removing the cholesteatoma, reconstruction of the ossicles and tympanic membrane