Approach to Ear Problems

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Approach to Ear Problems

• By
• Stacey Singer-Leshinsky R-PAC

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Includes

• Disease of the external ear
• Disease of the middle ear
• Disease of the inner ear

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Normal TM
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External Auditory CanalOtitis Externa

• Defenses include cerumen which acidifies the
  canal and suppresses bacterial growth.

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External Auditory CanalOtitis Externa

• Cerumen prevents water from remaining in canal
  and causing maceration.
• Etiology Pseudomonas aeruginosa and
  staphylococcus aureus, strep

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External Auditory CanalOtitis Externa

• Risk factors for Otitis Externa include
• Swimming, perspiration, high humidity, insertion
  of foreign objects,
• Eczema, psoriasis, seborrheic dermatitis

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External Auditory CanalOtitis Externa-Clinical
manifestations

• Otalgia/otorrhea
• Fever
• Pain
• Canal edematous and obscured with debris,
  discharge, blood, or inflammation
• Lymphadenopathy

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External Auditory CanalOtitis Externa-

• Complications
• malignant otitis externa caused by pseudomonas
• Differential diagnosis
• basal cell carcinoma
• squamous cell carcinoma

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External Auditory CanalOtitis Externa-Management

• Topical antibacterial drops such as Neomycin
  otic, polymyxin, Quinolone otic
• Otic steroid drops containing polymyxin-neomycin
  and a topical corticosteroid.
• Analgesics

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External Auditory CanalOtitis Externa-Management

• Discuss patient education issues such as
• Swimmer prophylaxis contains acid and alcohol

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External Auditory CanalChronic Otitis Externa

• Duration of infection greater than four weeks, or
  greater than 4 episodes a year
• Risks inadequate treatment of otitis externa,
  persistent trauma, inflammation or malignant
  otitis externa.
• Etiology Bacterial,fungal or dermatologic such
  as candida or Aspergillus, pseudomonas or
  psoriasis

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External Auditory Canal Chronic Otitis Externa

• Purulent discharge
• Dry or scaly.
• Pruritus
• Conductive hearing loss
• Diagnosis

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External Auditory CanalChronic otitis
externa-Management

• Cover fungi with clotrimazole(Lotrimin)
• Systemic antifungal include ketoconazole
• Cortisporin
• Wick with few drops of Domeboros astringent
• Differential diagnosis to include basal cell or
  squamous cell carcinoma, Foreign bodies, otitis
  media

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External Auditory CanalMalignant Otitis Externa

• Inflammation and damage of the bones and
  cartilage of the base of the skull
• Occurs primarily in immunocompromised
• Most common etiology is pseudomonas aeruginosa.

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External Auditory CanalMalignant Otitis Externa

• Otorrhea yellow green, foul smelling.
• Granulation tissue in external auditory canal
• Trismus
• Fever
• Facial and cranial nerve palsies

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External Auditory CanalMalignant Otitis Externa

• Diagnosis Culture of ear secretions and
  pathological examination of granulation tissue,
  CT
• Complications include sepsis, cranial nerve
  palsies, meningitis, brain abscess, osteomyelitis
  of the temporal bone and skull
• Differential diagnosis to include basal cell or
  squamous cell carcinoma

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External Auditory CanalMalignant Otitis Externa

• Need IV antibiotics
• Might need surgical debridement.
• If treatment interrupted rate of recurrence is
  100

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External Auditory CanalCerumen Impaction

• Cerumen is produced by apocrine and sebaceous
  glands in external ear canal.
• Often caused by attempts to clean the ear, or
  water in canal
• Cerumen is pushed down

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Cerumen ImpactionClinical Manifestations

• Hearing loss
• Stuffed or full feeling to ear
• Pain if cerumen touches TM

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External Auditory CanalCerumen Impaction

• Be sure TM is intact prior to lavage
• Irrigate ear with one part peroxide, and one part
  water
• Debrox and Cerumenex drops
• Ear irrigation and manual cerumen removal

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External Auditory CanalForeign body

• Can include toys, beads, nails, vegetables or
  insects.
• Damage depends on amount of time object has been
  in ear.

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External Auditory CanalForeign body-Clinical
Manifestations

• Might present with purulent discharge
• Pain
• Bleeding
• Hearing loss

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External Auditory CanalForeign body

• Complications include internal injury
• Differential diagnosis to include cholesteatoma,
  cerumen impaction, otitis externa

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External Auditory CanalForeign body- Management

• Irrigation is best provided the TM is not
  perforated
• Destroy insect with lidocaine or mineral oil.
• Irrigate and suction liquid.
• For inanimate objects suction or use alligator
  forceps.

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Tympanic MembraneBullous Myringitis

• Vesicles develop on the TM second to viral
  infections or bacterial infection
• Usually associated with middle-ear infection
• May extend into canal.

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Tympanic MembraneBullous Myringitis- Clinical
Manifestations

• Sudden onset of severe pain
• No fever usually
• No hearing impairment
• Bloody otorrhea possible
• Inflammation to TM
• Multiple reddened inflamed blebs possibly blood
  filled

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Tympanic Membrane Bullous Myringitis

• Differential diagnosis to include squamous or
  basal cell carcinoma, acute otitis media
• Complications

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Tympanic Membrane Bullous Myringitis-Management

• Antibiotics
• If pain is severe, rupture the vesicles with a
  myringotomy knife
• Analgesics

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Tympanic MembranePerforated TM

• Etiology is direct trauma, infection, pressure
  build up
• Bacteria can travel into middle ear and lead to
  secondary infection

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Tympanic MembranePerforated TM- Clinical
Manifestations

• Sudden severe pain
• Hearing loss
• Drainage
• Otoscope exam reveals puncture in TM, might be
  able to see bones of middle ear
• Purulent otorrhea may begin in 24-48 hours post
  perforation

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Tympanic MembranePerforated TM

• Differential diagnosis to include acute and
  chronic otitis media
• Complications include secondary infection into
  inner ear

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Tympanic MembranePerforated TM-Management

• Antibiotics to prevent infection or treat
  existing infection
• Surgical repair

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Middle EarAcute Otitis Media

• Viral respiratory infections cause inflammation
  of ET
• When ET is blocked, fluid collects in the middle
  ear.

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Middle EarAcute Otitis Media

• Common in fall, winter or spring
• ET in child is shorter and more horizontal in
  infants/children.
• Bacterial Etiology S.pneumoniae, H.influenzae,
  and M.Catarrhalis.
• Risks include URI,smoking at home, allergies,
  cleft palate, adenoid hypertrophy, bottle
  feeding, barotrauma

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Middle EarAcute Otitis Media

• Otalgia.
• Conductive hearing loss
• URI symptoms
• Vomiting, diarrhea
• Fever
• TM bulging and erythematous with decreased or
  poor light reflex.
• Decreased TM mobility on pneumatic insufflation

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Middle EarAcute Otitis Media -Diagnosis

• Tympanometry
• Differential diagnosis to include TM perforation,
  Tympanosclerosis, recurrent AOM, mastoiditis

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Middle EarAcute Otitis Media -Management

• Analgesics/ Antipyretics
• Auralgan
• Antibiotics
• Trimethoprim-sulfamethoxazole or Azithromycin
• Decongestants
• Avoid antihistamines

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Middle EarAcute Otitis Media Patient Education

• Myringotomy in patients with hearing loss, poor
  response to therapy or intractable pain
• Discuss patient education issues including breast
  feeding, no smoking in homes, pneumococcal
  vaccine

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Middle EarAcute Otitis Media -Complications

• TM perforation/ Tympanosclerosis
• Recurrent AOM or chronic OM
• Persistent middle ear effusion
• Mastoiditis
• Bacteremia

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Middle EarAcute Otitis Media -Recurrent OM

• Three episodes of AOM in 6 months or 4 episodes
  in 12 months
• Diagnosis
• Prevent by antibiotic prophylaxis, pneumovax,
  tympanostomy tubes, adenoidectomy

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Middle EarOtitis Media with Effusion

• Fluid accumulation behind TM in middle ear
• Build up of negative pressure and fluid in
  eustachian tube
• Common in children because of anatomy, cleft
  palate, allergies, barotrauma.

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Middle EarOtitis Media with Effusion

• Hearing loss
• Fullness, pressure
• TM neutral or retracted. Gray or pink.
• Landmarks visible or dull.
• Decreased TM mobility

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Middle EarOtitis Media with EffusionDiagnosis

• Tympanometry- most accurate,
• Audiometry-
• Differentials to include Acute Otitis Media,
  malignant tumors to nasal cavity, cystic fibrosis

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Middle EarOtitis Media with Effusion Management

• Decongestants/Oral steroids
• Antibiotics
• Myringotomy with or without tubes
• Adenoidectomy
• Complications

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Middle EarChronic Otitis Media

• Recurrent or persistent otitis media due to
  dysfunctional eustachian tube
• Risks allergies, multiple infections, ear
  trauma, swelling to adenoids.
• Bacteria P aeruginosa, proteus species,
  Staphylococcus aureus, and mixed anaerobic
  infections.

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Middle EarChronic Otitis Media

• Causes long term damage to middle ear due to
  infection and inflammation including
• Severe retraction of TM due to prolonged negative
  pressure
• Scaring or erosion of small conducting bones of
  middle ear and inner ear
• Erosion of mastoid
• Thickening of mucous secretions in ET
• Cholesteatoma
• Persistent OME

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Middle EarChronic Otitis Media

• Ear pain
• Fullness to ears
• Purulent discharge
• Hearing loss
• Dullness, redness or air bubbles behind TM

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Middle EarChronic Otitis Media

• Diagnosis clinical, audiometry, tympanometry,
  CT, MRI
• Differential diagnosis to include AOM,
  cholesteatoma
• Complications include bony destruction or
  sclerosis of mastoid air cells, facial paralysis,
  sensineural hearing loss, vertigo

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Middle EarChronic Otitis Media-Management

• Antibiotics , steroids, placement of tubes.
• Myringotomy
• Surgical tympanoplasty, mastoidectomy

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Cholesteatoma

• Epithelial cyst consists of desquamating layers
  of scaly or keratinized skin.
• Erosion of ossicles common. As more material is
  shed, the cyst expands eroding surrounding
  tissue.
• Two types congenital and acquired.
• Acquired due to tear in ear drum, infection

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Cholesteatoma

• Perforation of TM filled with cheesy white
  squamous debris
• Possible conductive hearing loss
• Drainage
• Differential Diagnosis squamous cell carcinoma

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Cholesteatoma-Management

• Large or complicated cholesteatomas require
  surgical excision
• Complications include erosion of bone and promote
  further infection leading to meningitis, brain
  abscess, paralysis of facial nerve.

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Barotrauma

• Physical damage to body tissue due to difference
  in pressure between an air space inside or beside
  body and surrounding gas.
• Ear barotrauma

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Barotrauma

• Etiology is a change in atmospheric pressure.
  Negative pressure in the middle ear causes
  Eustachian tube to collapse.
• Since air can not pass back through the ET,
  hearing loss and discomfort develop
• Risk factors
• Differential diagnosis should include serous,
  acute or chronic otitis media, bullous myringitis

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Barotrauma

• Hearing loss
• Otalgia

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Barotrauma-Management

• Auto inflation by yawning, swallowing or chewing
  gum to facilitate opening of ET to equalize air
  pressure in middle ear
• Decongestants
• Myringotomy
• Patient education to include valsalva maneuver.

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Mastoid

• Portion of temporal bone posterior to the ear.
• Mastoid air cells connect with the middle ear
• Fluid in the middle ear can lead to fluid in the
  mastoid

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Mastoiditis

• Middle ear inflammation spreads to mastoid air
  cells resulting in infection and destruction of
  the mastoid bone.
• Etiology Streptococcus pneumoniae, Haemophilus
  influenzae, streptococcus pyogenes, and other
  bacteria

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Mastoiditis

• Pain
• Bulging erythematous TM
• Erythema, tenderness, edema over mastoid area
• Postauricular fluctuance

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Mastoiditis-Diagnosis/differentials

• Diagnosis
• CT show bony destruction or drainable mastoid
  abscess
• Tympanocentesis to culture middle ear fluid.( S.
  pneumoniae, H. influenzae, M. catarrhalis)\
• Culture of fluid
• Differential diagnosis to include otitis media,
  Cellulitis, scalp infection with inflammation of
  posterior auricular nodes

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MastoiditisComplications

• Destruction of mastoid bone
• Spread to brain leading to brain abscess or
  epidural abscess

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Mastoiditis-Management

• Treat with antibiotics
• Patients with severe or prolonged
• May need to surgically remove a portion of the
  bone

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Labyrinthitis

• Viral infection
• Vestibular neural input disrupted to the cerebral
  cortex and brain stem
• Vertigo due to inflammation and infection of
  labyrinth
• Neurological exam normal
• Can also follow allergy, cholesteatoma, or
  ingestion of drugs toxic to inner ear

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Labyrinthitis

• Nausea/vomiting
• Vertigo with head or body movements lasts about 1
  min
• Nystagmus(rotary away from affected ear)
• Loss of balance

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Labyrinthitis-History and PE

• Diagnosis Audiologic testing, CT and MRI
• Differentiate other causes of dizziness by CT,
  MRI
• Differential diagnosis to include acoustic
  neuroma, vertigo, cholesteatoma, menieres disease

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Labyrinthitis-Management

• Steroids
• Sedatives
• Antivert
• Tigan
• Patient reassurance that symptoms usually last
  7-10 days with subsequent episodes up to 18
  months.
• Complications include spread of infection

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Menieres Syndrome

• Imbalance in secretion and absorption of
  endolymph fluid that causes buildup of fluid in
  cochlea.
• Swelling leads to hair cell damage

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Menieres Syndrome

• Episodic vertigo for 24-48 hours
• Sensorineural hearing loss
• Tinnitus
• Fullness/pressure in ears
• N/V/dizziness

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Menieres Syndrome

• Diagnosis Audiologic testing, CT
• Valium, tigan, antivert
• HCTZ
• Low sodium diet
• Labyrinthectomy if hearing already lost

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Vertigo

• Motion perceived when no motion, or exaggerated
  motion perceived in response to body movement
• Causes-
• Irritation to labyrinth
• CNS
• Brainstem or temporal lobe
• 8th cranial nerve dysfunction (acoustic neuroma)
• Labyrinthitis, Menieres disease

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Vertigo

• N/V
• In peripheral lesions nystagmus can be horizontal
  or rotational
• Central lesions nystagmus is bi-directional or
  vertical
• Evaluation

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Vertigo

• Differential diagnosis to include Diabletes
  mellitus, hypothyroidism, drugs such as alcohol,
  barbituates, salicylates, hyperventilation,
  cardiac origin
• Management Meclizine, Promethazine, Scopolamine

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Tinnitus

• Perception of abnormal ear noises
• Can be ringing, hissing
• Constant, intermittent, unilateral, or bilateral
• Can originate in outer, middle or inner ear

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Tinnitus- Causes

• Etiology can include damage to inner ear or
  cochlea, middle ear infection, medication such as
  Aspirin, stimulants such as nicotine, and
  caffeine, noise induced, hypertension, presbycusis

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Tinnitus-Treatment

• Some drugs such as antihistamines and CCB
• ENT referral-
• Antidepressants
• Surgical intervention-

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Example 1

• A 22 year old swimmer complains of pain when
  moving her ear. She also has noticed a bump in
  front of her ear. She has noticed difficulty in
  hearing. On otoscopic exam you visualize this.
• What is the complication associated with this?
• What is the treatment
• What are some patient education tips on this?

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Example 2

• A Diabetic patient is complaining of severe ear
  pain and otorrhea. On physical exam you note
  this.
• What is your differential diangosis?
• For what condition is this a complication?
• What is the etiology and treatment for this?

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Example 3

• This is a 44 year old female who complains of
  increasing hearing loss, and believes she is
  going deaf.
• What is the treatment of this?

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Example 4

• This patient recently had a viral infection. She
  now complains of a sudden onset of constant
  severe ear pain since yesterday. You see this on
  physical exam.
• What is this?
• How is this treated?

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Example 5

• This patient was SCUBA diving and had a non
  controlled ascent. He complains of tinnitus and
  severe ear pain since this incident. He thinks he
  has an ear infection.
• What is this?
• How is this treated?
• What are some complications of this?

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Example 6

• A 2 year old presents to your clinic crying
  tugging her ear. Mother states child has a bad
  cold for a few days. On otoscopic exam you note
  this.
• What is your differential diagnosis?
• What are some etiologies of this?
• What is the treatment for this?
• What is the name of the vaccine which tries to
  prevent this?

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Example 7

• A child with a history of allergies complains of
  hearing loss to her right ear. She has no fever.
  Otoscopic exam reveals this.
• What is this?
• What is the management of this?
• What is the treatment if child is not responsive
  to therapy?

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Example 8

• This 4 year old was not treated for AOM. Now the
  child has a fluctuant mass behind his ear. He
  also has a high fever. What is the diagnosis?
• How would this be treated?
• What diagnostics are necessary?

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Example 9

• A 35 year old female complains of vertigo with
  head movement. She also notices she is falling to
  the right side for the past 7 days. This is due
  to a viral infection.
• What is this?
• What is the pathophysiology of this?
• What is the management of this?

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Example 10

• This patient has episodes of dizziness lasting up
  to 2 days. She also notices difficulty hearing
  low frequency notes to her left ear. In addition
  her left ear feels stuffy. She also hears a
  ringing in that ear.
• What is the differential diagnosis?
• How is this managed?