approach to ear problems by stacey singer-leshinsky r-pac
TRANSCRIPT
Approach to Ear Problems
By Stacey Singer-Leshinsky R-
PAC
Includes:
Disease of the external earDisease of the middle earDisease of the inner ear
Normal TM
External Auditory CanalOtitis Externa
Defenses include cerumen which acidifies the canal and suppresses bacterial growth.
External Auditory CanalOtitis Externa
Cerumen prevents water from remaining in canal and causing maceration. Etiology: Pseudomonas aeruginosa and staphylococcus aureus, strep
External Auditory CanalOtitis Externa
Risk factors for Otitis Externa include:
Swimming, perspiration, high humidity, insertion of foreign objects, Eczema, psoriasis, seborrheic dermatitis
External Auditory CanalOtitis Externa-Clinical manifestations
Otalgia/otorrheaFeverPain Canal edematous and obscured with debris, discharge, blood, or inflammation Lymphadenopathy
External Auditory CanalOtitis Externa-
Complications malignant otitis externa caused by pseudomonas
Differential diagnosis basal cell carcinomasquamous cell carcinoma
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
External Auditory CanalOtitis Externa-Management
Discuss patient education issues such as:
Swimmer prophylaxis contains acid and alcohol
External Auditory CanalChronic Otitis Externa
Duration of infection greater than four weeks, or greater than 4 episodes a yearRisks: 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
External Auditory Canal Chronic Otitis Externa
Purulent dischargeDry or scaly. Pruritus Conductive hearing lossDiagnosis:
External Auditory CanalChronic otitis externa-Management
Cover fungi with clotrimazole(Lotrimin) Systemic antifungal include ketoconazoleCortisporin Wick with few drops of Domeboro’s astringent Differential diagnosis to include basal cell or squamous cell carcinoma, Foreign bodies, otitis media
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.
External Auditory CanalMalignant Otitis Externa
Otorrhea: yellow green, foul smelling. Granulation tissue in external auditory canalTrismusFeverFacial and cranial nerve palsies
External Auditory CanalMalignant Otitis Externa
Diagnosis: Culture of ear secretions and pathological examination of granulation tissue, CTComplications include sepsis, cranial nerve palsies, meningitis, brain abscess, osteomyelitis of the temporal bone and skullDifferential diagnosis to include basal cell or squamous cell carcinoma
External Auditory CanalMalignant Otitis Externa
Need IV antibiotics Might need surgical debridement. If treatment interrupted rate of recurrence is 100%
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
Cerumen ImpactionClinical Manifestations
Hearing loss Stuffed or full feeling to earPain if cerumen touches TM
External Auditory CanalCerumen Impaction
Be sure TM is intact prior to lavageIrrigate ear with one part peroxide, and one part water Debrox and Cerumenex drops Ear irrigation and manual cerumen removal
External Auditory CanalForeign body
Can include toys, beads, nails, vegetables or insects.Damage depends on amount of time object has been in ear.
External Auditory CanalForeign body-Clinical Manifestations
Might present with purulent dischargePainBleedingHearing loss
External Auditory CanalForeign body
Complications include internal injury Differential diagnosis to include cholesteatoma, cerumen impaction, otitis externa
External Auditory CanalForeign body- Management
Irrigation is best provided the TM is not perforatedDestroy insect with lidocaine or mineral oil. Irrigate and suction liquid. For inanimate objects suction or use alligator forceps.
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.
Tympanic MembraneBullous Myringitis- Clinical Manifestations
Sudden onset of severe pain No fever usuallyNo hearing impairmentBloody otorrhea possible Inflammation to TM Multiple reddened inflamed blebs possibly blood filled
Tympanic Membrane Bullous Myringitis
Differential diagnosis to include squamous or basal cell carcinoma, acute otitis mediaComplications
Tympanic Membrane Bullous Myringitis-Management
AntibioticsIf pain is severe, rupture the vesicles with a myringotomy knife Analgesics
Tympanic MembranePerforated TM
Etiology is direct trauma, infection, pressure build up Bacteria can travel into middle ear and lead to secondary infection
Tympanic MembranePerforated TM- Clinical Manifestations
Sudden severe painHearing loss Drainage Otoscope exam reveals puncture in TM, might be able to see bones of middle earPurulent otorrhea may begin in 24-48 hours post perforation
Tympanic MembranePerforated TM
Differential diagnosis to include acute and chronic otitis mediaComplications include secondary infection into inner ear
Tympanic MembranePerforated TM-Management
Antibiotics to prevent infection or treat existing infection Surgical repair
Middle EarAcute Otitis Media
Viral respiratory infections cause inflammation of ETWhen ET is blocked, fluid collects in the middle ear.
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
Middle EarAcute Otitis Media
Otalgia. Conductive hearing lossURI symptomsVomiting, diarrhea FeverTM bulging and erythematous with decreased or poor light reflex. Decreased TM mobility on pneumatic insufflation
Middle EarAcute Otitis Media -Diagnosis
Tympanometry Differential diagnosis to include TM perforation, Tympanosclerosis, recurrent AOM, mastoiditis
Middle EarAcute Otitis Media -Management
Analgesics/ AntipyreticsAuralgan Antibiotics Trimethoprim-sulfamethoxazole or AzithromycinDecongestants: Avoid antihistamines
Middle EarAcute Otitis Media –Patient Education
Myringotomy in patients with hearing loss, poor response to therapy or intractable painDiscuss patient education issues including breast feeding, no smoking in homes, pneumococcal vaccine
Middle EarAcute Otitis Media -Complications
TM perforation/ TympanosclerosisRecurrent AOM or chronic OMPersistent middle ear effusionMastoiditisBacteremia
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
Middle EarOtitis Media with EffusionFluid 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.
Middle EarOtitis Media with Effusion
Hearing loss Fullness, pressure TM neutral or retracted. Gray or pink. Landmarks visible or dull. Decreased TM mobility
Middle EarOtitis Media with EffusionDiagnosis
Tympanometry- most accurate, Audiometry- Differentials to include: Acute Otitis Media, malignant tumors to nasal cavity, cystic fibrosis
Middle EarOtitis Media with Effusion Management
Decongestants/Oral steroidsAntibioticsMyringotomy with or without tubes AdenoidectomyComplications:
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.
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 pressureScaring or erosion of small conducting bones of middle ear and inner ear Erosion of mastoid Thickening of mucous secretions in ETCholesteatoma Persistent OME
Middle EarChronic Otitis Media
Ear pain Fullness to earsPurulent discharge Hearing loss Dullness, redness or air bubbles behind TM
Middle EarChronic Otitis Media
Diagnosis: clinical, audiometry, tympanometry, CT, MRIDifferential diagnosis to include AOM, cholesteatomaComplications include bony destruction or sclerosis of mastoid air cells, facial paralysis, sensineural hearing loss, vertigo
Middle EarChronic Otitis Media-Management
Antibiotics , steroids, placement of tubes. Myringotomy Surgical tympanoplasty, mastoidectomy
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
Cholesteatoma
Perforation of TM filled with cheesy white squamous debrisPossible conductive hearing loss Drainage Differential Diagnosis: squamous cell carcinoma
Cholesteatoma-Management
Large or complicated cholesteatomas require surgical excisionComplications include erosion of bone and promote further infection leading to meningitis, brain abscess, paralysis of facial nerve.
Barotrauma
Physical damage to body tissue due to difference in pressure between an air space inside or beside body and surrounding gas. Ear barotrauma:
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 developRisk factors Differential diagnosis should include serous, acute or chronic otitis media, bullous myringitis
Barotrauma
Hearing lossOtalgia
Barotrauma-Management
Auto inflation by yawning, swallowing or chewing gum to facilitate opening of ET to equalize air pressure in middle earDecongestants Myringotomy Patient education to include valsalva maneuver.
Mastoid
Portion of temporal bone posterior to the ear. Mastoid air cells connect with the middle earFluid in the middle ear can lead to fluid in the mastoid
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
Mastoiditis
PainBulging erythematous TMErythema, tenderness, edema over mastoid areaPostauricular fluctuance
Mastoiditis-Diagnosis/differentials
Diagnosis: CT show bony destruction or drainable mastoid abscessTympanocentesis 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
MastoiditisComplications
Destruction of mastoid boneSpread to brain leading to brain abscess or epidural abscess
Mastoiditis-Management
Treat with antibiotics Patients with severe or prolonged May need to surgically remove a portion of the bone
Labyrinthitis
Viral infection Vestibular neural input disrupted to the cerebral cortex and brain stem Vertigo due to inflammation and infection of labyrinthNeurological exam normalCan also follow allergy, cholesteatoma, or ingestion of drugs toxic to inner ear
Labyrinthitis
Nausea/vomitingVertigo with head or body movements lasts about 1 minNystagmus(rotary away from affected ear)Loss of balance
Labyrinthitis-History and PE
Diagnosis: Audiologic testing, CT and MRI Differentiate other causes of dizziness by CT, MRIDifferential diagnosis to include acoustic neuroma, vertigo, cholesteatoma, meniere’s disease
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
Meniere’s Syndrome
Imbalance in secretion and absorption of endolymph fluid that causes buildup of fluid in cochlea. Swelling leads to hair cell damage
Meniere’s Syndrome
Episodic vertigo for 24-48 hours Sensorineural hearing loss TinnitusFullness/pressure in earsN/V/dizziness
Meniere’s Syndrome
Diagnosis: Audiologic testing, CT Valium, tigan, antivertHCTZ Low sodium dietLabyrinthectomy if hearing already lost
Vertigo
Motion perceived when no motion, or exaggerated motion perceived in response to body movementCauses- Irritation to labyrinth CNS Brainstem or temporal lobe 8th cranial nerve dysfunction (acoustic
neuroma) Labyrinthitis, Meniere’s disease
Vertigo
N/VIn peripheral lesions nystagmus can be horizontal or rotationalCentral lesions nystagmus is bi-directional or verticalEvaluation
Vertigo
Differential diagnosis to include Diabletes mellitus, hypothyroidism, drugs such as alcohol, barbituates, salicylates, hyperventilation, cardiac originManagement: Meclizine, Promethazine, Scopolamine
Tinnitus
Perception of abnormal ear noises Can be ringing, hissing Constant, intermittent, unilateral, or bilateralCan originate in outer, middle or inner ear
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
Tinnitus-Treatment
Some drugs such as antihistamines and CCB ENT referral- AntidepressantsSurgical intervention-
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 treatmentWhat are some patient education tips on this?
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?
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?
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?
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?
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?
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?
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?
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?
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?