E A RE A R : : Common conditions the GPs should know

Michael J. LaRouere, M.D, FACS

Board-Certified Otolaryngologist Head and Neck Surgeon

Ann Arbor, Michigan

June 14, 2011

ENT Examination

NB:The canal may be partly straightened by pulling the

pinna backwards and upwards during examinationIn infants pull the pinna more horizontally backwards

as the shape of the ear canal is different

Visit: http://uk.youtube.com/watch?v=I3sa2W83iuo&NR=1

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Physiology

Anterior direction

Inferior

PosteriorAnterio

r

Consider the malleus as an arrow; pointing in the forward direction

The normal tympanic membrane should appear:

. pearly grey

. have a light reflex

. generally concave

. With a visible malleus

Attic

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Ear Drum-normal Landmarks An  annulus fibrosus or more commonly referred to as the eardrum margin. This is important. Note how smooth and how ever so slightly blurry it is.

Um  umbo - the end of the malleus handle and usually marks the centre of the drum

Lr  light reflex or Cone of light –is usually seen antero-inferioirly

At  Attic also known as pars flaccida. Any perforations here are serious and need referral. 4

Examine out to inExternal: Pinna (shape, colour, position, tenderness, haematoma)

Mastoid

Internal:The Canal ( skin, spores, foreign bodies, discharge, debris, wax)

The Tympanic membrane (look ant, post, superior/ attic and inferior of malleus). Colour( opaque, white, red, patches & translucency). Retraction( landmarks behind it more visible). Perforation ( safe/ unsafe). Discharge (mucopurulent)

Behind the Eardrum. Fluid behind the drum( meniscus, colour, bubbles)

. Any red bits( glomus tumour, granulations or blood?, white-cholesteotoma) 5

Ear Wax● Wax is produced in the outer half of

the ear canal and migrates outwards along with the canal skin. Inappropriate instrumentation can cause impaction.

● Wax impaction can cause hearing loss, pain, tinnitus, vertigo, or chronic cough but not usually discharge.

● Sudden expansion after getting water in can cause sudden deafness or pain, but needs careful exclusion of other pathology behind it e.g. infection

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Management:

Refrain from using cotton buds.

If Symptomatic – use topical medsDifferent preparations available none superior to other.

Sodium bicarbonate drops might be better at disintegrating wax, but can cause dryness of the canal and/ or irritation. Syringing. When to refer to ENT clinic:

. Patients known to have a tympanic membrane perforation or previous ear surgery (need microsuction), only hearing ear . Syringing fails . Causes pain or vertigo, . Hearing loss persists after wax removal.

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External Otitis Infection of the external auditory canal. Mediterranean ear/Swimmers earCommonly unilateralGradual onset pruritis, pain, hearing

loss, and ear discharge which varies in consistency and colour.

Can result in a featureless ext aud- canal

Risk factors: trauma, water, Immunosuppression, eczema

Can be fungal- spores might not always be visible

If treatment fails or otitis externa recurs frequently consider sending an ear swab for bacterial and fungal microscopy and culture

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ManagementRemove or treat any precipitating or aggravating factors

A topical ear preparation for 7 days. Options include preparations containing:

a. Both a non-aminoglycoside antibiotic + a corticosteroid e.g. flumetasone–clioquinol (Locorten–Vioform®) ear drops. b. Both an aminoglycoside antibiotic and a corticosteroid (contraindicated if the tympanic membrane is perforated). c. Topical preparations containing only an antibiotic (gentamicin ear drops are contraindicated if the tympanic membrane is perforated).d. Antifungal or ? something containing all three

Aural toilet: if earwax or obstruct topical medication (may require referral).

Provide appropriate self-care advice 9

Glue Ear vs. Otitis Media

Factors suggestive of a diagnosis of glue ear include:. frequent attacks of otitis media . it is unusual for children to get multiple resolving episodes of otitis media . prolonged signs . otitis media will usually resolve within 6 weeks and certainly within three months

Other risk factors: cleft palate ,Down's syndrome, allergy, family history

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Eustachian Tube Dysfunction

A severely retracted eardrum. Margins are very clear as is the malleus and it looks very sunken.

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Eustachian Tube dysfunction

Chronic blockage of the Eustachian tube is called Eustachian tube dysfunction. The eustachian tube becomes congested and swollen so that it may temporarily close; this prevents air flow behind the ear drum and causes ear pressure, pain or popping just as you experience with altitude change when travelling on an airplane or an elevator.

This can occur when the lining of the nose becomes irritated and inflamed, narrowing the Eustachian tube opening or its passageway.

Illnesses like the common cold or influenza. Others: pollution, cigarette smoke, allergic rhinitis, obesityRarely nasal polyps, cleft palate, skull base tumour

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Eustachian Tube Dysfunction

. Chronic ETD may reveal retraction pockets or collapsed middle ear disease with erosion of incus/stapedius. Difficulty auto-inflating the ear drum

. Generally the fluid clears spontaneously over a period of several weeks

. The efficacy of treatments such as nasal decongestants, oral decongestants, antihistamines is unclear

. Antibiotics may help prevent infection in cases of severe barotrauma

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ETD & ChildrenYoung children (esp 1 to 6 years) at particular risk because of very narrow

Eustachian tubes. Also, they may have adenoid enlargement that can block the opening of the Eustachian tube.

Eustachian tube in infants and young children runs horizontally, rather than sloping downward from the middle ear. Thus, bottle-feeding should be performed with the infants’ head elevated, in order to reduce the risk of milk entering the middle ear space. The horizontal course of the Eustachian tube also permits easy transfer of bacteria from the nose to the middle ear space.

Most children older than 6 years have outgrown this problem and their frequency of ear infections should drop substantially.

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Ear Drum Perforations

● Safe vs Unsafe Perforations● Safe perforations

. may allow infection to enter the middle ear

. conductive deafness

● Unsafe perforations . in fact represent a retraction of the tympanic membrane. . essentially a part of the drum becomes sucked inwards and may gradually enlarge. .when the retraction becomes extensive, keratinous debris builds up in the retraction and may become infected and an acquired cholesteatoma develops

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Unsafe perforations area)In the attic orb)In the posterior region. These are often linear rather than ovalc)Or involve the eardrum margin

Anything else is generally Safe. i.e. a) In the anterior region orb) In the inferior regionc) And not involving the eardrum margin

MAKE SURE YOU ALWAYS INSPECT THE ATTIC AREA ON OTOSCOPY!

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Cholesteotoma

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Aa three dimensional epidermoid structure exhibiting independent growth, replacing middle ear mucosa, resorbing underlying bone, and tending to recur after removal." There is usually a persistent or recurrent scanty cream coloured offensive discharge and progressive hearing loss due to ossicular destruction or toxin induced sensory hearing loss.

Otoscopy : a pearly white mass usually in the pars tensa +/- discharge and sometimes erosion of the bone. A perforation is usually present, but is not always visible due to overlying keratin. Granulation tissue or polyps may be seen due to chronic inflammation and sometimes retraction pockets are present.

A crust adherent to the tympanic membrane is indicative of a cholesteatoma. They can be reviewed after a short course of steroid or ceruminolytic ear drops, but if it is persistent or reveals an underlying abnormality then you should refer