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Practical treatment of ear

diseases: A one hour tour

Wisconsin Academy of Physician Assistants

October 9, 2014

Ashley G. Anderson Jr., MD, MS

Professor-Division of Otolaryngology/Head and Neck Surgery

University of Wisconsin Medical School

Madison, Wisconsin

Objectives

• Review ear anatomy

• Improve diagnostic and treatment skills

• Understand proper radiologic, audiologic and

lab studies

• Don’t fear the ear!

Breaking down the spectrum of ear disease

Pain

Otitis media

External otitis

Non-otologic pain TMJ (most common)

Tumor (rare)

Hearing

Loss

Conductive

Sensorineural

Serous otitis media

Anatomical Conduction

problems

Otosclerosis

Perforation, ossicular

Problems

Sudden HL (SSHL)

Congenital

Noise induced

Tinnitus

Vertigo

Benign

Lesion induced

Vestibular

Neurologic

Basic ear anatomy

Tympanic membrane

Right Left-XShort process

Light Reflex

Stapes Stapes

Promentory

Maleus handle

Normal audiogram

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Audiogram Sensorineural hearing loss

Conductive hearing loss Tympanogram

Around $2000.00 Between $4000-$5000

Cerumen: The enemy!!

How to remove it?

1. Irrigation2. Cerumen curette

3. Otic drops4. Suction

5. Alligator forceps6. Referral

External ear

• Auricular hematoma

• Acute external otitis

• Chronic external otitis

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External canal anatomy

• Auricle is mostly skin-

lined cartilage

• External auditory meatus

– Cartilage: ~40%

– Bony: ~60%

– S-shaped

– Narrowest portion at bony-

cartilage junction

Tenderness starts here

Acute external otitis

• Progressive infection

• Symptoms

– Pain

– Increased pruritus

• Signs

– Erythema

– Increasing edema

– Canal debris, discharge

Treatment of acute external otitis

• Keep the ear DRY

• Otic drops

– Ciprofloxacin with or without hydrocortisone

– Ofloxacin drops

– Cortisporin otic solution (neomycin/polymixin)

• If necessary, cleaning of the ear

• Insertion of a “wick” (Pope oto-wick)

• Adequate control of pain

Chronic external otitis

Treatment:

•Avoid touching, cleaning with Q-tip•Avoid steroid drops

•Acetic acid? (Vo-sol HC)

Symptoms:

•Asteatosis (eczema)•Hypertrophied skin

•Otorrhea?

Otomycosis

• Canal erythema

• Mild edema

• White, gray or black

fungal debris

• Treatment:

– Repeat cleaning

– Acidification

– Antifungal drops

Necrotizing external otitis

• Potentially lethal infection of EAC and

surrounding structures

• Typically seen in diabetics and

immunocompromised patients

• Pseudomonas aeruginosa is the usual

culprit

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Auricular hematoma

• Trauma, but occasionally

spontaneous

• Need to be incised and drained

• Aspiration is seldom sufficient

• Occasionally, need treatment

with a bolster secured by

through and through suture

• May lead to permanent

deformity of the auricle

Herpes zoster oticus

• Early: burning pain in one ear,

headache, malaise and fever

• Herpes zoster infection

• Late (3 to 7 days): vesicles,

facial paralysis

• Antiviral medications

• Corneal protection if facial

paralysis

Acute otitis media

Acute otitis media

• Most common cause of

pediatric office visit

• 42% of antibiotic prescriptions

written for children

• 62% by age 1 year

• 83% by age 3 years

• 46% of three year olds have 3

or more infections

Acute otitis media

• Annual cost of

medical/surgical treatment

of otitis in US is $3-$4 billion

annually

• For all children under 2

years of age, by the time

they reach two, they will

have had a total of 9.3

million episodes of otitis

Bullous myringitis

• Inflammation limited to

TM & nearby canal

• Multiple reddened,

inflamed blebs

• Hemorrhagic vesicles

• Etiology uncertain, but

treat as OM in most cases

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The most important part of treatment

of acute otitis media is selection of the

proper antibiotic??

The most important aspect of

treatment of acute otitis media is

determining the necessity for treatment

Type 1 and Type 2 Errors

True Type I Error

Type II Error True

Reality

Your Diagnosis

Acute OM

Normal

Acute OM Normal

•A type I error suggests we are “trying our best”•We perceive that type I errors act in the best interest of the patient•Type I errors are culturally more acceptable to the patient

•In the absence of information we are more comfortable with type I errors

CDC Recommendations Implications of type 1 errors

• It’s likely we don’t miss many actual cases of

otitis media

• Most room for improvement is in reduction of

type 1 errors

• Greater diagnostic accuracy = reduced costs,

reduced medication reactions, accurate history

driving surgical decisions (tube insertions)

Factors resulting in over-diagnosis

(Type 1 errors)

• Bias towards treatment

• Difficulty with visualization of TM-”if I can’t

see it, I’ll treat it”

• Use of TM color as a determinant of infection

• Inadequate assessment of mobility

History

• Recent URI

• Irritable

• Fever

• Otaligia

• Hearing loss

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Ear exam • Assessment of mobility

– Pneumatic otoscopy

– Tympanogram

• Is the tympanic membrane

bulging? Where is the pars

flacida?

• Redness does not mean infection

Mobility

• Must have a good seal in external ear canal with pneumatic

otoscope-buy special tips, or use rubber ring

• Standard, disposable tips will not provide a good seal

• If the eardrum is mobile, the patient most likely does not

have acute otitis

• Office screening typmanometry can help rule out otitis

media

Acute otitis media treatment plan

• Accurate diagnosis

• Appropriate selection of antimicrobial agent

• Communication plan-phone if unimproved in 48 hours

• Follow up visit

• Modification of risk factors

– Tobacco use in home

– Sugar in diet

Risk factors for AOM & OME

• Environmental exposure to tobacco smoke

• Multiple child day care

• Anatomical abnormalities

• Poor diet

• Immune deficiency

• Allergy

• Male sex

Bacterial causes of acute otitis

media

35

23

28 14

1

3

1

1

16

Strep pneumoniae

H. influenzae

Other bacteria

M. Catarrhalis

Pseudomonas

Alpha Strep

Pseudomonas

Staph aureus

No Growth

Bacterial pathogens in AOM

• S. pneumoniae—Most common, >50% of infections.

Developing multi-drug resistance

• H. influenzae—Second in frequency ~20% or higher.

Strong biofilm developer

• Moraxella catarrhalis—up to 25% of children with OM.

Secretes cephalosporinases that may protect other

bacteria

• Strep pyrogenes—steady decline in frequency

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Antibiotic Coverage

• Beta-lactamase production increasing

– 40+% of H influenzae

– ~100% of M catarrhalis

• Increase in drug resistant S pneumoniae

– Rates as high as 60%

– Unaffected by beta-lactamase inhibitor as alteration

is based upon penicillin-binding protein

2013 Meta analysis of 3317 children with

3854 episodes of OM (antibiotic vs. placebo)

• Antibiotics reduced pain at 2-3d, (11.6 vs. 15.9%)

• Antibiotics reduced TM perforations (1.8 vs.5.2%)

• Antibiotics reduced contralateral episodes of AOM (10.6 vs.

18.8%)

• Antibiotics did not reduce rate of recurrence

• Antibiotics increased adverse events (vomiting, rash,

diarrhea), (27.3 vs. 20.2%)

• Serious complications rare in both groups

Venekamp RP, Sanders S, Glasziou PP, et. Al. Antibiotics for acute otitis media in children

Cochrane Database Syst Rev 2013; 1:CD000219.

Antimicrobial therapy• Amoxacillin (90mg/kg/day in 2 doses)-Children at

minimal risk for resistance

– No beta-lactam antibiotic within 30 days

– No concomitant purulent conjunctivitis-often caused by

beta-lactam resistant H.influenzae

• Amox-clavulanate (Amox 90mg/kg/day +

clavulante 6.4mg/kg/day in 2 doses

• PCN allergic patients: macrolydes

• Other options: cefdinir, cefuroxime, ceftriaxone

Source: Up-to-date, Through Aug 2014

Surgical treatment

• Indicated when infections become too frequent

(What does that mean?)

• Indicated for complicated infections (febrile seizures,

recurrent perforation)

• Indicated in patients with other social of physical

challenges

• Will reduce frequency of infections by 90%

Residual fluid following infection

Time in days

0 30 60 90

Percentage of

children withresidual serous

fluid

100

60

30

10

Otitis media with effusion

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Diagnosis of otitis media with

effusion

• Physical examination

• Tympanometry

– Flat, or Type-B tympanograms

• Audiometry*

– Conductive hearing loss

– Is hearing loss clinically significant?

Treatment for patients with OME

• Observation

• Modification of risk factors

• Antimicrobial prophylaxis?

• Valsalva

• Ineffective treatments:

– Decongestants

– Steroids

Consider an ENT referral when:

• Failure of medical therapy

• Bilateral fluid for 90-120 days and significant

hearing loss

• Speech and language delay

• Compliance/social difficulties

• OME secondary to recurrent otitis media

Sudden sensorineural hearing loss

(SSHL)

• Sudden drop in hearing, usually unilateral. (Drop of 30dB in 3

frequencies over 72 hours)

• Patient may awaken with hearing loss, or experience a sudden loss,

but some may report later with “fullness,” not fully appreciating

the loss

• Other symptoms: fullness, tinnitus (90%), vertigo (20-60%)

• Etiology is unknown. Viral? Autoimmune? Microvascular?

(associated with genes related to thrombotic state) HSV?

Tuning fork testing

• Weber-Place fork in midline. In which ear is

sound loudest? (Ernst Heinrich Weber 1795-

1878)

• Rinne-Fork in front of ear and mastoid. Which

sounds louder ? A positive Rinne test is normal.

(Heinrich Adolph Rinne 1819-1868)

• Frequency?

– 512 Hz

– 1024 Hz

• Cost?

– $15.00 each

– Set for $39.99

Diagnosis of SSHL

• Normal physical examination of ear

• Abnormal pure tone audiogram-normal tympanogram

• Tuning fork examination:

– Weber will lateralize to the good ear (“bad” cochlea cannot

receive sound as well) Most useful.

– Rinne test (air conduction and bone conduction are both

diminished). May pick up bone conduction better, but it’s in

the other ear.

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Sudden Sensorineural Hearing Loss

(SSHL)

• Very important to differentiate

from other causes of hearing loss

• Use Weber Test to rapidly screen

• Relative ENT emergency, as early

treatment is more successful

• Treat ASAP with high dose steroid

regime

• Refer to otolaryngology

Treatment and Prognosis

• Initial high dose steroid treatment for 1-3 weeks with weekly follow up

• Antiviral medications

• Consideration for “intratympanic” infusion of steroids

• MRI scan

• Laboratory studies

• Prognosis

– Better if loss is in high, or low frequencies

– Most patients have some recovery within 10 days. As many as 2/3 have complete recovery

– Greater than six months of hearing loss-recovery is poor

Vertigo Some quickies on vertigo

• Take vertigo in children very seriously. Proceed directly to CT / MRI /

neurology evaluation

• A good neurological history and exam are the first step in evaluation.

Exclude significant neurological disease first. When in doubt—MRI.

• Resist the temptation to treat acute vertigo with vestibular

suppressants, as this will delay habituation and recovery

• Vertigo of short duration, precipitated by movement, is often benign

paroxysmal positional vertigo (BPPV). Avoid doing the “Epley

maneuver” unless you have confirmed side of lesion with an ENG/VNG

Some quickies on tinnitus• Bilateral tinnitus is usually benign. Unilateral tinnitus

is a greater cause for concern

• Workup of tinnitus begins with a hearing test, the

results of which will guide further workup

• Aspirin and NSAIDs can cause tinnitus

• Noise exposure, and high frequency hearing loss are

the most common cause of tinnitus

And now, a rapid picture tour…

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Acute otitis media (AOM)

Note bulging pars flacida & injection of the TMExternal canal foreign body

Acute otitis media Serous otitis media

Otitis media with effusion and retraction-possibly

early infectionBone osteomata in ear canal

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Acute otitis media Otitis media with effusion

Otitis media with effusionOtitis media with effusion

Acute otitis media Purulent Otorrhea

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Purulent otorrhea Otitis media with effusion

Note air bubbles in fluid behind TM

Tympanostomy tube

Possible cholesteatoma developing in TM

Granuloma over tube

Foreign body reaction to a tympanostomy tube

Atelectasis of tympanic membrane Otitis media with effusion

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Superior retraction pocket with early cholesteatoma

Cholesteatoma

Classic attic retraction pocket with cholesteatoma Cholesteatoma in canal wall

Perforation with neomembrane Large anterior perforation

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Perforation with neomembrane Tympanosclerosis

Thank you!

Contact Information

Ashley G. Anderson Jr., MD, MS

Department of Ear, Nose, Throat and

Plastic Surgery

1 South Park Street, 6th Floor

Madison, WI 53715

(608) 287-2500

E-mail: aganders@wisc.edu