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Approach to Ear Problems

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Title: Approach to Ear Problems


1
Approach to Ear Problems
  • By
  • Stacey Singer-Leshinsky R-PAC

2
Includes
  • Disease of the external ear
  • Disease of the middle ear
  • Disease of the inner ear

3
Normal TM
4
External Auditory CanalOtitis Externa
  • Defenses include cerumen which acidifies the
    canal and suppresses bacterial growth.

5
External Auditory CanalOtitis Externa
  • Cerumen prevents water from remaining in canal
    and causing maceration.
  • Etiology Pseudomonas aeruginosa and
    staphylococcus aureus, strep

6
External Auditory CanalOtitis Externa
  • Risk factors for Otitis Externa include
  • Swimming, perspiration, high humidity, insertion
    of foreign objects,
  • Eczema, psoriasis, seborrheic dermatitis

7
External Auditory CanalOtitis Externa-Clinical
manifestations
  • Otalgia/otorrhea
  • Fever
  • Pain
  • Canal edematous and obscured with debris,
    discharge, blood, or inflammation
  • Lymphadenopathy

8
External Auditory CanalOtitis Externa-
  • Complications
  • malignant otitis externa caused by pseudomonas
  • Differential diagnosis
  • basal cell carcinoma
  • squamous cell carcinoma

9
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

10
External Auditory CanalOtitis Externa-Management
  • Discuss patient education issues such as
  • Swimmer prophylaxis contains acid and alcohol

11
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

12
External Auditory Canal Chronic Otitis Externa
  • Purulent discharge
  • Dry or scaly.
  • Pruritus
  • Conductive hearing loss
  • Diagnosis

13
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

14
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.

15
External Auditory CanalMalignant Otitis Externa
  • Otorrhea yellow green, foul smelling.
  • Granulation tissue in external auditory canal
  • Trismus
  • Fever
  • Facial and cranial nerve palsies

16
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

17
External Auditory CanalMalignant Otitis Externa
  • Need IV antibiotics
  • Might need surgical debridement.
  • If treatment interrupted rate of recurrence is
    100

18
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

19
Cerumen ImpactionClinical Manifestations
  • Hearing loss
  • Stuffed or full feeling to ear
  • Pain if cerumen touches TM

20
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

21
External Auditory CanalForeign body
  • Can include toys, beads, nails, vegetables or
    insects.
  • Damage depends on amount of time object has been
    in ear.

22
External Auditory CanalForeign body-Clinical
Manifestations
  • Might present with purulent discharge
  • Pain
  • Bleeding
  • Hearing loss

23
External Auditory CanalForeign body
  • Complications include internal injury
  • Differential diagnosis to include cholesteatoma,
    cerumen impaction, otitis externa

24
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.

25
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.

26
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

27
Tympanic Membrane Bullous Myringitis
  • Differential diagnosis to include squamous or
    basal cell carcinoma, acute otitis media
  • Complications

28
Tympanic Membrane Bullous Myringitis-Management
  • Antibiotics
  • If pain is severe, rupture the vesicles with a
    myringotomy knife
  • Analgesics

29
Tympanic MembranePerforated TM
  • Etiology is direct trauma, infection, pressure
    build up
  • Bacteria can travel into middle ear and lead to
    secondary infection

30
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

31
Tympanic MembranePerforated TM
  • Differential diagnosis to include acute and
    chronic otitis media
  • Complications include secondary infection into
    inner ear

32
Tympanic MembranePerforated TM-Management
  • Antibiotics to prevent infection or treat
    existing infection
  • Surgical repair

33
Middle EarAcute Otitis Media
  • Viral respiratory infections cause inflammation
    of ET
  • When ET is blocked, fluid collects in the middle
    ear.

34
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

35
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

36
Middle EarAcute Otitis Media -Diagnosis
  • Tympanometry
  • Differential diagnosis to include TM perforation,
    Tympanosclerosis, recurrent AOM, mastoiditis

37
Middle EarAcute Otitis Media -Management
  • Analgesics/ Antipyretics
  • Auralgan
  • Antibiotics
  • Trimethoprim-sulfamethoxazole or Azithromycin
  • Decongestants
  • Avoid antihistamines

38
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

39
Middle EarAcute Otitis Media -Complications
  • TM perforation/ Tympanosclerosis
  • Recurrent AOM or chronic OM
  • Persistent middle ear effusion
  • Mastoiditis
  • Bacteremia

40
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

41
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.

42
Middle EarOtitis Media with Effusion
  • Hearing loss
  • Fullness, pressure
  • TM neutral or retracted. Gray or pink.
  • Landmarks visible or dull.
  • Decreased TM mobility

43
Middle EarOtitis Media with EffusionDiagnosis
  • Tympanometry- most accurate,
  • Audiometry-
  • Differentials to include Acute Otitis Media,
    malignant tumors to nasal cavity, cystic fibrosis

44
Middle EarOtitis Media with Effusion Management
  • Decongestants/Oral steroids
  • Antibiotics
  • Myringotomy with or without tubes
  • Adenoidectomy
  • Complications

45
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.

46
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

47
Middle EarChronic Otitis Media
  • Ear pain
  • Fullness to ears
  • Purulent discharge
  • Hearing loss
  • Dullness, redness or air bubbles behind TM

48
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

49
Middle EarChronic Otitis Media-Management
  • Antibiotics , steroids, placement of tubes.
  • Myringotomy
  • Surgical tympanoplasty, mastoidectomy

50
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

51
Cholesteatoma
  • Perforation of TM filled with cheesy white
    squamous debris
  • Possible conductive hearing loss
  • Drainage
  • Differential Diagnosis squamous cell carcinoma

52
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.

53
Barotrauma
  • Physical damage to body tissue due to difference
    in pressure between an air space inside or beside
    body and surrounding gas.
  • Ear barotrauma

54
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

55
Barotrauma
  • Hearing loss
  • Otalgia

56
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.

57
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

58
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

59
Mastoiditis
  • Pain
  • Bulging erythematous TM
  • Erythema, tenderness, edema over mastoid area
  • Postauricular fluctuance

60
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

61
MastoiditisComplications
  • Destruction of mastoid bone
  • Spread to brain leading to brain abscess or
    epidural abscess

62
Mastoiditis-Management
  • Treat with antibiotics
  • Patients with severe or prolonged
  • May need to surgically remove a portion of the
    bone

63
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

64
Labyrinthitis
  • Nausea/vomiting
  • Vertigo with head or body movements lasts about 1
    min
  • Nystagmus(rotary away from affected ear)
  • Loss of balance

65
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

66
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

67
Menieres Syndrome
  • Imbalance in secretion and absorption of
    endolymph fluid that causes buildup of fluid in
    cochlea.
  • Swelling leads to hair cell damage

68
Menieres Syndrome
  • Episodic vertigo for 24-48 hours
  • Sensorineural hearing loss
  • Tinnitus
  • Fullness/pressure in ears
  • N/V/dizziness

69
Menieres Syndrome
  • Diagnosis Audiologic testing, CT
  • Valium, tigan, antivert
  • HCTZ
  • Low sodium diet
  • Labyrinthectomy if hearing already lost

70
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

71
Vertigo
  • N/V
  • In peripheral lesions nystagmus can be horizontal
    or rotational
  • Central lesions nystagmus is bi-directional or
    vertical
  • Evaluation

72
Vertigo
  • Differential diagnosis to include Diabletes
    mellitus, hypothyroidism, drugs such as alcohol,
    barbituates, salicylates, hyperventilation,
    cardiac origin
  • Management Meclizine, Promethazine, Scopolamine

73
Tinnitus
  • Perception of abnormal ear noises
  • Can be ringing, hissing
  • Constant, intermittent, unilateral, or bilateral
  • Can originate in outer, middle or inner ear

74
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

75
Tinnitus-Treatment
  • Some drugs such as antihistamines and CCB
  • ENT referral-
  • Antidepressants
  • Surgical intervention-

76
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?

77
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?

78
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?

79
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?

80
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?

81
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?

82
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?

83
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?

84
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?

85
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?
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