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Approach to Ear Problems

Approach to Ear Problems. By Stacey Singer-Leshinsky R-PAC. Includes:. Disease of the external ear Disease of the middle ear Disease of the inner ear. Normal TM. External Auditory Canal Otitis Externa. Defenses include cerumen which acidifies the canal and suppresses bacterial growth.

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Approach to Ear Problems

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  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 Domeboro’s 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

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