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EAR PAIN

EAR PAIN. Auricle. Hematoma Cellulitis Relapsing Polychondritis. Hematoma. A localized mass of extravasated blood within the auricle- “bruise”. Hematoma. Must be drained to prevent significant cosmetic deformity dissolution of supporting cartilage- cauliflower ear. Cellulitis.

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EAR PAIN

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  1. EAR PAIN

  2. Auricle • Hematoma • Cellulitis • Relapsing Polychondritis

  3. Hematoma • A localized mass of extravasated blood within the auricle- “bruise”

  4. Hematoma • Must be drained to prevent significant cosmetic deformity • dissolution of supporting cartilage- cauliflower ear

  5. Cellulitis • Inflammation of the cellular tissue • May include lobule • Treat with Augmentin or Keflex • Complications- perichondritis and its resultant deformity

  6. Relapsing Polychondritis • Auricular erythema and edema • Recurrent, frequently bilateral, painful • Does not include lobule- no cartilage • Systematic- may progress to involvement of the tracheobronchial tree • Treat- Corticosteroids might forestall cartilage dissolution

  7. External Otitis

  8. Otitis Externa • Otalgia • Pruritus • Purulent discharge • Often recent water exposure or mechanical trauma

  9. Examination • Erythema • Edema • Purulent exudate • Auricular pain with manipulation • TM- moves normally with pneumatic otoscopy

  10. Treatment • Avoid moisture • Otic drops containing aminoglycoside antibiotic and anti-inflammatory corticosteroid--neomycin sulfate, polymyxin B sulfate, and hydrocortisone • Ear wick

  11. Auricular Pruritis • Common site- meatus • usually self induced • excoriation • overly zealous ear cleaning • Otitis Externa?? • Dermatologic condition • seborrheic dermatitis • psoriasis

  12. Treatment • Regeneration of Cerumen “blanket” • Avoid drying agents- soap & water, swabs • Mineral oil • 0.1% Triamcinolone- topical corticosteroid • Oral antihistamine • Stop messing with it!!!!

  13. Malignant External Otitis • Persistent external otitis • Evolves into Osteomyelitis of the skull base • Diabetic or Immunocompromised • Pseudomonas aeruginosa

  14. Clinical Findings • Persistent foul aural discharge • Granulation in the ear canal • Deep otalgia • Progressive cranial nerve palsies • (VI, VII, IX, X, XI, XII) • Diagnosis confirmed with CT • osseous erosion

  15. Treatment • Prolonged (antipseudomonal) ATB therapy • IV or Oral ciprofloxacin • Occasional surgical debridement

  16. Serous Otitis Media • Caused by negative pressure • Blocked auditory tube • Transudation of fluid • children- tubes more narrow, more horizontal • common after URI • adults- persistent--think cancer

  17. Clinical Findings • Dull, hypomobile TM • Air bubbles in middle ear • Conductive hearing loss

  18. Treatment • Autoinflation • Oral corticosteroids • Oral ATB • All else fails, ventilating tubes

  19. Barotrauma • Negative pressure tends to collapse and lock the auditory tube • Rapid altitudinal change • Air travel • Scuba diving

  20. Treatment • Swallow, yawn, autoinflate • Systemic or topical decongestants • pseudoephedrine • phenylephrine nasal spray • If persists on ground after treatments listed above… • Myringotomy provides immediate relief • Ventilating tubes- frequent flyer

  21. Acute Otitis Media • Bacterial infection of the mucosally lined air-containing spaces of the temporal bone. • Usually precipitated by viral URI which causes auditory tube edema…accumulation of fluid that becomes secondarily infected with bacteria • Streptococcus pneumoniae (49%), Haemophilus influenzae (14%), Moraxella catarrhalis (14%)

  22. H&P Findings • Otalgia • Aural pressure • Decreased hearing • Fever • erythema • Decreased mobility of TM • TM bulge • perforation eminent

  23. Treatment • ATB • amoxicillin • erythromycin • sulfonamides • Decongestants • Tympanocentesis • Ventilating tubes • ppx • sulfamethoxazole • amoxicillin

  24. Chronic Otitis Media • Chronic infection • Perforation of TM usually present • Mucosal changes • P. aeruginosa, Proteus, Staphylococcus aureus

  25. Clinical Findings • Hallmark- purulent aural discharge • Pain- on/off • Conductive hearing loss

  26. Treatment • Removal of debris • earplugs to protect against water exposure • ATB drops for exacerbations • Definitive- surgical TM repair • eliminate infection • reconstruction of TM

  27. Cholesteatoma* • Special variety of chronic otitis media • Most common cause is prolonged auditory tube dysfunction, with resultant chronic negative middle ear pressure that draws inward the upper flaccid portion of the tympanic membrane. *see picture

  28. Cholesteatoma • Creates a squamous epithelium-lined sac • Becomes obstructed and fills with desquamated keratin and becomes chronically infected • Typically erodes bone, causes destruction of nerves, may spread intracranially

  29. Cholesteatoma • Physical examination • epitympanic retraction pocket or marginal tympanic membrane perforation that exudes keratin debris • Treatment • surgical marsupialization of the sac or its complete removal

  30. Mastoiditis- complication of OM • Postauricular pain and erythema • Spiking fever • X-ray reveals coalescence of the mastoid air cells due to destruction of their bony septa • IV ATB and myringotomy for culture and drainage • Mastoidectomy if other fails...

  31. Petrous apicitis- complication of OM • Medial portion of the petrous bone between the inner ear and clivus may become a site of persistent infection • Foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy • Prolonged ATB therapy and surgical drainage

  32. Otogenic skull base osteomylitis- complication of OM • Osteomyelitis of the skull base • Usually due to P aeruginosa

  33. Facial paralysis- complication of OM • Acute- • Results from inflammation of the nerve in its middle ear segment, perhaps through bacterially secreted neurotoxins • Myringotomy for drainage and culture • IV ATB • prognosis excellent

  34. Chronic • Evolves slowly due to chronic pressure on the nerve in the middle ear or mastoid by cholesteatoma • surgical correction of the underlying disease • prognosis less favorable

  35. Sigmoid sinus thrombosis - complication of OM • Trapped infection within the mastoid air cells adjacent to the sigmoid sinus may cause septic thrombophlebitis • Systemic sepsis- spiking fevers, chills • Increased intracranial pressure- HA, lethargy, nausea and vomiting, papilledema • Diagnosis- MR venography • Tx- IV ATB, surgical drainage

  36. Central Nervous System Infection - complication of OM • Otogenic meningitis- most common intracranial complication of ear infection

  37. Non-auditory causes of earache • Temporomandibular joint dysfunction • chewing (soft foods, massage) • psychogenic • dental malocclusion (dental referral) • Glossopharyngeal neuralgia • refractory to medical management, may respond to decompression of ninth nerve

  38. Non-auditory causes of earache • Infections and neoplasia that involve the oropharynx, hypopharynx, and larynx • persistent earache demands specialty referral to exclude cancer of the upper aerodigestive tract

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