2. Ear Assessment Glue Ear Flashcards
(92 cards)
1
Q
What structures should be assessed during an Ear Examination?
A
Pinna
Mastoid (process of the temporal bone)
Canal
The Tympanic Membrane
2
Q
What assessments/tests should be carried out as part of an ear examination?
A
Free Speech Hearing Assessment
Tuning Fork Test
Facial Nerve Exam
Post Nasal Space
3
Q
What should be looked for in or around the pinna?
A
Discharge Swelling. Erythema. Deformity. Scars. Symmetry
4
Q
Draw and label the parts of tympanic membrane
A
Malleus Handle of Malleus Pars Flaccida Chorda Tympani Long process of the incus Umbo Annulus Fibrosis Pars Tensa Cone of Light
5
Q
What is acute otitis media?
A
Inflammation of the middle ear
6
Q
In whom is acute otitis media common?
A
Children
7
Q
Is otitis media unilateral or bilateral?
A
Can be both
8
Q
What condition can precede acute otitis media?
A
URTI
9
Q
What are the causes of acute otitis media?
A
Bacterial
Viral
10
Q
What are the most common bacterial causes of acute otitis media?
A
Streptococcus Pneumoniae (35%) Haemophilus Influenzae (25%) Maraxella Catarhalis (15%) Group A Strep or Staph Aureus
11
Q
Describe the inflammatory steps in Otitis Media
A
Organisms invade mucous membrance
Oedema closes off the eustachian tube
Pressure from the pus rises, bulging the drum
Local necrosis of the Tympanic Membrane perforation
Spontaneous drainage from the ear until the infection resolves.
12
Q
What are the clinical features of acute otitis media?
A
Rapid Onset of Severe ear pain. \+/- Irritability, Anorexia, Vomitting, Tenderness of the Mastoid, Hearing loss. Temperature. (Fever, AKA pyrexia) Bulging TM. (Stages) Perforation of TM with accompanying purulent discharge Otorrhoea Often settles in 48 hours.
13
Q
Describe the inflammatory steps in Otitis Media
A
Organisms invade mucous membrance
Oedema closes off the eustachian tube
Pressure from the pus rises, bulging the drum
Local necrosis of the Tympanic Membrane perforation
Spontaneous drainage from the ear until the infection resolves.
14
Q
Describe the change in appearance of the Tympanic membrane as the inflammation progresses in acute suppurative otitis media?
A
Grey, with lack of luster Radial injection of small drum vessels. Redness and fullness of drum Bulging of drum, loss of landmarks Desquamation perforation.
15
Q
What is the Early Tx for Acute Otits Media?
A
A/B’s not always needed but if are oral penicillin (I.V. If necessary)
(Oxford says Amoxcillian +/- clavulanate for ≤7 days = 1st line adult, UCD say only in s )
Co-ammoxiclav in Moraxella
Analgesics, Nasal Vasoconstrictors (ephedrine drops)
Swab if discharge present for culture+sensitivity.
16
Q
What is the Late Tx for Acute Otits Media?
A
Late stage = Bulging Drum, failure to resolve with persistence of severe symptoms.
Hospital Admission for I.V. Antibiotics
Followed by Surgical Myringotomy with insertion of grommet.
Specimen Culture+Sensitivity
If discharge persists after acute phase passed. Specimen for culture+stain to inform use of targeted antibiotic or eardrops (A/B and/or steroids)
17
Q
What are the potential complications of Acute Otitis Media?
A
Mastoiditis Meningitis Extra-dural Abcess Sub-Dural Abcess Brain Abcess Lateral Sinus Thrombosis Facial Paralysis Gradenigo's Syndrome Citelli's Abscess Bezold's Abcess
18
Q
What should be suspected in recurrent acute suppurative otitis media?
A
IgA deficiency of Hypogammaglobulinaemia
19
Q
What Tx is indicated in the case of a child with recurrent attacks of acute suppurative otitis media, what might these attacks be associated with?
A
Insertion of a grommet.
The attacks in a child may be associated for example with teething
20
Q
How is success in treatment of acute otitis media defined?
A
- Symptoms have resolved
- Ear drum has returned to normal
- Hearing is normal
21
Q
What Ddx might be considered if Acute Otitis Media fails to resolve?
A
Residual source of infection within the Nose, sinus or adenoid.
Ineffective choice of antibiotic
A low grade mastoid infection “masked mastoiditis”
22
Q
What is chronic suppurative otitis media (C.S.O.M)?
A
Inflammation+middle ear fluid which develops from A.S.O.M, which fails to resolve. (ASOM of several months duration (oxford).
23
Q
What are the types of chronic suppurative otitis media? Identify those that are safe and unsafe.
A
- Tubotympanic (aka mucosal) Type = Safe
2. Atticoantral (aka bony) Type = Unsafe
24
Q
What are the predisposing factors for C.S.O.M?
A
Late treatment for ACOM
Inadequate/Inappropriate Antibiotic Tx
Persistent Upper Respiratory Sepsis
Lowered resistance, malnutrition, immunological defect etc.
Particularly virulent infection e.g. Measles.
25
What are the clinical features of mucosal (tubotympanic) C.S.O.M?
1. Perforation present, usually central with well defined rim.
2. Recurrent infection occurs with otorrhoea, frequently triggered by upper respiratory sepsis via the Eustachian Tube.
3. There may be periods of quiescence, where the only symptoms is hearing loss, which becomes progressive over years.
4. The perforation may spontaneously heal. This is less likely with larger perforations, which are likely to remain permanent.
Little pain
26
What is the Tx for mucosal (tubotympanic) COSM?
```
Swab for Culture+Sensitivity
Antibiotic Treatment as Indicated
Topical ear antibiotics ±steroids.
Admission for aural toilet and I.V AB
Surgery = Myringoplasty
```
27
What are the clinical features of bony type (atticoantral) COSM?
1. Perforation located postero-marginally, poster-superiorly or into the attic part of the ear through the pars flaccida (schrapnells membrane).
2. Granulations occur from areas of osteitis, these are bright red and bleed on contact.
3. Aural Polyps form from granulation tissue, appearing as cherry like growths at the external ear canal opening.
4. Cholesteatoma
Little pain
28
What is cholesteatoma?
Cholesteatoma or 'active squamous chronic otitis media' is a misnomer.
Rare 1:10,000, Peak 5-15yrs
Neither a cholesterol, nor a tumour. It is the progressive local invasion (and destruction) of the middle ear and mastoid by retracted tympanic membrane.
It is associated with perforation at the mouth of the membrane and the production of squamous debris within its depths as well as osteolytic activity at its periphery.
Attic choleseatoma (involvement of the pas tensa or flaccida) indicates serious disease.
Potentially lethal complications if untreated.
29
What are the symptoms indicate impending CNS complications due to cholesteatoma?
Foul discharge ± Deafness
Headache/Pain
Facial Paralysis
Vertigo
30
What is the Tx for bony (atticoantral) type COSM?
Safe Dry Ear by removal of disease a priority, hearing secondary.
Early Cases: Aural toilet may enable the abortion of small area of localised osteitis, as well as halt progression. Microscopic debridement may allow evacuation of small pocket of early cholesteatoma development in order to stabalise condition.
Following Failure of Period of Conservative Treatment: Major surgical intervention if failed or progression continued.
31
What are the major surgical interventions for the treatment of unsafe COSM?
Atticotomy
Combined Approach Tympanoplasty
Modified Radical Mastoidectomy
32
What are the main complications of Middle Ear Disease
Infratemporal and intracranial extension
33
What are the main complications of an infratemporal extension of ACOM/COSM?
Acute Mastoiditis
Labyrinthitis
Facial Nerve Paralysis
Petrositis (Gradenigo's Syndrome)
34
What are the main complications of an intracranial extension of ACOM/COSM?
```
Meningitis
Extradural Abscess
Subdural Abscess
Brain Abscess
Lateral Sinus Thrombosis
```
35
List the grades of central perforation of the tympanic membrane?
Dry (permanently)
Intermittent Discharge
Constant Discharge
Constant Discharge with Complication
36
What information should be collected as part of the Hx for a central perforation of TM?
```
Duration of Symptoms
Discharge (character, smell, periodicity)
Previous middle ear disease/surgery
Hearing on the contralateral ear
Other relevant disease.
```
37
What should be done during an examination of a centrally perforated TM?
Wax + Debris must be removed to give view of TM
| Tuning Fork Tests
38
What investigation should be conducted in central perforation of TM?
Pure Tone Audiometry
| Swab, especially if discharge continuous or fungal aetiology suspected
39
What is the Tx for central perforation of TM?
For Discharge: Drops( AB±Steroids)
Continued Discharge (post-drops): Systemic Antibiotics for 10 days
Review Patient every 10-14 days until the ear is dry.
Surgery if Indicated
40
What should be considered with regard to Rx of ear drops?
Recording of Dose + Length of Time/Usage
Should not be used for >10 days
Should not be used if otorrhoea ceases
Should not be used if patient complains of dizziness.
Review every 10-14 days until the ear is dry.
Extreme caution with repeat prescriptions.
41
What are the indications for surgery in the case of central perforation of TM?
```
Troublesome discharge
Hearing Loss
Patient wishes to swim
Hearing aid in use
Pain
Other complications
```
42
What are the contraindications for surgery in the case of central perforation of TM?
Avoid surgery if <10yrs, unless discharge persistent and may damage ossicular chain (Maleus, Incus, Stapes).
No tympanoplasty if no improvement in hearing or reduction in disability possible. (Glasgow Benefit Pilot)
43
What surgical procedures should be considered in the persistently discharging ear that has not responded to treatment?
Cortical Mastoidectomy (removal of mastoid air cells) and Myringoplasty should be considered
44
What is the usual length of stay for a patient following surgery for perforation of TM?
Discharge first post-operative day after uncomplicated operation.
45
What is acute mastoiditis?
Extension of middle ear infection into the mastoid air cell system with suppuration and bone necrosis.
46
What are the signs and symptoms of acute mastoiditis?
SIGNS
Pyrexia
Patient is ill
Tenderness of the mastoid on palpation
Swelling of the post auricular region with obliteration of the sulcus, the pinna may be pushed forward and downwards.
Sagging of the posterior canal wall on otoscopy.
Drum may be bulging or discharging.
SYMPTOMS
Pain – persistent
Otorrhoea – smelly and profuse
Increasing deafness
LESS COMMON
Subperiosteal abscess over the mastoid antrum
Bezolds abscess (presents in the neck as pus breaks through the mastoid tip).
Zygomatic mastoiditis results in swelling over the zygoma due to extension of the infection into the zygomatic air cells.
47
What is the Tx for mastoiditis?
Admission to hospital for I.V. Antibiotics (Amoxycillin, Metronidiazole).
Cortical Mastoidectomy - In the event of a periosteal abcess or if the condition does not settle rapidly (24hrs) with A/B Tx, Surgery that drills out the mastoid air cell system to exenterate.
48
What is lateral labyrinthitis?
Cholesteatoma erodes the labyrinth (the lateral semicircular canal).
49
What are the clinical features of labyrinthitis?
```
Veritgo
Nausea
Vomiting
Nystagmus towards diseased side
Positive fistula sign
Progressive sensorineural deafness
```
50
What is the Tx for labyrinthitis?
Antibiotics
Mastoid Exploration
Occasionally labyrinth drainage
51
In whom is acute otitis media more likely to cause facial nerve paralysis?
In children. Possibility that this is die to dehiscence (splitting) within the fallopian canal of the middle ear.
The pressure phenomenon usually resolves spontaneously with resolution of the infection – can be assisted sometimes by myringotomy drainage.
52
How can chronic otitis media cause facial nerve paralysis?
Cholesteatoma erodes the facial nerve canal and produces granulations of the facial nerve leading to paralysis.
Urgent exploration need – DO NOT MISTAKE FOR BELLS PALSY!
53
What is petrositis?
Infection spread form the petrous tip to involve the 5th cranial nerve (CNV).
54
What are the clinical features of petrositis?
Diplopia
Trigeminal Pain
Evidence of middle ear infection
55
How is petrositis managed?
CT Scanning
I.V. Antibiotics
Neurosurgical involvement with exploration of the temporal bone as far as the apical cells.
56
Where is a brain abscess most likely to occur from middle ear infection?
Temporal Lobe Cerebellum
57
How does infection from the middle ear spread intracranially?
Direct via Bone or Meninges.
| Septic Thrombophlebitis
58
How does a brain abscess present?
SYSTEMIC
Malaise
Pyrexia
```
RAISED ICP
Headache
Drowsiness
Confusion
Papilloedema
Neck Stiffness
```
Localising Signs
59
What is the Tx for a brain abscess secondary to a middle ear infection?
Surgical – Mastoidectomy, Neurosurgury
| IV Antibiotics
60
What is glue ear? What causes it?
Otitis media with effusion (OME). A build up of fluid, either serous or vicious within the middle ear cleft, resulting in conductive deafness. Ultimately it is a dysfunction of the eustachian tube. Cause unclear but association made with URTI, oversized adenoids.
61
What is the rate of OME in children?
Approx 1/3 will experience glue ear at some point in life.
62
In whom is OME most common? What other risk factors exist?
Small Children
| Risk: Boys, Downs Syndrome, Children of Smokers, winter, primary ciliary dyskinesia.
63
What is the main complication in OME?
Significant deafness with impaired development and academic potential.
Permanent Middle Ear Damage
64
How does glue ear usually present?
```
Hearing impariment noticed by parents in 80% of presentations.
Poor listening
Poor speech
Language delay,
Inattention,
Poor behaviour
Hearing flucuation
Ear/URT infections
Poor Balance
Poor School Work.
```
65
What are the main causes of glue ear (OME)?
Nasopharyngeal Obstruction – Large adenoids or tumour causing eustachian tube dysfunction.
Otitic Barotraumas – Most commonly cause by descent in aircraft – people with cold susceptible – The lack of middle ear ventilation causes middle ear effusion.
Acute Otitis Media – If untreated middle ear effusion may occur.
Allergic Rhinitis
No known cause apparent.
66
What are the symptoms of glue ear?
Deafness
Discomfort in the Ear (rarely severe)
Occasionally tinnitus (ringing of the ears) or unsteadiness
67
What are the signs of glue ear?
Fluid in the middle ear.
Dull appearance of radial vessels visible on the tympanic membrane.
Tuning fork test shoes conductive deafness.
Immobile drum on testing with pneumatic speculum
Flat impedance Curve.
68
What is the Tx for Glue Ear (OME)?
Observation ± Antihistamines and mucolytics – many cases resolve without any intervention.
SURGICAL
Myringotomy+Grommet – Indicated if secretory otitis media with poor hearing for >3months. TM incised antero-inferiorly, glue aspirated and grommet inseted. Purpose of the grommet is to ventilate the middle ear. Post operatively it should be kept dry. The grommet will extrude at ~6months.
Adenoidectomy – In the case of adenoid enlargement with post nasal obstruction.
69
What are the indications for myringotomy+Grommet insertion in OME?
Hearing loss to a level of <25db in best ear confirmed over 3 months then myringotomy + air conducting grommet ± Adenoidecotomy.
70
Is swimming allowed with grommet post MGY for OME?
Yes, but ear plugs advised and no diving.
71
What is the medical term for ear wax?
Cerumen
72
What produces cerumen?
Ceruminous glands located in the outer meatus.
73
What is the function of cerumen?
It migrates laterally along the acoustic meatus (outer 1/3 of the canal) to protect against maceration (to protect the skin).
74
What is the most common cause of impacted wax?
Attempted cleaning with cotton buds
75
What describe the procedure for removing impacted wax?
1. Patient Hx – Previous discharging history = possible dry perforation = do not syringe.
2. Inspection – Wax should be softened over a period of 1 week using warm olive oil drops administered nightly. 2nd line is sodium bicarb ear drops or a topical ceruminolytic.
3. Prepare sodium bicarbonate solution, 5g/500ml or normal saline. Ensure solution is at 38oC, otherwise patient may experience veritgo.
4. Use metal or rubber Bacon Needle. Adult external meatus 1inch long make sure need not too far in.
5. Direct stream of solution along roof of auditory canal.
6. After removal of wax be sure to inspect the ear throughly to ensure no wax remains.
76
What is acute external otitis?
Acute inflammation of the skin of the meatus
77
What factors predispose to acute external otitis?
1. Humidity
2. Psoriasis (itching)
3. Seborrhoea (oily discharge of sebaceous glands)
4. Trauma
5. Swimming
78
What aetiologies cause acute external otitis?
Gram negative organisms.
Fungi.
Viruses.
Sensitivity to ear drops.
79
What is the typical Hx at presentation in acute external otitis?
History of itching – usually progressing to pain.
Serous Otorrhoea.
Diffuse erythema and oedema of the ear canal.
80
What special consideration would be given in the case of a diabetic with acute external otitis?
Consider the possibility of malignant external otitis.
81
Describe the management of acute external otitis?
1. Careful history and examination.
2. Tuning fork tests rather than initial audiometry.
3. Careful cleaning under the microscope to exclude underlying middle ear conditions.
82
Describe the Tx for acute external otitis?
1. Careful cleaning under the microscope.
2. SEVERE = a dressing - Pope wick or ribbon gauze in the ear canal with Tri-adcortyl or Trimovate. MILD = otosporin ear drops.
3. Appropriate analgesia – consider admission if pain is severe and systemic antibiotics if there is spreading cellulitis.
4. Unless very mild, re-clean and inspect in 2-7 days.
5. Advise the patient to keep the ear dry and to resist the temptation to scratch the ears.
83
What furunculosis of the external auditory meatus?
Infection of hair follicle with the external meatus
84
What is aetiology of FEAM?
Staphylococcus infection
85
What are the signs and symptoms of FEAM?
Pain, especially on movement of the pinna or chewing.
| Erythema and oedema of the ear canal.
86
What should be excluded in suspected FEAM?
Mastoiditis
87
What is the Tx for furunculosis of the external auditory meatus?
Glycerine / Icthammol dressing.
Appropriate analgesics.
Systemic anti-staphylococcus antibiotics, probably Flucloxacillin.
88
How is traumatic perforation of the tympanic membrane diagnosed?
History of trauma.
Tympanic membrane perforation possibly with ragged edges.
Evidence of recent haemorrhage.
89
What are the common aetiologies for traumatic perforation of the TM?
```
Foreign bodies (eg., cotton buds, hairclips, matchsticks).
Explosion.
Slap on the ear.
Fractured skull.
Welding sparks.
Barotrauma.
Syringing.
Water sports.
```
90
Describe the assessment of traumatic perforation of the TM
1. History.
2. Careful examination of the ear, especially to exclude infection. Removal of blood clot should not be performed. If the perforation is clearly seen, its size and shape should be documented.
3. Audiogram if possible – if not possible Tuning Fork Test and clinical assessment of hearing.
4. If the patient has had head injury, it is important to record the function of the facial nerve and to note if any CSF leakage is present.
5. Simple vestibular assessment if indicated.
91
Describe the Tx for traumatic perforation of the TM
1. Reassurance: explain to the patient that there is a good chance of spontaneous resolution (unless due to a welding spark).
2. If the perforation is contaminated, consider either giving an oral antibiotic or an antibiotic + antibiotic drops or drops alone.
3. Keep water out of the ears until the perforation has healed.
4. Review within 6 weeks but if the ear discharges, the patient should be advised to see their general practitioner.
5. Consider surgery if the perforation persists for longer than two months.
92
What aetiology does not have any chance of resolving spontaneously?
Welding spark.
