Cholesteatoma; Ear wax & Glue Ear Flashcards
(17 cards)
Describe the pathophysiology of Cholesteatoma [3]
presence of keratinising squamous epithelium within the middle ear and/or mastoid process, leading to bone erosion and potentially severe complications.
ZtF:
* The pathophysiology is not fully understood. Squamous epithelial cells originate from the outer surface of the tympanic membrane. The main theory is that negative pressure in the middle ear, caused by Eustachian tube dysfunction, causes a pocket of the tympanic membrane to retract into the middle ear. Essentially, a small area of the tympanic membrane gets sucked inwards. The squamous epithelial cells of this pocket continue to proliferate and grow into the surrounding space, bones and tissues. It can damage the ossicles (the tiny bones of the middle ear involved in hearing), **resulting in permanent hearing loss. **
What are the typical features of cholesteatoma? [2]
The typical presenting symptoms are:
* Foul discharge from the ear
* Unilateral conductive hearing loss
Other features are determined by local invasion:
* vertigo
* facial nerve palsy
* cerebellopontine angle syndrome
Ix for cholesteotoma? [3]
The first step in investigating suspected cholesteatoma is Otoscopy.
- This allows direct visualisation of the tympanic membrane and middle ear, which can reveal signs suggestive of cholesteatoma such as retraction pockets, perforations or white keratin debris.
- However, otoscopy alone may not be sufficient to confirm the diagnosis due to limitations in visualising deep structures of the ear.
Audiometry is another essential first-line investigation that provides information about hearing function. It can identify conductive, sensorineural or mixed hearing loss associated with cholesteatoma.
- Pure tone audiometry (PTA) is typically used for this purpose.
A CT head can be used to confirm the diagnosis and plan for surgery. MRI may help assess invasion and damage to local soft tissues.
How do you differentiate cholesteotoma with Chronic Otitis Media with Effusion (COME)? [2]
Chronic Otitis Media with Effusion (COME)
* COME is characterised by a persistent middle ear effusion for more than three months without signs of infection. Unlike cholesteatoma, COME usually presents bilaterally and is common in children.
* Clinically, patients may report hearing loss or aural fullness but lack the recurrent otorrhoea seen in cholesteatoma
Tx for cholesteatoma? [1]
Surgical Management
* Canal Wall Up (CWU) Mastoidectomy: This procedure aims to eradicate the disease while preserving the posterior canal wall. It has a lower rate of post-operative cavity problems but a higher recurrence risk.
* Canal Wall Down (CWD) Mastoidectomy: This approach offers better disease eradication but results in a mastoid cavity that requires regular cleaning.
What is the most common intratemporal complication of cholesteatoma? [1]
Name another key complication [1]
Ossicular chain erosion: This is the most frequent complication, leading to conductive hearing loss. The incus is usually the first ossicle to be affected
.
also
Labyrinthitis: Cholesteatoma can erode into the labyrinth leading to sensorineural hearing loss, vertigo or both.
Name three intracranial complications of cholesteatoma? [3]
Meningitis: This is a serious complication that results from direct spread of infection through dural erosion. It presents with symptoms like headache, fever, neck stiffness and photophobia.
Brain abscess: This occurs due to spread of infection into the brain parenchyma. Symptoms include focal neurological deficits and altered mental status
.
Sigmoid sinus thrombosis: Thrombus formation in the sigmoid sinus can lead to increased intracranial pressure presenting as headaches, vomiting and seizures.
A patient presents with a dental abscess.
What do you prescribe if they can’t get to a dentist? [1]
How do you step up this management if they patient needs more management? [1]
If antibiotics are indicated or a patient is unable to attend a dentist amoxicillin or phenoxymethylpenicillin are first line (clarithromycin if there is a history of true penicillin allergy).
- If the infection is severe or spreading, or the patient has systemic signs of infection metronidazole should also be prescribed.
Analgesia may be necessary: ibuprofen and paracetamol are first-line (if not contraindicated).
Features of ear wax? [4]
pain
loss of hearing
tinnitus
vertigo
Tx for ear wax? [+]
In most cases, ear wax does not require any interventions. The ears should naturally regulate the amount of wax in the ear canal without any issues.
The main treatment options in primary care are ear drops or irrigation (‘ear syringing’). Treatment should not be given if a perforation is suspected. The following drops may be used:
* olive oil
* sodium bicarbonate 5%
* almond oil
Ear drops may be enough to clear the ears. If not, ear irrigation can often be performed in primary care. Where there are contraindications to ear irrigation (e.g., perforated tympanic membrane or infection), microsuction can be performed by specialist ear, nose and throat services.
Describe what is meant by glue ear [+]
otitis media with effusion: non-infected effusion in the middle ear
Describe the clinical features of glue ear (auditory vs non-auditory)
Auditory symptoms: These are the most common presenting features. They include:
* Hearing loss: This is typically mild to moderate, bilateral and conductive in nature. It may be fluctuating depending on the severity and chronicity of middle ear effusion.
* Tinnitus: Some patients, especially older children and adults, may complain of ringing or buzzing noises in the ears.
Non-auditory symptoms:
These are less specific but can provide additional clues towards the diagnosis:
* Speech and language delay: Particularly in younger children where early detection and intervention are paramount for normal development.
* Behavioural changes: Including reduced attention span, frustration or irritability due to difficulty in hearing.
* Balance problems: Rarely, patients might report episodes of imbalance or clumsiness due to vestibular involvement.
NB: glue ear presents with hearing loss or speech delay without signs of acute inflammation
Describe the otoscope findings of glue ear [2]
An otoscopic examination will typically reveal a dull or retracted tympanic membrane with limited mobility on pneumatic otoscopy. There may be visible bubbles or an air-fluid level behind the tympanic membrane indicating the presence of middle ear effusion.
Define Chronic Suppurative Otitis Media (CSOM) [1]
How do you differentiate from glue ear? [1]
Chronic Suppurative Otitis Media (CSOM):
- CSOM is defined as persistent purulent otorrhoea through a perforated tympanic membrane for more than two weeks.
It differs from OME in its chronicity and presence of active infection.
- The most common symptom is a continuous foul-smelling discharge from the affected ear
- Hearing loss may also occur due to damage to the ossicles or cochlea but it’s typically more severe than in glue ear.
- Otoscopic findings include a perforated tympanic membrane and purulent discharge within the middle ear or external auditory canal.
Mx for glue ear? [+]
Conservative Management
Watchful waiting: In the majority of cases, glue ear resolves spontaneously within three months without intervention. Therefore, watchful waiting is often recommended as the initial management approach for uncomplicated cases. During this period, it is essential to monitor the patient’s symptoms and provide regular follow-up appointments to assess changes in hearing status.
Medical treatment:
- While there is limited evidence supporting pharmacological interventions for glue ear, some studies suggest that systemic or topical nasal corticosteroids may have a modest effect on resolution rates. However, these benefits should be weighed against potential side effects before prescribing such treatments.
Autoinflation:
- Encouraging patients to perform autoinflation techniques such as Valsalva manoeuvre or Politzerisation may help improve Eustachian tube function and promote resolution of glue ear; however, further research is needed to confirm their efficacy.
Surgical intervention may be considered if conservative management fails or if there are complications such as persistent hearing loss or recurrent acute otitis media episodes.
Myringotomy and grommet insertion:
- This procedure involves making a small incision in the tympanic membrane (myringotomy) and inserting a ventilation tube (grommet) into the middle ear to equalise pressure and facilitate drainage of accumulated fluid. Grommets typically fall out spontaneously after 6-12 months, during which time they must be monitored for complications such as otorrhoea, tympanic membrane perforation or scarring.
Adenoidectomy:
- In cases of recurrent glue ear or when concurrent adenoidal hypertrophy is present, adenoidectomy may be beneficial in reducing the frequency of otitis media episodes by improving Eustachian tube function.
Tympanostomy and balloon dilation:
- This procedure involves inserting a tympanostomy tube through the eardrum and inflating a small balloon to dilate the Eustachian tube. While some studies have shown promising results, further research is required to establish its efficacy and safety profile.
What are the most likely complications of glue ear? [2]
Most likely complications:
Hearing loss: The presence of a thick, sticky fluid in the middle ear can cause conductive hearing loss. This is usually temporary but chronic OME may result in permanent damage to the middle ear structures leading to long-term hearing impairment.
Speech and language delay: Prolonged periods of hearing loss in children can lead to delays in speech and language development. This may have further impacts on academic performance and social interaction.
