Ear Flashcards

Question

Treatment of otitis externa?

Answer 1

Avoid potential causes. - Fungal suspected: topical antifungal (mild-to-moderate uncomplicated): Clotrimazole 1%, acetic acid 2%, or clioquinol & corticosteroid e.g. Locorten-Vioform). Seek specialist advice if inadequate response. - Irritant or allergic dermatitis: avoidance of irritant/allergen & topical corticosteroid - No cause evident: 7 days topical corticosteroid without antibiotic. Consider co-prescribing acetic acid spray. If adequate response continue but reduce potency / frequency (minimum required to maintain control). If inadequate, consider trial of topical antifungal preparation. If treatment needs to be continued beyond 2/3 months, seek specialist advice. Reinforce self-care advice. Refer if: does not respond to treatment in primary care, contact dermatitis suspected (patch testing useful), ear canal occluded / becoming occluded, malignant otitis expected.

Answer 2

Folliculitis (hair follicle infection that can progress to furuncle i.e. boil). Furunculosis causes severe throbbing with pyrexia, followed by abscess rupture (drainage under anaesthetic may be required). Boil in canal caused by Staph aureus. Treatment: antibiotics and dressing. Myringitis bullosa: blisters on eardrum & deep meatus – excruciating earache (presumed to be viral, treatment is symptomatic). Tx: If pain: analgesic & local heat e.g. warm flannel (folliculitis usually mild & self limiting). If infection: oral Abx rarely indicated, only for severe infection or high risk of severe infection (e.g. furunculosis or cellulitis spreads beyond ear canal  pinna/ neck/face, systemic signs such as fever, diabetes mellitus or compromised immunity). If required give 7 days flucloxacillin (or clarithromycin if allergic). Incision & drainage of pus if necessary (if causing severe pain & swelling)  usually requires referral although small pustule near ear canal entrance may be drained by incising it with a surgical needle. Refer if inadequate response to oral antibiotic treatment or if cellulitis spreads outside canal.

Answer 3

Necrotising Otitis Spreading osteomyelitis of the temporal bone caused by Psuedomonas pyocynaeus. Marked granulations formed in ear canal + infection spread to middle ear + lower cranial nerves. Rare: incidence not well known, Most common in elderly diabetics. May be fatal. 1. DIABETES MELLITUS: present in most cases 2. IMMUNOCOMPROMISE: HIV/AIDs, chemotherapy, CKD 3. RADIOTHERAPY TO HEAD/NECK 4. Aural irrigation with tap water (especially if other risk factors) Signs: Granulation tissue at bone-cartilage junction of ear canal, facial nerve palsy (drooping face on side of lesion), temperature >39C, otorrhea. Symptoms: Pain (often worse at night and with chewing), headache, more severe than clinical signs would suggest, vertigo, profound hearing loss. Management: ESR (usually raised), FBC, glucose + creatinine levels. Culture of ear secretions. Remove granulation tissue from ear canal for path examination (excludes malignant processes). CT & isotope scanning to show extent of osteomyelitis. Correct any immunosuppression if possible & strict control of diabetes: 1. Cleaning + debriding + topical Abx (start for pseudomonas + alter based on culture results). 2. Systemic antibiotics: 2 months. 3. Surgery (selected patients only)

Answer 4

Infected cartilage > swollen, red, tender pinna. Erythema, induration and possible fluctuance of part of / all of auricle. May follow severe otitis externa, or be subsequent to trauma. Pseudomonas aeruginosa most common. Oedema may spread to face & pretragal lymph nodes enlarged. Tx: local astringents (e.g. magnesium sulphate, betadine or boric acid wet-to-dry dressings to open wound). If progresses to chondritis with abscess, then incision, drainage and debridement of non-viable cartilage necessary - systemic Abx required to prevent permanent damage

Answer 5

Trauma to ear > blood collects beneath perichondrium (between perichondrium & cartilage). Tx by repeated aspiration under sterile conditions + mastoid pressure dressings. Risk = cauliflower ear: organisation and calcification of clot (or other fluid collection) which separates cartilage from overlying perichondrium that supplies the blood - necrosis of underlying cartilage causes permanent swelling / deformity of outer ear.

Answer 6

Herpes zoster oticus • Herpes zoster virus: infection of ear canal + facial nerve (shingles of facial nerve / complication of shingles) • Causes facial paralysis & loss of taste • Can produce pain in ear / other sensory areas supplied • Tx: acyclovir, steroids, eye care. Middle cranial fossa decompression of facial nerve if progressive degeneration.

Answer 7

Inflammation of middle ear cleft (bacteria). Eardrum becomes retracted as tube is blocked, Inflammatory middle ear exudate develops. Pressure in the middle ear > severe pain; eardrum becomes congested & bulging. Fever & tachycardia. Eardrum rupture may occur > bloodstained discharge + relief of pain. (Hyperemia > exudation > suppuration > resolution > coalescence > complications). - Children 2-5 years (common cause of severe childhood otalgia) - Usually follows URTI (ascends via Eustachian tube) 1. STREPTOCOCCUS PNEUMONIAE 2. HAEMOPHILUS INFLUENZAE B (less common if >5 years) 3. MORAXELLA CATARRHALIS 4. (Staph aureus)

Answer 8

Complications: acute surgical mastoiditis, facial nerve paralysis, acute labyrinthitis, sigmoid sinus thrombophlebitis, CNS infection – meningitis, abscess, lateral sinus thrombosis Management: Analgesics + nasal decongestants. Many cases of viral origin: if no spontaneous resolution 24-48 hours; broad-spectrum antibiotics to cover haemophilius & streptococci indicated: AMOXICILLIN. (or cefaclor, trimethoprim, erythromycin & sulfisoxazole) – depending on appropriate cultures. Discharging ear should be swabbed/mopped/kept clean. Usually resolves but effusion may persist. Hearing may remain muffled for >1 month in adults. In children, multiple episodes more common (if persisting middle ear effusions, may require adenoidectomy).

Answer 9

Chronic Suppurative Otitis Media (> 2 weeks) Tubotympanic Disease In rupture of the tympanic membrane in acute otitis media, eardrum usually heals quickly, but if inflammation persists and eardrum skin fails to heal over the margins of rupture > persistent perforation. Persistent or recurrent mucoid discharge may occur, especially if water enters middle ear, or in episodes of URTI / acute rhinitis. Perforations caused by acute otitis media usually occur in pars tensa & do not involve the annulus. Atticoantral Disease Long-standing Eustachian tube dysfunction  retractions & perforations of membrane in the attic region / may involve annulus. Associated with cholesteatoma. May be little discharge but offensive due to underlying osteitis / bone destruction may occur near middle or posterior cranial fossae – may go unrecognised until intracranial complication occurs.

Answer 10

Cleaning and steroid eardrops for chronic tubotympanic disease, hearing aid to overcome hearing difficulties or surgery if recurrent discharge, regular swimmer, or for hearing improvement (usually graft temporalis fascia). For atticoantral disease: surgery (excision of disease with preservation of hearing – mastoidectomy and drum defect may be grafted to minimise discharge and optimise hearing)

Answer 11

Otitis Media with Effusion (>12 weeks) Also called Serous Otitis Media (“Glue Ear”) Retention of transudate fluid in the middle ear: chronic OME diagnosed if fluid >12 weeks. Following otitis media: 70% persistent effusion at 2 weeks, 40% at 4 weeks, 20% at 2 months, 10% at 3 months. Typically caused by Eustachian Tube dysfunction. - Peak clinical age 2-6yrs (~30%), bimodal peaks 2 + 5yrs. - Seasonal variations: association with URTI (Oct-March) - Higher incidence in Down syndrome + cleft palate Unlike suppurative otitis media (infective), typically painless. Children typically present with conductive hearing loss (up to 40dB), or may have recurrent otalgia. Signs (tympanic membrane): o Dull grey / amber / red o Retracted / moves to negative pressure (eustachian tube dysfunction) o Thickened and increased vascularity → opaque Other signs: bubbles or air fluid levels, hearing loss (<30 DB).

Answer 12

Advise no improvement with any medication + active observation rarely results in long term complications. 1. Spontaneous resolution common: active observation (watchful waiting) 6-12 weeks – re-evaluate signs/symptoms & hearing/language development - Ideally: 2 pure tone audiometry tests 3 months apart + tympanometry - ENT referral based on severity of hearing loss + suspicion of delays to developmental milestones 2. Hearing aids: persistent bilateral OME & hearing loss (if surgery contraindicated / not acceptable) 3. Auto-inflation (ventilates middle ear & equilibrates pressure > fluid drainage): nasal balloon 2-3x daily or Vasalva manoeuvre without balloon in older children. May be considered during the active observation period for those likely to co-operate (usually older children). NOT if URTI & abandon if causes pain. 4. Surgical: Myringotomy, aspiration of fluid & insertion of ventilation tubes (Grommets) ± adenoidectomy. Improves hearing in short term but not proven to improve other aspects of development. Adjuvant adenoidectomy not recommended in absence of persistent and/or frequent URTI symptoms.

Answer 13

Advise no improvement with any medication + active observation rarely results in long term complications. 1. Spontaneous resolution common: active observation (watchful waiting) 6-12 weeks – re-evaluate signs/symptoms & hearing/language development - Ideally: 2 pure tone audiometry tests 3 months apart + tympanometry - ENT referral based on severity of hearing loss + suspicion of delays to developmental milestones 2. Hearing aids: persistent bilateral OME & hearing loss (if surgery contraindicated / not acceptable) 3. Auto-inflation (ventilates middle ear & equilibrates pressure > fluid drainage): nasal balloon 2-3x daily or Vasalva manoeuvre without balloon in older children. May be considered during the active observation period for those likely to co-operate (usually older children). NOT if URTI & abandon if causes pain. 4. Surgical: Myringotomy, aspiration of fluid & insertion of ventilation tubes (Grommets) ± adenoidectomy. Improves hearing in short term but not proven to improve other aspects of development. Adjuvant adenoidectomy not recommended in absence of persistent and/or frequent URTI symptoms.

Answer 14

Grommets Continue follow up until grommets extruded and eardrum healed. Usually stop functioning average ~10 months, 1/3 – ½ of children will need reinsertion within 5 years. If symptoms of OME recur, refer back to ENT. Complications: - Otorrhoea (affects 1 in 5 children) – consider topical/oral Abx if problematic or ENT. - Infection (acute otitis media) - Tympanosclerosis (~ 1/3 children <5 years of age) - TM perforation - Fibrosis - Cholesteatoma - Bleeding Encourage all normal activities (school, swimming as normal, flying etc.) but may warn against deep diving.

Answer 15

Hyalinisation and calcification of subepithelial connective tissue of TM & middle ear. Risk factors: long term glue ear, insertion of tympanostomy tube (especially if aspiration performed, larger tube used or procedure repeated), atherosclerosis, ? cholesteatoma – still researching, may be that 2 conditions co-exist. If restricted to tympanic membrane: may be known as myringosclerosis (symptoms rare). Intratympanic tympanosclerosis is more extensive within the middle ear: can cause significant hearing loss or chalky/white patches on middle ear / tympanic membrane. If necessary, managed with hearing loss or can have surgical treatment (but risky – can cause sensorineural hearing loss).

Answer 16

Acute Mastoiditis- preceded by acute otitis media, usually seen in young children. Labyrinthitis Lateral Sinus Thrombosis Complications of acute otitis media consists of perforation of the ear drum, infection of the mastoid space behind the ear (mastoiditis), and more rarely intracranial complications can occur, such as bacterial meningitis, brain abscess, or dural sinus thrombosis.[64] It is estimated that each year 21,000 people die due to complications of otitis media.[12]

Answer 17

Chronic inflammatory condition causing intermittent painless offensive discharge and hearing loss. Build up of squamous epithelium trapped behind the pars flaccida • Caused by repeated CSOM infections • Appears as dried keratin inside eardrum • Characteristic smell – anaerobic pus and keratin • Complications – cranial nerve lesions, meningitis, cerebral abscess, hearing loss, mastoiditis • Incidence – 1:10,000 • Peak age – 5-15 years • Tx - mastoid surgery to remove cholesteatoma and prevent complications

Answer 18

* Disease of the otic capsule (bony compartment of the middle ear. * Progressive conductive hearing loss * Usually age 20-40 * Women more affected by men * Associated with family history * Often resulting from pregnancy * Treatment – nil, hearing aid or surgery (stapedotomy)

Answer 19

* Complicates acute otitis media * Prolonged illness * Protrusion of pinna * Admitted for IV abx +/- surgery

Answer 20

Tender, cartilaginaous, inflamed nodule dwelling on the upper helix or antihelix. Commoner in men working outdoors and wimple-wearing nuns Cause: unknown, poor blood flow (avascular chondritis) from prolonged pressure Tx: relieve pressure. If not helpful, excise skin and underlying cartilage

Answer 21

Can be acquired (infective e.g. rubella, neonatal) or hereditary (syndromic or non syndromic) Need to pick up affected children early (before speech acquisition). Diagnosis: universal postnatal screening using probe in ear, testing for otoacoustic emissions (OAE). If this test is failed, the baby undergoes auditory brainstem responses. Early diagnosis allows special help at school prior to speech acquisition and possibly cochlear implantation. ``` Unilateral sensorineural hearing loss causes: o Viral o Vascular occlusion o Trauma o Meniere’s disease o Acoustic neuroma. ```

Answer 22

Short (seconds) vertigo on change in head position e.g. turning in bed, looking up, bending down

Answer 23

Sudden onset severe rotational vertigo, nausea and vomiting Vomiting settles over days, imbalance improves over weeks/months Jerk horizontal nystagmus Treatment: anti-seasick tablets (supportive)

Answer 24

12-24hr episodes of vertigo, hearing loss and tinnitus Hearing gets worse in affected ear, sometimes spreads bilaterally Endolymphatic hydrops is probable cause Not a common cause of vertigo Difficult to treat

Answer 25

Unilateral LMN facial palsy, causes 70% of facial palsies. Partly a diagnosis of exclusion. Features: Rapid onset (<48 hours), ear and facial discomfort, mouth sags, dribbling and watering eyes, impaired brow wrinkling, blowing, whistling, lid closure, cheek pouting, taste and speech. Can also have hyperacusis from stapedius palsy. Thought to be due to inflammatory oedema from entrapment of the facial nerve in the narrow bony facial canal. Treatment: Managed with oral steroids (prednisolone) and eye care (keep it lubricated). Treatment results in improved rate of recovery and shorter time to recovery. If it doesn’t resolve, it’s not Bell’s palsy. Referral: refer urgently to ENT or neurology if there is any doubt about the diagnosis, if recurrent Bell’s palsy, in bilateral facial palsy and if paralysis shows no sign of improvement after 1 month. Prognosis: 85% recover to near normal. 5% have permanent weakness that is cosmetically and clinically apparent.

Answer 26

Most common method to test hearing – quantifies hearing loss and determines nature. Headphones deliver tones at different dB over frequencies of 150-8000Hz in a sound proofed room. Air conducted sound measured initially above hearing threshold then reduced in 10dB increments until a 50% response rate is obtained Bone conduction threshold is also obtained by using a transducer over the mastoid process – representing by a triangle Masking prevents cross stimulation of the non test ear – represented by a bracket.

Answer 27

Objective way of measuring pressure in the middle ear and establishing the cause of conductive deafness * Principles: in normal ears, compliance of the drum (the amount of displacement in ml for a given sound) – hence transmission of sound – peaks when middle ear pressure equals ear canal pressure. So the peak of the tympanometry curve reflects middle ear pressure. * Procedure: a probe with an airtight seal is introduce into the meatus, it measure the proportion of an acoustic signal reflected back at varying pressures and generates a graph of compliance. * Results: a normal ear (middle ear space filled with air, ossicles intact) will show a normal peak with normal compliance – Type A. If there is disruption of the ossicles, or if part of the drum is flaccid, a large amount of energy will be absorbed into the drum, causing high compliance – Type AD. Fluid in the ear makes the drum still, so most of the sound is reflect back to the probe, causing low compliance – Type B. If there is normal ear canal volume = otitis media. If there is low middle ear volume = wax occlusion. If high = grommets or perforation. If there is negative middle ear pressure e.g. resolving otitis media = Type C.

Answer 28

Used to assess function of the cochlea by recording sound vibration produced by the outer hair cells in the cochlea. It is most commonly used in neonatal screening.

Answer 29

Record electrical activity along the auditory pathway in response to a sound stimulus.

Answer 30

NICE CKS suggests that inflammation is more likely to be severe if there is: a red, oedematous ear canal which is narrowed and obscured by debris conductive hearing loss discharge regional lymphadenopathy cellulitis spreading beyond the ear fever NICE recommend that for mild cases (mild discomfort and/or pruritus; no deafness or discharge), consider prescribing topical acetic acid 2% spray. When features of more severe inflammation are present, such as in this case, they advise 7 days of a topical antibiotic with or without a topical steroid. Taking swabs from the ear is not useful routinely as virtually all bacteria detected are sensitive to the high concentrations of antibiotic in topical medications. However, this should be done if there is no response to an initial course of treatment or infections are recurrent. All patients should be advised to use simple analgesia if needed and to avoid getting water into the ear until the infection has resolved. ``` Causes of otitis externa include: infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal seborrhoeic dermatitis contact dermatitis (allergic and irritant) ``` Features. ear pain, itch, discharge otoscopy: red, swollen, or eczematous canal The recommend initial management of otitis externa is: topical antibiotic or a combined topical antibiotic with steroid if the tympanic membrane is perforated aminoglycosides are traditionally not used* if there is canal debris then consider removal if the canal is extensively swollen then an ear wick is sometimes inserted Second line options include consider contact dermatitis secondary to neomycin oral antibiotics (flucloxacillin) if the infection is spreading taking a swab inside the ear canal empirical use of an antifungal agent Malignant otitis externa is more common in elderly diabetics. In this condition there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required. *many ENT doctors disagree with this and feel that concerns about ototoxicity are unfounded

Answer 31

Rinne's test tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over external acoustic meatus air conduction (AC) is normally better than bone conduction (BC) if BC > AC then conductive deafness Weber's test tuning fork is placed in the middle of the forehead equidistant from the patient's ears the patient is then asked which side is loudest in unilateral sensorineural deafness, sound is localised to the unaffected side in unilateral conductive deafness, sound is localised to the affected side

Answer 32

Inflammatory disorder of the membranous labyrinth, affecting both the vestibular + cochlear end organs. Can be viral, bacterial or associated with systemic diseases. Viral is most common form. (Vestibular neuritis = only vestibular nerve is involved, hence no hearing impairment. Labyrinthitis: both vestibular nerve and labyrinth involved, usually resulting in both vertigo + hearing impairment). Average age 40-70 years, one-year prevalence of all conditions causing vestibular dysfunctions varies 3.1% - 35.4%. One study reported that 37 of 240 patients presenting with positional vertigo had viral labyrinthitis. Patients typically present with an acute onset of: Vertigo: not triggered by movement but exacerbated by movement Nausea and vomiting Nearing loss: may be unilateral or bilateral, with varying severity Tinnitus Preceding or concurrent symptoms of URTI Signs of labyrinthitis: - spontaneous unidirectional horizontal nystagmus towards the unaffected side - sensorineural hearing loss: shown by Rinne's and Weber - abnormal head impulse test: signifies an impaired vestibulo-ocular reflex - gait disturbance: the patient may fall towards the affected side - normal skew test - abnormality on inspection of the external ear canal and the tympanic membrane e.g. vesicles in herpes simplex infection

Answer 33

Immediately if: Symptoms lasting more than 4 days or not improving Systemically unwell but not requiring admission Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease < 2 years with bilateral otitis media Otitis media with perforation and/or discharge in the canal If an Abx is given, a 5-day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.

Answer 34

The most common cause of a perforated tympanic membrane is infection. Other causes include barotrauma or direct trauma. A perforated tympanic membrane may lead to hearing loss depending on the size and also increase the risk of otitis media. No treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time. Common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines Myringoplasty may be performed if the tympanic membrane does not heal by itself

Answer 35

Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults ``` Onset is usually at 20-40 years - features include: conductive deafness tinnitus normal tympanic membrane* positive family history ``` Management hearing aid stapedectomy *10% of patients may have a 'flamingo tinge', caused by hyperaemia

Answer 36

Acute sinusitis Inflammation of the mucous membranes of the paranasal sinuses. The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses. Predisposing factors include: nasal obstruction e.g. Septal deviation or nasal polyps recent local infection e.g. Rhinitis or dental extraction swimming/diving smoking Features facial pain: typically frontal pressure pain which is worse on bending forward nasal discharge: usually thick and purulent nasal obstruction

Answer 37

Analgesia intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days oral antibiotics are not normally required but may be given for severe presentations. The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if 'systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications'

Answer 38

Acute mastoiditis: serious condition characterised by severe pain and protrusion of the ear forwards, with a tender, boggy and often reddened mass behind the ear. It needs urgent treatment due to its many complications. One of these is meningitis due to intracranial spread; others include cranial nerve palsies, hearing loss, osteomyelitis and carotid artery spasm. Acute mastoiditis begins when acute otitis media spreads out from the middle ear, and therefore otitis media is a cause, not a complication. Cholesteatoma is part of the spectrum of otitis media and can lead to chronic mastoiditis. Mastoiditis is not associated with skin necrosis or permanent ear deformity.

Answer 39

largely based on history + examination glucose is helpful in excluding hypoglycaemia. in most patients with suspected viral labyrinthitis, no other investigation is necessary Ix to consider if the diagnosis is uncertain or suspecting the more sinister causes: pure tone audiometry, FBC + culture: if systemic infection suspected culture and sensitivity testing if any middle ear effusion temporal bone CT scan: indicated if suspecting mastoiditis or cholesteatoma MRI scan: helpful to rule out causes such as suppurative labyrinthitis or central causes of vertigo vestibular function testing: may be helpful in difficult cases and/or determining prognosis

Ear Flashcards

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