Ear + balance Flashcards
(38 cards)
What is otitis externa?
- Localised: folliculitis (infection of hair follicle), can progress to become furuncle (boil)
- Diffuse (aka swimmer’s ear): widespread inflammation of skin = subdermis, can extend to tympanic membrane
Acute otitis externa causes
bacterial most common (Pseudomonas or S aureus)
fungal infection
seborrheic dermatitis (may also have dandruff/eyebrow scaling/blepharitis/facial redness)
contact dermatitis (allergic [sudden, red, itchy, oedema, exudate] or irritant [insidious, lichenification], both caused by ear drops/hearing aids/ear plugs)
trauma (e.g. cotton bud trauma, hearing aids)
environmental (humidity, perspiration, swimming esp in polluted water)
Chronic otitis externa causes
allergic/irritant contact dermatitis
seborrheic dermatitis
fungal infection (due to long term topical antibacterials/steroids
bacterial low grade infection causing thickening of skin
Malignant otitis externa
aggressive infection mostly immunocompromised/DM/elderly/radiotherapy to H+N, higher risk if irrigate ears with tap water, spreads into mastoid + temporal bones
granulation tissue, exposed bone, CNVII palsy, temp, ear/headache, vertigo, profound hearing loss. can spread causing meningitis
need emergency ENT r/v
CF of AOE
red/swollen/eczematous canal/external ear, shedding, swelling (may have pus), discharge in canal, inflamed ear drum, itchy (typical), ear pain disproportionate to size of lesion (typical), pain worse when moving tragus/pinna/with otoscope (typical), tender when move jaw, lymphadenitis, sudden relief of pain if furuncle bursts (rare), may lose hearing if lots of swelling (rare)
check there isn’t a spreading cellulitis
CF of COE
lack of earwax in external canal, dry hypertrophic skin, pain on manipulation of canal, constant itch, mild discomfort
Suspect fungal if whiteish strands (Candida) or small black/white balls (Aspergillus)
Complications of OE
abscess, chronic OE, regional spread e.g. auricular cellulitis, fibrosis leading to CHL, myringitis (TM inflammation), TM perforation, MOE
Differentials for otitis externa
- AOM: otorrhoea from OM causing OE, esp in children with grommets
- FB in ear, impacted wax (pain + DC)
- Cholesteatoma – discharge in canal
- Mastoiditis – v unwell, temp, HL, mastoid tenderness
- Neoplasm – esp if swelling bleeds easily on contact. Slower onset than localised OE
- Referred pain – sphenoid sinus, teeth, neck, throat
- Barotrauma – consider if diver/air travel/blow to ear
- Skin conditions – seborrheic dermatitis, psoriasis, acne, HZV, lupus
Management of AOE
AOE resolves within 48-72h of treatment or within 7-10d may resolve without, folliculitis may heal on its own
Self-care adv: avoid damage (safely remove wax professionally, do not use buds etc), use ear plugs when swimming, don’t swim for 7-10d with infection, try low heat hair dryer after showers, if allergy identified avoid these things, control any long term skin conditions
Localised otitis externa: analgesia + flannel usually enough. Oral Abx rarely used, only if signs of severe infection/high risk. Consider I+D if pus causing severe pain (rare). Adv on how to reduce re-infection
Acute otitis externa: analgesia if needed, topical Abx +/- topical steroid (usually for 7d up to max 14d), topical acetic acid 2% spray for mild cases as fewer s/e, may need ENT referral to clear debris with microsuction/syringing appt at GP
Swab if not responding
Oral Abx rarely needed, usually if spreading cellulitis beyond canal
Management of COE
Self-care adv: avoid damage (safely remove wax professionally, do not use buds etc), use ear plugs when swimming, don’t swim for 7-10d with infection, try low heat hair dryer after showers, if allergy identified avoid these things, control any long term skin conditions
o Fungal: topical antifungal e.g. clotrimazole 1%
o Dermatitis: avoid contact with the cause
o Seborrheic dermatitis: antifungal steroid combo
o No cause evident: give a 7d course of topical corticosteroid (without Abx) +/- acetic acid spray, if responding continue, if not try a topical antifungal. After 2/3m seek specialist advice
Otitis media?
inflammation in ME + effusion, rapid onset of CF of ear infection
Otitis media with effusion
fluid in ME without CF of acute ear infection).
see effusion + air fluid levels, normal TM landmarks
cause of CHL or chronic DC
Chronic suppurative otitis media
persistent inflammation + perforation of TM with draining DC >2w
Myringitis
erythema + injection of TM but no other features of OM
Causes of AOM
virus or bacteria but often both at the same time. Often H influenza, S pneumonia, Moraxella catarrhalis, Strep pyogenes; and RSV, adenovirus, rhinovirus, influenza, parainfluenza virus
RF for AOM
young, male, smoking, frequent contact with other kids, formula fed, craniofacial abnormalities, use of dummy, prolonged bottle feeding lying down, FH, GORD, not had pneumococcal vaccine, prematurity, recurrent URTI, immunodeficiency
CF of AOM
acute onset, earache, tugging/rubbing ear in younger kids (and non-specific stuff like fever, crying, poor feeding, restlessness, cough, rhinorrhoea); red/yellow/cloudy TM, bulging of TM (lose normal landmarks, air-fluid level behind TM indicating ME effusion), perforation of TM/DC into EAM
Management of AOM
- Admit immediately if <3m with temp 38+, severe systemic infection, suspected acute comps
- Adv usual course 3d but can be up to 1w, regular paracetamol/ibuprofen, adv no evidence for decongestants/antihistamines
- Abx usage depending on CF + patient, would give 5-7d course of amoxicillin (or clarithromycin/erythromycin if allergic)
When are Abx indicated for AOM?
o Immediate prescription: systemically very unwell or high risk of comps
o People more likely to benefit from Abx are people with otorrhoea or kids <2y with b/l infection – depends on CF but may neeed no abx but come back if not better in 3d, delayed prescription if not starting to improve within 3d/sx worsening, or immediate
o Other people less likely to benefit + make little difference to sx or development of comps – may say no prescription and come back if worse, or backup
Otological causes of balance disorders (vertigo)
o ME disease o Trauma – temporal bone #, post-stapedectomy surgery o BPPV, Meniere’s disease, labyrinthitis o Otosclerosis o Ototoxic drugs o Vestibular schwannomas
Non-otological causes of balance disorders (lightheaded rather than vertigo)
o Cervical spondylosis – v common. Arthritis in C spine – osteophytes constrict vertebral artery esp when hyperextend neck – fleeting imbalance cos of cerebral ischaemia. M – neck physio + NSAIDs
o Ageing – multifactorial. Poor proprioception (reduced vision + hearing), cervical spondylosis, more CV issues like hypotension/arrhythmia, meds. Best to avoid vestibular sedatives as they suppress what is normal
o Migraine – hemicranial headache, photophobia, aura, triggers
o CV causes – hypotension, arrhythmia
o Drugs – alcohol, antihypertensives, vestibular sedatives
o Epilepsy/neuro diseases. Clear history
o Hyperventilation/anxiety – a/w tingling in peripheries + tinnitus
o TIAs – imbalance, neuro deficit like dysarthria/amaurosis fugax/limb weakness
o Post-head injury
How do you assess a pt p/w a balance disorder?
- History: clarify what they mean, ask about changes to hearing, tinnitus, relation to activity e.g. head movements, effect of darkness (lose eyes as an input), CV disease, DH, alcohol, anxiety; duration important; course over time (ear causes tend to improve over time cos of central compensation)
o Vertigo – illusion of rotatory movement, worse in dark, usually peripheral vestibular disease
o Light-headedness – feeling of fainting, CV, ototoxic drugs, psychiatric
o Unsteadiness – difficulty with gait, veering to one side, falls. Ageing, sometimes neuro
o Blackouts – usually clear-cut history of either neuro seizures or arrhythmias
o Duration is important: seconds (cervical spondylosis, postural hypotension, BPPV), mins-hours (Meniere’s, labyrinthitis), hours-days (acute labyrinthine failure, ototoxicity, central vestibular disease); constant or episodic - Examination: TM for ME disease, nystagmus + CN + cerebellar tests, Romberg’s test, lying + standing BP, positional test
Management of sinusitis <10d?
don’t give Abx, adv self limiting virus (2% bacterial) takes 2-3w to resolve. Self care for sx, may want to try nasal decongestants/saline wash but evidence lacking, no evidence found for oral decongestants/antihistamines/steam inhalation/warm face packs/mucolytics. Come back if worsening sx, don’t improve in 3w
Management of sinusitis >10d?
consider high dose nasal steroid for 14d for people aged 12+ (may improve sx but not duration and can cause systemic s/e and often not used properly), consider no abx/back up prescription depending on sx (say make ltitle difference to length, possible ADRs, withholding them unlikely to cause comps), consider referral if recurrent etc
