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Flashcards in Ear disorders Deck (82)
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1

PE of ear?

- pull auricle up, back and out
- visualize canal as you put speculum in
- use largest speculum canal will accommodate - avoid touching the bony walls (inne 2/3rds) with speculum - can be painful
- stabilize examining hand against pts head

- landmarks should be visible: umbo, handle of malleus, light reflex, TM
- check mobility: pneumatic attachment of otoscope or valsalva maneuver - observe for motion and pain
- color variations

2

How is CN 8 tested?

- eval hearing - pt responding to questions
- whispered voice test
- ticking watch
- weber/rinne

3

What is ETD (eustachian tube dysfxn)?

- blockage of ET: ET doesn't open or close properly in response to pressure changes within middle ear or outside ear, failure of system at proximal end (ET, palate, nasal cavities, and nasopharynx) to regulate the middle ear and mastoid gas cell system at its distal end
- acute ETD may occur in setting of pressure chagnes (flying) or acute URI, or sinusitis
- chronic ETD may lead to negative middle ear pressure, retracted TM, serous effusions, otitis media, adhesive otitis media, or cholesteatoma
- Patulous ET (PET) - floppy, failure of ET to close. Often manifested as autophony, when individual's own breathing and voice sounds excessively loud
- sxs affected: auditory

4

Fxns of the ET?

- ventilation/regulation of middle ear pressure
- protection from nasopharyngeal secretions
- drainage of middle ear fluid
- ET is closed at rest and opens with yawning, swallowing, and sneezing

5

Pressure equalization of ET?

- normally ET closed, but can open to let small amt of air through to prevent damage by equalizing pressure b/t middle ear and atm
- pressure differences cause CHL by decreased motion of TM and ossicles of the ear
- various methods of ear clearing such as yawning, swallowing, chewing gum or performing the valsalva meneuver may be used intentionally to open tube and equalize pressure

6

Cycle of ETD?

structural or fxnl obstruction of ET compromises 3 fxns:
-negative prssure develops in middle ear
- serous exudate is drawn from the middle ear mucosa by negative pressure or refluxed into middle ear if ET opens momentarily
- infection of static fluid causes edema and release of inflammatory mediators, which exacerbates cycle of inflammation and obstruction

7

Epidemiology of ETD?
Considerations in peds?

- most common in children under 5
- usually decreases with age but may persist into adulthood in some

ETs more horizontal in kids - troubles with ventilation and drainage, shorter ET predisposes to reflux
- can be associated with URI, adenoid hypertrophy, allergic rhinits, or GERD
- refer to ENT if hearing loss or recurrent or chronic middle ear infections


8

RFs for ETD?

adults and peds:
-tobacco and pollutant exposures
-GERD
-allergy
-chronic sinusitis
- sleep apnea with cont positive airway pressure use
- adenoid hypertrophy or nasopharyngeal mass
- neuromusc. disease
- family hx
- altered immunity
- early onset of hx of ETD as child
- Native american, inuit, australian aborigine (shorter neck)

9

Pediatric risk factors for developing ETD?

- seond hand smoke
- prematurity and low birth wt
- young age
- craniofacial abnormalities (cleft palate, down syndrome)
- day care, exposure to many other kids
- crowded living situations
- low socioeconomic status
- prone sleeping position
- prolonged bottle use

10

Commonly assoc conditions with ETD?

- hearing loss
- middle ear effusion
- cholesteatoma
- allergic rhinitis
- chronic sinusitis
- URI
- adenoid hypertrophy
- GERD
- cleft palate
- down syndrome
- obesity
- nasopharyngeal carcinoma or other tumor

11

Tx of ETD?

- initiate tx based on individual pt's sxs and possible cause
- decongestants: OTC, avoid prolonged use over 3 days, avoid in pts with HTN or cardiac risk factors:
phenyledphrine (sudafed PE)
pseudoephedrine (sudafed)
oxymetazoline (afrin)

- nasal steroids: may be beneficial for those with allergic rhinitis
beclomethaasone (beconase, vancenase)
budesonide (rhinocort)
flunisolide (nasarel, nasalide)
fluticasone (flonase)
ciclesonide (omnaris)

- 2nd gen H1 antihistamines (allergic rhinitis):
claritin, clarinex, allegra, zyrtec
- antihistamine nasal sprays:
olotpatadine (patanase), astelin

- abx: not used unless ETD is assoc with acute OM:
amoxicillin 1st line, tx 10 days

12

What tx should be considered if TM perforation or ventilation tube present?

- consider topical abx drops with topical steroid in setting of d/c alone
neomycin-polymyxin-hydrocortisone suspension (cortisporin)
- ciprofloxacin-hydrocortisone suspension (cipro HC)
- pain control, anti-inflam: acetaminophen, NSAIDs

13

Diff categories of otitis media?

- acute - AOM
- recurrent AOM: 3 or more in 6 months or 4 or more in 1 yr
- otitis media with effusion (OME)

14

What is otitis media?

- an infection of middle ear with acute onset, presence of middle ear effusion (MEE), and signs of middle ear inflammation

- 75% of children havehad at least one episode by 3
peak incidence: 6-18 months
male greater than female

15

RFs for otitis media?

- bottle feeds while supine
- day care
- formula feeding
- smoking in house
- male gender
- family hx of middle ear disease

16

Signs and sxs of otitis media?

- earache (discomfort, pressure), otalgia - infection worsens and so does discomfort
- tugging on ears
- fever, most afebrile
- accompanying URI sxs
- irritability
- difficulty sleeping

17

What will you see on otoscope exam in otitis media?

- decreased visibility of landmarks
- TM mobility decreases
- bulging TM, opaque, red
- pus in middle ear (bacteria in MEE)

18

Dx of AOM?

- note sxs in taking hx of illness:
discomfort, ache, pain
fever
tugging at ears
hearing loss
- bulging, usually erythematous TM which doesn't move on pneumatic otoscopy

19

Bacterial culprits of otitis media?

- strep pneumo (30-35%)
- H flu (20-25%): up to 50% produce beta-lactamases
- M cat: 10-15%: 90% produce beta-lactamases

20

Expected course/prognosis of otitis media?

- sxs usually spontaneously resolve in 2/3 of children by 24 hrs and 80% at 2-10 days
- children tx immediately with abx had one less day of sxs (majority viral or small amt of bacteria)

21

Tx of otitis media?

- abx tx:
amoxicillin (strep pneumo)
augmentin
cephalosporins
erythromycin, azithromycin

-tx of pain and fever:
ibuprofen, tylenol, auralgan
(no aspirin in kids)

22

F/u of otitis media?

- failure to improve after 48-72 hrs of abx - confirm dx, eval other causes, determine if new abx is warranted
- resolved sxs - reexamined 14-21 days after initial presentation - resolution of infection

23

Managment guidelines of AOM?

- most cases improve spontaneously
- cases that require tx may be managed with abx and analgesics or observation alone
- acetaminophen or ibuprofen should be rx with or w/o abx
- abx should be rx for bilateral or unilateral AOM in children aged at least 6 m with severe signs or sxs and for nonsecure, bilateral AOM in children 6-23 months
- in unilateral nonsevere AOM - make jt decision with parents to either give abx or close f/u
- amoxicillin is abx of choice, unless CI

24

What is OME? Sxs?

-serous otitis media - glue ear, presence of MEE in absence of acute signs of infection

sxs of OME:
- hearing loss
- fullness in ear
- tugging at ear or inserting finger in ear (trying to open ear)
- delayed speech and language development or unclear speech
- in young children, an unsteady gait may occur
- pain rarely occurs

25

What will you see on otoscope exam if pt has an OME?

- TM is dull, retracted (usually not bulging)
- no mobility of TM
- straw or tan color of ear drum or translucent gray
- sterile fluid in middle ear

- pneumatic otoscopy: single most recommended dx method to establish dx of OME

26

Tx of OME?

- watchful waiting:
no tx for 3 months after onset
no hearing testing in first 3 months, 75-90% resolve spontanteously in 3 months, if middle ear effusion lasts longer than 3 months, 30% resolve within 12 months
- during this period do the following:
speak closely to child
face child when speaking
repeat phrases when needed, seating in front of classroom

- meds are of no use, antihistamines, decongestants aren't recommended, abx and steroids don't have long term efficacy
- hearing testing: after 3 months should be done, language testing should be conductd with children with hearing loss
- surveillance: re-exam at 3-6 month intervals until effusion is resolved, hearing loss is ID'd, or structural abnormal of TM or middle ear are suspected
- surgery: tympanostomy and tube

27

What is chronic suppurative otitis? Cause? risks?

- a perforated TM with persistent drainage from middle ear
chronic otorrhea (longer than 6-12 weeks) through a perforated TM
- cause: initial episode of acute infection:
cycle: inflammation - ulceration - infection - granulation of tissue

- risks:
-hx of multiple episodes of AOM
-living in crowded conditions
-daycare
-being a member of large family

28

Bacterial culprits of chronic suppurative otitis?

sequela?

- pseudomonas aeruginosa (50-98%)
- staph aureaus (15-30%)
- klebsiella and proteus

-sequela:
conductive hearing loss
intracranial complications

29

Presentation of chronic suppurative otitis?

- continually draining ear (otorrhea), fever, pain, vertigo may indicate intracranial or intratemporal complications
- external canal may/may not be edematous
- usually not tender
- granulation tissue often seen in medial canal of middle ear space
- middle ear mucosa visualized thru perforated TM may be edematous, polypoid, pale or erythematous
- d/c: fetid, purulent, cheeselike to clear and serous

30

Studies done for chronic suppurative otitis?

- labs: culture for drainage for sensitivity
- imaging: CT, MRI
usually not done unless suspecting neoplasm, cranial complications, or unresponsive to medical tx
- audiogram: hearing loss