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Earache Flashcards

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1
Q

What are the different anatomic landmarks of the ear? (TN)

A
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2
Q

What are 4 questions on history that should be asked of all patients presenting with earache?

A
  • Hearing loss
  • Tinnitus
  • Vertigo
  • Aural discharge
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3
Q

What are 2 sources of earache that should always be considered?

A
  • Local
  • Referred
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4
Q

What are 9 local causes of earache

A
  • Infection
    • Otitis Media
    • Otitis Externa
    • Malignant Otitis Externa
    • Mastoiditis
    • Herpes Zoster
  • Trauma
    • Barotrauma
    • Traumatic perforation
  • Cerumen impaction
  • Wegener’s granulomatosis
  • Cholesteatoma
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5
Q

What is mastoiditis? (TN)

A
  • Infection (usually subperiosteal) of mastoid air cells, most commonly seen approximately 2 weeks after onset of untreated or inadequately treated acute suppurative otitis media (same organisms)
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6
Q

What clinical triad is suggestive of mastoiditis? (TN)

A
  • Otorrhea
  • Tenderness to pressure over the mastoid
  • Retroauricular swelling with protruding ear
  • Can also see
    • Fever
    • Hearing loss
    • +/- TM perforation (late)
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7
Q

How is mastoiditis treated? (TN)

A
  • IV antibiotics
  • Surgical debridement
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8
Q

How can Herpes Zoster cause earache and what can it be associated with?

A
  • CN VII – can have concurrent Bell’s Palsy with pain and rash
  • Associated with vertigo, tinnitus and hearing loss
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9
Q

What are 2 risk factors for malignant otitis externa?

A
  • Diabetes
  • Immunocompromise
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10
Q

What are 3 findings associated with malignant otitis externa?

A
  • Refractory OE
  • Pain disproportionate
  • Granulation tissue on floor of external auditory canal
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11
Q

What is the cause of malignant otitis externa and how is it treated?

A
  • Pseudomonas (99%)
  • Admit for IV Cipro
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12
Q

What are 5 findings associated with Wegener’s Granulomatosis?

A
  • Arthralgia
  • Hearing loss
  • Oral/Nasal ulcers
  • Rhinorrhea
  • Myalgias
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13
Q

What is the presumed diagnosis for patients presenting with ear discharge (otorrhea) and (conductive) hearing loss?

A
  • Cholesteatoma
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14
Q

What are 5 findings that can be seen with a cholesteatoma?

A
  • Superior TM retraction (retraction pocket)
  • Pearly white spots on TM (granulation tissue)
  • Foul otorrhea
  • TM perforation
  • Conductive hearing loss
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15
Q

What are 11 causes of earache due to referred pain?

A
  • The 11 Ts
    • Teeth – cavities and abscess
    • Tongue
    • Trismus – spasm of mastication muscle, early sign of tetanus
    • TMJ dysfunction
    • Tonsillitis
    • Trigeminal neuralgia
    • Throat neoplasm
      • Risks: alcohol, smoking, age <50
      • Refer to ENT
    • Tracheitis
    • Thyroiditis
    • Thoracid aortic aneurysm and CAD
      • ECG, CXR, Trop
    • Temporal arteritis
      • Patient older than 50, PMR, constitutional symptoms, visual disturbances
      • Exam: tender artery/scalp, decreased temporal artery pulsation, eye exam
      • Get ESR
    • *Cervical arthritis
      • Referred from C2 and C3 nerve roots
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16
Q

What is the definition of AOM? (DFCM)

A
  • Presence of inflammation in the middle ear accompanied by rapid onset of signs and symptoms of an otalgia and decreased hearing
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17
Q

What is the definition of MEE? (DFCM)

A
  • Presence of fluid in the middle ear without signs and symptoms of an acute ear infection
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18
Q

What are 2 possible causes of MEE? (DFCM)

A
  • Inflammatory response following an episode of AOM
  • Spontaneously due to poor Eustachian tube function (post-URTI, seasonal allergies, airplane travel)
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19
Q

What symptoms may children experience with a MEE? (DFCM)

A
  • Transient hearing loss
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20
Q

How can a MEE be diagnosed on examination? (CPS)

A
  • Little or no mobility of the TM when both positive and negative pressure is applied using a pneumatic otoscope
  • Loss of bony landmarks
  • Presence of an air-fluid level
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21
Q

How long do sterile MEE persist for typically? (DFCM)

A
  • 1 month in 50% of children
  • 3 months in 30% of children (10% in MUMS)
  • Most resolve over 12 weeks with no intervention necessary
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22
Q

Are decongestants, antihistamines or steroids recommended for MEE? (DFCM)

A
  • Not in children
  • Decongestants may offer symptomatic relief in adults
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23
Q

What is the single most effective modifiable risk factor for MEE? (DFCM)

A
  • Discontinue exposure to passive smoking
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24
Q

How should MEE be managed? (DFCM)

A
  • Follow-up recommended at 3 month intervals until the effusion has resolved
  • Refer to ENT in the presence of significant hearing loss or structure abnormalities of the tympanic membrane
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25
**At what ages do the majority of AOM occur? (DFCM)**
* \<6 years
26
**What is believed to have lowered the incidence of AOM in Canada? (CPS)**
* Pneumococcal vaccine * PCV7 decreased incidence by 13% to 19% * PCV13 introduced in 2011 reduced further
27
**What are 11 risk factors for acute otitis media? (CPS)**
* Early age of first AOM * Male sex * Down’s syndrome * Orofacial abnormalities (clef palate) * Daycare attendance * Household crowding * Cigarette smoke exposure * Pacifier use * Shorter duration of breastfeeding * Prolonged bottle-feeding while lying down * Family history of AOM
28
**Why is the incidence of AOM higher in children than adults? (CPS)**
* Children acquire viral infections more often * Can cause Eustachian tube dysfunction or obstruction which impairs the normal mechanism that allows drainage of fluid in the middle ear * Fluid stasis can be lead to colonization with bacteria * Children have shorter and more horizontal ETs than adults
29
**What are 6 pathogens that can cause AOM and their relative proportion?**
* Steptococcus pneumoniae (40%) * Nontypeable Haemophilus influenza (25%) – less severe (more likely to resolve) * Moraxella catarrhalis (10%) – less severe (more likely to resolve) * Group A Streptococcus (2%) * Staphylococcus aureus (2%) * Viral (20-30%)
30
**What are 6 nonspecific symptoms that can be found in AOM? (DFCM)**
* Irritability * Fever * Night-waking * Poor feeding * Cold symptoms * Conjunctivitis
31
**What is the most sensitive and specific indicator on examination for acute inflammation consistent with AOM? (CPS)**
* Bulging TM
32
**What finding on otoscopy also strongly supports a bacterial cause? (CPS)**
* Acute perforation with purulent discharge (otorrhea) in the setting of AOM
33
**What are 2 causes of an erythematous TM on examination? (CPS)**
* Crying * Infection
34
**What are 2 aspects required for the diagnosis of AOM on physical exam?**
* Diagnosis should NOT be made if there is no middle ear effusion (MEE) * Diagnosis requires full visualization of ear drum – i.e. no ear wax
35
**What are the 3 diagnostic criteria required to diagnose AOM? (CPS)**
* Abrupt onset of symptoms (otalgia or suspected otalgia) * Middle Ear Effusion (MEE) * Middle Ear Inflammation (MEI) – doesn’t indicate AOM unless MEE * Erythema of TM * Distinct otalgia * If only fever and a red ear drum, look for another cause
36
**What are 6 findings seen with a Middle Ear Effusion (MEE)?**
* Loss of landmarks * Bulging TM * Opacity of TM * Fluid behind TM * Otorrhea * Decreased mobility of eardrum on tympanography
37
**For children \>6 months of age with suspected AOM that have MEE present AND bulging tympanic membrane, how should they be managed? (CPS)**
* Moderately or severely ill = treat * Irritable, difficulty sleeping, poor response to antipyretics, severe otalgia OR * ≥39C in ABSENCE of antipyretics OR * \>48h of symptoms * Mildly ill = observe 24h to 48 h * Alert, response, no rigors, responding to antipyretics, mild otalgia, able to sleep AND * \<39C in absence of antipyretics AND * \<48h of illness
38
**What are 3 findings that are associated with a diagnosis of moderate-severe AOM?**
* Moderate-severe pain * Pain persisting \>48h * Fever \>39
39
**What are 2 considerations in the treatment of AOM?**
* Pain management * Antibiotics
40
**How should pain be treated in patients with AOM?**
* Tylenol 15 mg/kg q6h (max 75 mg/kg/day) * Advil 10mg/kg q6h (max dose 400 mg, max daily dose 40 mg/kg/day)
41
**How should adults with AOM be treated? (DFCM)**
* Start antibiotic therapy immediately * If no improvement in 48-72 hours, patient should be re-examined as there may be a new focus of infection or inadequate therapy
42
**In which situations and ages should children with AOM be treated with antibiotics?**
**Age** **Uncertain Dx** **Unilateral AOM without Otorrhea** **Bilateral AOM without Otorrhea** **Severe Symptoms** **Otorrhea (perforation)** \<6 months Antibiotics for 10d Antibiotics for 10d Antibiotics for 10d Antibiotics for 10d Antibiotics for 10d 6 to 23 months _Severe_: Antibiotics 10d _Non-severe_: Tylenol _Severe_: Antibiotics 10d _Non-severe_: Tylenol Antibiotics for 10d Antibiotics for 10d Antibiotics for 10d \>2 years Observe and Tylenol _Severe_: Antibiotic 5d _Non-severe_: Tylenol _Severe_: Antibiotic 5d _Non-severe_: Tylenol Antibiotics for 5 days Antibiotics for 5-10 days
43
**What % of untreated children have resolution of AOM at 7-14 days? (TFP)**
* 70% * 80-90% (DFCM/MUMS)
44
**In which children with suspected AOM can watchful waiting be used? (MUMS)**
* Children \>2 years of age and previously healthy * Children 6 months to 2 years IF parents can observe for 48-72 hours * NOT recommended in children \<6 months
45
**What should all parents of children being treated for AOM be told? (MUMS)**
* Seek immediate medical reassessment if symptoms worsen or new symptoms appear (e.g. rash, drowsiness, difficulty breathing, vomiting) * If symptoms do not improve after 48 hours (fever, ear pain, fussiness) then return for reassessment and likely start antibiotics * 24-48h (CPS)
46
**What is the recommended duration of antibiotic therapy for children with AOM? (MUMS/CPS)**
* 5 days = \>2 years * 10 days = 6 months to 2 years * 10 days = \<6 months
47
**What is the first-line antibiotic for the treatment of AOM in adults and children? (MUMS/CPS)**
* Adults: Amoxicillin 500 mg TID * Children: Amoxicillin 80 mg/kg/day divided BID or TID (max 3g per day) if no previous amoxicillin in the last 30 days
48
**What is the second-line antibiotic for the treatment of AOM and its indication? (MUMS)**
* Adults: Amoxicillin-Clavulin 500 mg TID or 875 mg TID * Adults: Cefprozil 250-500 mg BID * Children: Amoxicillin-Clavulin 40-80 mg/kg/day divided BID (max 3g per day) * Recent Amoxicillin * Concurrent purulent conjunctivitis – more likely H. influenza or M catarrhalis * Recurrent AOM unresponsive to Amoxicillin – may be H. influenza or M catarrhalis * Children: Cefprozil 30 mg/kg/day divided BID * History of hypersensitivity to penicillins UNLESS previous reaction was life-threatening (i.e. angioedema, bronchospasm or hypotension)
49
**How do the doses recommended by the CPS differ from MUMS for treating AOM? (CPS)**
* Amoxicillin 45-60 mg/kgday divided TID as capsules or suspension
50
**How can Amoxicillin-Clavulin be prescribed to increase tolerance? (MUMS)**
* BID – reduces total amount of Clavulin
51
**What is the preferred Amoxicllin-Clavulin suspension for treatment of AOM in children and why? (CPS)**
* 7:1 formulation (most amoxicillin combined with the least amount of clavulin) * Each 5 mL of suspension contains 400 mg amoxicillin and 57 mg clavulanate * \<10 mg/kg/day dose of clavulanate associated with higher risk of diarrhea * For a child weight ≤35 kg, 45-60 mg/kg/day divided TID for 10 days * Specify 400 mg/5 mL suspension of 7:1 formulation * For a children weight \>35 kg, 500 mg tablets TID a day for 10 days
52
**What are third-line antibiotics for the treatment of AOM and their indications?**
* Azithromycin 10 mg/kg/day x1 and 5 mg/kg/day x4 * Penicillin allergy * Septra 5-10 mg/kg/day divided BID * Penicillin allergy * Use for 10 days if first-line failure
53
**How fast should symptoms improve and resolve after starting antimicrobials for AOM? (CPS)**
* Improve within 24h * RTC if no improvement within 24-48h * Resolve within 2-3 days
54
**What should all children with a perforated TM who present with symptoms of AM be treated with? (CPS)**
* Systemic antimicrobials * Examine for associated complications
55
**What is the preferred treatment for uncomplicated AOM in the presence of a chronic TM perforation or ventilation tubes? (MUMS)**
* Ciprodex 4 drops BID for 5 days * Superior to oral AM/CL in the median time to cessation of otorrhea (4 days vs 7 days), clinical cure rates (85% vs 59%) and adverse effects profile
56
**In which situations could Ciprodex be prescribed for AOM and what is the dose?**
* Ciprodex 4 drops BID for 5-10 days * Perforation * Venting tubes
57
**What should patients with otitis media with tympanic membrane perforation try to avoid? (DFCM)**
* Prevention of water entry into canal
58
**What is the NNT for antibiotics for AOM in children? (TFP)**
* NNT = 3 to 10
59
**What are the risks (NNH) for antibiotics prescribed for AOM in children? (TFP)**
* Diarrhea NNH = 5 * Diaper rash NNH = 7 * Eczema NNH = 19
60
**What is the evidence for delayed prescription of antibiotics for AOM in children? (TFP)**
* 4 studies * 2 studies found no difference * 2 studies found immediate prescriptions superior (NNT=6-7) * Delayed prescriptions may increase patient dissatisfaction
61
**Are prophylactic antibiotics for recurrent AOM appropriate? (MUMS)**
* No * Decrease ~1 episode per year vs Antibiotic Resistance
62
**What is the most common complication of AOM? (CPS)**
* Acute mastoiditis
63
**What are 6 potential complications of AOM? (CPS)**
* Meningitis * Facial weakness or paralysis (CN VII palsy) * Failure of ipsilateral eye abduction due to petrous bone inflammation or infection (CN VI palsy) = Gradenigo’s syndrome * Labyrinthitis or Vertigo (infection spreads to the cochlear space) * Hearing loss * Venous sinus thrombosis of the transverse, lateral or sigmoid venous sinuses
64
**What are 3 indications for tympanostomy tubes?**
* 3 episodes of AOM in 6 months * 4 episodes of AOM in 12 months, with 1 episode in the last 6 months * OME for ≥3 months with bilateral hearing loss ≥20 dB
65
**What are indications (2) to refer a patient to ENT with a history of AOM?**
* Retracted tympanic membrane * Need to rule out cholesteatoma * Clef palate or craniofacial malformations or Down syndrome * Recurrent infections (4 in 1 year, 3 in 6 months) * Severe signs and symptoms (high fever, intractable pain) despite adequate antibiotic therapy * Recurrent infections with colonization of multi-drug resistant bacteria * Persistent TM perforation (\>6 weeks) with or without suppurative drainage * Chronically draining (chronic suppurative otitis media) * May consider swabbing for possible candida and aspergillus species
66
**How should recurrent AOM be treated?**
* Treat with first-line agents if no previous antibiotics in 30 days and previously achieved good effect * Treat all ages for 10 days
67
**How does chronic perforation or tube ventilation with AOM present and how should it be treated?**
* Presents as painless otorrhea * If no systemic signs – Ciprodex 4 drops BID for 5 days * Otherwise regular antibiotics for 10 days (All Ages)
68
**What are 5 recommendations that can be may for prevention of AOM?**
* Pneumococcal vaccine to all children * Influenza vaccine to all children * Encourage breast feeding for 6 months – avoid bottle feeding in supine position * Avoid pacifiers after 6 months * Avoid tobacco smoke
69
**What should children with recurrent AOM be tested for?**
* Hearing loss
70
**How should children with middle ear effusion (MEE) be followed?**
* Reassessed in 3 months for effusion resolution * 10% will still have effusion – send for hearing test * Refer if hearing loss * Avoiding smoke is most effective intervention * Antihistamines and decongestants cause harm
71
**What is acute otitis externa also called? (CPS)**
* Swimmer’s ear
72
**What is the definition of AOE? (DFCM)**
* Presence of inflammation in the external auditory canal
73
**At what age is AOE less commonly seen? (CPS)**
* Children \< 2 years
74
**How can swimming lead to AOE? (CPS)**
* Skin desquamation leads to microscopic fissures that provide a portal of entry for infecting organisms
75
**What are 8 risk factors for AOE? (CPS)**
* Swimming * Trauma * Foreign body * Hearing aid * Certain dermatological conditions * Chronic otorrhea * Wearing tight head scarves * Immunocompromised * Ear piercing à infection of the pinna
76
**What findings are AOE most commonly associated with? (DFCM/CPS)**
* Otalgia (70%) * Pruritus/scaling (60%) * Aural fullness (22%) * Hearing loss (32%) * Ear canal pain with chewing * Otorrhea * Diffuse ear canal edema, erythema or both * Regional lymphadenitis * Pain with stretching of pinna * Pain with pushing of tragus
77
**What are 2 signs suggestive of AOE instead of AOM? (CPS)**
* Tenderness (out of proportion to visible inflammation) with: * Tragus push * Pinna pull
78
**What are 2 precipitants of AOE? (DFCM)**
* Excessive moisture * Moisture removes cerumen and increases the pH of the external canal, providing an ideal environment for pathogen growth and proliferation * Trauma * Q-tip use may cause abrasions and allow entry of pathogens to deeper tissue
79
**What are 4 possible causes of AOE? (DFCM)**
* Bacterial infection * Fungal * Allergic * Dermatitis
80
**What are the most common bacterial pathogens causing AOE? (DFCM)**
* Pseudomonas auruginosa * Staphylococcus aureus * 1/3 of cases polymicrobial
81
**How common is fungal AOE and what are the possible causes of it? (DFCM)**
* 2-10% of cases * Occurs after treatment with antibiotics * Superficial candida can occur in those who use hearing aids due to the moisture
82
**What complication of AOE should be examined for in patients presenting with signs of OE and how should they be managed? (DFCM)**
* Necrotizing (Malignant) AOE * Invasive infection of the external auditory canal with cartilage and bone involvement * May present with facial nerve palsy and pain as a prominent symptom * Immediate referral to ENT
83
**What should be done for the management of AOE if there is debris in the ear? (MUMS/CPS)**
* Aural toilet * If severely swollen, Merocel wick is recommended (expandable wick to decrease canal edema and facilitate topical medication delivery * NO evidence for effectiveness of aural toilet (CPS)
84
**What should be done in a patient with AOE if a defect in the TM cannot be ruled out? (MUMS)**
* Proceed as if there is a defect in the TM
85
**How can the external ear canal be cleaned of any debris or cerumen to examine the TM in patients presenting with AOE? (DFCM)**
* AVOID using a curette (inflammation can make the canal vulnerable to trauma) * AVOID flushing unless the TM can be clearly visualized * Best done with low suction or by using a fluffed-out cotton swab * Antibiotic drops or hydrogen peroxide may be used to moisten/soften any debris
86
**In which patients should systemic treatments be considered for AOE? (DFCM)**
* Diabetes * History of radiation to ear * Inflammation extending beyond ear canal * Significant edema preventing the application of topical therapy * Immunodeficiency
87
**What would recurrent AOE infections or infections resistant to topical treatment be concerning for? (DFCM)**
* Diabetes * Leukemia * DiGeorge Syndrome
88
**When would a culture be performed for a patient with suspected AOE? (DFCM)**
* Severe OE with fever and lymphadenopathy
89
**What is first-line treatment for AOE with intact TM? (DFCM)**
* Buro-Sol 2-3 drops TID or QID ($ cheapest $) * Contains aluminum acetate and benzethonium chloride * Less toxic, avoids resistance, lower cost
90
**How effective is Buro-Sol for treating AOE? (CPS)**
* Equally effective as topical antimicrobials in clinical cure rates at one week (Cochrane Review) * Inferior in clinical and microbiological cure at 2-3 weeks (Cochrane Review)
91
**If a patient with suspected AOE has no evidence of dermatitis and only infection, what can be used? (MUMS)**
* Polysporin or Polysporin/Lidocaine 1-2 drops QID
92
**What is second-line treatment for AOE with intact TM? (DFCM/MUMS)**
* Cortisporin 3 drops TID or QID (4 drops in adults) * Contains 10,000 U polymyxin, 5 mg neomycin and 10 mg hydrocortisone per mL (ototoxicity) * Neomycin can be sensitizing when used topically * Sofracort 2-3 drops TID or QID * Contains 5 mg framycetin and 0.05 mg gramicidin and 0.5 mg dexamethasone per mL (ototoxicity) * Garasone 3-4 drops TID * Contains 3 mg gentamicin and 1 mg betamethasone per mL * Beware risk of OTOTOXICITY * Ciprodex 4 drops BID ($$$) * Contains 3 mg ciprofloxacin and 1 mg dexamethasone per mL
93
**What is first-line treatment for AOE withOUT intact TM? (DFCM/MUMS)**
* Ciprodex 4 drops BID ($$$)
94
**For how long should treatment be for mild-to-moderate AOE with topical antibiotics? (CPS)**
* 7-10 days
95
**What is the cure rates for topical antimicrobials compared to placebo in the treatment of AOE? (CPS)**
* +46% absolute clinical cure rate compared to placebo (Cochrane Review) * +61% bacteriological cure rate compared to placebo (Cochrane Review)
96
**How soon should patients notice a response with topical antimicrobials for AOE and how long can full response take? (CPS)**
* 48-72 hours for clinical response * 6 days for full response
97
**What should be considered in patients that do not respond to topical antimicrobials? (CPS)**
* Obstruction * Foreign body * Non-adherence to therapy * Alternative diagnosis * Dermatitis from contact with nickel * Viral infection * Fungal infection * Antimicrobial resistance
98
**What are 3 reasons to discontinue treatment for AOE? (DFCM/MUMS)**
* Tinnitus * Hearing loss * Vertigo or Imbalance
99
**What is the risk associated with prolonged use of combination antibiotics for AOE? (DFCM)**
* Alter normal flora and result in a fungal infection
100
**What is first-line treatment for otomycosis? (DFCM/MUMS)**
* Clotrimazole 1% cream apply BID (am and qhs) * Tolnaftate 1% cream apply BID (am and qhs) * Locacorten Vioform drops 2-3 drops BID
101
**What is second-line treatment for otomycosis? (DFCM)**
* Keto-derm apply BID (am and qhs)
102
**When is Keto-derm used for otomycosis as second-line and what does it do? (DFCM)**
* Used if no response to above after 1 week * Contains ketoconazole, which covers for Aspergillus niger
103
**How can AOE be prevented after swimming? (DFCM)**
* Remove moisture * Warm air from a blow dryer * Tilting the head to allow drainage * Adding a few drops of vinegar to the ear * ONLY in the presence of an intact TM

Paediatrics (2 decks)

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