ENT Case 1 - Otorrhoea Flashcards
(25 cards)
What does otorrhoea (dischagring ear) often indicate?
Infection or inflammation of the middle ear (otitis media) or outer ear (otitis exeterna)
What symptoms commonly present with Otorrhoea?
- Ear pain (otalgia)
- Hearing loss
- Tinnitus
- Sometimes vestibular disturbance
What are the common features of otitis externa?
Features:
- Ear pain (otalgia)
- Otorrhoea (ear discharge)
- Itch
- Occasional pre / post auricular lymph node swelling
On otoscope:
- Erythema
- Swollen (ear canal is narrower than normal)
- Tender
What are the common causes otitis externa?
Infection:
- bacterial (staph. aureus, pseudomonas aeruginosa)
- fungal (aspergillus niger - commonest ear fungal infection)
- rarer than bacterial
- symptoms = more
itching than otalgia,
otorrohea is rare - Seborrhoeic dermatitis (skin inflammation in areas of sebaceous glands)
- Contact dermatitis (allergic and irritant)
How is otitis externa managed?
1st line:
- SWAB FIRST!!
- topical Abx OR combined topical Abx + corticosteroid
e. g. Sofradex (framycetin, dexamethasone and gramicidin) - some believe if tympanic membrane is perforated aminoglycosides (e.g. gentamicin, streptomycin, neomycin) are to be avoided due to otoxticity concerns
- keep ear dry
- remove excessive canal debris
- ear wick (cylindrical sponge) - if canal is swollen extensively, aids administration of ear drops
- oral analgesia - otitis externa can be very painful
2nd line:
- oral Abx:
- flucloxacillin - if no penicillin allergy
- clarithromycin - if penicillin allergy
- ciprofloxacin - if pseudomonas suspected
consider anti-fungal agent
consider contact dermatitis secondary to neomycin
Name 3 risk factors for developing otitis externa?
- Allowing water to enter ear
- Instrumentation of the ear canal e.g. cotton buds
- Skin conditions i.e. eczema or psoriasis
What is perichondritis?
Inflammation of the perichondrium (layer of connective tissue surrounding cartilage) - commonly used to refer to auricular perichondritis
- Infection of the pinna
- Often due to trauma, surgical wound or spread from local infections
- Left untreated –> can cause pinna necrosis + deformity
What is malignant otitis externa?
Rare form of otitis externa seen in immunocompromised patients. Infection begins in soft tissue of external auditory meatus –> progresses to bony ear canal –> progresses to temporal bone osteomyelitis
- 90% cases found in diabetics
- Pseudomonas aeruginosa = commonest organism
- Diagnosis = CT scan
Management:
- 6 weeks IV Abx that cover pseudomonal infections e.g. ciprofloxacin
- Regular clinical assessment + bloods (CRP / ESR) and MR of skull base
Symptoms:
- ear pain (otalgia) - severe, unrelenting, deep
- purulent otorrhoea
- temporal headaches
- possible facial nerve (CN VII) dysfunction
- other CN may be involved
- can cause sensorineural deafness
What are the possible complications of otitis externa?
- Facial cellulitis
- Otomycosis (fungal ear infection - often in immunosuppresed or after topical Abx)
- Canal stenosis w/ hearing loss
- Malignant otitis externa (w/ osteomyelitits of temporal bone)
- Sensorineural deafness
What questions might you want to cover in a ear discharge history?
SOCRATES each symptom:
- Which ear?
- Duration of discharge?
- Character of discharge; thick; watery; offensive?
- What precipitated it?
- Other symptoms:
- Ear pain (otalgia)
- Hearing loss (and how does this affect the patient?)
- Balance issues?
- Tinnitus?
- What treatments have they had so far and has it responded?
- What hobbies or sports are they involved in and do they get water in the ear (eg. swimming)
- Have they had any surgery to the affected ear?
- Do they have any other significant medical problems eg. allergic chronic rhinosinusitis, asthma, diabetes?
Name three causes of tympanic membrane rupture
- Recurrent infections
- Trauma eg. barotrauma or foreign body
- Iatrogenic eg. surgery
Name the 4 most common causative organisms of chronic otitis media?
- Pseudomonas aeruginosa
- Staph. aureus
- Streptococcus
- Anaerobic bacteria eg. peptostreptococcus
How is acute otitis media managed?
Generally, alike other self-limiting infections a no Abx / delayed Abx prescribing approach is suggested (policy for respiratory tract infections)
Prescribe Abx immediately IF:
- Symptoms lasting > 4 days / not improving
- Systemically unwell but not requiring admission
- Immunocompromised
- High risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
- Children < 2 yrs old with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
How long should an episode of acute otitis media last?
Around 4 days
What are the management options for a perforated tympanic membrane?
- No treatment (majority of cases) - membrane will heal in ~6-8 weeks
Don’t get ear wet!! - Combined topical Abx + corticosteroid (7-10 days) - if associated with active infection:
- Sofradex (framycetin, dexamethasone and gramicidin)
- Gentisone H/C (gentamicin and hydrocortisone)
- Otomise (dexamethasone, neomycin and acetic acid)
- Ciprofloxacin drops (covers pseudomonas)
- Myringoplasty (ear drum repair) - freshen edges of perforation + place graft underneath as scaffold for membrane to grow
How many episodes of acute otitis media must a patient have before they are termed as having recurrent acute otitis media?
> 4 episodes within 6 months
How long should an episode of acute otitis media last before it is classed as chronic otitis media?
3 months
What is a cholesteatoma?
-
What can cause a cholesteatoma?
-
What is a glomus jugulare?
-
What measures should be taken in a patient presenting with a cholesteotoma?
-
What is the difinitive treatment for a cholesteatoma?
-
Name some of the complications of any major middle ear surgery
-
Describe the following types of otitis media:
- Acute otitis media (AOM)
- Recurrent acute otitis media (RAOM)
- Chronic otitis media (COM)
- Otitis media with effusion
-
