ENT Case 1 - Otorrhoea Flashcards
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
