ENT I: Outer Ear Disorders

Question 1

What is pneumatic otoscopy used for?

Answer 1

Pneumatic insufflation used to evaluate TM mobility is described as normal, absent, decreased, or increased

Question 2

Give an example of a condition that can decrease TM mobility

Answer 2

Effusion

Question 3

1) Define cerumen impaction
2) What is it a common cause of?
3) Who is it most common in?

Answer 3

1) Accumulation of cerumen (aka, ear wax) causing bothersome symptoms and/or preventing needed assessment of ear canal
2) Common condition & common cause of hearing impairment
3) 1 in 10 children, 1 in 20 adults, 1 in 3 older adults

Question 4

Define cerumen

Answer 4

Naturally occurring from epithelial cells in the external auditory canal (EAC)

Question 5

What is the cause of cerumen impaction?

Answer 5

Disrupted/dysfunctional migratory pattern of epithelium

Question 6

Give 6 examples of things that can cause disrupted/ dysfunctional migratory pattern of epithelium

Answer 6

1) Canal disease
2) Canal narrowing
3) Aging
4) Foreign objects
5) Inappropriate removal attempts
6) Overproduction

Question 7

1) True or false: cerumen accumulation is usually asymptomatic
2) What are some symptoms of impaction?
3) How do you dx cerumen impaction?
4) What are two indications for removal?
5) When is removal not recommended?

Answer 7

1) True
2) Hearing loss, ear fullness, earache, itchiness, reflex cough, dizziness, and/or tinnitus
3) otoscopic exam (otoscopy)
4) Symptomatic patients & patients unable to express
symptoms
5) Not recommended for asymptomatic patients

Question 8

What is the most common ENT procedure?

Answer 8

Cerumen removal

Question 9

List potential removal methods for cerumen

Answer 9

1) Cerumenolytic agents
2) Irrigation
3) Manual

Question 10

1) What patients are Cerumenolytic agents appropriate for to remove cerumen?
2) Where can it be done and for how long?
3) What are some examples of these agents?
4) What may you need to follow up with?

Answer 10

1) Patients without h/o ear infections, TM perforation, or otologic surgery
2) In clinic or at home (no more than 3-5 days)
3) Water, saline, mineral oil, hydrogen peroxide, docusate sodium, carbamide peroxide (Debrox; OTC drops)
4) Irrigation

Question 11

1) Can irrigation be done alone?
2) What are the two tools used for irrigation?
3) What are some potential irrigants?
4) What is recommended for immunocompromised pts?

Answer 11

1) Yes; alone or with pre-treatment
2) Large catheter-tipped syringe or mechanical jet irrigator
3) Warm (body temp) irrigant: tap water, saline, or water + hydrogen peroxide
4) Post-irrigation acidification

Question 12

1) What does manual cerumen removal require?
2) What are some examples of different manual tools?
3) What is not an appropriate removal method?

Answer 12

1) Requires adequate visualization
2) Curettes, spoons, forceps, cotton-tipped applicators, suction
3) Ear candling (aka, ear coning or thermal auricular therapy)

Question 13

List potential complications for each of the 3 methods of cerumen removal

Answer 13

1) Cerumenolytics: allergic reactions, otitis externa, earache, transient hearing loss, dizziness
2) Irrigation: water retention, TM perforation, hearing loss, tinnitus, pain, vertigo
3) Manual: ear pain, bleeding, laceration, TM perforation

Question 14

What should you recommend patients with h/o recurring symptomatic cerumen impaction (>1/year despite removal) and otherwise normal ears do?

Answer 14

1) Cotton ball dipped in mineral oil in EAC x 10-20 min. once weekly
2) Routine cleaning q6-12 mos. by health professional
3) No chronic use of cotton swabs or cerumenolytics

Question 15

List 3 criteria for referral to otolaryngologist (seldom necessary

Answer 15

1) Hx of chronic cerumen impaction, perforated TM, or ear surgery
2) Purulence or necrotic tissue in ear canal
3) Persistence of otologic complaints after cerumen removal

Question 16

1) What is Otitis Externa (aka “Swimmer’s ear”)?
2) How common is it? When does it most commonly occur?
3) What are 3 things that can induce it?
4) What is the most common cause?

Answer 16

1) Inflammation of EAC
2) ~10% lifetime occurrence; childhood predominant; more likely to occur in summer
3) Infectious, allergic, & dermatologic disease
4) Acute bacterial infection

Question 17

1) What are the 3 most common bacteria to cause otitis externa?
2) What two fungi commonly cause otitis externa?

Answer 17

1) Pseudomonas aeruginosa, S. epidermidis, & S. aureus
2) Aspergillus, Candida

Question 18

List 6 risk factors for otitis externa

Answer 18

1) Water/swimming
2) Mechanical trauma
3) Allergic contact dermatitis
4) Dermatologic conditions
5) Devices (hearing aids, ear buds, diving caps)
6) Prior radiation therapy

Question 19

List 4 symptoms of otitis externa

Answer 19

Otalgia, pruritis, otorrhea, hearing loss

Question 20

What 6 Hx questions should you ask for otitis externa?

Answer 20

1) Known TM perforations
2) Previous ear infections
3) Prior ear surgery or radiation
4) Recent ear instrumentation
5) Use of devices in ear canal
6) Water exposure

Question 21

List the 5 signs of otitis externa during a PE

Answer 21

1) Erythema or signs of trauma to auricle or tragus
2) Tenderness with tragal pressure or auricle manipulation
3) Canal edema, canal erythema
4) May have purulent exudate (discharge), periauricular cellulitis, or TM erythema
5) Mobile TM with pneumatic insufflation

Question 22

With otitis externa:
1) If air-fluid level in TM, what should you suspect?
2) What should you suspect if the TM is perforated?

Answer 22

1) Middle ear effusion from underlying otitis media
2) Middle ear conditions

Question 23

Describe the 3 levels of severity of otitis externa based on H&P

Answer 23

1) Mild: minor discomfort, pruritis, minimal canal edema
2) Moderate: intermediate pain, pruritis, +/- partial canal occlusion
3) Severe: intense pain, complete canal occlusion; +/- fever, preauricular erythema, regional lymphadenopathy

Question 24

1) How do you Dx otitis externa?
2) What is a typical presentation?
3) When should cultures be taken?

Answer 24

1) Clinical (based on H&P)
2) Rapid onset (~within 48 hrs in previous 3 wks)
3) Severe, recurrent, chronic, immunosuppressed, infections after ear surgery, no response to initial therapy

Question 25

What are the 3 main components of treatment of otitis externa?

Answer 25

1) Cleaning EAC (aural toilet) 2) Treating inflammation & infection 3) Pain control (NSAIDs or acetaminophen)

Question 26

What is a mainstay of otitis externa treatment? Describe how it's used in mild and moderate cases

Answer 26

Topical therapy: 1) Mild: Topical acidifying agent + glucocorticoid (i.e., acetic acid + hydrocortisone TID-QID) x 7 days 2) Moderate: Topical antibiotic + glucocorticoid (i.e., Cipro HC BID, Cortisporin TID-QID) x 7 days (tl;dr use drops)

Question 27

1) How should you treat severe otitis externa? 2) What should you do for some patients?

Answer 27

1) Topical antibiotic + glucocorticoid (i.e., Cipro HC, Cortisporin) 2) Add wick placement & systemic antibiotics (if evidence of deep tissue infection)

Question 28

What systemic antibiotics are used on wicks for less severe otitis externa patients? What about more severe?

Answer 28

1) Less severe: PO levofloxacin 500 mg daily x 7d 2) More severe: IV vancomycin + IV cefepime

Question 29

1) What should you obtain for severe OE? 2) What should you do for immunocompromised OE pts?

Answer 29

1) Cultures of ear drainage 2) Same preferred antibiotics as with severe disease

Question 30

1) What should you do regarding otitis externa follow-up? 2) What two things should you counsel the pt on?

Answer 30

1) Depends on severity & resolution; consider culture & ENT referral if no response 2) Protect ear while recovering & ear hygiene

Question 31

1) How should a pt protect their ear when healing from otitis externa? 2) What should you tell them about ear hygiene?

Answer 31

1) Cotton ball while bathing Refrain from water sports x 7-10 days No hearing aids or earbuds until pain & discharge subside 2) EAC is self-cleaning; don’t insert fingers, towels, cotton swabs, or other foreign objects -Drying EAC: hair dryer, fan, isopropyl alcohol/white vinegar

Question 32

List 2 complications of otitis externa

Answer 32

Periauricular cellulitis & malignant external otitis (next)

Question 33

1) What is Malignant (Necrotizing) External Otitis? 2) Who is it most common in? 3) What is the #1 cause?

Answer 33

1) Invasive infection of EAC & skull base (osteomyelitis) 2) Diabetics over age 60, HIV, immunocompromised 3) Pseudomonas aeruginosa is #1 cause

Question 34

Malignant (Necrotizing) External Otitis: 1) What are its symptoms? 2) What should be cultured or biopsied? 3) What tests should be done? 4) What is treatment based on?

Answer 34

1) Deep otalgia (nocturnal), persistent & foul otorrhea, EAC granulation 2) Cultures of drainage & biopsy of granulation tissue 3) CT and/or MRI; bone scan 4) Severity (4 wks-6 months of PO or IV antibiotics)

Question 35

1) Who are foreign bodies in the EAC most common in? 2) What ear is it most common in? 3) List some common FBs

Answer 35

1) Most common in children aged 6 & younger 2) More common in right ear (predominant handedness) 3) Beads, pebbles, tissue paper, small toys, popcorn kernels, & insects

Question 36

What 3 groups of kids are foreign bodies in the EAC more common in?

Answer 36

1) Irritating conditions of the ear (i.e., cerumen impaction, otitis externa, otitis media) 2) Pica 3) ADHD

Question 37

What are 5 common presentations of foreign bodies in EAC?

Answer 37

1) Caregiver concern (witnessed placement or seeing FB in EAC) 2) Incidental finding during routine otoscopy 3) Decreased hearing or ear pain 4) Purulent or bloody ear drainage (rare) 5) Chronic cough or hiccups (rare)

Question 38

1) How are foreign bodies in the EAC examined? 2) How is it Dxd?

Answer 38

1) Otoscopy (also evaluate other ear & nostrils) 2) Visualization on otoscopy

Question 39

1) What foreign bodies require urgent removal? 2) Which require removal within a few days? 3) Which should be referred to an otolaryngologist?

Answer 39

1) Button batteries, live insects, penetrating FBs 2) Glass or other sharp FB, spherical or other FB wedged in medial EAC, & FB against TM 3) All of the above

Question 40

1) What non-specialists can remove FBs in the EAC? 2) What is important to do during removal?

Answer 40

1) Emergency department or primary care office 2) Ensure adequate restraint

Question 41

What are some commonly available instruments to remove foreign bodies from EAC?

Answer 41

1) Irrigation setup 2) Headlight 3) Otoscope 4) Alligator or Bayonet forceps 5) Plastic or metal cerumen curette

Question 42

1) Who is irrigation of ear for FB removal contraindicated in? 2) How is it done? 3) What solution is used?

Answer 42

1) T-tubes, perforated TM, vegetable matter, button batteries 2) 20-50 mL syringe of irrigation solution at body temp (tap water, sterile water or NS) via plastic butterfly needle tubing or 14-16 g plastic IV catheter 3) Mineral oil or 1% lidocaine

Question 43

What are the two main techniques for FB removal?

Answer 43

1) Irrigation 2) Instrumentation under direct visualization