ENT - Otorrhoea Flashcards
(27 cards)
What does otorrhoea (discharing ear) often indicate?
Infection or inflammation of the
middle ear (otitis media) or outer ear (otitis externa)
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 antifungal agent
- consider contact dermatitis 2ndary 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 otorrhea
- 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 treatment 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 e.g. swimming?
- Have they had any surgery to the affected ear?
- Do they have any other significant medical problems e.g. allergic chronic rhinosinusitis, asthma, diabetes?
What are the 2 issues in this ear drum image?
- Inferior perforation of pars tensa
- Anterior tympanosclerosis (white calcium deposits caused by healing from previous ear infections)
Name 3 causes of tympanic membrane rupture?
- Recurrent infections
- Trauma e.g. barotrauma or foreign body
- Iatrogenic e.g. ear surgery
Name the 4 most common organisms involved in chronic otitis media?
- Pseudomonas aeruginosa
- Staph. aureus
- Streptococcus
- Anaerobic bacteria ie 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 2ndary 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?
~ 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
What is a Cholesteatoma?
Cholesteatoma = non-cancerous growth of squamous epithelium that is ‘trapped’, often in a deep retraction of tympanic membrane
- Involves accumulation of keratin within the retraction (normally skin cells migrate out of the ear canal as they are refreshed - but the retraction causes build up –> kertain cyst)
- Epidemiology:
- commonest age = 10-20 yrs
- cleft palate = 100 fold risk
-
Features:
- Otorrhoea - foul-smelling, non-resolving discharge, resistant to Abx
- Hearing loss
- Can have tinnitus
- Depending on local invasion: dizziness (erosion of semicircular canal), facial nerve palsy (weakness, altered taste), deafness (erosion of ossicles)
- Not likely painful
-
Otoscopy:
- ‘attic crust’ - keratin cyst in the uppermost tympanic membrane w/ or wo/ perforation
-
Management:
- Refer to ENT for surgical removal
What can cause a Cholesteotoma?
- Otitis media - commonly precipitates cholesteotoma
- Eustachian tube dysfunction - can promote invagination of tympanic membrane, due to chronic -ve pressure in middle ear
- Otological surgery (iatrogenic)
- Trauma (barotrauma)
What is a Glomus jugulare?
A vascular tumour that presents as a ‘red mass’ behind an intact tympanic membrane
- Pt may complain of ‘pulsatile tinnitus’
What measures should be taken in a patient presenting with a cholesteotoma?
-
Pure tone audiogram
- Determines degree of hearing loss
- Enables pre / post surgery hearing assessment (see if hearing was improved or if surgery caused deafness)
- Topical Abx + steroid - helps if infection is present
-
Close inspection + cleaning under microscope
- pars flaccida (also called the attic) is often ignored and only the pars tensa is inspected, missing pathology in the attic area
What is the definitive treatment for a cholesteatoma?
Mastoidectomy
- Involves opening the mastoid air cells, removing the cholesteatoma from the middle ear
- Reconstruction of ossicles + tympanic membrane
Name some of the complications of any major middle ear surgery?
- Infection
- Bleeding
- No improvement in hearing
- Complete loss of hearing, called a dead ear (if the inner ear is damaged)
- Tinnitus
- Vertigo
- Facial nerve palsy
- Altered taste (chorda tympani nerve damage)
- Recurrence of disease needing revision 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
-
Acute otitis media (AOM)
- acute inflammation of middle ear with systemic upset (AOM is often precipitated by a URTI)
- otolgia, fever, cough, nasal discharge
-
Recurrent acute otitis media (RAOM)
- > 4 episodes of AOM in a 6-month period
-
Chronic otitis media (COM)
- inflammation of middle ear for > 3-months. There are 2 types:
-
Mucosal COM - inner cells of tympanic membrane
- Active - wet perforation (i.e. with middle ear infection)
- Inactive - dry perforation
-
Squamous COM - outer cells of tympanic membrane
- Active - cholesteatoma
- Inactive - shallow self-cleaning retraction of membrane
-
Mucosal COM - inner cells of tympanic membrane
- inflammation of middle ear for > 3-months. There are 2 types:
-
Otitis media with effusion
- inflammation (not infection) of middle ear + effusion –> conductive hearing loss
What are the intra-temporal and extra-temporal complications of COM?
Intra-temporal complications:
- Vertigo - inflammation spreads to vestibular apparatus
- Hearing loss - COM can cause either conductive (dmg to ossicles / tympanic membrane) or sensorineural (cochlea inflammation) hearing loss
- Acute otitis externa - discharge causing skin irritation
- Facial weakness - erosion of thin bony canal exposes CN VII
Extra-temporal complications:
- Meningitis - erosion through tegmen (roof of middle ear) to expose the dura
- Subdural abscess - same as above, infection spreads from extradural to subdural
- Temporal lobe abscess
- Sigmoid sinus thrombosis
