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EENT Exam 2 > Middle and External Ear > Flashcards

Middle and External Ear Flashcards

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1
Q

Auricular Hematoma epidemiology

A

● Direct trauma to the auricle
○ Shearing forces

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2
Q

Auricular Hematoma pathophysiology

A

● Accumulation of blood between the
cartilage and the skin
● Compromises blood flow to the
cartilage
○ Irregular cartilage formation
○ “Cauliflower Ear”

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3
Q

Treatment for Auricular Hematoma

A

● Ice
● Moderate compression
● Aspiration
● I & D – within 1 week (ENT)

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4
Q

Auricular Hematoma complications

A

● Infections
● Deformity
● Conductive hearing loss

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5
Q

Otitis Externa epidemiology

A

● Inflammatory and infectious process of the EAC
● 10% lifetime risk
● 35% of cases ages 5-14 years old
● More common in the summer months
● Water sports and humidity
○ “Swimmer’s ear”

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6
Q

Otitis Externa comorbidities

A

● Hearing aid/obstructive devices
● Trauma
● Dermatological condition (eczema, psoriasis)
● Diabetes
● Immunocompromised

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7
Q

Otitis Externa pathophysiology

A

● Inflammation due to heat, humidity, maceration, the absence of
cerumen, and an alkaline pH
● Results in edema and bacterial overgrowth
● Bacterial (most common)
○ Pseudomonas species 38-41%
○ Staphylococcus epidermidis (9%)
○ Staphylococcus aureus (8%)
○ Streptococci/gram negative rods
● Fungal (otomycosis) 2-10%
○ Aspergillus
○ Candida (hearing aids)
● Eczematoid

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8
Q

Otitis Externa treatment

A

● Mild (w/o discharge): Acetic acid w/ or w/ hydrocortisone
● Moderate: Topical antibiotics (typically fluoroquinolones)
■ Ciprofloxacin and ofloxacin (BID x 7-10 days)
■ Polymyxin B, neomycin, chloramphenicol,
gentamicin, and tobramycin
● Severe
○ Topical abx with addition of PO abx
■ Amox/clavulanate (BID x 7-10 days)
○ Possible ENT debridement

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9
Q

Otitis Externa treatment if fungal

A

Fungal (Otomycosis) – KOH positive on fungal culture
○ Acidify the canal and administering antifungal agents
■ Drops BID/TID x 10 days – Clotrimazole, nystatin (otic drops or powder), ketoconazole, cresylate otic drops – >80% effective
■ CSF powder
Eczematoid
○ Emollients (mineral oil)
○ Topical steroids
○ Possible ENT debridement

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10
Q

What does an Ear Wick do?

A

Allows liquid medication to delivered deeper in to the canal
■ Left in place for 2-3 days, or until it falls out as swelling decreases

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11
Q

Malignant Otitis Externa (MOE)

A

Complication of otitis externa
○ Necrotizing Otitis Externa (NOE)
90% Pseudomonas Aeruginosa
● DM, elderly, or immunosuppressed
patients with intense otalgia, otorrhea,
hearing loss, fullness, and pruritus.
○ Temporal bone pain → osteomyelitis

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12
Q

How does Malignant Otitis Externa occur?

A

Starts as OE → granulation tissue at the bony-cartilaginous junction
○ Progresses to osteomyelitis of the temporal bone may result in
neuropathies of CN V and VII
○ Can progress to meningitis, sepsis, and death

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13
Q

Malignant Otitis Externa (MOE) Treatment

A

Hospital admission for IV abx
○ Aminoglycosides, antipseudomonal beta-lactams
○ Blood sugar and immunosuppression control

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14
Q

Exostosis and Osteoma

A

● Firm broad-based bony lesions of the EAC (typically multiple lesions)
● Reactive bone formation associated with repetitive cold water or wind
exposure (periostitis)
○ Surfer’s Ear

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15
Q

Osteoma

A

● Benign neoplastic growth of the EAC (typically pedunculated lesions)
● Arise near the bony-cartilaginous junction of the EAC
● Fibrovascular core surrounded by bone
○ Unknown etiology
○ Rare

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16
Q

Exostosis and Osteoma Exam

A

● Narrowing of the canals
● Pedunculated bony mass

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17
Q

Exostosis and Osteoma Diagnosis

A

● High-resolution CT scan of the temporal bone

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18
Q

Exostosis and Osteoma Treatment

A

● Management of cerumen and otitis externa
● ENT referral for surgical management if indicated
○ Hearing loss

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19
Q

Prevention of Exostosis and Osteoma

A

Silicone earplugs to those frequently in cold water

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20
Q

Laceration of the Canal epidemiology

A

Direct trauma
○ Digital
○ Q-tip
○ Bobby pin
○ Car keys/Pen Caps
○ Foreign objects

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21
Q

Laceration of the Canal complications

A

With prolonged bleeding may need cautery
○ Silver nitrate sticks
○ Aluminum chloride topical (DrySol)

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22
Q

Cerumen Function

A

● Cleans and protects the EAC and TM
● Emollient
● Creates a difficult environment for bacteria and fungi to thrive

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23
Q

Cerumen Impaction presentation

A

● Hearing loss
● Earcaches
● Ear Fullness
● Itching
● Dizziness
● Tinnitus
● History of Q-tip, hearing aid, or earbud use

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24
Q

Cerumen Impaction Treatment

A

● Indication for removal — symptomatic
● Minimal cerumen without evidence of tympanic perforation
○ Mineral oil and hydrogen peroxide
○ OTC ear wax removal kits

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25
Ear Foreign Bodies common items
○ Beads, pebbles, popcorn kernels, tissue paper, cotton, small toys ○ Insects ○ Batteries – liquefactive necrosis, low voltage injury, pressure necrosis
26
Ear Foreign Bodies presentation
● Asymptomatic – delayed diagnosis ● Fidgeting with ear ● Pain ● Pruritus ● Conductive hearing loss ● Bleeding, odor or discharge
27
Bullous Myringitis
Inflammation/infection of the tympanic membrane ● Streptococcus pneumoniae, viral infection such as influenza or RSV
28
Bullous Myringitis Presentation
● Other URI symptoms ● Acute onset of ear pain ● Sensation of heaviness ● Hearing changes ● Mild discharge
29
Bullous Myringitis Exam
● Otoscopic examination ○ TM is red and deformed, light reflex is shortened or disappears completely ○ Bullae or blebs ○ TM appears to be weeping ● Audiogram often WNL ● Tympanometry reveals an intact TM with no negative pressure and good movement
30
Bullous Myringitis Treatment
● Amoxicillin (peds 80-90 mg/kg/day) ○ PCN allergy – Clarithromycin 500 mg BID x 10-14 days ● May need ENT for microscopic debridement/drainage of bullae ● Reevaluate after treatment – hearing test/audiogram
31
Tympanic Membrane Perforation presentation
● Audible whistling sounds/tinnitus ● Discharge from the ear ○ Otalgia resolves following discharge ● Decreased hearing ● Ear fullness ● Vertigo/balance issues
32
Tympanic Membrane Perforation Treatment
● Observation ○ Most heal spontaneously (3-4 wks) ▪ Monomeric membrane ○ Dry ear precautions ○ Abx drop (Ofloxacin 3-5 gtt 2-3 x daily for 5 days) ▪ NO STEROID DROPS ● Refer to ENT for surgical management if suspected damage to the ossicles or perforation persists > 3 weeks
33
Tympanosclerosis
Scarring of the TM ○ a.k.a. myringosclerosis ● Occurs after TM injury
34
Tympanometry
Tympanometry is helpful to determine the mobility of the tympanic membrane and the presence of effusion or perforation.
35
Tympanogram readings (A-F)
● A – Decreased motility of TM (typically fluid in behind the TM) ● B – Cerumen/ poor seal ● C – Perforation ● D – Not reliable ● E – Retracted TM ● F – Bulging TM
36
Serous Otitis Media
otitis media with effusion (OME) ● Collection of non-infected fluid in the middle ear space ○ Nearly always follows AOM ■ Infection resolves, effusion persists
37
Serous Otitis Media presentation
● Asymptomatic (i.e., painless) ● Hearing loss post AOM ○ Ear feels “full” or “plugged” following an episode of AOM
38
Serous Otitis Media Exam
● Air-fluid levels, dull or yellowish TM ● Decreased tympanic mobility ○ Tympanometry – Type B ● Conductive hearing loss
39
Serous Otitis Media Treatment
● Observation (may take 1-3 months to resolve) ○ Nasal decongestant and/or steroid spray ○ Autoinsufflation – equalize ear, “pop” open eustachian tube ● Oral steroids ● Refer to ENT
40
Serous Otitis Media Complications
● Children with otitis media with effusion are at risk for speech, language, and/or learning delays ● Promptly evaluate hearing, speech, language, and determine need for intervention
41
Acute Otitis Media
● Transudation of neutrophils, serum, and inflammatory mediators into the middle ear space ● Most common condition resulting in medical therapy for children younger than 5 years ● 70% of all children experience one or more attacks of AOM before age 2
42
Majority of AOM episodes are triggered by an ____
upper respiratory infection (URI)
43
Common AOM pathogens
● RSV ● Streptococcus pneumoniae ● Haemophilus influenzae
44
Acute Otitis Media
● Irritability ● Feeding difficulties ● Fever ● Otalgia and/or tugging at the ears ● Decreased hearing
45
Acute Otitis Media Exam
TM ○ Inflammation ○ Purulent middle ear effusion ○ Poor tympanic mobility with pneumatic otoscopy ○ May bulge in the posterior quadrants ○ Scalded appearance ● Tympanometry may confirm effusion
46
Acute Otitis Media Treatment
○ High dose Amoxicillin (Peds dose: 80-90 mg/kg/day) ○ Children less than 6 months of age should be treated immediately with an abx ○ > 6 months old with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours or longer or temperature 39°C or higher) and for non-severe, bilateral AOM in children aged 6-23 months
47
Acute Otitis Media Complications
● Tympanic perforation ● Persistent infection ● Persistent effusion (OME) ● Tympanosclerosis ● Hearing loss ● Lasting more than 3 weeks may result in mastoiditis Refer to ENT if complications arise
48
referred otalgia – “The 5 T’s”
○ Teeth ○ Tongue ○ TMJ ○ Tonsils ○ Throat
49
Recurrent Otitis Media is defined as
3 episodes within 6 months or 4 or more episodes within 1 year
50
Chronic Suppurative Otitis Media
● Perforated tympanic membrane with persistent drainage from the middle ear ● Cycle of inflammation, ulceration, infection, and granulation tissue formation may continue, eventually destroying the surrounding bony margins
51
Chronic Suppurative Otitis Media symptoms
● Ear drainage for some time (2-6 weeks) ● Typically, no pain or discomfort ● History of recurrent acute otitis media, traumatic perforation ● Hearing loss
52
52
Chronic Suppurative Otitis Media exam
● EAC is not typically tender ● Granulation tissue may be seen in the medial canal or middle ear space ● Middle ear mucosa visualized through the perforation, may be edematous or even polypoid
53
Chronic Suppurative Otitis Media Labs
● Labs typically not indicated ● Hearing test ● High-resolution CT scan of the temporal bone Referral to ENT ● Antibiotics (topical quinolones), microscopic debridements, surgery
54
Mastoiditis
● Complication of AOM ○ The infection spreads beyond the mucosa of the middle ear ○ Streptococcus pneumoniae ~ 25% ● Osteitis within the mastoid air-cells ● Possible subperiosteal abscess
55
5 Stages of Mastoiditis Development
○ Hyperemia of the mucosal lining of the mastoid air cells ○ Transudation and exudation of fluid and/or pus within the cells ○ Necrosis of bone by loss of vascularity of the septa ○ Cell wall loss with coalescence into abscess cavities ○ Extension of the inflammatory process to contiguous areas
56
Mastoiditis presentation
● Lethargy/Malaise (96%) ● Abnormal appearing TM (82%) ● Postauricular erythema/tenderness/swelling/protrusion (80%) ● Ear pain (67%) ● Otorrhea (50%) ● Persistent fever despite treatment (76%) ● AOM >3 weeks ● Hearing loss ● Children < 2 years of age
57
Mastoiditis exam
● Tenderness and inflammation over the mastoid process (periostitis) ● Subperiosteal abscess displaces the auricle laterally (seen on last slide) ● Otoscopic exam ○ Otitis media ○ Swelling of external auditory canal ○ Otorrhea (+/-)
58
Mastoiditis labs/imaging
○ CBC w/diff (left shift) ○ ESR and/or CRP (elevated) ● Possible audiometry ● Imaging ○ High resolution CT scan of the temporal bone
59
Treatment of Osteitis
● Acute mastoiditis without osteitis ○ 2-week course of broad-spectrum oral antibiotics ○ Possible tympanocentesis ● Acute mastoiditis with osteitis/periostitis ○ Broad spectrum antibiotics (likely IV – requires hospital admission) ○ Refer to ENT
60
Eustachian Tube Dysfunction
Eustachian tube is blocked or does not open properly
61
When the Eustachian tube does not function properly, ____ ____ occurs behind the TM
negative pressure
62
Eustachian Tube Dysfunction risk factors
● Family history ● Children under age 6: Eustachian tubes shorter and run horizontally
63
Eustachian Tube Dysfunction symptoms
● Muffled hearing ● Otalgia ● Ear fullness ● Difficulty “popping” the ears ● Tinnitus ● Dizziness/Balance disturbance
64
Eustachian Tube Dysfunction ear exam
○ May appear relatively normal if mild-moderate ○ Dull appearing TM ○ Decreased light reflex ○ Retraction pocket
65
Eustachian Tube Dysfunction treatment
● Nasal decongestant spray ○ Oxymetazoline (Afrin) ■ Rebound congestion (rhinitis medicamentosa)
66
When an ENT referral is needed with Eustachian Tube Dysfunction
○ Recurrent unilateral in an adult – nasopharyngoscopy ○ Myringotomy and/or tube placement
67
Eustachian Tube Dysfunction Complications
● Decreased hearing ● Otitis Media (OM) ● Cholesteatoma
68
Cholesteatoma
Presence of squamous epithelium in the middle ear or mastoid - Erode and destroy the ossicles and other structures within the temporal bone - May cause meningitis or brain abscess if left untreated
69
How is Cholesteatoma acquired?
● Acquired Primary ○ Chronic rectration of the TM – secondary to eustachian tube dysfunction ● Acquired Secondary ○ Squamous epithelial migration from a TM perforation (CSOM) or surgery
70
Cholesteatoma symptoms
● Recurrent or persistent purulent otorrhea ● Hearing loss ● Tinnitus ● Unresponsive to Abx therapy
71
Cholesteatoma Exam
● Retracted pars (primary) ● Matrix of squamous epithelium and often keratin debris (may or may not be visible) ● Purulent otorrhea ● TM perforation (secondary)
72
Cholesteatoma Imaging
○ In patients whose TM is opaque, further studies, such as imaging, may be required ○ High resolution CT scan of the temporal bone ▪ MRIs are finding a place

EENT Exam 2 (5 decks)

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