Otitis Media and Otitis Externa

Question 1

What are the layers of the eardrum?

Answer 1

The eardrum has three layers: cuboidal epithelium in the middle ear, a fibrous layer in the middle, and squamous epithelium on the outside.

When there is a perforation, all three layers start to proliferate, but if the squamous layer and the cuboidal layer meet, the fibrous layer will stop. This can lead to a chronic perforation in which the middle ear is constantly being exposed to the outside, and thus develops a low-grade inflammation.

Question 2

Inflammation of the middle ear space is called … ?

Answer 2

Otitis media

This is the second most common disease diagnosed in children.

Question 3

A child presents with sudden onset of fever, ear pain, and fussiness. On physical exam, the child has an eardrum that is bulging and yellow and white in color with dilated vessels, and there is decreased movement of with insufflation of air into the ear canal, what is the most likely diagnosis?

Answer 3

Acute otitis media

Question 4

The eardrum on pneumatic otoscopy with a patient with acute otitis media will be …

Answer 4

Bulging with decreased movement. This feature distinguishes acute otitis media from otitis with effusion.

Question 5

The most common bacteria that cause acute otitis media in children are …?

Answer 5

Streptococcus pneumoniae (most commonly)

Haemophilus influenzae

Moraxella catarrhalis

Question 6

What organism was the most common to cause blood-borne spread of the bacteria from the middle ear space into the meninges?

Answer 6

Historically, the most common offending organism was Haemophilus influenzae, though epidemiologic patterns have been changing since the advent of the Haemophilus influenzae vaccine.

Question 7

What factors increase the incidence of acute otitis media in children?

Answer 7

Daycare attendance, young siblings at home, and exposure to tobacco smoke, may predispose children to develop otitis media.

Question 8

What can decrease the incidence in acute otitis media in children?

Answer 8

Breastfeeding during infancy and vaccination with a pneumococcal conjugate preparation may decrease the incidence of acute otitis media in children.

Question 9

When is observation the treatment option for acute otitis media?

Answer 9

Observation for 48-hours is considered in healthy children older than two years of age who present with less severe symptoms. Treatment, however, is generally given to all adults, children younger than 2 years, or children (over two years old) who appear toxically ill (temperature > 102.2, bilateral, vomiting) or have had symptoms for more than 48 hours.

Question 10

If treatment is necessary, what is the treatment option for acute otitis media?

Answer 10

Amoxicillin dosed at 80 to 90 milligrams per kilogram per day is the first-line antibiotic therapy.

Azithromycin is used to treat patients who have a penicillin allergy.

A common second-line therapy for acute otitis media is high-dose amoxicillin-clavulanate. This is to address those who do not respond to first-line antibiotic therapy, which is likely due to a beta-lactamase-producing organism or a resistant Streptococcus organism. Alternatives are clindamycin and TMP-SMX (Bactrim), however TMP-SMX doesn’t treat some organisms like group A strep.

Question 11

What are the complications of Acute Otitis Media?

Answer 11

Meningitis, sigmoid sinus thrombosis, subperiosteal abscess of the mastoid, brain abscess, and facial nerve paralysis. If infection persists for a long time (generally 6 weeks), TM perforation and conductive hearing loss are possible. Another complication is tympanosclerosis.

Question 12

When acute otitis media also affects the bullae, this is called?

Answer 12

Bullous myringitis

Question 13

Firm submucosal scarring that can appear as a chalky white patch on the eardrum is due to

Answer 13

This is likely tympanosclerosis and is due to Tympanic membrane perforation.

Infrequently this condition can lead to conductive hearing loss if the middle ear, and ossicles are involved extensively.

Question 14

Tympanoplasty requires what component because the fibrous tissue will not grow with squamous epithelium meeting cuboidal epithelium … ?

Answer 14

Grafts using either:

Fascia temporalis
(the fibrous connective tissue overlying the temporalis muscle)

or

Tragal perichondrium
(the lining overlying the tragus ear cartilage)

Small, semicircular cuts in the skin of the external auditory canal (EAC) are made about five millimeters (mm) out from the annulus, which is the outermost portion of the eardrum. The surgeon scrapes the skin off the bone and sneaks under the annulus to access the medial aspect of the eardrum and the middle ear space. The middle ear is then filled with a sponge-like material made of hydrolyzed collagen, which acts as a scaffold to hold the graft up against the medial aspect of the eardrum. Then the TM and skin are replaced and the EAC is packed with more sponge-like material. The collagen substance is eventually reabsorbed; meanwhile, the fibrous layer proliferates along the scaffolding of the graft to close the hole.

Question 15

Pressure equalization (PE) tubes, or ear tubes, are indicated in children with:

Answer 15

Chronic OME for 3 months and evidence of hearing loss

or

3 to 4 bouts of acute otitis media in 6 months

or

5 to 6 bouts in a single year

An advantage of PE tubes is the ability to treat episodes of ear drainage with topical antibiotic therapy, such as fluoroquinolone ototopical drops applied to the ear canal. Fluoroquinolone drops are favored over neomycin/polymyxin B/hydrocortisone, due to the risk of ototoxicity.

Question 16

Do pressure equalization (PE) tube, or ear tubes need to be removed?

Answer 16

The PE tubes generally extrude on their own after one to two years.

Question 17

What helps to prognosticate the use of PE tubes in children?

Answer 17

Children usually grow out of the need for the tubes as they get older, as the eustachian tube assumes a longer and more downward-slanted course with time.

However, there are certain subsets of patients, such as children with a history of cleft palate or trisomy 21, who can have long-term problems with otitis media and eustachian tube dysfunction.

Question 18

What will generally occur after treatment of acute otitis media?

Answer 18

Otitis media with effusion (OME), or middle ear fluid without active infection, may occur after treatment of an acute episode of otitis media, this is due to the passage ways clearing out the prior infection. This may also be due to chronic eustachian tube dysfunction or barotrauma.

The majority of children will clear middle ear fluid within three months of an acute ear infection, those with eustachian tube dysfunction may have problems with persistent middle ear fluid. Children with OME are often asymptomatic, although they may complain of ear fullness or muffled hearing. These patients do not have the fevers, irritability, and ear pain, symptoms that are primarily associated with acute otitis media. On physical examination, there may be an air-fluid level behind the eardrum and decreased mobility of the eardrum.

Question 19

If ear drainage persists despite medical therapy, the patient requires referral to an otolaryngologist to rule out ______________

Answer 19

Cholesteatoma

Question 20

A retracted pars flaccida is due to ________ and over time can grow ______ ?

Answer 20

A retracted pars flaccida is due to chronic eustachian tube dysfunction and desquamated debris that consist with of a collection of keratin.

Over time, this can grow and become a Cholesteatoma

Question 21

What condition is due to keratinous debris that gets caught in the pars flaccida retraction pocket?

Answer 21

Cholesteatoma

This can develop in some patients who do not outgrow their eustachian tube dysfunction, and they go on to suffer from chronic negative middle ear pressure. This can result in retraction of the superior part of the eardrum, known as pars flaccida, back into the middle ear space. The outside of the eardrum is actually lined with squamous epithelium, which desquamates and produces keratin. Over time, the keratinous debris can get caught in the pars flaccida retraction pocket, which continues to accumulate, expanding the pocket, creating a cholesteatoma, which often gets infected.

Another way cholesteatoma can develop is when squamous epithelium migrates into the middle ear space through a hole in the eardrum. The perforation can come from a previous otitis media infection, a PE tube hole that did not heal, or trauma. Marginal perforations, or holes along the outer portion of the eardrum, are more likely to allow migration of epithelium than central perforations.

Question 22

Patients with cholesteatoma usually present with … ?

Answer 22

Patients with cholesteatoma usually present with chronic ear pressure, drainage, and retraction of the TM.

These patients may be put on ototopical antibiotic drops due to the drainage which is often due to Pseudomonas or Proteus bacteria.

Question 23

If the cholesteatoma is left untreated, it will …. ?

Answer 23

If the cholesteatoma is left untreated, it will continue to grow and erode bony structures.

Possible sequelae include hearing loss secondary to necrosis of the long process of the incus; erosion into the lateral semicircular canal, causing dizziness; subperiosteal abscess; facial nerve palsy; meningitis; and brain abscess.

Question 24

The treatment for cholesteatoma is … ?

Answer 24

surgical removal.

While excision gets rid of the cholesteatoma, the underlying eustachian tube dysfunction is still present.

Cholesteatoma has the propensity to recur. Once patients have undergone surgery for removal of a cholesteatoma, they will need continuous monitoring of their ears for the rest of their lives.

Question 25

What can possibly be done to reduce the need for pressure equalization (PE) tube, or ear tubes ?

Answer 25

An adenoidectomy, or removal of the adenoid tissue in the nasopharynx, has been shown to reduce the need for PE tubes in children, presumably by removing a focus of eustachian tube inflammation. Adenoidectomy is often recommended if a child requires a second set of PE tubes, or with the first set of tubes if the child has significant nasal symptoms.

Question 26

Purulent ear drainage in the setting of acute otitis media is likely due to ... ?

Answer 26

Eardrum, or tympanic membrane, perforation. The eardrum is the path of least resistance in the ear; thus, a build-up of middle ear purulence during an episode of acute otitis media can result in spontaneous tympanic membrane (TM) rupture. Treatment is similar to acute otitis media. Most commonly, the perforation will heal on its own within two weeks. However, persistent perforations may require surgical repair. Occasionally, eardrum perforations can be associated with chronic ear drainage, also known as chronic suppurative otitis media.

Question 27

What is the likely condition fever, ear pain, fluctuance behind the ear, and a protruding auricle ?

Answer 27

Acute mastoiditis This is a complication of AOM. Fluid collects in the air cells of the mastoid bone just behind the ear and often occurs when acute otitis media is present. If the fluid becomes infected and invades the bony structures, acute mastoiditis develops. Patients with acute mastoiditis present with fever, ear pain, and a protruding auricle. Over the mastoid bone, the patient may have erythema of the skin, tenderness, and even a fluctuant mass. A CT scan is a useful diagnostic tool if acute mastoiditis is suspected. IV Abx (vancomycin + cefepime) may initially be used to treat patients with acute mastoiditis. Surgery, including PE tube placement (myringotomy +/- tympanostomy) or mastoidectomy, may be necessary in patients who do not respond to medical therapy.

Question 28

Other rare CNS complications of AOM are ... ?

Answer 28

Other less common complications of otitis media include epidural and brain abscesses, sigmoid sinus thrombosis, and facial nerve paralysis. Epidural abscess or brain abscesses require surgical drainage. Sigmoid sinus becoming infected can lead to thrombosis, and can serve as a nidus of infection. This classically leads to showers of infected emboli, causing “picket fence fevers.” Facial nerve paralysis in the setting of acute otitis media is believed to be caused by inflammation around the nerve, and thus generally responds to appropriate intravenous antibiotic therapy as well as drainage of the pus. This can be done via either a myringotomy (an incision in the eardrum) or, if necessary, a mastoidectomy.

Question 29

What symptom usually accompanies OME?

Answer 29

Children with OME may have up to a 30- to 40-decibel (dB) conductive hearing loss, which in some studies affect speech development and learning.

Question 30

How is OME in children managed?

Answer 30

Patients with OME are sometimes treated with a short course of oral or topical nasal steroids, to decrease the swelling in the eustachian tube and allow ventilation of the middle ear space. Antibiotic therapy is not usually indicated for children with OME.

Question 31

Ear drainage in patients with PE tubes in place should be treated with ... ?

Answer 31

Ototopical fluoroquinolone drops

Question 32

The collection of trabeculated bony cavities lined with mucosa and connected with the middle ear is called the mastoid _________

Answer 32

Air Cells

Question 33

Other rare CNS complications of AOM are ... ?

Answer 33

Other less common complications of otitis media include epidural and brain abscesses, sigmoid sinus thrombosis, and facial nerve paralysis. Epidural abscess or brain abscesses require surgical drainage. Sigmoid sinus becoming infected can lead to thrombosis, and can serve as a nidus of infection. This classically leads to showers of infected emboli, causing “picket fence fevers.” Facial nerve paralysis in the setting of acute otitis media is believed to be caused by inflammation around the nerve, and thus generally responds to appropriate intravenous antibiotic therapy as well as drainage of the pus. This can be done via either a myringotomy (an incision in the eardrum) or, if necessary, a mastoidectomy.

Question 34

If a patient presents with a draining ear, appropriate therapy includes drops and _________

Answer 34

Oral Abx

Question 35

What is the appropriate action for a child with OME for at least 3 months?

Answer 35

When a child has at least three months of persistent middle ear effusion, referral to an otolaryngologist and placement of PE tubes is often entertained, especially for children with effusions that are associated with hearing loss.

Question 36

What are the features of distinguish otitis media with effusion?

Answer 36

hearing loss, mild pain, ear fullness, and tinnitus. Diagnosis is with pneumatic otoscopy that reveals air-fluid levels or opacification. Treatment is observation for 3 months as most cases resolve. Tympanostomy can be considered with symptoms persist longer than 3 months or with occurrences at a rate of 3 x in 6 months or 4 x in a year. With chronic conditions, there is a risk of developmental delays in children, which increase the need for tympanostomy. A consequence of otitis media with effusion is the development of conductive hearing loss, tympanosclerosis, or cholesteatoma.

Question 37

A patient has ear pain, canal edema and discharge, and pain with auricle manipulation. What is the diagnosis? What is the treatment?

Answer 37

Diagnosis: otitis externa Treatment: otic antibiotic drops Topical antibiotic/glucocorticoid preparations decrease canal inflammation and may speed symptom resolution.

Question 38

Inflammation of the external auditory canal, often due to bacterial infection is called?

Answer 38

Otitis Externa

Question 39

What are the most common pathogens causing Otitis Externa?

Answer 39

Pseudomonas aeruginosa (most common), Staphylococcus aureus.

Question 40

What are the risk factors for Otitis Externa?

Answer 40

Swimming (water exposure), ear trauma (e.g., Q-tips, hearing aids), skin conditions (eczema, psoriasis).

Question 41

What are the clinical features of Otitis Externa?

Answer 41

Ear pain, pruritus, discharge (otorrhea), hearing loss, tenderness with tragal or auricular manipulation

Question 42

How is Otitis Externa diagnosed?

Answer 42

Clinical; otoscopy shows an edematous, erythematous external ear canal, sometimes with debris or purulent discharge.

Question 43

What is the first-line treatment for Otitis Externa?

Answer 43

Ear canal cleaning, topical fluoroquinolone drops (e.g., ciprofloxacin) ± corticosteroids, avoidance of water exposure.

Question 44

What is an alternative treatment for mild cases of Otitis Externa?

Answer 44

Acetic acid ear drops can help restore normal pH and prevent bacterial growth.

Question 45

What are complications of Otitis Externa?

Answer 45

Progression to malignant otitis externa in immunocompromised patients, tympanic membrane perforation.

Question 46

What is the name for the infection spreads due to a severe infection of the external auditory canal to the temporal bone leading to osteomyelitis of the temporal bone?

Answer 46

Malignant Otitis Externa (Necrotizing otitis externa). This is a severe infection of the external auditory canal, usually caused by Pseudomonas organisms. The infection spreads to the temporal bone and, as such, is really an osteomyelitis of the temporal bone. This can extend readily to the base of the skull and lead to fatal complications if it is not adequately treated. This disease occurs most commonly in older patients with diabetes, and can occur in AIDS patients. Any patient with otitis externa should be asked about the possibility of diabetes. It can be caused by traumatic instrumentation or irrigating wax from the ears of patients with diabetes. Patients with necrotizing otitis externa present with deep ear pain, temporal headaches, purulent drainage and granulation tissue at the area of the bony cartilaginous junction in the external auditory canal and facial nerve followed by other cranial neuropathies.

Question 47

What is Malignant Otitis Externa?

Answer 47

Invasive necrotizing infection of the external auditory canal and skull base.

Question 48

What is the most common pathogen in Malignant Otitis Externa?

Answer 48

Almost always Pseudomonas aeruginosa.

Question 49

What are the risk factors for Malignant Otitis Externa?

Answer 49

Diabetes mellitus, immunocompromised state (HIV, chemotherapy).

Question 50

What are the clinical features of Malignant Otitis Externa?

Answer 50

Severe ear pain, otorrhea, granulation tissue in the external auditory canal, possible cranial nerve palsies (especially CN VII, facial nerve)

Question 51

What is required to diagnose necrotizing otitis externa?

Answer 51

To diagnose an actual infection in the bone, a computed tomography (CT) scan of the bone, with bone windows, must be obtained. A technetium bone scan will also demonstrate a “hot spot,” but is too sensitive to discriminate between severe otitis externa and true osteomyelitis.

Question 52

How is Malignant Otitis Externa diagnosed?

Answer 52

CT or MRI to assess for bone involvement (osteomyelitis of the skull base).

Question 53

What is the treatment regimen for necrotizing otitis externa?

Answer 53

The standard therapy is meticulous glucose control, aural hygiene, including frequent ear cleaning, systemic and topical anti-pseudomonal antibiotics (quinolones are the drugs of choice as they are active against Pseudomonas organisms). Hyperbaric oxygen is used in severe cases that do not respond to standard care.

Question 54

What is the treatment for Malignant Otitis Externa?

Answer 54

IV fluoroquinolones (e.g., ciprofloxacin) for at least 6-8 weeks, surgical debridement if needed

Question 55

What are the complications of Malignant Otitis Externa?

Answer 55

Cranial nerve palsies, osteomyelitis, meningitis, brain abscess.