Transcript Common Ear Conditions

Common Ear Conditions
Medway VTS
2013
Plan
Consider a few common presentations in general
practice related to ears
. Examining the ears
. Ear Wax and syringing
. Otitis Externa
. Otitis Media( Acute and Chronic)
. Eustacian tube dysfunction
. Perforations ( Safe vs. Unsafe)
Treatment
Few questions
ENT Examination
You tube video of ENT examination in an OSCE situation.
http://www.youtube.com/watch?v=mDbwAPr5RvU
Ear examination- You tube video
http://uk.youtube.com/watch?v=I3sa2W83iuo&NR=1
NB:
The canal may be partly straightened by pulling the pinna backwards
and upwards during examination
In infants pull the pinna more horizontally backwards as the shape of the
ear canal is different
Normal
Consider the malleus as
an arrow; pointing in
the forward direction
The normal tympanic
membrane should
appear:
. pearly grey
. have a light reflex
. generally concave
. With a visible malleus
Atti
c
Anterior
direction
Anterio
r
Posterio
r
Inferior
Ear Drum-normal Landmarks
An annulus fibrosus or more
commonly referred to as
the eardrum margin. This is
important. Note how
smooth and how ever so
slightly blurry it is.
Um umbo - the end of the
malleus handle and usually
marks the centre of the
drum
Lr light reflex or Cone of
light –is usually seen anteroinferioirly
At Attic also known as pars
flaccida. Any perforations
here are serious and need
referral.
Examine out to in
External:
Pinna (shape, colour, position, tenderness, haematoma)
Mastoid
Internal:
The Canal ( skin, spores, foreign bodies, discharge, debris, wax)
The Tympanic membrane (look ant, post, superior/ attic and
inferior of malleus)
. Colour( opaque, white, red, patches & translucency)
. Retraction( landmarks behind it more visible)
. Perforation ( safe/ unsafe)
. Discharge (mucopurulent)
Behind the Eardrum
. Fluid behind the drum( meniscus, colour, bubbles)
. Any red bits( glomus tumour, granulations or
blood?, white- cholesteotoma)
Ear Wax
Wax is produced in the outer half of
the ear canal and migrates
outwards along with the canal
skin. Inappropriate
instrumentation can cause
impaction.
Wax impaction can cause hearing
loss, pain, tinnitus, vertigo, or
chronic cough but not usually
discharge.
Sudden expansion after getting
water in can cause sudden
deafness or pain, but needs
careful exclusion of other
pathology behind it e.g.
infection
Crayon in a child’s ear
Management:
Cotton buds are not your friend
If Symptomatic – topical meds
Different preparations available none superior to other.
Sodium bicarbonate drops might be better at disintegrating
wax, but can cause dryness of the canal and/ or irritation
. Instructions for use:
e.g. Olive oil?
. Syringing
. When to refer to ENT clinic:
. Patients known to have a tympanic membrane perforation
or previous ear surgery (need microsuction), only hearing
ear
. Syringing fails
. Causes pain or vertigo,
. Hearing loss persists after wax removal.
Otitis Externa
Infection of the external auditory canal. Mediterranean
ear/Swimmers ear
Usually unilateral
Gradual onset pruritis, pain, hearing loss, and ear discharge
which varies in consistency and colour.
The pt is usually well.
Can result in a featureless ext aud canal
Risk factors: trauma, water, Immunosuppression, eczema
Can be fungal- spores might not always be visible
If treatment fails or otitis externa recurs
frequently consider sending an ear swab
for bacterial and fungal microscopy
and culture
Management
Remove or treat any precipitating or aggravating factors
A topical ear preparation for 7 days. Options include preparations
containing:
a. Both a non-aminoglycoside antibiotic + a corticosteroid e.g.
flumetasone–clioquinol (Locorten–Vioform®) ear drops.
b. Both an aminoglycoside antibiotic and a corticosteroid
(contraindicated if the tympanic membrane is perforated).
c. Topical preparations containing only an antibiotic (gentamicin
ear drops are contraindicated if the tympanic membrane is
perforated).
d. Antifungal or ? something containing all three
Aural toilet: if earwax or obstruct topical medication (may require
referral).
Provide appropriate self-care advice
Malignant Otitis Externa
"Malignant" otitis externa is a severe infection due to Pseudomonas
aeruginosa and anaerobes causing osteomyelitis of the skull base
characterised by severe pain, involvement of the floor of the ear
canal, sometimes with granulation tissue. If untreated, it can involve
the cranial nerves and brain.
Facial nerve palsy occurs in 50% of patients, IX to XII may also be
involved. immunocompromised patients, especially elderly diabetics.
It may be life threatening.
What to look for: Elderly, DM, ear otalgia, otorrhoea, hoarseness,
puffiness , trismus, failure to respond to drops, granulations, CN palsies
etc
Mx:
-Refer
-Intensive local and systemic antibiotics against Pseudomonas are
required if malignant otitis externa is present, e.g. ciprofloxacin or
ceftazidime, plus suitable anaerobic cover e.g. metronidazole.
Question 1
23 yr old man, 4 days Hx of itchy sore Rt ear; returned recently
from holiday in Spain
O/E= Rt ext auditory canal is inflamed but no debris seen.
T.membrane is visible and unremarkable. What is the most
appropriate management?
A.
B.
C.
D.
E..
Topical corticosteroid + Aminoglycoside
Topical corticosteroid
Tell him serves him right for going on a holiday while you work!
Topical corticosteroid +Clotrimazole
Oral Flucloxacillin
Answer 1
Correct Answer is A.
Dx- Otitis externa- Topical antibiotic or
combined Antibiotic + corticosteroid
preparation
Question 2
53 year old man, fastidiously
clean, previously normal
hearing, currently recent
onset ‘strange sensation in
me ear!’ + slightly reduced
hearing ‘have been trying
to pop them’. The cone of
light is normal, but what is
this?
A.
B.
C.
D.
Normal ear drum
Otitis Externa secondary to
ear buds use
Serous Otitis Media
Time waster/ Hidden
agenda
Answer 2
Serous Otitis media because of Eustacian tube
dysfunction
Has normal cone of light, mild redness
externally likely normal, fluid level, and mildly
retracted ear drum
Question 3
A 28 year old woman presents
with a 5 day Hx of pain in her Rt
ear, reduced hearing, and
yellow coloured discharge
Q.
What is the likely diagnosis
a. Acute Otitis Media
b. Acute Otitis Externa
c. Chronic Suppurative
Otitis media
Answer 3
Answer is Acute Otitis Externa
Question 4
Which of the following statements about
otitis externa is correct?
a.
b.
c.
d.
You should avoid removing canal debris
Its common in people not wearing ear protection while
working with loud power tools.
It may result in a featureless tympanic membrane
It is usually due to a Staphylococcus aureus infection
Answer 4
Correct answer- It may result in a featureless tympanic
membrane
Commonest causative organism for infective otitis externa is
Pseudomonas
Could be difficult to eradicate in someone wearing ear
protection in certain occupations e.g. forge/factory workers
Question 5
Which of the following statements about the use of topical
eardrops is correct?
a. Only use topical ear drops if the tympanic membrane is visible
b. Topical eardrops are contraindicated in children under the age of
12years
c. Topical eardrops cannot be used in the presence of a perforated
tympanic membrane
d. Topical eardrops can worsen otitis externa
e. If its difficult putting them in your ears, they are equally effective
putting them in your nose.
Answer 5
Correct answer- Topical eardrops can worsen otitis externa if
there is sensitivity to them
The use of ototoxic drops in the presence of a perforated
tympanic membrane is controversial due to reports of
sensorineural hearing loss as a result of their application.
Reports of this association are rare and often the validity of
such reports is questionable.
Certainly the risks of sensorineural hearing loss or of major
complications of otitis media are of more significance. Limiting
the course of treatment and ensuring that they are not used in
healthy ears can reduce any potential risks from the
administration of ototoxic medicines.
Otitis Media
Can be acute or chronic
Can be with or without serous effusion (acute or
chronic)
Can be Acute or chronic suppurative
Can co-exist with Otitis externa
Otitis media with serous effusion= Glue Ear
Acute Otitis Media
Common in children
Unwell/pyrexia, otalgia/discharge
there may be tenderness over the mastoid
discharge in meatus
loss of outline of drum and landmarks
TM: red, bulging,oedematous or perforation.
Mostly viral but can be Streptococcus/Haemophilus
Risk factors:
Passive smoker
Male
Family history of otitis media.
In day care
On formula feed
Current evidence for AOM
80% of children get better by day 3 without antibiotics
‘It is reasonable to prescribe analgesia.’Antibiotics should not be used routinely and prescribing them just
increases parental belief and re-attendance rates
Use def scripts if necessary
Adenoidectomy, as the first surgical treatment of children aged 10 to 24
months with recurrent acute otitis media, is not effective in
preventing further episodes. Neither is Chemoprophylaxis.
Current Evidence for CSOM
Randomised controlled trials (RCTs) found limited evidence that topical
quinolone antibiotics versus placebo improved otoscopic
appearances. RCTs found no clear evidence of significant
differences between topical antibiotics.
No benefits from anything else.
AOM (pus behind the eardrum)
AOM continued..
Analgesia: For most children helps most.
Antibiotics should not be routinely prescribed for uncomplicated AOM.
Some children may significantly benefit from antibiotics – ill.
Choice of antibiotic:
Amoxicillin is the usual first-line for 5 days. If severe symptoms present,
or there has been a previous episode of AOM within the last month,
use high doses
Erythromycin or Clarithromycin are alternative antibiotics if allergic to
penicillin
AOM contd 2….
A good compromise is to use issuing a delayed/deferred
prescription to be redeemed within 72 hours only if the
condition has not adequately improved.
Active Follow up for:
. under 2 years of age.
. systemic symptoms such as high temps (> 39°C) or
vomiting.
. There is discharge from the ear.
Visualisation of the tympanic membrane can be difficult. Re
examine after 2 weeks to assess the integrity of the membrane
and to check for complications. If there is a perforation still
present, monitor the situation and consider referral if it has not
healed after 6 weeks.
Serous Otitis Media
Serous Otitis Media/Secretory
□ Glue ear, commonest cause of deafness, and the commonest
indication for surgery, in children.
□ The condition is most frequent in early childhood,
□ Peaks prevalence at 2 and 5 years.
□
Half of 3-year-olds have at least one effusion in a year, and in
the UK, 1 in 200 children is operated on for the condition.
□
Ninety thousand operations are performed in England and
Wales annually, at an estimated cost of £30 million
Serous otitis media with retraction
Hearing tests?
A hearing test is not appropriate at the initial presentation if there
is no evidence of significant hearing loss or developmental
delay. If signs and symptoms of OME continue, hearing should
be assessed after 3 months, where OME can be regarded as
persistent.
Otitis media+effusion-Glue ear
Features
Dull retracted TM
May show air-fluid level
Conductive hearing loss
Common in children; often after AOM and can persist for weeks
Reduced hearing noticed by parents/teacher
Unsteadiness
80% clear at 8 weeks
Management
Adults presentation - the nasopharynx is examined to exclude tumour.
Secretory otitis media is uncommon in adults. It usually follows a cold
and spontaneously resolves; this may take up to 6 weeks
In Children- 50% of cases will resolve spontaneously within 6 weeks
Persistence of bilateral Otitis media with effusion (OME) and hearing loss
in a child should be confirmed over a period of 3 months before
intervention is considered
Surgery: adenoidectomy or myringotomy and grommet insertion.
however a systematic review suggests that the role of grommets in
the management of glue ear is unclear.
Treatments not recommended are antihistamines, decongestants, steroids ,
homeopathy, cranial osteopathy, acupuncture, dietary modification
(including pro-biotics), immuno-stimulants, massage
About glue ear
Secretory otitis media, or `glue ear', is the most frequent cause of
hearing problems in children. May produce pain or a
conductive hearing loss, or may remain symptomless. There is
concern that impaired hearing in early childhood may
interfere with education and normal development, but the
magnitude of these effects is not clearly established.
Over 50% of effusions resolve spontaneously within 8 weeks, but
bilateral hearing loss, persisting 12 months, occurs in 5% of
cases
Glue Ear vs. Otitis Media
Factors suggestive of a diagnosis of glue ear include:
. frequent attacks of otitis media
. it is unusual for children to get multiple resolving episodes of
otitis media
prolonged signs
. otitis media will usually resolve within 6 weeks and certainly
within three months
Other risk factors: cleft palate ,Down's syndrome, allergy, family
history
Eustachian Tube Dysfunction
A severely
retracted
eardrum. Margins
are very clear as is
the malleus and it
looks very sunken.
Eustachian Tube dysfunction
Chronic blockage of the Eustachian tube is called Eustachian tube
dysfunction. The eustachian tube becomes congested and
swollen so that it may temporarily close; this prevents air flow
behind the ear drum and causes ear pressure, pain or popping just
as you experience with altitude change when travelling on an
airplane or an elevator.
This can occur when the lining of the nose becomes irritated and
inflamed, narrowing the Eustachian tube opening or its
passageway.
Illnesses like the common cold or influenza.
Others: pollution, cigarette smoke, allergic rhinitis, obesity
Rarely nasal polyps, cleft palate, skull base tumour
Eustachian Tube Dysfunction
. Chronic ETD may reveal retraction pockets or collapsed middle ear
disease with erosion of incus/stapedius. Difficulty auto-inflating the
ear drum
. Generally the fluid clears spontaneously over a period of several
weeks
. The efficacy of treatments such as nasal decongestants, oral
decongestants, antihistamines is unclear
. Antibiotics may help prevent infection in cases of severe
barotrauma
ETD & Children
Young children (esp 1 to 6 years) at particular risk because of very
narrow Eustachian tubes. Also, they may have adenoid enlargement
that can block the opening of the Eustachian tube.
Eustachian tube in infants and young children runs horizontally, rather
than sloping downward from the middle ear. Thus, bottle-feeding
should be performed with the infants’ head elevated, in order to
reduce the risk of milk entering the middle ear space. The horizontal
course of the Eustachian tube also permits easy transfer of bacteria
from the nose to the middle ear space.
Most children older than 6 years have outgrown this problem and their
frequency of ear infections should drop substantially.
Chronic Otitis Media
Recurrent ear discharge
Hearing loss, painless
Perforation of the TM – central
Presence of cholesteatoma
Marginal, Attic perforation
Offensive discharge,
bleeding, granulations
Complications:
Vestibular symptoms
Facial palsy
Intracranial complications
Ear drum Perforations
□ Safe vs Unsafe Perforations
□ Safe perforations
. may allow infection to enter the middle ear
. conductive deafness
□ Unsafe perforations
. in fact represent a retraction of the tympanic membrane.
. essentially a part of the drum becomes sucked inwards and may
gradually enlarge.
.when the retraction becomes extensive, keratinous debris builds up
in the retraction and may become infected and an acquired
cholesteatoma develops
MAKE SURE YOU ALWAYS INSPECT
THE ATTIC AREA ON OTOSCOPY!
Unsafe perforations are
a)In the attic or
b)In the posterior region. These are
often linear rather than oval
c)Or involve the eardrum margin
Anything else is generally Safe.
i.e.
a) In the anterior region or
b) In the inferior region
c) And not involving the eardrum
margin
Safe anterior perforation
Perforations in
this position is a
persistent defect
after the
extrusion of a
grommet.
Safe inferior perforation
This is more likely to
be as a result of
chronic middle ear
infection.
Unsafe attic perforation
Any defect or
apparent perforation
in the attic must be
considered unsafe
and should be
referred for ENT
assessment. This
crust in the attic
represents a large
underlying
cholesteatoma sac.
Note the bulging
eardrum too.
Marginal perforation plus cholesteatoma formation
Unsafe because it is a
perforation involving the
drum margin (the yellowy
white flakes indicating a
cholesteatoma also gives
it away!).
Cholesteotoma
Cholesteatoma
Cholesteatoma is "a three dimensional epidermoid structure
exhibiting independent growth, replacing middle ear mucosa,
resorbing underlying bone, and tending to recur after
removal." There is usually a persistent or recurrent scanty
cream coloured offensive discharge and progressive hearing
loss due to ossicular destruction or toxin induced sensory
hearing loss.
Otoscopy : a pearly white mass usually in the pars tensa +/- discharge
and sometimes erosion of the bone. A perforation is usually present,
but is not always visible due to overlying keratin. Granulation tissue or
polyps may be seen due to chronic inflammation and sometimes
retraction pockets are present.
A crust adherent to the tympanic membrane is indicative of a
cholesteatoma. They can be reviewed after a short course of
steroid or ceruminolytic ear drops, but if it is persistent or
reveals an underlying abnormality then you should refer
Cholesteatoma is an important diagnosis
as it can cause irreversible hearing loss
from ossicular destruction as well as
facial nerve palsy, labyrinthitis, lateral
sinus thrombosis, meningitis, intracranial
abscess, and otitic hydrocephalus. It is
more easily treated in its earlier stages.
While waiting for their ENT appointment
patients should keep the ear dry and
any infective discharge can be treated
with a two week course of antibiotic
ear drops, with or without steroids.
Aural toilet is also advised if there is debris.
Question 7
A mother brings her 4 year old son to see you. He is complaining
of pain in his ear and his mother thinks that he pushed a
button battery into it. You try to examine him but the child is
horsing around . What should you do?
a. Bribe the child with sweets/ Smack him when mum’s not
looking…
b. Tell the mother to come back in a few days time when the
child is calmer
b. Refer him for immediate removal of the suspected foreign
body
c. Refer him to the ENT clinic routinely
d. Prescribe waxol drops
Answer 7
Correct Answer- Refer him urgently for FB removal.( Mum happy, the
kid’s out of your surgery, good clinical practice and the ENT people
you dislike are stuck with him - a definite win win situation)
Usually inert non organic FBs can be extracted over a number of days
.Indications for referral are pain, infection, organic FB, young child,
yourself not having the necessary equipment etc
Button batteries are a definite no-no for drops, because the electric
current can catalyse chemical reactions and release alkalis causing
nasty chemical burns; hence need to be extracted ASAP