Outer and Middle Ear Disorders

What structure separates the external ear from the middle ear?

The tympanic membrane (TM).

What is the normal length of the external auditory canal?

Approximately 2.5 cm.

What are the two main parts of the tympanic membrane?

Pars flaccida (superior) and pars tensa (inferior).

What is the primary function of cerumen?

Protects the ear canal by being acidic, hydrophobic, and trapping debris.

What are common symptoms of cerumen impaction?

Decreased hearing, intra-aural fullness, history of frequent impaction.

How is cerumen impaction diagnosed?

Clinical diagnosis: yellow, brown, red, or black mass in EAC.

Name one differential diagnosis for cerumen impaction.

Foreign body, tumor, or blood clot.

What is the first-line treatment for cerumen impaction without infection?

Cerumenolytics such as hydrogen peroxide-urea or carbamide peroxide.

Before irrigating an ear for cerumen removal, what must be ruled out?

Tympanic membrane perforation.

What season is otitis externa most commonly seen?

Summer months.

What is the hallmark symptom of otitis externa?

Otalgia out of proportion to exam findings.

What physical exam finding suggests otitis externa?

Pain with traction on the tragus or helix.

Which bacteria is most often responsible for green ear discharge in otitis externa?

Pseudomonas aeruginosa.

What color discharge suggests Staphylococcus aureus in otitis externa?

Yellow discharge.

Which fungal organism commonly causes cheesy discharge in otitis externa?

Candida.

What is the treatment for mild otitis externa?

Acetic acid/hydrocortisone drops.

What is the treatment for moderate otitis externa?

Ciprofloxacin/hydrocortisone or Cortisporin drops.

What is used to treat severe otitis externa with canal closure?

Cipro HC, Cortisporin, and use of a Pope otowick.

What complication can otitis externa lead to if untreated?

Osteomyelitis of the skull base.

What structure drains the middle ear into the nasopharynx?

The eustachian tube.

What is the clinical presentation of eustachian tube dysfunction?

Fullness, crackling/popping, mild hearing decrease, often after URI or allergies.

What is the best conservative maneuver to help open a blocked eustachian tube?

Valsalva maneuver.

What are complications of untreated eustachian tube dysfunction?

Conductive hearing loss, serous otitis media, TM perforation, cholesteatoma.

What is a common etiology of tympanic membrane perforation?

Diving/airplane descent, overpressure, infection, or trauma.

Most small tympanic membrane perforations heal by what mechanism?

Spontaneous healing.

What diagnostic finding is seen on otoscopy in cerumen impaction?

Light to dark yellow/brown/red/black appearing mass in EAC.

Why should cerumenolytics be avoided if there is suspected TM damage?

They can worsen infection and cause ototoxicity if middle ear is exposed.

What is the recommended follow-up after cerumenolytic treatment?

4 days of drops, then reassessment for resolution.

What complication may result from ear lavage in cerumen removal?

Infection due to iatrogenic trauma to the EAC.

What are risk factors for otitis externa?

Swimming, trauma, hearing aids, dermatologic conditions, allergic dermatitis.

How can fungal otitis externa (otomycosis) be confirmed?

KOH prep or culture of discharge.

List two differential diagnoses for otitis externa.

Acute otitis media, contact dermatitis, chronic suppurative otitis media, psoriasis, carcinoma

How soon should symptom improvement be expected after otitis externa treatment?

Within 36-48 hours; resolution ~6 days.

What is a serious complication of untreated severe otitis externa?

Malignant otitis externa leading to osteomyelitis of the skull base.

What is the most common pathogen in acute otitis media?

• Up to 48% viral

• H. influenza (50-60%) [MC in children]

• S. pneumonia (up to 15-25%)

• Moraxella catarrhalis (12-15%)

What is the peak incidence age of acute otitis media?

Under 2 years old.

Describe the typical otoscopic finding in acute otitis media.

Red, bulging TM with decreased mobility and possible otorrhea

What are complications of acute otitis media?

Chronic/recurrent OM, mastoiditis, osteomyelitis, facial nerve paralysis, CNS infection.

What is the diagnostic study of choice for mastoiditis?

: CT scan of mastoid air cells.

When is mastoidectomy indicated in mastoiditis?

No improvement with IV antibiotics after 24 hrs or intracranial/abscess complications.

What is the diagnostic hallmark of eustachian tube dysfunction?

Retracted TM with decreased mobility on Valsalva, normal color.

What are differential diagnoses for eustachian tube dysfunction?

Adenoid hypertrophy, nasopharyngeal carcinoma.

What are signs of cholesteatoma on otoscopy?

Attic retraction pocket or TM perforation with keratin debris.

What imaging is best for diagnosing cholesteatoma?

CT temporal bone.

What is the treatment of choice for cholesteatoma?

Surgical excision.

What are complications of chronic OME in children?

Poor school performance, adhesive otitis media (glue ear).

At what threshold should recurrent otitis media prompt ENT referral?

>3 episodes in 6 months OR >4 in 12 months.

What is the main surgical treatment for recurrent otitis media?

Tympanostomy tube placement (PE tubes).

What clinical signs suggest mastoiditis on exam?

Retroauricular edema, erythema, tenderness, protruding auricle, fever.

Which group always requires antibiotics for AOM?

Infants under 6 months.

A 40-year-old man presents with decreased hearing and ear fullness. He reports frequent use of cotton swabs. On otoscopy, a dark yellow mass is seen in the EAC. What is the most likely diagnosis?

A) Cerumen impaction

B) Otitis externa

C) Foreign body

D) Cholesteatoma

A

A 28-year-old woman complains of ear fullness. She has been using Debrox (hydrogen peroxide-urea) drops. Which contraindication should be checked before recommending these drops?

A) History of tympanic membrane perforation

B) History of allergic rhinitis

C) History of psoriasis

D) History of hearing aid use

A

A 25-year-old swimmer presents with ear pain worsened by tragus palpation. Canal is erythematous with purulent discharge. Which pathogen is most likely?

A) Staphylococcus aureus

B) Pseudomonas aeruginosa

C) Candida

D) Aspergillus

B

A 45-year-old man with hearing aids presents with pruritic ears and cheesy white discharge. KOH prep confirms fungal infection. Which organism is most likely?

A) Candida

B) Pseudomonas

C) Staphylococcus aureus

D) Aspergillus

A

A 55-year-old woman presents with severe ear pain, canal edema, and fever. What is the best initial management?

A) Oral antibiotics only

B) Ciprofloxacin/hydrocortisone otic drops with otowick

C) Acetic acid drops

D) Topical antifungal drops

B

A 22-year-old man has ear crackling with swallowing and mild hearing loss after a URI. Otoscopy shows retracted TM. Which condition is most likely?

A) Otitis media with effusion

B) Eustachian tube dysfunction

C) Cholesteatoma

D) Acute otitis media

B

A 7-year-old boy with chronic nasal obstruction presents with ear fullness and hearing difficulty. A likely cause is:

A) Adenoid hypertrophy

B) Cholesteatoma

C) Otitis externa

D) Psoriasis

A

A 25-year-old woman with allergic rhinitis complains of ear popping. Which is an appropriate conservative management?

A) Oral antibiotics

B) Valsalva maneuver

C) Mastoidectomy

D) Tympanostomy tubes

B

A 35-year-old diver experiences sudden ear pain and tinnitus during descent. Otoscopy shows a small TM perforation. What is the appropriate management?

A) Immediate tympanoplasty

B) Observation and keeping ear dry

C) Oral antibiotics

D) Mastoidectomy

B

A 42-year-old man with otitis media presents with large TM perforation and persistent otorrhea. Which treatment may be required?

A) Tympanoplasty

B) Valsalva maneuver

C) Topical acetic acid drops

D) No treatment necessary

A

A 50-year-old patient has unilateral hearing loss and persistent purulent otorrhea. Otoscopy reveals attic retraction pocket. Which is the likely diagnosis?

A) Otitis externa

B) Cholesteatoma

C) Otitis media with effusion

D) Mastoiditis

B

A 60-year-old woman presents with chronic ear drainage and CT showing bony erosion. Which is the definitive treatment?

A) Surgical excision

B) Topical antibiotics

C) Oral corticosteroids

D) Tympanostomy tube placement

A

A 2-year-old boy presents with fever, irritability, and pulling at his ear. Otoscopy reveals red, bulging TM with decreased mobility. What is the best diagnosis?

A) Otitis externa

B) Acute otitis media

C) Serous otitis media

D) ETD

B

A 6-year-old child presents with conductive hearing loss and retracted TM with air-fluid levels. What is the diagnosis?

A) Otitis externa

B) Acute otitis media

C) Otitis media with effusion

D) Cholesteatoma

C

A 7-year-old girl presents with poor school performance and chronic middle ear fluid. Which complication is suspected?

A) Mastoiditis

B) Adhesive otitis media (glue ear)

C) Cholesteatoma

D) Acute otitis media

B

A 3-year-old boy has had 4 episodes of acute otitis media in 12 months. Which intervention is appropriate?

A) Oral decongestants

B) ENT referral for tympanostomy tubes

C) Observation only

D) Intranasal corticosteroids

B

A 6-year-old child with otitis media presents with fever, ear pain, and retroauricular swelling. What is the most likely diagnosis?

A) Cholesteatoma

B) Otitis externa

C) Mastoiditis

D) ETD

C

A 9-year-old child hospitalized for mastoiditis has no improvement after 24 hours of IV antibiotics. CT shows subperiosteal abscess. Next best step?

A) Continue IV antibiotics

B) Mastoidectomy

C) Oral steroids

D) Observation

B