HEENT Ear

you should be able to see through the tympanic membrane indicating a normal tympanic membrane

visualize cone of light

locate the external acoustic meatus

locate the tympanic cavity

locate the Pharyngotympanic tube

identify the internal acoustic meatus

locate the vestibulocochlear nerve CN VIII

locate the cochlear nerve

locate the facial nerve

locate the vestibular nerve

locate the semicircular canals

locate the stapes incus and malleus

External Ear

Components:
Auricle (collects sound) - Entire External Ear

Ear canal (______ _______ ______) – conducts ______ to ______ _______
Leads inward through the tympanic part of the temporal bone to the tympanic membrane (TM

Contains ______ & _______ glands → produce cerumen (ear wax)

external acoustic meatus
ceruminous; sebaceous

______ = deepest depression

______ = elevated margin

concha
helix

Tympanic Membrane (TM)

~1 cm in diameter, thin, oval, semitransparent membrane

Function

_____ ________: Sound waves strike the TM and cause it to ______.
________: The TM forms a physical ________ between the external auditory canal and the ______ ear, helping protect the middle ear from water, debris, and microorganisms.

sound transmission
vibrate
protection
barrier
middle

Middle Ear Contents

______ _______: malleus, incus, stapes

auditory ossicles

MIDDLE EAR
Malleus (hammer): attached to the _____ ______ ; receives its ______. 

tympanic membrane
vibrations

_____ (anvil):acts as the middle ______ bone, transmitting vibrations from the malleus to the stapes. 

incus
connecting

_____ (stirrup): its footplate sits in the ____ ________ and transmits vibrations into the fluid of the inner ear. 

Stapes
oval window

Middle ear Function: ______ + _______ sound from the _______ ______ to the _____ _______

conduct; amplify

what are the 2 main parts of the internal ear

bony labrinth
membranous labyrinth

INTERNAL EAR
Bony Labyrinth
Hard, outer structure within the temporal bone

1. Filled with _______

2. Includes the _____ , _____ , ____ _______

perilymph
cochlea; vestibule, semicircular canal

Membranous Labyrinth
Soft, delicate structure suspended inside the bony labyrinth

Filled with ________

Contains the actual sensory organs for ______ (cochlear duct) and balance (_____, ______, semicircular ____)

endolymph
hearing
utricle, saccule, ducts

SNHL (inner ear): Weber lateralizes to _____ ear
Rinne (mastoid): Normal = ___ > ___

normal
AC;BC

conductive hearing loss (external/middle): Weber lateralized to ______ ear
Rinne (mastoid): ___ > ___

affect
BC> AC

Acute Otitis Externa

PATHOPHYSIOLOGY - Inflammation or infection of the ___ ___ ____.

external auditory canal

Acute Otitis Externa
RISK FACTORS

____ ______ aka "Swimmer’s ear" - excess moisture raises the pH from the normal acidic pH of the ear, facilitating _______ overgrowth

Local _______ _____ (cotton swabs or hearing aids)

Aberrant ear wax (too much or too little).

water immersion
bacterial
mechanical trauma

ACUTE OTITIS EXTERNA
ETIOLOGIES

________ - most common cause of acute otitis externa; especially associated with swimming/water exposure (“swimmer’s ear”).

_______ - another common cause; more likely with trauma or disruption of the external auditory canal, such as from cotton swabs, ____, hearing aids, or _____.

pseudomonas
staph A; scratching; earbuds

Other bacterial causes: Staphylococcus ______, ______ species, ______ species, and _______.

Fungal causes: Aspergillus and Candida; consider with chronic/recurrent symptoms or after prolonged topical antibiotic use.

epidermidis; streptococcus, proteus, anaerobes

ACUTE OTITIS EXTERNA

Fungal causes: Aspergillus and _____; consider with chronic/recurrent symptoms or after prolonged topical _____ use.

candida
antibiotic

CM of ACUTE OTITIS EXTERNA

• not painful to the touch

CLINICAL MANIFESTATIONS

Ear pain (otalgia) & erythema; pruritus in the ear canal (may have recent activity of swimming).

________ _________, ear pressure or fullness, hearing impairment or loss.
- canal could be edemitis, swollen

auricular discharge

Physical exam

_____ & ____ on traction of the ear canal or tragus, purulent auricular discharge.

Otoscopy; External auditory canal erythema of skin, edema, discharge, &/or debris.

edema
pain

Acute Otitis Externa
Management

• Clean the ear canal to remove debris and ____ topical medication to _____.

• Keep the ear ____ and avoid swimming or inserting objects into the canal.

• ______ therapy should provide coverage against Pseudomonas aeruginosa and Staphylococcus aureus.

allow; penetrate
dry
topical

Tx for Acute Otitis Externa

Mild

Acetic acid–hydrocortisone 

_____

Neomycin–polymyxin B–hydrocortisone otic (cortisporin otic)

Moderate

______–______, (steroid-Abx) Ciprofloxacin–hydrocortisone

ofloxacin
ciprofloxacin dexamethasone

ACUTE OTITIS EXTERNA if there is Severe/ Significant Canal Edema

Same topical antibiotic options as _____ 

____ ___ if canal edema prevents adequate penetration of drops

_______ as needed

ear wick
analgesia

Acute Otitis Externa
______ should Not used if tympanic _______ is suspected or if the TM cannot be visualized bc the are _____.

aminoglycosides
perforation
ototoxic

_______ (necrotizing) Otitis Externa

Invasive infection of the external auditory canal and skull base (temporal bone, soft tissue, and cartilage). 

Pseudomonas aeruginosa >___% of cases. 

Risk factors: immunocompromised states, elderly, diabetics, high-dose glucocorticoid therapy, chemotherapy, post-transplant 

malignant
95

Malignant Necrotizinf Otitis Externa
CLINICAL MANIFESTATIONS 

Severe auricular pain, persistent otorrhea. Cranial nerve palsies (eg, CN ?? ?? ?? ) if ____. 

May radiate to temporomandibular joint - pain with _____. 

Physical examination: severe auricular pain on ____ of the ear canal or tragus. 

6 7 9 ; osteomyelitis
chewing
traction

DIAGNOSIS - Malignant Otitis Externa 

Otoscopy: _____ of the external auditory canal with erythema, discharge, ______ _____ at the bony cartilaginous junction of the ear canal floor, frank ____ of the ear canal skin. 

___ or ____ to confirm the diagnosis. 

_____ is the most accurate test

High ____ & ____.

edema; granulation tissue
necrosis
CT MRI
Biopsy
ESR, CRP

MANAGEMENT of MALIGNANT NECROTIZING OTITIS EXTERNA (VERY dangerous)

• ______ + IV Antipseudomonal antibiotics - __ ______ first-line antibiotic. 

o Alternatives - Piperacillin-tazobactam (_____), Ceftazidime, or Cefepime. 

Admission; IV Ciprofloxacin
Zosyn

Buzzword for Malignant Otitis Externa on otoscopy

granulation tissue - confirm with imaging

risk factors for Malignant Otitis Externa

immunotherapy
HIV/AIDS
high dose glucocorticoids
AGE

what are we looking at

Acute Otitis Media

ACUTE OTITIS MEDIA
Pathophysiology

Viral uri --> blockage of the ________ tube --> infection of the ______ ear 

eustachian
middle

ACUTE OTITIS MEDIA
Organisms - _______ ________, H influenzae, Moraxella catarrhalis 

streptococcus pneumoniae

ACUTE OTITIS MEDIA
Clinical manifestations

____ 

Ear ______ in infants 

fever
tugging

ACUTE OTITIS MEDIA
Physical exam - absent cone of light reflex

Tympanic membrane findings
o ______, loss of _____ landmarks 

o Color – _____ – can be erythematous, opacified, pale or yellow

bulging
bony
varies

ACUTE OTITIS MEDIA
Diagnosis

_____

______ ________ – Gold standard
o Decreased TM mobility 

clinical
pneumatic otoscopy

what is more important than the color of the ear drum?

bulging - more likely an inner ear infection

acute otitis media is typically unilateral true or false

false

you always treat Peds acute otitis media with what?

amoxicillin - can exceed adult dosing

if there is a PCN allergy you could Rx what for acute otitis media

azithromycin

2nd line option for acute otitis media
_____-_____ ____ ___mg BID, cefuroxime, cefdinir, cefpodoxime

amoxicillin-clavulanic acid 875

if a child has recurrent otitis media what is the procedure based treatment

__________ with tympanostomy tube insertion 

Myringotomy

easier to get an ear infection as the ET is _____ for an infant

horizontal

Eustachian Tube Dysfunction

The Eustachian tube (________ tube) connects the _______ ear to the ________ and has three major functions:

pharyngotympanic
middle
nasopharynx

The Eustachian tube (pharyngotympanic tube) has three major functions:

pressure equalization
drainage
protection

Pressure equalization: Equalizes air pressure between the _______ ear and the _______, allowing the tympanic membrane to _______ normally. 

middle
atmosphere
vibrate

ET functions: Drainage: Allows middle-ear ________ and fluid to drain into the ________. 

secretions
nasopharynx

Eustachian Tube Dysfunction

Occurs when the eustachian tube does not ______ properly.

Often follows viral URI or allergic rhinitis sinusitis, tumors. Often precedes ____ ____ _____. 

close
acute otitis media

EUSTACHIAN TUBE DYSFUNCTION
CLINICAL MANIFESTATIONS 

Ear ______, pressure, or pain; popping of the ears with swallowing or yawning, underwater feeling, disequilibrium, discomfort with barometric pressure change, fluctuating conductive hearing loss, tinnitus, delayed _____ in children. 

fullness
speech

ET Dysfunction PHYSICAL EXAM - Otoscopic findings usually normal but may reveal tympanic membrane ______ or _____ behind the TM (Serous otitis media). 

retraction
fluid

ET dysfunction
DIAGNOSIS - Clinical diagnosis

MANAGEMENT 

1. Treating the _____ cause & symptom management is the mainstay of treatment. 

2. Auto insufflation eg, swallowing, yawning, blowing against a slightly-pinched nostril. 

3. _________ for congestive symptoms: Pseudoephedrine, Phenylephrine, Oxymetazoline nasal.
   o Patients should be counseled not to exceed 3 days of nasal decongestant use in order to prevent nasal mucosal ______ and Rhinitis medicamentosa (rebound congestion). 

• Intranasal corticosteroids if sinonasal inflammation is present. 

• Refractory: ______ tube.

underlying
decongestant
dependency
tympanostomy

_______

Damage to the tympanic membrane that can occur when ______ __________ in the middle ear & the external environment due to sudden pressure changes _______ the tympanic membrane [eg, ____- (most common, especially descent), rapid descent, diving, decompression, hyperbaric oxygen, blast injuries]. 

barotrauma
pressure difference
stretch
flying

Barotrauma
Stretching of the tympanic membrane TM may cause _____ of, bleeding into, or ____ of the TM. 

•May be associated with Eustachian tube dysfunction resulting in inability to _____ the barometric pressure on the middle ear; the pressure difference can damage the tympanic membrane. 

bruising
rupture
equalize

Barotrauma
PHYSICAL EXAMINATION: 

______ to the tympanic membrane: Tympanic membrane visualization may reveal rupture, _____, serous or bloody _____. 

May have ______ auricular discharge if traumatic. 

Damage
petechiae
effusion
bloody

MANAGEMENT - BAROTRAUMA

________ is the best treatment: i.e., avoidance of flying with a cold. 

_____ _______ eg, swallowing, yawning, chewing gum. 

Decongestants, ____ (eg, 1% ______ or Oxymetazoline nasal spray) or oral (Pseudoephedrine), may be administered prior to descent and before arrival to alleviate or prevent symptoms. 

______ may be used for severe or refractory cases. 

avoidance
auto insufflation
topical; phenylephrine
myringotomy

Acute ______ - any time you have an untreated ear infection you can develop, as the infection works its way into mastoid

Mastoiditis

Acute Mastoiditis 

______ of the mastoid air cells of the _____ ___. Largely a disease of childhood (esp. <__ years). Causes external ear to be displaced

infection
temporal bone
2

ACUTE MASTOIDITIS
ETIOLOGIES

Usually a complication of _____ _____ ____ (accumulation of _____ material in mastoid ___).

Streptococcus pneumoniae and Streptococcus _____ common pathogens.

Acute otitis media
purulent; cavity
pyogenes

ACUTE MASTOIDITIS
CLINICAL MANIFESTATIONS

____ ear pain (usually worse at ____), ____, fussiness, lethargy, malaise, pulling at ear.

deep
night
fever

PHYSICAL EXAMINATION- ACUTE MASTOIDITIS

______ (ear pain), fever, signs of Otitis _____ (bulging & erythematous tympanic membrane).

Mastoid (_______) tenderness, edema, erythema, &/or fluctuance (subperiosteal abscess).

______ of the auricle. Narrowed auditory canal. _____ nerve _____ if complicated.

otalgia; media
post auricular
protrusion; facial; plasy

DIAGNOSIS - ACUTE MASTOIDITIS

Clinical diagnosis

____________ is generally the first-line imaging study when imaging is needed.

MRI with contrast is particularly useful when _______ or ________ complications are suspected.

CT Temporal w/ IV contrast
intracranial; soft-tissue

MANAGEMENT - ACUTE MASTOIDITIS

_______

IV _____ (eg, IV _____-_______) + middle ear or mastoid drainage (______) +/- tympanostomy tube placement. 

• Piperacillin-tazobactam if recent ____ use. 

Severe: IV ______ + either Ceftazidime or ______ or Piperacillin-tazobactam

Tympanocentesis can be performed to get cultures

admissions
ABx - ampicillin sulbactam
myringotomy
ABx
Vancomycin
cefepime

any infection it’s best to do imaging with _____

contrast

ACUte mASTOIDITIS Refractory or complicated: _________ (surgery).

mastoidectomy

Chronic Otitis Media 

Recurrent or persistent infection of the ____ &/or ____ cell system in the presence of _______ _________ ________

middle ear
mastoid
tympanic membrane perforation > 6 weeks

Can also be a Complication of recurrent Acute otitis media, trauma, or Cholesteatoma. 

Chronic Otitis Media

Rupture TM - fluid will ____ and you would see auricular discharge

leak

ETIOLOGIES CHRONIC OTITIS MEDIA 

• _________ most common. S. aureus, gram-negative rods (eg, Proteus), anaerobes, Mycoplasma. 

• Purulent ______ can become worse after a URI or after water enters the ear. 

pseduomonas
otorrhea

CLINICAL MANIFESTATIONS - CHRONIC OTITIS MEDIA

[1] _______ tympanic membrane + [2] _______ or recurrent _______ _______ (often painless) >6 weeks, ear fullness, & [3] varying degrees of ______ _____ ____. 

• May have a primary or secondary Cholesteatoma. Usually no pain, fever, or signs of systemic infection. 

Perforated
persistent; purulent otorrhea
conductive hearing loss

MANAGEMENT for what???

Removal of infected debris + topical ____ drops first-line (eg, Ofloxacin or _______). 

In patients with a tympanic membrane rupture, avoid water, moisture, drying agents (eg, alcohol, acetic acid), & topical ________ in the ear (they are ototoxic). 

______ antibiotics reserved for severe cases. 

Surgical: tympanic membrane ______ or reconstruction. 

Chronic Otitis Media
Abx; ciprofloxacin
aminoglycosides
systemic
repair

Serous Otitis Media 

Middle ear fluid + no signs or symptoms of ______ ______ or _______ (no fever, no ear pain, & no marked erythema or bulging of the TM). Often as a result of a viral ____. 

May be seen after resolution of Acute otitis media or in patients with ___ dysfunction. 

•Most are ________. The most common symptoms are decreases in sound conduction & hearing, aural fullness, or a popping sensation. Tinnitus. 

•Children with ____ may exhibit impaired language development or communication difficulties. 

acute inflammation; infection
URI
ET
asymptommatic
OME

DIAGNOSIS - Serous Otitis Media 

Otoscopy: gray, amber, blue, or _____ ______ (air fluid levels or bubbles behind a cloudy membrane), loss of light reflex, retracted or flat (______) tympanic membrane hypomobile with insufflation.

Workup may include audiometry, tympanometry, measurement of auditory brainstem ______ 

colorless effusion
neutral
responses

MANAGEMENT - SEROUS OTITIS MEDIA 

________ (watchful waiting) in most - usually spontaneously resolves within 4-6 weeks. 

Significant symptoms: ________, oral decongestants, and/or nasal corticosteroids.i 

Persistent or complicated: ______ with _______ tube for drainage - eg, children with hearing impairment; speech, language, or learning delays; or specific conditions. 

observation
antihistamine
myringotomy
tympanostomy

whats this

Tympanic Membrane Perforation

Tympanic Membrane Perforation
Etiology

_____ (barotrauma, foreign body, blast injury)

_____ _____ _____ → rupture from pressure buildup

trauma
acute otitis media

Clinical Features - TM PERFORATION

______ ear pain, sometimes relief if otitis media ______

Hearing loss (conductive)

Tinnitus

______ bloody or purulent otorrhea

sudden
ruptures
possible

Diagnosis - TM PERFORATION

________: visible defect in tympanic membrane

Assess hearing loss (Weber/Rinne, audiometry if needed)

otoscopy

Management - TM PERFORATION

Most heal spontaneously within weeks

Keep ear ____ (no _____ entry)

AVOID ________ ear drops (e.g., aminoglycosides) if TM not _____

dry
water
ototoxic; intact

Indication for ENT referral - TM PERFORATION

1. Large ______

2. ______ infections

3. Persistent > __ months

perforation
recurrent
2

Cerumen function

_______ secretion of ______ ear canal

Canal is normally self-______ → no hygiene needed

protective
outer
cleansing

Etiology - CERUMEN IMPACTION

Most often ____-______ (cotton-tip applicators, digital trauma)

self induced

Treatment - CERUMEN IMPACTION

Patient self-care: ______ ear drops - 3% ______ _______ or 6.5% carbamide peroxide

Irrigation with _____-_________ water - Direct stream at _____ _____ wall &Only if tympanic membrane _____

detergent
hydrogen peroxide
body-temperature
posterior canal
intact

Precautions - CERUMEN IMPACTION

Avoid jet irrigators (e.g., _____) → risk of TM _____

Thoroughly dry ______ afterward - Hair dryer on low-power or Isopropyl alcohol drops

WaterPik; perforation
canal

Indication for Referral - CERUMEN IMPACTION

Frequently recurrent impaction

Failure of routine measures

Tympanic membrane _______

_____ _____ _____

perforation
chronic otitis media

Foreign Bodies the EAC

Can occur at any age but is most common in children ≤__ years of age. 

The most common site of foreign body impaction is the ____ __________ ______ where the external auditory canal narrows 

6
bony cartiliginous junction

why wouldn’t you want to leave foreign body in the ear?

skin starts to break down

CLINICAL MANIFESTATIONS 

Patients with foreign bodies of the EAC are often asymptomatic or present with ear pain and/or discharge as the ear canal becomes inflamed. Ear fullness or hearing loss may occur. 

With insects, acute onset of ____ ___ may occur, usually with the sensation of something moving in the ear. Nausea or vomiting. 

If the foreign body has been retained for a prolonged period, the patient may present with _____ ___ ______and an auricular _____ (may be foul smelling); EAC erythema &/or edema. 

extreme pain
Acute otitis externa
discharge

DIAGNOSIS - FOREIGN BODIES IN EAC

Diagnosis is confirmed by _____ visualization with otoscopy. The other ear and both _____ should be examined to assess for any additional foreign bodies. In patients with insects in the ear, a thorough examination of the external auditory canal should be performed after insect removal. 

direct
nostrils