Ear Disorders 1

Protective Function (Eustachian Tube)

Protective Function (Eustachian Tube)

-Nasopharyngeal sound pressure

-Secretions

-Dysfunction:

• Patulous Eustachian tube:

  • Autophony

  • Barotrauma (due to sneezing/coughing/blowing nose)

• Acute suppurative OM

  • Nasopharyngeal secretions access the middle ear space.

Clearance Function (Eustachian Tube)

-Secretions produced in the middle ear

-Dysfunction:

• Middle ear Effusion

Pressure Regulation (Eustachian Tube)

-Most important

-Closed at rest, open by contraction (swallow, yawning)

-Positive pressure easiest to clear vs. negative pressure

-Constant gas absorption from the middle ear requires frequent regulation.

-Dysfunction:

• TM retraction, effusion

• Complications include hearing loss, atelectasis, ossicular chain erosion, retraction pocket, cholesteatoma.

Acute Otitis Media

-Bacterial inflammation of the middle ear space

• Strep. pneumoniae, H. Flu, M. cat are three most common causes.

S/S:

• Fever, Otalgia, Hearing Loss, otorrhea

• Signs: bulging TM, Diminished mobility, cloudy/opaque TM, Color is white/yellow.

Treatment:

• Abx if …

  • <6 months

  • Immunocompromised

  • Toxic appearing

  • Craniofacial abnormalities (Cleft palate)

  • Severe AOM (pain > 48hrs, Temp > 39 C)

  • Bilateral AOM

  • Otorrhea

• Joint decision-making (observation)

  • >2 yrs

  • Non severe unilateral AOM

• Ensure there is mech for follow-up with Abx if no improvement in 48 hrs.

Low risk:

• Amoxicillin (90mg/kg/day bid x 7-10 days)

High risk: (for H. Flu infections)

• Treated in the past 30 days

• Concurrent purulent conjunctivitis

• h/o recurrent AOM unresponsive to amoxicillin

• Living in community with high uptake of pneumococcal conjugate vaccine (PCV).

• Treat with: Amoxicillin-clavulanate (90mg/kg/day BID, based on amoxicillin component x7-10 days)

What are the two different types of antibiotic treatment for Acute Otitis Media

Tympanostomy Tubes

• 3 episodes in 6 months or

• 4 episodes in one year

How Is Recurrent Acute Otitis media treated?

TM perforation

Tympanosclerosis

Meningitis (blood borne spread to meninges)

Mastoiditis

Sigmoid sinus thrombosis

Brain abscess

Facial Nerve paralysis

What are the complications for Acute Otitis Media?

Common risk factors:

• Age (6-12 months, 5-6 years)

• FH

• Bottle feeding, pacifier

• Daycare, Passive smoke

• Allergy (older kids)

• Cleft palate, Down syndrome

Any of the following:

• Moderate to severe bulging TM

• New Onset otorrhea not due to otitis externa

• Mild bulging AND recent onset of pain or intense erythema

-Must have middle ear effusion

• a patient with AOM (or any effusion) will have hearing loss.

What are the diagnostic Criteria for Acute Otitis Media?

-Pneumococcal conjugate vaccine (PCV)

-Annual Influenza vaccine

-Breastfeeding

-Avoid passive tobacco smoke exposure

-Avoid daycare

What are the methods of prevention for Acute otitis media?

Otitis Media with Effusion

-Effusions without signs of inflammation → typical finding for several weeks following AOM

• Can last a while….

Clinical concerns:

• Hearing loss, balance problems, speech delay, poor school performance.

Diagnostics (clinical findings)

• Impaired mobility on pneumatic otoscopy

• Type B tympanogram. (flat line)

• Air-fluid level, Retracted TM

• Amber-colored MEE

Management:

• Less than 3 months → observation

• >3 months → PE tube considered

  • Bilateral COME anddocumented hearing loss

  • Unilateral COME and other concerns

• Adults:

  • More likely to treat earlier (tend to be bothered more)

  • COME most commonly occurs in pts. with laryngopharyngeal reflux/allergy

  • Treat any underlying conditions.

Mastoiditis

-Suppurative infection of the mastoid air cells

• Any AOM will have associated mastoid involvement.

• Diagnosed when involvement is associated with bone destruction → Coalescent Mastoiditis.

Clinical Presentation:

• Postauricular tenderness, erythema, swelling, mass.

• Protrusion of the auricle, Lethargy/Malaise, Fever, Otorrhea

• Abnormal TM, EAC may be swollen.

Complications:

• Abscess

• Septic Thrombophlebitis of IJ/Sigmoid sinus

• Facial Nerve paralysis

Differential:

• Postauricular lymphadenopathy

• Periauricular cellulitis

• Auricular perichondritis

• Mumps

• Tumor

Tympanic membrane perforation

Types:

• Postinfectious → associated with AOM, will typically resolve spontaneously within a couple of weeks, observe.

  • Dry ear precautions

• Traumatic → consider ototopical antibiotic drops if associated otorrhea or contamination.

  • Dry ear precautions, Assess hearing loss.

Complications:

• OM due to contamination

• Basilar skull fracture → battle’s sign

• Ossicular disruption, Acute traumatic facial nerve paralysis.

• Peri lymphatic fistula

Indications for referral:

• Significant hearing loss

• Vestibular symptoms

• Persistence of perforation beyond 4 weeks

Cholesteatoma

-Epithelial material in the middle ear or mastoid cavity

• Can be congenital or acquired

• All require surgery due to risk of extension into the middle ear or mastoid cavity and ultimately to surrounding structures.

Congenital:

• Most commonly in the anterosuperior quadrant

• initially, vague pearly lesion which my be difficult to appreciate.

• Later, can become more apparent as it contacts the TM and enlarges.

Acquired:

• Occurs most commonly as the result of eustachian tube dysfunction, causing retraction of the TM → retraction deepens → epithelial debris becomes trapped.

• More common with marginal perforations (perforations that abut the rim of the TM or the malleus)

-Myringosclerosis (tympanosclerosis)

-Retraction

-Foreign body

-Bulging AOM

-EAC exostosis or osteoma

What are the Cholesteatoma mimics?

Reactive Exostosis

-Benign boney growths in the EAC

-Commonly hx of cold-water exposure

-Found the right ear of surfers alot

Osteoma

-Benign tumor of the bone

-Treatment only needed if the lesion causes occlusion of the canal

• Hearing loss

• Cerumen/Epithelial impaction

• Infection

Acute Otitis Externa

-Edema of the EAC, accumulation of debris, and accessibility for topical medication makes management difficult.

-Disruption of competitive balance between cerumen and bacteria (pseudomonas always), leads to infection.

• Edema can lead to sequestering of debris and infective material in the canal

• Treatment requires ototopical antibiotic/steroid combination; NOT SYSTEMIC ANTIBIOTICS.

Treatment:

• First line: Ciprodex, ofloxacin/dexamethasone

• Second line: Neomycin/polymyxin/HC is a distant second.

  • much lower potency

  • Risk of ototoxicity if TM not intact

  • High incidence of neomycin sensitivity.

Malignant Otitis

-Involvement of the bone (Skull base osteomyelitis) with an AOE

-Occurs in diabetic patients

-Presents with otalgia for several weeks, sometimes hearing loss, otorrhea.

-Always P. aeruginosa

Diagnosis:

• Clinical presentation

• Granulation in the EAC

• Imaging

Management:

• Control blood sugars

• Oral (or IV) Cipro BID, will need to treat 4-6 weeks.

• Regular debridement/toilet of the EAC

• Topical Ciprodex

• Dry ear precautions.

Auricular Cellulitis

-May occur as part of AOE but frequently isolated.

-Features unique from cellulitis everywhere:

• If part of AOE, Pseudomonas could be causative and antibiotic choice may be directed by this

• Involvement of cartilage may make management more difficult

• Diabetics/smokers tend to do worse due to vascular insufficiency

Relapsing Polychondritis

-Immune mediated condition associated with inflammation in cartilaginous structures

• Lab work may show inflammatory markers/autoantibodies

• Ear is one of he most commonly affected organs → presentation may be misdiagnosed as infection.

-Typically spares the lobule (no cartilage)

-Initial/local disease may be treated with NSAIDs or glucocorticoids. More extensive disease needs multispecialty care.

Auricular Hematoma

-Results from sheer injury between cartilage and perichondrium.

• Creates a barrier between cartilage and blood supply, causing necrosis, cartilage loss, fibrosis, disorganized neocartilage formation.

-Auricular Hematoma → soft → acute

-Cauliflower ear → hard → chronic

Treatment:

• I&D with bolster placement

• Bolster will remain in place for 7-10 days

• Prophylactic antibiotics

• OK to return to sports with bolster

Laceration of the Pinna

-Possible associated injuries

• Auricular hematoma

• Injury to the EAC → may require stenting

• Middle ear trauma (TM perforation, Ossicular disruption)

• Temporal bone fracture/Facial nerve injury

Repair:

• Layered closure, if possible

• May need to drain and bolster an auricular hematoma

• Avulsion (partial) → wide pedicle with good capillary refill will likely heal well.

Malignancy

-Skin cancer of the ear is common, due to sun exposure.

• Squamous cell carcinoma, basal cell carcinoma; Melanoma much less common.

-SCC of the EAC can occur

• Lesions of the EAC should respond readily to ototopical abx/steroids; if there is not a ready response, refer for evaluation and possible biopsy.