9External Auditory Canal Otitis Externa-Management Topical antibacterial drops such as Neomycin otic, polymyxin, Quinolone oticOtic steroid drops containing polymyxin-neomycin and a topical corticosteroid.Analgesics
10External Auditory Canal Otitis Externa-Management Discuss patient education issues such as:Swimmer prophylaxis contains acid and alcohol
11External Auditory Canal Chronic Otitis Externa Duration of infection greater than four weeks, or greater than 4 episodes a yearRisks: inadequate treatment of otitis externa, persistent trauma, inflammation or malignant otitis externa.Etiology: Bacterial,fungal or dermatologic such as candida or Aspergillus, pseudomonas or psoriasis
13External Auditory Canal Chronic otitis externa-Management Cover fungi with clotrimazole(Lotrimin)Systemic antifungal include ketoconazoleCortisporinWick with few drops of Domeboro’s astringentDifferential diagnosis to include basal cell or squamous cell carcinoma, Foreign bodies, otitis media
14External Auditory Canal Malignant Otitis Externa Inflammation and damage of the bones and cartilage of the base of the skullOccurs primarily in immunocompromisedMost common etiology is pseudomonas aeruginosa.
15External Auditory Canal Malignant Otitis Externa Otorrhea: yellow green, foul smelling.Granulation tissue in external auditory canalTrismusFeverFacial and cranial nerve palsies
16External Auditory Canal Malignant Otitis Externa Diagnosis: Culture of ear secretions and pathological examination of granulation tissue, CTComplications include sepsis, cranial nerve palsies, meningitis, brain abscess, osteomyelitis of the temporal bone and skullDifferential diagnosis to include basal cell or squamous cell carcinoma
17External Auditory Canal Malignant Otitis Externa Need IV antibioticsMight need surgical debridement.If treatment interrupted rate of recurrence is 100%
18External Auditory Canal Cerumen Impaction Cerumen is produced by apocrine and sebaceous glands in external ear canal.Often caused by attempts to clean the ear, or water in canalCerumen is pushed down
19Cerumen Impaction Clinical Manifestations Hearing lossStuffed or full feeling to earPain if cerumen touches TM
20External Auditory Canal Cerumen Impaction Be sure TM is intact prior to lavageIrrigate ear with one part peroxide, and one part waterDebrox and Cerumenex dropsEar irrigation and manual cerumen removal
21External Auditory Canal Foreign body Can include toys, beads, nails, vegetables or insects.Damage depends on amount of time object has been in ear.
22External Auditory Canal Foreign body-Clinical Manifestations Might present with purulent dischargePainBleedingHearing loss
23External Auditory Canal Foreign body Complications include internal injuryDifferential diagnosis to include cholesteatoma, cerumen impaction, otitis externa
24External Auditory Canal Foreign body- Management Irrigation is best provided the TM is not perforatedDestroy insect with lidocaine or mineral oil.Irrigate and suction liquid.For inanimate objects suction or use alligator forceps.
25Tympanic Membrane Bullous Myringitis Vesicles develop on the TM second to viral infections or bacterial infectionUsually associated with middle-ear infectionMay extend into canal.
26Tympanic Membrane Bullous Myringitis- Clinical Manifestations Sudden onset of severe painNo fever usuallyNo hearing impairmentBloody otorrhea possibleInflammation to TMMultiple reddened inflamed blebs possibly blood filled
27Tympanic Membrane Bullous Myringitis Differential diagnosis to include squamous or basal cell carcinoma, acute otitis mediaComplications
28Tympanic Membrane Bullous Myringitis-Management AntibioticsIf pain is severe, rupture the vesicles with a myringotomy knifeAnalgesics
29Tympanic Membrane Perforated TM Etiology is direct trauma, infection, pressure build upBacteria can travel into middle ear and lead to secondary infection
30Tympanic Membrane Perforated TM- Clinical Manifestations Sudden severe painHearing lossDrainageOtoscope exam reveals puncture in TM, might be able to see bones of middle earPurulent otorrhea may begin in hours post perforation
31Tympanic Membrane Perforated TM Differential diagnosis to include acute and chronic otitis mediaComplications include secondary infection into inner ear
32Tympanic Membrane Perforated TM-Management Antibiotics to prevent infection or treat existing infectionSurgical repair
33Middle Ear Acute Otitis Media Viral respiratory infections cause inflammation of ETWhen ET is blocked, fluid collects in the middle ear.
34Middle Ear Acute Otitis Media Common in fall, winter or springET in child is shorter and more horizontal in infants/children.Bacterial Etiology : S.pneumoniae, H.influenzae, and M.Catarrhalis.Risks include URI,smoking at home, allergies, cleft palate, adenoid hypertrophy, bottle feeding, barotrauma
35Middle Ear Acute Otitis Media Otalgia.Conductive hearing lossURI symptomsVomiting, diarrheaFeverTM bulging and erythematous with decreased or poor light reflex.Decreased TM mobility on pneumatic insufflation
36Middle Ear Acute Otitis Media -Diagnosis TympanometryDifferential diagnosis to include TM perforation, Tympanosclerosis, recurrent AOM, mastoiditis
37Middle Ear Acute Otitis Media -Management Analgesics/ AntipyreticsAuralganAntibioticsTrimethoprim-sulfamethoxazole or AzithromycinDecongestants:Avoid antihistamines
38Middle Ear Acute Otitis Media –Patient Education Myringotomy in patients with hearing loss, poor response to therapy or intractable painDiscuss patient education issues including breast feeding, no smoking in homes, pneumococcal vaccine
39Middle Ear Acute Otitis Media -Complications TM perforation/ TympanosclerosisRecurrent AOM or chronic OMPersistent middle ear effusionMastoiditisBacteremia
40Middle Ear Acute Otitis Media -Recurrent OM Three episodes of AOM in 6 months or 4 episodes in 12 monthsDiagnosisPrevent by antibiotic prophylaxis, pneumovax, tympanostomy tubes, adenoidectomy
41Middle Ear Otitis Media with Effusion Fluid accumulation behind TM in middle earBuild up of negative pressure and fluid in eustachian tubeCommon in children because of anatomy, cleft palate, allergies, barotrauma.
42Middle Ear Otitis Media with Effusion Hearing lossFullness, pressureTM neutral or retracted. Gray or pink.Landmarks visible or dull.Decreased TM mobility
43Middle Ear Otitis Media with Effusion Diagnosis Tympanometry- most accurate,Audiometry-Differentials to include: Acute Otitis Media, malignant tumors to nasal cavity, cystic fibrosis
44Middle Ear Otitis Media with Effusion Management Decongestants/Oral steroidsAntibioticsMyringotomy with or without tubesAdenoidectomyComplications:
45Middle Ear Chronic Otitis Media Recurrent or persistent otitis media due to dysfunctional eustachian tubeRisks: allergies, multiple infections, ear trauma, swelling to adenoids.Bacteria: P aeruginosa, proteus species, Staphylococcus aureus, and mixed anaerobic infections.
46Middle Ear Chronic Otitis Media Causes long term damage to middle ear due to infection and inflammation includingSevere retraction of TM due to prolonged negative pressureScaring or erosion of small conducting bones of middle ear and inner earErosion of mastoidThickening of mucous secretions in ETCholesteatomaPersistent OME
47Middle Ear Chronic Otitis Media Ear painFullness to earsPurulent dischargeHearing lossDullness, redness or air bubbles behind TM
48Middle Ear Chronic Otitis Media Diagnosis: clinical, audiometry, tympanometry, CT, MRIDifferential diagnosis to include AOM, cholesteatomaComplications include bony destruction or sclerosis of mastoid air cells, facial paralysis, sensineural hearing loss, vertigo
50CholesteatomaEpithelial cyst consists of desquamating layers of scaly or keratinized skin.Erosion of ossicles common. As more material is shed, the cyst expands eroding surrounding tissue.Two types: congenital and acquired.Acquired due to tear in ear drum, infection
51CholesteatomaPerforation of TM filled with cheesy white squamous debrisPossible conductive hearing lossDrainageDifferential Diagnosis: squamous cell carcinoma
52Cholesteatoma-Management Large or complicated cholesteatomas require surgical excisionComplications include erosion of bone and promote further infection leading to meningitis, brain abscess, paralysis of facial nerve.
53BarotraumaPhysical damage to body tissue due to difference in pressure between an air space inside or beside body and surrounding gas.Ear barotrauma:
54BarotraumaEtiology is a change in atmospheric pressure. Negative pressure in the middle ear causes Eustachian tube to collapse.Since air can not pass back through the ET, hearing loss and discomfort developRisk factorsDifferential diagnosis should include serous, acute or chronic otitis media, bullous myringitis
56Barotrauma-Management Auto inflation by yawning, swallowing or chewing gum to facilitate opening of ET to equalize air pressure in middle earDecongestantsMyringotomyPatient education to include valsalva maneuver.
57Mastoid Portion of temporal bone posterior to the ear. Mastoid air cells connect with the middle earFluid in the middle ear can lead to fluid in the mastoid
58MastoiditisMiddle ear inflammation spreads to mastoid air cells resulting in infection and destruction of the mastoid bone.Etiology: Streptococcus pneumoniae, Haemophilus influenzae, streptococcus pyogenes, and other bacteria
60Mastoiditis-Diagnosis/differentials CT show bony destruction or drainable mastoid abscessTympanocentesis to culture middle ear fluid.( S. pneumoniae, H. influenzae, M. catarrhalis)\Culture of fluidDifferential diagnosis to include otitis media, Cellulitis, scalp infection with inflammation of posterior auricular nodes
61Mastoiditis Complications Destruction of mastoid boneSpread to brain leading to brain abscess or epidural abscess
62Mastoiditis-Management Treat with antibioticsPatients with severe or prolongedMay need to surgically remove a portion of the bone
63Labyrinthitis Viral infection Vestibular neural input disrupted to the cerebral cortex and brain stemVertigo due to inflammation and infection of labyrinthNeurological exam normalCan also follow allergy, cholesteatoma, or ingestion of drugs toxic to inner ear
64Labyrinthitis Nausea/vomiting Vertigo with head or body movements lasts about 1 minNystagmus(rotary away from affected ear)Loss of balance
65Labyrinthitis-History and PE Diagnosis: Audiologic testing, CT and MRIDifferentiate other causes of dizziness by CT, MRIDifferential diagnosis to include acoustic neuroma, vertigo, cholesteatoma, meniere’s disease
66Labyrinthitis-Management SteroidsSedativesAntivertTiganPatient reassurance that symptoms usually last 7-10 days with subsequent episodes up to 18 months.Complications include spread of infection
67Meniere’s SyndromeImbalance in secretion and absorption of endolymph fluid that causes buildup of fluid in cochlea.Swelling leads to hair cell damage
68Meniere’s Syndrome Episodic vertigo for 24-48 hours Sensorineural hearing lossTinnitusFullness/pressure in earsN/V/dizziness
69Meniere’s Syndrome Diagnosis: Audiologic testing, CT Valium, tigan, antivertHCTZLow sodium dietLabyrinthectomy if hearing already lost
70VertigoMotion perceived when no motion, or exaggerated motion perceived in response to body movementCauses-Irritation to labyrinthCNSBrainstem or temporal lobe8th cranial nerve dysfunction (acoustic neuroma)Labyrinthitis, Meniere’s disease
71VertigoN/VIn peripheral lesions nystagmus can be horizontal or rotationalCentral lesions nystagmus is bi-directional or verticalEvaluation
72VertigoDifferential diagnosis to include Diabletes mellitus, hypothyroidism, drugs such as alcohol, barbituates, salicylates, hyperventilation, cardiac originManagement: Meclizine, Promethazine, Scopolamine
73Tinnitus Perception of abnormal ear noises Can be ringing, hissing Constant, intermittent, unilateral, or bilateralCan originate in outer, middle or inner ear
74Tinnitus- CausesEtiology can include damage to inner ear or cochlea, middle ear infection, medication such as Aspirin, stimulants such as nicotine, and caffeine, noise induced, hypertension, presbycusis
75Tinnitus-Treatment Some drugs such as antihistamines and CCB ENT referral-AntidepressantsSurgical intervention-
76Example 1A 22 year old swimmer complains of pain when moving her ear. She also has noticed a bump in front of her ear. She has noticed difficulty in hearing. On otoscopic exam you visualize this.What is the complication associated with this?What is the treatmentWhat are some patient education tips on this?
77Example 2A Diabetic patient is complaining of severe ear pain and otorrhea. On physical exam you note this.What is your differential diangosis?For what condition is this a complication?What is the etiology and treatment for this?
78Example 3This is a 44 year old female who complains of increasing hearing loss, and believes she is going deaf.What is the treatment of this?
79Example 4This patient recently had a viral infection. She now complains of a sudden onset of constant severe ear pain since yesterday. You see this on physical exam.What is this?How is this treated?
80Example 5This patient was SCUBA diving and had a non controlled ascent. He complains of tinnitus and severe ear pain since this incident. He thinks he has an ear infection.What is this?How is this treated?What are some complications of this?
81Example 6A 2 year old presents to your clinic crying tugging her ear. Mother states child has a bad cold for a few days. On otoscopic exam you note this.What is your differential diagnosis?What are some etiologies of this?What is the treatment for this?What is the name of the vaccine which tries to prevent this?
82Example 7A child with a history of allergies complains of hearing loss to her right ear. She has no fever. Otoscopic exam reveals this.What is this?What is the management of this?What is the treatment if child is not responsive to therapy?
83Example 8This 4 year old was not treated for AOM. Now the child has a fluctuant mass behind his ear. He also has a high fever. What is the diagnosis?How would this be treated?What diagnostics are necessary?
84Example 9A 35 year old female complains of vertigo with head movement. She also notices she is falling to the right side for the past 7 days. This is due to a viral infection.What is this?What is the pathophysiology of this?What is the management of this?
85Example 10This patient has episodes of dizziness lasting up to 2 days. She also notices difficulty hearing low frequency notes to her left ear. In addition her left ear feels stuffy. She also hears a ringing in that ear.What is the differential diagnosis?How is this managed?