1. Common Ear Conditions
F Bhatti ST2 Group B
9/12/08

2. Outline of the presentation
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 ( Evidence based)
Lots of pictures!
Few questions( AKT based)

3. Sources (With hyperlinks)
GP Notebook
CKS
ENT USA
Passmedicine
University of Bristol, Otoscopy tutorial
You Tube
BMJ Learning
Bradford VTS website ( With thanks to Dr R Mehay)

4. ENT Examination
You tube video of ENT examination in an OSCE situation.
Ear examination- You tube video
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.

5. 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
. and malleus should be visible
Abnormals:
. Retraction( bones more prominent)
. Perforations
. Bubbles (glue ear, resolving infection)
. White patches (tympanosclerosis or cholesteatoma)
. Granulations
. Red lesion at tip of malleus (glomus tumour)
. Grommets/FBs
Attic
Anterior direction
Posterior
Anterior
Inferior

6. 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 antero-inferioirly
At  Attic also known as pars flaccida. Any perforations here are serious and need referral.
Lp  Lateral process of the malleus
Hm  handle of the malleus
Lpi  long process of incus - sometimes visible through a healthy translucent drum

7. Go systematically…
External:
Pinna (shape, colour, position, tenderness, haematoma) etc
Mastoid (tenderness in AOE or mastoid abscess)
Internal:
The Canal ( skin, furuncle, scales,spores,FBs,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 (purulent, mucopurulent)
Behind the Eardrum
. Fluid behind the drum( meniscus, air fluid levels, colour, bubbles?..can ask for a valsalva if appropriate)
. Any red bits( glomus tumour, granulations or blood?, white- cholesteotoma)

8. 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. cholesteotoma
Be mindful of other possibilities
FB(crayon) in a child’s ear

9. Management: . Educate about non instrumentation of their ear canals.
Ear Wax….contd
Management:
. Educate about non instrumentation of their ear canals.
If Symptomatic
. Syringing (with use of drops) or wax hook.
. 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 drops warmed on a warm spoon.Put 2-3 drops in the ear and lie on the opposite side for 3-5 mins. Use BD. Get syringed in 5-7 days.
. 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.
. Keratosis Obturans

10. 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. Discharge not mucoid in consistency as no mucin glands are present in the ext aud canal.
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

11. Management Remove or treat any precipitating or aggravating factors.
Analgesic
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).
If there is extensive swelling of the auditory canal, consider inserting an ear wick (may require referral).
Provide appropriate self-care advice

12. Current Evidence
Topical corticosteroids are at least as effective as topical antibiotics combined with corticosteroids. However, because of methodological weaknesses in the clinical trials and because acute diffuse otitis externa is thought to be caused by an infection, topical corticosteroids on their own are not generally recommended as first-line treatment
Clioquinol is antibacterial and antifungal and has lower risks of skin reactions and ototoxicity than aminoglycosides. Therefore, on theoretical grounds, the combination flumetasone–clioquinol might be slightly preferred.
Oral Abx: usually where furunculosis and/or extensive spreading cellulitis- In 1997, GPs prescribed oral antibiotics for 21% of first episodes of otitis externa. Amoxicillin/ampicillin was the most frequently prescribed antibiotic (34%)
Flucloxacillin narrower spectrum but good tissue diffusion
Erythromycin wider spectrum- effective for most sensitive Gram + cocci and some Gram –ve cocci and anaerobes; Clarithromycin less GI side effects but more expensive

13. 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. It is not a neoplastic process.
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.

14. 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. Topical corticosteroid + Aminoglycoside
B. Topical corticosteroid
C. Tell him serves him right for going on a holiday while you work!
D. Topical corticosteroid +Clotrimazole
E.. Oral Flucloxacillin

15. Answer 1 Correct Answer is A.
Dx- Otitis externa- Topical antibiotic or combined Antibiotic + corticosteroid preparation

16. 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’. Perchance; you had a brilliant presentation on ENT conditions from a fellow registrar on the last VTS half day release and you recognise the cone of light is normal, but what is this…
Normal ear drum
Otitis Externa secondary to ear buds use
Serous Otitis Media
Time waster/ Hidden agenda

17. 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

18. 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.
A. Keeping this picture in mind what test on physical exam could have given you a clue about the diagnosis.
B. What is the likely diagnosis
a. Acute Otitis Media
b. Acute Otitis Externa
c. Chronic Suppurative Otitis media
d. Its actually a picture from a colposcopy examination!

19. Answer 3 Tragal tenderness Answer is Acute Otitis Externa
( for those who thought it was a picture from a colposcopy, may be its time for you to move on to your next job!)

20. Question 4
Which of the following statements about otitis externa is correct?
You should avoid removing canal debris
Its common in people not wearing ear protection while working with loud power tools as a divine punishment.
It may result in a featureless tympanic membrane
d. It is usually due to a Staphylococcus aureus infection

21. 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

22. 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 and standing on your head for 3.37 mins.

23. 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.
There is no quality evidence supporting putting ear drops in your nose and standing on your head; but there is certainly none to refute it.

24. 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

25. 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

26. 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 delayed 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.

28. AOM (pus behind the eardrum)

29. Analgesia: For most children, this is the mainstay of treatment.
AOM continued..
Analgesia: For most children, this is the mainstay of treatment.
Antibiotics should not be routinely prescribed for uncomplicated AOM.
Some children may significantly benefit from antibiotics
. All children aged 6 months and under
. Children aged between 6 months and 2 years where the diagnosis is reasonably certain.
. Children older than 2 years where there are severe symptoms:
. Moderate or severe ear pain (otalgia) with a fever of 39°C or above, or systemic features such as vomiting
. Severe local signs, such as perforation with purulent discharge
. Bilateral AOM
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 (double the standard dose).
.Erythromycin (use high doses) or Clarithromycin (use standard doses) are alternative antibiotics if documented allergy to penicillin.

30. AOM contd 2….
A good compromise is to use issuing a delayed 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.
Persistent AOM:
Pt returning within 2 weeks with same complaints
.Analgesia
.If not had Abx-give Abx e.g. Amoxicillin double the standard dose for 5/7
. If had Abx-check compliance-If good then try 2nd line Abx e.g. Co-Amoxiclav at double the standard dose for 5/7.

31. Complications from AOM
Complications from otitis media is extremely low.
> Progression to glue ear and associated hearing impairment
> Perforation. In one study 29.5 % children with AOM eardrum perfs. But spontaneously closed in 94 % of the patients within one month.
Rarely to mastoiditis, labyrinthitis, meningitis, intracranial sepsis or facial nerve palsy.
Recurrent episodes may lead to atrophy and scarring of the eardrum, chronic perforation and otorrhoea, cholesteatoma, permanent hearing loss, chronic mastoiditis and intracranial sepsis.

32. Serous Otitis Media

33. 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

34. Serous otitis media with retraction

35. 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.
Consider setting a lower threshold for referral for a hearing test in younger children (e.g. children aged less than 3 years old) as communication is more difficult

36. Otitis media+effusion-Glue ear
Features
Dull retracted TM
May show air-fluid level
Conductive hearing loss(whisper test, Rinne/weber tests)
Notes
Common in children; often after AOM and can persist for weeks
Reduced hearing noticed by parents/teacher
Unsteadiness- child falling over
80% clear at 8 weeks

37. 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.
Hearing aids: persistent OME, not for surgery
Treatments not recommended are antihistamines,decongestants, steroids , homeopathy,cranial osteopathy, acupuncture,dietary modification, including probiotics,immunostimulants, massage

38. About glue ear
A unilateral serous effusion in an adult is due to nasopharyngeal tumour until proven otherwise.
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

39. 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

40. Eustachian Tube Dysfunction
a severely retracted eardrum. Margins are very clear as is the malleus and it looks very sunken.

41. 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

42. 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

43. 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. Since children in daycare are highly prone to getting URTIs, they tend to get more ear infections compared to children that are cared for at home.
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.

44. 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

45. 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

46. UNSAFE SAFE Source Cholesteatoma Mucosa Odour Foul Inoffensive Amount
Usually scant, never profuse
Can be profuse
Nature
Purulent
Mucopurulent

47. MAKE SURE YOU ALWAYS INSPECT THE ATTIC AREA ON OTOSCOPY!
Unsafe perforations are
In the attic or
In the posterior region. These are often linear rather than oval
Or involve the eardrum margin
Anything else is generally Safe.
i.e.
In the anterior region or
In the inferior region
And not involving the eardrum margin

48. Safe anterior perforation
Perforations in this position is a persistent defect after the extrusion of a grommet. 48

49. Safe inferior perforation
This is more likely to be as a result of chronic middle ear infection. 49

50. Unsafe posterior perforation
Posterior perforation. Although posterior perforations may represent more serious disease such as cholesteatoma, this is well described and dry. It is possible to make out the posterior margin of this defect.  Traumatic perforations (e.g barotrauma) are often posterior and linear, like a tear rather than a round hole.
There’s also some tympanosclerosis in this picture. 50

51. 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. A 51

52. 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!).

53. Cholesteotoma

54. 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 until proved otherwise. 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

55. Why is it important to diagnose it
Why is it important to diagnose it? 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.

56. Another cholesteotoma

57. Serous Otitis media

58. Normal ear drum

59. Yet another cholesteotoma

60. Question 6
A 31 year old man with a history of recurrent Otitis media in childhood sees you on a Tuesday afternoon with his wife. C/O unilateral left sided hearing loss. Possibilities are:
Cholesteatoma
Tympanic membrane retraction pocket
He doesn’t get along well with the Missus.
Tympanic membrane perforation

61. Correct answer-Tympanic membrane retraction pocket
This is a pars tensa retraction pocket which is clean. It is retracted onto the long process of the incus. There is some incidental tympanosclerosis.
Generalised tympanic membrane retraction and retraction pockets are thought to be caused by thinning of the tympanic membrane and negative middle ear pressure.
Thinning of the tympanic membrane can be caused by middle ear fluid or infections, a poorly healed perforation, or after extrusion of a grommet
Retraction+ serous OM

62. Haemorrhagic blister on ear drum surface from shingles

63. Grommet
This grommet is in the correct position but is covered in infective granulation and blocked up. This will not be doing any good and may be responsible for a chronic discharge. Note also the extensive tympanosclerosis on the drum.

64. Glomus tumour . Rare vascular tumour . Causes pulsatile tinnitus
. Needs surgical removal
. Can erode bone etc over time

65. Glomus tumour

66. Chronic otitis externa

67. Serous Otitis Media

68. ‘Slag caused injury’
Despite what conclusions might be drawn from the title, it was claimed to be sustained while welding and when a spark entered Pt’s ear. He complained of pain and slightly muffled hearing. The picture to the right shows an eardrum one week after the injury. The eardrum is still red and had a crust on it. A small metal ball is seen at the bottom of the canal.

69. Haemotympanum

70. Middle ear FB
The moulding material entered middle ear while taking a cast for an elderly lady’s hearing aid.

71. Granulations
Granulations like this are often associated with underlying disease, particularly if they arise in the attic. 71

72. AOM (Purulent)

73. 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…(I seem to remember something along those lines from the ENT job.)

74. 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.

75. The End (finally..)