Common Ear Conditions

Medway VTS2013

PlanConsider a 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)

TreatmentFew questions

ENT Examination

You tube video of ENT examination in an OSCE situation. http://www.youtube.com/watch?v=mDbwAPr5RvU

Ear examination- You tube video http://uk.youtube.com/watch?v=I3sa2W83iuo&NR=1

NB:The canal may be partly straightened by pulling the pinna backwards

and upwards during examinationIn infants pull the pinna more horizontally backwards as the shape of

the ear canal is different

Normal

Anterior direction

Inferior

PosteriorAnterio

r

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

. With a visible malleus

Attic

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.

Examine out to inExternal:

Pinna (shape, colour, position, tenderness, haematoma)Mastoid

Internal:

The Canal ( skin, spores, foreign bodies, 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 (mucopurulent)

Behind the Eardrum

. Fluid behind the drum( meniscus, colour, bubbles). Any red bits( glomus tumour, granulations

or blood?, white- cholesteotoma)

Ear WaxWax 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. infection

Crayon in a child’s ear

Management:

Cotton buds are not your friend

If Symptomatic – topical medsDifferent 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?

. Syringing

. 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.

Otitis Externa

Infection of the external auditory canal. Mediterranean ear/Swimmers ear

Usually unilateralGradual onset pruritis, pain, hearing loss, and ear discharge

which varies in consistency and colour. The pt is usually well. Can result in a featureless ext aud canalRisk factors: trauma, water, Immunosuppression, eczemaCan be fungal- spores might not always be visibleIf treatment fails or otitis externa recurs

frequently consider sending an ear swab for bacterial and fungal microscopy and culture

Management

Remove or treat any precipitating or aggravating factors

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).

Provide appropriate self-care advice

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.

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.

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 + AminoglycosideB. Topical corticosteroidC. Tell him serves him right for going on a holiday while you

work!D. Topical corticosteroid +ClotrimazoleE.. Oral Flucloxacillin

Answer 1

Correct Answer is A.

Dx- Otitis externa- Topical antibiotic or combined Antibiotic + corticosteroid preparation

Question 253 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’. The cone of light is normal, but what is this?

A. Normal ear drumB. Otitis Externa secondary

to ear buds useC. Serous Otitis MediaD. Time waster/ Hidden

agenda

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

Question 3A 28 year old woman presents

with a 5 day Hx of pain in her Rt ear, reduced hearing, and yellow coloured discharge

Q. What is the likely diagnosis

a. Acute Otitis Mediab. Acute Otitis Externac. Chronic Suppurative Otitis media

Answer 3

Answer is Acute Otitis Externa

Question 4

Which of the following statements about otitis externa is correct?

a. You should avoid removing canal debrisb. Its common in people not wearing ear protection while

working with loud power tools.c. It may result in a featureless tympanic membraned. It is usually due to a Staphylococcus aureus infection

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

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.

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.

Otitis MediaCan 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

Acute Otitis Media

Common in children

Unwell/pyrexia, otalgia/dischargethere may be tenderness over the mastoiddischarge in meatusloss of outline of drum and landmarks

TM: red, bulging,oedematous or perforation. Mostly viral but can be Streptococcus/Haemophilus

Risk factors: Passive smokerMaleFamily history of otitis media. In day careOn formula feed

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 def 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 CSOMRandomised 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.

AOM (pus behind the eardrum)

AOM continued..

Analgesia: For most children helps most.

Antibiotics should not be routinely prescribed for uncomplicated AOM.

Some children may significantly benefit from antibiotics – ill.

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

Erythromycin or Clarithromycin are alternative antibiotics if allergic to penicillin

AOM contd 2….

A good compromise is to use issuing a delayed/deferred 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.

Serous Otitis Media

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

Serous otitis media with retraction

Hearing tests?

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.

Otitis media+effusion-Glue ear

Features

Dull retracted TMMay show air-fluid levelConductive hearing lossCommon in children; often after AOM and can persist for

weeksReduced hearing noticed by parents/teacherUnsteadiness

80% clear at 8 weeks

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 weeksPersistence 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.

Treatments not recommended are antihistamines, decongestants, steroids , homeopathy, cranial osteopathy, acupuncture, dietary modification (including pro-biotics), immuno-stimulants, massage

About glue ear

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

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

Eustachian Tube Dysfunction

A severely retracted eardrum. Margins are very clear as is the malleus and it looks very sunken.

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, obesityRarely nasal polyps, cleft palate, skull base tumour

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

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.

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.

Chronic Otitis Media

Recurrent ear dischargeHearing loss, painlessPerforation of the TM –

centralPresence of cholesteatomaMarginal, Attic perforationOffensive discharge,

bleeding, granulations

Complications:Vestibular symptomsFacial palsyIntracranial complications

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

Unsafe perforations area)In the attic orb)In the posterior region. These are often linear rather than ovalc)Or involve the eardrum margin

Anything else is generally Safe. i.e. a) In the anterior region orb) In the inferior regionc) And not involving the eardrum margin

MAKE SURE YOU ALWAYS INSPECT THE ATTIC AREA ON OTOSCOPY!

Safe anterior perforation

Perforations in this position is a persistent defect after the extrusion of a grommet.

Safe inferior perforation

This is more likely to be as a result of chronic middle ear infection.

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.

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!).

Cholesteotoma

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. 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

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.

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 routinelyd. Prescribe waxol drops

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