EAR DISCHARGE Calma.Capili.Coruña.Dagang. Datukon.Dayrit.De Castro.De La Llana

EAR DISCHARGE

Calma.Capili.Coruña.Dagang.Datukon.Dayrit.De Castro.De La Llana

Ear Discharge

• Drainage of fluid, blood, cerumen, or pus from the ear

• May be caused by a minor ear irritation or an infection

• Also called OTORRHEA

Types/Quality of Ear Discharge

Color Viscosity Odor

Serous(clear/watery)

Thick Foul smelling

Bloody Thin OdorlessPurulent

(yellow-brown)

Associated Signs and Symptoms

SIGNS and SYMPTOMSEar pain or otalgia

Ear swellingEar pruritus

VertigoTinnitus

Hearing loss

Differential Diagnoses

• Is it acute or chronic?– Acute: < 6 weeks– Chronic: ≥ 6 weeks

ACUTE EAR DISCHARGECause Suggestive Findings Diagnostic

Approach

Acute otitis media with perforated TM

Severe pain, with relief on appearance of purulent discharge

Clinical evaluation

Chronic otitis media

Otorrhea in patients with chronic perforation, sometimes with cholesteatomaCan also manifest as chronic discharge

Clinical evaluation; sometimes high-resolution temporal bone CT

Pathophysiology: Otitis Media

• Obstruction of the eustachian tube appears to be the most important antecedent event associated with AOM

• Physiologic functions of the eustachian are as follows:– Ventilation or pressure regulation of the middle ear– Protection of the middle ear from nasopharyngeal

secretions and sound pressures– Clearance or drainage of middle ear secretions into the

nasopharynx

Otitis MediaURTI

Inflammation of the nasopharynx extending to the eustachian tube

Stasis and inflammation within the eustachian tube

Altered pressures within the middle ear (negative, related to ambient pressure)

Acute inflammatory reaction: vasodilatation, exudation, leukocyte invasion, phagocytosis, and local immunological responses within the middle ear cleft


Approach

CSF leak from head trauma

Significant, clinically obvious head injury or recent surgeryFluid ranges from crystal clear to pure blood

Cranial CT, including skull base

Post-tympanostomy tube

After tympanostomy tube placementMay occur with water exposure

Clinical evaluation


Approach

Otitis externa (infectious or allergic)

Infectious: Often after swimming, local trauma; marked pain, worse with ear tractionOften a history of chronic ear dermatitis with itching and skin changesAllergic: Often after use of ear drops; more itching, erythema, less pain than infectiousTypically involvement of earlobe, where drops trickled out of ear canalBoth: Canal very edematous, inflamed, with debris; normal TM

Clinical evaluation

CHRONIC EAR DISCHARGECause Suggestive Findings Diagnostic

Approach

Cancer of ear canal

Discharge often bloody, mild painSometimes visible lesion in canalEasy to confuse with otitis externa early on

Biopsy, CT scan, MRI in selected cases

Cholesteatoma History of TM perforationFlaky debris in ear canal, pocket in TM filled with caseous debris, sometimes polypoid mass

CT scan, culture, MRI if intracranial extension suspected


Approach

Chronic purulent otitis media

Long history of ear infections or other ear disordersLess pain than with external otitisCanal macerated, granulation tissue, TM immobile, distorted, usually visible perforation

Clinical evaluationUsually culture


Approach

Foreign body Usually in childrenDrainage foul-smelling, purulentForeign body often visible on examination unless marked edema or drainage

Clinical evaluation

Mastoiditis Fever, history of untreated or unresolved otitis mediaRedness, tenderness over mastoid

Clinical evaluation, culture, sometimes CT


Approach

Necrotizing otitis externa

Usually history of immune deficiency or diabetesChronic severe painPeriauricular swelling and tenderness, granulation tissue in ear canalSometimes facial nerve paralysis

CT scan or MRICulture


Approach

Wegener’s granulomatosis

Often with respiratory tract symptoms, chronic rhinorrhea, arthralgias, and oral ulcers

UrinalysisChest x-rayAntineutrophilic cytoplasmic antibody testingBiopsy

Causes of Otorrhea

Causes of Otorrhea

Diagnostics

Otitis Media

• The diagnosis is made otoscopically revealing an opaque, thickened, erythematous and sometimes bulging tympanic membrane.

• The tympanic membrane is immobile by pneumatic otoscopy

Otitis Media with Effusion

• Otoscopically, the tympanic membrane often appears opaque, thickened and occasionally retracted

• Color may be pale, reddish, yellowish or bluish depending on the effusion

• Tympanogram – A graphic record of tympanic membrane mobility

will show a flat curve (type B) or occasionally a negative-pressure peak (type C) in mild and acute cases

Chronic Suppurative Otitis Media

• Otoscopic examination will reveal a central perforation in the tympanic membrane that does not involve the fibrocartilaginous ring– Often appreciated only in a dry ear– Valsalva maneuver may cause air bubbles to

appear in the secretions

• Smear , culture and sensitivity– Not routinely done except for severely resistant

infections• Imaging studies – Not routinely done– May be useful for diagnosing mastoiditis

Management

Otitis Externa

• Acidification of ear canal with drops– Reduced pH retards antibiotic growth– Acetic acid

• +/- topical antibiotics– Treats bacterial infection and reduces edema– Polymyxin B, neomycin and hydrocortisone; ciprofloxacin;

ofloxacin (bacterial growth)– Nystatin powder (fungal infections)

Otitis Externa• EarSol HC, VoSoL HC, Acetasol HC

– Treats superficial bacterial infections of the EAC

• Neomycin, polymyxin B, and hydrocortisone– for steroid-responsive inflammatory condition for which a

corticosteroid is indicated and where bacterial infection or a risk of bacterial infection exists.

• Ciprofloxacin / Ofloxacin– Inhibits bacterial growth by inhibiting DNA gyrase

• Nystatin powder– Fungicidal and fungistatic antibiotic

Administer until 48 H after disappearance of symptoms. – 1-2 puffs from handheld nebulizer for 1 wk administered by treating

physician

Otitis Externa

• Further Outpatient CareSuctioning of the external auditory canal on a weekly

basis until debris has been removed. Topical eardrops are the mainstay of both inpatient and outpatient treatment. Oral antibiotics or antifungal agents are usually reserved for refractory cases.

• PreventionOtitis externa can be prevented by avoiding use of

cotton-tipped swabs or objects such as bobby pins to clean ears. Use of cotton-tipped swabs or bobby pins can cause excoriation of the canal skin that can lead to otitis externa.

CSOM

• Medical Treatment– aim is to eliminate infection and to control otorrhea– topical liquid agents used in the treatment of chronic

middle ear disease include (combination of antibiotics, antifungals, antiseptics, solvents, and steroids)

– The most commonly used topical antibiotics for CSOM include quinolones and aminoglycosides

– Oral antibiotics should be prescribed to patients with severe infections & to those who are systemically ill

CSOM• Medical treatment should be accompanied by aural toilet.

• Principal aim of surgery for chronic suppurative otitis media– to clear out the disease – if possible, to reconstruct the patient's hearing

• General indications for surgery are as follows:– Perforation that persists beyond 6 weeks– Otorrhea that persists for longer than 6 weeks despite

antibiotic use– Cholesteatoma formation– Radiographic evidence of chronic mastoiditis, such as

coalescent mastoiditis– Conductive hearing loss

CSOM

• Tympanoplasty– Goal: to eradicate disease from the middle ear and

to reconstruct the hearing mechanism, with or without grafting of the tympanic membrane

– 2 primary types: • lateral graft technique - the graft material is laid

laterally to the annulus after the remnant of squamous tissue is denuded. • medial grafting - the annulus is raised and the graft

slipped medially

CSOM w/o Cholesteatoma• Myringoplasty - operation specifically designed to close

tympanic membrane defects.

• Tympanoplasty

• Mastoidectomy

– removal of the outer wall of the mastoid cortex and the exteriorization of all the mastoid air cells. This may be performed immediately in coalescent mastoiditis, in which case a drain may be left postoperatively.

Canal wall-up mastoidectomy - removal of mastoid air cells while retaining the posterior canal wall. This is also the common approach for cochlear implantation.

CSOM w/ Cholesteatoma

• Mastoidectomy

Modified radical mastoidectomy - the ossicles and the tympanic membrane remnants are preserved for possible hearing reconstruction

Radical mastoidectomy - eradication of all disease from the middle ear and the mastoid and exteriorization of these structures into a single cavity; includes removing the entire tympanic membrane and the ossicles (except the stapes footplate) and closing the eustachian tube opening.

AOM• Medical Management– Mostly viral in origin, especially those that accompany

coryza. Most common: RSV, influenza viruses, adenovirus, and parainfluenza

– Treatment is purely symptomatic and supportive– High doses of amoxicillin - result in middle ear fluid

levels that exceed the minimum inhibitory concentration of all S pneumoniae

AOM• Erythromycin– Has an antibacterial spectrum similar but not identical

to that of penicillin; alternative for patients who are allergic to penicillin.

• Penicillin G benzathine – Remains a useful antibiotic but is inactivated by

bacterial beta-lactamases. Parenteral therapy with benzylpenicillin is used initially in severe infections, followed by 3-7 days of oral Penicillin V

AOM• Gentamicin with hydrocortisone– Aminoglycosides although commonly used topical

antibiotics, controversy surrounds topical therapy because of its potential for ototoxicity. Literature contains sporadic reports of sensorineural hearing loss associated w/ use

• Ciprofloxacin– Quinolone derivatives have excellent antipseudomonal

activity. Inhibits bacterial DNA synthesis & growth. Also available as ototopical preparations, w/ little demonstrable systemic effects.

AOM

• Medical Management– Pain control is essential to treatment, especially in

the first 24 hours after diagnosis, since pediatric population is often undertreated for pain. In addition to ibuprofen and acetaminophen, topical benzocaine can also be given for pain control. Guidelines also include the use of narcotic analgesia with codeine for severe pain.

AOM

• Surgical Management– Myringotomy - an incision is made in the tympanic

membrane to adequately drain the middle ear; reserved for AOM associated with severe otalgia or high fever in patients who have had a poor response to antibiotics.

– Recurrent AOM in children may be due to chronic sinus infections, nasopharyngeal obstruction, or cleft palate. Surgically treating these conditions may decrease the number of ear infections.

Foreign Body

• Irrigation - simplest method, provided the tympanic membrane is not perforated. Irrigation w/ water is contraindicated for soft objects, organic matter, or seeds, w/c may swell

• Suction - sometimes a useful. Suction the ear with a small catheter held in contact with the object. Grasp the object with alligator forceps. Place a right-angled hook behind the object and pull it out. Form a hook with a 25-gauge needle to snag and remove a large, soft object such as an eraser.

• Avoid any interventions that push the object in deeper.

Foreign Body

• Cyanoacrylate adhesives (eg, Superglue) may be removed manually within 24-48 hours once desquamation occurs. If adhesive touches the tympanic membrane, remove it carefully and reevaluate

• Remove batteries immediately to prevent corrosion or burns. Do not crush battery during removal

Cancer of the Ear Canal

• Medical Management– Primary radiation is ineffective for curative treatment– For cases in which contraindications to surgery are serious

deterrents to surgery, palliative radiation and chemotherapy may be offered

– Most authors advocate full course postoperative radiation to stage T3 or T4 tumors as defined by the University of Pittsburgh staging system

– Literature supports a beneficial effect of postoperative radiation on survival. The temporal bone and neck should be treated with 50-60 Gy for tumors staged T3 and T4. Radiation may also be indicated for smaller lesions.

Cancer of the Ear Canal• Surgical– all patients who are medically able should undergo surgical

treatment– optimal surgery removes all of the cancer en bloc because

positive margins are associated with poor survival rates– The resection procedures that can be performed for the

temporal bone include: modified lateral temporal bone resection lateral temporal bone resection subtotal temporal bone resection total temporal bone resection.

Cancer of the Ear Canal• Surgical– Adjunctive surgical procedures - neck dissection,

parotidectomy, and craniotomy, should be performed when indicated

– Advanced tumors with intracranial invasion - palliation with less extensive (and less morbid) surgical procedures.

Wegener’s Granulomatosis

• Manage the primary condition– Immunosuppression– IVIG– Plasmapheresis

• wTucci, D. Otorrhea in http://ww.merck.com/mmpe/sec08/ch084/ch084c.html. January 2009. Accessed September 16, 2009.

• Causes of Otorrhea in http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A3683&rendertype=table&id=A3692. 1990. Accessed September 16, 2009.

Documents

EAR DISCHARGE Calma.Capili.Coruña.Dagang. Datukon.Dayrit.De Castro.De La Llana