keywords:
Bookmark and Share



Front Back
Otitis Externa

Etiology
Patho
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Infection of the skin of the ear canal. Exists in several forms: Acute localized, Acute diffuse (swimmer's ear), Chronic, Invasive. Pseudomonas aeruginosa 90%, Staph Aureus remainder.


Pathophysiology

Most common cause is loss of the protective function of cerumen


Risk Factors

Swimming, irritation from cotton swab, age, diabetes, eczema, seborrheic dermatitis, psoriasis


Symptoms

Itching, progression to severe pain


Clinical Findings

Painful erythema and edema of the ear canal skin with purulent exudate. Tenderness over tragus.


Dx/Labs

Head CT if invasive otitis externa suspected. Tympanogram, Invasive otitis externa if increase in ESR.


Treatment

  • Topical broad spectrum antibiotics with otic drops (ciprofloxacin (Cipro), Ciprodex)
  • Amoxicillin or erythromycin plus sulfonamide
  • Vinegar/water


Differentials

Atopic dermatitis, seborrheic dermatitis, psoriasis, dermatomycosis
Acute Otitis Media

Etiology
Patho
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Most common in childred 4-24 months old.
  • Strep. pneumonia
  • H. influenza
  • Moraxella catarrhalis
  • B-hemolytic Strep. pyogenes
Pathophysiology

Usually precipitated by viral URI that causes eustacian tube obstruction


Risk Factors


Daycare
URI
Down Syndrome
Smoking (not the child, silly)
Position of feeding


Symptoms

  • Pain
  • Unilateral conductive hearing loss
  • Preceding URI
  • Fever may or may not be present
  • Irritability
  • Diarrhea/vomitting
Clinical Findings

  • Decreased mobility of TM
  • TM is red or opacified with poorly visible landmarks
  • Bulging TM
  • Air fluid level behind TM (with effusion)
  • Otorrhea
Dx/Labs

  • Tympanometry reflects effusion
  • Tympanocentesis identify organism
Treatment

  • Pain management
  • Watchful waiting 48-72 hours without definitive dx.
  • Amoxicillin or erythromycin plus sulfonamide with definitive dx
  • When med fails, myringotomy, tympanostomy

Differentials

OME, mastoiditis, dental abscess, sinusitis, lymphadenitis, parotitis, peritonsillar abscess, trauma, TMJ dysfunction, immune deficiency
Otitis Media with Effusion

Etiology
Pathophysiology
Symptoms
Clinical Findings
Dx/Labs
Treatment
Etiology

Usually follows an episode of acute otitis media, viral illness, anatomic abnormalities, barotraumas or allergies. Results from (-) pressure produced by altered Eustachian tube function


Pathophysiology

Fluid in the middle ear but without evidence of local or systemic illness. Could cause hearing loss


Symptoms

Fullness in ear, "popping feeling" conductive hearing loss, dizziness or impaired balance, chronic vomiting


Clinical Findings

Decreased TM mobility, abnormal TM, described as dull, varying from bulging and opaque with no visible landmarks to retracted and translucent with visible landmarks and air-filled bubble


Dx/Labs

Pneumatic otoscopy
Tympanogram
Hearing Testing


Treatment

Surgical intervention of bilateral myringotomy with insertion of tympanostomy tubes if chronic
Perforated Eardrum

Etiology (6)
Pathophysiology
Symptoms (3)
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

  • Prior infection
  • Injury
  • Sudden loud noise
  • acute otitis media
  • Barotrauma
  • Foreign Body
Pathophysiology

  • Increase pressure of fluid in middle ear
  • Presents as a tear or hole in TM
  • Interrupted hearing process
  • Aural discharge = perforation
Symptoms

  • Otalgia
  • Conductive Hearing loss
  • Tinnitus


Clinical Findings

  • Peripheral perforation creates a risk for cholesteatoma
  • Otorrhea
  • Aural discharge
Dx/Labs

  • Ear exam
  • Weber and Rinne test
  • Whisper test
  • HEENT exam
  • Culture discharge
  • Inspect nose and oral cavity
Treatment

Perforation heals spontaneously within 2 weeks. If no healing within 3 months, surgical intervention; limited swimming until it heals.
Differentials
Bullous Myringitis

Etiology (4)
Pathophysiology
Symptoms (3)
Clinical Findings
Dx/Labs (4)
Treatment (3)
Etiology

  • Baterial or viral infection
  • Always associated with acute otitis media
  • Mycoplasm pneumoniae
  • Chlamydia Psittaci
Pathophysiology

Infectious disorder of the eardrum resulting in painful blisters on the surface of the TM


Symptoms

  • Short lived ororrhea
  • Hearing loss (conductive, sensorineural or both (reversible))
  • Severe throbbing otalgia
Clinical Findings

Fluid filled blisters may be red or yelow in color


Dx/Labs

  • HEENT exam
  • Weber and Rinne test
  • Whisper test
  • Culture of discharge
Treatment

  • Warm compress
  • Systemic analgesia with acetaminophen or NSAID
  • Oral antibiotics used in cases of an associated middle ear effusion
Mastoiditis

Etiology
Pathophysiology
Symptoms (3)
Clinical Findings (4)
Dx/Labs (4)
Treatment
Etiology

Complication of otitis media, approximately 2 weeks after initial AOM
  • Strep. pneumoniae
  • S. pygenes
  • Staph aureus and H. influnzea (sometimes)
Pathophysiology

bacteria spread from the middle ear to the mastoid air cells, where the inflammation causes damage to the bony structures


Symptoms

  • Otalgia
  • Fever
  • Diminished hearing
Clinical Findings

  • Postauricular erythema, swelling and tenderness
  • Outwardly displaced pinna
  • Acute otitis media usually present
  • Ear canal narrowed
Dx/Labs

  • HEENT full exam
  • X-ray or CT of mastoid sinuses
  • Mastoid radiography
  • Lumbar puncture if meningitis is suspected
Treatment

Oral antibiotics x 14 days or IV antibiotics and myringotomy for culture and drainage. Failure of medical therapy means mastoidectomy.
Malignant Otitis Externa

Etiology (with 2 most common causes)
Pathophysiology
Risk Factors (2)
Symptoms
Clinical Findings (3)
Dx/Labs (2)
Treatment (3)
Etiology

Persistent external otitis in diabetic or immunocompromised pt may evolve into osteomyelitis of skull
  • P. aeruginosa
  • Aspergillus
Pathophysiology

Begins as simple otitis externa that then spreads to deeper tissues of the external auditory canal and infects cartilage, periosteum and bone


Risk Factors

  • Diabetes
  • Other immune system compromised patients
Symptoms

Extremely painful external ear


Clinical Findings

  • Persistent foul aural discharge
  • Granulations in th ear canal
  • Cranial nerve palsies involving CN 6,7,8,9, 10,11 &12
Dx/Labs
  • Dx confirmed by demonstration of osseous erosion on CT and radionuclide scanning
  • Test cranial nerves

Treatment

  • IV therapy often required
  • selected pts may take ciprofloxacin 2x PO effective against pseudomonas
  • Surgical debridement of infected bone if necessary
Differentials
Sensorineural hearing loss

Etiology
Pathophysiology
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

  • Usually presbycusis
  • Congenital and hereditary factors
  • Noise exposure
  • Aging (presbycusis)
  • Meniere disease
  • Ototoxicity
  • Systemic disease
Pathophysiology

  • Impairment of the organ of corti or its central connections
  • Cranial nerve 8 impairment
  • Mutation in connexin 26
Risk Factors

See patho


Symptoms

  • Can't hear high frequency sounds
  • words sound broken
  • Difficulty hearing with background noise
  • Could be sudden onset or gradual progression
Clinical Findings

  • Rinne test: AC>BC (but less than 2:1)
  • Weber test: tuning fork is heard in the unaffected ear
Dx/Labs

  • Weber test
  • Rinne test
  • Whisper test
  • CT
  • MRI
Treatment

hearing aid


Differentials

Presbycusis, neuroma, MS, brain stem infarct, perilymph fistula, labyrinthitis, Meniere syndrome
Conductive Hearing Loss

Etiology (6)
Pathophysiology
Symptoms (4)
Clinical Findings
Dx/Labs
Differentials
Etiology

  • Dysfunction of the external or middle ear
  • Obstruction
  • Mass loading (eg. middle ear effusion)
  • Stiffness effect (eg otosclerosis)
  • Discontinuity
  • Trauma
Pathophysiology

Most common cause is impacted cerumen in external canal


Symptoms

  • Hearing loss of low and high tones
  • Muffled hearing
  • Listening to radio or TV at high volumes
Clinical Findings

  • Weber test: lateralizes to deaf ear
  • Rinne test: bone > air
Dx/Labs

HEENT, Whisper test, Rinne & Weber


Differentials

Impacted cerumen, acute otitis externa, otosclerosis, otitis media, choleateatoma, TM perforation, trauma, congenital malformations, glomus body tumor
Tinnitus

Etiology (11)
Pathophysiology
Symptoms
Clinical Findings
Treatment
Differentials (10)
Etiology
  • Damage to hair cells
  • Ear infections
  • Cerumen impactions
  • Acoustic Trauma
  • TMJ
  • Menieres Disease
  • Medication side effects
  • Hypertension
  • Anxiety/depression
  • Thyroid disease
  • Tumors
Pathophysiology

Can be either objective (hearing sounds that arise external to the auditory system (e.g. increased ICP, arteriosclerosis) or subjective (constant sound, unrelated to anything else). Reasons unknown.


Symptoms

Ringing, buzzing, roaring, hissing, hums or pulsatile and clicks.


Clinical Findings

Objective tinnitus has a cause that can be heard by the examiner. Subjective doesn't.


Treatment

Treating the underlying disorder in objective tinnitus. Otherwise, treat exacerbating problems.
  • Antidepressants
  • Hearing aid (if pt. has poor hearing)
  • Radio
  • Cognitive behavioral therapy


Differentials

Impacted cerumen, chronic otitis, otosclerosis, neuroma, noise damage, ototoxic drug, labyrinthitis, Meniere, perilymph fistula, presbycusis
Labyrinthitis (vestibular neuronitis)

Etiology
Pathophysiology
Risk Factors
Symptoms (3)
Clinical Findings (3)
Dx/Labs
Treatment
Differentials
Etiology

2nd most common cause of vertigo. Viral form caused by preceding URI. Bacterial associated with otitis media. Usually lasts 7-10 days, may be single or recurrent over 12-18 months


Pathophysiology

An inflammatory condition caused by bacteria or viruses that affects the labyrinth in the cochlea and vestibular system of the inner ear.


Risk Factors

Adolescents and young adults


Symptoms

  • Vertigo (lasting days to weeks)
  • hearing loss
  • tinnitus
Clinical Findings

  • Nystagmus
  • Vertigo with eyes opened and closed
  • Recent URI, sinusitis or OM
Dx/Labs

Weber, Rinne and audiogram


Treatment

  • Antibiotics for bacterial infection
  • Vestibular supressants but not for long-term dysequilibruim
  • Diazepam
  • Meclizine and scopolamine patches

Differentials

Meniere disease, vestibular neuritis, BPV, acoustic neuroma, temporal bone fracture, inner ear malformation
Meniere's disease

Etiology
Pathophysiology
Symptoms
Clinical Findings
Dx/Labs
Treatment (3)
Differentials
Etiology

Cause unknown.


Pathophysiology

Endolymphatic hydrops from increased production or impaired absorption of endolymph which causes distention and repture of Reissner membrane


Symptoms

Episodic vertigo lasting 20 minutes to several hours with sensorineural hearing loss, tinitus and aural pressure sensation


Clinical Findings

Positive Romberg test, inability to walk tandem


Dx/Labs

Based on documenting episodic severe attacks accompanied by fluctuating hearing levels on audiometric testing
CT and MRI


Treatment

  • Managed with diuretics and salt restriction
  • Diazepam (Valium) IM or PO
  • Tigan for N/V
Differentials

acoustic neuroma, vestibular migrane, vestibular neuronitis, viral labyrinthitis, vertebrobasilar insufficiency
Cerumen impaction

Etiology
Risk Factors
Symptoms
Clinical Findings
Treatment
Etiology

Often self-induced
- cotton tip applicator
- FB

Risk Factors

  • Old age
  • Q-tip use

Symptoms

Conductive hearing loss, possible tinnitus


Clinical Findings

May be unable to see TM

Treatment

Detergent ear drops, mechanical removal, suction, irrigation with body temp. water.
Barotrauma

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Treatment
Etiology

Persons with poor eustachain tube function (congenital, narrowness or acquired mucosal edema) may be unable to equalize barometric stress during altitude changes.


Pathophysiology

injury in ears of sinuses. Change of pressure pulls/pushes on TM causing pain.


Risk Factors

Changing altitude rapidly (driving/flying)
- not knowing how to swallow (infants)

Symptoms

Extreme pain. Can be bloody discharge with ruptured TM


Clinical Findings

May note petechiae, hemorrhagic blebs or ruptured TM


Treatment

Decongestants (pseudoephedrine)
Valsalva, chewing gum
Benign Positional Vertigo

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Most common cause of vertigo. Can occur after trauma of inner ear infection but most commonly it's spontaneous and in older people.


Pathophysiology

Occurs when otolith debris inadvertently enters a semicircular canal.


Risk Factors

URI 1-2 weeks prior, family members with similar symptoms. Also, head injury, labyrinthitis, vascular occlusion


Symptoms

Brief episodes of vertigo (<1min) with positional change with assoc. N & V
**no hearing loss or tinnitus


Clinical Findings

Paroxysmal positional nystagmus after rapid change from sitting to the head-hanging position (Dix-Halpike maneuver).


Dx/Labs

Dix-Halpike maneuver


Treatment

Simple bedside maneuvers or Epley maneuver (repositioning otolith debris)


Differentials

Meniere, Vestibular neuronitis, labyrinthitis, perilymphatic fistula, central disorders, infarcts in the posterior fossa
Cholesteatoma

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Treatment
Etiology

Keratinizing squamous epithelium in middle ear caused by prolonged eustacian tube dysfunction and chronic otitis media. TM is drawn in for a prolonged time and becomes keratinized.


Pathophysiology

Keratinized epithelium erodes ossicles and bony labyrinth resulting in mixed sensorineural and conductive hearing loss. Pseudomonas aeruginosa.


Risk Factors

recurrent otitis media


Symptoms

  • Hearing loss
  • Bleeding from ear
  • Dizziness/vertigo
  • Earache
  • HA
  • Tinnitus
  • Intermittent pain
  • 1-sided facial weakness
Clinical Findings

  • Chronically draining ear, usually with a foul odor.
  • TM perforation >90% patients.
  • Epitympanic retraction pocket (usually yellow)
Treatment

Surgical removal of the entire debris-filled sac or just draining it (a cholesteatoma is unresponsive to antimicrobial therapy)
Otosclerosis

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Etiology

An inherited disorder. Most requent cause of middle ear hearing loss in young adults. Commonly seen in women 15 to 30.


Pathophysiology

Causes progressive conductive hearing loss by immobilizign the stapes with new bone growth in front of and below the oval window


Risk Factors

Young, women, family members with disease


Symptoms

Slow progressive hearing loss, tinnitus, balance problems


Clinical Findings

Chronic conductive hearing loss or sensorineural hearing loss. 10% of people may have otosclerotic lesions of their temporal bone.


Treatment

Refer to otolaryngologist for hearing aid or surgical replacement of stapes with prosthesis (stapedectomy)
Presbycusis

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Etiology

Age-associated hearing loss, bilateral. Specifically high-frequency hearing loss.


Pathophysiology

Develops from damage to hair cells of organ of Corti. Occurs due to intense noise, ototoxic drugs, viral infections, meningitis or Meniere's disease.


Risk Factors

Age mo-fos!


Symptoms

Difficulty understanding speech when in noisy environments. Other hearing related symptoms.


Clinical Findings

Decreased high-frequency hearing with audiometry


Dx/Labs

Audiometry, whisper test


Treatment

Hearing aid
Genetic Basis for deafness

genetic basis of heredity deafness and be able to identify a number of syndromes which lead to this condition
Genetically determined deafness, usually from hair cell aplasia or deterioration, may be present at birth or may develop in adulthood.

Mutations in connexin 26, a key component of gap junctions in the inner ear, account for the majority of cases of recessively inherited deafness.

Intrauterine factors
resulting in congenital hearing loss include infection (especially rubella); toxic, metabolic, and endocrine disorders; and anoxia associated with Rh incompatibility and difficult deliveries.

Three genetic disorders that can cause hereditary deafness are:

  • Alport syndrome
  • Neurofibromatosis
  • Branchiootorenal syndrome
  • Waardenburg syndrome
x of y cards