Ear

Question 1

What is otitis media? Classification?

Answer 1

Inflammation of the middle ear

1. Acute suppurative - viral/bacterial infection –> pain and tenderness
2. Chronic suppurative - persistent drainage –> conductive hearing loss, not painful
3. Serous/secretory - non-suppurative fluid accumulation (eustachian tube dysfunction) –> hearing loss

Question 2

Who gets otitis media? Aetiology?

Answer 2

Common condition - children aged 3-6 years

Usually follows URTI (viral or bacterial)

• Viruses = RSV, parainfluenza, rhinovirus, enterovirus
• Bacteria = Strep, H.influenzae, Moraxella, group A staph/strep

Question 3

Signs and symptoms of otitis media?

Answer 3

Symptoms

• Ear pain (throbbing and severe)
• Pyrexia
• Ear rubbing in kids
• Otorrhoea (blood stained à thick and yellow)

Signs

• Conductive deafness/tinnitus
• Tympanic membrane = dull, ↓light reflex, red, ↓mobile, bulging –> perforation
• Tenderness in mastoid antrum

Question 4

Complications of otitis media?

Answer 4

Rare - intracranial/extracranial

• Persistent middle ear effusion
• Contiguous/ haematogenous spread to other structures (mastoid, inner ear, temporal bones, meninges, brain)
• Spread of infection –> facial palsy, brain/dural abscesses, endocarditis

Question 5

Management of otitis media?

Answer 5

Reassurance

• 80% recover in around 3 days without abx.
• No evidence for decongestants, or ear drops if intact eardrum

Analgeisa

• Paracetamol/ibuprofen (+ fluids)

Antibiotics

• No prescribing, delayed prescribing (if persisting for >4 days), or immediate prescribing.
• Amoxicillin or erythromycin

Question 6

Indications for offering immediate abx in otitis media?

Answer 6

• Patient is systemically very unwell
• Signs/symptoms suggestive of serious illness/complications (pneumonia, mastoiditis, peritonsillar abscess etc)
• If at high risk of complications because of co-morbidities (heart/lung/renal/liver disease, CF, prem babies)
• Older than 65 with acute cough and 2 or more of: hospitalised in previous year, type 1/2 DM, CCF, current steroid use.

Question 7

What is otitis externa and how does it occur?

Answer 7

• Inflammation of skin lining the external auditory meatus. Often called “swimmer’s ear”.
• Sac-like structure is prone to collection of water –> gets moist and dampened –> lovely environment for bacterial and fungal growth à infection.
• Removing or breaching the natural oil barrier in the meatus (trauma) allows bacteria to penetrate into the skin of the canal

Question 8

Causes of otitis externa?

Answer 8

• Infective - bacteria, fungi
• Allergy - eczema, contact allergy
• Iatrogenic - frequent ear syringing

RFs

• Moisture – swimming, bathing, perspiration, high humidity
• Foreign objects – cotton buds, finger nails, hearing aids
• Trauma – vigorous cleaning
• Chronic skin diseases – eczema, psoriasis

Question 9

Signs and Symptoms of Otitis Externa?

Answer 9

Symptoms

• No discharge (no mucous secreting glands in external ear)
• Pain – only if secondary bacterial infection occurs
• Hearing loss - mild

Signs

• Meatal tenderness – often marked, especially on movement of pinna
• Narrowed, oedematous meatus
• Meatal debris

Question 10

Complication of otitis externa?

Answer 10

Malignant otitis externa

• Otitis externa which has spread to cause osteomyelitis of the skull base
• Due to pseudomonas and anaerobes causing a mound of tissue in the external canal
• Facial nerve palsy occurs in 50% of cases
• Mostly immunocompromised patients – elderly diabetics.

Question 11

Investigations in otitis externa?

Answer 11

• Swab any discharge for culture
• Investigate for diabetes if patient over 50

Question 12

Management of otitis externa?

Answer 12

Advice

• Don’t poke ear; use olive oil for wax removal or irritation; don’t rub ears when drying after washing/swimming (drain by tilting head to side)

Eardrops

• Containing antibiotic and anti-inflammatory (Gentisone-HC contains gentamicin and hydrocortisone à appropriate for most bacteria)

Oral Abx

• May occasionally be prescribed with topical treatment (fluclox, or ciprofloxacin if pseudomonas suspected).

Question 13

What does cerumen (ear wax) contain?

Answer 13

• Complex mixture of lipids produced by sebaceous glands of EAM as means of protecting epithelial lining of the tract.
• Made of epithelial cells, hair and secretions of external ear.

Question 14

Risk factors for impacted earwax?

Answer 14

Old age, learning disability, use of cotton swabs in ears, hearing aids, earplugs

Question 15

Management of impacted ear wax?

Answer 15

Softening

• Use olive oil for at least 1 week before attempting syringing

Removal

• Irrigation (syringing) – contraindicated if perforated ear drum, recent otitis externa/media, or if only hearing ear.
• Removing wax manually – curette, forceps, suction.

Advice

• Never put cotton swabs or other objects in ear canal!

Question 16

Types of deafness?

Answer 16

• Conductive = lesions in outer or middle ear
• Sensorineural = lesions in inner ear or auditory nerve
• Mixed = conductive/sensorineural both involved

Question 17

Causes of conductive deafness?

Answer 17

• Wax/foreign body
• Eustachian tube dysfunction
• Otitis media/externa
• Otosclerosis
• Paget’s disease
• Barotrauma

Question 18

Acquired causes of sensorineural deafness? (think surgical seive)

Answer 18

• Infective – rubella, syphilis, CMV, HSV, meningitis, mumps
• Trauma – chronic noise exposure, petrous temporal bone fracture, surgery
• Autoimmune
• Metabolic – diabetes, hypothyroidism, Paget’s disease
• Neoplastic – acoustic neuroma
• Degenerative
• Toxic – drugs (aminoglycosides, loop diuretics, cytotoxics)
• Meniere’s disease

Question 19

Rinne’s and Weber’s interpretation?

Answer 19

Weber’s conductive

• Sound heard better in deaf ear (ipsilateral) because it’s only receiving input from bone and not air –> innear ear (functioning) picks up noise and middle ear doesn’t pick up ambient noise from room.

Weber’s sensorineural

• Sound heard better in good ear (contralateral) because affected ear not picking up input from bone.

Question 20

Investigations in deafness?

Answer 20

Simple voice tests, tuning fork tests

Audiometry

• Pure tone = measurement of indivual’s hearing sensitivity for calibrated pure tone

Screening (children)

Question 21

4 categories of dizziness?

Answer 21

1. Vertigo - hallucination of movement about the patient, or of the patient with respect to the environment
2. Presyncope - feeling of impending faint, caused by reduced total cerebral perfusion
3. Disequilibrium - feeling of unsteadiness or imbalance when standing
4. Light-headedness - “wooziness”

Question 22

What is labyrinthitis? Symptoms?

Answer 22

• Commonest cause of acute vertigo; associated with sweating, nausea, vomiting, pallor and occasional diarrhoea.
• Presumed to be of viral origin in most cases – in elderly it may be due to an ischaemic event.

Nystagmus – towards the side contralateral to the lesion

Profound sensorineural deafness (sometimes)

Question 23

Investigations in labyrinthitis?

Answer 23

Romberg’s test, provocation tests (Hallpike test)

Question 24

Differentials for dizziness?

Answer 24

Peripheral vertigo - BPPV, Meniere’s, vestibular neuronitis, cholesteatoma

Central vertigo – acoustic neuroma, MS, head injury,

Drugs – gentamicine, diuretics, co-trimoxazole, metronidazole

Question 25

Management of labyrinthitis?

Answer 25

**Anti-emetic** – prochlorperazine, promethazine, cyclizine **Vestibular sedatives** – cinnarizine, betahistine

Question 26

Vestibular Neuronitis/Acute Vestibular Failure?

Answer 26

* Acute inflammation of the vestibular nerve * Sustained non-positional vertigo in previously healthy young or middle age adult * Nystagmus/unsteady gait; N+V; no tinnitus/hearing loss/neurological signs

Question 27

Méniére’s disease?

Answer 27

Vertigo with... 1. Prostration (weakness) 2. Nausea/vomiting 3. Feeling of fullness in ear 4. Unilateral or bilateral tinnitus 5. Sensorineural deafness

Question 28

BPPV?

Answer 28

Displacement of otoconia in semi-circular canals. Brief episodes of vertigo/nausea on moving the head. No persistent vertigo, no speech, visual, motor or sensory problems, no tinnitus, headache, ataxia, facial numbness or dysphagia, no vertical nystagmus. HALLPIKE TEST. Fixed by Epley manoeuvres.

Question 29

What is cholesteatoma?

Answer 29

* Active squamous otitis media * Serious rare complications (meningitis/cerebral abscess). * Locally destructive around and beyond pars flaccida.

Question 30

Presentation of cholesteatoma? Management?

Answer 30

* Peak age: 5-15 years. * Foul discharge +/- deafness; headache, pain, facial paralysis and vertigo indicate impending CNS complications **_Management_** * Mastoid surgery needed to make a safe dry ear by removing disease.