Ear Disorders

Question 1

Cerumen impaction

Answer 1

• tx w/ cerumenolytic: mineral oil, baby oil, glycerin, peroxide-based ear drops, hydrogen peroxide, and saline irrigation

Question 2

Otitis externa

Answer 2

• 90% bact (pseudomonas, strep, staph): neo/poly/cipro if TM intact +/- steroid, topical FQ (ofloxacin) or PO if swollen canal/perf’d TM/immunocomp’d
• fungal: aspergillus, actinomyces, candida: acetic acid, cipro or clotrimazole drops
• think eczema if chronic: tx like flare + acetic acid ppx
• malignant OE: osteomyelitis of temporal bone from chronic inf in DM: emergent ENT ref, admit, parenteral abx

Question 3

Trauma

Answer 3

• 2nd MC cz of sensory hearing loss (presbycusis - 1st)

- > 85 dB can cz cochlear damage

Question 4

Acoustic neuroma

Answer 4

• b9 intracranial mass affecting CN VIII
• unilateral, prog HL w/ impaired speech discrimination, continuous vertigo
• dx via MR
• tx: surg/focused rad (consider overall health/comorbids)

Question 5

Barotrauma

Answer 5

• URI, mechanical ventilation, diving, high alts (esp descent)
• keep ear dry, control pain, decongestants/antihistamines, can consider myringotomy of sev pain/HL/
• ppx: decongestants b4 plane travel

Question 6

Eustachian tube dysfunction

Answer 6

• blockage allows air to exit middle ear, but not return = negative pressure
• s/s: TM retraction, pain, HL, fullness
• acute tx: nasal steroid spray, decongestants
• chronic tx: bilateral tube placement
• prog: risk of cholesteatoma if untx’d

Question 7

Labyrinthitis

Answer 7

• inf/inflam of inner ear, usually from latent virus
• vertigo + HL (sev, disabling vertigo x 24-48 hrs then wks of imbalance, V, pts think they’re dying)
• tx: steroids, PT (can do abx if F/signs of inf), vestibular suppressants (antichol’s, antihist’s, bzd’s)
• vestibular neuritis: only semicircular canals affected (no HL)

Question 8

Vertigo

Answer 8

• central: balance centers of brain (gradual onset, constant sx, +/- N, vertical nystagmus, usually no HL)
• vestibular suppressants for acute sx (diazepam, meclizine)
• ddx: CV, neuro, anemia, psych, metabolic (hyperthyroid, menopause), ortho, geriatric (polypharm)
• BPPV: otolith dislodged into semicircular canals
• intermittent, < 1 min, NO HL, better w/ head still (worse w/ R/L movements when lying down, vertical/horizontal nystagmus
• Dix-Hallpike maneuver = diagnostic (delayed, fatigable nystagmus w/ 90 deg turn when supine)
• Epley maneuver = therapeutic

Question 9

Cholesteatoma

Answer 9

• keratinized, desquamated epithelial collection in middle ear or mastoid
• s/s: HL, dizzy, otorrhea, white mass behind TM, TM retraction, obstructive polyp
• wu: CT or MR if comps present
• tx: surg removal

Question 10

Otitis media

Answer 10

• acute: strep, H flu, M cat, viral
• HL!!, pain/fullness, prior URI, F, irritable, pull at ears
• chronic suppurative: freq AOM w/ otorrhea as result of TM perf (MC) or tube placement
• psudomonas, s aureus, proteus, anaerobes
• w/ effusion: fluid behind TM w/o presence of infection
• due to chronic ET dysfxn, prev AOM, or barotrauma
• tx: NSAIDs if mild and pt > 2 y.o., inf/F: abx x 10-14 d (amox = DOC, erythro, augmentin, septra, ceftriaxone), surg ref if bilat effusion > 3 mos & bilat HL, consider chronic tx w/ amox qd during winter/spring w/ monthly appts (10 d FQ for chronic)

Question 11

TM perforation

Answer 11

• s/p trauma/inf
• acute onset pain +/- bloody otorrhea
• can have tinnitus, vertigo
• surg w/ persistent HL
• ENT ref if serious HL, facial nerve paralysis, N/V, ataxia
• usually self-limited, will heal, test hearing after, avoid water to ppx 2ndary inf

Question 12

Hearing impairment/loss

Answer 12

• urgent ENT ref for sudden hearing loss
• conductive: impaired transmission to inner ear
• MC cerumen impaction, otitis externa, otosclerosis (abnml bony growth of middle ear)
• Weber: lateralize to affected ear
• Rinne: BC > AC in affected ear
• tx: AC hearing aid, BC device
• sensorineuronal: damage of inner ear (cochlea)
• MC presbycusis (genetic, noise/med exposure), gradual, higher frequencies 1st
• Weber: lateralized to unaffected ear
• Rinne: AC > BC in affected ear
• contrasted CT/MR if progressive, asymmetric, labs (glucose, CBC, TSH, RPR if idiopathic
• tx: cochlear implant
• in peds, think MMR, pertussis, meningitis, flu, labyrinthitis

Question 13

Mastoiditis

Answer 13

• comp of acute/chronic OM
• F, posterior ear pain, pinna edema, auricle displaced infraposteriorly
• CT
• admit for IV abx (vanc, ceftriaxone) +/- mastoidectomy

Question 14

Meniere’s disease

Answer 14

• inc’d endolymphatic fluid/hydrops, unknown eti
• triad: recurrent vertigo (x mins-hrs) + low freq hearing loss + tinnitus
• can have ear fullness
• tx w/ low Na diet, diuretics, antivert meds (meclizine)

Question 15

Tinnitus

Answer 15

• wu: audiometry, ref for imaging if pulsatile (vasc/tumor)
• tx: cochlear implat if sensorineuronal HL, stop ototoxic meds (ASA too), avoid caffeine & nicotine, tx conductive eti

Question 16

Ototoxic meds

Answer 16

• aminoglycosides: gentamicin, neomycin, tobramycin, streptomycin, amikacin
• loop diuretics: furosemide, torsemide, bumetadine
• antiCA: cisplatin

Question 17

Invasive procedures

Answer 17

• tympanostomy: ET tube
• tympanocentesis: drain fluid from inner ear
• myringotomy: TM incision for fluid drain/pressure relief

Question 18

Ext ear hematoma

Answer 18

• regional auricular block w/ I&D or indwelling cath placement if large
• ENT ref for draining if > 7 days
• abx x 7-10 days for pseudomonas coverage (cipro, genta, carbapenems, aztreonam, ceftazidime)
• no contact sports x 1 wk, fu app in 3-5 days
• “cauliflower ear”

Question 19

FB tx/ref

Answer 19

• tx: local anesthesia w/ removal for embedded jewelry, irrigation, forceps
• sys abx if peri/chondritis present
• ENT ref for button batteries, vegetable matter (will swell s/p irrigation), penetrating FB, or assoc inj to TM