Ear pathology

Question 1

Conditions of the external ear

Answer 1

Haematoma
Otitis externa
Costochondritis
Ear wax

Question 2

Conditions of the middle ear

Answer 2

Otitis media with effusion 
Chronic suppurative otitis media
Tympanic perforation
Otitis media 
Sinusitis 
Cholesteatoma

Question 3

Inner ear conditions

Answer 3

Mastoiditis
Meniere’s disease
Labyrinthitis
Age relate hearing loss

Question 4

Red flag signs

Answer 4

Inflammation behind ear - mastoiditis

Facial droop - facial nerve palsy

Unilateral tinnitus - Acoustic neuroma

Smelly discharge that causes recurrent ear infections - cholesteatoma

Question 5

Otitis externa

Answer 5

Presentation: inflammation of the external ear canal

• red, swollen, or eczematous with shedding of the scaly skin.
• Discharge may be present in the ear canal
• Pruritis
• Severe ear pain
• Tender over jaw

Causes:

• bacterial infection
• fungal infection
• Seborrhoeic dermatitis
• Contact dermatitis
• Trauma

Prognosis :
- Symptoms usually improve within 48–72 hours of initiation of treatment

Question 6

Acute vs chronic otitis externa

Answer 6

Acute - lasts 3 weeks or less

Chronic - lasts longer than 3 months

Question 7

Malignant (necrotising) otitis externa

Answer 7

Aggressive infection that predominantly affects people who are immunocompromised.

Otitis externa spreads into the bone surrounding the ear canal (the mastoid and temporal bones).

Question 8

Common causative organism of otitis externa

Answer 8

Bacterial:
Psuedomonas aeruginosa
Staphylococcus aureus

Fungal:
Aspergillus
Candida
Deep - trichophyton

Question 9

Mx of otitis externa

Answer 9

Conservative:

• Analgesia and heat pad
• Clean external auditory canal

Medical:

• Otomize Ear Spray - topical abx + corticosteroid- minimum of 7 days
• Oral antibiotics for severe infection - 7-day course of flucloxacillin or clarithromycin

Chronic:
Fungal infection - topical antifungal - Acetic acid spray or clotrimazole
7-day course of a topical corticosteroid without antibiotic

Question 10

When are oral antibiotics indicated in otitis externa

Answer 10

Cellulitis extending beyond the external ear canal.

When the ear canal is occluded by swelling and debris, and a wick cannot be inserted.

People with diabetes or compromised immunity, and severe infection or high risk of severe infection, for example with Pseudomonas aeruginosa

Question 11

Methods for cleaning external auditory canal

Answer 11

Syringing or irrigation
Dry swabbing
Microsuction

Question 12

Complications of untreated ear haematoma

Answer 12

Cauliflower ear - costochondritis

Cartilage is avascular and receives blood supply from skin therefore if disrupted causes necrosis of cartilage

Question 13

Mx of ear haematoma

Answer 13

Pack skin against cartilage

Drain blood

Question 14

Acute otitis media definition and causes

Answer 14

Inflammation in the middle ear accompanied by the rapid onset of symptoms and signs of an ear infection - commonly in children

Causes: 
Bacterial: 
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
-  Streptococcus pyogenes

Viral:

• respiratory syncytial virus
• rhinovirus
• adenovirus
• influenza virus
• parainfluenza virus

Question 15

Acute otitis media with effusion

Answer 15

Fluid in the middle ear, not associated with symptoms and signs of an acute ear infection

Fluid caused by a build up of exudate and causes TM retraction

Question 16

Why are children more likely to get acute otitis media

Answer 16

Acquire viral infections more often

Have shorter and more horizontal eustachian tubes

Question 17

Presentation of acute otitis media

Answer 17

Otalgia

Younger children - tugging at ear, fever, crying

Coexisting systemic
illness, such as bronchiolitis

Hearing loss - conductive

Question 18

Otoscopic findings of acute otitis media

Answer 18

Distinctly red, yellow, or cloudy tympanic membrane.

Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks

• bubbles behind the tympanic membrane - indicates effusion

Perforation of the tympanic membrane and/or discharge in the external auditory canal - suppurative OM

Question 19

Mx of acute otitis media

Answer 19

1. Advise usual course of acute otitis media is ~ 3 days, but can be up to 1 week.
2. Regular doses of paracetamol or ibuprofen for pain
3. 5–7 day course of amoxicillin back up
4. 5–7 day course of co-amoxiclav 2nd line

Question 20

Otitis media with effusion causes and mx

Answer 20

Causes:

• Impaired eustachian tube function causing poor aeration of the middle ear.
• Low-grade viral or bacterial infection.
• Adenoidal infection or hypertrophy

Mx

• observe for 6 - 12 wks as active resolution is common
• hearing aid
• grommets

Question 21

Congenital deafness

Answer 21

Sx:

• Muffling of speech
• Difficulty understanding words
• Delayed speech development
• Not being startled by loud sounds

Question 22

Dx and Mx of congenital deafness

Answer 22

Dx:

• Neonatal hearing-screening programme
• Referral paeds ENT
• CT or MRI - temporal bone and internal acoustic meatus
• FHx & Genetic testing

Mx:

• Hearing aids
• Cochlear implants
• Surgery

Question 23

Cholesteatoma presentation

Answer 23

Sx:

• Smelly otorrhea
• Recurrent or chronic purulent discharge that does not respond to antibiotics
• Hearing loss
• Tinnitus

Signs:

• Inflamed lesion in ‘attic’ of pars flaccida
• Retracted tympanic membrane
• Crust or discharge
• Perforation - insight into middle ear

Question 24

Cholesteotoma Dx and Mx

Answer 24

Diagnosi:
- Clinical suspicion from history and otoscopy findings

Management:
Semi urgent referral to ENT (emergency if pt has facial nerve palsy or vertigo)

Audiology assessment
CT scan
Topical antibiotics for discharge

Surgery - canal wall up mastoidectomy + 9 - 12 month follow up

Question 25

Cholesteatoma

Answer 25

Abnormal accumulation of squamous epithelium and keratinocytes within the middle ear or mastoid air cell spaces

Question 26

Chronic suppurative otitis media

Answer 26

Chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation - Ear discharge persisting for more than 2 weeks, without ear pain or fever. - Hearing loss in the affected ear. - A history of acute otitis media (AOM), ear trauma, or glue ear and grommet insertion. - A history of allergy, atopy, and/or upper respiratory tract infection. - Tinnitus and/or a sensation of pressure in the ear may also be present.

Question 27

Chronic suppurative otitis media mx

Answer 27

Do not swab the ear or initiate treatment Refer for ENT assessment Secondary care: abx and steroids (usually topical), and intensive cleaning of the affected ear

Question 28

Mastoiditis

Answer 28

Acute inflammation of the mastoid periosteum and air cells occurring when AOM infection spreads out from the middle ear

Question 29

Presentation of mastoiditis

Answer 29

- History of acute or recurrent episodes of otitis media. - Intense otalgia and pain behind the ear. - Fever. - Swelling, redness or a boggy, tender mass behind the ear. - Tympanic membrane bulges and is erythematous.

Question 30

Mx of mastoiditis

Answer 30

Refer to secondary care

Question 31

Acoustic Neuroma

Answer 31

Inner ear pathology: Symptoms: - unilateral sensorineural hearing loss - tinnitus - vertigo - facial numbness - loss of corneal reflex

Question 32

Ramsey Hunt syndrome

Answer 32

Viral infection - Herpes Zoster - painful rash - vertigo - sensorineural hearing loss - facial palsy

Question 33

Vestibular neuronitis presentation

Answer 33

- episodes of vertigo - hours - occurs after a recent viral illness - nausea and vomiting - hearing is not affected

Question 34

Otosclerosis presentation and Mx

Answer 34

``` Presentation: Bilateral hearing loss - conductive Tinnitus Pink tinge on otoscopy FHx Onset is usually at 20-40 years ``` Mx: Hearing aid Stapedectomy

Question 35

Otitis media with perforation Mx

Answer 35

First line - amoxacillin | 2nd line - erythromycin

Question 36

When to give abx for otitis media

Answer 36

Symptoms lasting more than 4 days or not improving Systemically unwell but not requiring admission Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease Younger than 2 years with bilateral otitis media Otitis media with perforation and/or discharge in the canal - otorrhoea