What is pinna haematoma?
Shearing forces to auricle causes separation of perichondrium from cartilage which causes tearing of perichondrial blood vessels.
Hx includes trauma from rugby, football, wrestling, cage-fighting. Rule out any head injury and rule out hearing loss.
What is the management of pinna haematoma?
Early drainage within 24 hours of injury to prevent complications, oral antibiotics if infection and refer to ENT clinic for follow up.
What is pinna perichondritis?
Most common organism is pseudomonas (s. aureus if cellulitis)
Hx includes penetrating trauma such as piercing, OE, eczema/psoriasis and insect bite. There are systemic features of infection. There shouldn’t be neurological signs but can occur with diabetes and immunosuppression.
What is the management of pinna perichondritis?
Management includes topical and oral antibiotics, pinna swab and analgesia.
Topical gentamicin or flucloxacillin is usually used.
What are the complications of pinna perichondritis?
Complications include abscess causing cauliflower ear, necrotising fasciitis and systemic infection.
What is otitis media?
Otitis media (OM) is an umbrella term for a group of complex infective and inflammatory conditions affecting the middle ear. All OM involves pathology of the middle ear and middle ear mucosa.
What is the pathophysiology of OM in children?
Infecting organisms reach the middle ear from the nasopharynx. Children are particularly vulnerable to the transfer of organisms from the nasopharynx to the ear.
As children grow bigger, the angle between the Eustachian tube and the wall of the pharynx becomes more acute, so that coughing or sneezing tends to push it shut. In small children, the less acute angle facilitates infected material being transmitted through the tube to the middle ear.
In most cases, AOM can be regarded as a complication of a preceding or concomitant upper respiratory infection.
The most common bacterial pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Streptococcus pyogenes.
What are the risk factors of OM?
Younger age.
Male sex.
Smoking in the household.
Daycare/nursery attendance.
Formula feeding - breast-feeding for three months and above has a protective effect.
Craniofacial abnormalities - eg, Down’s syndrome, cleft palate.
Which factors are associated with recurrent OM?
Early first episode. Gastro-oesophageal reflux disease (GORD). Dummy use. Winter season. Supine feeding.
What is the presentation of OM in kids?
AOM commonly presents with acute onset of symptoms:
- Pain (younger children may pull at the ear).
- Malaise.
- Irritability, crying, poor feeding, restlessness.
- Fever.
- Coryza/rhinorrhoea.
- Vomiting.
Signs
- High temperature (febrile convulsions may be associated with the temperature rise in AOM).
- A red, yellow or cloudy tympanic membrane.
- Bulging of the tympanic membrane.
- An air-fluid level behind the tympanic membrane.
- Discharge in the auditory canal secondary to perforation of the tympanic membrane - this may obscure the view completely.
- The pinna may be red.
Children under 6 months of age may display nonspecific symptoms.
What are the differentials of OM?
OE Otitis media with effusion Respiratory tract infection Foreign body TMP joint pain Trauma Cholesteatoma
What are the investigations for OM?
Usually no investigation is required.
Culture of discharge from an ear may be indicated in chronic or recurrent perforation or if grommets are present.
Audiometry should be performed if chronic hearing loss is suspected; however, not during acute infection.
CT or MRI may be appropriate if complications are suspected.
What is the management of OM?
Admit children under 3 months of age with a temp of 38 and children with suspected complications of otitis media such as meningitis, mastoiditis or facial nerve paralysis.
Consider admitting children under 3 months, kids who are very unwell and kids between 3-6 months with a temp of 39 or more.
Treat pain and fever with paracetamol or ibuprofen. Don’t give both simultaneously.
For most children, adopt a no antibiotic prescribing strategy, or a delayed antibiotic prescribing strategy:
-No antibiotic prescribing strategy - reassure that antibiotics are likely to make little difference to symptoms but may have adverse effects and can contribute to antibiotic resistance.
Offer antibiotics to kids who are systemically unwell and those at high risk of complications and those whose symptoms have lasted for 4 days or more.
Prescribe a five-day course of amoxicillin or five day course for erythromycin or clarithromycin if there is an allergy.
What is the management of recurrent OM?
Consider referral to an ENT specialist especially if:
- The child has a craniofacial abnormality.
- Recurrent episodes are very distressing or associated with complications.
- Children with discharge or perforation have symptoms that have not resolved within three weeks
- Children have had recurrent AOM (more than three episodes in six months or more than four in one year).
- Children have impaired hearing following AOM. If aged under 3 with OME, bilateral effusions and mild hearing loss with no speech, language or developmental problems, observe initially. Otherwise, refer for consideration of grommets.
- Do not start long-term prophylactic antibiotics in primary care.
What are the complications of OM in kids?
Chronic suppurative otitis media Meningitis Labyrinthitis Facial nerve palsy Cholesteatoma Mastoiditis Petrositis
What is acute OM?
AOM is an acute inflammation of the middle ear and may be caused by bacteria or viruses. A subtype of AOM is acute suppurative OM, characterised by the presence of pus in the middle ear. In around 5% the eardrum perforates.
What are the risk factors for OM in adults?
Eustachian tube dysfunction. Upper respiratory infection. Allergies. Chronic sinusitis. Craniofacial abnormalities - eg, cleft palate, Down's Syndrome. Immunosuppression. Active or passive smoking.
What is the presentation of OM in adults?
Hearing loss
Otalgia
Fever
What are the differentials of OM?
GCA Trigeminal neuralgia Migraine Herpes zoster Trauma
What are the investigations of OM?
Culture of discharge may be helpful
CT/MRI to exclude complications
Tympanocentesis (piercing of the tympanic membrane to obtain fluid from the middle ear)
What is the management of OM?
Analgesics and antipyretics should be used as appropriate.
Antibiotic guidelines are as for children.
Nasal and oral steroids are sometimes indicated for adults with persistent AOM against a background of allergies.
More invasive interventions - eg, myringotomy - are virtually unheard of in adults since the advent of antibiotics.
What is otitis media with effusion?
Otitis media with effusion (OME), also called glue ear, is characterised by a collection of fluid in the middle-ear cleft. There is chronic inflammation but without signs of acute inflammation.
It is uncommon in adults, in whom Eustachian tube dysfunction is the predominant cause and suspicious aetiologies should be considered.
Most cases of OME will resolve spontaneously. However, in affected ears the average hearing loss is 20 decibels (dB) but may be as much as 50 dB.
What are the risk factors for OME in kids?
Same RF as otitis media
OME may then occur because of one or more of the following:
- Impaired Eustachian tube function reducing aeration of the middle ear.
- Low-grade infection (bacterial or viral).
- Chronic colonisation of the adenoids, which may act as a source of bacteria entering the middle-ear cleft.
- Persistent inflammation.
- Adenoidal infection or hypertrophy.
- OME is more common in children with craniofacial malformations, particularly cleft palate.
What are the risk factors for OME in adults?
Eustachian tube dysfunction (ETD) is the main aetiological factor in adults.
