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EAR PAIN Auricle Hematoma Cellulitis Relapsing Polychondritis Hematoma A localized mass of extravasated blood within the auricle- “bruise” Hematoma Must be drained to prevent significant cosmetic deformity dissolution of supporting cartilagecauliflower ear Cellulitis Inflammation of the cellular tissue May include lobule Treat with Augmentin or Keflex Complications- perichondritis and its resultant deformity Relapsing Polychondritis Auricular erythema and edema Recurrent, frequently bilateral, painful Does not include lobule- no cartilage Systematic- may progress to involvement of the tracheobronchial tree Treat- Corticosteroids might forestall cartilage dissolution External Otitis Otitis Externa Otalgia Pruritus Purulent discharge Often recent water exposure or mechanical trauma Examination Erythema Edema Purulent exudate Auricular pain with manipulation TM- moves normally with pneumatic otoscopy Treatment Avoid moisture Otic drops containing aminoglycoside antibiotic and anti-inflammatory corticosteroid--neomycin sulfate, polymyxin B sulfate, and hydrocortisone Ear wick Auricular Pruritis Common site- meatus usually self induced – excoriation – overly zealous ear cleaning Otitis Externa?? Dermatologic condition – seborrheic dermatitis – psoriasis Treatment Regeneration of Cerumen “blanket” Avoid drying agents- soap & water, swabs Mineral oil 0.1% Triamcinolone- topical corticosteroid Oral antihistamine Stop messing with it!!!! Malignant External Otitis Persistent external otitis Evolves into Osteomyelitis of the skull base – Diabetic or Immunocompromised Pseudomonas aeruginosa Clinical Findings Persistent foul aural discharge Granulation in the ear canal Deep otalgia Progressive cranial nerve palsies – (VI, VII, IX, X, XI, XII) Diagnosis confirmed with CT – osseous erosion Treatment Prolonged (antipseudomonal) ATB therapy – IV or Oral ciprofloxacin Occasional surgical debridement Serous Otitis Media Caused by negative pressure – Blocked auditory tube – Transudation of fluid • children- tubes more narrow, more horizontal • common after URI • adults- persistent--think cancer Clinical Findings Dull, hypomobile TM Air bubbles in middle ear Conductive hearing loss Treatment Autoinflation Oral corticosteroids Oral ATB All else fails, ventilating tubes Barotrauma Negative pressure tends to collapse and lock the auditory tube – Rapid altitudinal change • Air travel • Scuba diving Treatment Swallow, yawn, autoinflate Systemic or topical decongestants – pseudoephedrine – phenylephrine nasal spray If persists on ground after treatments listed above… – Myringotomy provides immediate relief – Ventilating tubes- frequent flyer Acute Otitis Media Bacterial infection of the mucosally lined air-containing spaces of the temporal bone. – Usually precipitated by viral URI which causes auditory tube edema…accumulation of fluid that becomes secondarily infected with bacteria – Streptococcus pneumoniae (49%), Haemophilus influenzae (14%), Moraxella catarrhalis (14%) H&P Findings Otalgia Aural pressure Decreased hearing Fever erythema Decreased mobility of TM TM bulge – perforation eminent Treatment ATB – amoxicillin – erythromycin – sulfonamides Decongestants Tympanocentesis Ventilating tubes ppx – sulfamethoxazole – amoxicillin Chronic Otitis Media Chronic infection Perforation of TM usually present Mucosal changes P. aeruginosa, Proteus, Staphylococcus aureus Clinical Findings Hallmark- purulent aural discharge Pain- on/off Conductive hearing loss Treatment Removal of debris earplugs to protect against water exposure ATB drops for exacerbations Definitive- surgical TM repair – eliminate infection – reconstruction of TM Cholesteatoma* Special variety of chronic otitis media Most common cause is prolonged auditory tube dysfunction, with resultant chronic negative middle ear pressure that draws inward the upper flaccid portion of the tympanic membrane. *see picture Cholesteatoma Creates a squamous epithelium-lined sac Becomes obstructed and fills with desquamated keratin and becomes chronically infected Typically erodes bone, causes destruction of nerves, may spread intracranially Cholesteatoma Physical examination – epitympanic retraction pocket or marginal tympanic membrane perforation that exudes keratin debris Treatment – surgical marsupialization of the sac or its complete removal Mastoiditis- complication of OM Postauricular pain and erythema Spiking fever X-ray reveals coalescence of the mastoid air cells due to destruction of their bony septa IV ATB and myringotomy for culture and drainage Mastoidectomy if other fails... Petrous apicitis- complication of OM Medial portion of the petrous bone between the inner ear and clivus may become a site of persistent infection Foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy Prolonged ATB therapy and surgical drainage Otogenic skull base osteomylitiscomplication of OM Osteomyelitis of the skull base Usually due to P aeruginosa Facial paralysis- complication of OM Acute– Results from inflammation of the nerve in its middle ear segment, perhaps through bacterially secreted neurotoxins • Myringotomy for drainage and culture • IV ATB • prognosis excellent Chronic – Evolves slowly due to chronic pressure on the nerve in the middle ear or mastoid by cholesteatoma – surgical correction of the underlying disease – prognosis less favorable Sigmoid sinus thrombosis complication of OM Trapped infection within the mastoid air cells adjacent to the sigmoid sinus may cause septic thrombophlebitis Systemic sepsis- spiking fevers, chills Increased intracranial pressure- HA, lethargy, nausea and vomiting, papilledema Diagnosis- MR venography Tx- IV ATB, surgical drainage Central Nervous System Infection - complication of OM Otogenic meningitis- most common intracranial complication of ear infection Non-auditory causes of earache Temporomandibular joint dysfunction – chewing (soft foods, massage) – psychogenic – dental malocclusion (dental referral) Glossopharyngeal neuralgia – refractory to medical management, may respond to decompression of ninth nerve Non-auditory causes of earache Infections and neoplasia that involve the oropharynx, hypopharynx, and larynx – persistent earache demands specialty referral to exclude cancer of the upper aerodigestive tract
