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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