Download Ear Infection - For Medical Professionals

Ear Infection or is it?
Roger D. Tuggle, M.D. FACS
Division of Otolaryngology
31st Annual Internal Medicine Review July 2012
Ear Infection or is it?
Objective
Ear pain does not equal infection
Referred more common in adults
Discuss “non-ear” and ear conditions
Evaluation and management
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Ear Infection or is it?
Otalgia
Myofascial – TMJ, hyoid bone syndrome
Neoplastic
Otic
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Ear Infection or is it?
Temporomandibular joint disorder
Common cause of otalgia
Usually myofascial tenderness along with joint itself
May have history of bruxism (grinding teeth at night)
May have history of joint clicking when chewing
NO ear sxs except pain (drainage, hearing loss)
Normal exam of ear canal, TM
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Ear Infection or is it?
Temporomandibular joint disorder
Exam
palpate joint with opening/closing jaw
palpate anterior wall ear canal with opening/closing
palpate temporalis muscles (lateral scalp)
palpate insertion of temporalis onto coronoid process
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TMJ – anatomy/exam
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Otalgia - TMJ
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Ear Infection or is it?
Temporomandibular joint disorder
Initial Treatment (14 days)
soft diet/no gum chewing
moist heat or ice to affected joint/muscle
OTC dental splint for nighttime wear
medications – NSAID of choice, Flexeril
persistent sxs – Dentist/Oral Surgeon (?ENT)
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Otalgia- TMJ
Patient Handouts
Online
Krames
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Otalgia - TMJ
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Ear Infection or is it?
Hyoid bone syndrome
First reported 1954
Hyoid unique – does not attach to other bones
Described as insertion tendinitis at greater horn
May produce otalgia as well as neck pain
Swallowing may exacerbate
NO other ear sxs / normal exam
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Ear Infection or is it?
Hyoid bone syndrome
Exam:
Form a “U” with thumb and index finger
Place tips of thumb, index finger on the greater horns
Move the hyoid from side-to-side; positive if painful
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Hyoid bone syndrome
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Ear Infection or is it?
Hyoid bone syndrome
Treatment:
Moist heat or ice // massage
NSAIDs, Flexeril
Trigger point injection (Marcaine 0.5%/Kenalog-40)
Rarely, excision of greater horn
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Ear Infection or is it?
Carotidynia
Controversial diagnosis
Exam: Tenderness along entire length of artery
Treatment: Indomethacin 25-50 mg TID x 14 days
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Ear Infection or is it?
Trigeminal neuralgia
Initially may present with otalgia
With time, will usually progress to classic symptoms
(episodic, severe, lancinating facial pain)
Treatment: carbamazepine, gabapentin (Neurology)
balloon compression of trigeminal ganglion
stereotactic radiation of ganglion
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Ear Infection or is it?
Temporal arteritis
Usually causes headache rather than otalgia alone
More often older women (>50)
Exam: thickened artery
Lab: elevated sed rate
Biopsy – obtain 5 cm segment due to “skip” areas
Ophthalmology consult
Treatment – prednisone
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Ear Infection or is it?
Neoplastic
Parotid Tumors
Tumors of the tonsil, tongue base, supraglottis,
hypopharynx.
Risk factors: smoking, alcohol use
Associated sxs: hoarseness, dysphagia, wt loss
Associated exam: neck mass/enlarged nodes
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Ear Infection or is it?
Neoplastic - evaluation
ENT -- thorough head and neck exam (with flexible
endoscopy if needed)
CT scan of neck with contrast (some prefer MRI)
FNA if neck masses present
+/- panendoscopy and biopsy of primary
PET/CT if cancer found
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Ear Infection or is it?
Ear disease
“Eczema” of ear canal
Fungal external otitis
Bullous myringitis
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Ear Infection or is it?
Eczema of ear canal
Severe itching of ear canal
Exam – no cerumen (chicken vs egg)
“smoothbore” appearance
Treatment – topical steroid prn; must avoid scratching
Cream - Betamethasone valerate / Lotrisone
Drops – Prednisolone Ophthalmic / Derm-Otic
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Ear Infection or is it?
Fungal external otitis
Less pain than bacterial OE, more indolent course
Less edema/erythema of canal
Canal filled with debris – if debris examined, usually has
fungal spores (black spots – Aspergillus niger)
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Fungal otitis externa
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Ear Infection or is it?
Fungal external otitis - treatment
Debride ear canal – may need to repeat
Water precautions (cotton balls, Vaseline)
Topical antifungal x 10-14 days
If no TM perforation - Tinactin, Lotrimin, Cresylate TID
If perforation present - Mycolog II cream
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Ear Infection or is it?
Bullous myringitis
Extremely painful
Bulla (blister) seen on TM
Viral vs mycoplasma
? Macrolide antibiotic
Send to ENT for incision of bulla
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Bullous myringitis
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Thank you
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