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Transcript
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 3 Ear Infection or is it? Otalgia Myofascial – TMJ, hyoid bone syndrome Neoplastic Otic 4 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 5 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 6 TMJ – anatomy/exam 7 Otalgia - TMJ 8 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) 9 Otalgia- TMJ Patient Handouts Online Krames 10 Otalgia - TMJ 11 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 12 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 13 Hyoid bone syndrome 14 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 15 Ear Infection or is it? Carotidynia Controversial diagnosis Exam: Tenderness along entire length of artery Treatment: Indomethacin 25-50 mg TID x 14 days 16 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 17 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 18 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 19 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 20 Ear Infection or is it? Ear disease “Eczema” of ear canal Fungal external otitis Bullous myringitis 21 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 22 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) 23 Fungal otitis externa 24 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 25 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 26 Bullous myringitis 27 Thank you 28