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S2 E068 External and Inner Ear from the PANCE Blue Print

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External Ear

Cerumen Impaction

  • Ear wax built up in the external ear canal
  • Cerumen can be impacted by the patients use of a cotton swab

Clinical Presentation

  • Routine office visit
  • Progressive hearing loss

Labs, Studies and Physical Exam Findings

  • Otoscope exam reveals cerumen in the ear canal
  • Hearing test comparing both ears

Treatment

  • Solvents may be applied to soften wax
  • Hydrogen peroxide
  • Mineral oil
  • Glycerine
  • Manual cerumen removal
  • Irrigation
  • Blunt curette or right angle hook for manual removal

Otitis Externa

  • Swimmer’s ear
  • Pseudomonas is the most common cause
  • Trauma from cleaning the ears is a risk factor

Clinical Presentation

  • Pain
  • Pruritus
  • Foul smelling discharge (yuck!)
  • Hearing loss

Labs, Studies and Physical Exam Findings

  • Pain with movement of the auricle, pinna or tragus
  • Otoscope exam
  • Red, swollen ear canal
  • Tympanic membrane moves with a pneumatic otoscope
  • Eardrum is intact

Treatment

  • Behavior
  • Don’t put things in the ear canal at home!
  • Careful use of earplugs
  • A drying agent after swimming may be helpful. Fifty percent alcohol or white vinegar work well.
  • Antibiotic
  • Moderate to Mild – drops several times a day for about seven days or 3-5 days past the end of symptoms
  • Fluoroquinolones
  • Ciprofloxacin
  • Ofloxacin

-Severe cases may require systemic antibiotics

  • Steroid drops are optional

Complications

Malignant otitis externa is an osteomyelitis of the temporal bone. This complication typically occurs in those with depressed immune systems and those at an increased risk of infection like diabetics. This can be extremely dangerous and can lead to nerve palsies in cranial nerve VI, VII, X XI, and XII. Big doses of IV Cipro are used in these cases.

External Ear Trauma

  • Cauliflower Ear
  • Blunt trauma creates a hematoma. The hematoma creates pressure preventing blood flow leading to avascular necrosis of the cartilage.

Middle Ear

Acute Otitis Media

  • Middle ear infection
  • Typically occur in children secondary to an upper respiratory infection.
  • The eustachian tubes become clogged and then bacteria settle in.
  • The most common pathogens include
  • Strep pneumoniae
  • Strep pyogenes
  • Haemophilus Influenzae

Risk Factors

  • Smoker in the house
  • Bottle feeding
  • Day care

Clinical presentation

  • Ear pain
  • Fever
  • Irritability
  • Decrease in hearing

Labs, Studies and Physical Exam Findings

  • Tympanic membrane may show
  • Erythema
  • Bulging
  • No light reflex
  • Decreased mobility with a pneumatic otoscope

Treatment

  • Pain killers
  • Acetaminophen
  • Ibuprofen
  • Antibiotics
  • Amoxicillin x 10 days

Chronic Otitis Media

  • Recurrent acute otitis media
  • Rupture of tympanic membrane
  • Bacteria are different from acute otitis media
  • Staph aureus
  • Proteus
  • Pseudomonas aeruginosa

Clinical Presentation

  • There is pus coming out of my ear!
  • Hearing loss
  • Only painful during an exacerbation

Labs, Studies and Physical Exam Findings

  • Frank pus may or may not be present
  • Ruptured eardrum

Treatment

  • Definitive treatment is surgery to repair the eardrum
  • Routine cleaning of debri from the ear
  • Antibiotics
  • Mild cases Cipro ear drops
  • More severe cases
  • Oral amoxicillin

Cholesteatoma

A cyst in the middle ear which is filled with keratin

Clinical Presentation

  • Unilateral hearing loss
  • Discharge from the ear

Labs, Studies and Physical Exam Findings

  • Typically the ear canal is filled with debri
  • Discharge from a defect in the tympanic membrane

Treatment

  • Surgical removal of the cyst which may imbed itself into the temporal bone and many delicate structures making this extremely difficult

Tympanic Membrane Perforation

Causes

  • Direct blow to the ear
  • Skull fracture
  • Foreign object pushed into the tympanic membrane
  • Otitis media
  • A very loud explosion nearby
  • Barotrauma

Clinical Presentation

  • Conductive hearing loss
  • Tinnitus
  • Earache
  • Discharge of fluids
  • Bleeding

Labs, Studies and Physical Exam Findings

  • Ruptured eardrum

Treatment

  • A patient with an open ear drum should be very careful of water.
  • Most will heal within weeks
  • Surgical repair may be necessary – Tympanoplasty
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