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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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