EAR PAIN. Auricle 4 Hematoma 4 Cellulitis 4 Relapsing Polychondritis.

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 cartilage- cauliflower 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 osteomylitis- complication 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