Welcome! [] of Health... · Welcome! Welcome to the wonderful world of earache! This tutorial should take you 30 minutes to complete (but don [t worry, you can do it as many times

Welcome! Welcome to the wonderful world of earache! This tutorial should take you 30 minutes to complete (but don’t worry, you can do it as many times as you like)

Learning Objectives:

By the end of this tutorial you will be able to:

1) Identify the commonest causes of earache in primary care 2) Know how to approach the patient with earache and diagnose through history and

examination 3) Manage the main causes of earache

To navigate:

Click on the and buttons to the right or the headings in the left-hand column. Have fun!

(All otoscopic photos reproduced with the kind permission of The Hawke Library – www.hawkelibrary.com1-11)

Causes of Earache Causes of earache can be local to the ear itself or referred from other structures. Local:

Middle ear – acute otitis media

Outer ear – otitis externa Note that there will always be clinical signs in the ear. Referred:

Cause Nerve root12

Dental abscess Auriculo-temporal branch of the trigeminal nerve

Tempero mandibular joint pain

Direct contact with ear (the back wall of the joint is the front wall of the ear canal)

Problems in the Tonsil or base of tongue (eg. infection or tumour)

Glossopharyngeal nerve

Problems in the pharynx or larynx (eg. infection or tumour)

Auricular branch of the vagus nerve

Acute otitis media and otitis externa are the most common causes of earache seen in primary care so we will look at both of these by working our way through 2 case studies. The ear will usually look normal.

Case 1 A mother, Mrs Morris, comes to your GP surgery with her 18 month old son, Oscar. She tells you he has been up in the night, has felt hot to touch and has been rubbing his ear. He’s been quite grouchy today and ‘not his usual self’. He is clinging to his mother but appears alert. What is your top differential at this point? Go to the next page to find out more…

Acute Otitis Media Unsurprisingly, we’re going to start with otitis media. The terminology of middle ear infections can be a bit confusing so here’s a quick breakdown:

Term Acute otitis media Glue ear*

Chronic suppurative otitis media

Definition Acute infection and

inflammation

Non-infected effusion in middle ear. Also known as secretory otitis media or otitis media with effusion

Perforation and discharge lasting ~>1 month

Photo1,2,3

This essentially shows:

Pus behind the ear drum. If left untreated, the ear drum will burst and pus will come out of the ear. This is normally painful, and patients will have a

fever.

Mucus behind the ear drum.

Patients will have a mild earache and no fever.

A perforation and ear discharge

Patients will have a mild earache and no fever.

This tutorial is on earache so we will look at the one that causes pain, acute otitis media. It is caused by infection and inflammation of the middle ear. The infection may be:

Bacterial – e.g. Strep. pneumoniae (25%), Haemophilus influenzae (25%), Moraxella catarrhalis (15%)

Viral

Both may be present

Epidemiology Though otitis media may occur at any age it is most common in children:

75% of cases seen in primary care are under the age of 10 ** REFERENCE NICE GUIDE

The peak incidence is 6-15 months of age13 The reason why it is mostly seen in children is thought to be due to Eustachian tube dysfunction The main functions of the Eustachian tube are to:

Drain middle ear secretions into the nasopharynx

Ventilate middle ear

Protect middle ear from nasopharyngeal secretions Infants have shorter, wider and more horizontal tubes with incomplete musculature which doesn’t effectively open and close the tube. However, children have large adenoids in the naso pharynx which can physically obstruct the eustachian tubes and harbour respiratory bacteria. It’s thought that an upper respiratory tract infection causes obstruction of the tube, preventing drainage of the middle ear secretions leading to effusion. If micro pathogens are present they may multiply and cause infection and inflammation.

Case 1 b You start by taking a full history. What risk factors for otitis media will you ask Mrs Morris about? Go to the next page to find out…

Risk Factors

Factors proven to increase the risk of otitis media include:14,15

Host factors Environmental factors Age Male Family history Prematurity

Passive smoking Nursery/day care attendance Use of a dummy

Craniofacial syndromes (cleft palate or Down’s syndrome)

As with any condition, asking about risk factors serves a dual purpose:

1) To add weight to a diagnosis 2) To identify modifiable risk factors which can then be addressed

In this case, it is particularly important to ask about parental smoking and to encourage quitting. The increased risk from passive smoking may be used in antenatal care (alongside other tactics) to encourage mothers to quit smoking. Also, breastfeeding has been shown to be protective against acute otitis media which is one of the reasons why it is encouraged. 16

Case 1 c Mrs Morris confirms that Oscar’s father had numerous ear infections when he was a child, Oscar attends nursery and she is a smoker, though she is ‘cutting down’. Oscar has no other medical history of note. You clearly explain that smoking not only affects her health but that of her son and you recommend she makes use of the NHS smoking cessation services. You then go on to examine Oscar. What findings would suggest otitis media? Go on to the next page to find out…

Presentation The signs and symptoms of otitis media are due to:

Earache (note that the pinna will not be tender)

Fever

Redness of the tympanic membrane. The ear drum may have perforated (giving ear discharge)

The following are signs of acute otitis media:

Bulging tympanic

membrane1 Effusion4 Otorrhoea6

The following show ears that are not acutely inflamed and show signs of glue ear.

Effusion4 Bubbles in themiddle

ear4 Bear in mind that most patients will be young children and may not be able to tell you that their ear is hurting. Therefore signs may be non-specific, such as tugging at an ear, fever (often very high), crying and poor feeding. Examination is a useful tool and it is good practice in all children presenting with fever to examine both their ears and throat.

Case 1 d You examine Oscar and see that his left ear has a red tympanic membrane with a bulging red tympanic membrane. The right ear is normal. He has a temperature of 37.8°C What are the treatment options and which do you feel is most appropriate for Oscar? Mrs Morris asks you about antibiotics. She says she is aware that it’s not always best to give them but she doesn’t understand why. How would you describe the pros and cons of giving antibiotics? Go to the next page to find out more…

Management

Investigations

Investigations are rarely required for the clinical diagnosis of acute otitis media. Culture of discharge may be of help in recurrent/chronic cases.

Treatment

Once you have expertly diagnosed acute otitis media there are 2 main steps to consider for treatment:

1) Treat the pain – paracetamol/ibuprofen 2) Consider whether to give antibiotics

Antibiotics

This is all about weighing benefits against risks. You must be able to decide whether to prescribe antibiotics and be able to justify your choice to the patient. The pros and cons of antibiotics are summed up in the table below:

Pros Cons May shorten symptom duration Side effects (vomiting, diarrhoea, rash)

Decreased risk of complications

Risk of allergy

Risk of antibiotic resistance

Cost

Complications

Mastoiditis – where the infection extends out of the back of the middle ear into the mastoid

bone. This in turn can lead to a mastoid abscess behind the ear. Theimage below shows how

the ear is pushed downwards and outwards.

Intra-cranial infection – the middle ear sits just below the middle fossa. Infection in the

meiddle ear can lead, rarely, to intracranial abscesses or meningitis. The risk of this

happening is about 0.04% but is easily prevented by using antibiotics.

Facial nerve weakness – the facial nerve has no bony covering within the middle ear in up to

10% of the population. This is why you should always examine the ears if someone presents

with a facial nerve palsy.

80% of cases of acute otitis media resolve spontaneously within 3 days of onset. In these cases the disadvantages of antibiotics are therefore thought to outweigh the benefits. Of course, when you first see a patient you don’t know whether they will be in this 80%. Therefore antibiotics are recommended for patients if symptoms persist for 4 or more days.

The treatment of choice is: amoxicillin (or erythromycin) for 5 days

There are 2 ways to arrange delaying treatment:

1) Ask the patient to return if they are no better after 3 days 2) Give them a delayed prescription which they can use in 3 days if they need it.

Delayed prescribing has been shown to lead to decreased antibiotic use.17 Also, the patient feels empowered and able to manage themselves reducing repeat visits.18

Case 1 e You decide that considering Oscar has only been symptomatic for 1 day you will prescribe analgesia and ask Mrs Morris to return if he does not improve after 3 days. Mrs Morris returns 4 days later and Oscar has still not improved. She asks whether he should have been given immediate antibiotics. What clinical features would make you think about giving immediate antibiotics? Go to the next page to find out…

Management 2 In some circumstances a patient should be offered immediate antibiotics, even at the first visit. These include:12

Systemically very unwell (e.g. temp ~>38.5°C, vomiting)

High risk of serious complications due to other health problems (e.g. cystic fibrosis, immunosuppression, significant heart/lung /renal disease)

Already had symptoms for 4 days without improvement

~< 2 years old with bilateral symptoms

Perforation/otorrhoea An important aspect of primary care is to know when to refer. Admission/referral may be indicated if:12

~<6 months old with a high fever

Suspected

(e.g. meningitis, mastoiditis, cholesteatoma)

Recurrent AOM (≥3 episodes in 6 months)

Repeated AOM in adults (especially elderly) – risk of nasopharyngeal carcinoma This may seem like a fairly long list but try and think of it in terms of:

High risk or recurrent = admit/refer

Moderate risk = immediate antibiotics

Treatment Flowchart Here is the same information displayed in a flowchart algorithm for those whose minds are that way inclined:

Case 1 f You explain that though it is unfortunate that Oscar’s symptoms have not yet resolved, at the time of their first appointment there was nothing to suggest the need for immediate antibiotics. You then affirm that she has done the right thing to bring him back and it would now be appropriate to give him antibiotics. You first take a brief history to see if anything has changed (and check for allergies to antibiotics) and you exam Oscar again. You prescribe a 5 day course of amoxicillin. Mrs Morris asks how long symptoms are likely to last and whether she should use anything else, such as over the counter decongestants. What advice would you give her? Go to the next page to find out more…

Other Treatments and Prognosis

Other Treatments

There is no evidence for the benefit of antihistamines, mucolytics, decongestants or inhaled steroids in otitis media19

Prognosis

The prognosis for acute otitis media is very good. Most symptoms resolve within a number of days though the effusion(glue ear plus mild hearing loss) may persist for a number of weeks. If antibiotics have been given remind patients to complete the full course, even if symptoms resolve before this.

Case 1 g Oscar’s symptoms improve with the antibiotics and he is back to his cherubic self within the next few days. You sleep comfortably at night knowing that you treated him in a safe and evidence-based manner.

Case 2 A Mr Oliver Edwards, a 50 year old accountant, attends your surgery complaining of earache. He says the problem has lasted for about 3 days. It is his right ear and it feels tender to touch. What is your top differential at this point? Go to the next page to find out more…

Otitis Externa We’re onto otitis externa now. Otitis externa is caused by inflammation of the skin lining the external auditory canal.

Acute Otitis Externa7

Causes & Epidemiology

Causes

The causes of otitis externa can be:

Infective: o Bacterial (90%) – e.g. Staphylococcus, Pseudomonas o Fungal (10%) – e.g. Candida, Aspergillus20

Epidemiology

Unlike otitis media, otitis externa is most common in adults.

Case 2 b Having decided from his presenting complaint and his age that otitis externa is the most likely cause, you take a full history. What risk factors for otitis externa will you ask about? Go to the next page to find out…

Risk Factors Risk factors for otitis externa include:

Foreign objects in the ear canal (e.g. cotton buds or hearing aids) r

Swimming, particularly warm swimming pools.20

Chronic skin diseases (e.g. eczema, psoriasis)

Swimmers ear – where the ear canal is narrowed by bony nodules called exostoses. It is caused by swimming in cold water over many years – it is very common in UK surfers.

Case 2 c You are interested to hear that Mr Edwards is a keen swimmer, and that following a dip he likes to clean his ears out with a cotton bud. You politely inform him that, although cotton buds are very well designed for pushing wax further into ears and perforating ear drums, he would perhaps do better without them. You continue with the history and examination. What symptoms will you ask about and what will you look for on examination? Go to the next page to find out more…

Signs and Symptoms There are important similarities and differences with the signs and symptoms of acute otitis media.

Symptoms:

Itching (this is the most common symptom)

Pain - which can be very severe

Otorrhoea (watery compared to the mucous discharge in otitis media)

Mild hearing loss may occur Signs:

Tenderness at the meatus and tragus (especially on movement of the pinna)

Erythema (at meatus and lining canal)

Swelling of the ear canal skin – you often can’t see the ear drum because of swelling

Skin debris in the ear canal

Canal swelling and erthythema8 Swimmer’s ear9

Case 2 d Mr Edwards confirms that his ear is very itchy and he has noticed a small amount of watery discharge. On examination the ear is tender, the canal is erythematous and the tympanic membrane looks normal. He is apyrexial. This all confirms your diagnosis of otitis externa. How will you go on to manage Mr Edwards? Go to the next page to find out more…

Management

Investigations

Like otitis media, in most cases no investigations are needed. If the initial treatment fails, a swab should be taken of any discharge for culture.

Treatment

1) Address risk factors:

Stop using cotton buds

Remove any potential allergens 2) Analgesia 3) Topical ear preparation for 7 days:

Antibiotic (e.g. aminoglycoside - gentamicin) & corticosteroid or

Antibiotic only drops

Antibiotic use is restricted to 7 days to reduce the risk of fungal infection. Gentamicin is contraindicated if the tympanic membrane is perforated because of the risk ototoxicity. However, in usual clinical practice, gentamicin drops are frequently used.

Case 2 e You prescribe regular ibuprofen and gentamicin & hydrocortisone drops for 7 days. You advise Mr Edwards to avoid swimming for a few weeks and to stop using cotton buds. He asks how long it is likely to be before he feels better. What will you tell him? Go to the next page to find out more…

Prognosis In most cases symptoms resolve completely within a few days of starting treatment. A rare complication is malignant otitis externa. This is where infection extends into the underlying bone causing an osteomyelitis. It usually affects patients with diabetes or the immunocompromised and may cause facial nerve palsy. If suspected an urgent ENT referral should be made.

Malignant otitis externa10

Case 2 f Mr Edwards takes the complete course of antibiotics and recovers fully by the end of the week. A few weeks later he goes on to win his local swimming gala, in part thanks to your good medical practice. Go to the next page for a few words on history and examination…

History and Examination

History

Remember that the majority of diagnoses come from the history so it’s important to practice. The information in this tutorial should slot nicely into the history taking structure that you already have.

Take a moment to consider what you would ask in each section.

Presenting complaint

History of presenting complaint

Past medical history

Drug history

Family history

Social history Go to the next page for a brief reminder of the important bits…

History and Examination 2 Presenting Complaint

Earache History of Presenting Complaint

Duration – important for whether to give antibiotics

Risk factors – important to aid diagnosis and if they are modifiable

Indications for immediate antibiotics or referral/admission Past Medical History

Craniofacial syndromes, eczema, psoriasis Drug History & Allergies

Allergy to penicillins important Family History Social History

Parental smoking (if not already asked) And remember the Calgary-Cambridge framework: A reminder of the Calgary-Cambridge framework21

Forward planning and safety netting is very important in the treatment of both acute otitis media and otitis externa. For example:

Make sure that the patient knows to come back if their condition worsens or if there is no improvement

Tell them of specific symptoms to look for, such as facial nerve palsy for malignant otitis externa (you can reassure them that the complication is unlikely)

Always review if unable to see drum in otitis media due to suppuration

Examination

This ear examination e-tutorial demonstrates the correct equipment required for each examination, how to conduct an examination of the ear and the special tests involved in testing hearing. It also shows how to recognise the landmarks and common pathologies associated with the outer ear and tympanic membrane.

Summary

To summarise everything we’ve covered, earache is a common presentation in primary care which can usually be resolved promptly provided the correct diagnosis and treatment is given. Some important differences that we have looked at between the 2 main causes are shown in the table below:

References

The Hawke Library (www.hawkelibrary.com) 1 http://otitismedia.hawkelibrary.com/aom/1_11?full=1 2 http://me.hawkelibrary.com/album03/Air_Fluid_Level_3?full=1 3 http://me.hawkelibrary.com/Chronic-Suppurative-Otitis-Media/CSOM_Mucopus_2_001?full=1 4 http://otitismedia.hawkelibrary.com/aom/1_12?full=1 5 http://otitismedia.hawkelibrary.com/som/5_4?full=1 6 http://otitismedia.hawkelibrary.com/aom/1_20?full=1 7 http://eac.hawkelibrary.com/aoe/50_G?full=1 8 http://eac.hawkelibrary.com/chronicoe/55_G?full=1 9 http://eac.hawkelibrary.com/aoe/51_G?full=1 10 http://eac.hawkelibrary.com/malignantoe/82_Left?full=1 11 http://otitismedia.hawkelibrary.com/aom/3_2_CSOM_Otorrhea?full=1

12 COMP 2 Primary Heath Care Study Guide, Chapter 7m Earache (Dr S Goodson). University of Bristol 13 http://www.patient.co.uk/doctor/Acute-Otitis-Media.htm 14 Niemela M, Uhari M, Mottonen M; A pacifier increases the risk of recurrent acute otitis media in children in day care centers. Pediatrics. 1995 Nov;96(5 Pt 1):884-8. 15 Strachan DP, Cook DG; Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children. Thorax. 1998 Jan;53(1):50-6 16 Duncan B et al. Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media. Pediatrics Vol. 91 No. 5 May 1, 1993 (pp. 867 -872) 17 Arroll B et al. Do delayed prescriptions reduce antibiotic use in respiratory tract infections? A systematic review. Br J Gen Pract. 2003 November; 53(496): 871–877. 18 Little P et al. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ. 2001 Feb 10;322(7282):336-42. 19 Diagnosis and management of childhood otitis media in primary care. SIGN (2003) 20 http://www.patient.co.uk/doctor/Otitis-Externa-and-Painful-Discharging-Ears.htm 21 http://www.gp-training.net/training/communication_skills/calgary/framwork/framework.htm 22 http://www.entusa.com/Ear_Photos/serous-otitis_08052002.jpg

Otitis Media Otitis Externa

Pain Deep Superficial

Fever Common Unusual

Tenderness of the pinna

No Yes

Erythema Tympanic membrane External auditory canal

Fluid behind the ear drum

Yes No

Discharge Mucous (if perforated) Scant, watery

Age Children Adults

Antibiotics Oral amoxicillin (if necessary)

Topical antibiotic (with steroid)