common ear problems

8/10/2019 Common Ear Problems

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Common Ear Problems

Paul Gidley, MD


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Common Ear Problems

Paul W. Gidley, MD, FACS

Otology-Neurotology

UT MD Anderson Cancer Center

Date: Feb 19, 2011 Time: 1:30pm


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Common Ear Problems

Learning Objectives:

1. Review findings in OE, ETD, TM perforation, OM,

OME, mastoiditis, cholesteatoma

2. Define for each the appropriate medical

treatment

3. Define for each the appropriate surgical

approach and indications


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Ear Interrogation

Hearing loss

Tinnitus

Dizziness and Vertigo

Otalgia

Otorrhea

Aural fullness

Autophony

Duration/onset

Character

Precipitating factor

Grading scale

Associated symptoms


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Ear Examination

Look at outer ear and

periauricular skin

Palpate tragus and pull on

outer ear

Otoscopic examination

Tuning fork examination

Microscopic examination

Audiogram Imaging study?


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Perichondritis

Bacterial infection ofouter ear

Often associated with

ear trauma Usually caused by

Pseudomonas spp

Treatment is oral abx for

mild cases IV abx for severe cases

or with co-morbidconditions


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Otitis Externa

Ear canal infection

Swimmers ear

Symptoms

Painful ear

Blocked ear

Decreased hearing

Physical signs

Painful tragus or outer ear

Swollen ear canal

Blocked by debris

Cant see TM


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Otitis Externa

Multiple potential

organisms

Bacterial

Pseudomonoasaeroginosa

Staph. aureus

Proetus, Klebsiella, E coli

Fungal

Aspergillus niger

Candida albicans


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Otitis Externa - Management

Clean ear canal

Debris and pus preventtopical medications fromreaching the infection

Debris and pus perpetuateinfection

Acidify ear canal

Most pathogens grow in analkaline environment

Most ototopicals are acidic

Acetic acid

Boric acid

Keep water out of ear


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Antibacterial Ototopicals

Cortisporin Contains: Neomycin, Polymyxin

B, Hydrocortisone

Solution vs Suspension

Dosage: 4 gtts 3x/day or

4x/day for 10 days Coverage:

Staph, proteus, gramnegatives (Pseudomonas, ecoli, klebsiella, andenterobacter)

Disadvantages: Middle ear burning

Theoretically ototoxic

Allergy to neomycin in 10%


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Fluoroquinolones

Ciprofloxacin andofloxacin otic drops

5 gtts BID x 10 days

Bactericidal to allrelevant pathogens sincetopical administrationyields very high

concentrations Not ototoxic

Can be expensive


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Gentamicin and

tobramycin ophthalmic

drops

Helpful forpseudomonas infections

Risk of ototoxicity

Boric acid and iodine

powder


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Antifungal Ototopicals

Clotrimazole (Lotrimin)

and nystatin

(Mycostatin)

Candida

Topical preparations

5 gtts BID for 7 days

Voraconizole

Aspergillus spp


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Antifungal Ototopicals

Nonspecific treatments

2% acetic acid drops

Domeboros soln

Vosol

3% boric acid in 70%EtOH drops

3% boric acid and iodinepowder

Cresylate (25% m-cresylacetate)paint; do notput in middle ear

Gentian violet - paint


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Anti-Inflammatory Ototopicals

Steroid containing help

to reduce inflammation

VoSol HC

Ciprodex

Cipro HC

Cortisporin


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Additional Measures

Ear wick

Pope merocel sponge

Helps to keep ear canal

patent Keeps drops in contact

with ear canal

Leave in canal for only 3-

5 days


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Cerumen Impaction

Wax is your friend Secreted by modified sweat

glands

Creates an acidic environment

Traps dirt

Self-cleaning mechanism Common condition

12 million US/yr

Contributors Narrow ear canal

Hearing aid use

Dermatologic conditions(seborrheic dermatitis, etc)

Q-tip abuse

MR Roland et al. Clinical practice guideline:

Cerumen impaction. Oto HNS 2008.


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Cerumen Impaction

Several methods

Ceruminolytic agents

Debrox

Hydrogen peroxide

Rubbing alcohol

Irrigation

Manual removal

Microscopic ear cleaning

Roland et al. Clinical practice guideline:



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Ear Candling

Complementary or

Alternative medicine

Used to treat a variety

of ear, nose, and headcomplaints

Meant to draw out the

disease

Not recommended

Roland et al. Clinical practice guideline:



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Foreign Body Ear Canal

Another commoncondition

Beads, pebbles, roaches

Dangerous: beans,hearing aid batteries

Best removed usingotomicroscope

Round objectsrightangle hook

Flat objectsalligatorforceps


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Eustachian tube

Connection between middleear and nasopharynx

Three important functions

Equalizes pressure in middle

ear Drains thin mucus produced

in middle ear

Prevents reflux of fluid intomiddle ear

E tube is normally closed Opened by palate muscles

Yawning, swallowing, etc

Closed by tissue elasticity


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Eustachian tube problems

The underlying cause ofmost middle ear problems.

Dysfunction Nasal mucosal diseases

Allergies

Viral URI

Obstruction Adenoid hypertrophy

Nasopharyngeal cancer

Patulous Rapid weight loss

TM moves with nasalrespiration


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Management of Eustachian tube

problems

Dysfunction

Treat underlying nasal

problems

Nasal steroid sprays

Airflight Gum chewing

Decongestant spray

Patulous Eustachian tube

Estrogen nasal drops

Weight stabilization

Surgery?


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TM perforation

Many different causes

Infection

Eustachian tube dysfunction

Penetrating trauma (q-tip)

Skull base fracture

Pressure changes

(barotrauma)

Tests

Pneumotoscopy Tuning fork examination

Audiogram


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TM perforation

Treatment for traumatic

perforation

Most close with time

Keep water out of ear

Ear drops?


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TM perforationLook-alikes


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Chronic TM perforation

Issues to consider

Degree of hearing loss

Size and location of

perforation Frequency of drainage

Eustachian tube

dysfunction


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Surgery

Day surgery

Local or general anesthesia

Approach

Transcanal

Postauricular

Graft material

Temporalis fascia


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Ossicular reconstruction

Variety of problems

Variety of prostheses


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Otitis Media

Very common problem,

especially in children

85% children will have at

least one episode of OMbefore the age of 3

years.

Symptoms

Ear pain Hearing loss

Fever?

Drainage?


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Otitis Media

Two types

Serous

Suppurative

Two durations Acute

Chronic

Two designations

With perforation

Without perforation


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Acute Otitis Media


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Acute Serous Otitis Media

Medical Management Treat underlying illness

Symptomatic & supportive

Decongestants, antihistamines, nasal steroid sprays

Blow your nose

Tincture of time Time to resolution: weeks to months

Not a middle ear infection, antibiotics not needed formiddle ear disease

Surgical drainage Tympanocentisis or myringotomy

Symptomatic relief, culture opportunity


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Acute Suppurative Otitis Media

Medical management of uncomplicated cases

Penicillins

HD Amoxicillin (90 mg/kg/day divided Q12h for 10 d)

Augmentin ES (600mg/5 cc)

PCN Allergic

Erythromycin or Clindamycin with Bactrim

Cephalosporins

Cefpodoxime (Vantin) - 5 mg/kg Q12h

Cefdinir (Omnicef)14 mg/kg daily

Ceftriaxone (Rocephin) IM50 mg/day every other day

for 3 treatments Fluoroquinolone (only for adults)

Levo-,gati-, moxi- floxacin

Pediatrics2004, 113:1451-1465


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Acute Suppurative Otitis Media

Surgical management of uncomplicated cases

Myringotomy or fluid aspiration

Drains fluid

Relieves pressure

Material for culture

Probably not need for most cases

Avoid PE tubes

Usually resolves without need for tubes

High incidence of otorrhea


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Suppurative OM with perforation

Management

Oral antibiotics

Same as above

Aural antibiotics Fluoroquinolone drops

Water precautions

F/U visit to assure

closure of perforation


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Complications of Otitis Media

Reason for referral

Facial paralysis

Coalescent mastoiditis

Subperiosteal abscess

Sigmoid sinus thrombosis

Meningitis

Brain abscess

Management will require

either surgical interventionor hospitalization for IV abx.


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Chronic Otitis Media

Chronic nonsuppurative otitismedia

Otitis media with effusion (OME)

Incomplete resolution of otitismedia

Might take 90 days for AOM to

resolve

Most common reason for PEtubes

Glue ear

Chronic serous otitis media

Serous effusion

Chronic suppurative otitis media

with perforation

media with cholesteatoma

Oto HNS 2004, 130: Suppl S95-S118


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Chronic Suppurative Otitis Media

Mixed infection with aerobes andanaerobes

Pseudomonas aeroginosa

Staph. aureusand epidermidis

Proteus spp

Klebsiella

E. coli

Anaerobic streptococcus

B fragilis

Since perforation is present,ototopical agents are effective

Fluoroquinolone drops

Oral antibiotics as directed byculture


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Cholesteatoma


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Chronic Otitis Media - Surgery

Indications for surgery Cholesteatoma

Chronic infection anddrainage

TM perforation

Hearing loss

Surgery will involve:

Post-auricular incision

Mastoidectomy

Removal of cholesteatoma Removal of infected tissues

Repair of ossicles

Tympanoplasty


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Questions?

Paul W. Gidley, MD, FACS

Associate ProfessorOtology-Neurotology

UT MD Anderson Cancer Center

713-792-1687

[email protected]
mailto:[email protected]:[email protected]

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