Otitis Externa

Содержание

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Otitis Externa Inflammation of the external auditory canal Most common in

Otitis Externa

Inflammation of the external auditory canal
Most common in children 7-14

years old
Risk factors: swimming, humidity, trauma and others

Causes: Pseudomonas aeruginosa, Staphylococcus aureus, Candida and Aspergillus species
Symptoms: otalgia, purulent discharge, pruritis
Exam: pain with movement of ear, auditory canal is erythematous and edematous

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Otitis Externa Diagnosis: clinical, otoscopy, culture (for refractory cases), imaging (mastoiditis)

Otitis Externa

Diagnosis: clinical, otoscopy, culture (for refractory cases), imaging (mastoiditis)

Treatment:
Clean the

ear canal
Antibiotic drops (ciprofloxacin)
Antiseptics, acetic acid
Control pain: glucocorticoids
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Malignant (necrotizing) Otitis Externa Infection of the temporal bone Most common

Malignant (necrotizing) Otitis Externa

Infection of the temporal bone
Most common in elderly,

diabetics, immunocompromised patients
Symptoms: severe ear pain, foul-smelling, purulent, CN paralysis 9,10,11

Dx: CT scan of the temporal bone, cultures, biopsy of the ear canal
Treatment: intravenous antibiotics (ciprofloxacin)

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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

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Acute otitis media Most common in children 3 month-3years Symptoms: blocked

Acute otitis media

Most common in children 3 month-3years
Symptoms: blocked ear feeling,

pain and fever. Discharge may follow if the TM perforates, with relief of pain and fever
Causes: adenovirus and enterovirus and the bacteria H. influenzae, S. pneumoniae, Moraxella Catarrhalis and β-haemolytic streptococci.
Diagnosis: the redness of the TM. Bulging eardrum, yellow or white in color with dilated vessels, decreased movement on pneumatic otoscopy

Children frequently present with:
Sudden onset of fever
Ear pain
Fussiness

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Acute otitis media Treatment Analgesics to relieve pain Adequate rest in

Acute otitis media

Treatment
Analgesics to relieve pain
Adequate rest in a warm room
Nasal

decongestants for nasal congestion
Antibiotics until resolution of all signs of infection (amoxycillin, doxycycline, cefaclor)
Treat associated conditions (e.g. adenoid hypertrophy)
Follow-up: review and test hearing audiometrically

Mild reddening or dullness of the eardrum and absence of systemic features (fever and vomiting) - antibiotics are not warranted

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Acute otitis media Complications: Conductive hearing loss Sensorineural hearing loss Tympanic

Acute otitis media

Complications:
Conductive hearing loss
Sensorineural hearing loss
Tympanic membrane perforation
Retraction pocket
Mastoiditis
Petrositis
Labyrinthitis

Perilymphatic fistula
Cholesteatoma
Tympanosclerosis
Cholesterol

granuloma
Facial paralysis
Ossicular chain fixation
Ossicular chain discontinuity
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Mandy, a 4 year old girl, is due to accompany her

Mandy, a 4 year old girl, is due to accompany her

parents on a flight to England in two months time. Her mother is worried about the effect of air travel on Mandy's ears. Which of the following will NOT increase the likelihood of ear pain during the flight?
a) A recent cold
b) Nasal congestion
c) Hay fever
d) Recent otitis media
e) Perforation of the ear drum
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A 8 year old boy with recurrent attacks of otitis media

A 8 year old boy with recurrent attacks of otitis media

is suspected of developing a glue ear. If his
sound conduction is tested, which of the following is most consistent with a unilateral middle ear
effusion?
A) Negative Rinne’s test on the ipsilateral side
B) Positive Rinne’s test on the ipsilateral side
C) Positive Webers and Rinnes test on the ipsilateral side
D) Positive Rinne’s test on the contralateral side
E) Negative Webers test only on the contralateral side
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

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Chronic otitis media Symptoms: deafness and discharge without pain Causes: Pseudomonas

Chronic otitis media

Symptoms:
deafness and discharge without pain
Causes:
Pseudomonas aeruginosa
Staphylococcus aureus
Proteus

sp.
E. coli
Bacteroides fragilis
Diagnosis: Cl, culture of drainage, imaging (erosion or abscess)

Safe
If aural discharge persists for >6 weeks after a course of antibiotics
Treatment: topical steroid and antibiotic combination drops, following ear toilet.
Unsafe
Perforation of the attic region
Treatment: antipseudomonal penicillin or cephalosporins (children), ear drops & quinolones (adults)

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Chronic otitis media ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Safe Perforation Affects mucosa of

Chronic otitis media

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Safe Perforation

Affects mucosa of the lower front

part of the ME cleft (tubotympanic portion)
Central perforation – always a rim of drum or annulus around the edge
Involves the vibrating part of the TM – pars tensa, below the malleolar folds at the level of the lateral process of the malleus

Unsafe Perforation

Threatens the hazard of spread of the infection intracranially
Associated with erosion of surrounding bone

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Chronic otitis media ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Signs of an unsafe perforation

Chronic otitis media

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Signs of an unsafe perforation on otoscopy:
Superior

and/or posterior edge of tympanic membrane perforation
Perforation involving the fibrous edge or annulus of the tympanic membrane
Associated granulation tissue
White mass within middle ear seen through perforation
Bone erosion
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ A 14-year old teenager is diagnosed with a

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

A 14-year old teenager is diagnosed with a tympanic

membrane perforation secondary to chronic otitis media. Which of the following conditions will not progress to significant complications if left untreated?
a. Perforation associated with a cholesteatoma
b. Marginal perforation with discharge
c. Continuously discharging central perforation
d. Perforation that is surrounded by granulation tissue
e. Large dry central perforation
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Cholesteatoma ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Expanding lesions of the temporal bone composed

Cholesteatoma

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Expanding lesions of the temporal bone composed of a

stratified squamous outer epithelial lining and a desquamated keratin center
Clinically defined as an abnormal extension of skin into the middle ear and mastoid air cell spaces
Red flags for cholesteatoma include meningitis-type features, cranial nerve deficits, sensorineural hearing loss and persistent deep ear pain.

Symptoms:
Presenting history (in order of most common)
Conductive Hearing Loss
Foul-smelling ear discharge
Persistent otitis media
Otalgia
Vertigo
Facial weakness

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Cholesteatoma ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Complications: Hearing loss secondary to necrosis of

Cholesteatoma

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Complications:
Hearing loss secondary to necrosis of the long process

of the incus
Erosion into the lateral semicircular canal
Dizziness
Subperiosteal abscess
Facial nerve palsy
Meningitis
Brain abscess
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Cholesteatoma Diagnosis: otoscopy, audiogram, CT scan Treatment: Surgery - Mastoidectomy and

Cholesteatoma

Diagnosis: otoscopy, audiogram, CT scan
Treatment:
Surgery - Mastoidectomy and removal of

cholesteatoma
Tympanoplasty – an operation to repair a hole in the eardrum (transcranial or post-auricular approach)
Continuous monitoring to look out for recurrence
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Audiology

Audiology

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Pure tone audiogram Sensorineural hearing loss Conductive hearing loss

Pure tone audiogram

Sensorineural hearing loss

Conductive hearing loss

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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ This pure tone audiogram is recorded from a

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

This pure tone audiogram is recorded from a 12

year old Maori girl complaining
of deafness in her right ear. The MOST likely explanation for this problem is:
a) Debris in the external auditory meatus
b) Cholesteatoma
c) Middle ear effusion
d) Toxin-induced nerve damage
e) Necrosis of the ossicular chain
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Tinnitus ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Exact cause is unknown but is though

Tinnitus

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Exact cause is unknown but is though to be

due to inappropriate activity in the hair cells of the cochlea
Diagnosis
Audiological examination by audiologist
Tympanometry and speech discrimination
MRI or CT scan (if serious cause suspected or head injury)
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Tinnitus Subjective Tinnitus Otologic Presbycusis Noise-induced hearing loss Otitis media with

Tinnitus

Subjective Tinnitus

Otologic
Presbycusis
Noise-induced hearing loss
Otitis media with effusion
Menière’s disease
Otosclerosis
Cerumen
Foreign body against

TM

Objective Tinnitus

Carotid stenosis
High jugular bulb
Hypertension
Hyper/hypothyroidism
Mechanical
Patulous eustachian tube
Palatal myoclonus
Stapedius muscle spasm

Vascular
Benign intracranial hypertension
Arteriovenous malformation
Glomus tympanicum
Glomus jugulare
Arterial bruits:
High-riding carotid artery
Vascular loop
Persistent stapedial artery

Drugs
ASA
NSAIDs
Aminoglycosides
Antihypertensives
Heavy metals

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Tinnitus ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Holistic approach (options) Mainly based on acoustic

Tinnitus

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Holistic approach (options)
Mainly based on acoustic de-sensitisation:
• Relaxation techniques
•

Tinnitus retraining therapy (clinical psychologist)
• Cognitive behaviour therapy
• Background ‘noise’ (e.g. music played during night
for masking)
• Tinnitus maskers
• Hearing aids (based on audiologist assessment)
• Consider hypnotherapy

Medical (trials of options)
Clonazepam 0.5 mg nocte
Minerals (e.g. zinc and magnesium)
Betahistine (Serc) 8–16 mg daily (max. 32 mg)
Carbamazepine
Antidepressants
Acute severe tinnitus
Lignocaine 1% IV slowly (up to 5 mL)

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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ You review a 70-year-old woman who is on

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

You review a 70-year-old woman who is on multiple

medications. For the past few
months she has noticed bilateral tinnitus and hearing loss. Which one of the following
medications may be responsible?
A) Lofepramine
B) Ezetimibe
C) Furosemide
D) Tramadol
E) Digoxin
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

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Benign paroxysmal positional vertigo ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Acute vertigo that is

Benign paroxysmal positional vertigo

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Acute vertigo that is induced by

changing head position
Caused by sediment, such as otoconia (calcium carbonate crystals) that have become free floating within the inner ear
Affects all ages, especially the elderly
The female to male ratio is 2:1
Recurs periodically for several days
Each attack is brief, usually lasts 10–60 seconds, and subsides rapidly
Severe vertigo on getting out of bed
Can occur on head extension and turning head in bed
Attacks are not accompanied by vomiting, tinnitus or deafness (nausea may occur)

Diagnosis:
Pathognomonic sign: nystagmus toward the affected ear on doing a Dix-Hallpike test
Treatment:
Avoidance measures: encourage the patient to move in ways that avoid the attack
Drugs are not recommended
Epley repositioning maneuver
Brandt-Daroff exercises
For pations: Brandt-Daroff Exercises

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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ A 52-year-old woman presents with dizziness and vertigo

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

A 52-year-old woman presents with dizziness and vertigo when

she moves her head towards right and in extension of head.
She is asymptomatic when she is lying still on the bed and is not moving her head. She is having these symptoms since last 3 hours. She had similar symptoms 5 years ago when she recovered in two days. There is no neurological deficit on examination apart from positional nystagmus.
Which of the following is best management?
a. Hallpike manoeuvre
b. Epley manoeuvre
c. Frusemide
d. Intravenous fluids
e. Steroids
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Vestibular neuritis Second most common disorder affecting the labyrinth Viral etiology

Vestibular neuritis

Second most common disorder affecting the labyrinth
Viral etiology with consequent

inflammation of the vestibular nerve
Frequently associated with recent flu symptoms
Signs/symptoms:
Sudden onset of severe rotatory vertigo
Nausea and vomiting
Spontaneous nystagmus and diminished VOR

Usually subsides over a course of several days or weeks
Differential diagnoses: cerebellar hemorrhage and infarction
Labyrinthitis refers to the simultaneous loss of hearing and balance in the affected ear

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Vestibular neuritis ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Treatment: Bed rest, vestibular sedatives and

Vestibular neuritis

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Treatment:
Bed rest, vestibular sedatives and anti-emetics in the

first 24-72 hours
Dimenhydrinate
Prochlorperazine
Diazepam
Short tapering course of oral steroids
Vestibular adaptation exercises/rehabilitation in the recovery phase
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Meniere’s disease ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ It is commonest in the 30–50

Meniere’s disease

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

It is commonest in the 30–50 years age

group
Triggers: high salt intake, chocolate, alcohol, smoking, stress, menstrual cycle
Attacks last 30 minutes to several hours.
There is a variable interval between attacks (twice a month to twice a year).
Nystagmus is observed only during an attack (often to side opposite affected inner ear).

Symptoms:
Typical history consists of recurrent attacks of vertigo, tinnitus, and ipsilateral hearing loss
Nausea and vomiting
SNHL is fluctuating and progressive

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Meniere disease ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ DxT vertigo + vomiting + tinnitus

Meniere disease

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

DxT vertigo + vomiting + tinnitus + sensorineural

deafenss → Ménière syndrome
Treatment:
Low salt diet +/- diuretic for maintenance treatment (hydrochlorothiazide, acetazolamide)
Vestibular sedative, antiemetic for acute episodes
Prochloperazine
Diazepam
Vasodilators - Betahistine
Meniette device
Intra-tympanic therapy – steroids, aminoglycosides
Surgery for refractive cases
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ An elderly patient has acute onset unilateral deafness,

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

An elderly patient has acute onset unilateral deafness, tinnitis

& vertigo. What is the
diagnosis?
a) Meniere’s disease
b) Acoustic neuroma
c) Vestibula neuronitis
d) Positional vertigo
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ A 39-year-old woman arrives at the hospital after

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

A 39-year-old woman arrives at the hospital after her

third episode of dizziness.
Her first episode was 6 months ago and her most recent episode occurred yesterday. She describes feeling as if the room was spinning around her. During each of these episodes she has experienced significant nausea, often accompanied by emesis. Upon further questioning she tells you that she has been hearing a low rumbling noise in her right ear.
What test is required to confirm your diagnosis?
(A) CT head
(B) MRI head
(C) Audiogram
(D) Tilt table test
(E) No need for further testing
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Acoustic neuroma (vestibular schwannomas) ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Benign tumour of Schwann

Acoustic neuroma (vestibular schwannomas)

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Benign tumour of Schwann cells surrounding

auditory nerve
Usually unilateral
Bilateral tumour associated with Type 2 Neurofibromatosis
Chromosome 22 abnormality
Autosomal dominant transmission
DxT (unilateral) tinnitus + hearing loss + unsteady gait → acoustic neuroma

Symptoms:
Unilateral progressive SNHL 85%
Sudden hearing loss 15%
Tinnitus 56%
Vertigo 19%
Midface hypesthesia,
Cranial nerve V and VII Facial paresis
Diplopia, dysphagia, hoarseness, aspiration,
cerebellar ataxia
Hydrocephalus: headache and vomiting

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Acoustic neuroma ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Diagnosis: audiometry (SNHL), MRI, CT Treatment:

Acoustic neuroma

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Diagnosis: audiometry (SNHL), MRI, CT
Treatment:
Conservative: monitoring
Surgical resection
Translabyrinthine, middle

fossa, or suboccipital retrosigmoid approaches
Stereotactic radiosurgery (gamma knife)
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Which of the following is least likely to

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Which of the following is least likely to cause

facial nerve palsy?
a) Skull fracture
b) Mastoiditis
c) Chronic parotitis
d) Parotid tumour
e) Acoustic neuroma
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

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Otosclerosis ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Disease of the bone surrounding the inner

Otosclerosis

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Disease of the bone surrounding the inner ear and

is the most common cause of conductive hearing loss in the adult with a normal tympanic membrane
The normal middle ear bone is replaced by vascular, spongy bone that becomes sclerotic

Features:
Progressive disease
Develops in the 20s and 30s
Family history (autosomal dominant)
Unilateral or bilateral
Female preponderance
Stapes footplate is affected
May progress rapidly during pregnancy
Conductive hearing loss

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Otosclerosis ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Treatment Referral to an ENT consultant Stapedectomy

Otosclerosis

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Treatment
Referral to an ENT consultant
Stapedectomy (approximately 90% effective)
Hearing aid

fitting (less effective alternative)
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Which of the following is most likely to

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Which of the following is most likely to be

associated with otosclerosis?
a) Normal tympanic membrane
b) Red & inflamed tympanic membrane
c) Tense & transparent tympanic membrane with fluid level behind
d) Blue gray sclera
e) Obstruction of the Eustachian tube
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ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

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Head and neck masses ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Head and neck masses

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

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Cystic lesions of the neck ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Cystic lesions of the neck

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

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Cystic hygroma ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Commonly involves the posterior cervical space

Cystic hygroma

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Commonly involves the posterior cervical space
 May be

macrocystic or microcystic
 MRI is the gold standard for radiologic evaluation
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Branchial deft cyst ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ located inferior to the external

Branchial deft cyst

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

located inferior to the external auditory meatus

or anterior to the sternomastoid muscle. The opening may
discharge mucous. A skin tag or cartilage remnant may be present. Refer when diagnosed for excision.

Most common cystic lesion of the anterior triangle of
the neck in children
 Unilocular, cystic mass displacing the submandibular
gland anteriorly and the sternocleidomastoid
muscle posteriorly

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Thyroglossal duct cyst ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ the most common childhood midline

Thyroglossal duct cyst

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

the most common childhood midline neck swelling
It

moves with swallowing and tongue protrusion. It is prone to infection, including
abscess formation. The cyst and its tract are best excised before it
becomes infected.

Midline lesion anywhere from foramen caecum and
the thyroid gland
 Moves with protrusion of the tongue
 May contain ectopic thyroid tissue
 May contain all of the functioning thyroid
 Ultrasound, thyroid scans
 Surgical excision -- Sistrunk procedure

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Carotid body tumor ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ Carotid body tumors (CBTs) present

Carotid body tumor

ДОБАВИТЬ НИЖНИЙ КОЛОНТИТУЛ

Carotid body tumors (CBTs) present most commonly

as an asymptomatic palpable neck mass in the anterior triangle of the neck
They are slow-growing tumors that can remain asymptomatic for many years.
Symptoms cranial nerve palsy 10%, pain, hoarseness, dysphagia, Horner syndrome, or shoulder drop.

Diagnosis: ultrasonography with color Doppler, CT,MRI
The carotid body is a small, reddish-brown, oval structure, located in the posteromedial aspect of the carotid artery bifurcation.
Treatment: surgery or radiotherapy

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