Approach to

Ear Problems

By
Ratna Suryati Halim
Stacey Singer-Leshinsky R-PAC
F Bhatti, MD
GP Murtaugh
Emedicine
Sanfort
 Normal
- Consider the malleus as
an arrow; pointing in
the forward direction. Attic Anterior
direction
- The normal tympanic
membrane should Po A
appear st nt
. pearly grey eri
. have a light reflex er
. generally concave or io
. and malleus should be Infer
r
visible ior
Abnormals:
. Retraction( bones more prominent)
. Perforations
. Bubbles (glue ear, resolving infection)
. White patches (tympanosclerosis or
cholesteatoma)
. Granulations
. Red lesion at tip of malleus (glomus
tumour)
Ear Drum-normal Landmarks
An annulus fibrosus or
more commonly referred to
as the eardrum margin. This
is important. Note how
smooth and how ever so
slightly blurry it is.

Um umbo - the end of the

malleus handle and usually
marks the centre of the
drum

Lr light reflex or Cone of

light is usually seen antero-
inferioirly

At Attic also known as pars

flaccida. Any perforations
here are serious and need
referral.

Lp Lateral process of the

malleus
Hm handle of the malleus
Lpi long process of incus -
sometimes visible through a
healthy translucent drum
Causes Ear Pain
What next?

Probability diagnosis
The commonest cause of ear pain is acute
otitis media.
Chronic otitis media and otitis externa are
also common.
Serious disorders not to be missed
carcinoma of the tongue, palate or tonsils
referred pain.
Locally destructive cholesteatoma associated
with chronic otitis media.
History taking?

In assessing the painful ear the relevant features are:

site of pain and radiation
details of the onset of pain
nature of the pain
aggravating or relieving factors, especially swimming
associated features such as deafness, discharge, vertigo,
tinnitus and irritation of the external ear, sore throat
Think also: perichondritis or furunculosis of the
external ear, herpes zoster (Ramsay Hunt syndrome).
Movement of the pinna acute otitis externa and
perichondritis
Movement of the jaw temporomandibular joint (TMJ)
arthralgia or severe otitis externa.
 Go
systematically
External:

Pinna (shape, colour, position, tenderness, haematoma) etc

Mastoid (tenderness in AOE or mastoid abscess)

Internal:
The Canal ( skin, furuncle, scales,spores,FBs,discharge, debris, wax)
The Tympanic membrane (look ant, post, superior/ attic and inferior of malleus)
. Colour( opaque, white, red, patches & translucency)
. Retraction( landmarks behind it more visible)
. Perforation ( safe/ unsafe)
. Discharge (purulent, mucopurulent)

Behind the Eardrum

. Fluid behind the drum
. Any red bits( glomus tumour, granulations or blood?, white- cholesteotoma)
Other investigation?

Investigations are seldom necessary.

Example: Hearing tests, Audiometry,
Tympanometry, Swabs from
discharge, Radiology and
computerised tomography may be
indicated for special conditions such
as a suspected extraotic malignancy.
Becarefull with loss of hearing
Topic:

Disease of the external ear

Disease of the middle ear
Disease of the inner ear
External Auditory Canal
Cerumen Impaction
Cerumen is produced by apocrine and sebaceous glands in
external ear canal.
Cause: attempts to clean the ear, or water in canal
Clinical manifestation:
Hearing loss
Stuffed or full feeling to ear
Pain if cerumen touches TM
Management:
Be sure TM is intact prior to lavage
Irrigate ear with one part peroxide, and one part water
Ear irrigation and manual cerumen removal
External Auditory Canal
Foreign body
Can include toys, beads, nails, vegetables or insects.
Damage depends on amount of time object has been in ear.
Clinical manifestation:
Might present with purulent discharge
Pain
Bleeding
Hearing loss
External Auditory Canal
Foreign body- Management
Irrigation is best provided if the TM
is not perforated
Destroy insect with lidocaine or olive
oil.
Irrigate and suction liquid.
For inanimate objects suction or
use alligator forceps.
 External Auditory Canal
Acute Otitis Externa
Bacteria:
m Pseudomonas sp.
m Escherichia coli
m Staphylococcus aureus
m Proteus sp.
m Klebsiella sp.
Fungi:
m Candida albicans
m Aspergillus sp. Risk factors:
Swimming, perspiration, high humidity,
insertion of foreign body
Eczema, psoriasis, seborrheic
dermatitis
External Auditory Canal
Acute Otitis Externa
External Auditory Canal
Acute Otitis Externa
Management:
Topical antibacterial drops such as
Neomycin otic, polymyxin, Quinolone otic
Otic steroid drops containing polymyxin-
neomycin and a topical corticosteroid.
Analgesics
External Auditory Canal
Malignant Otitis Externa
Inflammation and damage of the bones and cartilage of the base of
the skull
Occurs primarily in immunocompromised
Most common etiology is pseudomonas aeruginosa.
Clinical manifestation:
Otorrhea: yellow green, foul smelling.
Granulation tissue in external auditory canal
Trismus
Fever
Facial and cranial nerve palsies
External Auditory Canal
Malignant Otitis Externa
Diagnosis:
Culture of ear secretions and
Pathological examination of granulation tissue
CT Scan
Complications:
Sepsis
Cranial nerve palsies
Meningitis, brain abscess, osteomyelitis of the temporal bone and skull
External Auditory Canal
Malignant Otitis Externa

Need IV antibiotics
Might need surgical debridement.
If treatment interrupted, rate of
recurrence is 100%
Tympanic Membrane
Bullous Myringitis
Vesicles develop on the TM second to viral infections or
bacterial infection
Usually associated with middle-ear infection
May extend into canal.
Clinical manifestation:
Sudden onset of severe pain
No fever usually
No hearing impairment
Bloody otorrhea possible
Inflammation to TM
Multiple reddened inflamed blebs possibly blood filled
Tympanic Membrane
Bullous Myringitis
Management:
Antibiotics
If pain is severe, rupture the vesicles
with a myringotomy
Analgesics
Tympanic Membrane
Perforated TM
Etiology is direct trauma, infection, pressure build up
Bacteria can travel into middle ear and lead to secondary
infection

Clinical manifestation:
Sudden severe pain
Hearing loss
Drainage
Otoscope exam reveals puncture in TM,
might be able to see bones of middle ear
Purulent otorrhea may begin in 24-48 hours post perforation
Tympanic Membrane
Perforated TM
Complications include secondary
infection into inner ear
Management:
Antibiotics to prevent infection or treat
existing infection
Surgical repair
Middle Ear
Acute Otitis Media
Viral respiratory infections (adenovirus
and enterovirus) cause inflammation of
ET
When ET is blocked, fluid collects in the
middle ear.
Bacterial Etiology : Haemophilus
influenzae, Streptococcus pneumoniae,
Branhamella (previously Neisseria)
catarrhalisand b-haemolytic streptococci.
Risk factors:
Passive smoker
Male
Family history of otitis media.
In day care
On formula feed
 Middle Ear
Acute Otitis Media
Clinical manifestation:
Otalgia.
Conductive hearing loss
URI symptoms
Vomiting, diarrhea
Fever
TM bulging and erythematous
with decreased or poor light
reflex.
Decreased TM mobility on
pneumatic insufflation
 Complications from AOM

Complications from otitis media is extremely low.

> Progression to glue ear and associated hearing impairment
> Perforation. In one study 29.5 % children with AOM eardrum perfs.
But spontaneously closed in 94 % of the patients within one month.

Rarely to mastoiditis, labyrinthitis, meningitis, intracranial sepsis or

facial nerve palsy.

Recurrent episodes may lead to atrophy and scarring of the eardrum,

chronic perforation and otorrhoea, cholesteatoma, permanent hearing
loss, chronic mastoiditis and intracranial sepsis.
Middle Ear
Acute Otitis Media -Diagnosis

Management:
analgesics to relieve pain
adequate rest in a warm room
nasal decongestants for nasal
congestion
antibiotics until resolution of
all signs of infection
treat associated conditions,
e.g. adenoid hypertrophy
follow-up: review and test
hearing audiometrically
Middle Ear
Acute Otitis Media -Recurrent OM

Three episodes of AOM in 6

months or 4 episodes in 12
months
Prevent by antibiotic
prophylaxis, pneumovax,
tympanostomy tubes,
adenoidectomy
Middle Ear
Otitis Media with Effusion
Fluid accumulation behind TM in middle ear
Build up of negative pressure and fluid in
eustachian tube
Common in children because of anatomy, cleft
palate, allergies, barotrauma.
Clinical manifestation:
Hearing loss
Fullness, pressure
TM neutral or retracted. Gray or pink.
Landmarks visible or dull.
Decreased TM mobility
Middle Ear
Otitis Media with Effusion

Pdx:
Tympanometry
Audiometry
Managememnt:
Decongestants/Oral steroids
Antibiotics
Myringotomy with or without tubes
Adenoidectomy
Middle Ear
Chronic Otitis Media
Recurrent or persistent otitis media due to dysfunctional eustachian
tube
Risks: allergies, multiple infections, ear trauma, swelling to adenoids.
Bacteria: P aeruginosa, proteus species, Staphylococcus aureus, and
mixed anaerobic infections.
Causes long term damage to middle ear due to infection and
inflammation including
Severe retraction of TM due to prolonged negative pressure
Scaring or erosion of small conducting bones of middle ear and
inner ear
Erosion of mastoid
Thickening of mucous secretions in ET
Cholesteatoma
Persistent OME
Middle Ear
Chronic Otitis Media
Clinical manifestation:
Ear pain
Fullness to ears
Purulent discharge
Hearing loss
Dullness, redness or air
bubbles behind TM
Middle Ear
Chronic Otitis Media
Diagnosis: clinical, audiometry, tympanometry, CT, MRI
Differential diagnosis to include AOM, cholesteatoma
Complications include bony destruction or sclerosis of
mastoid air cells, facial paralysis, sensineural hearing loss,
vertigo
Management:
Antibiotics , steroids, placement of tubes.
Myringotomy
Surgical tympanoplasty, mastoidectomy
Cholesteatoma

Epithelial cyst consists of desquamating

layers of scaly or keratinized skin.
Erosion of ossicles common. As more
material is shed, the cyst expands eroding
surrounding tissue.
Two types: congenital and acquired.
Acquired due to tear in ear drum, infection
Cholesteatoma

Clinical manifestation:
Perforation of TM
filled with cheesy white
squamous debris
Possible conductive
hearing loss
Drainage
Differential Diagnosis:
squamous cell
carcinoma
Cholesteatoma-Management

Large or complicated cholesteatomas

require surgical excision
Complications include erosion of bone
and promote further infection leading
to meningitis, brain abscess, paralysis
of facial nerve.
Barotrauma

Barotrauma is damage caused by undergoing

rapid changes in atmospheric pressure in
the presence of an occluded eustachian
tube.
It affects scuba divers and aircraft
travellers.
Symptoms include temporary or persisting
pain, deafness, vertigo, tinnitus and
perhaps discharge.
Barotrauma

Inspection of the TM may reveal (in order

of seriousness):
Retraction,
Erythema,
Haemorrhage (due to extravasation of
blood into the layers of the TM),
Fluid or blood in the middle ear,
Perforation
Barotrauma

Treatment:
Most cases are mild and resolve
spontaneously in a few days; so treat
with analgesics and reassurance.
Menthol inhalations (Vicks inhaler) are
effective.
Refer if any persistent problems.
Mastoid

Portion of temporal bone posterior to

the ear.
Mastoid air cells connect with the
middle ear
Fluid in the middle ear can lead to
fluid in the mastoid
Mastoiditis

Middle ear inflammation spreads to

mastoid air cells resulting in infection
and destruction of the mastoid bone.
Etiology: Streptococcus pneumoniae,
Haemophilus influenzae, streptococcus
pyogenes, and other bacteria
Mastoiditis

Clinical
Manifestation:
Pain
Bulging
erythematous TM
Erythema,
tenderness,
edema over
mastoid area
Postauricular
fluctuance
Mastoiditis-
Diagnosis/differentials
Diagnosis:
CT show bony destruction or drainable mastoid
abscess
Tympanocentesis to culture middle ear fluid.( S.
pneumoniae, H. influenzae, M. catarrhalis)\
Culture of fluid
Differential diagnosis to include otitis
media, Cellulitis, scalp infection with
inflammation of posterior auricular nodes
Mastoiditis
Complications
Destruction of mastoid bone
Spread to brain leading to brain
abscess or epidural abscess
Mastoiditis-Management

Treat with antibiotics

Patients with severe or prolonged:
may need to surgically remove a
portion of the bone
Labyrinthitis

Viral infection
Vestibular neural input disrupted to the
cerebral cortex and brain stem
Vertigo due to inflammation and infection
of labyrinth
Neurological exam normal
Can also follow allergy, cholesteatoma, or
ingestion of drugs toxic to inner ear
Labyrinthitis
clinical manifestation
Nausea/vomiting
Vertigo with head or
body movements lasts
about 1 min
Nystagmus(rotary
away from affected
ear)
Loss of balance
Labyrinthitis

Diagnosis: Audiologic testing, CT and

MRI
Differential diagnosis : acoustic
neuroma, vertigo, cholesteatoma,
menieres disease
Labyrinthitis
Management
Steroids
Sedatives
Antivertigo
Patient reassurance that symptoms usually
last 7-10 days with subsequent episodes up
to 18 months.
Complications include spread of infection
Meniere disease

Endolymphatic hydrops refers to a condition of increased

hydraulic pressure within the inner ear endolymphatic
system.
Excess pressure accumulation in the endolymph can cause a
tetrad of symptoms:
(1) fluctuating hearing loss,
(2) occasional episodic vertigo (usually a spinning sensation,
sometimes violent),
(3) tinnitus or ringing in the ears (usually low-tone roaring),

(4) aural fullness (eg, pressure, discomfort, fullness

sensation in the ears).
Causes:
metabolic imbalance,
hormonal problems,
Infections
Autoimmune diseases (eg, lupus, rheumatoid arthritis)
Allergy
Work Up:
Laboratory test
Imaging
Audiometry
Treatment

In general, medications that decrease symptoms (eg, meclizine [Antivert],

droperidol [Inapsine], prochlorperazine [Compazine], diazepam [Valium], lorazepam
[Ativan], alprazolam [Xanax]) only mask the vertigo. These masking agents are
vestibulosuppressants and work by dulling the brain's response to signals from
the inner ear.
Some diuretics or medications with diuretic-like properties (eg,
hydrochlorothiazide and triamterene [Dyazide], hydrochlorothiazide [Aquazide],
acetazolamide [Diamox], methazolamide [Neptazane]) decrease fluid pressure in
the inner ear. These medications help prevent attacks but do not help after the
attack is triggered.
Steroids have also been helpful in treating endolymphatic hydrops because of
their anti-inflammatory properties. Steroids can reverse vertigo, tinnitus, and
hearing loss, probably by reducing endolymphatic pressure. Steroids can be given
orally, intramuscularly, or even transtympanically. Although the transtympanic
route is controversial, it is gaining wider acceptance throughout the otologic
community.
The histamine agonists that are used in countries outside of the United States
must be mentioned. Medications such as betahistine (Serc) are widely used in
Europe and South America. Although its mechanism of action is somewhat
controversial, many have reported success with its use in mitigating symptoms of
Mnire disease.