EAR

A.  Otitis Externa

Etiology:

1. Injury to canal wall skin (Foreign body, Q-tips, Insects) and moisture leads to  secondary infection with bacteria and fungus
2. Most commonly S. aureus, P. auruginosa, Aspergillis Niger, C. albicans (10-15%)

1. Pain within ear canal, pain on palpation of auricle (especially tragal pain),  and periotic discomfort.
    
2. Decreased hearing secondary to canal obstruction from edema and debris, associated with a feeling of fullness.
    
3. Clear to purulent otorrhea, may be foul smelling.  Rare vertigo.  Occasional tinnitus .  Pruritis.  Cellulitis may progress to involve external ear, skin around ear, and regional lymphadenopathy.
    
4. Deep boring pain associated with granulation tissue, refractory otitis externa (especially in a diabetic or immunocompromised patient) may indicate necrotizing otitis externa (Malignant otitis externa)
    

Treatment: 

1. The most important aspect of treatment is the phsyical removal of the debris/otorrhea from the ear canal.  This can be accomplished with a cerumen loop, or a small #5 suction.  If severe stenosis is noted, a "Pope" otowick may be inserted into the ear canal (recheck in two days and give systemic antibiotics).
    
2. Either acetic acid drops (Volsol) are administered, Dombero, or antibiotic drops +/- steroid (Cortisporin, Floxin, Cipro HC) are given.
    
3. For systemic symptoms of fever, malaise, and regional lymphadenopathy, systemic antibiotics are started. Amoxicillin is a good first line medication.  Pain medication is also given, acetaminophen and codeine, for severe discomfort.
    
4. Nystatin for persistant fungal infection.
    
5. Patient is also instructed to avoid instrumentation of the ear, and avoid water in the ear.  For showering/bathing, a cotton-ball smeared with Vasoline will help prevent water accumulation within the ear canal.
    
6. Follow up usually in one week or sooner if pain not improved.  Obtain culture for persistant infection.
    
7. Note:  If Necrotizing otitis externa is suspected, an otolaryngology consult should be obtained.  Such patients may require biopsy of granulation tissue, systemic and topical anti-pseudomonal therapy, and radiological diagnosis (CT, bone scan, gallium scan).

B.  Foreign Body External Auditory Canal

1. Commonly in young children. Small beads, crayons, pieces of paper, and insects (most common in adults).  Watch battery is an absolute emergency !
    
2. S & S: history of FB placement, pain, fullness, tinnitis, decreased hearing, bloody otorrhea, rarely vertigo.
    
3. Treatment: Ear canal is examined. 
    
1. Debris and cerumen are removed.  Take care not to push foreign body deeper into canal, or to traumatize canal wall and tympanic membrane.  Ossicular manipulation may lead to sensorineural hearing loss and perilymphatic fistula.
    
2. Insects must be killed prior to removal.  This may be accomplished with mineral oil or lidocaine 1%.
    
3. The child is stabilized.  The foreign body is removed with alligator forceps, a small curved ear pick  placed behind the object and pulled forward, a small #5 suction, and irrigation (especially for small  beads and round objects).
4. d)  If there is significant canal wall trauma, antibiotic drops may be prescribed.
    
5. Any perforation or noted decreased hearing after removal warrants a visit to the ENT clinic.

C.  Tympanic Membrane Perforation

1. Most commonly from Q-tip use. 
    
2. Pencils, bobby-pins, open hand blows to ear, and head trauma are other causes.
    
3. Rare causes include slag injury and high-voltage electricity (lightening).
    
4. More than 85% of these perforations will heal.  No antibiotic drops are necessary unless there is significant canal wall trauma, dirty penetrating objects, or associated swimming in pond/lake water.
    
5. Symptoms include pain, bloody otorrhea, hearing loss, tinnitis, and vertigo (must suspect perilymphatic fistula if present, may need surgical exploration).  Facial nerve paralysis is also possible and warrants immediate CT, ENT consult, and possible surgical exploration.
    
6. Follow up in the ENT clinic is necessary to monitor closure and obtain a baseline audiogram to rule out associated ossicular damage and sensorineural hearing loss.  Tympanoplasty reserved for non-healing perforations.

D.  Otitis Media: (include complications)

Etiology:

1. Most common organisms: Streptococcus pneumoniae, Haemophilus influenzae, and Morexella catarrhalis.
    
2. Predisposing factors: Young age, smoke exposure, day care attendance, bottle-feeding, craniofacial abnormalities/clefts, Down syndrome, immunodeficiency, ciliary dysfunction, allergy, and nasopharyngeal tumors.
    
3. Pathogenesis: a combination of eustachian tube dysfunction, middle ear colonization via nasopharyngeal reflux, a bacterial reservoir (adenoid (note: not size)), and other predisposing factors.

1. Based on history and pneumatic otoscopy.  Audiogram with tympanometry demonstrate a conductive hearing loss with a flat tympanic tracing (Type B).  Computed Tomography is reserved for complications of acute otitis media (suspicion of abscess, facial nerve paralysis, suspicion of cholesteatoma, etc.).

1. OM may result in cognitive delay, speech delay, hearing loss (both sensorineural and conductive), persistent effusion, tympanosclerosis, ossicular destruction, retraction pockets, cholesteatoma.
    
2. Complications:  cholesteatoma, mastoiditis, labyrinthitis, petrositis, meningitis, subdural/epidural/brain abscess, lateral sinus thrombosis, facial nerve paralysis.

E.  Mastoiditis

Etiology:

1. Caused by: Streptococcus pneumoniae > B-hemolytic streptococcus > Staphylococcus aureus > Haemophilus influenzae.
    
2. Presents with:
    
1. Edema, tenderness, and erythema of the postauricular skin overlying the mastoid.
    
2. Proptosis of the pinna may be noticed.
    
3. The tympanic membrane is usually intact with signs of acute otitis media.
    
4. The patient will have systemic signs including fever, irritibility, and malaise.
    
5. Symptoms related to complications of mastoiditis must be sought out (hearing loss, seventh nerve paralysis, labyrinthitis, coalescent mastoiditis with subperiosteal abscess, meningitis, intracranial abscess, and hydrochephalus).

1. An otolaryngology consult should be obtained.
    
2. Medical therapy includes initiation of empiric intravenous antibiotic therapy to cover the above organisms.  Ticarcillin (Timentin ), ceftriaxone with metronidazole, and other broad spectrum agents either alone or in combination, are good alternatives.  In general, antibiotic  treatment  should continue until symptoms resolve and soft tissue involvment resolves.
    
3. Careful monitoring for complications of mastoiditis should be initiated.  For patients with any complication of simple mastoiditis, a cortical mastoidectomy with tympanostomy tube insertion should be performed.

F.  Sudden Hearing Loss

1. By definition, sudden hearing loss (SHL) is the loss of  30 dB or more of sensorineural hearing over at least three contiguous frequencies occurring within 3 days or less.
    
2. The causes for SHL are numerous:  infectious, neoplastic, immunologic, toxic, traumatic, metabolic, circulatory, as well as many others.  Most cases of SHL remain undiagnosed with regards to the etiology.  Approximately 60-70% of patients will improve spontaneously.  In less than 15%, the hearing loss will progress.
    
3. The diagnostic workup should be geared toward confirming a sensorineural hearing loss.  This includes a history of trauma, straining, medications or ototoxins, recent viral infections, any systemic symptoms related to neoplasm, immunologic disease, vascular insufficiency, and many others.  The physical exam is centered on obtaining an audiogram to confirm a sensorineural hearing loss.  Any conductive component must be ruled out (cerumen, a TM perforation, ossicular discontinuity, OE).  Further diagnostic testing that may be required includes a MRI with gadolinium, electronystagmography, blood chemistries, FTA, lyme, viral titers.
    
4. Treatment: 
1. Immediate referral to an otolaryngologist.
    
2. Although controversial, treatment is centered on early intervention with corticosteroids and antivirals.
    
3. Prednisone, unless contraindicated, is begun at a dose of 1mg/kg/day.
    
4. Acyclovir (or related antiviral) is started at 1-2 g/d divided into 5 doses. 
    
5. A low salt diet and possibly hydrochlorothiazide with triamterene is begun.

G.  Acute Facial Paralysis

1. Not all facial paralysis is "Bell's Palsy".  Bell's Palsy, or idiopathic facial paralysis is a diagnosis of exclusion.  Idiopathic facial paralysis, most likely a viral reactivation syndrome, represents 60-80% of the cases of acute facial paralysis.  This is followed by Herpes Zoster Oticus (Ramsay Hunt Syndrome), temporal bone trauma, infection, otitis media, and much less commonly, tumor.
    
2. Clinical History:  important to discern timing of paralysis, any related ear infections, traumatic injury, prior history of paralysis, otalgia, otorrhea, tinnitis, vertigo, and any change in hearing.  Familial history, medication history, and other systemic signs should be asked.  Also important to determine if any trigeminal symptoms, dysgeusia, hyperacusis, or noted decreased tearing.
    
3. First, a full head and neck exam must be performed.  Any ear canal lesions, otorrhea, tympanic perforations, effusions, or masses are noted. Look for  vesicles along the trigeminal distribution, or within and around the ear.  Any palpable periauricular masses are noted.  It is important to document the degree of paralysis: i.e. partial or complete.
    
4. In the absence of any physical findings other than paralysis, imaging in the acute setting is not necessary.  For recurrent paralysis, or paralysis associated with a mass or chronic infection, an otolaryngology consult should be obtained as well as imaging studies:  MRI for suspected parotid or CNS lesions, and CT (fine cuts through the temporal bones) for infectious etiology (chronic otitis media, cholesteatoma,), temporal bone trauma.
    
5. Treatment remains controversial.  The current standard of care is to administer steroids and antiviral treatment.
    
1. Prednisone at 1mg/kg/day is begun, unless contraindicated.
    
2. Antiviral therapy consists of acyclovir or one of its newer derivatives.
    
3. Antacid therapy should be started as well.  Eye protection is very important.  Lacrilube, artificial tears, and eye protection during the night should be prescribed.    Finally, the patient should be given a follow-up appointment with an otolaryngologist.

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