Approach to

Ear Problems

By
Ratna Suryati Halim
 Normal
- Consider the malleus as
an arrow; pointing in
the forward direction. Attic Anterior
direction
- The normal tympanic
membrane should Pos
appear An
. pearly grey teri
. have a light reflex or ter
. generally concave ior
. and malleus should be Inferi
visible or
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)
. Grommets/FBs
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
 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( meniscus, air fluid levels, colour, bubbles?..can ask for a valsalva if appropriate)
. Any red bits( glomus tumour, granulations or blood?, white- cholesteotoma)
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
It is important not to overlook malignant diseases, such
as
carcinoma of the tongue, palate or tonsils that cause
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.
Physical examination
Inspected
Palpate the face and neck and include the
parotid glands, regional lymph nodes and
the skin.
Inspect both ear canals and tympanic
membranes, if the diagnosis is still
doubtful look for causes of referred pain;
inspect the cervical spine, the nose and
postnasal space and the mouth, including
the teeth, pharynx and larynx.
Sudden, jabbing pain neuralgia
(glossopharyngeal neuralgia or a severe
infection).
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
Debrox and Cerumenex drops
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 the TM is
not perforated
Destroy insect with lidocaine or
mineral oil.
Irrigate and suction liquid.
For inanimate objects suction or use
alligator forceps.
External Auditory Canal
Acute Otitis Externa
Defenses include cerumen :
acidifies the canal and suppresses
bacterial growth.
prevents water from remaining in
canal and causing maceration.
Etiology: Pseudomonas aeruginosa and
staphylococcus aureus, streptococcus
Risk factors:
Swimming, perspiration, high
humidity, insertion of foreign body
Eczema, psoriasis, seborrheic
dermatitis
External Auditory Canal
Acute Otitis Externa
Clinical manifestations:
Otalgia/otorrhea
Fever
Pain
Canal edematous and obscured
with debris, discharge, blood,
or inflammation
Lymphadenopathy
Complications
malignant otitis externa
caused by pseudomonas
Differential diagnosis
basal cell carcinoma
squamous cell carcinoma
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
Chronic Otitis Externa
Duration of infection greater than four weeks, or greater than 4
episodes a year
Risks: inadequate treatment of acute otitis externa, persistent
trauma, inflammation or malignant otitis externa.
Etiology: Bacterial,fungal or dermatologic such as candida or
Aspergillus, pseudomonas or psoriasis
Clinical manifestation:
Purulent discharge
Dry or scaly.
Pruritus
Conductive hearing loss
Differential diagnosis to include:
basal cell or squamous cell carcinoma,
Foreign bodies, otitis media
External Auditory Canal
Chronic otitis externa
Management:
Cover fungi with clotrimazole(Lotrimin)
Systemic antifungal include ketoconazole
Cortisporin
Wick with few drops of Domeboros astringent
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
Differential diagnosis:
basal cell or squamous cell carcinoma
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
Differential diagnosis to include acute
and chronic otitis media
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 cause
inflammation of ET
When ET is blocked, fluid collects
in the middle ear.
Common in fall, winter or spring
ET in child is shorter and more
horizontal in infants/children.
Bacterial Etiology : S.pneumoniae,
H.influenzae, and M.Catarrhalis.
Risks include URI,smoking at
home, allergies, cleft palate,
adenoid hypertrophy, bottle
feeding, barotrauma
 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
Middle Ear
Acute Otitis Media -Diagnosis
PDx: Tympanometry Complication:
Differential diagnosis:
TM perforation/
TM perforation Tympanosclerosis
Tympanosclerosis
Recurrent AOM or
Recurrent AOM chronic OM
Mastoiditis
Persistent middle ear
Management: effusion
Analgesics/ Antipyretics
Mastoiditis
Auralgan
Bacteremia
Antibiotics
Decongestants
Avoid antihistamines
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
Antivert
Tigan
Patient reassurance that symptoms usually
last 7-10 days with subsequent episodes up
to 18 months.
Complications include spread of infection