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ENT: Ear pain
Ear pain ENT
84
Anatomy
Graduate
10/03/2011

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Term
Ear pain:
Definition
Most common for office visits in primary care
Otitis media 3rd most common and 11th in reasons among more than 500,000 patient problems
In addition ear wax, serous otitis media, and otitis externa also ranked in top 50 for visits
Term
The ear is innervated by CN __, __, and __
Definition
7, 9, 10
Term
The conchae and external canal are innervated by __ __ of CN __, the __ nerve.
Definition
- somatic fibers of CN VII, facial nerve
Term
Parts of the external auditory canal are innervated by the __ branch of the __ nerve. This branch is known as __ __, which contains nerve fibers from CN __, __, and __.
Definition
- auricular
- Vagus
- Arnold's nerve
- CN VII, IX, and X
Term
The middle ear, throat, and tongue are innervated by __ _. This is why it is common for throat pain to be referred to the middle ear.
Definition
CN IX (glossopharyngeal)
Term
What are the 4 types of otitis media?
Definition
1. Acute suppurative otitis media
2. Chronic suppurative otitis media
3. Acute serous otitis media
4. Chronic serous otitis media
Term
most common dx made by clinicians who care for children?
Definition
otitis media
Term
peak prevalence of otitis media is in children ages __ __ to __ __.
Definition
6 months to 3 years
Term
Causes of acute suppurative otitis media:
Definition
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- group A streptococcus

(Some Have More Game)
Term
The early phase of acute suppurative otitis media lasts __ to __ days and is characterized by __, __ __, and __ __. The TM shows __, __, and loss of landmarks. __ __ is common.
Definition
- 1 to 2 days
- fever, pulsating pain, and hearing loss
- hyperemia, opacification
- Mastoid tenderness
Term
The middle phase of acute suppurative otitis media lasts _ to _ days. There is __ __, often __ __. During this time the __ and __ subside.
Definition
- 3 to 8 days
- purulent effusion
- spontaneous discharge
- fever and pain subside
Term
The healing phase of acute supporative otitis media lasts _ to __ __. During this time the tympanic membrane and middle ear normalize.
Definition
2 to 4 weeks
Term
Treatment of acute suppurative otitis media:
Definition
- DOC: AMOXICILLIN 80-100MG/KG/DAY divided into 3 doses

The following can also be used:
- Amoxicillin-clavulanic acid
- Cefuroxime
- Trimethoprim-sulfamethoxazole
Term
cannot give amoxicillin for otitis media if pt is allergic to __.
Definition
penicillin
Term
For severe acute suppurative otitis media, __ may have to be performed by an ENT. This is for patients with persistent pain, high fever, facial nerve palsy, acute meningitis, labrynthitis, or mastoiditis.
Definition
- myringotomy
Term
DDx of otitis media:
Definition
otitis externa
acute mastoiditis
Term
DDx of otitis media:
Definition
otitis externa
acute mastoiditis
Term
Consider acute mastoiditis when a patient with otitis media experiences worsening of symptoms along with mastoid tenderness, post auricular swelling and erythema, and prolapse or swelling of the posterior wall of the external canal.
Definition
Term
Mastoiditis is very close to brain structure> can rupture> get systemic and lead to meningitis, many other problems too.

Mastoiditis caused by untreated or undertreated acute otitis media.
Definition
Term
Mastoiditis is an infection of the mastoid process
It is usually caused by untreated acute otitis media
Used to be the leading cause of child mortality
Common complications include hearing loss and extension of the infectious process beyond the mastoid system
Acute mastoiditis affects mostly young children and peaks in those aged 6-13 months
Definition
Term
common complications of mastoiditis:
Definition
- hearing loss
- extension of infectious process beyond mastoid system
Term
peak age for mastoiditis:
Definition
6 to 13 months old
Term
Consider referring adults with unilateral otitis media to an otolaryngologist for evaluation of the nasopharynx if persistant
Definition
Term
Causes of Chronic Suppurative Otitis Media:
Definition
- Cholesteatoma
- conditions that cause irrersible changes to middle ear and lead to adhesions and congestion around the eustachian tube

infection is usually caused by Staphylococcus aureus, anaerobic bacteria, or Pseudomonas
Term
Cholesteatomas can lead to __ and __ or ossicles and chronic suppurative otitis media.
Definition
infection and erosion
Term
Bacteria causes of chronic suppurative otitis media:
Definition
Staph aureus
anaerobic bacteria
Pseudomonas
Term
Chronic suppurative otitis media is characterized by __ discharge of __, __, __ exudate. Periods of no drainage alternating with exacerbations are common. There is __ hearing loss. Pain is __ and the general condition is good.
Definition
- chronic
- mucoid, purulent, odorleess
- conductive
- pain is absent
Term
DDx of chronic suppurative otitis media:
Definition
- tuberculosis
- carcinoma
Term
Tmt of chronic suppurative otitis media caused by cholesteatoma:
Definition
refer to ENT for surgical tmt
Term
Tmt of chronic suppurative otitis media NOT caused by cholesteatoma:
Definition
- resolve infection with irrigation and antibiotics to avoid mastoidectomy
Term
whitish debris at or behind the TM indicates ___
Definition
cholesteatoma: refer for mastoidectomy
Term
Acute serous otitis media often precedes or follows an episode of __ __ __ __. It may also be associated with conditions that cause __ __ __.
Definition
- acute suppurative otitis media
- eustachian tube dysfunction
Term
Acute serous otitis media presents with a feeling of __ or __ in the ears, often accompanied by __ __ and __ or __ while swallowing. On otoscope exam, the TM may be __ and an __ color can be appreciated behind it, with or without air bubbles.
Definition
- fullness or pressure
- hearing loss
- crackles or popping
- hyperemic
- amber
Term
To diagnose acute serous otitis media, __ or __ should be used. A __ configuration will be seen with __ and ___ will be seen with ____.
Definition
- tympanometry
- pneumo-otoscopy
- flat configuration
- hypomobility
Term
DDx of acute serous otitis media:
Definition
- acute suppurative otitis media
- leakage of CSF into middle ear or mastoid air cells
Term
Tmt of acute serous otitis media:
Definition
Address cause of eustachian tube dysfunction and eradicate causative organism:
- Antihistamines: for pts with allergic rhinitis
- Decongestants: for pts with viral rhinosinusitis
- Antibiotics: warranted to ensure sterilization
Term
Refer adult pts with acute serous otitis media, especially when it is __ and not associated with an _ __ _. Need to rule out __ of the __ __ by a __ __.
Definition
- unilateral
- URI
- obstruction of the eustachian tube by a nasopharyngeal mass
Term
With chronic serous otitis media, the effusion must be present for at least __ __.
Definition
3 months
Term
Causes of chronic serous otitis media:
Definition
- eustachian tube dysfunction
- allergies
- adenoid/sinus/nasopharynx abnormalities
Term
Clinical manifestations of chronic serous otitis media:
Definition
- feeling of fullness in the ear
- hearing loss
- NO pain
Term
DDx of chronic serous otitis media:
Definition
- Hemotympanum
- CSF leak
Term
Chronic serous otitis media tmt:
Definition
Treatment: Address underlying cause of eustachian tube dysfunction and eradicate infection with 10- to 14-day course of antibiotics
Term
follow-up and referral of chronic serous otitis media:
Definition
Refer appropriate patients to otolaryngologist:
Adenoidectomy: Helpful in older children with chronic serous otitis media
Myringotomy: For patients with vertigo, hearing loss, or an effusion that has persisted for much longer than 3 months
Term
Otitis externa is aka __ __.
Definition
swimmers ear
Term
homemade swimmers ear drops:
Definition
- 1 part alcohol + 1 part white vinegar

Vinegar kills the organsims by making more acidic and the alcohol dries out the ear.
Term
when does swimmer ear occur?
Definition
spring and summer
Term
Otitis externa is caused by breakdown of the protective barrier normally formed by __ and __.
Definition
skin and cerumen
Term
Most common pathogens causing otitis externa:
Definition
- Pseudomonas aeruginosa
- Staphylococcus aureus
Term
4 major symptoms of otitis externa:
Definition
1. Pain (severe)
2. Pruritis
3. Hearing loss
4. Fullness/plugged sensation
Term
If otititis externa and canal is too swollen and closed, meds won’t get in> do ear wick. Ear wick= triangle shaped cotton- put in small ear opening and then put meds on cotton so it can get in.
Definition
Term
Pain when pressure is placed on the tragus, strongly suggests __ __.
Definition
otitis externa
Term
Inflammation and swelling of the __ itself is indicative of a more serious infection. What should you do?
Definition
- pinna
- refer
Term
Otitis externa is characterized by what 2 stages?
Definition
- Acute Inflammatory Stage
- Chronic Inflammatory Stage
Term
Otitis externa Acute inflammatory stage
Bacterial infection occurs; patient experiences pain in the affected ear

As infection becomes more severe, pain and swelling in the external auditory canal increase
Definition
Term
The chronic inflammatory stage of otitis externa is marked by __ of the skin of the __ __ __. Examination reveals flakes of __ __ __ and lumen of the canal is usually __.
Definition
- thickening
- external auditory canal
- dry scaly skin
- narrowed
Term
Otitis externa treatment:
Definition
- Neomycin/polymixin B ear drops
- Oxyfloxin ear drops
Term
If a pt with otitis externa has a ruptured TM or you cannot see the TM, you CANNOT give them __ and __ b/c these are __.
Definition
- aminoglycosides
- neomycin
- ototoxic
Term
Potentially fatal ear infection usually found in elderly and immunocompromised:
Definition
Necrotizing external otitis
Term
A long standing case of otitis externa that continues to get worse despite adequate treatment suggests __ __ __.
Definition
necrotizing external otitis
Term
Necrotizing external otitis pts have __ ___ and __ __ or __ pain. __ ___ __ may be detected of physical exam.
Definition
- ear discharge
- severe deep or boring pain
- cranial nerve deficits
Term
tmt of necrotizing external otitis:
Definition
refer
Term
Perichondritis and chondritis are infections of the __ or __ of the ear. These are serious and require prompt attention. Pts with this will present with __ __ and very __ __.
Definition
- perichondrium and cartilage
- diffusely swollen and very tender pinna
Term
With perichondritis or chondritis, if the ear gets too swollen they may lose part of their ear b/c the __ __ gets cut off. __ commonly cause this.
Definition
blood supply
earings
Term
Perichondritis/chondritis tmt:
Definition
- refer
- administer IV antibiotics covering both anaerobic and aerobic bacteria
- surgical debridement of necrotic cartilage may be necessary
Term
Furunculosis is __ __, which may be single or multiple, in the __ __ of the __ auditory canal.
Definition
- circumscribed swellings
- cartilagenous portion
- external
Term
Furuncle swellings may be __ and tenderness is often noted when the __ is pulled and __ inserted.
Definition
- fluctuant
- tragus
- speculum
Term
Treatment of furuncles:
Definition
- drain fluctuant areas and apply topical antibiotics
- systemic antibiotics only if cellulitis or systemic symptoms noted
Term
Dermatitis:
Definition
Contact allergy of the ear can be acute, chronic, or both
1. Clinical manifestations
Acute stage: Inflammatory findings with associated pruritus, desquamation, weeping
Chronic stage: Skin of external auditory canal is atrophic, dry, scaly
Term
Contact dermatitis tmt:
Definition
- steroid creams/solutions
Term
Severe cases of contact dermatitis can be treated with:
Definition
- Betamethasone valerate
- Fluocinonide

(These can only be applied for short period of time. If too long, atrophy of epithelium will occur)
Term
Chronic contact dermatitis tmt:
Definition
- 1% hydrocortisone cream/solution on a daily basis until rash disappears
Term
Herpes zoster oticus is aka __ __ __.
Definition
Ramsay Hunt Syndrome
Term
Herpes zoster oticus is Caused by infection of the cranial nerve ganglia, most likely by the virus that causes chicken pox.
Definition
Term
Painful herpetic lesions on auricle and in external auditory canal:
Definition
Herpes zoster oticus
Term
Severe cases of herpes zoster oticus can result in __ __ __, __ __, __ __. These occur b/c of damage to CN __, __, and __.
Definition
- facial nerve paralysis
- hearing loss
- balance disorders
- VII, VIII, and IX
Term
Bell's Palsy caused by herpes zoster oticus can progress to complete facial nerve paralysis. How do you treat these pts?
Definition
- Prednisone 60 mg/d PO tapered over 3 weeks
- Valacyclovir (Valtrex) 1000 mg PO q8h x7 days
- Analgesics: Ibuprofen, Narcotics

REFER
Term
Valcyclovir- expensive- 3 x day for 7 days
Acylcoivir- ggeneric, cheaper, 5 times a day for 10 days, poor compliance
Definition
Term
Otomycosis is aka __ __.
Definition
external mycotica
Term
Otomycosis is a fungal infection of the external auditory canal.
Definition
Term
Otomycosis has symptoms similar to __ __ but __ is more common than pain. A whitish exudate and black spots suggest __ __ infection.
Definition
- otitis externa
- itching
- Aspergillus niger
Term
Otomycosis treatment:
Definition
- acidify the ear canal

Itraconazole (Sporanox): 200-400mg/d PO with food or cola

Ketoconazole 200-400 mg/d
Term
DDx of ear pain:
Definition
Otits media
Cerumen impaction
Otitis externa
Referred pain from
throat/ temporal bone
Acoustic trauma
External ear dermatitis
Perichondritis
Foreign body in the canal
Furunculosis
Mastoiditis
Ear tumors
(eosinophyllic granulomas, rhabdosarcomas
Term
Non-infectious causes of ear pain:
Definition
- Foreign bodies: PAIN
- Cerumen impaction- usually hearing loss, occasionaly pain from so much pressure causing mucosal irritation
- local trauma
- dermatoses
- tumor
Term
How do you get an insect out of the ear?
Definition
lidocaine
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