How to become
an expert at the
ear exam
And… What to do!
http://1funny.com/little-ear-doctor/&docid=HEj7CJ5VfPUE4M&imgurl
Manuela Fina, M.D.
Health Partners
Department of Otolaryngology
Assistant Professor Department of
Otolaryngology
University of Minnesota,
Staff Physician, VAMC Veterans Affairs
medical Center
Normal Tympanic Membrane
www.commons.wikimedia.org
www. entjo.com
Serous Otitis Media
http://b.vimeo.com
otitismedia.hawkelibrary.com
http//:www.pedisurg.com
http://health-advisors.org
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Clinical Practice Guidelines:
Tympanostomy Tubes in Children
Rosenfeld, RM. et al. Otolaryngology - Head & Neck Surgery.
149 (1 Suppl):S1-35, 2013 June.
Age 6 months to 12 years
Recurrent Acute Otitis Media
3 infections in 6 months
4 infections in 1 year with at least 1 in the past 6 months
Chronic Otitis media with effusion
3 months (both ears or unilateral)
with hearing loss
or other symptoms such as: speech delay, vestibular problems, poor school
performance, behavioral problems. ear discomfort.
Persistent Acute Otitis Media
persistence of AOM within a month of completing antibiotic therapy
2 episodes of AOM within 1 month
Children younger than 6 months require individualized decision making based
on specific clinical circumstances.
Serous Otitis Media in the Adult
http://healthmango.com
http://www.m.advancedonc.com
Unilateral or bilateral
After URI, prolonged hospitalization,
surgery.
Nasal topical steroids
Role of antibiotics not effective
R/O tumor in nasopharynx
-antrochoanal polyp
-nasopharyngeal carcinoma
-extra nodal lymphoma
-chronic adenoiditis (HIV)
-minor salivary gland tumor
-nasal polyposis
PE tubes: Risks and Adverse Events
Tube plugged 4%
Otorrhea 16-26%
www. entusacom
www.subent.com
Granulation Tissue 4%
Perforation 1-6%
www.otitismedia.hawkelibrary.com
www.rcsullivan.com
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Otitis Externa
Acute Otitis Externa
Auricular Perichondritis Chronic Otitis Externa
http://odlarmed.com/?p=1300
www.healio.com/pediatrics/respiratoryinfections/news/online/%7Bbab56c87-246a-40d5-b24d05ffa2f4f207%7D/aoe-predisposing-factors-andpathogens
http://www.wikidoc.org/index.php/Auricular_perichondritis
http://entkent.com/otitis-externa.html
Acute Otitis Externa
Pathogens:
Pseudomonas aeruginosa , Staphylococcus
aureus
Proteus species, Staphylococcus
epidermidis, diphtheroids, and
Escherichiacoli.
Otowick
Ototopical Antibiotics +/steroids
Oral Ciprofloxacin if
cellulitis , perichondritis
Fissures of Santorini:
spread to parotid gland,
soft tissue, TMJ
www.healio.com/pediatrics/respiratoryinfections/news/online/%7Bbab56c87-246a-40d5-b24d05ffa2f4f207%7D/aoe-predisposing-factors-and-pathogens
http://www.keywordpictures.com/abuse/fissures%20of%20santorini///
http://www.enttoday.org/details/article/2544401/Advances_in_Facial_Paralysis.html
Herpes Zoster Oticus
Ramsey Hunt Syndrome
Herpes Virus reactivation at geniculate ganglion
Ear pain first
Vertigo, Hearing loss, deafness
Steroids and antivirals, antibiotic coverage for Pseudomonas
Worse prognosis than Bell’s palsy
www.howhealth.com
3
79 yo diabetic
Severe ear pain for 1 week
Tried quinolones ear drops and oral antibiotics for 2 weeks.
Change in mental status, disoriented.
http://www.aafp.org/afp/2003/0715/p309.ht
ml
•www.otoscopy.hawkelibrary.com
Malignant Otitis Externa
Necrotizing Skull Base Osteomyelitis
•www.otoscopy.hawkelibrary.com
Pseudomonas A. Aspergillus
http://www.aafp.org/afp/2003/0715/p309.html
Immunodepressed, diabetics, elderly
Severe deep ear pain
Granulation tissue polyps in ear canal
FN palsy 40% Multiple nerve palsy 24% (Jugular foramen CN IX, X, XI)
(Petrous apex V, VI)
CT scan for bone erosion
Mortality 50%
3rd 4th gen Cephalosporins, OR for mastoidectomy debridement
25 yo swam in lake now with ear pain
Week 1 :treated with topical fluoroqunolones
Week 2 : neomycin polymyxin & Hydrocortisone
Week 3: reports muffled ear, no improvement
http://eac.hawkelibrary.com/new/main.php?g2_itemId=19
http://otoscopy.hawkelibrary.com/album04/Fig7_29
http://www.ent-surgery.com.au/ent-resources/ear/swimmers-ear-otitis-externa
/
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Otomycosis
http://www.ent-surgery.com.au/ent-resources/ear/swimmers-ear-otitis-externa
http://gpent.blogspot.com/2013/02/definition-oe-is-inflammatory-typically_11.html
Aspergillus, Candida Albicans
Clotrimazole 1% , Gentian Violet, Acetic Acid
Chronic Eczematous Otitis Externa
Periodic exacerbations
Painless no drainage
Severe itching ear canal
Seborrheic Dermatitis,
Eczema, Psoriasis.
Cultures if drainage
Fluocinolone Acetonide
Bacitracin Ointment x 5
days
Dry ear canal precaution
http://entkent.com/otitis-externa.html
Traumatic TM Perforations
Q-tip manipulation
Excruciating pain, blood per
ear. Fell to the ground
Severe vertigo with fast
beating nystagmus to
opposite site of ear
Weber goes to opposite
side
www.merckmanuals.com
What do you do?
a. Prescribe topical ear drops, set up next week
to see ENT
b. You recommend dry ear precautions and
observation
c. Referral to ENT urgent
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Traumatic TM Perforations
Topical Ear drops, next week to
see ENT
Dry ear precautions observation
Referral to ENT urgent:
Vertigo, nystagmus
Stapes subluxation,
Perilymphatic fistula
Sensorineurial hearing loss
http://www.kids-ent.com/website/pediatric_ent/ear_infections/
To OR Emergently for Middle ear
exploration Round
Window/Oval window
grafting
Acute Otitis Media
http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/step18b.htm
www.utmb.edu/pedi_ed/aom.otitis
Ear tilted (proptosis)
Facial palsy
http://www.facialpalsy.org.uk/advice/children-young-adults/1401
/
http://www.entusa.com/mastoiditis/ap_child_coallescent_mastoiditis.jpg&w=354
Bezold’s (subperiosteal) abscess
Sagging of posterior canal wall
http://www.entusa.com/ear_infections.htm
http://en.wikipedia.org/wiki/Mastoiditis&docid=cCNF6zBfGCscvM&imgurl
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Acute Mastoiditis !
Facial nerve paralysis
Meningitis
Subperiosteal abscess
Otitic hydrocephalus thrombus in the lateral venous sinus impedes
venous drainage of the intracranial contents into the neck and produce a rise in the cerebral
venous pressure and a subsequent increase in the CSF pressure.
Sigmoid sinus thrombosis
Brain Abscess
Epidural abscess
Chronic Suppurative Otitis media
http//:kckentcentre.com
http://me.hawkelibrary.com
Cholesteatoma
http://www.radiologyassistant.nl/images/4a45c9d86f3edtek-cholesteatoma.jpg
http://www.bris.ac.uk/Depts/ENT/attic_defect_2.jpg
Keratinized squamous epithelium in middle
ear, mastoid
Primary Acquired – retraction pocket
Secondary Acquired– through TM
perforation
Ossicular Erosion
Facial Paralysis
Labyrinthine fistula
Perilymphatic fistula
Brain abscess
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Osteoma
www.exelixismedical.gr
Exostosis
www.sidneyentclinic.com
Subjective hearing loss for 1 day
Unilateral tinnitus
Mild URI 2-3 days prior
Normal TM exam
+/- vertigo
What do you do?
a.
b.
c.
d.
“It looks red”, Amoxicillin for 10 days
It must be Eustachian tube
dysfunction: Sudafed and Flonase
“I think it’s Menière (next avail. App.
in 4 weeks)
Find a tuning Fork, do Weber
& Call ENT and refer urgently
http://otitismedia.hawkelibrary.com/normal/1_G
http://://www.phsa.ca/NR/rdonlyres/5082BBF
Tuning Fork Test
http://quizlet.com
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Sudden hearing loss:
an otologic emergency !
TX: Steroids ASAP
Prednisone 60 mg x 14 days
Intratympanic Steroid injections
Poor Outcome:
Delayed presentation, Old age, + Vertigo, Profound HL
www.google.com/imgres?um=1&hl=en&biw=1366&bih=587&tbm=isch&tbnid=68UtdRQlb3686M:&imgrefurl=
Cochlear Implants: when?
A cochlear implant is a surgically implanted
electronic device that can be considered for
people with severe to profound Sensorineural
hearing loss in both ears.
http://urmcmenshealth.com/2011/11/15/cochlear-implants-when-hearing-aids-are-not-enough
/
http://www.alphaonenow.org/hear_in_maine.htm
Who is the candidate in your clinic?
Hearing aids provide minimal benefit
Spouse functions as interpreter
Depends on written notes
Telephone use abandoned unless yes no
answers or cap tell.
Unable to understand TV unless captioned
Socially withdrawn
Depends heavily on lip reading
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How does a Cochlear Implant
work?
The implant bypasses the
diseased or
nonfunctioning inner ear
hair cells by
converting the
sounds we hear to
electronic impulses
that directly stimulate the
inner ear nerve endings
Cochlea is Tonotopic:
High frequencies at base, low frequencies at apex
http://www.neuroreille.com/promenade/english/ear/inear/finear.htm
http://www.liquidarea.com/2011/01/sordita-messa-a-scacco-da-chirurgia-di-ultima-generazione/
Criteria for Adults
No upper limit of age
Medical evaluation
Psychological evaluation
Audiological testing with high powered
hearing aids
CT/MRI temporal bones
Pre-op vaccination with Pneumovax
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Our Cochlear
Implant
Team
2 Otology &Neurotology
Surgeons:
Manuela Fina, MD
Christopher Hilton, MD
2 Cochlear Implant
Audiologists
Aural rehabilitation
Sara Oberg, MA CCP-SLP
Sheryl Erenberg, Aud.
Laura Eklund, Aud.
Psychology
Counseling
Kristen Swan, MA-LP
Monthly
Cochlear Implant Support group
Conclusions & “Pearls”
Ear Drainage: topical quinolone antibiotic
drops are a safe bet for initial treatment.
Otitis Externa: Coverage for
Pseudomonas if cartilage involvement
Always Dry ear precautions!
Normal exam and subjective hearing loss:
suspect Sudden SNHL: Emergency
Referral !
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