++
Causes of otalgia that mainly afflict the elderly include herpes zoster (Ramsay–Hunt syndrome), TMJ arthralgia, temporal arteritis and neoplasia. It is especially important to search for evidence of malignancy.
++
Acute otitis media causes deep-seated ear pain, deafness and often systemic illness (see FIG. 50.8). The sequence of symptoms is a blocked ear feeling, pain and fever. Discharge may follow if the TM perforates, with relief of pain and fever.
++
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The commonest organisms are viruses (adenovirus and enterovirus), and the bacteria H. influenzae, S. pneumoniae, Moraxella (previously Neisseria catarrhalis) and β-haemolytic streptococci.
++
The two cardinal features of diagnosis are inflammation and middle ear effusion.
+++
Appearance of the tympanic membrane (all ages)
++
Translucency. If the middle ear structures are clearly visible through the drum, otitis media is unlikely.
++
Colour. The normal TM is a shiny pale-grey to brown: a yellow colour is suggestive of an effusion.
++
The main diagnostic feature is the redness of the TM. The inflammatory process usually begins in the upper posterior quadrant and spreads peripherally and down the handle of the malleus (see FIG. 50.9). The TM will be seen to be reddened and inflamed with engorgement of the vessels, particularly along the handle of the malleus. The loss of light reflex follows and anatomical features then become difficult to recognise as the TM becomes oedematous. Bulging of the drum is a late sign. Blisters are often seen on the TM and this is thought to be due to a viral infection in the epidermal layers of the drum.
++
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Treatment of acute otitis media (adults)
++
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
+++
Antibiotic treatment5
++
++
++
A longer course (up to 10 days) may be required depending on severity and response to 5-day course.
++
++
doxycycline 100 mg (o) bd for 5–7 days (daily for milder infections)
or
cefaclor 250 mg (o) tds for 5–7 days
or
(if resistance to amoxycillin is suspected or proven) amoxycillin/potassium clavulanate 500/125 mg (o) tds for 5 days (the most effective antibiotic)
++
Consider surgical intervention for failed therapy.
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There are two types of chronic suppurative otitis media and they both present with deafness and discharge without pain. The discharge occurs through a perforation in the TM: one is safe (see FIG. 50.10a), the other unsafe (see FIG. 50.10b).
++
+++
Chronic discharging otitis media (safe)5,13
++
If aural discharge persists for >6 weeks after a course of antibiotics, treatment can be with topical steroid and antibiotic combination drops, following ear toilet. The toileting can be done at home by dry mopping with rolled tissue spear. If persistent, referral to exclude cholesteatoma or chronic osteitis is advisable.
+++
Recognising the unsafe ear
++
Examination of an infected ear should include inspection of the attic region, the small area of drum between the lateral process of the malleus, and the roof of the external auditory canal immediately above it. A perforation here renders the ear ‘unsafe’ (see FIG. 50.1); other perforations, not involving the drum margin (see FIG. 50.2), are regarded as ‘safe’.13
++
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The status of a perforation depends on the presence of accumulated squamous epithelium (termed cholesteatoma) in the middle ear, because this erodes bone. An attic perforation contains such material; safe perforations do not.
++
Red flags for cholesteatoma include meningitis-type features, cranial nerve deficits, sensorineural hearing loss and persistent deep ear pain.
++
Cholesteatoma is visible through the hole as white flakes, unless it is obscured by discharge or a persistent overlying scab. Either type of perforation can lead to chronic infective discharge, the nature of which varies with its origin. Mucus admixture is recognised by its stretch and recoil when this discharge is being cleaned from the external auditory canal. The types of discharge are compared in TABLE 50.3.
++
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If an attic perforation is recognised or suspected, specialist referral is essential. Cholesteatoma cannot be eradicated by medical means: surgical removal is necessary to prevent a serious infratemporal or intracranial complication. Adjunct suction with care may be necessary to decompress the mass.
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DIAGNOSTIC STRATEGY FOR EAR DISCHARGE (OTORRHOEA) MASS
+
++
Otitis externa (see FIG. 50.11), also known as ‘swimmer’s ear’, ‘surfer’s ear’ and ‘tropical ear’, is common in a country whose climate and coastal living leads to extensive water sports. It is more prevalent in hot humid conditions and therefore in the tropics.
++
++
++
Predisposing factors are allergic skin conditions, ear canal trauma, water penetration (swimming, humidity, showering), water and debris retention (wax, dermatitis, exostoses), foreign bodies, contamination from swimming water including spas, and use of Q tips and hearing aids.
+++
Common responsible organisms
++
Bacteria:
– Pseudomonas sp.
– Escherichia coli
– S. aureus
– Proteus sp.
– Klebsiella sp.
Fungi:
– Candida albicans
– Aspergillus sp.
++
++
Oedema (mild to extensive)
Tenderness on moving auricle or jaw
Erythema
Discharge (offensive if coliform)
Pale cream ‘wet blotting paper’ debris—C. albicans
Black spores of Aspergillus nigra
TM granular or dull red
++
Obtain culture, especially if resistant Pseudomonas sp. suspected, by using small ear swab.
++
Note: ‘Malignant’ otitis externa occurs in diabetics due to Pseudomonas infection at base of skull.
++
Meticulous aural toilet by gentle suction and dry mopping with a wisp of cotton wool on a fine brooch under good lighting is the keystone of management. This enables topical medication to be applied directly to the skin.
++
This is appropriate in some cases but the canal must be dried meticulously afterwards. For most cases it is not recommended.
++
Dressings are essential in all but the mildest forms. After cleaning and drying, insert 10–20 cm of 4 mm Nufold gauze impregnated with a steroid and antibiotic cream.
++
For severe otitis externa, a wick is important and will reduce the oedema and pain in 12–24 hours (see FIG. 50.12). The wick can be soaked in an astringent (e.g. aluminium acetate 4% solution or glycerin and 10% ichthammol). The wick needs replacement daily until the swelling has subsided.
++
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Topical antimicrobials for acute diffuse otitis externa5
++
Most effective, especially when the canal is open, is an antibacterial, antifungal and corticosteroid preparation such as Kenacomb or Sofradex drops (2–3 drops tds), Locacorten-Vioform drops (2–3 drops bd) or Ciproxin HC (3 drops bd). Be cautious of ear drops with neomycin (hypersensitivity). The tragus should be pumped for 30 seconds after instillation by pressing on it repeatedly, within the limitation of any pain.
++
Strong analgesics are essential
Antibiotics have a minimal place in treatment unless a spreading cellulitis has developed (refer if in doubt)
Prevent scratching and entry of water
Use a wick soaked in combination steroid and antibiotic ointment for more severe cases
++
Practice tip for severe ‘tropical ear’
Prednisolone (o) 15 mg statim then 10 mg 8-hourly for six doses followed by:
++
Keep the ear dry, especially those involved in water sports
Protect the ear with various waterproofing methods:
– cotton wool coated with petroleum jelly
– an antiseptic drying agent (e.g. ethanol) after swimming and showering
– tailor-made ear plugs (e.g. EAR foam plugs)
– silicone putty or Blu-Tack
– a bathing cap pulled well forward allows these plugs to stay in situ
Avoid poking objects such as hairpins and cotton buds in the ear to clean the canal
If water enters, shake it out or use Aquaear (acetic acid) drops (spirit drops to help dry the canal)
+++
Necrotising otitis externa
++
This severe complication, usually due to Pseudomonas aeruginosa, can occur in the immunocompromised, diabetic or elderly patient. It involves cartilage and bone and should be considered with treatment failure, severe persistent pain, fever and visible granulation tissue. Urgent referral is advisable.
+++
Ear exostoses (‘surfer’s ear’)
++
These periosteal bony overgrowths are usually caused by water retention in the ear. They are often multiple. They tend to trap keratin, wax and water, leading to infection.
++
++
They may require surgical removal.
+++
Acute localised otitis externa (furunculosis)
++
Furunculosis is a staphylococcal infection of the hair follicle in the outer cartilaginous part of the ear canal. It is usually intensely painful. Fever occurs only when the infection spreads in front of the ear as cellulitis. The pinna is tender on movement—a sign that is not a feature of acute otitis media. The furuncle (boil) may be seen in the external auditory meatus (see FIG. 50.13).
++
++
If pointing, it can be incised after a local anaesthetic or freezing spray
Warmth (e.g. use hot washcloth, hot water bottle)
If fever with cellulitis—flu/dicloxacillin or cephalexin
++
Perichondritis is infection of the cartilage of the ear characterised by severe pain of the pinna, which is red, swollen and exquisitely tender. It is rare and follows trauma or surgery to the ear. As the organism is frequently P. pyocyaneus, the appropriate antibiotics must be carefully chosen (e.g. ciprofloxacin).
++
The cause is most likely a contact allergy to nickel in an earring, complicated by a S. aureus infection.
++
Discard the earrings
Clean the site to eliminate residual traces of nickel
Swab the site and then commence antibiotics (e.g. flucloxacillin or erythromycin)
Instruct the patient to clean the site daily, and then apply the appropriate ointment
Use a ‘noble metal’ stud to keep the tract patent
Advise the use of only gold, silver or platinum studs in future
+++
Eustachian tube dysfunction
++
This is a common cause of discomfort.15 Symptoms include fullness in the ear, pain of various levels and impairment of hearing. The most common causes of dysfunction are disorders causing oedema of the tubal lining, such as viral URTI and allergy when the tube is only partially blocked; swallowing and yawning may elicit a crackling or popping sound. Examination reveals retraction of the TM and decreased mobility on pneumatic otoscopy. The problem is usually transient after a viral URTI.
++
Systemic and intranasal decongestants (e.g. pseudoephedrine or corticosteroids in allergic patients)
Autoinflation by forced exhalation against closed nostrils (avoid in active intranasal infection)
Avoid air travel, rapid altitude change and underwater diving
++
Barotrauma is damage caused by undergoing rapid changes in atmospheric pressure in the presence of an occluded Eustachian tube (see FIG. 50.14). It affects scuba divers and aircraft travellers.
++
++
The symptoms include temporary or persistent pain or pressure in both ears, deafness, vertigo, tinnitus and perhaps discharge.
++
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. Perform conductive hearing loss tests with tuning fork.
++
Most cases are mild and resolve spontaneously in a few days, so treat with analgesics and reassurance. Menthol inhalations are soothing and effective. Refer if any persistent problems for consideration of the Politzer bag inflation or myringotomy.
++
Flying. Perform repeated Valsalva manoeuvres during descent. Use decongestant drops or sprays before boarding the aircraft, and then 2 hours before descent.
++
Diving. Those with nasal problems, otitis media or chronic tubal dysfunction should not dive.
+++
Penetrating injury to tympanic membrane
++
A penetrating injury to the TM can occur in children and adults from various causes such as pencils and slivers of wood or glass. Bleeding invariably follows and infection is the danger.
++
Remove blood clot by suction toilet or gentle dry mopping
Ensure no FB is present
Check hearing
Prescribe a course of broad-spectrum antibiotics (e.g. cotrimoxazole)
Prescribe analgesics
Instruct patient not to let water enter ear
Review in 2 days and then regularly
At review in 1 month, the drum should be virtually healed
Check hearing 2 months after injury
++
Complete healing can be expected within 8 weeks in 90–95% of such cases.16