Ear Disorders Evaluation - Chapter 64

Ear Disorders - Evaluation and Management

• Auricular Disorders (Chapter 64): Conditions affecting the external ear include benign conditions (e.g., Addison's disease, cartilage calcification, Hansen's nodules, keloids), those related to cultural practices (e.g., body piercing), and serious conditions requiring urgent referral (e.g., malignant otitis externa, basal cell cancer, auricle hematoma). Addison's disease is associated with other disease processes.

Symptoms and Diagnostics

• Symptoms depend on the underlying cause. Malignant otitis externa often follows infection or respiratory illness, particularly in immunocompromised or diabetic patients.
• Diagnostics depend on the underlying disease process. This may include a biopsy, rheumatoid arthritis panel, autoimmune profiles, and uric acid chemistry profile.

Management

• Management varies depending on the specific disorder. Topical alcohol and antibiotic ointments might be used for mild external ear infections. Oral cephalexin or dicloxacillin may be prescribed for milder infections, while intravenous antibiotics (cefazolin or nafcillin) are used for more severe infections. Severe conditions like perichondritis, malignant otitis externa, or mastoiditis require immediate referral to an otolaryngologist and aggressive antimicrobial therapy targeting Pseudomonas and/or Staphylococcus aureus.

Cerumen Impaction (Chapter 65)

• Cerumen impaction occurs when thickened earwax completely or partially blocks the external ear canal. Ear plugs, hearing aids, earbuds, and cotton-tipped swabs can contribute.
• Symptoms include unilateral or bilateral ear fullness, hearing loss, otalgia, itching, discomfort, tinnitus, cough, vertigo, and dizziness.
• Management involves inquiry about a history of ruptured eardrums, tympanostomy tubes, or recent ear surgery. Cerumen removal can be achieved with a spoon, curette, cerumenolytics (mineral oil, docusate sodium, hydrogen peroxide), or ear irrigation with warm water or saline. Irrigation with water or normal saline is a method.

Cholesteatoma (Chapter 66)

• Cholesteatoma is an abnormal accumulation of squamous epithelial cells, typically in the middle ear, mastoid air spaces, or epitympanum. Acquired cases are most common. Acquired cases can be caused by recurrent or persistent purulent ear infections.
• Cholesteatoma may remain asymptomatic for years but can cause impaired hearing, malodorous otorrhea, tinnitus, and vertigo as it progresses.
• Diagnostics include otoscopic exam, diagnostics, audiogram, CT scan, and MRI.
• Management involves removal of debris and ear canal care to avoid water entry; treatment with bacterial agents targeting common ear pathogens and reducing inner ear inflammation; definitive treatment may involve surgery.

Impaired Hearing (Chapter 67)

• Impaired hearing is a defect in sound detection or processing. It can affect communication and personal safety and be socially isolating. Hearing loss prevalence increases with age.
• Diverse abnormalities cause hearing loss and necessitate age-specific considerations. Sudden hearing loss can relate to autoimmune diseases, chronic renal failure, ischemia, infections, or trauma. Gradual hearing loss might stem from cholesteatoma, chronic renal failure, chronic otitis media, diabetes, hypothyroidism, noise exposure, otosclerosis, presbycusis, retrocochlear neoplasms, and other conditions.
• Diagnostics include Rinne and Weber tests, audiograms, tympanometric screening, and MRI/CT scans.
• Management can include cerumen removal, treating underlying conditions, otolaryngologist referrals for specific cases (e.g., trauma, congenital cases, tumors, and nonhealing tympanic membrane ruptures), stapedectomy or sound amplification for otosclerosis, and managing other causes like autoimmune disorders.

Inner Ear Disorders (Chapter 68)

• Vestibular Neuritis: Acute unilateral inner ear dysfunction causing severe vertigo, nausea, vomiting and imbalance. Symptoms last days to weeks or months. Management involves treating the underlying cause and providing symptomatic relief through pharmacotherapy (e.g., anticholinergics, antihistamines, benzodiazepines) or anitmetics, and vestibular exercises.
• Ménière's Disease: A chronic inner ear disorder presenting with recurrent vertigo and hearing loss along with low-frequency sensorineural hearing loss, tinnitus, and fullness. Treatment involves referral to an otolaryngologist; there is no cure but managing vertigo episodes and arresting the disease process can be a goal.
• Tinnitus: A perception of sound in the absence of an external sound source. Sounds can be various or constant and are frequently the result of a chronic condition, such as hearing conditions. Management can include hearing aids and cognitive-behavioral therapy, and consider hearing loss causes, and potentially vascular causes or other structural issues.

Otitis Externa (Chapter 69)

• Otitis Externa, commonly known as 'swimmer's ear', is an inflammation of the external ear canal.
• Acute otitis externa presents with pain, tenderness, draining and hearing loss typically lasting less than 48 hours.
• Chronic otitis externa involves a canal that is dry without cerumen and characterized by intense itching (pruritus).
• Management includes clearing debris, pain management using NSAIDs and opioids, topical anesthetic, and treating infection and inflammation with topical antibiotics.

Otitis Media (Chapter 70)

• Otitis media is a middle ear infection often related to upper respiratory issues and allergies.
• Types include acute otitis media (AOM) characterized by sudden onset and short duration; otitis media with effusion (OME) and middle ear effusion (MEE), where serous fluid accumulates in the middle ear without acute inflammation.
• AOM severity correlates with symptoms (otalgia and fever) and is often worse in a prone position. Common initial complaint is acute otalgia.
• Diagnostics involve otoscopic exam, tympanometry, audiogram, Rinne and Weber tests, sinus X-rays and CT/MRI scans. CBC/diff, and tympanocentesis
• Management often involves watchful waiting and analgesics, particularly in cases without acute medical need. Amoxicillin is the first-line antibiotic if an antibiotic is needed.

Tympanic Membrane Perforation (Chapter 71)

• A tympanic membrane perforation is an opening in the eardrum that separates the external from the middle ear, usually caused by a variety of conditions.
• It is a common cause of conductive hearing loss.
• Most perforations heal spontaneously but sometimes referral to a specialist is warranted.
• Symptoms include hearing loss, fullness, popping, tinnitus, and vertigo.
• Diagnostics include otoscopic exam, and noting potential skull fracture, facial nerve issues, or cerebrospinal fluid leakage issues.
• Management focuses on keeping water out of the ear until the perforation heals. If infection is present, antibiotics are often used. Repair is indicated for some cases that do not resolve without intervention.

Case Studies (Part 7)

• Case Study 1: A 58-year-old male with impacted cerumen and decreased hearing. Discussion questions concerning causes (age, earwax removal habits, and possible previous ear surgeries) and management options (irrigation, curettage, cerumenolytics) are relevant.
• Case Study 2: A 2-year-old boy with intermittent fever and ear pain. Discussion questions relate to appropriate examinations (otoscopy, viral swab) and management (analgesics, watchful waiting or antibiotics, and potential need for urgent referral to specialists).