Ear Disorders Overview

Ear Disorders

• Ear disorders encompass various conditions affecting the external, middle, and inner ear.
• Conditions affecting the external ear include benign conditions, those related to cultural practices (body piercing), and serious illnesses.
• Benign conditions may involve disease processes (Addison's disease, cartilage calcification, Hansen's nodules, keloids).
• Serious external ear illnesses requiring immediate referral include malignant otitis externa and basal cell cancer.
• Symptoms depend on the underlying cause of the disorder.
• Malignant otitis externa may result from infections or respiratory illnesses, often in immunocompromised or diabetic patients.
• Diagnostics vary depending on the disease process, including biopsy, rheumatoid arthritis panels, autoimmune profiles, and uric acid profiles.
• Management varies widely, from topical alcohol and antibiotic ointments for mild infections to hospitalization and intravenous antibiotics for severe cases.

Cerumen Impaction

• Cerumen impaction occurs when thickened earwax (cerumen) partially or completely occludes the external ear canal.
• Ear plugs, hearing aids, earbuds, and cotton-tipped swabs can contribute to impaction.
• Symptoms include unilateral or bilateral fullness, hearing loss, otalgia, itching, discomfort, tinnitus, cough, vertigo, and dizziness.
• Management involves evaluating for a history of ruptured eardrums (TM), tympanostomy tubes, or recent ear surgery.
• Removal may be with a cerumen spoon or curette.
• Cerumenolytic agents (mineral oil, liquid docusate sodium, hydrogen peroxide) can be inserted daily.
• Irrigation with water or normal saline using an ear syringe may be performed.

Cholesteatoma

• Cholesteatoma is an abnormal buildup of squamous epithelial cells usually within the middle ear, mastoid air spaces, or epitympanum.
• Cholesteatoma can be acquired, often associated with repeat infections or tinnitus, or congenital.
• Symptoms include impaired hearing, malodorous otorrhea, tinnitus, and vertigo (symptoms may not occur immediately).
• Diagnosis involves otoscopic exam, audiogram, CT, and MRI scans.
• Management involves removal of debris, avoidance of water entering the ear canal, treatment with bacterial agents, and reducing inner ear inflammation, possible surgical intervention for definitive treatment.

Impaired Hearing

• Impaired hearing is a defect in detecting or processing sound waves.
• It can negatively affect communication and safety.
• Prevalence increases with age.
• Hearing loss may present as sudden, progressive, or fluctuating.
• It can be caused by a myriad of abnormalities.
• Diagnostics include Rinne and Weber tests, screening audiograms, tympanometric screenings, MRI, and CT scans.
• Factors associated with gradual hearing loss include cholesteatoma, chronic renal failure, chronic otitis media, diabetes hypothyroidism, noise, otosclerosis, presbycusis, retrocochlear neoplasm, autoimmune disorders, Meniere's disease, migraine headaches, multiple sclerosis, otitis media, perilymphatic fistula, sarcoidosis, and syphilis.

Inner Ear Disorders

• Inner ear disorders can involve Vestibular neuritis, Meniere's disease, and tinnitus.
• Vestibular neuritis causes acute unilateral labyrinthine dysfunction, characterized by severe vertigo, nausea, and vomiting, with symptoms lasting days to months. Symptoms worsen with head movement.
• Meniere's disease involves recurrent vertigo, hearing loss, tinnitus, and fullness in the ear. Symptoms are often intermittent.
• Tinnitus is the perception of a sound in the absence of an external source.
• Treatment for each condition varies and can include pharmacological therapies (anticholinergics, antihistamines, benzodiazepines, antiemetics) and vestibular exercises.

Otitis Externa

• Otitis externa, commonly known as swimmer's ear, is an inflammation of the external ear canal.
• It can involve acute or chronic forms.
• Acute otitis externa is characterized by pain, tenderness around the tragus and with ear movement, drainage, and hearing loss.
• Chronic otitis externa involves a dry ear canal without cerumen and often intense itching.
• Management focuses on clearing debris from the canal, managing pain with NSAIDs or opioids, topical anesthetics, and treating any infection or inflammation with antibiotics.

Otitis Media

• Otitis media is inflammation of the middle ear, often associated with fluid buildup in the middle ear cavity.
• It can be acute (rapid onset and short duration) or chronic (associated with persistent middle ear effusion).
• Symptoms can vary from mild to severe, encompassing otalgia (ear pain), fever, and worse symptoms that tend to worsen when lying down, and can include hearing loss.
• Diagnostics typically include otoscopic exam, tympanometry, acoustic reflectometry, Rinne and Weber tests, sinus X-ray and CT scans, CBC with diff, and tympanocentesis tests, as needed.
• Management may range from watchful waiting for some cases, to antibiotics for more severe cases, to otolaryngological referrals as appropriate.

Tympanic Membrane Perforation

• Tympanic membrane perforation is an opening in the eardrum, which separates the outer from the inner ear (separates the external ear from the middle ear).
• It can cause conductive hearing loss.
• Most cases heal spontaneously without intervention; however, some may require referral to an otolaryngologist for repair using a patch or graft.
• Diagnoses may include otoscopic exams, and audiograms may be taken to assess the integrity and degree of hearing loss.
• Management focuses on keeping water out of the ear until healed.
• Antibiotic use may be necessary if infection is present.

Case Study 1 (58-year-old male with impacted cerumen)

• Possible Causes for impacted cerumen:* Age, use of earbuds/cotton swabs, and frequent ear cleaning.
• Appropriate removal methods:* Irrigation, manual removal (with curette), cerumenolytic agents.
• Important Questions for the patient:* History of ruptured TM, tympanostomy tubes, recent ear surgery, and prior cerumen impaction.

Case Study 2 (2-year-old boy with ear pain and fevers):

• Likely diagnosis:* acute otitis media
• Appropriate examination/diagnostics:* Otoscopic exam, possibly a viral respiratory nasal swab and CBC/chemistry depending on the specific presentation.
• Treatment:* Analgesics and watchful waiting; in some cases, antibiotics may be used (especially if there is a severe presentation), and otolaryngology referral should be considered if symptoms continue or worsen.
• (Important Considerations):* Immediate referral to an otolaryngologist may be necessary if symptoms are very severe or concerning, even if the preliminary treatment approach is watchful waiting.