Ear Infections.pdf

Ear Infections: An Overview K. C Uche-Okonkwo MBBS (NAU), MMCORL (Nigeria), MRCS (England), FWACS (WA). Consultant Ear, Nose and Throat/ Head and Neck Surgeon  Relevant Anatomy Classification Clinical features Outline Management Complic...

Ear Infections: An Overview K. C Uche-Okonkwo MBBS (NAU), MMCORL (Nigeria), MRCS (England), FWACS (WA). Consultant Ear, Nose and Throat/ Head and Neck Surgeon  Relevant Anatomy Classification Clinical features Outline Management Complications Conclusion Relevant Anatomy Classification Otitis Externa Otitis Media  Perichondritis  Acute Otitis Media  Localized Otitis externa (Furuncle)  Chronic Otitis Media  Diffuse otitis externa (Swimmer’s ear)  Fungal Otitis externa (Otomycosis)  Malignant Otitis externa  Herpes Zoster Oticus Otitis Externa Otitis Externa Inflammation of the ear, from the pinna to the epidermal layer of the tympanic membrane.  Perichondritis Usually follows ear piercings, lacerations or surgical procedures Could follow canal infections Causative organisms: Staph aureus, pseudomonas, mixed bacterial flora Presents as a hot, painful, swollen pinna Could result in abscess formation, cartilage necrosis and cauliflower deformity Perichondritis Treatment  Systemic broad spectrum antibiotics  Anti-inflammatory drugs  Cold compress  Aluminum acetate cream  Abscess: Incision and drainage, continuous IV antibiotic irrigation, wound care.  Localized Otitis externa  Ear canal Furuncle  Staphylococcal infection of the hair follicle  Usually single but may be multiple and recurrent particularly in the immune suppressed  May be associated with habitual ear cleaning/ probing  Presents with severe ear pain exacerbated by jaw movements. Minimal or no ear discharge  Treatment: Local/ systemic antibiotics, Ant—inflammatory drugs, ear packing with antibiotic drops(Cipro, neomycin, steroids), suctioning when ruptured.  Diffuse Otitis Externa Diffuse inflammation of the skin of the canal and the outer epidermal layer of the tympanic membrane Common in hot, humid climates and among swimmers. Also follows self-induced trauma Common organisms: S. aureus, P. pyocyaneus, B. proteus, E. Coli Presents as a hot, heavy painful ear with initial thin serous discharge, later purulent. Pain aggravated by jaw movements. There might be intermittent itching. Examination: Edematous, hyperemic canal, acquired stenosis, discharge, tragal/ pinnal tenderness.  Diffuse Otitis Externa Treatment:  Ear swab for m/c/s. Ear toilet  Otowick antibiotic dressing  Systemic broad spectrum antibiotics  Analgesics and anti-inflammatory drugs  Counsel against ear probing and self cleaning  Otomycosis Fungal infection of the external ear Most commonly caused by Aspergillus and Candida. Presents as intense itching, pain, sensation of fullness, ear blockage, scanty watery discharge Can be tenacious and require extended management  Otomycosis Treatment:  Ear swab for m/c/s  Ear syringing, toilet  Anti-fungal drops, otowick dressing.  Systemic anti-fungal  Counsel to keep ears dry and prevent self ear cleaning  Malignant Otitis Externa Also known as Necrotizing otitis externa Aggressive inflammatory condition of the ear and skull base Commonly seen in elderly diabetics and the immunosuppressed Pseudomonas aeruginosa, the most common organism. Other mixed organisms such as Aspergillus, E. Coli, S. Aureus. Presents with deep, excruciating pain, characteristically nocturnal with multiple cranial nerve palsies: VII, V, IX, X, XI, XII.  Malignant Otitis Externa Treatment  Multidisciplinary  Admit for in-hospital care  Blood glucose control  Ear swab for m/c/s  Aural toilet, debridement, sequestrectomy  Antibiotic ear drop/ otowick dressing  IV broad-spectrum antibiotics for 6 weeks  Anti-inflammatory, analgesics  Malignant Otitis Externa Examination: Acutely ill-looking elderly patient, facial weakness. Evaluation:  FBC, ESR, CRP,  Computed tomography of the head  Bone scan (Technetium-99, Gallium- 67)  MRI  Herpes Zoster Oticus Herpetic vesicular rash on the external ear with LMN Palsy of the ipsilateral facial nerve. Also known as Ramsay-Hunt syndrome Reactivated varicella zoster infection from dormant viral particles in the geniculate ganglion of the facial nerve Characterized by otalgia, facial weakness and an ear rash 50-80% will recover pre-morbid facial function Otitis media  Otitis Media Acute inflammation of the mucosa of the middle ear Middle ear: Middle ear cleft, mastoid antrum, aditus ad antrum, mastoid air cells, Eustachian tube.  Otitis Media Aetiology:  Usually follows infections of the upper respiratory tract.  Common Bacteriology: Streptococcus Pneumoniae, Hemophilus Influenza, Moraxella Catarrhalis.  Viral: RSV, Rhinovirus, Coronavirus Predisposing factors:  Low socio-economic status  Recumbent breastfeeding  Exposure to indoor smoke  Allergy  Recurrent URTI Otitis Media: Pathogenesis Eustachian Tube External Blood ear borne Otitis Media Otitis Media: Pathophysiology Tubal occlusion Pre- Complication suppuration Resolution Suppuration  Acute Otitis Media Clinical features: Deep throbbing otalgia Tinnitus Aural fullness Fever Ear discharge with resolution of pain and fever Irritability and ear tugging in younger children Preceding/ Co-existent nasal discharge, congestion and cough  Acute Otitis Media Management  Diagnosis is clinical  Ear swab m/c/s, Temporal bone x-rays/ CT  Broad-spectrum antibiotics  Antipyretics/Analgesics  Nasal/ systemic decongestants  Aural toilet/ Otowick Antibiotic dressing  Make sure to keep the dry and avoid recumbent feeding.  Chronic Otitis Media Failure of resolution of acute otitis media with a permanent defect in the tympanic membrane, and or with the presence of granulation tissue from the middle ear Used to be defined as an ASOM lasting > 3 weeks A major cause of childhood hearing loss in Sub-Saharan Africa  Chronic Otitis Media Predisposing factors Low socio-economic status Poorly managed ASOM Immune suppression  Chronic Otitis Media: Classification Previously classified into: Tubo-tympanic (safe) Attico-antral (Unsafe) Chronic Otitis Media: Current classification  Chronic Otitis Media Predisposing factors Low socio-economic status Poorly managed ASOM Immune suppression Bacteriology: P. aeruginosa, E. Coli, P. mirabilis, S, aureus, B. fragilis  Chronic Otitis Media Clinical Features  (Recurrent) Mucopurulent ear discharge  Hearing loss  Tinnitus  Recurrent nasal discharge  Chronic Otitis Media Evaluation Diagnosis is clinical Otoendoscopy/ microscopy  Ear swab m/c/s  Audiogram  Mastoid xrays/CT  Chronic Otitis Media Management  Aural toilet  Antibiotic ear drops/ Otowick dressing  Systemic antibiotics  Systemic decongestants  Keep ear dry! Surgery: To address complications and reconstruct damaged hearing apparatus Mastoidectomy Incision and drainage of abscess collections Craniotomy/ Cranioplasty Complications of Chronic Otitis Media Complications Extracranial Intracranial Extra- Intra-temporal temporal  Complications of Chronic Otitis Media *Apical Petrositis, Otitic Hydrocephalus Acute Otitis Externa vs Acute Suppurative Otitis Media Pain is usually superficial, Pain is usually deep and exacerbated by jaw movements throbbing. Non-radiating Tragal and pinnal tenderness Tragal and pinnal tenderness usually present usually absent Discharge usually scanty and Discharge usually muco- watery/ purulent purulent TM intact TM Perforated Summary Ear infections are mostly preventable by:  Avoiding self ear-cleaning and probing  Breastfeeding upright  Avoiding ear trauma  Proper management of co-morbid conditions Early and appropriate intervention is expedient to prevent life-threatening complications.