ENT - T - 10.1.3 - Ear Discharge.pdf
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OTORHINOLARYNGOLOGY: Topic 3 | Module 10.1 EAR DISCHARGE Dr. Ramon Rivera, M.D. d TOPIC OUTLINE I. C hronic Suppurative Otitis Media (CSOM) A. Definition B. Anatomy a. Types of CSOM C.Associated and Exacerbating Conditions of CSOM D.Complications IV....
OTORHINOLARYNGOLOGY: Topic 3 | Module 10.1 EAR DISCHARGE Dr. Ramon Rivera, M.D. d TOPIC OUTLINE I. C hronic Suppurative Otitis Media (CSOM) A. Definition B. Anatomy a. Types of CSOM C.Associated and Exacerbating Conditions of CSOM D.Complications IV. a. Extracranial b. Intracranial c. Cholesteatoma E. Safe vs. Dangerous Ear F. Treatment II. Acute Otitis Media (AOM) A. Common Pathogens B. Natural History C.Diagnosis D.Treatment E. Complications F. Prevention G.Risk Factors III. Chronic Nonsuppurative Otitis Media V. A. Types of Otitis Media I. V B. Adult vs. Infant Eustachian Tube a. Pathophysiology 📝 C.Eustachian Tube Dysfunction in Otitis Media a. Functional Obstruction b. Mechanical Obstruction c. Abnormal Patency D.Diagnosis E. Treatment Otitis Externa A. Pathogenesis for External Ear Otorrhea B. Common Pathogens C.Types of Otitis Externa a. Acute Diffuse Otitis Externa (Swimmer’s Ear) b. Necrotizing Otitis Externa c. Acute Circumscribed Otitis Externa (Furunculosis) d. Chronic Otitis Externa e. Otomycosis D.Otitis Externa vs. Otitis Media E. Cerumen References Review Questions A. Lecture Quiz B. Past Evals (2023) EGEND L - Notes from Face-to-Face Lecture - Nice to Know Important terms T/N (Transmaker’s notes) 💡 I. CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) lassic “luga” is a purulent unforgettably foul-smelling discharge C coming from an ear with chronic suppurative otitis media. These days, however, theterm“luga”isusedmorebroadlytoreferto most in any form of ear discharge including ear wax. Figure 2.Normal right tympanic membrane a. TYPES OF CSOM ACTIVE Onotoscopy,withproperPPEandprecautions,usualfindingsinactive CSOM are: → Mucoid to purulent discharge → Tympanic membrane perforation → Hyperemic middle ear mucosa INACTIVE No discharge Perforation remains Middle ear mucosa is either pink or pale HEALED Translucent membrane over the previous site of perforation which is often mistaken for an actual perforation Thisisbecausethehealedeardrumonlyhastheoutercutaneousand inner mucosal layers The middle fibrous layer does not regenerate Figure 1.Classic “luga” ase 1: 20/F with a 12 year history of on and off foul-smelling ear C discharge usually associated with colds. → (-) dizziness/progressive headache → (+) hearing loss, occasional tinnitus Thisisaclassicalcaseofchronicsuppurativeotitismedia(CSOM)with longstandingeardischarge.Therearesomepatientsthatwillnotadmit tolongstandingeardischargeduetosocialstigmastillassociatedwith it. A. DEFINITION C SOM usually starts as an acute case of otitis media that persists Persistent inflammation of the middle ear or mastoid cavity UsualcriteriaofdurationofeardischargeforittobelabeledasCSOM is6 weeks to 3 months. Presentswithpersistentorrecurrenteardischarge(otorrhea)over3 months through a perforation of the tympanic membrane. Synonyms: → Chronic otitis media (without effusion) (COM) → Chronic mastoiditis → Chronic tympanomastoiditis (CTM) . ANATOMY B Consistsoftheparstensa,parsflaccida,shortprocessofmalleus,long process of incus, umbo, light reflex, and annulus. Note that the light reflex is pointing anteriorly and the handle of the malleus points posteriorly. Group 3B, 4A, 4B Figure 3.Layers of the middle ear 📝 Notes from Face-to-Face Lecture | F2F lecture Chronic suppurative otitis media (CSOM) → Generally considered chronic if it’sabove 3 months C. ASSOCIATED AND EXACERBATING CONDITIONS OF CSOM ome conditions are associated and may exacerbate CSOM mainly S because of their effect on the eustachian tube It is important to treat these along with CSOM: Page1of13 EAR DISCHARGE Otorhinolaryngology - Dr. Ramon Rivera, M.D. Allergic rhinitis → → Chronic sinusitis → Adenoid hyperplasia → Cleft palate → If there is an extension of the infection upward to the lateral sinus, there is thrombophlebitis. → Cochleostomy ▪ A holeismadeatthebasal3rdofthecochlea,soit could be a possible source of infection or through hematogenous spread Table 1.Organisms cultured (usually mixed) erobes A Staphylococcus aureus Pseudomonas aeruginosa Klebsiellaspp. Proteusspp. Entero/acinetobacter 📝 Anaerobes Bacteroides Peptostreptococcus Propionibacterium a. EXTRACRANIAL Notes from Face-to-Face Lecture | F2F lecture S o these, especially the adenoidsandthecleftpalatedirectly involve the eustachian tube The microorganisms are usually a mixture of aerobes and anaerobesbecauseofthechronicity.Somepartsofthemiddle ear may have poor oxygenation C. COMPLICATIONS Figure 5.Postauricular mass and sagging of posteriorwall ubperiostealabscessformswhenpurulentinflammationbreaksdown S bone. →Inthiscasethemastoidaircellsandoutersurfaceofthemastoid, butnottheperiosteum,resultinginafluctuanttendermassusually in the postauricular area. →Mayalsooccurintheposteriorbonycanalwallwhichisanteriorto the mastoid causing sagging of the wall seen in otoscopy Labyrinthitis/labyrinthine fistula is the lysisoftheboneoverthelateral semicircular canal and may result in labyrinthine fistula causing vertigo. 📝 Complications → Subperiosteal abscess ▪ Why is it periosteal? - Because the periosteum is more resistant to infection than the bone itself so you get pus under the periosteum but the bone itself have already been lysed ▪ Most frequent periosteal abscess occur post- auricularly - You get labyrinthitis or labyrinthine fistula → Vertigowithtympanicmembraneperforationandahistory of chronic ear discharge ▪ If it enters through the preformed openings, its labyrinthitis - You get more or less continuous vertigo → If its labyrinthine fistula ▪ There is a bony break usually in the lateral semicircular canal ▪ You get vertigo only when you strain ▪ Youcangetfacialweaknessfromtheinvolvementof the facial nerve Figure 4.Middle Ear (SeeAppendix A) omplicationsarisefromdestructionofboneoverstructuresaroundthe C middle ear. The middle ear is bounded: → Anteriorly by the eustachian tube → Inferiorly by the jugular bulb → Posteriorly by the mastoid air cells → Medially by the facial nerve canal,lateralsemicircularcanal,and the round and oval windows → Superiorlybyitstegmenorroofwiththeduraofthetemporallobe above Infectionmayspreadtosurroundinganddistantstructuresbyerosionof thebonecoveringthese.Thrombophlebitisofadjacentvesselssuchas duralsinusesmayoccur.Whenembolibreakoffthesepticclots,these spread through the blood to cause sepsis. The aditus or opening to the mastoid antrumisanaturalpathwayfor spread of infection and cholesteatoma. 📝 Notes from Face-to-Face Lecture | F2F lecture natomy of the middle ear is usually seen under operating A microscope Thinkofthemiddleearasaboxwith6sides(refertofigure4 middle ear). → Lateral side: tympanic membrane → Medial side: VCS acial weakness is caused by the inflammation and pressure over a F lysed or dehiscent facial canal and will result in facial paresis or paralysis. →Inflammationgoingthroughtheovalandroundwindowswillresult in sensorineural hearing loss → This isontopoftheconductivehearinglossalreadypresentwith the perforated ear drum in the fixed or lysed ossicles Gradenigo’ssyndrome(petrositis)consistsofotorrhea,retro-orbital pain due to ophthalmic nerve involvement, and lateral rectus palsy due to sixth nerve involvement due to the proximity to the petrous apex. 📝 revious ear surgeryasforcochlearimplants,mayresultinspreadof P middleearinfectiontotheinnerear,butthisisseenmoreinacutenot chronic otitis media. Spread of infection beyond the middle ear / pathways for spread : → Bone erosion from cholesteatoma → Thrombophlebitis → Preformed opening of the windows → Surgical opening in cochlear implants → Hematogenous 📝 Notes from Face-to-Face Lecture | F2F lecture Notes from Face-to-Face Lecture | F2F lecture Notes from Face-to-Face Lecture T he petrous apex iswherethetrigeminalnerveisfoundand the abducens nerve enters the cavernous sinus. → If there isaninfection,yougetinvolvementofthetwo nerves, you get retro-orbital pain fromtheophthalmic branch, and lateral rectus palsy. The third component would be the ear discharge or ear pain. → This is another example ofsubperiostealabscess,inthe posterior bonycanalwallofthetympanicring(anteriorto the mastoid). → Causes sagging of the wall on otoscopy ou can infer the possible complications from these. The Y spread is usually by following these modes: Group 3B, 4A, 4B 2 Page2of13 EAR DISCHARGE Otorhinolaryngology - Dr. Ramon Rivera, M.D. . INTRACRANIAL b Resultfromeitherdirectextension,thrombophlebitis,orhematogenous route Examples include: → Meningitis → Subdural, epidural, perisinus, or brain abscess → Lateral sinus thrombosis/thrombophlebitis Present with symptoms such as: → Intractable headache → Neck rigidity → Picket fence fever, as seen in lateral sinus thrombophlebitis THEORIES OF CHOLESTEATOMA FORMATION The definite process by which cholesteatoma is formed is still under debate but there are several theories: → Metaplasia theory ▪ Transformation of respiratory epithelium into keratinizing squamous epithelium - Squamous metaplasia can be induced by chronic inflammation. Normally, the presence of the respiratory epithelium in the middle ear would inhibit squamous epitheliumfromtheexternalcanalfromproliferatingtoa perforation. → Loss of contact inhibition theory ▪ Because of the perforationthereisextension(accumulation) of the keratinizing squamous mucosa within the middle ear → Formation of retraction pouch theory ▪ Formed by negative middle earpressureduetoblockageof the eustachian tube pulling on the flaccid upper part of the tympanic membrane. ▪ It is a sac filled with keratin debris, which slowly expands where keratin debris accumulates. Figure 6.Diagram of “picket fence” fever seen inlateral sinus thrombophlebitis. It is a sign of septic emboli being thrown into the bloodstream. 📝 Notes from Face-to-Face Lecture | F2F lecture F orintracranialcomplications,yougothroughthelayersofthe meninges, you get subdural, epidural and eventually brain abscess. In lateral abscess thrombophlebitis, you can get picket-fence fever. c. CHOLESTEATOMA The bony destructioncausingtheabovecomplicationsareduelargely due to a cholesteatoma This is squamous epithelium trapped in the middle ear, whichshould normally have respiratory epithelium. Figure 9.Coronal CT scan of a patient with cholesteatomaon the left ear. Note the soft tissue in the left mastoid cavity, as compared to the radiolucent air cells on the right, and the bony break in the middle cranial fossa (blue arrow) 📝 Notes from Face-to-Face Lecture | F2F lecture lue arrow in figure 9 shows the cholesteatoma eating the B tegmen tympani. The lateral sinus is here, mostprobablythe patient has thrombophlebitis of the head. Figure 7.Cholesteatoma . SAFE VS DANGEROUS EAR D Appearance of a tympanic membrane perforation can determineifan with CSOM is safe or unsafe Knowing the difference between the two is important as it affects prognostication and treatment he keratin debris is lined by a metabolically active (stratified T squamous) matrix, which contains osteoclasts, which together with pressure effect cause bone destruction. Figure 10.Appearance of a safe (left) versus dangerous(right) ear Figure 8.Layers of a cholesteatoma 📝 Notes from Face-to-Face Lecture | F2F lecture C holesteatoma:awhitekeratinmaterialusuallyintheatticor thesuperiorpartofthemiddleear.Thewhitepart(fig.7)isthe keratinmasswhereinthere’samatrixofactivetissuecalledthe matrix. Matrix:osteoclastswhicharetheoneresponsibleforeatingthe bone. Group 3B, 4A, 4B 2 a. SAFE EAR Disease process is tubo-tympanic, due to a eustachian tube problem. → Usually a result of common colds, which is why ear discharge coincides with bouts of rhinitis Mucopurulent, non-foul, profuse otorrhea Mucosa is edematous with small granulation Perforation is central (i.e., within the pars tensa) Hearing loss → conductive X-Ray or CT Scan → no cholesteatoma Treatment → medical + surgery to preserve hearing 📝 Notes from Face-to-Face Lecture | F2F lecture T he safe perforation would be central, non-foul discharge and the hearing loss would only be conductive. Only confined to the membrane and ossicles. Page3of13 EAR DISCHARGE Otorhinolaryngology - Dr. Ramon Rivera, M.D. he treatment is medical only. Unless thepatientwishesto T have improved hearing, you can do surgery to preserve and improve hearing. b. DANGEROUS EAR Attico-antral → Starts at the attic or pars flaccida as a retraction pocket which developsintoacholesteatoma,whichreachesthemastoidantrum then lyses the mastoid air cells. Marginal, attic, total perforation Purulent, foul, scanty otorrhea → Does not coincide with bouts of rhinitis Large polyps and granulation Mixed hearing loss X-ray or CT-scan: with cholesteatoma Treatment: surgery (mastoidectomy) for complication Figure 11.Examples of unsafe perforation. Middleear polyp sometimes overlie a cholesteatoma (Upper right image). A marginal perforation involves part of the annulus allowing squamous epithelium from the external canal to migrate medially (lower left image) . TYMPANOSCLEROSIS E Tympano or myringosclerosis may sometimes be mistaken for cholesteatoma. This comes from scarring of the eardrum from non-suppurative otitis media or from previous myringotomy. Calcification is within the eardrum, usually the parstensa,andthe rest of the middle ear does not appear diseased Persistent otorrhea → → Complications → Unsafe ears → Inactive perforation: referred for auto logic rehabilitation (tympanoplasty), hearingaidfittingorbothdependingonthetype and degree of hearing loss Main objective of surgery: eradicate infection through amastoidectomy → Cleans out the mastoid air cells and createsacontinuouscavity between the mastoid and the middle ear cavities Figure 13.Mastoidectomy S econdary objective: improvement of hearing when possible through tympanoplasty → Repair or construction of the middle ear 📝 Notes from Face-to-Face Lecture F orsafeorunsafeears,aftertreatingout,tympanoplastycan be done to improve the hearing. → Ex. In surgery, wehaveapost-auricularincisionwiththe mastoid cavity. II. ACUTE OTITIS MEDIA ase2:8/Fwithfever,earpainandhearingloss2daysafteronsetofcolds, C eventuallyresultinginmucoideardischarge(relatedtothepatientfromcase 1 12 years ago). Figure 12.Tympanosclerosis 📝 Notes from Face-to-Face Lecture Tympanosclerosisshould not be mistaken for cholesteatoma. → This is calcification from previous trauma or infection. → Usually occurs not in the attic → Ear is usually dry . TREATMENT F Treatment starts at the clinic with suctioning of secretion to adequatelyvisualizethemiddleearandallowthetopicalmedicationsto reach the middle ear mucosa. This can be continued at home by the patient with Aural Toilet (hydrogenperoxide,alcohol,vinegar,etc.)dependingonthepreference and tolerance. Uncomplicated CSOM is treated withtopical antibiotics → Otic drops: ▪ Ofloxacin ▪ Ciprofloxacin ▪ Polymyxin ▪ Chloramphenicol ▪ Gentamicin ▪ +/- Steroids (antibiotic-steroid combinations are used for polypoid tissue) Keep dry → Canbedonewithusingearplugsorcottonwithpetroleumjellyon the other side Systemic antibiotics only given when there is: → Concomitant bacterial URTI → Complications Surgery Group 3B, 4A, 4B 2 A. COMMON PATHOGENS Table 2.Common Pathogens Viral espiratory syncytial virus R Rhinovirus Coronavirus Parainfluenza Adenovirus Enterovirus Bacterial S treptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis T hese are the commonly cultured pathogens in AOM. Note: These are also implicated in infectious rhinosinusitis → The connectionbeingtheeustachiantubelinkingthenasalcavity and nasopharynx of the middle ear Note: AOM is a possible but uncommon part of a covid infection, so COVID protection and guidelines should apply B. NATURAL HISTORY Acute otitis media evolves through a natural history a. STAGE OF HYPEREMIA/RETRACTION here is otalgia and fever, usually associated with colds T Generalized hyperemia of the mucoperiosteum Mild earache, ear fullness, fever Otoscopy:Tympanicmembraneiserythematousandmarkedlyretracted eardrum Page4of13 EAR DISCHARGE Otorhinolaryngology - Dr. Ramon Rivera, M.D. Figure 14.Stage of hyperemia b. STAGE OF EXUDATION T here is increased pain and ear fullness with persistence of fever The eardrum isbulgingwithfluidaccountingforthemarkedotalgiaas well as hearing loss and tinnitus Outpouring of fluid from dilated permeable capillaries Aggravated symptoms especially pain and fever Otoscopy: Erythematous and bulging eardrum Figure 17.Stage of mastoiditis e. STAGE OF RESOLUTION May occur at any stage disease 📝 Notes from Face-to-Face Lecture | F2F lecture T he fourth stage is either complication or resolution. One of the complications ismastoiditis → It has post-auricular swelling and tenderness. → The condition can resolve at any stage. ▪ E.g. hyperemia → resolution or exudation → resolution Figure 15.Stage of exudation 📝 Notes from Face-to-Face Lecture | F2F lecture T akenoteofthecluessuchasthedonutshapeanddiffuseand curving reflection of the otoscope light. This stage wouldbetheheightofthepaininAOMduetothe pressure inside. c. STAGE OF SUPPURATION/PERFORATION Eardrum perforates → There is actual discharge that may be clear or yellowish Decreased or absent pain and fever Worsening of hearing loss C. DIAGNOSIS linical history is poorly predictive of AOM especially in the younger C children as they will nottellyouanyspecificsymptomsexceptmaybe pain One relies on other signs and especially, otoscopy findings Pneumatic otoscopy maydemonstratetheinabilityoftheeardrumto move in the hyperemic but especially in the exudative stage Abrupt onset of otalgia/ear tugging Irritability in an infant/toddler Otorrhea/fever → non-specific and are also found in patients with URTI CLASSIFICATION OF AOM BothvirusesandbacteriamaycauseAOMsoantibioticsarenotalways needed. Treatment guidelines have been made to suggest when to use antibiotics and when to observe at least initially. Upon diagnosis, the case of AOM is classified as either mild or moderate to severe based on (1) severity of pain using a visual analogue scale (VAS), (2) temperature, and (3) duration of symptoms. Table 3.AOM Classification VAS (Visual analogue scale) Duration Temperature Figure 16.Stage of suppuration 📝 Notes from Face-to-Face Lecture | F2F lecture t the OPD when the patient presents with this, we have to A suction the discharge to see the perforation. Suctioning the dischargewillalsogivepainrelieftothepatientbutthehearing loss will be worse. d. STAGE OF COALESCENCE AND MASTOIDITIS Infection may spread beyondthemiddleearasinchronicsuppurative otitis media Themostcommonlocationofspreadwouldbetothemastoid,wherein the mastoid air cells which arelysedinthecourseofinfection,hence the term coalescence There is tender swelling of the post auricular area Recurrence of pain, mastoid tenderness and fever (milder degree) (+) mastoid tenderness and sagging of posterosuperior wall → Theposterosuperiorwallreferredtohereisthatofthebodycanal wall, just adjacent to the mastoid cells 📝 Group 3B, 4A, 4B Moderate To Severe VAS
