Ear Pain and Altered Hearing

Ear Pain and Altered Hearing Edmond Kay, MD, FAAFP Riverton Family Medicine http://divingdoc.com Copyright 2007 © Edmond Kay, MD and University of Washington Common Office Problems • • • • • • • Cerumen Impaction Otitis Externa Otitis Media Barotrauma Hearing Loss Foreign Body Tinnitus Study Guide Anatomy of External Ear Anatomy of External Ear Helix Tragus Concha Lobule Internal Anatomy Internal Anatomy Pinna The Exam The Exam Ear Wax is Your Friend! • • • • Waxy sebaceous secretions + skin cells Anti-pseudomonal due to acidic PH Moisture repelling waxy consistency Occasionally needs removal if: – Impairs hearing – Interferes with hearing aids – Impairs inspection – Cerumen “dam” causes water trapping Low Tech Wax Removal Doc’s Preferred View Doc’s Preferred View Pars Flaccida Incus Umbo Malleus Cone of Light Pars Tensa Proper Technique? Technique is Everything • • • • • • • • Position both you & patient for comfort Hold Otoscope at balance point Use largest possible speculum for comfort Straighten the external canal Inspect to identify landmarks Verify optical characteristics of TM Get a good air-tight seal Check mobility Middle Ear Diagnosis • Pneumatic Otoscopy – Visualize TM mobility (compliance) – Proper use of Insufflator requires practice – Oral vs. Bulb • Appearance of TM – red, bulging, opaque & immobile – erythema alone is not a reliable sign Pneumatic Otoscopy Exostosis Otitis Externa (O.E.) • • • • • • • more common in swimmers/divers most commonly bacterial 90% pain (otalgia), 10% itch pain with manipulation lymph node enlargement foul greenish-tinged discharge eczema, psoriasis, allergy & trauma Clinical Appearance of O.E. Otowick Bacteriology of O.E. • • • • Pseudomonas species (99%) Staphylococcus Aureus Streptococcus Others (rare) – Proteus – Escherichia coli – anaerobes – Aspergillus (Otomycosis) Suppurative O. E. Suppurative O. E. Clinical Features of O.E. Aggravated by chewing or manipulating Pinna Tenderness? Prominent at Tragus Systemic sx? Usually absent Lymph nodes? Often present Swelling? External Auditory Canal Otorrhea? Malodorous TM? Obscured but intact Pain? Atypical O.E. C/C Tenderness? Systemic sx? Lymph nodes? Swelling? Otorrhea? TM? Itch and muffled hearing Absent Absent Absent Absent Absent Coated with Exudate Treatments • Vosol (propylene glycol + acetic acid) • Navy potion – 7 drops vinegar in pint ethyl alcohol • • • • • Otic Domeboro Cortisporin (10-20% allergic rxn) Cipro HC Floxin Otowick Malignant Otitis Externa (Zebra) • Occurs in diabetics, or in the immunocompromised host – HIV – chemotherapy • Spreading Pseudomonas infection • Severe, unrelenting ear pain • 20% mortality rate Otitis Media Kim’s Good Ear Kim’s Bad Ear Clinical Features of O.M. Pain? Tenderness? Systemic sx? Lymph nodes? Swelling? Otorrhea? TM? deep ache, ↑ when supine absent URI sx usually present usually absent absent absent red, bulging & opaque Atypical Presentation (primarily children) • • • • Cough only Insomnia (↑ pain when supine) Hearing loss Fever and Abdominal pain Acute Otitis Media (pre-rupture) O.E. vs. O.M. Quality Pain? Tenderness? Systemic? Nodes? Swelling? Otorrhea? TM? O.E. with traction present absent present present present obscured O.M. deep ache absent present absent absent absent red Differential Diagnosis • • • • • • Dental Abscess TMJ Syndrome Lymphadenopathy Barotrauma Foreign Body or Cerumen Impaction Mastoiditis / Sinusitis / Cellulitis Middle Ear Effusion Perforation (chronic) Perforation (acute) Perforation (traumatic) Perforation (healed) OM 1 OM 2 The Bugs Common Pathogens Strep pneumoniae ~33% Remission Rates 10% 50% 90% Haemophilus influenza ~25% Moraxella catarrhalis ~15% Beta-hemolytic streptococci Mycoplasma pneumoniae. Viral Etiology? Spontaneous Resolution - Culture Negative Aspiration • • • • Respiratory syncytial virus Parainfluenza virus Rhinoviruses Adenoviruses The Drugs • • • • • • Amox-Clavulanate 875/125 BID x 10 Azithromycin Amoxicillin 500 TID x 10 Cephalosporins (2nd & 3rd) TMP-SMX DS BID x 10 Clindamycin (danger) Macrolides (2nd Tier) • Erythromycin (not used much) – GI intolerance, less active against PRSP • Biaxin (Clarithromycin) – GI intolerance, 10 day treatment • Zithromax (Azithromycin) – 2nd line therapy – 5 day treatment – never take with food Oral Cephalosporins • Ceftin (Cefuroxime) 500 BID x 10 – much less anti-pneumococcal activity • Cefzil (Cefprozil) 500 BID x 10 – disulfiram-like reaction • Vantin (Cefpodoxime) 400 BID x 10 – disulfiram-like reaction • Omnicef (Cefdinir) 600 QD x 10 – probably most active drug Cost x 10 days • • • • • • • • • • Amoxicillin 500 TID TMP-SMX DS BID Azithromycin Z Pac Amox-Clav 875 BID Biaxin 500 BID Omnicef (Cefdinir) 600 QD Clindamycin 300 Q6 Ceftin (Cefuroxime) 500 BID Cefzil (Cefprozil) 500 BID Vantin (Cefpodoxime) 400 BID           $8 - $10 $9 - $12 $40 - $60 $70 - $80 $80 - $90 $80 - $100 $80 - $100 $120 - $140 $150 - $180 $175 - $200 Treatment Failures • Drug Resistance (pen non-susceptible) – Streptococcus pneumoniae (DRSP) – Haemophilus influenzae • Noncompliance • Viral etiology • Neomycin allergy Medication Rational • • • • • • Cost – Cost – Cost – Cost – Cost Effectiveness (target pathogens) Compliance Side effects (get a PDA) Drug resistance Host issues… Hearing Loss • • • • Conductive Hearing Loss Sensory Neural Hearing Loss Foreign body obstruction Occupational – acoustic trauma – barotrauma • Selective hearing loss Selective Hearing Loss • Teenage adjustment disorder • Spousal adjustment disorder – male predominance • Patient denial – terminal illness – alcoholism Conductive Hearing Loss • • • • • Causes rarely severe or life threatening Detected by a lateralized Weber Test OCD (Ossicular discontinuity) Otosclerosis Middle Ear Effusion – serous otitis – mucoid otitis “glue ear” Sensory-Neural Hearing Loss • • • • • • • Presbycusis Ménière’s disease Brain Lesion Acoustic Neuroma (1% incidence) Tinnitus: all causes + acoustic trauma Ototoxic drugs or renal failure Inherited disorder of hearing 512 Tuning Fork Bedside Testing Weber’s Test Rinne’s Test • Tuning Fork to midline forehead or teeth • WNL: Sound radiates to both ears equally • ABN: Sound lateralizes to one ear – Ipsilateral = Conductive – Contralateral = Sensorineural • Bone Conduction – Tuning Fork on Mastoid • Air Conduction – Patient indicates when the sound ceases – Fork placed in front of ear • WNL: AC>BC • ABN: BC>AC Schwabach’s Test • Compares bone conduction of patient to that of normal examiner • Implies Sensorineural hearing loss • Subjective and contingent on the hearing of the examiner Consult a Colleague