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Ear and Sinuses Differentials itching

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					Ear and Sinuses Differentials
Ear pain
Subjective findings
Location
        Auricular, periauricular, inside the ear, or mastoidal locus of pain
Quality
        Sharp, stabbing, dull, throbbing, aching or just feels plugged; constant or intermittent
Timing
        Onset, course and duration of the pain. Previous episodes?
Setting
        History of recent swimming or diving, cleaning ears with instrument (cotton swab, etc.)
Modifying factors
        Effect of treatment, things that cause exacerbations or remissions
Associated symptoms (any maybe primary complaint especially in children)
        Hearing loss – mild to moderate, conductive or sensorineural, fluctuant or constant
        Drainage – amount, color, odor, viscousity
        GI complaints
        Itching
        Fever
        URI symptoms (URI = upper respiratory infection)
        Malaise, tinnitus, vertigo

Malaise is a generalized feeling of discomfort, illness, or lack of well-being that can be associated with a disease state. It
can be accompanied by a sensation of exhaustion or inadequate energy to accomplish usual activities.

TINNITUS ti-NIGHT-us or TIN-i-tus: the perception of sound in the ears or head where no external
source is present.

Vertigo - illusion of movement; a sensation as if the external world were revolving around an individual (objective vertigo) or as if the
individual were revolving in space (subjective vertigo).

Objective Findings
Palpation
       Auricles for lesions, masses or tenderness, pain on pinna pull or tragus pressure
       Mastoid process, temporomandibular joint, sinuses tender or swollen
       Lymph glands – preauricular, postauricular, cervical nodes for induration, enlargement and pain
Inspection
       General condition of the patient
       Auricles – lesions, excoriations (Excoriations are traumatized or abraded skin caused by scratching or
rubbing.)
       Canals – drainage – amount, color odor, consistency
              - foreign bodies (look before inserting speculum)
              - otoscope = In an ear examination, a health care provider looks inside the ear canal using an
                      instrument called an otoscope. The exam is performed to investigate an earache, ear infection,
                      hearing loss, or other ear symptoms.
         tympanic membrane
               color (erythema)
               injection
               landmarks (light reflex, umbo, long process, short process)
               mobility
               posture
Ear pain – Etiologies diagnosed by history and inspection
Foreign body
Furuncle in external canal (A furuncle is an infection of a hair follicle, a boil)
Dermatitis of canal
Impacted cerumen
TMJ inflammation
Sinus infection
Unerupted or impacted molars or wisdom teeth
Acute glossitis or stomatitis (Glossitis is an abnormality of the tongue that results from inflammation. Stomatitis is
inflammation of the mucous membrane of the mouth)
Acute pharyngitis
Peritonsillar abscess
Mumps
Postadenoidectomy (post-operative for removal of the adenoid growths in the nasopharynx) or tonsillectomy
(entire removal of the tonsil)


Acute otitis externa (AOE)
Inflammatory condition of the skin and glands of the external ear canal (infectious, traumatic)

Subjective
Pain is mild to moderate, exacerbated by pinna pull and tragus pressure, opening mouth widely, chewing or
coughing
Fever usually not more than 1 to 2 degrees, maybe absent
Drainage usually not much but maybe malodorous
History of swimming or water persisting in ear after exposure

Objective
Boil
Canal erythematous, macerated, swollen
Discharge and cerumen decries mixed in canal, maybe malodorous
Tympanic membrane if visible can be normal color, red, but is always mobile

Refer if
Ulceration is noted in the skin
Cartilage is visible or infected
Patient is diabetic
Infection has persisted after 2 weeks of adequate treatment

Complications
Chronic otitis externa (characterized by deep-seated itching rather than pain, canal scaling, or macerated, fungal
growth common)

    -   Swimmer’s ear
    -   Preinflammatory stage
    -   Acute inflammatory stage (mild, moderate, severe)
    -   Edema of stratum corneum and plugging of apopilosebaceous unit
    -   Symptoms (pruritus and sense of fullness; pruritus = itching)
    -   Signs: mild edema
    -   Starts the itch/scratch cycle
AOE:   mild to moderate stage, progressive infection
  -    Progressive infection
  -    Symptoms (pain, increased pruritus)
  -    Signs (erythema, increasing edema, canal debris, discharge)

AOE:   severe stage
  -    Severe pain, worse with ear movement
  -    Signs (lumen obliteration, purulent otorrhea, involvement of periauricular soft tissue)
  -    Otorrhea = discharge from ear




Chronic otitis externa (COE)
Chronic inflammatory process
Persistent symptoms (> 2 months)
Bacterial, fungal, dermatological etiologies
Symptoms (unrelenting pruritus, mild discomfort, dryness of canal skin)
Signs (asteatosis, dry, flaky skin, hypertrophied skin, mucopurulent otorrhea (occasional))
Asteatosis = diminished or arrested secretion of the sebaceous glands


Necrotizing External Otitis (NEO)
Potentially lethal infection of EAC and surrounding structures
Typically seen in diabetics and immunocompromised patients
Pseudomonas aeruginosa is the usual culprit
Symptoms (poorly controlled diabetic with a history of otitis externa, deep-seated aural pain, chronic otorrhea,
aural fullness)
Signs (inflammation, granulation, purulent secretions, occluded canal and obscured tympanic membrane,
cranial nerve involvement)


Furunculosis
Acute localized infection
Lateral 1/3 of posterosuperior canal
Obstructed apopilosebaceous unit
Pathogen: S. aureus
Symptoms (localized pain, pruritus, hearing loss (if lesion occludes canal))
Signs (edema, erythema, tenderness, occasional fluctuance)


Perichondritis/Chondritis
Infection of perichondrium/cartilage
Result of trauma to auricle
May be spontaneous (overt diabetes)
Symptoms (pain over auricle and deep in canal, pruritus)
Signs (tender auricle, induration, edema, advanced cases (crusting and weeping, involvement of soft tissues))
Relapsing Polychondritis
Episodic and progressive inflammation of cartilages
Autoimmune etiology?
External ear, larynx, trachea, bronchi, and nose may be involved
Involvement of larynx and trachea causes increasing respiratory obstruction
Symptoms/signs (fever, pain, swelling, erythema, anemia, elevated ESR = erythocyte sedimentation rate (the
rate of settling of red blood cells in anti-coagulated blood; increased rates are often associated with anemia or
inflammatory states)
Treat with oral corticosteroids


Herpes Zoster Oticus
Symptoms (early: burning pain in one ear, headache, malaise and fever); (late: 3 to 7 days, vesicles, facial
paralysis)


Erysipelas
Acute superficial cellulites
Group A, beta hemolytic streptococci
Skin: bright red; well-demarcated, advancing margin
Rapid treatment with oral or IV antibiotics if insufficient response

Ear pain – etiologies requiring differential diagnosis
Acute otitis media
Subjective
Acute OM (AOM) implies rapid onset of disease associated with 1 or more of the following symptoms
Otalgia (ear pain)
Fever
Otorrhea
Recent onset of anorexia
Irritability
Vomiting
Diarrhea

Def: OM is any inflammation of the middle ear without reference to etiology or pathogenesis. OM can be
classified into many variants on the basis etiology, duration, symptomatology, and physical findings. Most
commonly seen in age 1-8.
Etiology: bacterial, viral, Eustachian tube (ET) dysfunction

Objective
Abnormal otoscopic findings of the tympanic membrane ™, which may include the following:
Opacity
Bulging
Erythema
Middle ear effusion
Decreased mobility with pneumatic otoscopy
Increase temperature
Lymph glands may be present (auricular and cervical nodes)
Possible hearing loss
Complications
Chronic supportive OM is a chronic inflammation of the middle ear that persists at least 6 weeks and is
associated with otorrhea through a perforated TM
Hearing loss
Mastoiditis
Meningitis

Otitis media with Effusion (OME)
Formerly termed serous OM or secretory OM
Middle ear effusion (MEE) of any duration that lacks the associated signs and symptoms of infection (eg. fever,
otalgia, irritability) OME usually follows an episode of AOM.

Subjective (hearing loss, mild earache, feeling of fullness in the ear or “head in barrel when talking”
Objective
Tympanic membrane retracted, immobile, color changes
Light reflex maybe distorted or absent
Landmarks prominent
No discharge usually
Mild to moderate conductive hearing loss
Differentiate from:
Barotitis (similar objective findings but usually more painful and key is history of exposure to differing
atmospheric pressure (skin diving, airplane etc)


Acute Myringitis
Inflammation of the TM that occurs alone or in association with external otitis or AOM
      Bullous – one or more blisters are detected on the TM
      Hemorrhagic – very strong redness is seen on the TM

Subjective (very painful, sudden onset, impaired hearing, fever in bullous)
Objective (TM erythematous, vesicles covering TM)


Granular Myringitis
Symptoms (Foul smelling discharge from one ear, often asymptomatic, slight irritation or fullness, no hearing
loss or significant pain)
Signs (TM obscured by pus, “peeping” granulations, no TM perforations)


Bullous Myringitis
Viral infection
Confined to TM
Primarily involves younger children
Symptoms (sudden onset of severe pain, no fever, no hearing impairment, bloody otorrhea (significant) if
rupture))
Signs (inflammation limited to TM and nearby canal, multiple reddened inflamed blebs, hemorrhagic vesicles)

				
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Description: Ear and Sinuses Differentials itching