Ear Disorders

Otalgia

Otalgia, or ear pain, in the adult patient is more likely to be a secondary symptom from a primary problem, such as Eustachian Tube Dysfunction with allergic rhinitis or sinusitis, dental caries, or an abscess, among others. The patient may have primary otitis media or otitis externa, but these are more common in children than in adults.

Signs and Symptoms

Note the basic information regarding the chief complaint. Where does it hurt? What does it feel like? How long has it been a problem? Does anything make it better or worse? Are there any other associated signs and symptoms? Has the patient taken any medications—prescription or over-the-counter drugs—for these symptoms? When does the complaint seem to be better or worse? In other words, note the location, quality, quantity, severity, timing, duration, and onset or triggers. Also note any associated symptoms, such as sinus congestion. Inquire about recent travel, such as air travel, altitude changes, and deep-sea diving.

Evaluation

Inspect the external ear first and then move onto palpation and manipulation of the external ear. An otoscopic evaluation of the ear canal and then of the tympanic membrane should be performed. Note any erythema, drainage, cerumen, or signs of trauma. Are the ear canal and the tympanic membrane still intact? What color is the drainage, and where is it coming from exactly? Is a cone of light present on the tympanic membrane? Are there any signs of scarring or perforation? A hearing acuity screen should be performed. You may consider a CBC as well as culture and sensitivity if any purulent drainage is present and the clinical picture warrants such diagnostics. Note the difference between normal cerumen, purulent drainage, clear drainage, and exudates from dermatitis, including atopic or psoriatic eczema.

Acute Otitis Externa

Inflammation or infection of the external ear canal is also known as swimmer’s ear. Acute otitis externa (AOE) can occur from trauma from aggressive cleaning of the ear with foreign objects, such as cotton-tipped applicator swabs, bobby pins or hairpins, tips of keys, paper clips, etc. Pseudomonas and Staphylococcus aureus are common findings in otitis externa. Keep in mind that in patients with compromised immune systems, necrotizing otitis can begin and move as far as the temporal bone, creating damage that may not be repaired.

Signs and Symptoms

Pain with manipulation of the auricle or tragus as well as itching are primary symptoms. There may be a sensation of stuffiness or fullness in the ear canal. A detailed history, including recent travel, history of tympanic membrane perforations, previous ear infections, prior ear surgery, and water exposure is helpful.

Evaluation

Purulent drainage or clear drainage may be present. The entire ear canal may not be visible because of edema and errythema. There may be cheesy-like exudates, clear drainage or fluid, and purulent drainage. You may perform a culture, if desired.

Treatment

Treatment involves cleaning the ear canal. In the clinical setting using a 1:1 solution of water and hydrogen peroxide at body temperature will allow for the removal of debris and possibly visualization of the tympanic membrane. Topical antibiotics have a high cure rate in most cases. Oral antibiotics are usually only necessary in immunocompromised patients and those with deep tissue infection. Antibiotic ear drops, such as polymyxin, ciprofloxacin, and levofloxacin, may be useful. Caution the patient regarding the use of foreign objects to clean the ear canal. If significant edema is present, you may insert an ear wick into the ear canal in order to ensure that the medication reaches its desired goal.

Otitis Media

Acute otitis media (AOM) is a viral or bacterial infection of the middle ear. Viruses are more commonly the pathogens seen with AOM, and antibacterials are often overprescribed. There is suppurative effusion of the middle ear as a result of the lack of drainage by the Eustachian tube. Bacterial AOM is most frequently caused by Streptococcus pneumoniae. AOM is more common in children because of the number of viral infections they have, in addition to the horizontal placement of the Eustachian tube. In some children, AOM may become chronic and require an ear, nose, and throat (ENT) referral for possible placement of pressure equalization (PE) tubes.

The onset of AOM is associated with ear pain (otalgia) and decreased hearing. Some patients may also have a fever and lymphadenopathy. AOM is typically one sided and drainage may be present if the tympanic membrane has ruptured. With AOM the tympanic membrane is red, opacified, bulging, and immotile. Patients with AOM may also have conductive hearing loss (recall that you can demonstrate conductive hearing loss with both the Rinne’s and Weber’s test).

For adults with AOM it is recommended that empiric treatment is started with amoxicillin if there is no penicillin allergy. Penicillin provides adequate coverage for the most common bacteria that cause AOM including S. pneumoniae, H. influenzae, and M. catarrhalis. Adults that do not demonstrate improvement within 48–72 hours should be re-evaluated for treatment failure.

AOM with effusion refers to clear serous fluid behind the tympanic membrane from Eustachian tube dysfunction and fluid creation from either allergies or viral illness. Nasal steroids can be useful in decreasing the swelling in the nose and relieving the pressure on the Eustachian tube.

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Create a scenario for ear disorder and differential diagnosis and final diagnosis for this scenario using the tables below….

Name: Pt. Encounter Number: Date: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness. Medications: (List with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?” Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease? Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status Lab Tests Urinalysis—pending Urine culture—pending Wet prep—pending Special Tests Diagnosis o Include at least three differential diagnosis o Final diagnosis  Evidence for final diagnosis should be documented in your Subjective and Objective exams. PLAN including education o Plan:  Further testing  Medication  Education  Nonmedication treatments

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