Presented by Molly Jones, ENT PA
Painful ear conditions
Outer ear infections (otitis externa): infection of the ear canal, mostly bacterial but can be due to fungus or yeast. More common in swimmers. Present with pain (pre/post auricular), dizziness, hearing loss and discharge. If canal too swollen may need wick. Best treatment is aural toilet and topical steroid drops. Note - may well have mastoid tenderness but does not need mastoiditis.
Necrotising otitis externa is a chronic osteomyelitis of the ear canal is typically seen in diabetic/immunocompromised, elderly, overweight. Requires long course of IV abx.
Middle ear infections (otitis media): most common is acute otitis media, often presents with otalgia and high fever in children. Rupture of tympanic membrane results in relief of otalgia. Mostly viral. Needs urgent ENT involvement if any facial weakness. May progress to mastoiditis.
Mastoiditis: infection of the mastoid one, most common in toddlers. Requires IV abs and sometimes surgical intervention. Patient will be unwell with boggy, posterior auricular swelling, protruding pinna and loss of sulcus. Needs urgent ENT referral.
Inner ear infections: less common, usually viral, and can cause sudden hearing loss and dizziness
Cerumen (ear wax) impaction: Shouldn't require emergency intervention. Otax ear drops and olive oil.
Eardrum perforation: caused by infection or injury. Traumatic perforation may be caused by insertion of objects into the ear canal or direct impact to side of head, also sudden negative pressure. Will usually heal itself in about 6 weeks. Advised to see GP for examination in 6-8 weeks and if still present refer to ENT. Advise to keep dry for this period. May need surgical repair.
Cholesteatoma: a cyst or sac of skin that is growing backwards behind the ear drum into the middle ear and mastoid. Appears as small pearlescent object behind the tympanic membrane. Results in chronic, smelly discharge, and may cause damage to structures by erosion through local structures -> neurological features. May present acutely with pain/discharge. Require ENT referral as may need surgical excision.
Pinna cellulitis: Can be secondary to otitis externa. Presents with hot, swollen ear that may spread down to the cheek. Managed with aural toilet and antibiotics (flucloxacillin, oral may be sufficient).
Perichondritis: Infection of the cartilage in the ear. Involves the pinna and does not spread to the lobe. Managed with IV abx (tazocin). There is also a relapsing/remitting condition which is non-infective.
Pinna haematoma: Blood collects in the perichondrium after trauma. Requires drainage (aspiration or incision) to prevent avascular necrosis of the perichondrium, and compression dressings. May lead to longstanding deformity. Refer to ENT.
Pinna laceration: vary in degree, need good washout and closure. Consider regional block.
Other ear conditions
Surfers ear: bony exostoses within ear canal
Foreign body removal
Button battery: immediate ENT involvement
Organic material: urgent removal
Insects: if still alive, drown them with warm water
Inorganic material: if sharp then more urgent, smooth can be done routinely
Embedded earring: may need GA if child distressed or non-compliant.
Children should have as few attempts to remove as possible. If save to wait then review in SHO clinic probably best.
Post grommet insertion: blood/discharge from ear. May need drops (cipro) if infection but normally settles. ENT should be informed
Post major ear surgery: Will have posterior auricular wound and often the external auditory meatus with be packed with ribbon gauze and plugged with cotton wool at the entrance. Do not remove the packs, call ENT.
Sudden onset hearing loss (24 hours - 1 week)
May present to ED but usually referred directly by GP. Not usually painful.
Rule out infection, cerumen impaction or other blockage
Tuning fork tests, check ear for vesicles, check for CN VII palsy (i.e. Ramsay Hunt)
Sudden onset sensorineural hearing loss, needs treatment with steroids +/- acyclovir and ENT review
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