How to become an expert at the ear exam And… What to do!
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Manuela Fina, M.D. Health Partners Department of Otolaryngology Assistant Professor Department of Otolaryngology University of Minnesota, Staff Physician, VAMC Veterans Affairs medical Center
Normal Tympanic Membrane
www.commons.wikimedia.org
www. entjo.com
Serous Otitis Media
http://b.vimeo.com
otitismedia.hawkelibrary.com
http//:www.pedisurg.com http://health-advisors.org
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Clinical Practice Guidelines: Tympanostomy Tubes in Children Rosenfeld, RM. et al. Otolaryngology - Head & Neck Surgery. 149 (1 Suppl):S1-35, 2013 June. Age 6 months to 12 years Recurrent Acute Otitis Media 3 infections in 6 months 4 infections in 1 year with at least 1 in the past 6 months Chronic Otitis media with effusion 3 months (both ears or unilateral) with hearing loss or other symptoms such as: speech delay, vestibular problems, poor school performance, behavioral problems. ear discomfort. Persistent Acute Otitis Media persistence of AOM within a month of completing antibiotic therapy 2 episodes of AOM within 1 month Children younger than 6 months require individualized decision making based on specific clinical circumstances.
Serous Otitis Media in the Adult
http://healthmango.com
http://www.m.advancedonc.com
Unilateral or bilateral After URI, prolonged hospitalization, surgery. Nasal topical steroids Role of antibiotics not effective
R/O tumor in nasopharynx -antrochoanal polyp -nasopharyngeal carcinoma -extra nodal lymphoma -chronic adenoiditis (HIV) -minor salivary gland tumor -nasal polyposis
PE tubes: Risks and Adverse Events Tube plugged 4%
Otorrhea 16-26%
www. entusacom www.subent.com
Granulation Tissue 4% Perforation 1-6%
www.otitismedia.hawkelibrary.com www.rcsullivan.com
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Otitis Externa Acute Otitis Externa
Auricular Perichondritis Chronic Otitis Externa
http://odlarmed.com/?p=1300 www.healio.com/pediatrics/respiratoryinfections/news/online/%7Bbab56c87-246a-40d5-b24d05ffa2f4f207%7D/aoe-predisposing-factors-andpathogens
http://www.wikidoc.org/index.php/Auricular_perichondritis
http://entkent.com/otitis-externa.html
Acute Otitis Externa Pathogens: Pseudomonas aeruginosa , Staphylococcus aureus Proteus species, Staphylococcus epidermidis, diphtheroids, and Escherichiacoli.
Otowick Ototopical Antibiotics +/steroids Oral Ciprofloxacin if cellulitis , perichondritis Fissures of Santorini: spread to parotid gland, soft tissue, TMJ www.healio.com/pediatrics/respiratoryinfections/news/online/%7Bbab56c87-246a-40d5-b24d05ffa2f4f207%7D/aoe-predisposing-factors-and-pathogens
http://www.keywordpictures.com/abuse/fissures%20of%20santorini///
http://www.enttoday.org/details/article/2544401/Advances_in_Facial_Paralysis.html
Herpes Zoster Oticus Ramsey Hunt Syndrome Herpes Virus reactivation at geniculate ganglion Ear pain first Vertigo, Hearing loss, deafness Steroids and antivirals, antibiotic coverage for Pseudomonas Worse prognosis than Bell’s palsy www.howhealth.com
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79 yo diabetic Severe ear pain for 1 week Tried quinolones ear drops and oral antibiotics for 2 weeks. Change in mental status, disoriented.
http://www.aafp.org/afp/2003/0715/p309.ht ml
•www.otoscopy.hawkelibrary.com
Malignant Otitis Externa Necrotizing Skull Base Osteomyelitis
•www.otoscopy.hawkelibrary.com
Pseudomonas A. Aspergillus http://www.aafp.org/afp/2003/0715/p309.html Immunodepressed, diabetics, elderly Severe deep ear pain Granulation tissue polyps in ear canal FN palsy 40% Multiple nerve palsy 24% (Jugular foramen CN IX, X, XI) (Petrous apex V, VI) CT scan for bone erosion Mortality 50% 3rd 4th gen Cephalosporins, OR for mastoidectomy debridement
25 yo swam in lake now with ear pain Week 1 :treated with topical fluoroqunolones Week 2 : neomycin polymyxin & Hydrocortisone Week 3: reports muffled ear, no improvement
http://eac.hawkelibrary.com/new/main.php?g2_itemId=19
http://otoscopy.hawkelibrary.com/album04/Fig7_29
http://www.ent-surgery.com.au/ent-resources/ear/swimmers-ear-otitis-externa
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Otomycosis
http://www.ent-surgery.com.au/ent-resources/ear/swimmers-ear-otitis-externa
http://gpent.blogspot.com/2013/02/definition-oe-is-inflammatory-typically_11.html
Aspergillus, Candida Albicans Clotrimazole 1% , Gentian Violet, Acetic Acid
Chronic Eczematous Otitis Externa Periodic exacerbations Painless no drainage Severe itching ear canal
Seborrheic Dermatitis, Eczema, Psoriasis. Cultures if drainage Fluocinolone Acetonide Bacitracin Ointment x 5 days Dry ear canal precaution http://entkent.com/otitis-externa.html
Traumatic TM Perforations Q-tip manipulation Excruciating pain, blood per ear. Fell to the ground Severe vertigo with fast beating nystagmus to opposite site of ear Weber goes to opposite side www.merckmanuals.com
What do you do? a. Prescribe topical ear drops, set up next week to see ENT b. You recommend dry ear precautions and observation c. Referral to ENT urgent
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Traumatic TM Perforations Topical Ear drops, next week to see ENT Dry ear precautions observation Referral to ENT urgent: Vertigo, nystagmus
Stapes subluxation, Perilymphatic fistula Sensorineurial hearing loss
http://www.kids-ent.com/website/pediatric_ent/ear_infections/
To OR Emergently for Middle ear exploration Round Window/Oval window grafting
Acute Otitis Media
http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/step18b.htm
www.utmb.edu/pedi_ed/aom.otitis
Ear tilted (proptosis)
Facial palsy
http://www.facialpalsy.org.uk/advice/children-young-adults/1401
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http://www.entusa.com/mastoiditis/ap_child_coallescent_mastoiditis.jpg&w=354
Bezold’s (subperiosteal) abscess Sagging of posterior canal wall
http://www.entusa.com/ear_infections.htm
http://en.wikipedia.org/wiki/Mastoiditis&docid=cCNF6zBfGCscvM&imgurl
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Acute Mastoiditis ! Facial nerve paralysis Meningitis Subperiosteal abscess Otitic hydrocephalus thrombus in the lateral venous sinus impedes venous drainage of the intracranial contents into the neck and produce a rise in the cerebral venous pressure and a subsequent increase in the CSF pressure.
Sigmoid sinus thrombosis Brain Abscess Epidural abscess
Chronic Suppurative Otitis media
http//:kckentcentre.com
http://me.hawkelibrary.com
Cholesteatoma
http://www.radiologyassistant.nl/images/4a45c9d86f3edtek-cholesteatoma.jpg http://www.bris.ac.uk/Depts/ENT/attic_defect_2.jpg
Keratinized squamous epithelium in middle ear, mastoid Primary Acquired – retraction pocket Secondary Acquired– through TM perforation
Ossicular Erosion Facial Paralysis Labyrinthine fistula Perilymphatic fistula Brain abscess
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Osteoma
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Exostosis
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Subjective hearing loss for 1 day Unilateral tinnitus Mild URI 2-3 days prior Normal TM exam +/- vertigo What do you do?
a. b. c. d.
“It looks red”, Amoxicillin for 10 days It must be Eustachian tube dysfunction: Sudafed and Flonase “I think it’s Menière (next avail. App. in 4 weeks) Find a tuning Fork, do Weber & Call ENT and refer urgently
http://otitismedia.hawkelibrary.com/normal/1_G
http://://www.phsa.ca/NR/rdonlyres/5082BBF
Tuning Fork Test
http://quizlet.com
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Sudden hearing loss: an otologic emergency ! TX: Steroids ASAP Prednisone 60 mg x 14 days Intratympanic Steroid injections Poor Outcome: Delayed presentation, Old age, + Vertigo, Profound HL
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Cochlear Implants: when? A cochlear implant is a surgically implanted electronic device that can be considered for people with severe to profound Sensorineural hearing loss in both ears.
http://urmcmenshealth.com/2011/11/15/cochlear-implants-when-hearing-aids-are-not-enough
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http://www.alphaonenow.org/hear_in_maine.htm
Who is the candidate in your clinic? Hearing aids provide minimal benefit Spouse functions as interpreter Depends on written notes Telephone use abandoned unless yes no answers or cap tell. Unable to understand TV unless captioned Socially withdrawn Depends heavily on lip reading
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How does a Cochlear Implant work? The implant bypasses the diseased or nonfunctioning inner ear hair cells by
converting the sounds we hear to electronic impulses that directly stimulate the inner ear nerve endings
Cochlea is Tonotopic: High frequencies at base, low frequencies at apex
http://www.neuroreille.com/promenade/english/ear/inear/finear.htm
http://www.liquidarea.com/2011/01/sordita-messa-a-scacco-da-chirurgia-di-ultima-generazione/
Criteria for Adults No upper limit of age Medical evaluation Psychological evaluation Audiological testing with high powered hearing aids CT/MRI temporal bones Pre-op vaccination with Pneumovax
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Our Cochlear Implant Team 2 Otology &Neurotology Surgeons: Manuela Fina, MD Christopher Hilton, MD
2 Cochlear Implant Audiologists
Aural rehabilitation Sara Oberg, MA CCP-SLP
Sheryl Erenberg, Aud. Laura Eklund, Aud.
Psychology Counseling Kristen Swan, MA-LP
Monthly Cochlear Implant Support group
Conclusions & “Pearls” Ear Drainage: topical quinolone antibiotic drops are a safe bet for initial treatment. Otitis Externa: Coverage for Pseudomonas if cartilage involvement Always Dry ear precautions! Normal exam and subjective hearing loss: suspect Sudden SNHL: Emergency Referral !
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