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Terms Definitions
Battle's Sign, skull base fractureWhat is suggested by bruising behind
the ear?
Raccoon's Sign, craniofacial displacementWhat is suggested by bruising
circling the eyes?
MMA - spinosum, ovale - mandicular N, rotundum- maxillary N. Pterygoid - vidian N. (Max rotation,Ovale Man)
Name 4 foramen and their assocstructures in the anterior base of theskull
preseptal cellulitis. all other orbital cellulitis where
pt loses eye movement/vision
What orbital cellulitis is not an
emergency? What is?
oculomotor N palsy
What CN is afflicted if a pt cannot
move one eye well, has unilateral
slight ptosis and the pupil is dilated?
behind (deep to) the pars flaccida. Can grow todestroy the middle ear structures.
Where are cholestiatomas found?Why are the serious?
Rinne - louder bone conduction indicates
conductive hearing loss while no bone or air hearing indicates neurosensory. Weber - tuning
fork on forehead, sound lateralizes toward the side
of conductive loss and away from side of
sensorineural
Summarize the Rinne and Weber
tests
peripheral lesions can be suppressed by visualfixation while central lesions can't (goggles may
make central lesion nystagmus better)
For pts with dizziness/nystagmus,
how does visual fixation and exam
w/o visual fixation inform the likelylocation of the lesion?
tumors will destroy or significantly alter bonystructures of the skull
How can benign growths such as
nasal polips be distinguished from
tumors?
LMN lesion of facial N (perhaps disrupted as itgoes very near the inner ear canal). UMN lesion of
VII.
What is indicated by total
hemiparalysis of the face? What
about hemiparalysis of the lower facewith the upper still able to move?
upper esophageal sphincter, aortic arch/left
mainstem bronchus, lower esophageal sphincter
What are the 3 narrowings of the
esophagus?
hemistry English
True
T or F. Diseases and disorders of the ears are a
common clinical presentation occurring
ACROSS ALL AGE GROUPS.
Early recognition and adequate treatmentWhat is paramount in order to reduce the
serious morbidity that may occur?
20%
Ear related diseases account for nearly 1/2 of
all HEENT problems - and nearly what
percentage of Family Practice VisitsEar pain Otalgia =
Discharge from the ear Otorrhea =
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Fullness feeling in the ear Aural fullness =
Hearing loss HL =
Ringing in the ear Tinnitus =Itching Pruritis =
Otolaryngology ENT =
Right/Left/Both AD/AS/AUGENHEENT
DERM
NEURO- CNV-VIIILABS → Culture to r/o infx, CBC for
WBC, ESR/CRP inflammatory markers
Hearing Test
IMAGE (CT maybe if there is amalignancy)
What labs/PE need to be done on a patient with
ear problems
...
**You must be able to label the ear!
Auriculotemporal nerve
* The auricle is innervated superiorly andanteriorly
Greater Auricle and Lesser Occipital
Nerve
* The auricle is innervated posteriorly andinferiorly by the
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Vagus Nerve (If a laceration is moving
into the internal canal, refer them)
The concha and external auditory meatus are
innervated by the
External canal (EAC)
This is described as the following:approx. 2.5 cm long in an adult
S- Shaped
Cerumen (wax) secreted by sebaceous glands
in distal third of EACProvides protection
AIR! What should the middle ear be filled with?
Malleus
IncusStapes
What are the 3 ossicles of the middle ear?
Oval window
Round windowWhat are the 2 openings of the middle ear?
The temporal bone * What bone is the Mastoid process a part of?
True
T or F. The Mastoid process contains numerous
air cells
Because the mastoid processcommunicates with the middle ear space,
and this causes a POTENTIAL FOR
INFECTION
* What causes a patient to get mastoiditis?
Dermatological What are most disease of the ear?
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Drained to prevent deformity
(cauliflower ear) or EAC blockage
What must be done with Traumatic Auricular
Hematoma?
To prevent perichondritis and its resultantdeformity
Why must Cellulitis must be treated promptly?
By deflection of the auricleHow can Perichondritis be differentiated from
cellulitis?Most often occurs on the face
Where does Basal Cell Caricinoma (BCC)usually occur?
Usually brought to my attention before
they become very large - grow slowly!
* What is the main thing about the rate of
growth for BCC?Rarely Do BCC metastasize?
BIOPSY! How is BCC diagnosed?
-Dermatologists may freeze or curette
them-Facial plastic surgeons tend to excise
them with a small margin
How is BCC treated?
Mohs technique What technique to treat BCC but it takes longer and more costly than other methods, but
recurrence rate is lower
Minimize sun exposure
What is the prevention for BCC?
Squamous Cell Carcinoma (SCC) If BCC does not metastasize, what does?
SCC
This is more aggressive and generally requires
excision of a larger margin than BCC toassume complete removal
SCCWhat is the most common neoplasm of the ear
canal?Hard, nontender, red, indurated papule,
nodule or plaqueHow do most SCC present?
BIOPSY What should I do to diagnose SCC?
Recurrent lesions, > 2 cm, or aggressivehistology When should I use Mohs procedure?
Actinic Keratosis (AK)
"Crusty with Erythema"
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What is a precursor to SCC?
Check for regional lymphadenopathy What needs to be checked with BCC/SCC?
Malignant Melanoma
This is described as the following:
-Unpredictable tumor that affects patients of allages and has a high mortality rate
-Presents as pigmented lesion that changes by
either growth, color, or margin, ulceration, or
bleeding, or is deeply pigmented or raisedBegins in the epidermis and then invades
the dermis
-Depth of invasion is strongly predictiveof spread and, ultimately, patient survival
**How does Malignant Melanoma progress?
< 10%In Malignant Melanoma, what is the risk of
mets if it is thin?
> 90%In Malignant Melanoma, what is the risk of
mets if it is thick?
Epidermal Inclusion Cyst (EIC)This has the following clinical presentation
- Usually asymptomatic- Common around the ear
- Well defined, non-tender, soft, mobile, cystic
mass
- Slow growing
Yes
Is it possible for Epidermal Inclusion Cyst
(EIC) to spontaneously resolve?
ClinicallyHow is the diagnosis of Epidermal InclusionCyst (EIC) made?
ExcisionWhat is the treatment of Epidermal Inclusion
Cyst (EIC)?1) Infection
2) Recurrence
What are the complications of Epidermal
Inclusion Cyst (EIC)?
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Auricular Hematoma
This is an accumulation of blood in
subperichondrial space, usually due to blunttrauma (boxing, wrestlers, rugby, etc.), though
may occur following wound closure
1)Cartilage lacks its own blood supply;
relies on diffusion2) Hematoma develops and blocks this
diffusion3)Leading to necrosis of cartilage, predisposing to infection and further
injury
How does a Auricular Hematoma develop?
PROMPT drainage and application of pressure dressing are required!
What is the treatment for Auricular Hematoma?
Edematous, fluctuant, and ecchymotic
pinna with loss of normal landmarks
What is the clinical presentation of a Auricular Hematoma?
1) Evacuate hematoma (I&D or needle
aspiration), followed by:
2) Pressure dressing and Splinting-Prevents reaccumulation
-Cotton bolsters, plaster molds, silicon
putty, etc.
3) PO Antibiotics (diclox or cephalexinusually adequate) *Levofloxacin (adults)
*Augmentin (Child)
-Consider cipro if concerned about pseudomonas
4) Refer to ENT if hematoma > 7 days
old
What is the treatment of Auricular Hematoma?
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1) Necrosis and infection
2) Cauliflower deformity if not treated
promptly (48 to 72 hrs)
What are the complications of Auricular Hematoma?
1) Cleanse ear with antiseptic solution
and provide local anesthesia
2) Needle aspiration: (SMALL, ACUTEhematomas, <24 hrs old) --> because the blood is thin enough
OR -
3.Incision: (LARGE HEMATOMAS or those >24 hrs but <7 days old) This is
because if it has been longer than 24
hours, the blood will have clotted
4.Dressing x 1 week with a RECHECK AT 24 HOURS (by ENT recommended)
5.Antibiotic - pseudomonas and/or staph
• Levofloxacin (adult),Amoxicillin/Clavulanate (children)
How do I perform an evacuation of a
Hematoma?
Infiltration with local anestheticWith a Lacerations to the Ear, what can I do to
help facilitate my evaluation?
1) Advanced location and depth of injury2) Degree of CARTILAGE involvement
3) Extension of laceration into EAC
4) Presence of tissue AVULSION5) And, ASSOCIATED middle ear
trauma and basilar skull fracture
When should I consider consultation when a
patient has a laceration of the ear?
Middle Ear Trauma
What should I consider if a patient has the
following:
Hemotympanum
Amber/clear middle ear effusion
Otorrhea
Hearing deficit (HL) with Weber/Rinne
Retroauricular hematoma (Battle sign)
Typically appears 2 days after injury, but mayappear within 6- 12 hrs
Facial nerve dysfunction
Basilar Skull Fracture
What should I consider if a patient has the
following:
The signs of middle ear trauma and also havedeficits of VIII?
Facial Nerve or Parotid Gland
involvement
What should I consider if a patient has thefollowing:
Lacerations that extend anterior to the ear may
disrupt CN VII and/or parotid gland
1) Auricular avulsion2) Laceration with EAC extension
When should I make a Referral to the Plastic or maxillofacial surgeon, ENT, or neurosurgeon?
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3) Laceration with middle or inner ear
injury (HL, vestibular symptoms)
4) Laceration with basilar skull fracture5) Chronically split earlobe or cleft
caused by heavy earrings or allergy to
ring metalPrimary closure (Limit time underlyingcartilage is exposed = lower risk of
infection)
What is the preferred method of closure of a
laceration of the ear?
If the laceration is >24 hrs old and/or signs of inflammation (redness, warmth,
swelling, pus)
When would I want to do delayed closure of a
laceration of the ear?
1) 5-0 or 6-0 nonabsorbable nylon,
Novafil, or Prolene-Children 6-0 absorbable avoids trauma
of suture removal
What kind of suture material should I use onthe skin?
Undyed 5-0 absorbable Monocryl,Vicryl, or Dexon What kind of suture material should I use onthe Perichondrium?
10 mL syringe of 1% lidocaine using a
small 25g or 27g (1.5 inch) needle
What anesthetic should I use for suturing a
laceration?
NO EPINEPHRINE!**What should I absolutely not use insuturing?
Local Block (just sufficient)What type of anesthetic is sufficient for most
simple lacerations?
Regional Block (Preferred)
What type of anesthetic should be used for
extensive lacerations and best for avoiding
tissue distortion?
Total dose should not exceed 4mg/kg of 1%
**What is the absolute maximum dose of lidocaine for a regional block?
Auriculotemporal nerve
* The auricle is innervated superiorly andanteriorly
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Greater Auricle and Lesser Occipital
Nerve
* The auricle is innervated posteriorly and
inferiorly by the
Vagus Nerve (If a laceration is moving
into the internal canal, refer them)
The concha and external auditory meatus are
innervated by the1) Bites
2) Contamination
3) Vascular insufficiency
4) Immunodeficiency
Most lacerations of the ear do not warrant
empiric treatment with antibiotics, but may
decrease risk of infection in patients with what
conditions1) Daily cleansing followed by topical
antibiotics recommended, pressure
dressing reapplication2) F/u in 24-48 hrs (infection or
hematoma development)
3) Remove nonabsorbable suture in 7-10days if healed
What is the aftercare?
Cellulitis ( I can treat this) This is an infection of the skin
Perichondritis (can arise from trauma or
even simple closure)
This is an infection of the tissue surrounding
the cartilageChondritis This an infection of the cartilage
1) Swollen warm, tender, erythematous
auricle
2) Pain on deflection of auricle (pinch of auricle = pain)
3) May involve lobule
4) Chondritis "technically" does notinvolve the lobule
It is difficult to distinguish cellulitis from perichondritis, or chondritis, but what is the
general clinical presentation?
Due to poor blood supply to cartilage Why is chondritis difficult to treat?
P. aeruginosa - 95% What makes up 95% of the cases of chondritis?
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Start PO Levofloxacin; f/u in 24 hours
max**How is mild chondritis treated?
Require IV antibiotics and potentiallysurgical debridement
**How is moderate to severe treated?
ENT consult**What is highly advisable even with timely
and proper antibiotic treatmentPROTECTS the skin of the canal-It acidifies the canal to prevent
overgrowth of bacteria and fungus
-It is lipid rich (hydrophobic) which prevents skin penetration and maceration
Cerumen secreted by outer portion of EAC;What is its purpose?
Impaction affects 1/10 children and 1/20
adultsHow common is cerumen impaction?
1.Obstruction from EAC disease2.Narrowing of EAC
3.Failure of epithelial migration
•Inappropriate attempts at removal (q-tips, cotton buds) is the MOST common
cause
4.Overproduction
What is the main cause for cerumen impaction?
1) Usually asymptomatic - will noticemost often incidentally with otoscopic
examination
2) Symptomatic - hearing loss, otalgia or fullness, itching
What is the clinical presentation of cerumenimpaction?
Most, if not all, will have improvement
of symptoms with removal of earwax
accumulation (avg 10 dB hearingimprovement)*
**What if a patient with cerumen impaction is
symptomatic?
1) Cerumenolytic agents (PRIMARY
CARE SETTING FIRST-LINE)2) Irrigation (IF CERUMENOLYTICS
FAIL)
3) Manual removal (usuallyotolaryngologists)
-Provides direct visualization and limited
damage to EAC skin/TM
*No method is superior to another
For cerumen impaction that is symptomatic,
what are the 3 recommended therapeuticoptions for removal?
1) Leave it alone! - removal can result in
adverse outcomes
2) Many will clear it without intervention
3) Cerumen acts as a protective layer, preventing against infection and trauma
**What if a patient with cerumen impaction isasymptomatic?
Use a wash cloth once a week. DO NOT
use Q tips
What do I need to tell my patients about
cleaning their ear?In patients with no h/o infection, When should I use or have a patient use
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perforation, or otologic surgery Cerumenolytics?
If TM damage suspected When should Cerumenolytics be AVOIDED?
1) Can be applied by clinicians or patients at home
2) Should be followed up with otoscopic
exam to ensure no retention of drops inEAC3) Use should not exceed 3-5 days
How are Cerumenolytics applied?
Preps of "mineral oil" or "hydrogen
peroxide"**What are the OTC Cerumenolytics?
Carbamide Peroxide (Debrox), 5-10
drops in canal for 15 minutes bid x 4 days**What is the prescription strength?
1) Allergic reactions
2) Otitis externa3) Earache
4) Transient HL
5) Dizziness
**What are the complications of
Cerumenolytics?
Irrigation (But do not jump to irrigation
because it could cause infection as it
takes out all the protective cerumen)
Effective and safe, and tends to be more
effective for hard impactions
Gentle irrigation of EAC with a largesyringe (200mL) and warm water treated
with a bacteriostatic agent (dilute
hydrogen peroxide 1:10)- Saline or tap water may be just as
effective
- Ok for trained staff to perform
- Canal should be straightened as much as possible
- Tip of syringe should not be placed
beyond the lateral third of canal (usuallyabout 8 mm)
- Direct stream upwards in canal
How is irrigation performed?
When Cerumenolytics have failed When would I use irrigation?1) Retention of water behind
incompletely removed cerumen =
maceration of the skin and potential
infection2) If performed too aggressively, can
cause:
- TM perforation
- HL, tinnitus, and/or vertigo- Pain
*What are the complications of irrigation?
Only if proper equipment available,
trained and experienced, and patient ableto stay still
When can Manual removal of cerumen be
done?
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1) TM perforation
2) Recurrent impaction
3) No response to routine measures4) H/o chronic otitis media or TM
perforation
When should I consult ENT for cleaning under
microscopic guidance?
1) Ear pain - too aggressive!2) TM perforation - too far with curette!3) Bleeding/laceration - too aggressive
-Caution for those on anticoagulation
therapy
**What are the complications of manual
removal of cerumen?
SHOULD BE AVOIDED What about Ear candling?
1.Cotton ball dipped in mineral oil and
placed in EAC for 10-20 min once/week
•Combined with 8 hours of no hearing aiduse overnight, if applicable
•Helps liquefy cerumen and aid normal
elimination mechanisms2.Routine cleaning by health professional
q6-12 months also suggested
Most patients with conditions predisposing to
cerumen accumulation (eczema, otitis externa,
etc), cannot prevent recurrent episodes and theneed for regular removal. What can we do for
prevention?
1) Present with pain, pruritis, conductive
hearing loss, and/or bleeding2) A persistent FOB may lead to infection
and formation of granulation tissue
-More common in children than adults
What may a patient with a Foreign Body
present with?
Irrigation What is the #1 to get rid of foreign bodies?
Organic FOBs (beans, insects)
- Immobilize living insects first with 2%
lidocaine (kills insect and anesthatizes theskin of EAC
When should irrigation NOT be performed?
EXTERNAL OTITIS (AOE) **KNOW THE NEXT CARDS
Swimmers ear What is another name for External Otitis(AOE)?
BOTHIs External Otitis (AOE) an inflammatory or
infectious process of the EAC?S. aureus or gram (-) rods like
Pseudomonas
What is the most common cause of External
Otitis (AOE)?
1) Frequent or aggressive cleaning
2) Exposure to water 3) Scratching
4) Lack of cerumen
What are predisposing factors for ExternalOtitis (AOE)?
1) Otalgia
2) Pruritis3) Otorrhea
4) Aural fullness
5) Hearing loss
What is the clinical presentation of External
Otitis (AOE)?
1) Erythema and swelling of the canal, What will exam show with External Otitis
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with varying degrees of occlusion,
discharge and crusting
2) Pain on distraction of the auricle3) May have LAD in more advanced
disease
4) Lateral surface of TM is ear canal skinand may be erythematous, however, theTM will be mobile
(AOE)?
CultureWhat may be helpful if there is persistent
External Otitis (AOE)?1)Cleaning the ear
2)Treat inflammation and infection
3)Control pain
4)Avoid promoting factors
What are the fundamentals for treating External
Otitis (AOE)?
CLEANING (AURAL TOILET)what is the single most important aspect of
treating External Otitis (AOE)?
It provides removal of wax, desquamatedskin, and purulent material which greatly
facilitates healing and enhances
penetration of ear drops
Why is CLEANING (AURAL TOILET) so
important?
1) Use wire loop or cotton swab withdirect vision through an otoscope
2) May be irrigated with 1:1 solution of
3% hydrogen peroxide at bodytemperature if TM visible and intact
How is the CLEANING (AURAL TOILET)conducted?
Erythema, but no swelling What is MILD External Otitis (AOE)?
1) 2% Acetic Acid (VoSol): Inexpensive
, but can be irritating on inflamed skin2) Rx: Vosol; 5 gtts into canal tid-qid
What is the treatment of MILD External Otitis
(AOE)?
• Polymyxin B/hydrocortisone
(cortisporin): inexpensive, but containsneomycin which is potent sensitizer
• Aminoglycosides (gentamicin sulfate
0.3%): more expensive and potentiallyototoxic
• ****Quinolones (ciprofloxacin or
ofloxacin): highly effective but expensive
(qd - bid dosing)• Rx: **Ofloxacin Otic**; 10 gtts into
affected ear(s) once daily x 7 days
What is the treatment of MODERATE External
Otitis (AOE)?
1) Ciproloxacin
2) Ofloxacin Otic
What does LT Theomke like to use for
moderate External Otitis (AOE)?TID How are most topicals given?
Ofloxacin with or without a systemic oral
antibiotic
What antibiotic should I use if the TM is NOT
intact (Meaning it is not mobile)?1) Alcohol ***What should absolutely not be used if the
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2) Aminoglycoside
3) Neomycin/polymyxin
B/hydrocortisone
TM is NOT intact (Meaning it is not mobile)?
• Diabetes
• Immunodeficiency
• h/o radiation to the ear • Severe otitis externa • Significant edema inhibiting application
of topical medication
When should I use systemic antibiotics for External Otitis (AOE)?
NSAID - opioid analgesics (narcotics)depending on severity
How do you control the pain in External Otitis(AOE)?
1) Protect ear from water
-Cotton ball coated with petroleum jelly
is acceptable during bathing-No water sports x 10 days
2) Educate on proper ear hygiene
3) Recurrent ear infections
How can my patient avoid promoting factorsfor External Otitis (AOE)?
To inside a swollen ear canal and place
ear drops on itWhat are Earwicks for?
1) Most cases are self-induced either
from excoriation or by overly zealous ear cleaning
2) May be associated with external otitis
or with derm conditions such as psoriasisor seborrheic dermatitis
What causes Pruritis in most cases?
Mineral oil is safe to use; helps with
dryness and repels moistureWhat is the best treatment for Pruritis?
Topical isopropyl alcohol (which is whywe use mineral oil) What promptly relieves pruritis but is drying?
Allow the cerumen layer to regenerate
-Avoid use of soap or cotton swabs in thecanal; and no scratching
What must I tell my patient that has pruritis for
prevention?
Necrotizing Otitis Externa (aka
"Malignant" otitis externa)
This is described as the following:
Severe bacterial infection of the EAC andskull base
The most feared complication of AOEv
Elderly diabetics and
immunocompromised patients
Who are most commonly affected by
Necrotizing Otitis Externa?
Pseudomonas What is the usual culprit in Necrotizing OtitisExterna?
Starts as an external otitis that spreads to
the temporal bone and can further extendreadily to the skull base, leading to fatal
complications if not adequately treated
Described the onset of Necrotizing OtitisExterna
1) Deep Otalgia2) Persistent Foul Otorrhea
***What are the signs and symptoms of
Necrotizing Otitis Externa?
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3) EAC granulation
CT, with bone windowsLook for osseous erosion!!
How can I diagnose Necrotizing OtitisExterna?
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