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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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