otitis media, externa, impacted cerumen.pptx

8/9/2019 otitis media, externa, impacted cerumen.pptx

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otitis externa

otitis mediaImpacted cerumen


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Difuse otitis externa andeczema

Circumscribed“uruncle”

Necrotizing

Circumscribed lesioncaused by acutebaccterial infection of

cartilagionus portion ofear canal

Pathogenesis:

Inam. Cond’n of EACinvolving canal sin!ec"ema#dermatitis# $’%mech. In&ury#toxicity# allergy'acutebacterial infection () mixed

ora of gm !*' orgs.!P.aeruginosa# P. mirabilis' andanaerobes +(arm moist env’tpromote dev’t of ,-Es(immer’s otitis/

0ocal mechan. 1rauma2contaminationof ear canal!eg. Earplug# dusty env’t# bath(ater'obstruction of

hair follicles)glandularductsstaphylococcalinfection ofpilosebaceuos units

3,angerous form of-E3occur almostexclusively in olderpts. () ,4

3simple-Einfected () P.aeruginosaulceration and osteitis offoor of earcanal+bone infectionmay subse5uentlyspread to middle ar#

sull base#retromandibularfossa and parotidcompartment

6ymptoms

34ain initial *itching3pain * present () acuteinfection

3obst’n of earcanalconductive hearing loss

7ery painful# tenders(elling that can causemild hearing loss

3Initial hx: insidiuspersistent -E doesn8theal

3moderatepainsevere as thecondition taes a


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Difuse otitis externaand eczema


Necrotizing

,iagnosis

Eczema of ear canal, w/oacute infection: canal sinis dry# craced and scaly

Infection:di9use s(elling3fetiddischargeanaerobes+acteriologic exam*necessary only in pesistentr recurrent infection)diagnosis is uncertain

I&P: tragal tendernessaccompanied by acircumscribed, very painfulswelling in cartilaginous portionof ear canalOtoscopy: pronounced s(ellingof ear canal () debris in residuallumenSimple hearing test: canalmay be s(ollen shutsomedegree of conductive hearingloss

Bacteriologic exam: purulentcenter can be opened () a smallblunt hoo to obtain a smear+recurrent furuncles shouldprompt examination forpredisposing syst. Condition e.g.,4

I: signs of infxn insurrounding tissuesOtoscopy: almostal(ays sho( ulcer oncanal r. () exposedbro(nish bone andfetid dischargeSmear: P. aeruginosaCT: extent ofinfection and bonedestruction+DM –almost al(ays

present# otherimmune defectsshould be excluded

Complications

Craced sin in-E canallo( bacterialentryperichondritis##cellulitis or abscessformation+necroti"ing -E maydevelop in predisposed pts.

36pread to auricularcartilageperichondritis

36uperinfection ()Pseudomonasnecroti"ing -E

-titis media#mastoiditis# petrositis#soft tissue abscess#cranial nerve de;cits !7II# 7III# I


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Difuse otitis externaand eczema


Necrotizing

1reatment 3=st

# most impt. 6tep*meticulous# repeatdcleansing and drying ofear canal follo(ed byinstillation of antiseptic#antibiotic drops that (illreduce the s(elling

Ear canal*meticulouslycleaned then treatedlocally for =*$ days ()>?@ alcohol!appliedhourly to a selfexpanding foam)gau"e(ic inserted to the earcanal'+

Crusts-dissolved ()antibiotic containingointment stripsAter swellingsubsides-antibioticcontaining ointmentstrips instilled+nsaids*administered for

painAbscesses-incised onceclearly demarcated+systemic antibiotic*systemicsymptoms)severe localsigns of infection


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Otitis

Externa

Acute Otitis

Media

Cronic

Otitis Media 1ragal pain present absent absent

Ear Canal s(ollen normal normal

Ear drum n)red ulging)smallperforation

perforated

,ischarge 6ticy)yello(ish

4ucoid discharge thru a 14perforation

Bodes fre5uent 0ess fre5uent

ever !D' !D' !*'

earing Bormal or


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-1I1I6 E


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External auditory canal

•

,i9use• Circumscibed• Becroti"ing•

ullous• otomycosis


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Difuse otitis externa

!atogenesis"•

Inammatory condition of externalauditory canal involving canalsin!ec"ema# dermatitis# $’%mech. In&ury#toxicity# allergy'

acute bacterial infection (ith mixed ora ofgm !*' orgs. !P.aeruginosa# P. mirabilis'2anaerobes

+(arm moist environment romote


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$%m&toms

3itching* 4ain initial

3pain * present () acute infection

3conductive hearing loss $ %obst’n of ear canal

Diagnosis

Eczema of ear canal, w/o acute infection: canal sinis dry# craced and scaly

Infection:di9use s(elling

+fetid dischargeanaerobes


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Com&lications

Craced sin in -E

can allo( bacterial entry

perichondritis#cellulitis or abscess formation

+necroti"ing -E may develop in predisposed

pts.

'reatment3=st # most impt. 6tepmeticulous# repeatedcleansing and drying of ear canal follo(ed by instillation of antiseptic#

antibiotic drops !reduce the s(elling'


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Circumscribedfuruncle/

Circumscribed lesion caused by acute bacterialinfection of cartilaginous portion of ear canal

!atogenesis"0ocal mechanical

1rauma2contamination of ear canal!eg.Ear plug#dusty env’t# bath (ater'

obstruction of hair follicles)glandular ducts

staphylococcal infection of pilosebaceuos units

$%m&toms" 7ery painful# tender s(elling that cancause mild hearing loss


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Diagnosis"

• I&P: tragal tenderness accompanied by a circumscribed,very painful swelling in cartilaginous portion of ear canal

• Otoscopy: pronounced s(elling of ear canal () debris inresidual lumen

• Simple hearing test: canal may be s(ollen shutsomedegree of conductive hearing loss

• Bacteriologic exam: purulent center can be opened () a

small blunt hoo to obtain a smear

• +recurrent furuncles should prompt examination forpredisposing syst. Condition e.g. ,4


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Com&lications"

(6pread to auricularcartilage&ericondritis

36uperinfection ()Pseudomonasnecrotizing OE


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'reatment"Ear canal*meticulously cleaned treated locally for =*$ days

() )*+ alcool, (applied hourly to a self epandingfoam/gauze wic! inserted to the ear canal"

Crusts-dissolved () antibiotic containing ointment strips

Ater swelling subsides-antibiotic containing ointmentstrips instilled

Abscesses-incised once clearly demarcated

+nsaids*administered for pain

+systemic antibiotic*systemic symptoms)severe local signs ofinfection


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Becroti"ing -titis Externa

3,angerous form of -E

3occur almost exclusively in older pts. () ,4

!atogenesis"

3simple -Einfected () P. aeruginosaulcerationand osteitis of oor of ear canal

+bone infection may subse5uently spread to middleear# sull base# retromandibular fossa and parotidcompartment


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$%m&toms"

3Initial hx: insidious persistent -E doesn8t heal

3moderate pain

severe as the condition taes achronic course

Diagnosis"I: signs of infection in surrounding tissues

Otoscopy: almost al(ays sho( ulcer on canaloor. (ith exposed bro(nish bone and fetid

dischargeSmear: P. aeruginosa

CT: extent of infection and bone destruction

+DM –almost al(ays present# other immune defects

should be excluded


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Com&lications"

• -titis media# mastoiditis# petrositis#soft tissue abscess

• cranial nerve de;cits !7II# 7III# I


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'reatment"

Ear Canallocally debrided# cleaned at regularintervals

+minimal bone involvementhigh dose antibiotice9ective against P. aeruginosa admin. x G (ees

+,4*closely monitored and ade5. Controlled

3poor response to conservative treatment)extensive involvement) if complicationsarisea#ected bone is resected


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ullous -E

!atogenesis"

(lu*related) hemorrhagic -titis externa presumed tohave viral etiology but exact causal agent is unno(n

(inuen"a virus*isolated in sporadic cases

(infectiontoxic capillary damage in thin epithelial layerof meatal sin 2 tympanic membraneformationofhemorrhagic epithelial ullae


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$%m&toms"

3disease begins () severe otalgia of sudden onset

3often follo(ed by a bloody discharge from Ear canal

3both conductive 2 sensorineural hearing loss*may develop

Diagnosis"

-toscopy: serous or hemorrhagic bull formationnseen on bony portion ofear canal ) 14

3rupture of bullaspontaneous leedingdries# forms crust

Dif Dx"

1oxic or traumatic in&ury to EC or middle ear !barotrauma'

Com&lications"

4iddle) inner ear involvement !labyrinthitis'

associated sensorineuralhearing loss# and vertigo

'reatment"

6peci;c antiviral treatment*n)a

local anesthetic Ear drops 2 nsaids*Pain6ystemic antibiotics*suspicion of bacterial involvment of middle)inner ear


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-tomycosis

!atogenesis"

3cerumen often harbors saprophytic fungi thathave no speci;c pathologic signi;cance

3 Aspergillus, Candida albicans, ucor,&dermatophytes

may aggressively infect sin of medial earcanal if milieu has been altered (by the use ofsteroid $ antibiotic containing ear drops"

$%m&toms" severe itching and feeling offullness !less by pain'


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Diagnosis"

otosco&%"fungi appear as (hite# yello(# orblac membrane lining the s(ollenerythematous sin of ear canal

+bony portion of canal*a9ected almostexclusively

34ycelia*can be identi;ed in direct samples

Causative org. established by microbiologicexam.


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Course" refractory course# has a tendency to recur

Com&lications"ungal infection of 14 epithelium perforation 2subse5uent otitis media

'reatment"Ear cleaning 2 drying thoroughly*essential

local antimycotics can be administered

+salicylate containing solution*soften uppermostepithelium 0ayerenhance antifungal action ofmedication

+6ystemic antimycolytic tx*immune suppressed pts.


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-titis media

• Acute -4

• Fecurrent acute -4•

-titis media () e9usion• Chronic 6uppurative -titis 4edia

• Chronic -titis 4edia ()

cholesteatoma


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-titis media

E&idemiolog%" common in infants 2 smallchildren but may occur at any age

• H?@ of infants:= or more episode in =st yr of life

!atogenesis"

Infection that ascends to middle ear through

Eustachian tubeacteria isolated in $) of cases

%&pneumoniae

'& Inuenzae main causative org&

)& *atarrhalis

+espiratory virus-/. of cases

adenoidfre0uent nidus for infection in children,even if unenlarged


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• actors that: – Increase ris:

• Craniofacial anomalies# previousepisode of acute -4 or presenceof chronic serous -4

• Parental smoing• 0eaving infants at day care

centersexpose to a particularlyharmful microbiological ora

– ,ecrease ris:• Extending period -f breastfeeding


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$%m&toms"

initial: severe earache

,babies" rubbing a9ected ear or bynonspeci;c symptoms

ever*usually present during =st $J

hours

,inants"nonspec.: irritability#

vomiting# diarrhea3perforation of 14*aural discharge

and improvement or resolution ofotalgia


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Diagnosis"

Pe:mastoid sho(s no s(elling but may bemoderately 1ender to pressure

Otoscopy:opa5ue# thicened# erythematous#sometimes bulging 14

!1Mimmobile by pneumatic otoscopy

*onductive hearing losspresent

Bacteriologic exam: not performed (hen 14 is intact# + should al(ays be done inspontaneous rupture

Com&lication" acute mastoiditis*mostcommon

'x" nsaids or acetaminophen*pain relief

+decongestant nose drops or irrigations*maybe necessary for relieving nasal obstruction


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Fecurrent Acute -titis 4edia

• -ccurrence of H or moreacute middle earinammations in = year

• K episodes ()in G

months• ,ue to

relapse)reinfection• 4iddle ear heals

bet(een episodes

• Bo e9usion present intympanic membrane – A disease of infants

and children

F t A t -titi


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Fecurrent Acute -titis4edia

• 'reatment

– Prophylactic antibiotics*e9ective but controversialdue to dev’t of resistance

– 7accinations against pneumococci can helpprevent ne( episodes

– Adenotomy * can decrease the bacterial burden inthe nasopharynx and improve eustachian tubedysfunction


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6erous -titis 4edia

• ,e;nition: refers toan inammatorye9usion behind anintact tympanic

membrane notassociated (ith acuteotologic symptoms orsystemic signs

•

Classi;ed as: – Acute*upto (ees – 6ubacute*upto

months – Chronic 3L months

6erous -titis 4edia


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6erous -titis 4edia

E&idemiolog%"most common eardisease in preschool age. Menerally

both ears are a9ected

$%m&toms: hearing loss# speech and

language developmental delay 2perceptual impairment may occur inbilateral cases

,iagnosis:


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,iagnosis:• 4ade otoscopically:

– tympanic membrane often appears opa5ue#thicened# and occasionally retracted

– Color may be pale# reddish# yello(ish or bluishdepending on the e9usion

• Pneumatic otoscopy*decreased or absentmobility of tympanic membrane


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Com&lication" most fre5uent*acute otitismedia

'reatment" – 2cute/ subacute form*conservatively

– *hronic form*surgically if signi;cant hearing lossis present# paracentesis!incision of the tympanicmembrane'*provide access for aspiration ofe9usion (hich (ill immediately restore thehearing loss

– Incision closes spontaneously in =*$(ees#allo(ing ne( uic collection to

formprevented by inserting a myringotomy tube – 4yringotomy tube*not impair hearing but is

associated (ith ris of middle ear infection fromear canal


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Chronic suppurative -titis 4edia

• chronic tympanic membraneperforation# even (ithout activesigns of mucosal inammation – 14 perforation heal spontaneously

In fe( (s# non healingresult ofchronic Inammationn

• 4ay be dry !()o active signs ofinamm’n eg. Pain discharge# 2

s(elling'or "et#draining !bacteriahave infected middle ear through thenonintact 14N may be acute or chronic '

+ence clin. 4an.)otoscopic appearance changeover course of the disease


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!atogenesis

•

.suall% multiactorial/ ollowing actors!la% a role"

– Cronic in0ammation 1 2 Eustaciantube d%sunction

– 3enetic 4 constitutional actor tatafect ealing ca&acit% 4 resistance omucosa

– $&ecial anatomic car O middleear5 &neumatization 4 relati6e sizes7

– Nature/ &atogenicit%/ 6irulence 4

resistance o inecting org

• symptoms


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• Initially:chronic otorrhea!gen.

mucopurulent discharge throughthe non intact 14'

•

Infection clears# fe( or nosymptoms other than variabledegree of hearing loss

• Fecurrence:may cause pain!notal(ays present'

•

• symptoms


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Diagnosis

• 4ade from $x and otoscopic %ndings• Exam#n reveals:

– Central perforation in 14! appreciated only indry ear'

– 14 and middle ear may sho( addt’lfeatures: calci;cations# atrophic areas# retractions#ossicular dest’n

– Conducti6e earing loss*more pronounced indraining ear

– +smear should be taen for bacteriologic exam’n


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'reatment"0ocal measures:

– Fepeated# meticulous cleansing and drying of ear – Ear drops that contain ototoxic subst. !aminoglycoside' if used at

all# should be used only for acute s(elling and for Odays – Ade5. protection (hile bathing!ear plugs' 1o prevent reinfection

– +acute supppurative episodes occasionally re5uire systemic

antibiotics but not consistently necessary!selection should be directed by sensitivity testing'

• hen ear has been dry for approximately months#surgical closure of tympanic membrane can be performed

!tympanoplasty'

• Chronic# intractable supppuration*re5uire ablative surgeryof middle ear!mastoidectomy or modi;ed radical operation'


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• Course – 4ay be dry for years and cause

fe( complaints# if any – 4ay present (ith recurrent or

persistent otorrhea depends in largeon pt’s diligence in protecting ear 2 practicing

aural hygiene

•

Com&lications – 4astoiditis or abscess form’n*rare and atypical

– In chronic cases*conductive hearing loss is gen.accompanied by dev’t of coclear earinglossprob. the result of toxic serous labyrinthitis


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Chronic -titis 4edia () cholesteatoma

• ormed by s5uamous epithelium ()in middle earcleft starting as a retraction pocet in the 14results in accumulation of eratotic debris

• 7isible through the perforation as eratin aes*(hite 2 smelly

•

Expands 2 damages vital structures such asdura. 0ateral sinus# facial nerve and lateralsemicircular canal.+potentially lethal if untreated


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gen. ,e;nition• -steoclastic inamm’n of mucosal spaces

in middle ear• -ften () coexisting infection

Epidemiology:occur at any age group# rare

in small children

!atogenesis"

Primary cause:impairment of middle ear

ventilation


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• Eustachian tube dysfunctioncauses a neg. pressure to

develop in middle ear !continous* tubalpatencyN transient*negative pressure innasopharynx eg. sniQng'

•

Fetraction pocet forms in 14!lined by s5. epit. 1hattend to migrate on 14 and ext. canal'

• -n entering middle ear# causes inammation and

bone resoption

• 6econdary infection of s5uamous debris furtherintensify these e9ects


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• 1reatment

–6urgical*due to bone destruction

–4ain goal:eradicateinammatory process in mastoidand tympanic cavity

–$nd line goal:improve hearing!tympanoplasty'


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-togenic complication of otitis

• Complication

• se5uelae


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1emporal bone• 4iddle ear

– acial nerve paralysis# 14 perforation

• 4astoid –

Petrositis# reduced pneumati"ation• Inner ear

– 0abyrinthitis – 6ensorineural hearing loss

Extratemporal

• Intracranial – rain abscess# meningitis#etc.

• Extracranial – Rygomatic abscess# postauricular abscess


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Impacted Cerumen

• Cerumen or ear(ax is producedby cerumen and sebaceousglands in sin of ear canal

• orms a protective ;lm in (hich

fatty acids# lyso"ymes andcreation of acid milieu e9ectivelyprotect the sin of the ear canalfrom various bacterial infection

•

6elf cleansing of the ear canal#(ith natural removal ofaccumulated cerumen isnormally accomplished byepithelial migration fromtympanic membrane to(ard theexternal meatus

Impacted Cerumen


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Impacted Cerumen

&ato&%siolog%• Cerumen impaction may result

from a disturbane in the normalslef cleasing mechanism or fromexcessive cerumen secretion

• Cerumen plug consist mainly ofsecretion from the cerumenglands mixed (ith sebum#exfoliative debris and

contaminants

• Imprudent cleaning of ear canal!especially (ith cotton tippeds(abs' can displace the cerumentto(ard the tympanic membrane


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Impacted Cerumen• Causes

–

hen cerumen is pushed against the eardrumby cotton*tipped applicators# hair pins# orother ob&ects that people put in their ears

– hen cerumen is trapped against the eardrum

by a hearing aid – -verproduction of ear(ax by the glands in the

ear canal – Abnormally narro( ear canal that tends to

trap the (ax

http://www.answers.com/topic/overproduction-1http://www.answers.com/topic/overproduction-1


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Impacted Cerumen

• Fis factors

– -ld age – Sse of cotton

s(abs in ears – earing aids – Earplugs


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Impacted Cerumen

$%m&toms"

• pressure sensation

in ear (ithconcomitanthearing loss

• 6ome patientcomplain ofvertigo or tinnitus


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Impacted Cerumen

Diagnosis"3toscopy4obstruction of ear canal by

a yello(ish to bro(n to blac

material# consistency is variable


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Impacted Cerumen

• Complications

– -titis externa maydevelop butgenerallycomplications arevery rare


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ax removal

• =.' syringing

or instrumentation under direct vision

• $.'curettage

•

.'suction

s%ringing


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s%ringing

6hould never be done unless tympanic membrane is no(n to be normal

-nce the accumulated ear (ax has been softened using an ear wa removalsolution syringing enables the (ax removal by irrigation.

irrigation solution ept the same as the body temperature !avoid caloricresponse# thermal stimulation of the inner ear (herein pt. experiences anunpleasant transient di""iness' and a syringe is used to slo(ly and gently streamthe (ater into the ear

solution o(s out through the ear canal taing out the cerumen and other debrisalong.


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,irection of (ater issuperiorly against theear canal andtympanic membrane

axplug


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;g. A• 1he patient should be

seated comfortably

• a idney basin (hich thepatient holds tightlyagainst the side of thenec# is paced under theear to catch the eTuent

ig. • ,rying the canal after the

irrigation


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• hen introduction of (ater into

the earis

contraindicatedinstrumentatio

n !curettage) suctioning'becomes preferred methodsince entry of (ater leads to

infection: – no(n or suspected tympanic

membrane perforation – After recent trauma–

curettage


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curettage

Cerumen can also be removed (ith acurette (hich is another name for a earpic.

A modi;ed curette is used to dislodge thecerumen and scoop it out. Snlie cottons(abs (hich push the (ax much more

deeper into the ear canal# the curretecomes (ith a safet sto to mae sure that


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cerumenolytics – If syringing or instrumentation does not readily

dislodge a plug of (ax# further attempts at removalare liely to cause unnecessary trauma

– Pt. is then advised to instill a bland ceruminolytic

into the ear canal for H days before returning

– est ceruminolytic *$?*?@ solution of 6odiumicarbonate in distilled (ater

–

Cerumen*not signi;cantly softened by oily ororganic solution!ho(ever baby oil or olive oil is acheaper option that can be readily found at home'


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Feference

• asic -torhinolaryngology by Probst

• 0ecture Botes on ,iseases of Ear#Bose and 1hroat by P.,.ull

• Clinical -toscopy by a(e# Ueene#Alberti


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1han you for listeningV

otitis media, externa, impacted cerumen.pptx

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