Ear disorders

Tinnitus

• Most prevalent age 40-70
• Objective
  • Vascular
    • AV malformation
    • Arterial bruits
  • Mechanical
    • Enlarged Eustachian tube
    • Palatal myoclonus
    • Stapedial muscle spasm

Tinnitus

• Subjective
  • Sensorineural hearing loss
  • Hypertension
  • Conductive hearing loss
  • Head trauma
  • Medications
  • Anxiety/depression
  • TMJ disorders
  • Neurological – Acoustic neuroma, MS, benign intracranial HTN
  • Meniere’s
  • Cogan’s syndrome (Recurrent autoimmune corneal inflammation, fever, fatigue, vertigo, tinnitus and hearing loss)

Ototoxic agents associated with tinnitus and/or hearing loss

• Chemotherapeutics
  • Cisplastin, Carboplatin, vinblastine, vincristine
• Topical agents
  • Solvents
  • Propylene glycol
  • Antiseptics
  • Ethanol
  • Polymyxin B
  • Neomycin

Sudden hearing loss

• Over 3 days or less
• Sensorineural and conductive
• Conductive more likely to be reversible (e.g. otitis media, serous otitis or cerumen impaction)
• Poor prognostic factors are more severe hearing loss on presentation and presence of vertigo
• Viral infections long-associated with this entity e.g. mumps
• Cogen’s syndrome is bilateral sensorineural hearing loss, tinnitus and vertigo
• Consider rupture of TM’s and medications

Sudden hearing loss

• Evaluation
  • Hx and Ex
  • Weber + Rinne
  • Consider perforation
  • Co-existing tinnitus or vertigo suggests Meniere’s or Cogen’s
• Treatment
  • Consult ENT if no cause identifiable
  • Idiopathic sensorineural loss 60mg prednisolone daily for 7-14 days and ENT follow-up within 2 weeks

Sudden hearing loss

• DDx of sudden sensorineural hearing loss
  • Idiopathic 71%
  • Infectious (12.8%)
    • Non-specific viral, meningitis, GAS, EBV, Toxoplasma, Syphilis, Herpes simplex
  • Otologic (4.7%)
    • Meniere’s, Autoimmune inner ear disease, Drug toxicity
  • Trauma (4.2%)
    • Head injury, acoustic trauma, barotrauma
  • Vascular or haematological (2.8%)
    • Cardiovascular, neurovascular, brain haemorrhage
  • Neoplastic (2.3%)
    • Schwannoma, cerebellar angioma
  • Pregnancy-related

Acute diffuse otitis externa

• Risk factors
  • Trauma to skin of external auditory canal
  • Elevation of local pH
  • Frequent contact with water
  • Humid environment
• Organisms
  • Pseudomonas, S. aureus, Enterobacteriaeceae and Proteus
  • Otomycosis (fungal) seen in tropics, immunocompromised and recent prolonged antibiotic use
    • Aspergillus or Candida usually
  • Non-infectous contact dermatitis, seborrhoea or psoriasis

Acute diffuse otitis externa

• Clinical
  • Pruritis, pain, tender external ear
  • Erythema/oedema of external auditory canal (+- tragus/auricle)
  • Clear or purulent otorrhoea and crusting
  • Increasing oedema can narrow canal lumen and cause conductive hearing loss

Acute diffuse otitis externa

• Treatment
  • Analgesia, cleansing of external canal, acidifying agents and topical antimicrobials +- steroids
  • Gentle irrigation with saline or hydrogen peroxide +- gentle suction under direct vision
  • Non-ototoxic topical antimicrobials are first-line, especially if TM not visualised or tympanostomy tubes in situ
    • Oxofloxacin or ciprofloxacin
    • Hold for 3 minutes and use wick if obstructed canal
  • If unresponsive, obtain bacterial and fungal cultures
  • Oral antibiotics only if febrile or periauricular extension (consider malignant otitis externa)
  • Avoid predisposing factors, ear plugs with swimming/bathing, avoid removing ear wax and dry ears with hairdryer after bathing
  • If appears fungal, can add topical antifungal + steroid (e.g. sofradex)

Malignant otitis externa

• Potentially life-threatening infection involving pinna and soft tissues +- skull base osteomyelitis
• Spread of simple otitis externa to deeper tissues, cartilage, periosteum, soft tissue and bone
• Previously, >90% of cases were due to Pseudomonas, however, MRSA now causes 15% of cases in US
• Fungal disease is seen in diabetics and the immunocompromised
• Cerumen of diabetic patients has higher pH and leads to loss of local defense
• Small blood vessels of diabetics predispose to cartilagenous degeneration and spread of infection

Malignant otitis externa

• Clinical features
  • Persistent otitis externa despite 2-3 weeks of topical therapy
  • Severe otaligia
  • Oedema of auditory canal with otorrhoea
  • Granulation tissue on floor of external canal
  • May have parotitis, trismus (indicates involvement of masseter or TMJ)
  • CN involvement is a serious sign to check for
  • CN VII usually first nerve involved and subsequent IX, X, XI involvement indicates more extensive disease
  • Lateral or sigmoid sinus thrombosis + meningitis are possible complications

Malignant otitis externa

• Bloods often normal
• CT/MRI required for confirmation and definition of extent
• Treatment
  • Adults: Gentamicin + antipseudomonal penicillin (PipTaz)/Cefotaxime/Quinolone
  • If fungal disease from prior culture add IV voriconazole
  • Early milder cases may be treated with oral quinolones with close follow-up after ENT consult

Otitis media

• 70% preceded by viral URTI (RSV, adenovirus, CMV)
• Acute otitis media
  • Most common bacterial pathogens are S. pneumoniae (50%), H. influenzae and M. catarrhalis
• Chronic OM 
  • S. aureus, P. aeruginosa, Aspergillus and anaerobes
• OM with effusion in adults
  • Frequently associated with significant pathology
  • Acute or chronic sinusitis (66%), smoking-induced nasopharyngeal lymphoid hyperplasia and adult-onset adenoidal hypertrophy (19%), head and neck tumors (mostly nasopharyngeal carcinomas) in 4.8% and/or reflux

Otitis media

• Same signs as child
• Always assess facial nerve function due to proximity to middle ear
• OM with effusion presents in adults as ear discomfort or fullness, reduced hearing
  • Effusion behind TM without signs of inflammation 
  • Usually sinusitis or enlarged adenoids on examination
  • Check for co-existent reflux

Otitis media

• Treatment
  • Acute otitis media
    • Wait and see method used in children not been formally tested in adults
    • Amoxicillin 1g BD for 7-10 days
    • If unresponsive, change to augmentin or moxifloxacin
    • Pain control
  • OM with effusion
    • Same antibiotics but for 3 weeks
    • Treat reflux
    • Follow-up to ensure no anatomical obstruction/cancer

Otitis media

• Complications
  • TM perforation (pars tensa usually)
    • Healing occurs in 1 week although chronic perforation can result so needs f/u
  • Temporary conductive hearing loss
  • Acute serous labyrinthitis
    • Bacteria enter inner ear through round window with resultant acute vertigo syndrome
    • Managed medically
  • Acute purulent labyrinthitis
    • Intense vertigo, tinnitus, hearing loss, vomiting, nausea and acute toxicity
    • Managed surgically

Otitis media

• Complications
  • Facial nerve paralysis
  • Acute mastoiditis
    • Spread into mastoid air cells via the aditus ad antrum
    • S. pneumoniae, S. pyogenes, P. aeruginosa
    • Post-auricular erythema, swelling, tenderness with protrusion of auricle and obliteration of post-auricular crease
    • IV contrast CT confirms diagnosis
    • IV antibiotics, tympanocentesis and myringotomy
    • Ceftriaxone 1g IV daily
    • If recurrent, IV Vanc + PipTaz +- mastoidectomy
  • Cholesteatoma
    • Collections of epidermis and exfoliated keratin within middle ear or mastoid
    • Can erode ossicular chain, bony labyrinth or facial nerve canal
    • Often infection and intracranial extension can be life-threatening

Otitis media

• Intracranial complications
  • More likely if chronic OM
  • Meningitis and brain abscess
    • S. pneumoniae, N. meningititidis
  • Extradural abscess
  • Subdural empyema
  • Lateral sinus thrombosis
    • Extension into mastoid and then lateral or sigmoid sinus
    • Reactive thrombophlebitis with mural clot formation, intraluminal empyema or perforation of venous wall can occur
    • Most commonly presents with headache, papilloedema, CN VI palsy and vertigo
    • Venous angiography and MRI are more sensitive than CT
    • IV Ceftriaxone + Metronidazole

Bullous myringitis

• Painful condition of bullae on TM and deep external auditory canal
• Blisters between highly innervated outer epithelium and inner fibrous layer of TM
• May be blood-filled or serous
• Reactive middle-ear effusions are seen
• This is a severe manifestation of typical OM organisms
• Treat as for OM

Ear haematoma

• Due to lack of subcutaneous fat, blunt force to anterior surface of auricle often shears the perichondrium from the underlying cartilage and tears adjoining blood vessels
• Cartilage depends on perichondrial vessels for viability – tearing can then lead to necrosis
• Subperichondrial collections can lead to stimulation of overlying perichondrium, leading to asymmetric formation of new cartilage and forming ‘cauliflower ear’
• Haematoma may accumulate immediately or after several hours
• Aspiration alone does not completely evacuate clot or prevent cartilagenous stimulation

Ear haematoma

• Aspiration
  • Sterile techniqe after local anaesthesia (ear block technique)
  • Semicircular incision through skin being careful not to incise underlying perichondrium
    • Make incision at site least likely to suffer cosmetic issues and as small as possible
    • Usually inside inner curvature of helix or antihelix
  • Then remove haematoma by gentle suction
  • Suture the incision after haematoma removal
• Dressing
  • Pack helix with petroleum jelly-coated gauze then place regular gauze both in front and behind the ear
  • Circle head with compressive wrap
• Prophylactic antibiotics only if immunocompromised

Ear foreign bodies

• Drown live objects with 2% lignocaine or viscous lignocaine
• Then suction out or remove with forceps under direct visualisation
• Irrigation with warm room temperature water is also helpful for small objects
• Irrigation should only be used if TM definitely not perforated
• Organic matter that can expand when moistened should NOT be irrigated out
• Inspect for injury to canal skin, TM and ossicles after extraction
• Topical antibiotics should be considered if more serious cutaneous damage has occurred

Cerumen impaction

• Can soften with half-strength sodium peroxide, sodium bicarb, mineral oil or OTC products
• Leave in place for 30 minutes then remove with cerumen loops, suction or irrigation with warm water
• Irrigate from superior portion so that pressure hits wall of canal rather than TM

Tympanic membrane perforation

• Causes
  • Otitis media
  • Barotrauma
  • Blunt trauma – Pars tensa
  • Acoustic trauma – Pars tensa
  • Penetrating trauma
  • Lightning strikes
• Presentation
  • Acute pain, hearing loss +- bloody otorrhoea
  • Associated vertigo or tinnitus transiently unless oval or round window injury to inner ear involvement
• Most heal spontaneously
• Keep dry
• Perforations in posterosuperior quadrant or secondary to penetrating trauma have much higher rate of ossicular chain involvement and need ENT referral within 24 hours

TM perforation

• Indications for ENT involvement
  • Hearing loss >40dB
  • Basilar skull fracture
  • Suspected CSF leak
  • Facial nerve paralysis
  • Vestibular symptoms
  • Foreign body

TM perforation

• If minimal hearing loss and absence of vestibular findings
  • Water precautions
  • Cipro HC if contaminated
  • Re-examination by GP in 4 weeks with audiometry
  • ENT if persistent perforation or hearing loss at 4 week mark

Acoustic neuroma (Schwannoma)

• Schwann-cell derived tumours arising from vestibular portion of CN VIII
• Accounts for 90% of tumors in cerebellopontine angle
• 1/100 000 person years
• Median age at diagnosis of 50 years
• Unilateral in 90%
• Bilateral in NF type 2

Acoustic neuroma

• Present with CN dysfunction, cerebellar compression or tumor progression
  • Cochlear nerve impairment in 95% = Hearing loss and tinnitus
    • Rarely present with sudden sensorineural hearing loss
  • Vestibular nerve dysfunction in 60%
    • Usually mild as comes on gradually vs. acute spinning vertigo
  • Trigeminal dysfunction in 20%
    • Facial numbness, pain
  • Facial nerve in 6%

Last Updated on October 6, 2020 by Andrew Crofton