Objectives. Basic ear anatomy. Normal audiogram. Practical treatment of ear diseases: A one hour tour. Tympanic membrane 9/23/2014

Transcription

1 Practical treatment of ear diseases: A one hour tour Wisconsin Academy of Physician Assistants October 9, 2014 Ashley G. Anderson Jr., MD, MS Professor-Division of Otolaryngology/Head and Neck Surgery University of Wisconsin Medical School Madison, Wisconsin Objectives Review ear anatomy Improve diagnostic and treatment skills Understand proper radiologic, audiologic and lab studies Don t fear the ear! Breaking down the spectrum of ear disease Basic ear anatomy Pain Otitis media External otitis Non-otologic pain Tumor (rare) TMJ (most common) Serous otitis media Hearing Loss Conductive Anatomical Conduction problems Otosclerosis Perforation, ossicular Problems Sensorineural Sudden HL (SSHL) Congenital Tinnitus Vertigo Benign Lesion induced Vestibular Neurologic Noise induced Tympanic membrane Normal audiogram Right Short process Left-X Stapes Stapes Maleus handle Light Reflex Promentory 1

2 Audiogram Sensorineural hearing loss Conductive hearing loss Tympanogram Around $ Between $4000-$5000 Cerumen: The enemy!! External ear How to remove it? 1. Irrigation 2. Cerumen curette 3. Oticdrops 4. Suction 5. Alligator forceps 6. Referral Auricular hematoma Acute external otitis Chronic external otitis 2

3 External canal anatomy Acute external otitis Auricle is mostly skinlined cartilage External auditory meatus Cartilage: ~40% Bony: ~60% S-shaped Narrowest portion at bonycartilage junction Tenderness starts here Progressive infection Symptoms Pain Increased pruritus Signs Erythema Increasing edema Canal debris, discharge Treatment of acute external otitis Chronic external otitis Keep the ear DRY Oticdrops Ciprofloxacin with or without hydrocortisone Ofloxacin drops Cortisporin otic solution (neomycin/polymixin) If necessary, cleaning of the ear Insertion of a wick (Pope oto-wick) Adequate control of pain Symptoms: Asteatosis (eczema) Hypertrophied skin Otorrhea? Treatment: Avoid touching, cleaning with Q-tip Avoid steroid drops Acetic acid? (Vo-sol HC) Canal erythema Mild edema White, gray or black fungal debris Treatment: Repeat cleaning Acidification Antifungal drops Otomycosis Necrotizing external otitis Potentially lethal infection of EAC and surrounding structures Typically seen in diabetics and immunocompromised patients Pseudomonas aeruginosa is the usual culprit 3

4 Auricular hematoma Trauma, but occasionally spontaneous Need to be incised and drained Aspiration is seldom sufficient Occasionally, need treatment with a bolster secured by through and through suture May lead to permanent deformity of the auricle Herpes zoster oticus Early: burning pain in one ear, headache, malaise and fever Herpes zoster infection Late (3 to 7 days): vesicles, facial paralysis Antiviral medications Corneal protection if facial paralysis Acute otitis media Acute otitis media Most common cause of pediatric office visit 42% of antibiotic prescriptions written for children 62% by age 1 year 83% by age 3 years 46% of three year olds have 3 or more infections Acute otitis media Bullous myringitis Annual cost of medical/surgical treatment of otitis in US is $3-$4 billion annually For all children under 2 years of age, by the time they reach two, they will have had a total of 9.3 million episodes of otitis Inflammation limited to TM & nearby canal Multiple reddened, inflamed blebs Hemorrhagic vesicles Etiology uncertain, but treat as OM in most cases 4

5 The most important part of treatment of acute otitis media is selection of the proper antibiotic?? Themost important aspect of treatment of acute otitis media is determining the necessity for treatment Your Diagnosis Normal Acute OM Type 1 and Type 2 Errors Acute OM True Type II Error Reality Normal Type I Error True A type I error suggests we are trying our best We perceive that type I errors act in the best interest of the patient Type I errors are culturally more acceptable to the patient In the absence of information we are more comfortable with type I errors CDC Recommendations Implications of type 1 errors It s likely we don t miss many actual cases of otitis media Most room for improvement is in reduction of type 1 errors Greater diagnostic accuracy = reduced costs, reduced medication reactions, accurate history driving surgical decisions (tube insertions) Factors resulting in over-diagnosis (Type 1 errors) History Bias towards treatment Difficulty with visualization of TM- if I can t see it, I ll treat it Use of TM color as a determinant of infection Inadequate assessment of mobility Recent URI Irritable Fever Otaligia Hearing loss 5

6 Ear exam Assessment of mobility Pneumatic otoscopy Tympanogram Is the tympanic membrane bulging? Where is the pars flacida? Redness does not mean infection Mobility Must have a good seal in external ear canal with pneumatic otoscope-buy special tips, or use rubber ring Standard, disposable tips will not provide a good seal If the eardrum is mobile, the patient most likely does not have acute otitis Office screening typmanometry can help rule out otitis media Acute otitis media treatment plan Accurate diagnosis Appropriate selection of antimicrobial agent Communication plan-phone if unimproved in 48 hours Follow up visit Modification of risk factors Tobacco use in home Sugar in diet Risk factors for AOM & OME Environmental exposure to tobacco smoke Multiple child day care Anatomical abnormalities Poor diet Immune deficiency Allergy Male sex Bacterial causes of acute otitis media Strep pneumoniae H. influenzae Other bacteria M. Catarrhalis Pseudomonas Alpha Strep Pseudomonas Staph aureus No Growth Bacterial pathogens in AOM S. pneumoniae Most common, >50% of infections. Developing multi-drug resistance H. influenzae Second in frequency ~20% or higher. Strong biofilm developer Moraxella catarrhalis up to 25% of children with OM. Secretes cephalosporinases that may protect other bacteria Strep pyrogenes steady decline in frequency 6

7 Antibiotic Coverage Beta-lactamase production increasing 40+% of H influenzae ~100% of M catarrhalis Increase in drug resistant S pneumoniae Rates as high as 60% Unaffected by beta-lactamase inhibitor as alteration is based upon penicillin-binding protein 2013 Meta analysis of 3317 childrenwith 3854 episodes of OM (antibiotic vs. placebo) Antibiotics reduced pain at 2-3d, (11.6 vs. 15.9%) Antibiotics reduced TM perforations (1.8 vs.5.2%) Antibiotics reduced contralateral episodes of AOM (10.6 vs. 18.8%) Antibiotics did not reduce rate of recurrence Antibiotics increased adverse events (vomiting, rash, diarrhea), (27.3 vs. 20.2%) Serious complications rare in both groups Venekamp RP, Sanders S, Glasziou PP, et. Al. Antibiotics for acute otitis media in children Cochrane Database Syst Rev 2013; 1:CD Antimicrobial therapy Amoxacillin (90mg/kg/day in 2 doses)-children at minimal risk for resistance No beta-lactam antibiotic within 30 days No concomitant purulent conjunctivitis-often caused by beta-lactam resistant H.influenzae Amox-clavulanate(Amox90mg/kg/day + clavulante 6.4mg/kg/day in 2 doses PCN allergic patients: macrolydes Other options: cefdinir, cefuroxime, ceftriaxone Surgical treatment Indicated when infections become too frequent (What does that mean?) Indicated for complicated infections (febrile seizures, recurrent perforation) Indicated in patients with other social of physical challenges Will reduce frequency of infections by 90% Source: Up-to-date, Through Aug 2014 Residual fluid following infection 100 Otitis media with effusion Percentage of children with residual serous fluid Time in days 7

8 Diagnosis of otitis media with effusion Physical examination Tympanometry Flat, or Type-B tympanograms Audiometry* Conductive hearing loss Is hearing loss clinically significant? Treatment for patients with OME Observation Modification of risk factors Antimicrobial prophylaxis? Valsalva Ineffective treatments: Decongestants Steroids Consider an ENT referral when: Failure of medical therapy Bilateral fluid for days andsignificant hearing loss Speech and language delay Compliance/social difficulties OME secondary to recurrent otitis media Sudden sensorineuralhearing loss (SSHL) Sudden drop in hearing, usually unilateral. (Drop of 30dB in 3 frequencies over 72 hours) Patient may awaken with hearing loss, or experience a sudden loss, but some may report later with fullness, not fully appreciating the loss Other symptoms: fullness, tinnitus (90%), vertigo (20-60%) Etiology is unknown. Viral? Autoimmune? Microvascular? (associated with genes related to thrombotic state) HSV? Tuning fork testing Weber-Place fork in midline. In which ear is sound loudest? (Ernst Heinrich Weber ) Rinne-Fork in front of ear and mastoid. Which sounds louder? A positive Rinnetest is normal. (Heinrich Adolph Rinne ) Frequency? 512 Hz 1024 Hz Cost? $15.00 each Set for $39.99 Diagnosis of SSHL Normal physical examination of ear Abnormal pure tone audiogram-normal tympanogram Tuning fork examination: Weber will lateralize to the good ear ( bad cochlea cannot receive sound as well) Most useful. Rinnetest (air conduction and bone conduction are both diminished). May pick up bone conduction better, but it s in the other ear. 8

9 Sudden Sensorineural Hearing Loss (SSHL) Very important to differentiate from other causes of hearing loss Use Weber Test to rapidly screen Relative ENT emergency, as early treatment is more successful Treat ASAP with high dose steroid regime Refer to otolaryngology Treatment and Prognosis Initial high dose steroid treatment for 1-3 weeks with weekly follow up Antiviral medications Consideration for intratympanic infusion of steroids MRI scan Laboratory studies Prognosis Better if loss is in high, or low frequencies Most patients have some recovery within 10 days. As many as 2/3 have complete recovery Greater than six months of hearing loss-recovery is poor Vertigo Some quickies on vertigo Take vertigo in children very seriously. Proceed directly to CT / MRI / neurology evaluation A good neurological history and exam are the first step in evaluation. Exclude significant neurological disease first. When in doubt MRI. Resist the temptation to treat acute vertigo with vestibular suppressants, as this will delay habituation and recovery Vertigo of short duration, precipitated by movement, is often benign paroxysmal positional vertigo (BPPV). Avoid doing the Epley maneuver unless you have confirmed side of lesion with an ENG/VNG Some quickies on tinnitus And now, a rapid picture tour Bilateral tinnitus is usually benign. Unilateral tinnitus is a greater cause for concern Workup of tinnitus begins with a hearing test, the results of which will guide further workup Aspirin and NSAIDs can cause tinnitus Noise exposure, and high frequency hearing loss are the most common cause of tinnitus 9

10 Acute otitis media (AOM) Note bulging pars flacida& injection of the TM External canal foreign body Acute otitis media Serous otitis media Otitis media with effusion and retraction-possibly early infection Bone osteomata in ear canal 10

11 Acute otitis media Otitis media with effusion Otitis media with effusion Otitis media with effusion Acute otitis media Purulent Otorrhea 11

12 Purulent otorrhea Otitis media with effusion Note air bubbles in fluid behind TM Tympanostomy tube Possible cholesteatoma developing in TM Granuloma over tube Foreign body reaction to a tympanostomy tube Atelectasis of tympanic membrane Otitis media with effusion 12

13 Cholesteatoma Superior retraction pocket with early cholesteatoma Classic attic retraction pocket with cholesteatoma Cholesteatoma in canal wall Perforation with neomembrane Large anterior perforation 13

14 Perforation with neomembrane Tympanosclerosis Contact Information Thank you! Ashley G. Anderson Jr., MD, MS Department of Ear, Nose, Throat and Plastic Surgery 1 South Park Street, 6th Floor Madison, WI (608) aganders@wisc.edu 14