otitis

Otitis- inflammation of an area of the ear

Otalgia- pain in the ear

Note: many patients when confronted with a full sensation in the ear or ear pain will begin flushing the ear, performing candling, etc. If the ear is dry, the tympanic membrane is perforated or a bacterial or fungal infection is present, their efforts may worsen their situation. Be sure to caution them.

External ear extends from pinna to tympanic membrane.

Middle ear extends from tympanic membrane to oval and round window. The mastoid communicates with it. The eustachian tube drains the fluid that is made within this cavity. The eustachian tube has several, probably vestigial, muscles and is apparently passive influenced by changes in pressure and the action of the pharyngeal muscles.

Inner ear extends from the oval and round windows and includes the semicircular canals and labyrinth.

Tympanic membrane: cone of light points toward the tip of the jaw

Blockage of eustachian tube:

Initially leads to absorption of air and increase in cone of light

Serous otitis media: buildup of fluid causing outward pressure and decrease in cone

And shifting of its position

q Otitis externa or inflammation of the EAM

Mild to severe pain

Aggravated by movement of the tragus

Fever is not uncommon

Mild itching

Pink to red epithelium

Otorrhea is possible

Pus may be present if bacterial infection [white to green]

Swelling, if significant, may cause a conductive hearing loss and tinnitus [low frequency]

Lymphadenopathy anterior to the tragus

If infection: pseudomonas

Early on can be due to water exposure; it is like a diaper rash, and called Swimmer’s Ear.

The cerumen, meant to humidify, is washed away on a regular basis and the water exposure creates an irritation. An opportunistic infection by strep, staph, pseudomonas or fungi may occur. Therefore, it is important to monitor these cases.

If Swimmer’s Ear:

Use ear plugs when exposed to water to allow cerumen to build up

Remove any water, use a hairdryer or 1:2 solution of alcohol and water

Cortisone creams or triple antibiotics

Irrigate with a solution, at body temperature of:

1 part 70% peroxide, 2 parts water, 1 part 5% vinegar TID

q malignant otitis externa- aggressive form of otitis externa

typically in immunocompromised patients

[cancer tx, steroid, immunoglobulin, arteriosclerosis, etc.]

a spreading osteomyelitis and can lead to intracranial infection

Severe pain that extends beyond the ear

Purulent discharge

Often secondary to minor trauma

Pain on TMJ motion

Pain inferior to the EAM on palpation

Infection begins in EAM and progresses to parotid gland, cartilage, bone, nerves and blood vessels

Can lead to facial paresis- if seen, very bad.

Leads to osteomyelitis, brain abscess, meningitis, and death.

High mortality in elderly diabetics

Pseudomonas

q furunculosis- infection of hair follicle in EAM

usually staph aureus

severe throbbing pain with a red, tender mass with or without a pustule

leave it alone

may use warm compress to bring it to a head

q fungal infection-otitis externa

most common: aspergillus niger

see brown, black and white patches

painful

flush with vinegar and water

q myringitis bullosa

blisters on the tympanic membrane and deep in the EAM

viral

often associated with the flu

warm compresses

self-limiting

q herpes zoster oticus [Ramsey-Hunt Syndrome]

herpes zoster of the CN VII and VIII

facial paresis

vesicles in EAM and even TM

severe ear pain

problems with lacrimation, salivation and taste

often vertigo and sensorineural hearing loss

tx: same as with any herpes, inflammatory &/or neuro condition

[Vit. C with bioflavinoids, multimineral, B complex]

q perforations of the tympanic membrane

pain when perforated with abrupt cessation

conductive hearing loss

patient may state it sounds like they are talking in cotton

low frequency tinnitus

look like the black hole

can be traumatic, secondary to OM spontaneous rupture, unhealed from tympanstomy tube remaining in place for more than

perforations may not change hearing

central: usually benign, if there is discharge and it does not stop in 1 to 2 weeks

it could just be eustachian tube dysfunction or granulamatous changes

due to cholesteatoma

marginal: associated with cholesteatoma

typically a foul smelling discharge

if hearing is intact, the cholesteatoma is conducting the sound for the ossicles

q cholesteatoma

congential and acquired

congential

can occur in many sites of the ear and head

acquired: a pocket that forms in the attic due to chronic negative pressure in the middle ear

resulting in enzymatic erosion, desquamation and osteitis creating the cholesteatoma

location varies

can see it in the attic though

semicircular canal erosion with dizziness

facial nerve paralysis

Otitis Media

The result of eustachian tube blockage allowing back up of fluid within the middle ear. This can result in pain, but not necessarily. The presence and recurrence of the fluid can lead to permanent damage. Therefore, tympanostomies are performed to drain the middle ear.

Further, an infection may occur. The highest incidence is in those up to 4 years of age due to the horizontal orientation of the eustachian tube.

Pain occurs due to pressure and abruptly ceases if the TM ruptures.

According to a study, performed by an otolaryngologist and an allergist at Georgetown University, 2/3 of children by age of 2 in the US will have O.M. and is the most frequent etiology for childhood hearing loss.

104 children, up to 9 years of age, with recurrent ear problems were tested for food allergies by skin tests. They were looking for an IgE mediated relationship between food allergies and OM. 81 of the 104 were allergic to some food they ate. 1/3 were allergic to wheat and 1/3 to milk. Many of the children had multiple food sensitivities.

1 Food item 3.6% of the 81 children

2-4 Food items 81.5% “

5-7 Food items 3.7% “

8-10 Food items 1.3% “

Food items Number of children found sensitive

Cows milk 38%

Wheat 33%

Egg white 25%

Peanut 20%

Soy 17%

Orange 10%

Chicken 5%

Apple 4%

When they had the kids avoid those foods for four months, seventy of the children had a significant clearance of their ear problems. When the food were reintroduced into their diets, the problems recurred within four months in all but four of the children.

[Tympanometry was used to monitor the pressure within the children’s ears during the study.]

This study shows a significant relationship between food allergies and otitis media.

September 94 Annals of Allergy. SN 10/8, 1994

It is hypothesized that the children end up with stuffy noses. In order to have a stuffy nose, you have an allergic reaction with activation of the seromucinous cells increasing the amount of mucus production. The mucus drains in the throat to the eustachian tube and blocks it. It is also hypothesized that the tube itself may swell shut due to the allergic reaction. Either way a negative pressure is created in the middle ear.

Role of food allergy in serous otitis media

Annals of Allergy, 1994 Sept, 73(3): 215-9