Transcript The Right Patients for Tonsillectomy

Undersanding the Ear
Lawrence M. Simon, M.D.
Department of Pediatrics Noon Lecture Series
Louisiana State University Health Sciences Center
Children’s Hospital of New Orleans
September 17, 2010
Anatomy of the ear
Differential Diagnosis of Ear Disease
External Ear
• Cerumen impaction
• Auricular hematoma
• Perichondritis
• Otiis Externa
• Otomycosis
• Foreign Body
•External ear canal
laceration
-temporal bone fracture
Middle Ear
•
•
•
•
•
Acute otitis media
Serous otitis media
Chornic otitis media
Hemotympanum
Tympanic membrane
perforation
• Cholesteatoma
• Mastoiditis
Inner Ear
• Vestibular neuritis
• Meniere’s Disease
• Vestibular
migraine
External Ear
The auricle and EAC
• Cartilaginous structure designed to funnel sound to
TM
• Embryology: first branchial arch (Hillocks of His)
• Very poor vascular supply
• EAC: 2/3 cartilaginous (poor innervation) and 1/3
bony (very sensitive)
• Protected by cerumen and very delicate ecosystem
• Very sensitive to water
Cerumen impaction
• Not always pathologic
• 2 “flavors”
1. Thin sheet of cerumen occluding EAC
−
Often resolves with drops
2. Thick plug blocking entire EAC
−
Requires debridement under microscope
Cerumen impaction
Cerumen impaction
• Not always pathologic
• 2 “flavors”
1. Thin sheet of cerumen occluding EAC
−
Often resolves with drops
2. Thick plug blocking entire EAC
−
Requires debridement under microscope
• Avoid irrigation
• Use maintenance drops weekly once clear
• Refer to ENT if any concerns
Auricular hematoma
• Hematoma between perichondrium and auricular
cartilage
• Precipitated by trauma (wrestling)
• May result in loss of cartilage
• Treatment:
•
•
•
•
Immediate drainage and pressure dressing
Topical antimicrobial
Oral anti-staphylococcal antibiotic
Close follow-up (~48 hours)
Perichondritis
• Bacterial infection of perichondrium of auricle
• Usually precipitated by trauma
• May result in loss of cartilage
• Most common pathogen: Pseudomonas
• Treatment:
• Admission
• topical antimicrobials
• iv anti-pseudomonal antibiotics (convert to po with
improvement)
• Drain any associated abscess/fluid collection
Perichondritis
Otitis Externa
• Bacterial overgrowth in external auditory canal
• Prevented by cerumen
• Most common pathogen: Pseudomonas
• Common causes: water exposure, picking/
tramua (q-tips)
• Exam:
• Purulent debris in EAC, possible granulation
• Edema of EAC (may be completely closed off)
• Normal auricle
• Pain with movement of auricle (different than
perichondritis and otitis media)
Otitis Externa
Otitis Externa- treatment
• Aural toilet
• Dry ear precautions
• Topical antimicrobials
• Floxin
• Floxin-HC
• Ciprodex
• Cortisporin (topical dermatitis)
• May need ear wick
• Special sponge placed in EAC to facilitate
administration of drops
• Place under microscope
• Remove at 3-5 days
Otitis Externa- treatment
• IV antibiotics only for severe complications
• “Malignant otitis externa”
• May have associated perichondritis
• Chronic OE can result in scar/stenosis of EAC
• “Keratosis Obturans”
Otomycosis
• Fungal overgrowth of EAC skin
• Prevented by cerumen
• Usually associated with prolonged topical
antibiotic use
• Also seen after radical mastoidectomy and with
hearing aid use
• Treatment: topical antimicrobials
• Aural toilet
• Dry ear precautions
• Topical anti-funal (Acetic acid, clotrimazole,
ketoconazole)
Otomycosis
Foreign body
Ear Foreign Body
• Unless battery, can be removed in clinic the next day
• Ciprodex if pain/purulent otorrhea
• Treatment:
– Removal in office OK if isolated to cartilaginous EAC
(lateral, immediately at opening)
– Removal in OR if in medial/bony EAC or touching TM
Special foreign body cases
• Button Battery:
– Remove immediately
• Bean:
– Will swell with water and frequently fragments
• Insect in ear:
– Kill insect with lidocaine, ointment
– Typically remove with suction and microscope
Special foreign body cases
Special foreign body cases
• Button Battery:
– Remove immediately
• Bean:
– Will swell with water and frequently fragments
• Insect in ear:
– Kill insect with lidocaine, ointment
– Typically remove with suction and microscope
• Q-tip injury
− EAC laceration often mistaken for TM perf/rupture
− Ask about vertigo
− Audiogram once healed
Special foreign body cases
Temporal Bone Fracture
• Diagnosis: CT of Temporal bones (can often reformat
from CT head)
• Classification: Longitudinal, Transverse, Oblique
Complications
• EAC laceration
• EAC stenosis
• Hemotympanum
• TMJ dysfunction
• TM perforation
• Facial weakness
• Hearing loss
•
•
•
•
•
Vertigo
CSF otorhinorrhea
Meningitis
Intracranial hemorrhage
Pneumocephalus
Complications
• EAC laceration
• Frequently mistaken for perforation
• Treat with Floxin or Ciprodex for 7-10 days
• Usually heal spontaneously
• Small risk of residual stenosis
EAC Laceration
EAC Laceration
• Acute management:
–
–
–
–
Ciprodex
monitor for facial weakness
monitor for CSF otorhinorrhea
neurosurgical care
Hemotympanum
Facial Paralysis Classification
Facial Paralysis Management
• Immediate versus delayed onset
• Complete versus incomplete
–
–
–
–
–
Immediate, complete: decompression
Delayed and/or incomplete: steroids +/- valtrex
Surgery if >90-95% degeneration in 14-21 days
Must decompress entire nerve in order to get genu
Genu most common site of impaction
Temporal Bone Fracture
• Long term management
– audiogram once healed
– possible middle ear exploration;
– increased risk for meningitis (especially if otic capsule
fractured)