EARS

Derby GP Specialty Training Programme

Practical exercise

• Get into pairs

• Look in each others ears

• Draw and label what you see!

Normal eardrumRight or left?

The normal tympanic membrane should appear

•Pearly grey

•With a light reflex

•Concave

•Should be able to make out malleus – looks like an arm

1 = pars flaccida (=attic)2 = lat process of malleus3 = handle of malleus4 = end of malleus5 = light reflex6 = eardrum margin7 = pars tensa

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Anterior, posterior, inferior regions

Attic – this area is located above the elbow.

Anterior – this is the area the elbow is point towards(Face end of patient)

Posterior – this is the area opposite the elbow.

Inferior – this is the area below the hand.

Malleus

What are you looking for?

• Shape of the eardrum – bulging or retracted• Colour of the eardrum – red (infection), yellow (glue ear),

brown (blood), presence of blood vessels (injected?)• Light reflex present or not? (usually absent in bulging

ear drums)• Things that should not be there…

Case Study 12 ½ year old ♂

HistoryPresents with a 2 day history of irritability, runny nose and fever. He’s not been playing as much as usual and today his Mum noticed that he’s been pulling his left ear. He had an ear infection last year and was given some antibiotics, Mum would like the same again please.

ExaminationIrritable. HR 100, RR 22, Temp 37.4ºCHS I+II+0, cap refil <2sec.Chest clear, no signs of respiratory distressAbdo SNTENT – throat red, right ear nad, left ear – see picture...

http://upload.wikimedia.org/wikipedia/commons/3/39/Otitis_media_incipient.jpg

• What further information would you like to know?

• What are your differential diagnoses?

• How would you manage him? Who would you see again?

• When would you consider referral?

• Any advice to prevent further episodes?

What else would you like to know?

More common:

In winter

Have older siblings

At nursery

Uses a dummy

Parents smoke

Symptoms • Earache or pulling/tugging ear• URTI• Pain• Malaise• Fever• Irritability• Vomiting

Signs• Pyrexia• Red, bulging tympanic membrane• May be air-fluid level behind TM• Perforated TM +/or discharge in

canal• Possibly hearing loss

What are your differential diagnoses?

• Otitis Externa

• URTI – TM a little red

• Acute mastoiditis – swelling, erythema & tenderness over mastoid bone; displacement (downwards & outwards) of pinna

• Post auricular adenitis

• Referred pain from teeth

How would you manage him?• Pain relief & antipyretic – regular paracetamol, ibuprofen• Antibiotics

– For most people no or delayed Abx with appropriate explanation or risk vs benefit

– Consider if• <2yrs• Systemic Sx inc temp >38ºC or vomiting• Bilateral AOM• Perforated TM with discharge

– Amoxicillin (Erythromycin)– Co-amoxiclav (Azithromycin) if Rx failure

• Consider admission – systemically unwell• Safety netting – “Needs review if...”• Review at 2-3 weeks if perforated TM

When would you consider referral?

• 3+ episodes in 6 months or 4+ episodes in 1 year with the absence of disease between episodes

• Adults with >2 episodes in a year with suspicion of nasopharyngeal cancer – persistent Sx & signs, cervical lymphadenopathy, unilateral epistaxis

Any advice to prevent further episodes?

• Eliminate passive smoking

• Avoid dummies

• Avoid supine feeding

• ?pneumococcal vaccinations

Case study 2

• Red itchy ear

• 40 year old female

• 1 week history of an “Itchy Ear”, getting worse

• Keen Swimmer

• Type 2 Diabetic – on Metformin

• No other medical history of note

Red, Itchy Ear

On Examination

• BMI 35

• Swollen Ear Canal with erythema

• No discharge, some debris

• Pain on moving pinna

• Nil else of note

Red, Itchy Ear

Otitis Externa

• Often occurs after trauma– e.g. Scratching, ear cleaning, swimming

• Symptoms– Pain (Severe, also on pinna movement),– Discharge (May be offensive)

• Signs– Swollen ear Canal +/- Discharge / Debris– May have swollen pre/post auricular lymph glands

Otitis Externa

• Management– Aural Toilet (unless mild case)– ABX Ear Drops (Gentamicin 0.3%)– +/- steroid if eczematous (Gentisone HC)

– May need strong analgesia, and wick

– If refractory , need to swab - may be candida or aspergillus (Clotrimazole)

Otitis Externa

• Prevention– No cotton buds!

– Keep ears dry

• If mild itchiness / eczema • Short course steroid drops (Prednisolone 0.5%

TDS)

Case Study 3

• History: 28 year old woman with known anxiety problems presented with ear popping and occasional pain for the past 3 weeks following a cold. She has no history of ear problems and recently had a relaxing holiday in Turkey. She is very concerned and thinks she is becoming deaf. She is otherwise well and apyrexial.

• What further information would you like to know as the GP?

• What do you think is going on? Can you formulate a differential list?

• Can you think of a simple test to aid diagnosis?

• How are you going to manage this patient?

• When will you think about referring for ENT opinion?

Eustachian tube dysfunction

Symptoms: Muffled hearing, dull hearing, ear popping, ear pain, ringing, dizziness.

Causes: Blocked Eustachian tube – ENT infections, glue ear, allergies, blockages, air travel.

Test: Look at the ear drum whilst asking the patient to perform valsalva manoeuvre, if Eustachian tube dysfunction, the ear drum moves very little.

Treatment: Often no treatement is needed.

Antihistamine tablets, decongestant nasal sprays

or drops may help.

Referral: When symptoms persist despite treatment.

Case Study 4

• History: 57 year old man who works as a football manager came to see you because he thinks he needs a hearing aid. He has noticed whistling and ringing noise in his right ear for the past 8 months, he put this down to occupational related hearing changes. More recently, he has noticed some headache on the right hand side of the head with occasional tingling sensations. He has been to see the football club doctor, who thought he had tinnitus and advised him to come and see you to arrange assessment for a hearing aid. On examination, you cannot appreciate any obvious abnormality.

• What are you going to do next?

• Can you think of the possible differentials?

• What are you worried about?

• How will you manage this patient?

• When will you think about referring him for ENT opinion?

Acoustic neuroma (Schwannoma)

Symptoms: Unilateral hearing loss over months, unilateral ringing/buzzing. Occipital pain. Possible facial numbness.

Pathology: Slow growing neurofibroma arising from the acoustic nerve, associated with type II neurofibromatosis (especially bilateral cases).

Investigations: Audiometry to demonstrate unilateral sensorineural hearing loss. Contrast CT scan. MRI sometimes needed to identify small lesions.

Treatment: Conservative – elderly patients or high risk patients due to tumour location.

Sterostatic radiosurgery – small/medium tumours

Microsurgery – large tumours

Referral: Unilateral sensorineural deafness – 2WW referral criteria

Case Study 5

• 65 year old man, presented to you with hearing loss on one side. Gradual onset, wife has been telling him that the wax coming out from his ear has been very smelly. He wants some olive oil on prescription because he does not pay for his medications anymore.

How will you manage this patient if you see this during the examination?

• Cholesteatoma

• 9/100,000

• Offensive discharge

• Retracted eardrum

• Crusty lesion, typically attic

• Enzymatic destruction of ossicles or temporal

• Urgent referral for surgery

Conductive hearing loss

Sensorineural hearing loss

• Presbyacusis

• Greek: old, hearing

• Whisper (letters, numbers)

• Weber, Rinnes

• Pure tone audiometry

• 250, 500, 1000, 2000, 4000kHz

• http://www.phys.unsw.edu.au/jw/hearing.html

• “Mosquito” 17.4kHz

• Mild 20-40dB

• Moderate 41- 70dB

• Severe 71-95dB

• Profound >95dB

Case study 6

• 52 year old lady presents with 1 week history of dizziness and feels like the room keeps spinning. She feels sick with it and has vomited several times. She also complains of reduced hearing in her left ear.

This is what you see on examining her left ear…

• What else do you want to know?

• What are your differentials?

• What investigations do you want to do?

• What would your management be?

Vertigo

BPPV Menieres Viral labyrinthitis/ vestibular neuronitis

Duration seconds/mins Minutes to hours

>24hrs

Assc. Hearing loss

N Y N

Assc tinnitus N Y N

Related to position

Y N N

Diagnosis History & + Hallpikes History and assc Sx

History and duration

Refer If not settling for Epleys

All cases to confirm Dx

If persists>6wk

Examination

• Ears

• Cerebellar signs

• Cranial nerve exam

• Romberg’s sign

• Hearing – Webers + Rinnes

• Nystagmus

• Hallpike manoeuvre and Epleys

Management• BPPV

– Self limiting– Reassure– Physio, reduce alcohol– Prochlorperazine/ betahistine

• Viral labyrinthitis / vestibular neuronitis– Follows viral URTI– Prochlorperazine/ cyclizine

• Menieres

– Clusters of attacks of vertigo, nausea, tinnitus, SNHL and fullness in ear.

– Give info and support groups– Treat acutely with labyrinthine sedatives-

prochlorperazine /cyclizine– Mobilize– Consider: Betahistine, low salt diet, vestibular rehab,

tinnitus masker, HA– Look out for and treat depression/anxiety

Hallpike and Epley manoeuvre

Picture Quiz

Answers…

Bubbles

Glomus tumour

Acute Otitis Media

Otitis Media with retraction

Eustachian Tube dysfunction

Cholesteatoma

Tympanic sclerosis

Normal tympanic membrane

Safe Anterior Perforation

Inferior Perforation

Unsafe Posterior Perforation

Unsafe Attic Perforation

Grommet

Otitis Externa

This is a Monkey…This is a Bat…

This is a Tiger…This plant is called Elephant Ears…

Thank you for listening, and now it’s time to go

home!