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Diagnosis of Ear conditions

Ear conditions Diagnosis: Book Excerpts

• Ask the following questions - EARACHE
• Ask the following questions - EAR DISCHARGE
• Differential Diagnosis - Hearing Loss
• Differential Diagnosis - Otorrhea
• Differential Diagnosis - Ear Pain
• Differential Diagnosis - Otorrhea (Ear Discharge)
• Differential Diagnosis - Otalgia (Ear Pain)
• Differential Diagnosis - Hearing Loss – Acquired
• Differential Diagnosis - Hearing Loss – Congenital
• Approach to the Diagnosis - EARACHE
• Approach to the Diagnosis - AURAL DISCHARGE (OTORRHEA)
• History and physical examination - Earache
• History and physical examination - Hearing loss
• History and physical examination - Otorrhea
• Diagnosis - Hearing loss
• Diagnosis - Benign tumors of the ear canal
• History and physical examination - Hearing loss
• History and physical examination - Otorrhea
• History and physical examination - Earache [Otalgia]
• History - Hearing Loss
• Differential Overview - Hearing Loss
• Differential Overview - Ear Pain/Discharge
• Diagnosis - Hearing loss
• History - Earache
• History - Hearing loss
• History - Otorrhea
• Clinical Features and Diagnosis - Earache
• Clinical Features and Diagnosis - Hearing Loss and Deafness
• History and physical examination - Hearing loss
• History and physical examination - Otorrhea
• History and physical examination - Earache [Otalgia]
• Approach to the Diagnosis - EARACHE
• Approach to the Diagnosis - AURAL DISCHARGE (OTORRHEA)

Diagnosis of Ear conditions: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Ear conditions:

• Symptoms of old age may be similar to many other treatable conditions
• More news »

Diagnostic Tests for Ear conditions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Ear conditions.

EARACHE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Are there abnormalities on the ear examination? The ear examination may reveal severe otitis externa, an epithelioma of the pinna, a foreign body, or impacted wax. It may also show inflammation and bulging of the eardrum. A vesicular rash of the drum and external auditory canal may indicate herpes zoster.
2. Is there pain on moving the pinna? Pain on moving the ear suggests otitis externa, foreign body, impacted wax, or keratosis obturans.
3. Is there hearing loss? Hearing loss with an abnormal drum would suggest serous or bacterial otitis media. It may also suggest a cholesteatoma. Hearing loss with a normal ear exam suggests aero-otitis.
4. Could the pain be a referred pain? Dental caries, dental abscesses, impacted teeth, tonsillitis, and temporomandibular joint syndrome may refer pain to the ear.

DIAGNOSTIC WORKUP

It should go without saying that diagnosis begins with an adequate otoscopic examination. If the drum is obscured by wax, gentle lavage after using Cerumenex will usually clear the canal. If there is an exudate, a culture and sensitivity should be ordered. Perhaps a throat culture should be done also. X-rays of the mastoids and petrous bones should be done if the exudate is believed to be from a deeper source. Perhaps a CT scan is also needed. If there is hearing loss, an audiogram needs to be done and a tympanogram will be useful in diagnosing serous otitis media. A trial of carbamazepine (Tegretol®) or phenytoin (Dilantin®) may be useful in diagnosing glossopharyngeal neuralgia or tic douloureux. If the discharge is thought to be cerebrospinal fluid, a CT scan and RISA study should be done.

Referral to an ear, nose, and throat specialist or neurologist should be considered before ordering expensive diagnostic tests.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EAR DISCHARGE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it acute? Acute ear discharge suggests acute otitis media with rupture or an otitis externa, especially if it is painful. A chronic discharge would suggest cholesteatoma, chronic otitis media, and possibly cerebrospinal fluid.
2. Is it painful? A painful ear with a discharge is most likely acute otitis media with rupture. It may, however, be due to otitis externa, a foreign body, or serous otitis media.
3. Is there associated fever? An ear discharge with fever suggests otitis media, mastoiditis, and petrositis.
4. What is the character of the discharge? A mucopurulent discharge suggests chronic otitis media and mastoiditis, whereas a fetid discharge with whitish debris suggests a cholesteatoma. If the discharge is clear, a cerebrospinal fluid otorrhea should be suspected.

DIAGNOSTIC WORKUP

The most important test to do is a smear, culture, and sensitivity of the discharge. If there is fever, a CBC, sedimentation rate, and chemistry panel should be done. The ears should be examined after thorough irrigation. X-rays of the mastoids and petrous bones should be done if a deep source for the discharge is suspected. Audiograms are helpful if there is hearing loss. If the discharge is thought to be cerebrospinal fluid, a RISA study and CT scan of the brain may need to be done. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Hearing Loss: Differential Diagnosis
(In a Page: Signs and Symptoms)

Conductive hearing loss: Results from any process preventing sound from reaching the inner ear
–Obstruction of the ear canal, usually due to cerumen impaction or foreign body
–Otitis media with middle ear effusion (most common in children but also occurs in adults)
–Chronic otitis media: Permanent change in the ear (e.g., tympanic membrane perforation, ossicular chain discontinuity and fixation, cholesteatoma) secondary to otitis media
–Congenital atresia of the external auditory canal

• Sensorineural hearing loss: Nerve type hearing loss, either in the inner ear or the auditory nerve
  –Presbycusis is the most common form
  –Noise-induced hearing (occupational or nonoccupational)
  –Hereditary sensorineural hearing loss, usually autosomal recessive heritance
  –Medications (e.g., aminoglycosides, chemotherapeutics, diuretics)
  –Ménie're's disease: Hearing loss, tinnitus, vertigo, and aural fullness
  –Acoustic neuroma: Results in unilateral hearing loss and tinnitus as the initial symptoms in 90% of patients
  –Alport's syndrome: Hereditary nephritis, sensorineural deafness, ocular abnormalities)
• Mixed hearing loss (both conductive and sensorineural hearing loss)
  –Wardenberg's syndrome
  –Prolonged QT syndrome variant
  –Other causes of congenital deafness
  –Meningitis
  –Vascular (e.g., embolism, thrombosis, hemorrhage)
  –Viral (e.g., mumps, measles, influenza, varicella, adenovirus, EBV)

Workup and Diagnosis

• Otologic history should include duration of hearing loss, laterality, otorrhea, tinnitus, associated dizziness, family history, and a focused medical history (e.g., exposure to gentamicin, history of infections)
• Weber's and Rinne's tuning fork testing may be used to determine conductive hearing loss versus sensorineural; however, audiogram is the definitive test
• Otoacoustic emission and auditory brainstem response are objective tests of nerve function; these are increasingly being used to screen for hearing loss in newborns
• CT scan of the temporal bones may be helpful in evaluating conductive hearing loss
• MRI with gadolinium is indicated for all patients with unilateral sensorineural hearing loss or tinnitus to evaluate for acoustic neuroma

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Source: In a Page: Signs and Symptoms, 2004

Otorrhea: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Otitis externa (swimmer's ear)
  –Most common source of otorrhea
  –Usually associated with water contamination or cotton swab abuse
  –Pain with movement of pinna
  –Usually secondary to Pseudomonas or Staphylococcus infection

• Malignant otitis externa
  –Also known as necrotizing external otitis and skull base osteomyelitis
  –Suspect in patients with diabetes or immunosuppression who present with persistent otorrhea, ear pain, and granulation tissue in the ear canal
  –Usually secondary to Pseudomonas
• Foreign body
  –Frequently a retained cotton swab
  –Often occurs in toddlers
• Otitis media (acute or chronic) with perforated tympanic membrane
• Cholesteatoma
  –A skin-lined cyst of the middle ear or mastoid that occurs secondary to chronic otitis media
  –In most cases there is fullness, bulging, or a white mass of the tympanic membrane (may easily be confused with ear wax)
• Mastoiditis
  –Tenderness or bogginess over mastoid

• Cerebrospinal fluid otorrhea
  –Clear, colorless discharge through a tympanic membrane perforation or tympanostomy tube
  –Patients usually have a history of trauma or surgery, but CSF otorrhea may occasionally be spontaneous

Workup and Diagnosis

• History should focus on onset, duration, appearance of discharge, associated symptoms, activity history (e.g., swimming), and past history (e.g., frequent otitis, tympanostomy tubes, diabetes)

• A thorough cleaning of the ear canal under direct visualization (with magnification is ideal) with a curette or suction is necessary to determine the source of discharge
  –The presence or absence of tympanic membrane pathology must be determined
  –The absence of tympanic membrane pathology usually signifies that the source of otorrhea is limited to the external ear canal
  –Unless the ear canal is cleaned with suction, many pathologies will not be identified
  –Ear lavage should be avoided in the presence of otorrhea
• Ear cultures from the canal may be helpful in persistent cases; however, contamination by normal ear canal flora usually decreases their value
• If CSF otorrhea is suspected, an assay for β₂ transferrin will identify CSF from other fluids
• CT of the temporal bones is helpful in evaluation of patients with suspected cholesteatoma, mastoiditis, and CSF otorrhea
• Gallium and technetium scans may be helpful in patients with malignant external otitis

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Source: In a Page: Signs and Symptoms, 2004

Ear Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Otitis media
  –Most cases are of viral origin
  –Red tympanic membrane with decreased mobility
  –Male > female; peak incidence 6–18 months
  –Risk factors include day care, supine bottle feeding, smoking in household, siblings with otitis media, anatomic abnormalities (e.g., Down's syndrome)

• Eustachian tube dysfunction
  –Common in young children
• Otitis externa
  –Pain upon movement of tragus
• Malignant (necrotizing) otitis externa
  –Usually due to Pseudomonas –Mostly seen in diabetics
• Referred pain
  –TMJ: May result in ear pain, jaw pain, neck pain, and/or headache
  –Dental infection, trauma, or orthodontic intervention (e.g., tightening of braces)
  –Pharyngitis or tonsillitis
  –Post-tonsillectomy/adenoidectomy
  –Retropharyngeal abscess and other ENT deep-space infections
  –Cervical adenitis
  –Sinusitis/rhinitis
  –Laryngitis
  –Trigeminal neuralgia
  –Esophagitis
  –Cervical spine arthritis
  –Parotiditis/sialoadenitis (including mumps)
  –Angina/acute coronary syndrome

• Foreign body in ear canal (including impacted cerumen)
• Reaction to topical agents
• Trauma: Laceration, abrasion, barotrauma (e.g., deep sea diving, airplane)
• Cellulitis
• Tympanostomy tube obstruction
• Myringitis bullosa
• Furunculosis (localized abscess)
• Varicella or herpes simplex/zoster infection in the ear canal
• Mastoiditis
  –Ear protrudes anteriorly
• Tumor
• Eczema/psoriasis
• Mumps

Workup and Diagnosis

• History and physical examination, including otoscopic exam with pneumatic otoscopy and complete head and neck examination
  –Pain upon traction of pinna suggests otitis externa (hyperemic external canal)
  –Bulging, red, immobile tympanic membrane is consistent with acute otitis media (with or without otorrhea secondary to perforation)
  –Retracted, immobile tympanic membrane may be seen in serous otitis media
  –Mass lesion behind tympanic membrane suggests cholesteotoma or tumor
  –Tonsillar asymmetry or uvular deviation suggests peritonsillar abscess or mass

• Tympanometry may reveal otitis media with effusion, eustachian tube dysfunction, or tympanostomy tube obstruction
• Audiometry to evaluate for hearing loss
• Consider culture of otorrhea if perforation (not canal) or complicated (e.g., recurrent infection, spread of infection such as meningitis or mastoiditis)
• Lateral neck X-ray will diagnose retropharyngeal mass or abscess
• Head CT is indicated if intracranial lesion or basilar skull fracture is suspected
• Consider CBC and ESR if suspect malignant necrotizing otitis media
• Check glucose in recurrent severe otitis externa

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Source: In a Page: Signs and Symptoms, 2004

Otorrhea (Ear Discharge): Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Cerumen
  –Often brownish color
  –Rarely associated with otalgia or pruritis

• Otitis externa
  –Bacterial (frequently Pseudomonas and Staphylococcus aureus) vs fungal (especially after prolonged treatment with antibiotic drops)
  –Concern: Necrotizing (malignant) otitis externa (i.e., temporal bone osteomyelitis) in immunosuppressed patients, including brittle diabetics

• Acute otitis media with tympanic membrane (TM) perforation
  –Acute perforation may already have closed by the time the patient is examined
• Chronic perforation drainage
  –From water contamination (swimming, bathing) if patient is not maintaining dry ear precautions (ear plugs, occlusive head bands, shower caps, etc.)
• Tympanostomy tube drainage
  –If bloody, suspect granulation tissue surrounding the tube
  –Increased incidence when not maintaining dry ear precautions is debated (as small tube lumen diameter has considerable surface tension)
• Chronic suppurative otitis media
  –Chronic middle ear and/or mastoid infection with perforated TM
• Cholesteatoma
  –“Skin cyst” (keratinizing stratified squamous epithelium) in the middle ear/mastoid
  –Benign, but often very aggressively locally erosive (mechanical and enzymatic)
  –Surgical, not medical, condition
• Perichondritis
  –Spares the lobule (as there is no cartilage there)
• Myringitis
  –TM granulation or de-epithelialization
• Foreign body
• CSF leak
  –Watery drainage
  –Traumatic or congenital
  –With or without perilymphatic fistula
• Primary dermatologic condition
  –Eczema, psoriasis

Workup and Diagnosis

• History
  –Quality of otorrhea: Malodorous and purulent (infectious) vs bloody (traumatic, granulation tissue) vs clear and watery (CSF)
  –Associated symptoms: Pain and tenderness in acute otitis externa, aural pruritus in chronic or fungal otitis externa
  –Past medical/surgical history: Prior tympanostomy tubes, middle ear surgery (cholesteatoma), trauma or neurosurgery (CSF leak); dermatologic disease

• Physical exam
  –Must suction and debride the ear canal of debris to examine tympanic membrane
  –If canal is too narrow from swelling to see the tympanic membrane, place hydrocellulose wick to draw ototopical medication to affected areas; reexamine in several days
  –Visualize after suctioning (through otoscope) if source is external or middle ear

• Labs
  –Gram stain and culture specimen of otorrhea if diagnosis is in question, if patient is initially systemically symptomatic (febrile or other complications), or if patient fails initial treatment
• Imaging studies
  –CT scan of temporal bone (noncontrast, 1-mm slice thickness) if cholesteatoma or trauma is suspected

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Otalgia (Ear Pain): Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

External ear

• Otitis externa
  –Pinnae and especially tragus, are exquisitely tender
• Impacted cerumen
  –Hearing loss and aural fullness
• Foreign body
  –Items such as beads, toys, and even extruded tympanostomy tubes
• Trauma
  –Any object inserted into the ear canal may cause trauma, including Q-tips
• Perichondritis
  –Inflammation or infection of the cartilage of the pinna and canal, sparing the lobule (since there is no cartilage there)
• Myringitis
  –Tympanic membrane granulation or de-epithelialization

Middle ear/mastoid
• Acute otitis media
  –Otalgia may precede middle ear effusion
• Otitis media with effusion
  –May occur in the absence or presence of an active infection
• Eustachian tube dysfunction
  –Negative intratympanic pressure
• Barotrauma
  –Pretreatment with topical nasal decongestants may be effective prophylaxis
• Mastoiditis
  –Associated with postauricular pain and normal tympanic membrane/middle ear

Non-otologic (secondary)
• Cranial nerve referred pain
  –III: Dental infection, temporal-mandibular joint (TMJ) syndrome
  –VII: Herpes zoster oticus (Ramsay Hunt syndrome)
  –IX: Tonsillitis, pharyngitis
  –X: Laryngitis, GERD, thyroiditis
• Cervical nerve referred pain
  –Neck infections, lymph nodes, cysts
  –Cervical spine disorders
• Paranasal sinusitis
• Migraines
• Neuralgias

Workup and Diagnosis

• History
  –Onset, duration, and specific quality of pain
  –Ability to localize (may distinguish otologic from nonotologic)
  –Associated otologic symptoms: Otorrhea, hearing loss, imbalance, prior ear surgery, antecedent events
  –Pain associated with mastication, swallowing, voice change, purulent rhinorrhea
• Otologic exam
  –Inspection and palpation of pinna, tragus, and preauricular area, and mastoid bone
  –Direct otoscopy for signs of external- or middle-ear infection or inflammation
  –Obstructing cerumen or foreign bodies must be removed to evaluate deeper structures
• Complete head and neck exam
  –Nose and nasal cavities, oral cavity, and pharynx (particularly teeth and tonsils), TMJ
  –Examination of nasopharynx and larynx may require fiberoptic endoscopy
• Tympanometry, if middle ear status (fluid, retraction, perforation) is not evident from otoscopy
• CT or MRI
  –Useful to delineate extent of cholesteatoma, mastoiditis, petrous apicitis, tumor
  –May be necessary to evaluate either otologic disease or an ill child with nonotologic source (rule out abscess or tumor)

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Hearing Loss – Acquired: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Conductive (CHL)

• Cerumen impaction
• External auditory canal foreign body
• Middle ear effusion (MEE)
  –Frequently follows acute otitis media
• Tympanic membrane (TM) perforation
  –Usually due to trauma, chronic otitis media
• Cholesteatoma
  –Acquired cholesteatoma is accompanied by TM retraction or perforation
  –Congenital cholesteatoma is usually over an intact TM
• Ossicular erosion or fixation due to middle ear disease
• Ossicular chain discontinuity (generally posttraumatic)
• External auditory canal stenosis from chronic otitis externa
• Middle ear tumor
  –Paraganglioma (glomus tympanicum), facial neuroma, histiocytosis X, etc.

Sensorineural (SNHL)
• Meningitis, especially bacterial
• Viral, especially mumps
• Autoimmune disease
  –Vasculitis, scleroderma, Kawasaki disease
  –Idiopathic
• Acoustic trauma (noise-induced)
• Ototoxic medications
  –Aminoglycosides
  –Diuretics (especially loop diuretics)
  –Salicylates
  –Cytotoxic (chemotherapeutic) agents, e.g., cisplatinum
• Temporal bone fracture
  –SNHL more likely with transverse than longitudinal fracture
• Perilymphatic fistula (PLF)
  –Hearing loss may be progressive or fluctuating
  • Cerebellopontine angle (CPA) tumor
    –Vestibular schwannoma (a.k.a. acoustic neuroma, associated with type II neurofibromatosis), meningioma, etc.
    –SNHL will be unilateral
  • Ménière disease
    –Characterized by hearing loss, vertigo, tinnitus, sensation of aural fullness

  Workup and Diagnosis

  • History
    –Ask about risk factors for SNHL
  • Physical exam
    –Check external auditory canal for patency
    –Check TM for perforation or cholesteatoma
  • Audiometric testing
    –Classifies hearing loss as conductive, sensorineural, or mixed
    –Quantifies the extent of the hearing loss for the full spectrum of sound frequencies
    –If too young for ear-specific behavioral testing, obtain otoacoustic emissions and/or auditory brainstem response testing
    –Tympanometry to objectively assess mobility (can help with diagnosis of MEE, ossicular discontinuity, and otosclerosis)
  • CT scan of temporal bones (fine cuts, axial and/or coronal, noncontrast) for CHL if cholesteatoma or trauma suspected
    –Determines extent of bony erosion or involvement, and whether mastoid cavity is involved
  • MRI with gadolinium of internal auditory canals for asymmetric SNHL
    –Rule out CPA tumors

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Hearing Loss – Congenital: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Infections
  –CMV: Most common intrauterine infection causing hearing loss
  –Bacterial meningitis
  –Congenital rubella: Cataracts, cardiovascular anomalies, retinitis, mental retardation
  –Congenital syphilis
  –Toxoplasmosis
  –Lyme disease
• Metabolic
  –Hyperbilirubinemia (kernicterus): Consider phototherapy or exchange transfusion if serum bilirubin >20 mg/dL in newborn
  –Hypercholesterolemia

• Ototoxic medications
  –Aminoglycoside, gentamicin often needed for perinatal sepsis; >5 days risks hearing loss
• Temporal bone anomaly
  –Middle ear anomaly (results in conductive hearing loss)
  –Perilymphatic fistula
  –Dilated vestibular aqueduct (±Mondini deformity)
  –Michel cochlear aplasia
  –Scheibe aplasia: Membranous aplasia; bony labyrinth normal
  • Nonsyndromic hereditary congenital deafness (connexin 26 gene mutation is responsible for half of all genetic deafness)
  • Syndromic hereditary congenital deafness
    –Waardenburg: Telecanthus, confluent eyebrow, colored irides, white forlock
    –Usher: Retinitis pigmentosa (totally blind by second to third decade), ataxia, vestibular dysfunction
    –Alport: Progressive nephritis and hearing loss
    –Apert (acrocephalosyndactyly): Craniofacial dysostosis
    –Crouzon (craniofacial dysostosis): Prognathic mandibile, small maxilla
    –Jervell and Lange-Neilsen: Heart disease (prolonged QT interval)
    –Pendred: Euthyroid goiter
    –Oto-palatal-digital: Cleft palate, stubby clubbed digits
    –Congential aural atresia

  Workup and Diagnosis

  • Newborn hearing screening
    –Otoacoustic emissions and/or auditory brainstem response; behavioral audiometry when older
  • Medical history for risk factors
    –Infections, low birth weight (<1,500 g), prolonged intubation and ventilation
  • Family history for hearing loss, consanguinity
  • Physical exam, including otoscopy to rule out gross external or middle ear anomalies
  • CMV titers
  • CT scan to rule out temporal bone abnormalities, and determine whether patient is a cochlear implant candidate
  • β₂ gap junction protein (connexin 26) genetic testing
  • Urinalysis and renal ultrasound to rule out Alport syndrome
  • Electroretinography to rule out Usher syndrome in patients with associated progressive blindness
  • Electrocardiography (ECG) to rule out Jervell and Lange-Neilsen syndrome (prolonged QT interval, sudden death risk with athletics)
  • Thyroid function tests
  • Chromosomal testing
  >

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Source: In A Page: Pediatric Signs and Symptoms, 2007

EARACHE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis requires ear, nose, and throat examination, culture of any discharge, x-ray film of the mastoids, petrous bone, temporomandibular (TM) joints, and, in some cases, the sinuses and teeth. A careful neurologic examination is necessary in unexplained otalgia. Referral to an otolaryngologist or neurologist is probably best for the busy physician who is unable to find the cause on a routine examination.

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Source: Differential Diagnosis in Primary Care, 2007

AURAL DISCHARGE (OTORRHEA): Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.

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Source: Differential Diagnosis in Primary Care, 2007

Earache: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient to characterize his earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he localize the site of ear pain? Does he have pain in other areas such as the jaw? Does he experience any associated hearing loss?

Ask about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noise in his ears? Ask about dizziness or vertigo. Does it worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?

Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves.

Find out if the patient has flown, been to a high-altitude location, or been scuba diving.

Begin your physical examination by inspecting the external ear for redness, drainage, swelling, or deformity. Then apply pressure to the mastoid process and tragus to elicit tenderness. Using an otoscope, examine the external auditory canal for lesions, bleeding or discharge, impacted cerumen, foreign bodies, tenderness, or swelling. Examine the tympanic membrane: Is it intact? Is it pearly gray (normal)? Look for tympanic membrane landmarks: the cone of light, umbo, pars tensa, and the handle and short process of the malleus. (See Using an otoscope correctly.)

Perform the watch tick, whispered voice, Rinne, and Weber's tests to assess for hearing loss.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hearing loss: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient reports hearing loss, ask him to describe it. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient’s medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.

Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral, or continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience dizziness? If so, when did he first notice it?

Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, notify the physician to discuss whether an otoscopic examination should be done. (See Using an otoscope correctly, page 237.) During the otoscopic examination, note color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.

Next, evaluate the patient’s hearing acuity, using the ticking watch and whispered voice tests. Then perform Weber’s and the Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss, page 316.)

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Otorrhea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin your evaluation by asking the patient when otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.

Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.

Next, check the patient’s medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he’s an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.

Focus the physical examination on the patient’s external ear, middle ear, and tympanic membrane. (If his symptoms are unilateral, examine the uninvolved ear first as not to cross-contaminate.) Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit tenderness. Then insert an otoscope, using the largest speculum that will comfortably fit into the ear canal. If necessary, clean cerumen, pus, or other debris from the canal. Observe for edema, erythema, crusts, or polyps. Inspect the tympanic membrane, which should look like a shiny, pearl-gray cone. Note color changes, perforation, absence of the normal light reflex (a cone of light appearing toward the bottom of the drum), or a bulging membrane.

Next, test hearing acuity. Have the patient occlude one ear while you whisper some common two-syllable words toward the unoccluded ear. Stand behind him so he doesn’t read your lips, and ask him to repeat what he heard. Perform the test on the other ear using different words. Then use a tuning fork to perform Weber’s and the Rinne tests. (See Differentiating conductive from sensorineural hearing loss, page 316.)

Complete your assessment by palpating the patient’s neck and his preauricular, parotid, and postauricular (mastoid) areas for lymphadenopathy. Also, test the function of cranial nerves VII, IX, X, and XI.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hearing loss: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

CONFIRMING DIAGNOSIS Patient, family, and occupational histories and a complete audiologic examination usually provide ample evidence of hearing loss and suggest possible causes or predisposing factors.

The Weber, Rinne, and specialized audiologic tests differentiate between conductive and sensorineural hearing loss.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Benign tumors of the ear canal: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

CONFIRMING DIAGNOSIS Clinical features and patient history suggest a benign tumor of the ear canal; otoscopy confirms it. To rule out cancer, a biopsy may be necessary.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Hearing loss: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient reports hearing loss, ask him to describe it fully. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient’s medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.

Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral? Continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience any dizziness? If so, when did he first notice it?

Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, ask the physician whether an otoscopic examination should be done. (See Using an otoscope correctly, page 289.) During the otoscopic examination, note any color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.

Next, evaluate the patient’s hearing acuity, using the ticking watch and whispered voice tests. Then perform the Weber and Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Otorrhea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin your evaluation by asking the patient when the otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.

Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.

Next, check the patient’s medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he’s an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.

Focus the physical examination on the patient’s external ear, middle ear, and tympanic membrane. (If his symptoms are unilateral, examine the uninvolved ear first as not to cross-contaminate.) Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit tenderness. Then insert an otoscope, using the largest speculum that will comfortably fit into the ear canal. If necessary, clean cerumen, pus, or other debris from the canal. Observe for edema, erythema, crusts, or polyps. Inspect the tympanic membrane, which should look like a shiny, pearl-gray cone. Note color changes, perforation, absence of the normal light reflex (a cone of light appearing toward the bottom of the drum), or a bulging membrane.

Next, test hearing acuity. Have the patient occlude one ear while you whisper some common two-syllable words toward the unoccluded ear. Stand behind him so he doesn’t read your lips, and ask him to repeat what he heard. Perform the test on the other ear using different words. Then use a tuning fork to perform the Weber and Rinne tests. (See Differentiating conductive from sensorineural hearing loss, page 397.)

Complete your assessment by palpating the patient’s neck and his preauricular, parotid, and postauricular (mastoid) areas for lymphadenopathy. Also, test the function of cranial nerves VII, IX, X, and XI.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Earache [Otalgia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient to characterize his earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he localize the site of the pain? Does he have pain in any other areas, such as the jaw?

Ask about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noises in his ears? Ask about dizziness or vertigo. Does it worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?

Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves.

Finally, find out if the patient has recently flown, been to a high-altitude location, or been scuba diving.

Begin your physical examination by inspecting the external ear for redness, drainage, swelling, or deformity. Then apply pressure to the mastoid process and tragus to elicit any tenderness. Using an otoscope, examine the external auditory canal for lesions, bleeding or discharge, impacted cerumen, foreign bodies, tenderness, or swelling. Examine the tympanic membrane: Is it intact? Is it pearly gray (normal)? Look for tympanic membrane landmarks: the cone of light, umbo, pars tensa, and the handle and short process of the malleus. (See Using an otoscope correctly.) Perform the watch tick, whispered voice, Rinne, and Weber’s tests to assess for hearing loss.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hearing Loss: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Proactive detection of minor hearing alterations is necessary because most patients with hearing loss do not present with a hearing complaint. Many elderly patients, in particular, accept hearing loss as an expected part of aging.

A. Presentation. A small number of patients will present with a complaint of decreased hearing, a few more will admit to abnormal hearing, but most will have no specific hearing concern. A patient’s depression, confusion, social isolation, or poor job performance can be caused or complicated by hearing impairment. Family members may describe abnormal, slow, or overly loud answers. A sudden tendency to monopolize or disrupt conversation, or to tilt the head in conversation, may suggest hearing loss.

B. Duration. CHL is often of sudden onset but of a mild degree. Complete occlusion or rapid collection of fluid in middle ear causes abrupt change in hearing. SNHL can be abrupt and severe (stroke, idiopathic, trauma) or gradual (Ménière’s syndrome, acoustic neuroma, hypothyroidism). Some forms may be intermittent (such as Ménière’s syndrome.)

C. Quality of hearing. CHL often affects quality of hearing first. Described as muffled “like a head in a drum,” the patient may lose high frequency and voice discrimination, yet still be able to detect subtle sounds. SNHL, when not associated with tinnitus, can have good quality but diminished hearing that is usually more profound than CHL.

D. Associated symptoms. Tinnitus is classically associated with Ménière’s syndrome or disease, but may be seen with other causes of SNHL. Vertigo is associated with inner ear disorders, and is often self-limited (Chapter 6.9). Associated fluctuating neurologic defects of many sites suggest MS, whereas focal deficits suggest CNS tumors or vascular insufficiency.

E. Family history. This may be positive in presbycusis, Ménière’s, otosclerosis, and acoustic neuroma.

 F. Social and work history. Recreational history (loud music or target shooting) or work history (pilots, factory workers, firefighters) can implicate excessive noise exposure. Inquire about use of protective equipment and chronicity of exposure.

Physical examination

 Gross tests of hearing are only helpful to confirm significant hearing asymmetry or to detect profound hearing loss. With one ear covered, the patient tries to hear soft sounds such as the tick of a watch, scratching of two fingers rubbed together, or a softly whispered voice.

A. Visual examination of ears. Inspect the canal and TM to rule out obvious causes of CHL. Cerumen impaction is a remarkably common and easily corrected cause of hearing loss. Pneumoscopy to check for normal movement of the TM helps rule out perforation, atelectasis, eustachian tube dysfunction, stiffened TM, ossicular disruption, and middle ear effusion.

 B. Weber test. With a vibrating tuning fork placed on the top of the head, the patient is asked to describe the sound heard. The patient will perceive the sound to be louder in the affected ear in CHL, because the background noise will be absent on that side. The unaffected ear will be perceived as louder in SNHL.

C. Rinne test. With the vibrating tuning fork placed on the mastoid, the patient detects bone conduction (BC). The tuning fork is removed when the patient can no longer hear the sound. Then the tuning fork is held next to the ear to test for air conduction (AC). In an individual with normal hearing, AC is significantly better than BC. CHL will reduce AC, with little effect on BC.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Hearing Loss: Differential Overview
(Field Guide to Bedside Diagnosis)

Sensorineural

❑ Presbyacusis

❑ Noise-induced loss

❑ Drugs

❑ Ménière disease

❑ Eighth nerve injury

❑ Acoustic neuroma

❑ Multiple sclerosis

Conductive

❑ Impacted cerumen

❑ Otitis media

❑ Middle ear effusion

❑ Perforation of tympanic membrane

❑ Otosclerosis

❑ Exostoses

❑ Developmental defect

❑ Glomus tumor

Diagnostic Approach

Conductive hearing loss presents with loss of low tones and vowels. Sensorineural hearing loss produces impaired high tone perception, with diminished speech discrimination—especially for female voices—and hearing ringing sounds (tinnitus). Hyperacusis (the sensation that sounds are overly loud to the point of discomfort) is associated with sensorineural cochlear hearing loss. Paracusis (words perceived more clearly in a noisy environment) is associated with conductive middle ear hearing loss.

A reliable qualitative screen for high frequency hearing loss is the ability to hear whispered speech. Stand behind the patient at arm’s length and test one ear at a time. Whisper a combination of 3 letters and numbers (e.g., 4-K-2), and ask the patient to repeat it. The screen is passed when 3/6 are correctly identified. The 256 Hz tuning fork tests 10 to 15 dB, and the 512 Hz 20 to 30 dB. The Rinne test (bone conduction . air conduction) is sensitive to a 20 dB hearing loss. The Weber test is sensitive to 5 dB of hearing loss. A tuning fork is placed in the midline. With conductive loss, it lateralizes to the affected ear, and with sensorineural loss, to the unaffected ear.

Pneumoscopy is performed by first insufflating the ear then releasing. A nonmobile TM may be due to fluid or a mass in the middle ear cavity, or a stiff or sclerotic TM. A hypermobile TM may indicate ossicular chain disruption. A TM that moves only with negative pressure can be due to a retracted TM or a middle ear with a blocked eustacian tube, with resulting negative ear pressure.

Acute hearing loss occurs with infection, traumatic tympanic membrane rupture, or acute vascular event. Unilateral sensorineural loss suggests an inner ear disorder such as Meniere disease or an acoustic neuroma.

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Source: Field Guide to Bedside Diagnosis, 2007

Ear Pain/Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

Ear Pain

❑ Acute otitis media

❑ Acute otitis externa

❑ Eustachian dysfunction

❑ Temporomandibular joint arthritis

❑ Traumatic tympanic membrane rupture

❑ Foreign body, external auditory canal

❑ Erysipelas

❑ Herpes zoster oticus

❑ Dental abscess

❑ Frostbite

❑ Relapsing polychondritis

❑ Malignant otitis externa

❑ Acute mastoiditis

❑ Nasopharyngeal cancer

Ear Discharge

❑ Otitis externa

❑ Eczematoid dermatitis

❑ Low-viscosity cerumen

❑ Otitis media with perforation

❑ Foreign body

❑ Psoriasis

❑ Herpes zoster oticus

Diagnostic Approach

If ear pain is present without ear findings, consider referred pain from the tonsils, teeth, trachea, or temporomandibular joint. Ear pain may be an early sign of nasopharyngeal carcinoma. Lesions of the anterior portion of the tongue refer pain in front of the ear whereas the posterior one-third of the tongue refers pain to within the ear.

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Source: Field Guide to Bedside Diagnosis, 2007

Hearing loss: Diagnosis
(Handbook of Diseases)

Patient, family, and occupational histories and a complete audiologic examination usually provide ample evidence of hearing loss and suggest possible causes or predisposing factors. The Weber and Rinne tests and other specialized audiologic tests differentiate between conductive and sensorineural hearing loss.

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Source: Handbook of Diseases, 2003

Earache: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient to characterize the earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he pinpoint the site of the ear pain? Does he have pain in any other areas such as the jaw?

Also ask the patient about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noises in his ears? Ask about dizziness or vertigo. Do these symptoms worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?

Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves. Also find out if the patient has recently flown, been to a high altitude location, or been scuba diving.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Hearing loss: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient reports hearing loss, ask him to describe it fully. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient’s medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.

Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral, or continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience any dizziness? If so, when did he first notice it?

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Otorrhea: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin your evaluation by asking the patient when the otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.

Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.

Next, check the patient’s medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he’s an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Earache: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

External Ear Including External Auditory Canal

Pain-sensitive structures of external earare skin and perichondrium of auricle and skin of external auditorycanal.

Infection/Inflammation

Otitis Externa

Producesinflamed, painful external auditory canal ± discharge.

Predisposingfactors include swimming, chronic otitis media with otorrhea, excessive cleaning,hearing aid use, and skin disorders (e.g., eczema).

Common pathogens include S. aureus,P. aeruginosa, and other gram-negative enteric bacteria. Fungalinfections with Aspergillus and Candida species are also common.

Culture of discharge is diagnostic.

Rare severe form is called invasive,necrotizing, or malignant otitis externa.

Usual pathogens are gram-negative entericbacteria, most commonly P. aeruginosa.

Has been reported in children withcancer, neutropenia, malnutrition, and immunosuppression.

Usual findings include ear pain, fever,otorrhea, and swelling of pinna. Tympanic membrane necrosis, ossiculardestruction, and involvement of temporal bone can occur.

CT shows extent of soft tissue andbone involvement.

Cellulitis

Inflammation of pinna or skin around earcan lead to cellulitis. Usual pathogens are S. aureus and groupA Streptococcus.

Furuncle or Abscess

S. aureusis pathogen most commonly responsible for furuncle or abscess, whichcan involve pinna, external auditory canal, or skin around ear.

Mass is tender, warm, and sometimesfluctuant.

Incision and drainage of abscess followedby Gram stain and culture are diagnostic.

Perichondritis of Pinna

Common causesof ear cartilage inflammation are trauma, burns, frostbite, or extensionof otitis externa.

Pinna is exquisitely tender and swollen.

Fluctuance may occur with bacterialperichondritis. Common pathogens are S. aureus and Pseudomonas species.Aspirate with Gram stain and culture may be diagnostic.

Cerumen Impaction

May causemild earache.

Impaction is readily visible by otoscopy,and earache resolves after its removal.

Trauma

Any traumato external ear may cause pain, swelling, and tenderness.

Hematoma of pinna may appear as purplish,boggy mass.

History and physical exam are diagnostic.

Foreign Body

Childrensometimes place beads, paper, erasers, cotton balls, and other smallobjects in external canal.

Ear pain, bleeding, and foul-smellingear discharge are frequent findings.

Otoscopy is diagnostic.

Neoplasm

Tumors ofexternal canal are usually visible, but extension can occur intomiddle ear, temporal bone, and temporomandibular joint.

Ear pain, otorrhea, and conductivehearing loss are common findings.

See Bellet et al. (1992) for discussionof tumors of external auditory canal.

Middle Ear, Eustachian Tube, and Mastoid Disorders

Infection/Inflammation

Acute and Chronic Otitis Media

Acute otitismedia is most common cause of ear pain in childhood.

Most common pathogens are S. pneumoniae,nontypeable H. influenzae, and M. catarrhalis. In infants <6wks of age, pathogens include S. aureus, group B Streptococcus,and gram-negative enteric bacteria (e.g., E. coli and P. aeruginosa).In some cases, respiratory syncytial virus, parainfluenza viruses, influenzaviruses, and enteroviruses can be cultured from middle ear fluid.

P. aeruginosa is most common causeof chronic otitis media, which involves nonintact tympanic membranewith either perforation or placement of tympanostomy tube.

Typically, child presents with upperrespiratory infection for 1–2 days and then develops ear pain.Nonspecific symptoms of acute otitis media in infancy include excessivecrying, irritability, vomiting, and diarrhea. Fever is variablefinding.

Visualization of tympanic membraneconfirms diagnosis. There is loss of or distortion of normal architectureof tympanic membrane, which appears opaque or bright red in color.Tympanic membrane loses its normal mobility with pus in middle earspace. With perforation of tympanic membrane, pus is seen in externalcanal. Large bulla or bullae (bullous myringitis) involving tympanicmembrane also signifies acute otitis media.

Acute otitis media is usually due tobacterial infection and requires antibiotic treatment. If resolutionof infection fails to occur after 2 or 3 courses of treatment withdifferent antibiotics, fluid should be drained and cultured.

Other indications for tympanocentesisor myringotomy and culture of middle ear fluid are critically illchild with otitis media, immunologically compromised child, or presenceof complication (e.g., facial paralysis or brain abscess).

Otitis Media with Effusion

Pathogenesisof persistent middle ear effusion is related to eustachian tubedysfunction. Predisposing factors include recurrent otitis media,enlarged adenoids and/or tonsils, allergic rhinitis, and,less commonly, nasopharyngeal tumors.

Sensation of ear discomfort or fullness,ear tugging, and irritability are frequent findings.

Otoscopic exam including pneumaticotoscopy usually confirms diagnosis. Retraction of tympanic membrane,air-fluid level, or bubbles in middle ear may be seen. Pneumaticotoscopy reveals decreased or absent mobility of tympanic membrane.If uncertainty exists about presence of effusion, tympanometry maybe diagnostic. This technique is more reliable in children who are≥6 mos of age.

Mastoiditis

Acute mastoiditisis usually complication of acute otitis media.

Same pathogens that cause acute otitismedia also cause mastoiditis. S. pneumoniae and nontypeable H. influenzaeare most common.

Usual findings include ear pain, postauricularswelling, tenderness over mastoid bone, and fever.

Radiographs of mastoid bone show evidenceof osteitis with destruction of bony trabeculae.

Chronic mastoiditis is usually complicationof chronic otitis media. S. aureus and gram-negative enteric bacteria(E. coli, P. aeruginosa, and Proteus species) are frequent pathogens.

Trauma

Acute headinjury may result in basilar skull fracture with hemotympanum. Ecchymosisbehind ear and in periorbital area may be seen.

Acute head injury or explosive blastalso can cause rupture of tympanic membrane and acute ear pain.

Injuries severe enough to rupture tympanicmembrane also can damage ossicular chain.

CT should be performed to determineextent of injury.

Barotrauma with sudden changes in middleear pressure sometimes occurs with flying in airplane or scuba diving.

In airplane,individuals experience positive middle ear pressure on ascent andnegative middle ear pressure on descent. Opposite happens in scubadiving.

If eustachian tube fails to open andequilibration of pressure fails to occur, negative pressure in middleear causes transudation of fluid, resulting in ear pain, conductivehearing loss, and sometimes bleeding.

Tympanic membrane also can rupture.Swallowing helps relieve pain by keeping eustachian tube open andenhancing pressure equilibration.

Neoplasm

Tumors arisingin middle ear or temporal bone are rare in pediatric population.

Conductive hearing loss, tinnitus,ear fullness, or facial nerve palsy may signal presence of middleear mass, which may or may not be visible by otoscopy.

Extension of tumor into external auditorycanal may produce otorrhea, whereas sensorineural hearing loss,tinnitus and vertigo may occur with inner ear involvement.

Temporal bone tumors may produce sensorineuralhearing loss, tinnitus, vertigo, and facial nerve palsy.

CT is initial imaging exam for massesin middle ear and temporal bone.

See Bellet et al. (1992) for discussionof tumors that arise in middle ear and temporal bone.

Referred Ear Pain from Cranial Nerves (V, VII, IX, X) orCervical Nerves (C2, C3)

Cranial Nerve V

Auriculotemporalbranch of mandibular division of trigeminal nerve (CN V) supplies tragus,anterior portion of auricle, anterior and superior auditory canalwalls, and anterior portion of tympanic membrane.

Pain from structures innervated bymaxillary and ophthalmic divisions of trigeminal nerve also canbe referred to those areas supplied by mandibular branch. Sinusitis,sialadenitis, parotitis, and tumors involving any of these areascan cause earache. Tooth (erupting teeth, impacted third molars,caries, dental abscess), gingival (gingivitis, stomatitis, aphthousulcers), jaw, and temporomandibular joint pain also can cause earpain.

Cranial Nerve VII

Sensoryportion of facial nerve (CN VII) supplies part of posterior wallof external auditory canal and posterior portion of tympanic membrane.

Herpes zoster can cause neuritis offacial nerve, with severe earache and vesicular eruption of auricle,external auditory canal, and occasionally tympanic membrane. Tumorsinvolving facial nerve during its intracranial or temporal bonecourse also can cause ear pain.

Cranial Nerve IX

Glossopharyngealnerve (CN IX) supplies pharynx, tonsils, nasopharynx, posterior one-thirdof tongue, and eustachian tube. Branch of this nerve supplies posteriorportion of external auditory canal and surface of tympanic membrane.

Ear pain can be due to lesions of oropharynx(pharyngitis, tonsillitis, foreign body, tumor, peritonsillar abscess,retropharyngeal abscess) and nasopharynx (nasopharyngitis, foreignbody, enlarged adenoids, tumor).

Cranial Nerve X

Sensoryfibers of vagus nerve (CN X) supply portion of posterior externalauditory canal and tympanic membrane. This nerve also supplies sensationto larynx, esophagus, trachea, and thyroid gland.

Although uncommonly seen in childhood,earache mediated by vagus nerve can be associated with lesions oflarynx (trauma, foreign body), esophagus (foreign body, causticburn), trachea (tracheitis), and thyroid gland (thyroiditis).

Cervical Nerves (C2 and C3)

Upper cervicalnerves, especially great auricular nerve, supply skin and musclesof neck as well as external ear and posterior auricular area.

Cervical lymphadenitis is common causeof ear pain. Unusual causes are infected branchial cyst and disordersof cervical spine (dislocation/subluxation, osteomyelitis,tumor).

Psychogenic

Ear painmay be psychogenic if otologic exam is normal and no lesion canbe found responsible for pain, including referred pain from cranialor cervical nerves.

Often these individuals have anxietyor depression.

Psychosocial history provides cluesto this diagnosis.

Diagnostic Approach

Most commoncauses of ear pain are acute and chronic otitis media, otitis externa, cerumenimpaction, foreign body, and trauma.

History and careful exam of externalear, external auditory canal, and middle ear are diagnostic. Ifexam of these structures is normal, possibility of referred earpain must be considered. Head, face, nose, mouth, pharynx, and neckshould be carefully examined.

Radiographs of temporal bone and mastoidregion, CT, and MRI are helpful in diagnosis of suspected neoplasmof external auditory canal, middle ear, mastoid, or temporal bone.

>

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Hearing Loss and Deafness: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Conductive Hearing Loss

External Auditory Canal Disorders

Atresia of External Auditory Canal

Absenceof meatus under tragus signifies presence of external auditory canalatresia. External ear is usually small and deformed.

CT should be performed to identifyother abnormalities, especially in middle ear, and to help in evaluationof possible surgical repair.

Impacted Cerumen

Impacted cerumen (earwax) in external canalis common cause of conductive hearing loss. Hearing returns to normalafter its removal.

Otitis Externa

Inflammationof external auditory canal with discharge and swelling causes obstructionand diminished sound transmission. Hearing returns to normal afterinflammation subsides.

See Chap.16, Earache.

Exostosis

Exostoses(bone overgrowths) may be found in external auditory canal or middleear but are uncommon in pediatric population.

Usually bilateral and close to tympanicmembrane.

Although diagnosis is usually clinical,CT may be useful in defining their extent.

Masses

Foreignbodies (e.g., cotton balls, erasers, beads, and other small objects)that obstruct external canal can cause decreased hearing. Readilyseen by otoscopy.

Polyps are reddish or purplish massesthat bleed easily. Can arise from external canal and tympanic membraneor protrude from middle ear into canal through perforation in membrane.Often associated with cholesteatoma. Excisional biopsy is diagnostic.

Neoplasms arising from external auditorycanal are rare in pediatric population but include neurofibromas,eosinophilic granulomas, and rhabdomyosarcomas. CT shows locationand extent of lesion. Histologic diagnosis is definitive.

Middle Ear Disorders

Acute and Chronic Otitis Media and Otitis Media with Effusion

Most commoncauses of conductive hearing loss in children are acute and chronicotitis media and otitis media with effusion.

See Chap.16, Earache.

Tympanic Membrane Perforation

Most common causes of tympanic membrane perforationare acute otitis media and head trauma. The latter causes conductivehearing loss by accumulation of blood in external canal or middleear or by disruption of ossicular chain. Perforation is seen byotoscopy.

Hemotympanum

Direct blowto ear or basilar skull fracture may cause hemotympanum.

Tympanic membrane appears red or purplebecause of blood in middle ear space. Other findings that may beseen with basilar skull fracture include ecchymoses behind ear oraround eyes, and CSF drainage from nose or ears.

CT helps determine extent of injury.

Tympanosclerosis

Characterizedby whitish plaques in tympanic membrane and nodular deposits insubmucosal layers of middle ear. If deposits of calcium and phosphatecrystals involve ossicles, conductive loss can occur.

Predisposing factors are chronic otitismedia and tympanostomy tube placement.

Ossicular Chain Defect, Disruption, or Fixation

Should besuspected in cases of conductive hearing loss when external auditorycanal and middle ear appear normal on exam.

History of head trauma suggests ossiculardisruption.

CT of temporal bone shows ossicularchain and any abnormalities of otic capsule.

Cholesteatoma and Other Middle Ear Masses

Cholesteatomausually appears as whitish mass in middle ear. Other middle earmasses are discussed by Bellet et al. (1992).

Conductive hearing loss, tinnitus,ear fullness, or facial nerve palsy can indicate presence of middleear mass, regardless of whether it is visible by otoscopy.

CT is initial imaging exam for middleear masses.

Sensorineural Hearing Loss

Sensorineural Hearing Loss without Associated Abnormalities

In the past these disorders were usuallydistinguished from each other by mode of genetic transmission, ageof onset, severity of hearing loss, and type of audiogram (Gorlinet al., 1995). Recently, several genes for hearing loss have beenmapped to different chromosomes, permitting specific diagnosis (Willems,2000).

Sensorineural Hearing Loss with Associated Abnormalities

Several syndromes may be associated withsensorineural hearing loss: Hurler, Hunter, Cockayne, Alport, Klippel-Feil,Wildervanck, Waardenburg, Usher, Pendred, Jervell and Lange-Nielsen,and branchio-oto-renal.

Chromosomal Disorders

Although trisomies 13, 18, 21, and 22 maybe associated with sensorineural hearing loss, conductive loss dueto otitis media with effusion is more common.

Inner Ear Malformations

The following malformations can usually bediagnosed by CT, although sometimes MRI may be necessary.

Labyrinthine Aplasia

Michel malformation consists of aplasia ofcochlea, vestibule, and semicircular canals.

Common Cavity Malformation

Exists when there is single labyrinthinecavity without cochlea or semicircular canals.

Cochlear Malformations

Most commoncochlear malformation observed with imaging studies is Mondini malformation.

Axial CT shows single cochlear cavitywith normal cochlear basal turn.

Has been reported in many syndromes:DiGeorge, Goldenhar, Pendred, Waardenburg, and CHARGE association.

Pseudo-Mondini malformation is presenceof a cochlear vestige that communicates directly with vestibulewithout intervening bony cochlear basal turn.

With cochlear aplasia, nidus of scleroticbone replaces cochlea.

Large Vestibular Aqueduct

Both the vestibular aqueduct and endolymphsac are enlarged in this malformation Although hearing loss is progressive,it is often fluctuating. Head trauma may result in sudden, irreversible,profound sensorineural hearing loss.

Prematurity

Mechanism of hearing loss in premature infantswithout any other predisposing factor is unknown.

Hypoxic-Ischemic Encephalopathy

Perinatal asphyxia, including birth trauma,may result in hypoxic-ischemic encephalopathy and hearing loss.

Bilirubin Encephalopathy (Kernicterus)

Usuallycauses bilateral high-frequency hearing loss. Possible mechanismsinclude damage to cochlear nuclei and auditory pathways in brain.

See Chap.3, Alteration in Consciousness.

Infection

Congenitalinfection with rubella, cytomegalovirus, herpes simplex virus, toxoplasmosis,or syphilis (see Chap. 36, Jaundice)sometimes produces hearing loss and deafness.

Although acute and chronic otitis mediacause conductive hearing loss, it is postulated that inflammatorymediators or toxins pass from middle ear to inner ear through roundwindow membrane to cause sensorineural hearing loss.

Bacterial meningitis and encephalitiscan cause sensorineural hearing loss that can range from mild toprofound.

Trauma

Loud noiseof sufficient duration and intensity can destroy organ of Cortiand its associated neural connections in base of cochlea.

Tinnitus almost always occurs in noise-inducedhearing loss.

Direct trauma including temporal bonefractures and penetrating wounds may disrupt bony and membranouslabyrinth to cause sensorineural hearing loss. CT is imaging procedureof choice.

Drugs

Drugs takenduring pregnancy that may cause hearing loss in neonates includequinine, chloroquine, and isotretinoin.

Aminoglycosides (streptomycin, kanamycin,gentamicin, amikacin, neomycin), loop diuretics (furosemide, ethacrynicacid), and cisplatin can cause sensorineural loss in infants andchildren.

Perilymph Fistula

Abnormalleak of perilymph (cerebrospinal fluid) into middle ear or mastoidair cell system is caused by defects in temporal bone, particularlyin region of stapes footplate or round window.

Defects may be congenital or acquired(secondary to trauma of the temporal bone). They are associatedwith sudden fluctuating or progressive sensorineural hearing lossand can predispose to recurrent meningitis. Vertigo also may occurbut is rare.

Injection of intrathecal radioisotopeor dye with subsequent nuclear scintigraphy or CT, respectively,often identifies site of leak. See Chap.41, Nasal Discharge.

Neoplasm

Some neoplasticdiseases (e.g., leukemia and neuroblastoma) can invade temporal boneand damage cochlea or auditory pathways.

Acoustic neuroma, a benign tumor ofeighth cranial nerve, can cause sensorineural hearing loss, tinnitus,vertigo, and facial nerve paralysis. Presence of bilateral tumorssignifies neurofibromatosis.

Posterior fossa tumors in area of cerebellopontineangle (e.g., meningioma) can cause hearing loss, tinnitus and ataxia.CT and MRI can locate and define extent of tumor. Histologic diagnosisis definitive.

Ménière Disease

Sensorineural fluctuating hearing loss, tinnitus,and vertigo characterize Ménière disease.

Unknown

There are a number of cases of hearing lossin which the etiology is unknown.

Mixed Hearing Loss

In children with sensorineural hearing loss,presence of acute otitis media or otitis with effusion may produceconductive hearing loss.

Diagnostic Approach

Auditoryand language findings listed in Table26.1 are indications for possible hearing loss or deafness.

Suspected hearing loss should be investigatedto determine the type, severity, and cause.

Any child with suspected hearing lossshould be referred for audiologic evaluation. Speech and languageassessment is often necessary. Neurologic and otolaryngologic consultationmay be required, depending on suspected problem.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Hearing loss: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient reports hearing loss, ask him to describe it. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient's medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.

Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral, or continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience dizziness? If so, when did he first notice it?

Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, notify the physician to discuss whether an otoscopic examination should be done. (See Using an otoscope correctly, page 223.) During the otoscopic examination, note color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.

Next, evaluate the patient's hearing acuity, using the ticking watch and whispered voice tests. Then perform Weber's and the Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss, page 304.)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Otorrhea: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin your evaluation by asking the patient when otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.

Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.

Next, check the patient's medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he's an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.

Focus the physical examination on the patient's external ear, middle ear, and tympanic membrane. (If his symptoms are unilateral, examine the uninvolved ear first to avoid cross-contamination.) Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit tenderness. Then insert an otoscope, using the largest speculum that will comfortably fit into the ear canal. If necessary, clean cerumen, pus, or other debris from the canal. Observe for edema, erythema, crusts, or polyps. Inspect the tympanic membrane, which should look like a shiny, pearl-gray cone. Note color changes, perforation, absence of the normal light reflex (a cone of light appearing toward the bottom of the drum), or a bulging membrane.

Next, test hearing acuity. Have the patient occlude one ear while you whisper some common two-syllable words toward the unoccluded ear. Stand behind him so he doesn't read your lips, and ask him to repeat what he heard. Perform the test on the other ear using different words. Then use a tuning fork to perform Weber's and the Rinne tests. (See Differentiating conductive from sensorineural hearing loss, page 304.)

Complete your assessment by palpating the patient's neck and his preauricular, parotid, and postauricular (mastoid) areas for lymphadenopathy. Also, test the function of cranial nerves VII, IX, X, and XI.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Earache [Otalgia]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient to characterize his earache. How long has he had it? Is it intermittent or continuous? Is it painful or slightly annoying? Can he localize the site of ear pain? Does he have pain in other areas such as the jaw? Does he experience any associated hearing loss?

Ask about recent ear injury or other trauma. Does swimming or showering trigger ear discomfort? Is discomfort associated with itching? If so, find out where the itching is most intense and when it began. Ask about ear drainage and, if present, have the patient characterize it. Does he hear ringing, “swishing,” or other noise in his ears? Ask about dizziness or vertigo. Does it worsen when the patient changes position? Does he have difficulty swallowing, hoarseness, neck pain, or pain when he opens his mouth?

Find out if the patient has recently had a head cold or problems with his eyes, mouth, teeth, jaws, sinuses, or throat. Disorders in these areas may refer pain to the ear along the cranial nerves.

Find out if the patient has flown, been to a high-altitude location, or been scuba diving.

Begin your physical examination by inspecting the external ear for redness, drainage, swelling, or deformity. Then apply pressure to the mastoid process and tragus to elicit tenderness. Using an otoscope, examine the external auditory canal for lesions, bleeding or discharge, impacted cerumen, foreign bodies, tenderness, or swelling. Examine the tympanic membrane: Is it intact? Is it pearly gray (normal)? Look for tympanic membrane landmarks: the cone of light, umbo, pars tensa, and the handle and short process of the malleus. (See Using an otoscope correctly.) Perform the watch tick, whispered voice, Rinne, and Weber's tests to assess for hearing loss.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

EARACHE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis requires ear, nose, and throat examination; culture of any discharge; and x-ray film of the mastoids, petrous bone, TMJs; and, in some cases, the sinuses and teeth. A careful neurologic examination is necessary in unexplained otalgia. Referral to an otolaryngologist or neurologist is probably best for the busy physician who is unable to find the cause on a routine examination.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

AURAL DISCHARGE (OTORRHEA): Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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