Otic Emergencies

• The middle ear has direct communication with the nasopharynx via the eustachian tube whose patency helps keep the middle ear pressure equalized with the atmosphere. There is also direct communication with the middle cranial fossa via the mastoid antrum and air cells.
• Multiple nerves supply the ear including cranial nerves V, VII, IX, X, and XI as well as cervical nerves C2 and C3. As a result, ear pain can occur with nonotic pathology especially dental and oropharyngeal disease. Patients with complaints of otalgia and an unremarkable ear exam need to undergo evaluation of the teeth, oral cavity, pharynx, TMJ and neck. Disease of the larynx and upper esophagus should also be considered.

Risk Factors

• Eustachian tube dysfunction and obstruction: This leads to negative pressure within the middle ear and subsequent fluid collection. Children have a higher incidence because their Eustachian tube has less cartilaginous support. Other common etiologies of tube obstruction are adenoid hypertrophy and edema secondary to viral upper respiratory infection.
• Adults with OM and middle ear effusion who lack obvious risk factors need to be evaluated for possible mass lesions such as nasopharyngeal carcinoma.

• A significant percentage of OM is secondary to respiratory viruses, most commonly RSV.
• The most common bacterial etiologies are S. pneumoniae, H. influenzae and M. catarrhalis.

• Older children and adults present with otalgia and ear fullness. Infants and younger children who are unable to verbalize sometimes have ear pulling and nonspecific symptoms such as irritability, decreased PO intake, vomiting and diarrhea. Fever may be present; however, the majority of children with OM have only moderate temperature elevation.
• The most sensitive indicator of OM on physical examination is immobility of the TM with air insufflation. Other physical findings include: air-fluid levels or bubbles behind the TM, retraction or bulging of the TM, blurring of osseous middle ear landmarks and TM color change. Mild erythema of the TM occurs with crying and fever and should be considered indicative of OM only when other abnormalities are present.

• Although most practitioners still prescribe antibiotic therapy, it has been shown that a majority of pediatric OM will have spontaneous cure without antibiotics. The American Academy of Pediatrics Subcommittee on the Management of Acute Otitis Media now recommends a treatment approach that takes into account the patient’s age, the severity of disease, and the certainty of diagnosis. Observation alone is considered as an appropriate treatment option for children greater than 2 yrs of age with non-severe illness. For all others, the duration of antibiotic therapy is 10 days unless azithromycin is used. When making a treatment selection consider ease of dosing, side-effect profile, probability of bacterial resistance, cost and presence of any allergies.
  • High-dose amoxicillin (80 mg/kg/d)is still the recommended agent for most patients with OM
  • Alternate medications include macrolides, amoxicillin/clavulanate, various cephalosporins, trimethoprim/sulfamethoxazole, erythromycin/sulfisoxazole, and clindamycin.
• Ancillary treatment should include antipyretics and analgesics as needed.
• Suspect resistant pathogens or an alternate diagnosis in patients with persistent symptoms after 48-72 h of treatment. These patients as well as those with recurrent disease should be treated with amoxicillin/clavulanate or one of the second or third generation cephalosporins.
• Recurrent and persistent disease with middle ear effusion places pediatric patients at risk for deafness. These children should be referred to ENT for placement of pressure equalization (PE) tubes and consideration of tonsillectomy and adenoidectomy.
• Complications of OM include chronic otitis, meningitis, intracranial abscess, mastoiditis, labyrinthitis and invasion of neighboring structures including bone and facial nerve.

• Most OM patients are discharged home with ENT follow-up.
• Admission is indicated for febrile neonates, toxic patients (usually infants) and any patient in whom serious complication is present.

• Symptoms include otalgia, fever, malaise and purulent otorrhea.
• Physical examination reveals painful swelling and fluctuance over the mastoid process.
• The TM sometimes has signs of concurrent OM. Complications include hearing loss, facial nerve paralysis and intracranial infection. Look for corresponding physical signs. Emergent ENT consultation and admission for broad-spectrum IV antibiotics is necessary. Head and temporal bone CT should be obtained if complications are present.

Risk Factors

• Otitis externa (OE) occurs with auditory canal trauma and maceration of the canal skin.
• Trauma is usually secondary to foreign bodies such as Q-tips and hearing aids. Maceration occurs after prolonged exposure to water or in areas of high temperature and humidity.

• Most cases of OE are causes by Pseudomonas, Proteus or S. aureus.

• Symptoms include ear pain, hearing loss, itching and otorrhea. There is often a history of recent swimming, minor ear trauma or attempted cerumen removal using irrigation.
• On examination, the skin of the auditory canal will have varying degrees of edema and exudates that may be so severe as to prevent visualization of the TM. Exudates should be gently suctioned in order to allow for thorough evaluation. The TM itself may have moderate erythema. Palpation of the tragus and other external structures produces pain.
• Diagnosis of OE is usually obvious but the differential includes both Herpes zoster and necrotizing OE. With Herpes zoster, patients present with burning pain followed by a vesicular rash to the external ear and auditory canal.

• Therapy consists of topical polymyxin/neosporin/hydrocortisone solution. Consider topical ciprofloxacin for diabetic patients and suspected Pseudomonas. If edema is severe, an ear wick should be placed so that medication will be delivered the entire length of the canal.
• Systemic antibiotics are necessary only if there is cellulitic involvement of the external structures or for patients with diabetes/immunosuppression. Some practitioners also prescribe systemic antibiotics for OM when the TM cannot be adequately visualized.
• An alternative is to reevaluate these patients for concurrent OM in 24 h after canal edema has lessened.
• Instruct patients to follow dry ear precautions and avoid placement of Q-tips and other foreign bodies into the canal.

• With few exceptions, patients with OE are discharged home. However, follow-up is indicated to ensure that infection is resolving. Patients may also require repeat cleansing of the auditory canal and removal of ear wick if placed.

• NOE is associated with diabetes mellitus and other immunosuppressive states. Etiology is usually P. aeruginosa.
• Infection starts in the external ear and rapidly spreads to contiguous structures including bone, soft tissue, nerves and mastoid air cells. The facial nerve is commonly affected but other cranial nerves are sometimes involved as well.
• Pertinent examination findings include granulation tissue in the auditory canal, cellulitic changes of the external ear, ipsilateral facial nerve palsy and possibly other cranial nerve deficits. Patients describe deep, severe ear pain. They may be febrile and toxic.
• Patients with suspected NOE require CT scan to define extent of infection. Obtain emergent ENT consultation and initiate intravenous anti-pseudomonal antibiotics as soon as possible. These patients often require prolonged duration of therapy and surgical debridement by ENT.

• This soft tissue infection of the external ear follows trauma, burns/exposure and ear piercing.
• Symptoms are pain and swelling involving the entire external ear. Examination reveals erythema and tenderness.
• S. aureus and P. aeruginosa are most commonly involved.
• Mild disease is treated with oral ciprofloxacin. More severe cases require intravenous medications. Early ENT is encouraged as progression of infection could lead to chondritis and permanent cartilaginous deformity.

• Relapsing polychondritis is a rare inflammatory condition easily confused with perichondritis. Accurate diagnosis is important, as complications and treatment differ.
• Multiple cartilaginous sites are involved including the ear, larynx, epiglottis, joints, etc. Ear involvement is common and may spare the lobule. Other symptoms such as hoarseness occur as a result of widespread cartilage involvement.
• Treatment is with steroids. ENT should be involved in patient care.

Clinical Presentation and Diagnosis

• Otic FBs are seen most frequently in pediatric patients who will place any imaginable object into the auditory canal. In adults, insects and cotton Q-tips are commonly encountered.
• Patients present with ear pain, ear fullness and hearing loss. Purulent discharge is seen with long-standing FBs. Vertigo and facial nerve paralysis occur when the middle ear has been traumatized.
• Examination usually reveals the offending object although associated canal edema or bleeding will make visualization difficult. Attempt should be made to visualize the TM in order to rule out associated perforation.

• Removal of otic FBs can be accomplished with a variety of methods:
  • Irrigation using lukewarm water via a plastic 18 g angiocath attached to a 30 ml plastic syringe (avoid if TM perforation is a possibility).
  • Depending upon the shape and size, FBs are also removed with a small suction catheter, ear loop or alligator forceps. An alternative is Fogarty catheter placement just posterior to the object followed by gentle outward pressure after balloon inflation.
• Immobilize live insects prior to attempted removal by placing 2% lidocaine in the auditory canal. This reduces patient discomfort and maximizes cooperation.
• When the FB is lodged firmly in the auditory canal or cannot be easily removed, the patient should be referred to ENT. Repeated attempts at removal cause bleeding and edema and make the situation worse. Pediatric patients are often uncooperative; it may be necessary for ENT to remove the object under general anesthesia or to employ procedural sedation in the ED.
• Complications of FB removal are auditory canal laceration, TM perforation and ossicle disruption. Make sure to reexamine the ear after FB removal.

• Patients are discharged home after successful FB removal. Antibiotics are indicated only if there is associated infection. Follow-up is not necessary unless complications are present.
• Most patients with a difficult to remove FB can be referred nonemergently to ENT within 1-2 days. Emergent evaluation is warranted for organic, animate and corrosive FBs.

• Cerumen is cleared naturally via lateral migration of the underlying skin. Certain individuals are more prone to impaction based upon amount/consistency of cerumen produced as well as effectiveness of the migration process. People increase the likelihood of impaction by attempting to clean their ears with Q-tips or other similar objects.
• Impacted cerumen is easily cleared using lukewarm water via plastic angiocath attached to a syringe. Avoid irrigation if there is history of TM perforation. Another method is to soften the impacted material with triethanolamine (Cerumenex) by filling the ear canal and leaving the agent in place for 15-30 min. Cerumen is then removed with an ear loop.
• Prior to discharge, instruct patients to avoid future Q-tip use.

Etiology

• Blunt and penetrating trauma: includes temporal bone fractures, direct blows and attempted otic hygiene with Q-tips and iatrogenic injury from removal of cerumen impaction or FBs.
• Pressure changes from scuba diving, loud noise and lightning.

• Symptoms include ear pain, bloody otorrhea and mild hearing loss. Suspect injury to the ossicles or labyrinth if patients have vertigo, significant hearing loss or facial nerve deficits.
• Diagnosis is via direct visualization with an otoscope. Assess hearing if middle or inner ear damage is suspected.

• Most uncomplicated TM perforations heal without specific therapy. Smaller and more centrally located perforations tend to heal faster than larger, peripheral lesions. Persistent perforations sometimes require surgical treatment.
• Antibiotics have not been shown to improve healing and are rarely indicated. The exception to this rule is when there is concurrent OE or OM. In cases of OE, treat patients with topical antibiotic suspension (vs. solution) which is less likely to penetrate into the middle ear space.

• All cases of TM perforation mandate ENT follow-up. This is done on a routine basis unless middle or inner ear injury is suspected. Instruct patients to follow dry ear precautions.

• Hearing loss is either conductive or sensorineural. Conductive hearing loss is caused by occlusion of the auditory canal, middle ear fluid or dysfunction of the TM and ossicles. The etiology of sensorineural hearing loss varies. Sudden sensorineural hearing loss (SSHL) is that occurring within the preceding 3 days.
• Patients with hearing loss need a thorough ear exam to rule out obvious causes such as otic FB, otitis media/externa and cerumen impaction.
• If the ear exam is unremarkable, consider other etiologies as noted above. Obtain a thorough history and perform a complete physical assessment including neurologic exam. Laboratories and CT scan are indicated if metabolic or structural causes are a concern.

  Conductive hearing loss

  External ears	Congenital atresia Cerumen impaction, foreign bodies Otitis externa Obstructing lesions-osteomas, exostoses Trauma
  Middle ear	Congenital ossicular abnormalities Otitis media, middle ear effusion Cholesteatoma, otosclerosis TM perforation

  Sensorineural hearing loss

  Infectious	Syphilis Viral-MMR, VZV, CMV, others Meningitis Encephalitis
  Medications	Aminoglycosides Loop diuretics Antineoplastic agents Salicylates, NSAIDs
  Vascular	Sickle cell disease Cerebrovascular accident Coagulopathy
  Endocrine	Diabetes mellitus Hypothyroidism
  Traumatic	Noise Barotrauma Temporal bone fracture
  Neoplastic	Hematologic malignancy acoustic neuroma
  Misc.	Meniere’s disease Multiple sclerosis Autoimmune Congenital
  MMR-measles, mumps, rubella; VZV-varicella Zoster virus. CMV-cytomegalovirus

• The role of the EP in cases of hearing loss is to rule out life-threatening etiologies and to provide appropriate referral. SSHL is an indication for emergent ENT evaluation. Prompt initiation of care improves chances for hearing recovery. Therapy sometimes includes empiric high-dose steroids as well as treatment of the underlying disease process.