Infections of the Ear and Temporal Bone RSS 11/22/13

Acute Otitis Externa Also known as “swimmer’s ear” Involves skin of EAC Caused by: Aggressive washing of cerumen or retention of water causes alkalotic EAC and decreased production of lysozyme Microtrauma Moist, dark, and warm EAC =

Acute Otitis Externa

Acute Otitis Externa EAC is EDEMATOUS and ERYTHEMATOUS; TENDER Most common pathogen = Pseudomonas; then Staph, GN bacteria Immunocompromised or frequent exposure to water at increased risk Treatment Frequent cleaning Antibiotic drops; acidification or drying drops DON’T need oral abx unless cellulitis, concurrent OM, persistent/severe symptoms, or systemic dz Refractory or non-compliant = gentian violet

Otomycosis Aspergillus is most common, then Candida Risks: immunocompromised, poor hygiene,  moisture, prolonged abx use Exam shows moist, “tissue paper” sheets of keratin with dotted white, black, or grey membrane; canal erythematous, ITCHY Treat with debridement, acidifying/drying agent, fungal drops; gentian violet for refractory cases

Otomycosis

Chronic Otitis Externa Thickening of EAC from persistent low-grade infection or inflammation

Necrotizing Otitis Externa (Malignant OE) Extension of infection from the EAC into the temporal bone/skull base causing severe and progressive OSTEOMYELITIS Most common is Pseudomonas Radiation and immunocompromise are main risk factors Exam: granulation tissue at body-cartilaginous jxn is pathognomonic; persistent otalgia and otorrhea, CN involvement

Necrotizing Otitis Externa (Malignant OE)

Necrotizing Otitis Externa (Malignant OE) Evaluate with: CT temporal bone Technetium-99 bone scan – evaluates osteoblastic activity, localizes acute and chronic process, stays positive for long time Gallium-67 bone scan – evaluates inflammation; used to followed course; fades when disease resolves Indium-111 bone scan is newer; used for localization of acute infection Treated with prolonged IV abx, ear drops, diabetes control, debridement/cleaning; course is followed with gallium scans; possibly HBO Rarely require surgical debridement

Perichondritis Infxn of auricular cartilage; can be from extension of auricular cellulitis, exposed cartilage, trauma, OE, or infected endaural incision PSEUDOMONAS, staph, and strep Can get cauliflower ear if not treated Sx: tender, erythematous, warm, edematous auricle Treat with systemic anti-Pseudomonal abx

Perichondritis

Bullous Myringitis Inflammation of TM with formation of serous/hemorrhagic bullae on surface Caused by VIRUS or MYCOPLASMA after URI Sx: otalgia, serosanguinous otorrhea, HL Treatment: decompression of vesicles, analgesia, abx; steroids if SNHL

Bullous Myringitis

Acute Otitis Media (Acute Suppurative Otitis Media) Acute infxn (<3 wks), inflammation of ME 2nd most common dz in kids (URI #1); <2 yo most common ETD causes negative ME pressure leading to fluid collection in ME which gets infected Strep pneumo most common; often preceded by viral infxn Sx: otalgia, aural fullness, HL, tinnitus, fever, hyperemic or thickened TM, fluid in ME Medical Tx: 60% resolve spontaneously in 24°, 80% in 2-3 days; oral abx or topical if there’s a perf

Acute Otitis Media (Acute Suppurative Otitis Media)

Serous Otitis Media (Otitis Media with Effusion) Fluid in ME space infection Most common cause of pediatric HL Can be due to persistent fluid from AOM (10% at 3 mos) or due to ETD ME with serous fluid with air-fluid levels/bubbles, nonmobile or retracted TM, aural fullness, HL, tinnitus CHL<30 dB; type B or type C tymps Tx: observe for 3 months if not high risk, Valsalva, treat nasal congestion; myringotomy with PET ± adenoidectomy Unilateral, persistent ME effusion in adult = SCOPE NASOPHARYNX to r/o mass

Serous Otitis Media

Chronic Otitis Media w/ Perf Persistent (>6 wks) or recurrent otorrhea from infxn of ME/mastoid in presence of TM perf or PET Caused by chronically inflamed or infected ME/mastoid secondary to poor aeration (chronic ETD), chronic perf, or cholesteatoma Usually mixed flora Sx: otorrhea, TM perf, inflamed ME mucosa, CHL Medical Tx: cleaning/vinegar flush, water protection, abx drops, may consider 3-4 wks of PO abx; nasal steroid for ETD

Chronic Otitis Media w/ Perf

Surgery for OM: Myringotomy with PET placement Indications: recurrent OM (>3 AOM in 6 mos; >4 AOM in 1 yr), effusion >3 mos, poor response to abx, immunocomp, cleft palate, impending complication, severe retraction, barotitis media, autophony from ETD Complications: persistent otorrhea in 10%, early extrusion, persistent perf (1-2% with normal tube, 20-30% with t-tube), tympanosclerosis, granuloma, cholesteatoma, HL

Surgery for OM Adenoidectomy: Mastoidectomy: May harbor infxn or block ET; kids 1-4 yo with recurrent infxn or large adenoids Mastoidectomy: For persistent chronic OM despite medical tx, coalescent mastoiditis, subperiosteal abscess, cholesteatoma Goal: create a SAFE ear (1st priority); preserve hearing and vestibular fxn (2nd) Canal wall up or canal wall down Canal wall down ABSOLUTE indications: eroded canal wall, eroded lateral SCC, noncompliant pts, unresectable dz, failure of 1st stage CWU due to poor ET fxn RELATIVE indications: dz in only hearing or dead ear, medical illness, severe otologic or CNS complications, neoplasms

Tympanoplasty: Graft Technique Medial (Underlay) Technique Graft placed medial to annulus and remnant TM and either lateral or medial to malleus Adequate for most TM perfs Easier, shorter, fewer complications Lateral (Overlay) Technique Graft placed lateral to annulus Indicated for large perfs (esp anterior) and problem perfs Longer, risk of lateralizing and anterior blunting, longer healing time, risk of entering glenoid, greater postop CHL

Tympanoplasty: Graft Technique Medial Lateral

Zollner-Wullstein Tympanoplasty Classification Type 1: repair of TM only; intact ossicles Type 2: for malleus erosion; TM placed onto incus or malleus remnant

Zollner-Wullstein Tympanoplasty Classification Type 3: for malleus and incus erosion; TM or PORP placed onto intact mobile stapes superstructure Type 4: for malleus, incus, and stapes superstructure erosion; TM or TORP placed onto mobile stapes footplate Type 5: for fixed stapes footplate 5a – horizontal canal fenestration 5b - stapedectomy

Complications of OM High risk pathogens include type III pneumococcus, H flu type B, anaerobes Intracranial spread can occur thru direct extension from bone erosion, lymphatic/hema spread, invasion thru labyrinth, spread thru traumatic or iatrogenic defects, extension thru Hyrtle’s fissure (tympanomeningeal hiatus) – embryonic remnant that connects hypotympanum to subarachnoid space

Complications of OM: Extracranial Tympanosclerosis TM perforation Mastoiditis: acute coalescent, acute non-coalescent, or chronic Acute non-coalescent – IV abx with possible myringotomy/PET Acute coalescent and Chronic – mastoidectomy Subperiosteal Abscess: acute mastoiditis spreads to involve outer cortex of mastoid causing elevation of periosteum Edema, erythema, tenderness over abscess; most commonly postauricular Bezold’s abscess – spread thru perforation in mastoid cortex, tracks into SCM, presents as mass in posterior triangle of neck Treat with IV abx, mastoidectomy and drainage of abscess

Complications of OM: Extracranial Petrous Apicitis Extension of infxn into air cells of petrous apex Presents with Gradenigo’s triad (otorrhea, retroorbital pain, diplopia from involvement of CN 6 through Dorello’s canal) and fever Tx IV abx, possible mastoidectomy with petrous apicectomy Labyrinthine Fistula OM and cholesteatoma erodes into bone of labyrinth (most commonly HSCC) Can by asymptomatic, vertigo, SNHL Fistula test has low sensitivity Tx with surgical exploration via mastoidectomy with removal of cholesteatoma leaving matrix intact over the canal; fascia graft if fistula is exposed

Petrous Apicitis

Complications of OM: Extracranial

Complications of OM: Extracranial Facial nerve paralysis: Infection adjacent to dehiscent facial nerve Injury can occur due to swelling of nerve (inflammatory edema), direct pressure from pus, or bacterial toxic effects Tx: consider urgent surgical exploration/decompression or wide myringotomy, abx for AOM

Complications of OM: Intracranial Meningitis: Most common intracranial complication of OM (esp <5 yo) Increased risk with Mondini deformity H flu type B, pneumococcus, hemolytic Strep Kernig’s sign, Brudzinski’s sign Tx: IV abx, wide myringotomy with culture, possible mastoid/surgical exploration Epidural Abscess: Most commonly from direct extension via bone erosion Associated with lateral sinus thrombosis Can be asymptomatic, HA, fever, malaise Imaging with biconvex disk-shaped enhancement IV abx and surgical drainage

Complications of OM: Intracranial Subdural Abscess: Rapid neurologic deterioration (seizures, delirium, hemiplegia, aphasia, coma), N/V Imaging with crescent-shaped enhancement TX: IV abx, nsrg consult for drainage, surgical exploration with mastoidectomy and exploration of ME when stable

Epidural Abscess Subdural Abscess

Complications of OM: Intracranial Brain Abscess Temporal lobe and cerebellum most common Tx: IV abx, NSGY, surgical exploration with mastoidectomy and expl. of ME once stable Later Sinus Thrombophlebitis Inflammation with subsequent thrombus formation of the sigmoid and/or transverse sinus “PICKET FENCE” spiking fevers, HA, papilledema, Griesinger’s sign (edema and pain over mastoid from occlusion of mastoid emissary vein), torticollis Dx with imaging; Tobey-Ayer or Queckenstedt’s test (normal compression of IJV results in rapid increase in CSF pressure of 60-100 mm Hg, compression on side of the lateral sinus thrombosis results in a slow rise or no rise in CSF pressure secondary to obstruction) Tx: IV abx, possible surgical expl via mastoid with removal of thrombus, may require ligation of IJV for recalcitrant dz, anticoag is controversial

Complications of OM: Intracranial Otitic Hydrocephalus Raised ICP associated with OM Does not cause hydrocephalus, but mimics the symptoms Lateral sinus mural thrombosis prevents CSF absorption which results in intracranial HTN Sx: chronic course, papilledema, diplopia, nausea, HA, lethargy, abducens palsy Tx: address thrombophlebitis, lower ICP, consider surgical exploration once patient is stable Cx: blindness from compressive optic neuropathy