John Davis RN, MSN, FNP-BC Ear we go! John Davis RN, MSN, FNP-BC

Dark night, that does from the eye his function take, the ear the better sense does make. -William Shakespeare “A Midsummer Night’s Dream”

What is the smallest bone in the body?

Anatomy

Anatomy

How to Examine the Ear Use the largest speculum that will fit comfortably. Hold the otoscope with your thumb and fingers so that the ulnar aspect of your hand makes contact with the patient. Pull gently on the auricle/outer ear. For children- apply traction down and posterior on the helix/pinna to straighten the canal For teenagers/adults- apply traction up and posterior to straighten the canal

Middle Ear Anatomy

Examination of the Tympanic Membrane Vary light direction to observe entire membrane and annulus. Abnormal: Perforation Landmarks not visible Normal: Visible umbo Handle or Manubrium of Malleus Light reflex

TM Perforation

Note the color and translucency of the TM Shiny or Dull (retracted) Normal is a pinkish/gray color Bulging Red, inflammed White scarring

Otitis Externa Also known as Swimmers Ear. Caused by excessive moisture carrying bacteria into the the cerumen of the ear canal, leading to maceration and inflammation. Causative organisms: Pseudomonas species (most common) Staphylococcal species Streptococcal species Occasionally fungal infections

Otitis Externa Do not shove otoscope in. Oral antibiotics generally ineffective. Treatment: Cortisporin Otic

Cerumen Impaction Can cause hearing loss, pain or dizziness. Interferes with examination of the tympanic membrane. Prevention: Avoid using cotton swabs in the external auditory canal.

Cerumen Impaction To remove: Debrox- OTC Colace- liquid 1cc 15-30 minutes before irrigation 3% Hydrogen Peroxide- fill ear 15-30 minutes before irrigation. Mineral Oil- 3 drops in to the ear at bed time for 3 or 4 days. These treatments should be avoided in anyone with a suspected breach of the tympanic membrane from previous surgery, insertion of myringotomy tubes, or tympanic membrane perforation. Am Fam Physician. 2007 May 15;75(10):1523-1528.

Otitis Media Inflammation of the middle ear #1 cause of antibiotic prescription for children in the developed world. Results from disruption of eustachian tube patency. Commonly after or during an upper respiratory tract infection (cold) Can be related to allergic rhinitis Even positional changes can allow nasopharyngeal flora to reflux through the eustachian tube and colonize in the middle ear.

Otitis Media Risk Factors Allergies Second hand smoke exposure Age under 5 Not breastfeeding Day care or in school Downs syndrome Cleft Palate

Otitis Media

Otitis Media

Otitis Media Causes: Treatment: 40-60% Viral Serous Otitis Media/Otitis Media with Effusion Resolves in 4-6 weeks Bacterial: Haemophilus influenzae Streptococcus pneumoniae Moraxalla catarrhalis Treatment: Spontaneous clinical recovery is observed in more than 70% of patients with acute otitis media. Oral Antibiotics Wait and see- depends on age of patient, medical history, reliability of follow up.

What vaccine decreases the incidence of otitis media in children?

Eustachian Tube One way flutter valve that is closed at rest. Protects middle ear from sound and secretion of nasopharynx. Drains secretion from middle ear. Ventilates middle ear to maintain near ambient pressure. When you swallow or yawn, the tubes open briefly to let air in to make the pressure in the middle ears equal to the pressure outside of the ears. Sometimes fluid or negative pressure gets stuck in the middle ear. This causes ear pain and sometimes difficulty hearing.

Eustachian Tube Dysfunction Causes: Cold, sinus infection Allergies Changes in elevation- flying, driving up or down a mountain Swimming/ scuba diving Pharyngeal flutter valve is held closed Treatments: Yawn or chew gum Oral antihistamine or Intranasal corticosteroid Oxymetazoline (Afrin) Oral Decongestants

Myringotomy AKA TM Tubes Made of plastic, metal or Teflon. Procedure performed for chronic / recurrent otitis media, especially if a speech delay is present. Usually not done after age 5 as most children will have wider and longer eustachian tubes, thus, allowing for better drainage of fluids from the ear.

Scarring on the Tympanic Membrane

Cholesteatoma Can be a birth defect, but more commonly a complication of chronic ear infection. Poor function in the eustachian tube leads to negative pressure in the middle ear. This pulls a part of the tympanic membrane into the middle ear, creating a pocket or cyst that fills with old skin cells and other waste material. The cyst may get bigger and break down some of the middle ear bones or other structures of the ear, affecting hearing, balance, and possibly function of the facial muscles.

Cholesteatoma

Cholesteatoma Treatment: Surgery to remove cyst.

Mastoiditis Infection of the bony air cells in the mastoid bone, located just behind the ear. Rarely seen in children today because of the use of antibiotics to treat ear infections. Emergency treatment and hospitalization necessary because of proximity to the central nervous system.

Mastoiditis

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