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

2. 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 =

3. Acute Otitis Externa

4. 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

5. 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

6. Otomycosis

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

8. 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

9. Necrotizing Otitis Externa (Malignant OE)

10. 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

11. 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

12. Perichondritis

13. 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

14. Bullous Myringitis

15. 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

16. Acute Otitis Media (Acute Suppurative Otitis Media)

17. 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

18. Serous Otitis Media

19. 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

20. Chronic Otitis Media w/ Perf

21. 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

23. 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

24. 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

25. Tympanoplasty: Graft Technique
Medial
Lateral

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

27. 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

28. 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

29. 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

30. 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

31. Petrous Apicitis

32. Complications of OM: Extracranial

33. 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

34. 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

35. 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

36. Epidural Abscess
Subdural Abscess

37. 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 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

39. 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