237. Ear Disorders


Tinnitus: perception of sound without sound. ‘auditory hallucination.’ Possible due to damaged cochlear hair cells. 10% due to drugs: aspirin, NSAIDs, antibiotics (aminoglycosides), loop diuretics, topical agents. Referral to ENT. Antidepressants help somewhat with idiopathic tinnitus.

Acute Otitis Externa: swimmer’s ear – pruritis, pain, tenderness over external auditory canal. Can spread to tragus and auricle. RF: frequent contact from swimming or bathing in hot tubs, pools, freshwater lakes; trauma due to scratching or disimpaction frequently. MC organism Pseudomonas, enterobacteriaceae, and proteus. Tx: nonototoxic abx such as ofloxacin and cipro have antistaph and antipseudomonas activity. Ofloxacin approved for open middle ear as well and children/infants. Instill medication with ear facing superiorly for 3 minutes. If significant edema, may need to add wick into canal. Oral abx for fever or periauricular extension.

Malignant Otitis Externa: involving pinna and soft tissues extending into skull base. 90% of the time caused by pseudomonas. RF: DM and immunosuppression. 3-4 drug therapy OE concerning for MOE. CNVII involvement first nerve to be involved if CN affected. Tx: Imipenem in children, cephalosporin or quinolone in adults. Mild cases can be managed orally while advanced stages managed with IV abx and surgical debridement.

Otitis Media: 70% of all OM were viral. MC bacteria strep pneumoniae, H. influenzae, and moraxella catarrhalis. Chronic OM due to Staph and pseudomonas. Ear pain with/without fever. TM retracted or bulging, red in color or yellow/white due to fluid. Tx: If >2yo and afebrile without severe ear pain, consider analgesia only and wait 48 hours. High dose amoxicillin is effective. Adult dose 500-875mg q12hrs x 7-10 days. If ineffective, switch to cefuroxime or augmentin. Topical analgesia (antipyrine/benzocaine) helps with pain. OM with effusion may require extended course of abx (3 weeks). Complications: perforation usually in pars tensa portion of TM – causes otorrhea. Healing occurs in 1 week though chronic perforation can occur. Hearing loss can occur, though usually resolves once fluid resorbs. Meningitis/brain abscesses can occur, due to strep and H.flu.

Acute Mastoiditis: infection spread from middle ear to mastoid cells. Ear pain and fever along with postauricular redness, swelling and tenderness with protrusion of auricle. Doesn’t necessary require CT scan for confirmation. Tx: Admission for IV abx (Vancomycin or nafcillin), tympanocentesis, and myringotomy (incision into TM).

Bullous Myringitis: bulla (blood filled blisters) on TM and deep canal. Usually supportive care only. Usually viral in origin – does not need abx most of the time.


Ear burns: mild second degree – keep clean, apply non-sulfa containing antimicrobial (not sulfadiazine). Osteochrondritis is difiguring complication of otic burns.

Hematoma: due to lack of subcutaneous fat, perichondrium is torn from underlying cartilage and adjoining blood vessels. A subperichondrial hematoma can result in stimulation of overlying perichondrium, resulting in asymmetric formation of new cartilage growth – ‘cauliflower ear.’ Tx: remove fluid collection and maintain pressure to prevent reaccumulation. Xeroform inside pinna with dry gauze to back and front on ear with ace wrap.

Foreign Bodies: Live objects drowned with 2% lidocaine or viscous lidocaine. Use alligator forceps.

Cerumen Impaction: Can use cerumen loops/scoops, consider half-strength hydrogen peroxide, mineral oil or debrox (carbamide peroxide). Leave in place for 30 minutes to soften cerumen. If irrigation is necessary, 18g catheter with butterfly tubing and syringe – irrigate along superior portion of canal – direct toward wall of canal and not TM.

Tympanic Membrane Perforation: due to OM or barotrauma, sometimes lightning strikes. Sometimes associated vertigo or tinnitus. Heal spontaneously. Do not allow water in canal, no need for topical or systemic abx unless contamination present (ofloxacin 0.3% otic).


Tintinalli, Seventh Edition, Chapter 237: Common Disorders of the External, Middle, and Inner Ear


Q. Most common region of TM that is perforated? A. Pars tensa. Wrong answers: pars flaccida, malleolar folds.

Q. Picture of Bullous Myringitis. A. Wrong answers: malignant OE, mastoiditis, perforation, tinnitus.

Q. Clinical history for mastoiditis. Tx? A. Admission/IV abx. Wrong answers: topical abx, topical analgesia, oral abx, reassurance, bedside I&D.

Q. Which medication is not commonly associated with tinnitus? A. Wrong answers: furosemide, aminoglycosides, aspirin.

237. Ear Disorders

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