Painful external ears (otalgia)
Thursday, 27 October 2022
15:11
OTITIS EXTERNA
Presentation:
Discharge
Ear pain
Itch
Tragal tenderness - acute inflammation of the skin of the meatus (excess
canal moisture)
Causes:
Excess canal moisture
Trauma e.g. fingernails
High humidity
Absence of wax
Narrow ear canal
Hearing aids
Bacteria:
Pseudomonas
Staph aureus
Types:
>MILD OE:
Scaly skin with some erythema
Normal diameter of external auditory canal (EAC)
Treatment:
o Clean the EAC ***
o Ears should be kept water free during treatment
o Hydrocortisone cream on the pinna
o Acetic acid spray acts as an antifungal/bacterial
>MODERATE OE:
Painful ear
Narrowed EAC with malodorous creamy discharge
Treatment:
o Swab for microscopy
o Clean the EAC***
o Topical antibiotic +- steroid drops
Due to ototoxicity of aminoglycosides, they are
contraindicated in patients with grommets or perforation
Use drops for 7 days or less as fungal infections can arise.
These can be treated with clotrimazole 1% solution
>SEVERE OE:
The EAC is occluded.
Treatment:
o A thin ear wick with aluminium acetate
o After a few days, the meatus will open up enough for either
microsuction or careful cleansing
, Beware persistent unilateral otitis externa in diabetics/ immunosuppressed
-> necrotising otitis externa
MALIGNANT/NECROTISING OTITIS EXTERNA
Aggressive, life-threatening infection of the external ear that can lead to
temporal bone destruction and base-of-skull osteomyelitis. 90% have diabetes.
Treatment:
Surgical debridement
Systemic antibodies
Specific Igs
FURUNCULOSIS
Very painful staphylococcal abscess arising in a hair follicle within the canal.
Consider lancing. If there is pinna cellulitis start oral antibiotics (e.g.
flucloxacillin). Diabetes is an important predisposing factor.
BAROTRAUMA
If the Eustachian tube is occluded, middle ear pressure cannot be equalised
during descent in an aircraft or diving, hence causing damage.
Symptoms:
Severe pain as the drum becomes indrawn initially then a secondary
effusion may occur as a transudate or a hemotympanum
Prevention:
Don't fly with an URTI
Decongestants into the nose
Repeated yawns/swallows/jaw movements
Treatment:
Supportive if simple
Effusions usually clear spontaneously
Most perforations heal
TEMPOROMANDIBULAR JOINT (TMJ) DYSFUNCTION
Symptoms:
Earache
Facial pain
Joint clicking/popping related to teeth-grinding, joint derangement, and
stress
Signs:
Joint tenderness exacerbated by lateral movement of the open jaw, or
trigger points in the pterygoids
Treatment:
Most improve without treatment
Reassure and explain
Simple analgesia
Specialist treatment:
o Dental occlusion therapy (e.g. oral splinting)
o Physiotherapy
, o Cognitive behavioural therapy
o Surgery
CLEANING THE EXTERNAL AUDITORY CANAL
Gentle syringing or irrigation to remove debris
Dry mopping:
o Under direct vision using a Jobson Horne probe with a small piece of
cotton wool
Microsuction - referral to ENT
REFERRED OTALGIA
Nerve Notes
V Auriculotemporal nerve (branch of trigeminal)
which supplies the upper lateral half of the
pinna may refer pain from dental disease and
TMJ dysfunction
VII Sensory branch of the facial nerve (lateral
surface of the ear drum) may refer pain from
geniculate herpes
IX Primary glossopharyngeal neuralgia
IX&X Tympanic branch of the glossopharyngeal
nerve and auricular branch of the vagus
(medial surface of drum) refer pain from the
posterior 1/3 of the tongue, pyriform fossa, or
larynx, e.g. from cancer, or from the throat to
the ear e.g. in tonsilitis or quinsy. Otalgia is
common post tonsillectomy
C2 & The great auricular nerve (lower 1/2 of the
3 pinna) refers pain from soft tissue injury in the
neck and from cervical spondylosis/arthritis
Discharging ears and otitis media
Saturday, 29 October 2022
18:49
Character of discharge:
External ear - inflammation, i.e. otitis externa produces a scanty (small
amounts) discharge, as there are no mucinous glands. Blood can result
from trauma to the canal. Liquid wax can sometimes leak out
Thursday, 27 October 2022
15:11
OTITIS EXTERNA
Presentation:
Discharge
Ear pain
Itch
Tragal tenderness - acute inflammation of the skin of the meatus (excess
canal moisture)
Causes:
Excess canal moisture
Trauma e.g. fingernails
High humidity
Absence of wax
Narrow ear canal
Hearing aids
Bacteria:
Pseudomonas
Staph aureus
Types:
>MILD OE:
Scaly skin with some erythema
Normal diameter of external auditory canal (EAC)
Treatment:
o Clean the EAC ***
o Ears should be kept water free during treatment
o Hydrocortisone cream on the pinna
o Acetic acid spray acts as an antifungal/bacterial
>MODERATE OE:
Painful ear
Narrowed EAC with malodorous creamy discharge
Treatment:
o Swab for microscopy
o Clean the EAC***
o Topical antibiotic +- steroid drops
Due to ototoxicity of aminoglycosides, they are
contraindicated in patients with grommets or perforation
Use drops for 7 days or less as fungal infections can arise.
These can be treated with clotrimazole 1% solution
>SEVERE OE:
The EAC is occluded.
Treatment:
o A thin ear wick with aluminium acetate
o After a few days, the meatus will open up enough for either
microsuction or careful cleansing
, Beware persistent unilateral otitis externa in diabetics/ immunosuppressed
-> necrotising otitis externa
MALIGNANT/NECROTISING OTITIS EXTERNA
Aggressive, life-threatening infection of the external ear that can lead to
temporal bone destruction and base-of-skull osteomyelitis. 90% have diabetes.
Treatment:
Surgical debridement
Systemic antibodies
Specific Igs
FURUNCULOSIS
Very painful staphylococcal abscess arising in a hair follicle within the canal.
Consider lancing. If there is pinna cellulitis start oral antibiotics (e.g.
flucloxacillin). Diabetes is an important predisposing factor.
BAROTRAUMA
If the Eustachian tube is occluded, middle ear pressure cannot be equalised
during descent in an aircraft or diving, hence causing damage.
Symptoms:
Severe pain as the drum becomes indrawn initially then a secondary
effusion may occur as a transudate or a hemotympanum
Prevention:
Don't fly with an URTI
Decongestants into the nose
Repeated yawns/swallows/jaw movements
Treatment:
Supportive if simple
Effusions usually clear spontaneously
Most perforations heal
TEMPOROMANDIBULAR JOINT (TMJ) DYSFUNCTION
Symptoms:
Earache
Facial pain
Joint clicking/popping related to teeth-grinding, joint derangement, and
stress
Signs:
Joint tenderness exacerbated by lateral movement of the open jaw, or
trigger points in the pterygoids
Treatment:
Most improve without treatment
Reassure and explain
Simple analgesia
Specialist treatment:
o Dental occlusion therapy (e.g. oral splinting)
o Physiotherapy
, o Cognitive behavioural therapy
o Surgery
CLEANING THE EXTERNAL AUDITORY CANAL
Gentle syringing or irrigation to remove debris
Dry mopping:
o Under direct vision using a Jobson Horne probe with a small piece of
cotton wool
Microsuction - referral to ENT
REFERRED OTALGIA
Nerve Notes
V Auriculotemporal nerve (branch of trigeminal)
which supplies the upper lateral half of the
pinna may refer pain from dental disease and
TMJ dysfunction
VII Sensory branch of the facial nerve (lateral
surface of the ear drum) may refer pain from
geniculate herpes
IX Primary glossopharyngeal neuralgia
IX&X Tympanic branch of the glossopharyngeal
nerve and auricular branch of the vagus
(medial surface of drum) refer pain from the
posterior 1/3 of the tongue, pyriform fossa, or
larynx, e.g. from cancer, or from the throat to
the ear e.g. in tonsilitis or quinsy. Otalgia is
common post tonsillectomy
C2 & The great auricular nerve (lower 1/2 of the
3 pinna) refers pain from soft tissue injury in the
neck and from cervical spondylosis/arthritis
Discharging ears and otitis media
Saturday, 29 October 2022
18:49
Character of discharge:
External ear - inflammation, i.e. otitis externa produces a scanty (small
amounts) discharge, as there are no mucinous glands. Blood can result
from trauma to the canal. Liquid wax can sometimes leak out
