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| TEXT BOOK of MEDICINE |
Section XXVI Eye, Ear, Nose, and Throat Diseases
| 452 APPROACH TO THE PATIENT WITH NOSE, SINUS, AND EAR DISORDERS Andrew H. Murr • |
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Patients with nose, sinus, and ear disorders may present with a variety of chief complaints. Nasal symptoms most commonly relate to rhinorrhea or congestion, both of which may be due to allergic, infectious, inflammatory, or structural causes. Sinus disorders, which commonly arise as a feeling of stuffiness or congestion but sometimes also manifest as pain or even headache (Chapter 421), have a similar set of causes. Common ear complaints include pain, loss of hearing (Chapter 454), and vestibular symptoms (Chapter 454), commonly described by the patient as dizziness but recognized by the physician as vertigo that is different from the lightheadedness that characterizes presyncope and syncope (Chapter 427). Epistaxis, which is bleeding from the nose, is usually easy to distinguish from hemoptysis from the bronchial tree (Chapter 83) or hematemesis from the gastrointestinal tract (Chapter 137).
Loss of hearing (Chapter 454) and vestibular symptoms (Chapter 454) are discussed elsewhere, as are smell, the related sensation of taste (Chapter 453), and the details of head and neck tumors (Chapter 200). This chapter focuses on the approach to patients with other common nose, sinus, and ear complaints.
▪NASAL AND SINUS COMPLAINTS
▪Rhinitis and Sinusitis
Definition
Rhinitis is generally defined as any inflammatory process in the nose, with the common result being a sensation of excess mucous or nasal congestion. The patient may have a sensation of fluid dripping from the nose, either coming from the nose anteriorly or coming from the nose posteriorly. Anterior nasal drainage may be perceived by the patient as being accompanied by an activity such as eating (gustatory rhinitis) and may be visible to an observer. Posterior nasal drainage is more nebulous and subjective, but it is very common and is referred to as postnasal drip.
In general, acute rhinitis and sinusitis describe inflammatory conditions of the nose and sinuses that last less than 4 weeks. Chronic rhinitis and sinusitis persist for more than 3 months despite treatment. Recurrent acute rhinitis and sinusitis are defined by exacerbations that occur four or more times per year and last 7 to 10 days per episode. Subacute rhinitis and sinusitis define symptoms that persist between 4 weeks and 12 weeks and resolve completely with treatment.
Epidemiology
The most common reason that a patient seeks the advice of a physician in the United States concerns problems relating to rhinitis and sinusitis. Over 20 million visits by patients per year are devoted to this complaint, and billions of dollars are spent on medications that are expected to improve the condition.
Pathobiology
Humans normally produce about 2 L of mucus per day from their nasal lining. The nose functions primarily as a humidification and filtration system, with a clean and refreshed nasal mucous blanket serving to trap particulate matter and organisms. The nasal and sinus lining consists of a ciliated respiratory epithelium; the cilia function in a highly organized and orderly fashion under normal circumstances to transport particulate matter trapped in the mucous blanket in a consistent fashion to allow the mucus to be swallowed, thereby avoiding deposition in the bronchi. The nose also serves as the organ of olfaction (Chapter 453) to allow patients to discern tastes and avoid spoiled foods that could cause illness.
The parasympathetic nervous system controls both vascular tone and mucus production in the nose. Inflammatory conditions, such as a common cold, can cause the nasal and sinus lining to swell, highlighting the nasal cycle governed by parasympathetic neural control. In a normal state, one side of the nose is relatively decongested and one side of the nose is relatively congested owing to vascular engorgement. This vascular dilatation allows humidification and warming of inspired air and can also affect the ability to discern odors in the process of olfaction. During rhinitis, the inflammation exaggerates the normal relative comparison between the decongested and congested sides of the nose and can be perceived as an uncomfortable nasal stuffiness that shifts from side to side over several hours.
Sinusitis differs from rhinitis because the term implies an infectious etiology rather than physiologic dysfunction. Nevertheless, many different mechanisms of inflammation besides infection may give rise to what is currently generally termed sinusitis.
Clinical Manifestations
When normal nasal mucosal function is lost, patients often complain of nasal crusting or obstruction, hypersecretion or postnasal drip, coughing, facial pressure, and fatigue. Nasal obstruction that shifts from side to side during the day is common in many types of rhinitis and may be considered an exaggeration of normal physiology.
Major symptoms of sinusitis (Table 452-1) include facial pressure, facial congestion or fullness, nasal obstruction, nasal discharge, and anosmia. Minor symptoms include headache, halitosis, fatigue, dental pain, cough, and ear pressure. Major signs include purulence in the nose noted on examination and, in acute sinusitis, fever. Pain is a frequent complaint with acute sinusitis but infrequent in chronic sinusitis. Patients with chronic sinusitis often note a dull facial pressure that seems to worsen with dependency. Patients with acute sinusitis may have discrete facial pain or dental pain but also have obvious purulent nasal discharge, often with a frank fever. It is important to note that facial pain is not a symptom of chronic sinusitis in the absence of other nasal signs and symptoms. Generally, sinusitis is thought to be present on the basis of at least two major factors, one major factor and two minor factors, or purulence on nasal examination.
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Diagnosis (Fig. 452-1)
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| FIGURE 452-1 The caudal aspect of the septum is often the site of origin of anterior epistaxis. |
History
A thorough history should probe whether patients have tried over-the-counter or prescription medications, including antihistamines, decongestants, mucolytics, analgesics, mast cell stabilizers, and even steroids, and whether they have helped improve the condition. In addition, other prescription medications have side effects that affect nasal physiology, including birth control pills, antihypertensive medications that cause systemic vasodilation, aspirin, steroids, and antibiotics. Specific questions regarding allergies are important, including seasonality or environmental triggers, the presence or absence of pets, food sensitivities, recent changes in environment, and living conditions, with a focus on old or new carpets, mattresses, furnace filters, or freshly painted interior walls. A patient should be questioned about past allergy skin testing or other testing.
A recent history of other family members or coworkers being ill suggests an infectious process. An astute physician often suspects an infectious process by noting the similarity and time course of symptoms in other patients; this information can be related to patients so that they know what to expect in terms of time course and recovery. A careful past medical history should determine whether relevant conditions such as prior nasal surgery or trauma, granulomatous diseases, cystic fibrosis (Chapter 89), rheumatologic conditions, immune deficiencies (Chapter 271), or other problems may be contributing factors. Unilateral nasal congestion raises a concern for either an anatomic abnormality such as a septal deviation, perhaps related to prior trauma, a polyp or other neoplastic mass, or perhaps even a foreign body.
Physical Examination
The nose should be inspected with a nasal speculum to assess the nasal septal anatomy, the most caudal aspect of the inferior turbinates (Fig. 452-2), and the possibility of large nasal polyps (Fig. 452-3) or other masses. In allergic rhinitis, the physical examination may reveal pale and swollen inferior turbinates, whereas copious nasal secretion are more apparent in viral infections. By spraying the nose with a topical decongestant such as phenylephrine (Neo-Synephrine), the middle meatus, which is the air space between the middle turbinate and lateral nasal wall, can often be visualized to assess for nasal polyps or purulent discharge. Examination of the mouth, oropharynx, and posterior pharyngeal wall, with a tongue blade if necessary, can sometimes identify a stream of postnasal discharge or pus. Sinus palpation and transillumination, although part of the art of medicine, are not sufficiently reliable for diagnosis. The patient's ability to open the mouth without limitation helps exclude trismus, which can sometimes be caused by a deep neck infection.
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| FIGURE 452-2 Edematous inferior turbinates narrowing the nasal airway in a patient with hay fever. (From Dhillon RS, East CA [eds]: Ear, Nose and Throat and Head and Neck Surgery, 2nd ed. Edinburgh, Churchill Livingstone, 1994, p 34.) |
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| FIGURE 452-3 Bilateral nasal polyps in the nasal vestibules. A polyp can easily be confused with a normal inferior turbinate. (From Dhillon RS, East CA [eds]: Ear, Nose and Throat and Head and Neck Surgery, 2nd ed. Edinburgh, Churchill Livingstone, 1994, p 36.) |
A complete examination of the head and neck should look for signs of recent or old trauma such as ecchymosis under the eyelids, swelling of the soft tissue of the face, or a deviation of the nasal dorsum. The neck should be palpated for adenopathy (Chapter 174) or other masses.
A basic eye examination should assess pupillary function, extraocular movements, and possible nystagmus (Chapter 450). An ear examination should assess the tympanic membranes bilaterally. In patients with an abnormality of the membrane or concomitant complaints of hearing loss or disequilibrium (Chapter 454), pneumotoscopy using an air bulb attached to the otoscope can be used to insufflate the ear canal and assess for mobility of the tympanic membrane; decreased mobility suggests a middle ear effusion. Weber and Rinne testing using a tuning fork screens for conductive hearing loss, especially unilateral.
Endoscopic examination of the nose, almost always by a specialist, is the “gold standard” for evaluating rhinitis and sinusitis. A flexible or rigid fiberoptic scope can allow fine inspection of the septum, turbinates, middle meatus, and sphenoethmoid recess as well as direct inspection of the nasopharynx, orifice of the eustachian tube, and the fossa of Rosenmüller, which is just rostral to the eustachian tube in the nasopharynx and is often the site of origin of nasopharyngeal carcinoma (Chapter 200). Flexible endoscopy can further inspect the oropharynx, larynx, and most of the hypopharynx (Chapter 455).
Laboratory Findings
Cultures
Cultures of the nostril or lower nasal cavity are not useful and are not recommended. An endoscopically guided culture by a specialist may help guide treatment for acutely ill immunocompromised patients, cases of refractory chronic rhinosinusitis, or patients whose sinusitis is suspected of causing secondary meningitis, epidural or subdural abscess, brain abscess, orbital involvement, or cavernous sinus thrombosis.
Other Tests
A nasal smear can reveal eosinophils, which are consistent with allergic rhinitis (Chapter 272). Likewise, skin testing or radioallergosorbent testing can help pinpoint allergic triggers (Chapter 270). In patients with acute sinusitis, a white blood cell count with differential may be useful. In patients with chronic sinusitis, serum immunoglobulin levels can be helpful: highly elevated immunoglobulin E (IgE) levels can raise suspicions for allergic fungal sinusitis, whereas low levels of IgG and other subclasses suggest immunodeficiency (Chapter 271). If the patient has chronic nasal crusting as a primary complaint, screening serologies for sarcoid (Chapter 95), Wegener's granulomatosis (Chapter 291), T-cell lymphomas (Chapter 196), syphilis (Chapter 340), tuberculosis (Chapter 345), Sjögren's syndrome (Chapter 289), and other chronic inflammatory diseases can be considered. In a patient with a lifelong history of sinusitis since childhood, cystic fibrosis should also be considered (Chapter 89).
Imaging
Noncontrast computed tomographic (CT) scanning is indicated for patients with known or suspected rhinitis and sinusitis. CT scans are generally ordered to document the presence of disease or the effects of treatment to improve the disease. CT scan examination is also used to evaluate complications of sinusitis or to investigate sinusitis in immunocompromised patients. Finally, the CT scan is critical prior to any surgical treatment of the sinuses. Opacification or other findings on a CT scan (Fig. 452-4) can often differentiate among the various causes of sinusitis. Plain films have little utility and are not generally recommended. Magnetic resonance imaging (MRI) is occasionally helpful.
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| FIGURE 452-4 Coronal computed tomography scan showing bilateral acute pansinusitis. There is a fluid level in the left maxillary sinus, which, if aspirated, can be sent for microbiology. (From Dhillon RS, East CA [eds]: Ear, Nose and Throat and Head and Neck Surgery, 2nd ed. Edinburgh, Churchill Livingstone, 1994, p 50.) |
Differential Diagnosis
A rapid onset of symptoms present for a short time suggests a viral upper respiratory infection, especially if the patient also has typical systemic symptoms, such as arthralgias, myalgias, fever, chills, gastrointestinal symptoms, and cough in addition to nasal congestion, postnasal drip, and headache. By comparison, acute bacterial rhinosinusitis arises with facial pressure and purulent postnasal discharge. Often, viral disease can progress to a secondary bacterial infection, which can become chronic. The acute onset of inhalant allergy is often seasonal or can be traced to a particular precipitant (Chapter 272). Allergic rhinitis typically responds to an empirical trial of antihistamines, whereas viral or bacterial rhinitis does not.
Chronic sinusitis must be differentiated from rhinitis, which is not accompanied by the same degree of incessant inflammation. Types of rhinitis include gustatory rhinitis associated with eating, rhinitis of pregnancy, rhinitis associated with abuse of topical vasoconstrictors, rhinitis associated with illicit drug use (e.g., cocaine or methamphetamine), rhinitis of aging, vasomotor rhinitis presumably related to a hypersecretory state mediated by the parasympathetic nervous system, and perennial allergic rhinitis, whose hallmark is a lack of seasonality.
Chronic sinusitis may be caused by chronic viral infection, chronic bacterial infection, chronic fungal infection, and chronic allergy. It is often difficult to pinpoint a specific cause, but the common underlying factor is often inflammatory in nature. Whereas maxillary antral punctures were used for diagnosis and treatment in the pre-CT era, endoscopically guided culture techniques combined with CT imaging are now the standard of care, except in acute bacterial maxillary sinusitis, for which surgical decompression is desirable, or in some cases of refractory sinusitis in immunocompromised patients or in the intensive care unit, where direct culture can guide antibiotic therapy.
Nasal polyps may be caused by Samter's triad (asthma, aspirin sensitivity, and nasal polyposis related to upregulation of leukotrienes caused by prostaglandin blockade). Human papillomavirus (Chapter 396) may cause an inverted papilloma, which responds to surgical excision but can transform to frank malignancy. Polyps are also seen in patients with cystic fibrosis (Chapter 89) and allergic fungal sinusitis, which is manifested by an elevated IgE level, positive fungal cultures (usually for aspergillosis), Charcot-Leyden crystals on histopathology, characteristic densities on CT imaging, and nasal polyposis that is often, but not always, unilateral. Antral choanal polyps may extend into the nasal cavity or nasopharynx and cause obstruction.
CT imaging can reveal mucoceles, blocked individual sinuses that continue to secrete mucus and can slowly erode bone, expand to involve the eye and brain, or become acutely infected. A mycetoma, which is an isolated “fungus ball” of a sinus, has a characteristic hyperdensity within a sinus opacification. Unilateral nasal polyposis is suggestive of antral choanal polyps, malignancy, inverted papilloma, or allergic fungal sinusitis; early biopsy is recommended. Mucus retention cysts, often present in the maxillary sinus, are manifested by a spherical opacification; an estimated 10% of the population has a mucus retention cyst, which is often asymptomatic.
Treatment
Medical Therapy
Viral rhinitis is treated with supportive care, including fluid replacement and treatment of the febrile component of the syndrome with acetaminophen or nonsteroidal anti-inflammatory medications. Steam has a mild decongestant effect, and vitamin C and good nutrition may help hasten the resolution of symptoms. Oral decongestants (such as pseudoephedrine 120 mg every 12 hours for several days), mucolytics (such as guaifenesin 200 to 400 mg every 4 to 6 hours for several days), and ipratropium bromide (0.03 or 0.06%, two sprays on each side of the nose every 12 hours for several days) are of potential benefit.
Allergic rhinitis (Chapter 272) responds to various antihistamines, such as diphenhydramine hydrochloride (25 to 50 mg every 4 to 6 hours), loratadine (5 mg twice a day or 10 mg a day), cetirizine hydrochloride (10 mg a day), and fexofenadine hydrochloride (60 mg twice a day or 120 mg a day), and topical nasal steroids, including triamcinolone acetonide (two sprays [55 μg] to each side of the nose every day), mometasone furoate (two sprays [50 μg] to each naris every day), fluticasone propionate (two sprays [50 μg] to each naris every day), and budesonide (two sprays [32 μg] to each naris every day). Oral steroids such as prednisone and methylprednisolone in various doses are sometimes useful as well. Allergic desensitization is sometimes recommended when a discrete allergen elicits a strong reaction in a patient. Allergic desensitization may specifically be beneficial in some inflammatory disorders, such as allergic fungal sinusitis.1 Nasal polyps frequently respond to oral steroids, either in a tapered burst dose or, in rare cases, in small amounts of titrated daily oral steroids such as prednisone or methylprednisolone.
Bacterial sinusitis should be treated with antibiotics directed toward Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, and Staphylococcus aureus. Antibiotics such as amoxicillin 500 mg three times a day or erythromycin 500 mg twice a day for 2 to 3 weeks with a subsequent follow-up examination to document resolution are reasonable first-line coverage. β-Lactamase–stable antibiotics are used as a second-line treatment, as are antibiotics that have good anaerobic coverage: amoxicillin with clavulanic acid at 875 mg twice a day for β-lactamase stability or clindamycin at 300 mg three times a day for anaerobic coverage. The use of antifungals including itraconazole in an oral or aerosolized form and amphotericin B in an aerosolized form is controversial in the treatment of chronic sinusitis.2
Surgical Therapy
Surgery is recommended in patients with mucoceles, inverted papilloma, antral choanal polyps, juvenile nasopharyngeal angiofibroma, and malignancies. Surgery can correct septal deviations and anatomically related nasal obstruction. Surgery on the inferior turbinates may be beneficial in refractory rhinitis. Surgery for benign nasal polyposis can improve symptomatic control and reduce the need for oral steroids. Functional endoscopic surgery, which is designed to preserve mucociliary function and is performed with endoscopes through the nostril without large incisions, can be useful in recurrent acute sinusitis and in chronic rhinosinusitis.
▪Epistaxis
For a patient with epistaxis, it is first critical to determine the severity of the blood loss. Persistent bleeding may result from warfarin, antiplatelet agents, or any underlying platelet or (Chapter 179) clotting deficiency (Chapter 180). Physical examination should focus on inspection of the anterior septum, which is the most frequent point of origin for epistaxis. Often, dilated blood vessels on the caudal septum can be seen upon anterior rhinoscopy (Fig. 452-5). The combination of unilateral otitis media, epistaxis, nasal congestion, and a neck mass would be concerning for nasopharyngeal carcinoma. Rare tumors that can arise with bleeding include juvenile nasal angiofibromas in male patients.
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| FIGURE 452-5 Dilated nasal vessels and crusting typical of a patient with epistaxis. |
Epistaxis can be treated by local pressure, packing (using nasal sponges, balloons, or petroleum jelly–impregnated 1/2 inch by 72 inch gauze), humidification, and hydration. Hospitalization and transfusion are rarely required. Offending medications should be reduced in dose or discontinued temporarily if possible. Occasionally, lasers are used or other types of cautery can address a specific bleeding area.
▪EAR PAIN
Definition
Ear pain (Table 452-2) is discomfort perceived by a patient in the area of the temporal bone. Although the discomfort can often be localized by the patient, at times the cause of the discomfort may in fact be distant from the site where the pain is felt. This referred pain can be due to problems in the oral cavity, oropharynx, hypopharynx, or larynx.
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Pathobiology
The ear is well supplied with sensory nerves and is positioned on the side of the skull. The ear is divided into the outer ear or pinna and ear canal; the middle ear, which encompasses the tympanic membrane and ossicles; and the inner ear, which includes the cochlea and the vestibular canals, including the utricle and saccule. In general, otalgia is due to problems in the outer or middle ear. The trigeminal nerve innervates the anterior superior quadrant of the pinna, whereas the C2 and C3 cervical cutaneous nerves innervate the rest of the majority of the outer ear. However, there are contributions by ninth and tenth nerves in the ear canal and even a small patch of sensory innervation by the seventh nerve in the posterior superior ear canal. It is the overlap in distribution of the ninth and tenth cranial nerves that establishes the anatomic basis for referred otalgia in diseases of the oral cavity, oropharynx, and larynx. Therefore, ear pain may be due to inflammatory conditions of the skin of the outer ear, the ear canal, or the middle ear, or it may be due to disease processes unrelated to the ear itself.
Clinical Manifestations
Patients with ear pain often present with complaints referable directly to the ear itself. In cases of otitis externa, frankly obvious erythema and swelling of the ear canal may be present. Even minute physical manipulation of the ear may be excruciating. In chondritis of the pinna, which may be related to rheumatologic disorders, infection, or trauma, the entire pinna may be swollen and painful. Hearing loss accompanying otalgia may indicate middle ear disease, especially otitis media. Patients sometimes complain of pain in the ear after air travel or driving from a mountainous region. Quick changes in pressure, such as are encountered in scuba diving, may indicate barotrauma (Chapter 94), in which the eustachian tube is unable to compensate rapidly enough for the pressure changes that are encountered. Pain may also be a post-traumatic symptom from relatively minor percussion injury, more severe head trauma, or percussion injury related to a blast. Pain related to noise exposure may also indicate damage to the middle ear or even inner ear. Deep-seated boring pain over the temporal area accompanied by retro-orbital pain can be due to petrous apex disease, including petrous apicitis.
Diagnosis
History
A patient with ear pain should be asked to reveal the location of the discomfort, the duration of the symptoms, and any activities related to the onset of the condition. As an example, recent swimming would make otitis externa more likely, whereas a recent upper respiratory infection with hearing loss would suggest otitis media. Questions should address possible hearing loss, vertigo, otorrhea, hoarseness, voice change, dysphagia, odynophagia, dyspnea, hemoptysis, hematemesis, and weight loss. A social history with specific concentration on tobacco and alcohol use should be obtained. A possible family history of upper aerodigestive tract and nasopharyngeal carcinoma should be sought. A past surgical history can reveal distant ear or throat surgery.
Physical Examination
A complete head and neck examination, including a general assessment for trauma and a basic eye examination, is required. The outer ear and pinna should be examined first. The ear canal should be first palpated, then inspected. An otoscope with a pneumatic bulb attachment is critical to establish the presence or absence of a middle ear effusion. Inspection of the tympanic membrane should be accomplished with notations made about patency and perforation, translucency of the eardrum, position and definition of the malleus, and the eardrum's mobility with the ear canal sealed and a puff of air delivered by the pneumatic bulb (Fig. 452-6). Abnormalities may be caused by infection (Fig. 452-7) or barotrauma (Fig. 452-8). A tuning fork examination with a 512-Hz tuning fork should be accomplished to determine lateralization of the sound (Weber examination) and should be used to determine whether air conduction is superior to bone conduction (Rinne examination). Facial nerve function should be assessed (Chapter 446) by determining whether the patient can close the eyes. The presence or absence of nystagmus should be recorded. Inspection of the nose, oral cavity, oropharynx, and neck should be accompanied by a cranial nerve examination (Chapter 418). Palpation of the tongue and tonsils is especially important if the ear pain is intense and persistent. A careful neck examination should look for masses. Oral cavity infections (Chapter 451) such as a peritonsillar abscess or severe tonsillitis may arise as ear pain, and the physical examination should reveal trismus, erythema, mass effect, and other common signs of pharyngitis.
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| FIGURE 452-6 A normal tympanic membrane. (From Dhillon RS, East CA [eds]: Ear, Nose and Throat and Head and Neck Surgery, 2nd ed. Edinburgh, Churchill Livingstone, 1994, p 2.) |
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| FIGURE 452-7 Otoscopic appearance in otitis media with effusion. The handle and short process of the malleus are brought into relief by retraction of the eardrum. There is a slightly yellow appearance of the eardrum related to the middle ear effusion. (From Dhillon RS, East CA [eds]: Ear, Nose and Throat and Head and Neck Surgery, 2nd ed. Edinburgh, Churchill Livingstone, 1994, p 7.) |
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| FIGURE 452-8 Blood in the middle ear (hemotympanum). Causes include otitic barotraumas, secretory otitis media, and high jugular bulb. (From Dhillon RS, East CA [eds]: Ear, Nose and Throat and Head and Neck Surgery, 2nd ed. Edinburgh, Churchill Livingstone, 1994, p 26.) |
Laboratory
An audiogram can assess hearing loss (Chapter 454). A tympanogram measures compliance of the middle ear system and is an accurate method used to diagnose otitis media. Cultures are rarely used because they require tympanocentesis, and cultures of the external ear can reveal a vast variety of organisms that are often treated empirically with antibiotics. If a fever and middle ear effusion are present and neck stiffness is part of the physical examination picture, a lumbar puncture may rarely be recommended (Chapter 437).
Imaging
In general, imaging is indicated if there are suspected complications of acute or chronic otitis media or to look for occult causes in the upper aerodigestive tract. If a patient is suspected to have meningitis, epidural or subdural abscess, brain abscess, or sagittal sinus thrombosis, imaging is mandatory. Imaging is also useful for operative planning in cases of chronic otitis media or (rarely) to evaluate tumors of the middle or external ear.
Differential Diagnosis
Otitis externa, which is an infection of the skin of the ear canal, is often due to manipulating the ear after swimming or trying to scratch an ear canal that itches because of skin irritation. Erythema of the canal skin and extreme pain on manipulating the ear canal are present. In the presence of concomitant cranial neuropathies, especially in diabetic or otherwise immunocompromised patients, malignant otitis externa with osteomyelitis should be suspected. Inspection of the tympanic membrane may reveal fluid (see Fig. 452-7), consistent with otitis media; the tuning fork examination should support the presence of a conductive hearing loss. Vesicles on the conchal portion of the pinna, especially when accompanied by a facial nerve paralysis, strongly suggest herpes zoster oticus with Ramsay Hunt syndrome (Chapter 454). A perforation of the eardrum suggests either acute or chronic otitis media, traumatic perforation, or possibly cholesteatoma (Chapter 454) if the perforation is in the posterior superior quadrant. Chronic draining otorrhea of long standing with a deep boring pain and a perforation of the tympanic membrane suggests a complication of otitis media.
If the ear and cranial nerve examination is negative but the patient's complaints of otalgia are persistent, special efforts need to be made to visualize the upper aerodigestive tract including the nasopharynx, oral cavity, oropharynx, larynx, and hypopharynx to be sure that infection or tumor is not present in these hard-to-examine areas. MRI can be very useful in these cases.
Treatment
Otitis externa is often treated with office suctioning of debris using a microscope and the application of antibiotic drops (ciprofloxacin, tobramycin, neomycin, polymyxin B) with or without hydrocortisone in various combinations. Often, a small wick or sponge is placed into the ear canal to help maintain patency of the canal and to allow facile application of the medications. For otitis media, oral antibiotic treatment is directed at eradicating H. influenzae, M. catarrhalis, S. pneumoniae, and S. aureus with amoxicillin or erythromycin as for sinusitis (see earlier). The benefit is notable for children aged 2 years or younger with bilateral otitis and for older children with otitis plus otorrhea, whereas other patients can be observed without antibiotics.3 Interestingly, the natural history of acute otitis media is acute perforation of the eardrum, which often results in otorrhea and a relief of pain. Most middle ear effusions clear spontaneously within 3 months whether or not they are treated. Most perforations of an eardrum caused by trauma heal without surgical intervention, but if an eardrum perforation persists for more than about 3 months, surgical closure utilizing tympanoplasty with or without mastoidectomy can be contemplated. Chronic draining perforations, especially if located in the posterior superior quadrant of the tympanic membrane, may require tympanomastoid surgery.
Patients with suspected herpes zoster can be started on acyclovir 800 mg by mouth every 4 hours for about 10 days with or without prednisone (Chapter 398). Intracranial complications of otitis media often need to be addressed surgically.
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