Common Ear Conditions

1
Common Ear Conditions

• F Bhatti ST2 Group B
• 9/12/08

2
Outline of the presentation

• Few common presentations in general practice
  related to ears
• . Examining the ears
• . Ear Wax and syringing
• . Otitis Externa
• . Otitis Media( Acute and Chronic)
• . Eustacian tube dysfunction
• . Perforations ( Safe vs. Unsafe)
• Treatment ( Evidence based)
• Lots of pictures!
• Few questions( AKT based)

3
Sources (With hyperlinks)

• GP Notebook
• http//www.gpnotebook.co.uk/homepage.cfm
• CKS
• http//cks.library.nhs.uk/home
• ENT USA
• http//www.entusa.com/index.html
• Passmedicine
• http//www.passmedicine.com/index.php
• University of Bristol, Otoscopy tutorial
  http//www.bris.ac.uk/Depts/ENT/otoscopy_tutorial.
  htm
• You Tube
• BMJ Learning
• Bradford VTS website ( With thanks to Dr R Mehay)

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ENT Examination

• You tube video of ENT examination in an OSCE
  situation. http//www.youtube.com/watch?vmDbwAPr
  5RvU
• Ear examination- You tube video
  http//uk.youtube.com/watch?vI3sa2W83iuoNR1
• NB
• . The canal may be partly straightened by pulling
  the pinna backwards and upwards during
  examination.
• . In infants pull the pinna more horizontally
  backwards as the shape of the ear canal is
  different.

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Normal
- Consider the malleus as an arrow pointing in
the forward direction. - The normal tympanic
membrane should appear . pearly grey . have a
light reflex . generally concave . and malleus
should be visible Abnormals . Retraction( bones
more prominent) . Perforations . Bubbles (glue
ear, resolving infection) . White patches
(tympanosclerosis or cholesteatoma) .
Granulations . Red lesion at tip of malleus
(glomus tumour) . Grommets/FBs
Anterior direction

• Attic

Posterior
Anterior
Inferior
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Ear Drum-normal Landmarks
An  annulus fibrosus or more commonly referred
to as the eardrum margin. This is important.
Note how smooth and how ever so slightly blurry
it is. Um  umbo - the end of the malleus
handle and usually marks the centre of the
drum Lr  light reflex or Cone of light is
usually seen antero-inferioirly At  Attic also
known as pars flaccida. Any perforations here
are serious and need referral. Lp  Lateral
process of the malleus Hm  handle of the malleus
Lpi  long process of incus - sometimes visible
through a healthy translucent drum
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Go systematically

• External
• Pinna (shape, colour, position, tenderness,
  haematoma) etc
• Mastoid (tenderness in AOE or mastoid abscess)
• Internal
• The Canal ( skin, furuncle, scales,spores,FBs,di
  scharge, debris, wax)
• The Tympanic membrane (look ant, post,
  superior/ attic and inferior of malleus)
• . Colour( opaque, white, red, patches
  translucency)
• . Retraction( landmarks behind it more
  visible)
• . Perforation ( safe/ unsafe)
• . Discharge (purulent, mucopurulent)
• Behind the Eardrum
• . Fluid behind the drum( meniscus, air fluid
  levels, colour, bubbles?..can ask for a
  valsalva if appropriate)
• . Any red bits( glomus tumour, granulations or
  blood?, white- cholesteotoma)

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Ear Wax

• Wax is produced in the outer half of the ear
  canal and migrates outwards along with the canal
  skin. Inappropriate instrumentation can cause
  impaction.
• Wax impaction can cause hearing loss, pain,
  tinnitus, vertigo, or chronic cough but not
  usually discharge.
• Sudden expansion after getting water in can cause
  sudden deafness or pain, but needs careful
  exclusion of other pathology behind it e.g.
  cholesteotoma
• Be mindful of other possibilities

FB(crayon) in a childs ear
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Ear Wax.contd

• Management
• . Educate about non instrumentation of their ear
  canals.
• If Symptomatic
• . Syringing (with use of drops) or wax hook.
• . Different preparations available none superior
  to other.
• Sodium bicarbonate drops might be better at
  disintegrating wax, but can cause dryness of the
  canal and/ or irritation
• . Instructions for use
• e.g. Olive oil drops warmed on a warm spoon.Put
  2-3 drops in the ear and lie on the opposite side
  for 3-5 mins. Use BD. Get syringed in 5-7 days.
• . When to refer to ENT clinic
• . Patients known to have a tympanic membrane
  perforation or previous ear surgery (need
  microsuction), only hearing ear
• . Syringing fails
• . Causes pain or vertigo,
• . Hearing loss persists after wax removal.
• . Keratosis Obturans

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Otitis Externa

• Infection of the external auditory canal.
  Mediterranean ear/Swimmers ear
• Usually unilateral
• Gradual onset pruritis, pain, hearing loss, and
  ear discharge which varies in consistency and
  colour. Discharge not mucoid in consistency as no
  mucin glands are present in the ext aud canal.
• The pt is usually well.
• Can result in a featureless ext aud canal
• Risk factors trauma, water, Immunosuppression,
  eczema
• Can be fungal- spores might not always be visible
• If treatment fails or otitis externa recurs
• frequently consider sending an ear swab
• for bacterial and fungal microscopy
• and culture

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Management

• Remove or treat any precipitating or aggravating
  factors.
• Analgesic
• A topical ear preparation for 7 days. Options
  include preparations containing
• a. Both a non-aminoglycoside antibiotic a
  corticosteroid e.g. flumetasoneclioquinol
  (LocortenVioform) ear drops.
• b. Both an aminoglycoside antibiotic and a
  corticosteroid (contraindicated if the tympanic
  membrane is perforated).
• c. Topical preparations containing only an
  antibiotic (gentamicin ear drops are
  contraindicated if the tympanic membrane is
  perforated).
• d. Antifungal or ? something containing all
  three
• Aural toilet if earwax or obstruct topical
  medication (may require referral).
• If there is extensive swelling of the auditory
  canal, consider inserting an ear wick (may
  require referral).
• Provide appropriate self-care advice

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Current Evidence

• Topical corticosteroids are at least as effective
  as topical antibiotics combined with
  corticosteroids. However, because of
  methodological weaknesses in the clinical trials
  and because acute diffuse otitis externa is
  thought to be caused by an infection, topical
  corticosteroids on their own are not generally
  recommended as first-line treatment
• Clioquinol is antibacterial and antifungal and
  has lower risks of skin reactions and ototoxicity
  than aminoglycosides. Therefore, on theoretical
  grounds, the combination flumetasoneclioquinol
  might be slightly preferred.
• Oral Abx usually where furunculosis and/or
  extensive spreading cellulitis- In 1997, GPs
  prescribed oral antibiotics for 21 of first
  episodes of otitis externa. Amoxicillin/ampicillin
  was the most frequently prescribed antibiotic
  (34)
• Flucloxacillin narrower spectrum but good tissue
  diffusion
• Erythromycin wider spectrum- effective for most
  sensitive Gram cocci and some Gram ve cocci
  and anaerobes Clarithromycin less GI side
  effects but more expensive

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Malignant Otitis Externa

• "Malignant" otitis externa is a severe infection
  due to Pseudomonas aeruginosa and anaerobes
  causing osteomyelitis of the skull base
  characterised by severe pain, involvement of the
  floor of the ear canal, sometimes with
  granulation tissue. If untreated, it can involve
  the cranial nerves and brain. It is not a
  neoplastic process.
• Facial nerve palsy occurs in 50 of patients, IX
  to XII may also be involved. immunocompromised
  patients, especially elderly diabetics. It may be
  life threatening.
• What to look for Elderly, DM, ear otalgia,
  otorrhoea, hoarseness, puffiness , trismus,
  failure to respond to drops, granulations, CN
  palsies etc
• Mx
• -Refer
• -Intensive local and systemic antibiotics against
  Pseudomonas are required if malignant otitis
  externa is present, e.g. ciprofloxacin or
  ceftazidime, plus suitable anaerobic cover e.g.
  metronidazole.

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Question 1

• 23 yr old man, 4 days Hx of itchy sore Rt ear
  returned recently from holiday in Spain
• O/E Rt ext auditory canal is inflamed but no
  debris seen. T.membrane is visible and
  unremarkable. What is the most appropriate
  management?
• A. Topical corticosteroid Aminoglycoside
• B. Topical corticosteroid
• C. Tell him serves him right for going on a
  holiday while you work!
• D. Topical corticosteroid Clotrimazole
• E.. Oral Flucloxacillin

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Answer 1

• Correct Answer is A.
• Dx- Otitis externa- Topical antibiotic or
  combined Antibiotic corticosteroid preparation

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Question 2

• 53 year old man, fastidiously clean, previously
  normal hearing, currently recent onset strange
  sensation in me ear! slightly reduced hearing
  have been trying to pop them. Perchance you
  had a brilliant presentation on ENT conditions
  from a fellow registrar on the last VTS half day
  release and you recognise the cone of light is
  normal, but what is this
• Normal ear drum
• Otitis Externa secondary to ear buds use
• Serous Otitis Media
• Time waster/ Hidden agenda

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Answer 2

• Serous Otitis media because of Eustacian tube
  dysfunction
• Has normal cone of light, mild redness externally
  likely normal, fluid level, and mildly retracted
  ear drum

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Question 3

• A 28 year old woman presents with a 5 day Hx of
  pain in her Rt ear, reduced hearing, and yellow
  coloured discharge.
• A. Keeping this picture in mind what test on
  physical exam could have given you a clue about
  the diagnosis.
• B. What is the likely diagnosis
• a. Acute Otitis Media
• b. Acute Otitis Externa
• c. Chronic Suppurative Otitis media
• d. Its actually a picture from a colposcopy
  examination!

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Answer 3

• Tragal tenderness
• Answer is Acute Otitis Externa
• ( for those who thought it was a picture from a
  colposcopy, may be its time for you to move on to
  your next job!)

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Question 4

• Which of the following statements about otitis
  externa is correct?
• You should avoid removing canal debris
• Its common in people not wearing ear protection
  while working with loud power tools as a divine
  punishment.
• It may result in a featureless tympanic membrane
• d. It is usually due to a Staphylococcus aureus
  infection

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Answer 4

• Correct answer- It may result in a featureless
  tympanic membrane
• Commonest causative organism for infective otitis
  externa is Pseudomonas
• Could be difficult to eradicate in someone
  wearing ear protection in certain occupations
  e.g. forge/factory workers

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Question 5

• Which of the following statements about the use
  of topical eardrops is correct?
• a. Only use topical ear drops if the tympanic
  membrane is visible
• b. Topical eardrops are contraindicated in
  children under the age of 12years
• c. Topical eardrops cannot be used in the
  presence of a perforated tympanic membrane
• d. Topical eardrops can worsen otitis externa
• e. If its difficult putting them in your ears,
  they are equally effective putting them in your
  nose and standing on your head for 3.37 mins.

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Answer 5

• Correct answer- Topical eardrops can worsen
  otitis externa if there is sensitivity to them
• The use of ototoxic drops in the presence of a
  perforated tympanic membrane is controversial due
  to reports of sensorineural hearing loss as a
  result of their application. Reports of this
  association are rare and often the validity of
  such reports is questionable. Certainly the risks
  of sensorineural hearing loss or of major
  complications of otitis media are of more
  significance. Limiting the course of treatment
  and ensuring that they are not used in healthy
  ears can reduce any potential risks from the
  administration of ototoxic medicines.
• There is no quality evidence supporting putting
  ear drops in your nose and standing on your head
  but there is certainly none to refute it.

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Otitis Media

• Can be acute or chronic
• Can be with or without serous effusion (acute or
  chronic)
• Can be Acute or chronic suppurative
• Can co-exist with Otitis externa
• Otitis media with serous effusion Glue Ear

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Acute Otitis Media

• Common in children
• Unwell/pyrexia, otalgia/discharge
• there may be tenderness over the mastoid
• discharge in meatus
• loss of outline of drum and landmarks
• TM red, bulging,oedematous or perforation.
• Mostly viral but can be Streptococcus/Haemophilus
• Risk factors
• Passive smoker
• Male
• Family history of otitis media.
• In day care
• On formula feed

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Current evidence for AOM

• 80 of children get better by day 3 without
  antibiotics
• It is reasonable to prescribe analgesia.-
• Antibiotics should not be used routinely and
  prescribing them just increases parental belief
  and re-attendance rates
• Use delayed scripts if necessary
• Adenoidectomy, as the first surgical treatment of
  children aged 10 to 24 months with recurrent
  acute otitis media, is not effective in
  preventing further episodes. Neither is
  Chemoprophylaxis.
• Current Evidence for CSOM
• Randomised controlled trials (RCTs) found limited
  evidence that topical quinolone antibiotics
  versus placebo improved otoscopic appearances.
  RCTs found no clear evidence of significant
  differences between topical antibiotics.
• No benefits from anything else.

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(No Transcript)
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AOM (pus behind the eardrum)
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AOM continued..

• Analgesia For most children, this is the
  mainstay of treatment.
• Antibiotics should not be routinely prescribed
  for uncomplicated AOM.
• Some children may significantly benefit from
  antibiotics
• . All children aged 6 months and under
• . Children aged between 6 months and 2 years
  where the diagnosis is reasonably certain.
• . Children older than 2 years where there are
  severe symptoms
• . Moderate or severe ear pain (otalgia) with a
  fever of 39C or above, or systemic features
  such as vomiting
• . Severe local signs, such as perforation with
  purulent discharge
• . Bilateral AOM
• Choice of antibiotic
• Amoxicillin is the usual first-line for 5 days.
  If severe symptoms present, or there has been a
  previous episode of AOM within the last month,
  use high doses (double the standard dose).
• .Erythromycin (use high doses) or Clarithromycin
  (use standard doses) are alternative antibiotics
  if documented allergy to penicillin.

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AOM contd 2.

• A good compromise is to use issuing a delayed
  prescription to be redeemed within 72 hours only
  if the condition has not adequately improved.
• Active Follow up for
• . under 2 years of age.
• . systemic symptoms such as high temps (gt 39C)
  or vomiting.
• . There is discharge from the ear.
  Visualisation of the tympanic membrane can be
  difficult. Re-examine after 2 weeks to assess the
  integrity of the membrane and to check for
  complications. If there is a perforation still
  present, monitor the situation and consider
  referral if it has not healed after 6 weeks.
• Persistent AOM
• Pt returning within 2 weeks with same complaints
• .Analgesia
• .If not had Abx-give Abx e.g. Amoxicillin double
  the standard dose for 5/7
• . If had Abx-check compliance-If good then try
  2nd line Abx e.g. Co-Amoxiclav at double the
  standard dose for 5/7.

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Complications from AOM

• Complications from otitis media is extremely low.
• gt Progression to glue ear and associated hearing
  impairment
• gt Perforation. In one study 29.5 children with
  AOM eardrum perfs. But spontaneously closed in 94
  of the patients within one month.
• Rarely to mastoiditis, labyrinthitis, meningitis,
  intracranial sepsis or facial nerve palsy.
• Recurrent episodes may lead to atrophy and
  scarring of the eardrum, chronic perforation and
  otorrhoea, cholesteatoma, permanent hearing loss,
  chronic mastoiditis and intracranial sepsis.

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Serous Otitis Media
33
Serous Otitis Media/Secretory

• Glue ear, commonest cause of deafness, and the
  commonest indication for surgery, in children.
• The condition is most frequent in early
  childhood,
• Peaks prevalence at 2 and 5 years.
• Half of 3-year-olds have at least one effusion
  in a year, and in the UK, 1 in 200 children is
  operated on for the condition.
• Ninety thousand operations are performed in
  England and Wales annually, at an estimated cost
  of 30 million

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Serous otitis media with retraction
35

• A hearing test is not appropriate at the initial
  presentation if there is no evidence of
  significant hearing loss or developmental delay.
  If signs and symptoms of OME continue, hearing
  should be assessed after 3 months, where OME can
  be regarded as persistent.
• Consider setting a lower threshold for referral
  for a hearing test in younger children (e.g.
  children aged less than 3 years old) as
  communication is more difficult

36
Otitis mediaeffusion-Glue ear

• Features
• Dull retracted TM
• May show air-fluid level
• Conductive hearing loss(whisper test, Rinne/weber
  tests)
• Notes
• Common in children often after AOM and can
  persist for weeks
• Reduced hearing noticed by parents/teacher
• Unsteadiness- child falling over
• 80 clear at 8 weeks

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Management

• Adults presentation - the nasopharynx is examined
  to exclude tumour. Secretory otitis media is
  uncommon in adults. It usually follows a cold and
  spontaneously resolves this may take up to 6
  weeks
• In Children- 50 of cases will resolve
  spontaneously within 6 weeks
• Persistence of bilateral Otitis media with
  effusion (OME) and hearing loss in a child should
  be confirmed over a period of 3 months before
  intervention is considered
• Surgery adenoidectomy or myringotomy and grommet
  insertion. however a systematic review suggests
  that the role of grommets in the management of
  glue ear is unclear.
• Hearing aids persistent OME, not for surgery
• Treatments not recommended are antihistamines,deco
  ngestants, steroids , homeopathy,cranial
  osteopathy, acupuncture,dietary modification,
  including probiotics,immunostimulants, massage

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About glue ear

• A unilateral serous effusion in an adult is due
  to nasopharyngeal tumour until proven otherwise.
• Secretory otitis media, or glue ear', is the
  most frequent cause of hearing problems in
  children. May produce pain or a conductive
  hearing loss, or may remain symptomless. There is
  concern that impaired hearing in early childhood
  may interfere with education and normal
  development, but the magnitude of these effects
  is not clearly established.
• Over 50 of effusions resolve spontaneously
  within 8 weeks, but bilateral hearing loss,
  persisting 12 months, occurs in 5 of cases

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Glue Ear vs. Otitis Media

• Factors suggestive of a diagnosis of glue ear
  include
• . frequent attacks of otitis media
• . it is unusual for children to get multiple
  resolving episodes of otitis media
• prolonged signs
• . otitis media will usually resolve within 6
  weeks and certainly within three months
• Other risk factors cleft palate ,Down's
  syndrome, allergy, family history

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Eustachian Tube Dysfunction
a severely retracted eardrum. Margins are very
clear as is the malleus and it looks very sunken.

41
Eustachian Tube dysfunction

• Chronic blockage of the Eustachian tube is called
  Eustachian tube dysfunction. The eustachian tube
  becomes congested and swollen so that it may
  temporarily close this prevents air flow behind
  the ear drum and causes ear pressure, pain or
  popping just as you experience with altitude
  change when travelling on an airplane or an
  elevator.
• This can occur when the lining of the nose
  becomes irritated and inflamed, narrowing the
  Eustachian tube opening or its passageway.
• Illnesses like the common cold or influenza.
• Others pollution, cigarette smoke, allergic
  rhinitis, obesity
• Rarely nasal polyps, cleft palate, skull base
  tumour

42
Eustachian Tube Dysfunction

• . Chronic ETD may reveal retraction pockets or
  collapsed middle ear disease with erosion of
  incus/stapedius. Difficulty auto-inflating the
  ear drum
• . Generally the fluid clears spontaneously over a
  period of several weeks
• . The efficacy of treatments such as nasal
  decongestants, oral decongestants, antihistamines
  is unclear
• . Antibiotics may help prevent infection in cases
  of severe barotrauma

43
ETD Children

• Young children (esp 1 to 6 years) at particular
  risk because of very narrow Eustachian tubes.
  Also, they may have adenoid enlargement that can
  block the opening of the Eustachian tube. Since
  children in daycare are highly prone to getting
  URTIs, they tend to get more ear infections
  compared to children that are cared for at home.
• Eustachian tube in infants and young children
  runs horizontally, rather than sloping downward
  from the middle ear. Thus, bottle-feeding should
  be performed with the infants head elevated, in
  order to reduce the risk of milk entering the
  middle ear space. The horizontal course of the
  Eustachian tube also permits easy transfer of
  bacteria from the nose to the middle ear space.
• Most children older than 6 years have outgrown
  this problem and their frequency of ear
  infections should drop substantially.

44
Chronic Otitis Media

• Recurrent ear discharge
• Hearing loss, painless
• Perforation of the TM central
• Presence of cholesteatoma
• Marginal, Attic perforation
• Offensive discharge, bleeding, granulations
• Complications
• . Vestibular symptoms
• . Facial palsy
• . Intracranial complications

45
Ear drum Perforations

• Safe vs Unsafe Perforations
• Safe perforations
• . may allow infection to enter the middle ear
• . conductive deafness
• Unsafe perforations
• . in fact represent a retraction of the tympanic
  membrane.
• . essentially a part of the drum becomes sucked
  inwards and may gradually enlarge.
• .when the retraction becomes extensive,
  keratinous debris builds up in the retraction and
  may become infected and an acquired cholesteatoma
  develops

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(No Transcript)
47
MAKE SURE YOU ALWAYS INSPECT THE ATTIC AREA ON
OTOSCOPY!

• Unsafe perforations are
• In the attic or
• In the posterior region. These are often linear
  rather than oval
• Or involve the eardrum margin
• Anything else is generally Safe.
• i.e.
• In the anterior region or
• In the inferior region
• And not involving the eardrum margin

48
Safe anterior perforation
Perforations in this position is a persistent
defect after the extrusion of a grommet.
49
Safe inferior perforation
This is more likely to be as a result of chronic
middle ear infection.
50
Unsafe posterior perforation
Posterior perforation. Although posterior
perforations may represent more serious disease
such as cholesteatoma, this is well described and
dry. It is possible to make out the posterior
margin of this defect.  Traumatic perforations
(e.g barotrauma) are often posterior and linear,
like a tear rather than a round hole. Theres
also some tympanosclerosis in this picture.
51
Unsafe attic perforation
Any defect or apparent perforation in the attic
must be considered unsafe and should be referred
for ENT assessment. This crust in the attic
represents a large underlying cholesteatoma
sac. Note the bulging eardrum too.
52
Marginal perforation plus cholesteatoma formation
Unsafe because it is a perforation involving
the drum margin (the yellowy white flakes
indicating a cholesteatoma also gives it away!).
53
Cholesteotoma
54
Cholesteatoma

• Cholesteatoma is "a three dimensional epidermoid
  structure exhibiting independent growth,
  replacing middle ear mucosa, resorbing underlying
  bone, and tending to recur after removal." There
  is usually a persistent or recurrent scanty cream
  coloured offensive discharge and progressive
  hearing loss due to ossicular destruction or
  toxin induced sensory hearing loss.
• Otoscopy a pearly white mass usually in the
  pars tensa /- discharge and sometimes erosion of
  the bone. A perforation is usually present, but
  is not always visible due to overlying keratin.
  Granulation tissue or polyps may be seen due to
  chronic inflammation and sometimes retraction
  pockets are present.
• A crust adherent to the tympanic membrane is
  indicative of a cholesteatoma until proved
  otherwise. They can be reviewed after a short
  course of steroid or ceruminolytic ear drops, but
  if it is persistent or reveals an underlying
  abnormality then you should refer

55

• Why is it important to diagnose it? Cholesteatoma
  is an important diagnosis as it can cause
  irreversible hearing loss from ossicular
  destruction as well as facial nerve palsy,
  labyrinthitis, lateral sinus thrombosis,
  meningitis, intracranial abscess, and otitic
  hydrocephalus. It is more easily treated in its
  earlier stages.
• While waiting for their ENT appointment patients
  should keep the ear dry and any infective
  discharge can be treated with a two week course
  of antibiotic ear drops, with or without
  steroids. Aural toilet is also advised if there
  is debris.

56
Another cholesteotoma
57
Serous Otitis media
58
Normal ear drum
59
Yet another cholesteotoma
60
Question 6

• A 31 year old man with a history of recurrent
  Otitis media in childhood sees you on a Tuesday
  afternoon with his wife. C/O unilateral left
  sided hearing loss. Possibilities are
• Cholesteatoma
• Tympanic membrane retraction pocket
• He doesnt get along well with the Missus.
• Tympanic membrane perforation

61
Correct answer-Tympanic membrane retraction
pocket

• This is a pars tensa retraction pocket which is
  clean. It is retracted onto the long process of
  the incus. There is some incidental
  tympanosclerosis.
• Generalised tympanic membrane retraction and
  retraction pockets are thought to be caused by
  thinning of the tympanic membrane and negative
  middle ear pressure.
• Thinning of the tympanic membrane can be caused
  by middle ear fluid or infections, a poorly
  healed perforation, or after extrusion of a
  grommet

Retraction serous OM
62
Haemorrhagic blister on ear drum surface from
shingles
63
Grommet
This grommet is in the correct position but is
covered in infective granulation and blocked up.
This will not be doing any good and may be
responsible for a chronic discharge. Note also
the extensive tympanosclerosis on the drum.
64
Glomus tumour
. Rare vascular tumour . Causes pulsatile
tinnitus . Needs surgical removal . Can erode
bone etc over time
65
Glomus tumour
66
Chronic otitis externa
67
Serous Otitis Media
68
Slag caused injury

• Despite what conclusions might be drawn from the
  title, it was claimed to be sustained while
  welding and when a spark entered Pts ear. He
  complained of pain and slightly muffled hearing.
  The picture to the right shows an eardrum one
  week after the injury. The eardrum is still red
  and had a crust on it. A small metal ball is seen
  at the bottom of the canal.

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Haemotympanum
70
Middle ear FB

• The moulding material entered middle ear while
  taking a cast for an elderly ladys hearing aid.

71
Granulations
Granulations like this are often associated with
underlying disease, particularly if they arise in
the attic.
72
AOM (Purulent)
73
Question 7

• A mother brings her 4 year old son to see you. He
  is complaining of pain in his ear and his mother
  thinks that he pushed a button battery into it.
  You try to examine him but the child is horsing
  around . What should you do?
• a. Bribe the child with sweets/ Smack him when
  mums not looking
• b. Tell the mother to come back in a few days
  time when the child is calmer
• b. Refer him for immediate removal of the
  suspected foreign body
• c. Refer him to the ENT clinic routinely
• d. Prescribe waxol drops(I seem to remember
  something along those lines from the ENT job.)

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Answer 7

• Correct Answer- Refer him urgently for FB
  removal.( Mum happy, the kids out of your
  surgery, good clinical practice and the ENT
  people you dislike are stuck with him- a definite
  win win situation).
• Usually inert non organic FBs can be extracted
  over a number of days .Indications for referral
  are pain, infection, organic FB, young child,
  yourself not having the necessary equipment etc.
• Button batteries are a definite no-no for drops,
  because the electric current can catalyse
  chemical reactions and release alkalis causing
  nasty chemical burns hence need to be extracted
  ASAP.

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• The End (finally..)