This is the first post in a monthly series on LitFL featuring the latest evidence-based review from EBMedicine‘s Emergency Medicine Practice. First up is July 2010’s ‘Evaluation and treatment of common ear complaints in the emergency department’.
Siegeilman J, Kazda G, Lindberg D. (2010). Evaluation and treatment of common ear complaints in the emergency department. Emergency Medicine Practice, 12(7). [Abstract and subscription link]
To be honest I don’t often find myself lying awake at night thinking about ear complaints. Maybe that’s about to change — it turns out there is much to know…
What’s covered in the review?
The review provides a ‘to-the-point’ and comprehensive approach to these common ear complaints:
- Tinnitus — subjective and objective causes
- Otalgia — including acute otitis media, otitis externa, auriculitis, polychondritis, perichondritis, mastoiditis, Ramsay Hunt syndrome and secondary causes such as TMJ dysfunction
- Hearing loss — including sensorineural and conductive hearing loss (e.g foreign bodies)
- Trauma — external ear laceration, auricular haematoma, tympanic membrane perforation, barotrauma
The tables for the differential diagnoses of tinnitus and sudden hearing loss are purest gold.
Top tips from this month’s review
Here are some of the enlightening ‘need to know’ facts and surprising findings I discovered about common ear complaints from this article:
- Think about referred ear pain
- this accounts for 28% of otalgia in adults.
- the origin can be pretty much anywhere in the head and neck because the ear receives sensory afferents from cranial nerves V, VII, IX and X as well as the cervical plexus.
- Although many cases are idiopathic, there are 4 main types of possible etiology for sudden sensorineural hearing loss (SSHL):
- viral (a bit like Bell’s Palsy; treat with steroids for what it’s worth)
- vascular (SSHL occurs in 6% of patients with vertebrobasilar ischemia — don’t miss a stroke!)
- ruptured intracochlear membrane (?!… where’s an interrobang when you need one…)
- autoimmune (e.g. Wegener’s granulomatosis)
- Tinnitus can be subjective or objective (the examiner can also also detect a noise in the latter!). The nasty, ‘not to miss’ diagnoses include:
- chronic salicylate poisoning must not be missed as cause of subjective tinnitus (other features may be subtle — get a salicylate level)
- vascular lesions (like carotid artery dissection) are an important cause of objective tinnitus.
- Also, remember that tinnitus can be caused by high output states like anemia and hyperthyroidism.
- Regarding acute otitis media (AOM):
- you may be missing something important if you diagnose AOM without identifying objective signs (e.g. an erythematous tympanum, a bulging tympanum with effusion, or lack of mobility on pneumatic otoscopy).
- be sure to distinguish AOM from the transient erythema of the crying child and chronic otitis media with effusion.
- consider a ‘wait-and-see’ approach to antibiotic treatment (delay 48-72 hours) in low risk patients older than 2 years of age that have good follow up.
- Don’t misunderestimate otitis externa:
- thorough aural toilet is often needed for topical antibiotics to be effective.
- malignant otitis externa can be very nasty and tends to occur in the elderly, diabetic and the immunosupressed. It’s a potentially life-threatening emergency. 10% of MOE is fungal — look out for fungi if the patient has been taking antibiotic ear drops for a while.
- When examining the ear:
- If you find a foreign body in a child’s ear, check the other ear and the nose for more surprises!
- Get the patient to hum to perform a ‘poor man’s Weber’s test’ — the noise localises to the affected ear in conductive deafness, and the contralateral ear in sensorineural deafness.
- Remember to check the ears of patients with fever (especially the demented or comatose), you may find the focus.
- If you can’t rule out a ruptured tympanic membrane avoid ototoxic ear drops such as:
- aminoglycosides (e.g. neomycin, gentamicin)
- acidic solutions (low pH)
- Suspect autoimmune polychondritis if:
- inflammation spares the ear lobe or affects other cartilagenous sturctures
- the patient has other autoimmune condition(s).
- Trauma to the ear:
- Defects in the auricular cartilage resulting from external ear laceration should be closed with absorbable sutures that include the anterior and posterior perichondrium. Start at the natural curves and grooves of the ear. Don’t trim away skin or cartilage or a big cosmetic mess with be the end result.
- Simple aspiration of auricular hematomas is likely to fail if the hematoma originates from within the cartilage — incision and drainage is better. Re-expansion can be prevented by suturing in cotton pledgets either side of the ear using mattress sutures that traverse the ear.
- Remember that a bruised pinna is a red flag for NAI in children of any age.
- Have a look at the free EMRAP.TV Episode 87: Ear laceration and dressing for some more tips (the action stats at the 2min 50 sec mark).
Check out the full 20+ page article to find out a whole lot more!