Ent - Kj Lee 10Th Ed - Chapter 14 - Infections Of The Temporal Bone

Front 1

Pinna

Superficial infections are commonly related to which two bacterial organisms?

Back 1

Staph & Strep

Front 2

Pinna

Any infection of deeper depth should include tx for which bacterial organism?

Back 2

Pseudomonas

Front 3

Pinna

List some etiologies that can cause bacterial infections to occur

Back 3

- Trauma - mcc (blunt trauma rsulting in hematoma & secondary infx; ear piercing)
- Burn
- Extension of otitis externa (OE)
- Extension of subperiosteal abscess
- Posop complication of otology surgery
- Rule out relapsing perichondritis (autoimmune; spares the lobule!), cutaneous lymphoma & gouty tophus

Front 4

Pinna

What is the most commonly cultured organism from abscess contents?

Back 4

Pseudomonas

Also common are staph aureus, e. coli & proteus

Front 5

Pinna

How long do you give ABx for in perichondritis or chondritis?

Back 5

2-4 weeks (need to cover pseudomonas, ie fluoroquinolone or aminopencillin)

Front 6

Is the prognosis for Ramsey Hunt syndrome better or worse than Bell's palsy?

Back 6

Worse, only 60% regain normal fnct

Front 7

In herpes zoster, what test looks for multinucleated giant cells at the base of the ruptured vesicle?

Back 7

Tzanck smear

Front 8

What viral infections is Tzanck smear positive in?

Back 8

Herpes zoster, herpes simplex, CMV and pemphigus vulgaris

Front 9

Pinna

What is the tx for herpes zoster in this case?

Back 9

High-dose oral steroids (1mg/kg/d x 14days) + antivirals

Surgical decompression not generally advocated as the neural degeneration is wide-spread rather than localized to geniculate and labyrinthine segment as seen in Bell's palsy

Front 10

Pinna

What are some funal pathogens causing infections?

Back 10

Aspergillus
Histoplasma
Mucormyces
Candida
Coccidiomyces
Blastomyces
Dermatophyses
Sprothrix sp.

Front 11

Pinna

What are some rare parasitic & mycobacterial infections?

Back 11

Parasites - scabies & cutaneous leishmaniasis

Mycobacterial - leprosy (mycobacterium leprae) & cutaneous tuberculosis

Front 12

External Auditory Canal

What are some beneficial aspects of cerumen?

Back 12

It is antibacterial
- acidic
- contains lysozyme
- antibodies

Front 13

External Auditory Canal

Is fever common in acute otitis externa?

Back 13

fever is rare unless there is significant periauricular cellulitis

Front 14

External Auditory Canal

Which bacterial pathogens are responsible for AOE?

Back 14

pseudomonas
s. aureus
other gram-negative rods

Front 15

External Auditory Canal

Once a wick is placed for AOE, do you need to change it out?

Back 15

Should replaced every 3-5 days to avoid toxic shock syndrome

Front 16

External Auditory Canal

Which drug may cause a dermatitis in some pts that is indistinguishable from AOE?

Back 16

Neomycin

Front 17

External Auditory Canal

Do you use oral ABx for AOE?

Back 17

Not used for uncomplicated AOE

May be considered for pts with sevre periauricular cellulitis and immunocompromise

Front 18

External Auditory Canal

What % of pts with AOM will develop bullous myringitis?

Back 18

2%

Front 19

External Auditory Canal

How do you differentiate between acute vs chronic bullous myringitis?

Back 19

Acute - <1 month

Chronic (Granular) - >1 month

Front 20

External Auditory Canal

What is the difference between primary & secondary acute bullous myringitis?

Back 20

Primary - no middle ear pathology

Secondary - associated with AOM

Front 21

External Auditory Canal

What are the signs and sx of acute bullous myringitis?

Back 21

- severe pain lasting for 3-4 days then subsiding
- blisters on the lateral suface of TM or medial EAC
- hemorrhagic myringitis demonstrates no blisters but extravascular blood in the middle layer of the TM

Front 22

External Auditory Canal

What are the pathogens that can cause acute bullous myringitis?

Back 22

- strep pneumo
- H. inf (non-typable)
- Moraxella catarrhalis
- Mycoplasma pneumo is no longer felt to be a primary pathogen for primary bullous myringitis

Front 23

External Auditory Canal

What is the tx for acute bullous myringitis?

Back 23

- topical Abx
- lance the bullae for pain control
- if secondary, then tx AOM with oral Abx
- dry ear precautions

Front 24

External Auditory Canal

Chronic myringitis is characterized by what?

Back 24

- Loss of epithelium of the TM and repalcement with granulation tissue
- Uncommon, prolonged, and difficult to tx infection of the lateral surface of the TM
- Relapsing and recurring sx are common

Front 25

External Auditory Canal

What are the signs & sx of chronic myringitis?

Back 25

- Painless otorrhea
- Pruritis
- Lack of middle ear pathology
- Severe cases can result in conductive hearing loss due to TM thickening and blunting
- Late stages - scarring of the anterior angle resulting blunting or acquired canal stenosis or obliteration
- Replacement of epithelium with beefy, weeping granulation tissue
- 33% of pts develop TM perfs at some time during the dz process, frequently heals spontaneously

Front 26

External Auditory Canal

What are the pathogens that can cause chronic bullous myringitis?

Back 26

Pseudomonas aeurinosa
Staph aureus
Proteus mirabilis

Front 27

External Auditory Canal

What is the tx for chronic bullous myringitis?

Back 27

- drying agents
- topical Abx
- cautery with lasers or chemicals
- tympanoplasty with canalopasty eserved for severe or obliterative dz

Front 28

External Auditory Canal

What is the etiology of chronic bacterial otitis externa?

Back 28

- assoc with chronic skin conditions such a seborrhea dermatitis and atopic dermatitis
- chronic inflammation within the dermis and surrounding the apocrine glands resulting in increased depth of rete pegs
- loss of normal subaceous glands

Front 29

External Auditory Canal

What are the S&Sx of chronic bacterial otitis externa?

Back 29

- thickened skin of the cartilaginous canal
- keratosis - adherent skin debris
- lichenification
- pruritis
- lack of otalgia
- canal obliteration in late stage dz

Front 30

External Auditory Canal

What are the pathogens of chronic bacterial otitis externa? How do you typically diagnosis this?

Back 30

- gram-negative species, especially Proteus

- Bx is the best way, especially if granulation is present

Front 31

External Auditory Canal

What are other names for skull base osteomyelitis?

Back 31

Malignant Otitis Externa or Necrotizing Otitis Externa

Front 32

External Auditory Canal

What are the mortality rates in Malignant Otitis Externa?

Back 32

Between 5-20%

Front 33

External Auditory Canal

In malignant otitis externa, how do microorganisms invade the bone?

Back 33

proposed that they invade the bone through the fissues of Santorini (locatedin the cartilagenous portion of the EAC) and progress medially

Front 34

External Auditory Canal

Describe the typical S&Sx of malignant otitis externa

Back 34

- deep-seated aural pain - pain out of proportion to exam findings
- otorrhea
- granulation tissue along the TM suture line
- edema
- CN palsy - CN 7 most commonly affected, but 6, 9, 10, 11, 12 may also be affected.
- involvement of cavernous sinus & CN 3, 4, 6
- thrombosis of the sigmoid and transverse sinuses then propagating to the internal jugular vein
- intracranial abscess and meningitis are usually terminal events

Front 35

External Auditory Canal

Which imaging study is best to diagnose malignant otitis externa?

Which is best for following tx response?

Back 35

Bone scan (technetium (Tc99) scintigraphy)

Gallium 67 is used to follow tx response (scan q4 weeks)

Front 36

External Auditory Canal

Which pathogens cause malignant otitis externa?

Back 36

- P. aeruginosa mcc
- Other bacterials - S. eureus, Klebsiella, and Proteus mirabilis
- Fungal is 15% of cases (aspergillus & mucormycoses)

Front 37

External Auditory Canal

Which is the first-line abx for malignant otitis externa?

Second-line?

Back 37

- monotherapy with oral FQ is first line

- antipseudomonal aminopenicillins are 2nd line (ie piperacillin)

Front 38

External Auditory Canal

How do you distinguish the S&Sx of otomycosis from acute bacterial OE?

Back 38

- Usually indistinguishable from acute bacterial OE
- Fungal hyphae may be visible
- Pruritis is a more common complaint than in bacterial infections

Front 39

External Auditory Canal

How do you diagnose otomycosis?

Back 39

- Bx with tissue culture in immunocompromised pts or atypical presentations

Front 40

External Auditory Canal

What are the common pathogens seen in otomycosis?

Back 40

- candida
- aspergillus
- penicillium

Front 41

External Auditory Canal

What are the different treatment options for otomycosis?

Back 41

- meticulous canal debridement
- acidify canal, drying agents, and dry ear precautions
- topical antifungal agents
- systemic antifungal therapy (for severely immunocompromised with suspicion of invasive fungal dz)

Front 42

External Auditory Canal

For otocomycosis, you may use CFS-H powder, which requires a compounding pharmacy. What are the ingredients?

Back 42

CHS-H

Chloromycetin
Amphotericin B
Sulfanilamide
Hydrocortisone

Front 43

What is the mcc for pediatrician visits in the US?

Back 43

Acute otitis media

Front 44

What are Gerlach's tonsils?

Back 44

small inclusions of lymphoid tissue within the lip of each eustachian tube orifice

may become inflamed during an URI and compromise ET function

Front 45

Infections of the Middle Ear & Mastoid

Which S&Sx is the best indicatoAOM?

Back 45

bulging TM

Front 46

Infections of the Middle Ear & Mastoid

Name the most common pathogens in AOM

Back 46

S. pneumo is the mcc - serotype 19A is a highly multidrug-resistant strain

H. influenza (non-typable)
M. catarrhalis

Viruses (RSV, rhino, corona, parainfluenza, enterovirus, adenovirus) - up to 75% of AOM aspirates may have viruses

Front 47

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: In kids with severe AOM, when do we tx with ABx?

Back 47

Prescribe antibiotic therapy for AOM (bilateral
or unilateral) in children 6 months and older with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher).

Front 48

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: Do we treat non-severe bilateral AOM in children 6-23mo?

Back 48

Nonsevere BILATERAL AOM in young children: The clinician should prescribe antibiotic therapy for bilateral AOM in children 6 months through 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]).

Front 49

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: Do we treat non-severe unilateral AOM in children 6-23mo?

Back 49

Nonsevere unilateral AOM in young children: The clinician should EITHER prescribe antibiotic therapy OR offer observation with close follow-up based on joint decision making with the parent(s)/caregiver for unilateral AOM in children 6 months to 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]).

When observation is used, a mechanism must be in place
to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms.

Front 50

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: Do we treat non-severe AOM in children 24mo and up?

Back 50

Nonsevere AOM in older children: The clinician
should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/caregiver for AOM (bilateral or unilateral) in children 24 months or older without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]).

When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms.

Front 51

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: What must we considered when prescribing amoxicillin for AOM?

Back 51

Should prescribe amoxicillin for AOM when a decision to treat with antibiotics has been made AND the child has not received amoxicillin in the past 30 days
OR
the child does not have concurrent purulent conjunctivitis OR
the child is not allergic to penicillin.

Front 52

Infections of the Middle Ear & Mastoid

When treating AOM with amoxicillin, what is the done and length of treatment?

Back 52

Dose is typically 90mg/kg/d, divided TID

Length of tx is controversial (ie 7 days course may have higher rates or recurrance but less SE; 10 day course has more SE but less recurrence)
- Children <2yr - 10 days of therapy
- Children 2-5yr - 10days of therapy
- Chidlren >6yrs - 5-7 days of therapy if mild-moderate dz

Front 53

Infections of the Middle Ear & Mastoid

Which bacterial pathogens causing AOM tend to be B-lactamase positive

Back 53

H. inf - 50% B-lactamase positive

M. catarrhalis - 100% B-lactamase positive

Front 54

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: When should prescribe an antibiotic with additional B-lactamase coverage?

Back 54

Clinicians should prescribe an antibiotic with additional β-lactamase coverage for AOM when a decision to treat with antibiotics has been made, AND the child has received amoxicillin in the last 30 days
OR
has concurrent purulent conjunctivitis
OR
has a history of recurrent AOM unresponsive to amoxicillin.

Front 55

Infections of the Middle Ear & Mastoid

When tx severe AOM (ie. fever >39*C, severe otalgia) or in whom H. influenza or M. catarrhalis are suspected, which ABx is the first choice? What is the dose?

Back 55

Augmentin - 90mg/kg/d amox and 6.4mg/kg/d of clavulanate)

Front 56

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: When should tympanostomy tubes be offered?

Back 56

For recurrent AOM:
- 3 episodes in 6 months
- 4 episodes in 12 months with 1 episode in the past 6 months

Front 57

Infections of the Middle Ear & Mastoid

Per 2013 AAP guidelines: How long is breastfeeding recommended?

Back 57

Clinicians should encourage exclusive breastfeeding
for at least 6 months.

Front 58

Infections of the Middle Ear & Mastoid

When tx AOM, which ABx do you consider in a penicillin allergic pt?

What if a pt harbors the highly resistant S. pneumo strain?

Back 58

- Azithromycin (10mg/kg x 1d, then 5mg/kg x 4d)
- Clarithromycin
- Erythromycin-sulfisoxazole

If highly-resistant S. pneumo strain (serotype 19A), give clindamycin (30-40mg/kg/d divided TID)

Front 59

Infections of the Middle Ear & Mastoid

Pt's with cochlear implants should receive which vaccines as a prophylaxis for AOM?

Back 59

13-valent pneumococcal vaccine at least 2 weeks prior to implantation (CLOSE contacts should also receive this)

23-valent pneumo vaccine should be give after 24 mo of age

Front 60

Infections of the Middle Ear & Mastoid

Pt's with cochlear implants who get AOM are at a higher risk of developing what?

Back 60

Meningitis

Front 61

Infections of the Middle Ear & Mastoid

How do you treat pt's with cochlear implants who get AOM?

Back 61

CI pt's should NOT undergo a period of observation if a dx of AOM is made

AOM within the first 2 months after implantation = aggressive parenteral Abx to prevent meningitis & device infx

AOM developing after 2 months of implantation = tx like regular AOM, but monitor closely; if any sign of tx failure = parenteral Abx; consider tympanocentesis to guide tx

Front 62

Infections of the Middle Ear & Mastoid

Pt's with cochlear implants who has a hx of AOM prior to implantation, what are the tx options?

Back 62

May consider subtotal petrosectomy, eustachian tube ablation with ear canal closure and second-stage CI.

Front 63

Infections of the Middle Ear & Mastoid

Recurrent AOM is most commonly seen in children younger than ___ yrs with highest incidence in the _________ age group.

Back 63

2 yrs

6-12 month age group

Front 64

Infections of the Middle Ear & Mastoid

Define recurrent acute otitis media

Back 64

- 3 episodes in 6 months
- 4 episodes in 12 months (Acad of Peds = with 1 episode in the past 6 months)
- must be assx between episodes

Front 65

Infections of the Middle Ear & Mastoid

Is there a benefit in AOM following adenoidectomy?

Back 65

Cochrane review demonstrated NO benefit in decreased number of AOM events following adenoidectomy

Front 66

Infections of the Middle Ear & Mastoid

List some possible etiologies of chronic supperative otitis media

Back 66

1) Biofilms - highly organized networks of bacteria encased within a matrix containing oligopolysaccarides which inhibits systemic reaction and Abx penetration; typically culture negative

2) ET dysfunction

Front 67

Infections of the Middle Ear & Mastoid

What are some risk factors for chronic suppurative otitis media?

Back 67

- Genetic - higher incidence in native populations (native Americans, Inuit, naitve Australians, or native New Zealanders)

- Nasopharyngeal reflux

- Chronic ME or TM dysfunction (ie, tubes or TM perf exposes ME mucosa to contamination from the EAC)

Front 68

Infections of the Middle Ear & Mastoid

What are some of the S&Sx of chronic suppurative otitis media?

Back 68

- TM perf
- HL (usually CHL)
- Aural fullness
- Chronic or intermittent otorrhea
- Middle ear mucosa inflamed
- Granulation tissue or aural popyls may be visible and obscure normal landmarks
- TM retraction pockets +/- keratin debris

Front 69

Infections of the Middle Ear & Mastoid

What are the most common pathogens found within OM biofilms?

Back 69

1) H. inf (non-typable) - most common
2) Pneumococcus, M. catarrhalis, S. aureus, P. aeruginosa are other pathogens

Front 70

Infections of the Middle Ear & Mastoid

What are the treatment goals of chronic suppurative otitis media? Is adenoidectomy recommended?

Back 70

Goal is to create a dry & safe ear
- Dry = no otorrhea
- Safe = no collection of keratin debris (no reduce risk of cholesteatoma)

Current standard is to tx with topical Abx in cases with perforated TM
- 4-6 week couse following debridement
- Polymyxin B or Neomycin or Hydrocortisone
- Fluoroquinolone

Adenoidectomy is not routinely advocated in this pt population, but consider on individual bases (they can harbor bacteria causing biofilms)

Front 71

Infections of the Middle Ear & Mastoid

What are some tx of eustachian tube dysfunction?

Back 71

None have demonstrated long-term efficacy in providing a functional ET. A few below:
- ballon tuboplasty
- laser tuboplasty
- finger manipulation of ET orifice
- ET implants

Front 72

Infections of the Middle Ear & Mastoid

Bacterial infection of the ME effusion can result in clinical infection. What serves as the reservoir for the bacteria?

Back 72

Typically the adenoids

Front 73

Infections of the Middle Ear & Mastoid

What sx are lacking in chronic OM with effusion that distinguishes it from AOM?

Back 73

lack of otalgia & systemic sx such as pyrexia and malaise

Front 74

Infections of the Middle Ear & Mastoid

What is the tx for chronic OM with effusion?

Back 74

Watchful waiting is appropriate in children w/o evidence of HL, speech or developmental delay or TM complications. May place tubes if these occur.

ABx, steroids, antihistamines and dcongestants do not have long-term benefits and should not be routinely used

Front 75

Infections of the Middle Ear & Mastoid

Is adenoidectomy recommended in chronic otitis media with effusion?

Back 75

Cochrane review demonstrated a reduction in rate of COME following adenoidectomy.

Front 76

Infections of the Middle Ear & Mastoid

List the etiologies of tuberculous otitis media?

Back 76

Hematogenous spread from a 1* lung infection
Direct inoculation of bacillus through the ear canal from respiratory droplets
Direct extension from nasopharynx and ET

TOM was common in early 20th century, and has been increasing incidence again due to multidrug-resistant strains, rise of immunocompromised pts (AIDS, transplant recipients, malignancy) and immigration from endemic regions.

Front 77

Infections of the Middle Ear & Mastoid

List the S&Sx of tuberculous otitis media?

Back 77

Thin, cloudy, painless otorrhea
Thickened TM
Early dz - multiple TM perfs
Late dz - subtotal or total TM perf
HL, usually conductive
Polypoid granulation tissue in the ME cleft
Pale thickened mucosa within the antrum or mastoid
Facial paresis or paralysis in 10%
Hx of failed ME or mastoid surgery
COM that is unresponsive to standard antibiotics

Front 78

Infections of the Middle Ear & Mastoid

What is the tx for tuberculous otitis media?

Back 78

Start RIPE tx for TB (rifampin, isoniazid, pyrazinamide, ethambutol)
Surgery for TM or ossicular chain repair or for biopsy

Front 79

Complications of Otitis Media and Mastoiditis

Where is the most common finding of ossicular chain erosion in COM?

Back 79

fibrous union at incudostapedial joint

Front 80

Complications of Otitis Media and Mastoiditis

What is usually the cause of SNHL and vestibular dysfunction in COM?

Back 80

usually mediated by bacterial exotoxins and inflammatory cytokines

Front 81

Complications of Otitis Media and Mastoiditis

What is the incidence of spontaneous rupture of the TM in AOM?

What percentance heal without intervention?

Back 81

5% incidence of spontaneos M rupture in AOM

90% heal spontaneously

Front 82

Complications of Otitis Media and Mastoiditis

What is the most common cultured organism in mastoiditis?

Back 82

S. pneumo (rates now increasing due to more virulent strains not covered by vaccine)

Also pseudomonas, s. aureus, s. pyogenes, & other GNR

Front 83

Complications of Otitis Media and Mastoiditis

What is the first line tx for mastoiditis?

Back 83

IV Abx - empirix tx with 3rd gen cephs or antipseudomonals

If no improvement after 24-48hrs, consider surgical intervention

Front 84

Complications of Otitis Media and Mastoiditis

What are the indications for surgery in mastoiditis?

Back 84

If no improvement after ABx & tubes

Mastoidectomy indicated in coalescent mastoiditis (evidence of bony erosion and destruction of mastoid air cells on CT)

Front 85

Complications of Otitis Media and Mastoiditis

What complication can occur when removintg matrix from the surface of the lateral canal during cholesteatoma surgery?

Back 85

Labyrinthine fistula

tx of this is controversial - either complete matrix removal with fistula repair, or exteriorization (leaving matrix over the exposed canal)

Front 86

Complications of Otitis Media and Mastoiditis

What's another name for Petrous Apicitis (it's a syndrome)?

Back 86

Gradenigo syndrome
- otorrhea
- retro-orbital pain
- diplopia caused by CN 6 palsy

Front 87

Complications of Otitis Media and Mastoiditis

What is the tx for Gradenigo Syndrome?

Back 87

IV Abx are first line
- if does not improve, or intracranial complications suspected, then consider petrous apicectomy

Front 88

Complications of Otitis Media and Mastoiditis

Describe the following complications of acute mastoiditis:

Subperiostial abscess
Citelli abscess
Bezold abscess
Luc's abscess
Zygomatic root abscess

Back 88

Subperiostial abscess - may do aspiration & IV Abx in kids; I&D with cortical mastoidectomy in older children & adults

Citelli abscess - involvement of occipital bone

Bezold abscess - erosion of mastoid tip; fluid collection within the SCM muscle

Luc's abscess - involvement of the temporal bone (subperiosteal)

Zygomatic root abscess - erosion of the zygoma; may cause temporal soft tissue infx as well, but not bone involvement

Front 89

Complications of Otitis Media and Mastoiditis

What is the most common intracranial complication of AOM and COM?

Back 89

Meningitis

Front 90

Complications of Otitis Media and Mastoiditis

What is the spread of meningitis from AOM or COM?

Back 90

- Hematogenous
- Direct extension via bony erosion
- Direct extension through bony channels (ie, Hyrtl fissures)

Front 91

Complications of Otitis Media and Mastoiditis

How long is the ABx tx for meningitis secondary to AOM/COM?

Back 91

10 days of IV Abx followed by 2-3 weeks of oral Abx

(IV steroids in the acute period decreases long-term neurologic complications)

Front 92

Complications of Otitis Media and Mastoiditis

What is the etiology of lateral sinus thrombosis?

Back 92

Usually a complication of AOM and COM with infection or inflammation of dura around the sinus, resulting in coagulation of blood within

Front 93

Complications of Otitis Media and Mastoiditis

Describe the S&Sx of a pt presenting with lateral sinus thrombosis

Back 93

- "Picket-fence" fevers - spiking fevrs that tend to cluster a a particular time of day
- Severe headache
- Otorrhea
- Edema and tenderness of mastoid (Griesinger sign)
- Pappilledema
- Septic emboli to lungs
- Jugular vein thrombosis (can present with lower cranial nerve deficits)

Front 94

Complications of Otitis Media and Mastoiditis

Describe the delta sign in a patient with lateral sinus thrombosis

Back 94

A rim enhancement of the venous sinus with central hypodensity seen on CT brain with contrast

Front 95

Complications of Otitis Media and Mastoiditis

Describe the etiology of subdural empyma as a complication of AOM/COM

Back 95

- Severe infection of the leptomeninges of the brain
- Presumed same possible routes of spread that cause meningitis (hematogenous & bone)

Long-term neurologic deficits are common
High mortality rate, even in the ABx era (5-30%)

Front 96

Complications of Otitis Media and Mastoiditis

What are the S&Sx and diagnosis of subdural empyma caused by AOM/COM?

Back 96

S&Sx
- AMS
- Focal neurologic deficits
- Increased ICP common and must be r/o prior to lumbar puncture to prevent tonsillar herniation

Diagnosis
- MRI with contrast (enhancing fluid collection within the subdural space
- Lumbar puncture if normal ICP

Front 97

Complications of Otitis Media and Mastoiditis

What is the S&Sx of epidural abscess? What are the tx options?

Back 97

S&Sx - those of coalescent mastoiditis

Tx - surgical drainage & culture-directed Abx
- Middle fossa approach = risk of encephalocele
- Posterior fossa approach = no of encephalocele

Front 98

Complications of Otitis Media and Mastoiditis

What are the three stages of brain abscess secondary to a AOM/COM complication?

Back 98

1) Encephalitis - HA, AMS, fever, seizures, increased ICP
2) Coalescence - may be assx
3) Rupture - increasing HA, meningeal sx, systemic collapse

Front 99

Complications of Otitis Media and Mastoiditis

Focal deficits are seen in what percentage of people affected by an intraparenchymal abscess secondary to a AOM/COM?

Back 99

70%

cerebellum - ataxia, dysmetria, nystagmus, N&V
temporal lobe - if dominant hemisphere, results in aphasia, visual defect & headache

Front 100

Complications of Otitis Media and Mastoiditis

Which pathogens are most commonly involved in intraparenchymal abscess secondary to a AOM/COM?

Back 100

S. aureus mcc
Polymicrobial infx particularly common in COM
GNR such as Klebsiella, Proteus, E. coli and Pseudomonas
Anaerobic bacteria - bacteroides

Front 101

Complications of Otitis Media and Mastoiditis

Describe the etiology of otitic hydrocephalus

Back 101

Characterized by elevated intracranial pressure without focal neurologic abnormalities other than those due to the elevated pressure.

Usually secondary to lateral sinus thrombosis
- impedes venous drainage and consequently CSF reabsorption through the arachnoid granulations
- particularly if clot propagates to the transverse sinus

May occur without evidence of sinus thrombosis.

Front 102

Infections of the Inner Ear

What are the different types of infections seen?

Back 102

Bacterial (including serous and suppurative)
Spirochetes
Viral

Front 103

Infections of the Inner Ear - Bacterial

Serous labyrinthtis is most commonly seen in which population (peds, adults, elderly)?

Back 103

Pediatric - as this age group is mostly at risk for AOM

Front 104

Infections of the Inner Ear - Bacterial

What is the etiology of serous labyrinthitis?

Back 104

Bacterial toxins and inflammatory mediators from otitis media enter the labyrinth by crossing the round window (RW) membrane or via labyrinthine fistula
- animal models show that RW permeability is increased in the presence of inflammatory mediators in the middle ear

NO BACTERIA in the middle ear

Possible that labyrinthine dysfunction is related to changes in ionic potentials induced by inflammatory mediators rather than destruction of neuroepithelium or neural elements.
- as endocochlear or labyrinthine electrical potentials are regenerated, end-organ function can return which implies preservation of viable cochlear and vestibular hair cells.

Front 105

Infections of the Inner Ear - Bacterial

What is the etiology of suppurative labyrinthitis?

Back 105

Otogenic infection results from infections of the middle ear or mastoid
- most commonly associated with cholesteatoma in the modern era
- bacterial entry usually occurs through labyrinthine fistula or congenital abnormality

Meningitic labyrinthitis results from infection transmitted via CSF through the internal auditory canal to the cochlear modiolus or cochlear aqueduct

Front 106

Infections of the Inner Ear - Bacterial

What are the S&Sx of suppurative labyrinthitis?

Back 106

Profound HL, frequently bilateral in meningitic labyrinthitis
Severe vestibular sx
Fever
Meningeal signs
Evidence of OM or cholesteatoma
May develop cranial neuropathies if dz spreads outside of otic capsule

Front 107

Infections of the Inner Ear - Bacterial

What are the pathogens responsible for suppurative labyrinthitis?

Back 107

S. pneumo is mcc (also the mc pathogen associated with HL)
H. influ
N. meningitidis

Polymicrobial or GNR may be found in otogenic suppurative labyrinthitis

Front 108

Infections of the Inner Ear - Bacterial

Post meningitic hearing loss should prompt urgent eval of what?

Back 108

Labyrinthitis ossificans - obtain a CT, and then serial CT's for monitoring

Front 109

Infections of the Inner Ear - Spirochetes

Why is otosyphilis considered the great masquerader?

Back 109

Otologic sx may present at any stage of dz
- also may have variable patterns of HL

Front 110

Infections of the Inner Ear - Spirochetes

What percent of pts with congenital syphilis will have hearing loss?

What about those with neurosyphilis?

Back 110

Congenital syphilis - 30%

Neurosyphilis - 80% will have SNHL

Front 111

Infections of the Inner Ear - Spirochetes

Pt's with otosyphilis may have sx consistent with endolymphatic hydrops. What are those sx?

Back 111

Fluctuating SNHL
Aural fullness
Episodic vertigo
Tinnitus
May be unilateral

Front 112

Infections of the Inner Ear - Spirochetes

What is a positive Tullio phenomenon?

Back 112

May be seen in otosyphilis

Induction of vertigo with visible nystagmus with loud sounds

Front 113

Infections of the Inner Ear - Spirochetes

What is a positive Hennebert sign?

Back 113

May be seen in otosyphilis

Nystagmus produced by pressure applied to a sealed external auditory canal; may be seen in labyrinthine fistula or with intact tympanic membrane in syphilitic involvement of the otic capsule

False-positive fistula test
Thought to be due to scar band between the saccule and the footplate

Possitive Hennebert sign may be due to third window phenomenon in non-syphillitic pt's (Superior Semicircular Canal Dehiscence)

Front 114

Infections of the Inner Ear - Spirochetes

What percentage of pt's will have improvement in hearing and balance function following tx of syphilis?

Back 114

35-50% will have improvement

Front 115

Infections of the Inner Ear

Is Lyme dz a common cause of SNHL?

Back 115

Extremely rare cause

HL is a late sx of Lyme dz, other systemic sx usually present

Routine testing for Lyme's titers not warranted for unilateral SNHL unless risk factors present or lving within endemic areas.

Front 116

Infections of the Inner Ear

Is mycobacterium a common cause of SNHL?

Back 116

Rare cause

Associated with tuberculous meningitis
Inflammatory infiltrates in the perilymphatic spaces, cochlear modiolus & Rosenthal canal; also causes degeneration of organ of Corti and spiral ganglions

Front 117

Infections of the Inner Ear

What is the most common cause of nonsyndromic congenital SNHL?

Back 117

CMV
- 1% of infants born with CMF infection
- 10% of these will have symptomatic infections

Front 118

Infections of the Inner Ear

What is the median age for identification of HL in asymptomatic children who were infected at birth?

Back 118

18 months - most are thus not detected on newborn screening

Front 119

Infections of the Inner Ear

What are the acute and late changes of CMV infection?

Back 119

Acute changes - viral inclusion cysts in neuroepithelium, stria vascularis, and supporting cells

Late changes - hydrops, extracellular calcifications, strial atrophy, loss of sensory, and support cells in the organ of Corti

Front 120

Infections of the Inner Ear

What are the S&Sx of cytomegalovirus inclusion disease?

Back 120

Deafness
Hepatosplenomegaly
Jaundice
Microcephaly
Intracerebral calcifications
Variable hearing loss

Front 121

Infections of the Inner Ear

Is mumps a common cause of HL?

Back 121

May be a very common cause of unilatral HL in childhood

Incidence of HL is 1:2000 pts with mumps infection

Hearing loss affects 1 in 2000 pts with mumps infection.

Front 122

Infections of the Inner Ear

What is the etiology of infection/damage done by mumps?

Back 122

Predominately affects the cochlear duct
Atrophy of organ of Corti and stria vascularis
Vestibular dysfunction is rare but reported
Vestibular testing in subjects with balance dysfunction suggests there may also be injury to the neural components of the balance system.
Demyelination of CN8
Route of spread is either hematogenous viral invasion of the cochlea or through CSF viremia through the cochlear aqueduct or modiolus
May result in delayed endolymphatic hydrops years after infections

Front 123

Infections of the Inner Ear

What are the S&Sx of mumps?

Back 123

Range of hearing impairement - mild/severe/profound
Usually sudden in onset
Usually unilateral but bilateral loss reported
Mild lossed may be recoverable
Severe loss usually permanent
Unilateral caloric weakness
Salivary adenitis
Orchioepididymitis
Meningitis (occurs in 10% of pts)

Front 124

Infections of the Inner Ear

What family of viruses is the mumps virus?

Back 124

Paramyxovirus family (RNA virus)

Front 125

Infections of the Inner Ear

What is the tx for mumps?

Back 125

No antiviral therapy currently available
Oral steroids may be used with varied success for sudden hearing loss
Supportive tx
Primary prevention with MMR vaccine

Front 126

Infections of the Inner Ear

What viral infection has been implicated as one of the causes of otosclerosis?

Back 126

Chronic infection of the otic capsule with the measles virus (Rubeola)
- viral particles found in the footplates of surgical patients
- perilymphatic titers of IgG for measles virus higher than in serum

Front 127

Infections of the Inner Ear

What is the etiology of the inner ear infection caused by Rubeola?

Back 127

The measles virus causes inflammation, fibrous infiltration and ossification of the basal turn of the cochlea

Degeneration of the organ of Corti, stria, and vestibular neuroepithelium.

CN8 demyelination

Front 128

Infections of the Inner Ear

What are the S&Sx of Rubeola?

Back 128

Koplik spots - pathognomonic ("grain of rice" on red base of the oral mucosa)
Three C's - cough, coryza, conjunctivities
Maculopapular rash
High fever
Encephalitis
Subacute Sclerosing Panencephalitis (SSPE) - rare, delayed neural degeneration; fatal, unless dx early

Front 129

Infections of the Inner Ear

What family of viruses is the measles virus?

Back 129

Rubeola (Measles virus) = paramyxovirus family (RNA virus)

Front 130

Infections of the Inner Ear

Which vitamin has been shown to reduce morbidity and mortality in measles?

Back 130

Vitamin A

Front 131

Infections of the Inner Ear

What are the S&Sx of herpes simplex virus 1 infection?

Back 131

Sudden SNHL
Vertigo
May have flu-like prodrome

Front 132

Infections of the Inner Ear

Is herpes simplex virus an RNA or DNA virus?

Back 132

DNA virus

Front 133

Infections of the Inner Ear

What is the tx for herpes simplex virus?

How about herpes zoster virus?

Back 133

Herpes simplex - acyclovir, valacyclovir; studies show no added benefit of using steroids

Herpes zoster - high-dose oral steroids; studies of using antivirals in herpes zoster oticus are lacking

Front 134

Infections of the Inner Ear

Congenital rubella is associated with HL in ___% of patients. How about acquired infection?

Back 134

50% - may develop months to years after acute infection

Acquired infection generally NOT associated with HL

Front 135

Infections of the Inner Ear

What is the etiology of rubella?

Back 135

Rubella = German Measles

Congenital infection (Gregg Syndrome)
- maternal infection during FIRST trimester
Cochlear and saccule degeneration
Atrophy of the stria vascularis
Utricle and semicirc canals not generally involved

Front 136

Infections of the Inner Ear

What are the S&Sx of congenital rubella?

Back 136

Cataracts
Microphthalmia
Cardiac defects (ASD, VSD)
"Blueberry muffin" rash
Developmental delay
Hearing loss - usually severe to profound

Front 137

Infections of the Inner Ear

What tests are ordered to diagnose rubella?

Back 137

Viral isolation from nasopharyngeal swab or urine is diagnostic procedure of choice

Serologies are very difficult to interpret in congenital rubella due to transplacental transmission of IgG

Front 138

Infections of the Inner Ear

What family of viruses is Rubella part of?

Back 138

Togavirus family (RNA virus)