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Pneumatoscopy, the use of the pneumatic otoscope to determine mobility of the tympanic membrane (TM), has not been widely adopted in emergency medicine. The loss of TM mobility occurs with fluid in the middle ear and provides a reliable indication of all forms of otitis media. This communication advocates pneumatoscopy as a simple, safe, and useful technique.
STUDY OBJECTIVES: To determine whether isolated eardrum perforation is a marker for concealed blast lung injury in survivors of terrorist bombings. METHODS: Survivors who arrived at hospitals after 11 terrorist bombings in Israel between April 6, 1994, and March 4, 1996, were examined otoscopically by ear, nose, and throat specialists. All patients with eardrum perforation underwent chest radiography and were hospitalized for at least 24 hours for observation. The clinical course and final outcome of patients with isolated perforation of the eardrums and of those with other blast injuries were surveyed. RESULTS: A total of 647 survivors were examined; 193 (29.8%) of them sustained primary blast injuries, including 142 with isolated eardrum perforation and 51 with other forms of blast injuries (18 with isolated pulmonary blast injury, 31 with combined otic and pulmonary injuries, and 2 with intestinal blast injury). Blast lung injury was promptly diagnosed on admission by physical examination and chest radiography. No patient presenting with isolated eardrum perforation developed later signs of pulmonary or intestinal blast injury (mean 0%; 95% confidence interval, 0% to 2.7%). CONCLUSION: Isolated eardrum perforation in survivors of explosions does not appear to be a marker of concealed pulmonary blast injury nor of a poor prognosis. Therefore, in a mass casualty event, persons who have sustained isolated eardrum perforation from explosions may safely be discharged from the emergency department after chest radiography and a brief observation period.
Otitis media with effusion is the leading cause of hearing loss in children. The pathogenesis of this disease process continues to be controversial. Diagnosis requires precise otoscopic evaluation coupled with audiometric investigation. Therapy has traditionally included medical and surgical regimens. Recent findings indicate that some basic changes may be required in both these therapeutic avenues. Aggressive therapeutic intervention may be required in patients presenting with complications of otitis media with effusion. Available information strongly indicates that a more intensified research effort must be undertaken to better identify and treat this difficult disease process.
Isolated abnormalities of the tympanic membrane have been postulated to affect tympanometry. The authors tested 33 abnormal tympanic membranes in 19 patients with tympanosclerosis and/or thin membranes (having no middle or fibrous layer) against a control group of 32 normal ears in 16 age- and sex-matched patients. All selected patients were free of middle ear disease on the basis of normal hearing, normal pneumatic otoscopic findings, and the presence of crossed acoustic reflexes or normal findings at paracentesis. All patients in the control group had normal type A tympanograms, while 20 (61 per cent) of the tympanic membranes in the experimental group produced abnormal tympanograms. Of the 20 abnormal tympanic membranes, 35 per cent were type As, 35 per cent were type Ad, 5 per cent were type B, and 25 per cent were type C. The tympanosclerotic membranes were more likely to have increased stiffness on the tympanogram, such as As, or B, while the thin membranes had an Ad configuration. The greater the extent of the abnormality within the tympanic membrane, the more abnormal was the tympanogram. This study has demonstrated that isolated abnormalities of the tympanic membrane, such a tympanosclerosis and thin membranes, can alter the tympanogram in the absence of middle ear disease, and that the type of tympanogram can be predicted from the nature and extent of the abnormality. Therefore, an abnormal tympanogram may indicate middle ear disease, abnormality of the tympanic membrane, or both. The presence of an acoustic reflex is important in this differentiation.
PURPOSE: The objectives of this study were to determine the cold water exposure necessary to produce exostoses of the external auditory canal in individuals who predominantly surf along the Oregon and/or the northern California coastline and to ascertain from surfers' otologic histories symptoms attributable to exostoses. MATERIALS AND METHODS: Free ear examinations were provided at two surf shops in northern Oregon. The ear canals were examined with an otoscope, and each surfer was given a summary score indicating the percentage of both canals that was obstructed by exostoses. Surfers were then categorized according to the number of years surfing and the number of sessions surfing per year. RESULTS: Twenty-one surfers met our criteria for analysis. The degree of ear canal obstruction significantly increased with increasing number of years surfing (P < .001) and with increasing number of sessions surfing per year (P < .01). The median summary scores were 7.5, 63.0, and 93.0 for individuals who respectively surfed between 1 and 5 years, between 6 and 15 years, and greater than 15 years. The median summary scores were 10.0 for individuals who surfed 50 sessions or less per year versus 87.5 for individuals who surfed greater than 50 sessions per year. Most surfers with exostoses had minimal complaints. Only one patient had a history of surgical treatment. CONCLUSION: Individuals who surf 5 years or less are unlikely to develop exostoses unless they are surfing greater than 50 sessions per year. Exostoses are typically a benign malady that do not require surgical therapy.
PURPOSE: The aim of the present study was to determine the factors that make a patient of chronic suppurative otitis media more susceptible to the development of a complication. MATERIALS AND METHODS: A prospective study of 125 patients of both complicated and uncomplicated cases of chronic suppurative otitis media who underwent mastoid surgery was undertaken to study the percentage proportion of various complications and to correlate various variables, such as age, sex, duration of ear discharge, otoscopy, operative findings, state of pneumatization, and microbiology of the ear. RESULTS: It was found that patients with complicated ear disease had ear discharge for a shorter duration compared with those without complications. The difference was statistically significant (P < .05). There was no significant difference in the otoscopic findings in both the groups. At surgery, presence of granulation tissue was significantly seen in the group with complications (P < .05). Radiologically, degree of mastoid pneumatization had no significant difference in the two groups, except the presence of lytic lesion in patients more than 15 years of age in the group with complications. Bacteriological examination showed significant isolation of anaerobes in patients with complications (P < .01). CONCLUSION: A history of ear discharge for a short duration in a younger patient less than 15 years of age, the presence of anaerobes in the ear discharge, and granulation tissue at surgery increase the probability of development of a complication in patients with chronic suppurative otitis media.
The efficacy of a novel avermectin, selamectin, was evaluated against naturally acquired aural infestations of Otodectes cynotis on dogs and cats. In four controlled and masked studies conducted in the USA and Europe, animals were allocated randomly to treatment with either selamectin at a minimum dosage of 6mgkg(-1) (range, 6-12. 5mgkg(-1)) or the vehicle only from the commercial formulation of selamectin (negative control). Treatments were administered topically in a single spot to the skin of each animal's back at the base of the neck in front of the scapulae. Cats were treated on day 0 only, and dogs were treated either on day 0 only or on days 0 and 30. The ears of dogs were examined otoscopically on day 14 for the presence of viable mites. Mite counts were conducted on day 30 for animals that had received one dose and on day 60 for animals that had received two doses. Percentage reductions in geometric mean mite counts for selamectin treatment compared with the vehicle were 100% for all animals on all count days. Analysis of variance, confirmed by Savage Scores, showed that ln(mite count+1) values were significantly (P< or =0.0015) lower for selamectin than for the vehicle for all animals on all count days. Thus, selamectin administered topically at a minimum dosage of 6mgkg(-1) was safe and 100% effective against naturally acquired aural infestations of O. cynotis in dogs and cats after a single dose or after two doses administered 1 month apart.
The efficacy of a novel avermectin, selamectin (Stronghold, Pfizer), was evaluated against naturally acquired aural infestations of Otodectes cynotis. Selamectin was administered topically in a single spot to the skin of each animal's back at the base of the neck in front of the scapulae at a minimum dosage of 6mgkg(-1). Thirty cats of a cattery of 120 animals with an endemic infestation were treated on days 0 and 30. Including untreated control cats was therefore not possible because of animal welfare consideration. Clinical examination and visualization of mites by otoscopic examination of the external ear canal and microscopic examination of aural debris/exudate were performed twice weekly from days 0 to 30. On day 0 (and day 28 if the ears canals were erythematous), a swab was taken from each canal and sent to bacteriology and mycology units for detection and identification of bacteria (Staphylococcus mainly) and yeast (Malassezia pachydermatis only). Selamectin was safe, parasites were killed before day 3 and eliminated before day 17. Selamectin was 100% effective against natural aural infestations, even if erythema (26-33% of cats) and scratch reflex (23-40% of cats) persisted for 2 weeks after the cats tested negative for mites.
A 63-year-old woman with rheumatoid arthritis sought medical assistance for dull and chronic pain in her left ear two and half years after her initial diagnostic examination. Otoscopic examination revealed that the posteroinferior wall of the bony external ear canal was eroded and that the small cavity was filled with squamous debris. The condition was diagnosed as external auditory canal cholesteatoma (EACC). The existence of EACC might suggest complications of bone disease, aging cerumen gland, or a low migratory rate of the epithelium.
OBJECTIVE: There is only limited knowledge of the factors influencing the results of nonsurgical treatment of secretory otitis media (SOM) in adults. The present study was carried out to determine the effect of the middle ear (ME) inflation and to clear up the factors affecting the results of conservative treatment of SOM. METHODS: A total of 198 adult patients were randomized to either a group receiving treatment with ME inflation for 10 days or to a group receiving ME inflation and antibiotics (oral Amoxicillin 500 mg 3/day) for 10 days or to a control group. A wide variety of anamnestic and clinical pre-treatment variables were assessed by administered questionnaires. Pneumo-otoscopy, tympanometry and pure-tone audiometry were performed before the treatment and at the 3-5th, 10th+/-2 and 60th+/-5 day of the study. For the prognostic factors, univariate analyses were first performed to determine the significant predictors, which were afterwards entered into a stepwise logistic regression model. RESULTS: The effectiveness of treatment was 50.6% in Group A and 58.7% in Group B (control group-11%, P<0.001). The results of treatment were stable and were found unchanged 6 weeks after the treatment. The most important prognostic criteria were defined by analyzing the dynamics of tympanometry (OR, 2.17) and audiometry (OR, 10.27) during conservative treatment. The results of the treatment were related to the mastoid pneumatization, the pathology of paranasal sinuses, the previous history of SOM, the age, and the pre-treatment otoscopic data. CONCLUSIONS: The results suggest, that daily ME inflation can be effective treatment for adults patients with SOM having regard to the factors significant for the prognosis of treatment.
We report here a case of a carcinoid tumor observed in the middle ear (ME), which was initially diagnosed as ME adenoma. The patient was a 64-year-old woman who was first seen in our hospital in March 2001 for a 7-month hearing loss. On otoscopic examination, a whitish mass could be observed through the intact tympanic membrane. High-resolution computed tomography demonstrated a tumor-like lesion in the ME with no evidence of bone destruction. A myringotomy and biopsy were performed and an initial diagnosis of ME adenoma was made. Light microscopy showed fragments of cellular tissue in which both glandular (adenomatous) and trabecular (carcinoid) growth patterns could be identified, but neuroendocrine differentiation was not detected by immunohistochemistry (negative staining for chromogranin A and synaptophysin). On the basis of this diagnosis, the patient underwent a tympanomastoidectomy in June 2001, in which the presumed ME adenoma was completely excised and the diagnosis was modified to ME carcinoid tumor. Immunohistochemical examinations at that time showed positive staining of the tumor cells for chromogranin A and synaptophysin. This case suggests the difficulties in distinguishing ME carcinoid tumors from ME adenomas. The patient is without recurrence of her disease to date.
Purified peptidoglycan-polysaccharide from Group A Streptococcus pyogenes cell wall (PG-APS) was prepared under sterile, pyrogen-free conditions and injected percutaneously into the middle ear cavities (MEC) of groups of gerbils. Each group was observed otoscopically at 1, 2, 5, 7, 9, 12 and 14 days. Histologic specimens were obtained from each group at 2, 5, 7, 9 and 14 days. Histologically, PG-APS produced mild, acute inflammation during the first 3 days and mild to moderate inflammation with features of both acute and chronic pathology from days 5 through 9. An early response by plasma cells and macrophages was seen. Most animals had recovered with minor sequelae by day 14. Challenge intraperitoneally with 20 micrograms of PG-APS at 14 days following MEC injection of PG-APS did not exacerbate the middle ear inflammation. Five chinchillas, tested for comparison, responded similarly to PG-APS.
We report the case of a 29 year-old woman who complained of pulsatile tinnitus and impaired hearing. On otoscopic examination, her right tympanic membrane was observed to be in contact with a mass in the middle ear cavity, with the formation of a meniscus at the point of contact. Using a high-sensitivity microphone inserted into the external auditory canal, we recorded pulsatile tinnitus that was synchronous with the electrocardiogram. Magnetic resonance angiography revealed that the middle ear mass was an aberrant internal carotid artery coursing through the hypotympanum.
Acute otitis media is the subject of many unresolved points of controversy: 1) correct diagnosis; 2) whether or not bacteria are present in each case of acute otitis media; 3) spontaneous course; 4) indication of antibiotherapy; 5) treatment of recurrent acute otitis media; and 6) the place of alternative medicine, such as homeopathy. There is no ideal response. It is important, however, to take into account the knowledge of the different otoscopic stages of acute otitis media and the fact that the course of the disease is spontaneously favorable in the majority of cases. Selective prescription of an antibiotic in cases of purulent otitis only, and attention directed towards early recognition of complications, appear to be the most appropriate attitudes in the management of the disease, helping to reduce the alarmingly increasing numbers of resistant bacteria.
DESIGN: To determine the impact of the emergence of penicillin-resistant strains of pneumococci on the frequency of acute mastoiditis in children, and to assess the importance of laboratory and imaging studies in the treatment of acute mastoiditis. METHOD: Retrospective review of the medical records of children with postauricular swelling and otoscopic signs of acute otitis media from January 1993 through December 2000. RESULTS: Forty-eight children aged three months to 14 years (median 17 months) were identified. The number of cases was almost the same from one year to another. All children had bacteriological examinations. The mastoid pus and the otorrhea was sterile in 22 cases. The most frequent pathogen was Streptococcus pneumoniae (17 cases), which was resistant to penicillin in 71% of cases. The initial body temperature, the number of polymorphonuclears and the CRP were not different between the group of 18 children with periostitis, which required medical treatment alone, and the group of 30 children who had a mastoid abscess which required surgery. The difference between periostitis and mastoid abscess was seen on clinical examination and CTscan.
A case of abnormal course of the facial nerve is described. It was observed in a patient without malformations of the auricle or the external auditory meatus and with a normal otoscopic picture; but multiple malformations, especially of the upper limbs and the genitalia, were present. The chromosome conditions were normal.
A review of medical records of unselected children in whom the otoscopic diagnosis of middle ear effusion was uncertain, showed that tympanometry resolved the diagnostic uncertainty with an accuracy of 88 per cent for the prediction of a dry middle ear and an accuracy of 85 per cent for predicting fluid in the middle ear. Tympanometry itself gave inconclusive findings in II per cent of cases. Tympanometry can greatly reduce the need for diagnostic aspiration of the middle ear.
Tympanometry and otoscopy were performed by the authors on 893 school-children in Kuwait during early 1983. Based on tympanometry 31.3 per cent were found to have tympanograms indicating secretory otitis media. The otoscopic findings confirmed this high prevalence (30.0 per cent). At re-examination three months later, the point prevalence had decreased by almost 5 per cent which is well in accordance with the seasonal variation of this disease.