Ear complaints frequently bring patients to adult and pediatric emergency departments (EDs). Although rarely life-threatening, these disorders have a significant impact on the patient's daily life. The emergency clinician needs to be able to distinguish complaints that need immediate evaluation and treatment in the ED from those that are best handled by the primary care clinician or in an otolaryngologist's office. This review will cover 4 common complaints involving the ear: pain (otalgia), hearing loss, tinnitus, and trauma.
You are moonlighting in a small community ED with no in-house support. The EMS team arrives with your next patient who has been in a bar fight. He is intoxicated and bleeding through the gauze wrapped around his head. When you remove the gauze to examine the wound to his ear, you find that he has sustained a 5-cm laceration through the pinna. You wish you were back in the city where you could call facial plastics to repair this, but here in this ED you are on your own. How will you approach this repair?
Meanwhile, as your tech is setting up for the ear repair, you return to the wailing 2-year-old in the room next door and diagnose an acute otitis media. The mother asks which antibiotic you will be prescribing. The child appears well, has only a low-grade fever, and is otherwise healthy. You wonder whether you need to give antibiotics at this point. What factors need to be considered in making that decision?
Finally, a middle-aged gentleman presents with unilateral hearing loss that has developed over the preceding 24 hours. When your examination fails to reveal cerumen impaction, you wonder what to do next and whether any steps should be taken tonight...
An Ovid MEDLINE® (www.ovid.com) search of the literature on emergencies of the ear was undertaken, using the following search terms: acute otitis media, otitis media with effusion, otitis externa, otalgia, hearing loss, tinnitus, foreign body, herpes zoster, andtrauma in conjunction with the terms ear, diagnosis, treatment, epidemiology, microbiology, acute, andemergent. The search was limited to literature in English that reported on clinical trials, randomized controlled trials (RCTs), practice guidelines, meta-analyses, and review articles published within the last 10 years. Other sources queried included the Cochrane Library and the National Guideline Clearinghouse (www.guidelines.gov). The search initially yielded 335 articles, the titles and abstracts of which were reviewed for relevance, and was then extended to include the relevant references cited in articles identified. Analysis of data was weighted according to the strength of each study, with greater emphasis placed on well-conducted RCTs and on professional society guidelines, and less value placed on case reports and retrospective studies. Evidence on which to base recommendations varied by topic; it was particularly rich in the area of otitis media (OM) and less strong on the topics of tinnitus and sudden hearing loss. Three sets of guidelines related to topics relevant to emergency practice that were published by major medical societies and several other guidelines from individual hospital systems were identified. (See Table 1.) None of these guidelines were written by an emergency medicine society. All were evidence-based reviews of the current literature and were guided by preset criteria for levels of evidence. Each delivered recommendations on a scale ranging from "strong recommendation" to "recommendation" to "option" to "no recommendation" and did so using an evidence grading scale from A (multiple RCTs) to D (case reports, expert opinion). For a review and comment on the 2006 guideline on otitis externa from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF), see EM Practice Guidelines Update November 2009 issue, which is available online at www.ebmedicine.net/EMPGU.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
Jeffrey Siegelman; George Kazda; Daniel Lindberg
July 2, 2010