Evaluation And Treatment Of Common Ear Complaints In The Emergency Department
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Evaluation And Treatment Of Common Ear Complaints In The Emergency Department

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Table of Contents
Table of Contents
  1. Abstract
  2. Practice Recommendations (key points from the issue)
  3. Case Presentations
  4. Critical Appraisal Of The Literature
  5. Epidemiology
  6. Anatomy Of The Ear
  7. Etiology
    1. Otalgia
      1. Acute Otitis Media
      2. Otitis Externa
    2. Hearing Loss
    3. Tinnitus
  8. Prehospital Care
  9. ED Evaluation
    1. History
    2. Physical Examination
  10. Diagnostic Studies
    1. Imaging
    2. Blood Tests
  11. Treatment
    1. Otalgia
      1. Otitis Media
        • Acute Otitis Media
        • Otitis Media With Effusion
      2. Otitis Externa
      3. Other Conditions Of The External Ear That Cause Otalgia
        • Mastoiditis
        • Perichondritis
        • Herpes Zoster Oticus (Ramsay Hunt Syndrome)
        • Foreign Body
        • Temporomandibular Joint Disorders
    2. Hearing Loss
    3. Tinnitus
    4. Ear Trauma
      1. Lacerations Of The External Ear
      2. Auricular Hematoma
      3. Tympanic Membrane Perforation
      4. Barotrauma
  12. Special Circumstances
    1. Pediatrics
    2. Pregnancy
    3. Diabetes Mellitus
  13. Controversies/Cutting Edge
  14. Summary
  15. Risk Management Pitfalls For Ear Complaints In The ED
  16. Time- And Cost-Effective Strategies
  17. Case Conclusion
  18. Tables and Figures
    1. Table 1. Recent Practice Guidelines
    2. Table 2. Differential Diagnosis Of Sudden Hearing Loss
    3. Table 3. Causes Of Tinnitus
    4. Table 4. Antibiotic Therapy In Acute Otitis Media
    5. Table 5. Indications For Tympanostomy Tube Placement In OME
    6. Table 6. Ototoxic Treatment To Be Avoided In Possible Or Confirmed Rupture Of The TM
    7. Figure 1. Anatomy Of The External Ear
    8. Figure 2. Normal Left Tympanic Membrane As Viewed Through An Otoscope
    9. Figure 3. Mastoiditis
    10. Figure 4. Injection Sites For Alternative Methods Of Anesthesia
    11. Figure 5. Auricular Hematoma
    12. Figure 6. Technique For Bolster Of A Drained Auricular Hematoma
  19. Clinical Pathway For Treatment Of Acute Otitis Media
  20. References


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.

Practice Recommendations (key points from the issue)

Click here to download a PDF of the Evidence-Based Practice Recommendations for this issue.

Case Presentations

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...

Critical Appraisal Of The Literature

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.

Risk Management Pitfalls For Ear Complaints In The ED

  1. "I thought compression would help his swollen ear."Do not overlook an auricular hematoma; it must be incised and drained. This is an easy fix, but if left untreated, is likely to result in a cauliflowerear deformity.
  2. "The ear looked fine; I couldn't find a cause for his pain."Remember to look for sources of referred pain in patients who present with otalgia but have a normal ear examination. The ear shares sensory innervation with multiple cranial nerves, and pain can commonly be referred from the pharynx, the TMJ, and even the thyroid gland.
  3. "I told him to follow up for his tinnitus — wasn't that enough?"Know which patients presenting with tinnitus to worry about. Be on the lookout for carotid artery dissection, aspirin toxicity, and anemia, all of which can be manifest as tinnitus. These diagnoses need to be ruled out before the patient is referred for outpatient follow-up.
  4. "I thought I knew where it was in the canal."If you can't see it, don't go after it. When attempting to remove a foreign body from the external ear canal, do not blindly insert instruments without proper visualization, since damage to the TM or ossicles can result in hearing loss. If you can't easily access the foreign body, refer the patient to an otolaryngologist.
  5. "My own toddlers have bruises all over their foreheads, why should I worry about a few bruises on the ear?"Remember to consider nonaccidental trauma in children who present with ear injuries, because doing so may save a life.
  6. "I saw most of the TM so I didn't think there was a perforation."When prescribing topical medications for the ear, first consider a possible perforation of the TM; if this cannot be ruled out, avoid ototoxic preparations.
  7. "I gave the mother a wait-and-see prescription, but she didn't fill it."Remember that the wait-and-see prescription is not appropriate for everyone. It's important to consider whether the family has good follow-up, access to pharmacies, and the ability to determine whether or not the child is improving.
  8. "It was a really busy night and I didn't have time to walk the patient."The possibility of focal neurologic deficits is a key factor in determining whether certain ear complaints, especially tinnitus and SSHL, require more emergent evaluation. Furthermore, when stroke is a possibility, consider specialist consultation as well.
  9. "I gave her drops for her OE; that has always worked for my patients before."When treating patients with OE, remember that diabetics and immunocompromised patients will require systemic therapy, since this infection can easily spread to bone, brain, and elsewhere, and these patient groups are at higher risk for such complications.

Tables and Figures

Table 1. Recent Practice Guidelines


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.

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Jeffrey Siegelman; George Kazda; Daniel Lindberg

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July 2, 2010

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