What Do I Do Next - Otitis Gone Wild

Kurt Hummer NP, Mike Weinstock MD, MIzuho Spangler DO

Case

A 48 yo female presents to the Urgent Care (UC) with left ear pain. She has had intermittent cold symptoms. After seeing her primary care doctor, she is now finishing a 10-day course of amoxicillin/clavulanate (Augmentin). She initially felt better after starting the antibiotic, but the pain returned and is getting worse. She has some mild drainage and fullness in her left ear. She denies hearing loss and recent trauma to the ear, but states having had a tympanic membrane (TM) rupture in the same ear from a piece of wood several years ago. She works in an auto supply shop and often wears ear plugs.

Risk factors: None. She denies diabetes, smoking, or alcohol use.

Exam: Classic otitis externa with an inflamed canal and purulent drainage. The exam is notable for pain that is out of proportion to the findings. There is no mastoid tenderness and the portion of the TM that can be seen is erythematous.

Differential Diagnosis of Ear Pain

INTRINSIC EAR PAIN REFERRED EAR PAIN Otitis externa (Swimmer’s Ear) Treat with an ear wick and ciprofloxacin (Ciprodex) otic drops Dental pain Axial load each tooth, and run your finger along the gum line. Trauma Self-inflicted by Q-tips; Externally inflicted Temporomandibular Joint Syndrome (TMJ) Palpate the TMJ joint for tenderness; place finger just inside ear canal and feel for clicking when patient opens mouth. Mastoiditis Palpate mastoid for tenderness Peritonsillar or retropharyngeal abscess Asymmetric, fluctuant swelling in posterior oropharynx. Malignant otitis externa Primarily caused by Pseudomonas. Severe, deep otalgia, with or without purulent otorrhea. Tx: IV antibiotics. 90% have diabetes. Laryngeal mass Listen for stridor or voice changes; ask about risk factors including smoking and alcohol. Acute otitis media May occur with or without a suppurative effusion. Bell’s Palsy (early) Before the nerve is paralyzed, patients will often report sharp pain or tinnitus. Foreign bodies Always inspect the ear and look for them. Temporal arteritis Elderly; temporal tenderness. Neuralgia May be due to herpes zoster or trigeminal neuralgia.

Patients with malignant otitis externa usually appear quite sick with fevers, posterior ear pain, local erythema, and tenderness over mastoid bone, as well as edema over the pinna of the ear.

If there is concern about malignant otitis externa (MOE) or mastoiditis, the patient needs to be referred to the Emergency Department (ED) for a CT of the temporal bone and further evaluation. The management of these two diagnoses are different, so the correct diagnosis must be established.

Case Conclusion:

In the UC, there are 3 choices:

Send the patient home with medication Have the patient follow up with ENT Send the patient to the ED

The patient is treated for otitis externa with antipyrine/benzocaine (Auralgan) and ciprofloxacin otic drops. She is also given a small number of hydrocodone/acetaminophen (Vicodin) tablets to help with the pain at night. She is instructed to go to an ENT specialist for follow-up in 48 hours, if she is not improving.

As she is getting ready to be discharged, the patient goes to the bathroom and the staff notices that she is slightly off-balance. The provider sees her again and she continues to deny dizziness.

The provider gives detailed discharge instructions. “We treated you today for the signs and symptoms that are here, and we’ve given you things to help with the pain and the infection. However, the disease can progress and if things get worse, you should not wait to go to the ENT specialist; instead, you should go to the Emergency Department for further diagnostic testing.”

The next morning, the provider goes to the ED for a meeting and walks by the same patient, who is now intubated.

She presented that morning to the ED febrile, confused, and unable to maintain her airway. A CT scan, labs, and lumbar puncture were performed, which demonstrated that she had both meningitis and a subdural empyema in her brain.

The discharge with return precautions and aftercare instructions is critical in high-risk patients. Be honest with your patients that there is a small amount of diagnostic uncertainty, and ensure your discharge instructions are action- and time-specific. Tell patients what you think is going on, but that you cannot 100% exclude other dangerous things. Make sure they understand that if things get worse, they should not sit at home taking Vicodin. They should come back to the UC or go to the ED because their disease could progress and require different treatments or interventions.