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Evaluation and Treatment of Common Ear Complaints in the Emergency Department Siegelman J, Kazda G, Lindberg D

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Evaluation and Treatment of Common Ear Complaints in the Emergency Department Siegelman J, Kazda G, Lindberg D July 2010 Evaluation And Treatment Of Volume 12, Number 7 Common Ear Complaints In The Authors Jeffrey Siegelman, MD Emergency Medicine Physician, Harvard Affiliated Emergency Emergency Department Medicine Residency Program, Brigham and Women’s Hospital, Boston, MA George Kazda, MD You are moonlighting in a small community ED with no in-house support. Director, ENT Emergency Department, Massachusetts Eye and The EMS team arrives with your next patient who has been in a bar fight. Ear Infirmary, Boston, MA He is intoxicated and bleeding through the gauze wrapped around his head. Daniel Lindberg, MD Attending Physician, Emergency Department, Brigham and When you remove the gauze to examine the wound to his ear, you find that Women’s Hospital and Children’s Hospital, Boston, MA he has sustained a 5-cm laceration through the pinna. You wish you were Peer Reviewers 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? Michael Bessette, MD, FACEP Chairman of Emergency Medicine, Jersey City Medical Center, Meanwhile, as your tech is setting up for the ear repair, you return to Jersey City, NJ the wailing 2-year-old in the room next door and diagnose an acute otitis Sigrid Hahn, MD, MPH media. The mother asks which antibiotic you will be prescribing. The child Assistant Professor, Department of Emergency Medicine, Mount appears well, has only a low-grade fever, and is otherwise healthy. You won- Sinai School of Medicine, New York, NY der whether you need to give antibiotics at this point. What factors need to CME Objectives be considered in making that decision? Upon completion of this article, you should be able to: Finally, a middle-aged gentleman presents with unilateral hearing loss 1. Understand the diagnosis of common emergencies involving the ear. that has developed over the preceding 24 hours. When your examination 2. Be able to develop a differential diagnosis for ear fails to reveal cerumen impaction, you wonder what to do next and whether complaints. any steps should be taken tonight... 3. Formulate an evaluation plan of ear complaints that is efficient, parsimonious, and thorough. 4. Develop evidence-based treatment strategies for ar complaints frequently bring patients to adult and pediatric complaints of the ear. Eemergency departments (EDs). Although rarely life-threat- Date of original release: July 1, 2010 ening, these disorders have a significant impact on the patient’s Date of most recent review: April 15, 2010 Termination date: July 1, 2013 daily life. The emergency clinician needs to be able to distinguish Method of participation: Print or online answer form and complaints that need immediate evaluation and treatment in the evaluation Prior to beginning this activity, see “Physician CME Information” ED from those that are best handled by the primary care clinician on page 20. Editor-in-Chief Nicholas Genes, MD, PhD General Hospital, Harvard Medical Corey M. Slovis, MD, FACP, FACEP Research Editor Andy Jagoda, MD, FACEP Instructor, Department of Emergency School, Boston, MA Professor and Chair, Department Medicine, Mount Sinai School of of Emergency Medicine, Vanderbilt Lisa Jacobson, MD Professor and Chair, Department Charles V. Pollack, Jr., MA, MD, Medicine, New York, NY University Medical Center; Medical Chief Resident, Mount Sinai School of Emergency Medicine, Mount FACEP Director, Nashville Fire Department of Medicine, Emergency Medicine Sinai School of Medicine; Medical Michael A. Gibbs, MD, FACEP Chairman, Department of Emergency and International Airport, Nashville, Residency, New York, NY Director, Mount Sinai Hospital, New Chief, Department of Emergency Medicine, Pennsylvania Hospital, TN York, NY Medicine, Maine Medical Center, University of Pennsylvania Health International Editors Portland, ME System, Philadelphia, PA Jenny Walker, MD, MPH, MSW Editorial Board Peter Cameron, MD Assistant Professor; Division Chief, William J. Brady, MD Steven A. Godwin, MD, FACEP Michael S. Radeos, MD, MPH Chair, Emergency Medicine, Family Medicine, Department Professor of Emergency Medicine Associate Professor, Associate Chair Assistant Professor of Emergency Monash University; Alfred Hospital, of Community and Preventive and Internal Medicine, Vice Chair and Chief of Service, Department Medicine, Weill Medical College of Melbourne, Australia Medicine, Mount Sinai Medical of Emergency Medicine, University of Emergency Medicine, Assistant Cornell University; Department of Center, New York, NY of Virginia School of Medicine, Dean, Simulation Education, Emergency Medicine, New York Giorgio Carbone, MD Charlottesville, VA University of Florida COM- Hospital Queens, Flushing, NY Ron M. Walls, MD Chief, Department of Emergency Jacksonville, Jacksonville, FL Professor and Chair, Department of Medicine Ospedale Gradenigo, Peter DeBlieux, MD Robert L. Rogers, MD, FACEP, Emergency Medicine, Brigham and Torino, Italy Professor of Clinical Medicine, LSU FAAEM, FACP Gregory L. Henry, MD, FACEP Women’s Hospital, Harvard Medical Health Science Center; Director Assistant Professor of Emergency Amin Antoine Kazzi, MD, FAAEM CEO, Medical Practice Risk School, Boston, MA of Emergency Medicine Services, Assessment, Inc.; Clinical Professor Medicine, The University of Associate Professor and Vice Chair, University Hospital, New Orleans, LA of Emergency Medicine, University Maryland School of Medicine, Scott Weingart, MD, FACEP Department of Emergency Medicine, of Michigan, Ann Arbor, MI Baltimore, MD Assistant Professor of Emergency University of California, Irvine; Wyatt W. Decker, MD Medicine, Mount Sinai School of American University, Beirut, Lebanon Professor of Emergency Medicine, John M. Howell, MD, FACEP Alfred Sacchetti, MD, FACEP Medicine; Director of Emergency Mayo Clinic College of Medicine, Clinical Professor of Emergency Assistant Clinical Professor, Hugo Peralta, MD Critical Care, Elmhurst Hospital Chair of Emergency Services, Rochester, MN Medicine, George Washington Department of Emergency Medicine, Center, New York, NY University, Washington, DC; Director Thomas Jefferson University, Hospital Italiano, Buenos Aires, Francis M. Fesmire, MD, FACEP of Academic Affairs, Best Practices, Philadelphia, PA Senior Research Editor Argentina Director, Heart-Stroke Center, Inc, Inova Fairfax Hospital, Falls Joseph D. Toscano, MD Erlanger Medical Center; Assistant Scott Silvers, MD, FACEP Maarten Simons, MD, PhD Church, VA Emergency Physician, Department Professor, UT College of Medicine, Chair, Department of Emergency Emergency Medicine Residency of Emergency Medicine, San Ramon Chattanooga, TN Keith A. Marill, MD Medicine, Mayo Clinic, Jacksonville, Director, OLVG Hospital, Amsterdam, Assistant Professor, Department of FL Regional Medical Center, San The Netherlands Emergency Medicine, Massachusetts Ramon, CA Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Siegelman, Dr. Kazda, Dr. Lindberg, Dr. Bessette, Dr. Hahn, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support. or in an otolaryngologist’s office. This review will area of otitis media (OM) and less strong on the cover 4 common complaints involving the ear: topics of tinnitus and sudden hearing loss. Three pain (otalgia), hearing loss, tinnitus, and trauma. sets of guidelines related to topics relevant to emergency practice that were published by major Critical Appraisal Of The Literature medical societies and several other guidelines from individual hospital systems were identified. (See An Ovid MEDLINE® (www.ovid.com) search of Table 1.) None of these guidelines were written by the literature on emergencies of the ear was under- an emergency medicine society. All were evidence- taken, using the following search terms: acute otitis based reviews of the current literature and were media, otitis media with effusion, otitis externa, otalgia, guided by preset criteria for levels of evidence. hearing loss, tinnitus, foreign body, herpes zoster, and Each delivered recommendations on a scale rang- trauma in conjunction with the terms ear, diagno- ing from “strong recommendation” to “recom- sis, treatment, epidemiology, microbiology, acute, and mendation” to “option” to “no recommendation” emergent. The search was limited to literature in and did so using an evidence grading scale from A English that reported on clinical trials, randomized (multiple RCTs) to D (case reports, expert opinion). controlled trials (RCTs), practice guidelines, meta- For a review and comment on the 2006 guideline analyses, and review articles published within on otitis externa from the American Academy of the last 10 years. Other sources queried included Otolaryngology-Head and Neck Surgery Founda- the Cochrane Library and the National Guideline tion (AAO-HNSF), see EM Practice Guidelines Update Clearinghouse (www.guidelines.gov). The search November 2009 issue, which is available online at initially yielded 335 articles, the titles and abstracts www.ebmedicine.net/EMPGU. of which were reviewed for relevance, and was then extended to include the relevant references Epidemiology cited in articles identified. Analysis of data was weighted according to the strength of each study, Ear pain (otalgia)
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