Otologic Emergencies
In our 30th episode, we tackle otologic emergencies - from sudden hearing loss to infections, trauma, and foreign bodies. Tune in for a clear, practical framework to spot and manage these “don’t-miss” ear emergencies when every minute counts.
Show notes
Introduction:
Hey everyone, and welcome to The Oto Approach, a podcast created by medical students for medical students, to teach you about all things otolaryngology. I’m your host Emily, and today we’re tackling a practical, high-yield topic: otologic emergencies.
The ear, although small, connects to important structures such as the brain, major blood vessels, and the meninges. Missing an otologic emergency can lead to permanent hearing loss, intracranial infection, facial paralysis, or sepsis. Think of today’s episode as your “don’t-miss” list and practical guide on acting fast when every minute counts.
Today, we’ll walk through otologic emergencies by group: sudden-onset classics, aggressive infections, trauma-related problems, and other must-know cases for every medical learner and clinician:
Acute Emergencies: Sudden Sensorineural Hearing Loss
Serious Infections: Necrotizing Otitis Externa, Mastoiditis, Perichondritis
Trauma Related Conditions: Auricular Hematoma, Temporal Bone Fractures
Miscellaneous: Ear Foreign Body
1. Acute Emergencies
Our first topic, which is often described as a classic otologic emergency, is Sudden Sensorineural Hearing Loss (SSNHL). It is defined as unilateral hearing loss >30 decibels (dB) across 3 contiguous frequencies within 72 hours or less [1-3]. It most often affects adults in their late 40s to early 50s [3], with similar rates among males and females [4,5]. Reported incidence varies, ranging from 11-77 cases per 100,000 people annually [6]. Clinically, patients will present with sudden hearing loss in one ear, often upon awakening [7]. They may say something like, “my ear just went dead overnight” and can also have the sensation of aural fullness, tinnitus, or vertigo [1,3]. Patients may describe this as a feeling of having fluid or wax stuck in their ear.
Patients often first present to the emergency department or a walk-in-clinic, where audiology services are readily not available for formal hearing testing. Physicians may rely on tuning forks to differentiate conductive from sensorineural deficits (i.e., Weber and Rinne tests) and perform an otoscopic examination to assess for external or middle ear pathology. The key is to distinguish sensorineural from conductive hearing loss, and the best way to do this is with an urgent audiogram. This should be organized as soon as possible; however, if clinically there are no signs of a conductive cause for hearing loss (e.g., a middle ear effusion), corticosteroids should be started without delay.
Initial treatment for SSNHL typically involves a course of high dose oral corticosteroids (for example 50-60mg of Prednisone daily) for 7 days, unless contraindicated [8]. Patients should also be urgently referred to an otolaryngologist for a repeat audiogram after 1 week of steroids, and possible intratympanic steroid injections. While most cases of SSNHL are idiopathic, it should be a diagnosis of exclusion. A detailed history and physical exam are important when assessing a patient with SSNHL.
History should include questions on the hearing loss itself, such as onset, triggers, and whether there has been any improvement or worsening in hearing since the hearing loss was first noticed. You should also ask about otorrhea (fluid draining from the ears), otalgia (ear pain), vertigo, and tinnitus. Does the patient have any systemic symptoms that could suggest a viral etiology for the SSNHL? The physical exam should include careful otoscopy (ideally otomicroscopy), a cranial nerve examination, a head thrust test, and a vestibular examination if necessary. Flexible nasopharyngoscopy may also be considered to rule out lower cranial nerve deficits. Some features that might suggest the hearing loss is not idiopathic include bilateral sudden hearing loss, a history of fluctuating hearing loss, recent head or ear trauma, focal neurologic symptoms or signs, down-beating nystagmus, or concurrent eye pain, redness, lacrimation, and photophobia. All cases of SSNHL, regardless of hearing recovery, should have an MRI of their head to rule out any underlying retrocochlear pathology (for example, a vestibular schwannoma). Additionally, some centres may choose to test for syphilis and Lyme disease as a cause for SSNHL, depending on the history and local epidemiologic data.
Clinical pearl #1: Do not delay steroids while waiting for formal audiometry. Time is ear.
2. Infections: Necrotizing Otitis Externa, Mastoiditis, Perichondritis
Our first infectious otologic emergency to discuss today is necrotizing otitis externa, previously referred to as malignant otitis externa. Necrotizing Otitis Externa, or NOE for short, is a rare yet potentially life-threatening infection that can lead to skull base osteomyelitis. The infection usually starts in the external auditory canal and is commonly caused by Pseudomonas aeruginosa, a Gram-negative bacterium [9]. NOE typically affects older adults with comorbidities such as diabetes mellitus [10] or other immunocompromised states.
Its progression typically begins as a simple otitis externa with symptoms of otalgia and otorrhea, with the infection spreading to the temporal bone itself, where it causes periostitis and ultimately osteomyelitis. NOE can lead to severe complications such as cranial nerve palsies, brain abscesses, meningitis, and dural venous sinus thrombosis [11, 12].
Patients with NOE typically present with severe, persistent otalgia (often worse at night) and otorrhea that is unresponsive to standard topical treatments for otitis externa [13]. Pain is commonly out of proportion to the exam findings. Examination may reveal a red, swollen auricle, marked tenderness of the external auditory canal near the bony-cartilaginous junction (Santorini’s fissure), and granulation tissue visualized in the canal at that site, which is pathognomonic. Cranial neuropathies, including facial palsy (CN VII dysfunction), can also occur in advanced cases [10].
The initial management approach includes debridement of the ear canal under microscopy and sending a sample of any drainage for culture and antibiotic sensitivities. Relevant investigations should include WBC count, CRP, ESR, hemoglobin A1C, and blood cultures if systemic infection is suspected. Imaging is also critical. CT of the temporal bone (with contrast) is helpful for assessing bony erosion, however, it does not give you enough information about soft tissue and intracranial involvement. MRI with contrast may therefore be indicated.
Patients with early NOE and minimal comorbidities may be managed as outpatients with oral as well as topical fluoroquinolones, such as ciprofloxacin. However, it is important to have a low threshold for hospital admission and IV antibiotics in higher-risk situations (e.g., immunocompromised patients, uncontrolled diabetes, evidence of bony involvement on imaging, presence of cranial nerve palsies, or lack of clinical response) [14]. Surgical treatment is infrequently required, typically reserved for severe cases with abscess formation or failure to respond to medical therapy.
Clinical pearl: Immunocompromised or diabetes + severe ear pain + granulation tissue in the external auditory canal = Necrotizing Otitis Externa until proven otherwise.
Next let’s discuss mastoiditis, which is an infection of the mastoid bone. This is a potential complication of acute otitis media (AOM), although now with the widespread use of antibiotics to treat AOM, it is rare – particularly in adults. When mastoiditis develops, infection in the mastoid bone can lead to “coalescence”, or destruction of the bony septae dividing the bone into air cells . Findings on CT will show loss of trabecular bone structure in the mastoid. If mastoiditis extends beyond the mastoid bone, it can cause serious complications because the mastoid is close to critical structures such as the posterior cranial fossa, the lateral venous sinuses (sigmoid sinus), the facial nerve, the semicircular canals, and the petrous portion of the temporal bone. Patients may present with an abscess behind the ear – a subperiosteal abscess, under the mastoid periosteum – if infection spreads through the mastoid cortex.
Mastoiditis is more common in children than in adults. Symptoms include fever, postauricular pain, swelling and erythema behind the ear, protrusion of the auricle, and persistent otorrhea. On examination, the tympanic membrane may appear bulging or show evidence of middle ear effusion or perforation, or it may not be visualized at all due to swelling of the external auditory canal if the ear drum is perforated and drainage of purulent material from the middle ear has led to a secondary otitis externa. Importantly, when assessing a patient with suspected mastoiditis, make sure to test cranial nerve function, particularly the facial nerve (CN VII), as it can be affected in severe cases. Complications include brain abscess, sigmoid sinus thrombosis, meningitis, and cranial nerve palsies [15].
The diagnosis of mastoiditis is clinical. Mastoid fluid may be incidentally found on CT or MRI, but this does not indicate active mastoiditis. In a true mastoiditis, management includes admission to hospital for IV antibiotic therapy and middle ear drainage with myringotomy in children. If IV antibiotic and myringotomy alone are not effective, surgical intervention including mastoidectomy for debridement of necrotic bone may be warranted [15]. If symptoms are not improving after 48 hours of antibiotics or if surgery is being considered, a CT scan of the temporal bones is warranted. An MRI is indicated if intracranial complications are suspected.
Clinical pearl #1: Always examine behind the ear in febrile children with acute otitis media – do not miss mastoid swelling.
Clinical pearl #2: Mastoiditis is a clinical diagnosis.
Finally, our last infection to discuss today is perichondritis. Perichondritis is infection of the auricular cartilage, usually after a piercing or trauma. Common causative bacteria include Pseudomonas and Staphylococcus aureus. Patients will present with a red, painful, swollen pinna – but the earlobe is spared (as it contains no cartilage). If left untreated it can cause cartilage destruction and permanent deformity. Management includes antibiotics – usually anti-pseudomonal coverage (such as Ciprofloxacin) – and urgent drainage of any abscess, if present.
3. Trauma Related Conditions: Auricular Hematoma, Temporal Bone Fracture
Trauma related otologic emergencies in today’s talk include auricular hematoma and temporal bone fracture. Let’s start with auricular hematoma. An auricular hematoma is a collection of blood between ear cartilage and perichondrium, usually after trauma. You often see this in wrestlers, boxers, or rugby players. If left untreated, it can lead to cartilage necrosis resulting in the famous cauliflower ear. Presentation includes a fluctuant, painful swelling of pinna, often on the anterior surface.
Management includes prompt drainage – either by needle aspiration or incision and drainage – and applying a pressure dressing to prevent re-accumulation.
Clinical pearl: In any ear trauma with swelling, check for an auricular hematoma. Treat early with drainage and pressure to prevent permanent deformity.
Our next traumatic topic to review is temporal bone fracture. Temporal bone fractures – a subtype of basilar skull fracture – can occur after severe blunt trauma, such as a motor vehicle collision. This type of fracture puts patients at higher risk for extra-axial hematomas, bleeding beneath the skull but outside of the brain parenchyma (e.g., epidural hematoma) [16], due to the temporal bone’s proximity to the middle meningeal artery and vein. Signs to look for include Battle’s sign (postauricular ecchymosis), clear rhinorrhea or otorrhea (which may indicate CSF leak), hemotympanum (blood behind the tympanic membrane), facial nerve palsy, hearing loss, and vertigo. Urgent neurosurgery and otolaryngology consultation are indicated in such cases for possible surgical repair and management. Pediatric patients should also undergo a hearing test and receive a pneumococcal vaccine, as they are at higher risk of pneumococcal meningitis [17].
Clinical pearl: Temporal bone fractures can be longitudinal, transverse or mixed. The most common are longitudinal (70-90%) fractures, which can cause conductive hearing loss, while sensorineural hearing loss and vestibular dysfunction (e.g. vertigo) are more commonly seen in transverse fractures [18]. Both types can cause facial paralysis, however, it is more common with transverse fractures.
4. Miscellaneous: Ear foreign body
Our final otologic emergency topic in today’s episode is aural foreign bodies. Foreign bodies present in the external auditory canal can lead to infection, tympanic membrane damage and hearing loss. While aural foreign bodies are most common in the pediatric population, adults may also present with foreign bodies, often due to cotton buds or insects. In children, the foreign body is often located in the right ear, due to majority of children being right-handed [19]. Three-quarters (75%) of patients with aural foreign bodies may be asymptomatic on presentation [20]. Otherwise, they may present with unilateral otalgia, bleeding, otorrhea, hearing loss or aural fullness. Removal timing depends on the type of foreign body – the most urgent being button batteries, live insects, and penetrating foreign bodies.
Button batteries in the ear canal are an emergency. They can cause rapid burns, so the battery needs to be removed right away under direct visualization with microscopy. Management includes the use of alligator or bayonet forceps, or suction, to remove the object. If it is wedged, a right-angle hook or curette can help lever it out. Never irrigate in the case of a button battery – irrigation accelerates tissue injury due to electrolysis.
In uncomplicated cases not involving batteries, a known perforated ear drum, or organic materials that can swell (e.g., bean), irrigation can be a good option for removal. Using a syringe, warm water or saline have the patient lie with the bad ear up, tuck a towel underneath, and insert the tubing approximately a centimeter into the external ear canal. Aim the stream along the back wall and flush until the object comes out. If irrigation is not an option —like with a perforated eardrum— instruments can be used instead. An ear speculum can be used to improve visualization. Soft objects like foam or paper can be removed with alligator or bayonet forceps. Round or fragile objects often need a right-angle hook, while smooth, wedged objects can sometimes be lifted carefully using a bit of super glue on a cotton swab. For insects, first kill it with mineral oil, lidocaine, or ethanol, then remove it with forceps.
Complications of aural foreign bodies can range from mild discomfort to severe ear pain, otitis externa, tympanic membrane perforation, labyrinthitis, or even profound hearing loss [20]. Prompt removal is essential to prevent serious outcomes like tissue necrosis or osteomyelitis.
Clinical pearl: Button batteries in the ear canal are an emergency and must be removed immediately to prevent liquefactive necrosis – never irrigate as this will worsen tissue damage.
Take Home Points:
That was a lot of information. Let’s summarize the “must-know” otologic emergencies:
1.Acute Emergencies: Sudden Sensorineural Hearing Loss → suspect this when a patient has sudden unilateral hearing loss that is sensorineural, or without obvious conductive causes → start steroids immediately, and obtain an urgent audiogram plus an otolaryngology referral
2. Infectious:
Necrotizing otitis externa → suspect in patients with diabetes or immunocompromised patients with severe ear pain and drainage → start IV antibiotics and admit to hospital
Mastoiditis → suspect in pediatric patients with AOM and postauricular swelling/erythema, protruding auricle, and fever → start IV antibiotics and arrange drainage (myringotomy)
Perichondritis → suspect in patients with cartilaginous erythema and edema that spares earlobe → start antibiotics with Pseudomonal coverage
3. Trauma Related:
Auricular hematoma → suspect in boxers, rugby players → drain and compress early to prevent permanent deformity
Temporal bone fracture → suspect if major head trauma → stabilize the patient, test facial nerve function, and obtain urgent neurosurgery and otolaryngology consultation → get an audiogram when the patient is stable
4. Miscellaneous: Ear foreign body → organic objects can cause infection and swelling, and button batteries can cause rapid tissue injury → remove these urgently to prevent infection and irritation to the external auditory canal
If you remember nothing else: new sudden hearing loss, disproportionate ear pain, or postauricular swelling → think otologic emergency.
Conclusion:
That’s it for today’s episode of The OTO Approach! I hope this gives you a solid framework for recognizing and managing otologic emergencies — because these are the kinds of cases where your quick action can make a huge difference.
This script was written by Emily Kraft, it was revised by Dr. Victoria Taylor, PGY1 and Dr. Alexandra Quimby.
Thank you so much for listening to our podcast! We hope you’ll tune in to our next episode!
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