Ohrerkrankungen in der Allgemeinpraxis

About 5% of consultations in general practice are related to an otological disease. If the outer ear or middle ear is affected – which can usually be deduced from medical history and clinical findings – treatment can usually take place in general practice. Decisive examinations are the otoscopy and the tuning fork tests according to Weber and Rinne. Ideally, if a middle ear disease is suspected, otoscopy should be combined with pneumatic testing or Valsalva maneuver; this makes it possible to check whether the eardrum is moving or whether there is an effusion in the middle ear; however, even experts admit that pneumatic testing is often difficult to evaluate.

The main symptoms of diseases of the outer ear and middle ear are pain or discomfort in the ear, discharge and hearing loss; for the sake of completeness, one will also ask about tinnitus and dizziness; The "5S rule" (pain, secretion, hearing loss, buzzing, dizziness) serves as a mnemonic aid. In the case of ear pain, the first thing to think about is something local (infection, trauma); more rarely, it is persistent pain caused by a disease outside the ear area (temporomandibular joint, throat). Discharge from the ear is usually caused by an affection in the outer ear or middle ear. Hearing loss can have a variety of causes; primarily, a distinction can be made between conductive and sensorineural disorders; important assessment criteria are how severe the hearing loss is, how quickly it has developed and whether it is present on one or both sides.

Infektionen der Ohrmuschel

Perichondritis develops as a result of an injury (e.g. piercing) or spreading otitis externa; it is characterized by a reddened, swollen and painful auricle with a recess in the earlobe. Pseudomonas is the most common pathogen. The therapy consists of anti-inflammatory compresses and the oral administration of a fluoroquinolone such as ciprofloxacin (ciproxin®, etc.).

If earlobes and possibly also surrounding soft tissues are also affected, erysipelas must be suspected, which must be treated with an appropriate antibiotic.

Otitis externa

Otitis externa is an inflammation of the external auditory canal that presents clinically as a diffuse form (dermatitis) or as a circumscript form (boils). It can be both infectious and non-infectious, spreading to the auricle and eardrum. Rarely, it spreads to soft tissues and bones, which is especially common in older people with diabetes; this course, known as malignant (necrotizing) otitis externa, requires an urgent specialist assessment (with inpatient and often surgical treatment).

Otitis externa is favored by factors that impair the protection mediated by cerumen. These include moisture in the ear canal (swimming, sweating), mechanical stimuli (forced cleaning, earplugs, hearing aids), dermatological diseases (eczema, psoriasis) or unfavorable anatomical conditions (very narrow or very hairy ear canal). It is part of the therapy plan for otitis externa to eliminate such predisposing factors as far as possible.

Acute otitis externa

The acute form accounts for over 95% of external otitis and is usually caused by a bacterial infection, with Pseudomonas and staphylococci as the most common pathogens. In about one third of cases, there is a mixed bacterial infection. Fungal infections with Aspergillus or Candida tend to occur secondarily or in the context of chronic otitis externa.(1)

Acute otitis externa is characterized by rapidly occurring symptoms, which can range from itching or discomfort to severe pain that extends to the auricle. Otorrhea and hearing loss may also occur. Fever and general malaise would be indications that the process has extended beyond the ear canal. Diagnostically groundbreaking are pain when pressure is applied to the tragus or when the auricle is pulled, as well as the findings of otoscopy with redness, secretion and swelling of the ear canal. The main differential diagnosis is otitis media.

In the case of acute otitis externa, local treatment with antibiotics is usually sufficient . (A pathogen culture is only necessary in case of treatment failure, relapses or malignant otitis externa.) The focus is on aminoglycosides or fluoroquinolones, which are used to detect the relevant germs. In Switzerland, there are still two preparations of antibiotic ear drops: one with the combination of neomycin/polymyxin B (Panotile®) and one with ciprofloxacin (ciproxin® HC). With a local antibiotic treatment, the result is a "number needed to treat" (NNT) of about 2 compared to placebo, which is equivalent to doubling the cure rate; there are no significant differences between the antibiotics used.(2) If the eardrum is intact, the inexpensive ear drops with an aminoglycoside are primarily suitable, while fluoroquinolone should be preferred if the eardrum is injured (or if the findings are unclear).(3) However, neomycin often causes hypersensitivity. Antiseptics, for example with acetic acid, seem to be as effective as antibiotics. The addition of a steroid – as is the case with all antibiotic ear drops available in Switzerland – accelerates decongestion and symptom relief, but does not improve the cure rate.(2,4) The proposed duration of treatment is 7 to 10 days, but exact data are not available.(3)

Contact with the epithelium is important for the local effect of antibiotics. If there is severe swelling of the ear canal, a foam tampon soaked in the drops or a strip of ointment of an aminoglycoside/steroid combination can be inserted to ensure contact with all parts of the ear canal. If the ear canal is filled with cerumen or detritus, it must be carefully rinsed – which should only be done if the eardrum is intact and may require preparation with analgesics. If a general practice lacks the knowledge or prerequisites for these manipulations, it is advisable to refer to a medical specialist.(3)

Systemic antibiotics are only needed if the infection has spread through the external auditory canal, if there is an immune suppression or if local treatment is not feasible. Systemic analgesics should always be prescribed.

Chronic otitis externa

Otitis externa is called chronic if it lasts more than 3 months. It is usually due to an allergy or another dermatological disease (eczema, psoriasis, etc.). Contact allergens include metals (nickel, chromium, etc.) and any chemical substances found in cosmetics, soaps or plastics. On the soil of chronic otitis externa, acute otitis externa can also develop.

Symptoms of chronic otitis externa include itching, a feeling of pressure, pain, discharge and hearing loss. Many sufferers experience a changeable course with worsening and improving symptoms. Otoscopically, one often finds indications of the underlying dermatological affection. If an infection cannot be ruled out, a bacterial and fungal culture should be ordered.

In the treatment of chronic otitis externa, the first step is to identify and eliminate triggering factors. Secondly, drug treatment will be carried out depending on the etiology. If there is a dermatological disease, steroids alone can be used; in the case of a fungal infection, antifungal agents are used, and a bacterial infection is treated in the same way as in acute otitis externa. Pure steroids and antifungal agents are not available as otological preparations in Switzerland; you therefore have to switch to eye drops or ointments that are applied with cotton swabs or as ointment strips.

Otitis media

The middle ear corresponds anatomically to a cavity bounded laterally by the tympanic membrane, medially by the inner ear and posteriorly by the mastoid cells; anteriorly, the Eustachian tube departs. The term otitis media can be used to describe a spectrum of infectious or inflammatory diseases that take place in the middle ear. The most common middle ear disease is acute otitis media; a distinction must be made between tubal middle ear catarrh or tympanic effusion (known in Anglo-American countries as "otitis media with effusion"), otitis media perforata chronica simplex and otitis media perforata chronica cholesteatomatosa (cholesteatoma).(5)

Acute otitis media

Acute otitis media occurs mainly in infants and young children and is one of the most common infections in this age group. It is usually associated with a viral infection of the upper respiratory tract, which leads secondarily to a bacterial infection in the middle ear, with pneumococci, haemophilus and Moraxella being the main pathogens. Influenza otitis, a special form of otitis media that occurs in children and adults and is characterized by the formation of bloody blisters in the ear canal and on the eardrum, is purely viral.

Typical symptoms of acute otitis media are ear pain, hearing loss, otorrhea (when the eardrum is perforated) and general symptoms such as fever and malaise. In order to be able to make the diagnosis of acute otitis media, inflammation of the tympanic membrane and (purulent) secretions in the middle ear must be detected – which would show up on otoscopy as a reddened or purulent-yellowish, bulging eardrum, with a lack of mobility during pneumatic testing. The Weber test finds lateralization into the diseased ear, and the Rinne test is negative for otitis media. Especially in young children, it may be difficult to make a meaningful assessment of the eardrum and hearing, which means that one has to be content with a suspected diagnosis for further action.

In rare cases, acute otitis media spreads to neighboring structures, causing mastoiditis, facial nerve palsy, labyrinthitis, sinus vein thrombosis, meningitis or other intracranial processes. Such otogenic complications can be detected, for example, by inspection and palpation of the mastoid, examination of the facial nerve (encouraging small children to grimace) or by indicating vertigo; sensorineural hearing loss may also develop, as indicated by the fact that the Weber test reports lateralization into the healthy ear.

Because pain tends to dominate in acute otitis media, analgesics such as paracetamol (Dafalgan,® etc.) or non-steroidal anti-inflammatory drugs such as ibuprofen (Brufen®, etc.) are the top priorities in treatment. According to a meta-analysis, analgesics lead to a significant reduction in pain within two days.(6) Decongestants (sympathomimetics) or antihistamines, such as those administered intranasally or orally in the form of "cold medicines", have no significant influence on symptoms and duration of the disease.(7) Nevertheless, specialists recommend prescribing decongestant medication for concomitant rhinitis.

The most discussed question is whether an antibiotic is needed for the treatment of acute otitis media . According to a Cochrane study, otitis media heals without antibiotics in about 80% of cases. The proportion of children who suffer from more severe pain is slightly reduced with an antibiotic: after 2 to 3 days, the difference between the antibiotic and placebo groups is 5% (NNT = 20), after 4 to 7 days 6% (NNT = 16) and after 10 to 12 days 14% (NNT = 7). However, this comes at the price of more side effects such as vomiting, diarrhea or skin rashes; the difference is 7%, resulting in a "Number needed to harm" (NNH) of 14. The frequency of tympanic membrane perforation is reduced by antibiotics by 3% (NNT = 33) and that of contralateral otitis media by 9% (NNT = 11). Antibiotics do not have a significant effect on the risk of relapses and complications (mastoiditis, etc.).(8) However, this conclusion from the Cochrane review is not fully shared by all experts. In infants and young children, the benefit of antibiotic administration seems to be more prominent, as interpreted by the result of a study in which children with an average age of 16 months received either an antibiotic or placebo; the proportion of children in whom the condition did not improve or complications occurred was 19% in the antibiotic group and 45% in the placebo group.(9) The current recommendations are therefore that antibiotics should be prescribed depending on the patient's age and symptoms. For antibiotic therapy, the following indications are formulated: (1) infants under 6 months of age (even with an uncertain diagnosis); (2) Children under 2 years of age with bilateral otitis media; (3) Children with severe ear pain, fever above 39 °C, otorrhea or perforated eardrum. In other cases, especially in children who are not seriously ill, do not have severe ear pain and are under reliable care, antibiotic therapy can be delayed. If an antibiotic is dispensed with, a follow-up must take place after 2 to 3 days or the parents must report immediately in the event of a deterioration in condition.

Amoxicillin (clamoxyl®, etc., 2 times 25 to 50 mg/kg/day) is usually listed as the antibiotic of choice, as suggested by the Swiss Group for Pediatric Infectiology. (10) This proposal is based on the fact that amoxicillin has a narrow antibacterial spectrum, is effective against pneumoccocci as the main cause of acute otitis media, is relatively well tolerated and is available in a widely accepted flavour. If amoxicillin is dosed higher, even a twice-daily administration ensures sufficient concentrations of active ingredients in the middle ear. Recommendations to use Co-Amoxiclav (Augmentin®, etc.) as an initial therapy come mainly from North America and are based on the infection epidemiological situation there. If penicillin allergy is confirmed, cephalosporins such as cefuroxime (Zinat® et al., 2 times 15 mg/kg/day) or cefpodoxime (podomexef et al., 2 times 5 mg/kg/day) serve as alternatives; they differ from penicillins in their side chains in such a way that the risk of cross-reactions is classified as low.® (11) Macrolides or co-trimoxazole (Bactrim® et al.) are considered to be of little use because they are not effective against pneumococci and haemophilus. If oral administration is not possible, ceftriaxone (rocephine®, etc., 50 mg/kg/day i.v. or i.m. for 3 days) can be administered.(12) If there is no improvement within 2 to 3 days, a specialist assessment should be carried out and a change of antibiotic should be considered (if necessary, paracentesis to create a culture). If Amoxillin was initially prescribed, it should be replaced with Co-Amoxiclav; if Co-Amoxiclav was started, ceftriaxone or clindamycin (dalacin® and others, 3 times 30 to 40 mg/kg/day) are mentioned as alternatives. The optimal duration of therapy has not been precisely evaluated. For younger children (under 2 years of age) a 7 to 10 day treatment is recommended, for older children a 5 to 7 day treatment may be sufficient (depending on the eardrum findings).(13)

Bis zum Verschwinden des Mittelohrergusses können Wochen bis Monate verstreichen. Mit Valsalvamanövern oder Nasenballons kann versucht werden, die Rückbildung zu beschleunigen.(12)

Inwieweit Impfungen das Risiko einer Otitis media reduzieren, kann man zurzeit nicht exakt beantworten. Der Nutzen der Pneumokokkenimpfung wird widersprüchlich und bestenfalls als mittelgradig beurteilt. Allerdings sind die Studien mit den älteren, 7-, 9- oder 11-valenten Impfstoffen durchgeführt worden; zu den heute angebotenen 13- und 23-valenten Impfstoffen existieren keine Daten.(14) Die Grippeimpfung vermindert die Häufigkeit von Mittelohrentzündungen; der Unterschied zu ungeimpften Kontrollgruppen ist aber nicht signifikant.(15)

Wenn innerhalb von drei Monaten drei- oder innerhalb eines Jahres viermal eine Mittelohrentzündung auftritt, spricht man von einer rezidivierenden Otitis media. Prophylaktische Massnahmen, die man uneingeschränkt empfehlen kann, gibt es keine. Der Stellenwert der Impfungen ist oben erörtert. Eine Antibiotikaprophylaxe vermindert zwar das Auftreten von Mittelohrentzündungen,(16) wird aber wegen der möglichen Nebeneffekte nicht empfohlen.

Sowohl bei einem Mittelohrerguss, der länger als drei Monate dauert, wie bei rezidivierender Otitis media können sich spezialärztliche Interventionen anbieten wie eine Parazentese mit Paukenröhrcheneinlage oder eine Adenotomie. Ein längerfristiger Nutzen dieser Massnahmen lässt sich anhand der Literaturdaten nicht klar bestätigen.(17,18) Ihr Stellenwert ist aber aus Sicht und klinischer Erfahrung der Fachleute unbestritten, auch weil sie eine rasche symptomatische Besserung versprechen.

Tubenmittelohrkatarrh

Beim Tubenmittelohrkatarrh (Paukenerguss) handelt es sich um eine chronische entzündliche Erkrankung, die ebenfalls mehrheitlich Kinder betrifft und zum Beispiel als Folge einer akuten Otitis media auftreten kann. Sie ist charakterisiert durch einen serösen oder mukösen Erguss hinter dem Trommelfell ohne akut-entzündliche Zeichen. Pathogenetisch spielt eine vermehrte Schleimproduktion in Kombination mit einer Dysfunktion der Eustachischen Röhre eine Rolle.

Häufigstes Symptom ist die Hörminderung. Beim Weber-Test wird der Ton ins betroffene Ohr lateralisiert, der Rinne-Test ist negativ. Zur Diagnose führt der Otoskopiebefund mit pneumatischer Prüfung sowie die Tympanometrie. Der Erguss bildet sich in vielen Fällen spontan zurück. Ein aktives Vorgehen mit fiberoptischer Untersuchung des Nasopharynx wird als nötig erachtet, wenn der Erguss über drei Monate andauert, wenn er an beiden Ohren oder bei jüngeren Kindern auftritt oder wenn Erwachsene betroffen sind (bei denen z.B. auch ein Tumor im Nasopharyngealbereich vorliegen kann). Die Behandlung besteht primär in der Einlage eines Paukenröhrchens, bei Kindern oft mit einer Adenotomie verbunden. Auch steroidhaltige Nasensprays werden häufig verschrieben, der Nutzen ist allerdings nicht belegt.(19) Die Wahrscheinlichkeit, dass sich der Erguss zurückbildet, lässt sich sowohl durch Antibiotika wie durch systemische Steroide erhöhen; dem sind aber die potentiellen Nebenwirkungen entgegenzustellen. Inwieweit mit diesen chirurgischen oder medikamentösen Massnahmen Langzeitparameter wie Redefähigkeit oder Sprachentwicklung beeinflusst werden, ist nicht umfassend dokumentiert.(19-21)

Andere chronische Mittelohrerkrankungen

Die Otitis media perforata chronica simplex ist durch eine nicht zuheilende Perforation des zentralen Trommelfells gekennzeichnet und oft von einer Tubenfunktionsstörung begleitet. Sie äussert sich in Form von rezidivierender Otorrhoe und Hörminderung. Die Therapie besteht aus einer Kombination von medikamentösen (lokale Antibiotika u.a.) und chirurgischen Massnahmen. Wichtig ist auch der Schutz vor eindringendem Wasser.

Bei der Otitis media perforata chronica cholesteatomatosa (Cholesteatom) besteht eine randständige Trommelfell-Perforation, so dass Plattenepithel ins Mittelohr einzuwachsen vermag, was eine operative Behandlung erfordert.

Literatur

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