An interesting day in the ER

[Hemegroup]

Something interested happened. I saw a patient, he was in extreme pain in his right ear. He said it had happened out of the blue, as he was watching TV. He had been dealing with some URI symptoms over the week prior. Checked his ears, no pain in the pinna/tragus/mastoid regions. Looked inside, the tympanic membrane looked okay but then when I peered upwards I saw what looked to me to be a tear, with blood on its edges. I went back to my supervising PA, told her the patient needed pain meds asap, and told her I believed his eardrum had ruptured. She ordered him a percocet, and went in to check him out. She looked in his ear and said, "yup, you've got a perforated eardrum." The PA still called for a Doc to check it, in case there was anything we could have missed.


The Doc didn't come to speak with us, saw the patient and re-diagnosed him with acute otitis externa/media and specifically noted that there was no perforation of the tympanic membrane. When my supervising PA saw that he had changed the diagnosis, she went off. "What is he talking about? How could he say it's involving otitis externa, he doesn't have any outer ear pain and there's no sign of infection! The guy said it hit him like a thunderbolt, how does that history say anything other than a rupture? And the student and I both saw it! Plus he had a history of ruptured eardrums as an infant!"


So, the patient was sent home with prescriptions for steroid and abx drops. Now, steroid drops are contraindicated in tympanic membrane ruptures as they can slow down healing. The abx, there's no problem there since the patient should probably have them either way. I'm just glad that the PA told the patient to see an ENT specialist asap, just to be on the safe side. I know that my future will be bringing these types of situations, but it was interesting to finally encounter one first-hand. All that matters to me is that the patient is treated properly. I suppose I might have mis-judged what looked to me to be a tear, but as the PA saw it also it leaves me to think 'hmmm', you know? It was on the upper right hand top edge of the drum, so what if the Doc didn't see it? Then again, what if we both mis-judged, and the patient would have gotten inadequate treatment from our side.


I think that the key point I took home was that there were two conflicting diagnoses, but it was the PA who, even when she had made her diagnosis, still told the patient that he needed to follow up with an ENT specialist. The Doc did not. I'm not saying that their different licenses had anything to do with it, it could have easily been the other way around. But I do think it's better to be safe than sorry, especially in light of any disagreement or possible discrepancy.

[chiaroscuro27]

Interesting case, Heme. It's unfortunate that the doc didn't discuss this case with both you and your supervising PA. Perhaps s/he could have explained why they changed the diagnosis, and didn't feel the need to have the pt. consult an ENT.

[CAdamsPAC]

Something interested happened. I saw a patient, he was in extreme pain in his right ear. He said it had happened out of the blue, as he was watching TV. He had been dealing with some URI symptoms over the week prior. Checked his ears, no pain in the pinna/tragus/mastoid regions. Looked inside, the tympanic membrane looked okay but then when I peered upwards I saw what looked to me to be a tear, with blood on its edges. I went back to my supervising PA, told her the patient needed pain meds asap, and told her I believed his eardrum had ruptured. She ordered him a percocet, and went in to check him out. She looked in his ear and said, "yup, you've got a perforated eardrum." The PA still called for a Doc to check it, in case there was anything we could have missed.


The Doc didn't come to speak with us, saw the patient and re-diagnosed him with acute otitis externa/media and specifically noted that there was no perforation of the tympanic membrane. When my supervising PA saw that he had changed the diagnosis, she went off. "What is he talking about? How could he say it's involving otitis externa, he doesn't have any outer ear pain and there's no sign of infection! The guy said it hit him like a thunderbolt, how does that history say anything other than a rupture? And the student and I both saw it! Plus he had a history of ruptured eardrums as an infant!"


So, the patient was sent home with prescriptions for steroid and abx drops. Now, steroid drops are contraindicated in tympanic membrane ruptures as they can slow down healing. The abx, there's no problem there since the patient should probably have them either way. I'm just glad that the PA told the patient to see an ENT specialist asap, just to be on the safe side. I know that my future will be bringing these types of situations, but it was interesting to finally encounter one first-hand. All that matters to me is that the patient is treated properly. I suppose I might have mis-judged what looked to me to be a tear, but as the PA saw it also it leaves me to think 'hmmm', you know? It was on the upper right hand top edge of the drum, so what if the Doc didn't see it? Then again, what if we both mis-judged, and the patient would have gotten inadequate treatment from our side.


I think that the key point I took home was that there were two conflicting diagnoses, but it was the PA who, even when she had made her diagnosis, still told the patient that he needed to follow up with an ENT specialist. The Doc did not. I'm not saying that their different licenses had anything to do with it, it could have easily been the other way around. But I do think it's better to be safe than sorry, especially in light of any disagreement or possible discrepancy.

It's been my experience that Cortisporin Otic SUSPENSION is an appropriate medication to treat an acute TM perforation. (I highlight suspension as the ENT guys tell me the solution isn't very effective at staying in the ear.)A follow up with ENT is aa reasonable and good recommendation. BTW did you or your PA mentor perform either a Weber or Rinne test as part of your exam? No finger pointing here just asking and exchanging experiences.

[Hemegroup]

It's been my experience that Cortisporin Otic SUSPENSION is an appropriate medication to treat an acute TM perforation. (I highlight suspension as the ENT guys tell me the solution isn't very effective at staying in the ear.)A follow up with ENT is aa reasonable and good recommendation. BTW did you or your PA mentor perform either a Webber or Rinne test as part of your exam? No finger pointing here just asking and exchanging experiences.

Duly noted. That's not what my Atlas of Emergency Medicine recommended as to steroids, but I'll take it to mind. As for the tests, I was so concerned for his pain that I truthfully did not perform them (he was pale and diaphoretic). The PA didn't perform them either (I've not seen anyone with a tuning fork, other than myself). I will be sure to do them next time, after the pain meds kick in. I'm finding that my adrenaline kicks in when there's an emergent situation, so it's important to stay calm and not forget anything. Even what seems minor and insignificant could possibly lead to important information. Thanks for the reminder.

[CAdamsPAC]

Duly noted. That's not what my Atlas of Emergency Medicine recommended as to steroids, but I'll take it to mind. As for the tests, I was so concerned for his pain that I truthfully did not perform them (he was pale and diaphoretic). The PA didn't perform them either (I've not seen anyone with a tuning fork, other than myself). I will be sure to do them next time, after the pain meds kick in. I'm finding that my adrenaline kicks in when there's an emergent situation, so it's important to stay calm and not forget anything. Even what seems minor and insignificant could possibly lead to important information. Thanks for the reminder.

The tuning fork would have helped to make and confirm the dx. Check with your local ENT folks on how they evaluate and treat an acute TM perforation. EM handbooks are just that EM, your consultants and specialist have their own style and methods. Curbsiding consultants will not only give you good information it shows that you are trying to learn and to be a more informed student/provider and the facetime will make them prone to teach you more.
Always remember to pee first before getting involved with an "emergency" and always check your pulse first.

[Hemegroup]

Excellent suggestion, I will give the ENT on call a buzz when I have some extra time this week. Curious tho ... wouldn't AC hearing loss be expected in either a rupture or OM?

[CAdamsPAC]

Excellent suggestion, I will give the ENT on call a buzz when I have some extra time this week. Curious tho ... wouldn't hearing loss be expected in either a rupture or OM?

I'm going to pimp you by having YOU look up the type(s) of hearing loss from a TM rupture and get back to the forum with your findings.


Hint read about the Weber and Rinne tests.

[Hemegroup]

I'm going to pimp you by having YOU look up the type(s) of hearing loss from a TM rupture and get back to the forum with your findings.


Hint read about the Weber and Rinne tests.

Well, Bates says unilateral conductive loss is expected in both cases. Current's says that conductive hearing loss (which I'm taking to mean AC) results from destruction of the tympanic membrane. And yes, I'm aware the rupture can result in loss of pain (Current's), but it can also result in acute pain (Tintinalli's). Anyhow, Current's Otolaryngology reads a bit deeper:

A tympanic membrane perforationcan occur after the use of a cotton-tipped applicator, a bobby pin, a pencil, or the entry of a hot metal slag into the ear canal during welding. Finally, barotrauma, such as a slap to the ear or a blast injury, can cause a perforation. In all cases, patients usually complain of pain and hearing loss, and the perforation can be diagnosed by otoscopy. It is important to note how much of the tympanic membrane has been perforated. A central perforation does not involve the annulus of the eardrum, whereas a marginal perforation does. In addition, the Weber tuning fork test should be performed to verify that it radiates to the affected ear, and the eyes should be checked for nystagmus. If the Weber test does not radiate to the affected ear and the patient has nystagmus, it is likely that stapes subluxation with sensorineural hearing loss has occurred. This is termed a perilymphatic fistula and requires urgent treatment (see Perilymphatic Fistula, Treatment).

If no evidence of sensorineural hearing loss is found, no specific treatment is required because traumatic tympanic membrane perforations, especially central perforations, typically heal spontaneously. However, strict dry ear precautions should be followed to prevent water from getting into the ear. Instructions to the patient include no swimming and the use of a cotton ball thoroughly coated with petrolatum (eg, Vaseline) in the affected ear during bathing. An audiogram should be performed after about 3 months to verify that hearing has returned to normal and that there is no ossicular chain discontinuity. If the perforation has not healed by 3 months, a tympanoplasty will likely need to be performed.

Good to know!

[CAdamsPAC]

Well, Bates says unilateral conductive loss is expected in both cases. Current's says that conductive hearing loss (which I'm taking to mean AC) results from destruction of the tympanic membrane. And yes, I'm aware the rupture can result in loss of pain (Current's), but it can also result in acute pain (Tintinalli's). Anyhow, Current's Otolaryngology reads a bit deeper:

Good to know!

I wanted you to find out the difference and significance between conductive loss(Rinne) and sensorineural loss (Weber)in the setting that you described in the ED. You also now see that ENT/Otolaryngology approaches this problem from a different perspective than EM does. I haven't encountered acute pain in a patient with sensorineural hearing loss.
Another cheap test is to have the patient valsava and you may actually hear air being blown out of the affected EAC or the patient will tell you they feel the air flow in the subject ear. Keep asking "why" of the PAs and Docs you are with on rotations.

[EMEDPA]

most of the ent docs around here like cipro otic or floxin otic (quinolones) for om with perf. but I remember before these were around that we all used cortisporin otic as cadams mentioned.

[CAdamsPAC]

most of the ent docs around here like cipro otic or floxin otic (quinolones) for om with perf. but I remember before these were around that we all used cortisporin otic as cadams mentioned.

As always EMEDPA is correct. My practice is unfortunately predominately Medicade and semi-government agency in nature so the quinolones are often not covered or on the pharmacy formulary.