ENT Objectives

Mucous stage of acute viral rhinits

- Venous Stasis/Secondary Infection - Nasal discharge thickness/becomes "mucopurulent" - Mucosa becomes dusky - Nasal obstruction and toxemia are at worst.

Stages of acute viral rhinitis

1. Prodromal 2. Catarrhal 3. Mucous 4. Resolution

Organisms that cause Otitis Media

H. influenza Moraxella catarrhalis Group A strep Strep. pneumoniae most common!

Acute epiglottitis

Pediatric presentation usually Haemophilus influenza type B Drooling, stridor, septic Do not use tongue blade if stridulous--could close off due to inflammation. Tripod position Xray- Thumbprint sign Intubate in O.R. with pediatric Anesthesia and ENT teams

Laryngeal polyps

Pedunculated or sessile Mid anterior cord, free edge Mucoid versus angiomatous--more red due to excess blood vessels Unilateral Treatment Voice therapy Surgery

Facial Paralysis

o Complication of acute and chronic otitis media o Results from inflamed 7th nerve in middle ear o Treatment ♣ Myringotomy for drainage and culture ♣ IV antibiotics based on culture

Parotitis

Acute infection of the parotid gland -Affects ductal epithelium and local inflammation •Can be caused by both viral and bacterial causes -Mumps (Paramyxovirus family) is most common viral cause •More common in children, but more serious in adults •More common in unvaccinated -Staph aureus most common bacterial cause •More common in elderly, postoperative patients and those with debilitation, dehydration, and/or poor oral hygiene

Infectious Mononucleosis

Primarily EBV M:F, adolescents and young adults Sore throat, fever, malaise Atypical lymphs Elevated AST/ALT Monospot Can't participate in high activity sports--could hit spleen

Exostoses

o Bony overgrowths of the ear canal o Skin covered bony mounds in the medial ear canal obscuring the tympanic membrane o Multiple may be acquired from repeated exposure to cold water—surfer's ear ♣ May need to be surgically removed

Sinonasal inflammatory disease (granulomatosis with polyangiitis and sarcoiditis)

o Granulomatosis with polyangitis ♣ 90% of cases in this area ♣ bloodstained crusts and friable mucosa ♣ biopsy shows necrotizing granulomas and vasculitis o sarcoiditis ♣ involves paranasal sinuses commonly ♣ rhinorrhea, nasal obstruction, hyposmia precedes ♣ turbinates are engorged with small, white granulomas

Rinne Test

(Tuning Fork at mastoid) Abnormal in Conductive Hearing Loss. Bone conduction will exceed air. Air conduction better than bone conduction Ratio should be 2:1

Weber Test

(Tuning Fork at midline forehead) Hit tuning fork and place at the midline of the forehead. Sound radiates TO Conductive Hearing Loss ear; poor ear Sound radiates AWAY from Sensorineural Hearing Loss; to better ear

Catarrhal stage of acute viral rhinits

(hours to days) Infection spreads over mucosal surface via Lymphatics - sneezing, profuse watery discharge nasa1 obstruction - mucosal erythema and edema mild fever

Strep pharyngitis treatment for adults

-Empiric treatment if high suspicion and throat culture pending -Penicillin V Oral x 10 daysor Bicillin IM x 1 dose -Azithromycin, Clarithromycin, or Clindamycin if beta-lactam allergy

Prodromal stage of acute viral rhinitis

-Hours Local invasion and nasal ischemia - hot, tickling sensation - Patients describe "unusually clear nose"

Viral pharyngitis treatment for adults

-Ibuprofen or acetaminophen for analgesia -heavily studied and both very effective -OTC throat sprays or lozenges -Salt water gargles (1/2 tsp. salt with 8 oz. warm water) Patient education!!!! -Counsel about not needing antibiotics for a viral infection -Duration of illness ~ 1 week -Discuss warning symptoms and reason to seek further care

Acute Pharyngitis and tonsilitis

-Inflammation and infection of the pharynx and/or tonsils Symptoms -Throat pain -Pain with swallowing -Cervical adenopathy -Tonsillar exudates (common in strep & mononucleosis) -Fever (more common with bacterial etiology) -Headache -Congestion, cough, hoarseness, sinus pain, ear pain (common with viral etiology) -Nausea, vomiting (common in peds) -Scarlatiniform rash Differential Infectious mononucleosis Herpangina: Coxsackie A Viruses Hand, Foot, Mouth Disease: Enteroviruses (most commonly Coxsackie A) Diphtheria Epiglottitis: Haemophilus influenza B Peritonsillar abscess--Strep, Staph common Complications -Scarlet fever •Rheumatic Fever •Poststreptococcal glomerulonephritis (PSGN) •Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) •Peritonsillar abscess

Streptococcal pharyngitis Treatment pediatrics

-Initiate empiric therapy if highly suspicious of GAS while culture is pending -Penicillin V oral x 10 days or Bicillin (penicillin G benzathine/procaine penicillin) IM x 1 -Azithromycin, Clarithromycin, or Clindamycin can be used if allergic to beta-lactam antibiotics -Analgesia with acetaminophen or ibuprofen Anticipatory guidance -Must finish entire course of antibiotics to prevent complications, even though symptoms improve quickly -Follow up if not improved in 3 days -Discuss warning signs -May return to school 24 hours after 1st dose of antibiotics

Viral pharyngitis Treatment for pediatrics

-Symptomatic treatment is hallmark; typically lasts 2-7 days -Gargle with warm salt water in children ≥6 -Warm liquids with honey in kids ≥1 -Acetaminophen 10-15 mg/kg every 6 hours -Ibuprofen 10mg/kg every 6 hours

Peritonsillar abscess

Abscess between palatine tonsil and the pharyngeal muscles (deep space infection) •Often polymicrobial, most common are Streptococcus pyogenes(GAS), Streptococcus anginosus, Staphylococcus aureus •Symptoms: severe sore throat (usually unilateral), fever, "hot potato" voice, drooling, pooling of secretions •Exam: -Determine the presence & amount of airway obstruction -Extremely swollen and fluctuant tonsil with deviation of the uvula to the opposite side Trismus—jaw spasms Deviation of uvula Dysphagia/ odynophagia--painful Unilateral swelling Fever Elevated WBC •Diagnosis: •Obtain blood cultures before IV antibiotics and culture of drainage from I&D -CT Soft Tissue Neck with contrast is imaging of choice •Treatment: -I&D (usually by ENT) -IV Antibiotics (Clindamycin or Unasyn IV) -Glucocorticoids to reduce swelling and pain (Decadron IV) -Analgesia

Mumps (viral)

Acute infection of the parotid gland (Paramyxovirus family) is most common viral cause of parotitis Peak incidence is late winter to early spring Transmission: -Highly infectious and spreads rapidly by respiratory droplets, direct contact, or fomites Infectious period is three days before to nine days after symptoms begin Parotid tenderness and facial edema are the most common physical findings (present in 95% of cases) -Can be unilateral or bilateral swelling -Lasts up to 10 days •Stensen's duct may be red and swollen •Trismus can occur •Asymptomatic cases & cases with URI symptoms alone may occur Complications -Orchitis -Oophritis -Rare complications include encephalitis, deafness, Guillain-Barre Syndrome, transverse myelitis, facial palsy, pancreatitis, and myocarditis Prevention Immunization Elevated serum IgM is considered diagnostic Treatment is symptomatic: -Analgesics -Antipyretics -Topical application of warm or cold packs to parotid or testes •Indications for hospitalization: -Meningitis -Pancreatitis -Dehydration

Vocal nodules

Bilateral Children and young adults Results from vocal overuse/abuse No sex predilection Mid-fold Involve mucosa and submucosa Treatment Voice therapy is mainstay

Tympanosclerosis

Calcium patches on TM in response to infection usually involves the TM, ossicles, middle ear mucosa - "stiffens" the system ENT referral Signs Irregular white patch of calcium deposit on TM

Post-streptococcal glomerular nephritis

Caused by nephritogenic strains of GABHS; 1-3 week latency following pharyngitis •Immune complexes are deposited in glomerular basement membrane •Presentation: -Varies from asymptomatic to acute nephritic syndrome -Symptoms: red/brown urine, edema, hypertension •Lab abnormalities: -Decreased GFR, increased serum creatinine -Hematuria with proteinuria, often pyuria -Low complement levels (C3 and CH50) -Positive Streptozyme test (measures 5 different streptococcal antibodies) •Diagnosis: -Acute nephritis with documentation of recent GAS infection •Treatment: -Admit -Treat for streptococcal infection (also treat cohabitants) -Control hypertension, edema -dialysis rarely needed •Prognosis -Children typically have complete resolution -Adults/elderly have worse prognosis

Tympanic Membrane parts

Chorda Tympani Nerve Pars Flaccida Pars Tensa Lateral process of Mallelus Malleus Cone of Light Annulus fibrosis Umbo Long process of Incus

sialadenitis

Complication of sialolithiasis infection of the gland, can occur with stones •Pain, swelling, erythema, and pus draining from gland •Systemic symptoms may include fever or chills •Treat with antibiotics: dicloxacillin or cephalexin PO q6 hours x 10 days •ER if any indication of airway compromise from swelling, signs of systemic illness, or worsening infection despite antibiotics

Diptheria

Corynebacterium diphtheriae -Both endotoxin producing and non-toxigenic strains •Spread by respiratory secretions -Rare in developed countries because of immunization •Can cause respiratory, systemic, and cutaneous manifestations -Bacterial endotoxin causes respiratory & systemic disease •Respiratory manifestations: development of a grey, coalescing pseudomembrane -Bleeds with scraping -Location of membrane correlates to symptoms •Systemic manifestations: cardiac, neurologic, renal •Diagnosis: Culture including portion of membrane and positive toxin assay -Notify state department of health & lab of suspected diagnosis •Treatment: Diphtheria antitoxin & Erythromycin or Penicillin •Complications: Respiratory Failure d/t Airway Compromise ("bull neck")

Herpangina

Coxsackie A virus •Transmission primarily occurs via fecal-oral route •Clinical presentation: -Abrupt onset high fever (102˚F-104˚F) -Sore throat -Headache, stiff neck, nausea, abdominal pain also accompany frequently •Physical Exam: -Throat reveals <10 hyperemia and yellow/gray-white papulovesicular lesions •Diagnosis: Clinical -High fever plus oral exanthema •Disease Course & Treatment -Generally, fever resolves in 2-4 days, lesions resolve in 5-6 days -Supportive care: antipyretics and analgesia •Complications almost never occur -Dehydration due to decreased oral intake from pain is possible; admit if unable to maintain adequate oral intake

Scarlet fever

Diffuse erythematous eruption occurring with strep pharyngitis; requires previous exposure to S. pyogenes •Can predispose to rheumatic fever •Diffuse, erythematous, 1-2mm papularrash, blanches with pressure, "sandpaper"quality •Starts in groin & armpits and spreads diffusely; ultimately desquamates •Skin folds have rash in linear appearance, known as Pastia's Lines •Accompanied by circumoral pallor and strawberry tongue •Test using RADT and throat culture •Treat the strep pharyngitis; no treatment needed for the rash

Glomus tumor

Epidemiology Most common in 40 to 50 year old women Pathophysiology Neuroendocrine tumor arising from from glomus bodies Jugular bulb origin or Middle ear neural plexus Tympanic Membrane invasion follows Hearing Loss May involve Cranial Nerves Symptoms Pulsating Tinnitus Hearing Loss Signs Dark blue, purple or red-blue mass behind TM Diagnosis CT Temporal Bone Differential Diagnosis Anomalous Carotid Artery Anomalous jugular bulb Management Do not biopsy (very vascular) Surgical excision

Vasomotor rhinitis

Idiopathic nasal congestion and rhinorrhea not associated with sneezing or pruritus. Autonomic imbalance with parasympathetic predominance causes vasodilatation and hyper-responsive glandular secretions. Profuse bilateral, watery secretion, deep red mucosa, and marked turbinate swelling during attacks. (color of the nose is not diagnostic) -Between attacks: mucosa pale Attacks may be triggered by various physical, chemical, climatic, and emotional factors Treatment Medical: Steroid (topical, submucosal, systemic). Ipratropium bromide (Atrovent): anti-cholinergic. Surgical: Directed to Inferior Turbinate.

Hoarseness

If Hoarseness for more than 2 weeks, need to refer to the ENT; could be stridor

Squamous cell carcinoma of the larynx

If hoarseness x 2 weeks or more, then refer directly to ENT CT/MRI can miss vocal cord cancers! Don't get them to diagnose hoarseness! Risk factors for Head and Neck Cancer -tobacco use -alcohol use -HPV exposure (orogenital contact)

Ludwig's angina

Infection of submandibular and sublingual AND the submental compartments Posterior and superior displacement of the tongue Collar of brawny edema Poor dental hygiene Manage airway--Airway can close! May require incision and drainage though pus is rare Stridor Medical emergency!

Nasal foreign body

Most commonly toddlers & preschoolers •Most cases are asymptomatic •Urgent ENT referral: button batteries, paired disc magnets, posterior FBs, penetrating/hooked/impacted FBs •Signs/symptoms: -History of nasal FB insertion without symptoms (witnessed or child reported it) -Mucopurulent nasal discharge (often unilateral) -Foul odor -Epistaxis •Diagnosis: -Visualization is confirmatory -Plain films only helpful if ruling out radiopaque object (ex: metal) •Treatment: -Instrument removal (preferred) -Positive pressure techniques -ENT referral for magnet, button battery, penetrating/sharp object, or object that cannot be visualized -Treat infection if present: Augmentin x 10 days

Acute sinusitis

Mostly Strep pneumo, nontypable H. flu, and Moraxella catarrhalis Staph aureus (rare), Strep pyogenes Symptoms: heaviness in sinus; pain over sinus; Malodorous; mucopurulent discharge Symptoms - Facial pain/pressure - Facial congestion/fullness - Nasal obstruction/blockage - Nasal discharge/purulence/discolored postnasal drainage - Hyposmia/anosmia - Purulence in nasal cavity on exam - Fever (< 50% of adult cases). - Pus may be seen intranasally - Nasal mucosa red and edematous - Tenderness may occur over sinus Treatment - Antibiotics (empiric): if symptoms persist for 7-10 days - Decongestant nose drops - Analgesics - Adjunctive/Ancillary Measures: steam, saline, irrigations, corticosteroid sprays - Decongestants with Mucolytic - Antihistamines (prevent onset due to allergy) Culture-directed Antibibiotics if empiric therapy fails

Intracordal cyst

Much deeper in than a vocal polyp Treat with surgery

PANDAS (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections)

Obsessive compulsive disorder or tic disorder exacerbated by GAS infection -Similar to Syndenham's chorea, but without evidence of rheumatic fever •Controversial diagnosis •Diagnostic criteria: -OCD and/or tic disorder -Pediatric onset (ages 3-puberty) -Abrupt onset and episodic exacerbations -Relationship between GAS and onset or exacerbation -Neurologic abnormalities (ex: adventitious movement) during exacerbations •Treatment: -Treat with antistrep agent (cephalosporins may be preferable to penicillins), even if previously treated -Neuropsychiatric therapy •Refer to neurologist and mental health provider •SSRI if OCD symptoms •Cognitive behavior therapy •Prognosis is unknown

Rheumatic fever

Occurs 2-4 weeks following GAS pharyngitis •Damage to cardiac valves can be chronic and progressive •Diagnosis: Modified Jones Criteria -Two major manifestations -One major with two minor -Heart or Joints can only count once -Repeat episodes can be diagnosed with 3 minor criteria -Exception: may diagnose with chorea alone & carditis alone following GAS •Diagnosis -Positive throat culture, RADT, or elevated/rising ASO titer -CBC, CRP, ESR -EKG & Echocardiogram •Treatment -Anti-inflammatory: Aspirin -Eradicate GAS: Penicillin IM or Oral (also strep test & treat cohabitants) -Heart failure treatment, if present -Monitor CRP or ESR for normalization

Whisper Test

Patient occludes opposite ear Examiner whispers questions or commands Patient answers or follows commands Avoid testing with finger snapping or ticking watch. Not accurate for Hearing Testing

sialolithiasis

Presence of stones in the salivary ducts or glands (parotid, submandibular, and sublingual) -80-92% from submandibular glands -More common in men •Risk factors: dehydration, diuretics, anti-cholinergic medications, trauma, gout, smoking, hx nephrolithiasis, chronic periodontal disease •Primarily calcium based •Clinical presentation: -History of pain/swelling of the gland aggravated by eating or anticipation of eating -Symptoms often wax and wane Physical Exam: -Palpate glands; clear saliva should flow with palpation in normal glands -Stones may be visible at duct orifice •Diagnosis: -Imaging studies useful when diagnosis is suspected, but stone not visible or palpable -Noncontrast CT is imaging of choice •Treatment: -Hydration -Apply moist heat & massage duct -Sialogogues are helpful (tart hard candies) -NSAIDS for pain -Refer to ENT or OMF specialist with persistent or severe symptoms -Stones >2mm may require surgery Complications Infection Chronic obstruction •Gland persistently swollen and will become firm

Subglottic stenosis

Presentation Stridor Dyspnea--difficulty breathing Risk factors Prolonged intubation Idiopathic- females of child bearing age Wegener's Disease Diagnosis- Flexible (endoscope) Laryngoscopy (can be awake) Treatment Direct Larynogoscopy with dilation (need to be asleep)

Resolution stage of acute viral rhinits

Regression of signs and symptoms within 10 days (usually)

What are three tests that can be used for hearing?

Rinne Test Weber Test Whisper Test

Allergic Rhinitis

Seasonal Allergic Rhinitis (SAR) --caused by pollens. --Perennial allergic rhinitis (PAR) caused by season-independent allergens Diagnosis of Allergic Rhinitis - History - Physical Exam - Skin Testing (intradermal, prick, patch) - In Vitro (RAST or ELISA) Local Findings -Pale, boggy nasal mucosa -Swollen inferior turbinates -Large amounts of clear secretions. Differential Diagnosis -Vasomotor Rhinitis -Acute Rhinitis Treatment Causal: Avoidance, Specific Desensitization (Immunotherapy) Symptomatic: Antihistamines (pharmacotherapy) Steroids (nasal, systemic) Decongestant (nasal, systemic)

Hearing loss--conductive

Sound conduction is impeded through the external ear, middle ear, or both ♣ Dysfunction of the external or middle ear ♣ Obstruction—cerumen impaction ♣ Mass loading—middle ear effusion ♣ Stiffness effect—otosclerosis ♣ Discontinuity—ossicular disruption ♣ Commonly happens due to cerumen impaction or an ear infection, trauma

Acute supraglottitis

Staph infection--compared to epiglottitis Pediatric presentation usually Haemophilus influenza type B Drooling, stridor, septic Do not use tongue blade Xray- Thumbprint sign Intubate in O.R. with Anesthesia and ENT teams

What are the three parts of the larynx?

Supraglottis Glottis Subglottis

Presbycusis

Symmetric, progressive deterioration of hearing usually in older adults and elderly Diagnosis of exclusion Loss of cochlear hair cell function Etiology is combination of genetic disposition and environmental factors May also be secondary to neurovascular injury from chronic conditions: HTN, DM High frequency hearing and speech discrimination ability are affected Tx: Audiology consult, hearing aids

Stridor

The sound of airway obstruction, usually pitched Think Darth Vader breathing NOT "WHEEZING" If you can hear it in the room without a stethoscope, it is is stridor, stertor-->snoring Can be inspiratory and/or expiratory

Mumps (bacterial)

Typically occurs in dehydrated or intubated elderly postoperative patients •Clinical manifestations: -Sudden onset firm, erythematous swelling of pre & postauricular areas extending to angle of mandible -Purulent material at orifice of Stensen's duct -most frequently isolated pathogen is Staphylococcus aureus •Diagnosis: -Suspected with physical exam findings -Elevated serum amylase -Send purulent drainage for gram stain & culture •Imaging indicated -CT with contrast or ultrasound -Assesses Surgical exploration & drainage may be required for diagnosis & therapy Treatment •Immunocompetent -Nafcillin q4 hours PLUS -Metronidazole q6 hours OR Clindamycin Q6-8 hours •Immunocompromised -Vancomycin q8-12 hours OR Linezolid q12 hours PLUS -Imipenem q6 hours OR Meropenem q8 hours OR Piperacillin-tazobactam Q6hours -Typically 10-14 days depending on immune state •Complications: progression to deep space infection, Lemierre's syndrome, septicemia, respiratory obstruction, facial nerve palsy, and osteomyelitis

Recurrent Respiratory Papillomatosis

Unpredictable Affects mucous membrane of the respiratory tract Viral etiology- HPV 6, 11 Vaccines cover this Vertical transmission Juvenile and adult onset Treated with surgery Grapelike clusters

Auricular hematoma (cauliflower ear)

o A complication that results from direct trauma to the anterior auricle and is a common facial injury in wrestlers. o Shearing forces to the anterior auricle can lead to separation of the anterior auricular perichondrium from the underlying, tightly adherent cartilage. o This may lead to tearing of the perichondrial blood vessels and subsequent hematoma formation. o Treatment Best to do in 7 days completely evacuate subperichondrial blood and to prevent its reaccumulation

olfactory dysfunction

o AKA—hyposmia or anosmia o Diminished sense of smell or taste sensation o Lack of nasal obstruction o Decrease in olfaction by testing o May be caused by polyps, septal deformities, and nasal tumors o Often accompanies common cold, allergies, rhinitis o CNS neoplasms affect olfactory groove or temporal lobe o Head trauma causes shearing of olfactory neurons o Parkinson and Alzheimer disease affect olfactory o Need to do a thorough history of systemic illness and medications and physical exam o Scratch and sniff tests o Treatment ♣ Secondary to nasal polyposis, obstruction, and chronic rhinosinusitis responds to endoscopic sinus surgery ♣ Degree of hyposmia is the greatest predictor of recovery ♣ No treatment for primary causes ♣ Counseling for seasoning foods and table salt

Presbyacusis

o Age-related hearing loss o Progressive loss of high frequency sounds o Genetic and noise exposure play a role

Auricular frostbite

o Ambient temperature decreased more than body temperature adjustment range, cause auricular excessive local heat, pain, blistering o Eventual necrosis and loss of tissue may occur, but even then, delineation by sloughing gives a better result than premature surgery o Surgery Let it warm up to room temp

Osteomas

o As long as they don't cause obstruction or infection—not significant o Benign bony overgrowth tumor of the bone May be surgically removed

Pruritis

o Associated with external otitis or seborrheic dermatitis and psoriasis o Can be self-induced due to over cleaning or scratching o Treatment ♣ Do no scratch or clean the area ♣ Can apply mineral oil if dry ♣ Topical corticosteroid—triamcinolone

Malignant nasopharyngeal and paranasal sinus tumors

o Asymptomatic till late in the course o SCC most common; in nasopharynx where it obstructs the Eustachian tube to result in serous otitis media o Elevated IgA antibody o Early symptoms are unilateral nasal obstruction, otitis media, discharge, recurrent hemorrhage o Biopsy to diagnose and do an MRI o Treatment ♣ Megavoltage radiation ♣ Chemotherapy with cisplatin and fluorouracil ♣ Surgery and irradiation for SCC

Inverted papilloma

o Benign tumors caused by HPV on lateral nasal wall o Unilateral nasal obstruction and hemorrhage o Cauliflower like growths in middle meatus o Excise because SCC can be a possibility o Follow up clinically and radiologically due to high recurrence rates

epistaxis

o Bleeding from the unilateral anterior nasal cavity o Posterior, bilateral, or large volume should be taken to a specialist o Commonly due to nasal trauma—nose blowing, picking, foreign bodies, deviation of nasal septum, alcohol, cocaine, anticoagulation medications, hereditary hemorrhagic telangiectasia o Higher BP Kesselbach's plexus (anterior-septal)-90% of the time it occurs here o 5%-10% of the time it is posterior and associated with atherosclerotic disease and hypertension Have them blow their nose to see the area of bleeding. o Treatment ♣ Treat with direct pressure for 15 minutes ♣ Topical sympathomimetics and nasal tamponade methods ♣ Topical 4% cocaine as an anesthetic and vasoconstrictor; tetracycline or lidocaine ♣ Cauterized with silver nitrate, diathermy, electrocautery --Clinician sprays nares with oxymetazoline (Afrin) --nasal packing ♣ Posterior—pack and go to hospital • Ligation of nasal arterial supply—internal maxillary artery and ethmoid arteries • Maybe even the external carotid artery • Avoid straining and vigorous exercise • Nasal saline for the pack to stay moist • Bacitracin • Anti-staphylococcal antibiotics—cephalexin or clindamycin, vancomycin ♣ Ongoing bleeding beyond 15 minutes take to the ER Complications Toxic Shock Syndrome -Staphylococcus aureus exotoxin

Serous otitis media

o Blocked Eustachian tube remains for a long time o Negative pressure will result in transudation of fluid o Common in children because their tubes are narrower and more horizontal o Adults get it due to URI, allergic rhinitis, barotrauma o Tympanic membrane is hypomobile and dull accompanied with air bubbles in the middle ear and conductive hearing loss o Treatment ♣ Oral corticosteroids—prednisolone ♣ Oral antibiotics—amoxicillin ♣ Or combo of the two ♣ Ventilating tube through the tympanic membrane or laser expansion

Endolymphatic hydrops (Meniere syndrome)

o Caused by syphilis and head trauma o Distension of the endolymphatic compartment of the inner ear TRIAD 1. Episodic vertigo with N&V - lasts HOURS 2. Tinnitis with aural fullness and noise recruitment 3. Fluctuating hearing loss - LOW frequency, unilateral o 20 minute spells to hours with tinnitus, unilateral aural pressure, sensorineural hearing loss o can have thermally induced nystagmus on the involved side o Treatment ♣ Low salt diet and diuretics ♣ Intratympanic corticosteroid injection ♣ Endolymphatic sac decompression ♣ Vestibular nerve section ♣ Gentamicin ♣ Surgical labyrinthectomy Antiemetic for N&V (compazine, tigan) Vestibular suppressant for vertigo (meclizine) CATS- caffeine, alchohol, tobacco, salt, stress

chronic otitis media

o Chronic otorrhea with/out otalgia o Tympanic membrane perforation with conductive hearing loss from destruction of tympanic membrane or ossicular chain o Develops as a consequence of recurrent acute otitis media o P. aeruginosa, Proteus species, staph. Aureus o Hallmark—purulent aural discharge that is continuous or intermittent o Treatment ♣ Removal infected debris ♣ Topical antibiotic drops—ofoxacin or ciprofloxacin with dexamethasone ♣ Surgical repair of tympanic membrane using temporalis muscle fascia ♣ May have to do a mastoidectomy

acute viral rhinosinusitis (common cold) (ACUTE NASOPHARYNGITIS)

o Clear rhinorrhea, hyposmia, nasal congestion, sneezing --Due to rhinovirus (30-50% of the time) --transmission through contact/particle droplets --Viral shedding peaks on 2nd-3rd day of illness, corresponding with a peak in symptoms o Malaise, headache, cough, dry throat o Erythematous, engorged nasal mucosa on examination without intranasal purulence; clear discharge. Mucus color is not indicative. -normal vital signs -Risk factors: chronic disease, stress, smoking, sleep deprivation, malnutrition o Adults: 3-10 days Children: 14 days o Can develop into or exacerbate—acute bacterial sinusitis, acute otitis media, asthma, CF, bronchitis Differential -Allergic or seasonal rhinitis -Pharyngitis -Sinusitis -Influenza -Pertussis o Treatment ♣ Antibiotics are NOT helpful and neither are antivirals --Oral hydration & warm fluids --antipyretics for fever ♣ Zinc may be helpful ♣ Oral decongestants—pseudoephedrine ♣ Nasal sprays—oxymetazoline or phenylephrine ♣ May get addicted—rhinitis medcamentosa ♣ Taper with flunisolide—intranasal corticosteroid or oral prednisone

allergic rhinitis

o Clear rhinorrhea, sneezing, tearing, eye irritation, pruritus o Cough, bronchospasm, eczematous dermatitis o Environmental allergen exposure with allergen-specific IgE o Commonly caused by spores and pollens; ragweed, molds o Vasomotor rhinitis—increased sensitivity of the vidian nerve in elderly o Mucosa of the turbinates is usually pale or violaceous due to venous engorgement o Nasal polyps, yellowish boggy masses in long standing allergic rhinitis o Treatment ♣ Intranasal corticosteroids • Beclomethasone • Flunisolide • Fluticasone propionate • Tip head forward and hold bottle straight up ♣ Antihistamines and H1 receptor antagonists • Loratadine • Desloratadine • Fexofenadine ♣ Antileukotriene • Montelukast • Cetirizine • Loratadine ♣ Intranasal anticholinergic agents • Ipratropium bromide spray—help treat vasomotor rhinitis ♣ Avoid exposure to allergens ♣ Serum radioallerosorbent test for skin testing by an allergist ♣ Family history of atopy Do immunotherapy with allergist

Petrous Apicitis

o Complication of otitis media o Petrous bone between inner ear and clivus can be persistently infected o Foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy, meningitis o Treatment ♣ Antibiotic therapy based on culture ♣ Surgical drainage via petrous apicectomy

Cholesteatoma

o Complication of otitis media o The flaccid part of the tympanic membrane is drawn inward due to the negative pressure from a Eustachian tube dysfunction o Sac of keratin that becomes infected --Pseudomonas, Strep, Staph, Proteus --hearing loss and purulent otorrhea o Erode bone and penetrate the mastoid and destroy the ossicular chain o Can erode into the inner ear and involve the facial nerve and spread intracranially o Treatment ♣ Remove the keratin sac that is infected; may create a "mastoid bowl" --yearly follow up

Labrynthitis

o Continuous severe vertigo—days to a week o Recovery period may last weeks—back to normal or be impaired o Unknown cause Treat symptoms - antiemetic (compazine) Vestibular suppressants—diazepam or meclizine If suspect bacterial infection - antibiotics vestibular rehabilitation Oral steroids Antivirals for recurrent symptoms- Herpes o Antibiotics if bacterial infection

Cerumen impaction

o Ear is self-cleaning and secretes cerumen which is a protective secretion in the outer ear --hydrophobic protective covering --Protects skin from water, trauma, infection o Should wash it out with a washcloth over your finger and don't go into the canal --curette and cerumen spoons o If impacted; use detergent ear drops—hydrogen peroxide or carbamide peroxide ♣ Can also do mechanical removal ♣ Suction ♣ Irrigation; if tympanic membrane is intact • Dry it out with isopropyl alcohol or hair dryer

hyperacusis

o Excessive sensitivity to loud sounds despite a reduced sensitivity to softer sounds o Wear ear plugs o Hearing aid

Nasal Vestibulitis and Staph aureus Nasal colonization

o Folliculitis of the hairs that line the nasal vestibule o Treatment ♣ Antibiotics—dicloxacillin ♣ Topical—mupirocin or bacitracin ♣ Rifampin ♣ I&D a furuncle

Foreign bodies

o Frequent in children o Remove with a loop or hook Insects are immobilized with lidocaine before removal

mastoiditis

o Inadequately treated acute otitis media leads to mastoiditis o Postauricular pain and erythema with a fever o Mastoid cells are coalesced due to destruction o Treatment ♣ IV antibiotics—cefazolin • To treat against S. pneumoniae, H. influenza, S. pyogenes May have to do a surgical drainage Admit children to the hospital

fungal sinusitis

o Includes rhinocerebral mucormycosis and aspergillus o Spreads rapidly through vascular channels o Patients are usually immunocompromised o AIDs patients o Nasal drainage is straw colored and clear o Visual symptoms o Classic finding is a black eschar on the middle turbinate o Mucosa will appear normal and dry o Early diagnosis with nasal biopsy with silver stains to reveal broad nonseptate hyphae and necrosis o Treatment ♣ Surgical debridement ♣ Amphotericin B by IV infusion ♣ Antifungals like voriconazole and caspofungin ♣ Prognosis • Usually lose one eye due to surgery • Death in 20% of diabetics • 50% death rate in kidney disease and AIDs or hematologic malignancy • survival is 18%

Sigmoid sinus Thrombosis

o Infection in mastoid air cells can cause septic thrombophlebitis o Fevers, chills, increased intracranial pressure o Treatment ♣ IV antibiotics ♣ Surgical drainage with ligation of internal jugular vein if embolization is suspected

Ototoxicity

o Medications like aminoglycosides, loop diuretics, antineoplastic agents o Can cause irreversible hearing loss—affecting auditory and vestibular systems Some topical agents can be absorbed through the round window

nasal trauma

o Most frequently fractured bone in the body o Epistaxis and pain o Look for additional facial, pulmonary or intracranial injuries o Treatment ♣ Maintaining long term nasal airway patency and cosmesis ♣ Closed reduction decreases need to subsequent septoplasty or rhinoplasty ♣ Rule out septal hematoma which could result in a saddle nose deformity and can get infected with staph aureus ♣ Packing for 2-5 days ♣ Antibiotics with antistaph—cephalexin and clindamycin

Acute otitis media

o Otalgia, with URI that causes Eustachian tube obstruction o Leads to fluid accumulation and mucus that is infected by bacteria—strep. pneum., H. influenza, Moraxella catarrhalis o Erythema and hypomobility of tympanic membrane o Bacterial infection of the mucosally lined air-containing spaces of the temporal bone o Purulent material forms in the mastoid air cells and petrous apex o Decreased hearing, fever, pain o If there is a lot of purulence in the ear, the tympanic membrane can bulge out and rupture --red behind the TM due to fluid o Persistent perforation, leads to chronic otitis media o Mastoid can be tender oTreatment ♣ Antibiotics with nasal decongestants •Amoxicillin or erythromycin plus sulfonamide •Can do a tympanocentesis for a bacterial or fungal culture oDo this for persistent otitis media ♣Surgical drainage of the middle ear if severe—myringotomy ♣ If antibiotics don't help, may have to ventilate the ear with tubes

Otitis externa

o Painful erythema and edema or the ear canal o Purulent exudate o Evolves into osteomyelitis of the skull base o History of recent water exposure or mechanical trauma o Caused by gram negative rods or fungi o Can be persistent in diabetics and immunocompromised patients to be malignant external otitis from pseudomonas aerguginosa leading to osteomyelitis o Red tympanic membrane; but will move normally with pneumatic otoscopy o Foul discharge, deep otalgia, and even cranial nerve palsies—VI, VII, IX, X, XI, or XII o Treatment ♣ Protect from additional moisture and mechanical damage ♣ Use isopropyl alcohol/white vinegar for swimmer's ear; hydrogen peroxide ♣ Infected use: • Antibiotic drops with fluoroquinolone with/out corticosteroids o Neomycin sulfate o Polymyxin B sulfate o Hydrocortisone o Use drops 5 times a day ♣ Can do a wick to facilitate entry of the medication ♣ Can use oral—ciprofloxacin against pseudomonas Topical --Cipro HC bid is excellent. --Cortisporin, Tobrdex, Pred-G. -Analgesics for pain and oral NSAIDS ♣ Treatment of malignant external otitis for several months • IV ciprofloxacin • Surgical debridement of infected bone

nasal polyps

o Pale, edematous, mucosally covered masses seen in patients with allergic rhinitis o Result in nasal obstruction and diminished sense of smell o Avoid aspirin in patients with a history of asthma—cause broncospasm = triad asthma o Polyps in children could mean CF o Treatment ♣ Topical intranasal corticosteroids—1-3 months • Beclomethasone • Flunisolide • Fluticasone propionate ♣ Oral corticosteroids • Prednisone ♣ Surgical removal if massive ♣ Allergen testing to determine offending allergen

Tinnitus

o Perception of abnormal ear or head noises o Persistent—indicating sensory loss o Intermittent periods of mild, high-pitched tinnitus lasting minutes to seconds are common in normal persons o Can cause severe annoyance, interfere with sleep and ability to concentrate, distress o Pulsatile tinnitus—hearing one's own heartbeat o Staccato tinnitus—middle ear muscle spasm; hearing clicking/popping o Do an MRI to rule out retrocochlear lesion and magnetic resonance angiography/venography to rule out a vascular lesion If bilateral, NOT pulsatile, not instrusive, and mild hearing loss → considered secondary to hearing loss o Treatment ♣ Avoid exposure to excessive noise ♣ Can wear hearing aid ♣ Oral antidepressants—nortipyline ♣ Transcranial magnetic stimulation Masking technique; music, fans

Barotrauma

o Poor eustachian tube functioning; unable to equalize the barometric stress exerted on the middle ear by air travel, diving, altitudinal change o Negative pressure in the ear collapses the tube to block it o Need to swallow, yawn during descent while flying o Hemotympanum—oval or round window ruptures which leads to hearing loss and acute vertigo o Avoid diving when you have an URI Treatment o Take oral decongestants—pseudoephedrine or topical—phenylephrine nasal spray o Myringotomy—creating small perforations in small eardrum o Can get ventilating tube

Otosclerosis

o Progressive disease with lesions that involve the footplate of the stapes --Stapes fixed to oval window o Impedes passage of sound through ossicular chain—conduction deafness; fixation of the stapes preventing vibration Presents bilaterally with conductive hearing loss and mixed hearing loss Twice as common in women. Family history o Treatment ♣ Stapedectomy—prosthetic stapes ---Stapedotomy ♣ Hearing aid ♣ Permanent sensory hearing loss if affecting the cochlea Sodium fluoride: halts or retards progression

acute and chronic bacterial rhinosinusitis (sinusitis)

o Purulent yellow-green nasal discharge or expectoration o Facial pain or pressure over the affected sinus/es o Nasal obstruction, altered smell o Acute onset of symptoms o Cough, malaise, fever, headache, fatigue o Result of impaired mucociliary clearance and obstruction of the osteomeatal complex or sinus o Accumulation of mucus secretion in the sinus cavity that becomes secondarily infected by bacteria o Middle meatus is the main area affected o Strep. pneumoniae, strep., H. influenza, and S. aureus and Moraxella catarrhalis o Lasts more than 10 days after onset or worsening of symptoms within 10 days after initial improvement o Can last 4-12 weeks o Acute maxillary ♣ Most common form because the maxillary sinus is the largest sinus with a single drainage pathway easily obstructed ♣ Can have unilateral facial fullness, pressure, and tenderness over the cheek ♣ Pain into teeth because of involvement of CN V ♣ Purulent nasal discharge noted in nasal airway obstruction or facial pain ♣ Can result from dental infection; need to remove or drain abscess o Acute ethmoiditis ♣ Accompanied by maxillary sinusitis ♣ Pain and pressure that radiates to the orbit and is between the eyes o Spheniod sinusitis ♣ With pansinusitis ♣ Pain in the middle of the head o Acute frontal ♣ Pain and tenderness of the forehead ♣ Palpate the orbital roof by medial eyebrow o Hospital associated ♣ May present without symptoms in the head and neck ♣ Source of fever o Imaging ♣ Only done when the patient does not respond to antibiotics, intracranial involvement is suspected, CSF, or dental infection ♣ Noncontrast screening—coronal CT scan ♣ MRI if intracranial extension or opportunistic infection o Treatment ♣ NSAIDs ♣ Oral or nasal decongestants—pseudoephedrine, oxymetazoline ♣ Intranasal corticosteroids ♣ High dose mometasone furoate ♣ Antibiotics if symptoms last more than 10 days or are severe • Amoxicillin for 7-10 days • Tetracycline if penicillin allergy ♣ Use amoxicillin-clavulante or cephalosporins for multidrug resistant bacteria ♣ Hospital acquired—broad spectrum antibiotic coverage for P. aeruginosa and S. aureus o Complications ♣ Cellulitis—use IV antibiotics to treat ♣ Osteomyelitis—prolonged antibiotics and removal of necrotic bone ♣ Cavernous sinus thrombosis—get MRI; treat with IV antibiotics ♣ Get a CT scan if ocular problems ♣ Refer to ENT if facial cellulitis, proptosis, vision change, cavernous sinus involvement, change in mental state, failure to respond

Noise Trauma

o Second most common cause of hearing loss o Exceeding 85 dB are injurious sounds to the cochlea o Industrial workers, weapons, loud music o Wear earplugs!

Vertigo

o Sensation of motion when there is no motion or exaggerated sense of motion in response to movement o Associated with hearing loss o Peripheral: sudden onset with tinnitus and hearing loss, horizontal nystagmus o Central: onset is gradual; no auditory symptoms o Evaluate with audiogram and electro/videonystagmography, and MRI o Peripheral ♣ Unable to walk or stand; nausea and vomiting with tinnitus ♣ Ask about history, duration, diet, stress, fatigue, bright lights ♣ Observe for nystagmus, Romberg testing, cranial nerve exam • Visual fixation can suppress nystagmus o Central ♣ Nystagmus is not always present; can occur in any direction; dissociated in eyes • Unsuppressed by fixation • Use ENG and MRI ♣ Could be caused by a cerebral lesion, antibiotic, anticonvulsant, analgesic, alcohol

vestibular neuritis

o Single attack occurs without impairment of auditory function and lasts for several days to a week o Nystagmus o Presumed to be a viral cause o Treatment --antiemetic ♣ Vestibular suppressants—diazepam or meclizine ♣ Vestibular therapy Antihistamines, benzodiazepines, anticholinergics

Neoplasia of the Ear

o Squamous cell carcinoma most common o Biopsy if otitis externa does not resolve o Tumor can invade the lymphatics or the cranial base and needs to be widely surgically resected with radiation therapy

benign positional vertigo

o Suffer from vertigo for minutes due to positional change of the head o Latency period of 10-15 seconds before symptoms occur; can remain unbalanced for hours o Get an MRI o Do physical therapy

Eustachian tube dysfunction

o Tube that connects the middle ear to the nasopharynx o Normally closed and open only when yawning or swallowing o Causesdiseases associated with edema of the tubal lining like viral URI and allergy o When blocked, it may make a popping or cracking sound with swallowing and yawning o Retracted tympanic membrane o Aural fullness o Fluctuating hearing o Discomfort with barometric pressure change o Lasts days to weeks o At risk for serous otitis media o Can get a patulous Eustachian tube—fullness in the ear and autophony o Treatment ♣ Systemic and intranasal decongestants • Pseudoephedrine-oral • Oxymetazoline-spray ♣ Allergies • Intranasal corticosteroids

Trauma to middle ear

o Tympanic membrane perforation from explosive injury or trauma ♣ Usually heals o Persistent perforation with water exposure Could get hemorrhages behind tympanic membrane following blunt trauma

Identifying Group A Strep (GAS) pharyngitis for adults

•Centor Criteria (1 point each) -Tonsillar exudates -Tender anterior cervical adenopathy -Fever by history -Absence of Cough •Centor Scoring: -0-2 points -no testing or antibiotics -3+ points -testing with Rapid Antigen Detection Test (RADT) •Centor criteria most useful to eliminate patients who don't need testing or antibiotic treatment •It is not routinely necessary to perform back up throat culture in adults with negative RADT -Low risk of rheumatic fever

Identifying Group A Strep pharyngitis for pediatrics

•Who to test: -Evidence of tonsillitis or pharyngitis on exam AND absence of viral URI symptoms (coryza, conjunctivitis, cough, hoarseness, diarrhea) -Exposure to GAS at home or school or high prevalent of GAS in the community with symptoms of GAS -Kids <3 years with prolonged nasal discharge, tender anterior cervical adenopathy, and fever, especially if exposed to GAS -Suspected scarlet fever, rheumatic fever, or poststreptococcal glomerulonephritis •Testing method: -Throat culture, if can be obtained in <48 hours, is gold standard -RADT can be utilized, but if negative, reflex throat culture must be performed Clinical pearl: Swab with both the RADT and Throat Culture Swab at the same time

Auditory-vestibular Schwannoma (acoustic neuroma)

♣ Eight cranial nerve schwannomas are common benign intracranial tumors ♣ Associated with hereditary neurofibromatosis, spinal tumors ♣ Grow in the internal auditory canal and grow to involve the cerebellopontine angle to compress the pons; result is hydrocephalus Symptoms of hearing loss and tinnitis hearing loss usually gradual and progressive; can be sudden ♣ Unilateral hearing loss ♣ Diagnosis made by MRI ♣ Treatment • Stereotactic radiotherapy • Microsurgical excision • Bevacizumab—vascular endothelial growth factor blocker

Neural Hearing Loss

♣ Lesions involving the eight nerve—vestibulocochlear nerve, auditory cortex, ascending tracts, auditory nuclei ♣ Caused by MS, acoustic neuroma

Hearing loss--sensory

♣Deterioration of the cochlea; loss of hair cells in the organ of Corti ♣Gradually progressive—high frequency loss ♣Caused by noise exposure, head trauma, systemic disease ♣Genetics requires urgent ENT referral if cause cannot be found by history and physical exam