2 - Otolaryngology Flashcards
Functions of the eustacian tube?
Pressure equalization
- yawning/swallowing
Mucus drainage
- from middle ear to posterior pharynx
Why are ear infections common in kids not but adults?
Kids
- Shorter ET
- Horizontal ET
- Immature floppy elastic cartilage
- Larger adenoids
Tube resembles adult tubes by age 6
S/s of eustachian tube dysfunction (ETD)
Aural fullness
Fluctuating hearing
Discomfort w barometric pressure changes
ETD pts are at risk for?
Otitis media w effusion (OME)
Serous otitis media (SOM)
Ways to assess the TM integrity and mobility?
Valsalva
Otoscope w bulb
Tympanogram
What 2 main dysfunctions cause ear problems?
Dilatory dysfunction (common) - cannot dilate well
Patulous dysfunction (uncommon)
Dilatory dysfunction causes?
- Any type of inflammation
- infection
- allergies
- irritants
- hormones - Pressure dysregulation (altitude)
- Anatomic congenital abnormalities
- atresias
- masses
- trauma
- hypertrophied adenoids
- downs
Patulous dysfunction presentation?
Over patent eustation tube “i hear my body functions”
benign condition caused by
- wt loss (6lbs)
- scarring
- neuromuscular d/o
- hormonal functions (high estrogen)
Clinical symptoms of dilatory vs patulous dysfunctions?
Dilatory
- HL,
- TM retraction/effusion
Patulous
- autophony (looks normal w/o HL)
- movement w inspiration/expiration
Dilatory dysfunction tx?
URI
- Decongestants
- Antihistamines
- Nasal steroids
Education
- stop smoking
Behavioral
- PPI (acid reflux)
Patulous dysfunction tx?
Mild symptoms
- reassure/education
- hydration
- NS spray
Severe symptoms
surgery
- TM tubes
- cartilage grafting
What is SOM aka OME
Serous otitis media
Otitis media w effusion
- eustachian tube remains blocked for a long time
- negative pressure results in transudation of fluid
- fluid in middle ear w/o illness/inflammation
Presentation of SOM/OME?
Conductive HL
Aural fullness
Reduced TM mobility - viscous bubbles
Adults - h/o
- URI
- Allergies
- barotrauma
Adults w persistent unilateral SOM?
Must r/o:
nasopharyngeal carcinoma
Using nasopharyngeal endoscopy
Tx of SOM?
Mild HL
- observe x 3 mo
- freq valsalva
- steroids/abx/antihistamines (controversial)
Why are meds controversial for SOM tx?
If the pt has seasonal allergic rhinitis or URI meds are useful
The controversial part is only using these empirically
Refractory SOM tx?
PE tubes (pressure equalization) Adenoidectomy - relieves nasal obstruction
Indications for PE tubes?
I think she said this is a test q
- Severe or recurrent AOM
- HL >30db w OME
- Impending mastoiditis or intra-cranial complications due to OME
- SOM >3mo
- Chronic retraction of tympanic membrane (ETD)
- Prevention or tx of barotrauma
- Autophony due to patulous eustacion tube (PET)
- Craniofacial anomalies that predispose mid ear dysfunction
- Mid ear dysfunction due to head/neck radiation and skull base surgery
With TM PE tubes you must educate pt?
Mid ear should be sterile so swimming and similar activities gets bacteria in there (prob bad)
With acute otitis media (AOM) you often see?
Otalgia, oft w URI
Erythema and hypomobility of TM
AOM is a sequela of?
ETD
- infection of URT leads to mucosal inflammation -> diminishes the diameter of ET
- leads to inadequate ventilation and backflow of secretions from throat into mid ear
70-90% of AOM cases?
Resolve spontaneously w/o abx
- but they are still often given
Risk factors for AOM?
Pacifier use
Bottle feeding
Day care attendance
Second hand smoke
Clinical presentation of otitis media?
Young kids
- fever
- irritability
- crying
- drainage of ears
- altered sleep
- ear pulling
Older kids/adults
- otalgia (sudden onset)
- mastoid tenderness
- aural pressure
- decrease hearing
- fever
Otitis media PE?
Erythema Decreased mobility Bulging TM - w/o landmarks Occasionally bullae
Pics on slide 27
Common AOM pathogens
S. Pneumoniae
H. Influenzae
S. Pyogenes
- GABHS
AOM tx?
Abx
Antipyretics/analgesics
Or observation if:
- > 2y/o
- otherwise healthy
- fever <102.2
- able to return if needed
Most spontaneously get better in 48-72hrs
Tympanocentesis for culture
- immunocompromised or recurrent
Myringotomy
- sever otalgia or complications of AOM (mastitis, meningitis)
Abx in preschoolers?
50% of abx in preschoolers are for ear infections
This is why observation is suggested now, trying to reduce resistant bacteria
Abx for AOM?
Amoxicillin 80-90 mg/kg/day
- 1st line
Amox-clavulante 20-40mg/kg/day
PCN allergy
- cefdinir or ceftriaxone
oh SNAP
Safety Net approach to Antibiotic Prescriptions
Based on clinical suspicion of AOM
- give prescription w instructions to only fill after 2 days or if sxs get worse
76% of kids get better w only pain management and dont need the abx
1 in 10 kids taking amoxicillin gets?
Itchy maculopapular rash >72hrs after beginning the meds
If the pt gets amoxicillin rash?
Its not contraindication for future amoxicillin use, nor should current regimen be stopped
Be careful though amoxicillin rash can also be?
Infectious mono
- 80-90% of pts w acute EBV infection given amoxicillin develop rash
I smell a new EBV test…
AOM prognosis?
At 2 weeks
- 50% will have fluid in ears
10 weeks
- 10% will have residual fluid
Many kids have cyclical infections
- recurrent acute otitis media
Can become chronic otitis media
Definition of recurrent AOM?
> /= 3 distinct episodes of AOM w/in 6 months
> /= 4 episodes w/in 12 months
Tx for recurrent AOM?
PE tubes
What is chronic otitis media (COM)
Chronic infection of mid ear and mastoid, consequence of recurrent AOM or trauma
- Chronic otorrhea w/ or w/o otalgia
- TM perforation w conductive HL
- often amenable to surgical correction
When does AOM become COM?
Usually between 2-3 months
COM definition?
Chronic otorrhea through a perforated TM
- mucosal changes and osseous changes are present
- bacterialolgy different from AOM (anaerobes)
Hallmark of COM?
Purulent discharge that is continuous or intermittent w increased severity during URI or following water exposure
Presentation of COM?
Purulent discharge Pain is (during exacerbations) CHL from destruction of ossicular chain, or TM TM perforation
Tx for COM?
Remove infected debris Earplugs to keep water out Topical antibiotics (drops) - ofloxacin, ciprofloxacin w dexmethasone Ciprofloxacin PO x 1-6 wks Surgical TM repair Mastoidectomy
Complications of otitis media?
Perforation of TM Cholesteatoma Mastoiditis Facial paralysis CNS infection - otogenic meningitis
What causes the TM perforation in COM?
Purulence must go somewhere
- the TM is the path of least resitance
Tx for TM perforation?
Oral and topical abx
- ofloacin otic or cipro HC otic
- oral abx
Prevent water in ear
TM perforation prognosis?
Most heal sponataneously if <25% of TM surface
- > 6 weeks refer to ENT
- persistent subjective HL get audiogram and dump on ENT
TM anatomy?
JK i dont care
- pretty sure she said she wont ask this but its slide 43 if you want that hundo
What is cholesteatoma?
Prolonged ETD w neg mid ear pressure draws the upper flaccid protion of the TM inwards (pars flaccida)
Progression of cholesteatoma?
Pars flaccida leads to
- squamous epithelium lined sack
- fills w desquamanated keratin
- chronically infected
- bony erosion penetrates the mastoid
- ossicular chain is destroyed
- eventually hits CN VIII and spreads intracranially
Pics on 45, 46
Presentation of cholestematoma?
TM retaction pocket
Perforation w either
- Keratin debris
- granulation tissue
Imaging for cholesteatoma?
CT - test of choice
MRI - cannot delineate bony anatomy but can ID non-specific opacification
Tx for cholesteatoma?
Surgical excision
- recurrence is common
- doesnt fix the ET dysfunction
PE tubes - prevent chronic neg pressure
Several weeks of inadequately AOM or COM can lead to?
Mastoiditis
Clinical presentation of mastoiditis?
Children>adults
- fever
- posterior ear pain
- erythema over mastoid
- edema of pinna
- displacement of auricle
- protruding auricle
- loss of postauricular crease
If you suspect mastoiditis?
CT
-Immediate ENT consult if pos
** ct findings : coalescence of the mastoid air cells due to destruction of the bony septa
Increased attenuation of the right middle ear w no osseious defects?
Axial CT finding for acute mastititis
Pic on slide 50
Mastoiditis tx?
IV abx
- cefazoline 0.5-1.5g q 6-8 hrs
Refractory
- myringotomy for culture and drainage
- mastoidectomy - surgical drainage
MC bugs for mastoiditis?
S. Pneumoniae
H. influenzae
S. Pyogenes
What if the AOM infection spreads w/in the temporal bone into the petrous apex?
Petrous apicitis aka petrositis
Diagnosis of petrositis?
Classic triad
- Retro-orbital pain
- AOM
- Abducens nerve paresis (CN VI)
+
Radiographic findings of bony destruction of petrous apex
Tx for petrositis?
Abx (prolonged)
- based on culture results
Surgical drainage
How do AOM or COM cause facial paralysis?
AOM
- inflammation of CN VII in the middle ear
COM
- chronic pressure on CN VII by cholesteatoma (evolves slowly)
AOM/COM facial nerve paralysis tx and prognosis?
AOM - Good prognosis
- myringotomy (drain + culture)
- IV abx
COM - poor prognosis
- surgery - fix the cholesteatoma
Rare but serious consequence of neglected AOM?
Otogenic meningitis (CNS infetion) - MC intracranial complication of ear
Treat w myringotomy
What is tymnpanosclerosis?
Firm submucosal scarring that can appear as milky white patch on TM
- hylaine deposits
- calcification
Injuries, PET, chronic disease
Tympanosclerosis can lead to?
Chronic hearing loss
- decreased mobility of TM and immobilization of the ossicular chain
What is otosclerosis?
Abnormal bony growth footplate of the stapes resulting in hearing loss
- max 60dB
- familial tendency
Presentation of otosclerosis?
Slow progressive unilateral/bilateral CHL
Early onset 3-4th decade
To diagnosis otosclerosis you must r/o other causes using?
CT/MRI
Webber
Rinne
Tympanometry
Tx for otosclerosis?
Observation (mild)
Ampilficaiton
- if normal cochlear function + speech discrimination
Surgery
- stapes prosthesis (stapedectomy)
Explain the mechanism of barotrauma
Middle ear is air filled
Rapdi/extreme pressure change must be equalized via eustachian tube
-If this doesnt happen the TM will retract from neg pressure
Sxs of barotrauma?
Aural fullness Pain HL Tinnitis N/V
PE for baotrauma?
TM retraction
Hemotympanum
+/- perforation
Your pt is a skydiver on the US pro team. She has concerns that she will suffer barotrauma during an upcoming competition.
What can you give her?
Medication aimed at reducing obstruction around the Eustachian tube
- pseudoephedrine 60-120mg
- oxymetazoline (afrin)
Education
- swallow, yaw, or valsalva freq
Ventilating tubes may be need for freq fliers
Tx for ear barotrauma
Usually self resolve
Meds
- analgesics prn
- abx (only if indicated)
Surgery (if severe)
Not useful
- glucocorticoids
- decongestants
- antihistamines
Who needs an ENT referral (barotraum)
Sever otalgia Hearing loss Vertigo Persistence beyond 4-5 days Blast injury
Impact injury, or explosive acoustic trauma can cause?
TM perforation
Hemotympanum
Disruption of ossicular chain
Consider disruption of the ossicular chain if?q
CHL >30 dB x 3 months following trauma
TM perforation summary?
HEENT exam
- webber/rinne
Treat
- infection-> abx
- hearing loss
- referral
No injection/comorbids/hearing loss?
- observe
- avoid water
- f/u in 2-3 months
Though rare, you can have primary middle ear tumors.
What type of tumors are they?
Glomus tumors arise either in middle ear or in jugular bulb with upward erosion into he hypotympanum
Presentation of glomus tumurs?
Pulsitle tinnitus
Conductive HL
PE:
- vascular mass behind intact TM
- CN neuropathies
Large glomulus jugulare tumors lead to?
- large glomus jugulare tumors = multiple cranial neuropathies of CN VII, IV, X, XI, and XII
tx for glomus tumors?
Surgery
Radiotherapy
Pulsatile tinnitus?
MRA and venography to r/o vascular mass
MCC of earache?
OE
AOM
Earache w pain out of proportion can be?
Herpes zoster oticus
- vesicles in ear canal/auricle
Non-otologic causes of earache?
Referred otalgia from CN V, VII, IX, X and upper cervical
Glossopharyngeal neuralgia
Infection/neoplasm of oropharynx, hypopharynx and larynx
What is glossopharyngeal neuralgia?
repeated episodes of severe lancinating otalgia (back of throat and ear)
- if refractory to medical management, microvascular decompression of CN IX is required
Being sick is just your body’s way of saying
That your too awesome and you need to slow down for everyone else to catch up
