Earache + Epistaxis Flashcards
Bacteria causing OM
S. pneumonia
H. influenza
M. Catarrhalis
Classes of abx used for OM
Penicillin (B-Lactams)
Cephalosporins
Macrolides
Sulfonamides
Treatment of OM with tubes present
Ciprodex ear drops
Approach to hearing loss - types + causes
1) Conductive
Normal otoscopic exam
- Otosclerosis
Ear canal abnormalities
- Cerumen impaction
- FB
- Otitis externa
- Neoplasm
Abnormalities on or behind ™
- Membrane perforation
- OM
- Middle ear effusion
- Glomus tumor (unilateral, pulsatile tinnitus, bulging red mass behind ™)
- Cholesteatoma
2) Mixed
- Otosclerosis
- Chronic OM
- Neoplasm
- Temporal bone trauma
- Inner ear malformations
3) Sensorineural
Gradual onset
- Presbycusis
- Noise induced
- Drug induced (aminoglycosides, macrolides, glycopeptides, chemo drugs, NSAIDs, ASA, antimalarial, loop diuretics)
- Cerebellopontine angle tumor (acoustic neuroma)
Progressive onset
- TORCH infections
- Genetic
Fluctuating
- TORCH infections
- Meniere’s
- Endolymphatic hydrops
Approach to tinnitus - categories + causes
Pulsatile:
Pulse synchronous w/ HR:
Idiopathic intracranial HTN
Systemic HTN
Arterial bruits
Venous hum
Arteriovenous malformation
Vascular tumors
Pulse asynchronous:
Middle ear muscle myoclonus
Palatal muscle contraction
Eustachian tube dysfunction
Nonpulsatile:
Unilateral hearing loss:
Neuro signs:
Brainstem infarct
Cerebellopontine angle tumor
MS
No neuro signs:
Chronic noise exposure
Acoustic trauma
Meniere’s
Abnormal otoscope findings:
Cerumen impaction
OM
™ perforation
Cholesteatoma
Bilateral hearing loss:
Presbycusis
Noise exposure
Otosclerosis
Where do you get otalgia referred pain?
TMJ
Tonsils
Throat
Tube (Eustachian)
Teeth
Tongue
Trachea
Thyroid
Tics
Tendons
Trigeminal Neuralgia
Pathogens causing OE
pseudomonas, staph aureus, fungal, herpes zoster
RF for OE
humidity, warm temps, swimming, local trauma, hearing aid, immunocompromised
Sx of OE
pruritus, pain, fullness, erythema
Prevention of OE
dry ear canals after swimming, avoid cotton swabs, alcohol drops during high risk times, hair dryer use
Rx OE
No perforation: polysporin eye + ear 1-2 drops QID
Perforation: ciprodex otic suspension 4 drops BID
Fungal: clotrimazole 1% cream BID
Age peak for OM
6-9mo
RF for OM
daycare, male, family hx, enlarged tonsils, cigarette smoking, first nations
Sx of OM
acute onset middle ear fluid + inflammation, earache, fever, vomiting, rhinitis, Bulging tm
Physical findings OM
bulging TM, perforation, effusion behind TM, loss of TM landmarks
Complications of OM
mastoiditis, meningitis, intracranial abscess, facial paralysis
Rx for OM (<6mo, >6mo w/perf, w/bulging TM, w/middle ear effusion)
> 6mo, perforated TM w/ purulent DC = amox
6mo, middle ear effusion + bulging ™, mild = observe, ensure FU, if not improving = amox
6mo, middle ear effusion + bulging ™, mod = amox
6mo, no middle ear effusion = reassess in 24-48 hrs
<6mo: amoxicillin
If recurrent in kids, test for hearing loss
When to refer OM
OME >3mo w/ bilateral hearing loss
>3 episodes in 6 mo
>4 episodes in 12 mo
Retracted ™
cleft palate
DDx for otalgia
Tooth abscess
Trigeminal neuralgia
TMJ dysfunction
Pharyngitis
Tumors
Temporal arteritis
Mastoiditis
Sx TMJ dysfunction
Unilateral dull ache radiating to ear + jaw, worse w/ chewing
Locking of jaw
Ear clicking/ popping
Increasing pain through day
Limited jaw opening
Palpable muscle spasm
Rx TMJ
NSAIDs
TCAs
Location of epistaxis - most common, names
90% anterior (Kiesselbach’s - blood supply from internal and external carotid), 10% posterior (sphenopalatine - more common in elderly)
Anterior nose is also called Little’s area
Causes of epistaxis
Nose picking
Trauma
Infectious (cold, sinusitis)
Medications: ASA /clopidogrel/ NSAIDs/ Vitamin K antagonists (warfarin, dabigatran etc) /steroids (oral, topical nasal spray)
Alcohol use (may increase risk)
Post-operative
Intranasal neoplasm (juvenile nasopharyngeal angiofibroma - facial swelling, pain)
Allergic or viral rhinitis (causes mucosal hyperemia)
Coagulopathy/bleeding disorder
Chronic intranasal drug use (cocaine or Rx drug)
Hypertension
Ix + when to do it for epistaxis
for recurrent epistaxis, severe, <2y/o, systemic sx, family history:
CBC, INR, PTT, ferritin
Group + screen
Bleeding disorder testing
Liver dysfunction
Management of epistaxis
Assess hemodynamic stability, secure airway
Anterior rhinoscopy to identify source of bleeding
Lean forward
Prolonged pressure on distal nares (10-20 min)
Anterior and/or posterior packing soaked in topical decongestant
Pack nares from posterior to anterior with ribbon with neosporin
Packing methods: with lubricated gauze/“Rhino Rocket”/ Merocel /Foley catheter/Balloon
Vasoconstrictors: lidocaine + phenylephrine
Decongestants: oxymetazoline (topical decongestant)
Cautery – Silver nitrate x30s or electrical cautery
Surgical arterial ligation
Prevention of epistaxis
Emollient application
Humidification
Topical vasoconstrictors
Nasal cautery
Oral propranolol
How to assess tinnitus + what Ix to order?
Auscultate for bruits over neck, mastoid and preauricular area
Otoscope examination
Neurological examination
Order MRA + venogram of brain + neck
RF for AOM
maternal smoking, daycare, pacifier use, bottle feeding
Dx criteria for AOM
effusion, inflammation and acute sx
Rx for AOM in penicillin allergy
penicillin rash = cefuroxime, anaphylaxis = clarithromycin
Rx for AOM w/ treatment failure
clavulin or IM ceftriaxone
Indications for ventilation tubes
recurrent AOM 6/yr or chronic OME >3mo or retracted TM
Management of mild epistaxis
blow nose, 2 sprays oxymetazoline, pinch x10 mins
