Ears and nose Flashcards
what type of hearing occurs in the middle ear
- conductive hearing
what type of hearing occurs in the inner ear
- sensorineural hearing
pathogenesis of AOM
- eustachian tube dysfunction
- allergies
- viral infections
- bacterial infections
what does AOM stand for?
- acute otitis media
what does OME stand for?
- otitis media with effusion (chronic OM)
what is the gold standard for dx of otitis media?
- pneumatic otoscopy
AOM
- rapid onset < 48 hours
- si/sx of inflammation in middle ear
- mild pain
- bulging of TM
- intense redness
- +/- otorrhea
severe AOM
- AOM
- mod-severe pain OR fever > 102.2
- bulging of TM
- intense redness
- +/- otorrhea
OME
- inflammation of middle ear
- liquid collection
- no pain associated
middle ear effusion (MEE)
- liquid in middle ear
- no reference to etiology, pathogenesis, pathology, or duration
otorrhea
- discharge from ear
- can come from external auditory canal, middle ear, mastoid inner ear, intracranial cavity
otitis externa
- infection of external auditory canal
tympanometry
- measure acoustic immittance of ear
- function of ear canal pressure
causes of AOM
- strep pneumoniae **
- h. flu
- m. catarrhalis
- virus
- ostiomeatal complex disfunction
causes of OME
- osteomeatal complex/ eustachian tube dysfunction
- sequelae of AOM
- viral
- unknown
- bacteria
- biofilm
when is watchful waiting appropriate tx for OME?
- kids not at increased risk of speech, language, or learning problems
- 3 mo from date of effusion onset/ dx
- no suspected abnormalities in structure or TM
- must reexamine kid at 3-6 mo intervals until effusion gone
tx options for OME
- watch and wait
- tubes
- surgery
- PO or topical prednisone (off guidelines)
- antihistamines (off guidelines)
treatment guidelines for non-severe AOM
- 6-23 mo. abx or watch and wait IF you have good f/u
- 24 mo. bilat give abx
- > 24 mo. abx or observe
abx options for treatment of AOM in kids
- gold standard= amoxicillin 80-90 mg/kg BID to max dose of 1000 mg/dose
- quinolone drops if perf present
- Augmentin ES
- bactrim if > 2 mo
- 2nd or 3rd gen cephalosporin
- IM ceftriaxone
- azithromycin
- clindamycin
treatment for AOM in adults
- **worried about secondary causes like tumor*, sinusitis, allergies
- f/u is mandatory
- abx for kids plus tetracyclines and quinolones PO
general management of AOM (besides abx)
- pain relief- APAP, NSAIDs, topical numbing drops
- topical decongestants (avoid in peds)
- no cold meds if kid < 2 yo
- prob no cold meds in kid < 4 yo
- maybe cold meds in kid > 4 yo
what should a normal TM look like
- cone of light around 5 o’clock
- pearly gray color
- umbo present in middle
- lateral process of malleus
- TM intact
AOM follow up
- should see improvement in 24-48 hours
- reeval in 2 weeks
- middle ear effusion can persist for a few months, does not mean AOM has not resolved
AOM prophylaxis
- vaccines*
- breast feeding
- smoke free environment
- no bottles in bed
- abx prophylaxis NOT recommended
otitis externa (OE)
- painful external ear
- **tragal movement pain
causes of OE
- pseudomonas aeruginosa most common bacteria
- fungal
- furuncles
- allergies
- injury
predisposing factors for OE
- inadvertent injury
- allergies
- psoriasis or eczema
- seborrheic dermatitis
- decreased canal acidity
- irritants
si/sx of OE
- dainage thay may be foul smelling
- painful otoscopic exam
- red swollen ear canal
- purulent debris inside ear canal
- tenderness/pain over tragus
- hearing loss
- crusting outside of ear
OE treatment
- debridement
- sx management with APAP or NSAIDs
- topical abx
- topical steroids
- acetic acid
- PO meds if they have comorbidities
- consider using a wick for topical treatment
prevention of OE
- 1:1 mix of rubbing alcohol and white vinegar if TM is intact after swimming
- no q tips
common causes of TM perforation
- infection
- trauma
- atmospheric overpressure
- excessive water pressure
- improper attempts at wax removal or ear cleaning***
treatment for TM perforation
- most heal spontaneously
- refer if doesnt heal in 2 months, have significant hearing loss, or ossicular trauma
- systemic abx if also hav otorrhea
- surgery
- paper patch, gelfoam plug, fibrin glue in office
auricular hematoma
- from direct trauma
- shearing forces separate anterior auricular perichondrium from cartilage
treatment of auricular hematoma
- early ID
- drain
- splint
- compression
mastoiditis
- infection of mastoid air cells
- very concerning dx
treatment for mastoiditis
- consult
- medical tx same as AOM
- surgery to remove infected bone
what are the most concerning FB in the nose?
- button batteries
- cause serious damage d/t alkaline tissue necrosis
- can result in septal perforation within 4 hours
- most other FB are removed at initial presentation and dont require ENT f/u
common locations for nasal FB
- most on floor of nasal passage
paired disk magnets in nose
- if have one in each nostril they are difficult to manually remove
- prolonged attachment -> perforation of septum
clinical presentation of nasal FB
- usually in kids or adults with intellectual disabilities
- mucopurulent nasal discharge
- foul oder
- unilateral epistaxis
- nasal obstruction and mouth breathing
dx of nasal FB
- usually just done with otoscope or headlight
- most FB are radiolucent so XR is not helpful
- XR can detect button batteries or magnets and most pass easily through GIT
removal of intranasal FB
- using positive pressure techniques
- direct instrumentation
- most dont require surgery
intranasal FB that require ENT referral
- posterior FB not readily visualized
- chronic or impacted FB with inflammation
- penetrating or hooked FB
- any FB that cant be removed after initial attempt
positive pressure techniques
- have pt occlude opposite nose and blow out
- occlude unaffected nostril and have someone blow into mouth
intranasal FB removal via instrumentation
- can be painful- use topical anesthesia
- no nasal drops or pts with lodged button battery
- may need procedural sedation if uncooperative
- avoid forceps
- can use hooks or catheters
prognosis of intranasal FB
- depends on size, shape and contents of FB
- duration of FB
- result of removal attempts
intermittent allergic rhinitis
- sx occur in response to specific exposure
- i.e. cat allergy
seasonal allergic rhinitis
- aka hay fever
persistent/ perennial allergic rhinitis
- sx occur year round
- i.e. mold allergy
what key feature distinguishes allergic rhinitis from other forms of rhinitis
- nasal itching
physical exam findings for allergic rhinitis
- nasal mucosa is edematous and pale
- allergic shiners
- nasal crease/ “allergic salute”
- clear mucous
- polyps
- septal issues
management of allergic rhinitis
- environmental control
- topical intranasal steroids**
- 2nd gen antihistamines
- montelukast
- mast cell stabilizers
- immunotherapy
nonallergic rhinitis
- chronic presence of nasal congestion, rhinorrhea, post nasal drainage
- sx are perennial
- no nasal or ocular itching
vasomotor rhinitis
- nonallergic
- intermittent sx from nonspecific irritants
mixed rhinitis
- combo of allergic and nonallergic rhinitis
gustatory rhinitis
- nonallergic
- rhinorrhea triggered by hot or spicy foods
rhinitis of pregnancy
- nonallergic
- usually occurs in last six weeks
- no known allergic cause
- disappears 2 weeks after delivery
rhinitis medicamentosa
- caused by nasal decongestants
- should only use decongestants for 3 days
- can also be caused by antiHTN meds, ED meds, antidepressants, BZDs, NSAIDs, estrogen
what are the most common causes of rhinosinusitis
- rhinovirus
- influenza virus
- parainfluenza virus
acute rhinosinusitis duration
- < 4 weeks
chronic rhinosinusitis duration
- > 12 weeks
- usually seen in middle aged adults
viral rhinosinusitis
- sx usually dev after first day of inoculation
- nose blowing propels fluid from nasal cavity to sinuses
- decreased cilliary motility
- mucosal edema, thick secretions, obstructed sinuses
clinical presentation of viral rhinosinusitis
- usually < 10 days
- nasal congestion/ obstruction
- purulent d/c- yellow or green
- fever, fatigue, cough
- hyposmia/ anosmia
- ear pain, HA
- facial pain/pressure worsens when bending forward
- mucosal edema and narrowed middle meatus
- inferior turbinate hypertrophy
diagnosis of rhinosinusitis (viral or bacteria)
- mainly clinical
- bacterial cultures are unreliable- should be performed by ENT
- xray not indicated for uncomplicated
- CT is modality of choice if complicated
treatment for viral rhinosinusitis
- fluids
- OTC decongestants
- intranasal steroids
- limit nasal spray to 3-5 days use
- analgesics
- PO antihistamines
- mucolytics
- saline irrigation (neti pot)
- tx does NOT shorten duration
acute bacterial rhinosinusitis
- sx usually last > 10 days
- purulent d/c
- usually unilateral sinus pain and is exacerbated by bending forward
- usually URI that begins to improve then worsens
predisposing factors for bacterial rhinosinusitis
- usually a complication of viral infection
- nasal mechanical obstruction
- tooth infection
- impaired mucocilliary clearance
- immunodeficiency
- smoker
most common causes of acute bacterial rhinosinusitis
- s. pneumoniae
- h flu
- m catarrhalis
treatment for bacterial rhinosinusitis
- same supportive tx as viral
- augmentin for 5-7 days
- doxycycline for PCN allergy
- macrolides NOT recommended
- should respond in 3-5 days, if not switch to high dose augmentin
acute fungal rhinosinusitis
- occurs in immunocompromised pts
- usually d/t apergillus
- treat with amphotericin
acute fungal rhinosinusitis clinical manifestation
- facial pain and nasal congestion
- facial numbness, diplopia if facial n involvement
- epistaxis
- necrotic tissue
- gingival eschars, sloughing of septum
diagnosis of fungal rhinosinusitis
- urgent ENT referral
- biopsy/ debridement
chronic rhinosinusitis risk factors
- allergic rhinitis
- asthma
- perennial allergies
- smoking
- immunodeficiency
- anatomic abnormalities
- defects in mucocilliary clearance
cardinal si/sx of chronic rhinosinusitis
- anterior or posterior mucopurulent drainage
- nasal obstruction
- facial pain/ pressure/ fullness
- hyposmia (adults), cough (kids)
- need at least 2 cardinal sx to dx chronic
- may also see evidence of mucosal thickening
subtypes of chronic rhinosinusitis
- CRS with nasal polyposis
- CRS without nasal polyposis- most common
- allergic fungal rhinosinusitis
CRS with nasal polyposis
- bilateral nasal polyps that are gray/white color
- polyps are not painful
- gradual worsening nasal congestion/ obstruction
- sinus fullness and pressure
- hyposmia or anosmia
what is the biggest way to tell the difference between nasal polyps and nasal turbinates
- polyps= painless
- turbinates= VERY sensitive
samter’s triad
- combo of asthma, CRS with NP, and aspirin sensitivity
CRS without polyposis
- persistent sx with periodic exacerbations
- acute flares respond well to abx
allergic fungal RS
- chronic intense allergic reaction to colonizing fungi
- usually in immunocompetent that show evidence of allergy to at least one fungi
- presents subtly over years
- gross facial asymmetry and/or visual changes
CRS diagnostics
- sinus CT
- mucosal thickening bilaterally
- obstruction of osteomeatal complex
- sinus opacification without facial pain/ pressure/ HA
CRS with NP treatment
- PO steroids to shrink polyps
- nasal steroids after
- leukotriene inhibitor for maint
CRS without NP treatment
- PO steroids
- abx for 6 weeks
- follow with nasal steroids
- 2nd gen antihistamines
- leukotriene receptors
allergic fungal CRS treatment
- remove inspissated mucus
- prolonged PO steroids
anterior nosebleeds
- usually occur in kiesselbach’s plexus
- most common type of nosebleed
posterior nosebleeds
- usually d/t sphenopalatine artery
- not usually associated with trauma
- can result in serious hemorrhage
cause of anterior nosebleeds
- nose picking
- mucosal trauma/ irritation
- low moisture content
- allergic or viral rhinitis
- FB
- facial trauma
- chronic excoriation
- OTC nasal spray
- nasal steroids
- alcohol
- anticoag pts
cause of posterior nosebleeds
- carotid artery aneurysm
- nasal neoplasm
- anticoag pts
treatment of anterior nosebleed
- compress nares for 5-10 min
- pt lean foward
- short acting topical nasal decongestants
- topical cocaine or spray
- electrocautery
treatment of posterior nosebleeds
- topical sympathomimetics
- double ballon packs
- ENT consult for packing
- rhino rocket X 3 days with keflex
tinnitus
- perception of sound when no external noise present
- ringing, buzzhing, hissing, whistling, swooshing
- men > women
- more common in smokers
subjective tinnitus
- noise only perceivable to patient
- traceable to auditory or neurological rxn to hearing loss
- most common type of tinnitus
- usually occurs d/t RTI
objective tinnitus
- head or ear noises that are audible to others
- produced by internal fn in body circulation
- rare
causes of tinnitus
- ototoxic meds
- hearing loss- sensorineural
- otosclerosis
- chiari malformations
- often d/t ear wax plug
diagnosis of tinnitus
- requires good history
- HEENT exam, eval TM, CN exam, auscultate neck
- MRI if unilateral esp with hearing loss- r/o retrocochlear lesion
treatment of tinnitus
- avoid excessive noise and ototoxic drugs
- correct comorbidities
- hearing aids
- sound and behavioral therapy
- TMJ tx
- cochlear implants
nystamgus
- repetitive uncontrolled movements of eyes
- cause reduced vision, depth perception, and affect balance/ coord
- usually sx of another eye or medical prob
infantile nystagmus
- usually horizontal swinging
- congenital cause
spasmus nutan nystagmus
- occurs in kids
- usually improves on its own without tx
- kids often nod or tilt their head
- eyes can move in any direction
acquired nystagmus
- develops later in childhood or adulthood
- cause is usually unknown
causes of nystagmus
- neuro problems
- lack of eye development
- astigmatism
- congenital cataracts
- inflammation of inner ear
- medications (anti-seizure meds)
- CNS diseases
diagnosis of nystagmus
- history
- visual acuity assessment
- det lens power needed to correct error
treatment of nystagmus
- glasses/ contacts
- usually improves with time
- treat underlying cause
vertigo
- illusion of motion, rotary sensation
- associated n/v, sweating, pallor
causes of vertigo
- hypofunction- vestibular neuritis
- hyperfunction- BPPV
- central neurological disorder- migraines
central vertigo
- gradual onset
- cerebellum and brainstem affected
- disproportionate gate
- visual field defects
- hemisensory loss
- limb weakness
- diplopia
- slurred speach
- difficulty swallowing
peripheral vertigo
- sudden onset
- semicircular canals, otolith organs affected
- tinnitus
- hearing loss
- aural fullness
what is the most common cause of severe spontaneous vertigo
- vestibular neuritis or labrythitis
common cause of neuritis or labrythitis
- usually ear infection
- disrupts transmission of sensory info
- typically viral cause
neuritis
- inflammation of vestibular n
- NO hearing impact
- dizziness and vertigo sx
labrynthitis
- inflammation of labyrinth in inner ear
- hearing changes
- dizziness and vertigo sx
treatment for neuritis and labrythitis
- usually pretty self limited : 2-3 weeks
- steroids
- antivert meds- meclizine
- antiemetics- zofran
- antivirals and abx rare
benign paroxysmal positional vertigo
- crystal gets displaced into semicircular canal
- excessive response to head movement
- commonly in females > 60
- rapid onset dizziness or spinning
- short duration
clinical manifestations of BPPV
- clockwise rotary nystagmus
- rapid onset dizziness lasting sec- min
- precipitated by sudden head movement
- nystagmus
- nausea
- no impact on hearing
diagnosis of BPPV
- dix- hallpike maneuver to determine which canal is affected
- may need MRI/CT to r/o other causes
epley maneuver
- tx for BPPV in posterior canal
deep head hanging maneuver
- tx for BPPV in superior canal
lamperet (BBQ) maneuver
- tx for BPPV in lateral canal
tx of BPPV
- epley, deep head hanging, or lampered maneuvers
- symptomatic tx
- antihistamines
- antiemetics
- bzds
- neuro referral
- PT
- surgery (rare)
Meniere’s disease
- inner ear disorder -> vertigo, tinnitus, hearing loss, feeling of fullness in ear
- frequent “drop attacks”
- usually in one ear
- sudden onset of sx that are separated by periods of time
- usually seen in adult females
what is the cause of meniere’s disease
- fluid build up in inner ear -> impaired balance and hearing signals to brain
associated diseases of meniere’s
- allergies
- stress
- viral infections
sx associated to diagnose meniere’s disease
- usually done by ENT
- 2+ episodes of vertigo lasting 20 min each
- tinnitus
- temporary hearing loss
- fullness in ear
- can get MRI and labs to r/o more serious causes
treatment for meniere’s disease
- meclizine
- bzds
- salt restriction and diuretics
- dietary changes- no caffeine, alcohol, chocolate
- cognitive tx
- gentamicin injection (caution)- - steroids
- pressure pulse tx
drugs that can cause vertigo
- aminoglycosides
- antidepressants
- anxiolytics
- furosemide
- amiodarone
- ASA
- alcohol
- cocaine
central causes of vertigo
- migraines
- tumors of CN VIII
- chiari malformations
- brain ischemia
- MS
- brain injuries
eustachian tube dysfunction
- occurs when tube is blocked or doesn’t open
- air pressure outside TM > air pressure in middle ear
- TM gets pushed in
- TM becomes tense, doesn’t vibrate or move
causes of eustachian tube dysfunction
- cold or other sinus/throat infections** - sx can persist for 1 week after all other sx resolve
- allergies
- blockages- i.e. enlarged adenoids
- air travel
clinical manifestations of eustachian tube dysfunction
- fullness in ear**
- possible hearing loss
- popping when yawning or swallowing
- ear pain
dilatory eustachian tube dysfunction
- tube doesnt dilate
- causes hearing loss
- see effusions, scarring, and thickening of TM
- treat underlying cuase
patulous eustachian tube dysfunction
- valve incompetency
- pt hears own voice amplified
- movement of TM on otoscopic exam
- tx only if sx severe and last > 6 weeks
treatment of eustachian tube
- swallow, yawn, or chew to increase flow of air in and out of tube
- valsalva maneuver
- decongestants
- antihistamines
- steroid nasal spray
- if sx are persistent refer to ENT
what type of hearing loss is associated with outer ear problems?
- conductive hearing loss
what type of hearing loss is associated with middle ear problems?
- conductive hearing loss
what type of hearing loss is associated with inner ear problems
- sensorineural hearing loss
exostosis
- multiple bony growths
osteoma
- solitary bony growth
what is the most common cause of middle ear hearing problems?
- eustachian tube dysfunction
presbycusis
- age related hearing loss
what are endocrine issues associated with hearing loss?
- DM
- hyperthyroidism
- anemia
what are autoimmune diseases associated with hearing loss?
- RA
- SLE
- polyarteritis nodosa
what drugs are commonly associated with hearing loss?
- gentamycin, tobramycin, tetracycline
- cisplatin, 5-FU
- high dose ASA
- PDE-5 inhibitors
- quinine, chloroquine
- cocaine
- lead, mercury, cadmium, arsenic
vestibular schwannomas
- overproduction of schwann cells on vestibular nerve
- slow growing
- typically unilateral
neurofibromatosis type 2 (NF2)
- mutation in merlin gene
- causes bilateral vestibular schwannomas
- more likely to dev other NS tumors
clinical presentation of vestibular schwannomas
- disequilibrium
- hearing loss- asymmetric sensorineural loss
- tinnitus
- if tumor is large enough can compress other CN
risk factors for vestibular schwannomas
- NF2 mutation
- childhood low dose radiation
- hx of parathyroid adenoma
- ? cellphones
- exposure to loud noise
diagnosis of vestibular schwannomas
- audiometry- best initial screening
- CT
- MRi
management of vestibular schwannomas
- surgery- good longterm control
- radiation
- observation
indications for conservative management of vestibular schwannomas
- > 60 years old
- significant comorbidities
- small tumor size
- lack of sx
- risk further hearing loss
- pt preference
complications of vestibular schwannomas
- hearing loss
- facial weakness
- vestibular disturbances
- persistent HA
- CSF leakage
- hemorrhage
- infections
causes of ear barotrauma
- flying- most common
- driving/hiking up mountains
- diving
- blast injuries
what cause of barotrauma is associated with inward rupture of TM
- diving
clinical manifestations of ear barotrauma
- ear pressure- most common
- pain
- hearing loss
- tinnitus
- vertigo
prevention for barotrauma
- plan for pressure changes
- avoid flying/ diving
- decongestants and antihistamines
- ear plugs
- ventilation tubes
- surgical tympanoplasty if required
