ENT 1 OLDCARTS + Tx + Examples Flashcards
Cerumen Impaction
O) Accumulation usually asymptomatic; impaction may cause Sx
L) EAC
D) Until it’s removed
C) Hearing loss, ear fullness, earache, itchiness, reflex cough, dizziness, and/or tinnitus
A) None
R) None
T) N/A
S) Not extreme
3 Tx for cerumen impaction
1) Cerumenolytic agents
-Patients without h/o ear infections, TM perforation, or otologic surgery
2) Irrigation
-If TM intact
3) Manual
Otitis Externa (aka “Swimmer’s ear”)
O) Rapid onset (~within 48 hrs in previous 3 wks)
-Water/swimming, mechanical trauma, allergic contact dermatitis, dermatologic conditions, devices (hearing aids, ear buds, diving caps), prior radiation therapy
L) EAC
D) N/A
C) Inflammation of EAC; Otalgia, pruritis, otorrhea, hearing loss
-May have purulent exudate (discharge), periauricular cellulitis, or TM erythema
A) Tenderness with tragal pressure or auricle manipulation
R) In severe cases, entire auricular region can be inflamed
T) Childhood predominant; more likely to occur in summer; induced by infectious, allergic, & dermatologic disease
S) Mild: minor discomfort, pruritis, minimal canal edema
-Moderate: intermediate pain, pruritis, + partial canal occlusion
-Severe: intense pain, complete canal occlusion; + fever, preauricular erythema, regional lymphadenopathy
Otitis externa Tx
1) Main components of treatment: Cleaning EAC (aural toilet)
-Treating inflammation & infection
-Pain control (NSAIDs or acetaminophen)
2) Topical therapy is mainstay
-Mild: Topical acidifying agent + glucocorticoid (i.e., acetic acid + hydrocortisone TID-QID) x 7 days
-Moderate: Topical antibiotic + glucocorticoid (i.e., Cipro HC BID, Cortisporin TID-QID) x 7 days
3) Severe/ immunocompromised cases: Topical antibiotic + glucocorticoid (i.e.,Cipro HC, Cortisporin)
-Some patients: add wick placement & systemic antibiotics (if evidence of deep tissue infection)
–Less severe: PO levofloxacin 500 mg daily x 7d
–More severe: IV vancomycin + IV cefepime
-Obtain cultures of ear drainage
Malignant (Necrotizing) External Otitis
(Invasive infection of EAC & skull base (osteomyelitis)
O) Nocturnal otalgia
L) EAC
D) Deep
C) Deep otalgia (nocturnal), persistent & foul otorrhea, EAC granulation
A)
R)
T) Diabetics over age 60, HIV, immunocompromised
S)
Malignant (Necrotizing) External Otitis Tx
Based on severity (4 wks-6 months of PO or IV antibiotics)
FBs in EAC
O) Sudden
L) More common in right ear (predominant handedness)
D) Not long; until FB is removed
C) Decreased hearing or ear pain, purulent or bloody ear drainage (rare), chronic cough or hiccups (rare)
A)
R)
T) Most common in children aged 6 & younger, esp with:
-Irritating conditions of the ear (i.e., cerumen impaction, otitis externa, otitis media), pica, or ADHD
S)
FBs in EAC Tx
1) Referral to otolaryngologist:
-Urgent removal: button batteries, live insects, penetrating FBs
-Removal within a few days: glass or other sharp FB, spherical or other FB wedged in medial EAC, & FB against TM
2) Non-specialists: Irrigation setup, alligator or Bayonet forceps, plastic or metal cerumen curette
AOM
(Acute otitis media: acute bacterial infection of middle ear (aka suppurative otitis media))
O)
L) Middle ear (TM bulging, air-fluid levels, perforation, retraction pockets, & cholesteatoma)
D)
C) Young children/infants: fever, fussiness, disturbed or restless sleep, poor feeding/anorexia, vomiting, diarrhea
-Children: otalgia, ear rubbing, hearing loss, ear drainage, + fever
-Adults: otalgia, decreased/muffled hearing, purulent otorrhea (TM rupture)
A) Pneumatic otoscopy: painful in children with AOM
R)
T) Usually precipitated by viral URI or seasonal allergic rhinits (adults); most common in infants & children (ages 6-24 mos)
S)
AOM Tx in kids
1) Immediate treatment with antibiotics (at risk kids & <2))
-If NO antibiotics in prior month: amoxicillin
-If antibiotics in prior month: amoxicillin-clavulanate (Augmentin)
-PCN/beta-lactam allergy: If no severe reaction (i.e., rash), oral cephalosporin (i.e., cefdinir), if severe use a macrolide (i.e., clindamycin)
-Duration of therapy: 10 days for < 2 y/o & 5-7 days for > 2 y/o
OR:
2) Observation with initiation of antibiotic therapy if signs & symptoms worsen or fail to improve after 48-72 hours (different criteria depending on reference used)
-Pain control for both: PO ibuprofen or acetaminophen (alternate topical anesthetics), tympanocentesis, or myringotomy
AOM Tx in adults
Treat all adults with antibiotics! (and acetaminophen or ibuprofen for pain):
1) Patients with no PCN allergy: Amoxicillin-clavulanate
2) Alternate: cephalosporin (i.e., cefpodoxime, cefdinir)
-Duration: 7-10 days
AOM with TM perforation Tx
1) Children: PO antibiotics only
2) Adults: If topical antibiotic added, avoid topicals with ototoxicity (aminoglycosides) & treat for 7-10 days.
Chronic Otitis Media (Recurrent infection of middle ear and/or mastoid in presence of TM perforation)
O) Persistent (6-12 weeks) purulent otorrhea with perforated TM despite treatment
L)
D)
C) Hallmark = purulent aural discharge
-Hearing loss, aural fullness, otalgia, & occasionally vertigo
A) None
R)
T)
S)
Chronic Otitis Media Tx (adults)
-Removal of infected debris
-Earplugs
-Topical antibiotic drops (ciprofloxacin or ofloxacin) x 2-4 weeks
-Avoid aminoglycosides (ototoxicity)
-Consider PO ciprofloxacin
-Possible surgical reconstruction of TM
Otitis Media with Effusion (OME)/ Serous Otitis Media
(Presence of middle ear effusion without signs of acute infection)
O) Often occurs after AOM, but may occur with ETD (in absence of AOM)
L) Multiple air-fluid levels visible through a translucent, slightly retracted, nonerythematous tympanic membrane, impaired TM mobility
D)
C) Conductive hearing loss (predominant)
Other: feeling of ear fullness, tinnitus, balance problems
A)
R)
T) More common in children (pre-school) than adult:
-FHx of otitis media (otitis-prone parents), bottle feeding, male, daycare (or in-person school) attendance, adenoidal hypertrophy, exposure to tobacco smoke, low SE status
S)
OME Tx in kids
1) Watchful waiting (most common)
-Most cases spontaneously resolve in 3-6 months
-If not at risk for speech, language, or learning problems and otherwise have normal hearing (also an option for children with mild CHL)
-F/u: clinical eval & hearing tests q3-6 months
2) Myringotomy with T-tube placement (w/wo adenoidectomy)
-If at risk for speech, language, or learning problems
TM changes (retraction pockets), persistent OME-associated hearing loss (threshold > 40 dB), bilateral OME > 3 months, unilateral > 6 months, or recurrent episodes
OME Tx in adults
1) Mild Sx: no treatment/reassurance
2) More Sx: intermittent auto-insufflation
3) Moderate Sx due to seasonal allergic rhinitis: short-term(< 12 wks) antihistamines, PO decongestants, and/or nasal steroids
4) Moderate Sx due to URI: short-term (6-10 wks) nasal saline, PO decongestants, and/or nasal steroids (topical decongestant for air travel)
Cholesteatoma (Abnormal accumulation of squamous epithelium within the middle ear & mastoid)
O)
L) Congenital: white mass behind intact TM, deep retraction pocket + granulation, TM surface granulation
Acquired: deep retraction pockets, white mass behind TM, granulation at periphery of TM, new onset hearing loss, chronic drainage
D) Continued growth and/or infection if not surgically excised
C) Asymptomatic or chronic ear drainage/ persistent otorrhea or HL
-HL: Progressive, unilateral, conductive
A)
R)
T) History of recurrent AOM and/or chronic OME, 1st T-tubes placed at older age, cleft palate, craniofacial anomalies, turner syndrome, down syndrome, FHx of chronic middle ear disease and/or cholesteatoma
S)
Tx of Cholesteatoma in kids and adults
1) Early kids: ventilation & retraction pocket reduction or surgery
-Advanced: surgery
2) Adults: surgery with tympanoplasty + mastoidectomy & + ossicular reconstruction
Eustachian Tube Dysfunction (ETD)
(failure of functional valve of eustachian tube to open or close properly)
O)
L) possible retraction of the TM with decreased mobility on pneumatic otoscopy
D)
C) Aural fullness, +/- mild hearing impairment, popping/crackling with swallowing or yawning
A)
R)
T) Viral UI, allergies, etc
S)
(ETD) Eustachian tube dysfunction Tx (for 6 causes)
1) Rhinosinusitis: nasal steroids, intranasal/sinus rinses, nasal decongestants (pseudoephedrine, oxymetazoline), antibiotics (bacterial), & pain medications
2) Allergic & non-allergic rhinitis: trigger avoidance, PO & topical antihistamines, topical intranasal steroids, smoking cessation
3) Laryngopharyngeal reflux: lifestyle & dietary modifications, PPIs
4) Mass lesions: surgery for adenoid hypertrophy & nasopharyngeal carcinoma
5) ET insufflation: modified Valsalva maneuver
6) Surgery for failure of medical management: T-tubes, eustachian tuboplasty, balloon dilation of eustachian tube
Acoustic Neuroma/ Vestibular Schwannoma
(Schwann cell-derived tumor that commonly arise from the vestibular portion of the eighth cranial nerve)
O)
L) CN8: Unilateral (95%), benign lesion (among the most common intracranial tumors); 5% associated with hereditary syndrome neurofibromatosis type 2 (bilateral tumors)
D) Lasts hours
-gradually grow to involve the cerebellopontine angle, eventually compressing the pons & resulting in hydrocephalus
C) Progressive Unilateral SNHL, deterioration of speech discrimination, continuous disequilibrium
A)
R)
T)
S)
Tx for acoustic neuroma
Observation, microsurgical excision, or sterotactic radiotherapy
NOTE: Anyone with unilateral or asymmetric SNHL should be evaluated for intracranial mass lesion!
Peripheral vertigo Sx
Vertigo onset is sudden, often with tinnitus & hearing loss, usually horizontal nystagmus
Central vertigo Sx
Onset is gradual, not associated with auditory symptoms
Benign Paroxysmal Positioning Vertigo (BPPV)
(Due to small calcified otoliths moving around loose in the inner ear (posterior canal))
O) Recurrent episodes of vertigo lasting < 1 minute & provoked by specific types of head movements
L) Inner ear (posterior canal)
D) <1 min episodes that occur in clusters lasting several days; episodes recur periodically for weeks to months without therapy
-Dix-Hallpike maneuver usually provokes paroxysmal vertigo & nystagmus when affected ear turned downward
C) Vertigo (short episodes), + nausea & vomiting
-Typically NO hearing loss & other Sx.
-Nystagmus + vertigo during DH maneuver = usually appear with latency of a few seconds & lasts < 30 seconds, nystagmus in opposite direction upon sitting up
A) Specific types of head movements provoke; DH maneuver vertigo/ nystagmus intensity & duration diminish with repetition to same side
R)
T) Idiopathic or prior head trauma; residual effect of Meniere disease, vestibular neuronitis, ear surgery, herpes zoster oticus, or inner ear ischemia
S) Adaptive
Tx for BPPV
Particle repositioning via Epley maneuver
