ENT I: Middle + Inner Ear Disorders Flashcards
Pt 2 of the first ppt
1) Define middle ear effusion
2) Define acute otitis media
3) Define otitis media with effusion (OME)
1) Fluid in middle ear cavity (occurs with acute otitis media & otitis media with effusion)
2) Acute bacterial infection of middle ear (aka suppurative otitis media)
3) Middle ear fluid, but is not infected (aka serous, secretory, or nonsuppurative otitis media)
1) What is Acute Otitis Media (AOM)?
2) What often is the cause? What is this usually precipitated by in adults?
3) Who is it most common in?
1) Acute bacterial infection of middle ear fluid (aka, suppurative otitis media)
2) Obstruction of the eustachian tube; viral URI or seasonal allergic rhinits
3)Infants & children (ages 6-24 mos)
1) Are bacteria or viruses the more common cause of AOM?
2) What are the 3 most common bacteria?
3) What are 6 common viruses?
1) Bacteria
2) Streptococcus pneumonia, Haemophilus influenzae, & Moraxella catarrhalis
3) Rhinovirus, RSV, parainfluenza, coronavirus, adenovirus, COVID-19
Describe the symptoms of Acute Otitis Media (AOM) in young children, children, and adults
1) Young children/infants: fever, fussiness, disturbed or restless sleep, poor feeding/anorexia, vomiting, diarrhea
2) Children: otalgia, ear rubbing, hearing loss, ear drainage, + fever
3) Adults: otalgia, decreased/muffled hearing, purulent otorrhea (TM rupture)
1) What is necessary for AOM?
2) What may be a necessary procedure?
1) Accurate diagnosis is vital & otoscopy is necessary
2) Cerumen removal
Describe the classic exam findings of acute otitis media (AOM). Include the results of pneumatic otoscopy.
1) Middle ear effusion
2) TM that is bulging, opaque, yellow, or white
3) TM with decreased or absent mobility
4) Pneumatic otoscopy: painful in children with AOM & not necessary with bulging TM
Diagnosis of AOM is made clinically from seeing one of what two things?
1) Bulging of the TM
OR
2) Perforation of TM with acute purulent otorrhea (if acute otitis externa has been excluded)
For AOM, what should you assess the TM for?
1) Position, mobility, color, & translucency
2) Bulging, air-fluid levels, perforation, retraction pockets, & cholesteatoma.
What are the two strategies for AOM treatment in kids? What do both have in common?
1) Immediate treatment with antibiotics
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)
-Both: PO ibuprofen or acetaminophen (alternate topical anesthetics), tympanocentesis, or myringotomy
What does effusion mean in the context of ENT?
Fluid in middle ear
What 4 groups of children are at risk for severe infection, complications, and/or recurrent AOM?
1) Infants < 6 months
2) Immunocompromised
3) Toxic-appearing
4) Craniofacial abnormalities (ie, cleft palate)
What is the difference in treatment between AOM treatment in at-risk kids and not at-risk kids?
1) At-risk: immediate antibiotic therapy
2) Not at-risk: immediate antibiotic therapy or observation
1) How should you treat AOM with antibiotics in children if they haven’t had antibiotics in the past month?
2) What about if they have?
3) How long should it last?
4) In most cases you should treat children ages <_____ y/o with antibiotics.
1) Amoxicillin 80-90 mg/kg/day divided q8h or q12h
2) Amoxicillin-clavulanate (Augmentin) 90/6.4 mg/kg/day PO divided BID
3) Duration of therapy: 10 days for < 2 y/o & 5-7 days for > 2 y/o
4) <2 y/o
What are the two main treatment options for kids w AOM? (review)
1) Immediate treatment with antibiotics
2) Observation with initiation of antibiotic therapy if signs & symptoms worsen or fail to improve after 48-72 hours.
1) How should you treat AOM in kids with a PCN/ beta-lactam allergy if the rxn is not severe (i.e. rash)?
2) What about if there’s a severe allergy to PCN/beta-lactam or cephalosporins?(i.e., anaphylaxis, urticaria, angioedema, Stevens-Johnson syndrome)
1) Oral cephalosporin (i.e., cefdinir)
2) Avoid cephalosporins & use a macrolide (i.e., clindamycin)
slide 57
1) How should you treat adults for AOM?
2) How should low-risk adults be treated?
3) How should high risk adults be treated?
4) What’s the alternate treatment?
1) Treat all adults with antibiotics! (and acetaminophen or ibuprofen for pain
2) Amoxicillin-clavulanate
-875/125 mg 1 tab PO BID
-1000/62.5 mg 2 tabs PO BID
3) Amoxicillin-clavulanate (higher dose)
-1000/62.5 mg ER 1 tab PO BID (lower weight or milder infection)
-2000/125 mg ER 1 tabs PO BID (higher weight or more severe infection)
4) Cephalosporin (i.e., cefpodoxime, cefdinir)
1) How should you treat adults with PCN allergy for AOM if there’s no severe rxn i.e., rash) or no known allergy to cephalosporin?
2) What about if known severe allergy to PCN or known severe allergy to cephalosporins (i.e., anaphylaxis, urticaria, angioedema, Stevens-Johnson syndrome)?
1) Oral cephalosporin (i.e., cefdinir, cefpodoxime, cefuroxime)
2) Avoid cephalosporins & use doxycycline or a macrolide (i.e., azithromycin, clarithromycin)
1) True or false: most TM perforations in both children and adults assoc. with AOM heal spontaneously
2) True or false: there’s data showing benefit of combination topical & PO antibiotics vs PO antibiotics alone (children & adults)
1) True
2) False; there’s no data showing that
1) How should you treat children with perforated TM assoc with AOM?
2) What abt for adults?
3) What should you counsel both on?
1) PO antibiotics only
2) If topical antibiotic added, avoid topicals with ototoxicity (aminoglycosides) & treat for 7-10 days.
3) Appropriate water precautions until healed
1) What often precedes AOM?
2) True or false: For AOM persistence of middle ear effusion after the resolution of acute symptoms is common
3) What are some potential complications of AOM?
1) Middle ear effusion often precedes AOM
2) True
3) Mastoiditis, labyrinthitis, cholesteatoma, meningitis, brain abscess, epidural or subdural abscess, lateral or cavernous sinus thrombosis
What are the 3 referral criteria for AOM?
1) Recurrent otitis media (> 2 episodes in 6-month period)
2) Persistent hearing loss following AOM (> 1-2 weeks)
3) Chronic TM perforation (> 6 weeks)
1) Define chronic otitis media.
2) What’s its hallmark?
3) What is it usually a consequence of?
4) What are 3 commonly involved bacteria?
5) What are its symptoms?
6) What is it commonly associated with?
1) Recurrent infection of middle ear and/or mastoid in presence of TM perforation
2) Purulent aural discharge
3) Recurrent AOM
4) P. aeruginosa, Proteus species, S. aureus
5) Hearing loss, aural fullness, otalgia, & occasionally vertigo
6) Cholesteatoma
1) How is chronic otitis media diagnosed?
2) How is it treated?
3) What should you avoid?
1) Persistent (6-12 weeks) purulent otorrhea with perforated TM despite treatment
2) Removal of infected debris, earplugs, topical antibiotic drops (ciprofloxacin or ofloxacin) x 2-4 weeks, consider PO ciprofloxacin
-Possible surgical reconstruction of TM
3) Avoid aminoglycosides (ototoxicity)
1) Define Otitis Media with Effusion (OME) (aka Serous Otitis Media)
2) What does it often occur after?
3) Who is it more common in, kids or adults?
4) What is the criteria for chronic OME?
1) Presence of middle ear effusion without signs of acute infection
2) Often occurs after AOM, but may occur with ETD (in absence of AOM)
3) Children (pre-school)
4) _/>3 months
1) What are rarely associated w OME (serous otitis media)?
2) What are the risk factors for OME?
1) Rare obstruction of eustachian tube by mass (NP carcinoma) or radiation Tx (nasopharyngoscopy + CT for recurrent unilateral OME)
2) FHx of otitis media (otitis-prone parents), bottle feeding, male, daycare (or in-person school) attendance, adenoidal hypertrophy, exposure to tobacco smoke, low socioeconomic status
1) What is the main sign of OME?
2) What are the other signs and symptoms of OME?
3) List 5 common exam/ otoscopic OME findings
1) Conductive hearing loss (predominant)
2) Feeling of ear fullness, tinnitus, balance problems
3) Impaired mobility of TM, type B tympanometry, air-fluid levels + bubbles, amber (or gray) middle ear fluid, neutral or retracted TM
What are the 3 main ways OME is diagnosed? What is within each category?
1) Standard otoscopy
2) Pneumatic otoscopy
3) Adjunctive testing:
-Audiology (CHL + flat tympanogram suggests OME)
-Tympanometry
-Acoustic reflectometry
What are the two main treatments of OME for children?
1) Watchful waiting (most common)
2) Myringotomy with T-tube placement (w/wo adenoidectomy)
1) What are unproven/ ineffective OME treatments?
2) When do most cases spontaneously resolve?
1) Antibiotics, PO & intranasal steroids, nasal balloon auto-inflation, antihistamines, decongestants, complementary & alternative therapies, myringotomy alone
2) In 3-6 months
1) What groups of kids are the watchful waiting treatment plan for OME appropriate for?
2) What should you follow up with? When?
1) Not at risk for speech, language, or learning problems and otherwise have normal hearing (also an option for children with mild CHL)
2) Clinical eval & hearing tests q3-6 months
What are 4 potential indications for T-tubes for kids with OME
1) At risk for speech, language, or learning problems
2) TM changes (retraction pockets)
3) Persistent OME-associated hearing loss (threshold > 40 dB)
4) Bilateral OME > 3 months, unilateral > 6 months, or recurrent episodes
1) How should adults with mild OME symptoms be treated?
2) What about if there’s more symptoms?
3) What about if the symptoms are moderate due to seasonal allergic rhinitis?
4) What if the symptoms are moderate due to URI?
1) No treatment/reassurance
2) Intermittent auto-insufflation
3) Short-term(< 12 wks) antihistamines, PO decongestants, and/or nasal steroids
4) Short-term (6-10 wks) nasal saline, PO decongestants, and/or nasal steroids (topical decongestant for air travel)
1) Define cholesteatoma
2) List factors that put cholesteatoma pts at risk
1) Abnormal accumulation of squamous epithelium within the middle ear & mastoid
2) 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
What are the two types of cholesteatoma in children? Describe each
1) Congenital: intact TM, no h/o middle ear disease (median age 4-5 y/o)
2) Acquired: most commonly result from middle ear disease
What are the two types of acquired cholesteatoma in adults? What causes each?
1) Primary: due to ETD
2) Secondary: due TM perforation
1) How is asymptomatic cholesteatoma found?
2) What are the two main symptoms of cholesteatoma pts present with?
3) What will happen if not surgically excised?
4) What are some potential complications of cholesteatomas?
1) Asymptomatic: found on routine exam
2) Chronic ear drainage or hearing loss
3) Continued growth and/or infection
4) HL, CN palsies, neuro symptoms (i.e., vertigo), venous thrombosis, brain abscess, meningitis
Describe the otoscopic findings for both congenital and acquired cholesteatoma (adults)
1) Congenital: white mass behind intact TM, deep retraction pocket + granulation, TM surface granulation
2) Acquired: deep retraction pockets, white mass behind TM, granulation at periphery of TM, new onset hearing loss, chronic drainage
How are cholesteatomas evaluated? (3 ways)
1) Clinical suspicion (characteristic findings, new onset HL, persistent otorrhea)
2) Hearing eval
3) Refer to otolaryngologist to confirm diagnosis & management
1) How is cholesteatoma Dx’d?
2) How is it treated if found early?
3) What about if it’s advanced?
4) What about in adults?
1) confirmed by otolaryngologist with visual microscopic exam, temporal bone CT, DW-MRI, and/or surgical exploration
2) Ventilation & retraction pocket reduction or surgery
3) Surgery
4) Surgery with tympanoplasty + mastoidectomy & + ossicular reconstruction
1) Define Eustachian Tube Dysfunction
2) What are its signs/ symptoms?
1) Failure of functional valve of eustachian tube to open or close properly
2) Aural fullness, +/- mild hearing impairment, popping/crackling with swallowing or yawning
1) What is a rare cause of eustachian tube dysfunction?
2) What is a more common cause of eustachian tube dysfunction? What is this often assoc. with?
1) Obstructive to patulous (rare) dysfunction
2) Obstructive: air trapped within the middle ear becomes absorbed and negative pressure results
-Often associated with viral URI & allergies
1) What may be found upon exam with eustachian tube dysfunction?
2) How should you treat eustachian tube dysfunction?
1) Possible retraction of the TM with decreased mobility on pneumatic otoscopy
2) By treating its underlying cause
Underlying causes of eustachian tube dysfunction:
1) How should you treat rhinosinusitis?
2) What about allergic & non-allergic rhinitis?
1) Nasal steroids, intranasal/sinus rinses, nasal decongestants (pseudoephedrine, oxymetazoline), antibiotics (bacterial), & pain medications
2) Trigger avoidance, PO & topical antihistamines, topical intranasal steroids, smoking cessation
Underlying causes of eustachian tube dysfunction:
1) How is Laryngopharyngeal reflux treated?
2) How are mass lesions treated?
1) Lifestyle & dietary modifications, PPIs
2) Surgery for adenoid hypertrophy & nasopharyngeal carcinoma
1) Underlying causes of eustachian tube dysfunction:
A) Which cause is treated w a modified Valsalva maneuver?
B) How is surgery for failure of medical management treated?
2) What is a complication of eustachian tube dysfunction?
1A) ET insufflation
1B) T-tubes, eustachian tuboplasty, balloon dilation of eustachian tube
2) OME
1) Define Acoustic Neuromaaka Vestibular Schwannoma
2) Is it unilateral or bilateral? Is it benign?
3) What are 5% of cases associated with?
4) What will they gradually grow to involve?
1) Schwann cell-derived tumor that commonly arise from the vestibular portion of the eighth cranial nerve.
2) Unilateral (95%), benign lesion (among the most common intracranial tumors).
3) 5% (bilat) associated with hereditary syndrome neurofibromatosis type 2 (bilateral tumors).
4) The cerebellopontine angle, eventually compressing the pons & resulting in hydrocephalus.
1) What are the signs and symptoms of acoustic neuroma?
2) How is it Dx’d?
3) How is it treated?
4) When should pts be evaluated for intracranial mass lesion?
1) Unilateral SNHL (sensorineural hearing loss); deterioration of speech discrimination; continuous disequilibrium
2) MRI or CT
3) Observation, microsurgical excision, or sterotactic radiotherapy
4) Anyone with unilateral or asymmetric SNHL
1) Is vertigo a diagnosis? Explain
2) Define vertigo
3) What can cause it?
1) Symptom of illusory movement (not a diagnosis)
2) Sensation of motion when there is no motion or an exaggerated sense of motion in response to movement
3) Asymmetry of vestibular system due to damage to or dysfunction of the labyrinth, vestibular nerve, or central vestibular structures in the brainstem.
1) How may vertigo be described?
2) What are the key to diagnosis?
1) -Transient spinning dizziness after turning around several times
-Sense of swaying or tilting
-Self motion vs motion of environment
2) Duration of vertigo episodes and association with hearing loss
1) List some peripheral causes of vertigo
2) List some central causes of vertigo
3) List some mixed causes of vertigo
1) Peripheral causes: Vestibular neuritis/ labyrinthitis, Meniere disease, BPPV, ethanol intoxication, inner ear barotraumas, semicircular canal dehiscence
2) Central causes: Seizure, MS, Wernicke encephalopathy, Chiari malformation, cerebellar ataxia syndromes
3) Mixed:
A) Migraine
B) Stroke + vascular insufficiency
-incl: cerebellar artery strokes, Cogan + Susac syndromes, vestibular schwannoma, meningioma, etc
C) Infections
-incl: lyme disease, Syphilis, hyperthyroidism, etc
1) What 3 things should vertigo be distinguished from? Are these vestibular in origin?
2) What two etiologies do you need to differentiate between?
1) Imbalance, lightheadedness, & syncope (all non-vestibular in origin)
2) Peripheral and central
You must differentiate between 2 etiologies of vertigo; describe the general symptoms of each
1) Peripheral: onset is sudden, often with tinnitus & hearing loss, usually horizontal nystagmus
2) Central: onset is gradual, not associated with auditory symptoms
Vertigo caused by peripheral vestibular disease:
1) What Hx question should you ask?
2) What is an associated symptom?
3) What can trigger it?
4) What things should you check/ do during physical exam? (4)
1) Thorough history: duration of episodes (seconds, minutes, hours, or days)
2) Associated symptoms: hearing loss
3) Diet, stress, fatigue, bright lights
4) Ears, eye motion & nystagmus in response to head turning, cranial nerves, Romberg testing
What is different about central causes of vertigo diagnosis and treatment?
Same as with peripheral, but may need ENG and/or MRI
List some common vertigo medications
1) Meclizine (Antivert)
2) Dimenhydrinate (Dramamine)
3) Diazepam (Valium)
4) Lorazepam (Ativan)
5) Metoclopramide (Reglan)
6) Prochlorperazine (Compazine)
7) Promethazine (Phenergan)
1) Define BPPV (Benign Paroxysmal Positioning Vertigo)
2) How often do symptoms occur?
3) How often do episodes recur?
4) What causes it?
1) Recurrent episodes of vertigo lasting < 1 minute & provoked by specific types of head movements
2) Occur in clusters lasting several days
Episodes recur periodically for weeks to months without therapy
4) Small calcified otoliths moving around loose in the inner ear (posterior canal)
1) Who is BPPV most common in?
2) What are some common underlying causes?
1) F > M, onset is usually around 50s
2) Idiopathic or prior head trauma; residual effect of Meniere disease, vestibular neuronitis, ear surgery, herpes zoster oticus, or inner ear ischemia
1) What are the signs and symptoms of BPPV?
2) How is it diagnosed?
3) What should the results of the diagnostic procedure be if positive?
1) Vertigo (short episodes), + nausea & vomiting
Hearing loss & other symptoms typically absent
2) Observing nystagmus during provoking maneuver (Dix-Hallpike maneuver)
3) Usually provokes paroxysmal vertigo & nystagmus when affected ear turned downward
Describe the nystagmus characteristic of BPPV
1) Involuntary & rhythmic oscillation/movement of the eyes
2) Vertigo & nystagmus usually appear with latency of a few seconds & lasts < 30 seconds
3) Nystagmus in opposite direction upon sitting up
4) Adaptation: Intensity & duration diminish with repetition to same side
Treatment of BPPV involves a particle repositioning maneuver called __________ maneuver
Epley
1) What are the other names for Labyrinthitis?
2) What is its typical presentation?
3) What is its cause?
4) What does it look like during an exam?
1) Vestibular neuritis/neuronitis, neurolabyrinthitis, acute peripheral vestibulopathy (called labyrinthitis with unilateral hearing loss)
2) Rapid onset of continuous & usually severe vertigo with nausea, vomiting, & gait instability lasting several days to a few weeks
3) Unknown; likely viral or post-inflammatory disorder affecting vestibular portion of 8th cranial nerve
4) Spontaneous unilateral, horizontal, or horizontal-torsional nystagmus suppressed with visual fixation
1) How is labrynthitis diagnosed?
2) How is it treated? (3 things)
1) Based on H&P
2) Treatment:
-Supportive: vestibular suppressants during acute phase (antiemetics, antihistamines, anticholinergics, benzodiazepines)
-Glucocorticoids may help during acute period (10-day prednisone taper)
-Vestibular rehabilitation
List other peripheral causes of vertigo (Besides BPPV)
1) Traumatic vertigo
2) Perilymphatic fistula (rare)
3) Cervical vertigo
4) Migrainous vertigo
1) Define traumatic vertigo
2) Describe the symptoms of a perilymphatic fistula (rare). What may Tx require?
1) Labyrinthine concussion secondary to head injury, may result in chronic posttraumatic vertigo
2) Fluctuating hearing loss from injury (barotrauma, valsalva); may require tissue graft for window sealing
1) Describe cervical vertigo/ what triggers it
2) Describe Migrainous vertigo. What is it similar to?
1) Triggered by neck movement to certain positions; neck injury or cervical DJD
2) Episodic vertigo; visual & motion sensitivity, auditory sensitivity, photosensitivity; similar to Meniere’s but NO hearing loss or tinnitus
What are the two main types of external ear trauma? Describe each
1) Open: lacerations (+ cartilage exposure) & avulsions
2) Closed: blunt trauma may cause hematoma of pinna
1) What are some common causes of closed external ear trauma?
2) What can lack of treatment cause?
1) Amateur wrestling, rugby, boxing, mixed martial arts
2) Necrosis & chronic scarring or further cartilage formation & permanent deformity (“cauliflower ear”)
1) How is auricular (pinna) hematoma treated?
2) Complex lacerations & avulsions usually require what?
1) I&D or large-needle aspiration, pressure dressing, anti-staph antibiotics, ENT(or plastic surgery) referral
2) ENT or plastic surgery consultation.
What should you evaluate about external ear lacerations? What should you do next?
Eval for cartilage involvement:
1) No cartilage: primary closure with 6-0 suture (or surgical glue), pressure dressing
2) Cartilage: copious irrigation, closure, & PO antibiotics
1) Define Barotrauma
2) What structures can this involve?
3) What are some causes?
1) Injury to middle & inner ear structures due to impact injury/blunt trauma or explosive acoustic trauma (barotrauma)
2) TM rupture, hemotympanum, round & oval membrane rupture, ossicular disruption
3) Causes: flying, diving, decompression chambers, & hyperbaric oxygen chambers
1) What are some symptoms of barotrauma?
2) How is it diagnosed?
1) Symptoms: pressure, then pain; CHL, SNHL, vertigo, tinnitus
2) H&P
How should pts prevent barotrauma?
1) Avoid flying & diving if URI or nasal allergy
2) Premedicate before exposure (PO decongestants, PO antihistamines, and/or nasal decongestants sprays)
3) Swallowing and/or Valsalva maneuver
4) Earplugs
5) Ventilation tubes
6) TM perforation is absolute contraindication to diving
1) How do most barotrauma injuries heal?
2) When is emergent surgery necessary for barotrauma injury?
3) What two things can be repaired for barotrauma injuries?
1) Most injuries heal/resolve spontaneously with time
2) Peri lymphatic fistula
3) Tympanoplasty or patching of round or oval window
