Otolaryngology Flashcards
External ear causes of ear pain?
Cerumen Impaction Otitis Externa Cellulitis of the Auricle Herpes Zoster Oticus Malignant OE
Signs/symptoms of otitis externa?
Infection of the external ear canal – recent swimming, pain in the tragus, feeling of fullness in the ear, pruritis in the ear canal, hearing loss, swelling, erythema/macerated ear canal, discharge, may see erythematous TM
Signs/symptoms of herpes zoster oticus?
Burning pain, hyperesthesia, pruritis preceding vesicle eruption, headache/fever/malaise/fatigue
What causes 99% of malignant OE?
Pseudomonas
When should you suspect malignant OE?
Immunodeficient + insulin dependent DM + otalgia + facial nerve involved
Signs/symptoms of malignant OE?
Otalgia and purulent otorrhea that is refractory to medical therapy
Tx of malignant OE?
Requires hospital admission, debridement, IV antibiotics, hyperbaric O2
Middle ear causes of ear pain?
AOM, Cholesteatoma, Barotrauma, Mastoiditis, Auricular Hematoma
What is malignant OE?
Osteomyelitis of the temporal bone
What is cholesteatoma?
A cyst composed of keratinized desquamated epithelial cells occurring in the middle ear, may present with sense of ear fullness and presence of a red or yellow mass typically involving the posterior aspect of the TM
Signs and symptoms of cholesteatoma?
Symptoms:
- Progressive hearing loss (predominantly conductive, although may get SNHL in late stage)
- Otalgia, aural fullness, fever
Signs
- Retraction pocket in TM, may contain keratin debris
- TM perforation
- Granulation tissue, polyp visible on otoscopy
- Malodourous, unilateral otorrhea
What is barotrauma?
History of rapid change in air pressure (eg, air travel, scuba diving). Often hemorrhage on or behind TM
What is mastoiditis and when is the onset?
Infection (usually subperiosteal) of mastoid air cells, most commonly seen approximately two wk after onset of untreated or inadequately treated AOM (suppurative)
Symptoms of mastoiditis?
Otorrhea, tenderness to pressure over the mastoid , retroauricular swelling with protruding ear, fever, hearingloss, ± TM perforation (late)
Nonotologic causes of ear pain?
Tumors of the External Auditory Canal
TMJ Dysfunction
Oropharyngeal Infections
Who should be evaluated for the possibility of a tumor in the ear canal?
Patients that appear to have a relapsing or unremitting case of otitis externa or perforated otitis media should be evaluated for the possibility of a tumor in the ear canal
Symptoms of TMJ dysfunction?
Pain, crepitus at TMI exacerbated by jaw movement, palpation of the TMJ region may reveal tenderness, or a palpable clicking sensation with joint motion
What should be done on physical exam for ear pain?
o Ear: Pinna + mastoid, ear canal and TM
o Throat
o TMJ
o Neck - LN
What is AOM?
Infection of middle ear caused by fluid stasis due to lack of middle ear drainage
▪ Often preceded by URTI
Risk factors of AOM?
Non-modifiable: young age, family history of OM, prematurity, orofacial abnormalities, immunodeficiencies, Down syndrome, race, and ethnicity
Modifiable: lack of breastfeeding, daycare attendance, household crowding, exposure to cigarette smoke or air pollution, pacifier use
Common organisms of AOM?
S. Pneumo > H. Influenza > Moraxella Catarhallis > GAS
Which organism is most likely pathogen associated with perforate TMs?
GAS
Triad for AOM?
Triad of otalgia + fever (especially in younger children) + conductive hearing loss;
What might be seen on otoscope for AOM?
Hyperemia, bulging, pus may be seen behind TM, loss of landmarks (e.g. handle and long process of malleus not visible)
Criteria for diagnosis of AOM?
1) Acute Onset Otalgia - Systemic symptoms: Difficulty sleeping, irritability, fever. Otalgia, otorrhea
2) Middle Ear Effusion w/ Inflammation (seen via decreased tympanic membrane mobility or bulging tympanic membrane on otoscopy)
Approach for generally healthy child >6mo of age with unilateral, non-severe, suspected AOM, without MEE or with MEE but non-bulging or mildly erythematous TM?
Consider viral etiology - reassess in 24-48h for worsening or change
Supportive care and symptom management: maintain hydration, analgesic, and antipyretic (acetaminophen, ibuprofen)
MEE Present + Bulging TM:
- Mildly Ill: alert, responsive, no rigors, responding to antipyretics, mild otalgia, able to sleep - <39C in absence of antipyretics, <48h of illness
Reassess 24-48h with analgesia, if no improvement then treat
MEE Present + Bulging TM:
- Mod-Severely Ill: irritable, difficulty sleeping, poor response to antipyretics, severe otalgia, OR =>39C in absence of antipyretics or >48h of symptoms
Treat with antimicrobials: 10 d course if 6-24 mo, 5 d if >2 yr old
Perforated TM +/- Purulent Discharge
Treat with antimicrobials for 10d
What antibiotic is 1st line for AOM
Amoxicillin 80 mg/kg/day BID - If someone fails amoxicillin, the next line is amoxi-clav 90 mg.
Extracranial complications of AOM?
Hearing loss and speech delay (secondary to persistent middle ear effusion), TM perforation, extension of suppurative process to adjacent structures (mastoiditis, petrositis, labyrinthitis), cholesteatoma, facial nerve palsy, middle ear atelectasis, ossicular necrosis, vestibular dysfunction)
What is otitis media with effusion?
Residual fluid in middle ear without signs of acute infection, can persists for weeks but self-limited and generally don’t need treatment
Otoscopy of TM from OM w/ effusion
Discolouration (amber or dull grey), meniscus fluid level behind TM, air bubbles, retraction pockets/TM atelectasis, flat tympanogram, immobility of TM
Tx of OM w/ effusion
90% resolve on their own, document hearing loss with audiogram
- If >3-6 Months/Affected Speech Development/Learning difficulties: consider myringotomy tubes (tubes fall out after 6-12 months)
What are the indications for myringotomy tubes?
Indications: persistent MEE (3 m bilateral or 6m unilateral) recurrent AOM (3 episodes/6 mo; 4 episodes/12 mo)
What is otitis externa?
Diffuse inflammation of external auditory canal +/- infection
Risk factors for otitis externa?
Prolonged water exposure (impairs natural defense mechanism in external ear - washes away cerumen, desquamation of keratin layer, altered pH), micro fissures from dermatologic conditions, hearing aids
Two most common organisms for otitis externa
90% pseudomonas aeruginosa and staphylococcus aureus
Presentation of otitis externa?
Rapid onset (w/n 48h) inflammation - Otalgia, itching, jaw pain, tenderness of tragus and/or pinna, edematous and erythematous ear canal
Management of otitis externa?
- Antipyretics
- Clean ear under magnification with irrigation, suction, dry swabbing, and C&S
- Antipseudomonal otic drops (e.g. ciprofloxacin) or a combination of antibiotic and steroid (e.g. Cipro HC)
- ± 3% acetic acid solution to acidify ear canal (low pH is bacteriostatic)
Tx of chronic otitis externa (pruritus without obvious infection)?
Corticosteroid alone (e.g. diprosalic acid)
Prevention of otitis externa?
Remove water from ears after swimming
Ddx of dizziness can be divided into which 2 categories?
o Vertigo (vestibular) o Nonvertiginous (nonvestibular)
What is the definition of vertigo?
Objective (external world seems to revolve around individual) or subjective (individual revolves in space)
Vertigo is a problem with the _____
Inner ear a.k.a. labyrinthine system
Vertigo can be divided into 2 categories
▪ Central (15%): brainstem / cerebellar (tumour, cerebrovascular disorders – TIA, Migrainous vertigo, Multiple sclerosis, drugs - anticonvulsants, hypnotics, alcohol))
▪ Peripheral (85%): inner ear / vestibular nerve (Meniere’s, BPPV, acoustic neuroma, trauma, drugs, labyrinthitis)
What are the symptoms of nonvestibular dizziness?
Feeling light-headed, giddy, dazed, disoriented
Causes of nonvestibular dizziness?
▪ Cardiac- Arrhythmias, Aortic stenosis ▪ Vasovagal ▪ Orthostatic hypotension - should do orthostatic BP lying down, sitting up, standing to see if any change in BP and HR ▪ Anemia ▪ Hypoglycemia ▪ Peripheral neuropathy ▪ Visual impairment ▪ Psychogenic: diagnosis of exclusion – panic disorder, anxiety, depression
What is the most common cause of vertigo?
Benign Paroxysmal Positional Vertigo
Signs and symptoms of BPPV?
Brief, recurrent episodes (30 seconds to 2 minutes) usually worse in morning (triggered by head movements), +/- nausea and vomiting, sensation of aural fullness, usually unilateral, tinnitus
What is vestibular neuronitis?
Inflammation of the vestibular portion of CN VIII
Signs and symptoms of vestibular neuronitis?
Sudden, incapacitating, severe vertigo with no hearing loss, leaving a residual imbalance that lasts days to weeks. Lasts up to 1 week, with gradual lessening of symptoms. Accompanied by N/V, unilateral horizontal nystagmus (towards offending ear in acute phase)
Treatment of vestibular neuronitis?
Bed rest, antivertiginous drugs, corticosteroids (methylprednisolone) ± antivirals
Signs and symptoms of Ménière’s disease?
Recurrent episodic episodes (minutes to hours), fluctuating hearing loss, tinnitus, vertigo, and aural fullness.
What causes Ménière’s disease?
Caused by inner ear filling up with fluid
Diagnostic Criteria for Meniere’s Disease
● Two spontaneous episodes of rotational vertigo > min
● Audiometric confirmation of SNHL (often low frequency)
● Tinnitus and/or aural fullness
MUST HAVE ALL 3
Treatment of ménière’s disease?
Tx: Managed with low sodium diet, dietary changes, diuretics, intratympanic gentamicin to destroy vestibular end-organ, results in complete SNHL
What is acoustic neuroma?
Schwannoma of the vestibular portion of CN VIII
Clinical features of acoustic neuroma?
● Usually presents with unilateral progressive SNHL (chronic) or tinnitus.
● Dizziness and unsteadiness may be present, but true vertigo is rare as tumour growth occurs slowly, and thus compensation occurs
● Facial nerve palsy and trigeminal (V1) sensory deficit (corneal reflex) are late complications
Treatment of acoustic neuroma?
● Expectant management if tumour is very small, or in elderly
● Definitive management is surgical excision
Which drugs are cause vestibular toxicity?
Aminoglycosides, loop diuretics, ASA, NSAIDs, amiodarone, quinine, cisplatin
Vertiginous Work-Up?
ENT/neurologic exams + Dix Hallpike Maneuver + Audiometry + MRI if indicated (meniere disease)
How do you perform the Dix Hallpike Maneuver?
Seat patient with legs extended, head at 45o rotation, rapidly shift patient to supine position with head fully supported in slight extension (for 45s) – observe for rotatory nystagmus + ask re: vertigo sensation
Syncopal Work-Up
o Orthostatic hypotension - Investigate underlying etiology. New meds or alcohol? Consider CBC and electrolytes.
o Vasovagal - If recurrent episodes or pt is at risk of injury, consider referral for tilt test (+/- carotid sinus massage if >40 yo)
What is an antihistamine anti-vertigo medication one could use to treat vertigo?
Betahistine, sold under the brand name Serc
What is the physiotherapy treatment called for BPPV?
Epley’s
When should you refer your patient to an ENT specialist for vertigo?
When significant central disease is suspected, when peripheral vertigo persistent (lasting >2-4wks), or if atypical presentation
What percentage of pharyngitis is viral and what is the most common bacteria?
90% viral, most common bacterial is Group A Strep
What is pharyngitis?
Inflammation of the oropharynx
Viral etiology of pharyngitis?
Viral Etiology: rhinovirus, adenovirus, influenza, coronavirus, respiratory syncytial virus are the most common viral causes, but occasionally Epstein-Barr virus (the cause of mononucleosis), herpes simplex , cytomegalovirus , or primary HIV infection is involved.
Presentation of viral pharyngitis?
Presentation: rhinorrhea, cough, congestion, hoarseness, Nonspecific flu-like symptoms such as fever, malaise, and myalgia Likely sick contacts
When should infectious mononucleosis be considered for pharyngitis?
Infectious mononucleosis should be considered when there is posterior cervical or generalized adenopathy, hepatosplenomegaly, and fatigue and malaise for > 1 week.
Bacterial etiology of pharyngitis?
Bacterial Etiology: Group A β-Hemolytic Streptococcus (GABHS), Group C + Group β-Hemolytic Streptococcus, Neisseria gonorrhoeae, Chlamydia pneumoniae, Mycoplasma pneumoniae, Corynebacterium diphtheriae
Potential complications of bacterial pharyngitis?
Complications: rheumatic fever, glomerulonephritis, suppurative complications (abscess, sinusitis, otitis media, cervical adenitis, pneumonia), meningitis, impetigo
S/S of bacterial pharyngitis?
▪ Symptoms: pharyngitis, fever, malaise, headache, abdominal pain, absence of cough
▪ Signs: fever, tonsillar/pharyngeal erythema/exudate, swollen/tender anterior cervical nodes, halitosis
Red flags for pharyngitis?
RED FLAGS: persistence of symptoms longer than a week without improvement, respiratory difficulty (particularly stridor, croup, etc.), difficulty in handling secretion (peritonsillar abscess), difficulty in swallowing (Ludwig’s angina), severe pain in the absence of erythema (supraglottis/epiglottitis), palpable mass (neoplasm), blood in the pharynx or ear (trauma)
Workup for pharyngitis?
Throat culture (gold standard), rapid test for streptococcal antigen
What is the centor criteria for bacterial tonsillitis?
Centor Criteria (criteria of likelihood of bacterial tonsillitis): Absence of cough, fever, tonsillar exudates and anterior cervical lymphadenopathy. ● 0-1 points – no antibiotic or throat culture ● 2-3 points – throat culture ● 4 points – treat with antibiotics empirically, consider culture
Management of viral pharyngitis?
▪ Antibiotics not indicated
▪ Supportive + honey + acetaminophen, ibuprofen, saline nasal spray, adequate hydration, and rest
▪ A single low dose of a corticosteroid such as oral dexamethasone—0.6 mg per kg for children at least five years of age and up to 10 mg for adults—is effective in decreasing pain in the first 24 hours.
Workup for suspected EBV?
▪ Suspected EBV (Infectious Mononucleosis): peripheral blood smear, heterophile antibody test (i.e. the latex agglutination assay or “monospot”)
Management for EBV Mono Pharyngitis
Acetaminophen/NSAIDs for fever/myalgias/pharyngitis/malaise, avoid heavy physical activity and contact sports for 1 month or until splenomegaly resolves (risk rupture)
▪ If Acute Airway Obstruction: corticosteroids + consult ENT
For GABHS pharyngitis is the incidence of glomerulonephritis or rheumatic fever decreased with the use of antibiotics?
Incidence of glomerulonephritis is not decreased with antibiotic treatment but rheumatic fever is
Pediatrics 1st line treatment for GABHS pharyngitis?
Pediatrics 1st Line: penicillin V 40 mg/kg/d PO BID-TID (max 750 mg/d) x 10 d (use adult dose if >27 kg) or amoxicillin 40 mg/kg/d PO BID-TID x 10 d
Adults 1st line treatment for GABHS pharyngitis?
Adults 1st Line: penicillin V 300 mg PO TID or 600 mg BID x 10 d
