Download Disease Etiology and Risk Manifestations/Complications DDx

Disease
Etiology and Risk
Manifestations/Complications
Acoustic Trauma
Exposure to single, extreme
noise
Bilateral sensorineural hearing loss
Acoustic Neuroma
Schwannomas involving CNVIII
that grow slowly - enlargement
of mass causes ataxia and brain
stem dysfunction
Unilateral hearing loss, tinnitus, vertigo
Acute HIV Syndrome
High levels of HIV-1 replication
Sore throat, oral ulcers, fever,
maculopapular rash, lymphadenopathy,
arthrology, malaise, anorexia and weight
loss
Beings after incubation period of
few days to weeks post exposure
DDx
Treatment
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Usually lasts 3 days, full recovery in 2
weeks
Dx: MRI of brain with
gadolinium to evaluate
for retrocochlear tumor
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Surgical removal
Dx: detection of HIV1
replication w/o
antibodies, plasma HIV-1
RNA elevated, low CD4
originally, CD8 elevated
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Antiretroviral therapy
Dx: laryngoscopy if
suspect mass, infx, vocal
cord dysfunction
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Voice rest, smoking/alcohol cessation,
hydration, surgery if chronic
Dx: hx, nasal secretions
with eosinophils, serum
IgE, skin testinng, ELISA
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Avoid allergen
Cold compresses
Antihistamines (use 2nd gen)
Leukotriene antagonists
Vasoconstrictor eye drops, topical nasal
agents - Azelastine, cromolyn
Corticosteroids
Desensitization
Ddx: mononucleosis
Acute Hoarseness/Acute Laryngitis
Allergic Rhinoconjunctivitis
Laryngeal mucous membrane
infx, usually viral
(adenovirus/influenza, RSV,
coxsackie, rhinovirus); trauma to
throat, vocal abuse, toxic
exposure, GI complications,
smoking, allergy
Hoarseness, cough, sore throat, fever,
vesicles on soft palate (r/o her angina),
lympahdenopathy
Type I hypersensitivity
Sneezing, rhinorrhea, obstruction of nasal
passages (pale, boggy), nasal polyps
w/eosinophils, conjunctival, nasal,
pharyngeal itching, conjunctiva injected,
red, stringy eye discharge, puffiness,
increased lacrimation, unremarkable
pharynx
Trees (March to June), Grass
(June - July), Ragweed (August October)
Risk: atopic hx, family hx
If hoarseness > 2 weeks, evaluate for
cancer
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Comp: discomfort, secondary infx
Allergies - Asthma
Environmental, allergens,
respiratory infections, exercise,
drugs, hormones, emotional,
gastric reflux
Risk: eczema, hay fever, genetic
Bronchoconstriction, SOB, wheezing,
cough, chest tightness, airway
inflammation, airway hyper
responsiveness, reversible airflow
obstruction
Dx: clinical, hx and PE,
lab findings (elevated
IgE), pulmonary function
studies, pyrometer, peak
flow normal, CXR, ABG
Extrinsic: atopic IgE response
Intrinsic: not related to allergens
Ddx: upper airway
disorders, COPD
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Avoid exposure to irritants
Relaxation techniques
Desensitization
Inhaled B2 agonists
Inhaled corticosteroids
Systemic steroids
Leukotriene modifiers for prophylaxis
Cromolyn sodium for prophylaxis
Anticholinergics
Acute asthma: inhaled B2 agonists,
corticosteroids, IV magnesium for smooth
muscle relaxation, supplemental O2, abx,
intubation
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Avoidance of food that provokes allergy
Antihistamines
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Allergies - Food
Milk, eggs, soy, tree nuts, fish,
shellfish
Can progress to anaphylaxis
Skin: pruritis, erythema, urinary,
angioedema
GI: N/V/D, abdominal pain
Respiratory: SOB, dyspnea
Symptoms w/i 2 hours of ingesting food
Dx: food hx, eliminate
food from diet then
reintroduce
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Allergies - Insect
Yellow jackets, honeybees,
wasps, hornets
Local: non-allergic: localized swelling, pain,
pruritis, redness (subsides in few hours)
Allergic: marked swelling and erythema
over larger area
Allergies - Latex
Type I or Type IV
Risk: prolonged exposure to latex
- cutaneous exposure, mucous
membrane exposure, inhalation,
intravascular exposure
Type I - urticaria, rhinorrhea,
conjunctivitis, anaphylaxis
Type IV - nonimmunologic response develops 48-96 hours post contact, dorsum
of hands, vesicular rash - may lichenify
Anaphylaxis
Antigens - Type I
Hypersensitivity response systemic manifestation
Cutaneous: pruritis, erythema,
angioedema, urticaria
Respiratory: respiratory distress, airway
obstruction
Cardiovascular: tachycardia, low BP,
syncope, shock, diaphoresis
GI: nausea, vomiting, cramping abdominal
pain, diarrhea
Aphthous Ulcer
Idiopathic, antigen, ACE
inhibitors
Localized edema of eyelids, lips, tongue,
genitalia, hands and feed, nonpitting puffy
skin with edema, tender and burning
rather than pruritis - lesion fluid thicker
than urticaria
Nonspecific acute inflammation herpes virus 6?
Painful small round ulcerations with yellowgray centers surrounded by erythematous
halos on buccal and labial mucosa,
oropharynx, tongue
Complications: infection
Barotrauma
Bullous Myringitis
Antihistamines, analgesics, ice
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Airway - ventilation assistance
Breathing - High conc O2, nebulized
bronchodilators
Circulation: epinephrine, IV fluids,
vasopressors (dopamine)
Antihistamines - inhibit vasodilation
Severe - ICU admission
Epi Pen
Corticosteroids
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Complications: Death.
Angioedema
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Antihistamines
Systemic corticosteroids
SC epinephrine for laryngeal edema
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Self limited
Topical analgesics, top steroids
Triamcinolone acetonide (orabase,
kenalog), betamethasone mouth rinse
Avoid spicy food, citrus
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Dx: clinical, biopsy if
>10 days
Ddx: erythema
multiform, drug allergy,
IBD, SCC
Inability to equalize barometric
stress in middle ear
Negative pressure in middle ear
causes ET to collapse
Risk: flying, underwater diving
Hearing loss, sensation of fullness, otalgia,
dizziness, ruptured TM, bulging inward pull
of the eardrum, other signs of
decompression sickness (pain in bones,
joints)
Ddx: serous, acute,
chronic otitis media,
bullous myringitis
Vesicles develop on TM second
to previous viral or bacterial infx
- inflammation of TM
Sudden onset of severe pain, no fever, no
hearing impairment, bloody otorrhea
possible, inflammation to TM and canal,
multiple reddened blebs (possibly blood
filled) -- may cause hearing loss
BCC, SCC, AOM
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Autoinflation by yawning, swallowing, etc
Decongestants, antihistamines, steroids
Myringotomy
Abx only if severe
Pt education - valsalva maneuver
Usually self-limiting
Hard to tell bacterial from viral - use abx
If pain is severe, rupture vesicles
w/myringotomy knife
Analgesics
Complications: temporary hearing loss
Cerumen Impaction
Caused by attempts to clean the
ear, excessive water in canal
Most common cause of treatable
hearing loss
Progressive conductive hearing loss,
stuffed or full feeling in ear, pain
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Remove cerumen (currette)
Irrigate w/one part H2O2, one part H2O
Debrox, Cerumenex drops (do not use if
tympanoscopy tubes, TM perforation)
Cholesteatoma
Benign, slow-growing lesion
located behind TM composed of
stratified squamous epithelium
that destroys bone, normal tissue
- destructive to bone in path
TM perforation, retraction,
infection
Congenital - epithelium in temp.
bone in embryonic development
Acquired: tear in TM
Dental Abscess
Strep mutans
Perforation of TM filled with cheesy white
squamous debris, possible conductive
hearing loss and pressure in ear, drainage
and granulation tissue not responding to
antibiotic therapy - distorted cone of light
Congenital - pearly white mass behind
intact TM w/unilateral con. hearing loss
Acquired - retracted TM w/ingrowth of
epithelium
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Cleaning of debris
Top abx
Large or complicated cholesteatomas
require surgical excision
Severe toothache - localized pain, swelling,
fever, leukocytosis
Comp: facial cellulitis
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I&D
PO abx (PCN, azithromycin)
Dental referral - root canal
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Analgesics, abx, dental consult, chew gum
(forms saliva)
Dx: clinical, culture on
selective medium
(tellurite)
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Isolation
Antitoxin to neutralize toxin, erythromycin,
penicillin
Dx: PE - swollen cherry
red epiglottis,
radiography (thumb
sign), culture of
epiglottis and blood,
immunologic tests
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Ventilatory support
IV abx
Surgical then medical: 2nd or 3rd gen
cephalosporins x 7-10 d
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ABC
Direct pressure - pinch nostrils sit forward
Cautery - chemical, electric, thermal, silver
nitrate sticks (only if location identified)
Vasoconstrictor sprays (oxymetazoline,
phenylephrine - afrin)/anesthetic agents
Packing - merocel - compressed sponge
Remove any visualized clots
Anterior epistaxis balloons
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Comp: erosion of bone, further infx 
meningitis, brain abscess, CNVII paralysis
Dental Carie
Streptococcus mutans present in
plaque
Toothache, presents as aching pain when
dentin is exposed, sensitivity to hot or cold
Diphtheria
Corynebacterium diphtheriae - G
positive - produces potent
exotoxin that leads to formation
of pseudo membrane on
respiratory mucosa, tissue
destruction
Incubation 2 - 4 days, severe sore throat,
fever, adherent whitish blue pharyngeal
exudates that cover pharynx - reveal
underlying inflammation and edema when
scraped, cervical adenopathy
Bacterial - h. flu type B
Viral - HSV, parainfluenza, VZV,
EBV
Abrupt onset of high fever, toxic
appearance, respiratory distress, stridor,
drooling, inability to swallow, cyanosis
Epiglottitis
Dx: clinical, CT
DDX: SCC,
tympanosclerosis, middle
ear osteoma, chronic
otitis media
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Comp.: myocarditis, peripheral neuritis
More serious than croup
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Ddx: bacterial tracheitis,
croup, retropharyngeal
abscess, foreign body
aspiration, diphtheria,
mono, thermal or
chemical airway burn,
trauma to airway,
laryngomalacia, severe
pharyngitis
Epistaxis - Anterior
Infection, trauma, allergic
rhinitis, renal failure, nasal
defects, HTN, tumors, blood
thinners, ASA
Hx (comorbid conditions? Bruise easily?
Medications? How common?), unilateral
bleeding, no post nasal drip, blood is bright
red
Kiesselbach’s plexus most common
Complications of nasal packing: septal
hematomas/abscess, sinusitis, pressure,
necrosis
Dx: Hg/Hematocrit, CBC,
Bleeding time
Ddx: local irritation,
occupational exposure,
allergies, malignancy
(Wegener’s sarcoidosis),
hereditary hemorrhagic
telangiectasia (oslerweber-rendu syndrome excessive bleeding)
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Epistaxis - Posterior
Same as above, *HTN,
atherosclerotic disease (fragility
of vasculature)
Nausea, hematemesis, anemia,
hemoptysis, melena, no visualized anterior
source of bleeding, postnasal drip, blood is
dark red
Dx: Hg/hematocrit, CBC,
history of bleeding
disorder, INR, PTT for
clotting time
Sphenopalatine artery
Ddx: above, + bleeding
disorders, HTN
Complications (both ant and post):
sinusitis, airway obstruction, TSS from
packing, septal perforation (cauterization)
Epstein Barr/Mononucleosis
Activation of cytotoxic T
lymphocytes from EBV exposure
- transmitted through infected
saliva of asymptomatic individual
Prodrome of 1-2 weeks of malaise,
myalgia, headache and fatigue, posterior
cervical or generalized lymphadenopathy,
pharyngeal erythema with possible
exudate, petechiae @ junction of hard and
soft palate, splenomegaly, maculopapular
rash from amoxicillin
Comp: splenic rupture, hepatitis,
thrombocytopenia, guillain-barre
syndrome, chronic fatigue, erythema mult.
Foreign Body
Damage depends on amt of time
object has been in ear
Most often seen in children
Purulent discharge, pain, bleeding,
conductive hearing loss, feeling of bubbling
or crawling in ear
Nutritional deficiencies, drug
rxns, dehydration, psoriasis
Red, smooth, surface of tongue
HSV
HSV types I and II - transmission
through direct contact w/mucous
or saliva
First episode - gingivostomatitis,
pharyngitis, fever, malaise, myalgia,
anorexia, irritability, cervical
lymphadenopathy, pharynx: exudative
ulcerative lesions, grouped vesicles on
erythematous base to buccal mucosa and
hard/soft palate
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Attempt to locate the source
Vasoconstrictive/anesthetic agents
Posterior nasal packing (may cause staph
infx)
Immediate otolaryngologist referral
Prophylactic abx for staph
Hospitalization and monitoring
Indications for surgery: continued
bleeding with packing, required
transfusion, pt intolerance
Dx: elevated WBC in
second or third week monospot, assay for EBV
antibodies (elevated
IgM, IgG), blood smear atypical lymphocytosis,
possible elevated LFTs,
throat culture to r/o
strep throat
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Cholesteatoma, cerumen
impaction, otitis externa
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Irrigation (not if TM is ruptured)
Kill insect with lidocaine or mineral oil
Irrigate and suction liquid
For inanimate objects suction or use
alligator forceps
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Tx underlying illness
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Self-limited
Acyclovir, valacyclovir
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Complications: internal injury
Glossitis
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Dx: clinical, HIV RNA
viral load measurement,
P24 antigen blood test,
HIV ELISA/Western blot,
Tzanck smear
w/multinucleated giant
cells
Supportive - rest/fluids, analgesics such as
ibuprofen, Tylenol, antipyretics
Corticosteroids if tonsillitis
Avoid activity if splenomegaly
Full recovery can take up to 4 months
Ddx: erythema
multiforme, IBD, SCC
Halitosis
Impaired salivary flow
Foul breath odor arising from oral cavity or
nasal passage
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Find source, good oral hygiene
Hearing Loss - Autoimmune
Idiopathic
Rapidly progressive bilateral sensorineural
hearing loss and poor speech
discrimination - progresses over 3 - 4
months
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PO prednisone and/or low-dose
methotrexate
Hearing Loss - Idiopathic unilateral
sudden sensorineural
Viral infx and vascular insults
Unilateral sensorineural hearing loss, Loss
of 30 dB within a three-day period,
tinnitus, vertigo, aural fullness, hx of
recent URI
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Oral steroids within three weeks
Dx: audiometry,
radiographic imaging
Hearing Loss - Noise-induced
Hearing Loss - Toxin Mediated
Herpangina
Occupational, recreational,
accidental noise source
MC preventable cause of
sensorineural hearing loss
Bilateral hearing loss, high frequencies
affected first, accompanied by high pitched
tinnitus
Salicylates, NSAIDs, AMGs, abx,
loop diuretics,
chemotherapeutics
Coxsackie group A, echovirus,
enterovirus, coxsackie type B,
typically occurs in summer transmitted through fecal/oral,
respiratory or fomites
Bilateral hearing loss, usually manifests as
tinnitus - high-frequency hearing loss
Acute onset of fever, anorexia, malaise;
sore throat/dysphasia, erythematous
macules that evolve into vesicles that
ulcerate centrally - erythematous halo,
located on soft palate, anterior pillars of
tonsils, uvula, bilateral anterior cervical
lymphadenopathy
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Prevention: aggressive use of noise
protection
Foam-insert earplugs
Turn down the music
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Reversible with discontinuation of drug
therapy
Ddx: r/o strep throat
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Hydration, antipyretics, topical analgesics
Abrupt onset, sore throat, exudates to
pharynx possible, fever/chills, myalgias,
N/V/D, headache located to frontal areas,
can be retro orbital, non-productive cough,
rhinitis
Dx: viral culture, rapid
quick-vue
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Supportive - antipyretics
Pt education
Anti-virals: oseltamivir, zanamivir
Seasonal flu vaccine recommended
Lasts 7-10 days, vertigo with head or body
movements, unilateral hearing loss (high
frequency sounds), involuntary eye mov’ts,
loss of balance, ear fullness, tinnitus,
otorrhea, otalgia, CNS assessment normal
Dx: audiologic testing,
CT, MRI to rule out other
etiologies
Ddx: acoustic neuronal,
vertigo, cholesteatoma,
meniere’s disease
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Dx: usually clinical,
radiographic studies
(steeple sign), CBC may
show leukocytosis
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Hand, foot, mouth disease: tender
vesicular lesions on dorsum of hands and
palms which form bullae and ulcerate
comp: CNS lesions, cardiopulmonary failure
Influenza
Labyrinthitis
Influenza virus - transmission
through respiratory droplets
Viral infx of labyrinth - vestibular
neural input disrupted,
neurological exam normal
Can follow allergy,
cholesteatoma, ototoxic drugs
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Steroids to decrease inflammation
Supportive: sedatives, antivert, melamine,
scopolamine, tigan for nausea
Pt reassurance
Comp: spread of infx to brain, injury from
vertigo, permanent hearing loss
Laryngeal Carcinoma
Laryngotracheobronchitis (Croup)
Progressive hoarseness, pain when
swallowing second to ulceration, fetid
breath
Respiratory viruses,
*parainfluenza type 1, luminal
narrowing occurs secondary to
airway edema
Prodrome: coryza, nasal congestion, sore
throat and (barking) cough, progressing to
fevers, subglottic narrowing
Sx worsen at night
Complications: bacterial tracheitis - due to
staph aureus, haemophilus, influenzae,
strep pneumoniae, moraxella catarrhalis
Ddx: bacterial
tracheitis*,
retropharyngeal abscess,
diphtheria, vascular ring,
epiglottitis, peritonsillar
abscess, laryngomalacia,
aspiration, inhalation
injury
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Improve air exchange!
Cold mist? Humidifier
Nebulized epinephrine
Corticosteroids
Endotracheal intubation last resort
Leukoplakia on Vocal Cords
Hyperkeratotic changes to vocal
cords
Hoarseness with no pain - premalignant
Smoking/drinking
Ludwig’s Angina
Infx to lower molars,
streptococcus, staph
Fever, edema and erythema of upper neck
under chin and floor of mouth (seems
rigid), tongue displaced posteriorally,
dysphonia, dysphasia, trismus, drooling,
stridor
Dx: culture, CT
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Secure airway
ENT/dental consult
I&D
IV abx - PCN, augmentin
Admit to ICU
Complications: airway obstruction, sepsis
Mastoiditis
Middle ear inflammation spreads
to mastoid air cells
S. pneumoniae, h. influenzae, s.
pyogenes, etc
Otalgia, bulging erythematous TM,
Erythema, tenderness, edema over
mastoid area, post auricular fluctuance,
auricular protrusion, fever/ headache
Comp: recurrence, hearing loss,
destruction of mastoid bone, spread to
brain
Meniere’s Syndrome
Recurring attacks of disabling
vertigo, hearing loss, tinnitus
Imbalance in secretion and
absorption of endolymph fluid 
over-accumulation in cochlea
Episodic severe vertigo for2-24 hours with
N/V, horizontal or rotatory nystagmus,
sensorineural unilateral fluctuating hearing
loss (low frequency), tinnitus,
fullness/pressure in ears
Dx: CBC, blood cultures,
culture of fluid behind
TM, CT, tympanocentesis
Ddx: OM, cellulitis, scalp
infection w/inflammation
of post. auricular nodes
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Dx: audiologic testing,
CT
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Myringosclerosis
Infection, inflammation
Harmless, irregular white calcium patches
that develop on TM, rarely cause
conductive hearing loss
Nasal Polyps (+asthma, ASA
allergy)
Teardrop shaped growths around
sinus Ostia - develop in pts with
allergies or asthma - reflect
chronic inflammation
Increased nasal congestion, hyposmia to
anosmia, changes in taste, persistent
postnasal drainage, headaches and facial
pain/discomfort in periorbital and maxillary
regions, fleshy mass in nasal cavity, usually
in superior nasal vault or ethmoid region
Spirochetes and fusiform bacilli
Rapid onset of pain with ulceration,
swelling and sloughing off of dead tissue,
interdentally necrosis and bleeding, foul
breath, bad taste in mouth
Risk: tobacco, stress, poor
hygiene, poor nutrition
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Onset in 5th decade of life
Necrotizing Ulcerative Gingivitis
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Dx: clinical, coronal sinus
CT (delineate underlying
pathology, extent of
disease, bony
destruction)
Comp.: fever, cervical lymphadenopathy,
leukocytosis, destruction of bone and
surrounding tissue, gangrene
Acute needs admission and IV abx
(ceftriaxone)
Tx w/abx similar to AOM (clindamycin,
gentamycin)
Myringotomy
Tympanocentesis
May need surgical removal of bone
Supportive - valium, tigan, antivert,
scopolamine
HCTZ - diuretic (for buildup of endolymph)
Low sodium diet
Short course of steroids
Labyrinthectomy if hearing already lost
Endolymphatic sac decompression
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Oral corticosteroids
Intranasal steroid sprays
Intrapolyp steroid injections
Leukotriene inhibitors
Endoscopic sinus surgery if polyps cause
obstruction
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Debridement - refer to dentist
Half strength peroxide
*PCN 250 mg po x 10d/tetracycline
Prevent with good oral hygiene
Avoid smoking
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Neoplasm (Glomus Tumors)
Neuroendocrine tumors in middle
ear
Females 40 - 50 years
Pulsating reddish-blue mass behind intact
TM, pulsatile tinnitus and hearing loss
Dx: CT
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Surgical removal
Oral Candidiasis
Opportunistic infx in infants,
anemic pts, nutritional
deficiencies, corticosteroid use,
immunocompromised - yeast infx
Whitish plaques to mouth/tongue above
erythemic tissue, white patches leave a
raw, inflamed area if rubbed off
Comp: spread to esophagus, brain
Dx: KOH prep
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Antifungal mouth wash (nyastin)
Oral Leukoplakia
Oral Lichen Planus
Hyperkeratosis from chronic
irritation of tissue
Risks: trauma, alcohol, tobacco,
chronic cheek biting
Flat or raised white lesion that cannot be
removed by rubbing mucosal surface
Erythroplakia is reddish, velvety lesion on
oral mucosa or tongue
Erythroplakia, hairy leukoplakia
Comp: infx, oral cancer - esp verrucous
Chronic autoimmune disease
Located on side of tongue/cheek/gums,
painful oral mucosa/gums, white striations
(*wickham’s striae) with erythematous
border, lesions can erode to ulcers
Dx: biopsy, cytologic
exam
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Ddx: SCC, oral
candidiasis
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Dx: bx,
immunofluorescencehistological confirmation,
deposition of fibrinogen
along basement
membrane
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Systemic or topical corticosteroids
Cyclosporine mouthwash
Txment depends on pt!
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Cleanse canal of infected cerumen &
debris - use wick if extremely swollen
Top abx drops - FQ (ofloxacin,
cipro/dexamethasone)
Otic steroid drops containing polymyxinneomycin and top corticosteroid
(cortisporin) - do not use if TM is ruptured
Analgesics
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ENT referral
B-carotene and retinoid, vit E to regulate
epithelial growth
If biopsy + for oral squamous carcinoma,
surgery and chemotherapy
Ddx: pemphigus
vulgaris, chronic
candidiasis, SCC
Otitis Externa
Bacteria - pseudomonas, staph,
strep
Risk: swimming, perspiration,
humidity, foreign objects,
removal of cerumen, eczema,
psoriasis, seborrhea dermatitis
Otitis Externa - Chronic
Repeated local irritation >4
weeks
Fungal, allergic, inadequately
treated AOE, psoriasis, recent
tympanostomy
Otitis Externa - Malignant
Pseudomonas immunocompromised, elderly,
diabetics - inflammation and
damage of the bones and
cartilage of the base of the skull
1 - 2 day hx of progressive
otalgia/otorrhea, fever, pain with
tragal/auricle mov’t, canal edematous and
obscured with debris, discharge, blood,
inflammation, conductive hearing loss,
pruritis, full feeling, pressure, preauricular
adenitis
Basal cell carcinoma,
squamous cell carcinoma
Erythematous, scaling dermatitis,
persistent drainage from ear, pruritis,
conductive hearing loss, lichenification
possible
Dx: culture
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BC/SC carcinoma,
foreign bodies, otitis
media
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Severe otalgia (worse @ night), otorrhea
(foul, yellow, green), granulation tissue in
external auditory canal near junction of
bone and cartilage, trismus, fever,
facial/cranial nerve palsies  worse
prognosis (indicates bacterial spread)
Dx: culture, biopsy, CT
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R/O SCC, BCC
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Prolonged
Treat as otitis externa
Corticosteroids, cover fungi with
clotrimazole
IV abx against identified pathogen:
pseudomonas (piperacillin/cetazidime, FQ)
Topical drops (ciprofloxacin)
Surgical debridement may be necessary
If tx interrupted, rate of recurrence is
100%
Comp: sepsis, cranial nerve palsies,
meningitis, brain abscess, osteomyelitis of
temporal bone and skull
Otitis Media - Acute
Bacterial: s. pneumoniae, h.
influenzae, m. catarrhalis
Risks: URI, smoking at home,
allergies, cleft palate, adenoid
hypertrophy, bottle feeding,
barotraumas, enlarged adenoids
MCC of conductive hearing loss
in children
Otalgia, conductive hearing loss, vomiting,
diarrhea, fever, TM bulging and
erythematous with decreased light reflex,
decreased visible landmarks, cloudy
purulent material behind TM, decreased
TM mobility on pneumatic insufflation
Cone of light diffuse, flattened
Comp: Tm perforation/tympanosclerosis,
recurrent AOM or chronic OM, persistent
effusion, mastoiditis, bacteremia/meningitis
Dx: Tympanometry
(clinical)
Ddx: TM perforation,
tympanosclerosis,
recurrent AOM,
mastoiditis
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Analgesics/Antipyretics
Auralgan q2h for ear pain
*Abx (amoxicillin - <2 y.o. treat 10days,
>2 treat 5-7 days; 2nd and 3rd gen
cephalosporins esp cefdinir - tastes like
strawberries; amoxicillin-clavulanate)
Erythromycin if pt is PCN allergic
Decongestants to relieve ET blockage
Otitis Media - Chronic
Dysfunctional ET, TM perforation
that did not heal
Bacteria: p. aeuruginosa,
proteus, s. aureus, mixed
anaerobes
Ear pain, usually mild, fullness to ears,
purulent discharge, hearing loss, dullness,
redness or air bubbles behind TM,
problems with balance
Dx: clinical, audiometry,
tympanometry, CT, MRI
Ddx: AOM,
cholesteatoma
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Comp: bony destruction, sclerosis of
mastoid air cells, facial paralysis
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Otitis Media - Recurrent
Three episodes of AOM in 6
months or 4 episodes in 12
months
Otitis Media - Serous
Serous or mucoid secretions fill
middle ear and interfere with TM
mobility
Common in children
TM retracted, clear or dull with normal
bony landmarks, decreased mov’t on
pneumatic otoscopy
Fluid accumulation behind TM in
middle ear without
manifestations of infection
Common in children
Conductive hearing loss, fullness, pressure,
popping, TM neutral or retracted - gray or
pink, landmarks visible or dull, decreased
TM mobility, usually no fever or pain
Otitis Media - With Effusion
Comp: hearing loss, speech delays in kids
Otosclerosis
Abnormal bone deposition at
footplate - fixation of stapes at
oval window
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Prevent by Abx prophylaxis, pneumovax,
tympanostomy tubes, adenoidectomy
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Oral decongestants (Sudafed)
Antibiotics
Steroids (controversial)
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Dx: tympanometry,
audiometry
Ddx: AOM, malignant
tumors to nasal cavity,
cystic fibrosis
Progressive bilateral conductive hearing
loss in middle-aged white women, tinnitus,
low-frequency conductive hearing loss
Tx underlying cause
Aural irrigation (H2O2/H2O before Abx)
Broad spectrum abx: FQ (cipro) with
steroids (ciprodex) - reduce tissue buildup
If failure, add PO abx such as cipro,
pipericillin, ceftazidime (IV abx) for 3 - 4
weeks
Myringotomy if pressure on ear drum
Surgical tympanoplasty, mastoidectomy,
removal of granulation tissue
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Pt ed: avoid smoke, breast feeding,
allergens
Decongestants - associated symptoms
Abx: 2nd/3rd gen ceph, amoxicillin
Myringotomy then adenoidectomy for
persistent/>3 months
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Amplification with hearing aids
Surgical repair by stapedectomy
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MCC of con. hearing loss in
adults without effusion or hx
Parotitis
Viral or bacterial - paramyxoviral,
s.aureus most common
Swelling and erythema to preauricular and
post auricular areas, local pain and
tenderness, fever
Can lead to septicemia and osteomyelitis
Dx: aspiration of duct
and culture
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Augmentin, clindamycin
Perforated TM
Direct trauma, infection, pressure
buildup, bacteria in middle ear
Hearing loss/tinnitus, otorrhea (blood,
serous fluid, purulent fluid), otoscope exam
reveals puncture in TM, Weber - lateralizes
to side of perforation, vertigo
Ddx: AOM, COM
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Avoid AMG ear drops
Otic susp (ciprodex) or ciprofloxacin
If from AOM, systemic Abx (cipro, amox)
Tympanoplasty
Complications: 2ndary infx to inner ear,
permanent hearing loss
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Peritonsillar Abscess/ Cellulitis
Polymicrobial aerobic and
anaerobic bacteria - s. pyogenes,
h. influenzae, strep milleri, strep
viridans - can be complication of
mono, tonsillitis, peritonsillar
cellulitis
2 -3 day hx of sore throat and worsening
unilateral pharyngeal discomfort,
inflammation, pocket of pus in
supratonsillar space, trismus, fever,
odynophagia, h/a, malaise, referred ear
pain, drooling, *deviated uvula to opposite
side with peritonsillar swelling and
erythema to posterior pharynx, lymph node
enlargement, cervical muscle inflammation
Dx: CT, culture of
aspirate, CBC,
monospot, throat culture
to r/o strep, blood
cultures
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I&D of pus from peritonsillar fold followed
by tonsillectomy
Analgesics
IM/IV PCN, cephalosporins - cephalexin,
augmentin
Antipyretics, analgesics
Comp.: extension of infx to
retropharyngeal deep neck, posterior
mediastinal space, pneumonia
Pharyngitis - Acute
Viral: respiratory viruses,
influenza*, EBV, HSV, her angina
Bacterial: s. pyogenes, n.
gonorrhoae, cornynebacterium
diphtheriae, haemophilus
influenzae
Non-infectious: allergy,
inhalation of irritating fumes,
gastro esophageal reflux, trauma
Infection or irritation of pharynx and/or
tonsils - can coexist with conjunctivitis,
cough, rhinitis, systemic symptoms
Pharyngitis - Bacterial
S. pyogenes - GABHS streptomycin O and S toxins
have b-hemolytic properties transmission through direct
contact
Acute onset of severe sore throat and
dysphasia, NO coryza, NO cough, NO
hoarseness, fever >101 degrees, N/V,
abdominal pain, hyperemic pharyngeal
membrane with tonsillar hypertrophy and
exudates, beefy red swollen uvula, tender
anterior cervical adenopathy
Dx: *throat culture,
rapid antigen-detection
test
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Penicillin x 10 days (amoxicillin)
Non-infectious after 24 hours of abx
therapy
Can also use cefdinir, cefpodoxime x 5
days
Erythromycin or azithromycin
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Comp.: scarlet fever (caused by bacterial
toxin), rheumatic fever, glomerulonephritis,
peritonsillar abscess, otitis media,
mastoiditis, sinusitis, pneumonia, TSS
Pharyngitis - Gonococcal
Neisseria gonorrhoeae - gram
negative intracellular aerobic
diplococcus
Sore throat, dysphasia, fever,
lymphadenopathy, may coexist w/genital
infx
Dx: throat swab on
Thayer martin media
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Ceftriaxone or quinolones
Rhinovrius, adenovirus,
parainfluenza - transmitted
through direct, respiratory
contact
Sore throat (second to postnasal drip),
coryza, conjunctivitis (esp with
adenovirus), cough (with or without
sputum), fever, malaise, headache,
myalgia, chills, fatigue, loss of appetite etc
Dx: rapid strep
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Adequate hydration
Rest and analgesics
Cough suppressant (Dextromethorphan)
Acyclovir generally not effective unless
<72 hours after onset
Symmetric, progressive
deterioration of hearing in elderly
pts that results from age-related
changes, chronic effects of noise
exposure
MCC sensorineural hearing loss
Bilateral, affects highest frequencies early
on, gradually lower frequencies - loss of
clarity, worsened in noisy environments,
high-pitched tinnitus - irreversible
Dx: exclude everything
else
Risk: orogenital sex
Pharyngitis - Viral
Presybycusis
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Hearing aids
Cochlear implants
Experimentation with cochlea hair cell
regeneration
Prevention: aggressive noise protection,
ear plugs
Retropharyngeal Abscess
Aerobes and anaerobes GABHS,
s aureus
Risk: acute pharyngitis, otitis
media, tonsillitis, dental infx,
Ludwig’s angina, penetrating
trauma
Constitutional symptoms, sore throat,
dysphasia and trismus, neck pain/stridor,
drooling, neck stiffness, tracheal rock sign
(mov’t of larynx causes pain), cervical
adenopathy, bulge in posterior pharyngeal
wall
Dx: Lateral neck x-ray or
CT shows soft tissue
masses
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Clear the airway
Surgical drainage
IV abx to cover g+, -, anaerobes:
clindamycin, PCN, timentin
Dx: haziness with
inflammation on CT scan
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Sympathomimetics: oral decongestants
(phenylephrine), pseudoephedrine (afrin)
for congestion
Anticholinergics: ipratroprium bromine
nasal spray for rhinorrhea alone
Nasal corticosteroids
Antihistamines
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Comp.: extension of disease  pericarditis,
rupture of abscess leading to aspiration
pneumonia, airway obstruction,
mediastinitis
Rhinitis - Acute (Viral)
Rhinovirus, corona virus,
adenovirus, parainfluenza virus,
respiratory syncyntial virus
Rhinorrhea, sneezing, congestion,
postnasal drip, cough, low-grade fever
Rhinitis medicamentosa - rebound
vasodilation from prolonged use of nasal
sympathomimetics - extensive nasal
congestion and rhinorrhea - discontinue
Rhinitis - Allergic
Rhinitis - Atrophic (Ozena)
Type I hypersensitivity rxn to an
environmental trigger - dust,
molds, pollens, grasses, trees,
cockroaches, animals
Atrophy of nasal mucosa
including the glands, turbinates,
nerves supplying the nose
Pts with previous sinus surgery,
prolonged nasal bacterial infx
Itching, sneezing, rhinorrhea, stuffiness,
itchy, watery eyes, congestion, mouthbreathing, dennie-morgan lines (creasing
under eyelids from swelling), allergic
shiners (dark areas under eye), transverse
nasal crease, hypertrophic pale and boggy
bluish turbinates, profuse nasal secretions,
postnasal discharge
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Dx: clinical, nasal
cytologic studies, skin
testing,
radioallergosororbent
test (RAST)
Roomy nasal cavities filled with dry, foul
smelling crusts (black or dark green),
saddle-nose deformity, epistaxis, atrophic
changes in pharynx, nasal congestion,
anosmia
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Rhinitis - Chronic
Rhinitis - Nonallergic with
Eosinophilia Syndrome (NARES)
Diseases that lead to formation
of granulomas, destruction of
soft tissue, cartilage, bone, nasal
mucosa: syphilis, TB, sarcoidosis,
Wegener’s, rhinoscleroma,
rhinosporidiosis, leishmaniasis,
blast mycosis, histoplasmosis,
leprosy, substance abuse, nasal
deformities, hormonal
imbalances
Extension of rhinitis - nasal obstruction,
pus-filled discharge from nose, frequent
bleeding
Eosinophilic rhinitis - abnormal
prostaglandin metabolism precursor to aspirin triad of
intrinsic asthma, nasal polyposis,
ASA intolerance
Nasal congestion, sneezing, rhinorrhea,
nasal pruritis, hyposmia
Dx: culture or biopsy for
bacterial etiology
Avoidance, pharmacotherapy,
immunotherapy
Nasal corticosteroid sprays (flonase,
nasonex)
2nd gen antihistamines preferred txment
Immunotherapy (desensitization)
Nasal irrigation
Top abx (bacitracin) inside the nose, PO,
IV abx may help
Estrogen sprays (premarin)
Intranasal or oral vitamins A, D promote
mucosal secretions
Young’s surgery - closure of nasal passage

Tx underlying disorder
Nasal saline solution, exercise, pseudo
ephedrine for hormonal-induced rhinitis
Appropriate abx if bacterial
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Nasal steroids
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Rhinitis - Vasomotor
Sialadenitis
Response to irritants: dust,
pollen, perfumes, pollution
Gustatory rhinitis after eating,
esp hot and spicy foods
Nasal congestion, sneezing, profuse watery
rhinorrhea, swollen mucous membrane,
bright red - purple in color, profuse watery
discharge, congestion
Dx: endoscopy of nose,
CT of sinuses
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Avoid smoke and irritants
Humidified air, vaporizer
Nasal antihistamines (Azelastine)
S. aureus, autoimmune, viral
Risk: Sjogren’s syndrome
Acute swelling of parotid or submandibular
gland, swelling with meals, pain and
erythema at opening of duct, fever, pus
massaged from duct
Dx: ultrasound to see
whether solid tumor or
cyst
Ddx: ductal stricture,
stone, tumor
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IV abx - nafcillin
Increase salivary flow
Warm compresses
Lemon
Surgery
Swelling to duct, partial obstruction leads
to enlargement and pain on eating, total
obstruction leads to chronic enlargement
and infx, palpate gland for calculi, examine
all glands for masses, symmetry, purulence
Dx: x-ray, CT
Wharton duct: calculi
usually radiopaque,
stenson smaller
(sialography)
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More common Wharton’s duct (submand)
than stenson’s duct (parotid gland by
upper molar)
Inject dye into duct,
then x-ray for better
visualization
Nasal drainage and congestion, headache,
facial pain/pressure worsened with bending
the head forward, thick purulent or
discolored discharge, cough, sneezing,
fever, tooth pain, halitosis, decrease
transillumination of sinuses, Pott’s puffy
tumor (soft tissue swelling and pitting
edema over frontal bone from
subperiosteal abscess - severe)
Dx: clinical: symptoms
>7 days in adults, >1014 days in children with
purulent nasal discharge,
X-ray (water’s view), CT
scan, sinus aspirate,
C&S, for
immunocompromised
pts: biopsy specimens
for evidence of fungal
hyphae elements
Comp: cellulitis, Ludwig’s angina, parotitis
Sialolithiasis
Sinusitis - Acute
Inspirated secretions, ductal
debris, calcium phosphate due to
inflammation or stasis
Sinusitis of <4 weeks duration,
consequence of viral URI: allergic
rhinitis, barotraumas, chemical
irritants, nasal and sinus tumors,
glaucomatous diseases, CF
Viral rhinovirus - *rhinovirus,
parainfluenza, influenza virus,
RSV, adenovirus, enterovirus
*Bacterial: s. pneumoniae, h.
influenzae, m. catarrhalis
Nocosomial: S. aureus,
pseudomonas, serratia
Fungi: immunocompromised pts
- rhinocerebral mucormycosis
(deadly)
Sphenoid and ethmoid sinusitis: severe
frontal or retro-orbital pain radiating to
Occiput, thrombosis of cavernous sinus,
signs of orbital cellulitis - severe eye pain,
blindness
Fungal - orbital swelling and cellulitis,
proptosis, ptosis, decreased EOM, retroorbital/periorbital pain, nasopharyngeal
ulcerations, epistaxis, involvement of CN V
and VII, bony erosions
Nocosomial: asymptomatic, assume in
hospitalized pts of nasotrcheal intubation
who develop fever of unknown origin
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Hydration, warm compresses, massage to
gland area
Abx only if infection
Surgery to remove the stone
Most pts improve w/abx
Preferred initial tx: oral and topical
decongestants, nasal saline lavage, nasal
glucocorticoids
Consider abx in 1) adults who do not
improve after 7 days, 2) children after 1014 days, 3) pts with severe symptoms
Amoxicillin DOC - active against s.
pneumoniae and h. influenzae
If allergic, use macrolide - erythromycin,
z-pak
Surgical intervention and IV abx for severe
disease or those with intracranial
complications
Tx immunocompromised pts with fungal
sinusitis with extensive surgical
debridement, IV amphotericin B
Nocosomial sinusitis - tx initially with
broad spectrum abx to cover s. aureus
and gram negative bacilli, narrow
spectrum abx following results of C&S
Sinusitis - Chronic
Sinusitis > 12 weeks impairment of mucociliary
clearance from repeated infx
Constant nasal congestion and sinus
pressure, postnasal drip, hyposmia, sore
throat, halitosis, malaise, ear fullness,
absence of fever and facial pain
Pts w/allergic fungal sinusitis present
w/thick, esoinophilic mucus (peanut butter)
and pansinusitis
Dx: contrast-enhanced
sinus CT scan (hazy
borders) - nonspecific
mucosal changes on CT
for mild, opacification of
single sinus due to
mycetoma in severe
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TMJ Dysfunction
Consequence of bruxism 
masticatory muscle fatigue,
spasm
Chronic, dull, aching unilateral discomfort
to the jaw, behind eyes, ears or neck
Temporal Bone Fracture
Fracture line involves the bony
labyrinth (cochlea or vestibule),
associated w/facial nerve
paralysis, CSF leakage,
intracranial injuries
Tinnitus
Mild disease: endoscopic surgery is
curative without antifungal therapy
Severe disease: surgical w/an fungal
therapy
Topical decongestants, steriods, nasal
saline, steam inhalation
Trial of antibiotics: augmentin,
clindamycin, moxifloxacin, metronidazole
+ macrolide or 2nd/3rd gen ceph
Functional endoscopic sinus surgery
(FESS) is surgical procedure of choice for
refractory disease

Dietary advice
Avoid clenching
Relax muscles with moist heat
Unilateral sensorinueral hearing loss

Surgery
Damage to inner ear or cochlea,
middle ear infx, medication (ASA,
stimulants - nicotine, caffeine,
noise induced, hypertension,
presbycusis)
Perception of abnormal ear or head noises
- ringing, hissing, roaring, buzzing,
humming
Constant, intermittent, unilateral, or
bilateral
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
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Tx underlying disease
Switch any ototoxic drugs
Some drugs such as antihistamines and Ca
channel blocks - not proven effective
ENT referral
Antidepressants
Surgical intervention - last resort
Tympanosclerosis
Extensive fibrosis and stiffening
of the TM, ossicular chain and
middle ear mucosa
Significant conductive hearing loss - diffuse
calcification
Urticaria
Idiopathic/antigen - release of
mediators from mast cells with
increase in vascular permeability
Circumscribed wheals with erythematous
raised borders, blanch with pressure,
intense pruritis and stinging, lesions
increase with scratching
Symptom of vestibular disease motion perceived when no
motion or exaggerated motion
perceived in response to body
mov’t
Peripheral or central lesions, irritation to
labyrinth, CNS, brainstem or temporal lobe,
CNVIII dysfunction, labyrinthitis, Meniere’s
disease, N/V, central lesions nystagmus is
bi-directional or vertical
Vocal abuse
Smooth paired lesions
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Vertigo
Vocal Cord Lesions


Dx: Romberg test,
evaluation of gait, look
for nystagmus
Ddx: DM, hypothyroidism, drugs (EtOH,
barbituates, salicylates,
hyperventilation, cardiac
origin)
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Antihistamines
Systemic corticosteroids for severe
Meclizine
Promethazine
Scopolamine
Voice rest and vocal therapy
Surgery
Vocal Cord Paralysis
Paralysis second to laryngeal
nerve injury, brainstem injury,
trauma second to traumatic or
chronic intubation; systemic
disorders - hypothyroidism,
rheumatoid arthritis, GERD