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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 Usually lasts 3 days, full recovery in 2 weeks Dx: MRI of brain with gadolinium to evaluate for retrocochlear tumor Surgical removal Dx: detection of HIV1 replication w/o antibodies, plasma HIV-1 RNA elevated, low CD4 originally, CD8 elevated Antiretroviral therapy Dx: laryngoscopy if suspect mass, infx, vocal cord dysfunction Voice rest, smoking/alcohol cessation, hydration, surgery if chronic Dx: hx, nasal secretions with eosinophils, serum IgE, skin testinng, ELISA 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 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 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 Avoidance of food that provokes allergy Antihistamines 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 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 Airway - ventilation assistance Breathing - High conc O2, nebulized bronchodilators Circulation: epinephrine, IV fluids, vasopressors (dopamine) Antihistamines - inhibit vasodilation Severe - ICU admission Epi Pen Corticosteroids Complications: Death. Angioedema Antihistamines Systemic corticosteroids SC epinephrine for laryngeal edema Self limited Topical analgesics, top steroids Triamcinolone acetonide (orabase, kenalog), betamethasone mouth rinse Avoid spicy food, citrus 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 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 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 Cleaning of debris Top abx Large or complicated cholesteatomas require surgical excision Severe toothache - localized pain, swelling, fever, leukocytosis Comp: facial cellulitis I&D PO abx (PCN, azithromycin) Dental referral - root canal Analgesics, abx, dental consult, chew gum (forms saliva) Dx: clinical, culture on selective medium (tellurite) Isolation Antitoxin to neutralize toxin, erythromycin, penicillin Dx: PE - swollen cherry red epiglottis, radiography (thumb sign), culture of epiglottis and blood, immunologic tests Ventilatory support IV abx Surgical then medical: 2nd or 3rd gen cephalosporins x 7-10 d 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 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 Comp.: myocarditis, peripheral neuritis More serious than croup 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) 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 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 Cholesteatoma, cerumen impaction, otitis externa 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 Tx underlying illness Self-limited Acyclovir, valacyclovir Complications: internal injury Glossitis 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 Find source, good oral hygiene Hearing Loss - Autoimmune Idiopathic Rapidly progressive bilateral sensorineural hearing loss and poor speech discrimination - progresses over 3 - 4 months 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 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 Prevention: aggressive use of noise protection Foam-insert earplugs Turn down the music Reversible with discontinuation of drug therapy Ddx: r/o strep throat 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 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 Dx: usually clinical, radiographic studies (steeple sign), CBC may show leukocytosis 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 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 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 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 Dx: audiologic testing, CT 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 Onset in 5th decade of life Necrotizing Ulcerative Gingivitis 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 Oral corticosteroids Intranasal steroid sprays Intrapolyp steroid injections Leukotriene inhibitors Endoscopic sinus surgery if polyps cause obstruction Debridement - refer to dentist Half strength peroxide *PCN 250 mg po x 10d/tetracycline Prevent with good oral hygiene Avoid smoking 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 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 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 Ddx: SCC, oral candidiasis Dx: bx, immunofluorescencehistological confirmation, deposition of fibrinogen along basement membrane Systemic or topical corticosteroids Cyclosporine mouthwash Txment depends on pt! 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 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 BC/SC carcinoma, foreign bodies, otitis media 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 R/O SCC, BCC 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 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 Comp: bony destruction, sclerosis of mastoid air cells, facial paralysis 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 Prevent by Abx prophylaxis, pneumovax, tympanostomy tubes, adenoidectomy Oral decongestants (Sudafed) Antibiotics Steroids (controversial) 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 Pt ed: avoid smoke, breast feeding, allergens Decongestants - associated symptoms Abx: 2nd/3rd gen ceph, amoxicillin Myringotomy then adenoidectomy for persistent/>3 months Amplification with hearing aids Surgical repair by stapedectomy 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 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 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 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 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 Penicillin x 10 days (amoxicillin) Non-infectious after 24 hours of abx therapy Can also use cefdinir, cefpodoxime x 5 days Erythromycin or azithromycin 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 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 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 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 Clear the airway Surgical drainage IV abx to cover g+, -, anaerobes: clindamycin, PCN, timentin Dx: haziness with inflammation on CT scan Sympathomimetics: oral decongestants (phenylephrine), pseudoephedrine (afrin) for congestion Anticholinergics: ipratroprium bromine nasal spray for rhinorrhea alone Nasal corticosteroids Antihistamines 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 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 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 Nasal steroids 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 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 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) 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 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 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 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 Vertigo Vocal Cord Lesions Dx: Romberg test, evaluation of gait, look for nystagmus Ddx: DM, hypothyroidism, drugs (EtOH, barbituates, salicylates, hyperventilation, cardiac origin) 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