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OTOLARYNGOLOGY 2014 PANRE Recertification Review Joshua F. Smith, MMS, PA-C Duke Otolaryngology, Head & Neck Surgery Disclosure I am the chair of the Professional Development Review Panel for the NCAPA and am a paid speaker. I have no other financial disclosures or conflicts of interest. Goals Review ENT Anatomy and Physiology Discuss Common ENT Disorders Signs and Symptoms Physical Exam Diagnostics Treatment Answer 100% of ENT PANRE questions correctly OTOLOGY Cochlea The Mechanism of Hearing Sensorineural Hearing Loss Presbycusis Ototoxicity Noise induced SNHL Acute Labyrinthitis Idiopathic Sudden SNHL Meneire’s Disease Acoustic neuroma Presbycusis •Age related hearing loss •Bilateral, high frequency SNHL •Onset is subtle, gradual, stable •Difficulty with social situations •Better in quiet environments •Treat with hearing aids Noise Induced SNHL •Sudden or prolonged Noise exposure •Notched Audiogram 3000-6000Hz •Recovery high frequency •Unilateral or Bilateral •Loss is permanent •Advise Hearing protection Acoustic Neuroma •Slow growing, non-cancerous tumor arising from Schwann cells CN 8 (vestibulocochlear nerve) •Causes Asymmetric SNHL •Symptoms: hearing loss, tinnitus, imbalance, poor speech discrimination •Diagnosed with MRI of Internal Auditory Canals with contrast •Treatment includes: observation, stereotactic radiation, and/or surgery. Sudden SNHL Any SNHL that has occurred within 72 hours Possible causes Usually has no warning or prodrome Often patient complains of dizziness/vertigo, ear fullness and tinnitus Viral Labyrinthitis Autoimmune Vascular compromise An otologic emergency Refer to ENT without delay When in doubt, treat with steroids! Prednisone 60mg x 8 days, 40mg x 2 days, 20mg x 2 days Medications which can cause Ototoxicity • Aminoglycoside antibiotics • (Streptomycin, Dihydrostreptomycin, Kanamycin, Gentamicin, Neomycin, Amikacin, Tobramycin, Netilmicin) • Vancomycin • Erythromycin • Chemotherapy (Cisplatin, Nitrogen mustard) • Loop diuretics (Furosemide) • Salicylates • Quinine Sample PANRE question #1 Tina Tanner is a 62 year old female with gradual loss of hearing in her right ear for more than a year. Associated symptoms includes right sided tinnitus and imbalance. After performing a proper history and physical exam, you astutely decide to order an audiogram. The audiogram reveals an asymmetric sensorineural hearing loss on the right side. What is the next appropriate intervention? a. b. c. d. e. Order a contrasted MRI of the internal auditory canals Place the patient on a 12 day course of prednisone Order a non-contrasted CT of the temporal bone Start Meclizine 25mg TID for her imbalance Advise the patient to utilize a right sided hearing aid Conductive Hearing Loss EAC swelling/stenosis/obstruction TM perforation TM retraction/ETD Middle ear effusion/infection Otosclerosis Cholesteatoma EXTERNAL EAR External Auditory Canal Obstruction Attempt to remove if it appears you can get it on the first try. If completely obstructing EAC, if TM perf present, or if touching the TM, consult ENT Do not attempt to remove batteries, consult ENT and do not lavage. Auricular Hematoma Physical trauma to the auricle which causes shearing of the tissues and a perichondral hematoma. The auricle will be very swollen. Auricular Hematoma Failure to treat early can lead to permanent remodeling of the auricle, cauliflower ear. Treat with I&D, then bolster both sides with dental rolls. Otitis Externa (OE) Infection or Inflammation of the external auditory canal Differential Diagnosis: Acute Bacterial Acute Fungal Chronic OE Associated Symptoms Pain Hearing Loss Otorrhea Fullness Itching Physical Exam Tenderness of tragus/auricle Swollen EAC Purulent drainage Otitis Externa (OE) Bacterial Streptococcus Staphylococcus Pseudomonas MRSA Fungal (otomycosis) Aspergillus Candida Acute Bacterial OE •Remove purulent debris •Suction if possible •If the canal is too narrow, insert a wick •Topical Antibiotic Drops: •Neo/Poly/HC..use only if TM is intact •Fluoroquinolone •Ciprofloxacin •Ofloxacin •Culture otorrhea (aerobic and fungal) if topical antibiotics fail Acute Fungal OE •Fungal ear infections are usually very itchy •They can look like bacterial infections •Suspect fungal infections if antibiotic drops fail to resolve the problem Treatment of Fungal OE Remove Debris if possible Topical Acetic acid ear drops Antifungal drops (clotrimazole) Powders CASH powder: Chloramphenicol Amphotericin B Sulfamethoxazole Hydrocortisone Chronic OE •A chronic skin condition, usually eczema •Treat any acute infection first •Then, treat underlying cause of OE •Topical steroid cream for eczema •Water and vinegar lavage (acidify canal) •Avoidance of trauma (No more Q-tips!) Malignant Otitis Externa OE that causes temporal bone destruction Aka Temporal Bone Osteomyelitis Seen in diabetics and immunocompromised patients Usually caused by Pseudomonas aeruginosa Rads: MRI with contrast Gallium uptake CT Temporal Bone Emergency, refer to ENT if suspected Treatment IV antibiotics Mastoidectomy if not responsive MIDDLE EAR DISORDERS Normal Tympanic Membrane Eustachian Tube Dysfunction and tympanic membrane retraction Causes: •Nasal Allergy •URI •Nasopharynx mass •Anatomic Signs: •TM retraction Symptoms: •Hearing Loss •Ear Fullness •Popping/Crackling •Improvement with Valsalva Eustachian Tube Dysfunction Treatment If acute ETD, counsel patience and time Nasal steroid spray If ETD is chronic and hearing loss is present, bilateral myringotomy with tube placement ETD and TM retraction- Risk of cholesteatoma Cholesteatoma Non-cancerous skin cyst Can arise from retraction pocket or after the middle ear is seeded with skin cells following perforation Causes a conductive hearing loss Destroys bone through enzymatic action Requires surgical excision Cholesteatoma Otitis Media with Effusion (aka Serous Otitis Media) Caused by: •Chronic ETD •Acute OM •Barotrauma •Nasopharynx Mass Signs: • Bubbles •Amber coloration •Air-Fluid Line •Immobile TM to pneumatic Symptoms: •Conductive Hearing Loss •Ear Fullness Otitis Media with Effusion This is treated very similarly to TM retraction. Counseling is very important! Hearing loss may be present for 3-4 months Patience is key! Nasal steroids Myringotomy with tube placement if not better in 3-4 months. Rule out Nasopharyngeal Mass/Tumor Tympanostomy Tube Acute Otitis Media (AOM) Symptoms Ear Pain Hearing Loss Tinnitus Ear Fullness Sharp pain with otorrhea -> perf Treated with oral antibiotics Signs: •Bulging ear drum •White middle ear mucus/pus •Loss of landmarks •Obscured malleus Complications of AOM Mastoiditis Labyrinthitis Meningitis/Intracranial abscess TM perforation Hearing loss Tympanosclerosis Facial nerve paralysis Acute Mastoiditis Complication of OM and is defined as spread of infection to the mastoid air cells Physical exam findings include fever, otalgia, post auricular erythema, swelling, and tenderness with protrusion of the auricle. Treatment includes IV abx, ENT consult, admission for observation and often mastoidectomy Tympanic Membrane Perforation TM Perforation Symptoms Hearing loss Tinnitus Otorrhea Ear pain if acute Bleeding Treatment Watchful waiting Treat infections with topical drops (quinolones only) Tympanoplasty Paper patch Temporal muscle fascia graft Acute TM perforation Chronic TM perforation Traumatic TM Perforation Usually posterior Bloody Symptomatic hearing Loss Get audiogram Put on non-ototoxic ear drops (ofloxacin, ciprofloxacin) Keep ear dry and give TM time to heal and recheck hearing in 1-2 months Barotrauma Rapid pressure changes cause negative pressure in the middle ear resulting in effusion and ruptured blood vessels. Treat with nasal steroids and time, generally will resolve Audiogram will help determine if any significant hearing loss occurred. Bullous Myringitis Likely caused by Mycoplasma, H. Flu, or Strep pneumo Very painful, especially when coughing, sneezing Treat with antibiotics (macrolide like clarithromycin) and topical antibiotics if vesicles rupture Pain management with opiate is acceptable for the short term. Otosclerosis •Caused by fusion of the stapes footplate to the oval window •Usually has family history •Causes a conductive hearing loss •Can be treated surgically with a stapedectomy •Otherwise, can be treated with hearing aids Sample PANRE question #2 Alice Cooperton is a 35 year old with Type 1 diabetes mellitus. He has had multiple sets of pressure equalization tubes in the past. He presents for an evaluation of chronic ear drainage. He has been on multiple oral and topical antibiotics without improvement. His physical exam reveals an inflamed retraction pocket in the pars flaccida with granulation and keratinous debris. The most likely diagnosis is: a. b. c. d. e. Malignant otitis externa Chronic otitis media with a TM perforation Chronic fungal otitis externa Pars flaccida cholesteatoma Bullous Myringitis MISCELLANEOUS • Tuning Fork Tests • Tinnitus • Vertigo Tuning Fork Test Weber 512c without weights Tuning Fork Test Tuning Fork Test- Rinne Interpreting Tuning Fork Results Fork Placement Normal Hearing Conductive Loss Sensorineural Loss Test Purpose Weber To determine Conductive versus Sensorineural loss in unilateral loss Midline Midline sensation; tone heard equally in both ears Tone louder in poorer ear Tone louder in better ear Rinne To compare patient’s air and bone Conduction hearing Alternately between patient’s mastoid and entrance to ear canal Positive Rinne: Tone louder at Ear. (Air Conduct > Bone Conduct) Negative Rinne: Positive Rinne: Tone louder at Ear. (Air Conduction > Bone Conduct) Tone louder on Mastoid. (Bone Conduct > Air Conduct) Tinnitus Any abnormal sound in the ear Treatment Get a hearing test- Tinnitus may be a sign of hearing loss No studies have shown definitively that surgical or pharmacological interventions help resolve benign tinnitus due to SNHL If tinnitus caused due to HL which is correctable, then often resolving the HL will reverse the tinnitus (wax, fluid, TM perforation) Patient Education Anxiety relief Background Noise Stop medications which can cause Tinnitus Avoid caffeine/nicotine Tinnitus Retraining Therapy Differential Diagnosis Dizziness– caused by many, many conditions Cardiologic orthostatic HTN, arrhythmia, CAD, etc. Neurologic Acoustic neuroma, TIA, stroke, Parkinson's, neuropathy, Migraine Hematologic Anemia Psychological Anxiety, panic Metabolic/Endocrine Hypothyroidism Menopause Orthopedic Cervical disk disease Lower extremity arthritis Geriatric Proprioception Center of balance Pharmacologic Polypharmacy Side effects Differential Diagnosis Vertigo (a false impression of movement) Peripheral (otologic) Benign Paroxysmal Positional Vertigo (BPPV) Meniere’s Disease Acute Labyrinthitis / Vestibular Neuritis Central (Neurologic) MS, Migraine HA’s, benign intracranial hypertension BPPV (Benign Paroxysmal Positional Vertigo) • Intermittent vertigo which lasts less than a minute, usually seconds •Provoked by supine head movements to the right or left •Better when holding head still •Caused by displaced otoliths in the semicircular canals •Positive Dix-Hallpike maneuver •Treated with Epley maneuvers Meniere’s Disease •A disorder of increased endolymphatic fluid pressure •Classic Triad•Episodic SNHL, Vertigo x hours, and Roaring Tinnitus •Low-frequency SNHL, ascending, and usually unilateral. •Treatment: •Diuretics •Low sodium diet •Anti-vertigo medication •Surgery (to prevent vertigo) •Surgical options include: •Endolymphatic sac decompression •Gentamicin injection •Selective vestibular nerve resection •Labyrinthectomy Vestibular Neuritis/ Labyrinthitis Infection or inflammation of the inner ear. V. Neuritis- affects semicircular canals only- vertigo only Acute Labyrinthitis- vertigo and sudden hearing loss Vertigo is severe, lasts 24-48 hours, is disabling. Vertigo subsides and the patient will have several weeks of imbalance Treat with physical therapy Treat sudden SNHL with high dose prednisone Vertigo Recap BPPV- lasts seconds, head movements, no hearing loss Meniere’s- lasts several hours, associated hearing loss, tinnitus, ear fullness Neuritis/Labyrinthitis- lasts 1-2 days, gradual recovery Sample PANRE question #3 Axel Rosenthal, age 43 presents with a complaint of loss of hearing in his right ear. Tuning fork tests revealed that air conduction is greater than bone conduction bilaterally. The Weber test lateralized to the left. What is the probable diagnosis? a. b. c. d. e. Right sided conductive hearing loss Right sided sensorineural hearing loss Left sided conductive hearing loss Left sided sensorineural hearing loss The patient has normal hearing Sample PANRE question #4 Pat Benicar is a 75 year old female who presents with momentary room-spinning vertigo which occurs whenever she looks up or rolls over in bed. She denies hearing loss, tinnitus, and ear fullness. What is the appropriate treatment? a. b. c. d. e. Low salt diet, 1500-2000mg per day. Meclizine 25mg TID Prednisone, high dose x 12 days Epley Maneuvers Amoxicillin 500mg TID RHINOLOGY Epistaxis Anterior- Kiesselbach’s plexus Posterior- Woodruff’s plexus Local risk factors Digital manipulation Septal deviation Inflammation (allergies, infection) Cold dry air Foreign body Juvenile angiofibroma Septal perforation Drug use Nasal steroids Illicit drugs Systemic Causes of Epistaxis Systemic Causes of Epistaxis Clotting Disorder Hypertension Leukemia Liver disease Medication (aspirin, plavix, coumadin) Thrombocytopenia Wegner’s Granulomatosis Epistaxis Treatment Manual compression Afrin Cautery Anterior/Posterior Packing Surgical Arterial Ligation Embolization Cauterization RHINITIS Allergic Rhinitis IgE mediated reaction causing mast cells and basophils to release histamine, leukotriene, serotonin, and prostaglandins Common allergens: Grass/Tree pollen, mold, dust, dander This causes inflammation of the nasal mucosa. Nasal congestion Rhinorrhea Sneezing Itching Watery eyes Allergic Shiner Allergic Rhinitis Treatment Avoidance of allergens Nasal Saline lavage ------- > Nasal steroids (fluticasone, mometasone, budesonide) Antihistamines 2nd generation (fexofenadine, cetirizine, loratadine) Topical nasal: (azelastine) eye: (olopatadine, azelastine) Leukotriene inhibitor (monteleukast) Immunotherapy (allergy shots) Nasal Polyposis Seen with chronic rhinosinusitis, Samter’s Triad, and cystic fibrosis Treat allergies Nasal steroids Systemic steroids Surgical if obstructive, frequent infections, bony destruction Samter’s Triad Triad consisting of Aspirin allergy Nasal polyposis Asthma Often seen with allergic rhinitis and causes severe pansinusitis due to severe nasal polyposis. Vasomotor (Non-Allergic) Rhinitis Similar to allergic rhinitis, but caused by non- allergy mediated inflammation due to irritation of nasal mucosa Temperature Exercise Foreign body Fumes Food Medication Rhinitis Medicamentosa Drug induced rhinitis caused by overuse of topical decongestants (phenylephrine, oxymetazaline) Rebound congestion Treatment: STOP using the spray May substitute nasal steroids or antihistamine Afrin taper Prednisone taper Viral Rhinitis Upper respiratory tract infection caused by adenovirus, parainfluenza, corona virus, rhinovirus (and many more). Symptoms usually last <7 days Sore throat Nasal congestion Rhinorrhea (may be yellow/green) Fever Cough (may be productive) Malaise Fatigue Treatment: Supportive and Time. OTC antihistamines, decongestants, mucolytics, fluids, ibuprofen, acetaminophen, rest. SINUSITIS Acute Bacterial Rhinosinusitis ABRS Signs and Symptoms Persistent Symptoms (>10 days) Localized Facial Pain Upper Tooth Pain Purulent nasal discharge Nasal congestion Severe Sx (3-4 days): Fever >102 AND Purulent discharge OR Facial pain Double Sickening (3-4 days) New onset of headache, fever, nasal d/c following viral URI which was improving after 5-6 days Acute Sinusitis Primary Treatment Empiric Antibiotics Pathogens Strep. pneumo, H. flu, M. catarrhalis, Staph. aureus 1st Line (5-7 days adults, 10-14 days children) Amoxicillin-clavulanate (Augmentin) 2nd Line (10-14 days all) High dose amox/clav (2g BID or 90mg/kg/day BID) doxycycline (adults) levofloxacin (adults) moxifloxacin (adults) clindamycin/3rd gen cephalosporin (option for children) Not Recommended for empiric treatment: amoxicillin alone, azithromycin, clarithromycin, TMP/SMX, 1st, 2nd gen cephalosporins Subacute Sinusitis Sinusitis for 4-12 weeks Chronic Sinusitis Sinusitis for >12 weeks Pathogens • Same as acute (S. pneumo, H. flu, M. cat., S. aureus) • Klebsiella, Pseudomonas, Proteus, Enterobacter, MRSA • Consider anaerobic and fungal etiologies • Consider antibiotic resistance as cause • Culture and sensitivity • Consider structural abnormality: (non-contrasted CT Sinus) obtained after appropriate antibiotics Sinus CT Nasal Foreign Body •Seen often in pediatrics •Consider if patient has foul nasal odor, chronic nasal discharge, nasal obstruction, sinusitis •Chronic foreign bodies can cause pressure ulcers, infection, abscess •Once removed, treat with antibiotics if signs of infection are present Sample PANRE Question #5 Small E. Biggs is one of your frequent patients who is Notorious for asking for antibiotics whenever he is sick. He complains of an itchy runny nose, nasal congestion, cough and post-nasal drip. His symptoms have been present for 2 months. What is the most effective medication for this patient? a. b. c. d. e. Two pack of azithromycin 250mg Diphenhydramine 25mg Moxifloxacin 400mg a day Guaifenisen/dextromethorphan elixir Fluticasone nasal spray PHARYNGITIS Pharyngitis Differential Diagnosis Post-nasal drip Viral pharyngitis Group A strep Tonsillitis Mononucleosis Peritonsillar abscess Cancer HIV Rare: gonorrhea, HSV Viral Pharyngitis Pathogens adenovirus, coronavirus, rhinovirus, influenza, parainfluenza, coxsackievirus Self-limiting illness Symptoms Erythema Edema Dysphagia Pain Fever Lymphadenopathy Upper respiratory illness symptoms Resolves in 3-7 days Treat with OTC supportive meds Strep Pharyngitis •Signs and Symptoms •Sore throat •Dysphagia and Odynophagia •Erythema (w/ or w/o exudate) •Airway obstructive symptoms •Tender lymphadenopathy •Fever and malaise •Only a culture can distinguish between viral tonsillitis and GABHS •Rapid Strep Test •If negative, 24 hour culture •Treat initially with GP (strep/staph) coverage x 10 days •1st Line: PenVK, Bicillin injection, Amox/clav •2nd Line: 1st gen cephalosporin (not if PCN allergy), clindamycin, clarithromycin Acute Tonsillitis Can be viral or bacterial Common bacteria Group A Strep pyogenes Peritonsillar Abscess A collection of mucopurulent material in the peritonsillar space Often follows tonsillitis Signs/Symptoms “Hot potato” voice Severe throat pain and dysphagia Inability to open jaw (trismus) Asymmetric swelling of soft palate Uvula deviation Copious salivation Fever, severe malaise Peritonsillar Abscess Treatment Incision and Drainage Antibiotics with anaerobic coverage Amox/clav Clindamycin Mononucleosis Pathogens EBV- Epstein Barr Virus CMV- Cytomegalovirus Most mono patients were asymptomatic Signs/Symptoms Fatigue Malaise Severe sore throat with tonsillar edema/erythema/exudate Lymphadenopathy Hepatosplenomegaly Labs: Monospot (heterophile antibody test) CBC diff may show atypical lymphocytes Treatment: OTC, pain control, consider steroids, avoid contact sports, seatbelt counseling Parotitis/Sialadenitis Painful swelling of parotid/salivary gland Can often express pus from the parotid duct (Stensen duct) Bacterial- usually staph Rarely: extrapulmonary TB Viral- Mumps Treat with antibiotics, sialagogues and warm compresses Sialolithiasis Salivary duct calculus Most commonly located at the submandibular (Wharton’s) duct. Intense swelling of the salivary gland with salivation Symptoms subside between meals Treat with hydration, warm compresses, sialagogues. If not better, may need surgical removal. Sample PANRE QUESTION #6 Will I. Amherst is a 40 year old male who is seen on an urgent work-in for “sore throat” for the past 1 day. Upon exam he appears ill, is sitting uncomfortably with his neck extended. He speaks with a deep muffled voice. Upon exam, he is febrile, has trismus. His right soft palate is bulging, causing the uvula to shift past mid-line. The most likely diagnosis is: a. b. c. d. e. Acute mononucleosis Acute streptococcal pharyngitis Acute peritonsillar abscess Viral pharyngitis Squamous cell carcinoma of the right tonsil ORAL TUMORS AND LESIONS Oral Candidiasis Candida albicans Usually when host flora is altered Antibiotics Steroid inhalers Immunocompromise Signs: Erythematous mucosa with white satellite lesions Treat with antifungals Oral Nystatin solution 5cc swish and swallow QID Fluconazole 200mg day 1, 100mg po day 2-5 Squamous Papilloma Caused by Human Papilloma Virus Has the potential to become squamous cell carcinoma Excisional biopsy is recommended Often return despite biopsy Leukoplakia • • • • • Precancerous white plaque on a mucous membrane Can have different levels of dysplasia • Mild/Moderate/Severe Biopsy to confirm benign finding and stratify risk based on dysplasia Recommend routine monitoring Smoking cessation Aphthous Ulcers •Idiopathic ulcerations of mucous membranes •Benign and self limiting •Very painful, lasting 10-14 days Oral Herpes Simplex Caused by herpes simplex virus. Very contagious. Painful grouped vesicles, located outside the oral cavity. Will crust over after 3-4 days Symptoms usually last 2 weeks. Treat with antivirals within 72 hours of symptoms (oral or topical) Squamous Cell Carcinoma Lateral Surface of Tongue Posterior Pharyngeal Wall HOARSENESS Hoarseness Duration of symptoms Acute or chronic Associated: sore throat, dysphagia, cough, hemoptysis, reflux, heartburn, allergies Occupation (teacher, singer, phone operator) Smoking and alcohol Recent surgery Thoracic Surgery Hoarseness Differential Diagnosis Acute but benign Infectious Laryngitis (viral, bacterial, or fungal) Recent Intubation Acute and severe Vocal Fold Paralysis Vocal Cord Hemorrhage Chronic and benign Allergic Post-Nasal Drip LPR/GERD Inflammation caused by irritants (smoking) Vocal Abuse Vocal Nodules, cysts, papilloma, and Polyps Chronic and severe Cancer Acute Laryngitis Normal Larynx Acute Laryngitis Usually self-limiting Can be caused by viral infection, vocal misuse, or exposure to noxious agents Treat with voice rest and fluids Smoking cessation a must Steroids and antihistamines not indicated Squamous Cell Carcinoma of the Larynx Risks include Tobacco and ETOH Usually very hoarse Associated symptoms Throat pain Dysphagia/Odynophagia Weight Loss Ear pain Hemoptysis Treated with a combination of modalities: Surgery, chemo, XRT QUESTIONS?