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John Leffert, MPAS, PA-C
OTOLARYNGOLOGY REVIEW 2012
OTOLOGY
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Hearing Loss
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Three types of hearing
loss: conductive,
sensorineural, and mixed
HEARING LOSS CAUSES
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Sensorineural (SNHL):
Presbycusis: hearing loss associated with
aging
Trauma: head or ear trauma
Unilateral sensorineural hearing loss has
also been noted after open-heart surgery
Noise: frequently associated with tinnitus
Infectious: Viral or Bacterial
Meniere's disease
Idiopathic sudden SNHL with no apparent
cause: suspected causes - viral,
autoimmune, or vascular (i.e. nerve
infarction)
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Conductive (CHL):
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Infectious:
Traumatic/tympanic membrane rupture:
Cerumen impaction
Foreign body in external canal
Canal atresia
Exostoses
Otosclerosis
Ossicular discontinuity
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Mass lesions of the middle ear
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Mixed hearing loss (MHL):
Cholesteatoma/chronic infection
Trauma: skull or temporal bone fractur
ACUTE AND CHRONIC OTITIS MEDIA-CAUSES
Most cases of acute otitis
media are viral in origin:
 Rhinovirus
 Influenza virus
 Adenovirus
 Enteroviruses
 Parainfluenza viruses
 Respiratory syncytial
virus
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Common bacterial causes of acute
otitis media include:
Streptococcus pneumoniae - the most
prevalent (30-50%)
Haemophilus influenzae - a significant
cause of otitis media in older children,
adolescents, and adults (20-30%)
Moraxella catarrhalis (2-15%)
Group B Streptococcus (20% in
neonates and young infants)
Staphylococcus aureus
ACUTE AND CHRONIC OTITIS MEDIA-CAUSES
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Common causes of chronic otitis media:
Pseudomonas aeruginosa
 Staphyloccus aureus
 Escherichia coli
 Proteus spp.
 Anaerobes (Peptostreptococcus, Fusobacterium spp.,
and Bacteroides spp.)
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Immunization against H. influenzae, S.
pneumoniae, and influenza can reduce the
incidence of otitis media and other infections
caused by these organisms.
CLINICAL PRESENTATION
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Specific symptoms include:
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Otalgia (cardinal sign)
Hearing loss
A sense of fullness in the ear
Vertigo
Tinnitus
Purulent otorrhea
Fever
Tugging on the ears
Nonspecific symptoms include:
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Lethargy
Anorexia
Nausea and vomiting
Diarrhea
Headache
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In infants and neonates, symptoms are
generally nonspecific and include:
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Fever
Irritability
Generalized malaise
Diarrhea
Vomiting
Signs
Redness of the tympanic
membrane
Immobile tympanic membrane on
pneumotoscopy
Leukocytosis (may be subtle or
absent) - white blood cell
measurement is rarely needed in
workup
TREATMENT
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Acute otitis media:
Viral etiology and recover spontaneously
within a week. Observation is generally all
that is
Antibiotic treatment is generally
recommended in patients <2 years of age.
Patients >2 years of age with ambiguous
or mild symptoms should be observed for
48-72h, after which a further assesment
should be made. If worsening of symptoms
or no improvement occurs, antibiotic
treatment may be indicated
First-choice antibiotic is amoxicillin.
Penicillin-allergic patients can be treated
with a macrolide. Cephalosporins may also
be used;
Patients <2 treat for 10 days,
patients >2 years of age treat for 5-7 days.
Acetaminophen or ibuprofen may be used
for relief of pain; however, decongestants
and antihistamines are not recommended
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Chronic otitis media:
Patients not at risk of speech, language, or
learning problems associated with hearing
loss of <20dB should undergo a period of
watchful waiting for 3 months.
Treat with amoxicillin for short-courses of
10-14 days may be indicated where infective
complications are identified
Antihistamines, decongestants, and
corticosteroids may be prescribed for
symptomatic treatment; however, these are
not standard treatments
Surgical management of persistent middle
ear effusions includes myringotomy,
adenoidectomy, and the placement of
tympanostomy tubes for children with otitis
media with effusion causing hearing
impairment
Up to 80% of children with recurrent otitis
media have proven food and/or inhalant
allergies. and chronic otitis media
OTITIS EXTERNA-COMMON CAUSES
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Gram-positive organisms:
Staphylococcus aureus
Streptococci groups D and G
Gram-negative organisms:
Pseudomonas aeruginosa
Escherichia coli
Proteus mirabilis
Klebsiella pneumoniae
Anaerobic bacteria:
Bacteroides spp.
Clostridium spp.
Anaerobic streptococci
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Fungi:
Aspergillus niger (these occur
in 10% of otitis externa cases
in the US)
Candida albicans
Secondary to primary skin
conditions (eczematous otitis
externa):
Eczema
Psoriasis
Seborrheic dermatitis
Allergies
SYMPTOMS
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Pruritus
Pain
Foul-smelling discharge
Reduced hearing
Vertigo
Difficulty with mastication
Hearing loss
SIGNS
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Tenderness of the ear made worse
by pulling on the pinna and putting
pressure over the tragus
Eczema of the skin of the pinna
Ear canal erythema and swelling
Exudative and debris - mixed
discharge from the ear
Decreased conductive hearing
Lymphadenopathy - postauricular,
preauricular, and lateral cervical
lymph nodes
Trismus may occur from extension
into the temporomandibular joint
and the parotid gland
Erythema may extend to the skin
over the mastoid, pinna, and infraauricular skin
CLINICAL PRESENTATION
TREATMENT
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Acetic acid and a topical antibiotic-corticosteroid preparation such as ciprofloxacinhydrocortisone or neomycin-polymyxin B-hydrocortisone. These agents cover
Pseudomonas and Staphylococcus aureus adequately. Combination formulations
are considered more effective than either antibiotics or corticosteroids alone
If otitis externa with perforation is present, topical ofloxacin is a better option owing
to its lower acidity and lower risk of ototoxicity
Cleansing and debridement of the external ear can be done with irrigation, by
suction, or with a cotton swab under direct visualization. This helps to improve the
effect of the topical medications
If the ear canal is quite red and edematous, a wick can be inserted into the external
ear canal for about 24h and the ear drops inserted through this wick
SINUSITIS- CAUSES
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Most cases of acute sinusitis follow a viral upper respiratory
infection.
The following bacteria can be found in patients with acute sinusitis:
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Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Additional pathogens can be isolated from the sinuses of patients
with chronic sinusitis, including:
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Pseudomonas aeruginosa
Group A Streptococcus
Staphylococcus aureus
Anaerobes (Bacteroides spp., Fusobacterium spp.,
Propionibacteriumacnes)
SYMPTOMS
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Nasal congestion
Purulent nasal secretion
Facial 'pressure' pain
Headache
Maxillary toothache
Persistent cough
Postnasal drip
Poor response to
decongestants
SIGNS
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Tenderness over the involved
sinus cavities is sometimes
present
Periorbital edema in the case of
cellulitis
Dark circles beneath the eyes
(may reflect allergic diathesis
more than infection)
Absence of transillumination
(neither very sensitive nor
specific)
Mucosal edema
Increased posterior pharyngeal
secretions
Purulent secretions from
middle meatal region
CLINICAL PRESENTATION
TREATMENT
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First-line therapy is amoxicillin; it is generally effective,
inexpensive, and well tolerated
Trimethoprim/sulfamethoxazole is a good alternative to
amoxicillin, especially in patients who are allergic to
penicillins, although Streptococcus pneumoniae may be
resistant to it
For patients allergic to both amoxicillin and trimethoprim,
alternatives include cephalosporins such as cefuroxime (but
note the 10% allergic cross-reactivity between penicillins and
cephalosporins) or macrolide antibiotics such as
erythromycin or clarithromycin
Other options include: amoxicillin-clavulanate, a quinolone
such as levofloxacin, or a cephalosporin such as cefuroxime
PHARYNGITIS
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Viral causes are the most common (90% in adults, 6075% in children)
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Bacteria:
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rhinovirus, adenovirus, parainfluenza virus, coxsackievirus,
herpes simplex virus, Epstein-Barr virus, cytomegalovirus,
respiratory syncytial virus
group A beta-hemolytic streptococci, especially
Streptococcus pyogenes, Neisseria gonorrhoeae,
Corynebacterium diphtheriae, Haemophilus influenzae,
Moraxella catarrhalis, nontypable Haemophilus
Fungi :
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Candida - may be found in immunocompromised individuals
SYMPTOMS
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Sore throat
Odynophagia
Chills
Malaise
Headache
Anorexia
Abdominal pain
SIGNS
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Pharyngeal erythema
Pharyngeal exudate
Enlarged edematous tonsils
Fever
Anterior cervical adenopathy
Rash - may or may not be
present
CLINICAL PRESENTATION
VIRAL
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Acetaminophen
Ibuprofen
Saltwater gargling
Soft, cool foods
BACTERIAL
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TREATMENT
Penicillin V: drug of first choice for group A
beta-hemolytic streptococcal pharyngitis
Penicillin G: alternative to penicillin V, given
intramuscularly for noncompliant patients with
streptococcal infections
Amoxicillin: may be preferred in children with
streptococcal infections because of increased
palatability compared with penicillin V
Erythromycin: alternative to penicillin V in
penicillin-allergic patients with streptococcal
infections
Clarithromycin: alternative to penicillin for
erythromycin-resistant streptococcal strains
Azithromycin: alternative to penicillin for
erythromycin-resistant streptococcal strains
Clindamycin: for refractory cases with concern
regarding anaerobic cover
TONSILLITIS
Influenza A and B viruses
 Respiratory syncytial virus (RSV)
 Adenovirus
 Streptococcus groups A and G, group A betahemolytic streptococci
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SYMPTOMS
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Sore throat
Possible breathing difficulty
Drooling
Difficult and painful swallowing
of saliva, liquids, and food
Fever
Headache
Otalgia
Malaise
Vomiting
Signs
SIGNS
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Swollen hyperemic red tonsils,
often coated with a yellow or
thin white nonconfluent
membrane that peels away
without bleeding
Throat may be edematous, be
blistered, or have painful ulcers
White particulate matter in
tonsillar crypts is found in
chronic tonsillitis
Cervical lymph nodes may be
swollen, enlarged, or tender
Fever
Dry mucous membranes
CLINICAL PRESENTATION
TREATMENT
Gargle with warm salt water
 Drink warm fluids
 For streptococcal tonsillitis, prescribe penicillin
V or penicillin derivative, cephalosporins (e.g.
cephalexin, cefixime, or cefuroxime),
erythromycin, or clindamycin
 For children under 16 years of age, prescribe a
non-aspirin over-the-counter analgesic such as
acetaminophen for pain and fever
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EPIGLOTTIS-CAUSES
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Haemophilus influenzae type b (Hib) - most common cause
in children and adults; incidence has decreased dramatically
in countries that immunize against Hib
Streptococci (groups A, B, and C), including Streptococcus
pneumoniae and S. pyogenes; group A streptococcus is the
second most common cause in adults
Klebsiella pneumoniae
Candida albicans
Staphylococcus aureus
Haemophilus parainfluenzae
Neisseria meningitidis
Varicella-zoster virus
SYMPTOMS
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Sore throat
Dysphagia
Drooling
Fever - frequently high in
children; adults may be
afebrile
Difficult and labored
breathing
Cough
Sudden onset
SIGNS
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Cervical adenopathy
Toxic appearance of patient,
bacteremia
Stridor
Muffled voice (54%)
'Tripod position' (sitting up on hands
with tongue out and head forward)
Hypoxia
Respiratory distress
Mild cough
Severe pain on gentle palpation of
larynx or hyoid bone (seen in 80% of
adults)
CLINICAL PRESENTATION
CLINICAL PEARLS
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MEDICAL EMERGENCY
Airway obstruction
Never lay the patient
FLAT!
Never induce the gag
reflex
Hospitalize
IMMEDIATE ACTIONS
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Secure patient's airway before
initiation of empiric antibiotic
therapy
Once airway is secure, initiate
empiric antibiotic therapy that
covers group A streptococci, S.
pneumoniae, S. pyogenes, and
H. influenzae before obtaining
culture results
Admit to the intensive care unit
to assure careful monitoring of
the airway
PERITONSILLAR ABSCESS
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Common causes
Group A hemolytic
streptococci
 Polymicrobial
infections are
common, including
anaerobes (such as
Bacteroides) and
aerobes (including
Gram-positive cocci
and Gram-negative
rods)
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SYMPTOMS
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Symptoms are typically more
severe than during the usual
case of tonsillitis:
Unilateral, severe throat pain
Dysphagia
Odynophagia
Trismus (difficulty opening the
mouth wide)
Neck pain
Referred ear pain
Drooling
Muffled ('hot potato') voice
Fever
SIGNS
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Fever
Severe dehydration
Possibly extreme distress may
occur if the airway is compromised
due to pharyngeal or laryngeal
edema (rare)
Tonsillar hypertrophy
Palatal edema
Contralateral deflection of the
swollen uvula
Fluctuant peritonsillar fullness
Tender cervical adenopathy
Inflamed oropharyngeal mucosa
Drooling
Rancid breath
CLINICAL PRESENTATION
TREATMENT
Early recognition and diagnosis
 Appropriate referral to ENT specialist
 Incision and drainage and/or needle aspiration
 Antibiotic therapy-erythromycin or amoxicillinclavulanic acid to cover streptococci and
metronidazole or clindamycin for oral anaerobes
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