Download ENT

ENT
Ear, Nose, Throat
EAR
Otitis Externa
a.
b.
c.
d.
e.
f.
Repeated wetting (swimmer’s ear).
MCC: Pseudomonas, S. aureus.
Sx: ear pain on moving the ear canal, inflamed ear canal, clumpy discharge.
Tx: topical antibiotics.
Prevention: alcohol in the ear after swimming.
Malignant Otitis externa: necrotizing, even to bone, diabetics, immunocompromised.
 If early caught: ciprofloxacin.
 If too late: parenteral antibiotics.
 If CN VII is involved: IV antibiotics and poor prognosis.
Otitis Media
a. High risk: infants and children (up to 6 years), males, daycare setting, second hand
smoking, formula feeding.
b. Craniofacial anatomy, Eustachian tube dysfunction.
c. MCC: S. pneumoniae, nontypable Haemophilus influenzae and Moraxilla.
d. Other causes: viruses.
e. Sx: otalgia, fever, ear pulling, irritability, fever, vomiting, diarrhea, hearing loss (older
children), drainage from the ear.
f. DT: pneumatic otoscopy reveals redden and bulging TM, loss of landmarks, poor mobility.
g. Tx:
 First 72 hour: amoxicillin.
 If otalgia or ferver persists: high-dose augmentin or cephalosporins.
 Supportive treatment.
h. Complications: the most common is hearing loss, others: persistent middle ear effusion,
recurrent OM (Mx: myringotomy, ventilating tubes), effusion without symptoms (Mx: wait 3
months then antibiotics, ventilating tubes, decongestants), perforation, mastoiditis
(inflammation marks and moving forward and outward), cholesteatoma (a pocket of
sqamous epithelium, Mx: surgery), meningitis, labyrinthitis.
Hearing Loss
a. Types:
 Conductive: causes in the external and middle ear, e.g. OM, Eustachian tube
blocking, otosclerosis, TM perforation, impaction of the external ear.
 Sensory: affect the inner ear, e.g. cochlear damage caused by infection, toxic drugs
(furosemide) and sclerosis.
 Neural: e.g. cerebellar angle tumers.
b. Diagnostic Procedures:
i. The Rinne test: placing a vibrating 256 Hz over the mastoid then next to ear.
ii. The Weber test: placing a vibrating 256 or 512 Hz on the middle the forehead.
TYPE OF HEARING LOSS
Normal
Sensorineural loss (in the left)
Conductive loss (in the left)
RINNE
A: next to ear
B: over the mastoid
Sound A > B
Sound A > B
Sound A < B
WEBER
Sound doesn’t lateralize
Lateralize to the right ear
Lateralize to the left ear
c. Conditions:
a. Presbycusis:
i. Aging ear.
ii. The MCC of the hearing loss in the elderly.
iii. Hearing loss on more than 2000 Hz.
b. Meniere dz:
i. Attacks last hours of: vertigo, vomiting, prostration.
ii. Sx: tinnitus, fullness in the ear, progressive one-sided hearing loss until deaf at
which symptoms stop.
c. Acoustic neuromas:
i. Benign, very slow-growing vestibular schwannomas (eighth CN).
ii. Sx: Tinnitus, unilateral hearing loss, gait disturbance.
iii. DT of choice: MRI.
iv. Tx: surgery.
d. otosclerois:
i. Autosomal dominant with poor penetrance more common in Caucasians.
NOSE
The Common Cold (Upper Respiratory Infection)
a.
b.
c.
d.
Viral infection.
More common in children.
Incubation: 2-5 days.
Sx: fever, malaise, nasal congestion, rhinorrhea, sneezing and pharyngitis.
Resolved by 5-7 days.
e. Tx: not needed.
f. Complications: OM, sinusitis, pneumonia.
Sinusitis
a. Acute = up to 4 weeks, chronic = more than 4 weeks, recurrent = 3 or more episodes per
year.
b. Mostly bacterial.
c. The most two common cause in both acute and chronic: blocked secretions, impaired ciliry
movement.
d. The most common causative organisms in both: S. pneumoniae, nontypable Haemophilus
influenzae and Moraxilla. Addition organisms can cause chronic: S. aureus, group A Step,
P. aeruginosa (esp. CF), and anaerobes.
e. Sx:
a. Acute: pain by leaning forward, purulent nasal discharges, tenderness over the
affected sinus, fever and malaise. Usually: no sneezing or rhinorrhea (DDx: rhinitis).
b. Chronic: refractory sinus congestion, bad breath, postnasal drip, cough, headache.
c. Any cold symptoms in children persists more than 10 days the SUSPECT sinusuits.
f. Fungal:
a. Diabetics, cancers, immunosuppressed pts.
b. MCC: Mucor.
c. Sx: maybe only sinusitis OR offensive dz with necrotizing resulting distinctive black
eschar on the palate &/or nasal mucosa.
g. Diagnostic procedures:
a. The golden is: CT Scan (subtle thickening, differentiate infections from tumors).
b. Nasal smears: to differentiate allergic from bacterial, we can’t do that by the number
of eosinophils, but by the number of neutrophils and bacteria (high in bacterial).
c. Sinus culture: invasive, DO NOT use it except in refractory cases.
d. A sweat chloride: with Pseudomonas in the culture.
e. X-ray: minor role, opacification.
h. Tx:
a. Wait 7-10 days before treatment.
b. Acute: 14 days of amoxicillin or augmentin if there is resistance, others: quinolones,
azithromycin, 2nd generation cephalosporines.
c. Chronic: same drugs, but at least 3-4 weeks, and a week after symptoms resolved.
d. If medical therapy fails THEN endoscopic surgery.
e. Fungal: EMERGENT, surgery PLUS amphoterecin B.
i. Complications: orbital cellulitis, abcess, or meningitis.
Epistaxis
a. Most common in children.
b. MCC: picking the nose.
c. Other causes: trauma, recurrent URI, foreign body (+ purulent discharge). Juvenile
nasopharyngeal angiofibroma must be roled out in boys with profuse bleeding and onesided mass.
d. Tx: mostly resolved spontaneously. If not, compress the nares. Topical vasoconstrictor can
help. Packing and cautery in very severe bleeding.
Chanal Atresis
a. A septum between the nose and pharynx.
b. Associated with CHARGE syndrome (Coloboma, Heart dz, Atresia choanae, Retarded
growth, Genetal abnormalities, Ear abnormalities).
c. Sx: cyanosis relieved by crying.
d. DT: inability to pass a catheter through the nostril. Fiberoptic rhinoendoscopy.
e. Tx: Establishment of the airway then surgery.
THROAT
Pharyngitis
a. It’s the inflammation of the throat, usually acute.
b.
c.
d.
e.
MCC: Viral.
The most common causative bacteria: group A -hemolytic Strep. (GABHS).
Rare under 1 year of age.
Sx:
a. erythema, exudate, petechiae, enlarged tonsils and cervical adenopathy.
b. For viral: gradual onset and moderate URI symptoms. Conjunctivitis may be seen.
c. For GABHS is common in 5-15 years old children, may present with headach,
vomiting and abdominal pain, URI symptoms usually abscent. Diffuse erythema
highly suggest it.
d. Vesicles and ulcers suggest HSV and coxackievirus.
f. DT: the golden standard is throat culture, Rapid Strep antigen detection is useful.
g. Tx:
a. Viral: symptomatic.
b. Streptococcal: penicillin or amoxicillin.
h. complications: Rhuematic fever, Glomerulonephritis, abcess.
Cervical Lymphadentits
a. Usually infectious esp. in children.
b. DDx: thyroglossal duct cysts, brachial cleft cysts, mumps.
c. Indications for:
i. Tonsillectomy:
1. Persistent oral obstruction
2. Suspected tonsillar tumors
3. Recurrent peritonsillar abcesses or cervical adenitis.
ii. Adenoidectomy:
1. Persistent nasal obstruction.
2. Repeated/chronic OM.
3. Hyponasal speech.
4. Snoring and snorting.
iii. Tonsillectomy/ adenoidectomy:
1. Sleep apnea
2. Cor pulmonale
3. Recurrent aspiration pneumonia.
From:
1. Medstudy 07-08
2. Kaplan Pediatrics 05-06
KMG
Friday, March 14, 2008