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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