Otorhinolaryngology Disorders of the Ear, nose and throat

1. Amanda Thomas, MS, PA-C May 23rd, 2012 OtorhinolaryngologyDisorders of the Ear, nose and throat

2. Cerumen Impaction/Foreign Body Otitis Externa (bacterial and viral) Otitis Media Mastoiditis Tympanic Membrane Perforation Barotraumas Conductive Hearing Loss Sensorineural Hearing Loss Tinnitus Vertigo Labyrithitis Meniere’s Disease Disorders of the Ear

3. Anatomy of the Ear

4. Acidic component prevents infestation and decrease bacterial growth, promotes complete evacuation of water. • Most self induced by Q tip. • Presents often with unilateral hearing loss. • Treatment: • Small amount-spoon • Mild amount: irrigation • Total impaction: Suction, Debrox; irrigate only if TM is intact. • May need ENT referral . Cerumen Impaction

5. Patients may be in significant discomfort and complain of nausea or vomiting if a live insect is in the ear canal. Patients may present with hearing loss or sense of fullness. * Children older than 9 months often present with foreign bodies in the ear; at this age the pincer grasp is fully developed, which enables children to maneuver tiny objects. In adults, insects (eg, cockroaches, moths, flies, household ants) are the foreign bodies most commonly found in the ear. Treatment includes removal of the object and Antibiotic ear drops if evidence of trauma is present. Contraindications of removal include: perforation of the tympanic membrane or presence of hearing aid batteries other caustic materials- emergent ENT consultation is always warranted because time-sensitive liquefaction necrosis may lead to subsequent tympanic membrane perforation and further complications. In fact, irrigation should never be attempted in such cases, as it accelerates the necrotic process. Foreign body in the ear

6. Ear Foreign body

7. Otitis Externa-The External Ear Canal:

8. Viral OE Often caused by Varicella Zoster Virus (VZV/shingles). Presents as vesicles in the external auditory canal and around the ear with severe pain. Ramsey-Hunt Syndrome: OE plus CN7 palsy. Treat with Zovirax, Valtrex, Famvir +/- steroids if CN7 involvement. Otitis Externa-The External Ear Canal:

9. Innervations of Facial NerveCranial Nerve VII:

10. Bacterial OE (“Swimmer’s Ear”) • Infection of the external ear canal. • P. aeruginosa, proteus (see green), S.aureus/MRSA • Characterized by otalgia, erythema, purulent discharge within the external auditory canal. • Tragal/Auricale motion tenderness (patient screams). • Prevent by limiting water contact or use acetic acid drops after exposure. • Swimming pools are more likely to be causative because chlorine breaks down cerumen and normal ear flora. • Treatment • For Pseudomonal infections: Cipro, Tobramycin otic drops • For Staphylococcus infections: sulfacetamide ophthalmic soln • Use 3-5 drops 2x a day • Limit exposure-no swimming for at least 1 week. • If the auditory meatus is swollen shut- an ear wick can be used. Otitis Externa-The External Ear Canal:

12. Caused by dysfunction/obstruction of Eustachian tube. Negative pressure within middle ear. Collection of fluid in middle ear. Proliferation of bacteria. 40%-50% Strep pneumoniae, 20-25% H. Influenza, 10-15% M. Catarrhalis. Viruses: 1/3 of AOM. Acute Otitis Media (AOM)-The Middle Ear

13. Recent, abrupt onset of signs and symptoms. • Presence of Middle Ear Effusion. • Signs and Symptoms: • Bulging TM, decrease mobility, pus, air fluid level, possible fever. • Distinct erythema of TM, or distinct otalgia (disrupts sleep). Acute Otitis Media

14. Otoscopy reveals erythematous, opaque bulging TM, loss of landmarks, and light reflex. Pneumatic otoscopy shows decreased compliance of TM. Acute Otitis Media, Physical Exam

15. Acute Otitis Media, Physical Exam

16. URI Young Age Previous AOM Smoking Exposure Daycare Attendance Formula Feeding Low Economic Status Risk factors for AOM

17. Option 1: Pain control and watchful waiting. • Tylenol/ Motrin • Ear numbing drops, such as Auralgan. • Option 2: Antibiotics • Amoxicillin-80-90mg/kg/day orally in 2 to 3 divided doses for 10 days if less than 6 yrs or 5-7 days if 6 and older. • If PCN allergic, Zithromax as directed for 5 days. • Rocephin IM every 3 days for 9 days. • If under two years with bilateral OM- treat • OM with fever- treat • Referral ENT for ear tubes AOM-Management

18. Definition: Bullae form between the outer and inner layers of TM. Most common bacterial pathogen is Streptococcus pneumoniae. Pathology: Viral; underlying AOM. Presentation: Patients usually complain of ear pain; exam reveals one to three bullae that may cover 20-90% of the drum. Minimal erythema. Treatment: Abx and analgesics. I and D by ENT only if pain is significant and unrelenting. Bullous Myringitis:

19. Bullous Myringitis:

20. Infection of the mastoid bone, the inferior portion of the temporal bone of skull. Usually caused by untreated AOM. Mastoid air cells are lined with respiratory epithelium that connects to inner ear. S & S: Post auricular pain, erythema and fever. Cause: S. Pneumoniae, S. Pyogenes, H. Influenza. Treatment: Broad spectrum antibiotics. Mastoiditis

21. Mastoiditis

22. Often caused by a slap injury (water skiing) or F.B. insertion. Presentation: Otalgia, hearing loss, bleeding, dizziness, hemotympanum. Watchful waiting for 2-3 weeks; monitor for infection. Get audiogram after healing. Refer to ENT if not healing or dizziness is present. Tympanic Membrane Perforation

23. Tympanic Membrane Perforation

24. Scuba diving or flying. Inability to equalize barometric pressure. Presents with TM perforation, hemotympanum, vertigo. Prevention/treatment: yawning, swallowing or topical decongestants. Don’t’ go diving if you have a cold, allergy, or AOM. Barotrauma

25. 1.Outer ear 2. Middle ear 3. Inner ear 4.Acoustic Nerve The ABC’s of Audiology

26. The Weber and Rinne Tests • Tuning Forks (a 512-Hz is used, since frequencies below this level elicit only a tactile response). • Weber Test: put fork on center of head and see if sound lateralizes: • Lateralizes to bad ear if there is a conductive hearing loss (think cerumen-increases vibratory sensation). • Lateralizes to better ear with sensorineural problem (can’t hear if the sensorineural components aren’t working, so the neurology of the good ear will pick up the elicited sound). The Weber Test

27. Rinne: put fork on mastoid and then up to ear (should continue to hear sound). • Conduction problem if bone conduction > air conduction. • Sensorineural problem if air conduction > bone conduction. The Rinne Test

28. TWO TYPES: Conductive Hearing Loss- Think “Blockage” Sensorineural Hearing Loss- Think “Nerve” Hearing Loss:

29. Definition: • Disease of the external ear auditory canal, tympanic membrane, or ossicles. • Interference with reception or amplification of sound (usually low frequencies). Conductive Hearing Loss

30. CerumenImpaction • TX-Removal of cerumen • Chronic Otitis Media • TX-Oral antibiotics, corticosteroid nasal sprays(Flonase, Nasonex) • TM Perforation • TX- paper patch; most heal without intervention • Cholesteatoma: • condition where the upper flaccid portion of the TM is drawn inward because of chronic negative pressure which creates a small sac that becomes infected. Treatment- Surgical marsupilization of the sac. • Diagnostic Evaluation: Audiology • Treatment: Surgery, hearing aids Common Conductive Hearing Loss Etiologies:

31. Definition: • Deterioration of the cochlear hair cells or from lesions in the CN 8 pathway. Sensorineural Hearing Loss (SNHL)

32. Presbycusis (most common cause) • Progressive, age related hearing loss • Nose-induced • Meniere’s Disease • Medication (ASA, loop diuretic, chemotherapy) • Autoimmune Diseases (MS and Diabetes) • Acoustic Neuroma • Stroke Testing • Audiogram, CT scan for masses, MRI for Acoustic Neuroma, ENT referral. Treatment • Decrease noise exposure(ear plugs), d/c meds; hearing aids, cochlear implants. SNHL Etiologies and Treatment:

33. Definition: The sensation of noise that is only heard by the patient. Noise can be described as high pitched-ringing or low pitched-humming Sound is produced by the brain; not the ear. May be unilateral or bilateral. Associated with hearing loss(either conductive or sensorineural) and noise exposure. Tinnitus

34. Pulsatile (hearing one's heartbeat) must be distinguished from tonal. Pulsatile indicates a possible vascular abnormality (carotid vaso-occlusive disease, aneurysm. Evaluate with MRA. Audiogram deciphers between conductive or sensorineural etiology. For treatment of nocturnal tinnitus- white noise(radio) Tinnitus masking device Medical treatment with benzodiazepines or antidepressants. Tinnitus cont…

35. Vertigo Acute Labyrithitis Meniere’s Disease Vestibular Pathology

36. Definition: Sensation of spinning motion when there is no motion. • Cardinal symptom of vestibular disease. • Associated with migraines, meds (Abx, anticonvulsants, ETOH, analgesics). • Must differentiate Dizziness from Vertigo. • Physical Exam: Includes a Rhomberg test, an evaluation of gait, and evidence of nystagmus. • Testing- Dix-Hallpike maneuver to rule out BPPV, Videonystagmography(VNG) and/or CT scan. • Treatment: May try conservative measures, rest, antivert for 2 weeks. • Refer to ENT Vertigo

37. Like vertigo, but associated with URTI. -Acute onset of severe vertigo lasting several days to weeks, Tinnitus and hearing loss. Supportive treatment, Antivert or low dose Valium(vestibulostabilization). Acute Labyrithitis

38. Results from distention of endolymphatic compartment of inner ear. • Trauma and syphillis; symptoms wax and wane as the endolymphatic pressure rises and falls. • Classic symptoms: • Episodic vertigo • SNHL • Tinnitus-low tone and blowing sensation • Sensation of ear pressure • Treat with low sodium diet, diuretics, Antivert; Refer to ENT. Meniere’s Disease

39. Allergic Rhinitis Viral Rhinitis Nasal Foreign Body Acute/Chronic Sinusitis Nasal Polyps Disorders of the Nose and Paranasal Sinuses

40. Disorders of the Nose and Paranasal Sinuses

41. Disorders of the Nose and Paranasal Sinuses

42. Definition: IgE -mediated immune response to various allergens. Caused by degranulation of masts cells releasing histamine, prostaglandins and kinans. Types include: • Perennial (dust, dander) • Seasonal (seasonal 10x as popular) • Clinical Manifestations: • Headache, nasal congestion, sneezing, itchy, watery eyes; worse in am. • Post nasal drips, boggy turbinates. Allergic Rhinitis

43. Avoidance Intranasal cromolyn sodium (Nasalcrom) Antihistamines (Claritin, Allegra, Zyrtec) Decongestants (PSE); careful with HTN Intranasal steroids (Flonase: takes 1-2 weeks to work). Monolukast (Singular) Immunotherapy(allergy shots) Allergic Rhinitis Treatment:

44. Caused by rhinovirus, coronavirus, RSV. Headache, nasal congestion, rhinorrhea, sneezing. Nasal exam: reddened, edematous mucosa. Symptomatic Treatment: supportive, PSE, cough suppressants. Viral Rhinitis

45. The patient may feel that something is in his nose and blocking the air as he breathes. He may have trouble breathing if the object is very deep in the nasal cavity. Nasal foreign bodies may also cause itching, pain, headache, sneezing, and nosebleeds. If the foreign body is alive, the patient may feel movement inside his nose.Sometimes, the patient may have no symptoms. This may be caused by the foreign body staying inside the nose for a long time. If this happens, infection may set in. A thick, yellowish fluid is usually seen draining from one of the nostrils. The patient may also have a foul (bad) odor coming from his nose and he may develop a fever. Diagnosis includes carefully inspecting the nose using a nasal speculum. A nasal speculum is an instrument used to open the nostrils to better see the inside of the nose. Also, look for other problems, such as bleeding, infection, or injury. Sometimes, an x-ray may be done if the foreign body cannot be clearly seen. Treatment includes prompt removal, if infection is present antibiotic therapy is recommended, intranasal application of Polysporin if nasal trauma is present. Nasal Foreign body

46. Nasal Foreign Body

47. Definition: inflammation of 1 or more of the paranasal sinuses. • Maxillary most common. • Follows URI; most are viral. • Pathophysiology: • Mucosal inflammation>ostial obstruction>negative pressure>retained secretions>secondary infections. Acute Bacterial Sinusitis

48. Maxillary sinusitis: nasal congestion, pressure, maxillary tooth pain, fever. Frontal: forehead pain/pressure. Sphenoid sinusitis: headache in the middle of the head. Acute Bacterial SinusitisClinical Manifestations:

49. Physical Exam: • Nasal cavity/turbinate edema, purulent discharge, or pain over affected sinus. • Diagnostic Evaluation: • Diagnosis is clinical mostly. X-rays have low sensitivity for sinusitis. CT scan used for chronic sinusitis. Acute Bacterial SinusitisContinued

50. General Measures: Increased fluids, humidity, nasal saline/ irrigation-Netti pots. • Symptomatic Treatment: Decongestants, cough suppressants, NSAIDS, Tylenol, antihistamines, nasal steroids • Antibiotics: only if symptoms last longer than 10-14 days. • 1st line: Amox, Bactrim • 2nd Line: Augmentin, Ceftin • 3rd line: Fluoroquinolones, such as Avelox Acute Bacterial Sinusitis Treatment