Otolaryngological emergencies ahd jan 31 2013
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Otolaryngological Emergencies AHD Jan 31, 2013. Hans Rosenberg MD CCFP(EM). Objectives. Ear Anatomy Otitis Media Otitis Externa Mastoiditis. Anatomy. Clinical Examination. Start with External: helix, antihelix, tragus, outer ear canal Otoscope: external auditory canal, TM Syringing

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Otolaryngological Emergencies AHD Jan 31, 2013

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Otolaryngological emergencies ahd jan 31 2013

Otolaryngological EmergenciesAHD Jan 31, 2013

Hans Rosenberg MD CCFP(EM)


Objectives

Objectives

  • Ear Anatomy

  • Otitis Media

  • Otitis Externa

  • Mastoiditis


Anatomy

Anatomy


Clinical examination

Clinical Examination

  • Start with External: helix, antihelix, tragus, outer ear canal

  • Otoscope: external auditory canal, TM

  • Syringing

  • Pneumatoscopy


Question 4

Question 4

  • What is the DDx of Ear pain, list 5 primary causes and 5 non-ear causes? (10)


Ddx for ear pain

DDx for Ear Pain

Ear

Non-Ear

Pharyngitis

Sinusitis

Upper Respiratory Tract Infection

Dental pain

Bell’s Palsy

Foreign bodies

  • Otitis Media

  • Otitis Externa

  • Otitis Media with Effusion

  • Mastoiditis

  • Labyrinthitis

  • Dysbarism

  • Ramsay Hunt Syndrome

  • Malignant External Otitis


Case 6

Case 6

  • 4 year old brought in by mom because he has pain in his right ear, fever and coryza


Otitis media

Otitis Media

  • #1 diagnosis in patients <15 yo

  • #1 reason for Rx of antimicrobials

  • Definitions:

  • Inflammationof the middle ear

    • AOM: signs and symptoms of an acute infection with an effusion

    • OM with Effusion: effusion without symptoms and signs of acute infection

    • Recurrent AOM: 3 episodes in 6/12 or 4 in 1 year


Question 5

Question 5

  • What are the 5 most common bacteria that cause AOM?


Otitis media1

Otitis Media

  • Bacteriology

    • S. pneumoniae, H. influenzae (primarily nontypeable), and M. catarrhalis.

    • Streptococcus pyogenes, Staphylococcus aureus, and gram-negative bacteria are much less common

  • Virology

    • RSV, parainfluenza, influenza, enterovirus, rhinovirus, and adenovirus


Clinical

Clinical

  • Hx

    • otalgia, fever, ear pulling, coryza, cough, anorexia, vomiting, diarrhea

  • Risk Factors

    • 6m-3y, male, daycare, smoking,

      pacifier, cleft palate, Downs

  • Sequelae

    • mastoiditis, bacterial meningitis,

      H/L, labyrinthitis, CN VII palsy


Tm anatomy

TM Anatomy

  • P/E

    • TM

      • Normal: pars flaccida, malleus, light reflex, moves with insufflation


Clinical1

Clinical

  • P/E

    • TM

      • AOM: bulging/retracted, erythematous*, effusion, A/F level, dull (loss of anterior light reflex), no movement


Otitis media2

Otitis Media


Otitis media guidelines

Otitis Media - Guidelines

  • 1. Recent, usually abrupt, onset of signs and symptoms of middle-ear inflammation and MEE.

  • 2. The presence of MEE that is indicated by any of the following:

    • a. Bulging of the tympanic membrane

    • b. Limited or absent mobility of the tympanic membrane

    • c. Air fluid level behind the tympanic membrane

    • d. Otorrhea


Otitis media3

Otitis Media

  • 3. Signs or symptoms of middle-ear inflammation as indicated by either

    • a. Distinct erythema of the tympanic membrane OR

    • b. Distinct otalgia (discomfort clearly referable to the ear[s] that results in interference with or precludes normal activity or sleep)


Management

Management

  • Pain Control

    • Tylenol

    • Advil

    • Narcotic Analgesics

    • Benzocaine-Antipyrenegtts (Auralgan)


Management1

Management

  • Note:Nonsevere illness is mild otalgia and fever <39C in the past 24 hours. Severe illness is moderate to severe otalgia or fever >39C.


Management2

Management

<2yr old or complex case use 10 day course, otherwise may use 7 day course


Management3

Management

  • Recurrent AOM

    • If > 6 weeks since last AOM use first line agents

    • If < 6 weeks since last AOM use second line agents

    • Consider ENT referral

      • OME for ≥ 3 months with bilateral hearing loss ≥ 20 dB.

      • ≥ 3 episodes in 6 months

      • ≥ 4 episodes in 12 months

      • Retracted tympanic membrane

      • Cleft plate or craniofacial malformations.


Management controversies

Management Controversies


Management controversies1

Management Controversies

  • Primary Outcome – not statistically significant

  • Changed protocol, from single Primary Outcome to four primary outcomes

  • Lead author has received multiple honoraria from makers of Amox-Clav ES

  • Make little to no mention of secondary outcome which was statistically significant - Diarrhea


Mastoiditis

Mastoiditis

  • Inflammation of mastoid air cells

  • commonly associated with AOM

  • Bacteriology

    • S. pneumoniae, group A streptococci, S. aureus, S. epidermidis, M. catarrhalis, H. flu


Clinical2

Clinical

  • Hx

    • PAIN, Fever, h/a, erythema posterior to auricle, AOM symptoms for >2 weeks

  • P/E

    • tenderness, erythema

    • displaced auricle

    • TM  erythema/bulging/fluid

  • Complications

    • SubperiostialAbscess

    • BezoldAbscess – below pinna, behind SCM

    • Petrositis/Osteomyelitis

  • Diagnostic Imaging

    • CT (Sens 87-100%)/MRI


Management4

Management

  • Antibiotics: Ceftriaxone, Clindamycin + Gentamycin, Pip-Tazo

  • ENT for possible myringotomy, tympanostomy tubes, mastoidectomy


Case 7

Case 7

  • 23 year old male returns from his weekend at his cottage early due to unbearable pain in his right ear. His vital signs are all stable but when you touch his helix he screams out in pain.


Otitis externa

Otitis Externa

  • Infection of the external auditory canal

  • DDx

    • AOM

    • Otomycosis – Aspergillosis

    • Furunculosis – infection of cartilagenous portion of ext. canal

    • Herpes Zoster Oticus – Ramsay Hunt Syndrome

  • Bacteriology

    • P. aeruginosa, S. aureus, and other gram-negative organisms often occurring as polymicrobial infection.


Clinical3

Clinical

  • Hx

    • otalgia, ear fullness, H/L, redness, swelling, jaw pain, discharge, pruritis

  • Risks

    • moisture, maceration, trauma

  • P/E

    • erythema, edema, narrowing of canal, discomfort with pulling on the auricle or tragus


Otitis externa1

Otitis Externa

  • Analgesia – NSAID’s, opiates

  • Ear Wick

  • Antifungals

    • Thimerosolgtts

    • Gentian Violet gtts

  • Antimicrobials

    • Ciprodex 4gtts bid

    • Cortisporin 4gtts qid


Necrotizing malignant external otitis

Necrotizing (Malignant) External Otitis

  • Osteomyelitis of temporal bone secondary to OE

    • potentially life threatening

    • almost exclusively in immunocompromised

    • Pseudomonas

    • 50 % mortality if left untreated

    • Hx: severe pain, h/a, discharge

    • P/E: erythema, tenderness, edema of external ear or adjacent structures, POOP, granulation tissue


Malignant external otitis

Malignant External Otitis

  • Oral Ciprofloxacin 750mg po bid if uncomplicated

  • IV Ceftazidime 1-2g IV q8h

  • Hyperbaric

  • ENT consultation

  • Treatment length guided by

    bone scan


Case 8

Case 8

  • http://www.youtube.com/watch?v=S3Mrh52-pzs


Epistaxis

Epistaxis


Epistaxis1

Epistaxis

  • Nasal Anatomy

  • Etiology

  • Management of Anterior Bleeds

  • Management of Posterior Bleeds


Question

Question

  • What are the arteries which are involved in anterior epistaxis (ie. Kiesselbach’s Plexus)?(5)


Epistaxis2

Epistaxis

  • Most cases in children although bimodal distribution

  • Anterior ~90% of cases in Kiesselbach’s Plexus

    • ant. ethmoid, sphenopalatine, greater palatine, superior labial arteries

  • Posterior Epistaxis from posterior branch sphenopalatine artery


Nasal anatomy

Nasal Anatomy


Epistaxis3

Epistaxis

  • Causes

    • TRAUMA – self, assault, surgical

    • Mucosal – URTI, allergies, cold/dry weather

    • Bleeding diatheses

    • Etc.

    • Hypertension – NOT a cause of bleeding but may worsen active bleeding


Epistaxis4

Epistaxis

  • Preparation, proper equipment and an organized step-wise approach will be the key to success or…


Management anterior

Management - Anterior

  • Clear clots

  • Apply pressure for 15-20 min with clips – over septum!!!

  • With nose parallel to ground use nasal speculum

  • Use headlight or assistant for light source

  • Suction as necessary

  • Check  if continued bleeding…


Management anterior1

Management - Anterior

  • Apply pledgets soaked in:

    • Lidocaine w/ Epi

    • Cocaine

    • Xylometazoline (Otrivin)

  • Re-examine  if bleeding persists…


Management anterior2

Management - Anterior

  • If light or no bleeding but identify source

    • Silver Nitrate

      • Outside to inside

      • Avoid on both sides of septum

      • Re-examine  if bleeding persists…


Management anterior3

Management - Anterior

  • Nasal Packing

    • Nasal Packing with Vaseline gauze

    • Nasal Tampon/Rhino-Rocket – 8 or 10cm sizes

    • May need bilateral packs

*warn patient that Nasal tampon insertion will be painful for about 10 seconds


Management anterior4

Management - Anterior

  • If success leave packing in for 48hrs, consider antibiotic prophylaxis

  • Prevention: avoid blowing nose, picking, closed mouth sneezing, apply Polysporin cream

  • If STILL bleeding

    • Consider posterior bleed


Management posterior

Management - Posterior

  • Commercial Balloon Cather – Epistat

  • Foley Catheter

  • Prophylaxis with Keflex/Clavulin

  • ENT consultation


Management5

Management

  • If all of above fails time to call ENT

  • In case of massive, life threatening bleed

    • ABC’s

    • Establish Advanced A/W

    • Nasal Packing

    • Fluids/Blood Products – PRBC’s, FFP, Plts, PCC

    • call ENT/IR/Vascular


Summary

Summary

  • AOM is common – be aware of treatment guidelines and rare complications including mastoiditis

  • OE is very painful but quite benign, be aware of NOE as a complication

  • Have an approach to the patient with epistaxis, consider posterior bleed if unable to achieve hemostasis with above techniques


References

References

  • American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media: Diagnosis and management of acute otitis media. Pediatrics 113:1451, 2004

  • eMedicine: Otitis Externa, Otitis Media

  • Guidelines for the Diagnosis and Management of Acute Otitis Media. Towards Optimized Practice. Alberta Medical Association. 2008

  • Treatment of Acute Otitis Media in Children under 2 Years of Age. Alejandro Hoberman, M.D. et al. NEJM January 13, 2011


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