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COMMON E.N.T. PROBLEMS






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COMMON E.N.T. PROBLEMS. B. WAYNE BLOUNT, MD, MPH PROFESSOR EMORY FAMILY MEDICINE. Learning Objectives. IN SYLLABUS. Acute Otitis Media. B. WAYNE BLOUNT, MD, MPH PROFESSOR, EMORY. Otitis Media - Classification. Acute OM - rapid onset of signs & sx , < 3 wk course
COMMON E.N.T. PROBLEMS

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Slide 1

COMMON E.N.T. PROBLEMS

B. WAYNE BLOUNT, MD, MPH

  • PROFESSOR

  • EMORY FAMILY MEDICINE

Slide 2

Learning Objectives

  • IN SYLLABUS

Slide 3

Acute Otitis Media

B. WAYNE BLOUNT, MD, MPH

PROFESSOR, EMORY

Slide 4

Otitis Media - Classification

  • Acute OM - rapid onset of signs & sx, < 3 wk course

  • Subacute OM - 3 wks to 3 mos

  • Chronic OM - 3 mos or longer

Slide 5

Otitis Media et al

  • Acute otitis media (AOM)

  • Otitis media with effusion (OME)

  • Otitisexterna

  • Other ear findings, common and uncommon

Slide 6

Recommendation #1

  • To diagnose acute otitis media the clinician should confirm:

  • 1) a history of acute onset,

  • 2) identify signs of middle-ear effusion (MEE), and

  • 3) evaluate for the presence of signs and symptoms of middle-ear inflammation.

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 7

Recommendation #2

  • The management of AOM should include assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain.

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 8

Recommendation #3A

  • Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up.

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 9

Recommendation 3B

  • If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. When amoxicillin is used the dose should be 80 to 90 mg/kg/day.

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 10

Recommendation #4

  • If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent(s), the clinician should change the antibacterial agent(s).

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 11

Acute Otitis Media - Risk Factors

  • Male gender

  • Sibling hx or recurrent otitis media

  • Early age of onset of AOM ( before 4 mo)

  • Bottle feeding, or breastfeeding for < 4 mo

  • Group day care

  • Exposure to tobacco smoke

    Swanson, Jill, Otitis Media in Young Children, Mayo Clinic Proceedings, 71(2), Feb 1996, pp 179-183

Slide 12

Eustachian tube

  • Usually closed

  • Opens during swallowing, yawning, and sneezing

Slide 13

Acute Otitis Media - Positive Predictive Value of TM Findings

Finding PPV

Bulging TM 89

Cloudy TM 80

Distinctly impaired mobility 78

Distinctly red TM 65

Slightly impaired mobility 33

Slightly red TM 16

Karma et al, Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media, Int J Pediatr Otolaryngol, 1989, 17, pp 37-49

Slide 14

Normal Ear Drum

Slide 22

Microbiology

  • S. pneumoniae - 30-35%

  • H. influenzae - 20-25%

  • M. catarrhalis - 10-15%

  • Group A strep - 2-4%

  • Infants with higher incidence of gram negative bacilli

Slide 23

Virology

  • RSV - 74% of middle ear isolates

  • Rhinovirus

  • Parainfluenza virus

  • Influenza virus

Slide 24

PCN-resistant Strep

1979 - 1.8%

1992 - 41%

Altered PCN-binding proteins

Lysis defective

Age, day-cares, and previous tx

H. flu and M. catarrhalis

beta-lactamase production

All M. catarrhalis +

45-50% H. flu

Microbiology

Slide 25

Acute Otitis Media - Pneumatic Otoscopy

  • Pneumatic otoscopy/insufflation will demonstrate decreased mobility of the tympanic membrane in cases of middle ear effusion with increased middle ear pressure.

  • Mobility of the TM is not consistent with a diagnosis of AOM.

Slide 26

Acute Otitis Media - Tympanometry

  • This instrument is used to detect fluid within the middle ear.

  • Several types of tympanograms

  • Highly sensitive when disease present.

  • Lower specificity when disease absent - will be abnormal in

    children with

    normal TMs.

Slide 27

Onusko, E, Tympanometry, AFP, Nov. 1, 2004, pp 1713-1720

Slide 28

Acute Otitis Media - Acoustic Reflectometry

  • An instrument similar to the tympanogram is used to bounce sound waves off the TM.

  • More waves are reflected when the middle ear is full of fluid.

  • Sensitivity = 90% and specificity = 86% for middle ear effusion or abnormal pressure.

Slide 29

Recommendation #2

  • The management of AOM should include assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain.

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 30

Acute Otitis Media - Treatment

  • Ensure that the patient has adequate analgesia.

  • Tylenol

    • 10-15 mg/kg up to q4hr

  • Motrin

    • 5-10 mg/kg up to q6-8hr, max dose of 20 mg/kg/24hr

  • Don’t forget topical analgesia with Auralgan (topical benzocaine)

Slide 31

Acute Otitis Media - Treatment

  • In the USA, one study has demonstrated that AOM due to S. Pneumonia spontaneously resolved in 20%, while 50% cases of H. influenza resolved spontaneously.

    McCracken, Considerations in selecting an antibiotic for treatment of acute otitis media, Pediatr Infect Dis J, 1994, 13(Suppl), pp 1054-1057

  • The difficulty is in choosing which patient not to give antibiotics.

Slide 32

Recommendation #3A

  • Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up.

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 33

Recommendation 3B

  • If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. When amoxicillin is used the dose should be 80 to 90 mg/kg/day.

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 34

Acute Otitis Media - Treatment

  • Amoxicillin is still the first line therapy.

    • $1.00 per bottle

  • May also consider Septra/Bactrim

    • $0.82 per bottle

  • Please remember this before writing for Zithromax, which costs WAY more.

    • $15.00 per bottle

Slide 35

Acute Otitis Media -Treatment

  • Ceftriaxone has been shown in multiple studies to be equally efficacious when given as a one-time IM injection of 50 mg/kg (max).

    Comparison of Ceftriaxone and Trimethoprim-Sulfamethoxazole for Acute Otitis Media, Pediatrics, 99(1), January 1997, pp 23-28.

Slide 36

Treatment - Recurrent AOM

  • Chemoprophylaxis

    • Sulfisoxazole, amoxicillin, ampicillin, pcn

    • less efficacy for intermittent propylaxis

  • Myringotomy and tube insertion

    • decreased # and severity of AOM

    • otorrhea and other complications

    • may require prophylaxis if severe

  • Adenoidectomy

    • 28% and 35% fewer episodes of AOM at first and second years

Slide 37

Acute Otitis Media - Treatment

  • Antihistamines and decongestants are not established therapies for AOM.

  • However, remember that 70-90% of children with AOM have/had an antecedent URI/cold, so this may not really be bad medicine.

Slide 38

Acute Otitis Media - Treatment Duration

  • The standard treatment is 10 days.

  • A study in Pediatrics demonstrated that treating for a full 20 day course was no more efficacious than treating for 10 days

    Efficacy of 20- Versus 10-Day Antimicrobial Treatment of Acute Otitis Media, Pediatrics, 96(1), July 1995, pp 5-13

Slide 39

Acute Otitis Media - Follow-Up

  • Patients with AOM should have a decrease, if not resolution, in their symptomatology over the 48-72 hours after a diagnosis is made and treatment instituted.

  • If no resolution in symptoms, consider a beta-lactamase producing bacteria or other process, not to exclude poor patient compliance.

Slide 40

Recommendation #4

  • If the patient fails to respond to the initial management option within 48 to 72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent(s), the clinician should change the antibacterial agent(s).

AOM Guideline at http://www.aafp.org/x26481.xml

Slide 41

Acute Otitis Media - Follow-Up

  • The party line - 2 week ear check.

  • Hathaway et al found the following criteria to be 97% accurate in determining if a child had AOM at follow-up:

    • Parental impression of resolved AOM

    • Absence of symptoms

    • Age > 15 months

    • No family history of recurrent AOM in a sib.

      Hathaway et al, Acute Otitis Media: Who Needs Posttreatment Follow-Up?, Pediatrics, 94(2), August 1994, pp 143-147.

Slide 42

Acute Otitis Media - Recurrence/Prophylaxis

  • In general 3 episodes in 6 months or 4 episodes in 1 year deserve consideration for antibiotic prophylaxis.

    • Knowledge at large, also in Conn’s 1998

  • Drugs

    • Amoxil at 20 mg/kg qd

    • Gantrisin 50-75 mg/kg divided bid

Slide 43

Acute Otitis Media - Recurrence/Prophylaxis

  • Follow-up is usually once per month, at least initially.

  • If a child had breakthrough infections on prophylaxis, consider an ENT referral.

  • How long to continue prophylaxis? Needham et al (unpublished data) 6-12 months minimum. Use your best judgement.

Slide 44

Acute Otitis Media - Recurrence/Prophylaxis

  • The goal of prophylaxis is to allow the child to age enough so that his/her eustachian tube apparatus will become less likely become infected (usually age 3-ish, again, more unpublished data, i.e., opinion).

  • Use the antibiotic prophylaxis to avoid surgery, although the surgery takes all of 2 minutes.

Slide 46

Otitis Media with Effusion

“OME”

Slide 47

Otitis Media with Effusion-Some Sticky Business

  • Simply defined as fluid in the middle ear without symptoms or signs of AOM.

  • Clinical Practice Guideline - expert panel comprised of members from AAP, AAFP, and American Academy of Otolaryngology-Head and Neck Surgery, with review and approval of the Agency for Health Care Policy and Research.

Slide 48

OM - persistent middle ear effusion (MEE)

  • High incidence of MEE, avg of 40 days

  • Children less that 2 years much more likely to have persistent MEE

  • White children with higher incidence of MEE

Slide 49

Chronic MEE

  • Previously thought sterile

  • 30-50% grow in culture

  • over 75% PCR +

  • Usual organisms

Slide 53

Otitis Media with Effusion- Some REALLY Sticky Business

  • Glue ear, the REAL glue ear.

    • Otoscopic findings

    • Thick yellow fluid behind the TM

    • A different fish from plain ol’ OME - this is the hog bass from the bog swamp. He ain’tmovin’ fonuttin’.

Slide 54

Treatment - OME

  • MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, discomfort

  • Antibiotics

    • shown to be of benefit, 75% PCR + bacterial DNA

  • Antibiotics + steroid

    • 21% improvement compared to abx alone

    • prednisone 1 mg/kg day x 7 days

    • varicella?

  • Myringotomy & tympanostomy +/- adenoidectomy

Slide 55

Tympanostomy tube insertion

  • Unresponsive OME >3 mosbil, or >6 mosuni, sooner if assoc hearing problems

  • Recurrent MEE with excessive cumulative duration

Slide 56

Glue ear

Slide 58

OtitisExterna

Slide 59

OtitisExterna

  • Commonly referred to as Swimmer’s Ear

  • Usual infections are skin bacteria.

  • If you see green, foul discharge, think of Pseudomonas.

  • In diabetics, people on steroids, and immunocompromised, don’t forget fungal infections.

Slide 61

Do you think it would hurt to pull on this tragus?

Slide 64

OtitisExterna - Treatment

  • Cortisporin suspension - safe in all ears

    • Neomycin, Polymyxin B, Hydrocortisone

  • Cortisporin solution - more burn for your money. Don’t use if the TM is ruptured.

  • Zoto HC -Chloroxylenol, pramoxine, HC

  • PO antibiotics

Slide 65

Acute and Chronic Sinusitis

A Practical Guide for Diagnosis and Treatment

Slide 66

Development of Sinuses

  • Maxillary and ethmoid sinuses present at birth

  • Frontal sinus developed by age 5 or 6

  • Sphenoid sinus last to develop, 8-10

Slide 67

Normal Water’s and Towne’ s Views of the Sinuses

Slide 68

Lateral View Showing Normal Sphenoid Sinus

Slide 69

Classification of Bacterial Sinusitis

  • Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days)

  • Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 30-90 days)

  • Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days)

  • Some guidelines add treatment failure + a positive imaging study

Slide 70

Recurrent Acute Bacterial Sinusitis

  • Episodes lasting fewer than 4 weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic

  • 3 episodes in 6 months or 4/year

Slide 71

Sinusitis

Nasal congestion

Purulent rhinorrhea

Postnasal drip

Headache

Facial pain

Anosmia

Cough, fever

Rhinitis

Nasal congestion

Rhinorrhea clear

Runny nose

Itching, red eyes

Nasal crease

Seasonal symptoms

Differentiating Sinusitis from Rhinitis

Slide 72

X-Ray Image of Sinuses with Maxillary Sinusitis

Slide 73

Acute Bacterial Sinusitis

  • Usually begins with viral upper respiratory illness

  • Symptoms initially improve, but then …

  • Symptoms become persistent or severe

  • Persistent… 10-14 days but fewer than 4 weeks

  • Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill

  • Disease clears with appropriate medical treatment

Slide 74

Physical Findings

  • Mucopurulent nasal discharge

    • Highest positive predictive value

  • Swelling of nasal mucosa

  • Mild erythema

  • Facial pain (unusual in children)

  • Periorbital swelling

Slide 76

Treatment of Acute Sinusitis

  • Antihistamines recommended if allergy present

    • Oral or topical

  • Decongestants

    • Oral or topical

  • Antibiotic when indicated (bacteria)

  • Nasal irrigation

  • Guaifenesin 200-400 mg q4-6 hrs

  • Hydration

Slide 77

Decongestants

  • Topical nasal sprays (limit use to 3-7 days)

    • Phenylephrine

    • Oxymetazoline

    • Naphthazoline

    • Tetrahydrozoline

    • Zylometazoline

  • Topical nasal spray (unlimited daily use)

    • Ipatropium

  • Oral

    • Pseudoephedrine 30-60 mg

    • Phenylephrine 2-4 times/day

Slide 78

Treatment of Acute, Uncomplicated Sinusitis

  • Antibiotic may not be indicated

    • Many are viral

    • Benefit of antibiotics are only moderate

    • Weigh factors of cost, side effects, antibiotic resistance, and antibiotic reactions

Slide 79

Bacteria Involved in Acute Bacterial Sinusitis

  • Streptococcus pneumoniae 30%

  • Haemophilus influenza 20%

  • Moraxellacatarrhalis 20%

  • Sterile 30%

Slide 80

Antibiotics for Acute Bacterial Sinusitis

  • Amoxicillin 500 mg tid for 10-14 days

    • First line choice in most areas

    • Local differences in antibiotic resistance occur

  • Where beta-lactanase resistance is an issue

    • Amoxicillin/clavulanate

    • Cefuroxime

    • Cefpodoxime

    • Cefprozil

Slide 81

Additional Antibiotics for Acute Bacterial Sinusitis

  • Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days)

  • If penicillin-allergic clarithromycin or azithromycin

  • Erythromycin does not provide adequate coverage

  • Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance

Slide 82

Secondary Antibiotics for Acute Sinusitis

  • Cefdinir (Omnicef)

  • Cefuroxime (Ceftin)

  • Cephpodoxime (Vantin)

  • Azithromycin

  • Clarithromycin

Slide 83

Optimal Duration of Antibiotics

Give antibiotic until patient free of symptoms then add 7 days

Slide 84

Nasal Irrigation

  • Commercial buffered sprays

  • Bulb syringe

    • 1/4 tsp of salt to 7 ounces water

  • Waterpik with lavage tip

    • 1 tsp salt to reservoir

  • Disposable enema bucket

    • 2 tsp salt, 1 tsp soda per quart of water

Slide 85

When Medical Therapy for Acute Bacterial Sinusitis Fails…

Assess for chronic causes

  • Identify allergic and nonallergic triggers

    • Allergy testing, nasal smears for eosinophilia

  • Consider other medical conditions associated with sinusitis

  • Rhinolaryngoscopy

  • Imaging studies

    Sinus x-rays

    CT scanning (limited, coronal views)

Slide 86

Rhinoscope

Slide 87

Recommendations for CT Scans

  • Patients presenting with complications of sinusitis

    • Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema

  • Patients with sinus symptoms accompanied by severe, boring, mid-head pain

    • Rule out sphenoid sinusitis

Slide 88

CT Scan Maxillary and Ethmoid Sinuses

Slide 89

Recommendation 1

The diagnosis of acute bacterial sinusitis is based on clinical criteria with patients presenting with URI symptoms that are either persistent or severe.

Slide 90

Recommendation 2a

  • Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children younger than 6 years (older than age 6 years is controversial)

  • Children with persistent symptoms (>10 days, < 30 days) predicted abnormal radiographs 80% of the time

  • Children < 6 symptoms predicted 88% of the time

  • Normal x-ray suggests ABS is not present

Slide 91

Recommendation 2b

  • CT scans of the paranasal sinuses should be reserved for:

    • Patients in whom surgery is being considered as a management strategy

    • Patients who do not respond to medical regimes which include adequate antibiotic use

    • Assisting in diagnosis of anatomical changes interfering with airflow or drainage

Slide 92

Recommendation 3

  • Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cure

  • Patients must meet requirements of persistent or severe disease

  • Response improved with doses >Minimal Inhibition Concentration

Slide 93

No EB Recommendations Found for Use of Adjunctive Therapy in ABS, May be Helpful

  • Nasal saline irrigation

  • Oral decongestants

  • Oral or nasal antihistamines

  • Topical decongestants

  • Mucolytic agents

  • Topical steroids

Slide 94

Evidence-Based Recommendations

  • Practice Recommendation: Reduce unnecessary use of antibiotics. Providers should be consistent with the recommended criteria for prescribing antibiotics in acute sinusitis endorsed by the CDC, American Academy of Family Physicians, the American College of Physicians-American Society of Internal Medicine, and the Infectious Diseases Society of America.

  • All recommendations available at: http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=148. Accesses August 2003.

Slide 95

Evidence-Based Recommendations

  • Practice Recommendation: Use first line antibiotics, which are amoxicillin or trimethoprim-sulphamethoxazole (TMP/SMX).

  • Practice Recommendation: Use an antibiotic that covers resistant bacteria (amoxicillin-clavulanate [Augmentin] or another second line agent) to treat patients if failed on 10-14 days of amoxicillin.

http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=148.

Slide 96

PHARYNGITIS

Slide 97

> 1 SORE THROAT PER DAY

  • Idiopathic 30 - 65 %

  • Viral 30 - 60 %

  • Bacterial 5 -10 %

  • Usually cannot tell the difference by exam

  • Concerned about the bacterial causes

Slide 98

MOST VALIDATED SCORING SYSTEM‘B’ Rec

SymptomPoints

Fever 1

Absence of cough 1

Tender Ant. Cvcladenopathy 1

Tonsillar swelling or exudate 1

AGE

< 15 yo +1

15-45 0

> 45 -1

Slide 99

SCORING SYSTEM

  • POINTSMEANING

    < 0 No GABHS (2%)

    1 – 3 Rapid strep test

    4 – 5 Probable GABHS (52%)

Slide 100

TESTS ?‘B’ Rec

  • Rapid Strep tests :

    • Sensitivity and Specificity > 94 %

    • 3 mins

  • Throat Cultures :

    • “Gold Standard”

    • Sens = 97%

    • Spec = 99%

    • 24 hrs.

Slide 101

ENSURE ADEQUATE SWAB

Slide 102

GABHS TREATMENT

  • GOALS :

    • PREVENT ACUTE RHEUMATIC FEVER

    • PREVENT SUPPARATIVE COMPLICATIONS

    • IMPROVE CLINICAL SX

    • REDUCE TRANSMISSION

    • MINIMIZE ANTIBIOTIC ADVERSE EFFECTS

Slide 103

GABHS TREATMENT

  • Penicillins ‘A’ Rec

  • Pcn-allergic pts :

    • Macrolides ‘A’ Rec

    • 1st gen cephalosporin ‘A’ Rec

    • Steroids , short-acting, relieve Sx : ‘B’ Rec

Slide 104

GABHS TREATMENT

  • Mutiple recurrences?

    • Clindamycin

    • Augmentin

    • PCN G

    • All ‘B’ Rec

Slide 105

IS IT MONO ?

  • Posterior lymphadenopathy ?

  • Mono spot :

    • 67 % sens in 1st week

    • 80 % in 2nd wk

  • CBC :

    • > 10 % atypical lymphs :

      92 % spec.

Slide 106

IS IT G.C. ?

  • HAVE TO THINK ABOUT IT 1ST

  • ASK ABOUT ORAL/GENITAL SEX

  • GET C & S

Slide 107

Approach to the Dizzy Patient

Slide 108

Overview

  • Practical approach to vertigo

  • Brief introduction to dizziness and vertigo- central vs peripheral

Slide 109

Dizziness- is it vertigo?

  • Lightheadedness (>90% non- neurological cause)

    • vasovagal response

    • orthostasis

    • cardiogenic causes

    • hyperventilation

    • hypoglycemia

    • medication effects

Slide 110

Dizziness- is it vertigo?

  • Vertigo (usually neurological)

    • sensation of motion

      • spinning

      • feeling motion sick

      • feeling of tilting to one side

      • results from asymmetric impairment of sensory input or of integration into CNS

Slide 111

Vertigo- central

  • ~20% of all vertigo

  • Usually accompanied by other brainstem, cerebellar, or long-tract sx’s/signs, e.g. incoordination, visual changes or diplopia, perioral numbness, dysarthria, drop attacks, weakness, numbness, etc.

  • However, up to 25% of vertebrobasilar insufficiency can present with isolated vertigo.

  • Acute cerebellar infarcts can mimic vestibular neuritis, may only have vertigo, gait ataxia, and nystagmus

    • look at nystagmus (gaze evoked or vertical, increases in amplitude ipsi to lesion)

    • Focal dysmetria would suggest ipsilateralcerebellar

Slide 112

Vertigo- peripheral

  • History: focus on onset, duration.

    - Note that all vertigo can worsen with position changes

  • Exam: should not have focal neurologic findings, besides hearing loss/tinnitus

    - Nystagmus: unilateral, amplitude decr in direction away from fast phase (Alexander’s law), fatigues, decr with fixation

    - Gait: although uncomfortable, pts with peripheral vertigo typically can walk, unlike those with central

  • Note: vertigo + hearing loss can be vascular

    - infarction of inner ear by occlusion of internal auditory artery (branch of AICA)

    - causes vertigo c hearing loss

Slide 113

Clues towards a central process

1. Risk factors

-age, HTN, DM, lipids, smoking

2. Focal neurological findings

-suggestive of central process

3. Nystagmus

-central: vertical, not unilateral, does not

fatigue, does not decr with fixation

-peripheral: unilateral, decr in direction away

from fast comp, fatigues, decr with fixation

4. Severity of ataxia

-central: more severe, unable to walk

-peripheral: uncomfortable, but able to walk

Slide 114

Vestibular Neuritis

  • Sudden onset of peripheral vertigo

  • Usually without hearing loss

  • Period of several hours - severe

  • Lasts a few days, resolves over weeks

  • Inflammation of vestibular nerve - presumably of viral origin

  • Spontaneous, complete symptomatic recovery with supportive treatment

  • Treatment aimed at stopping inflammation

Slide 115

Meniere’s Disease

  • Hallpike and Cairns - 1938 found endolymphatichydrops by histology

  • Classic triad

    • Recurrent vertigo

    • Fluctuating SNHL

    • Tinnitus

    • (aural fullness very common)

Slide 116

Meniere’s Disease

  • Widely accepted medical treatment

    • Dietary salt restriction

    • Diuretics

  • Thiazide diuretics

    • Decrease Na absorption in distal tubule

    • Side effects - hypokalemia, hypotension, hyperuricemia, hyperlipoproteinemia

  • Combination potassium sparing agents

    • Maxzide, Dyazide

    • Avoids hypokalemia

Slide 117

Meniere’s Disease

  • At least 3 months of diuretic therapy recommended before discontinuing

  • Sulfa allergies - can try loop diuretics or alternate therapies

Slide 118

Meniere’s Disease

  • Carbonic anhydrase inhibitors (acetazolamide)

    • “inner ear glaucoma”

    • Decreased Na-H exchange in tubule

    • Decreased CSF production

    • Diuretic effect not as long-lasting

    • Side effects - nephrocalcinosis, mild metabolic acidosis, GI disturbances

Slide 119

BPPV

  • Most common cause : 50% of peripheral vertigo

  • Dysfunction of posterior SCC

  • Cupulolithiasis vs. Canalithiasis

  • Cupulolithiasis

    • Calcium deposits embedded on cupula

    • PSCC becomes dependent on gravity

  • Canalithiasis

    • Calcium debris (otoconia) displaced into PSCC

    • Does not adhere to cupula

Slide 120

BPPV

  • Head movements

    • Looking up

    • Lying down

    • Rolling onto affected ear

  • Result in displacement of “sludge” / otoconia

  • Vertigo lasting a few seconds

  • Treatment approaches

    • Liberatory maneuvers

    • Particle repositioning

    • Habituation exercises

Slide 121

BPPV

Cupulolithiasis

  • Liberatory maneuver

  • Single treatment

  • Cure rates

    • 84%-one treatment

    • 93%-two treatments

Slide 122

BPPV

  • Epley

  • Canalithiasis

  • Canalith repositioning

  • Move into vestibule

  • Cure rates

    • 80% - one treatment

    • 100% - multiple

Slide 123

BPPV - Epley

Slide 124

BPPV

  • Habituation technique

  • Move to provoking position repeatedly

  • 98% success rate after 3 to 14 days of exercises

Slide 125

Etiology RecurOnsetDurationAssociated features

BPPV + sudden <1 min elderly, induced by

position change

Meniere’s + gradual hours ear fullness, tinnitus,

low freq hearing loss

Vestibular - gradual days-weeks 50% c preceding viral

neuritis or sudden illness, +/- hearing loss

Migraine + gradual sec-days young F, HA, positive

visual phenomenon

VB TIA + sudden mins CN, long-tract sx’s/

signs

Labryinth - sudden days-months hearing

stroke loss +/- tinnitus

Brainstem - sudden days-months CN, long-tract

stroke sx’s/ signs

Cerebellar - sudden days-months unil dysmetria,

stroke “central” nystagmus

Slide 126

Medical Treatment

  • Symptomatic

  • Specific therapy

  • Vestibular

    rehabilitation

Slide 127

Symptomatic Pharmacotherapy

  • Predominant targeted vestibular neurotransmitters:

    • Cholinergic

    • Histaminergic

    • GABA neurotransmitters - negative inhibition

  • Vomiting center transmitters:

    • Dopaminergic (D2)

    • Histaminergic (H1)

    • Seratonergic

  • Multiple classes of drugs effective

Slide 128

Symptomatic Pharmacotherapy

  • Antihistaminergic - dimenhydrinate

  • Anticholinergics - scopolamine, meclizine

  • Anti-dopaminergic - droperidol

  • (gamma)-aminobutyric acid enhancing (GABA-ergic) agents - lorazepam, valium

Slide 129

Symptomatic Pharmacotherapy

  • Some drugs of the antihistamine class are useful for symptomatic control of vertigo

  • Have anti-motion sickness properties in large part due to inhibition of vestibular system H1 histaminergic neurotransmitters

  • Examples include dimenhydrinate (Dramamine) and promethazine (Phenergan)

  • Also suppress the vomiting center

Slide 130

Conclusion

1. Is this vertigo?

2. Is this central or peripheral?

3. History- focus on age, PMH, duration

4. Exam- focus on CN and coordination,

focal neurological findings, Dix-Hallpike

Slide 131

Bibliography

Baloh, R.W. (1998). Dizziness: neurological emergenices. Neurologic Clinics 16, 305-321.

Delaney, K.A. (2003). Bedside Diagnosis of Vertigo: Value of the History and Neurological Examination. Acad. Emerg. Med. 10, 1388-1395.

Neuhauser, H. and Lempert T. (2004). Vertigo and dizziness related to migraine: a diagnostic challenge. Cephalalgia 24, pp. 83–91.

Neurology in Clinical Practice (2000), ed. Bradley, W.G., Daroff, R.B., Fenichel, G.M., and Marsden, C.D., pp. 239-251.

Strupp et al. (2004). Methylprednisolone, Valacyclovir, or the Combination for Vestibular Neuritis. NEJM 351, pp. 354-361.

Slide 132

Tympanogram Site

http://www.utmb.edu/pedi_ed/AOM-Otitis/tympanometry/default.htm

  • Nice ear drum site

  • http://www.entusa.com/eardrum_and_middle_ear.htm

  • Acute Otitis Media Guidelines

  • http://www.aafp.org/x26481.xml

Slide 133

Additional Bibliography

  • Dykewicz M. Rhinitis and Sinusitis. J All Clin Immunol, 2003; 111:S520-9.

  • Hamilos DL. J Allergy Clin Immunol 2000;106:213-27.

  • Kaliner MA. Current Review of Rhinitis. Current Medicine, Inc., 2002.

  • Kaliner MA. Current Review of Allergic Diseases. Current Medicine, Inc., 2000.

  • Agency for Healthcare Research and Quality

  • American Academy of Pediatrics

  • New England Medical Center Evidence-based Practice Center

Slide 134

Additional Bibliography

  • Vincent MT et al. Pharyngitis. AFP 2004;69:1465-70.

  • Practice Guidelines. Dx & Rx of GABHS Pharyngitis. AFP 2003;67.

  • Kiderman A et al. Adjuvant prednisone therapy in pharyngitis. Br J Gen Pract Mar 2005;55:218-21.

Slide 135

You’ve had an earful…Any questions?

Slide 136

Acute Otitis Media -Infant Anatomy

  • As a child grows, the eustachian tube assumes a steeper angle, allowing more draining into the posterior pharynx.

  • The nerves to the tensor veli palatini, tensor tympani, and levator veli palatini become functional as Schwann cells lay down myelin. This then allows the eustachian tube to maintain its’ patency.

Slide 137

Adults

ant 2/3- cartilaginous

post 1/3- bony

45 degree angle

isthmus 1-2 mm

nasopharyngeal orifice 8-9 mm

Children

longer bony portion

10 degree angle

isthmus larger

nasopharyngeal orifice 4-5 mm in infants

Eustachian tube

Slide 140

Onusko, E, Tympanometry, AFP, Nov. 1, 2004, pp 1713-1720

Slide 141

Acute Otitis Media - Other Tid-bits

  • What about wax?

    • Cerumenolytics - Debrox, mineral oil, glycerin

    • Water irrigation/lavage - the nurses just love it when you order this!

    • Loop - code as cerumenectomy – JOKE!

    • Water Pik - probably not a good idea as it can cause a perforation when aimed directly at the TM

Slide 142

Acute Otitis Media - Other Tid-bits

  • What about an occluded PE/tympanostomy tube?

    • Gentamicin 0.3% ophthalmic drops in the ear can help reopen the PE tube (anecdotal evidence)

Slide 143

Acute Otitis Media - Other Tid-bits

  • Eustachian tube dysfunction - neat exam trick

  • Ask the patient to clear their ears (clamp their nostrils and blow) while you look in their ears.

  • The TM should move/pop - if it doesn’t, the eustachian tube is at least partially occluded.

Slide 144

The Dreaded Q-Tip Complication

Slide 145

Quiz – What is this?

Slide 146

And This?

Slide 147

How about this?

Slide 148

AUDIOMETRY

Slide 149

Case history

  • 1 1/2 year old wm presents to ENT clinic with 2nd episode of “ear infections” in last month

  • Normal history with no medical problems and no prior surgical procedures

  • Mother describes a “cold” for the last few days and then started running a fever and pulling at ears. Describes the child as very irritable

Slide 150

Physical Exam

  • Temp 100 F, VS wnl

  • Irritable child

  • Ears - eac clear, tms erythematous, bulging with yellowish MEE AU

  • Nose - clear rhinorrhea

  • otherwise wnl

Slide 151

Case history

  • Returns to clinic one month later with same complaints again

  • Dx as AOM

  • 3rd episode in last 2 mos and 5th in last year

Slide 152

Case history

  • Placed on sulfisoxizol prophylaxis

  • 3 wks later presents with recurrent AOM

Slide 153

Case history

  • BM&T performed, doing well at 3 wks

  • Mother calls at 3 mos and says has had to be tx with po abx and ear gtts 3 times by pcp for bilateral otorrhea

Slide 154

New Frontiers

  • Prevention more cost effective than treatment

  • Even slight decrease would have profound economic impact

    • Vaccines

    • Xylitol

Slide 155

Vaccines

  • Pneumococcal vaccine

    • poorly immunogenic in children

    • did exhibit antibody response

  • H. influenzae

    • no polysaccharide capsule

    • serum bactericidal antibody

  • M. catarrhalis

    • human pathogen

Slide 156

Vaccines

  • 150 viral immunotypes

  • 100 rhinoviruses with poor prognosis for vaccine development

  • RSV most common - developing intranasal delivery system

Slide 157

Xylitol

  • Sweetening substitute

  • Inhibits growth of pneumococcus and inhibits adhesion of pneumococcus and H. flu in nasopharynx

  • Gum and syrup reduced incidence of AOM 40% and 30%

Slide 158

Otoscopic oddities

  • 15 yo male with a h/o recurrent episodes of AOM as a child, now with a cold.

  • Otherwise normal exam except for these findings in the ears.

Slide 162

Otoscopic oddities

  • Tympanosclerosis - simply note it in the chart and keep movin

Slide 163

Otoscopic oddities

  • 8 yo female with dry cough for 2 weeks. Seems to be getting better but Mom wants her checked out.

  • You look in the ears and you see...

  • May also want to really check that lung exam thoroughly.

Slide 165

Otoscopic oddities

  • Bullous myringitis

    • Etiology - 50% influenza, 50% Mycoplasma

    • This helps your choice of antibiotics - use a macrolide, erythromycin is the board answer, may consider other macrolides (azithromycin or clarithromycin) although I have no literature to support this.

Slide 167

Otoscopic oddities

  • 35 yo female with a remote h/o a TM perforation now presents with ringing in her ears and mild pain. Occasional otorrhea.

  • Otoscopy shows ...

Slide 171

Otoscopic oddities

  • Cholesteatoma

    • Refer to ENT - enough said.

    • Separate talk but I just wanted you to at least see a few examples.

Slide 172

Otoscopic oddities

  • 50 yo female, had an MI 2 weeks ago, just discharged 3 days ago, now with pain in his left ear. Also states that she is having trouble drinking and has to use a straw because the fluid is leaking out the side of his mouth (What in the world?!!!)

  • Otoscopy shows vesicles in the external auditory canal

Slide 174

Otoscopic oddities

  • Herpes Zoster of the external auditory canal and a seventh nerve palsy on the right (lower motor neuron-type, patient unable to raise his eyebrow/wrinkle her forehead).

  • This is called Ramsey Hunt Syndrome.

Slide 175

Pathogenesis of Nasal Obstruction

  • Viral upper respiratory infections

    • Daycare centers

  • Allergic and nonallergic stimuli

  • Immunodeficiency disorders

    • Immunoglobulin deficiency (IgA, IgG)

  • Anatomic changes

    • Deviated septum, conchabullosa, polyps

Slide 176

Sinus Transillumination

  • Helpful in older children and adults

  • Normal transillumination decreases chance of pus in the sinus

  • No light reflex suggests mucopurulent material or thickening of nasal mucosa

  • Inexpensive screening tool

Slide 177

Sinus Transillumination

  • Have patient sit at your eye level in darkened room (the darker the better)

  • Let eyes get accustomed to dark

  • Place bright light (transilluminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinuses

  • Look at palate for presence/absence of transilluminated light

Slide 178

Transillumination of Frontal Sinus

Slide 179

Transillumination of Maxillary Sinus

Slide 180

Chronic Sinusitis

  • Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children

  • Eosinophilic inflammation or chronic infection

  • Associated with positive CT scans

  • Poor (if any) response to antibiotics

Slide 181

Sx of Chronic Sinusitis

  • Nasal discharge

  • Nasal congestion

  • Headache

  • Facial pain or pressure

  • Olfactory disturbance

  • Fever and halitosis

  • Cough (worse when lying down)

Slide 182

Conditions Causing Chronic Sinusitis

  • Allergic and nonallergic rhinitis

  • Uncorrected anatomic conditions

  • Ciliary dyskinesia

  • Cystic fibrosis

  • Tumors

  • Immunodeficiency disorders

    • IgA, IgM

  • Granulomatous diseases

Slide 183

Evaluation of Chronic Sinusitis

  • CT or MRI scanning

    • Anatomic defects, tumors, fungi

  • Allergy testing

    • Inhalants, fungi, foods

  • Sinus aspiration for cultures

    • Bacterial

    • Fungal

  • Immunoglobulins

Slide 184

Treatment of Chronic Sinusitis

  • Nasal steroid spray

  • Guafenesin

  • Decongestants

  • Steam inhalation

  • Nasal irrigation

  • Antibiotics with exacerbations

Slide 185

Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown

  • Streptococcus pneumoniae

  • Haemophilus influenza

  • Moraxella catarrhalis

  • Staph aureus

  • Coagulase negative staphylococcus

  • Anerobic bacteria

Slide 186

Sinus Aspiration and Culture

  • Correlation of routine nasal culture and sinus culture are poor

  • Endoscopically guided aspiration of cultures from medial meatus do correlate with sinus culture

    • Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997;107: 1586.

Slide 187

Recommendations Made for Antibiotic Prophylaxis in ABS

  • Has not been evaluated as has its use in otitis media

  • Increasing evidence of antibiotic resistance is an issue

  • May be tried in chronic or recurrent disease

Slide 188

Complications of Sinusitis

  • Orbital

    • Diplopia, proptosis

    • Periorbital erythema, swelling

  • Bone

    • Periosteal abscesses

  • Brain

    • Intracranial abscesses causing neurologic symptoms

Slide 189

Indications for Referral

  • Allergy testing, possible immunotherapy

  • Sinus aspiration for bacterial culture

  • Surgical intervention

    • Correct obstructive process

    • Drain sinus abscesses

    • Consideration to remove nasal polyps

Slide 190

Indications for Hospitalization

  • Acutely ill child or adult with high fever, severe head pain

  • Suspected sphenoid sinusitis

  • Anytime complications of eye, bone or intracranial structures are present

Slide 191

Pathophysiology

  • Vestibular labyrinth - detects linear and angular head movements

  • Semicircular canals - angular

    • Hair cells organized under cupula

  • Otolithic organs (utricle, sacule) - linear

    • Hair cells attached to a layer of otoconia

  • Vestibular nerve - superior, inferior branch

  • Afferent nerve fibers are bipolar - cell bodies lie within Scarpa’s ganglion

Slide 192

Pathophysiology

  • Balance requires –

    • Normal functioning vestibular system

    • Input from visual system (vestibulo-ocular)

    • Input from proprioceptive system (vestibulo-spinal)

  • Central causes compromise central circuits that mediate vestibular influences on posture, gaze control, autonomic fx

  • Disruption of balance between inputs results in vertigo

  • Goal of treatment: restore balance between different inputs

Slide 193

Pathophysiology

  • Vestibular system influences autonomic system

  • Intimate linkage in brainstem pathways between vestibular and visceral inputs

  • Alteration of vestibular inputs results in:

    • nausea, vomiting

    • Pallor

    • Respiratory/circulatory changes

Slide 194

Migraine

  • Concomitant vertigo and disequilibrium

  • Headache control improves vertigo

  • Diagnostic criteria

    • Personal/family history

    • Motion intolerance

    • Vestibular symptoms - do not fit other causes

  • Theories - vascular origin, abnormal neural activity (brainstem), abnormal voltage-gated calcium channel genes

Slide 195

Migraine

  • Treatment

    • Modifying risk factors

      • Exercise and diet

      • Avoid nicotine, caffeine, red wine and chocolate

    • Abortive medical therapy

      • Ergots

      • Sumatriptin

      • Midrin

    • Prophylactic medical therapy

      • B blockers, Ca channel blockers, NSAIDs, amitryptiline, and lithium

Slide 196

Vertebrobasilar insufficiency

  • Vertigo, diplopia, dysarthria, gait ataxia and bilateral sensory & motor disturbance

  • Transient ischemia - low stroke risk

  • Antiplatelet therapy - aspirin 325mg qD

  • Ticlid

    • Platelet aggregate inhibitor

    • Risk of life-threatening neutropenia

    • Only in patients unable to tolerate aspirin

Slide 197

Meniere’s Disease

  • Vasodilators

    • Based on hypothesis - pathogenesis results from ischemia of striavascularis

    • Rationale - improve metabolic function

    • IV histamine, ISDN, cinnarizine (CA agonist), betahistine (oral histamine analogue)

    • Anecdotal success

    • No demonstrated beneficial effects in studies

Slide 198

Meniere’s Disease

  • Newer theories

    • Multifactorial inheritance

    • Immune-mediated phenomena

    • Association of allergies

  • Study by Gottschlich et al.

    • 50% meeting criteria have antibodies to 70-kD heat-shock protein

    • 70-kD HSP implicated in AI-SNHL

Slide 199

Meniere’s Disease

  • Immunosuppressive agents gaining favor

    • Systemic and intra-tympanic glucocorticoids

    • Cyclophosphamide

    • Methotrexate

  • Shea study - intractable Meniere’s

    • 48 patients IT dexamethasone

    • 66.7% elimination of vertigo

    • 35.4% improvement in hearing (>10dB and/or 15% change in word recognition score)

Slide 200

Meniere’s Disease

  • Chemical labyrinthectomy

    • Disabling vertigo

    • After trial of adequate medical therapy

  • Intratympanicaminoglycoside (ITAG)

  • Allows treatment of unilateral disease

  • Gentamicin

    • Primarily vestibulotoxic

    • may impair vestibular dark cells (endolymph)

  • Inherent hearing loss risk - 30%

Slide 201

Symptomatic Pharmacotherapy

Slide 202

Specific Pharmacotherapy

  • Vestibular Neuritis *

  • Meniere’s Disease *

  • Benign Paroxysmal Positional Vertigo *

  • Otosyphilis

  • Vertebrobasilar Insufficiency

  • Migraine (with vertigo)

    * more common

Slide 203

Vestibular Rehabilitation

  • Promoting vestibular compensation

  • Habituation

  • Enhancing adaptation of VOR & VSR

  • May have initial exacerbation

Slide 204

Vestibular Rehabilitation

  • Habituation of pathologic responses

  • Postural control exercises

  • Visual-vestibular interaction

  • Conditioning activities

  • B.I.D., most improve after 4-6 weeks


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