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AUD spring 19 Medical > First Exam > Flashcards

First Exam Flashcards

1
Q

perichondritis/ Condritis basics

A

infectious

  • inflam of perichondrium and the underlying cartilage
  • painful swelling
  • refer to physician
  • fever and other signs of infection
  • tender auricle
  • edema
  • in advanced cases: crusting, involvement of soft tissues, induration
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2
Q

perichondritis causes

A

pathogens:

  • pseudomonas aeruginosa
  • staphylococcus aureus

viral infections: varicella zoster virus which will cause facial paralysis

noninfectious causes:

  • trauma (includes post-op)
  • allergy
  • spontaneous–overt diabetes
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3
Q

perichondritis treatment

A

mild: debridement, topical and oral antibiotic
advanced: hospitalization and IV antibiotics
chronic: surgical intervention with excision of necrotic tissue and skin coverage

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4
Q

relapsing polychondritis

A
  • episodic and progressive inflammation of cartilage
  • fever and pain
  • swelling erythema
  • lab: anemia, elevated ESR
  • autioimmune disease is likely cause
  • treat with oral corticosteroids
  • **other sites affected: larynx, trachea, bronchi, and nose
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5
Q

acute otitis externa

A

swimmer’s ear

  • preinflammatory stage is self-limited
  • acute inflammatory stage (mild, moderate, severe)
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6
Q

what happens during the preinflammatory stage of Acute Otitis Media?

A

edema of stratum corneum and plugging of apopilosebaceous unit (apocrine, sebacaous glands, and hair follicles)

  • symptoms: pruritis and sense of fullness
  • signs: mild edema, starts the itch/scratch cycle
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7
Q

pruritis

A

itching

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8
Q

causes of acute otitis externa

A

swimming in unclean water:

  • pseudomonas aeruginosa= main cause
  • staph aureus and albus, proteus, bacillus, and coliforms
  • fungus in tropical climates
  • heat, humidity, and mositure

trauma due to ear cleaning:

  • cerumen/ foreign body removal
  • HAs
  • earplugs/earphones
  • cotton swabs
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9
Q

mild to moderate acute otitis externa

A
  • progressive infection
  • symptoms: pain and increased pruritis
  • signs: erythema, increasing edema, canal debris, discharge
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10
Q

severe acute otitis externa

A
  • severe pain, worse with ear movement
  • signs: lumen obliteration, involvement of periauricular soft tissue, purulent otorrhea (greenish gray color and unique odor which is pungent and sweet), polyp of debris
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11
Q

acute otitis externa treatment

A
  • pathogens: p. aeruginose and S. aureus
  • *debridement
  • *topical antibiotics (neomycin= staphylococcus; polymycin= pseudomonas and G-; hydrocortisone=minimise edema and erythema)
  • *pain control
  • *instructions for prevention

–less often used: acetic acid, boric acid, alcohol drops, garamycin, opththalmic solution

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12
Q

chronic otitic externa causes

A

dermatological etiologies (would have improved with antibiotics if it were bacterial)

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13
Q

what makes chronic otitis exterma different from acute?

A
  • chronic is persistent symptons for more than 2 months and is less about bacterial infection
  • chronic is dull ache and acute is sharp pain
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14
Q

manifestations of chronic otitis externa

A
  • common in elderly because they use q-tips
  • symptoms: pruritis and mild discomfort
  • signs: dry and flaky skin, hypertrophied skin, mucopurulent otorrhea ( occasional)
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15
Q

chronic otitis externa treatment

A
  • similar to that of AOE: frequent cleaning and topical antibiotics
  • topical steroids
  • surgical intervention: failure of medical treatment; the goal is to enlarge and resurface to external ear canal
  • ***DIFFICULT TO TREAT: it takes a long time to improve the condition
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16
Q

Chronic malignant OE basics

A

necrotizing OE

  • osteomyelitis of the skull base:
  • spread of infection from soft tissue to the bone
  • potentially lethal infection
  • pseudomonas aeruginose is the usual culprit
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17
Q

risk factors of malignant oe

A
  • diabetes
  • immunocompromised
  • advanced age
  • swimming
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18
Q

three pathogens which can cause malignant otitis externa

A
  • pseudomonas aeruginose (main cause)
  • staphlococcus aureus
  • aspergillus species (rarely)
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19
Q

symptoms of malignant OE

A
  • poorly controlled diabetic with history of OE
  • similar to acute OE:
  • -otalgia (deep-seated aural pain)
    • chronic otorrhea
  • -aural fullness
  • malignant symptoms:
  • -hearing loss
  • -hoarseness of voice
  • -aspiration
  • -dysphagia
  • -facial palsy
  • -cranial neuropathies
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20
Q

Malignant OE signs

A
  • inflammation and granulation*
  • purulent secretions
  • occluded canal and obscured TM
  • -canal edema
  • cranial nerve involvement*
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21
Q

stage I malignant OE

A

infection of the EAC and soft tissues; with or without VII nerve involvement

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22
Q

stage II malignant OE

A

extension of the infection to include osteitis of the skull base and skull base cranial nerves

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23
Q

stage III malignant OE

A

intracranial extension

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24
Q

malignant OE differential diagnosis versus acute OE

A

Rule:

  • acute OE pt will not have any cranial nerve signs or symptoms
  • cranial neuropathies are common with malignant OE (VII nerve weakness, etc.)
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25
Q

malignant OE diagnosis

A
  • physician’s suspicion
  • clinical findings
  • laboratory evidence
  • imaging
  • plain films
  • CT scan (most used)
  • MRI
  • Gallium Scan with Technetium 99
  • –signs of osteomyelitis
  • –also useful for evaluating Rx
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26
Q

Gallium Scan Technetium 99m

A

temporal bone osteomyelitis

  • nuclear medicine studies technique
  • highly sensitive to temporal bone osteomyelitis
  • enhancement along the entire temporal bone
  • -increased uptake
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27
Q

necrotizing/malignant otitis externa treatment

A

*main line of Rx:
–IV antibiotics for at lease 4 weeks
—-aminoglycoside, Cephalosporin, Quinolones
—-with serial Gallium scans monthly
+
–local canal debridement until healed
–pain control
–control of diabetes
—-watch renal function b/c diabetes-renal failure
–surgical debridement for refractory cases

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28
Q

necrotizing/malignant otitis externa fatalities

A
  • death rate= 37%-23% which is essentially unchanged despite newer antibiotics
  • higher with multiple cranial neuropathies (60%)
  • recurrence not uncommon (9-27%)
  • may recur up to 12 months after treatment
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29
Q

radiation-induced otitis externa

A
  • OE ocurring after radiotherapy
  • treatment:
  • -often difficult to treat
  • -limited infection—treated like COE
  • -involvement of bone
  • —surgical debridement and
  • —skin coverage
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30
Q

Otomycosis causes (pathogens)

A
  • fungal infection of the EAC skin (primary and secondary)
  • causes:
  • -aspergillus niger and Candida (most common)
  • —causing otomycosis in 50-90% of cases
  • -chronic OE
  • —debris build-up from the end-product of chronic OE after cleaning
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31
Q

otomycosis symptons

A

similar to OE

  • pruritis deep within the ear
  • dull pain
  • discharge with black spots
  • hearing loss (obstructive)
  • tinnitus
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32
Q

otomycosis signs

A
  • canal erythema
  • mild edema
  • white, gray, or black fungal debris
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33
Q

otomycosis vs otitis externa

A

often indistinguishable from OE

  • suspected when typical “swimmers ear”:
  • does not respond to antibiotic Rx
  • tinnitus
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34
Q

otomycosis treatment

A

primarily: aural cleaning and drying of the ear canal (this is the most important line of treatment)
* rarely: topical antifungal (not necessary)

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35
Q

furunclosis (what is it?)

A

*acute localized OE
an abscess or blister of the hair follicle (in lateral 1/3 or posterosuperior canal because this is where hair follicles are)

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36
Q

furunclosis cause

A
  • staph. aureus

* obstructed apopilosebaceous unit=abscess

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37
Q

furunclosis symptons

A
  • localized pain
  • pruritis
  • hearing loss (if lesion occludes canal)
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38
Q

furunclosis signa

A

in the cartilaginous canal:

  • edema
  • erythema
  • tenderness
  • —-bony canal and TM are normal
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39
Q

furunclosis treatment with no abscess

A
  • warm compresses
  • oral anti-staphylococcal antibiotics
  • analgesics (aka painkiller)
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40
Q

furunclosis treatment with abscess

A
  • localized: incision and drainage

* soft tissue extension: IV antibiotics

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41
Q

causes of stenosis of the EAC

A

(non-infectious)

  • chronic OE
  • trauma to the ear (penetrating or blunt)
  • otologic operations
  • dermatologic diseases–stricture formation
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42
Q

treatment of stenosis of the EAC

A
  • early: stenting and antibiotic-steroid solutions
  • late (stenosis): surgery
  • canaloplasty and meatoplasty
  • —removal or the diseased skin and bone, then relined with a skin graft
  • —packed for 10-14 days with gauze coated with antibiotic ointment
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43
Q

Atresia Epidemiology

A

1-20,000 live births

  • bilateral 30% of cases
  • more common in males than females and also more common in the right ear
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44
Q

atresia etiology

A
  • inherited defects or syndromes
  • aquired:
  • intrauterine infection such as rubella or syphilis
  • ischemic injury: hemifacial microsomia
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45
Q

crouzon syndrome

A
  • syndrome associated with atresia and microtia
  • AD inheritance
  • craniafacial dysostosis
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46
Q

MR

A
  • syndrome associated with atresia and microtia

* central nervous system

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47
Q

1st and 2nd branchial arch syndromes

A
  • syndrome associated with atresia and microtia

* oral cavity

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48
Q

branchial fistulas

A
  • associated with atresia and microtia

* the neck

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49
Q

chromosonal anomalities affecting external and middle ears

A
  • turner syndrome

* trisomies (13, 14, 15, 18, 21, 22)

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50
Q

list of syndromes associated with atresia and microtia

A
  • crouzon syndrome
  • MR
  • 1st and 2nd branchial arch syndromes
  • branchial fistulas
  • chromosomal anomalies
  • —turner syndrome
  • —trisomies
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51
Q

list of syndromes associated with congenital aural atresia

A
  • VATER (or VATERL) association
  • CHARGE syndrome
  • Treacher Collins syndrome (AD)
  • Pierre-Robin syndrome
  • Goldenhar
  • Alport
  • others
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52
Q

VATER or VATERL association

A 
vertebral defects
anal atresia
tracheoesphageol fistula
esophageal atresia
renal defects
limb abnormalities
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53
Q

CHARGE syndrome

A 
coloboma (optic fissure)
heart defect
atresia
retarded growth
genitourinary defects
ear anomalies
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54
Q

Type I atresia

A

mild
small ear canal
almost normal middle ear

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55
Q

type II atresia

A

medium
a bony atresia plate replaces the canal
ossicular malformation is common

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56
Q

type III atresia

A

severe
both the ear canal and the middle ear space are small or absent
(hearing loss with atresia is usually conductive (but may be mixed) in varying degrees depending on the severity of the atresia and whether it is bony or membranous

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57
Q

management for unilateral atresia

A
  • preferential seating in classroom

* possible CROS hearing aid and/or BAHA

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58
Q

management for bilateral atresia

A

BC hearing aids or BAHA or surgical intervention

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59
Q

management for atresia and microtia

A

correct microtia first, as the degree of atresia will likely change as the child growa

*post-op results of 15-20 dB improvement can be expected in 30-80% of patients

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60
Q

surgical complications of atresia

A
  • facial paresis= 10% of pts
  • lateral meatal stenosis= 25% of pts
  • graft failure of TM= 5-10% of pts
  • cholesteatoma= 3-15% of pts
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61
Q

causes of trauma of pinna and EAC

A
  • penetrating or blunt trauma
  • —laceration of EAC
  • temporal bone fracture
  • burns:
  • —chemical
  • —thermal
  • —electrical
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62
Q

complications of trauma to pinna and EAC

A
  • severe OE
  • perichondritis
  • loss of canal skin
  • secondary stenosis
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63
Q

management of trauma to pinna and EAC

A
  • no specific Rx
  • chemical burns: wash out ASAP
  • thermal and electrical burns are destructive: remove burned tissue and inspection under magnification
  • packing with gelatin foam soaked with antibiotic solution to avoid secondary infection
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64
Q

primary pruitis

A

itching in the EAC without apparent cause

  • predisposing factors
  • secondary causes associated with:
  • —allergy: inhalant or food
  • —systematic: DM, hepatic or renal disease, lymphoma or leulemia
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65
Q

treatment of primary pruritis

A

steroid cream or ointment for primary pruritis

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66
Q

three types of dermatitis

A

a. contact type
b. allergic type
c. infectious eczematoid dermatitis

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67
Q

contact type dermatitis

A

secondary to irritating agents

*earmold materal (use hypoallergenic material

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68
Q

allergic type dermatitis

A

hypersensitivity reaction of the skin

  • causes:
  • —shampoo or hairspray
  • —earmold solvents, ear drops (neomycin)
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69
Q

treatment for contact type and allergic type dermatitis

A

stop use

  • clean ear with saline or mild acetic acid solution
  • steroid ointment of systemic steroids and antipruritis (severe cases)
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70
Q

infectious eczematoid dermatitis

A

contact with purulent middle ear discharge

*EAC: inflamed, yellow plaques

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71
Q

treatment for infectious eczematoid dermatitis

A
  • treat the cause=chronic OM
  • supportive: cleaning, suction, topical antibiotics
  • steroids
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72
Q

melanoma

A

benign tumor of the EAC (skin lesion)

  • occur in the cartilagenous part
  • —melanocytes are only present there
  • diagnosed through biopsy
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73
Q

exostosis

A

bony lesion of EAC

  • reactive “refrigeration periostitis”
  • young adults
  • non-occlusive
  • multiple
  • bilateral
  • histology-sessile lamellar bone
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74
Q

osteoma

A

bony lesion of EAC

  • neoplasm
  • —tympanosquamous suture
  • —tympanomastoid suture
  • middle-aged adults
  • occlusive
  • single
  • unilateral
  • histology-pedunculated trabecular
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75
Q

what are angiomas?

A

congenital tumors–common in childhood

  • —soon after birth and may grow in the first 2 yrs of life
  • may involve auricle and other areas of the face and neck
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76
Q

types of angiomas

A
  • capillary hemangioma

* cavernous hemangioma/strawberry tymor

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77
Q

capillary hemangioma

A

type of angioma

  • benign lesions of the skin
  • masses of capillary-sized vessels usually forms a flat mass
  • —spider nevus: not major problem (treated with needle coagulation)
  • —port-wine stain: problematic (it increases in size until adolescence–generally disfiguring)
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78
Q

cavernous hemangioma/strawberry tumor

A

type of angioma

  • consists of raised masses of blood filled endothelial spaces- “strawberry tumor”
  • increases rapidly in size during the first year of life then regresses thereafter
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79
Q

treatment of angiomas

A
  • no intervention is required if
  • —smaller on involuted (return to normal size, after the age of 2 or 3)
  • indication of treatment
  • —no involution
  • —bleeding or infection
  • treatment options
  • —systemic steroid-arrest growth
  • —injection with sclerosing agents
  • —surgical excision
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80
Q

adenoma

A

ceruminal gland

  • 40-60 yrs; 3-1 male predominance
  • symptoms
  • —small=asymptomatic
  • —large=obstruction of EAC and infection
  • sign
  • —non ulcerated nodule in the lateral wall of the EAC
  • histology
  • —grayish red, cystic. in-defined capsule
  • treatment
  • —excision of the lesion
  • —skin graft when needed
  • —incomplete excision= recurrence
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81
Q

adenocarcinoma

A

ceruminal gland

  • middle age or older; male predominance
  • symptoms
  • —otalgia; bloody aural discharge
  • —hearing loss
  • sign
  • —erythema and ulceration of the EAC
  • histology
  • —same grayish red, cystic, in-defined capsule and more mitotic activity and invasion
  • treatment
  • —same excision of the lesion
  • —skin graft when needed
  • —post-op radiation
  • recurrence is common: 10-50% of pts
  • metastasis is uncommon
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82
Q

list the benign lesions/tumors of the pinna

A
  • cyst and fistula
  • keloid
  • appendages
  • papilloma (benign tumor)
  • —irritation, similar to warts
83
Q

list the primary malignant neoplasms of the auricle and EAC

A
  • squamous cell carcinoma (most common)
  • basal cell carcinoma (rare)
  • adenoidcyctic
  • *melanoma
84
Q

warning signs of malignancy

A
  • persistent otalgia
  • bloody otorrhea
  • exposure of bone
  • response failure to routine therapy
  • VII nerve paralysis
  • regional lymphadenopathy
85
Q

squamous cell carcinoma management

A
  • limited to the EAC
  • —en block resection of the EAC, TM, and parotid gland
  • —control rate:80-85% if limited to EAC
  • extension to middle ear, mastoid VII nerve, or medial structures
  • —complete resection of the temporal bone
  • ——mandibular condyle
  • ——squamous and petrous portions
  • ——any involved middle fossa dura
  • —post-op radiation
  • —control rate is bad
86
Q

list of tumor-like lesions of the EAC

A
  • EAC cholesteatoma
  • keratosis obturans
  • inflammatory polyps
87
Q

Keratosis Obturans

A

Involved ear: bilateral

  • debris: Attached occluding
  • symptoms: otalgia, CHL
  • bronchietasis: +
  • bone exposure: no
  • age: young
  • origin: diffuse
88
Q

Canal Cholesteatoma

A
  • involved ear: unilateral
  • debris: loose, nonoccluding
  • symptoms: otorrhea
  • bronchiectasis: no
  • bone exposure: yes
  • age: old
  • origin: focalized
89
Q

Inflammatory Polyps

A

Causes:

  • rare from canal wall
  • TM perf, cholesteatoma
  • Trauma/ Postop trauma
  • squamous cell carcinoma or glomus tumor of the middle ear (rare)
90
Q

inflammatory polyps exam

A
  • smooth, pale, pedunculated
  • purulent discharge around it
  • affect ossicles, VII nerve
91
Q

Inflammatory polyps management

A
  • conservative- topical antibiotic-steroid preparation and aural cleaning
  • cautery- with silver nitrate
  • surgical removal-middle ear exploration and excision
  • pathologic exam- is required to rule out the possibility of a tumor
92
Q

Two lesions of the TM

A

granular myringitis

bullous myringitis

93
Q

granular myringitis basics

A
  • localized chronic inflam of pars tensa with granulation tissue
  • Tonybee described in 1860
  • sequela of:
  • -primary acute myringitis
  • -previous OE, perforation of TM
94
Q

granular myringitis common organisms

A
  • pseudomonas

* proteus

95
Q

granular myringitis symptoms

A
  • foul smelling discharge from one ear
  • often asymptomatic
  • slight irritation or fullness
  • no hearing loss or significant pain
96
Q

granular myringitis signs

A
  • TM obscured by pus
  • “peeping” granulations
  • no TM perforations
97
Q

granular myringitis (GM) treatment

A
  • careful and frequent debridement
  • topical anti-pseudomonal antibiotics
  • -occasionally combined with steroids
  • at least two weeks of therapy
  • careful destruction of granulation tissue if no response
98
Q

bullous myringitis basics

A
  • viral infection
  • confined to TM
  • primarily involves younger childres
99
Q

bullous myringitis symptoms

A
  • sudden onset of severe pain
  • no fever
  • no hearing impairment
  • bloody otorrhea (significant) if rupture
100
Q

bullous myringitis signs

A
  • inflam limited to TM and nearby canal
  • multiple reddened, inflamed blebs
  • hemorrhagic vesicles
101
Q

bullous myringitis treatment

A
  • self-limiting
  • analgesics
  • topical antibiotics to prevent secondary infection
  • incision of blebs is unnecessary
102
Q

referred pain

A
  • sensation to the ear is provided by cranial nerves V, VII, IX, X, and the C1-2 plexus
  • diseases elsewhere in the hear and neck may refer pain to the ear
  • the 10 T’s of otalgia
103
Q

list the 10 T’s of otalgia

A
  • TMJ
  • tonsils
  • throat
  • Tube (eustachian)
  • teeth
  • tongue
  • tics (glossopharyngeal)
  • trachea
  • thyroid
  • tendons
104
Q

basic, basic definition of otitis media (OM)

A

inflammatory condition of the middle ear space

105
Q

classification of OM (list them)

A
  • OM without effusion or perforation
  • OM with effusion without perforation
  • OM with perforation (with or without discharge)
106
Q

OM without effusion or perforation

A
  • inflam of the ME mucous membrane and TM

* it may involve only the TM which is called myringitis

107
Q

OM with effusion, without perforation

A
  • acute: serous, purulent
  • subacute: serous, purulent, mucoid
  • chronic: serous, purulent, mucoid
108
Q

OM with perforation (With or without discharge)

A
  • acute (0-21 days)
  • subacute: (22 days-8 weeks)
  • chronic: (longer than 8 weeks)
109
Q

otitis media and children

A
  • most common reason for visit to pediatrician
  • tympanostomy tube placement is 2nd most common surgical procedure in children
  • development of multi-drug resistant bacteria
110
Q

OME in adults and causes

A
  • less common without predisposing conditions
  • causes:
  • -nasopharyngeal carcinoma or lymphoma
  • -sinustis= decongestant and antibiotics
  • -nasogastric or nasotracheal tube= obstruct ET orifices by the tube and nasopharyngeal inflammation
  • -barotrauma= negative ME pressure= transudate in the ME and rupture of small blood vessels
  • -adenoid hypertrophy+ OME= HIV test
111
Q

Acute Otitis Media (AOM) basics

A
  • one point in a continuum of the disease process of OM

* TM is red and thickened/bulged

112
Q

acute otitis media pathogens

A

in order of symptom severity and complication from most to least:

  • S. Pneumonia
  • H Flu-type B
  • H. flu-nontypable
  • M. catarrhalis
  • ———–the antibiotic resistance to the drug depends on the use of antibiotic therapy/year. The more courses of antibiotic/year, the more the resistance to penicillin
113
Q

clinical course of acute otitis media

A
  • self limited
  • 10-15dB CHL
  • up to 25 dB if there is effusion
  • serious complications possible

—-nonspecific (general) and ear specific symptoms

114
Q

percent of acute otitis media that resolves spontaneously

A

95% of cases

115
Q

initial treatment of acute otitis media

A
  • antimicrobial therapy: 10-14 days

* antihistamines and oral decongestants?

116
Q

if acute otitis media symptoms have not improved with initial treatment of AOE

A
  • tympanocentesis for culture

* possible myingotomy for drainage may be indicated

117
Q

duration of acute otitis media with effusion

A
  • clear within 6 wks in 75-85% of cases
  • may last up to 12 weeks
  • —unresolved AOM= progressing of bacterial infection
118
Q

Acute Suppurative otitis media (ASOM) definition

A

an acute exudative ME disease secondary to bacterial infection
*exudate: serum, fibrin, red cells, and leuocytes–fills ME cavity under pressure

119
Q

Acute suppurative otitis media symptoms

A
  • otalgia; relieved by TM rupture
  • ear stuffiness
  • CHL
120
Q

Acute suppurative otitis media signs

A
  • the TM is thickened and bulging–CHL , otalgia, and fever
  • vascular TM (erythema stage)
  • mastoid may be swollen and tender
  • TM rupture (late stage)
121
Q

acute suppurative otitis media with discharge:

general/medical Rx

A
  • self limiting in 80% of cases
  • general Rx for acute infection:
  • -bed rest, hydration, light diet, no smoking
  • avoid nasal dryness and crusting
  • -decongestants, humidifier, warm steam vaporizers
  • systemic antibiotics, better after culture–for 10-14 days
122
Q

acute suppurative otitis media with discharge: treatment/surgical Rx

A
  • antibiotics + myringotomy:
  • -when the TM is inflamed and bulging, severe otalgia and fever
  • follow up (otoscopy and audiometric eval)
  • -for any persistent MEE–recurrent suppurative OM
123
Q

acute suppurative otitis media: acute complications

A
  • acute mastoiditis
  • VII nerve paralysis
  • acute labyrinthitis–mixed HL
  • sigmoid sinus thromboplebitis
  • intracranial infection:
  • -meningitis, brain abscess
124
Q

acute suppurative otitis media: chronic complications

A
  • TM perforation
  • cholesteatoma
  • tympanosclerosis
  • ossicular necrosis
  • toxic/suppurative labyrinthitis
  • intracranial suppuration
125
Q

three types of otitis media with effusion

A
  • serous otitis media
  • nonpurulent otitis media
  • glue ear
126
Q

what would you see in otoscopy with serous otitis media?

A
  • amber color of TM

* some dilated vessels

127
Q

otitis media with effusion basics

A
  • follows acute otitis media
  • self-limited
  • insidious symptoms and signs–go undetected
  • hearing loss–concern of patients
  • average of 25 dB hearing loss
128
Q

pathogenesis of OME

A
  • ET dysfunction primary
  • -developmental
  • -cleft palate
  • mechanism
129
Q

otitis media with effusion findings

A
  • otoscopy:
  • -bulging of TM (atrophic area)
  • -diminished mobility
  • -dull and opaque TM
  • -retraction signs
  • -fluid level and air bubbles
  • tymp, wideband tymp, PTA (you should know this)
130
Q

management of Otitis media with effusion for kids 1-3 yrs with no neurologic or craniofacial abnormalities

A
  • observation for 3 months or antibiotic RX

* counseling on predisposing factors

131
Q

management for persistent otitis media with effusion after three months

A
  • hearing eval
  • observation or antibiotics
  • -bilateral or unilateral loss < 20 dB
  • antibiotics or myringotomy + tube
  • -bilateral loss>/= 20 dB
  • myrungotomy + tube application
  • -bilateral loss >/= 20 dB +
  • -unresponsive OME for > 3 months
  • -recurrent OME: 3-4 episodes/year
  • -recurrent AOM .3/6 months or > 4/12 months
  • -cleft palate
  • -suppurative complication
132
Q

complications with T-tube

A
  • none: 54% of pts
  • otorrhea
  • TM perf
  • hearing loss (10-30 dB) (15%)
  • granulation tissues
  • early occlusion of the tube
  • early extrusion of the tube: replace/reinsertion
  • attic retraction: 17%
  • -cholesteatoma (1%)
133
Q

chronic otitis media basics

A
  • chronic/persistent inflammation/infection
  • -the ME and mastoid
  • -duration> 3 months
  • associated with TM perf
  • -failure of medical Rx of acute suppurative process
134
Q

chronic otitis media pathogens

A
  • common:
  • -pseudomonas aeruginose
  • -staphylococcus aureus
  • other forms:
  • -aerobic bacteria: escherichia coli
  • -anaerobes: bacteroids
  • -B-lactamase-producing bacteria
  • -streptococci and a-hemolytic
135
Q

chronic otitis media pathogensis (course)

A

1) unresolves OME + pathogens
2) mucosal edema of the ME and mastoid cells
3) “aditus block” (oblit of air cells and aditus ad antrum)
4) repeated infections
- -5) accurulation of MEE
- -6) TM perf

136
Q

chronic otitis media clinical findings (symptoms)

A

relatively asymptomatic

  • Hx of freq earaches during childhood
  • bilateral ear problems
  • Hx of ME/mastoid surgery
  • otorrhea: intermittent or continuous malodor discharge
  • otalgia: active infection, mastoiditis, intracranial complications
  • vertigo: rare-labyrinthitis or labyrinthine fistula
  • hearing loss
137
Q

chronic otitis media clinical finding (audiometry)

A
  • pure tone audio
  • -CHL 18-33 dB
  • -high frequency SNHL (6-13 dB) due to bacterial toxins
  • bone conduction and WRS
  • -within normal
  • tymps: flat, normal volume
  • vestibular eval
  • -if there is vertigo
138
Q

chronic otitis media clinical findings (imaging)

A
  • radiographic evaluation
  • -mastoid films
  • -CT scan: staging
  • -MRI
  • indications (CT or MRI):
  • -persistent otorrhea
  • -VII weakness or
  • -labyrinthine symptoms
139
Q

chronic otitis media without cholesteatoma treatment

A
  • aural toilet
  • -topical antibacterial agents–possible ototoxicity
  • -frequenct suctioning
  • parental antibiotics:
  • -culture and sensitivity for otorrhea
  • -penicillin + amnioglycoside
  • -ceftazidime
  • -Rx 14-21 days or 3 days after dry
  • —dry ears (1 year) in the majority of patients (75-90%)
140
Q

COM with cholesteatoma

A

*tympanoplasty
*mastoidectomy (tympanomastoidectomy)
*efficacy of surgery in 90% of patients
–hearing improvement
–dry ear
*pediatric cholesteatomas:
more difficult to remove surgically; grows at a faster rate, frequency ME infection from ET dysfunction

141
Q

COM sequelae

A

irreversible damage to ME structures

  • otoscopic exam
  • -tympanosclerosis
  • -retraction pockets
  • -adhesive otitis
  • -atrophy
  • -TM perforation
  • -cholesteatoma
  • -erosion of ossicles
142
Q

complications of COM: extratemporal/extracranial

A
  • neck abscess (Bezolds)

* subperiosteal abscess

143
Q

cholesteatoma another name and definition

A

keratoma

  • a pearly tumor of fat, among sheets of polyheadral cells
  • keratin-producing squamous epithelium in the ME, mastoid or petrous apex
  • -grows–replaces mucosa and resorbs bone
144
Q

cholesteatoma histology

A

made up of:

  • cystic content-anucleate keratin squamous
  • matrix-keratinizing squamous epithelium
  • perimatriz-granulation tissue in contact with bone (prodces proteolytic enzymes) causing bone destruction
145
Q

granulation (in terms of cholesteatoma)

A

contains proteases, acid phosphatases, bone resorption proteins, osteoclast-activating factors, prostaglandins

146
Q

cholesteatoma manifestation

A
  • in the attic with dry discharge covering it up
  • prevalence: 6 in 100,000 middle class population
  • age: 10-30 yr old with peak age 15 yrs
  • unilateral or bilateral
  • 68% male
147
Q

2 classifications of cholesteatomas

A
  • congenital
  • acquired
  • -primary acquired (retraction pocket)
  • -secondary acquired
148
Q

pathogenesis of congenital cholesteatoma

A
  • arise from embryonal rests of epithelial cells
  • location (petrous pyramid, mastoid and middle ear cleft)
  • levenson criteria
  • -white mass medial to normal TM
  • -normal pars flaccida and tense
  • -no history of otorrhea and perforations
  • -no prior otologic procedures
  • *prior bouts of otitis media
  • mean age: 4.5 yrs
  • more males: 80%
149
Q

cholesteatoma pathogenesis (primary acquired)

A

ET dysfunction leads to accumulation of keratin and sac enlargement

150
Q

cholesteatoma pathogenesis of primary and secondary

A
  • implantation: surgery, foreign body, blast injury
  • invasion/migration: medial migration along permanent TM perf
  • papillary ingrowth: inflam in prussack’s space
  • metaplasia: chronic infection(transfer to cuboidal to squamous epithelium)
  • -cords of epithelium migrate inward
  • -intact pars flaccida
151
Q

epitympanic cholesteatoma patterns of spread

A

from:

  • prussack’s space
  • posterior epitympanum
  • -via superior incudal space
  • posterior mesotympanum
  • -via posterior pouch of von troesltsch
  • anterior epitympanum
  • -via anterior pouch of von troeltsch
152
Q

cholesteatoma spread from posterior epitympanum

A

mastoid antrum

153
Q

cholesteatoma spread from posterior mesotympanum

A

inferiorly through posterior pouch of von Troeltsch to stapes, round window, and facial recess

154
Q

cholesteatoma spread from anterior epitympanum

A

anterior to head of malleus, may gain access to supratubal recess via anterior pouch of von Troeltsch

  • anterior extension is rare
    1) petrositis
    2) grandenigo’s syndrome
  • -Trigeminal pain (retroorbital)
  • -lateral rectus palsy (V and VI involvement)
  • -ipsilateral otorrhea/ OM
155
Q

cholesteatoma iatrogenic complications

A

iatrogenic complications:

  • VII palsy-nerve camouflaged by the disease
  • dead ear: trauma (surgical–otic capsule or ossicular chain)
  • permanent otorrhea from radical mastoidectomy
156
Q

medical treatment of COM with cholesteatoma

A
  • tympanoplasty
  • mastoidectomy
  • pediatric cholesteatomas:
  • -more difficult to remove surgically
  • -grows at a faster rate, frequent ME infection from ET dysfunction
157
Q

mastoidectomy for cholesteatoma

A

surgical management

  • canal-wall-down procedures
  • intact-canal-wall procedure
  • transcranial anterior atticotomy
  • bony modified radical procedure
158
Q

acute mastoiditis basics

A

infection of the mastoid

  • spread of infection from aditus ad antrum into the mastoid air cells
  • -mastoiditis= edema, granulation tissue, pus
  • diffuse osteitis followed by breakdown of the bony septae in the mastoid air cells
  • more in children
  • antibiotics dimished the incidence of the disease
  • ear is sticking out of the child’s head
  • postauricular space increased and blunted
159
Q

causes of acute mastoiditis

A
  • incompletely treated acute otitis media or chronic otitis media
  • streptococcus pyogenes (main)
  • initial sign of congenital chlesteatoma
160
Q

incidence of acute mastoiditis

A

is increased due to resistance of S. Pneumococcus to antibiotics

161
Q

acute mastoiditis symptoms

A
  • otalgia
  • discharge (serous, seropurulent or mucupurulent)
  • hearing loss
  • headache, general malaise, fever
162
Q

acute mastoiditis signs

A
  • postauricular area is erythematous, tender, obliteration or its crease, abscess formation
  • otoscopy: TM perf, otorrhea, sagging of the postersuperior wall of the EAC
  • Tuning fork tests: CHL
163
Q

acute mastoiditis Rx

A

1) observation for 2-4 days
2) medical RX
* systemic antibiotics
- -standard of care in US
- —–amoxicillin, trimethoprime, sulfamethoxasone (first line)
- —–amoxicillin, ceftriaxone, ceruroxime (second line)
3) surgery
* myringotomy
* mastoidectomy
* incision to subperiosteal abscess
- —untreated cases=extension of infection to cortex

164
Q

complications with untreated acute mastoiditis

A
  • spread to the mastoid cortex
  • erode cortical bone
  • formation of a subperiosteal abscess
  • –relatively late development of the disease
165
Q

tuberculous otomastoiditis

A
  • incidence: 9% of TB cases
  • Hz of active pulmonary disease and positive TB test
  • treatment: treat system infection: combination of anti TB drugs
  • –reconstruction surgery
166
Q

myringoplasty

A

reconstruction of a perforation of the TM

  • assumes normal ME mucosa and ossicles
  • TM is not elevated from its sulcus
167
Q

Tympanoplasty

A

reconstruction of the TM

  • also includes addressing middle ear pathology
  • -cholesteatoma, adhesions
  • -ossicular chain problems
  • -usually involves elevating the TM from its sulcus
168
Q

indications for surgery of TM perforations

A

no spontaneous healing

  • age>30 years
  • large, kidney bean-shaped central perf
  • posterosuperior perforations
  • infection
169
Q

indications for surgery with chronic condition (TM perf)

A
  • CHL or progressive hearing loss due to
  • -perf, ossicular dysfunction or chronic ME pathology
  • perforation or hearing loss persistent>3 months
  • -trauma, infection, or surgery
  • —–chronic or recurrent OM secondary to contamination
  • inability to participate in water sports safely
170
Q

goals of TM surgery

A
  • establish an intact TM
  • eradicate middle ear disease and create an air-containing middle ear space
  • restore hearing by building a secure connection between the ear drum and the cochlea
171
Q

tympanoplasty techniques

A
  • overlay technique (lateral grafting)
  • underlay technique (medial grafting)
  • associated type of ossicular chain reconstruction (OCR)
172
Q

overlay grafting advantages

A

*excellent exposure
*high graft take rates
*applicable to all cases
(anterior or total perf)

173
Q

overlay grafting disadvantages

A
  • requires precision
  • longer healing time (months vs weeks)
  • possibility of blunting, lateralization, epithelial pearls
174
Q

underlay grafting advantages

A
  • less blunting or lateralization
  • high graft take rate
  • simpler technique
175
Q

underlay grafting disadvantages

A
  • limited visualization
  • large, anterior perforation less suitable
  • difficult with small external auditory canal
176
Q

Wullstein Type I tympanoplasty

A

TM is grafted to an intact ossicles

177
Q

Wullstein Type II typmpanoplasty

A

malleus is partially eroded

*TM +/- malleus remnant is grafted to incus

178
Q

Wullstein type III typanoplasty

A
  • malleus and incus are eroded

* TM is grafted to the stapes suprastructure

179
Q

Wullstein Type IV tympanoplasty

A
  • stapes suprastructure is eroded

* TM is grafted to a mobile footplate

180
Q

Wullstein Type V tympanoplasty

A

TM is grafted to a fenestration in the horizontal semicircular canal (not done not)

181
Q

Belluci Classification for tympanoplasty

A

proposed a dual classification

*added status of middle ear

182
Q

Belluci tympanoplasty classification Group I

A

dry ear

183
Q

Belluci tympanoplasty classification Group II

A

occasional drainage

184
Q

Belluci tympanoplasty classification Group III

A

persistent drainage with mastoiditis

185
Q

Belluci tympanoplasty classification Group IV

A

persistent drainage and nasopharyngeal malformatio (cleft palate and choanal atresia)

186
Q

Austins classification for tymanoplasty

A

describes the residual ossicular remnants

187
Q

austin’s classification for tympanoplasty

A 
(M+/I+/S+) intact ossicular chain
m=malleus
s=stapes
i=incus
- is absent 
\+ is present
188
Q

postop care for tympanoplasty

A
  • day surgery
  • mastoid dressing remove postop day one
  • incisions cleaned bid with H202 and topical abx
  • patient instructions
  • one week stapes or steri-strips are removed and ear drops are started
  • three weeks, gelfoam is removed from the EAC
  • 2-3 months, postop audiogram is performed
189
Q

tympanoplasty in children

A
  • controversial
  • considered less successful than adults
  • –higher incidence of ETD and otitis media
  • wide range of success rates
  • –35-95%
190
Q

tympanoplasty complications

A
  • infection
  • –poor aseptic technique
  • –prior contamination
  • graft failure
  • –infection
  • –inadequate packing (anterior mesotympanum)
  • –inadequate overlay of graft with TM remnant (underlay)
191
Q

tympanostomy complications

A
  • chondritis
  • injury to the chorda tympani nerve
  • SNHL and vertigo
  • increased conductive hearing loss
  • external auditory canal stenosis
192
Q

amount of hearing loss which can be caused by complete cerumen obstruction

A

30-40dB CHL

193
Q

complications of impacted cerumen (6)

A
  • sensation of obstruction (mild CHL)
  • tinnitus (common if HL present)
  • otalgia
  • cholesteatoma (if build up is severe)
  • vertigo (uncommon)
  • coughing (stim of arnold nerve)
194
Q

keratosis obturans

A

skin disorder of the EAC-plugs the skin within the canal with wax, requires frequent microscopic debriment

195
Q

contraindications of canal irrigation

A
  • TM perf
  • atrophic TM
  • unknown TM status
  • atelectatic middle ear
  • only hearing ear
  • frequent episodes of otitis externa
196
Q

complications during cerumen/foreign object removal

A
  • coughing
  • pain
  • iaterogenic canal injury (local trauma/bleeding or otitis externa)
  • iaterogenic middle ear injury (TM perf, otitis media or ossicular chain injury or extruding prothesis
  • iaterogenic inner ear injury (stpes footplate subluxation or perilymphatic sidtula
  • delayed consequences of injury
197
Q

delayed consequences of injury from cerumen removal

A

litigation (legal action) for vertigo and tinnitus as well as cholesteatoma
*“it was fine until the Dr. injured it while cleaning wax”

198
Q

ear candeling and how it is supposed to work

A
  • heat melts wax and vacuum pulls wax out of canal
  • research shows no reduction in canal wax and deposition of candle wax
  • complications are burn, impaction with candle wax, and perforated TM
199
Q

prevention of cerumen impaction

A
  • counseling about not using cotton swabs
  • mineral oil weekly to prevent impaction and otitis externa
  • peroxide: helpful if used often for -3months
  • self irrigation: under guidance of a physician
  • —use vinegar and water or alcohol
  • —bulb and syringe or syringe with angiocatheter tip
200
Q

causes of eustachian tube dysfunction

A
  • URI
  • adenoid: hypertrophy–otitis media or chronic
  • nasopharyngitis, allergy
  • cleft palate (mucosal or submucosal)
  • nasopharyngeal mass
201
Q

weber’s test

A

tuning fork on the middle of forehead is perceived at midline or lateralized

  • if lateralized with unilateral CHL: hear tone in ear with loss best
  • in lateralized with unilateral SNHL: hear tone in better ear best
202
Q

Rinne test

A
  • compare loudness when the fork is on the mastoid vs. just outside the ear canal
  • louder at ear canal (AC is better than BC) means normal hearing or SNHL
  • louder at mastoid (BC is better than AC) conductive HL
203
Q

what does ENT nasal exam look for

A
  • unusualy broad nose with flat base and short length (saddle nose)
  • unusually small nostrils and notched alae
  • deviated nasal septum
  • nasal polyps, masses
  • allergic rhinitis
204
Q

when would you refer from otologic exam?

A

1) congenital or traumatic deformity of the ear
2) active drainage within previous 90 days
3) history of sudden or rapid progressive HL within previous 90 days
4) acute or chronic dizziness
5) sudden unilateral HL within previous 90 days
6) audiometric ABG more than 15 dB at 0.5, 1,and 2 kHz
7) significant cerumen or foreign body in ear
8) otalgia in and around the ear

AUD spring 19 Medical (3 decks)

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