Earache + Epistaxis

Question 1

Bacteria causing OM

Answer 1

S. pneumonia
H. influenza
M. Catarrhalis

Question 2

Classes of abx used for OM

Answer 2

Penicillin (B-Lactams)
Cephalosporins
Macrolides
Sulfonamides

Question 3

Treatment of OM with tubes present

Answer 3

Ciprodex ear drops

Question 4

Approach to hearing loss - types + causes

Answer 4

1) Conductive
Normal otoscopic exam
- Otosclerosis
Ear canal abnormalities
- Cerumen impaction
- FB
- Otitis externa
- Neoplasm
Abnormalities on or behind ™
- Membrane perforation
- OM
- Middle ear effusion
- Glomus tumor (unilateral, pulsatile tinnitus, bulging red mass behind ™)
- Cholesteatoma
2) Mixed
- Otosclerosis
- Chronic OM
- Neoplasm
- Temporal bone trauma
- Inner ear malformations
3) Sensorineural
Gradual onset
- Presbycusis
- Noise induced
- Drug induced (aminoglycosides, macrolides, glycopeptides, chemo drugs, NSAIDs, ASA, antimalarial, loop diuretics)
- Cerebellopontine angle tumor (acoustic neuroma)
Progressive onset
- TORCH infections
- Genetic
Fluctuating
- TORCH infections
- Meniere’s
- Endolymphatic hydrops

Question 5

Approach to tinnitus - categories + causes

Answer 5

Pulsatile:

Pulse synchronous w/ HR:
Idiopathic intracranial HTN
Systemic HTN
Arterial bruits
Venous hum
Arteriovenous malformation
Vascular tumors

Pulse asynchronous:
Middle ear muscle myoclonus
Palatal muscle contraction
Eustachian tube dysfunction

Nonpulsatile:

Unilateral hearing loss:

Neuro signs:
Brainstem infarct
Cerebellopontine angle tumor
MS

No neuro signs:
Chronic noise exposure
Acoustic trauma
Meniere’s

Abnormal otoscope findings:
Cerumen impaction
OM
™ perforation
Cholesteatoma

Bilateral hearing loss:
Presbycusis
Noise exposure
Otosclerosis

Question 6

Where do you get otalgia referred pain?

Answer 6

TMJ
Tonsils
Throat
Tube (Eustachian)
Teeth
Tongue
Trachea
Thyroid
Tics
Tendons
Trigeminal Neuralgia

Question 7

Pathogens causing OE

Answer 7

pseudomonas, staph aureus, fungal, herpes zoster

Question 8

RF for OE

Answer 8

humidity, warm temps, swimming, local trauma, hearing aid, immunocompromised

Question 9

Sx of OE

Answer 9

pruritus, pain, fullness, erythema

Question 10

Prevention of OE

Answer 10

dry ear canals after swimming, avoid cotton swabs, alcohol drops during high risk times, hair dryer use

Question 11

Rx OE

Answer 11

No perforation: polysporin eye + ear 1-2 drops QID
Perforation: ciprodex otic suspension 4 drops BID
Fungal: clotrimazole 1% cream BID

Question 12

Age peak for OM

Answer 12

6-9mo

Question 13

RF for OM

Answer 13

daycare, male, family hx, enlarged tonsils, cigarette smoking, first nations

Question 14

Sx of OM

Answer 14

acute onset middle ear fluid + inflammation, earache, fever, vomiting, rhinitis, Bulging tm

Question 15

Physical findings OM

Answer 15

bulging TM, perforation, effusion behind TM, loss of TM landmarks

Question 16

Complications of OM

Answer 16

mastoiditis, meningitis, intracranial abscess, facial paralysis

Question 17

Rx for OM (<6mo, >6mo w/perf, w/bulging TM, w/middle ear effusion)

Answer 17

> 6mo, perforated TM w/ purulent DC = amox
6mo, middle ear effusion + bulging ™, mild = observe, ensure FU, if not improving = amox
6mo, middle ear effusion + bulging ™, mod = amox
6mo, no middle ear effusion = reassess in 24-48 hrs
<6mo: amoxicillin
If recurrent in kids, test for hearing loss

Question 18

When to refer OM

Answer 18

OME >3mo w/ bilateral hearing loss
>3 episodes in 6 mo
>4 episodes in 12 mo
Retracted ™
cleft palate

Question 19

DDx for otalgia

Answer 19

Tooth abscess
Trigeminal neuralgia
TMJ dysfunction
Pharyngitis
Tumors
Temporal arteritis
Mastoiditis

Question 20

Sx TMJ dysfunction

Answer 20

Unilateral dull ache radiating to ear + jaw, worse w/ chewing
Locking of jaw
Ear clicking/ popping
Increasing pain through day
Limited jaw opening
Palpable muscle spasm

Question 21

Rx TMJ

Answer 21

NSAIDs
TCAs

Question 22

Location of epistaxis - most common, names

Answer 22

90% anterior (Kiesselbach’s - blood supply from internal and external carotid), 10% posterior (sphenopalatine - more common in elderly)
Anterior nose is also called Little’s area

Question 23

Causes of epistaxis

Answer 23

Nose picking
Trauma
Infectious (cold, sinusitis)
Medications: ASA /clopidogrel/ NSAIDs/ Vitamin K antagonists (warfarin, dabigatran etc) /steroids (oral, topical nasal spray)
Alcohol use (may increase risk)
Post-operative
Intranasal neoplasm (juvenile nasopharyngeal angiofibroma - facial swelling, pain)
Allergic or viral rhinitis (causes mucosal hyperemia)
Coagulopathy/bleeding disorder
Chronic intranasal drug use (cocaine or Rx drug)
Hypertension

Question 24

Ix + when to do it for epistaxis

Answer 24

for recurrent epistaxis, severe, <2y/o, systemic sx, family history:
CBC, INR, PTT, ferritin
Group + screen
Bleeding disorder testing
Liver dysfunction

Question 25

Management of epistaxis

Answer 25

Assess hemodynamic stability, secure airway
Anterior rhinoscopy to identify source of bleeding
Lean forward
Prolonged pressure on distal nares (10-20 min)
Anterior and/or posterior packing soaked in topical decongestant
Pack nares from posterior to anterior with ribbon with neosporin
Packing methods: with lubricated gauze/“Rhino Rocket”/ Merocel /Foley catheter/Balloon
Vasoconstrictors: lidocaine + phenylephrine
Decongestants: oxymetazoline (topical decongestant)
Cautery – Silver nitrate x30s or electrical cautery
Surgical arterial ligation

Question 26

Prevention of epistaxis

Answer 26

Emollient application
Humidification
Topical vasoconstrictors
Nasal cautery
Oral propranolol

Question 27

How to assess tinnitus + what Ix to order?

Answer 27

Auscultate for bruits over neck, mastoid and preauricular area
Otoscope examination
Neurological examination

Order MRA + venogram of brain + neck

Question 28

RF for AOM

Answer 28

maternal smoking, daycare, pacifier use, bottle feeding

Question 29

Dx criteria for AOM

Answer 29

effusion, inflammation and acute sx

Question 30

Rx for AOM in penicillin allergy

Answer 30

penicillin rash = cefuroxime, anaphylaxis = clarithromycin

Question 31

Rx for AOM w/ treatment failure

Answer 31

clavulin or IM ceftriaxone

Question 32

Indications for ventilation tubes

Answer 32

recurrent AOM 6/yr or chronic OME >3mo or retracted TM

Question 33

Management of mild epistaxis

Answer 33

blow nose, 2 sprays oxymetazoline, pinch x10 mins