EENT #2 (Ears)

Question 1

Otitis Externa
-What is it?
-Risk Factors
-Etiologies (MCC)
-Symptoms
-Diagnostics
-Management
–Initial
–ABX

Answer 1

-Inflammation of the external auditory ear canal.
-RF: Water immersion (swimmer’s ear), local mechanical trauma (Q-tips), age 7-12, aberrant ear wax (too much or too little)
-Pseudomonas Aeruginosa MCC
-Symptoms: Ear pain, pruritus in ear canal auricular discharge, hearing loss, full ear, pain on traction of tragus, purulent auricular discharge.
-Diagnostics: Clinical and otoscopy: edema of external canal with erythema, debris, discharge.
-Management
–Protect ear against moisture (isopropyl alcohol and acetic acid) + removal of debris and cerumen + ABX
–Topical ABX: Ciprofloxacin-Dexamethasone, Ofloxacin.
–Aminoglycoside combination: Neomycin/Polymyxin B/Hydrocortisone otic.

Question 2

Why should you NOT use aminoglycosides if TM rupture is suspected?

Answer 2

They are ototoxic

-These include: Neomycin, Polymyxin B, Hydrocortisone, etc.

Question 3

Malignant (Necrotizing) Otitis Externa
-What is it?
-MCC
-Risk Factors
-Symptoms
-Diagnostics
-Management

Answer 3

-Invasive infection of external auditory canal and skull base. Complication of acute otitis externa.
-Pseudomonas aeruginosa is the MCC.
-RF: Immunocompromised states (elderly diabetics MC, high dose steroids, chemo, HIV)
-Severe auricular pain, otorrhea. Cranial nerve palsies (CN VII) if osteomyelitis occurs. May radiate to TMJ (Pain with chewing), Severe pain with tragus movement.
-Diagnostics
–Otoscopy: edema of external canal, granulation tissue at bony cartilaginous junction of ear canal floor, frank necrosis of ear canal skin.
–CT or MRI to confirm the diagnosis.
–Biopsy is the most accurate test.
-Management
–Admission + IV Ciprofloxacin

Question 4

Acute Otitis Media
-What is it?
-Risk Factors
-4 MC Organisms
-Pathophysiology
-Symptoms
-Exam Findings
-Diagnostics (what is definitive)
-Management
-When should T-tubes be done?

Answer 4

-Infection of middle ear, temporal bone, and mastoid air cells.
-RF: 6-18 months, day care, pacifier or bottle use, second hand smoke, not being breastfed.
-Strep Pneumo MC, H. Flu, Moraxella Catarrhalis, GABHS
-Patho: MC preceded by viral URI, leading to blockage of Eustachian tube.
-Fever, otalgia, ear tugging in infants, stuffiness, conductive hearing loss.
-Exam: Bulging and erythematous TM with effusion, loss of landmarks. Decreased TM mobility with otoscopy (most sensitive)
-Tympanocentesis for culture is definitive, otherwise clinical diagnosis.
-Observation can be done. Children over 2 need ABX.
–Amoxicillin is treatment of choice (80-90 mg/kg/day)
–PCN Allergy: Azithromycin, Clarithromycin.
–Severe or recurrent: myringotomy with T-tubes if 3 in 6 months or 4 in 1 year.

Question 5

Chronic Otitis Media
-What is it?
-Etiologies (MC)
-Symptoms
-Management

Answer 5

-Recurrent or persistent infection of middle ear in presence of TM perforation > 6 weeks.
-Pseudomonas MC etiology
-Persistent purulent painless otorrhea + TM rupture, conductive hearing loss
-Management
–Remove infected debris + Topical Ofloxacin or Ciprofloxacin.
–Avoid water, moisture, and topical aminoglycosides.

Question 6

Serous Otitis Media with Effusion
-What is it?
-Diagnostics
-Management

Answer 6

-Middle ear fluid + no signs or symptoms of acute inflammation (no fever, no pain, no bulging of TM)
-Diagnostics
–Otoscopy: effusion with TM that is retracted or flat. Hypermobiliy with insufflation.
-Management: Observation in most cases. Usually spontaneously resolves.

Question 7

Mastoiditis
-What is it?
-Symptoms
-Exam Findings
-Diagnostics
-Treatment

Answer 7

-Infection of the mastoid air cells of temporal bone. Complication of AOM.
-Deep ear pain worse at night, fever, lethargy, mastoid (post auricular) tenderness, edema, erythema. Protrusion of the auricle. Fluctuance. Narrowed auditory canal.
-Diagnostics: CT scan with contrast.
-Treatment: IV Vanco + Ceftazidime or Cefepime + mastoid drainage (myringotomy) with or without T-tubes.
-Refractory = mastoidectomy

Question 8

Eustachian Tube Dysfunction
-Explain what it is
-Often follows ________
-Symptoms
-Management

Answer 8

-ET swelling inhibits the ET ability to autoinsufflate, causing negative pressure.
-Often follows viral URI or allergic rhinitis
-Ear fullness or pressure, popping of ears, underwater feeling, fluctuating conductive hearing loss, tinnitus.
-Autoinsufflation (swallowing, yawning, blowing against pinched nostril). Decongestants for congestive symptoms.

Question 9

Barotrauma
-What is it?
-Symptoms
-Exam Findings
-Management

Answer 9

-Damage to the TM with sudden pressure changes (flying, diving, hyperbaric oxygen)
-Ear pain, fullness, hearing loss after event.
-Bloody auricular discharge may be present, TM rupture or petechiae may also be present.
-Avoidance is the best treatment. Avoid flying with a cold. Autoinsufflation.

Question 10

Cerumen Impaction
-Symptoms
-What kind of hearing loss does this present with?
-Management
–Cerumen softening with…

Answer 10

-Conductive hearing loss and fullness
-Conductive hearing loss. Weber = lateralization to the affected ear. Rinne = BC > AC.

-Cerumen softening with Hydrogen Peroxide or Carbamide Peroxide.
-Aural Toilet: Irrigation, curette removal of cerumen with suction.

Question 11

Weber Test
-Explain it
-What is normal?
-Conductive Hearing Loss Findings
-Sensorineural Hearing Loss Findings

Answer 11

-Place tuning fork on top of head
-Normal = No Lateralization
-Conductive = Lateralized to affected ear
-Sensorineural = Lateralizes to normal ear

Question 12

Rinne Test
-Explain it
-What is normal?
-Conductive Hearing loss findings
-Sensorineural Hearing loss findings

Answer 12

-Place tuning fork on mastoid by ear
-Normal = AC > BC
-Conductive = BC > AC (Negative)
-Sensorineural = AC > BC (Normal/Positive)

Question 13

Conductive Hearing Loss
-Where does it occur in the ear?
-MCC
-Other causes

Answer 13

-External or middle ear disorders
-MCC is Cerumen impaction
-Others: Otosclerosis, cholesteatoma, mastoiditis, otitis media

Question 14

Sensorineural Hearing Loss
-Where does it occur in the ear?
-MCC
-Other Causes

Answer 14

-Inner ear disorders
-MCC is Presbycusis
-Others: Acoustic Neuroma, Meniere Syndrome, Labyrinthitis, Chronic Loud Noise Exposure

Question 15

Tympanic Membrane Perforation
-Etiologies
-Symptoms
-Management

Answer 15

-MC occurs due to penetrating or noise trauma (MC at pars tensa)
-Acute ear pain, hearing loss. Sudden pain relief with bloody otorrhea. Tinnitus, vertigo.
-Most heal spontaneously. Avoid water and topical aminoglycosides**

Question 16

Cholesteatoma
-What is it?
-MC etiology
-Symptoms
-Diagnostics (what is seen on otoscopy)
-What kind of hearing loss does this cause?
-Management

Answer 16

-Abnormal keratinized collection of desquamated epithelium in middle ear that leads to bony erosion of the mastoid.
-MC due to chronic middle ear disease or ET dysfunction.
-Painless otorrhea, brown or yellow discharge with a strong odor. May develop peripheral vertigo, tinnitus, dizziness, cranial nerve palsies.
-Otoscopy: granulation tissue (cellular debris).
-Conductive hearing loss
-Surgical excision of debris, reconstruction of ossicles.

Question 17

Otosclerosis
-What is it
-What kind of hearing loss does this cause?
-What gene pattern does this follow?
-Symptoms
-Management

Answer 17

-Abnormal bony overgrowth of the footplate of the stapes
-Conductive hearing loss
-Autosomal dominant disorder (family history of conductive hearing loss)
-Slowly progressive conductive hearing loss, especially low-frequencies, tinnitus.
-Stapedectomy with prosthesis or hearing amplification (hearing aid). Cochlear implant if severe.

Question 18

Peripheral Vertigo
-Location of Problem
-Etiologies
-Symptoms

Answer 18

-Labyrinth or Vestibular Nerve (CNVIII)
-BPPV (MC), Meniere, Vestibular Neuritis, Labyrinthitis, Cholesteatoma.
-Horizontal Nystagmus (beats away from affected side), fatiguable.
-Sudden onset of tinnitus and hearing loss.

Question 19

Central Vertigo
-Location of problem
-Etiologies
-Symptoms

Answer 19

-Brainstem or Cerebellar
-Migraine, tumors, MS, Vestibular Neuroma
-Vertical nystagmus (continuous, nonfatigable), gradual onset, positive CNS signs.

Question 20

Treatment for Vertigo and Nausea Associated with it

-First line
-Side effects
-Contraindications

Answer 20

-Meclizine (first line)
–Side effects: anticholinergic = dry mouth, blurry vision, dilated pupils, urinary retention, constipation, dry skin, fever.
–Contraindications: Acute narrow angle glaucoma, BPH

Question 21

Benign Paroxysmal Positional Vertigo
-Why does this occur?
-MCC of _______
-Symptoms
-How to diagnose?
-How to treat?

Answer 21

-Displaced otolith particles within the semicircular canals of the inner ear (canalithiasis)
-MCC of peripheral vertigo
-Recurrent episodes of sudden peripheral vertigo (lasting 60 seconds or less) and provoked with specific head movements. NO hearing loss, tinnitus, or ataxia.
-Diagnose with Dix Hallpike: lean back with head off bed, turn head toward side, look for nystagmus.
-Treat with Epley Maneuver to reposition canaliths

Question 22

Vestibular Neuritis and Labyrinthitis
-VN what is it?
-Labyrinthitis what is it?
-Etiologies
-Symptoms
–Both
–Labyrinthitis only
-Diagnostics
-Management

Answer 22

-VN: Inflammation of vestibular part of CNVIII
-Labyrinthitis: Inflammation of vestibular and cochlear part of CNVIII (both)
-Etiologies: Idiopathic. May be associated with viral or postviral inflammation.
-Both Symptoms = continuous peripheral vertigo, dizziness. Nystagmus is horizontal and rotary (away from affected side).
-Labyrinthitis Symptoms Only = Unilateral hearing loss, tinnitus

-Diagnostics: Clinical, MRI to rule out causes if not consistent.
-Management: Glucocorticoids (first line) = Prednisone, Dexamethasone, Cortisone. Symptomatic relief with Meclizine, antihistamines. Both are self-limited.

Question 23

Meniere Disease
-What is it?
-Symptoms
-Management

Answer 23

-Idiopathic distention of the endolymphatic compartment of the inner ear due to excess fluid.
-Episodic peripheral vertigo, fluctuating sensorineural hearing loss, tinnitus, ear fullness. Horizontal nystagmus, nausea, vomiting.
-Management
–Initial: Dietary (avoid salt, caffeine, nicotine, chocolate, alcohol).
–Medical: Antihistamines (Meclizine), Benzos, Diuretics (HCTZ) to reduce pressure.
–Refractory: surgical decompression, labyrinthectomy, intraaural Gentamicin.

Question 24

Acoustic (Vestibular) CNVIII Neuroma
-What is it
-Arises in the…
-Symptoms
-Diagnostics
-Management

Answer 24

-Vestibular Schwannoma - benign tumor involving Schwann cells, which produce myelin sheath.
-Arises in the cerebellopontine angle and can compress structures, resulting in cranial nerve palsies.
-Unilateral sensorineural hearing loss is an acoustic neuroma until proven otherwise***. Tinnitus, vertigo, facial numbness (CNV) or facial paresis (CNVII).
-MRI is the imaging study of choice. Audiometry is the lab study of choice.
-Management: surgery or focused radiation therapy.

Question 25

Unilateral sensorineural hearing loss is an ________ until proven otherwise!

Answer 25

Acoustic neuroma

Question 26

Peripheral Vertigo Causes
-BPPV: ______________
-Meniere: ___________
-Vestibular Neuritis: _____________
-Labyrinthitis: __________
-Cholesteatoma

Answer 26

-BPPV: episodic vertigo, no hearing loss
-Meniere: episodic vertigo, hearing loss
-VN: continuous vertigo, no hearing loss
-Labyrinthitis: continuous vertigo, hearing loss

Question 27

Ototoxic Medications
-Name some!

Answer 27

-Vancomycin
-Aminoglycosides (Gentamicin)
-Macrolides (Erythromycin)
-Tetracyclines
-Aspirin, NSAIDs (Anti-Inflammatories)
-Hydroxychloroquine, Chloroquine (Anti-Malarials)
-Furosemide (Loop Diuretics)