Midterm Flashcards
(104 cards)
1
Q
Nasal turbinates: pale, edematous
Allergic shiners
Otitis media d.t. allergic eustachian tube obstruction.
Post Nasal Drip – racing stripes in pharynx.
A
Allergic Rhinitis
PE Findings
2
Q
Skin Prick Allergy Test
vs.
RAST Blood Test
A
Skin Prick Allergy Test:
Needle dipped in purified allergen.
(Reaction->Rash/hives/anaphylaxis)
Not appropriate for extremely sensitive patients.
Antidepressants, antacids, and antihistamines interfere with results. ((Go off for several days))
RAST: ((Radioallergosorbent test))
More sensitive than skin prick test.
Detect IgE antibodies for specific allergens.
Can circulate for years even when pt. is no longer having allergic sx.
Patient does not have to d/c antihistamines.
3
Q
Sublingual immunotherapy (SLIT)
A
Sublingual immunotherapy drops or tablets, placed under the tongue, containing a specific allergen.
The antigen is taken up by dendritic cells.
Goal = immunologic tolerance
Best initiated 2-4 months BEFORE allergy season
4
Q
- required for the methylation of histamine
Supplement during active allergic states - Promotes non-enzymatic histamine degradation.
A
- Vitamin B-12 and folate (B9)
2. Vitamin C
5
Q
BIOFLAVINOIDS:
Quercitin, hesperidin, catechin, nettles
Hawthorn berry – high in antioxidant flavinoids, carotenoids, vitamin C.
- All decrease degranulation of mast cells
- Inhibit lipoxygenase, phospholipase, and phosphodiesterase**
A
- Qurecetin:
Mast cell stabilizer-less like to release histamine
Possibly low absorption
Useful to mediate GI allergic reaction - Hesperidin Methyl-Chalcone (HMC)=>Acute allergy tx.
- Catechin inhibits histamine decarboxylase
a. Enzyme responsible for converting histidine to histamine
Nettles (One of his favs- frozen)- Study of pt. with urticaria and food allergies, administered catechin prior to consumption of food antigens – pt. gastric mucosa protected from an increase in histamine
6
Q
Calcium
A
Calcium supplements=>Discontinue during acute allergic response.
*Phospholipase A2- releases arochadonic acid
Calcium supplements:
Can accentuate the allergic response by increasing activity of phospholipase A2->Phospholipase A2- releases arochadonic acid
*Get your Ca from vegetables instead.
7
Q
Botanical Medicines and Allergy:
- Blocks 4 series Leukotrienes (Chalcone portion)
-
Quercitin-like flavone (baicalein) inhibits phospholipase.
((Indicated for migraine assoc. with food sensitivity.))
A
Glycyrrhiza glabra
- Blocks 4 series Leukotrienes.
- Chalcone portion of licorice.
Scutellaria baicalensis:
- Quercitin-like flavone (baicalein) inhibits phospholipase.
- Indicated for migraine assoc. with food sensitivity.
8
Q
Food Allergies: Diet and Lifestyle Considerations
- IgE-mediated- (ex.: peanuts) vs. 2. IgG-mediated
A
- Immediate onset:
- Delayed onset:
- Reduce arachadonic acid sources (vegetable oils). (Linolaic acid releases)->Animal proteins have more. So reducing meat is beneficial.)
- **Oils used in baking could be a factor in why pt. react to eating bread.
- Increase omega 3 – cod liver oil, flax oil
- Decrease stress to increase conversion of ALA into EPA. (Improves digestion)
- Improve digestion and eliminate foods that are perpetuating GI inflammation
9
Q
Inflammatory Cascade:
- Arachadonic Acid
- Fish Oil
- Flax Oil
A
*Arachadonic Acid (AA) Inflammatory cascade Linoleic acid in vegetable oils and AA in animals Delta 5 desaturase coverts DHGLA into AA Stimulated by insulin Inhibited by EPA and DHA
*Fish Oil:
Source of EPA/DHA
Anti-inflammatory eicosanoid cascade.
*Flax Oil:
Source of ALA which is poorly converted into EPA in the body.
Delta 6 desaturase: conversion ALA to EPA.
Inhibited by stress, age, CA
10
Q
Inflammatory Cascade:
Phospholipase A2
A
- Omega 3 EFAs compete with AA for release.
- Blocked by corticosteroids, feverfew
- AA, EPA, and GLA also all compete for cyclooxygenase and lipoxygenase enzymes.
11
Q
Inflammatory Cascade:
Lipoxygenase
A
Lipoxygenase converts AA into HPETE, and ultimately into leukotrienes.
Allergen mediated asthma.
Blocked by quercitin
12
Q
Inflammatory Cascade:
Cyclooxygenase
A
COX-1
Asprin binds COX-1, reducing clot formation. This also decreases prodxn of prostaglandins that protect stomach lining, leading to GI SE of NSAIDs.
Ibuprofen does at a lower rate vs other NSAIDS.
COX-2 Pain and inflammation Prostacyclin (cardioprotective) Inc. CVD risk with long-term NSAID use. Naproxen (Aleve) reduces the least.-=>Least worst
13
Q
Chronic Hyperglycemia/Hyperinsulinemia
1.-2.->((Glycation & Insulin))
- Hypercortisolemia
A
- Glycation of proteins inc. free radicals
- Insulin
a. Stimulates delta-5-desaturase and NF-kappaB——————>inflammatory eicosanoids & prostaglandins
b. Inhibits delta-6-desaturase–> decreased prdxn EPA and DHA
Promotes leptin resistance–> impaired satiety and thermogenesis
Impairs phase 1 and phase 2 detoxification in the liver - Hypercortisolemia
a. Exhaustion phase of stress response
b. Promotes dysglycemia-> High cholesterol-promotes dysglycemia
c. Promotes GI damage
14
Q
Homeopathic Treatment of Allergies:
Nose: burning d/c
Better open air
A
Allium cepa
15
Q
Homeopathic Treatment of Allergies:
Eyes: inflamed, burning, itchy
d/c may cause eyelids to stick together on waking
Nasal d/c bland
A
Euphrasia
16
Q
Histamine Blockers:
1st Generation: Diphenhydramine
2nd Generation: Loratadine
A
1st Generation: Diphenhydramine (Benadryl)
Major side effect?->Sleepy & Tired
Caution with glaucoma, enlarged prostate, asthma, thyroid disease, CVD, or HTN
2nd Generation: Loratadine (Claritin), Cetirizine (Zyrtec), Fexofenadine (Allegra)
Caution with hepatic or renal dz-> long term use
17
Q
Antibiotic Selection in EENT Complaints:
A
UR organisms are typically gram (+):
- Treat with Penicillins. (Amoxicillin-good place to start)
- **Augmentin with beta-lactamase producing organisms.
-If allergic, use Macrolides (Erythro or Azithromycin)
18
Q
Trauma to the ext. ear,
Pseudomonas aeruginosa-Infection of the cartilage
Auricular hematoma
A
Perichondritis:
Trauma to the ext. ear=>Can result in “cauliflower ear”
((Auricular hematoma – needs to be I&D with needle or small incision.))
Infection of the cartilage
-Pseudomonas aeruginosa (Gram Neg- cephalosporin)
Auricular crusting, erythema, weeping
Commonly treated with antibiotics
-1st generation cephalosporin (Cephalexin) x5-7 days
19
Q
Foreign Bodies in the Ear:
Refer to otolaryngologist with: Perforation of TM (otorrhea one indication) Difficult to remove Completely excluding ext. canal Hearing loss
A
Irrigation- not w/ruptured TM-> Loss of conductive hearing loss (renne test- Sensory is greater than >bone conduction= Good TM)
Foreign bodies that do not completely occlude canal.
Irrigation of ear canal –direct behind foreign body.
***CI if foreign body is a bean (or any natural material that could expand with water) or with batteries (spread caustic battery acid)
Following removal – inspect canal and TM
20
Q
Accumulation:
Sx: decreased hearing (conductive), itching.
Cerumen can vary in color from yellow to dark brown.
A
Cerumen Accumulation
21
Q
Cerumen Removal
A
- Pt prep
*Possibility of TM rupture and trauma to ear canal.
*Cerumen can be tightly adhered and cause minor bleeding – normal to see a little after the procedure. - Wax hook
- Ear lavage
A. Safest way to remove cerumen
-Gentle irrigation to avoid perforation of TM.
-Warm irrigating solution to prevent caloric stimulation.
-Aim irrigating stream at superior wall of ear canal or towards mastoid.
B. Debrox solution drops x 4-7 days before procedure.
C. If irrigation doesn’t work:
-2-3 gtt mineral oil in pt’s ear, wait 5-10 min, repeat.
D. Pt f/u
- Stop using Q-tips – assoc with cerumen accumulation - Esp. important to f/u w/diabetic or immune compromised patients - higher risk of infection. - EFA supplementation - Garlic-mullein oil – 5gtt for 2-4 nights following removal of cerumen.
22
Q
Possible TM Findings:
- Tympanosclerosis
- Serous effusion
- Bullous Myringitis
** All these presentations can have sequelae of TM rupture.**
A
- Tympanosclerosis - secondary to repeat infections, perforations, and age. (EX-Scarring, tympanic tubes)
- Serous effusion - bubbles or a fluid line.
- Bullous Myringitis - vesicular infection ON the TM.
** All these presentations can have sequelae of TM rupture.**
23
Q
- 2o to viral or bacterial infections.
- Sudden onset of severe pain
- PE: small, red, inflamed blebs in the canal or on the TM.
- —>Produce a bloody d/c if they rupture - Resolves spontaneously
A
Myringitis:
Do nothing- watch & wait
24
Q
- Benign bony tumor.
- Hx of exposure to cold and wind. Water- surfers & Swimmers
Asymptomatic unless blockage traps water, leading to otitis externa. - PE
Skin covered mounds
Hearing test - No treatment needed if does not interfere with hearing.
A
Extoses of External Ear Canal
25
1. Inflammation of external ear canal and/or pinna
2. Sx: pruritis, foul-smelling d/c, potentially hearing loss
3. Tenderness w/manipulation of the pinna and/or tragus
4. Erythema and swelling of canal
Otitis Externa
```
**Increased risk**
Loss of protective cerumen – Q-tips
Maceration from moisture
Allergy – atopic dermatitis of ext ear canal
Seborrheic dermatitis
```
26
Treatment Considerations – Otitis Externa
- Immune support
- Ear drops
1. Stop using Q-tips
2. Immune support: vit C, vit A, Zn
3. Ear drops:
- CI if TM perforated.
- Warm to body temperature by placing in your pocket for 15 minutes before use.
- Pt lies on their side with the affected ear facing up.
- Pull the ear gently backwards to help funnel ear drops into canal.
- Place 1-3 drops into the ear canal and cover with a cotton ball
- Massage the tragus (the piece of skin that sticks out just in front of the ear canal like an open trapdoor) to force the drops down into the eardrum.
4. Soothe and dry the ear canal
- Drop of mineral or olive oil in ear.
- 50/50 blend of white vinegar/isopropyl alcohol
27
Treatment Considerations – Otitis Externa
| -Botanical Medicine
Botanical Medicine – external applications or internal
- Hydrastis canadensis (antimicrobial)
- Monkshood (topical analgesic)
- Verbascum anodyne, astringent, antiseptic
- Vinegar extracts ideal for otitis externa (high ethanol extracts can irritate inflammed skin)
28
Treatment Considerations – Otitis Externa
- Ear wick
- Hydrotherapy
-Ear wick
may be needed if canal swollen enough to prevent administration of medication to ear canal.
Use bayonet forceps to “jam” ear wick into canal.
Medication reaches ear canal through capillary action.
- Contrast hydrotherapy to ext. ear to reduce inflammation.
- Use antibiotics in the presence of fever or cellulitis.
29
Treatment Considerations – Otitis Externa
| -Antibiotics
-Use antibiotics in the presence of fever or cellulitis.
-Follow-up: 3-5 days
If pt still does not respond, consider antibiotics
*Cover Pseudomonas and Staphylococcus species.
*Ofloxacin (generic OK) ear drops – 10 gtt into affected ear bid x10-14 days (adults) – ½ this dose for children
*Ciprofloxacin with hydrocortisone (otic preparation)
*Cephalosporins, penicillinase-resistant penicillins
30
Homeopathy and Otitis Externa:
1. Right side, sudden onset
Pt is flushed, feverish, restless, thirstless
2. thick offensive d/c
Pt is worse at night, better warmth
Pain is stitching, sensitive to touch
3. Thin purulent d/c, worse in bed at night
Pt is perspiring
Assoc sx: swollen glands, bad breath
4. thick bland d/c, red swollen pinna
Pt is weepy, thirstless, clingy, better open air
5. pain behind ear, itchy, offensive d/c
Sensation ear stopped
Modalities: worse at night/noise, worse cold
6.Nose: burning d/c
Better open air
7. Eyes: inflamed, burning, itchy
d/c may cause eyelids to stick together on waking
Nasal d/c bland
1. Belladonna:
2. Hepar sulph:
3. Mercury
4. Pulsatilla:
5. Silica:
6. Allium cepa:
7. Euphrasia :
31
More common in elderly, diabetic, and immunocompromised pt.
Otitis externa that does not resolve.
Progressively worse, constant, severe pain.
Presence of granulation tissue in canal is characteristic.
Malignant Otitis Externa:
PE: Obs granulation tissue.
Can be fatal 2o to intracranial infection.
Hospitalization with IV abx.
32
- Invasion of the 8th CN & facial nv by Herpes zoster virus.
- Signs and Sx: Severe ear pain, hearing loss, vertigo, paralysis of face
- Painful, burning blisters in and around the ear, on the face, in the mouth, and/or on the tongue.
***S/Sx's & tx...
Herpes Zoster Oticus:
Tx
**Acyclovir – to shorten course and reduce risk of sequelae, a good consideration.
800mg PO 5 times per day x 7-10 days.
**For post-herpetic pain
Topical capsaicin preparations: Depletes substance P in peripheral sensory neurons, causing skin and joints to become less sensitive to pain.
33
```
a. Essential PE
Inspection and palpation of external ear
Pneumatic otoscopy
Hearing bilaterally
Inspection of oropharynx
```
Otalgia
34
Otalgia Algorithm
1. Normal vs. abnormal
2. Painful vs Non-painful
1. Otoscopic exam
a. Normal
No hearing loss: referred pain (TMJD, tonsillitis, pharyngitis, dental lesion), trigeminal neuralgia
Hearing loss: eustachian tube dysfunction
b. Abnormal
No exudate: otitis media without perforation, myringitis, glomus tumor (rare)
Exudate: go to #2
2. Manipulation of external ear
A. Painful: otitis externa, foreign body, impacted cerumen
B. Not painful: otitis media with perforation, perforation of TM associated with cholesteatoma or barotrauma, CSF leakage secondary to skull fracture
35
Middle ear effusion —> MEE
1. Middle ear effusion (MEE) refers to fluid in the middle ear cavity. MEE occurs in both otitis media with effusion and AOM
36
Middle ear fluid that is not infected. Obs fluid line or bubbles behind TM.
Precedes the development of AOM or follows its resolution. Asymptomatic presentation.
OME: OTITIS MEDIA WITH EFFUSION
1. Otitis media with effusion (OME) --- Middle ear fluid that is not infected. Obs fluid line or bubbles behind TM.
2. OME frequently precedes the development of AOM or follows its resolution. Asymptomatic presentation.
3. DO Nothing: 75-90% of residual OME following AOM resolves spontaneously in 3 months
4. 55% of newly diagnosed OME improve in 3 months, but 1/3 will relapse in the next 3 months
5. Longer duration predicts poorer prognosis
37
Bulging of the tympanic membrane, tugging or batting at ear, drilling fingers in ear with crying, painful, severe erythema w/Middle ear effusion.
AAP Guidelines for Dx of AOM
1. Bulging of the tympanic membrane—retraction of the TM excludes the dx of AOM
Bulging TM’s had a positive bacterial culture 75% of the time
2. PAIN (preverbal: tugging or batting at ear, drilling fingers in ear with crying, verbal: have to say their ears hurt) OR severe erythema
3. Middle ear effusion—demonstrated via pneumatic otoscopy or tympanometry
Pneumatic otoscopy—TM will be immobile
38
Bacteria Causing AOM
1. Strep pneumonia
2. H. flu – 50% amoxicillin resistant
3. Moraxella catarrhalis – 100% amoxicillin resistant
4. Amoxicillin or Augmentin as 1st line abx treatment.
* **(If they don’t respond in 1st 2-3 days)***
5. Augmentin if initial course of Amoxicillin produces no results after 48-72 hours.
39
```
Remedy?
Sudden onset of ear pain following exposure to wind/elements-
Pt. irritable/fearful
Skin dry and hot
Worse night and warmth
Thirsty for cold drinks
```
Achonite
40
Remedy?
Clear rhinitis
thick d/c
Earache
Norcurious
41
Remedy?
Exquisitely painful & very sensitive to pain
Worse: hates to be examined or touched, night, cold air, wind, stooping
Better: being carried, motion, warm wrapping
One cheek warm and hot, the other pale and cold
Screaming; unbearably irritable
Chamomilia
42
Remedy?
Sudden onset of pulsing, unbearable pain
TM bright red, injected, bulging
External ear often red
Worse 3 pm, screaming after midnight, drafts, noise, jarring, lying down
Better warm wraps
High fever, red face, glassy eyes, dilated pupils, hot face but cold hands and feet
Belladonna
43
Remedy?
Cold that develops into AOM
Painful fullness or bursting sensation,
Pulsatilla
44
* 3+ acute otitis media infections in the past 6 months or 4+ in past year.
* Perforation and scarring of TM – results in conductive hearing loss
Chronic Otitis Media
Hallmark of chronic otitis media = purulent aural d/c
Pain uncommon
Persistent unilateral otitis media in an adult without obvious cause (such as a URI) – must r/o nasopharyngeal carcinoma blocking eustachian tube.
45
Chronic OM Predisposing Factors
```
1. Inflammation
Allergy: foods, airborne, esp. cigarette smoke
Infection: esp. viral cold/flu
2. Cranial development/deformities
Cleft palate
Down syndrome
3. Behaviors
Pacifiers, Bottle feeding (Sit up right & large tonsils)
Feeding lying down
4. Obstruction: adenoids
```
46
Chronic AOM: Treatments
1. Mucolytics
2. Xylitol gum
3. Vitamins
4. Antibiotics
1. Earlier age of onset = greater risk conductive hearing loss, impaired language development.
2. Allergy elimination diet for chronic OM cases.
3. Mucolytics:
- Guiafenasen,
- Steam with eucalyptus,
- NAC= Dr. Anderson: NAC at HIGH doses may help (2-3 grams tid) acutely; Better as a long term agent at 1000 – 1500 mg/day
4. Xylitol gum
- Prevents bacterial adhesion to respiratory mucosa (esp. S. pneumoniae and H. flu)
- 2 pieces of gum five times per day after meals or snacks 40% effective in preventing AOM.
5. Vitamin A, beta-carotene, Vitamin C, EFAs
6. Antibiotics given once or twice daily will reduce the probability of AOM while the child is on treatment. Long-term antibiotics (equal to or more than six weeks) reduced the number of episodes of AOM per year from around three to around 1.5.
47
Case:
Your new patient is a 4-year-old girl with an extensive history of recurrent otitis media, having 8 episodes in the last 2 years. The first one was successfully treated with antibiotics. When the second one came 4 months later, the antibiotics were repeated for a longer duration and, while symptoms resolved temporarily, they came back 6 weeks later. Although they used several different antibiotics, it seemed that no matter what they gave her she still has another infection every 4-12 weeks.
1. What organisms are most commonly associated with AOM?
2. What are some alternatives to antibiotics that we can use.
3. What are the risks associated with not using antibiotics?
4. Do you think the patient’s otitis will recur? What are the causes of otitis media that must be taken into consideration with her treatments?
5. The child also presents with developmental delays in speech acquisition and learning difficulties. Might this be associated with the ear problems? What diagnosis are you now considering?
1. a. Strep pneumonia
b. H. flu – 50% amoxicillin resistant
c. Moraxella catarrhalis
2.
A. Allergy elimination diet
B. Mucolytics: (HIGH doses NAC, eucalyptus, Guiafenasen)
C. Vitamin A, beta-carotene, Vitamin C, EFAs
3. Two rare complications of OME are transient hearing loss potentially associated with language delay, and chronic anatomic injury to the tympanic membrane requiring reconstructive surgery.
4. Resistance
5. Yes, OME in children who are at risk of speech, language, or learning problems, regardless of hearing status—referral within 3 months
48
Severe, throbbing pain in and behind the ear.
Worse with palpation of mastoid process.
Fever, malaise, bulging TM
Hx of acute otitis media - typically precedes acute mastoiditis by 10-14 days.
Acute Mastoiditis:
- Infection of the mastoid air cells – medical attention needed immediately.
- Unusual before age 2 since air cells aren’t well developed.
- Clinically apparent 2 + weeks after acute otitis media
49
OM complications: mastoiditis, meningitis, brain abscess.
-1 study 5000 children with OM tx with analgesics – only 2 cases of mastoiditis which were successfully treated with abx. (van Buchem et al 1985)
- Meningitis, brain abscess extremely rare but serious
* **Sx: swollen fontanels, mydriasis, neck pain, unable to turn head, projectile vomiting, mastoiditis, high fever, lethargy, positive Brudzinski sign (flxn of head by examiner results in involuntary flxn of hip joint – pt lifts legs).
50
1. May obs displacement of pinna laterally and inferiorly.
2. Redness, swelling, tenderness over mastoid process.
- -Doughy feeling over mastoid process
3. Fever, bulging TM
4. May have creamy, profuse d/c (otorrhea) from ear
- -Collect sample for culture and sensitivity.
Acute Mastoiditis:
Refer out and antibiotics:
PE
1. May obs displacement of pinna laterally and inferiorly.
2. Redness, swelling, tenderness over mastoid process.
- -Doughy feeling over mastoid process
3. Fever, bulging TM
4. May have creamy, profuse d/c (otorrhea) from ear
- -Collect sample for culture and sensitivity.
5. X-ray: destruction and coalescence of air cells in mastoid.
51
Most commonly occurs as a complication of chronic otitis media with TM perforation.
White debris in the middle ear and destruction of the ear canal bone adjacent to the TM perforation.
Cholesteatoma:
Most commonly occurs as a complication of chronic otitis media with TM perforation.
PE
White debris in the middle ear and destruction of the ear canal bone adjacent to the TM perforation.
Tx
1. Refer immediately for surgical evaluation and tx.
- -->Sequelae: deafness in affected ear, erosion into facial nn (causing facial paralysis), formation of brain abscess, meningitis.
2. Untreated cholesteatoma will cause irreversible destruction of ossicles, meninges, and facial nerve.
52
Hearing Loss:
Conductive Hearing Loss
((Refer pt. with new onset of hearing loss (without an obvious cause) to an audiologist and/or otolaryngologist for evaluation.))
1. Unilateral conductive hearing loss: Speaking louder to pt. inc. hearing, pt. speaks with soft voice (since BC is normal); on PE may see visible defect/blockage
2. Bilateral conductive hearing loss: hearing does not improve with louder noise.
3. Most common cause in adults: cerumen impaction or eustachian tube dysfunction (2o to URI)
4. Other causes: otitis media/otitis externa, perforated TM, otosclerosis
53
Hearing Loss:
Loss of hair cells from organ of Corti most common cause.
Unilateral: Hearing worse with noise, patient’s voice is loud, nothing remarkable on PE
Nerve-Deficit (Sensorineural)
1. Loss of hair cells from organ of Corti most common cause.
- ->Presbycusis: gradually progressive loss of hearing (high-frequency tones especially) with age.
- ->Noise exposure
2. Unilateral: Hearing worse with noise, patient’s voice is loud, nothing remarkable on PE
3. Bilateral: Dec. hearing b/l
54
Sudden Deafness:
| Questions and HX
A. Develops over a period of a few hours.
***Typically unilateral sensorineural hearing loss
1. Potential otologic emergency that needs to be urgently evaluated and managed.
2. Pertinent Hx questions
- -Ask about signs and sx of concurrent viral infection
- -Blast injuries
- -Strenuous activities that put severe pressure on inner ear, such as weight lifting
3. Tends to occur more in children and young adults
4. Tinnitus and vertigo often accompany hearing loss
- -Vertigo subsides in a few days
55
Sudden Deafness
| DDX
1. Ddx
Pt calls reporting abrupt hearing loss - over phone can do the Hum test
Technique: Patient occludes one ear at a time with a finger; Patient then hums and detects in which ear they hear the sound.
Interpretation: Hum Test lateralizes to the good ear suggests Sensorineural Hearing Loss which requires immediate evaluation. If test lateralizes to the bad ear suggests Conductive Hearing Loss, less concerning.
2. Sudden onset of conductive hearing loss
a. TM perforation
b. Serous otitis media
c. If complete hearing does not return within 14 days, refer to a specialist.
3. Sudden onset of sensorineural hearing loss
A. Vascular accident in CNS ((embolism, thrombosis, hemorrhage))
B. Viral etiology – mumps or measles, influenza, varicella, mono, adenovirus
4. Course of Disease
a. Most people completely recover their hearing within 10-14 days
b. If complete hearing does not return within 14 days, refer to a specialist.
56
Conductive or Sensorineural
Hearing Loss?
Otoscopic exam shows: cerumen, foreign body, extoses, otitis externa, TM perforation
Conductive Hearing Loss
57
Conductive or Sensorineural
Hearing Loss?
Fluid in middle ear inhibits transmission of sound through the TM.
Serous otitis media:
| Conductive Hearing Loss
58
Conductive or Sensorineural
Hearing Loss?
White plaques on TM
Tympanosclerosis:
| Ddx of Conductive Hearing Loss:
59
Conductive or Sensorineural
Hearing Loss?
Progressive hearing loss in a pt. under 50yo, both ears involved, often a family hx, otoscopic exam nl.
Otosclerosis: (Progressive conductive hearing loss)
| Ddx of Conductive Hearing Loss:
60
Conductive or Sensorineural
Hearing Loss?
White debris in ext. canal with TM perforation
Cholesteatoma:
| Ddx of Conductive Hearing Loss:
61
Conductive or Sensorineural
Hearing Loss?
Rare cause of conductive hearing loss
Mostly women age 40-50
Pulsatile tinnitus and hearing loss
May vary with heart rate.
Glomus Tumors
62
Conductive or Sensorineural
Hearing Loss?
Most common cause of sensorineural hearing loss
Noise damage:
| Ddx of Sensorineural
Hearing Loss
63
Conductive or Sensorineural
Hearing Loss?
High frequency hearing loss (eventually progressing to lower frequencies) that occurs with age
Presbycusis :
| Ddx of Sensorineural
Hearing Loss
64
* Sensorineural hearing loss present at birth typically genetically inherited.
* Importance of early hearing tests to screen for this.
Hereditary/congenital
| Ddx of Sensorineural
Hearing Loss
65
```
Fluctuating hearing loss
Unilateral
Episodic vertigo
Aural fullness and/or tinnitus that may be:
“Ringing” between attacks
“Roaring” during attacks
Nausea and vomiting
```
Meniere’s Disease
66
Sensorineural Hearing Loss
:
| Bilateral? (3)
Bilateral:
| Presbycusis, noise/trauma, ototoxin exposure
67
Sensorineural Hearing Loss
:
| Unilateral? (5)
Unilateral:
1. Meniere’s disease
2. Idiopathic, sudden hearing loss may be urgent:
* Common: vascular insults (CVA)
* *Temporal bone fractures
* **Acoustic neuromas
68
Conductive or sensorineural?
| -otosclerosis, rare tumors/cysts
Conductive
69
Unilateral or bilateral?
| -presbycussis, ototoxicity, noise trauma, autoimmune
Bilateral
70
Neurologic symptoms?
1. -MS, temporal bone fracture, CVA, advanced acoustic neuroma
2. -Meniere’s disease, early acoustic neuroma
1. Yes
| 2. No
71
Pt complains of ringing in the ears.
Often see along with sensorineural hearing loss.
Often associated with hearing loss.
Injury from noise, head trauma, chemical, or vascular causes
Tinnitus-ask about meds
Ddx of tinnitus extensive – a possible sx of almost all ear disorders as well as CVD, anemia, and hypothyroidsim.
72
Young, obese females
Hearing loss, aural fullness, dizziness, headache, visual disturbance
Pulsatile tinnitus
Benign Intracranial Hypertension
a.k.a. pseudotumor cerebri
Tx: Weight loss and BP control
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Tinnitus Workup and treatment:
Labs
CBC, hematocrit, ferritin: r/o anemia
Thyroid panel
Chem, lipids, A1c: r/o DM, CVD
Tx:
1. Prophylaxis
- discontinue nicotine, limit caffeine, manage HTN
- Work with anxiety assoc with tinnitus.
2. Masking: device on non-affected ear that produces noise.
Overrides the tinnitus signal to the brain and gives temporary relief.
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Nasal Discharge:
| Unilateral vs Bilateral?
Bilateral d/c: more likely systemic condition
Unilateral discharge ddx: tumor, foreign body, trauma
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1. Condition characterized by nasal congestion without rhinorrhea or sneezing that is triggered by the use of topical vasoconstrictive medications for more than 4-6 days.
2. Treatment???
Rhinitis medicamentosa (Aka-rebound rhinitis or chemical rhinitis)
Treatment:
Replace with saline nasal sprays as taper medications.
Investigate underlying cause of rhinitis
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Acute Vs. Chronic Sinusitis
Acute: <4 wks
Chronic (CRS): >12 wks
With or without nasal polyps
Associated with:
Otitis media
Bronchial asthma
Infection: viral, bacterial, fungal
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Viral Vs. Bacterial Sinusitis
| Nearly all cases resolve without antibiotics
1. If viral infxn, expect improvement within 7 days.
2. If sx continue for more than 10 days, suspect bacterial superinfection.
* Abx considered if sx last >10-14 days or w/ severe fever, facial pain, or swelling.
* 1st line = Augmentin or Amoxicillin: 1000mg tid x 10 days
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Sinusitis: Predisposing Factors
* Allergic rhinitis
* Tobacco smoke
* Defects in mucociliary clearance —> All children with nasal polyps should be evaluated for cystic fibrosis.
* Anatomic abnormalities-> Repeated sinus surgeries.
* Dental infections ("odontogenic sinusitis")
ASSOCIATED CONDITIONS
* Asthma : 20 percent of CRS patients have concomitant asthma.
* Aspirin-exacerbated respiratory disease:
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Anterior and/or posterior mucopurulent drainage
Nasal obstruction
Facial pain, pressure, and/or fullness (more common with acute sinusitis)
Decreased sense of smell
Chronic rhinosinusitis
(Four signs/symptoms)
* Facial symptoms are common in patients with CRS, although they are least specific of the cardinal symptoms (could be caused by HA).
* The mucosal linings of the paranasal sinuses are poorly innervated, which probably contributes to the nonspecific nature of facial pain in CRS. Most patients describe vague discomfort, fullness, or pressure in the cheeks, above or below the eyes, or across the bridge of the nose.
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Bad breath/foul taste, cough, hoarseness (if enters larynx) – worse on rising
PND one of the main causes of chronic cough – mucus irritates cough centers in pharynx, larynx, trachea, and bronchi
“Racing stripes” visualized upon examination of oropharynx
Purulent nasal d/c-->Allergic Rhinitis
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Unilateral facial pressure and tenderness over the cheek.
| Pain may refer to the upper incisor and canine teeth (via branches of the trigeminal nn)
Maxillary Sinusitis: most commonly affected.
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Sinusitis:
A. Pain and pressure between the eyes.
B. HA in the middle of the head at their vertex.
C. Pain and tenderness at the forehead.
A. Ethmoid sinusitis
B. Sphenoid sinusitis
C. Frontal sinusitis
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Chronic rhinosinusitis:
| With or without nasal polyposis:
1. CRS without nasal polyposis is the most common form of CRS.
2. CRS with nasal polyposis
Nasal polyps: translucent, yellowish-grey to white, glistening masses.
1/3 adults with asthma and nasal polyps also have an aspirin sensitivity.
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Nasal Culture & Imaging
1. Sinus cultures:
Consider in patients w/persistent sx's despite previous antibiotic tx.
*** Nasal swabs are not reflective of sinus contents and should NOT be used to guide treatment.
2. Sinus CT:
Preferred imaging modality for eval. of CRS.
***Nasal endoscopy can directly visualize the nasal cavities and sinuses.
Can obtain a more reliable sinus culture to guide antimicrobial therapy.
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Sinusitis: Treatment
1. Avoid dairy and wheat products until mucus clears.
2. Steam inhalation for 5 minutes twice daily
3. Botanical Medicines
* **Armoracia (horseradish), Thyme, Bromelain
4. 2/3 of pt will improve within 2 weeks without abx
5. Typically culture and sensitivity only performed if 1st line abx does not work.
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True or False:
| 30 to 40 % adults with asthma and nasal polyps have aspirin sensitivity.
True!!!
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Shooting pain with brushing of teeth or touching cheek.
Typically 2nd (maxillary) or 3rd division of trigeminal nn.
Unilateral.
Trigeminal Neuralgia (tic douloureux)
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bilateral, nonthrobbing, frontal/temporal regions, worsen as the day goes by, worse with stress, responds to NSAIDS
Tension HA:
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Vasoconstriction followed by dilation of branches of ext. carotid aa.
Recurring, throbbing HA in frontotemporal area (most commonly).
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Hemicranial HA (Migraine):
Most common--> Recurring, throbbing HA in Fronto-temporal area
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***Classic migraine (<10% of migraine pt.) prodrome w/vision disturbance.
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Young men, woken at night with unilateral stabbing pain behind the eye/temple.
Cluster HA
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Elderly women with constant unilateral facial pain
PE: nodular temporal aa. (can be absent).
ESR >40 mm/h
Sequelae: blindness in 1/3
Temporal Arteritis
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Nose picking
| Low humidity or supplemental nasal oxygen
Epistaxis
Tx:
Direct pressure x 15 minutes will resolve most cases.
If bleeding site visible use silver nitrate stick.
Refer with:
Recurrent epistaxis
Large volume epistaxis
Bleeding persists after 15 min of direct pressure
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Bulging TM
PAIN OR severe erythema
Middle ear effusion
Diagnoses of Acute Otitis Media (AOM)
1. MOD. to SEV. BULGING of the TM = the most important charactheristic in the dx of AOM
===>Retraction of TM specifically excludes the dx of AOM
2. PAIN OR Severe Erythema
(Preverbal: tugging or batting at ear, drilling fingers in ear w/crying.
Verbal: have to say their ears hurt
3. Middle ear effusion—demonstrated via pneumatic otoscopy or tympanometry
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AOM practice guideline
1. About 70% of children who present w/ear infxns get better on their own w/in 2 or 3 days.
2. About 80% are better w/in a week to 10 days.
3. Kids must present w/mod.-to-severe bulging of the TM.
4. Management should include a pain reducing tx.
5. “observation” or “watchful waiting” course (Most kids get better on their now-->clear up within three to five days)
6. Re-eval. kids whose sx's worsen or not respond to the initial antibiotic tx w/in 48 to 72 hrs & change tx if indicated.
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Bacteria vs viral etiology=> AOM
1. Bulging TM was highly associated with the presence of a bacterial pathogen.
2. Bulging TM’s had a positive bacterial culture 75% of the time.
3. If color of TM was YELLOW, positive cultures for baterial pathogen increased to 80%.
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Ear pain
Fever
Bulging TM
Ossicular landmarks blurred
Middle ear effusion (Red)
Pulling at the ears
Worse at night
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Acute Otitis Media
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Bacteria most common in Acute Otitis Media
Haemophilus Influenza (50% Amoxicillin resistant)
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* More likely to occur in the summer bc of increased humidity & bc of outdoor water activities.
* Infectious, allergic, and dermatologic disease
* Acute bacterial infection is the most common cause
* Trauma from excessive cleaning or aggressive scratching removes cerumen & create abrasions along the thin layer of skin in the ear canal, allowing organisms to gain access to deeper tissue.
Otitis externa
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Treatment for Otitis Externa
Topical otic solutions either of acetic acid, Polytrim (neomycin, polymyxin B, and hydrocortisone), or ciprofloxacin plus hydrocortisone drops.
Debris in the EAC must be removed in order for the topical applications to be effective.
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Treatment for Otitis Media
Naturopathic treatment
Botanical medicine, NAC or guaifenesin, wet sock treatment, lymphatic/eustachian tube drainage
Local therapy
Garlic-mullein drops, onion ear muffs
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Antibiotic:
1st: Amoxicillin (not allergic to penicillin)
***Cefuroxime (Ceftin) w/allergy***
2nd: amoxicillin/clavulanate (Augmentin)
( β-lactamase–positive organisms)
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Antibiotic tx for Otitis Media
Antibiotic:
1st: Amoxicillin (not allergic to penicillin)
* **Cefuroxime (Ceftin) w/allergy***
2nd: amoxicillin/clavulanate (Augmentin)
( β-lactamase–positive organisms)
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Monday: Brought in by mom, reporting 3 nights of very poor sleep, a little more fussy during the day, and decreased appetite for solids and breastmilk.
She’s had a runny nose for about a week and has had a low-grade fever of 101.0 F or less for the last 2 nights.
She’s been grabbing her right ear this morning.
1. What is your diagnosis?
2. What is your treatment plan?
1. Has a URI w/mild ear involvement or mild OME (moving towards AOM)
2. Watch and wait (Garlic-mullein drops, onion ear muffs) give analgesic.
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Monday: Brought in by mom, reporting 3 nights of very poor sleep, a little more fussy during the day, and decreased appetite for solids and breastmilk.
She’s had a runny nose for about a week and has had a low-grade fever of 101.0 F or less for the last 2 nights.
She’s been grabbing her right ear this morning. (Watched & Waited)
Friday: She calls you 4 days later, reporting a fever of 103.5 F, no interest in solids but will breastfeed somewhat. She is having wet diapers, but is irritable, and having great difficulty sleeping. (Has Bulging TM)
1. What is your diagnosis?
2. Plan?
1. Mod B/L AOM
| 2. Amoxicillin or Augmentin (Very High doses ->800-900mg/5ml)
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Tx of migraine HA:
Avoid high tyramine foods – cheese, wine, beer, avocado, sauerkraut
