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ENT Infections and Trauma
Terms in this set (77)
What is rhinosinusitis?
Inflammation of the paranasal sinuses and nasal cavity caused most commonly by virus
What are the timeline qualifications for the different kinds of rhinosinusitis?
υ Acute (< 4 weeks)
υ Subacute (4-12 weeks)
υ Chronic (> 12 weeks)
υ Recurrent (4 or more episodes per yr with complete resolution between episodes)
What is the MOST COMMON cause of rhinosinusitis?
VIRUS!!! Lasts 7-10 days. Bacterial pathogens: streptococcus pneumoniae, Haemophilus influenzae, and Moraxella cararrhalis.
What are the symptoms of rhinosinusitis?
υ Nasal congestion
υ Facial, ear pressure
υ Hyposmia (reduced sense of smell)
υ Dental pain
What will you find on PE with rhinosinusitis?
υ +/- Fever
υ Purulent nasal discharge
υ Sinus tenderness to palpation
υ May have diffuse mucosal edema of nasal cavity
υ Hypertrophy of nasal turbinate
What would you do for management of acute rhinosinusitis?
1. High volume saline Irrigation
2. Intranasal glucocorticoids may be useful, esp with h/o allergic rhinitis (ie Flonase)
3. Antibiotic if acute bacterial rhinosinusitis
What characteristics would need to be present in order to be diagnosed with acute bacterial rhinosinusitis?
1. Symtpoms>10 days without improvement
2. Severe symptoms (≥102.2F or 39C) PLUS
¬ Purulent nasal drainage for > 3 days
¬ Or facial pain for > 3 days, usually greater on 1 side
What would be the medication choices for bacterial rhinosinusitis?
¬ Amoxicillin-clavulanate (875 mg amoxicillin/125 mg clavulanate) PO bid
If the patient has a penicillin allergy:
2. Doxycycline 100mg bid
3. Levofloxacin 500mg daily
What should be the length of empiric treatment for bacterial rhinosinusitis?
What is the most common age of kids to get bacterial rhinosinusitis?
What is the tx for kids with bacterial rhinosinusitis?
2. DON'T GIVE KIDS UNDER 8 DOXY! So use Clindamycin
What are some of the causes of chronic rhinosinusitis?
- Allergens, irritants, bacteria, viruses, immunodeficiency, mucociliary dysfunction, fungi that cause inflammation
- Anaerobes (Fusobacterium nucleatum, pigmented Prevotella spp, Porphyromonas spp, and Peptostreptococcus spp)
What is the ultimate goal in the management of rhinosinusitis and what are some of the management options?
Goal is to reduce inflammation/edema therby improving sxs & manage superimposed infections as indicated!
1. High volume saline irrigation (100 ml tid), Neti-Pot, saline nasal rinse kit
2. Nasal steroid for at least 8-12 weeks for inflammation
3. Acute on chronic may consider a steroid burst for severe symptoms or those with nasal polyps
(ie prednisone 30 mg/day x 4 days, reduce by 5 mg q 2 days x 10 days)
4. Antibiotic selection should include coverage for aerobic and anaerobic bacterium
What is the antimicrobial therapy for chronic rhinosinusitis?
Antimicrobial therapy is 3 weeks duration, mixed evidence supporting up to 6 weeks
- Augmentin (Adults: 500 mg tid or 875 bid or two 1000 mg ER tabs bid)
- Kids: 45 mg/kg/day divided bid
If PCN allergic
- Clindamycin (300 qid or 450 tid)
Kids: 20-40mg/kg/day divided q 6-8 hr
- Doxycycline (200 mg x1, then 100mg daily)
Parts of the ear
What is the function of the eustachian tube?
ET is an air filled space that is intermittently vented
1. Helps to equalize pressure
2. Drains mucous
3. Helps prevent reflux
When your ear feel like "it needs to pop," the sensation is coming from here.
What are the 2 kinds of eustachian tube dysfunction?
1. Dilatory dysfunction
2. Patulous dysfunction—chronic patency (open all the time)
How do these types of eustachian tube dysfunction occur?
- Occurs when the mechanisms for venting are not functioning properly thereby causing pressure dysregulation
- Venting occurs with yawning, chewing, swallowing--Greater than 80 x daily
What are a few of the many specific etiologies for eustachian tube dysfunction?
- Inflammation, edema, increased secretions (MC)-URIs/allergies/smoking
- Musculatory failure limiting dilation of tube (less common)
- Craniofacial abnormalities-congenital (Cholesteatoma, cleft palate, Turners syndrome)
- Loss of mucociliary function (CF)
- GERD (gastrophar reflux disease)
- Anatomic abnormality (Hypertrophic adenoids, tumor, or trauma)
- Pressure dysregulation (scuba diving or air travel)
What will the exam appear with eustachian tube dysfunction?
υ Effusion marked by dull grey vs yellow coloration of TM (serous effusion)
υ Inflammation marked by erythema or pinkish TM (injected TM)
υ Pneumatic otoscope will show normal TM as mobile with insufflation
What is the management for eustachian tube dysfunction?
1. Tx underlying source (e.g. allergic rhinitis, GERD, mass lesions)
2. Decongestants if congestion present
3. Antihistamines if allergic sxs present
4. Topical nasal steroids only if signs of sinus/nasal inflammation
When should you refer eustachian tube dysfunction to ENT?
υ Effusions persisting > 1 month
υ Hearing loss
υ Recurrent AOM
υ TM perforation
υ Myringotomy-small slit in TM & suction of fluid
What are some of the sx with eustachian tube dysfunction?
Ears feel plugged or full.
Sounds may seem muffled.
A popping or clicking sensation (children may say their "ear tickles").
Pain in one or both ears.
Ringing in your ears (tinnitus).
Trouble keeping balance.
What is serous otitis media?
υ Middle ear effusion without infection
υ Effusion resulting from ET dysfunction that persists
υ 30-40% of children have recurrent OME
υ MC resolves without intervention
υ Hearing evaluation
What is the magic number that will be referred to ENT with hearing loss?
If abnormal (loss of >40 dB) - refer to ENT
What will you find on exam with serous otitis media?
Serous effusion with dull TM without purulence
Decreased mobility of TM with insufflation
Fluid levels may be seen with "bubbles"
What is the management for serous otitis media?
υ Watchful waiting for up to 3 months
υ No antibiotics are indicated
υ No antihistamines, steroids, or decongestants are recommended in children
υ Tympanostomy by ENT
ENT may consider tonsillectomy & adenoidectomy if indicated
How many layers does the tympanic membrane have?
What are 3 potential etiologies of TM perforation?
Iatrogenic (e.g. myringotomy)
Surgical incision into the eardrum, to relieve pressure or drain fluid
of or relating to illness caused by medical examination or treatment.
TM perforation sx
+/- pain, decreased hearing, otorrhea
TM perforation management?
Most small perforations will heal w/o intervention (weeks to months)
- Keep Ear DRY!! Or Increase infection risk
- Hearing test, if ossicle injury, will need f/u repair within 48 hrs
- Antibiotic ear drops (ofloxacin)
¬ Potential ototoxicity with aminogycosides if TM perforation present
ENT Approach: TM patching, fat plug tympanoplasty, fibrin glue OR surgical tympanoplasty
What is acute otitis media (AOM)?
Middle ear inflammation that leads to eustacian tube obstruction causing middle ear fluid collect causing pain and pressure within the ear
Epidemiology of AOM?
>80 % of children will experience 1 + ear infections in their life
Improves due to anatomical changes by age 6
What is the etiology of AOM?
υ Eustacian tube dysfunction
υ Bacterial (MAINLY BACTERIAL!)
What are the symptoms of AOM?
υ Otalgia or aural fullness
υ Decreased hearing
υ Associated URI sxs
υ Crackling/popping sounds
What is seen on exam with AOM?
υ Bulging TM
υ Erythemia of TM
υ Middle ear effusion
υ Limited or no mobility of TM
υ Air-fluid level
What is the treatment for AOM?
1. Oral analgesics:
Ibuprofen or acetaminophen
2. Topical analgesic (>2 years of age):
Benzocaine (e.g. Auralgan): 3 drops in affected ear q 1-2 hours prn
3. Antibiotics if indicated:
Augmentin (if been on abx in last 30 days)
Azithromycin if PCN allergy
When should you NOT use topical analgesics like Benzocaine with ear infection?
WHEN THERE IS A PERFORATED TM!
What is acute mastoiditis?
- Suppurative infection and inflammation of the mastoid air cells
- Subcategories of acute mastoiditis
What are the 2 forms of acute mastoiditis?
1. Acute mastoiditis with periosteitis - Purulent fluid in mastoid cavity
2. Acute mastoid osteitis or coalescent mastoiditis - Purulent fluid with localized destruction of bone
What are the etiologies and risk factors of acute mastoiditis?
Secondary to AOM
Streptococcus pyogenes, staphylococcus aureus
RF: recurrent AOM
Highest incidence in kids <2 yo but can occur at any age
What are some of the associated sx that would warrant emergent referral or imaging with acute mastoiditis?
υ Facial nerve palsy
υ Hearing loss
υ Mass or concern for abscess
υ Altered Mental status
υ Meningeal signs
General sx of acute mastoiditis?
υ TM abnormality
υ Ear pain
υ Protrusion of auricle
υ Mastoid tenderness
υ Postauricular edema
υ Postauricular warmth and erythema
What is the diagnostic testing for acute mastoiditis?
- CBC, ESR, CRP elevated
- If toxic appearance, Lactate, blood cultures, consider CSF/LP
- MRI with contrast is GOLD standard
- Temporal bone CT reserved for severe sxs & may be used in ED settings more
What is the management of acute mastoiditis?
1. IV ABX
2. Myringotomy if not already draining (ENT will do)
3. If abscess, above plus mastoidectomy
What is otitis externa?
Infection of the external auditory canal (EAC)
What is the etiology of otitis externa?
¬ Bacterial, rarely fungal
¬ Most commonly excessive moisture and trauma of the EAC
(Swimming, mechanical removal of cerumun, insertion of FB, trauma, dermatologic conditions like eczema or psoriasis)
¬ Cerumun is hydrophobic and protective
¬ Keratin debris absorbs water and promotes bacterial growth
How will otitis externa present itself?
SIGIFICANT TENDERNESS AND PURULENT DRAINAGE!
υ Otalgia or pruritis
υ Decreased hearing
υ Pain exacerbated by movement of the ear
¬ Tenderness over pinna or movement of auricle
υ Visualization of TM may be difficult due to edema and drainage
Do NOT FLUSH if the TM is not visualized
Risk of damaging ossicles may cause vestibular-cochlear damage
What is the treatment of otitis externa?
- Antibiotics combined with steroid may help improve sxs faster
- Fluoroquinolones are 1st line & may be used with TM rupture
¬ Ciprodex (ciprofloxacin 0.3% with dexamethasone 0.1%) otic solution
¬ Cipro 0.3% opthalmic solution
¬ Ofloxacin 0.3% otic or ophthalmic
¬ Cortisporin (neomycin 0.35%, polymyxin B 10,000 units/mL, hydrocortisone 1%)
o Should not be used w/ ruptured TM
- NSAIDs or APAP only
What should you NOT use with otitis externa?
TOPICAL ANALGESICS! Like Auralagan.
Can you use eye drops in the ear?
Yes. You may uses eye drops in the ears, but NEVER ear drops in the eyes
What is necrotizing otitis media and what is the main cause?
υ Invasive disease involving osteomyelitis of temporal bone
υ Most commonly pseudomonas
Another name for necrotizing otitis media?
Who is more at risk for necrotizing otitis media?
- 70-95% with necrotizing OE are Elderly diabetic
- Immunocompromised adults and children, and HIV + patients
- CD4 count < 100 at risk for Fungal
- May involve facial nerve palsy which lies over temporal bone
- Cerebral abscess, meningitis may occur with progressive dz
What are sx of necrotizing otitis media?
υ Auricular fullness
υ Purulent drainage
υ Febrile - However, may not mount fever!
What will you see on PE with necrotizing otitis media?
υ Granulation tissue on floor of canal and bony cartilaginous junction
υ May see exposed bone in EAC
υ TM may appear normal
υ Periauricular adenopathy
υ Assess for facial nerve paralysis (MC), and CN 9,10,11
υ May be septic with AMS—Check Ears!
What is the management of necrotizing otitis media?
2. Control blood sugars if DM
3. IV abx with admission
- Outpatient 6-8 weeks of PO Cipro 750mg bid after d/c
- If fungal then Amphotercin B---CONSULT ID/ENT!
- 15-20% recurrence
- May need surgical intervention
- Facial nerve paralysis associated with severe disease with higher mortality rate
- CT scan to assess for bony involvement for more readily available results
- CRP, ESR, CBC, +/- blood cultures, lactate
MRI is better study marrow edema, soft tissues
What causes auricular hematoma?
- Provoked by trauma
- Auricular perichondrium separates from underlying cartilage and space fills with blood causing swelling
- Blood supply is mostly anterior and posterior auricular artery from branch of temporal artery with associated veins
Tx of auricular hematoma?
1. Needle aspiration or I&D
2. Apply compressive dressing
How should you numb the area before tx of auricular hematoma?
1. Prep the area with betadine or alcohol
2. 1.5 inch 22 gauge needle
3. 1% lidocaine with or without epinephrine
4. Inject 3-4 cc of lidocaine while hugging base of ear
What is epistaxis and where is the MOST COMMON place it occurs?
1. Anterior (90%)
What are some of the etiologies of epistaxis?
υ Dry mucosa
υ Foreign body
υ Intranasal drug use
υ Visual inspection
υ +/- CBC, coagulation studies (won't do as many bld test for a young and healthy person without a history of epistaxis. ED will do more testing)
Tx of epistaxis?
1. Blow Your Nose to evacuate clots
2. Anesthesia and vasoconstriction
υ Spray lidocaine, oxymetazoline (2 spray q nostril) or phenylephrine
4. Pressure (minimum of 15 min)—It may be a slow 15 minutes!
υ Anterior or posterior packing with Rhino Rocket or Merocel
υ May consider chemical cautery with silver nitrate
Should you do chemical cautery on one or two sides of the septum?
Describe nasal packing
υ Anterior or Posterior packing
¬ Ensure anesthesia has been provided
¬ Merocel, Rhino Rocket, nasal sponges
¬ Toxic Shock Syndrome (TSS) prophylaxis with Augmentin!!!!
¬ Removal in 24-48 hours
υ Posterior packing
¬ Consider hospital admission for observation if bilateral
o Some admit for observation with unilateral
¬ Airway monitoring
¬ ENT consult for refractory bleeds
υ Complications of packing
Dislodgement, recurrent bleeding, sinusitis, TSS
What is the general treatment for a nasal or ear foreign body?
¬ Oxymetolazine & topical lidocaine
¬ May need sedation
¬ Nasal forceps, suction catheters, hooked probes, balloon-tipped catheters, Q-tip with glue
Refer to ENT if unable to remove in acute setting or sharp objects (or with objects like button battery)
What is vertigo?
Vertigo is a room spinning sensation, swaying movements
Involves the vestibular system / semicircular canals
Central causes of vertigo?
Central causes (~20%)
υ Multiple Sclerosis
υ Vestibular migraine
υ Posterior circulation abnormality
o Wallenberg Syndrome (lateral medullary infarction)
υ Cerebellar infarction or hemorrhage
Peripheral causes of vertigo?
Peripheral causes (80%)
υ Vestibular neuronitis
υ Meniere Disease
What is the most common cause of peripheral vertigo?
BPPV - Benign Paroxysmal Positional Vertigo
υ Lifetime prevalence is 2.4 %
υ 7x more likely in pts >60 years of age
Etiology of BPPV?
υ Calcium carbonate crystals within the semicircular canal
υ Head injury
υ Can be residual from other peripheral vestibulopathies
Sx of BBPV?
υ Room spinning sensation
υ May last minutes to hours
o Average is for 2 weeks
υ Provoked by certain head movements, positional changes of body (lying to sitting)
υ +/- nausea or vomiting
o More common w/ peripheral sources
o Ataxia or gait instability
PE signs of BBPV?
υ Nystagmus reproduced by Dix-Hallpike (50-88% sensitive)
υ Dix hall pike
¬ Vertical with superior or anterior canal BPPV
¬ Horizontal nystagmus with lateral canal
¬ Torsional or rotary with posterior canal
Tx of BBPV?
υ Meclizine 25mg PO
υ Diphenhydramine 25-50mg IV, IM, or PO
υ Metoclopramide 10-20 mg IV or PO
υ Promethazine 25-50 mg IM or PR
May need referral to ENT
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