Table of contents
- 1. Sinusitis
- 1.1. Diagnostic Criteria
- 1.2. Management
- 2. Vertigo Approach
- 3. Thyroid Nodules
- 4. Vestibular Neuritis
- 5. Meniere's
- 6. Outer Ear - Hearing Loss
- 6.1. Otitis Externa
- 6.2. Cerumen Impaction
- 6.3. Exostosis
- 7. Middle Ear - Hearing Loss
- 8. Middle
- 8.1. Cholesteotoma
- 8.2. Otosclerosis
- 8.3. Ossicular Trauma
- 8.4. ET Tube Dysfunction
- 8.5. Perforation
- 8.6. Other rare things
- 9. Inner Ear Hearing Loss
- 9.1. Congenital
- 9.2. Presbicusis
- 9.3. Noise Induced
- 9.4. Ototoxicity
- 9.5. Sudden SNHL
- 9.6. Meniere's Disease
- 9.7. Temporal Bone Fractures
- 9.8. CPA Tumors
- 10. Tinnitus
Sinusitis
- Inflammation of mucosal lining of the sinuses.
- Most common obstructive: anything blocking mucus exiting sinuses under middle meatus can cause inflammation)
- Etiology:
- Obstruction
- Inflammation (URTI, Allergy)
- Mechanical (septal deviation, polyps, adenoids, etc.)
- Immune (Wegeners, lymphoma, Immune suppression)
- Systemic (Cystic fibrosis, Ciliary defect)
- Direct Extension (dental abscess, facial fractures)
- Obstruction
- Classifcation:
- Acute <4wks
- Subacute 4wks - 3mo
- Chronic >3mo
- Organisms: (bacterial more common in kids)
- Viral: rhinovirus, influenza, parainfluenza
- Bacterial: S. pneumoniae (35%), H. influenzae (35%), M. catarrhalis, anerobes (dental)
- Fungus: if immunosuppressed.
- Viral lasts <10days,
- Bacterial if mucopurulent, worsening after 5 days, or >10days.
Diagnostic Criteria
- Requires 2 major criteria, or 1 major and 2 minor:
-
Major Criteria Minor Criteria - Face Pain/Pressure
- Face Fullness/Congestion
- Nasal Obstruction
- Purulent/Discolored Nasal discharge
- Hyposmia/anosmia
- Fever
- Headache
- Halitosis
- Fatigue
- Dental Pain
- Cough
- Ear Pressure
Management
- Symptoms improve after 5 days.
- If symptoms worse after 5 days add intranasal corticosteroid (INCS) x48hrs. If improvement with it, continue using for 14 days.
- Use abx only if chronic (>3mo) or if no improvement after 5 days and refractory to INCS (can also prescribe amoxil, clarithromycin or clavulin to use if no imrpovement with INCS) Also likely needs ENT referral for scope + surgery.
Vertigo Approach
Thyroid Nodules
Vestibular Neuritis
- Distinguish vs. stroke.
- If vestibular neuritis:
- No focal neuro deficits!
- Abnormal head thrust test (head thrust will cause loss of fixation when turned to affected side) = peripheral lesion
- If head thrust normal = may be stroke
- Usually horizontal unidirectional nystagmus (peripheral)
- Scew deviation.
- Tx:
- In ER (Acute symptomatic vertigo - Nausea)
- Prochlorperazine (Stemetil) - 10mg IV or IM
- Metoclopramide (Maxeran) - 10mg IV or IM
- At home
- Dimenhydrinate (Gravol) - 50mg po q4h prn
- vestibular neuritis rehab clinic?
- In ER (Acute symptomatic vertigo - Nausea)
Meniere's
- Attacks distinguish vs. BPPV
- Attacks are hours
- Aural fullness
- Low frequency hearing loss (eventually)
Outer Ear - Hearing Loss
Otitis Externa
- Ciprodex drops
- Refer if completely occluded. They will open under microscope and put a whick in for Abx delivery.
- Malignant otitis externa - (if diabetic etc..) need to cover psuedomonas. Need debridement.
- admission + IV abx.
- If use abx for long periods of time, can get fungal infection.
- use antifungals.
Cerumen Impaction
- Syringe or curette
- Contraindications to Syringing:
- Non-occlusive cerumen
- Previous Surgery in ear
- Only hearing ear
- TM perforation
Exostosis
- If swimming in cold water. CAn get bone protrusions in ear canal.
Middle Ear - Hearing Loss
- Pathogens:
- S. pneumoniae
- H. influenza
- Moraxella catarrhalis.
- Tx:
- Antibiotics
- Pressure decompression tube. (for recurrent otitis media)
- To replace the eustatian tube.
- Stays temporarily... eventually they won't need them. (rarely adults come back for tubes).
- Generally fall out in 6-12 mo, if hang on, can remove and surgically patch them. Rarely fall out.
- Need ENT following q6mo.
Middle
Cholesteotoma
- Skin cells growing into the
- Perforation, longstanding retration, skin cells migrate into middle ear.
- Skin cyst grows behind the ear drum. Causes conductive hearing loss. (mass within the ossicles).
- Often get draining ear (skin cysts comprised of dead skin).
- Foul smelling ear.
- They can erode away at the ossicles and innear ear (causing progressive hearing loss, and dizziness).
- Key giveaway:
- Conductive hearing loss, and draining ear. ==> Must get seen by ENT! (cholesteotoma)
- Can also get
- Meningitis, Cavernous sinus thrombosis etc... (depends on how far they erode).
Otosclerosis
- Stapes gets scarred down to the foot plate (last bone) => conductive hearing loss
- Open up the ear, and replace the stapes with prosthesis ==> normal hearing.
- Diagnosed on audiogram. -- at 2 kHz see a notch. ==> audiologist usually suggest referral for otosclerosis.
- Very curable.
- Worsens in pregnancy
- Management:
- Serial audiograms.
- Stapedectomy + prosthesis
- Hearing aid.
Ossicular Trauma
- Using Q-tip and fall etc.. Hit ossicles.
ET Tube Dysfunction
- Cannot equialize ear pressure. ---> Serous Otitis Media
Perforation
- Safe to leave for 3 months to see if heal on their own (>75% will heal)
- Document hearing loss with audiogram.
- Tell them not to put anything in the ear, and no water in the ear.
- If persists can refer.
- Use foam ear plugs in showers.
- If ok with level of hearing now, and no other patology, don't need a referral
- If at 3 months still perforated. can decide hearing aid, referral for surgery to patch the hole.
Other rare things
- Glomus typanium
- Pulsatile tinnitus: Can hear their own pulse.
- distinguish from stapedius muscle, which is like "typewriter going fast".
- See reddish blush.
- Need further workup, may have bigger tumor etc..
Inner Ear Hearing Loss
Congenital
- Torch etc..
Presbicusis
- Often genetic
- Death of hearing cells in the inner ear.
- Classic: Sensorineural hearing loss at high frequency. (for conductive hearing loss need difference of 15dB)
- If presbicusis:
- Repeat audiogram in 1 year
- Can refer further on to audiologist or ENT for hearing aids.
Noise Induced
- Hearing in normal range
- Dips down at 2kHz, nadir of hearing loss at 4kHz, then at high end can be better.
- Can counsel about hearing loss. Can get WSIB to fund hearing aids.
Ototoxicity
- Lots of lawsuilts: gentamycin or other aminoglycosides.
- Use alternatives if possible. If use it, need to write clear in the chart.
- Now: indefensible, settlement with CMPA.
- Others:
- Salicylates
- Antimalarials
- Loop Diuretics:
- Lasix (high doses)
- Chemotheraputics
- Cisplatin/Carbaplatin
- Mechanisms:
- Absorbed in inner ear -> free radicals --> deat of hair cells.
Sudden SNHL
- If sudden onset, can treat with steroids.
- Idiopathic - autoimmune, viral, vascular.
- Must r/o retrocochlear pathology (MRI)
- Oral steroids or intratympanic injections (if diabetic) within 72hrs.
- Can reverse if early enough.
Meniere's Disease
- Low frequency SNHL
- Many treatments:
- Medical (low salt diet, circ, diuretics (diazide, HCTZ)
- Surgical options too.
- Refer for further management esp if frequent attacks.
- Aural fullness.
Temporal Bone Fractures
- Different classifications, but best one is:
- Otic Capsule Involving (fracture through cochlea etc.)
- Otic Capsule Sparing
- Blood in middle ear, conductive hearing loss
CPA Tumors
- Rare tumors. Present with tinnitus.
- Will have hearing loss + other findings (vertigo, fascial palsys etc..)
- Need to have high index of suspicion to pick it up.
- Do audiogram
- Lose high frequency (vs. meniere's)
- If asymmetric sensorineural hearing loss. If difference between two audiograms need to see if there is a difference -> refer to ENT. Need MRI
Tinnitus
- Can be ringing, whistling, blowing, humming, pulsing.
- Classifications:
- Subjective vs. Objective
- Pulsatile vs. Non-Pulsatile (preferred).
- Pulsatile:
- Often find cause: high flow (hyperthyroidism, hypertension, pregnancy etc..)
- First one to rule out!
- Non-Pulsatile
- Different frequencies along each point
- First hair cells in cochlea are high-pitched. Get broken after trauma from lifetime noise.
- When hair cells broken - wires still discharge spontaneously.
- Pulsatile:
- Very long list of causes.
- Reversible:
- Treat identifiable cause
- Counsel patient
- Masking (put some white noise in the room, fan , TV, music, nature Cds etc..)
- Avoid stress, caffeine, alcohol.
- Tinnitus pillow - has soft speaker embedded into it. Can help drift off sleep.
- Hearing aid (often not great choice)
- Medications (Alloville??)
- Tinnitus CBT (Canadian Hearing Society). Other therapies to deal with tinnitus.
- Extreme cases:
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