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)
    • 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

    VertigoApproach.png

     

     

    Thyroid Nodules

    ThyroidAlgorithmAAFP.gif

    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?
    •  

     

    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.
      • 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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