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  1. Approach To Medicine
  2. Surgical Specialties
  3. ENT

ENT

Modified 19:08, 11 Dec 2013 by apavel | Page History
    Table of Contents
    1. 1. Sinusitis
      1. 1.1. Diagnostic Criteria
      2. 1.2. Management
    2. 2. Vertigo Approach
    3. 3. Thyroid Nodules
    4. 4. Vestibular Neuritis
    5. 5. Meniere's
    6. 6. Outer Ear - Hearing Loss
      1. 6.1. Otitis Externa
      2. 6.2. Cerumen Impaction
      3. 6.3. Exostosis
    7. 7. Middle Ear - Hearing Loss
    8. 8. Middle
      1. 8.1. Cholesteotoma
      2. 8.2. Otosclerosis
      3. 8.3. Ossicular Trauma
      4. 8.4. ET Tube Dysfunction
      5. 8.5. Perforation
      6. 8.6. Other rare things
    9. 9. Inner Ear Hearing Loss
      1. 9.1. Congenital
      2. 9.2. Presbicusis
      3. 9.3. Noise Induced
      4. 9.4. Ototoxicity
      5. 9.5. Sudden SNHL
      6. 9.6. Meniere's Disease
      7. 9.7. Temporal Bone Fractures
      8. 9.8. CPA Tumors
    10. 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)
    • 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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