ENT Disorders

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Author:
jknell
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194770
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ENT Disorders
Updated:
2013-01-23 19:02:06
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MBB II
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MBB II
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  1. Otitis Externa
    • Epidemiology:
    • -warm, wet environment
    • -80% in summer

    • Presentation:
    • -pain and tenderness
    • -otorrhea
    • -pruritis
    • -CHL
    • -aural fullness
    • -difficult to visualize TM

    • Pathophysiology:
    • -disruption of protective cerumen layer
    • -Bacterial: pseudomonas, staph
    • -Fungal: candida, aspergillus

    • Treatment:
    • -debridement
    • -wick
    • -dry ear precautions
    • -topical abx (quinolones)
    • -drying agents
  2. Otitis Media: Three types
    1. Acute Otitis Media (infection, <3 wks)

    2. Otitis Media with Effusion (serous effusion, no infection)

    3. Chronic Otitis Media (chronic otorrhea due to TM perforation)
  3. Acute Otitis Media
    • Epidemiology:
    • -peak incidence 6-12 months
    • -recurrence is common
    • -more common in winter

    • Presentation:
    • -irritability, fever, anorexia
    • -otalgia
    • -thick hyperpemic TM
    • -purulent effusion behind TM
    • -immobile TM

    • Pathophysiology:
    • -blockage of PT tube creates negative pressure in middle ear
    • -vacuum causes transudative effusion
    • -stasis of effusion can lead to infection

    • 1. Bacterial: S. pneumo, H. flu, Moraxella
    • 2. Viral: often preceeded by URI

    • Treatment:
    • -observation
    • -abx (fever >39C, age < 6mo)
    • -myringotomy and tympanostomy tube placement if fail medical tx
  4. Otitis Media with Effusion
    • Epidemiology:
    • -very common
    • -incidence declines after 7 years

    • Presentation:
    • -frequently asymptomatic
    • -CHL
    • -aural fullness
    • -decreased TM compliance
    • -bubbles behind TM

    • Pathophysiology:
    • -similar to AOM: negative pressure effusion
    • -NO inflammation

    • Treatment:
    • -spontaneous resolution is common
    • -if long term: tympanostomy tubes, adenoidectomy

    • Complications:
    • -rule out neoplasm of nasopharynx in adults
    • -can cause learning delays if long term
  5. Chronic Otitis Media
    • Presentation:
    • -otorrhea
    • -CHL
    • -hole in TM
    • -CT often shows pneumatization of mastoid

    • Pathophysiology:
    • -persistent or recurrent purulent otorrhea due to TM perforation
    • -loss of gas cushion allows reflux of nasopharyngeal contents
    • -pseudomonas
    • -almost always associated with chronic infection of mastoid

    • Treatment:
    • -topical abx
    • -tympanoplasty
    • -mastoidectomy

    • Complications:
    • -granulation tissue
    • -ossicular erosion
    • -cholesteatoma
  6. Cholesteatoma
    • Presentation:
    • -hearing loss
    • -chronic otorrhea
    • -waxy keratin debris

    • Pathophysiology:
    • -keratin pearls form in middle ear
    • 1. acquired: retraction pocket of TM into middle ear (associated with COM)
    • 2. secondary acquired:  surgery introduces epithelium into middle ear
    • 3. Congenital: keratin pearl behind intact TM

    • Treatment:
    • -surgery (mastoidectomy, tympanoplasty, ossicular reconstruction)

    • Complications:
    • -erosion and destruction of local structures
    • -erosion of ossicles and mastoid
  7. Mastoiditis
    • Presentation:
    • -pain and tenderness over mastoid
    • -edema
    • -erythema
    • -protrusion of pinna
    • -CT: erosion of mastoid air cells

    • Pathophysiology:
    • -infection of mastoid
    • -commonly associated with COM

    • Treatment:
    • -Uncomplicated: IV Abx, tympanostomy tube, inpatient observation
    • -Complicated: mastoidectomy

    • Complications
    • -meningitis
    • -sinus thrombosis
    • -extracranial abscess
  8. Acoustic Trauma
    • Presentation:
    • -sensorineural hearing loss

    • Pathophysiology:
    • -loss of hair cells (outer, higher frequency are more susceptible)

    • Diagnosis:
    • -audiometric testing

    • Treatment:
    • -no effective treatment
    • -prevention: OHSA
    • -hearing aids
  9. Presbyacusis
    • Epidemiology:
    • -30% of ppl >35 years
    • -50% of ppl >75 years
    • -worse in men (probably due to exposure)

    • Presentation:
    • -SNHL
    • -progressive high frequency loss
    • -worsening speech discrimination (out of proportion)

    • Pathophysiology:
    • -population of spiral ganglia decreased with age

    • Treatment:
    • -no effective medical treatment
    • -amplification
  10. Otosclerosis
    • Epidemiology:
    • -FHx is a significant risk factor
    • -measles virus reactivation?
    • -non-whites rarely affected
    • -women > men
    • -2nd to 4th decade
    • -bilateral in up to 70%

    • Presentation:
    • -progressive CHL

    • Pathophysiology:
    • -dense bone of otic capsule is replaced
    • 1. Otospongiosis: replacement with disorganized woven bone
    • 2. Sclerosis: at oval window leading to fixation of stapes footplate

    • Treatment:
    • -stapedectomy, stapedotomy
    • -sodium fluoride may stabilize otospongiotic phase
  11. Vestibular Schwannoma
    "acoustic neuroma"

    • Epidemiology:
    • -95% spontaneous
    • -5% associated with NF2
    • -most present around 40 (except NF2)

    • Presentation:
    • -unilateral SNHL
    • -less vestibular sx due to central compensation
    • -tinnitus
    • -large tumors can cause CNVII and CNV sx

    • Pathophysiology:
    • -nerve sheath tumor of CNVIII
    • -may arise in internal auditory canal or closer to cerebellopontine angle
    • -rarely malignant
    • -sx usually due to compression

    • Treatment:
    • -surgical resection (risk damage to CNs)
    • -gamma knife irradiation
  12. BPPV
    • Epidemiology:
    • -most common cause of vertigo
    • -may be associated with head trauma

    • Presentation:
    • -vertigo lasting seconds
    • -provoked by position
    • -latency of 1-2 seconds
    • -nausea
    • -Dix Hallpike maneuver (nystagmus)

    • Pathophysiology:
    • -otoliths detached from utricular or saccular macule and migrate into a semicircular canal (90% posterior)
    • -otoliths stimulate vestibular sensory organ in SCC

    • Treatment:
    • -most resolve spontaneously
    • -Epley maneuver
  13. Meniere's
    • Epidemiology:
    • -10% of patients with vertigo
    • -typically 40-60 year olds

    • Presentation:
    • -HIGHLY VARIABLE
    • -vertigo lasting minutes to hours
    • -fluctuating SNHL
    • -tinnitus
    • -aural fullness
    • -nystagmus (slow phase to lesion)
    • -fall to side of lesion

    • Pathophysiology:
    • -increased endolymph pressure distorts membranous labyrinth
    • -in ea episode: membrane between endolymph and perilymph ruptures allowing flow of K+ into the perilymph
    • -leads to paralysis of vestibular nerve fibers and may damage cochlear hair cells
    • -etiology uncertain

    • Treatment:
    • -spontaneous recovery common (so is relapse)
    • -dietary salt restriction
    • -diuresis
    • -acute vestibular suppressants
    • -gentamycin to ablate vestibular system
  14. Vestibular Neuritis
    • Epidemiology:
    • -third most common cause of vertigo
    • -5% of patients who present to ED with dizziness
    • -onset commonly in middle age

    • Presentation:
    • -vertigo lasting days
    • -hearing unaffected
    • -spontaneous horizontal nystagmus (slow phase to lesion)
    • -fall to side of lesion

    • Pathophysiology:
    • -uncertain etiology
    • -may have viral origin

    • Treatment:
    • -supportive
    • -acutely vestibular suppressants
    • -oral steroids
  15. Labyrinthitis
    • Epidemiology
    • -viral infection most common cause

    • Presentation:
    • -vestibular dysfunction
    • -unilateral hearing loss with onset over hours to days (vs Vestibular neuritis)

    • Pathophysiology:
    • 1. Viral: 50% follow URI, Ramsay hunt (VZV)
    • 2. Bacterial (worse): complication of AOM, typically results in complete loss of function
    • 3. Autoimmune

    • Treatment:
    • -supportive
    • -steroids of CNVII affected (Ramsay Hunt)
  16. Maxillofacial and skull base fractures
    • Epidemiology:
    • -assault, MVC, recreation
    • -substance abuse common
    • -highest incidence in young males

    • Presentation:
    • -varied depending on site of trauma

    • Pathophysiology:
    • 1. Nasal- low energy
    • 2. Midface- low energy
    • 3. Zygomaticomaxillary
    • 4. Naso-orbito-ethmoid- high energy, eyes separate
    • 5. Orbital blow out- low energy
    • 6. Mandibular

    • Treatment:
    • -some may be observed
    • -most require reduction and fixation
    • -soft tissue repair
  17. Temporal Bone Fractures
    • Epidemiology:
    • -temporal bone is the most complex bone in the body
    • -most injuries due to MVCs

    • Presentation:
    • -depends on structures involved
    • -hearing loss
    • -vertigo
    • -CSF otorrhea
    • -Facial paresis
    • -blood in external ear canal

    • Pathophysiology:
    • -high energy force (MVC, falls, assault)
    • -Longitudinal (runs through mastoid process, tends to miss otic capsule, less CNVII palsy and hearing loss) = 80%
    • -Transverse (perpendicular to petrous ridge, more frequently involve otic capsule)

    • Treatment:
    • -CSF leak: Abx prophylaxis
    • -Facial paresis: decompress nerve
    • -CHL: elective exploration months later

    • Complications:
    • -CSF leak can cause meningitis
  18. TMJ Disorder
    • Epidemiology:
    • -5-10% of US
    • -women increased risk by 4x

    • Presentation:
    • -jaw and facial pain
    • -tenderness of TMJ
    • -limited jaw movement
    • -clicking or popping
    • -crepitus

    • Pathophysiology:
    • -degenerative joint disease
    • -anterior displacement of articular disk

    • Treatment:
    • -soft diet
    • -NSAIDs
    • -compress
  19. TMJ Dislocation
    • Epidemiology:
    • -less common than TMJ

    • Presentation:
    • -pain
    • -malocclusion
    • -trismus
    • -open bite deformity

    • Pathophysiology:
    • -poorly coordinated muscle contraction during extreme mouth opening

    • Treatment:
    • -manual reduction

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