OTOLARYNGOLOGY REVIEW 2012

John Leffert, MPAS, PA-C

OTOLOGY

Hearing Loss Three types of

hearing loss: conductive, sensorineural, and mixed

HEARING LOSS CAUSES Sensorineural (SNHL): Presbycusis: hearing loss

associated with aging Trauma: head or ear trauma Unilateral sensorineural hearing

loss has also been noted after open-heart surgery

Noise: frequently associated with tinnitus

Infectious: Viral or Bacterial Meniere's disease Idiopathic sudden SNHL with no

apparent cause: suspected causes - viral, autoimmune, or vascular (i.e. nerve infarction)

Conductive (CHL): Infectious: Traumatic/tympanic membrane

rupture: Cerumen impaction Foreign body in external canal Canal atresia Exostoses Otosclerosis Ossicular discontinuity Mass lesions of the middle ear Mixed hearing loss (MHL): Cholesteatoma/chronic infection Trauma: skull or temporal bone

fractur

ACUTE AND CHRONIC OTITIS MEDIA-CAUSES

Most cases of acute otitis media are viral in origin:

Rhinovirus Influenza virus Adenovirus Enteroviruses Parainfluenza viruses Respiratory syncytial

virus

Common bacterial causes of acute otitis media include:

Streptococcus pneumoniae - the most prevalent (30-50%)

Haemophilus influenzae - a significant cause of otitis media in older children, adolescents, and adults (20-30%)

Moraxella catarrhalis (2-15%) Group B Streptococcus (20% in

neonates and young infants) Staphylococcus aureus

ACUTE AND CHRONIC OTITIS MEDIA-CAUSES

Common causes of chronic otitis media: Pseudomonas aeruginosa Staphyloccus aureus Escherichia coli Proteus spp. Anaerobes (Peptostreptococcus, Fusobacterium

spp., and Bacteroides spp.) Immunization against H. influenzae, S.

pneumoniae, and influenza can reduce the incidence of otitis media and other infections caused by these organisms.

CLINICAL PRESENTATION

Specific symptoms include: Otalgia (cardinal sign) Hearing loss A sense of fullness in the ear Vertigo Tinnitus Purulent otorrhea Fever Tugging on the ears

Nonspecific symptoms include:

Lethargy Anorexia Nausea and vomiting Diarrhea Headache

In infants and neonates, symptoms are generally nonspecific and include:

Fever Irritability Generalized malaise Diarrhea Vomiting

Signs Redness of the tympanic

membrane Immobile tympanic membrane

on pneumotoscopy Leukocytosis (may be subtle

or absent) - white blood cell measurement is rarely needed in workup

TREATMENT Acute otitis media: Viral etiology and recover

spontaneously within a week. Observation is generally all that is

Antibiotic treatment is generally recommended in patients <2 years of age. Patients >2 years of age with ambiguous or mild symptoms should be observed for 48-72h, after which a further assesment should be made. If worsening of symptoms or no improvement occurs, antibiotic treatment may be indicated

First-choice antibiotic is amoxicillin. Penicillin-allergic patients can be treated with a macrolide. Cephalosporins may also be used;

Patients <2 treat for 10 days, patients >2 years of age treat for 5-7

days. Acetaminophen or ibuprofen may be

used for relief of pain; however, decongestants and antihistamines are not recommended

Chronic otitis media: Patients not at risk of speech,

language, or learning problems associated with hearing loss of <20dB should undergo a period of watchful waiting for 3 months.

Treat with amoxicillin for short-courses of 10-14 days may be indicated where infective complications are identified

Antihistamines, decongestants, and corticosteroids may be prescribed for symptomatic treatment; however, these are not standard treatments

Surgical management of persistent middle ear effusions includes myringotomy, adenoidectomy, and the placement of tympanostomy tubes for children with otitis media with effusion causing hearing impairment

Up to 80% of children with recurrent otitis media have proven food and/or inhalant allergies. and chronic otitis media

OTITIS EXTERNA-COMMON CAUSES

Gram-positive organisms: Staphylococcus aureus Streptococci groups D and G Gram-negative

organisms: Pseudomonas aeruginosa Escherichia coli Proteus mirabilis Klebsiella pneumoniae Anaerobic bacteria: Bacteroides spp. Clostridium spp. Anaerobic streptococci

Fungi: Aspergillus niger (these

occur in 10% of otitis externa cases in the US)

Candida albicans Secondary to primary

skin conditions (eczematous otitis externa):

Eczema Psoriasis Seborrheic dermatitis Allergies

CLINICAL PRESENTATION

SYMPTOMS SIGNS

Pruritus Pain Foul-smelling discharge Reduced hearing Vertigo Difficulty with

mastication Hearing loss

Tenderness of the ear made worse by pulling on the pinna and putting pressure over the tragus

Eczema of the skin of the pinna Ear canal erythema and swelling Exudative and debris - mixed

discharge from the ear Decreased conductive hearing Lymphadenopathy - postauricular,

preauricular, and lateral cervical lymph nodes

Trismus may occur from extension into the temporomandibular joint and the parotid gland

Erythema may extend to the skin over the mastoid, pinna, and infra-auricular skin

TREATMENT

Acetic acid and a topical antibiotic-corticosteroid preparation such as ciprofloxacin-hydrocortisone or neomycin-polymyxin B-hydrocortisone. These agents cover Pseudomonas and Staphylococcus aureus adequately. Combination formulations are considered more effective than either antibiotics or corticosteroids alone

If otitis externa with perforation is present, topical ofloxacin is a better option owing to its lower acidity and lower risk of ototoxicity

Cleansing and debridement of the external ear can be done with irrigation, by suction, or with a cotton swab under direct visualization. This helps to improve the effect of the topical medications

If the ear canal is quite red and edematous, a wick can be inserted into the external ear canal for about 24h and the ear drops inserted through this wick

SINUSITIS- CAUSES

Most cases of acute sinusitis follow a viral upper respiratory infection. 

The following bacteria can be found in patients with acute sinusitis: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis

Additional pathogens can be isolated from the sinuses of patients with chronic sinusitis, including: Pseudomonas aeruginosa Group A Streptococcus Staphylococcus aureus Anaerobes (Bacteroides spp., Fusobacterium spp.,

Propionibacteriumacnes)

CLINICAL PRESENTATION

SYMPTOMS SIGNS Nasal congestion Purulent nasal secretion Facial 'pressure' pain Headache Maxillary toothache Persistent cough Postnasal drip Poor response to

decongestants

Tenderness over the involved sinus cavities is sometimes present

Periorbital edema in the case of cellulitis

Dark circles beneath the eyes (may reflect allergic diathesis more than infection)

Absence of transillumination (neither very sensitive nor specific)

Mucosal edema Increased posterior pharyngeal

secretions Purulent secretions from middle

meatal region

TREATMENT

First-line therapy is amoxicillin; it is generally effective, inexpensive, and well tolerated

Trimethoprim/sulfamethoxazole is a good alternative to amoxicillin, especially in patients who are allergic to penicillins, although Streptococcus pneumoniae may be resistant to it

For patients allergic to both amoxicillin and trimethoprim, alternatives include cephalosporins such as cefuroxime (but note the 10% allergic cross-reactivity between penicillins and cephalosporins) or macrolide antibiotics such as erythromycin or clarithromycin

Other options include: amoxicillin-clavulanate, a quinolone such as levofloxacin, or a cephalosporin such as cefuroxime

PHARYNGITIS

Viral causes are the most common (90% in adults, 60-75% in children) rhinovirus, adenovirus, parainfluenza virus,

coxsackievirus, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, respiratory syncytial virus

Bacteria: group A beta-hemolytic streptococci, especially

Streptococcus pyogenes, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Haemophilus influenzae, Moraxella catarrhalis, nontypable Haemophilus

Fungi : Candida - may be found in immunocompromised

individuals

CLINICAL PRESENTATION

SYMPTOMS SIGNS

Sore throat Odynophagia Chills Malaise Headache Anorexia Abdominal pain

Pharyngeal erythema Pharyngeal exudate Enlarged edematous

tonsils Fever Anterior cervical

adenopathy Rash - may or may not

be present

TREATMENT

VIRAL BACTERIAL

Acetaminophen Ibuprofen Saltwater gargling Soft, cool foods

Penicillin V: drug of first choice for group A beta-hemolytic streptococcal pharyngitis

Penicillin G: alternative to penicillin V, given intramuscularly for noncompliant patients with streptococcal infections

Amoxicillin: may be preferred in children with streptococcal infections because of increased palatability compared with penicillin V

Erythromycin: alternative to penicillin V in penicillin-allergic patients with streptococcal infections

Clarithromycin: alternative to penicillin for erythromycin-resistant streptococcal strains

Azithromycin: alternative to penicillin for erythromycin-resistant streptococcal strains

Clindamycin: for refractory cases with concern regarding anaerobic cover

TONSILLITIS

Influenza A and B viruses Respiratory syncytial virus (RSV) Adenovirus Streptococcus groups A and G, group A

beta-hemolytic streptococci

CLINICAL PRESENTATION

SYMPTOMS SIGNS

Sore throat Possible breathing difficulty Drooling Difficult and painful

swallowing of saliva, liquids, and food

Fever Headache Otalgia Malaise Vomiting Signs

Swollen hyperemic red tonsils, often coated with a yellow or thin white nonconfluent membrane that peels away without bleeding

Throat may be edematous, be blistered, or have painful ulcers

White particulate matter in tonsillar crypts is found in chronic tonsillitis

Cervical lymph nodes may be swollen, enlarged, or tender

Fever Dry mucous membranes

TREATMENT

Gargle with warm salt water Drink warm fluids For streptococcal tonsillitis, prescribe

penicillin V or penicillin derivative, cephalosporins (e.g. cephalexin, cefixime, or cefuroxime), erythromycin, or clindamycin

For children under 16 years of age, prescribe a non-aspirin over-the-counter analgesic such as acetaminophen for pain and fever

EPIGLOTTIS-CAUSES

Haemophilus influenzae type b (Hib) - most common cause in children and adults; incidence has decreased dramatically in countries that immunize against Hib

Streptococci (groups A, B, and C), including Streptococcus pneumoniae and S. pyogenes; group A streptococcus is the second most common cause in adults

Klebsiella pneumoniae Candida albicans Staphylococcus aureus Haemophilus parainfluenzae Neisseria meningitidis Varicella-zoster virus

CLINICAL PRESENTATION

SYMPTOMS SIGNS

Sore throat Dysphagia Drooling Fever - frequently high in

children; adults may be afebrile

Difficult and labored breathing

Cough Sudden onset

Cervical adenopathy Toxic appearance of patient,

bacteremia Stridor Muffled voice (54%) 'Tripod position' (sitting up on

hands with tongue out and head forward)

Hypoxia Respiratory distress Mild cough Severe pain on gentle palpation of

larynx or hyoid bone (seen in 80% of adults)

CLINICAL PEARLS

MEDICAL EMERGENCY

Airway obstruction Never lay the

patient FLAT! Never induce the

gag reflex Hospitalize

IMMEDIATE ACTIONS

Secure patient's airway before initiation of empiric antibiotic therapy

Once airway is secure, initiate empiric antibiotic therapy that covers group A streptococci, S. pneumoniae, S. pyogenes, and H. influenzae before obtaining culture results

Admit to the intensive care unit to assure careful monitoring of the airway

PERITONSILLAR ABSCESS

Common causes Group A hemolytic

streptococci Polymicrobial

infections are common, including anaerobes (such as Bacteroides) and aerobes (including Gram-positive cocci and Gram-negative rods)

CLINICAL PRESENTATION

SYMPTOMS SIGNS Symptoms are typically

more severe than during the usual case of tonsillitis:

Unilateral, severe throat pain

Dysphagia Odynophagia Trismus (difficulty opening

the mouth wide) Neck pain Referred ear pain Drooling Muffled ('hot potato') voice Fever

Fever Severe dehydration Possibly extreme distress may

occur if the airway is compromised due to pharyngeal or laryngeal edema (rare)

Tonsillar hypertrophy Palatal edema Contralateral deflection of the

swollen uvula Fluctuant peritonsillar fullness Tender cervical adenopathy Inflamed oropharyngeal mucosa Drooling Rancid breath

TREATMENT

Early recognition and diagnosis Appropriate referral to ENT specialist Incision and drainage and/or needle aspiration Antibiotic therapy-erythromycin or amoxicillin-

clavulanic acid to cover streptococci and metronidazole or clindamycin for oral anaerobes