COMMON E.N.T. PROBLEMS

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COMMON E.N.T. PROBLEMS

• B. WAYNE BLOUNT, MD, MPH
• PROFESSOR
• EMORY FAMILY MEDICINE

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Learning Objectives

• IN SYLLABUS

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Acute Otitis Media

• B. WAYNE BLOUNT, MD, MPH
• PROFESSOR, EMORY

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Otitis Media - Classification

• Acute OM - rapid onset of signs sx, lt 3 wk
  course
• Subacute OM - 3 wks to 3 mos
• Chronic OM - 3 mos or longer

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Otitis Media et al

• Acute otitis media (AOM)
• Otitis media with effusion (OME)
• Otitis externa
• Other ear findings, common and uncommon

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Recommendation 1

• To diagnose acute otitis media the clinician
  should confirm
• 1) a history of acute onset,
• 2) identify signs of middle-ear effusion (MEE),
  and
• 3) evaluate for the presence of signs and
  symptoms of middle-ear inflammation.

AOM Guideline at http//www.aafp.org/x26481.xml
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Recommendation 2

• The management of AOM should include assessment
  of pain. If pain is present, the clinician
  should recommend treatment to reduce pain.

AOM Guideline at http//www.aafp.org/x26481.xml
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Recommendation 3A

• Observation without use of antibacterial agents
  in a child with uncomplicated AOM is an option
  for selected children based on diagnostic
  certainty, age, illness severity, and assurance
  of follow-up.

AOM Guideline at http//www.aafp.org/x26481.xml
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Recommendation 3B

• If a decision is made to treat with an
  antibacterial agent, the clinician should
  prescribe amoxicillin for most children. When
  amoxicillin is used the dose should be 80 to 90
  mg/kg/day.

AOM Guideline at http//www.aafp.org/x26481.xml
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Recommendation 4

• If the patient fails to respond to the initial
  management option within 48 to 72 hours, the
  clinician must reassess the patient to confirm
  AOM and exclude other causes of illness. If AOM
  is confirmed in the patient initially managed
  with observation, the clinician should begin
  antibacterial therapy. If the patient was
  initially managed with an antibacterial agent(s),
  the clinician should change the antibacterial
  agent(s).

AOM Guideline at http//www.aafp.org/x26481.xml
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Acute Otitis Media - Risk Factors

• Male gender
• Sibling hx or recurrent otitis media
• Early age of onset of AOM ( before 4 mo)
• Bottle feeding, or breastfeeding for lt 4 mo
• Group day care
• Exposure to tobacco smoke
• Swanson, Jill, Otitis Media in Young
  Children, Mayo Clinic Proceedings, 71(2), Feb
  1996, pp 179-183

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Eustachian tube

• Usually closed
• Opens during swallowing, yawning, and sneezing

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Acute Otitis Media - Positive Predictive Value of
TM Findings

• Finding PPV
• Bulging TM 89
• Cloudy TM 80
• Distinctly impaired mobility 78
• Distinctly red TM 65
• Slightly impaired mobility 33
• Slightly red TM 16
• Karma et al, Otoscopic diagnosis of middle ear
  effusion in acute and non-acute otitis media, Int
  J Pediatr Otolaryngol, 1989, 17, pp 37-49

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Normal Ear Drum
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Microbiology

• S. pneumoniae - 30-35
• H. influenzae - 20-25
• M. catarrhalis - 10-15
• Group A strep - 2-4
• Infants with higher incidence of gram negative
  bacilli

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Virology

• RSV - 74 of middle ear isolates
• Rhinovirus
• Parainfluenza virus
• Influenza virus

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Microbiology

• PCN-resistant Strep
• 1979 - 1.8
• 1992 - 41
• Altered PCN-binding proteins
• Lysis defective
• Age, day-cares, and previous tx

• H. flu and M. catarrhalis
• beta-lactamase production
• All M. catarrhalis
• 45-50 H. flu

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Acute Otitis Media - Pneumatic Otoscopy

• Pneumatic otoscopy/insufflation will demonstrate
  decreased mobility of the tympanic membrane in
  cases of middle ear effusion with increased
  middle ear pressure.
• Mobility of the TM is not consistent with a
  diagnosis of AOM.

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Acute Otitis Media - Tympanometry

• This instrument is used to detect fluid within
  the middle ear.
• Several types of tympanograms
• Highly sensitive when disease present.
• Lower specificity when disease absent - will be
  abnormal in
• children with
• normal TMs.

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Onusko, E, Tympanometry, AFP, Nov. 1, 2004, pp
1713-1720
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Acute Otitis Media - Acoustic Reflectometry

• An instrument similar to the tympanogram is used
  to bounce sound waves off the TM.
• More waves are reflected when the middle ear is
  full of fluid.
• Sensitivity 90 and specificity 86 for
  middle ear effusion or abnormal pressure.

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Recommendation 2

• The management of AOM should include assessment
  of pain. If pain is present, the clinician
  should recommend treatment to reduce pain.

AOM Guideline at http//www.aafp.org/x26481.xml
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Acute Otitis Media - Treatment

• Ensure that the patient has adequate analgesia.
• Tylenol
• 10-15 mg/kg up to q4hr
• Motrin
• 5-10 mg/kg up to q6-8hr, max dose of 20
  mg/kg/24hr
• Dont forget topical analgesia with Auralgan
  (topical benzocaine)

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Acute Otitis Media - Treatment

• In the USA, one study has demonstrated that AOM
  due to S. Pneumonia spontaneously resolved in
  20, while 50 cases of H. influenza resolved
  spontaneously.
• McCracken, Considerations in selecting an
  antibiotic for treatment of acute otitis media,
  Pediatr Infect Dis J, 1994, 13(Suppl), pp
  1054-1057
• The difficulty is in choosing which patient not
  to give antibiotics.

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Recommendation 3A

• Observation without use of antibacterial agents
  in a child with uncomplicated AOM is an option
  for selected children based on diagnostic
  certainty, age, illness severity, and assurance
  of follow-up.

AOM Guideline at http//www.aafp.org/x26481.xml
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Recommendation 3B

• If a decision is made to treat with an
  antibacterial agent, the clinician should
  prescribe amoxicillin for most children. When
  amoxicillin is used the dose should be 80 to 90
  mg/kg/day.

AOM Guideline at http//www.aafp.org/x26481.xml
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Acute Otitis Media - Treatment

• Amoxicillin is still the first line therapy.
• 1.00 per bottle
• May also consider Septra/Bactrim
• 0.82 per bottle
• Please remember this before writing for
  Zithromax, which costs WAY more.
• 15.00 per bottle

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Acute Otitis Media -Treatment

• Ceftriaxone has been shown in multiple studies to
  be equally efficacious when given as a one-time
  IM injection of 50 mg/kg (max).
• Comparison of Ceftriaxone and Trimethoprim-Sulfame
  thoxazole for Acute Otitis Media, Pediatrics,
  99(1), January 1997, pp 23-28.

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Treatment - Recurrent AOM

• Chemoprophylaxis
• Sulfisoxazole, amoxicillin, ampicillin, pcn
• less efficacy for intermittent propylaxis
• Myringotomy and tube insertion
• decreased and severity of AOM
• otorrhea and other complications
• may require prophylaxis if severe
• Adenoidectomy
• 28 and 35 fewer episodes of AOM at first and
  second years

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Acute Otitis Media - Treatment

• Antihistamines and decongestants are not
  established therapies for AOM.
• However, remember that 70-90 of children with
  AOM have/had an antecedent URI/cold, so this may
  not really be bad medicine.

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Acute Otitis Media - Treatment Duration

• The standard treatment is 10 days.
• A study in Pediatrics demonstrated that treating
  for a full 20 day course was no more efficacious
  than treating for 10 days
• Efficacy of 20- Versus 10-Day Antimicrobial
  Treatment of Acute Otitis Media, Pediatrics,
  96(1), July 1995, pp 5-13

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Acute Otitis Media - Follow-Up

• Patients with AOM should have a decrease, if not
  resolution, in their symptomatology over the
  48-72 hours after a diagnosis is made and
  treatment instituted.
• If no resolution in symptoms, consider a
  beta-lactamase producing bacteria or other
  process, not to exclude poor patient compliance.

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Recommendation 4

• If the patient fails to respond to the initial
  management option within 48 to 72 hours, the
  clinician must reassess the patient to confirm
  AOM and exclude other causes of illness. If AOM
  is confirmed in the patient initially managed
  with observation, the clinician should begin
  antibacterial therapy. If the patient was
  initially managed with an antibacterial agent(s),
  the clinician should change the antibacterial
  agent(s).

AOM Guideline at http//www.aafp.org/x26481.xml
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Acute Otitis Media - Follow-Up

• The party line - 2 week ear check.
• Hathaway et al found the following criteria to be
  97 accurate in determining if a child had AOM at
  follow-up
• Parental impression of resolved AOM
• Absence of symptoms
• Age gt 15 months
• No family history of recurrent AOM in a sib.
• Hathaway et al, Acute Otitis Media Who Needs
  Posttreatment Follow-Up?, Pediatrics, 94(2),
  August 1994, pp 143-147.

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Acute Otitis Media - Recurrence/Prophylaxis

• In general 3 episodes in 6 months or 4 episodes
  in 1 year deserve consideration for antibiotic
  prophylaxis.
• Knowledge at large, also in Conns 1998
• Drugs
• Amoxil at 20 mg/kg qd
• Gantrisin 50-75 mg/kg divided bid

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Acute Otitis Media - Recurrence/Prophylaxis

• Follow-up is usually once per month, at least
  initially.
• If a child had breakthrough infections on
  prophylaxis, consider an ENT referral.
• How long to continue prophylaxis? Needham et al
  (unpublished data) 6-12 months minimum. Use your
  best judgement.

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Acute Otitis Media - Recurrence/Prophylaxis

• The goal of prophylaxis is to allow the child to
  age enough so that his/her eustachian tube
  apparatus will become less likely become infected
  (usually age 3-ish, again, more unpublished data,
  i.e., opinion).
• Use the antibiotic prophylaxis to avoid surgery,
  although the surgery takes all of 2 minutes.

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Otitis Media with Effusion

• OME

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Otitis Media with Effusion-Some Sticky Business

• Simply defined as fluid in the middle ear without
  symptoms or signs of AOM.
• Clinical Practice Guideline - expert panel
  comprised of members from AAP, AAFP, and American
  Academy of Otolaryngology-Head and Neck Surgery,
  with review and approval of the Agency for Health
  Care Policy and Research.

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OM - persistent middle ear effusion (MEE)

• High incidence of MEE, avg of 40 days
• Children less that 2 years much more likely to
  have persistent MEE
• White children with higher incidence of MEE

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Chronic MEE

• Previously thought sterile
• 30-50 grow in culture
• over 75 PCR
• Usual organisms

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Otitis Media with Effusion- Some REALLY Sticky
Business

• Glue ear, the REAL glue ear.
• Otoscopic findings
• Thick yellow fluid behind the TM
• A different fish from plain ol OME - this is the
  hog bass from the bog swamp. He aint movin fo
  nuttin.

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Treatment - OME

• MEE gt 3 mos or assoc hearing loss, vertigo,
  frequency, ME pathology, discomfort
• Antibiotics
• shown to be of benefit, 75 PCR bacterial DNA
• Antibiotics steroid
• 21 improvement compared to abx alone
• prednisone 1 mg/kg day x 7 days
• varicella?
• Myringotomy tympanostomy /- adenoidectomy

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Tympanostomy tube insertion

• Unresponsive OME gt3 mos bil, or gt6 mos uni,
  sooner if assoc hearing problems
• Recurrent MEE with excessive cumulative duration

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Glue ear
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Otitis Externa
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Otitis Externa

• Commonly referred to as Swimmers Ear
• Usual infections are skin bacteria.
• If you see green, foul discharge, think of
  Pseudomonas.
• In diabetics, people on steroids, and
  immunocompromised, dont forget fungal infections.

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Do you think it would hurt to pull on this tragus?
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Otitis Externa - Treatment

• Cortisporin suspension - safe in all ears
• Neomycin, Polymyxin B, Hydrocortisone
• Cortisporin solution - more burn for your money.
  Dont use if the TM is ruptured.
• Zoto HC -Chloroxylenol, pramoxine, HC
• PO antibiotics

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Acute and Chronic Sinusitis

• A Practical Guide for Diagnosis and Treatment

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Development of Sinuses

• Maxillary and ethmoid sinuses present at birth
• Frontal sinus developed by age 5 or 6
• Sphenoid sinus last to develop, 8-10

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Normal Waters and Towne s Views of the Sinuses
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Lateral View Showing Normal Sphenoid Sinus
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Classification of Bacterial Sinusitis

• Acute bacterial sinusitis- infection lasting 4
  weeks, symptoms resolve completely (children 30
  days)
• Subacute bacterial sinusitis- infection lasting
  between 4 to 12 weeks, yet resolves completely
  (children 30-90 days)
• Chronic sinusitis- symptoms lasting more than 12
  weeks (children gt90 days)
• Some guidelines add treatment failure a
  positive imaging study

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Recurrent Acute Bacterial Sinusitis

• Episodes lasting fewer than 4 weeks and separated
  by intervals of at least 10 days during which the
  patient is totally asymptomatic
• 3 episodes in 6 months or 4/year

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Differentiating Sinusitis from Rhinitis

• Sinusitis
• Nasal congestion
• Purulent rhinorrhea
• Postnasal drip
• Headache
• Facial pain
• Anosmia
• Cough, fever

• Rhinitis
• Nasal congestion
• Rhinorrhea clear
• Runny nose
• Itching, red eyes
• Nasal crease
• Seasonal symptoms

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X-Ray Image of Sinuses with Maxillary Sinusitis
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Acute Bacterial Sinusitis

• Usually begins with viral upper respiratory
  illness
• Symptoms initially improve, but then
• Symptoms become persistent or severe
• Persistent 10-14 days but fewer than 4 weeks
• Severetemperature of 102, purulent nasal
  discharge for 3-4 days, child appears ill
• Disease clears with appropriate medical treatment

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Physical Findings

• Mucopurulent nasal discharge
• Highest positive predictive value
• Swelling of nasal mucosa
• Mild erythema
• Facial pain (unusual in children)
• Periorbital swelling

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Treatment of Acute Sinusitis

• Antihistamines recommended if allergy present
• Oral or topical
• Decongestants
• Oral or topical
• Antibiotic when indicated (bacteria)
• Nasal irrigation
• Guaifenesin 200-400 mg q4-6 hrs
• Hydration

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Decongestants

• Topical nasal sprays (limit use to 3-7 days)
• Phenylephrine
• Oxymetazoline
• Naphthazoline
• Tetrahydrozoline
• Zylometazoline
• Topical nasal spray (unlimited daily use)
• Ipatropium
• Oral
• Pseudoephedrine 30-60 mg
• Phenylephrine 2-4 times/day

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Treatment of Acute, Uncomplicated Sinusitis

• Antibiotic may not be indicated
• Many are viral
• Benefit of antibiotics are only moderate
• Weigh factors of cost, side effects, antibiotic
  resistance, and antibiotic reactions

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Bacteria Involved in Acute Bacterial Sinusitis

• Streptococcus pneumoniae 30
• Haemophilus influenza 20
• Moraxella catarrhalis 20
• Sterile 30

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Antibiotics for Acute Bacterial Sinusitis

• Amoxicillin 500 mg tid for 10-14 days
• First line choice in most areas
• Local differences in antibiotic resistance occur
• Where beta-lactanase resistance is an issue
• Amoxicillin/clavulanate
• Cefuroxime
• Cefpodoxime
• Cefprozil

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Additional Antibiotics for Acute Bacterial
Sinusitis

• Amoxicillin should be considered because of its
  efficacy, low cost, side-effect profile, and
  narrow spectrum (45-90 mg/kg/d in children 500
  mg tid or qid in adults for 10 to 14 days)
• If penicillin-allergic clarithromycin or
  azithromycin
• Erythromycin does not provide adequate coverage
• Trimethoprim/suflamethoxazole and
  erythro/sulfisoxazole have significant
  pneumococcal resistance

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Secondary Antibiotics for Acute Sinusitis

• Cefdinir (Omnicef)
• Cefuroxime (Ceftin)
• Cephpodoxime (Vantin)
• Azithromycin
• Clarithromycin

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Optimal Duration of Antibiotics

• Give antibiotic until patient free of symptoms
  then add 7 days

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Nasal Irrigation

• Commercial buffered sprays
• Bulb syringe
• 1/4 tsp of salt to 7 ounces water
• Waterpik with lavage tip
• 1 tsp salt to reservoir
• Disposable enema bucket
• 2 tsp salt, 1 tsp soda per quart of water

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When Medical Therapy for Acute Bacterial
Sinusitis Fails

• Assess for chronic causes
• Identify allergic and nonallergic triggers
• Allergy testing, nasal smears for eosinophilia
• Consider other medical conditions associated with
  sinusitis
• Rhinolaryngoscopy
• Imaging studies
• Sinus x-rays
• CT scanning (limited, coronal views)

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Rhinoscope
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Recommendations for CT Scans

• Patients presenting with complications of
  sinusitis
• Neurologic symptoms, diplopia, periorbital or
  facial swelling with or without erythema
• Patients with sinus symptoms accompanied by
  severe, boring, mid-head pain
• Rule out sphenoid sinusitis

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CT Scan Maxillary and Ethmoid Sinuses
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Recommendation 1

• The diagnosis of acute bacterial sinusitis is
  based on clinical criteria with patients
  presenting with URI symptoms that are either
  persistent or severe.

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Recommendation 2a

• Imaging studies are not necessary to confirm a
  diagnosis of clinical sinusitis in children
  younger than 6 years (older than age 6 years is
  controversial)
• Children with persistent symptoms (gt10 days, lt 30
  days) predicted abnormal radiographs 80 of the
  time
• Children lt 6 symptoms predicted 88 of the time
• Normal x-ray suggests ABS is not present

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Recommendation 2b

• CT scans of the paranasal sinuses should be
  reserved for
• Patients in whom surgery is being considered as a
  management strategy
• Patients who do not respond to medical regimes
  which include adequate antibiotic use
• Assisting in diagnosis of anatomical changes
  interfering with airflow or drainage

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Recommendation 3

• Antibiotics are recommended for the management of
  acute bacterial sinusitis to achieve a more rapid
  clinical cure
• Patients must meet requirements of persistent or
  severe disease
• Response improved with doses gtMinimal Inhibition
  Concentration

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No EB Recommendations Found for Use of Adjunctive
Therapy in ABS, May be Helpful

• Nasal saline irrigation
• Oral decongestants
• Oral or nasal antihistamines
• Topical decongestants
• Mucolytic agents
• Topical steroids

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Evidence-Based Recommendations

• Practice Recommendation Reduce unnecessary use
  of antibiotics. Providers should be consistent
  with the recommended criteria for prescribing
  antibiotics in acute sinusitis endorsed by the
  CDC, American Academy of Family Physicians, the
  American College of Physicians-American Society
  of Internal Medicine, and the Infectious Diseases
  Society of America.
• All recommendations available at
  http//www.icsi.org/knowledge/detail.asp?catID29
  itemID148. Accesses August 2003.

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Evidence-Based Recommendations

• Practice Recommendation Use first line
  antibiotics, which are amoxicillin or
  trimethoprim-sulphamethoxazole (TMP/SMX).
• Practice Recommendation Use an antibiotic that
  covers resistant bacteria (amoxicillin-clavulanate
  Augmentin or another second line agent) to
  treat patients if failed on 10-14 days of
  amoxicillin.

http//www.icsi.org/knowledge/detail.asp?catID2
9itemID148.
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PHARYNGITIS
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gt 1 SORE THROAT PER DAY

• Idiopathic 30 - 65
• Viral 30 - 60
• Bacterial 5 -10
• Usually cannot tell the difference by exam
• Concerned about the bacterial causes

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MOST VALIDATED SCORING SYSTEMB Rec

• Symptom Points
• Fever 1
• Absence of cough 1
• Tender Ant. Cvcl adenopathy 1
• Tonsillar swelling or exudate 1
• AGE
• lt 15 yo 1
• 15-45 0
• gt 45 -1

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SCORING SYSTEM

• POINTS MEANING
• lt 0 No GABHS (2)
• 1 3 Rapid strep test
• 4 5 Probable GABHS (52)

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TESTS ?B Rec

• Rapid Strep tests
• Sensitivity and Specificity gt 94
• 3 mins
• Throat Cultures
• Gold Standard
• Sens 97
• Spec 99
• 24 hrs.

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ENSURE ADEQUATE SWAB
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GABHS TREATMENT

• GOALS
• PREVENT ACUTE RHEUMATIC FEVER
• PREVENT SUPPARATIVE COMPLICATIONS
• IMPROVE CLINICAL SX
• REDUCE TRANSMISSION
• MINIMIZE ANTIBIOTIC ADVERSE EFFECTS

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GABHS TREATMENT

• Penicillins A Rec
• Pcn-allergic pts
• Macrolides A Rec
• 1st gen cephalosporin A Rec
• Steroids , short-acting, relieve Sx B Rec

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GABHS TREATMENT

• Mutiple recurrences?
• Clindamycin
• Augmentin
• PCN G
• All B Rec

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IS IT MONO ?

• Posterior lymphadenopathy ?
• Mono spot
• 67 sens in 1st week
• 80 in 2nd wk
• CBC
• gt 10 atypical lymphs
• 92 spec.

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IS IT G.C. ?

• HAVE TO THINK ABOUT IT 1ST
• ASK ABOUT ORAL/GENITAL SEX
• GET C S

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Approach to the Dizzy Patient
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Overview

• Practical approach to vertigo
• Brief introduction to dizziness and vertigo-
  central vs peripheral

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Dizziness- is it vertigo?

• Lightheadedness (gt90 non- neurological cause)
• vasovagal response
• orthostasis
• cardiogenic causes
• hyperventilation
• hypoglycemia
• medication effects

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Dizziness- is it vertigo?

• Vertigo (usually neurological)
• sensation of motion
• spinning
• feeling motion sick
• feeling of tilting to one side
• results from asymmetric impairment of sensory
  input or of integration into CNS

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Vertigo- central

• 20 of all vertigo
• Usually accompanied by other brainstem,
  cerebellar, or long-tract sxs/signs, e.g.
  incoordination, visual changes or diplopia,
  perioral numbness, dysarthria, drop attacks,
  weakness, numbness, etc.
• However, up to 25 of vertebrobasilar
  insufficiency can present with isolated vertigo.
• Acute cerebellar infarcts can mimic vestibular
  neuritis, may only have vertigo, gait ataxia, and
  nystagmus
• look at nystagmus (gaze evoked or vertical,
  increases in amplitude ipsi to lesion)
• Focal dysmetria would suggest ipsilateral
  cerebellar

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Vertigo- peripheral

• History focus on onset, duration.
• - Note that all vertigo can worsen with position
  changes
• Exam should not have focal neurologic findings,
  besides hearing loss/tinnitus
• - Nystagmus unilateral, amplitude decr in
  direction away from fast phase (Alexanders
  law), fatigues, decr with fixation
• - Gait although uncomfortable, pts with
  peripheral vertigo typically can walk, unlike
  those with central
• Note vertigo hearing loss can be vascular
• - infarction of inner ear by occlusion of
  internal auditory artery (branch of AICA)
• - causes vertigo c hearing loss

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Clues towards a central process
1. Risk factors -age, HTN, DM, lipids,
smoking 2. Focal neurological
findings -suggestive of central process 3.
Nystagmus -central vertical, not unilateral,
does not fatigue, does not decr with
fixation -peripheral unilateral, decr in
direction away from fast comp, fatigues, decr
with fixation 4. Severity of ataxia -central
more severe, unable to walk -peripheral
uncomfortable, but able to walk
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Vestibular Neuritis

• Sudden onset of peripheral vertigo
• Usually without hearing loss
• Period of several hours - severe
• Lasts a few days, resolves over weeks
• Inflammation of vestibular nerve - presumably of
  viral origin
• Spontaneous, complete symptomatic recovery with
  supportive treatment
• Treatment aimed at stopping inflammation

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Menieres Disease

• Hallpike and Cairns - 1938 found endolymphatic
  hydrops by histology
• Classic triad
• Recurrent vertigo
• Fluctuating SNHL
• Tinnitus
• (aural fullness very common)

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Menieres Disease

• Widely accepted medical treatment
• Dietary salt restriction
• Diuretics
• Thiazide diuretics
• Decrease Na absorption in distal tubule
• Side effects - hypokalemia, hypotension,
  hyperuricemia, hyperlipoproteinemia
• Combination potassium sparing agents
• Maxzide, Dyazide
• Avoids hypokalemia

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Menieres Disease

• At least 3 months of diuretic therapy recommended
  before discontinuing
• Sulfa allergies - can try loop diuretics or
  alternate therapies

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Menieres Disease

• Carbonic anhydrase inhibitors (acetazolamide)
• inner ear glaucoma
• Decreased Na-H exchange in tubule
• Decreased CSF production
• Diuretic effect not as long-lasting
• Side effects - nephrocalcinosis, mild metabolic
  acidosis, GI disturbances

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BPPV

• Most common cause 50 of peripheral vertigo
• Dysfunction of posterior SCC
• Cupulolithiasis vs. Canalithiasis
• Cupulolithiasis
• Calcium deposits embedded on cupula
• PSCC becomes dependent on gravity
• Canalithiasis
• Calcium debris (otoconia) displaced into PSCC
• Does not adhere to cupula

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BPPV

• Head movements
• Looking up
• Lying down
• Rolling onto affected ear
• Result in displacement of sludge / otoconia
• Vertigo lasting a few seconds
• Treatment approaches
• Liberatory maneuvers
• Particle repositioning
• Habituation exercises

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BPPV

• Cupulolithiasis
• Liberatory maneuver
• Single treatment
• Cure rates
• 84-one treatment
• 93-two treatments

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BPPV

• Epley
• Canalithiasis
• Canalith repositioning
• Move into vestibule
• Cure rates
• 80 - one treatment
• 100 - multiple

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BPPV - Epley
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BPPV

• Habituation technique
• Move to provoking position repeatedly
• 98 success rate after 3 to 14 days of exercises

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Etiology Recur Onset Duration
Associated features BPPV
sudden lt1 min elderly, induced
by position change Menieres
gradual hours ear fullness,
tinnitus, low freq
hearing loss Vestibular - gradual
days-weeks 50 c preceding viral
neuritis or sudden illness, /- hearing
loss Migraine gradual
sec-days young F, HA, positive
visual phenomenon VB TIA
sudden mins CN, long-tract
sxs/ signs Labryinth
- sudden days-months
hearing stroke loss
/- tinnitus Brainstem
- sudden days-months
CN, long-tract stroke sxs/ signs
Cerebellar - sudden
days-months unil dysmetria,
stroke central nystagmus
126
Medical Treatment

• Symptomatic
• Specific therapy
• Vestibular
• rehabilitation

127
Symptomatic Pharmacotherapy

• Predominant targeted vestibular
  neurotransmitters
• Cholinergic
• Histaminergic
• GABA neurotransmitters - negative inhibition
• Vomiting center transmitters
• Dopaminergic (D2)
• Histaminergic (H1)
• Seratonergic
• Multiple classes of drugs effective

128
Symptomatic Pharmacotherapy

• Antihistaminergic - dimenhydrinate
• Anticholinergics - scopolamine, meclizine
• Anti-dopaminergic - droperidol
• (gamma)-aminobutyric acid enhancing (GABA-ergic)
  agents - lorazepam, valium

129
Symptomatic Pharmacotherapy

• Some drugs of the antihistamine class are useful
  for symptomatic control of vertigo
• Have anti-motion sickness properties in large
  part due to inhibition of vestibular system H1
  histaminergic neurotransmitters
• Examples include dimenhydrinate (Dramamine) and
  promethazine (Phenergan)
• Also suppress the vomiting center

130
Conclusion


1. Is this vertigo? 2. Is this central or
peripheral? 3. History- focus on age, PMH,
duration 4. Exam- focus on CN and
coordination, focal neurological findings,
Dix-Hallpike
131
Bibliography
Baloh, R.W. (1998). Dizziness neurological
emergenices. Neurologic Clinics 16,
305-321. Delaney, K.A. (2003). Bedside
Diagnosis of Vertigo Value of the History and
Neurological Examination. Acad. Emerg. Med. 10,
1388-1395. Neuhauser, H. and Lempert T.
(2004). Vertigo and dizziness related to
migraine a diagnostic challenge. Cephalalgia 24,
pp. 8391. Neurology in Clinical Practice
(2000), ed. Bradley, W.G., Daroff, R.B.,
Fenichel, G.M., and Marsden, C.D., pp.
239-251. Strupp et al. (2004).
Methylprednisolone, Valacyclovir, or the
Combination for Vestibular Neuritis. NEJM 351,
pp. 354-361.
132
Tympanogram Site

• http//www.utmb.edu/pedi_ed/AOM-Otitis/tympanometr
  y/default.htm
• Nice ear drum site
• http//www.entusa.com/eardrum_and_middle_ear.htm
• Acute Otitis Media Guidelines
• http//www.aafp.org/x26481.xml

133
Additional Bibliography

• Dykewicz M. Rhinitis and Sinusitis. J All Clin
  Immunol, 2003 111S520-9.
• Hamilos DL. J Allergy Clin Immunol
  2000106213-27.
• Kaliner MA. Current Review of Rhinitis. Current
  Medicine, Inc., 2002.
• Kaliner MA. Current Review of Allergic Diseases.
  Current Medicine, Inc., 2000.
• Agency for Healthcare Research and Quality
• American Academy of Pediatrics
• New England Medical Center Evidence-based
  Practice Center

134
Additional Bibliography

• Vincent MT et al. Pharyngitis. AFP
  2004691465-70.
• Practice Guidelines. Dx Rx of GABHS
  Pharyngitis. AFP 200367.
• Kiderman A et al. Adjuvant prednisone therapy in
  pharyngitis. Br J Gen Pract Mar 200555218-21.

135
Youve had an earfulAny questions?
136
Acute Otitis Media -Infant Anatomy

• As a child grows, the eustachian tube assumes a
  steeper angle, allowing more draining into the
  posterior pharynx.
• The nerves to the tensor veli palatini, tensor
  tympani, and levator veli palatini become
  functional as Schwann cells lay down myelin.
  This then allows the eustachian tube to maintain
  its patency.

137
Eustachian tube

• Adults
• ant 2/3- cartilaginous
• post 1/3- bony
• 45 degree angle
• isthmus 1-2 mm
• nasopharyngeal orifice 8-9 mm

• Children
• longer bony portion
• 10 degree angle
• isthmus larger
• nasopharyngeal orifice 4-5 mm in infants

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140
Onusko, E, Tympanometry, AFP, Nov. 1, 2004, pp
1713-1720
141
Acute Otitis Media - Other Tid-bits

• What about wax?
• Cerumenolytics - Debrox, mineral oil, glycerin
• Water irrigation/lavage - the nurses just love it
  when you order this!
• Loop - code as cerumenectomy JOKE!
• Water Pik - probably not a good idea as it can
  cause a perforation when aimed directly at the TM

142
Acute Otitis Media - Other Tid-bits

• What about an occluded PE/tympanostomy tube?
• Gentamicin 0.3 ophthalmic drops in the ear can
  help reopen the PE tube (anecdotal evidence)

143
Acute Otitis Media - Other Tid-bits

• Eustachian tube dysfunction - neat exam trick
• Ask the patient to clear their ears (clamp their
  nostrils and blow) while you look in their ears.
• The TM should move/pop - if it doesnt, the
  eustachian tube is at least partially occluded.

144
The Dreaded Q-Tip Complication
145
Quiz What is this?
146
And This?
147
How about this?
148
AUDIOMETRY
149
Case history

• 1 1/2 year old wm presents to ENT clinic with 2nd
  episode of ear infections in last month
• Normal history with no medical problems and no
  prior surgical procedures
• Mother describes a cold for the last few days
  and then started running a fever and pulling at
  ears. Describes the child as very irritable

150
Physical Exam

• Temp 100 F, VS wnl
• Irritable child
• Ears - eac clear, tms erythematous, bulging with
  yellowish MEE AU
• Nose - clear rhinorrhea
• otherwise wnl

151
Case history

• Returns to clinic one month later with same
  complaints again
• Dx as AOM
• 3rd episode in last 2 mos and 5th in last year

152
Case history

• Placed on sulfisoxizol prophylaxis
• 3 wks later presents with recurrent AOM

153
Case history

• BMT performed, doing well at 3 wks
• Mother calls at 3 mos and says has had to be tx
  with po abx and ear gtts 3 times by pcp for
  bilateral otorrhea

154
New Frontiers

• Prevention more cost effective than treatment
• Even slight decrease would have profound economic
  impact
• Vaccines
• Xylitol

155
Vaccines

• Pneumococcal vaccine
• poorly immunogenic in children
• did exhibit antibody response
• H. influenzae
• no polysaccharide capsule
• serum bactericidal antibody
• M. catarrhalis
• human pathogen

156
Vaccines

• 150 viral immunotypes
• 100 rhinoviruses with poor prognosis for vaccine
  development
• RSV most common - developing intranasal delivery
  system

157
Xylitol

• Sweetening substitute
• Inhibits growth of pneumococcus and inhibits
  adhesion of pneumococcus and H. flu in
  nasopharynx
• Gum and syrup reduced incidence of AOM 40 and
  30

158
Otoscopic oddities

• 15 yo male with a h/o recurrent episodes of AOM
  as a child, now with a cold.
• Otherwise normal exam except for these findings
  in the ears.

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162
Otoscopic oddities

• Tympanosclerosis - simply note it in the chart
  and keep movin

163
Otoscopic oddities

• 8 yo female with dry cough for 2 weeks. Seems to
  be getting better but Mom wants her checked out.
• You look in the ears and you see...
• May also want to really check that lung exam
  thoroughly.

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165
Otoscopic oddities

• Bullous myringitis
• Etiology - 50 influenza, 50 Mycoplasma
• This helps your choice of antibiotics - use a
  macrolide, erythromycin is the board answer, may
  consider other macrolides (azithromycin or
  clarithromycin) although I have no literature to
  support this.

166
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167
Otoscopic oddities

• 35 yo female with a remote h/o a TM perforation
  now presents with ringing in her ears and mild
  pain. Occasional otorrhea.
• Otoscopy shows ...

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171
Otoscopic oddities

• Cholesteatoma
• Refer to ENT - enough said.
• Separate talk but I just wanted you to at least
  see a few examples.

172
Otoscopic oddities

• 50 yo female, had an MI 2 weeks ago, just
  discharged 3 days ago, now with pain in his left
  ear. Also states that she is having trouble
  drinking and has to use a straw because the fluid
  is leaking out the side of his mouth (What in the
  world?!!!)
• Otoscopy shows vesicles in the external auditory
  canal

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174
Otoscopic oddities

• Herpes Zoster of the external auditory canal and
  a seventh nerve palsy on the right (lower motor
  neuron-type, patient unable to raise his
  eyebrow/wrinkle her forehead).
• This is called Ramsey Hunt Syndrome.

175
Pathogenesis of Nasal Obstruction

• Viral upper respiratory infections
• Daycare centers
• Allergic and nonallergic stimuli
• Immunodeficiency disorders
• Immunoglobulin deficiency (IgA, IgG)
• Anatomic changes
• Deviated septum, concha bullosa, polyps

176
Sinus Transillumination

• Helpful in older children and adults
• Normal transillumination decreases chance of pus
  in the sinus
• No light reflex suggests mucopurulent material or
  thickening of nasal mucosa
• Inexpensive screening tool

177
Sinus Transillumination

• Have patient sit at your eye level in darkened
  room (the darker the better)
• Let eyes get accustomed to dark
• Place bright light (transilluminator) over
  inferior orbital ridge to look at maxillary
  sinuses, under superior orbital rim for frontal
  sinuses
• Look at palate for presence/absence of
  transilluminated light

178
Transillumination of Frontal Sinus
179
Transillumination of Maxillary Sinus
180
Chronic Sinusitis

• Symptoms present longer than 8 weeks or 4/year in
  adults or 12 weeks or 6 episodes/year in children
• Eosinophilic inflammation or chronic infection
• Associated with positive CT scans
• Poor (if any) response to antibiotics

181
Sx of Chronic Sinusitis

• Nasal discharge
• Nasal congestion
• Headache
• Facial pain or pressure
• Olfactory disturbance
• Fever and halitosis
• Cough (worse when lying down)

182
Conditions Causing Chronic Sinusitis

• Allergic and nonallergic rhinitis
• Uncorrected anatomic conditions
• Ciliary dyskinesia
• Cystic fibrosis
• Tumors
• Immunodeficiency disorders
• IgA, IgM
• Granulomatous diseases

183
Evaluation of Chronic Sinusitis

• CT or MRI scanning
• Anatomic defects, tumors, fungi
• Allergy testing
• Inhalants, fungi, foods
• Sinus aspiration for cultures
• Bacterial
• Fungal
• Immunoglobulins

184
Treatment of Chronic Sinusitis

• Nasal steroid spray
• Guafenesin
• Decongestants
• Steam inhalation
• Nasal irrigation
• Antibiotics with exacerbations

185
Bacteria Involved in Chronic Sinusitis Role of
Viruses is Unknown

• Streptococcus pneumoniae
• Haemophilus influenza
• Moraxella catarrhalis
• Staph aureus
• Coagulase negative staphylococcus
• Anerobic bacteria

186
Sinus Aspiration and Culture

• Correlation of routine nasal culture and sinus
  culture are poor
• Endoscopically guided aspiration of cultures from
  medial meatus do correlate with sinus culture
• Gold SM, Tami TA. Role of middle meatus
  aspiration culture in the diagnosis of chronic
  sinusitis. Laryngoscope 1997107 1586.

187
Recommendations Made for Antibiotic Prophylaxis
in ABS

• Has not been evaluated as has its use in otitis
  media
• Increasing evidence of antibiotic resistance is
  an issue
• May be tried in chronic or recurrent disease

188
Complications of Sinusitis

• Orbital
• Diplopia, proptosis
• Periorbital erythema, swelling
• Bone
• Periosteal abscesses
• Brain
• Intracranial abscesses causing neurologic
  symptoms

189
Indications for Referral

• Allergy testing, possible immunotherapy
• Sinus aspiration for bacterial culture
• Surgical intervention
• Correct obstructive process
• Drain sinus abscesses
• Consideration to remove nasal polyps

190
Indications for Hospitalization

• Acutely ill child or adult with high fever,
  severe head pain
• Suspected sphenoid sinusitis
• Anytime complications of eye, bone or
  intracranial structures are present

191
Pathophysiology

• Vestibular labyrinth - detects linear and angular
  head movements
• Semicircular canals - angular
• Hair cells organized under cupula
• Otolithic organs (utricle, sacule) - linear
• Hair cells attached to a layer of otoconia
• Vestibular nerve - superior, inferior branch
• Afferent nerve fibers are bipolar - cell bodies
  lie within Scarpas ganglion

192
Pathophysiology

• Balance requires
• Normal functioning vestibular system
• Input from visual system (vestibulo-ocular)
• Input from proprioceptive system
  (vestibulo-spinal)
• Central causes compromise central circuits that
  mediate vestibular influences on posture, gaze
  control, autonomic fx
• Disruption of balance between inputs results in
  vertigo
• Goal of treatment restore balance between
  different inputs

193
Pathophysiology

• Vestibular system influences autonomic system
• Intimate linkage in brainstem pathways between
  vestibular and visceral inputs
• Alteration of vestibular inputs results in
• nausea, vomiting
• Pallor
• Respiratory/circulatory changes

194
Migraine

• Concomitant vertigo and disequilibrium
• Headache control improves vertigo
• Diagnostic criteria
• Personal/family history
• Motion intolerance
• Vestibular symptoms - do not fit other causes
• Theories - vascular origin, abnormal neural
  activity (brainstem), abnormal voltage-gated
  calcium channel genes

195
Migraine

• Treatment
• Modifying risk factors
• Exercise and diet
• Avoid nicotine, caffeine, red wine and chocolate
• Abortive medical therapy
• Ergots
• Sumatriptin
• Midrin
• Prophylactic medical therapy
• B blockers, Ca channel blockers, NSAIDs,
  amitryptiline, and lithium

196
Vertebrobasilar insufficiency

• Vertigo, diplopia, dysarthria, gait ataxia and
  bilateral sensory motor disturbance
• Transient ischemia - low stroke risk
• Antiplatelet therapy - aspirin 325mg qD
• Ticlid
• Platelet aggregate inhibitor
• Risk of life-threatening neutropenia
• Only in patients unable to tolerate aspirin

197
Menieres Disease

• Vasodilators
• Based on hypothesis - pathogenesis results from
  ischemia of stria vascularis
• Rationale - improve metabolic function
• IV histamine, ISDN, cinnarizine (CA agonist),
  betahistine (oral histamine analogue)
• Anecdotal success
• No demonstrated beneficial effects in studies

198
Menieres Disease

• Newer theories
• Multifactorial inheritance
• Immune-mediated phenomena
• Association of allergies
• Study by Gottschlich et al.
• 50 meeting criteria have antibodies to 70-kD
  heat-shock protein
• 70-kD HSP implicated in AI-SNHL

199
Menieres Disease

• Immunosuppressive agents gaining favor
• Systemic and intra-tympanic glucocorticoids
• Cyclophosphamide
• Methotrexate
• Shea study - intractable Menieres
• 48 patients IT dexamethasone
• 66.7 elimination of vertigo
• 35.4 improvement in hearing (gt10dB and/or 15
  change in word recognition score)

200
Menieres Disease

• Chemical labyrinthectomy
• Disabling vertigo
• After trial of adequate medical therapy
• Intratympanic aminoglycoside (ITAG)
• Allows treatment of unilateral disease
• Gentamicin
• Primarily vestibulotoxic
• may impair vestibular dark cells (endolymph)
• Inherent hearing loss risk - 30

201
Symptomatic Pharmacotherapy
202
Specific Pharmacotherapy

• Vestibular Neuritis
• Menieres Disease
• Benign Paroxysmal Positional Vertigo
• Otosyphilis
• Vertebrobasilar Insufficiency
• Migraine (with vertigo)
• more common

203
Vestibular Rehabilitation

• Promoting vestibular compensation
• Habituation
• Enhancing adaptation of VOR VSR
• May have initial exacerbation

204
Vestibular Rehabilitation

• Habituation of pathologic responses
• Postural control exercises
• Visual-vestibular interaction
• Conditioning activities
• B.I.D., most improve after 4-6 weeks