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Amecan Acaemy of OtolaynoloyHea an Nec Sey Fonaton

Pmay CaeOtolaynoloy

Th Eton


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2011 All materials in this eBook are copyrighted by the AmericanAcademy o OtolaryngologyHead and Neck Surgery Foundation, 1650Diagonal Road, Alexandria, VA 22314-2857, and are strictly prohibited tobe used or any purpose without prior express written authorizations romthe American Academy o OtolaryngologyHead and Neck SurgeryFoundation. All rights reserved.

For more inormation, visit our website at www.entnet.org.Print: First Edition 2001, Second Edition 2004

eBook Format: Second Edition 2004, Tird Edition 2011

ISBN: 978-0-615-46523-4


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Preace

Dr. Gregory Stael rst authored this short introduction to otolaryngologyor medical students at the University o exas School or the HealthSciences in San Antonio in 1996. Written in conversational style, pepperedwith hints or learning (such as read an hour a day), and short enough todigest in one or two evenings, the book was a hit with medical students.

Dr. Stael graciously donated his book to the American Academy oOtolaryngologyHead and Neck Surgery Foundation to be used as abasis or this primer. It has been revised and edited, and is now in its third

printing. Tis edition has undergone an extensive review, revision, andupdating. We are grateul to the many authors and reviewers who havecontributed over the years to the success o this publication. We believethat you, the reader, will nd this book enjoyable and inormative. Weanticipate that it will whet your appetite or urther learning in the disci-pline that we love and have ound most intriguing. It should start your

journey into otolaryngology, the eld o head and neck surgery.

Enjoy!

Mark K. Wax, MD, Editor

Coordinator, Education Steering CommitteeAmerican Academy o OtolaryngologyHead and Neck SurgeryFoundation

Chapter 1


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Contents

1. Introduction to Clinical Rotation ..............................................................4

2. Evaluating and Keeping rack o Patients.................................................9

3. Presenting on Rounds................................................................................17

4. EN Emergencies.......................................................................................21

5. Otitis Media ................................................................................................31

6. Hearing Loss ...............................................................................................41

7. Dizziness ......................................................................................................49

8. Facial Nerve Paralysis ................................................................................55

9. Rhinology, Nasal Obstruction, and Sinusitis..........................................60

10. Allergy.........................................................................................................69

11. How to Read a Sinus C Scan ..................................................................74

12. Maxilloacial rauma.................................................................................79

13. Facial Plastic Surgery.................................................................................86

14. Salivary Gland Disease ..............................................................................93

15. Tyroid Cancer ...........................................................................................98

16. Head and Neck Cancer............................................................................105

17. Skin Cancer ...............................................................................................115

18. Pediatric Otolaryngology........................................................................120


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Chapter 1

Introduction toClinical Rotation

Te goals o this book are to make good clinicians out o medical studentsand to teach the basics o OtolaryngologyHead and Neck Surgery.

Sometimes individuals have trouble transitioning rom being second-yearmedical students, where they are truly students, to becoming healthcareproessionals. Tis metamorphosis over the third and ourth years o med-ical school involves learning how to carry yoursel and act as a healthcareproessional.

o meet this rst goal and become a good clinician, it is helpul or stu-dents to be careully observant o their proessors in important but unno-ticed aspects, such as their demeanor, comments, and interaction withhouse sta and patients. Students learn a lot through observing care opatients. Te process starts with the students appearance (clothing andgrooming), punctuality, composure, acceptance o responsibility, andinteractions with patients and other healthcare team members. You needto really listen to patients.

It can be dicult to understand a medical students role in the healthcare

team. Work to become an active member o the team. Interns, residents,and attendings are overworked and spread quite thin. However, medicalstudents requently have extra time to spend with their patients, talking tothe patients about their past medical problems, amily, and social historyas they pertain to their disease process. Most important, work towardestablishing a true patient-physician relationship. Tis type o relationshipestablishes the medical student as an important part o the healthcareteam, benecial to the overall care provided to the patient. For the medicalstudent, it also establishes long-term behaviors that translate into the

development o an excellent uture physician.A ew basic rules will help you to become a good clinician. During thethird year, there may be conicting responsibilities, such as being at a lec-ture while needing to draw a patients blood. In general, the priority


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should be the care o the patient. I it is an important blood test and you

cannot get someone to do it or you, you may need to miss the lecture.Tese situations dont actually come up that oen, and i patient care is themain goal, over the long run, most people will respect these decisions.

Tere are two kinds o physicians: those who read and those who dont.Read about your patients conditions. You should read textbooks becausethey cover the basics, and 90 percent o people do not know what is inthem. Articles are or later. It does not matter which textbook you read,because i the inormation is important, it will come up again in laterreading. I the inormation is unimportant, it will not come up very oen.

So now you have our patients and you go home. You got up at 5:00 a.m.to make it to rounds. You get home at 7:00 p.m. aer your last post-opnote. Aer you have petted the dog and had something to eat, it is 8:30.You deserve a break, so you watch V or an hour. You are ready to read,and recall rom your notes that your patient has hypertension, chronicobstructive pulmonary disease, diabetes, and a pleomorphic adenoma.Tere is no way you can read about all that tonight, and you have to get upat 5:00 a.m. tomorrow. So you go to bed, and the next morning you do not

really know why we even treat asymptomatic hypertension in the rstplace. Solution: Read or an hour every day. Aerward you can do what-ever you want and not eel guilty or overwhelmed. You will also be amazedat how well you do. Most students do not average anywhere near an houro daily reading. Read about your patients. Remember Darwins theory omedical education: It cannot be that rare i you are seeing it.

We know that you, as medical students, aspire to the highest ideals o pro-essionalism. We know that you will always have a neat appearance and apleasant personality. We know that you will do completely thorough histo-ries and physicals. You will be very compassionate to all your patients andcoworkers, and you will always be willing and ready to learn. It has beenour experience that all students know this is expected o them. However,there is one important caveat that is oen not addressed in medical educa-tion: It is as much your responsibility to know your limitations as it is toknow about treating patients. I you are trying hard, reading an hour everyday, and truly interested, then i you are asked a question to which you donot know the answer, it is perectly legitimate, and indeed expected, thatyou simply answer, I dont know. Nobody knows everything.

I you use the inormation you already have, you will oen do surprisinglywell i you guess at an answer. But i your answer is only a guess, qualiy itby pointing out that you do not specically know the answer. Integrity


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an absolute commitment to honestyis a prerequisite or becoming a

physician.Although you may not know that much yet in your clinical career, youhave one secret weapon as a student: enthusiasm. Residents are oen tiredand grouchy, as you probably have noticed, but having an enthusiastic stu-dent around makes a dierence.

Te second goal o this book is to teach you a little about common ear,nose, and throat (EN) problems. Since the great majority o you will notbecome otolaryngologists, it becomes much more important or you to

understand how to recognize potentially dangerous problems that shouldbe reerred to an otolaryngologist, as well as how to manage uncompli-cated problems that can be taken care o at the primary care level.


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QuESTiONS

1. Your highest proessional priority throughout your third year and therest o your career should be _____________.

2. One way to learn as much as possible, without eeling overwhelmed,during the third year is to _____________.

3. When aced with two conicting responsibilities, _________ shouldalways be your highest priority.

4. I you guess at a question on rounds, you should ________________.

5. Te key to a happy career in medicine is to make ____________ yourhighest proessional priority.

6. In all countries o the world, a common vein through medicine is tokeep as the rst priority _____________.

ANSwErS

1. Te care o the patient

2. Read or an hour every day


4. Qualiy your answer




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Notes

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Chapter 2

Evaluating and Keepingrack o Patients

Tan an Otolaynoloy Hstoy an Pefomna Hea an Nec Exam

Te EN history begins with the chie complaint ollowed by a descrip-tion o the location, duration, requency, and qualityo the presentingsymptoms. In addition, always inquire about the aggravating and reliev-ing actors. Next, ask the patient about associated symptoms. Te ollow-ing is a short list that can be used:

General/systemic symptoms (ever, chills, cough, heartburn, dizziness,

etc);

Otologic (tinnitus, otalgia, otorrhea, aural ullness, hearing loss, ver-tigo);

Facial (swelling, pain, numbness);

Nasal (congestion, rhinorrhea, post-nasal drip, epistaxis, decreasedsmell);

Sinus (pressure, pain);

Troat (soreness, odynophagia, dysphagia, globus sensation, throatclearing);

Larynx (vocal changes or weakness, hoarseness, stridor, dyspnea); and

Neck symptoms (pain, lymphadenopathy, torticollis, supine dyspnea).

Te head and neck exam involves inspection (and palpation i practical)o all skin and mucosal suraces o the head and neck. Otolaryngologistsutilize special equipment to better assess the ears, nose, and throat. A bin-

ocular microscope provides an enlarged, three-dimensional image, givingthe physician a superior view o the ear canal and tympanic membrane.Te microscope also permits the bimanual removal o wax and oreignbodies. Indirect mirror exam with a headlight permits examination o the


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larynx, hypopharynx, and nasopharynx. Fiberoptic instruments provide a

similar ability to examine these regions, but with superior optics.

Te Ear

Assess the external auricle or congenital deormities, such as microtia,promin auris, or preauricular pits. Te external auditory canal should beexamined byotoscopyaer being thoroughly cleaned i it is blocked bycerumen. Te canal should be assessed or swelling, redness (erythema),narrowing (stenosis), discharge (otorrhea), and masses. Te tympanicmembrane is normally pearly gray, shiny, translucent, and concave.

Changes in the appearance o the eardrum may indicate pathology in themiddle ear, mastoid, or eustachian tube. White patches, called tympano-sclerosis, are oen clearly visible and provide evidence o prior signicantinection. An erythematous, bulging, opacied tympanic membrane indi-cates acute bacterial otitis media. A dull, retracted, amber eardrum can bea sign o serous otitis. I a peroration is present, then the middle earmucosa may be viewed directly. Healed perorations are oen more trans-parent than the surrounding drum and may be mistaken or actual holes.

Pneumatic otoscopyshould be perormed to observe the mobility o thetympanic membrane with gentle insufation o air. Mobility may be lim-ited by scarring, middle ear eusion, or peroration. Eustachian tube unc-tion may be assessed by watching the eardrum as the patient executes agentle Valsalva.

uning orks can be used to grossly assess hearing and to dierentiatebetween conductive and sensorineural hearing loss. A tuning ork placed inthe center o the skull (Weber test) will normally be perceived in the mid-line. Te sound will lateralize and be perceived as louder on the aected

side in cases o conductive hearing loss. I a sensorineural loss exists, thesound will be perceived in the better or normal hearing ear. Te tuningork is then placed just outside the external auditory canalor the Rinnestest o air conduction hearing. Placing the base o the tuning ork over themastoid process allows bone conduction hearing to be assessed. In conduc-tive hearing loss, the tuning ork is heard louder behind the ear (bone con-duction is better than air conduction in conductive hearing losses).

A proper, complete assessment o hearing requires audiometry. Tis isindicated in any patient with chronic hearing loss, or with acute loss thatcannot be explained by canal occlusion or middle ear inection. It is alsoan integral part o the evaluation o the patient with vertigo.


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Te Nose

Anterior rhinoscopyshould be perormed utilizing a bivalve speculum.Evaluate the septum and anterior portions o the inerior turbinates.opical vasoconstriction with oxymetazoline permits a more thoroughexamination and allows or assessment o turbinate response to deconges-tion. Nasal patency may be compromised by swollen boggy turbinates,septal deviation, nasal polyps, or masses/tumors. Te remainder o thenasal cavity can be more careully examined by perorming exibleberoptic or rigid nasal endoscopy. Tis allows a more thorough evalua-tion o the nasal cavity and mucosa or abnormalities, including obstruc-

tion, lesions, inammation, and purulent sinus drainage. Te sense osmell is rarely tested due to the diculty in objectively quantiyingresponses. However, ammonia umes can be useul or distinguishing trueanosmics rom malingerers because ammonia will stimulate trigeminalendings, and thus produce a response in the absence o any olaction.

Te Mouth

An adequate light and tongue depressor are necessary or examining themouth. Te tongue depressor should be used to systematically inspect allmucosal suraces, including the gingivobuccal sulci, the gums and alveo-lar ridge, the hard palate, so palate, tonsils, posterior oropharynx,buccal mucosa, dorsal and ventral tongue, lateral tongue, and the ooro mouth. Dentures should always be removed to permit a completeexamination. Te parotid duct orice (Stensons duct) can be seen on thebuccal mucosa, opposite the upper second molar. Massage o the parotidgland should express clear uid. Te submandibular and sublingual glandsempty into the oor o the mouth via Whartons ducts. Complete exami-nation o the mouth includes bimanual palpation o the tongue and theoor o the mouth to detect possible tumors or salivary stones.

Te Pharynx

Te posterior wall o the oropharynx can be easily visualized via themouth by depressing the tongue. Inspection o the nasopharynx, hypo-pharynx, and larynx requires an indirect mirror exam or use o a exibleberoptic rhinolaryngoscope. All mucosal suraces are evaluated, toinclude the eustachian tube openings, adenoid, posterior aspect o the sopalate, tongue base, posterior and lateral pharyngeal walls, vallecula, epi-glottis, arytenoid cartilages, vocal olds (alse and true), and pyriormsinuses. Vocal old mobility should be assessed by asking the patient toalternately phonate and sni deeply. Te glottis opens with inspiration(sning) and closes or phonation.


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Te Salivary Glands

Te parotid and submandibular glands should be inspected and palpatedto detect enlargement, masses, and/or tenderness.

Te Neck

Te normal neck is supple, with the laryngotracheal apparatus easily pal-pable in the midline. A complete examination should include externalobservation or symmetry and thorough palpation o all tissue or possiblemasses. Te exact position, size, and character o any mass should be care-ully noted, along with its relationship to other structures in the neck (thy-roid, great vessels, airway, etc.).

Cranial Nerves

A complete head and neck exam includes testing o cranial nerves (CN)IIXII. A pocket eye chart should be used to test the patients vision(Optic - CN II). Extraocular eye movements should be tested, along withthe pupillary response to light (oculomotor, trochlear, and abducensCN III, IV, and VI, respectively). Te trigeminal nerve (CN V) can betested by testing areas o the ace using a pin and a wisp o cotton. Havingthe patient clench his teeth and then open his jaw against resistance alsotests CN V. est the acial nerve (CN VII) by having the patient raise hiseyebrows, squeeze his eyes shut, scrunch his nose, pucker his lips, andsmile. Tevestibulocochlearnerve (CN VIII) can be tested with a tuningork. CN IX (glossopharyngeal) and CN X (vagus) control swallowing,the gag reex, and speech, and so are tested by observing these actions.Have the patient swallow and say ah, ah, ah. You can also touch the backo the throat with a tongue depressor to check the gag reex. Assessmento vocal cord unction by exible beroptic laryngoscopy also providesinormation on the status o the vagus nerve. Assess the unction o thespinal accessory nerve (CN XI) by asking the patient to push his headlaterally against resistance and shrug his shoulders against resistance.Finally, assess the hypoglossal nerve (CN XII) by having the patient stickout his tongue. Deviation to one side indicates a weakness or paralysis othe nerve on that side.

Dierential Diagnosis

Every time you see a new patient, you begin to ormulate a diferentialdiagnosis or him or her. Most o us begin by doing this randomly, usuallythe ve most recent diagnoses we have seen or this set o symptomsand physical ndings. Tis works when you have seen several thousandpatients, but it is not as useul i you have seen only 100 or so. A useul


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trick is to use an acronym that represents a system based on disease cat-

egories (such as Vitamin C in the accompanying box).ry it or yoursel, and practice using it on all your patients. You will ndthat this or another system will be a big help in organizing your thoughtswhen you are conused or during high-stress rounds.

V ascular

I nectious

raumatic

A utoimmune (or anatomic)

M etabolic

I atrogenic or idiopathic

N eoplastic

C ongenital

On the otolaryngology service, most patients spend very little time in thehospital, and keeping track o everything about each patient is not worthyour time. However, certain key inormation is needed on each patient,

and you should learn how to keep this inormation in a usable ormat.Physicians need a good system or keeping track o patients, and we oerthis system to help you with your inpatient duties.

Perhaps most important, a list o patients and their diseases is an ideal wayto review and select topics or additional reading. (Remember, you arereading an hour every day.)

One system involves 3 x 5-inch note cards. Te basic idea is shown inFigures 2.1 and 2.2. Other alternatives include using Personal Digital

Assistants (PDAs) or other mobile devices with commercial data soware.Tis system allows storage o the data, so should you wish to retrieve amemorable patient experience, the inormation will be available.

What you will notice iyou look closely andunderstand the systemis that you know every-thing about the patientduring their whole stay.

When the chie residentasks, What was his cre-atinine three days ago?you know it! Fe 2.1.


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Please be aware that

identiable patientinormation is pro-tected, and even stu-dents are responsibleor protecting patientprivacy. Tis is animportant aspect o

medicine that is outlined in the Health Insurance Portability andAccountability Act (HIPAA) o 1996.

Fe 2.2.


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QuESTiONS

1. Vitamin C is one way o organizing a dierential diagnosis list.

V ____________________________________________

I _____________________________________________

_____________________________________________

A ____________________________________________

M ____________________________________________

I _____________________________________________

N ____________________________________________

C ____________________________________________

2. A complete head and neck exam includes examination o_____________________, as well as the_________ _________.

ANSwErS

1. Vascular

Inectious

raumatic

Autoimmune (or anatomic)

Metabolic

Iatrogenic or idiopathic

Neoplastic

Congenital

2. Skin o the head and neck, mucosal and cranial nerves


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Notes

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Chapter 3

Presenting on Rounds

Patient presentations should be goal directed and ollow this ormat:

Mr. Jones is a 63-year-old man with a 3 cancer o the tonsil thatailed radiation. He initially presented with a two-month historyo pain and a nonhealing ulcer on the le tonsil. He underwentsix weeks o radiotherapy and was disease ree or seven months.His tumor recurred, and three days ago, he underwent a mandi-bulotomy, neck dissection, hemiglosectomy and partial pharyngec-tomy with tracheostomy. A radial orearm ree-tissue transer was the

reconstruction. He is aebrile (less than 38.5C), and his perioperativeantibiotics have been discontinued. He is tolerating his tube eeds at100 cc per hour, and his drains have each put out 30 cc over the last 24hours.

Te last sentence in your presentation should always start with Te planis. For example:

Te plan is to remove the drains today, continue the tube eedings,and start eeding the patient by mouth at one week post surgery. We

also plan to cap his tracheostomytube and remove it i he tolerateshaving it plugged. We have contacted social work in order to makesure that he has a place to go when we are ready to discharge him atday 8 or 9 post-op.

For a general surgery patient, the presentation may be something like this:

Tis is day 1 post colon resection or Mrs. Jones, a 60-year-old womanwith colon cancer ound on endoscopy obtained because o a positivetest or occult blood in the stool.

Discuss ins, outs, and drains. Once again, your last sentence should startwith Te plan is.


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Always think o what you need to do to send the patient home. For exam-

ple, i she still is not eating and needs IVs or uid intake, the object wouldbe to get her eating.

Postopeatve Feves

In surgery, the dierential diagnosis, as it relates to specic symptoms,depends on the time since the procedure has been completed. For exam-ple, i a person has a ever, the most likely cause is dictated somewhat bythe postoperative day (POD). Remembering the ve Ws o post-opeverWind, Water, Walking, Wound, and Wonder drugsas a useul

memory tool when you are ollowing patients aer surgery.POD 12: Wind Atelectasis (without air) oen causes a ever.Reasons include being on a ventilator, inadequate sighs during surgery,and (in the general surgery patient) incisional pain on deep breathing.Tis is treated with incentive spirometrybecause there is evidence thatdeep inspiration prevents atelectasis better than just coughing.

POD 35: WaterUrinary tract inections are common during thistimerame. Foley catheters are sometimes still in place.

POD 46: WalkingDeep venous thrombosis can occur. Tis is moreo a problem in patients undergoing pelvic, orthopedic, or general sur-gery than in head and neck surgery. Subcutaneous, low-dose heparinandvenous compression devices reduce the incidence othromboem-bolization. Walking the patient on POD 1 is the best way to preventthis complication.

POD 57: WoundMost wound inections occur during this period.Preoperative antibiotics are important to prevent or reduce the risk o

inection in head and neck surgery that crosses mucosal linings.POD 7+: Wonder drugsDrugs can cause evers. (Note that in obstet-rics and gynecology, this W is Womb, and it precedes Wonderdrugs.)


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QuESTiONS

1. Te ve Ws o postoperative ever are: ___________, ___________,___________, __________, and ___________.

2. A ever on postoperative day 57 may be due to an inection o the_____________.

3. A ever on the night o surgery is most likely due to _____________.

ANSwErS

1. Wind, water, walking, wound, wonder drugs

2. Wound

3. Atelectasis


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Notes

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Chapter 4

EN Emergencies

Aay

Airway emergencies are uncommon, but devastating when they do hap-pen. Whether the patient lives or diesor worse, lives or years in acomadepends on the ability o those caring or him or her to recognize,access, and manage the airway. EN physicians are experts in airwaymanagement, but oen are not nearby when needed. Te advanced trau-ma lie support course you probably have taken or will take emphasizesmanagement o airway emergencies. Predicting when diculty will occur

and being able to manage the dicult airway without it becoming anemergency is an even more valuable skill. Later, this chapter will list threetypes o airway diculties that you might encounter.

A good rule o thumb about a tracheotomyis: I you think about per-orming one, you probably should. It is easier to revise a scar on the neckthan to bring the dead back to lie. I you are not an experienced surgeonand need an immediate surgical airway, then a cricothyrotomyis the pre-erred procedure. It is easier and less bloody than a tracheotomy. Pleaseremember the airway is best ound in the neck bypalpation, not inspec-

tion. ake a moment and palpate your own cricothyroid membrane,immediately below your thyroid cartilage. o do an emergencycricothy-rotomyyou need only a knie. Feel the space, cut down and stick your n-ger in the hole, eel, and cut again, and again until you are in the airway.Do not worry about bleeding. Place an endotracheal tube in the hole(again, by eel). Be sure not to push it past the carina. By this time, youwill be shaking like a leait is okay to let someone else squeeze the bag.Pressure with a dressing will address most bleeding. Occasionally, youmight need to use some sutures to stop the bleeding.

Choanal atresia is a congenital disorder in which the nasal choana isoccluded by so tissue, bone, or a combination o both. When unilateral,it presents with unilateral mucopurulent discharge. When bilateral, theneonate is unable to breathe. Since newborns are obligate nasal breathers,


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establishing an airway is an acute otolaryngologic emergency. While this

should be done in the operating room, a Montgomery nipple can be usedas an interim measure prior to surgery.

Dicult Intubations

Anatomic characteristics o the upper airway, such as macroglossia or con-genital micrognathia (e.g., Pierre Robin syndrome), can result in dicultlaryngeal exposure. Tis syndrome is more commonly encountered in theyoung, muscular, overweight man with a short neck. Anesthesiologistsare trained to recognize and manage the airway in these patients, but

everyone caring or them must be aware o the potential diculty. Teneed or a surgical airway in these patients oen represents a ailure orecognition and planning.

LudwigS ANgiNA ANd dEEP NECk iNFECTiONS

Ludwigs angina is an inection in the oor o the mouth that causes thetongue to be pushed up and back, eventually obstructing the patients air-

way. reatment requires incision anddrainage o the abscess. Te most

common cause o this abscess is inec-tion in the teeth. Te mylohyoid lineon the inner aspect o the body o themandible descends on a slant, so thatthe tips o the roots o the second andthird molars are behind and belowthis line. Tereore, i these teeth areabscessed, the pus will go into thesubmandibular space and may spread

to the parapharyngeal space. Patientswith these inections present with uni-lateral neck swelling, redness, pain,and ever. Usually, the inected tooth

is not painul. reatment is incision and drainage over the submandibularswelling. Antibiotic coverage should include oral cavity anaerobes.

I, however, the tooth roots are above the mylohyoid line, as they are romthe rst molar orward, the inection will enter the sublingual space,above and in ront o the mylohyoid. Tis inection will cause the tongueto be pushed up and back, as previously noted. Tese patients usually willrequire an awake-tracheotomy, as the inection can progress quite rapidlyand produce airway obstruction. Te rm tongue swelling prevents stan-dard laryngeal exposure with a laryngoscope blade, so intubation should

Fe 4.1.

This photograph depicts a gentleman with

severe Ludwigs angina. Notice the swollen

oor o the mouth and the arched, protruding

tongue obstructing the airway.


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not be attempted. Even i there is no airway obstruction on presentation, it

may develop aer you operate and drain the pus. Tis results rom post-operative swelling, which can be worse than the swelling on initial presen-tation.

ACuTE SuPrAgLOTTiC

SwELLiNg

Angioneurotic edema, either amil-ial or due to a unctional or quanti-tative deciency o C1-esterase

inhibitor, can also result in dramaticswelling o the tongue, pharyngealtissues, and the supraglottic airway.Swelling can progress rapidly, andoral intubation may quickly becomeimpossible, urgently requiring a sur-gical airway. Common medical treat-ments are IV steroids, and H1 andH2 histamine blockers.

PEriTONSiLLAr AbSCESS

Tis is a collection o purulence inthe space between the tonsil and thepharyngeal constrictor. ypically,the patient will report an untreatedsore throat or several days, whichhas now gotten worse on one side.Te hallmark signs o peritonsillar

abscess are ullness o the anteriortonsillar pillar, uvular deviation awayrom the side o the abscess, a hotpotato voice, and, in some patients, trismus (diculty opening the jaws).reatment includes drainage or aspiration, adequate pain control, andantibiotics. onsillectomy may be indicated, depending on the patientshistory.

Fe 4.2.

Lateral neck, sot-tissue x-ray o a child with

acute epiglottis. Note the lack o defnition o the

epiglottis, oten reerred to as a thumb sign (seeChapter 18, Pediatric Otolaryngology). This can

occur as a result o inectionse.., eplottts,

which was once common in children. Today,

however, these inections are rare because o

the widespread utilization o vaccination against

Haemophilus infuenzae. Epiglottic or supraglottic

edema prevents swallowing. Early recognition o

the constellation o noisy breathing, high ever,

drooling, and the characteristic posturesitting

upright with the jaw thrust orwardmay be

liesaving. Relaxation and an upright position

keep the airway open. These children must notbe examined until ater the airway is secured.


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Foreign Bodies

Foreign bodies can present as airway emergencies. Usually, however, bythe time the patient gets to the emergency room, the oreign body in the

airway has been expelled (oen by theHeimlich maneuver), or else thepatient is no longer able to be resusci-tated. Foreign bodies in the pharynxor laryngeal inlet can oen beextracted byMagill orceps aerlaryngeal exposure with a standard

laryngoscope. Te patient will usuallyvomit, so suction is mandatory.Bronchial oreign bodies will requireoperative bronchoscopyor removal.Occasionally, a tracheotomy will berequired, such as or a patient who hasaspirated a partial denture withimbedded hooks. Children oen aspi-rate peanuts, small toys, etc., into their

bronchi. Occasionally these patientspresent as airway emergencies,although they more typically presentwith unexplained cough or pneumo-nia. Chevalier Jackson, the amousbronchoscopist, has noted, All thatwheezes is not asthma. In otherwords, always remember to think ooreign body aspiration when a pedi-

atric patient presents with unexplained cough or pneumonia. I a ball-valve obstruction results, hyperination o the obstructed lobe or seg-ment can occur. Tis is easier to visualize on inspiration-expirationlms.

Mucormycosis

Tis is a ungal inection othe sinonasal cavity that occurs in immuno-compromised hosts. ypically it appears in patients receiving bone mar-row transplantation or chemotherapy. It is a devastating disease, with asignicant associated mortality.Mucoris a ubiquitous ungus that canbecome invasive in susceptible patients, classically those with diabeteswith poor glucose regulation who became acidotic. I there is any othersystem ailure (e.g., renal ailure), mortality goes up signicantly. Te

Fe 4.3.

A coin is seen here trapped in the patients

esophagus.


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ungus grows in the blood vessels, causing thrombosis and distal isch-

emia and, ultimately, tissue necrosis. Tis also leads to an acidic environ-ment in which the ungus thrives.

Te primary symptom is acial pain, and physical exam will showblackturbinates due to necrosis o the mucosa. Diagnosis is made bybiopsy.Acutely branching nonseptate hyphae are seen microscopically. Usuallythe inection starts in the sinuses, but rapidly spreads to the nose, eye, andpalate, and up the optic nerve to the brain. reatment is immediate cor-rection o the acidosis and metabolic stabilization, to the point wheregeneral anesthesia will be saely tolerated (usually or patients in diabeticketoacidosis who need several hours or rehydration, etc.). Ten, widedebridement is necessary, usually consisting o a medial maxillectomybut oen extending to a radical maxillectomyand orbital exenteration(removal o the eye and part o the hard palate) or even beyond.

Amphotericin B is the drug o choice.Many patients with mucormycosisalso have renal ailure, which pre-cludes adequate dosing. Newer lyso-

somal orms o amphotericin B havebeen shown to salvage these patientsby permitting higher doses o drugs. Ithe underlying immunologic problemcannot be arrested, survival is unlikely.In patients who are neutropenic,unless the white blood cell countimproves, there is no chance orsurvival.

Sinus Trombosis

See Chapter 9, Rhinology, NasalObstruction, and Sinusitis.

Epistaxis

Epistaxis is common and occurs in allpeople at some time. I the conditionis severe or persistent, these people

become patients. Te most commonbleed is rom the anterior part o theseptum. Tis area, called Kiesselbachsplexus, has many blood vessels. In

Fe 4.4.

Septal peroration may be secondary to trauma,

cocaine (or even Arin) abuse, or prior surgery.

Epistaxis commonly accompanies this condition

and may be problematic.


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children, these nosebleeds should be treated with oxymetazoline or phe-

nylephrine nasal spray and digital pressure or 510 minutes. It is impor-tant or patients to look at the clock while applying the pressure; just 30seconds can seem like an hour in such a situation, and the patient (or par-ent) may release the pressure too soon (which allows new blood to washout the clot that was orming). Te most common initiating event orthese kinds o nosebleeds is digital trauma rom a ngernail. Childrensngernails should be trimmed, and adults should be inormed aboutavoiding digital trauma. Another consideration may be an occult bleedingdisorder; thereore, adequate coagulation parameters should be studied i

the patient continues to have problems. Cocaine abuse is a possible etiol-ogy in any patient and must be considered. A perorated nasal septum canbe a warning sign.

Recurrent nosebleeds in a teenager can be especially problematic. Bleedingrom the back o the nose in an adolescent male is considered to be a juve-nile nasopharyngeal angiobroma until proven otherwise. Tese patientsrequently also have nasal obstruction. Diagnosis is made by physicalexamination with nasal endoscopy.

Some adult patients, oen with hypertension and arthritis (or which theyare taking aspirin), have requent nosebleeds. When they present to theemergency room, they have a signicant elevation o blood pressure, whichis not helped by the excitement o seeing a brisk nosebleed. reatment orthese patients is topical vasoconstriction (oxymetazoline, phenylephrine),which almost always stops the bleeding. When the oxymetazoline-soakedpledgets are removed, a small red spot, which represents the source o thebleeding, can oen be seen on the septum. Oen, i such a bleeding sourceis seen, it can be cauterized with either electric cautery or chemical cauter-

ization with silver nitrate. Nasal endoscopes permit identication o thebleeding site, even i it is not immediately seen on the anterior septum.Tese patients should also be treated with medication to lower their bloodpressure. Te diastolic pressure has to be reduced below 90 mm Hg. Manypatients can then go home, using oxymetazoline or a ew days. Further-more, methycellulose coated with antibiotic ointment can be placed intothe nose to prevent urther trauma and allow the mucosal suraces to heal.Tis is usually le in place or three to ve days.

Sometimes the bleeding cannot be completely stopped, and packing isused as a pressure method o stopping the bleeding. I the bleeding is com-ing rom the posterior aspect o the nose, then a posterior pack may needto be placed. An alternative is to place any one o various commercially


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available balloons to stop the nosebleed. Patients who undergo anterior

packing on one side may go home. However, i bilateral nasal packing isused or a posterior pack is placed, patients will need to be admitted to thehospital and careully watched, because they can suer rom hypoventila-tion and oxygen desaturation. In general, the packing is le in place orthree to ve days and removed. During this time, prophylactic oral or par-enteral antibiotics should be administered to decrease risk o inectiouscomplications. I the patient re-bleeds, the packing should be replaced,and arterial ligation, endoscopic cautery, or embolization can be consid-ered. As always, these patients should be worked up or bleeding disor-

ders. A patient with a severe nosebleed can develop hypovolemia, or sig-nicant anemia, i uid is being replaced. Tese conditions necessitateincreased cardiac output, which can lead to ischemia or inarction o theheart itsel.

Necrotizing Otitis Externa

Malignant otitis externa is an old name or what should more appropri-ately be called necrotizing otitis externa. Tis is a severe inection o theexternal auditory canal, usually caused byPseudomonas organisms. Te

inection spreads to the temporal bone and, as such, is really an osteomy-elitis o the temporal bone. Tis can extend readily to the base o the skulland lead to atal complications i it is not adequately treated. Tis diseaseoccurs most commonly in older patients with diabetes, and can occur inAIDS patients. Any patient with otitis externa should be asked about thepossibility o diabetes. It can be caused by traumatic instrumentation orirrigating wax rom the ears o patients with diabetes. Patients with necro-tizing otitis externa present with deep ear pain, temporal headaches, puru-lent drainage and granulation tissue at the area o the bony cartilaginous

junction in the external auditory canal and acial nerve ollowed by othercranial neuropathies in severe cases.

o diagnose an actual inection in the bone (which is the sine qua non othis disease), a computed tomography (C) scan o the bone, with bonewindows, must be obtained. A technetium bone scan will also demon-strate a hot spot, but is too sensitive to discriminate between severe otitisexterna and true osteomyelitis. Te standard therapy is meticulous glucosecontrol, aural hygiene, including requent ear cleaning, systemic and topi-cal antipseudomonal antibiotics, and hyperbaric oxygen in severe casesthat do not respond to standard care. Quinolones are the drugs o choicebecause they are active against Pseudomonas organisms.


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QuESTiONS

1. Abscessed teeth can rupture through the medial mandibular cortexinto the sublingual space. Tis can cause the tongue to be pushed upand back. Te biggest danger in this is loss o _____________.

2. Te easiest way to ensure that the airway isnt lost in this situation isto perorm a ____________.

3. Immunocompromised patients, especially patients with diabetes, canget a devastating ungal inection o the sinuses called________________.

4. Necrotizing otitis externa is a Pseudomonas inection o the _______and _____, which can lead to atal complications.

5. Oen, _______ tissue is seen at the junction o the bony-cartilaginousjunction in the external auditory canal in patients with necrotizingotitis externa.

6. Te most common cause o a nosebleed in children is injury to vesselsin ________________.

7. A posterior nosebleed in an adolescent male is considered to be a___________ until proven otherwise.

8. wo topical vasoconstrictors oen used in the nose are __________and __________.

ANSwErS1. Airway

2. racheotomy

3. Mucormycosis

4. Skull base or temporal bone

5. Granulation

6. Kiesselbachs plexus

7. Juvenile nasopharyngeal angiobroma

8. Oxymetazoline, phenylephrine


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Notes

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Chapter 5

Otitis Media

Otitis media may simply be dened as inammation o the middle earspacethe space between the eardrum and the inner eardue to anycause. It is the second most common disease diagnosed in young children.Otitis media can be classied by duration, patient symptoms, and physicalexam ndings. It is important or the clinician to be amiliar with two com-mon variants o otitis media: (1) acute otitis media and (2) otitis mediawith efusion (OME).

Children with acute otitis media requent-

ly present with sudden onset o ever, earpain, and ussiness. In patients with acuteotitis media, the eardrum is bulging andyellow or white in color with dilated ves-sels, and there is decreased movement othe eardrum on pneumatic otoscopy(insufation o air into the ear canal).Common bacteria that cause acute otitismedia in children are Streptococcus pneu-

moniae, Haemophilus infuenzae, andMoraxella catarrhalis. In healthy childrenolder than two years o age who presentwith less severe symptoms, observation or48 hours may be considered. I the deci-sion is made to treat with antibacterial agents, amoxicillin dosed at 80 to90 milligrams per kilogram per day is the rst-line antibiotic therapy.Azithromycin can be used to treat patients who have a penicillin allergy.

Te high incidence o resistant organisms can make the treatment o acute

otitis media challenging. For example, in patients who do not respond torst-line antibiotic therapy, a beta-lactamase-producing organism or aresistant Streptococcus organism may be responsible or treatment ailure.While treatment choices in such patients will be dictated by the prevalence

Fe 5.1.

This tympanic membrane demonstrates the

bulging seen with an acute inection.


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o resistant organisms in your community, a common second-line therapy

or acute otitis media is high-dose amoxicillin-clavulanate.Breasteeding and vaccination with apneumococcal conjugate preparationmay decrease the incidence o acuteotitis media in children, while otheractors, such as daycare attendance,young siblings at home, and exposure totobacco smoke, may predispose chil-dren to develop otitis media. Some chil-dren develop recurrent acute otitismedia, orrecurring acute, symptomaticear inections. Such children may ben-et rom pressure equalization (PE)tube, or ear tube, insertion i they havethree to our bouts o acute otitis mediain six months or ve to six bouts in asingle year.

Insertion o PE tubes involves placing small tubes in the eardrum to venti-late the middle ear and prevent the negative pressure and uid buildup. Ina child with an open PE tube, ear drainage typically indicates an ear inec-tion. An advantage o PE tubes is the ability to treat episodes o ear drain-age with topical antibiotic therapy, such as uoroquinolone ototopicaldrops applied to the ear canal. Currently, there is a trend to use uoroqui-nolone drops rather than traditional neomycin/polymyxin B/hydrocorti-sone preparations, due to the theoretical risk o ototoxicity associated withthese medications. Te PE tubes generally extrude on their own aer one

to two years. In the past, antibiotic prophylaxis or a three- to six-monthtrial was an alternative treatment or children with recurrent acute otitismedia. Due to concern over the development o resistant organisms, theroutine use o antibiotic prophylaxis or recurrent acute otitis media inotherwise healthy children has been largely abandoned.

OME, or middle ear uid without active inection, may occur aer treat-ment o an acute episode o otitis media, or due to chronic eustachian tubedysunction. While the majority o children will clear middle ear uidwithin three months o an acute ear inection, those with eustachian tubedysunction may have problems with persistent middle ear uid. Childrenwith OME are oen asymptomatic, although they may complain o earullness or mufed hearing. Tese patients do not have the evers, irritabil-ity, and ear pain that are associated with acute otitis media. On physical

Fe 5.2.

Photograph o a tympanic membrane with a

pressure equalizing (PE) tube in place. The

tube permits aeration o the middle ear space.


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examination, there may be an air-uid level behind the eardrum and

decreased mobility o the eardrum. Children with OME may have up to a30- to 40-decibel (dB) conductive hearing loss, which in some studiesafected speech development and learning. Antibiotic therapy is not usu-ally indicated or children with OME. Patients with OME are sometimestreated with a short course o oral or topical nasal steroids, to decrease theswellingin the eustachian tube and allow ventilation o the middle earspace. Reerral to an otolaryngologist should be considered or childrenwith at least three months o persistent middle ear eusion. Placement oPE tubes is oen entertained or such children whose eusions are associ-

ated with hearing loss.An adenoidectomy, or removal o the adenoid tissue in the nasopharynx,has been shown to reduce the need or PE tubes in children, presumablyby removing a ocus o eustachian tube inammation. Adenoidectomy isoen recommended i a child requires a second set o PE tubes, or withthe rst set o tubes i the child has signicant nasal symptoms. Childrenusually grow out o the need or the tubes as they get older, as the eusta-chian tube assumes a longer and more downward-slanted course withtime. However, there are certain subsets o patients, such as children witha history o cle palate or trisomy 21, who can have long-term problemswith otitis media and eustachian tube dysunction.

OME in an adult, especially i it is o recent origin and unilateral, shouldprompt an examination o the nasopharynx or a disease process aectingthe eustachian tube. Early nasopharyngeal carcinoma is well known orits silent natureoen the only sign is unilateral OME. Later in the diseaseprocess, the tumor metastasizes to the cervical lymph nodes and extendsinto the skull base, causing cranial neuropathies. In the past, nasopharyn-

geal examination was perormed with mirrors, but most otolaryngologistsnow routinely use rigid or exible endoscopic instrumentation.

Complcatons of Acte Otts Mea

Complications o acute otitis media were common in the pre-antibioticera. It is largely because o those complications that otolaryngology devel-oped as a specialty more than 100 years ago. With advances in the diagno-sis and treatment o otitis media, such complications as mastoiditis andmeningitis have decreased in incidence. However, as the prevalence o

resistant organisms increases, especiallyStreptococcus pneumoniae, thereis a chance that these complications may again become more common.Tereore, even i you never see a case during your medical school years,you must know about these complications and be able to recognize themi you encounter them in your practice. I untreated, acute otitis media can


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lead to several complications, including peroration o the eardrum,

tympanosclerosis, mastoiditis, and meningitis.Purulent ear drainage in the setting o acute otitis media is likely due toeardrum, or tympanic membrane, peroration. Te eardrum is the path oleast resistance in the ear; thus, a build-up o middle ear purulence duringan episode o acute otitis media can result in spontaneous tympanicmembrane (M) rupture. reatment is similar to that described above oracute otitis media. Most commonly, the peroration will heal on its ownwithin two weeks. However, persistent perorations may require surgicalrepair. Occasionally, eardrum perorations can be associated with chronicear drainage, also known as chronic suppurative otitis media.

Another residual efect o acute otitis media and M rupture is tympano-sclerosis. ympanosclerois is the rm submucosal scarring that canappear as a chalky white patch on the eardrum. It can inrequently lead toconductive hearing loss i the middle ear, and ossicles are involvedextensively.

Other more severe complications o otitis media include meningitis andmastoiditis. Meningitis originating rom otitis media is believed to occur

byblood-borne spread o the bacteria rom the middle ear space into themeninges. Historically, the most common oending organism wasHaemophilus inuenzae, though epidemiologic patterns have been chang-ing since the advent o the Haemophilus inuenzae vaccine. Meningitis

caused by otitis media is most oentreated with intravenous antibiotics. Apotential complication o pediatricmeningitis is hearing loss.

Fluid collection in the air cells o themastoid bonejust behind the ear oenoccurs when acute otitis media is pres-ent. However, ithe uid becomesinected and invades the bony struc-tures, acute mastoiditis develops.Patients with acute mastoiditis presentwith ever, ear pain, and a protrudingauricle. Over the mastoid bone, the

patient may have erythema o the skin,tenderness, and even a uctuant mass.

A C scan is a useul diagnostic tooli acute mastoiditis is suspected.

Fe 5.3.

Photograph o a tympanic membrane withchronic otitis media with eusion. Note the

bubbles in the uid behind the drum. While

most eusions will resolve spontaneously,

patients with persistent uid may require

tympanostomy tube placement.


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Fe 5.4.

Otoscopic view o let eardrum with

cholesteatoma involving thepars faccida.

The white material is keratin flling the canal.

Intravenous antibiotics may initially

be used to treat patients with acutemastoiditis. Surgery, including PE tubeplacement or mastoidectomy, may benecessary in patients who do notrespond to medical therapy.

Other less common, but potentiallydevastating, complications o otitismedia include epidural and brainabscesses, sigmoid sinus thrombosis,and acial nerve paralysis. A collectiono pus can occur just outside the dura(termed an epidural abscess), or with-in the brain itsel (a brain abscess),and surgical drainage is required. Tesigmoid sinus can become inected and thrombosed, and can serve as anidus o inection. Tis classically leads to showers o inected emboli,causing picket ence evers. Facial nerve paralysis in the setting oacute otitis mediais believed to be caused byinammation around thenerve, and thus generally responds to appropriate intravenous antibiotictherapy as well as drainage o the pus. Tis can be done via either a myrin-gotomy (an incision in the eardrum) or, i necessary, a mastoidectomy.

Cholesteatoma

As mentioned above, some patients do not outgrow their eustachian tubedysunction, and they go on to suer rom chronic negative middle earpressure. Tis can result in retraction o the superiorpart o the ear drum,known aspars faccida, back into the middle ear space. Te outside o theeardrum is actually lined with squamous epithelium, which desquamatesand produces keratin. Over time, the keratinous debris can get caught inthepars faccida retraction pocket. Tis can continue to accumulate,expanding the pocket, and is then called a cholesteatoma, which oengets inected. Patients with cholesteatoma usually present with chronic eardrainage, oen due to Pseudomonas or Proteus bacteria. Tese patients maybe put on ototopical antibiotic drops, and their drainage may getbetter, only to return when the treatment is stopped. I the cholesteatoma isle untreated, it will continue to grow and erode bony structures. Possiblesequelae include hearing loss secondary to necrosis o the long process othe incus; erosion into the lateral semicircular canal, causing dizziness;subperiosteal abscess; acial nerve palsy; meningitis; and brain abscess.


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Te treatment or cholesteatoma is surgical removal. While excision gets

rid o the cholesteatoma, the underlying eustachian tube dysunction isstill present. Tus, cholesteatoma has the propensity to recur. Oncepatients have undergone surgery or removal o a cholesteatoma, they willneed continuous monitoring o their ears or the rest o their lives.

Another way cholesteatoma can develop is when squamous epitheliummigrates into the middle ear space through a hole in the eardrum. Teperoration can come rom a previous otitis media inection, a PE tubehole that did not heal, or trauma. Marginal perorations, or holes alongthe outer portion o the eardrum, are more likely to allow migration oepithelium than central perorations. Remember that the eardrum hasthree layers: cuboidal epithelium in the middle ear, a brous layer inthe middle, and squamous epithelium on the outside. When there is aperoration, all three layers start to prolierate, but i the squamous layerand the cuboidal layer meet, the brous layer will stop. Tis can lead toa chronic peroration in which the middle ear is constantly being exposedto the outside, and thus develops a low-grade inammation.

Clncal Example

A 14-year-old boy comes to your oce complaining o painless right eardrainage. He is otherwise healthy, although he did have PE tubes in hisears as a child. On examination, you nd he has slightly turbid drainagecoming rom a hole in his right eardrum. You diagnose chronic otitismedia and learn that he does not know he has a peroration. He has notbeen trying to keep water out o his ear. You assume he has a Pseudo-monas aeruginosa inection and prescribe ooxacin otic solution (0.3%)twice a day or 10 days. He returns in two weeks with a dry ear and a smallresidual eardrum peroration. You next order an audiogram, a hearingtest that shows a 15-dB conductive hearing loss with normal discrimina-tion (ability to understand words). You tell the patient to keep water out ohis ear. He comes back in our to six weeks and has not had any moredrainage, so you reer him or a tympanoplasty.

Tympanoplasty

ympanoplasty, an operation to repair a hole in the eardrum, is gener-ally perormed either through the ear canal or rom behind the ear. Tesurgeon reshens up the edges o the hole. Ten, because the brous tissue

will not grow with squamous epithelium meeting cuboidal epithelium,a piece oascia temporalis (the brous connective tissue overlying thetemporalis muscle) or tragal perichondrium (the lining overlying the


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tragus ear cartilage) is harvested as a gra. Small, semicircular cuts in the

skin o the external auditory canal (EAC) are made about ve millimeters(mm) out rom the annulus, which is the outermost portion o the ear-drum. Te surgeon scrapes the skin o the bone and sneaks under theannulus to access the medial aspect o the eardrum and the middle earspace. Te middle ear is then lled with a sponge-like material made ohydrolyzed collagen, which acts as a scaold to hold the gra up againstthe medial aspect o the eardrum. Ten the M and skin are replaced andthe EAC is packed with more sponge-like material. Te collagen substanceis eventually reabsorbed; meanwhile, the brous layer prolierates along

the scaolding o the gra to close the hole. Te patient is usually instruct-ed not to get water in the ear or three weeks. Aer this time, the surgeonwill gently suction out any remaining collagen substance rom the EAC.

As an example, a 49-year-old, non-diabetic male comes to your clinic witha draining right ear. He says it has drained o and on or years. Onceagain, the EN exam is normal, except or copious purulence coming outo a M peroration. You prescribe oral antibiotics and an antibiotic ear-drop. You tell him to keep water out o his ear, which he does, and hecomes back in two weeks, cleared up. You order an audiogram, whichshows a 20-dB conductive hearing loss and good discrimination. He isthen scheduled or a tympanoplasty in six weeks, but he comes in drainingagain in two weeks. He has not gotten his ear wet. You repeat medicaltherapy and, once again, he clears but drains a month later. He has a deepnidus o inection in his mastoid cavity that needs to be cleared. Youschedule him or a C scan, which shows no cholesteatoma, and then youperorm a tympanomastoidectomy. At surgery, you nd normal air cellsthroughout the mastoid cavity, with the exception o a ew inected cells atthe very tip o the mastoid. He does well post-op.

Now, say you have the same history and you could not see a cholesteatomaby physical exam, but the C scan shows opacication o the middle earspace that is suspicious or cholesteatoma. Te audiogram is the same. Youperorm the same operation (a tympanomastoidectomy) and remove thecholesteatoma. Te patient does well post-op. Did you notice that whenpatients present with a recurrent draining ear, appropriate initial therapyincludes systemic antibiotics as well as antibiotic-containing topical ear-drops? Tis includes patients who have a previously placed PE tube.

Patients with persistent otorrhea that does not respond to this initial ther-apy necessitate reerral to an otolaryngologist or urther evaluation.


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QuESTiONS

1. Te most common organisms causing acute otitis media are________, __________, and ________.

2. Te rst-line antibiotic therapy or acute otitis media in children is_______.

3. Children with persistent otitis media with eusion or ___ monthsand evidence o hearing loss are candidates or PE tube placement.

4. Ear drainage in patients with PE tubes in place should be treated with_______________________.

5. Te presence o bilateral uid in the ears may cause up to a__________ dB conductive hearing loss.

6. It is important to examine the ____________ in any adult with uni-lateral otitis media with eusion.

7. In a patient with acute otitis media, in addition to being opaque andbulging, the eardrum has ____________ mobility on pneumatic otos-copy.

8. Te collection o trabeculated bony cavities lined with mucosa andconnected with the middle ear is called the mastoid ______________.

9. Tepars accida o the eardrum can become _______________whenthere is chronic negative pressure in the middle ear.

10. Te outside o the M, including thepars accida, is lined with____________ epithelium.

11. _________________ is suspected in a child presenting with ever, ear

pain, a protruding auricle, and uctuance behind the ear.12. In patients with chronic eustachian tube dysunction, desquamated

debris, consisting mainly o keratin, collects in the retractedpars ac-cida. Over time, this can grow and become a __________.

13. I a patient presents with a draining ear, appropriate therapy includesdrops and ________________.

14. I ear drainage persists despite medical therapy, the patient requiresreerral to an otolaryngologist to rule out ______________.

15. ____________________is the rm submucosal scarring that canappear as a chalky white patch on the eardrum.


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ANSwErS

1. S. pneumoniae, H. inuenzae, M. catarrhalis

2. Amoxicillin

3. Tree

4. Ototopical uoroquinolone drops

5. 30 to 40

6. Nasopharynx

7. Decreased

8. Air cells

9. Retracted

10. Squamous

11. Acute mastoiditis

12. Cholesteatoma

13. Oral antibiotics14. Cholesteatoma

15. ympanosclerois


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Notes

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Chapter 6

Hearing Loss

Hearing loss can be caused by a wide variety o actors. Patients may pres-ent with the complaint o being unable to hear, or they may complain odiculty understanding. Oen, a amily member brings the patient or ahearing test because o communication diculties. Older individualsoen complain otinnitus, which may be described as a sound like ring-ing, buzzing, or crickets in the ears. While tinnitus is usually a manies-tation o hearing loss, it may have other causes as well. Hearing loss inchildren may be particularly dicult to detect, and is oen conused withinattention or speech delay.

Depending o the specic type and etiology o the hearing loss, dramati-cally dierent treatments may be prescribed. It is important to determinewhether the problem is with the conductive pathway o the ear (conduc-tive) or with the inner ear or eighth cranial nerve (sensorineural).Conductive hearing loss can be due to cerumen impaction, swelling othe external auditory canal, tympanic membrane perorations, middle earuid, or ossicular chain abnormalities. Sensorineural hearing loss canoccur as a result o injury to the hair cells in the cochlea or neural ele-

ments innervating the hair cells. Te most common etiologic actors arepersistent noise exposure, age-related changes o the eighth cranial nerve(presbycusis), genetic actors, and inectious or postinammatory pro-cesses. umor growth (acoustic neuroma) along the course o the eighthcranial nerve can also be the etiology o sensorineural loss and must beincluded in the dierential diagnosis.

Pure-tone audiometry(the hearing test) is requently used to assess thepatients hearing levels. Te test requires that the patient is able and willingto cooperate. It can be especially dicult in the case o very young chil-dren. Hearing threshold levels are determined between 250 and 8000Hertz (Hz) or pure tones and measured in decibels (dB). Te 0-dB level isnormalized to young, healthy adults and doesnt mean there is absenceo detectable sound. Some patients hear 0 dB, but reaching the threshold


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o hearing usually requires louder test signals. Te higher the threshold is,

the poorer the patients hearing. Tresholds higher than 25 dB are consid-ered abnormal.

During the audiogram, independent thresholds are determined or eachear or both air conduction (conductive hearing) and bone conduction(sensorineural hearing). Air conduction measures the ability o the exter-

nal and middle ear to transmitsound to the cochlea. Conductivehearing loss can result rom any bar-rier that could block sound trans-mission in this pathway (cerumen,peroration, middle ear uid). Tiswill create an air-bone gap betweenthe air and bone conduction thresh-olds on the audiogram.Sensorineural hearing loss can bediagnosed i the air conduction andbone conduction thresholds areequal but higher than 25 dB.

Our ability to hear is more complexthan just listening to single puretones in a sound-proo booth.Tereore, a test o the patients abil-ity to understand spoken wordsshould be perormed as well. In aspeech discrimination test, the

patient is presented with phonetically balanced words (i.e., love, boat,

pool, sell, raise) that are amplied to a comortable hearing level as neces-sary. Te results o this test, the speech discrimination score, should bebetween 90 percent and 100 percent or normal speech discrimination.Tis test o clarity also assesses the unction o the auditory division o theeighth cranial nerve. Te ability to understand speech is very important,especially with respect to determining to what degree a hearing aid willhelp a particular patient. Ampliyinggarbled speech (with a hearing aid)has limited benet or patients with very poor speech discrimination.

ympanometryis commonly used to evaluate the tympanic membrane(M) and middle ear status. Tis test assesses the mobility o the M andits response to pressure changes in the external auditory canal. Tree com-mon patterns are shown in Figure 6.2. ype A plots arise when the exter-nal auditory canal is patent and the middle ear and M are healthy (maxi-

Fe 6.1.

A conductive hearing loss in the let ear due tootitis media with eusion. Note that bone

conduction thresholds are normal in both ears,

but air conduction on the let is 30 dB poorer

than that measured on the right. Remember that

zero (0) dB does not reer to absence o sound,

but rather represents an average threshold or

young, healthy adults.


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mum M mobility when pressure

in the canal is atmospheric). ypeB plots occur when the middleear is lled with uid or the Mhas a peroration (no peak in ear-drum mobility). Te two prob-lems can be dierentiated byexamining the volume read by theimpedance bridge. Middle earuid will generate normal vol-

umes, while tympanic membraneperorations will generate large

volumes. ype C plots (peak ear-drum mobility when pressure issubatmospheric) are typical opatients with retracted Ms sec-ondary to eustachian tube dys-unction. ympanometry resultscan help detect middle ear uid

when the physical exam isunclear.

Conctve Hean Loss

Careul physical examination othe ear with the aid o a micro-scope, tuning ork testing, andaudiometric testing can requent-ly determine the cause o a con-

ductive hearing loss. Most causeso conductive hearing loss can bemedically or surgically correct-edthey can be improved orresolved with treatment and with-out use o a hearing aid. Swellingo the external auditory canal sec-ondary to otitis externa can betreated with appropriate topical

medication. Cerumen impactioncan be cleaned with irrigations,ear drops, or specialized instru-ments. Middle ear uid, the mostcommon cause o hearing loss in

Fe 6.2.

Three tympanograms demonstrating change incompliance o the middle ear (vertical axis) withchanges in ear canal pressure. Type A is normal,with the greatest compliance at the point where thepressure in the ear canal is equal to that o atmo-spheric pressure (peak is at 0). Type B demon-strates very poor compliance at any requency,suggestive o a tympanic membrane (TM) immobi-lized by uid in the middle ear or a TM peroration

(no peak). Type C represents a tympanogram inwhich the compliance o the membrane is greatestat a point where the pressure in the canal is 200mm o water below that o atmospheric pressure(peak shited to the let). This suggests inefcienteustachian tube unction with persistent negativepressure in the middle ear.


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children, can be treated with antibiotic therapy or myringotomy tubes,

and tympanic membrane perorations can be surgically repaired.Cholesteatoma oen presents with hearing loss, and in the physicalexamination, it can be conused with cerumen.

Conductive hearing loss present on the audiogram but not readily appar-ent on the physical exam suggests problems with the ossicular chain. Onecommon disease process aecting the ossicular chain is otosclerosis, ahereditary disease process that involves bony prolieration within the tem-poral bone. Tese bony changes commonly occur at the ootplate regiono the stapes, causing gradual xation o the ossicular chain. Tis xation,in turn, decreases the mobilityo the stapes ootplate and creates a con-ductive hearing loss. Surgical correction stapedotomyis available. Astapedotomy procedure re-establishes ossicular continuityby removingthe xed stapes ossicle and placing a prosthesis between the incus and the

vestibule o the inner ear. Sound vibrations can then be transmitted romthe ossicular chain, through the prostheses and into the inner ear, restor-ing the patients hearing.

Sensoneal Hean Loss

Sensorineural hearing loss (SNHL) is the most common orm o hear-ing loss. It is generally not treatable with surgery, although cochlearimplants and other implantable audiologic devices may be helpul in caseso proound sensorineural or mixed hearing loss. Tere are many causes othis type o hearing loss, but age-related changes to the cochlea causingpresbycusis are by ar the most requent cause. As we age, the outer haircells within the cochlea gradually deteriorate, causing a symmetricalSNHL that begins in the high requencies (Figure 6.2). Patients with pres-bycusis may also complain o tinnitus and have diculty with speech dis-crimination.

Another common type o hearing loss is secondary to acoustic trauma ornoise exposure. Noise exposure is common in certain industries and isclosely regulated by a ederal government agency, the Occupational Healthand Saety Administration.Recreational target shooting, hunting with re-arms, use o personal stereos or iPods or other MP3 devices with head-phones, loud music exposure, power tools, etc., can cause a specic type ohearing loss with a characteristic audiometric pattern (Figure 6.3). Patients

suering rom noise-induced hearing loss have a symmetric noise notchin bone-conduction thresholds at approximately 4000 Hz. Prevention is

vital, and counseling should be part o routine health maintenance.reatment consists o hearing education, noise avoidance when possible,and appropriate hearing protection with ear plugs or ear mus when loud


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Fe 6.3.

This audiogram suggests noise exposure that may be

encountered occasionally in younger individuals who have

been exposed to hazardous or toxic noise. Note the

high-requency dip, with a maximum loss at 4000 Hz.

noise is present. Patients

should also have regularlyscheduled audiometric ol-low-up.

Sudden sensorineural hearingloss is an acute loss o hearingthat represents an EN emer-gency and deserves specialmanagement. Please reer toChapter 4, EN Emergencies,or urther discussion o thisproblem.

Patients with asymmetricSNHL require a more thor-ough evaluation to ruleout a benign tumor o theeighth cranial nerve, knownas an acoustic neuroma.

Although most patientswith an asymmetric hearingloss do not have an acoustic neuroma, hearing loss is by ar the most com-mon presenting complaint in patients with such tumors. In addition, thesepatients will requently have very poor speech discrimination scores andtinnitus in the aected ear. Tey may also occasionally have disequilib-rium complaints, although truevertigo is rare. Specialized audiometrictesting can be done to assist in the diagnosis o acoustic neuromas, butmagnetic resonance imaging (MRI) with gadolinium is the diagnostic test

o choice. Physical exam and testing may elucidate an easily treatablecause o hearing loss. However, more serious causes can be present thatrequire careul assessment and complex management. o ensure that diag-noses o serious conditions such as cholesteatoma or acoustic neuroma aremade, patients with hearing loss should be reerred to an otolaryngologistor evaluation and management o their care. For this reason, many statesrequire an evaluation by a physician beore a hearing aid can be tted.

Hearing aids are eective in rehabilitation o hearing loss in mostpatients. Aids vary widely in their power (gain), requency response, size,and cost. Optimal tting requires a proessional knowledgeable in thenuances o amplication technology. Even or some patients with totalSNHL, a cochlear implant can provide direct stimulation o the cochlearnerve and can be very helpul. Currently, patients with bilateral proound


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hearing loss are candidates.

Younger children are implant can-didates as well. Tis has provenextremely helpul in their languageand social development. All new-borns should undergo hearingscreening, so that appropriate mea-sures may be taken as soon as pos-sible.

Fe 6.4.

Audiogram o a patient with presbycusis. Note that

low-tone thresholds are relatively normal, with a

drop in thresholds at higher requencies. This is a

consequence o the normal aging process and

may vary widely rom patient to patient.


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QuESTiONS

1. Te most common cause o a conductive hearing loss in children is________________.

2. Te magnitude o a hearing loss is documented in the _______.

3. Te two major types o hearing loss are ______________ and________.

4. Conductive hearing loss is present when there is a dierence between__________ and _____________ conduction thresholds.

5. Sensorineural hearing loss is present when air and bone conductionthresholds are ______ but show a hearing loss.

6. Noise-induced hearing loss oen produces a high-requency_________________ in the audiogram.

7. Otitis media with eusion produces a ______________ tympano-gram.

8. Presbycusis produces a hearing loss that slopes to the _____________side o the audiogram.

9. A patient with an asymmetric sensorineural hearing loss must beevaluated or the potential o having an ________.

ANSwErS

1. Fluid in the middle ear (otitis media with eusion)2. Audiogram

3. Conductive, sensorineural

4. Air, bone

5. Approximate, similar

6. Notch

7. ype B (at)

8. Downward, right

9. Acoustic neuroma


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Notes

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Chapter 7

Dizziness

People oen come to the otolaryngologist with a complaint o dizziness,including symptoms such as disequilibrium, syncope, lightheadedness,ataxia, andvertigo. As otolaryngologists, we ocus on disease processesthat produce true vertigo (an illusion o motion), which is primarily asso-ciated with the balance organs o the inner ear. Tese are reerred to asperipheral vestibular disorders. When central vestibular disorders areconsidered, the dierential diagnosis or dizziness becomes quite broad.Tereore, i your patient does not complain o the true illusion o motion,redirect your questioning to the evaluation o syncope or episodichypotension. You may also want to consider imaging studies o the brainto rule out neoplasm, demyelinating disease, or a vascular abnormality.Tese patients may also need reerral to a neurologist or cardiologist.

Vestla Testn

Vestibular testing can be perormed to help determine whether the prob-lem exists within the vestibular (balance) portion o the inner ear.Vestibular testing may include an audiogram, electronystagmography(ENG), rotational chair test, posturography, and electrocochleography(ECOG), depending on the clinical situation.

Tere are our main parts to ENG testing: the calibration test, which mea-sures rapid eye movements; the tracking test, which evaluates the ability othe eyes to track a moving target; the positional test, which measuresresponses

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