Common Problems in Otolaryngology Thomas C. Spalla, M.D. Assistant Professor: Cooper Medical School at Rowan University Adjunct Professor: Drexel University College of Medicine, Dept of Otolaryngology – Head & Neck Surgery March 2014 Disclosures • None The Ear http://www.tchain.com/otoneurology/images/master-ear.jpg Auricular Hematoma • Result of trauma • Treatment – Drainage – Pressure dressing • Non-treatment – “Cauliflower” ear Otitis Externa Otitis Externa • Pathophysiology – Breakdown of barriers – skin, cerumen, immune system – Erythema → Exudate → Edema → Cellulitis • Organisms – Pseudomonas >> S. aureus • Treatment – – – – Debridement & keep ear dry Ototopicals Wick Oral Abx (reserved) Pseudomonas Aeruginosa • Gram negative • Aerobic • Coccobacillus Fungal Otitis Externa • Organisms – Aspergillus – Candida • Treatment – – – – – Debridement Antifungal creams Acidification Gentian violet Keep ear dry Fungi • Aspergillus • Candida Malignant Otitis Externa • Osteomyelitis of the temporal bone – Typically immunocompromised • Organism – Pseudomonas #1 • Treatment – IV Abx – Hyperbaric oxygen – Correct underlying immunosuppression – Wide resection Ramsay Hunt Syndrome (Herpes Zoster Oticus) • Etiology – Latent VZV in geniculate ganglion • SSx – Vesicular eruption & pain (80-90%) – Facial palsy (50%) – SNHL (50%) – Vertigo (30%) • Work-up – Tzanck smear – MRI – Viral serum titers • Treatment – Famciclovir/Valcyclovir for 10-14 d. – Steroids Otitis Media ACUTE OTITIS MEDIA • Symptoms SEROUS OTITIS MEDIA  Ear pain  Sick/URI  Decreased hearing • Signs  Pus behind TM  Bulging, red TM  Conductive hearing loss Symptoms •    Aural fullness Decreased hearing Autophony Signs •    Straw‐colored, non‐infected fluid behind TM Retracted TM Conductive hearing loss Middle Ear Infections • Acute Otitis Media (AOM) – – – – – Pain Fever Thickened, bulging TM Hearing loss ±Otorrhea • Relieves pain • TM ruptured Organisms • Streptococcus pneumoniae – G+ – -hemolytic – Anaerobic • Haemophilus influenzae – G– Coccobacillus – Facultatively anaerobic • Moraxella catarrhalis – G– Diplococcus – Aerobic Acute Otitis Media Complications • Extracranial – – – – – – – TM perforation Mastoiditis Petrositis Facial paralysis Labyrinthitis Petrous apicitis Ossicular erosion – Intracranial – Abscess • Subdural • Epidural • Brain – Meningitis – Lateral sinus thrombosis – Otic hydrocephalus AOM Treatment • Watchful waiting • Antibiotics are slightly better than placebo – Amoxil – still 1st line – Augmentin or other -lactamase coverage for resistant cases • Myringotomy + Tubes for recurrent cases • Consider adenoidectomy in recurrent cases Serous Otitis Media • Evaluate nasopharynx if it’s not classic (after URI) or unresolving • Treatment – – – – – – Autoinsufflation Decongestants Allergy management Adenoidectomy Myringotomy ± tube Eustachian tube surgery Chronic Suppurative Otitis Media • Signs/Symptoms – Chronic or recurrent otorrhea – Hearing loss – TM perforation • Pain is NOT common and needs worked up • Consider cholesteatoma Inner Ear Infections VESTIBULAR NEURITIS LABYRINTHITIS • Etiology • Etiology – Thought to be viral • Symptoms – Severe vertigo • Hours to days then slowly resolving • May have residual symptoms for weeks • Treatment – Supportive – Viral – Bacterial – very severe! • Symptoms – Severe vertigo – Hearing loss • Treatment – Antibiotics – Steroids – Supportive Tympanic Membrane Perforation • Causes – Infection – Barotrauma – Mechanical trauma • Treatment – Keep ear clean and dry – Watchful waiting – Repair if not healing Hearing Loss Tuning Fork Tests Weber Rinne • Place on mastoid or • Place on forehead temporal bone, ask pt (even better on upper if louder here or about teeth) 6” or so from ear • Lateralizes to side of • “Positive” = normal = conductive loss or air > bone conduction better hearing ear in sensorineural loss Tympanometry • A measure of energy transmission through the TM and middle ear • Types: – A – normal • As – shallow • Ad – deep – B – flat – C – negative pressure Tympanometry Audiogram Treating Conductive Hearing Loss • Reverse cause (if possible) • Treat eustachian tube dysfunction if effusion • Allergy therapy, nasal corticosteroids, decongestants, tubes if these fail • Repair TM if perforated (after determining why it was) • Repair/replace ossicles • Hearing aid – Standard – BAHA – Bone Anchored Hearing Aid Otosclerosis • Background – 8‐12% of white population – F:M = 2:1 – Autosomal Dominant penetrance = 25‐40% • Presentation – Usually a female in her early 30s with progressive conductive or mixed HL Sensorineural Hearing Loss  Hearing loss secondary to damage to the cochlear or distally  Causes  Aging (presbycusis)  Ototoxic medications (aminoglycosides)  Noise trauma  Tumors  Iatrogenic  Autoimmune  Infection  Numerous!!!! Sudden Sensorineural Hearing Loss  True emegency!!!  History: sudden loss, often with preceding URI, occasionally complaining of severe sounds in ear just preceding  Treatment  Start high dose steroids ASAP (e.g. Prednisone 1mg/kg)  Others: antivirals, aspirin, carbogen, pentoxifylline  Work‐up  Audiogram  MRI – non‐emergent unless CVA is suspected Inner Ear Infections Vertigo • Vertigo is a symptom • Has numerous causes • History is THE most important part of determining cause – If nothing else, ask how long the vertigo lasts • Vestibular suppressants slow recovery but do help symptoms (if symptoms last long enough) – e.g., Diazepam (Valium), Meclizine (Antivert) Inner Ear Infections VESTIBULAR NEURITIS • Etiology LABYRINTHITIS • – Viral – Bacterial – very severe! – Thought to be viral • Symptoms – Severe vertigo • Hours to days then slowly resolving • May have residual symptoms for weeks • Treatment – Supportive Etiology • Symptoms – Severe vertigo – Hearing loss • Treatment – Antibiotics – Steroids – Supportive BPPV • Benign Paroxysmal Positioning Vertigo • Signs/Symptoms – Vertigo lasting SECONDS – Often precipitated by head turning, rolling over in bed, looking up – No neurologic changes – No loss of consciousness Benign Paroxysmal Positioning Vertigo (BPPV) • Cause – Otolith malposition • Diagnosis – History – Dix-Hallpike maneuver • Treatment – Epley maneuver – Surgery for resistant cases Dix‐Hallpike Maneuver Epley Maneuver Meniere’s Disease  Endolymphatic hydrops  Signs/Symptoms     Vertigo lasting hours Aural fullness Tinnitus Fluctuating low frequency hearing loss  Treatment  Low NaCl (<2gm/day)  Diazide  Surgery if all else fails Rhinitis • • • • • • • • Allergic Nonallergic with or w/o eosinophilia Viral Occupational Vasomotor Rhinitis medicamentosa During pregnancy Vasculitides, autoimmune, & granulomatous Allergic Rhinitis • SSx – – – – Itching Obstruction Runny Sneezing • Treatment – – – – Avoidance Saline rinse Decongestants Antihistamines • Oral • Topical – – – – Intranasal steroids Leukotriene inhibitors Mast cell stabilizer Immunotherapy Immunotherapy • Indications – SSx • Due to IgE Abs • Severe – Seasons • Long or multiple – Complications • Asthma • Recurrent OM/Sinusitis • Lost productivity – Medications • Intolerance • Not controlled • Contraindications – SSx • Mild • Controlled w/ meds – Atopic dermatitis or food allergies – Non-compliance – -blockers Rhinoscopy Middle Turbinate Nasal Polyp Treatment of Nasal Polyps • Treat underlying cause • Topical therapies – Steroids – Saline – Diuretics • Oral therapies – Antibiotics (when appropriate) – Steroids (reserved for flare-ups or pre- and postop) • Allergy management – Antihistamines – Anti-leukotrienes – Immunotherapy • Surgical removal Epistaxis • Causes – Dry nasal cavity – Trauma • Picking • Nasal cannula – Medications • Anticoagulants • Sites – 90% are anterior Epistaxis Management  Basics  Pinch nose and hold for at least 5‐10 minutes  Lean forward  Nasal topical decongestant  Moderate  Above + consider packing  Severe      “ABCs” Type & Cross, CBC, PT/PTT, FFP, Packs Angioembolization Surgery Sinusitis Acute Sinusitis Bacterial infection lasting < 4 weeks, often heralded by worsening symptoms during the 2nd week of a URI Signs/Symptoms Facial pain/pressure Purulent nasal discharge Nasal congestion Hyposmia Tooth pain Poor response to decongestants Acute Sinusitis • Organisms (same as AOM) – S. pneumoniae – H. influenzae (nontypable) – M. catarrhalis Acute Sinusitis Treatment • Watchful waiting is appropriate • Antibiotics (Amoxil, Augmentin, Bactrim) may be helpful • Saline rinse • Oxymetazoline (Afrin®) for a few days • Reserved for complications – Surgery – CT scan Chandler Classification  Stage I—Preseptal cellulitis  Inflammatory edema of the eyelids  Stage II—Orbital cellulitis  Proptosis, chemosis, reduced eye movements, and possible visual loss  Stage III—Subperiosteal abscess  Proptosis and visual loss  Stage IV—Orbital abscess  Complete ophthalmoplegia, visual loss, and marked proptosis  Stage V—Cavernous sinus thrombosis  Bilateral signs may be present  May lead to loss of vision and meningitis Sinusitis Complications Preseptal cellulitis with chemosis Subperiosteal abscess Chronic Rhinosinusitis MAJOR FACTORS MINOR FACTORS • Facial pain/pressure • Nasal obstruction • Nasal discharge/discolored postnasal drip • Hyposmia/anosmia • Purulence on examination • Fever (only in acute sinusitis). • • • • • • • Headache Nonacute fever Halitosis Dental pain Fatigue Cough Ear pain/pressure/fullness. Chronic Sinusitis  Symptoms > 6 weeks  Treatment  Purulent nasal drainage  Hyposmia  Face/tooth pain  Cough  Post nasal drip  Fatigue  Halitosis     Saline rinses Topical steroids Antileukotrienes Immunotherapy  Surgery  Not 1st line  Beneficial  If an anatomic cause is found  Failed medical therapy  To deliver medications better Fungal Sinusitis • Non‐Invasive – Mycetoma – “fungal ball” – Allergic Fungal Sinusitis (AFS) – “peanut butter” – Chronic • Slowly expansile, remodeling of bone • Invasive – Acute – a true emergency! • Rhyzipus species typically – Chronic • Slowly erosive changes Mucormycosis Rhinovirus • • • • #1 cause of URI Enterovirus ssRNA Binds to ICAM-1(CD54) Oral Cavity Leukoplakia • White lesion which does not readily scrape off • 4 – 6% give rise to oral carcinoma • Causes – Tobacco, EtOH, Trauma, Viral • Treatment – Reverse cause – Biopsy if it persists – Follow‐up Erythroplakia • Premalignant lesion • Some feel 40% have invasive cancer in them at presentation53 • 90% chance of being a carcinoma in situ or 54 invasive carcinoma 21 Squamous Cell Carcinoma • Most common type of • malignancy of aerodigestive tract • Etiologies – Tobacco – HPV – EtOH Treatment – Surgery – Radiation – Chemotherapy Human Papilloma Virus • DNA • Infects basal cells of stratified epithelial cells and only replicates there • Carcinogenic – 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82 Waldeyer’s Ring • Components – – – – Adenoid Torus tonsils Palatine tonsils Lingual tonsils Adenoid Hypertrophy  Causes       Failure to regress Allergy Chronic infection HIV Lymphoma Cancer  Signs/Symptoms  Aural fullness  Eustachian tube dysfunction  Nasal obstruction  Hyponasal voice Acute Pharyngitis  Treatment  Avoid antibiotics if there no obvious bacterial cause  Rapid strep  Sensitivity 95%  Specificity 98%  GABHS  Treat with PCN to prevent Rheumatic fever  Consider STDs given history Centor Criteria • Lack of cough • Swollen/tender anterior cervical lymph nodes • (Marked) tonsillar exudates • Fever No. of criteria • • • • • 0 1 2 3 4 → → → → → Chance of strep 2.5% 6-7% 14-17% 30-34% 56% Peritonsillar Abscess  Signs/Symptoms  Muffled “Hot Potato” Voice  Trismus  Fever  ILL  Poor po intake  Uvula deviation  Edema  Treatment  Incision & Drainage  Antibiotics  Pain meds Ludwig’s Angina • Mixed floor of mouth infection • Organisms – -hemolytic streptococci – Staphylcocci – Bacteroides • SSx – Drooling – Fever – Ill Ludwig’s Angina • Treatment – Secure airway – IV Abx – Drainage Lemierre’s Syndrome • Cause – May occur due to a peritonsillar abscess, parotitis, sinusitis, otitis • Microbe – Classically Fusobacterium necrophorum • Results – Internal jugular thrombophlebitis – Septic thrombi – often to lungs or joints – Sepsis • Lipopolysaccharide (bacterial toxin) leads to cytokines release from WBCs • Hemaglutinin – platelet aggregration  DIC, thrombocytopenia Lemierre’s Syndrome • Treatment – Penicillin-based + lactamase inhibitor (e.g., clavulinic acid) + metronidazole – Clindamycin Mononucleosis 31 Squamous Cell Carcinoma • Risk factors – Tobacco – EtOH – HPV 32 Tonsillar Lymphoma  Symptoms  Maybe none  B symptoms  Night sweats  Fevers  Weight Loss  Signs  Tonsil asymmetry  Cervical lymphadenopathy  Treatment  Tonsillectomy for diagnosis  ChemoRT 30 Tonsillectomy • Indications – Obstruction – Infection • Chronic • Recurrent • Recurrent PTAs – Malignancy • Suspected • Known – Halitosis/tonsilliths – IgA nephropathy Sialoadenitis Sialoadenitis • Signs/Symptoms – PAIN!!!! – Swelling – Erythema – Dehydration – Fevers, chills, feel ill • Organisms – S. aureus >>>> S. pneumoniae, E coli, H flu, Klebsiella Sialoadenitis Treatment • • • • • • • Hydration Warm compresses Antibiotics – cover S. aureus Sialogogues (lemon wedges, sour candy, etc) Massage (in the direction of the drainage) Dilation & Sialolithotomy – if present Remove gland if recurrent problem – during a period of quiescence Obstructive Sleep Apnea • Degrees – Mild – Moderate – Severe • Findings (not always present of course) – Obesity – Thick neck – Micrognathia • Symptoms – – – – – Snoring Daytime fatigue Unrefreshed after sleep Morning headaches Falling asleep easily during day Obstructive Sleep Apnea • Sequelae – – – – – – – – Hypertension Diabetes Obesity Car accident Arrythmia Pulmonary HTN Erectile dysfunction Death • CPAP – Gold Standard Treatment Surgery for Obstructive Sleep Apnea Turbinate reduction Septoplasty Tonsil & Adenoidectomy Palatal surgery Tongue base reduction/suspension  Maxillofacial advancement  Tracheotomy  Bariatric surgery      Neck Mass • HPI How long? Enlarging? Painful? Response to antibiotics? – Any work-up? – – – – • SHx – Tobacco + EtOH • Physical Exam – Thorough! H&N exam – All mucosal surfaces examined – Thyroid exam – Mass • • • • Where? Fixed? Fluctuant? Other masses? Head & Neck Cancer • Squamous cell carcinoma is the most common overall by far if excluding thyroid & skin cancer • A neck mass in an adult is cancer (> 50%) until proven otherwise • A neck mass in a child is usually congenital or inflammatory Neck Mass • Work‐up – Imaging • CT neck with contrast • Consider CT chest, PET/CT – Labs • Lytes, CBC, Coags, LDH, Albumin, Tox screen – Biopsy • FNA, FNA, FNA (if no reason to think it’s vascular) • Still no answer, core needle can be considered • Open biopsy???? ‐ LAST RESORT Pediatric Neck Mass • Inflammatory – Lymphadenitis – Cat scratch • Congenital – Lateral • Think branchial cleft cyst – Midline • Think thyroglossal duct cyst Hoarseness • Causes – Reflux – Laryngitis – Benign • • • • Polyps Hemorrhage Nodules Granuloma – Malignant • Squamous cell carcinoma #1 35 Laryngitis • Almost always viral or post URI • Exam – Endolaryngeal exam is usually fairly unremarkble (minor inflammation) compared to amount of dysphonia • Treatment – No antibiotics – Humidification, plenty of fluids – Voice rest – Steroids if they must use their voice Reflux Laryngitis • Symptoms – “Lump” in the throat – Hoarseness – worse in morning – Heartburn – Constant throat clearing – Cough – Water brash • Treatment – Conservative • • • • Weight loss HOB elevation Dietary modifications Smoking cessation – Medical • H2 blockers • PPI – Surgical • Nissen fundoplication Vocal Fold Lesions Epiglottitis • Causes – – – – – Hib SHM again… S agalactiae S aureus S pyogenes • Hib vaccination has helped • DDx: – Croup – Abscess • Retropharyngeal • Parapharyngeal • Peritonsillar – Foreign body Epiglottitis • Presentation – – – – – Stridor Drooling Fever Ill-appearing Tripod position • Treatment – Secure airway – IV Abx Croup • Laryngotracheobronchitis • S/Sx – Barking cough • DDx – – – – – – Epiglottitis Foreign body Vocal fold paralysis Subglottic tumor Angioedema Bacterial tracheitis • “Steeple Sign” Tracheotomy • Indications VDRF Obstruction Pulmonary toilet Bilateral vocal fold paralysis – OSA – Vent wean – Not for aspiration!!! – – – – Questions?