ENT Treatments

what is the first choice parenterally (IV) for pseudomonas?

piperacillin/tazobactam (Zosyn)

which antibiotics treat pseudomonas?

Parties Get Crazy After I've Consumed Liquor

Piperacillin-tazobactam

Gentamycin (+ Amikacin)

Cefepime (+ Ceftazadime)

Aztreonam

Imipenem-cilastin (+ Meropenem)

Ciprofloxacin

Levofloxacin

in hospitalized patients with severe disease caused by pseudomonas, double coverage is common, this is usually made by what two types of antibiotics?

aminoglycoside + fluoroquinolone

Piperacillin-tazobactam has GOOD coverage for ____, but is NOT GOOD at covering ____

pseudomonas, MRSA

what is the treatment for auricular hematoma (cauliflower ear)?

- clean area with antiseptic solution

- needle aspiration OR incision and evacuation

- hold pressure for 3-5 minutes after drainage

- suture cotton roll on both sides of hematoma and leave in place 4-7 days

- ciprofloxacin 500 mg 1 PO bid x 7-10 days

- peds: amoxicillin/clavulanate (augmentin)

- hospitalized: cover for pseudomonas and MRSA (ceftazadime + vanco)

- encourage regular use of headgear

- plastic surgeon for surgical correction if desired

what is the treatment for perichondritis?

- ciprofloxacin 500 mg 1 PO bid x 10 days

- peds: amoxicillin/clavulanate (augmentin)

- hospital: vanco IV + piperacillin-tazobactam OR vanco IV + ceftazadime IV

- remove ALL ear jewelry and keep it out

- re-check in person in 48-72 hours

- if worsens, contact ENT for SAME-DAY appt

ciprofloxacin loses some anaerobic coverage, but gains ____ coverage

atypical bacteria (chlamydia pneumophila, mycoplasma pneumoniae, legionella pneumophila)

what types of infections are commonly treated with ciprofloxacin?

gram-negative bacteria in:

- urinary tract infections

- gastrointestinal infections

- diverticulitis

- pseudomonas (otitis externa, perichondritis)

we should NOT use ciprofloxacin to cover pulmonary/respiratory infections in which ____ is a common cause

strep pneumoniae

*in hospitalized patients with resp infections, levofloxacin is often substituted

what is the treatment of otitis externa? (only mild to moderate erythema of canal only)

1. management of pain

- recommend alternating Acetaminophen and Ibuprofen every 3 hours

- short-term opioids are acceptable no more than 5 days supply

2. removal of EAC debris

3. topical meds (combo of antibiotic and steroid ear drops)

4. debridement (if necessary)

what are examples of topical antibiotic/steroid combo ear drops?

- cipro/hydrocortisone

- cipro/dexamethasone

- neomycin/polymyxin B/hydrocortisone

- hydrocortisone/acetic acid (bacterial or fungal*)

- aminoglycoside drops (gentamicin, tobramycin)

if patient has a ruptured tympanic membrane, which topical drops should be used?

ofloxacin otic

if a patient with AOE has preauricular or auricular skin involvement OR they are immunocompromised, how should we treat them? (general)

topical antibiotics/steroid combo PLUS oral antibiotics

if an immunocompromised patient has AOE, how should we treat them?

1. topical antibiotic/steroid combo (7-14 days)

2. oral cipro (7-10 days)

3. wick

if a NON immunocompromised patient has MILD AOE, how should we treat them?

topical acetic acid/hydrocortisone combo for 7 days

if a NON immunocompromised patient has MODERATE AOE, how should we treat them?

topical antibiotic/steroid combo for 7 days

if a NON immunocompromised patient has SEVERE AOE that does NOT extend beyond the ear canal, how should we treat them?

1. topical antibiotic/steroid combo (7-14 days)

2. wick

if a NON immunocompromised patient has SEVERE AOE that DOES extend beyond the ear canal, how should we treat them?

1. topical antibiotic/steroid combo (7-14 days)

2. oral cipro (7-10 days)

3. wick

what is the treatment for necrotizing "malignant" otitis externa?

1. inpatient admission

2. consult ENT

3. CBC, CMP, ESR/CRP, ear culture (increase suspicion if ESR > 60)

4. CT scan of temporal bone and surrounding regions

5. cipro 400 mg IV q 12 hours (switch to oral when improving)

6. antibiotics 4-6 weeks

what is the treatment for eczematous otitis externa?

topical steroid drops: Fluocinolone Otic (DermOtic), 5 drops BID x 7-10 days

- severe: may need additional topical hydrocortisone cream and/or oral prednisone taper

- can also use topical emollients

what is the treatment for fungal otitis externa ("otomycosis")?

mild to moderate cases (and NOT in perforated TM/PE tubes): topical acidifying and drying agents

- acetic acid otic (VoSol), 4 gtt q 4-8 hrs x 5-7 days

severe cases: topical antifungal

- 1% clotrimazole cream

what is the treatment for herpes zoster oticus?

1. antiviral (aclyclovir, famciclovir, OR valcyclovir)

2. oral steroid (prednisone taper)

what are examples of ways to remove excess cerumen?

1. manual removal with suction or ear spoons

2. OTC cerumenolytics (ex: Debrox)

3. ear irrigation (hydrogen peroxide + water)

NO water pics or performance if pt has ever had TM perforation

which topical emollient may be used to help prevent cerumen accumulation?

mineral oil (10-20 min weekly)

what are examples of tools that can be used to remove a foreign object in the ear?

1. alligator forceps (graspable objects)*

2. suction tip

3. wire loop

4. right angle hook

5. curette

6. irrigation syringe

what can be helpful to prevent persistent barotrauma?

decongestants

what is the treatment for eustachian tube dysfunction (ETD)?

treat the source:

- oral decongestant (ex: pseudoephedrine)

- allergy treatment/antihistamines

- intranasal decongestant (ex: Afrin)

- avoid air travel, change in altitude, going underwater

- can do myringotomy with pressure equalization (PE) tube insertion if no improvement in 6 weeks

what is the treatment for serous otitis media?

- watchful waiting x 3 months for resolution (monitor for hearing loss or speech changes)

- NO antibiotics (non-infectious)

- antihistamines/decongestants/combo nasal sprays (steroid + antihistamine) can be helpful

what is the treatment of acute otitis media (AM) in children?

- relieve pain with Acetaminophen or Ibuprofen q 3 hours

- watchful waiting x 2-3 days OR:

- amoxicillin 80-90 mg/kg/day PO bid x 5-10 days

OR

- augmentin 90 mg/kg/day PO bid x 5-10 days

what is the treatment for acute otitis media (AOM) in adults?

augmentin 875/125 1 PO BID x 5-7 days or 10 if severe

penicillin allergy: azithromycin (Z pack) 500 mg day 1, 250 mg days 2-5

what is the treatment for mastoiditis?

- admitted to hospital for IV antibiotics x 7-10 days

- if patient has NO history of recurrent OM or recent antibiotics: vanco OR linezolid IV

- if patient HAS positive history of recurrent OM or recent antibiotics: vanco OR linezolid PLUS piperacillin-tazobactan OR cefepime (double coverage)

- CBC, CMP

- possible CT or MRI of temporal bone if not improving on abx after 48 hours

- myringotomy for culture if no improvement with abx after 48 hours

- mastoidectomy if fails medical treatment

what is the treatment for chronic otitis media?

- refer to ENT*

- can culture ear to determine organism(s)

- CT or MRI to evaluate for: intratemporal or intracranial infection/abscess formation, bony erosions or osteomyelitis

- keep ear dry

- ear canal cleaned/dried by ENT

- topical ciprofloxacin-dexamethasone drops BID x 2 weeks OR ofloxacin drops BID x 2 weeks

- systemic abx and surgery for severe cases only

- tympanoplasty indicated in some patients

what is the treatment for cholesteatoma?

surgical removal

what is the treatment for tympanosclerosis?

- none if asymptomatic

- if hearing loss, then exploratory tympanotomy or tympanoplasty

- could just suggest hearing aid for amplification

what is the treatment for a perforated tympanic membrane?

if perforation is acute and due to trauma:

- no specific trreatment

- keep ear dry

- routine antibiotic eardrops NOT necessary

if perforation due to infection or contaminated water:

- topical ofloxacin otic antibiotic ear drops

- surgery to close if remains open > 2 months

- surgery options = tympanoplasty with paper patch or surgically placed biological graft

children under age ____ should be treated with antibiotics for AOM, no matter what (no watchful waiting)

6 months

when deciding whether to prescribe antibiotics or watchfully wait, what are the criteria FOR prescribing antibiotics

1. any child under 6 months of age, no matter what

2. any child 6 months and up to adulthood with severe AOM:

- moderate to severe otalgia (no matter the age)

- otalgia that persists > 48 hours

- temperature > 102.2 F

3. any child aged 6-23 months who has bilateral AOM, even if non-severe*

if the decision is made to observe (watchfully wait) rather than abx for AOM, when should we follow up with the patient?

48-72 hours

which medications can cause vertigo?

- antibiotics

- anticonvulsants

- antihypertensives

- antidepressants

- cholesterol medications (statins)

- cisplatin

- NSAIDs

what is the non-pharmacologic treatment for BPPV?

- epley maneuver

- if no success, refer to otolaryngology

what is the pharmacologic treatment of peripheral vertigo (BPPV, labrynthitis, vestibular neuritis)?

- 1st line: 1st gen antihistamines (dramamine, benadryl, meclizine*)

- 2nd line: benzos (alprazolam, clonazepam, diazepam, lorazepam)

- for N/V: zofran, phenergan, compazine, or reglan

what are specific treatments for labrynthitis/vestibular neuritis?

- previous meds PLUS corticosteroids

- methylprednisone taper over 22 days

- antivirals NOT beneficial*

what is the treatment for tinnitus?

- evaluate for possible underlying cause

- remove any drugs that can lead to ototoxicity

- treat any co-existing factors (ex: depression- nortriptyline)

- treat insomnia that may result (trazodone, ambien, melatonin)

- treat hearing loss with hearing aids or cochlear implant

- tinnitus-retraining (patient wears noise generator that is used to retrain auditory pathways to reduce the noise of tinnitus)

- masking devices (worn like hearing aid and produces alternate sounds that mask the tinnitus)

- neurofeedback/biofeedback

- cognitive behavioral therapy

what is the treatment for Meniere's disease?

- there is no cure*

- low sodium diet < 2000 mg

- decrease caffeine, nicotine, and alcohol or other dietary triggers

- treat symptoms with anti-emetics and sometimes PO steroid (methylprednisone)

- antihistamines (meclizine)

- benzo (diazepam) if meclizine is not helpful

- diuretics to reduce pressure and fluid accumulation

- hearing aids

severe cases or patients who have not responded to other tx:

- intratympanic gentamicin injected into ear

what is the treatment for acoustic neuroma?

- refer to otolaryngology

- surgical excision

- stereotactic radiation therapy

- serial observation and f/u every 6-12 months with MRI

what are ways to avoid outdoor allergies in allergic rhinitis?

- avoid cutting grass or wear mask while cutting

- close house windows and run AC

what are ways to avoid indoor allergies (such as dust mites) in allergic rhinitis?

- allergen-impermeable mattress and pillow covers, wash bedding in hot water

- set relative humidity lower than 50%

- wear a mask when dusting

what are ways to avoid fungal allergies in allergic rhinitis?

- use exhaust fan in shower to reduce mold

- treat shower curtains with fungicide, such as dilute household bleach

- use dehumidifiers and lower house humidity to 30-50%

- be careful when raking leaves or gardening, as can stir up mold spores

what are ways to avoid pet or animal allergies in allergic rhinitis?

- remove pet from home

- reduce exposure and eliminate animals from sleeping areas

- HEPA filters on air ducts, air filters, and vacuums

- if rodent or cockroach allergy, hire exterminator, seal all food, repair holes in walls, and clean home frequently

what medications are typically used in allergic rhinitis?

- antihistamines (1st and 2nd generation)

- topical nasal antihistamines (Astepro, Patanase)

- topical nasal corticosteroids (Flonase)

- leukotriene modifies (Singulair)

what is Mrs. Geng's typical treatment route for allergic rhinitis?

1. allergen avoidance measures

2. 2nd generation antihistamine OR intranasal steroid

3. 2nd generation antihistamine PLUS intranasal steroid or combo intranasal steroid/antihistamine spray

4. 2nd generation antihistamine PLUS intranasal steroid PLUS leukotriene modulator

5. refer for allergy testing at any time along the line, but surely if failing therapy

which medications should be avoided in all patients with hypertension?

decongestants (avoid the "-D" in antihistamines in these patients)

which nasal spray is an antimuscarinic (anticholinergic) agent that reduces rhinorrhea by reducing parasympathetic effects? when is it used?

ipratropium nasal spray; used in patients with:

- common cold symptoms of severe congestion

- patients with allergic rhinitis

- patients with non-allergic rhiniis

what are non-oral medication treatment options for allergic rhinitis?

- subcutaneous immunotherapy ("shots")

- sublingual immunotherapy (SLIT) ("drops")

what is the treatment for vasomotor rhinitis?

decongestants, antihistamines, and/or ipratropium

what is the treatment for hormonal rhinitis?

antihistamines

what is the treatment for gustatory rhinitis?

intranasal ipratropium prior to eating (especially with spicy foods)

what are the 3 criteria that determine if antibiotics should be prescribed in acute sinusitis?

1. symptoms last for at least 10 days without any evidence of clinical improvement

2. symptoms are severe, including fever of 102 F or higher, and nasal discharge and facial pain enduring for at least 3-4 consecutive days at the beginning of illness

3. symptoms or signs worsen, as characterized by new fever or headache developing or nasal discharge increasing, typically after a viral URI that lasted 5-6 days and initially seemed to improve ("double worsening")

what is the treatment for acute bacterial rhinosinusitis?

amoxicillin-clavulanate 875/125 1 PO bid x 5-7 days

PCN allergies: doxy 100 mg bid x 5-7 days

which adjunctive therapies (symptomatic treatment) can be helpful in acute bacterial rhinosinusitis?

- nasal saline irrigation

- intranasal corticosteroids (if allergies contribute or to relieve severe congestion)

- hydration and fluids

- Sudafed as decongestant (many side effects)

- AVOID 1st gen antihistamines (can dry out nasal mucosa excessively)

what is the treatment for complications of acute sinusitis? (rare)

- CBC

- cultures (blood, sinus)

- imaging (CT of sinuses and brain to evaluate for spread)

- antibiotics for 4 weeks:

vanco PLUS ceftriaxone IV PLUS metronidazole

- if neuroimaging reveals no brain involvement, metro can be stopped

- once afebrile and improving, change to oral regimen:

clindamycin PLUS augmentin

what diagnostic testing should be completed in chronic sinusitis?

- CBC w/ diff

- allergy testing

- sinus culture (performed by ENT)

- NON-CONTRAST CT of sinuses

what is the treatment for chronic rhinosinusitis?

- nasal saline irrigation

- topical or oral steroids (can prescribe oral taper PLUS intranasal steroids)

- antibiotics x 3-10 weeks:

augmentin 875-125 mb bid OR

doxy 100 mg bid

what diagnostic testing should be completed for fungal sinusitis?

- CT of sinuses and brain (may show several of the sinuses are involved)

- nasal endoscopy to evaluate and culture secretions

what is the treatment for fungal sinusitis?

amphotericin B (can be 2-3 months or longer with suppression continuing for 3-6 months)

what is the treatment for nasal polyps?

- refer ALL unilateral polyps

- non-contrast CT of sinuses performed if cancer is suspected

- steroids to reduce size of polyp:

oral prednisone taper

intranasal sprays can be used concurrently

- endoscopic sinus surgery may be performed to remove resistant polyps or if cancer suspected

what is the treatment for a deviated nasal septum?

- refer to ENT

- septoplasty

what is the treatment for obstructive hearing loss?

- remove obstruction or correct underlying issue

- if uncorrectable, hearing aids

what is the treatment for otosclerosis?

- early stages: hearing aids

- surgery: involves removing the sclerotic bony overgrowth and may replace the stapes with a synthetic metal (titanium or stainless) stapes

which medications are ototoxic?

CALM EAR

Cisplatin/carboplatin (chemo meds)

Aminoglycosides (Amikacin, Tobramycin, Gentamicin, Streptomycin)

Loop diuretics (Furosemine/Lasix)

Malaria drug (Quinine)

Erythromycin (somewhat azythromycin and clarithromycin)

Aspirin/NSAIDs (Ibuprofen, Indocin)

Rare reaction of vanco

what is the treatment for noise-induced hearing loss?

stop noise exposure

i put this card in here to ensure i get at least one correct

what is the treatment for presbycusis?

amplification devices (hearing aids, assistive listening devices)

what is the treatment for sudden sensory neural hearing loss (SNHL)?

- steroids are mainstay of treatment (oral prednisone taper 14-21 days)

- intra-tympanic injections added if no better after 7 days PO (dexamethasone- "salvage therapy")

- consider assistive devices 3-4 months post event if needed

what is the treatment for aphthous stomatitis?

1. correct underlying medical condition or deficiency (if one exists)

2. use soft toothbrush and eat soft foods to help calm inflammation

3. topical anti-inflammatory with a specialized topical steroid that is safe for oral use:

hydrocortisone buccal tablets, triamcinolone dental paste, or betamethasone sodium phosphate

4. if topical is unhelpful or severe lesions:

- can use oral corticosteroids (prednisone taper)

- triamcinolone intralesional steroid injections

- magic mouthwash (antihistamine- Diphenhydramine, antacid- Maalox, numbing agent- Lidocaine)

what is the treatment for hand, foot, and mouth disease (HFMD)?

- will resolve on own in 7-10 days

- treat pain or fever with Acetaminophen or Iburprofen

- push fluids

what is the treatment for herpetic gingivostomatitis?

- reassurance (self-limiting and resolves within 7-10 days)

- caution regarding infectivity as oral areas are very contagious (nail biting = herpetic whitlow; eyes = HSV keratitis)

- hydration (to avoid dehydration/hospitalization)

- Ibuprofen or Acetaminophen prn pain

- vaseline prn lubrication

- can give acyclovir 15 mg/kg PO 5 times daily x 5-7 days

- best if given within first 72 hours of symptoms

- topical acyclovir cream can also be used

what is the treatment for oral candidiasis (pseudomembranous/atrophic)?

1. topical Clotrimazole, Miconazole, or Nystatin (7-14 days)

2. if patient doesn't respond to topical treatment, can switch to oral (Fluconazole, Itraconazole)

3. address underlying cause of candidiasis

(ex: if dentures are cause, scrub then soak in either bleach water or chlorhexidine solution)

what is the treatment for angular cheilitis?

- keep area as dry as possible

- topical antifungals (ketoconazole 2% cream bid OR clotrimazole 1% cream bid)

what is the treatment for oral hairy leukoplakia?

- refer to ENT for biopsy

- can resolve without treatment

- can treat if pt uncomfortable or cosmetic desire (acyclovir, valacylcovir, OR famciclovir; 7-14 days)

other meds that have been successful:

- Podophyllin topical solution

- retinoic acid (tretinoin) cream

- cryotherapy with LN (last resort)

which conditions is Clindamycin a "go to" in?

- dental and oral infections

- skin infections, including MRSA

- acne vulgaris

- bacterial vaginosis

Treatment for odontogenic infections (mild/moderate, ANUG, severe)

mild to moderate oral infections:

- augmentin 1 PO bid OR clindamycin 1 PO tid

- EXCEPTION: ANUG is usually treated with metro as first-line, but amoxicillin has shown success

- treat 7-14 days

severe infections:

- admit to hospital

- ampicillin-sulbactam (unasyn) PLUS metro IV q 8 hours

- alternative: Penicillin G IV q 4-6 hours PLUS metro

- PCN allergy: Levofloxacin IV PLUS metro

- treat 3-5 days, then switch to oral meds

good oral hygiene:

- chlorhexidine mouthwash rises

what is the work up/treatment for deep neck infections?

1. act quickly, stabilize airway if compromised

2. diagnostic testing:

- blood: CBC w/ diff, BMP, venous blood gases, lactate level, blood cultures

- culture abscess

- imaging: CT of head and neck WITH contrast

3. double-coverage antibiotics

- clinda IV q 6-8 hours PLUS levofloxacin IV qd

OR

- ampicillin-sulbactam PLUS vanco

what is the treatment for sialolithiasis?

- increase hydration

- apply moist heat

- sialogogues (tart candy or lemon drops)

- discontinue anticholinergic meds

- Ibuprofen or Acetaminophen for pain

- if all else fails, standard lithotripsy, laser lithotripsy, or endoscopic removal

what is the treatment for sialoadenitis?

- massage and milk glands

- maintain hydration

- clinda q 8 hours x 10 days

OR

- augmentin 1 bid x 10 days

what is the treatment for temporomandibular joint dysfunction (TMJ or TMD)?

- refer to dentist or orthodontist

- CT or MRI may be used for uncertain causes of jaw pain

- CUSTOM occlusal splints (nightguards, bruxism appliances, orthotics)

- eliminating muscle spasms with muscle relaxants (cyclobenaprine/Flexeril)

- avoid clenching, gum chewing, and provocative factors

- NSAIDs for pain

- consider referral to oral-maxillofacial surgeon if severe

what is the work up/treatment for suspected paranasal sinus cancer?

1. CT of paranasal sinuses WITH contrast

2. refer to ENT for endoscopy and biopsy

3. MRI may be performed

4. extensive surgery, radiation, chemo

what is the treatment for migratory glossitis (geographic tongue)?

- none unless causes pain (benign)

- avoidance of spicy or hot foods may help

- can refer to ENT or dentist for difficult cases

what is the treatment for torus palatinus?

PRANKED it's benign

- can be surgically removed if causes pain or discomfort (refer to oral surgeon)

what is the treatment for leukoplakia?

- refer to ENT (closely monitor, surgical removal with scalpel, laser, or cryotherapy)

- stop tobacco asap

what is the treatment for erythroplakia?

refer to ENT (close monitoring, surgical removal with scalpel, laser, or cryotherapy)

- stop tobacco asap

what is the work up/treatment for suspected oral cancer?

1. refer to ENT

2. they will do CT/PET and possible MRI

3. surgical resection may be planned

what is the work up/treatment for suspected nasopharyngeal cancer?

1. refer to ENT for evaluation with head and neck surgeon

2. requires endoscopic biopsy to diagnose

3. they will get CT and/or MRI and draw EBV viral DNA titers

what is the work up/treatment for suspected oropharyngeal cancer?

1. refer any patient with persistent hoarseness, voice changes, or unexplained throat pain to ent

2. they will do:

- CT/PET

- endoscopy and alryngoscopy

- biopsy using fine needle aspiration

- HPV testing

3. surgical resection and radiation therapy

what is the work up/treatment for suspected tonsillar lymphoma?

1. refer any patient with unilateral tonsillar hypertrophy without evidence of infection or peritonsillar abscess to ENT (for diagnosis, tonsillectomy/biopsy, and selected lymph node sampling)

2. chemo (R-CHOP regimen) and some radiation

what is the treatment for acute laryngitis (< 2 weeks)?

- voice rest (decrease talking time) (could never be me)

- hydration

- humidifier

- reassure patient that this is viral and generally heals in 1 week (follow-up if persists)

- antibiotics do NOT hasten recovery time or aid voice recovery and should only be used if OTHER bacterial infection is suspected (ex: sinusitis, strep, pneumonia)

what should we do with EVERY patient who has laryngitis OR hoarseness OR throat pain for more than 2 weeks with no identifiable cause?

refer to ENT for complete evaluation of voice quality, through examination of the head and neck and visualization with indirect laryngoscopy with a mirror or transnasal/transoral laryngoscopy (must visually inspect throat)

what is the treatment for nodules and polyps on the vocal cords?

- polyps are frequently removed surgically

- nodules are treated with alteration of voice habits that caused them

what is the treatment for chronic laryngitis?

treat underlying cause:

- voice rest if underlying condition causing edema of the vocal cords

- PPIs if GERD is cause

- antibiotics for chronic sinus drainage

- voice therapy/training

what is the work up/treatment for suspected laryngeal cancer?

1. refer to ENT

2. CT +/- PET

3. surgical resection and radiation therapy

what is the treatment for suspected head/neck cancer?

- regimens vary based on cancer stage

- treatment managed by oncologist, interventional radiologist, dietician

- may include surgery, chemo + radiation, radiation alone (chemo avoided in patients > age 70)