ENT

Tympanic membrane (TM) function

To transmit sound from the external environment to the middle ear.

Regions of the tympanic membrane (TM)

Pars flaccida (fragile, two layers) and pars tensa (robust, three layers).

Pressure maintenance in the middle ear

Maintained by constant air absorption through the mucosa and reaccumulation via the Eustachian tube.

Eustachian tube collapse s/s

pain

Weber test purpose

To compare bone conduction between ears to differentiate the type of hearing loss.

Interpretation of Weber test

Sound louder in affected ear
→ conductive loss; louder in unaffected ear
→ sensorineural loss.

Rinne test purpose

To compare air versus bone conduction hearing loss

Interpretation of Rinne test

Air > bone = normal or sensorineural hearing loss; bone > air = conductive hearing loss.

Common causes of conductive hearing loss

Wax impaction, TM rupture, ossicular damage, or middle ear fluid.

Common causes of sensorineural hearing loss

Cochlear or nerve damage, or central nervous system pathology.

Symptoms of cerumen impaction

Ear fullness, otalgia, nausea, vertigo, disequilibrium, and hearing loss.

When to treat cerumen impaction

When patients experience pain, hearing loss, vertigo, or disequilibrium.

Contraindications to ear irrigation

TM perforation, myringotomy, absent TM, or active infection.

Treatment for cerumen impaction

Soften with Colace for 10–15 minutes, then irrigate using a 10cc syringe with an 18g needle and warm water.

Warning during irrigation of cerumen

Possible nausea and vertigo during the procedure.

Why avoid Q-tips in ear care

They stimulate more cerumen production.

Common symptoms of an ear foreign body

Ear pain, buzzing, and a crawling sensation.

Method for removing live insects from the ear

Lay the patient on the unaffected side and instill mineral oil or alcohol to kill the insect.

Methods for removing foreign bodies from the ear

Irrigation, Dermabond (cyanoacrylate), magnets, curettes, suction, or forceps.

Substance that dissolves Styrofoam foreign bodies

Ethyl chloride.

Common causes of a ruptured tympanic membrane

Diving, explosions, barotrauma, slap injury.

Symptoms of a ruptured tympanic membrane

Sudden otalgia, tinnitus, conductive hearing loss, vertigo, nausea, bleeding.

Type of hearing loss from TM rupture

Conductive hearing loss.

Treatment for ruptured tympanic membrane

Cotton pledget, avoid water, oral analgesic, and ENT follow-up.

Use of antibiotics for ruptured TM

Only if infection is suspected.

Symptoms of otitis externa

Ear pain, pruritus, whitish-yellow discharge, decreased hearing, red edematous canal.

Common causes of otitis externa

Swimming, trauma, hearing aids, earbuds, allergies, dermatitis.

Bacterial organisms associated with otitis externa

P. aeruginosa, S. aureus, E. epidermidis, Bacteroides, Peptostreptococci.

Treatment for otitis externa

Irrigate and suction warm water, insert pope wick, instill Cipro HC otic.

Follow-up for otitis externa

Re-evaluate 3–4 days or ENT follow-up; wick removed as swelling decreases.

Risk groups for necrotizing otitis externa

Elderly, diabetic, and immunocompromised patients.

Complications of necrotizing otitis externa

Osteomyelitis, nerve palsy, meningitis.

Causative organism of necrotizing otitis externa

Pseudomonas aeruginosa.

Pathophysiology of necrotizing otitis externa?

Invasive infection of canal and skull base
→ osteomyelitis/CNS spread.

Symptoms of necrotizing otitis externa?

Severe otalgia, profuse discharge, cellulitis, TMJ pain, facial palsy.

Diagnosis of necrotizing otitis externa?

Clinical,
↑WBC/CRP, CT/MRI for bone or CNS.

Treatment for necrotizing otitis externa?

Ciprofloxacin and IV antibiotics; avoid steroids.

Definition of Otitis Media with Effusion (OME)

Middle ear fluid without acute infection or inflammation.

Treatments for severe or chronic OME

Myringotomy tubes.

Causes of OME?

Post-AOM, barotrauma, allergy, ETD, rarely nasopharyngeal CA.

Symptoms (S/S) of OME?

Crackling sound, aural fullness, conductive HL, dull TM with visible fluid, no erythema.

Treatment (Tx) for OME?

Auto-insufflation, phenylephrine/oxymetazoline nasal spray q4h, fluticasone 50 mcg 2 spr BID, pseudoephedrine 60 mg QID.

Definition of acute otitis media (AOM)

Acute middle ear infection with effusion and mucosal inflammation.

Most common pathogens for AOM

H. flu, GAS, S. aureus, M. catarrhalis.

Symptoms of acute otitis media

Unilateral otalgia, fever, decreased hearing.

How is AOM diagnosed (Dx)?

Clinical.

Treatment (Tx) for AOM?

Amox 500 mg BID; if PCN allergy

→ Cefdinir 300 mg BID, Cefpodoxime 200 mg BID, Cefuroxime 500 mg BID, or Ceftriaxone 2 g IM/IV x1.

Supportive treatment for AOM

NSAIDs or Tylenol.

Complications of AOM

Mastoiditis, facial paralysis, labyrinthitis (vertigo), otic meningitis, epidural abscess.

Definition of mastoiditis?

Infection of mastoid air cells after AOM
→ pus and bone erosion.

Symptoms of mastoiditis?

Tender, red mastoid with fever after ear infection.

Diagnosis of mastoiditis?

Clinical,
↑WBC/CRP, CT with contrast.

Treatment for mastoiditis?

Admit, ENT consult, IV antibiotics.

Mechanism of nasal bone fracture?

Direct blow to nose from sports, falls, or trauma.

Structures to assess with nasal fracture?

Head injury, C-spine, orbits, zygoma, maxilla, mandible.

Clinical signs of nasal fracture?

Swelling, bruising, deformity, epistaxis, crepitus.

Complication of septal hematoma?

Must be drained to prevent necrosis.

When to suspect CSF leak?

Halo sign or high glucose in nasal drainage.

Treatment for nasal fracture?

Ice, elevate HOB, avoid sports 6 weeks, nasal spray, ENT follow-up.

Antibiotic for open nasal fracture or laceration?

Cephalosporin.

Most common site of anterior epistaxis?

Kiesselbach’s plexus.

Posterior epistaxis source?

Sphenopalatine or carotid artery.

Common causes of epistaxis?

Nose picking, dry air, rhinitis, trauma, anticoagulation.

Who is high risk for epistaxis?

Anticoagulated patients, bleeding disorders.

Does hypertension cause epistaxis?

No, but prolongs bleeding.

Post-treatment note for nasal packing?

Possible tear duct bleeding; antibiotics if packed.

Define sialolithiasis

Stone in salivary duct, most commonly in the submandibular gland.

Presentation of sialolithiasis

Unilateral swelling and pain with eating.

Who gets sialolithiasis?

Older men.

Causes of sialolithiasis?

Dehydration, diuretics, anticholinergics, gout, smoking, Parkinson’s meds.

Diagnosis of sialolithiasis?

CT scan.

How to treat sialolithiasis

Sour candy (e.g., lemon drops) and ENT removal if no relief.

Causes of pharyngitis

Viral (77%), bacterial, non-infectious.

Clinical symptoms of pharyngitis

Sore throat, odynophagia, fever, LAD, malaise.

Symptoms of pharyngitis?

Sore throat, odynophagia, fever, LAD, HA, congestion, rhinorrhea, cough, ear pain.

Diagnosis of pharyngitis?

Exam, rapid strep, or culture.

Why treat Group A Strep (GAS) pharyngitis

To prevent rheumatic fever and its complications.

Treatment for pharyngitis GAS+

Decadron, saltwater gargles, NSAIDs, penicillin, or amoxicillin.

Complications of strep throat?

Rheumatic fever, glomerulonephritis.

Signs of rheumatic fever?

Migratory arthralgia, subQ nodules, carditis.

Signs of post-strep GN?

AKI, edema, hematuria, HTN.

Treatment for pharangits negative for GAS

Supportive care only — use Decadron for swelling, saltwater or pickle juice gargles, NSAIDs or acetaminophen for pain/fever, and ensure hydration and rest (no antibiotics needed).

Symptoms of peritonsillar abscess?

Unilateral sore throat, “hot potato” voice, drooling, trismus, swollen tonsil, deviated uvula.

Diagnosis of peritonsillar abscess?

CBC, rapid strep, culture, CT neck with contrast.

Treatment for peritonsillar abscess?

IV fluids, analgesia, antibiotics (Unasyn or Clindamycin), needle aspiration or I&D, admit.

Complication of peritonsillar abscess?

Retropharyngeal abscess.

Cause of retropharyngeal abscess?

Untreated bacterial sore throat spreading to deep neck space.

Main risk of retropharyngeal abscess?

Airway compromise.

Sources of deep neck infections?

Mandibular teeth, parotids, middle ear, sinuses, FB.

Symptoms of retropharyngeal abscess?

Sore throat, fever, dysphagia, neck pain, pharyngeal edema, drooling, stridor.

Diagnosis of retropharyngeal abscess?

CBC, GAS swab, CT with contrast.

Treatment for retropharyngeal abscess?

Airway support, fluids, steroids, Unasyn or Clindamycin, ENT and anesthesia bedside.

Definition of Ludwig’s angina?

Life-threatening cellulitis of floor of mouth from dental infection.

Symptoms of Ludwig’s angina?

Fever, tachycardia, submental woody edema, dysphagia, dysphonia, SOB.

Treatment for Ludwig’s angina?

Airway management and IV antibiotics.

Cause of Ramsay Hunt syndrome?

Reactivation of VZV in geniculate ganglion of facial nerve.

Symptoms of Ramsay Hunt syndrome?

Unilateral facial droop, ear pain,
↓ taste, dry mouth/eye, vesicular rash.

Treatment for Ramsay Hunt syndrome?

Valacyclovir.

Definition of Lemierre’s syndrome

Rare, fatal complication of bacterial pharyngitis/tonsillitis

→ septic IJV thrombophlebitis.

Causative organism of Lemierre’s Syndrome?

Fusobacterium necrophorum.