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©2018 MFMER | slide-1

ENT Anthony Mendez, MMS PA-CCarrlene Donald, MMS PA-C

Mayo Clinic ArizonaDepartment of Otolaryngology and

Head & Neck Surgery


No Disclosures


OBJECTIVES

• 1. Identify important anatomic structures of the ears, nose, and throat

• 2. Assess and treat disorders of the external, middle and inner ear

• 3. Assess and treat disorders of the nose and paranasal sinuses

• 4. Assess and treat disorders of the oropharynx and larynx

• 5. Educate patients on the risk factors for head and neck cancers


Otology


External Ear Disorders


External Ear Anatomy


Ear Canal Obstruction• Adults – Cerumen • Kids – Foreign bodies

• Hearing loss, ear fullness/pain, drainage (+/- malodor).

• Exam under microscopic otoscopy. Check for infection.

• Remove under direct visualization. Can try to neutralize bugs with mineral oil/lidocaine. Do not attempt to irrigate organic material with water. Treat infection with otic drops (Corticosporin/Ciprodex/Ofloxacin).


Seed sprouting in the ear canal


Cockroach


Fungal Ball


Acute Otitis Externa• aka Swimmer’s Ear

• Usually bacterial –P. aeruginosa or S. aureus

• Ear fullness, pruritis, drainage and tragal motion tenderness.

• Debridement and antibiotic drops (Corticosporin, Ofloxacin,Ciprodex)+/- otowick.

• Immunocompromised hosts at risk for malignant otitis externa (necrotizing invasive infection of the ear canal and skull base). Topical and oral antibiotics indicated.

• Ramsay-Hunt – herpes zoster oticus.


Chronic Otitis Externa• Fungal vs. Dermatologic

• Treat both with debridement

AND• Fungal infections -

Acidifying drops (Acetic acid) or topical antifungals (Clotrimazole).

• Dermatologic –Steroid creams/drops (Triamcinolone/Dermotic)


Middle Ear Disorders


Middle Ear Anatomy

Middle Ear

Ossicles:

Malleus

Incus

Stapes


Eustachian Tube Dysfunction

• Eustachian tube inflammation or blockage resulting in negative middle ear pressure

• Ear fullness, recurrent middle ear effusions, and hearing loss.

• Exam: Retracted tympanic membrane with prominent bony landmarks.

• Diagnosis made by clinical exam and tympanogram (Type C).

• Treat with corticosteroid nasal spray, allergy mgmt, decongestants, valsalvas and pressure-equalizing (PE) tubes for refractory cases.


Tympanic Membrane Perforation

• Most common cause is otitis media.

• Diagnosis is made by exam and supported bya tympanogram.

• Water precautions.• 95% resolve without

treatment. • Tympanoplasty for

refractory cases.


Otitis Media with Effusion• Serous Otitis Media• Persistence of fluid in the middle

ear space without infection.• Due to eustachian tube dysfunction.• Ear fullness and hearing loss

(“talking in a barrel”).• Clear to amber-colored fluid with

an air fluid level or bubbles.• Treat with observation (3 mos.),

topical nasal steroids or decongestants. PE tubes optional.

• Nasopharyngeal exam for any adult with persistent, unilateral middle ear effusion.


Acute Otitis Media

• Ear pain, hearing loss, fever.

• Red, cloudy, and bulging TM with poor mobility.

• Antipyretics, analgesics, decongestants +/- antibiotics x 7 to 10 days (1st line = augmentin) (2nd line = doxycycline or azithromycin). Myringotomy/PE tubes for recurrent OM.

• Middle ear infection <3 weeks in duration.• Usually viral – RSV, rhinovirus, influenza.• Bacterial - S. pneumoniae (most common), H. influenza, and

Moraxella.


Chronic Otitis Media• 3 or more episodes of otitis media in 6 months

or at least 4 episodes in 12 months.• Microbiology: Gram negative bacteria (Pseudomonas), Staph

aureus and anaerobes.• Can be due to chronic eustachian tube dysfunction,

cholesteatoma, or TM perforation.• CT temporal bone if concern for mastoiditis or a

cholesteatoma.• Obtain cultures if possible. Treat with systemic abx

(quinolones). Debride any otorrhea. Start otic drops (ciprodex) if TM perforation or otorrhea.

• Chronic suppurative OM – “chronically draining ear” –differential should include a cholesteatoma.


Mastoiditis• Inflammation and/or infection of the mastoid air cells.

• Inflammation: Asymptomatic with normal exam.

• Infection: Fever, ear pain, post-auricular tenderness, malaise, otorrhea, etc.

• Diagnose with CT head and cultures if available.

• Refer to ENT. May start empiric oral antibiotics if immuno-competent. Mastoidectomy and consideration of IV antibiotics if recalcitrant disease or immunocompromised.

• Complications – abscess, osteomyelitis, meningitis, hearing loss, venous sinus thrombosis, etc.


Inner Ear Disorders


Inner Ear Anatomy


Audiogram


Tympanogram

• Type A – normal middle ear function.

• Type B – restricted TM mobility.

• Type C – negative middle ear pressure.


Hearing Loss

•Three types: •1. Sensorineural Hearing Loss •2. Conductive Hearing Loss •3. Mixed Hearing Loss


Acute Sensorineural Hearing Loss

• Sudden onset of hearing loss with or without dizziness. ≥10dB loss in ≥3 consecutive frequencies.

• Etiology: Viral, autoimmune, drug-induced ototoxicity, acoustic neuroma, vascular insult.

• Confirm diagnosis with audiogram.

• MRI brain/IAC with and without contrast.

• Treat empirically with oral steroids (prednisone 60mg/day x 7 days). Follow up with ENT after completing medications with repeat audiogram.


Tinnitus

• Perception of sound, in the absence of an external source.• Ringing, waves, “whooshing”, wind, buzzing, chirping, etc.• Continuous or intermittent, unilateral or bilateral• Typically associated with high frequency sensorineural hearing loss

• Evaluation: Audiogram

• Treatment: Patient education, bio-feedback, masking

• Unilateral Tinnitus: MRI brain and ENT referral

• Pulsatile Tinnitus: MRA/MRV head and neck and ENT referral


Benign Paroxysmal Positional Vertigo

• Vertigo lasting a few seconds to one minute, initiated by head movement, +/- nausea, no hearing loss.

• Diagnosis: Dix-Hallpike

• Treatment: Canalith repositioning using Epley Maneuver.


Vestibular Neuritis• Spontaneous vertigo lasting hours to days, + nausea,

without hearing loss.

• Acute onset after URI, slow recovery over 6-8 weeks.

• Diagnosis: Clinical presentation, vestibular testing to confirm peripheral vestibulopathy.

• Treatment: Consider oral corticosteroids (prednisone 60mg/day x 7 days) if diagnosed within 72 hours. Lower dose and duration of anti-emetics and vestibular suppressants (anti-histamines/benzos).


Vestibular Labyrinthitis• Vertigo lasting hours to days, with hearing loss +/-

tinnitus.

• Acute onset after URI, slow recovery over 6-8 weeks.

• Diagnosis: Clinical presentation. Audiogram to confirm hearing loss. Vestibular testing to confirm peripheral vestibulopathy. MRI brain/IAC.

• Treatment: Oral corticosteroids and symptomatic treatment as above. Follow up with ENT after completing medications with repeat audiogram.


Meniere’s Disease• Endolymphatic Hydrops

• Episodic vertigo lasting minutes to hours, hearing loss, tinnitus, ear fullness.

• Recovery between episodes may be incomplete, resulting in a progressive hearing loss.

• Treatment: Low salt diet (<1500mg/day), diuretics (maxzide), and vestibular rehabilitation for maintenance. Vestibular suppressants, anti-emetics, and oral corticosteroids for acute exacerbations. Destructive procedures (IT gentamicin, neurectomy, labyrinthectomy) for refractory cases.


Rhinology


Nasal Disorders


Nasal Anatomy


Nasal Anatomy cont…


Nasal Foreign Body

• Children

• Unilateral, malodorous, and purulent nasal discharge

• Remove under direct visualization


Allergic Rhinitis

• Seasonal vs. Perennial

• Paroxysms of sneezing, nasal obstruction and rhinorrhea

• Nasal crease (“allergic salute”), clear rhinorrhea, boggy nasal mucosa, and periorbital puffiness (“allergic shiners”)

• Diagnosis: Allergy testing

• Treatment: Allergy avoidance, saline irrigations, oral antihistamines, topical antihistamines, topical glucocorticoids, and immunotherapy


EpistaxisAnterior vs. posterior bleeds

Kiesselbach’s Plexus (convergence of vessels on the anterior septum) - most common site

• Chronic epistaxis in kids: r/o juvenile nasal angiofibroma (most likely they’re nose pickers!)

• Risk factors: dryness, trauma, nasal sprays, anticoagulants, structural deformity

• Treatment options include simple control (apply topical vasoconstrictor and hold pressure), cauterization (silver nitrate), nasal packing, embolization and surgery


Sinus Disorders


Sinus Anatomy

CT sinuses – Coronal View


Acute Sinusitis (Rhinosinusitis)• Inflammation and infection of the paranasal sinuses lasting

7 days to 4 weeks.

• Viral (98%) vs. Bacterial (2%). S. pneumo, H. influenza and M. catarrhalis.

• Nasal congestion, discolored nasal discharge, and facial pressure, +/- teeth pain.

• CT sinuses = gold standard diagnostic tool. Cultures if available.

• Treat viral symptomatically. Treat bacterial with saline irrigations and intranasal steroids, add antibiotics (Amoxicillin/Augmentin – 1st line) (Doxycycline – 2nd line) if symptoms persist >7 days


Chronic Rhinosinusitis• >12 weeks

• Staph aureus, Pseudomonas

• 4 cardinal signs/symptoms:• facial pressure• nasal obstruction• mucopurulent nasal discharge• anosmia (cough in children)

• 3 subtypes:• CRS without nasal polyposis (60-65%• CRS with nasal polyposis (20-33%)• Allergic fungal rhinosinusitis (8-12%)


Chronic Rhinosinusitis

• Treatment goals• Control of mucosal inflammation• Maintain sinus ventilation and drainage• Treatment of micro-organisms• Reduce number of acute exacerbations

• Treat with culture-directed antibiotics, intranasal and systemic glucocorticoids and saline flushes. Surgery for cases refractory to medications.

• Refer to ENT for nasal endoscopy, CT scan, cultures if available. Patients require long term follow up in specialty setting for optimization of their condition


Fungal Sinusitis

• Three types:• Allergic fungal sinusitis - Immunocompetent

patients. Allergic reaction to mold spores. Presents in bilateral nasal and sinus cavities.

• Fungal ball – aka mycetoma. Immunocompetent patients. Growth of fungal debris usually within a single, isolated sinus cavity.

• Invasive fungal sinusitis – Immunocompromisedpatients. Angioinvasion of nasal and sinus tissues leads to rapid necrosis. Surgery and reversal immune status is essential in treatment.


Laryngology


Epiglottitis• H. influenza

• Leaning forward (tripod sign), fever,

drooling, and stridor.

• Thumb sign on

lateral neck x-ray

• Be prepared for

intubation!


Laryngitis

• Inflammation of the laryngeal mucosa• Acute causes include viral infection, vocal

abuse, trauma, and inhaled toxin exposure• Chronic causes include GERD, voice misuse,

allergies, and smoking• Treatment depends on cause. Send to ENT for

direct laryngeal exam if hoarseness >3-4 weeks


Croup• Laryngotracheobronchitis

• Parainfluenza Virus

• Common in children

• “Barking seal” cough, stridor, hoarseness, and fever

• Steeple sign on AP neck Xray

• Be prepared for intubation!

• Treatment: IV steroids and O2 (if sats less than 92%). Consider nebulized epinephrine if signs of stridor or chest retractions


Oral Cavity/Oropharyngeal Disorders


Aphthous Ulcers• Simple or Complex aphthosis

• Simple: several episodes per year lasting up to 2 weeks, limited to oral mucosa

• Complex: may involve both oral and genital mucosa, larger (>1cm), 4-6 weeks to resolve (rule out Behcet syndrome)

• Multiple etiologies: viral, nutritional, autoimmune, trauma, food allergy, emotional stress

• Painful, round/oval, shallow ulcer with yellow-gray fibrinous center and erythematous rim

• Treatment is conservative – Ulcers usually will resolve within a week. May use topical analgesics vs steroids (kenalog with orabase)


Oral Candidiasis• a.k.a. thrush

• Candida albicans

• Pain, slight bleeding, loss of taste, etc.

• Exam reveals mucosal erythema and white patches. Lesions may bleed when scraped

• Common in immunocompromised patients (babies), after antibiotic use or with use of corticosteroid inhalers.

• Treatment:• topical antifungals

• Clotrimazole troches• Miconazole buccal tablets• Nystatin swish

• If refractory, fluconazole 200mg loading dose, then 100-200 daily for 7-14 days


Oral Leukoplakia

• “white patch”

• Most common pre- malignant lesion of the oral cavity. Represents cancer until proven otherwise with biopsy

• Usually due to chronic irritation (tobacco)

• Follow closely for malignancy transformation


Acute Pharyngitis and Tonsillitis• Etiology: mostly viral, Group A strep most

common bacterial cause.

• Sx: Fever, sore throat, odynophagia.

• Si: Red swollen and exudative

tonsils, cervical lymphadenopathy,

and halitosis

• Culture (gold standard) vs Rapid Strep (RSAT)

• Antibiotics (for + GAS culture): 1st line Penicillin/Amoxicillin

• PCN Allergic: Cephalosporin (if mild allergy), Macrolide or Clindamycin


Peritonsillar Abscess• Extension of a tonsil

infection into the retro-pharyngeal space

• Drooling, trismus, fever, soft palate asymmetry and “hot potato voice”

• I&D, IV hydration and antibiotics

• Augmentin• Clindamycin

• Surgery “Quincy Tonsillectomy”


Other ENT andHead & Neck Stuff


Parotitis• Inflammation and/or infection of the parotid glands

• Acute – Staph aureus. Treat with warm compresses, massages, sialogogues, hydration, and antibiotics (Augmentin; Clindamycin).

• Chronic – Usually secondary to systemic disease (Sjogren’s), dry mouth from medications, radiation/surgical scarring, and obstructive salivary duct stones. CT scan to check for stones or tumor.


Oropharyngeal Papilloma


Hairy Tongue


Tongue Cancer


Vocal Cord Nodules“singer’s nodules”


Vocal Cord Polyp


Thank You!


Post-Graduate PAFellowship in ENT/Head and

Neck Surgery

• 12 month: October-September• 2 fellows/year• Contact: [email protected]• http://www.mayo.edu/mshs/careers/physici

an-assistant/physician-assistant-fellowship-otolaryngology-arizona

mailto:[email protected]

http://www.mayo.edu/mshs/careers/physician-assistant/physician-assistant-fellowship-otolaryngology-arizona

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