Ear Nose and Throat

Ear Nose and Throat Debbie King CFNP CPNP 8800

EARS • Otitis Externa- a painful inflammation of the membranous lining of the auditory canal and/or contiguous structures. • Refers to acute and chronic inflammatory process • It may be diffuse or localized • Is largely benign and self-limiting • Invasive otitis externa is potentially life threatening • Malignant OE-- now know as Necrotizing OE

EARS • OE continued • Epidemiology • 2-3 % of family practice office visit • 10-20% more common in the summer months • Patho- inflammation is most commonly caused by microbial infection. Colonization of the external ear is prevented immune and anatomic mechanisms

EARS • OE patho continued • Squamous epithelia of the canal constantly slough, while hair follicles sweep laterally, cleaning and act as a barrier. The canal maintains an acidic pH and repels moisture and the presence of normal flora inhibit the overgrowth of virulent bacteria. If any of this is broken compromised there may be colonization by bacteria

EARS • OE patho continued • Bacteria • Pseudomonas aeruginosa is most common of diffuse infections and most cases of invasive OE • Staphylococcus aureus typically causes a localized infection from a hair follicle • Streptococcus pyogenes associated with local infection presenting as folliculitis • Polymicrobial infection found in up to 1/3 of cases of diffuse disease

EARS • OE patho continued • Other causes of OE • Fungal agents • Aspergillus niger- usually local infection, but can cause invasive infection • Pityrosporum • Candida albicans • Hyperkeratotic processes • Eczema, psoriasis, seborrheic, or contact dermatitis

EARS • OE • Necrotizing Otis externa is the most severe infectious form of OE • Bacterial infection extends from the skin of canal into soft tissue or bone • Cranial nerves may be involved • Pseudomonas is most common • May have bad outcomes!

EAR • OE • Presenting complaints • severe ear pain (otalgia) of sudden or acute onset • Pain worse at night • Worse with pulling on the pinna or earlobe or pushing on tragus • Severe cases- pain with chewing • May have purulent discharge may be noted • Chronic OM • May present with dryness and itching

EAR • OM • Physical findings • Tenderness with palpation • Otoscopic exam- canal appears swollen and red with drainage with bacterial infections • Diffuse cases present with complete involvement • Localized cases present with focal lesion • Pseudomonas produces a copious green exudate • Staphylococcal produces yellow crusting in purulent exudate • Fungal infections presents as a fluffy, white or black malodorous growth • Except in invasive disease there is no lymphadenopathy • TMJ pain indicates invasive disease

EAR • OE • Diagnostic testing • Rarely needed • Cultures may be done of discharge if indicated in healthy patients • CT or MRI may be needed if suspect invasive disease

EARS • OE • Differential DX • OM • TMJ • Dental disease • Trigeminal or glossopharyngeal neuralgia • Parotitis • Impetigo • Herpes zoster • Insect bites • Mastoiditis • Rupture of membrane • Excessive cerumen buildup (wax)

EARS • Management and Treatments • Pain meds • Heat or ice • Keep dry- no swimming ECT… for 7 days • Treatment for basic OE • Irrigation if indicated • Pain drops • Antibiotic drops • Ciprodex, Floxin Cortisporin • May need a wick if very swollen

EARS • Otitis Media- OM- inflammation of the structures in the middle ear. • Otitis media with effusion –OME involves the transudation of plasma from middle ear blood vessels leading to chronic fluid; this can be chronic • Acute Otitis Media-AOM is infection in the middle ear

EARS • OM • Epidemiology • Accounts for 2-3% of all family practice office visits. Number of visits increases in the winter. More common in colder weather and in children. • Contributing factors include; allergies, rhinitis, pharyngitis due to swelling of upper airway membranes. Most common factor is upper airway infections (colds), caused by many different viruses. • Influenza, RSV, pneumovirus, adenovirus

EARS • OM • Patho-bacterial infection (or viral) by nasopharyngeal microorganisms follows eustachian tube dysfunction in which the isthmus becomes obstructed. Inflammation results in response to the bacterial products such as endotoxins, creating infection behind the tympanic membrane in the middle ear

EARS • OME • Patho- caused by collection of plasma fluid from engorged blood vessels resulting from the loss of Eustachian tube patency, either from swelling of the lining or direct blockage • Pathogens • Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis are most common. Less common are streptococcus pyogenes and aureus • Up to ½ are viral

EARS • OME symptoms • Stuffiness, fullness, decreased hearing, pain is rare, may have popping. Rarely vertigo • Usually a history of recent URI, allergies • Remember the great photos provided in the therapeutics lectures on OM

EARS • AOM- symptoms • Deep pain, fever, sometimes decreased hearing, discharge with a perf, sometimes dizziness or ringing in the ear • Recurrent AOM means there is clearing of the infection between episodes • Chronic OM- presents with history of repeated bouts of AOM followed by effusion with hearing loss being the biggest concern

EARS • Objective • OME- mucous membranes of nose and mouth red/swollen, with recent history of URI. TM may be dull • AOM- yellow-orange, maybe fiery red and bulging with an area of yellow noted. Bone landmarks and cone of light are not seen. Grayish/white collection of tissue on or behind the TM may be a cholesteatoma. There may be adenopathy of the preauricular and/posterior cervical. With an infected ear and pain at the mastoid bone- more work up may be needed

EARS • Diagnostic Tests • Tests are rarely needed. Should use pneumatic otoscopy. Tympanogram may be helpful otitis with effusion. Cultures are rarely done, but are helpful. X-ray or CT of sinuses or of mastoid area maybe indicated. CBC with severe illness maybe indicated. Hearing tests are needed in some cases or at follow-up

EARS • Differentials for OM • OE • Barotrauma • TMJ • Mastoiditis (always with AOM) • Cerumen impaction • Parotitis

EARS • Otitis Management/Follow-up • OM • If over 2 years, watchful waiting for three days • If present longer than three days treat for most common organism • Recheck children in 2-3 weeks, adults if pain or other symptoms return • OME • Watchful waiting is indicated, recheck every 4-6 weeks for 3-4 months • Steroids are sometimes used for 7 days • Nasal steroids used more often for 3 months • Rarely an antibiotic is tried

Rhinitis • Rhinitis or coryza –inflammation of the nasal mucosa with congestion, rhinorrhea, sneezing, pruritus, post nasal drip • Allergic • Seasonal or perennial • Nonallergic • Infectious, irritant related, vasomotor, hormone-related, associated with medication, or atrophic • May be chronic or acute • Most common types • Viral • Perennial (hay fever)

Rhinitis • Epidemiology/Causes • Actual prevalence is undocumented, but is very common • Occurs at least as much as the common cold • Estimated 40-50 million American adults suffer • Seasonal allergic rhinitis parallels pollen production fall/spring • Allergic occurs in all age groups • Most common in adults 30-40 years • Non allergic rhinitis may be acute or chronic • Chronic maybe associated with bacterial sinusitis

Rhinitis • Epidemiology/Causes • Atrophic rhinitis affects older adults, but symptoms may begin in the teens • VIRAL URI’s are more frequent in families with young children • Exposure to offending allergens is the main risk factor of allergic rhinitis • Vasomotor rhinitis is aggravated by low humidity, sudden temperature or pressure change, cold air, strong odors, stress, smoke • Certain drugs may precipitate rhinitis- ACE, beta-adrenergic antagonists, some anti-inflammatory agents, even asa

Rhinitis • Rhinitis Patho • Viral • Viral replication in the nasopharynx with varying degrees of nasotracheal inflammation. Associated with viral upper respiratory tract infection (COLD) • Etiologic agents • Rhinovirus, influenza, parainfluenza, respiratory syncytial, coronavirus, adenovirus, echovirus, coxsackievirus • Most rhinosinusitis is viral • Bacterial super-infection rarely occurs

Rhinitis • Rhinitis Patho continued • Allergic rhinitis • results from immunoglobulin E (IgE) mediated type I hypersensitivity to airborne irritants affecting the eyes, nose, sinuses, throat, and bronchi • IgE antibodies bind to eosinophils and basophils in the bloodstream and the mucosal mast cells. These leukocytes degranulate, releasing chemo inflammatory substances including histamine, leukotrienes, prostaglandin's, slow-reacting substance of anaphylaxis, and erythrocyte chemotactic factor, resulting in increased vasodilatation, capillary permeability, mucus production, smooth muscle contraction and eosinophilia- wow that sounds BAD • May also be caused by food allergies

Rhinitis • Rhinitis Patho continued • Vasomotor rhinitis is chronic, noninfectious process of unknown etiology without accompanying eosinophilia, characterized by periods of abnormal autonomic responsiveness and vascular engorgement unrelated so specific allergens • Causes include- hormonal changes, medication overuse, bacterial infection-which can cause atrophic rhinitis

Rhinitis • Rhinitis – symptoms • Viral-malaise, HA, substernal tightness, rare fever, sneezing and coughing • Allergic-itching of all upper air way mucosa, watery eyes, sore throat, sneezing, coughing • Vasomotor-watery nasal discharge, nasal speech, mouth breathing, nasal obstruction that switches sides

Rhinitis • Rhinitis –objective findings • Viral- nasal mucosa appears erythematous, throat will appear erythematous and edematous, external nose may appear erythematous, with a crease across the nose (allergic salute). May have swollen turbinates and tonsils. On palpation, the nasal mucosa appear friable. • With a secondary bacterial infection the discharge may be green/yellow – in adults only!! Color is children does not matter!!

Rhinitis • Allergic – mucosa are pale, boggy (swollen) and may look bluish. Yellowish, gray or red mucosa may also be seen. Polyps of various colors may be seen with chronic perennial rhinitis. Conjunctivae are inflamed with palpebral conjunctiva and cobble-stoned in appearance. Dark circles under the eyes (allergic shiners) may be seen. Wrinkles across the bridge of the nose may be seen.

Rhinitis • Vasomotor rhinitis- nasal mucosa will be anywhere from bright red to bluish with swollen turbinates • Atrophic rhinitis appear crusted with dried mucus or blood from repeated bouts of epistasis.

Rhinitis • Rhinitis testing • Not usually indicated • CBC- may show • Eosinophilia in allergic rhinitis • IgE and skin testing for allergic • Atrophic may be confirmed by biopsy • Usually diagnosis is made on history and exam

Rhinitis • Rhinitis differentials • Sinusitis • Foreign body • Nasal polyps • Deviated septum • Cocaine snorting, inhalant abuse • Sarcoidosis • Hormonal changes • Thyroid disease

Rhinitis • Rhinitis treatments • Centers on • relieve of symptoms • Self care measures • Environmental issues • HA- acetaminophen • Rhinorrhea- decongestants • Coughs -dextromethorphan ? , Or codeine

Rhinitis • Treatments continued • Allergic rhinitis • Avoid the triggers • Antihistamines • Allegra, Claritin, Clarinex, Zyrtec, Astelin • Nasal steroids • Flonase, Nasonex, Nasacort • Leukotriene receptor antagonists • Singular • Desensitizing immunotherapy • Atrophic- bacitracin to nares, saline, irrigation

Rhinitis • Rhinitis follow up • Recheck as needed • Advise patient of possible complications and their symptoms to indicate need for follow up • OM, sinusitis, high fevers, restless sleeping, asthma, allergic attacks • Referral as needed to allergist for skin testing • Referral to an ENT as needed

Rhinitis • Rhinitis –patient education • Avoid exposures • People with URI, environmental irritants • Windows doors kept closed, use a HEPA filter air clearer, consider pets outside, clean for mold and dust mites, cover bedding for dust mites…dusting,….ECT..

Sinusitis • Sinusitis is an inflammation of the mucous membranes of one or more of the paranasal sinuses; frontal, sphenoid, posterior ethmoid, anterior ethmoid, and maxillary • Acute-abrupt onset of infection and post-therapeutic resolution lasting no more than four weeks • Subacute with a purulent nasal discharge persist despite therapy, lasting 4-12 weeks • Chronic, with episodes of prolonged inflammation with repeated or inadequately treated acute infection lasting greater than 12 consecutive weeks

Sinusitis • Epidemiology and causes • Frequency of colds accounts for the frequent occurrence of sinusitis. About 0.5 % of all colds are complicated by bacterial infection of one or more of the paranasal sinuses • Acute bacterial sinusitis accounts for 16 million visits a year • Chronic sinusitis is the most common chronic disease in the US

Sinusitis • Sinusitis – Patho • Vast majority of acute sinusitis are caused by the same viruses found in URI’s • Viral rhinosinusitis is most common • Which is the most common cause for acute bacterial sinusitis, from complications in about 2% • Sneezing sends fluid from the nares and nasal cavity into the sinuses which is a great place for microbial replication • The only reliable way of identifying causative organisms in acute sinusitis is direct sinus aspiration

Sinusitis • Sinusitis Patho continued • Pathogens • Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes, staph aureus

Sinusitis • Clinical presentation • Gradual onset of symptoms • Pain over the affected sinus, with increasing pain • Pain is worse with coughing • Area of pain corresponds the sinus affected • Develop over at least 2 weeks of URI symptoms • Nasal congestion, runny nose, pressure, cough, sore throat, eye pain, malaise, and fatigue, headache, cough, fever

Sinusitis • Sinusitis objective findings • Purulent secretions, red swollen nasal mucosa, purulent secretions from middle meatus • On palpation there is tenderness • Sinusitis testing • None is usually indicated • X-rays or CT’s may be very helpful • Shows air-fluid levels and more than 4mm of mucosal thickening • CBC to look for leukocyte elevation • Stains or cultures of mucus may be indicated • Allergy testing

Sinusitis • Sinusitis Differentials • Dental abscess • Migraine • Trigeminal neuralgia • Any of the – rhinitis • Viral URI • Sinusitis diagnosis • URI for 7 days plus two or more • Colored mucus, facial pain, headache, documented history, fever over 102, tooth pain

Sinusitis • Sinusitis Management • Remember this is usually VIRAL! • Supportive care is most helpful • Sinus rinse • Few meds are helpful • Sudafed, nasal spray, expectorants, • Rarely use steroids –po, or antihistamines • Localized sinus infections are self limited

Sinusitis • Sinusitis- management • Amoxil • Biaxin • Vantin • Omnicef • Levaquin • Augmentin • Ceftin • Cleocin • Review the therapeutic handouts

Sinusitis • Sinusitis follow up • Varies per provider • With increase symptoms recheck • If no better in 5-7 days recheck • With reoccurrence of symptoms shortly after completing medication • Complications to watch for • Visual changes, cellulites, severe fever, aphasia, palsy, seizures, altered mental status, osteomyelitis, swelling, meningitis, empyema, abscess

Sinusitis • Sinusitis patient education • Should focus on the worsening of symptoms • Avoid all contributing factors • Smoke, allergens, antihistamine • Increase fluids!

Pharyngitis • Pharyngitis and tonsillitis are generalized inflammatory process of both infectious and non infectious etiology • Most cases are viral and self-limiting • Most cases of pharyngitis are contagious • All cases of tonsillitis are contagious

Ear Nose and Throat