Logan Class of December 2011
EENT – 5/21/08
Eustachian tube functions to aerate the middle ear helping to equate pressure between middle ear and external environment. When you pop your ears, air enters the inner ear and heads to the middle ear via the tube. This can cause popping of the ear drum. When the tube is narrow and swollen, too much pressure can cause dizziness due to the overflow of pressure.
Eustachian Tube Dysfunction
Defective middle ear drainage – Typical to children with URT infections
Eustachian tube dysfunction resulting in defective middle ear ventilation. This can be due to a variety of causes and results in a middle ear effusion. Viruses tend to affect all the cells in one area. Eustachian tube can swell up and if it swells it can’t open up. There will be build up of air and fluid. If the air can’t leave the tube, the locked in air is removed by perfusion of the middle ear. The capillaries suck out the air. There will be a decrease in pressure and retraction of the ear drum.
Serous fluid stuck in the middle ear can be problematic.
In the early stages, the ear drum may present as sucked in medially. The pars flaccida will not move (become immobile). This will lead to hearing loss, since the pars flaccida should move.
Light reflex should be anterior and inferior.
Middle Ear
Eustachian Tube
Increased Sound: Impedance matching device sound energy air --- fluid…Sound waves are amplified. During vibration the ossicles move helping to amplify sound up to 20x. Conductive hearing sounds can affect the tympanic membrane and the ossicles causing loss of amplification of sound.
Tympanic membrane and 3 ossicles (malleus, incus – middle, stapes – contacts oval window)…The oval window is smaller and there will be more pressure
Two small muscles: stapedius (CN #7) and tensor tympani (CN 5)
Ear Drum
The color is not very important as the orientation of the ear drum. Bulging vs. retracted vs. conformed.
Red eardrum is called erythematous.
Look for the reflex – light (ant. and inferior)
Check for mobility of the ear with an otoscope attachment (bulb attached to tube and you pump air to check for movement of the eardrum.) Mobile eardrum is healthy meaning aeration and healthy Eustachian tube.
Normal Ear Drum
Cones shaped ear drum tightly suspended. Handle and short process of malleus visible. Light reflex ant. and inferior from the umbo. TM is mobile. Non-erythematous
Ear Drum Problems
2. OME: Sterile, noninfectious secretory otitis media, secondary to a viral URTI…accumulation of body fluid in the ear. Fullness with mild hearing loss due to Eustachian tube occlusion and absorption of air…Prominent appearance with retraction of ear drum …The manubrium appears shorted and more horizontal
3. Pathological AOM
This is a pathological condition with thickener, red, erythematous ear drum with radiating red vessels towards the center. There is increased blood pressure in the area. There is lateral bulging of the ear drum... There is an increase in pressure in the ear. The ear drum can be painful…An acute bacterial infection of the middle ear secondary to a viral URTI, often after OME. Bulging ear drum, pus accumulation in the middle ear, thickened eardrum with erythema, distorted/absent light reflex. May lead to TM perforation or rare complications. Check mobility of the ear drum…It may be immobile due to the bulging of the eardrum
4. Ruptured eardrum (AOM)
It looks worse with a hole and drainage of pus in the ear canal. Mobility can actually occur, because the eardrum is not so tensely attached and it will flicker.
5. Normal TM
Malleus (short process and handle), Cone of Light, Incus, Pars Tensa, Pars Flaccida, Umbo
Acute Otitis Media
Red Bulging, TM, hyperemia, dullness of light reflex
Serous OM = OME
Cerumen in EAM (ext. auditory meatus)…Too much earwax attaches to the wall and cause conductive hearing loss. Some people may have more conduction of it. It is important to get rid of it to be able to take a look at the eardrum. Eardrops can be used. Patient may soften cerumen first using carbamide peroxide/glycerin drops and then repeatedly irrigate with water with a rubber bulb. Ear wax is typically yellow and it doesn’t have definite surface. At the ENT office: Removal of ear wax with irrigation or manual removal with curette.
Bullous Myringitis
A bulla is a “big blister” with bulging of ear drum. The think skin near the drum is stretched out and very painful. Bullous Myringitis is inflammation of the ear drum (myringitis) with bulla (blister). Usually results from viral infection (idiopathic virus) by painful bulging or may accompany AOM
TM Perforation
Usually results from purulent middle ear infection (AOM). The eardrum typically heals by itself. This condition is more common in children. This condition may also occur due to traumatic perforation (ore common in adults). Ex.—Q-tip inserted in the ear way too deep.
Tympanostomy tubes are like artificial perforations when put in. Chronic infections lasting for long times with possible hearing loss are indications to put in the tubes. These tubes are surgically inserted in children with series of otitis medial. The major goal is preventing conductive hearing loss.
EENT – 5/29/08
Common URTI symptoms and Signs
Rhinitis: Swelling of nasal mucosa and obstruction
Conjuctivitis
Coryza: runny nose and eyes
Rhinorrhea: nasal drainage
Pharyngitis
Tonsillitis
Earache (mild with some popping)
Dysphagia: difficult to swallow
Sore throat: odynophagia
Cough
Hoarseness
Fever
Fatigue
Malaise
Abdominal pain
Vomiting
Diarrhea
Mouth Breathing
Why distinguish between viral and bacterial infection?
Bacterial infections tend to spread
Bacterial infections may cause severe complications (more so than viral)
Diagnostic means available for bacterial and viral infections
Effective antibiotic tx. Is still effective for bacterial infections
Risk of over-prescirption and over-consumption of antibiotic
Restrict use of antibiotics
How do we tell the difference between viral and bacterial infections?
Diversity of symptoms
Many symptoms = viral infection, generally spread in the whole URT/pharyngeal mucosa vs. bacterial infections which colonize to 1 local site only
If cough = viral infection (just a cough)
One dominant symptoms = bacterial infection (ex. Severe temperature rise)
Degrees of pharyngeal erythema…intense erythema = bacterial infection (not always)
Purulent discharge (yellow/green/brown) = b bacterial infection
Exudates on tonsil = bacterial infection (dots on the tonsils, white or yellow, seen mostly in bacterial infections)
Strep Throat
Intense redness in throat…Uvula swollen…Uniform redness…Tonsils Enlarged…Spots on the Tonsils with exudates (pus stuck in tonsil crevasse)...pain
How do we tell the difference?
Patient gets worse
1. Fever spike and new symptoms = secondary bacterial infection
CBC findings = neutrophilia = bacterial infection
Lymphocytosis = Viral Infection
Increase CRP = Acute Bacterial Infection (CRP reacts quickly to infection activity)…Chronic conditions may also show rise, but acute is a more pronounced rise.
Increase ESR: Chronic bacterial or viral infection (TB, osteomyelitis)
How do we tall the difference?
Rapid Streptococcal Antigen Test:
Group A Beta-hemolytic Streptococcus (GABHS)
Specificity: Greater than 95 percents
Sensitivity 80-97% depending on the test
Bacterial Viral Cultures may be done
Serologic Tests (Increased titer of pathogen-specific antibodies (IgM, IgG)
Infectious Mononucleosis
Monospot test (rapid slide agglutination test for mononucleosis aka heterophile antibodies)
Overall sensitivity 86%
Overall Specificity 88%
First week: sensitivity 69%, specificity 88%
Second week: sensitivity 81% specificity 88%
Usually negative in children less than 6-8 years old
Serologic tests (increased titers of EBV-specific antibodies)
Strept Pneumoniae
G+ coccus
Habitat URT (endogen)
Causes: AOM, sinusitis, pneumonia, meningitis, conjunctivitis
Treatment: Penicillin, fights G+ cocci
Most common cause of acute meningitis in children (US)…Usually goes from the ear to the brain.
Hemophilus Influenzae
Gram – bacillus
Habitat: URT (endogen)
Causes: AOM (2nd most common), sinusitis (2nd most common), tonsillitis, pneumonia, chronic bronchitis
Capsulated form: H. influezae type B
Epiglotitis and Meningitis
Epiglottis: Swells up and can be dangerous…Typically occurs in a child and suffocate the child. The treatment can be a tracheotomy. They have a cherry red epiglottis
Epiglottis Pathology
HI type B: As a child gets older immunity can go away. Children are vaccinated early in life.
Strept Pneumoniae
GABHS
Candida
The presentation is quick obstruction of the URT and possible croup.
Croup is really parainfluenza virus. Originally it was though to be corynebacterium diptheriae. The para virus causes swelling of the upper bronchi. Diptheriae is very dangerous creating membranes that may suffocate the children. The para virus does not do this.
Brionchiolitis: Caused by RS virus and can be dangerous in children because of swollen smaller bronchioles.
Diptheria
Cause pseudomembranes that adhere to the mucosa going down the larynx and trachea. The pseudomembranes can then swell up and further constrict.
Epiglotitis
Bacteria
Caustic burns and trauma
High fever
Typically age 2-12
Inspiratory Stridor: hallmark for URT problems
As child inhales, they inhale into restriction and can present with chest retraction
Unable to talk: Because of pain and breathing struggles
Unable to swallow
Cherry red epiglottis
They can drool
Refer immediately (ambulance)
Croup-Laryngotracheobronchitis
Viral (parainfluenzae virus)
Common in the fall
After a cold/viral URTI
Sudden Inspiratory stridor
Barking Cough
Acute Airway Obstruction – especially infants
Tx: Fluids, most air, be calm, stories, lullabies, toys
Medication: Bronchodilateros, Glucocorticoids
When UAO: Refer with ambulance, intubation/tracheotomy
Acute Upper Airway Obstruction – Airway Collapse
Acute Bronchiolitis
Respiratory syncytial virus (RSV)
Common in the winter
Infection of respiratory and ciliated epithelial cells of the bronchioles
Mucus secretion and submucosal edema
Critical narrowing and obstruction of small airways
Hypoxia. Risk for respiratory failure
Age group: Infants 2-24 months
Tx: Supportive tx. O2 humidified air, chest clapping, rest, clear fluids, bronchodilators, glucocorticoids
Most deaths occur in infants under 6 months
EENT 6/12/08
Review Questions for Midterm
What is the most common cause of sore throat in adults?
Virus
What causes strep throat?
Palatine tonsil, bacterium, pharyngitis, screaming and/or smoking
What term means signs and symptoms?
Etiology, Age and gender, vital signs, earache, presentation
What is a common presentation of AOM?
Fever, Clear middle ear effusion, middle age patient, Streptococcus Pneumoniae
What is an example of a complication of AOM?
Strep throat, Eustachian tube dysfunction, bulging eardrum, mastoiditis
Strep throat can be a cause of AOM, not a complication
Mastoiditis is a complication, although it is a rare complication
Most cases of URTI are caused by?
Strep, Hemophilus Influenzae, Viruses
Which of the following are viruses?
Strep pneumoniae, Hemophilus influenzae, Staph, GABHS
Which of the following are viruses?
EBV, Rhinovirus, Hemophilus influezae GABHS, VAV, HSV, Adenovirus, Influenzae Virus
All except for GABHS
Which of the following are most often viral infections?
Epiglotitis, Strep Throat, Croup (laryngotracheobronchitis), Brionchitiolis, URTI
Croup is caused by para virus
URTI are most often viral
EENT REVIEW
*** Picture of AOM *** If redness goes to center of ear it indicates erythema. The light reflex is good in the ear, but erythema in the center indicates Otitis Media. You can treat this patient, but keep an eye on this patient. At this stage, you can check for mobility of the eardrum with a pump of air into the eardrum. NO mobility would indicate dysfunction.
*** Picture of tubes in the ear ***
*** Picture of tympanosclerosis….Three is bulging, blisters and tympanosclerosis….this indicates several bouts of OME. It may be chronic causing changes in the eardrum. There is intense pain and lack of mobility of the eardrum ***
*** Very red and bulging ear picture…Indicates AOM ***
*** Picture of Bell’s Palsy…A complication of AOM…***
*** Picture of Bacterial Infection of the tonsils….There is inflammation, possible cough, conjunctivitis, fever, hurts to swallow and has exudates on the mouth ***
*** Complication (purulent)…Picture of a puffy mass under the ear…A complication of strep with lymphadenitis ***
*** Picture of Kissing Tonsils…Kissing disease can be herpes or infectious mononucleosis. Exudates can form similar to those of strep throat. You can take a lab test for atypical lymphocytes. More than 10% in blood would indicate, mono along with a – test for strep, splenomegaly and liver enlargement. The lymph nodes may be enlarged in the mouth, axilla, clavicle, etc. ***
*** Odonophagia – Mild sore throat, sickness, tiny ulcers….Indicates a viral infection with possible herpangina ***
*** Picture of Herpangina – Small blisters of the mouth, hand, foot ***
*** Vincent’s Angina…Really bad cases may have bleeding ulcers on the tongue and mouth ***
Why doesn’t plain penicillin work as treatment for OME?
OME is caused by Eustachian tube dysfunction. Giving somebody antibiotics may cause resistant strains.
OME presents with?
Clear middle ear fluid (obstruction of tube causes accumulation of fever)….If a fever, it will be a low grade fever, not high grade.
What is typical for OME but not for AOM?
Both causes have Eustachian tube dysfunction and immobile of the TM. Both can show red eardrum or cause conductive hearing loss. Retracted TM (best choice).
Match the following conditions and complications?
Strep Throat – Endocarditis, Glomerulonephritis
Herpangina – Myocarditis
Scarlet Fever – Endocarditis, Glomerulonephritis
AOM – Perforated eardrum
Chronic OME – cholesteatoma
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