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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