1. Conductive

2. Sensory

3. Neural

2&3- "Sensorineural"

Obstruction- *cerumen impaction

Transient auditory tube dysfunction- respiratory illness

(Usually a temporary condition)

Cerumen impaction

S/Sx: Hearing loss, itching,

tinnitus, ear fullness, pain

Tx: cerumenex or dobrox, Water irrigation, Antibiotic drops

Cx: dizziness, pain, nausea, vomiting, otitis externa

- Chronic ear infections (otitis media)

- Trauma (blunt, penetrating, barotrauma)

- Otosclerosis- abn bone growth

- Cochlear deterioration- hair-cell loss

- CN8 lesions- acoustic neuroma, MS, cerebrovascular disease (CVA, TIA)

Acoustic neuroma, "vestibular schwannoma"

-rare, but most common brain tumor

-30-60yo pts

-Aminoglycosides (-mycin drugs)

-Loop diuretics- furosemide, bumetanide

-Chemotheraputics- cisplatin

Gradually progressive high-freq loss

Causes: aging, excessive noise exposure, head trauma, diabetes mellitus

Persistent abnormal ear or head noises

(ringing, rushing water, heartbeat, blowing)

Tx: avoid precipitants, PT, hearing aid amplification, tricyclic antidepressants (Notriptyline)

• Compares perception of sounds, as transmitted by air or bone conduction through the mastoid
• Unilateral loss, bone conduction greater than air conduction

• Spinning sensation, sense of stumbling, or a feeling of falling forward or backward.
• Sudden onset, inability to walk or stand, nausea/vomiting, tinnitus

What causes:

Peripheral vertigo

Central vertigo

Tx?

• Peripheral- disorders affecting the vestibular apparatus and CN8. Sudden.
• Central- disorders affecting the brainstem & cerebellum. Sudden or slow, more serious
• Tx: Diazepam/Valium

A mechanical disorder of the inner ear causing transient vertigo and nystagmus that is precipitated by certain head movements.

Cause?

• Benign paroxysmal positional vertigo (BPPV)
• Cause: Inappropriate activation of the posterior semicircular canal by free-floating particles (canalolithiasis)

• Diagnosis: Dix-Hallpike position test to induce horizontal nystagmus to affected side
• Tx: Epley maneuver, scopolamine, antihistamines

• Sudden onset- duration 20min-12h
• Nausea/vomiting
• Attacks 2-3/wk to several/month
• Assoc. w/: roaring tinnitus, dec hearing, ear fullness

• Glycerol induction- glycerol placed in inner ear
• Positive = temporary improvement in postural control w/ accompanied decrease in vertigo

• Antihistamines
• Diuretics (Triamterene, HCTZ)
• Ca channel blockers
• Intratympanic steriod injection

• Nystagmus that is elicited by pneumatic otoscopy
• Tx: Symptomatic- antihistamines
• Bed rest, ENT referral (surgical repair)

A sudden onset of severe vertigo that decreases rapidly within several days. Often accompanied by nystagmus, but rarely hearing loss. Thought to be associated with viral illness.

Tx?

• Vestibular neuronitis
• Tx: Antihistamines, antiemetic medications (promethazine/Phenergan)

Sudden onset of vertigo with accompanying tinnitus and hearing loss. 

Etiology?

Tx?

Labyrinthitis

Viral illness- measles, mumps

Bacterial- otitis media, mastoiditis, meningitis 

Viral- antihistamines, antiemetics

Bacterial- antibiotics

Otitis externa- *Moisture, trauma

• Pseudomonas aeruginosa (38-50%)
• StaphA
• Fungi- aspergillus, candida
• Psoriasis/eczema

• Ear pain- mild-severe
• Itching
• Purulent discharge
• Hearing loss
• Fullness or pressure (edema)
• Fever

• Pain with palpation
• Conductive hearing loss
• Edema & erythema in external canal
• Purulent discharge
• Scaling

• Drops- aminoglycoside, antibiotic, antiinflammatory - Fluoroquinolone- *cipro, Floxin otic
• Fungal-acidifying drops
• Don't usually need systemic antibiotics

• Acidifying drops (alcohol/vinegar mix- 50,25,25)
• Ear plugs while swimming
• No soap in ears

Malignant/necrotizing otitis externa

(Osteomyelitis)

Diabetics & immunocompromised 

Malignant/necrotizing otitis externa

Organism?

Symptoms?

Physical findings

Tests?

Tx?

• Pseudomonas aeruginosa
• Persistant, foul discharge, deep pain, headache
• Granulations, ear nerve palsies
• CT- osseous erosions
• Surgery, fluoroquinolones

• *Age- kids 6mo-3y
• Allergies
• GERD
• Males
• URI
• 2nd hand smoke
• Bottle feeding/pacifier use

Symptoms of Serous otitis media

Physical findings?

Tugging/pulling ears, Hearing difficulties

Loss of balance, Delayed speech

Dull, hypomobile TM, air bubbles

conductive hearing loss

Controversial

AAPA- "watchful waiting"

tympanostomy tubes

No- Antimicrobials, antihistamines

Inflammation of the middle ear, complication of a URI

*Organisms*?

Acute otitis media

Strep pneumoniae

H. influenzae

Moraxella catarrhalis

Strep pyogenes

Infants: irritability, pulling on ear, fever

Older children & adults- otalgia, pressure, dec hearing, headache, lethargy, fever

-Pain control- tylenol, Ibuprofen

-PO antibiotics- *amoxicillin, augmentin,

How is recurrent OM defined?

Complications?

-3 episodes of acute OM w/in 6mo or 4+ w/in a year

-Cx: Serous OM, Chronic OM, mastoiditis, perforated TM

-Day care

Breastfeeding at least 6mo

No pacifier after 6mo

Chronic inflammation of the middle ear, lasting >6weeks with otorrhea

Organisms?

Chronic otitis media

Pseudomonas aeruginosa

Proteus sp.

StaphA

mixed anaerobes

*different orgs than acute!

Symptoms of chronic otitis media?

Physical findings?

-*purulent drainage

-little to no pain

Dull TM

Erythema 

Perforation w/ drainage

Conductive hearing loss

Tx for chronic otitis media?

Complications?

-Antibiotics, surgical

Mastoiditis, cholesteatoma,

epidural abcess, hearing loss

Mastoiditis

(mostly young children)

Sx of Mastoiditis?

Physical findings?

-Otalgia & pain behind ear, fever

-Bulging, red TM, erythema tenderness, edema over mastoid, postauricular fluctuance, protrusion of auricle

-CBC- leukocytosis

Elevated ESR

Fluid sent out for culture

X-rays- mastoid cell coalescence

*CT shows demineralization of mastoid bone

MRI- shows fluid

-IV antibiotics

-PO antibiotics

Myringotomy

Mastoidectomy

-Ear clogging

Ear pain/discomfort

Hearing loss

Dizziness

Tinnitus

Hemorrhage from the ear

Retracted TM

Erythema & injected TM

Hemotympanum

Cx: perforation

Swallow, yawn, chew gum

PO decongestants

Myringotomy

• Clear rhinorrhea
• Nasal congestion
• Dec smell (hyperosmia)& taste
• Erythematous nasal mucosa
• Assoc- headache, cough, scratch throat, malaise
• GI involvement unusual

• NO antiviral therapy
• Decongestants- pseudophedrine
• Nasal preps-oxymetazoline (Afrin,Vicks) or phenylephrine (Neo-Synephrine)
• Fluids
• Analgesics & anti-inflammatory meds

• Bacterial sinusitis
• Acute otitis media
• Acute exacerbations- asthma, COPD-related illnesses, immunocompromised

• *Maxillary/frontal/ethmoid pain/pressure
• Purulent or mucoid discharge

• S. pneumoniae
• H. influenzae
• less common: S. aureus, M. catarrhalis

• 2/3 resolved w/o Tx w/in 2 weeks
• Antibiotics- >14d, Amoxicillin, augmentin; penicillin allergy- Bactrim, Doxycycline)
• Sx tx- nasal preps & decongestants (oxymetazoline "Afrin", pseudoephedrine "PSE")
• Quinolones- see notes; Cipro, Levaquin, Avelox, Zagam
• Macrolides- see notes; Zithromax, Biaxin

• *Periorbital cellulitis- emergency!
• Osteomyelitis of frontal bone
• Intracranial complications rare

Nasal vestibulitis

Tx: Dicloxacillin, mupirocin (Bactroban)

• Fungus spreads rapidly through mucosa & vascular channels
• Medical & surgical emergency- lethal if not treated
• Clear, straw-colored drainage
• Black eschar on middle turbinate
• Tx: Amphotericin B, surgical debridement

• Red, itchy, watery eyes
• Sneezing, congestion, runny nose
• Itchy or sore throat
• Pale mucosa

• OTC antihistamines- Dimetapp, Actifed, Tavist
• H1 receptor agonists- Zyrtec, Allegra, Claritin
• Nasal sprays- Livostin, Astelin
• Intranasal corticosteroids- Beconase, AeroBid, Nasonex, Flonase
• Leukotriene inhibitors- Singulair
• Mast-cell stabilizers- Cromolyn sodium

• Anterior portion of the nose
• *Kiesselbach's plexus- anterior/inferior septum
• Nasal trauma
• Rhinitis
• Dry mucosa
• Deviated septum
• Anticoagulants

• Direct pressure
• Topical nasal preparations- NeoSynephrine
• Vasoconstriction agent- Cocaine 4%, oxymetazoline (Afrin)
• Packing- MeroCel, balloon
• Cautery- electrical or chemical (silver nitrate)
• BP control

• Crepitus & mobility
• Epistaxis, pain, hematoma
• Tx: Stabilize, surgery

Benign- inverted papilloma, juvenile angiofibroma

Malignant- nasopharyngeal & paranasal sinus tumors

• Wegener's
• NK cell & T-cell EBV positive lymphoma
• Sarcoidosis

• Sore throat
• fever
• anterior cervical adenopathy
• tonsillar exudate
• *no cough*
• strawberry tongue
• petechial rash on soft papate

• Fever >38C
• Tender anterior cervical adenopathy
• *Lack of cough*
• Pharyngotonsillar exudate

• Rapid antigen testing (5min)- >90% accuracy if also have 3-4 Centor criteria
• Blood agar culture
• Test 2-3 criteria, treat +
• Treat all 4 critera, no test needed

• Benzathine penicillin (Bicillin-LA)- IM!
• Penicillin V (Pen-Vee K)
• Alt: erythromycin, cephalosporins, macrolides
• Tylenol, NSAIDs, tonsillectomy

• Severe sore throat
• Odynophagia
• Trismus
• Medial deviation of the soft palate & peritonsillar fold
• "Hot potato" voice

• Inhalation of noxious materials
• Improper use of asthma inhalers
• Prolonged vocal misuse
• GERD
• Vocal cord nodules or tumors

• Hoarse voice
• URI (fever, cough, rhinitis)
• Chronic- otolaryngologist for laryngoscopy

• Time, vocal rest, irritant avoidance
• Humidified air
• Smoking cessation
• Tx of underlying conditions: foreign bodies, GERD, squamous cell carcinoma

• Assoc w/ HH6
• Non-keratinized mucosa (buccal & labial)
• Small, painful, round ulcerations w/ a yellow/gray center & surrounded by a erythematous halo

• Herpesvirus
• CMV
• Varicella
• Coxsackievirus
• Topical corticosteroids- Cortaid, Kenalog

Oral candidiasis, "thrush", Candida albicans

KOH prep: (+) for pseudohyphae

• Denture wearers
• Immunocompromised
• Diabetics
• Chemo pts
• On corticosteroids or antibiotics

• Infants: Nystatin suspension or heals in 2wks
• Adults: treat underlying problem, glucose stabilization in DM, nystatin lozenges
• HIV+: Ketaconazole (Nizoral), Fluconazole (Diflucan), HAART

Hairy leukoplakia

EBV, often in the immunocompromised.

• Parotid, sublingual, submandibular glands
• StaphA
• Acute pain & edema in affected gland
• Pus expression with massage
• Tx: hydration, antibiotics (Naficillin)

• Calculi near the opening of Wharton's (mc) or Stensen's duct
• Pain & localized edema near duct
• Tx: lemon drops, massage, stone removal, lithotripsy, basket retrieval, gland excision

• Dx: Dentoalveolar abscess
• Tx: Analgesia, antibiotics, drainage, dental/maxillofacial surgeon referral

• Localized pain & temperature sensitivity
• Gingival erythema, warmth & edema
• Fluctuant mass
• Dental erosion
• Trismus
• Ludwig's angina- cellulitis in floor of mouth, lethal

• CBC
• Blood cultures
• Aspiration or incision & drainage
• IV antibiotics
• CT
• Maxillofacial oral surgery consult

Penicillin- Pen-VeeK, Penicillin G

Erythromycin

Clindamycin

• Airway compromise
• Uncontrollable oral secretions
• Deep space infection of face or neck
• Systemic involvement
• Outpatient therapy failure

• Malaise, sore throat, fever
• Exudative pharyngitis/tonsillitis
• Palatal petechiae
• Cervical lymphadenopathy
• Splenomegaly
• Maculopapular rash in <15% of cases (presents in >90% of pts after ampicillin or amoxicillin)

- Blood smear- lymphocytosis

-Heterophil agglutination test, 'monospot'

• Acute bacterial pharyngitis
• Splenic rupture
• Generally following trauma
• Hepatitis
• Neurological involvement- myelitis, encephalitis, Guillain-Barre syndrome

Symptomatic tx:

• Tylenol, NSAIDs
• Warm water +/- salt gargles
• Corticosteroids if airway obstruction
• Avoid ampicillin or amoxicillin for 2ndary
• Avoid physical infection
• 95% recover w/o antiviral therapy

"Droopy" eyelid

Most common cause is eyelid disease

Neurological cause- Horner's syndrome

OD= right eye

OS= left eye

OU= both eyes

- Visual fields- gross screening for peripheral vision

- Pupils

- Extraocular movements

- Eyebrows/eyelids

- Conjuctiva & sclera (blue-osteogenesis imperfecta)

- Cornea & lens

- Emmetropia- infinity clearly seen

- Hyperopia- infinity not clearly seen

- Myopia- very near in focus

- Astigmatism- horizontal & vertical axis deviation

- Presbyopia- natural loss of accommodation

-Hordeolum (internal)

-Tx: Warm compresses, Abx ointment/soln, incision & drainage

Chalazion

-Freq follows internal hordeolum

-Tx: warm compresses, I&D

Blepharitis

Tx: clean w/ soap & water, Abx oint/soln

Entro- eyelid turn in

Ectro- eyelid turn out

Eye infections due to obstruction.

Acute: Pain, eyrethema, and tenderness.

Chronic: tearing, discharge, purulent mucus

DacroCystitis (c=center)- lacrimal gland

Dacroadenitis (outside)- meiobian gland

Tx: Systemic abx, surgery

Conjunctivitis

-Viral or bacterial

-Highly infectious & contagious

- Staphylococci

-Streptococci (S. pneumoniae, Haemophilus, Pseudomonas, Moraxella)

*Esp pseudomonas for contact wearers

Tx: Hand washing, abx (Polytrim)

- Adenovirus type 3

-Assoc. w/ s/sx of URI

Tx: Handwashing, Abx

-Benign, seasonal

- S/sx: Allergic rhinitis, itchy, tearing eyes, sleral injection, clear discharge, history

Trauma, forceful coughing or vomiting

- Feels "full & itchy", painless

Herpes simplex keratitis

Recurrent

Pinguecula

-Common >35yo

-Often bilateral

Pterygium

-Related to exposure to wind, sand, & dust

- Often bilateral

-Threatens vision if it approaches the visual axis

Keratoconjunctivitis sicca

- Physiological, systemic, envt'l disorders

-Schirmer test- meas tear prod

Misalignment of eyes

- 4% in children

Orbital cellulitis

C: infection of the paranasal sinuses

Tx: IV abx to prevent optic N damage & infection spread

Significant discomfort (pain) and photophobia

Tx: Polymyxin-bacitracin

-Pain & photophobia 6-12h post-exposure

-Punctate fluorescein staining over entire conjunctiva

-Resolves in 24-48h