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Clerkship Lecture

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Otolaryngology Otolaryngology for Medical Students for Medical Students Orientation, Goals, Tips and Key Orientation, Goals, Tips and Key Topics Topics
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Page 1: Clerkship Lecture

Otolaryngology Otolaryngology for Medical Studentsfor Medical Students

Orientation, Goals, Tips and Key Orientation, Goals, Tips and Key TopicsTopics

Page 2: Clerkship Lecture

ItineraryItinerary

WelcomeWelcomeOtolaryngology StaffOtolaryngology StaffTips and ResourcesTips and ResourcesMCQ PreMCQ Pre--TestTestThe ENT HistoryThe ENT HistoryThe head and neck examThe head and neck examImportant ENT TopicsImportant ENT Topics

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Otolaryngology StaffOtolaryngology StaffVictoria

Dr. D. MacRae - Peds/OtologyDr. M. Husein - PedsDr. J. Yoo - H&NDr. K. Fung - H&NDr. J. Franklin – H&NDr. H. Lampe - H&NDr. S. Sukerman - General

University

Dr. L. Parnes - Otology

St. Joseph’s

Dr. E. Wright - RhinosinologyDr. V. Janzen - RhinosinologyDr. C. Moore - Facial PlasticsDr. R. Ruby - Otology

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Tips for ENT RotationTips for ENT RotationGoal is to gain exposure to the breadth of ENT, not Goal is to gain exposure to the breadth of ENT, not mastery of every subjectmastery of every subjectYour personal objective should be to gain proficiency Your personal objective should be to gain proficiency with ENT history and exam, and familiarity with a range with ENT history and exam, and familiarity with a range of Primary Care ENT topicsof Primary Care ENT topicsReview your 1st and 2nd year lecture notes, ENT for Review your 1st and 2nd year lecture notes, ENT for Primary Care text, Primary Care text, emedicineemedicine, , mdconsultmdconsultTry to review appropriate lecture notes prior to related Try to review appropriate lecture notes prior to related clinic/ORclinic/OR

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The ENT HistoryThe ENT HistoryBriefer than the Internal Medicine history (think Briefer than the Internal Medicine history (think surgical)surgical)Key points (especially important in ENT):Key points (especially important in ENT):

Smoking/alcohol historySmoking/alcohol historyNumbers of infections (e.g. ear, sinus, throat) in last Numbers of infections (e.g. ear, sinus, throat) in last 1, 2, 3 yrs1, 2, 3 yrs

previous treatments (e.g. which previous treatments (e.g. which AbxAbx and how recently)and how recently)

Ears: hearing loss, pain, d/c, tinnitus, vertigoEars: hearing loss, pain, d/c, tinnitus, vertigoPrevious ENT surgeriesPrevious ENT surgeries

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The Head and Neck ExamThe Head and Neck Exam

As with other specialties, the head and neck exam is to As with other specialties, the head and neck exam is to be used to supplement clinical information acquired from be used to supplement clinical information acquired from a detailed historya detailed historyHave an approachHave an approach……be effective and make sure it can be be effective and make sure it can be replicated so as not to miss findingsreplicated so as not to miss findingsMost of all, practice, practice, practiceMost of all, practice, practice, practice

You wonYou won’’t know what is normal until you see it many timest know what is normal until you see it many times

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The Ear The Ear -- HistoryHistory

OtologicOtologic::Hearing lossHearing loss

Onset and rate of progressionOnset and rate of progressionOtalgiaOtalgia

Otologic vs. referredOtologic vs. referredOtorrheaOtorrhea

Consistency?Consistency?TinnitusTinnitusVertigoVertigo

Differentiate from Differentiate from ‘‘dizzynessdizzyness’’Noise exposureNoise exposure

Nasal:Nasal:Obstruction, discharge etcObstruction, discharge etc

Drugs:Drugs:OtotoxicOtotoxic agentsagents

Family HistoryFamily HistoryOf hearing loss etc.Of hearing loss etc.

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The EAR The EAR -- ExaminationExamination

Inspect auricles and Inspect auricles and mastoid regionmastoid region

size, shape, symmetry, size, shape, symmetry, landmarks, color, position, landmarks, color, position, deformities or lesionsdeformities or lesions

Palpate auricles and Palpate auricles and mastoidmastoid

tenderness, swelling, tenderness, swelling, nodulesnodules

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The Tympanic MembraneThe Tympanic Membrane

Inspect external auditory canal Inspect external auditory canal (with pneumatic (with pneumatic otoscopyotoscopy))

cerumencerumen, color, lesions, d/c, , color, lesions, d/c, foreign bodiesforeign bodies

Inspect tympanic membraneInspect tympanic membranelandmarkslandmarkscolor, contourcolor, contourperforations, mobilityperforations, mobilityall 4 quadrantsall 4 quadrants

Examples of Abnormalities...Examples of Abnormalities...

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Normal Tympanic MembraneNormal Tympanic Membrane

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Acute Acute OtitisOtitis MediaMedia

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TympanosclerosisTympanosclerosis

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Perforation with Perforation with TympanosclerosisTympanosclerosis

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OsteomaOsteoma

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OtitisOtitis ExternaExterna

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CholesteatomaCholesteatoma

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The Ear The Ear –– Hearing AssessmentHearing Assessment

Formulation:Formulation:1.1. Conductive Hearing LossConductive Hearing Loss

Disease affecting Disease affecting outer/middle earouter/middle ear

2.2. SensorineuralSensorineural Hearing LossHearing LossDisease affecting cochlea or Disease affecting cochlea or CN VIIICN VIII

3.3. Mixed Hearing LossMixed Hearing LossDisease involving both Disease involving both middle & inner earmiddle & inner ear

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The Ear The Ear –– Hearing AssessmentHearing Assessment

Response to questions Response to questions during historyduring historyResponse to a whispered Response to a whispered voicevoice

Tuning fork Tuning fork –– air/bone air/bone conductionconduction

RinneRinne (image above)(image above)Weber (image below)Weber (image below)

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Interpretation of Tuning Fork TestInterpretation of Tuning Fork Test

Air Conduction Air Conduction better than bone better than bone

conductionconduction

Bone conduction Bone conduction better than air better than air

conduction (conduction (RinneRinnenegative)negative)

Air Conduction better Air Conduction better than bone conductionthan bone conduction

((RinneRinne positive)positive)RinneRinne

Lateralization to Lateralization to better hearing earbetter hearing ear

Lateralization to ear Lateralization to ear with losswith loss

No LateralizationNo LateralizationWeberWeber

SNHLSNHLCHLCHLExpected Expected FindingsFindingsTestTest

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The Audiogram The Audiogram ---- the Basicsthe Basics

Bone conduction lineBone conduction lineAir conduction lineAir conduction lineAirAir--bone gap = bone gap = conductive hearing conductive hearing losslossDepressed bone Depressed bone conduction line = conduction line = sensorineural losssensorineural loss

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The Nose and The Nose and ParanasalParanasal Sinuses Sinuses --HistoryHistory

NasalNasalRhinorrheaRhinorrheaNasal obstructionNasal obstructionSneezingSneezingDischargeDischargeOlfactionOlfactionAllergiesAllergies

SinusesSinusesFacial painFacial painDental painDental painHearing lossHearing lossPost Post –– nasal dripnasal dripOlfactionOlfactionCongestionCongestionDischargeDischarge

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The Nose & The Nose & ParanasalParanasal Sinuses Sinuses ––ExamExam

Inspect the external noseInspect the external noseshape, size, color, shape, size, color, naresnares

Palpate the ridge and soft tissues of the nosePalpate the ridge and soft tissues of the nosetenderness, displacement cartilage/bone, massestenderness, displacement cartilage/bone, masses

Evaluate Evaluate patencypatency of of naresnares

Inspect nasal mucosa and septumInspect nasal mucosa and septumcolor, alignment, discharge, swelling of color, alignment, discharge, swelling of turbinatesturbinates, perforation, perforation

Inspect and palpate regions of the sinusesInspect and palpate regions of the sinuses

Flexible/Rigid Flexible/Rigid EndoscopyEndoscopy

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SinusitisSinusitis

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Examples Examples -- PolypsPolyps

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SeptalSeptal PerforationPerforation

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Nasopharyngeal CarcinomaNasopharyngeal Carcinoma

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Upper Upper AerodigestiveAerodigestive Tract Tract -- HistoryHistory

Oral Cavity/Oropharynx:Oral Cavity/Oropharynx:PainPainBleedingBleedingDysarthriaDysarthriaNumbness/Numbness/DysgeusiaDysgeusiaReferred Referred otalgiaotalgiaDry mouthDry mouth

Swallowing:Swallowing:DysphagiaDysphagia

Solids Solids vsvs liquidsliquidsOdynophagiaOdynophagiaAspirationAspirationRefluxReflux

HypopharynxHypopharynx/Larynx/LarynxDysphoniaDysphoniaDysphagiaDysphagiaCough/Cough/hemoptysishemoptysisPainPainShortness of breathShortness of breathStridorStridorGlobusGlobus

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The Oral Cavity The Oral Cavity -- ExaminationExaminationInspect lips and vermilion bordersInspect lips and vermilion borders

symmetry, color, edema, surface abnormalitiessymmetry, color, edema, surface abnormalities

Inspect and palpate Inspect and palpate gingivagingivacolor, lesions, tendernesscolor, lesions, tenderness

Inspect teethInspect teethocclusion, caries, loose or missing teethocclusion, caries, loose or missing teeth

Inspect and palpate tongue and Inspect and palpate tongue and buccalbuccal mucosamucosacolor, symmetry, swelling, ulcerationscolor, symmetry, swelling, ulcerations

Inspect palate, floor of mouth, uvula, tonsils, oropharynxInspect palate, floor of mouth, uvula, tonsils, oropharynx

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The Neck The Neck -- ExaminationExamination

Inspect the neckInspect the necksymmetry, alignment of trachea, fullness, masses, webbing, skin symmetry, alignment of trachea, fullness, masses, webbing, skin folds, jugular vein distribution, carotid artery prominencefolds, jugular vein distribution, carotid artery prominence

Evaluate range of motion of neckEvaluate range of motion of neck

Palpate the neckPalpate the necktracheal position, tracheal tug, tracheal position, tracheal tug, movmov’’tt hyoid bone and cartilages hyoid bone and cartilages with swallowingwith swallowing

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Lymph Node GroupsLymph Node GroupsPalpate lymph nodesPalpate lymph nodes

size, consistency, size, consistency, tenderness, warmth, tenderness, warmth, mobilitymobility

PrePre--auricularauricularPostPost--auricularauricularOccipitalOccipitalJugulodigastricJugulodigastricSubmental/submandibularSubmental/submandibularFacialFacialAnterior&Posterior CervicalAnterior&Posterior CervicalSupraclavicularSupraclavicular

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The NECKThe NECK

Palpate the thyroid glandPalpate the thyroid gland

Size, shape, configuration, Size, shape, configuration, consistency, tenderness, consistency, tenderness, nodulesnodules

Examine on deglutitionExamine on deglutition

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The LarynxThe Larynx

Indirect Indirect laryngoscopylaryngoscopyhold pthold pt’’s tongue wrapped in s tongue wrapped in guazeguazewith one handwith one handhold mirror in other hand against hold mirror in other hand against soft palatesoft palateassess vocal cord mobility, lesions assess vocal cord mobility, lesions in regionin region

Direct Direct laryngoscopylaryngoscopyposterior pharyngeal wall, posterior pharyngeal wall, posterior posterior cricoidcricoid region, region, piriformpiriformrecessesrecessesvocal cord mobility and vocal cord mobility and appearanceappearancearytenoidarytenoid mucosa/cartilages, mucosa/cartilages, aryepiglotticaryepiglottic foldsfoldsepiglottis, epiglottis, valleculaevalleculae, base of , base of tonguetongue

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Examples of Oral Cavity Examples of Oral Cavity -- TorusTorus

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Oral Cavity Oral Cavity –– Traumatic Traumatic FibromaFibroma

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Oral Cavity Oral Cavity -- HemangiomaHemangioma

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Oral Cavity Oral Cavity -- PapillomaPapilloma

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Oral Cavity Oral Cavity -- Squamous Cell Squamous Cell CarcinomaCarcinoma

Leukoplakia

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Examples Examples -- HypopharynxHypopharynx/Larynx/Larynx

Foreign Body (Fish Bone)Foreign Body (Fish Bone)

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Vocal CordsVocal Cords

Papilloma

Nodule

Cyst

Polyp

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Vocal Cord Vocal Cord -- SCCSCC

LeukoplakiaLeukoplakia

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Hypopharynx/SupraglottisHypopharynx/Supraglottis

Pyriform Sinus CaEpiglottitis

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Cranial NervesCranial Nerves

Examine cranial nerves II Examine cranial nerves II -- XIIXII

Consider screening Consider screening neurological exam in neurological exam in ““dizzydizzy””patients:patients:

Mental StatusMental StatusCranial NervesCranial NervesGross MotorGross MotorGross SensoryGross SensoryReflexesReflexesCerebellar Tests (Cerebellar Tests (RhombergRhomberg, , fingerfinger--toto--nose, heelnose, heel--shin, rapid shin, rapid alternating hand movements)alternating hand movements)

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Common Topics in ENT Common Topics in ENT (based on the clerkship objectives)(based on the clerkship objectives)OtitisOtitis Media and Media and OtitisOtitis ExternaExternaTinnitus and Hearing LossTinnitus and Hearing LossVertigoVertigoFacial ParalysisFacial ParalysisEpistaxisEpistaxisAcute and Chronic SinusitisAcute and Chronic SinusitisObstructive Sleep ApneaObstructive Sleep ApneaCancers of the Head and NeckCancers of the Head and Neck

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OtitisOtitis MediaMedia

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OtitisOtitis MediaMediaMost common disease diagnosed by cliniciansMost common disease diagnosed by clinicians

Incidence rapidly increasing each year, almost 90% of kids have Incidence rapidly increasing each year, almost 90% of kids have at at least one bout by their 2least one bout by their 2ndnd bb--dayday

Presentation: fever, pain, irritability (in kids) also conductivPresentation: fever, pain, irritability (in kids) also conductive HL, e HL, behaviouralbehavioural changes, changes, otorrheaotorrhea, anorexia, , anorexia,

Organisms: Organisms: Strep. Strep. PneumoniaePneumoniae (40%)(40%)HaemophilusHaemophilus influenzaeinfluenzae (25%)(25%)MoraxellaMoraxella catarrhaliscatarrhalis (12%)(12%)

Risk Factors: dayRisk Factors: day--care, passive smoking, family history, noncare, passive smoking, family history, non--breast breast fed, no vaccinefed, no vaccine

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OtitisOtitis MediaMedia

Why?Why?Eustachian tube dysfunction in childrenEustachian tube dysfunction in children ((ieie. Anatomy of infant . Anatomy of infant skull)skull)

Treatment considerations: antibiotics for AOM, OME, Treatment considerations: antibiotics for AOM, OME, RAOMRAOM

antbxantbx 77--10 day regime 10 day regime vsvs 66--8 weeks8 weeksrole of role of tympanostomytympanostomy tubes +/tubes +/-- adenotonsillectomyadenotonsillectomy (see (see Bluestone figures)Bluestone figures)

When to referWhen to refer……

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OtitisOtitis Media Media -- complicationscomplications

Features of high risk: neonate, Features of high risk: neonate, immunocompromisedimmunocompromisedstate (diabetes, HIV, state (diabetes, HIV, neutropenianeutropenia))

Symptoms of intracranial pathology:Symptoms of intracranial pathology:fever, severe headache, fever, severe headache, meningealmeningeal signs, seizuressigns, seizures

Symptoms of Symptoms of otologicotologic pathology:pathology:pain (pain (retroorbitalretroorbital, mastoid), vertigo, SNHL, displaced , mastoid), vertigo, SNHL, displaced pinnapinna, , cranial nerve 6,7,8cranial nerve 6,7,8

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OtitisOtitis Media Media -- complicationscomplications

OtologicOtologicMastoiditis/subperiostel

abscessPetrous ApicitisLabyrinthitisFacial Paralysis

IntracranialIntracranialMeningitisEpidural abscessSigmoid sinus

thrombosisBrain abscess

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OtitisOtitis ExternaExterna

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OtitisOtitis ExternaExterna

Presentation: Presentation: otalgiaotalgia, fullness, , fullness, pruritispruritis, hearing loss, hearing lossEtiology: Etiology: OtitisOtitis media, water exposure, canal traumamedia, water exposure, canal traumaOrganisms: pseudomonas, Organisms: pseudomonas, proteusproteus, , StaphStaph, fungal, fungalTreatment:Treatment:

DebridementDebridementototopicalototopical agents (agents (CiprodexCiprodex, , GarasoneGarasone, , SofracortSofracort) 3) 3--7 days7 daysPO antibiotics if severe (PO antibiotics if severe (cellulitiscellulitis/nodes)/nodes)analgesicsanalgesicswater precautions, pt educationwater precautions, pt education

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TinnitusTinnitus

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Tinnitus Tinnitus -- DDxDDx

Presbycuisis Presbycuisis -- ageage--related sensorineural lossrelated sensorineural lossCardiovascular Cardiovascular dzdz -- pulsatilepulsatileMeniereMeniere’’ss -- assocassoc’’dd w/ episodic vertigo, aural w/ episodic vertigo, aural fullness, hearing lossfullness, hearing lossBrain neoplasm Brain neoplasm -- espesp CPA tumorsCPA tumorsTrauma/noise Trauma/noise -- assocassoc’’dd w/ temporary hearing lossw/ temporary hearing lossPsychosocial Psychosocial DzDz -- aural hallucinations, esp. aural hallucinations, esp. SchizSchizDrugDrug--induced induced -- ASA most common, usually highASA most common, usually high--pitched, reversiblepitched, reversibleOtosclerosisOtosclerosis -- otospongiosisotospongiosis of cochlea, labyrinthof cochlea, labyrinthMultiple SclerosisMultiple Sclerosis

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Hearing LossHearing Loss

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Hearing LossHearing Loss

Conductive Hearing LossConductive Hearing Lossimpedes amplification and/or transmission of sound impedes amplification and/or transmission of sound to cochleato cochleacan involve external ear, EAC, TM, middle ear can involve external ear, EAC, TM, middle ear space, and/or contentsspace, and/or contents

Sensorineural Hearing LossSensorineural Hearing Lossinvolves inner ear (i.e. cochlea), acoustic nerve, involves inner ear (i.e. cochlea), acoustic nerve, and/or central auditory pathwaysand/or central auditory pathways

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Hearing Loss: Hearing Loss: DDxDDx

ConductiveConductiveExternal EarExternal Ear

congenital congenital atresiaatresiacerumencerumenforeign bodyforeign bodymalformationsmalformationsinfectionsinfectionsneoplasmsneoplasms

Middle EarMiddle Earcongenitalcongenitaleffusions (serous OM)effusions (serous OM)acute OMacute OMneoplasmsneoplasmsotoclerosisotoclerosisTM perforationTM perforationossicularossicular discontinuitydiscontinuitytympanoscerosistympanoscerosisotosclerosisotosclerosisossicularossicular fixationfixationmastoiditismastoiditis

SensorineuralSensorineuralcongenitalcongenitalacquiredacquired

presbycuisispresbycuisisnoisenoise--induced HLinduced HLhead traumahead traumadrug toxicitydrug toxicityMeniereMeniere’’sssudden SNHLsudden SNHLtumortumorperilymphaticperilymphatic leakleakCNS disease (e.g. MS)CNS disease (e.g. MS)labyrinthitislabyrinthitis

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VertigoVertigo

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VertigoVertigo

false perception of movementfalse perception of movementimportant Qimportant Q’’s: onset, duration, frequency, s: onset, duration, frequency, associated ear symptoms, positional associated ear symptoms, positional triggers, triggers, hxhx ear ear dzdz/head trauma/head traumaENT exam, plus ENT exam, plus HallpikeHallpike maneuver, maneuver, CN+cerebellar testingCN+cerebellar testing

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Common Causes of VertigoCommon Causes of VertigoMeniereMeniere’’ss DzDz

episodes lasting episodes lasting minsmins--hrshrsroaring tinnitus, aural roaring tinnitus, aural fullness, lowfullness, low--pitched pitched hearing losshearing loss

LabyrinthitisLabyrinthitis/Vestibular /Vestibular NeuronitisNeuronitis

sudden onsetsudden onsetlasts hrs, subsides over lasts hrs, subsides over daysdayshxhx viral infectionviral infection

Benign Paroxysmal Benign Paroxysmal Positional Vertigo (BPPV)Positional Vertigo (BPPV)

most common causemost common causeepisodes lasting episodes lasting secssecstriggered by head triggered by head movmov’’tt+/+/-- hxhx injury, infectioninjury, infection

CentralCentralassocassoc’’dd other other neuroneuro S+SS+S+/+/-- LOCLOCvascularvasculartemporal lobetemporal lobecerebellarcerebellar

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Facial ParalysisFacial Paralysis

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Acute Facial ParalysisAcute Facial ParalysisRecall/review anatomy of the facial nerve; itRecall/review anatomy of the facial nerve; it’’s intras intra--extracranialextracranialcomponentscomponents

History: onset, duration, rate of progression, recurrence (BellHistory: onset, duration, rate of progression, recurrence (Bell’’s , MR s , MR syndrome)syndrome)

Associated symptoms: numbness middle and lower face, Associated symptoms: numbness middle and lower face, otalgiaotalgia, , hyperacusishyperacusis, diminished tearing, taste alteration , diminished tearing, taste alteration –– BellBell’’s; intense ear s; intense ear pain and vesicular eruption pain and vesicular eruption –– HZ infectionHZ infection

Complete Head and Neck exam/ CN assessment, palpation of Complete Head and Neck exam/ CN assessment, palpation of parotid gland and neckparotid gland and neck

Facial palsy; complete Facial palsy; complete vsvs incomplete, segmental incomplete, segmental vsvs uniform uniform involvinvolv’’tt, , unilateral unilateral vsvs bilateral (<1%)bilateral (<1%)

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Acute Facial Paralysis: Acute Facial Paralysis: InvestigationsInvestigations

CBC with diff and ESRCBC with diff and ESRSerum antibody tests; serum ANA and RFSerum antibody tests; serum ANA and RF

ElectrophysiologicElectrophysiologic teststestsnerve excitability test (NET)nerve excitability test (NET)maximal stimulation test (MST)maximal stimulation test (MST)ElectroneurographyElectroneurography ((ENoGENoG))Electromyography (EMG)Electromyography (EMG)

CT, MRICT, MRI……+/+/-- CXRCXR

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Acute Facial Paralysis Acute Facial Paralysis –– BellBell’’ss

Rapid onset palsy, minimal assoc symptoms, Rapid onset palsy, minimal assoc symptoms, spontaneous recoveryspontaneous recovery

1/3 pts develop only paresis, 95% total recovery1/3 pts develop only paresis, 95% total recovery2/3 complete paralysis, facial tone/2/3 complete paralysis, facial tone/movmov’’tt 85% in 3 wks; 85% in 3 wks; expect 3expect 3--6 months6 months

The longer the delay in recovery, the greater the The longer the delay in recovery, the greater the liklihoodliklihoodof adverse of adverse sequelaesequelae

? HSV evidence for etiology? HSV evidence for etiology

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Acute Facial Paralysis Acute Facial Paralysis --TreatmentTreatment

Treatment must be initiated promptly for maximal efficiency Treatment must be initiated promptly for maximal efficiency –– delay delay of > 3 days decreases efficiencyof > 3 days decreases efficiency

Medical Medical txtx::Prednisone 1mg/kg/day for 7Prednisone 1mg/kg/day for 7--10 days10 daysAcyclovir 400mg Acyclovir 400mg popo 5 times daily for 7 days5 times daily for 7 days

Surgical Surgical TxTx::Decompression (>90% Decompression (>90% degendegen on on ENoGENoG w/in 14 days onset + no w/in 14 days onset + no voluntary motor unit potentials EMG)voluntary motor unit potentials EMG)

Eye Care Eye Care avoid vents, liberal use of ophthalmic lubricants, shielded glasavoid vents, liberal use of ophthalmic lubricants, shielded glassessesPotential gold weight implants, Potential gold weight implants, canthoplastycanthoplasty, , tarsorrhaphytarsorrhaphy for long termfor long term

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EpistaxisEpistaxis

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EpistaxisEpistaxis

Most common bleeding d/o of head and neckMost common bleeding d/o of head and neckVery common Very common –– 60% incidence through one60% incidence through one’’s lifes life10% seek medical attention; 610% seek medical attention; 6--10% ENT consult10% ENT consult

Seasonal incidence Seasonal incidence –– Winter > SummerWinter > Summer

POTENTIALLY LIFE THREATENINGPOTENTIALLY LIFE THREATENING

Etiology Etiology –– consider local and systemic factors consider local and systemic factors

Site of bleed Site of bleed -- Anterior 90%Anterior 90%Posterior 10%Posterior 10%

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EpistaxisEpistaxis –– first thingfirst thing’’s firsts first

History: side, duration, amount, temporal pattern, History: side, duration, amount, temporal pattern, traumatrauma

PMHxPMHx: liver disease, : liver disease, coagcoag d/o, family d/o, family hxhx, HTN, previous , HTN, previous epistaxisepistaxis, nutrition, nutrition

Medications: ASA, NSAIDS, Medications: ASA, NSAIDS, warfarinwarfarin, heparin, , heparin, chloramphenicolchloramphenicol, , dipyridamoledipyridamole

Examination:Examination:-- ABCABC’’s and vitals (s and vitals (orthostaticsorthostatics))-- General exam (General exam (purpurapurpura, , petechiaepetechiae))-- Nasal exam (head light, suction, decongest, Nasal exam (head light, suction, decongest,

determine bleeding site) determine bleeding site)

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EpistaxisEpistaxis –– Acute ManagementAcute Management

Reassure patientReassure patientIV hydration depending on extent of bleed IV hydration depending on extent of bleed control HTNcontrol HTNBloodworkBloodwork –– CBC, INR/PTT, Group and CrossCBC, INR/PTT, Group and CrossTreatmentTreatment

-- depends on etiologydepends on etiology-- those with systemic factors, conservative, those with systemic factors, conservative, noncauterizingnoncauterizing, cartilage, cartilage--sparing techniques for sparing techniques for initial therapyinitial therapy --

correct correct coagscoags, d/c meds, d/c meds

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EpistaxisEpistaxis –– Acute ManagementAcute Management

Anterior : localize bleedAnterior : localize bleed-- silversilver--nitrate nitrate cauterycautery-- surgicel/oxycelsurgicel/oxycel ((cellulose),gelfoamcellulose),gelfoam (gelatin)(gelatin)-- anterior packing (anterior packing (merocelmerocel vsvs impregimpreg guazeguaze))-- PO antibiotics with packing (TSS)PO antibiotics with packing (TSS)

Posterior: difficult to see etiologyPosterior: difficult to see etiology-- posterior packing (posterior packing (foleyfoley/rockets/formal pack)/rockets/formal pack)-- embolizationembolization-- IMAX , IMAX , ethmoidethmoid ligationligation-- endoscopic cauterizationendoscopic cauterization

Consider ENT referral if posterior pack requiredConsider ENT referral if posterior pack required

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SinusitisSinusitis

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SinusitisSinusitis

Inflammation of mucosal lining of the sinusesInflammation of mucosal lining of the sinuses

PathophysiologyPathophysiology:: patencypatency of of ostiaostiafunction of ciliafunction of ciliaquality of nasal secretionsquality of nasal secretions

Predisposing factors: local, regional, systemicPredisposing factors: local, regional, systemic

Be aware of complications Be aware of complications –– very seriousvery serious

GET CULTURE for diagnosisGET CULTURE for diagnosis

Treat for at least 10 days Treat for at least 10 days –– 3 weeks to prevent relapse3 weeks to prevent relapse

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Sinusitis Sinusitis -- ClassificationClassification

RhinosinusitisRhinosinusitis classified according to 5 axes:classified according to 5 axes:clinical presentation: clinical presentation: acute, acute, subacutesubacute, chronic, chronicsinus involved: sinus involved: ethmoidsethmoids, maxillary, frontal, , maxillary, frontal, sphenoidsphenoid……pansinusitipansinusitisscausative organism: bacterial, viral, fungal, protozoancausative organism: bacterial, viral, fungal, protozoanpresence of complication: presence of complication: extrasinusextrasinus extensionextensionmodifying or aggravating factors: modifying or aggravating factors: immunosuppressionimmunosuppression, diabetes, malnutrition, NG tube, , diabetes, malnutrition, NG tube, IgGIgG deficiencydeficiency

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Sinusitis Sinusitis -- bacterialbacterial

Acute Acute –– lasts 1 day lasts 1 day –– 4 weeks4 weeks-- management management –– antbxantbx for at least 7 days postfor at least 7 days post--sxsx-- surgery rarely necessary surgery rarely necessary –– complicationscomplications

SubacuteSubacute–– lingers 4 weeks lingers 4 weeks –– 3 months3 months-- inflammation still reversible inflammation still reversible –– med. med. managemanage’’tt

Chronic Chronic -- persisted disease > 3 monthspersisted disease > 3 months-- generally irreversible damage to sinus drainagegenerally irreversible damage to sinus drainage-- surgical surgical managemanage’’tt

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Page 84: Clerkship Lecture

SinusitisSinusitis

Viral sinusitis:Viral sinusitis:follows viral URIfollows viral URIdamage cilia from cilia damage cilia from cilia ciliotoxinsciliotoxinspredisposes to bacterial sinusitispredisposes to bacterial sinusitis

Fungal sinusitis:Fungal sinusitis:noninvasive (noninvasive (mycetomamycetoma, AFS), AFS)invasive ( invasive ( fulminantfulminant FS, indolent)FS, indolent)

Complications of sinusitisComplications of sinusitisorbitalorbitalintracranialintracranialneed aggressive medical AND surgical need aggressive medical AND surgical txtx

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Page 86: Clerkship Lecture

Obstructive Sleep Obstructive Sleep ApneaApnea

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Obstructive Sleep ApneaObstructive Sleep Apnearepeated reductions/cessations in airflow, w/ apnea index >=5, respiratory disturbance index (RDI) of at least 10 on polysomnograph

central apnea: absence of airflow assoc’d w/ lack of inspiratoryeffort

Snoring: 28% of women, 44% of men aged 30-60OSA: 9% of women, 24% of men (RDIs of 5 or higher)

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OSA: Pathophysiology

tongue contacts the soft palate and posterior pharyngeal wall inthe presence of lateral collapse of the pharynx, thus generatingocclusion

risk factors: obesity, redundant tissue in the neck, retrognathia, craniofacial anomalies

Alcohol and other sedating medications may contribute

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OSA Management

Investigations: Polysomnogram (Sleep Study)

TreatmentConservative Measures: weight loss, avoid sedatives, sleep on side

Continuous Positive Airway Pressure (CPAP)

Oral Appliance

Surgery in select patients: Uvulopalatopharyngoplasty, septoplasty

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NeoplasmsNeoplasms of the of the Head and NeckHead and Neck

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NeoplasmsNeoplasms of the Head and of the Head and NeckNeck

66--8 % of all malignancies in the body8 % of all malignancies in the body

historically M>F but historically M>F but ↑↑inging in women due to in women due to smokingsmoking

90% Squamous Cell Ca90% Squamous Cell Ca

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H&N Tumors: Risk FactorsH&N Tumors: Risk Factors

Nose/Sinuses: Nose/Sinuses: asianasian descent, hardwood dust, nickel, chromiumdescent, hardwood dust, nickel, chromiumLip: UV exposure, poor oral hygiene, smoking/Lip: UV exposure, poor oral hygiene, smoking/EtOHEtOHSalivary Gland: smaller gland, Salivary Gland: smaller gland, ↑↑ risk malignantrisk malignantOral Cavity: smoking, Oral Cavity: smoking, EtOHEtOH, poor oral hygiene, chronic dental , poor oral hygiene, chronic dental irritation, betel nut chewingirritation, betel nut chewingPharynx: smoking, Pharynx: smoking, EtOHEtOHThyroid: family history, radiation exposureThyroid: family history, radiation exposure

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PeritonsillarPeritonsillarAbscessAbscess

Common complication of tonsillitis in adolescents and Common complication of tonsillitis in adolescents and young adultsyoung adults

Symptoms: Symptoms: trismustrismus, painful swelling in throat, , painful swelling in throat, dysphagiadysphagia, , odynophagiaodynophagia, fever, , fever, otalgiaotalgia, , ““hot potatohot potato”” voicevoice

Classic findings: Classic findings: unilateral swelling unilateral swelling peritonsillarperitonsillar region with bulging soft palateregion with bulging soft palateDeviation of midline of palate and uvula to Deviation of midline of palate and uvula to contralateralcontralateral sideside

HxHx: sore throat > 5 days with ineffective : sore throat > 5 days with ineffective antbxantbx txtx

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PeritonsillarPeritonsillar abscessabscessManagement:Management:

ClindamycinClindamycin 300mg QID x 7 days + analgesics300mg QID x 7 days + analgesicsNeedle aspiration and I&D (effective >90%)Needle aspiration and I&D (effective >90%)

-- risk of recurrence 10risk of recurrence 10--15%15%-- pts younger than 40 yrs with pts younger than 40 yrs with hxhx of recurrent tonsillitis @ of recurrent tonsillitis @

greatest riskgreatest risk>2 bouts of >2 bouts of peritonsillarperitonsillar abscess candidate for tonsillectomyabscess candidate for tonsillectomyInability to swallow fluids, poor airway, Inability to swallow fluids, poor airway, immunosuppressionimmunosuppression, , young patients may be factors for admissionyoung patients may be factors for admissionTonsillectomy for some surgeonsTonsillectomy for some surgeons

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Upper Airway ObstructionUpper Airway Obstruction

Can present as a lifeCan present as a life--threatening hypoxemia and threatening hypoxemia and hypercapniahypercapnia

First priority is to establish airway; donFirst priority is to establish airway; don’’t forget about the t forget about the nasopharyngeal a/wnasopharyngeal a/w

Signs: Signs: inspiratoryinspiratory stridorstridor (decreased (decreased intraluminalintraluminalpressure compared to atmospheric pressure pressure compared to atmospheric pressure –– BernouilleBernouilleprincipleprinciple

Most important step in initial evaluation is determining Most important step in initial evaluation is determining whether an airway needs to be established immediatelywhether an airway needs to be established immediately

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Upper Airway Obstruction Upper Airway Obstruction --DiagnosticsDiagnostics

ObstnObstn @ @ glotticglottic levellevelSevere hoarsenessSevere hoarseness

angioedemaangioedemaHxHx HTN or HTN or famfam. . HxHx obstnobstn

Post. Post. GlotticGlottic closure or closure or subglotticsubglottic scar tissuescar tissue

HxHx previous previous intubationintubation

RLN injury RLN injury –– VC paralysisVC paralysisRecent neck/chest surgeryRecent neck/chest surgery

? Infection ? site? Infection ? siteFevers/chills/painFevers/chills/pain

? Cancer in upper a/w? Cancer in upper a/wHxHx tobacco/ETOHtobacco/ETOH

? Immediate a/w? Immediate a/wSeverity of symptomsSeverity of symptoms

ConsiderationsConsiderationsHistory/Symptom History/Symptom FeaturesFeatures

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Upper A/W obstruction Upper A/W obstruction -- DxDx

Main points in Main points in hxhx: timing, age, : timing, age, PMHxPMHx, other systemic , other systemic d/od/o, , ability to sleep lying downability to sleep lying downPhysical exam: pt may need antihistamines, epinephrine, Physical exam: pt may need antihistamines, epinephrine, steroids, steroids, antbxantbx during during dxdx evaluationevaluationPulse Pulse oximetryoximetry demonstrates enddemonstrates end--point point obstnobstn, no info , no info during progressionduring progressionHypercapniaHypercapnia, acidosis early signs of hypoventilation, acidosis early signs of hypoventilationAgitation, cyanosis, Agitation, cyanosis, respresp effort on inspectioneffort on inspectionNasal flaring, neck retractions, accessory muscle use Nasal flaring, neck retractions, accessory muscle use signs of fatigue; listen to chest for symmetry/noisessigns of fatigue; listen to chest for symmetry/noises

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Upper A/W obstruction Upper A/W obstruction -- DxDx

Complete head and neck exam: nose, oral cavity, larynx Complete head and neck exam: nose, oral cavity, larynx highlight examhighlight exam

Radiology: may not be time for soft tissue lateral views, Radiology: may not be time for soft tissue lateral views, generally not great aid to generally not great aid to dxdx

CT and MRI usefulCT and MRI useful

Management related to diagnosis and urgencyManagement related to diagnosis and urgency

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Differential DiagnosisDifferential DiagnosisUpper A/W obstructionUpper A/W obstruction

““MISI BOVOMISI BOVO””Malignant tumours Malignant tumours (SCC, Adenoid cystic of trachea, thyroid Ca)(SCC, Adenoid cystic of trachea, thyroid Ca)

Infections Infections ((EpiglottitisEpiglottitis, , supraglottitissupraglottitis, , TracheitisTracheitis, , cellulitiscellulitis FOM FOM ––LugwigLugwig’’ss, Retropharyngeal abscess), Retropharyngeal abscess)

SubglotticSubglottic stenosisstenosis ((hemangiomahemangioma, , intubationintubation))

Inflammatory Inflammatory (GERD (GERD larygospasmlarygospasm, , AngioedemaAngioedema))

Benign tumours Benign tumours (recurrent (recurrent papillomaspapillomas, , chondromaschondromas, , lipomaslipomas, , fibromasfibromas))Body (Foreign)Body (Foreign)

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Differential DiagnosisDifferential DiagnosisUpper A/W obstructionUpper A/W obstruction

Other Vocal Cord lesions Other Vocal Cord lesions (polyps, (polyps, glotticglottic webs)webs)

Vocal cord paralysis Vocal cord paralysis (recurrent nerve injury, systemic (recurrent nerve injury, systemic neurologicneurologicdisorder, idiopathic)disorder, idiopathic)

Other Vocal Cord Mobility D/O Other Vocal Cord Mobility D/O ((cricoarytenoidcricoarytenoid joint fixation, joint fixation, inspiratoryinspiratory adduction adduction –– ““functional functional laryngospasmlaryngospasm””, scar tissue in , scar tissue in interarytenoidinterarytenoid region)region)

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AngioedemaAngioedema

Presentation: acute painless mucosal edemaPresentation: acute painless mucosal edema-- face, lips, tongue, larynxface, lips, tongue, larynx-- airway obstruction 20%airway obstruction 20%

Etiology Etiology –– ACE Inhibitor sensitivity most commonACE Inhibitor sensitivity most common-- see chartsee chart

Treatment Treatment –– aggressiveaggressive-- high humidity oxygen, epinephrine, high humidity oxygen, epinephrine,

antihistamines, steroidsantihistamines, steroids-- secure airway (observe, ET Tube, tracheotomy)secure airway (observe, ET Tube, tracheotomy)-- D/C ACE inhibitors and Med consult (HTN)D/C ACE inhibitors and Med consult (HTN)

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Page 103: Clerkship Lecture

Temporal Bone FracturesTemporal Bone Fractures

Blunt and penetrating trauma Blunt and penetrating trauma –– MVA, fallMVA, fallThree types : longitudinal, transverse, mixedThree types : longitudinal, transverse, mixedLongitudinal: most common 70Longitudinal: most common 70--80%80%

-- facial nerve injury 10facial nerve injury 10--20%20%-- ruptured TM, ruptured TM, hemotympanumhemotympanum, CSF leak, CSF leak-- persistent conductive HL (persistent conductive HL (ossicularossicular chain)chain)

Transverse: # usually involves bony labyrinthTransverse: # usually involves bony labyrinth-- profound SNHLprofound SNHL-- facial nerve injury (~ 50%)facial nerve injury (~ 50%)-- CSF CSF otorrhea/rhinorrheaotorrhea/rhinorrhea, meningitis, meningitis

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Temporal Bone FracturesTemporal Bone Fractures

Management:Management:-- trauma protocol trauma protocol –– ABCABC’’s, Cs, C--spinespine-- Ear examEar exam-- Assess facial nerve early (immediate Assess facial nerve early (immediate vsvs

delayed)delayed)-- Assess hearing Assess hearing –– Audiogram, tuning forksAudiogram, tuning forks-- Radiology Radiology –– Head CT (brain injury) + CT Head CT (brain injury) + CT

temporal bone windowstemporal bone windows

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Temporal Bone FracturesTemporal Bone Fractures

Treatment:Treatment:immediate facial nerve paralysis immediate facial nerve paralysis –– OR to repairOR to repairdelayed FN paralysis delayed FN paralysis –– observe, steroids, eye observe, steroids, eye

protectionprotectionCSF leak CSF leak –– conservative bed rest, >90% resolve conservative bed rest, >90% resolve

in two weeksin two weeksSNHL SNHL –– hearing aidhearing aidconductive HL conductive HL –– ossicularossicular reconstructionreconstructionvertigo vertigo –– txtx symptomatically, symptomatically, SercSerc, , MeclizineMeclizine, PT, PT

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Page 107: Clerkship Lecture

Nasal FractureNasal Fracture

Very common; most common facial fractureVery common; most common facial fractureHigh index of suspicion for fractureHigh index of suspicion for fracture

-- mechanism, appearance, mechanism, appearance, epistaxisepistaxis, obstruction, obstructionExamine entire face (nose, orbit, Examine entire face (nose, orbit, zygomazygoma, mandible), mandible)

-- instability, mobility, instability, mobility, crepitationcrepitation-- septalseptal hematomahematoma, lacerations, lacerations

Facial xFacial x--rays rays –– variable reliabilityvariable reliabilityCT face CT face –– indicated if other fractures presentindicated if other fractures presentENT REFERRAL ENT REFERRAL -- < 5 days for closed reduction< 5 days for closed reduction

-- > 12 days for > 12 days for septorhinoplastyseptorhinoplasty

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Page 109: Clerkship Lecture

Sudden Sudden SensorineuralSensorineural Hearing Hearing LossLoss

Hearing Loss Hearing Loss –– sudden, usually unilateral sudden, usually unilateral no trauma historyno trauma historyrapidly progressive (<3 days)rapidly progressive (<3 days)

Etiology Etiology –– UncertainUncertain-- Viral (30Viral (30--50% assoc viral URTI)50% assoc viral URTI)-- see chartsee chart

Associated Symptoms Associated Symptoms –– Aural fullness, tinnitus, vertigoAural fullness, tinnitus, vertigo

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Page 111: Clerkship Lecture

Sudden SNHLSudden SNHL

Diagnostics: 90% no etiology foundDiagnostics: 90% no etiology found-- normal P/Enormal P/E-- Audiogram, ABR, Audiogram, ABR, OtoacousticOtoacoustic emissionemission

-- Lab tests (see chart)Lab tests (see chart)-- possible MRI with gadolinium (1possible MRI with gadolinium (1--3% AN)3% AN)

Management: 2/3 recover spontaneouslyManagement: 2/3 recover spontaneously-- AntiinflammatoryAntiinflammatory –– steroids steroids -- vasodilators vasodilators –– carbogencarbogen, histamine, , histamine, papaverinepapaverine-- rheologicrheologic agents agents –– LMW LMW dextransdextrans, heparin, heparin-- antivirals/diuretics/triiodobenzoicantivirals/diuretics/triiodobenzoic acid acid derivderiv-- surgerysurgery

Bottom line: EARLY REFERRALBottom line: EARLY REFERRAL

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