Otolaryngology Potpourri

Transcription

1 Otolaryngology Potpourri Robert C. Langan, MD, FAAFP Program Director St. Luke s Family Medicine Residency Bethlehem, PA 1 Neither I nor my family have any financial interest or relationship with any proprietary entity producing health care goods or services 2 Goals & Objectives 1. Review pertinent ENT anatomy 2. Describe presentations, signs, and symptoms of common ENT disorders as well as laboratory and diagnostic studies 3. Discuss non pharmacologic and pharmacologic therapy of common ENT disorders 4. Identify indications for ENT referral 3 1

2 According to the IDSA, which antibiotic is first line for the treatment of acute bacterial sinusitis? A. High dose amoxicillin B. Amoxicillin clavulanic acid C. Trimethoprim sulfamethoxazole D. Levofloxacin E. Clarithromycin 4 According to the AAP, diagnosis of acute otitis media requires which of the following? A. Moderate to severe middle ear effusion (MEE) B. New onset otorrhea without otitis externa C. Mild MEE AND <48 hours of ear pain/erythema of the tympanic membrane D. A or B or C E. A and B and C 5 The preferred first line treatment for allergic rhinitis is: A. Sedating antihistamines B. Non sedating antihistamines C. Intranasal corticosteroids D. Intranasal cromolyn E. Leukotriene receptor agonists 6 2

3 Outer Ear 7 Otitis Externa 98% caused by bacteria (Pseudomonas, Staph aureus) RF: swimming, eczema, seborrhea, trauma Diagnosis: Acute onset AND ear pain AND ear canal edema/erythema Fever, otorrhea, lymphadenitis, TM erythema unnecessary Treatment: Effective (NNT = 2) No evidence that 1 topical antibiotic is superior to another Topical steroids improve resolution of symptoms No RCT evaluating preventive measures (ear plugs, acetic acid, avoiding self cleaning) 8 Necrotizing Otitis Externa Formerly called malignant OE Usually caused by Pseudomonas More common in diabetics, elderly Spread of infection from canal to temporal bone Presents with severe ipsilateral ear pain Urgent ENT evaluation: Debridement IV and topical anti Pseudomonal antibiotics 9 3

4 Middle Ear Acute Otitis Media Guideline AAP (2013), endorsed by AAFP Applies to healthy children aged 6 months to 2 years Diagnosis requires: Moderate to severe middle ear effusion (MEE) OR New onset otorrhea without otitis externa OR Mild MEE AND <48 hours of ear pain/erythema of TM Parental suspicion of OM and ear tugging have the highest positive likelihood ratio (3) Treat pain (how to treat not specified) 12 4

5 When to Treat AOM AGE SEVERE* NONSEVERE 6 months 23 months Antibiotics Antibiotics for bilateral OM Antibiotics or observation** for unilateral OM >24 months Antibiotics Antibiotics or observation** for bilateral OR unilateral OM *SEVERE: Moderate/severe otalgia, otalgia for >48 hours, temperature >102.2 F (39 C) **OBSERVATION requires follow up with initiation of antibiotics if symptoms do not improve in hours. 13 AOM Initial Treatment High dose amoxicillin (90 mg/kg/day) is the preferred 1 st line antibiotic for patients who are not allergic AND have not received amoxicillin in the last 30 days If amoxicillin has been used in the last 30 days OR conjunctivitis is present, high dose amoxicillin clavulanic acid is recommended 14 AOM Treatment PCN Allergic (non severe) Cefdinir 14 mg/kg/day in 1 or 2 daily doses Cefuroxime 30 mg/kg/day in 2 daily doses Cefpodoxime 10 mg/kg/day in 2 daily doses Ceftriaxone 50 mg/kg/day IM Clindamycin mg/kg/day in 3 daily doses Macrolides, TMP/SMX not recommended DURATION: 10 days (<2 years old) 7 days (>2 years old) 15 5

6 Other AOM Pearls Prophylactic antibiotics not recommended Consider PE tubes for 3 episodes of AOM/6 months OR 4 episodes/12 months Encourage exclusive breastfeeding for the first 6 months Avoid passive tobacco exposure Appropriate vaccinations 16 OTITIS MEDIA WITH PERFORATION 1. Otorhea + AOM: Treat like AOM. 2. Traumatic Perforation: Small perforations (<30%) usually heal spontaneously in 4-6 weeks. Large perforations or perforations in specific professions (i.e. pilots) need ENT. 3. Keep ear dry. 4. Avoid ototoxic eardrops (gentamicin, neomycin, tobramycin). 5. Pain from AOM DECREASES with perforation; if pain INCREASES consider mastoiditis. 17 SEROUS OTITIS MEDIA 1. May be post-aom (4-6 weeks). 2. Other causes include AR, exposure to tobacco, other URI. 3. More common in children; usually asymptomatic. 4. Treat underlying conditions (i.e. allergic rhinitis, avoidance of tobacco). 5. Hearing test for speech delay, persistent (>4-6 months) SOM. 6. Role of PE tubes. 18 6

7 TYPE A: NORMAL TYPE B: MIDDLE EAR FLUID TYMPANOGRAMS TYPE C: SINUS/ALLERGY CONGESTION 19 Hearing Loss 20 Screening for Hearing Loss: Infants All newborns should be screened for hearing loss prior to 1 month of age (USPSTF B) Otoacoustic Auditory brainstem response Children who fail both should see ENT/audiology within 3 months RF: NICU 2 days Family History of hereditary hearing loss Craniofacial abnormalities Congenital syndromes 21 7

8 Screening for Hearing Loss: Geriatrics Inadequate evidence to recommend for or against screening for hearing loss in adults (USPSTF I) Increasing age is the leading RF for hearing loss Hearing aids improve self reported hearing, communication, and social functioning Prevention: Avoid loud noises Hearing protection Tobacco cessation Check medications 22 Hearing Loss CONDUCTIVE: hearing loss due to the conductive pathway of the ear Cerumen impaction, swelling of external auditory canal, TM perforation, effusion SENSORINEURAL: hearing loss due to problems with the inner ear/8 th cranial nerve; most common type of hearing loss Persistent noise exposure, presbycusis, familial/genetic factors, postinflammatory, tumor 23 Testing for Hearing Loss WEBER TEST Tuning fork on forehead Sound radiates to side with conductive hearing loss Sound radiates away from sensorineural loss RINNE TEST Tuning fork at mastoid, then ear Should still hear sound Abnormal in conductive loss Unhelpful for sensorineural loss Audiology evaluation is superior to both Weber and Rinne for evaluation of hearing loss. 24 8

9 Hearing Loss Pearls Sudden sensorineural hearing loss: ENT evaluation Unilateral hearing loss in adults: consider acoustic neuroma; test of choice is MRI Unilateral hearing loss + tinnitus + dizziness: consider Ménière s Disease Avoid loud noises for 14 hours prior to hearing tests 25 Dizziness 26 Dizziness May encompass dysequilibrium, syncope, lightheadedness, or vertigo VERTIGO: the sensation of spinning or whirling that occurs as a result of a disturbance in balance Causes: vestibular neuritis (labyrinthitis), benign paroxysmal positional vertigo, Ménière s Disease 27 9

10 Vestibular Neuritis One of the most common etiologies of vertigo Caused by inflammation of the vestibular portion of the 8 th cranial nerve Usually viral; may occur after URI Intense symptoms that improve over several days; hearing unaffected Nausea and/or vomiting common Treat with vestibular suppressant medication (meclizine) short term, fluids 28 BPPV Caused by otoconia (calcium carbonate crystals) that have become free floating and enter one of the semicircular canals Sudden turning of the head/arising from bed in the morning creates intense vertigo that lasts for less than 30 seconds Meclizine ineffective Treat with Dix Hallpike maneuver, vestibular therapy

11 Ménière s Disease Precise etiology unknown; thought to be due to distention of endolymphatic space Intense, episodic vertigo (lasting minutes to hours) associated with hearing loss, tinnitus Treatment is difficult ENT evaluation, salt restriction, thiazide diuretics 31 Facial Nerve Disorders 32 Facial Nerve Paralysis 33 11

12 Bell s Palsy Sudden onset, unilateral Idiopathic, but felt to be due to HSV 1 Do not routinely screen for Lyme Disease, DM Imaging if symptoms do not improve with treatment Prednisone mg daily x 7 days; start as soon as possible No evidence for effectiveness of antivirals + prednisone 34 Ramsay Hunt Syndrome Varicella zoster infection of geniculate ganglion of facial nerve Facial nerve paralysis accompanied by severe pain and vesicular eruption in external auditory canal; pain precedes rash by hours to days Rash may not be present May represent up to 20% of cases of Bell s Palsy No good evidence that antivirals, corticosteroids help but usually treated similarly to Bell s Palsy Less likely to have complete resolution compared to Bell s Palsy 35 Allergic Rhinitis 36 12

13 AR Definitions (AAOHNS, 2014) Inflammatory, IgE mediated disease Characterized by nasal congestion, rhinorrhea, sneezing, nasal itching May be classified according to: Temporal Pattern (seasonal, perennial, episodic) Frequency of symptoms (intermittent, persistent) Severity (mild, severe) Classification scheme clinically not useful PE: clear rhinorrhea, nasal congestion, pale nasal mucosa, red/watery eyes 37 AR Pearls Recommend allergy testing only for patients who do not respond to empiric therapy, when the diagnosis is uncertain, or when knowledge of specific allergens is needed to target therapy Do not routinely recommend imaging for patients Environmental modification may be recommended Evaluate patients for asthma, atopic dermatitis 38 AR Treatment Nasal steroids are first line medical treatment Non sedating antihistamines (NSAH) for patients with primarily sneezing/itching Leukotriene receptor antagonists (LTRA) should not be primary therapy UNLESS asthma is also present Combination therapy is reasonable if monotherapy does not control symptoms Recommend immunotherapy for patients who fail combination therapy No recommendations about herbal therapy based on lack of strong evidence 39 13

14 Sinusitis 40 Signs and Symptoms of Sinusitis Sign/Symptom PPV NPV Preceded by URI 81% 88% Facial pain/pressure/fullness 77% 75% Purulent rhinorrhea 61% 55% Maxillary toothache 56% 59% Nasal obstruction 43% 35% DIAGNOSIS OF ACUTE SINUSITIS: Up to 4 weeks of purulent rhinorrhea accompanied by nasal obstruction OR facial pain/pressure/fullness (AAOHNS, ACP, AAFP, IDSA) 41 Acute Bacterial Rhinosinusitis IDSA (2013) recommends treatment for: Persistent and not improving ( 10 days) Severe symptoms ( 3 4 days) OR Double sickening Assess risk of antibiotic resistance Age <2 years or >65 years Antibiotics within the past month Hospitalized in the past 5 days Co morbidities (incl. immunocompromised) 42 14

15 Acute Bacterial Rhinosinusitis Low Risk of Resistance: 1 st Line antibiotic x 5 7 days High Risk of Resistance: 2 nd Line antibiotic for 7 10 days Worsening: Broaden coverage, consider imaging/ent evaluation 1 st LINE: Amoxicillin/Clavulanate 2 nd LINE: Amoxicillin/Clavulanate (high dose; 2 grams/day) PCN ALLERGIC: Doxycyline or Respiratory Fluoroquinolone or Clindamycin AND Cefiximine 43 Acute Bacterial Rhinosinusitis Adjuvant Therapy: Intranasal Steroids (h/o AR) Saline irrigation NOT Recommended: Topical decongestants Oral decongestants Antihistamines 44 Chronic Sinusitis DEFINTION (AAOHNS) At least 2 of the following for >12 weeks: A. Facial pressure/pain B. Nasal obstruction* C. Nasal discharge* D. Reduction in smell At least 1 of the following signs of inflammation: A. Nasal polyps (rhinoscopy/endoscopy) B. Edema/purulence of middle meatus C. Inflammation on CT of paranasal sinuses 45 15

16 Chronic Sinusitis Recommendations (JAMA 2015) Topical steroids for all patients ( Grade A) High volume (>100 ml) saline irrigation for all patients ( Grade A) AR: Consider NSAH, LTRA Sinus surgery for persistent symptoms (Grade C) POLYPS NO POLYPS Oral steroids (14 21 d) Clarithromycin (90 d) Doxycycline (21 d) Oral steroids (14 21 d) Culture (per ENT) Culture (per ENT) AR: Allergic Rhinitis; NSAH: Non-Sedating Antihistamine; LTRA: Leukotriene- Receptor Antagonist 46 Salivary Gland Disorders 47 Salivary Gland Disorders Acute suppurative sialadenitis: Bacterial infection (usually S. aureus) after duct obstruction More common in hospitalized, debilitated patients, use of anticholinergic medications Affects 1 gland, usually parotid Warm compresses, oral hygiene, antibiotics,? drainage Recurrent/chronic sialadenitis: Repeated episodes of sialadenitis causes fibrosis of duct Imaging, ENT to try to identify cause of obstruction Surgical therapy 48 16

17 Salivary Gland Disorders Bilateral salivary gland enlargement: viral infection, HIV, autoimmune disorder (Sjögren s disease) Mumps is the most common cause of nonsuppurative acute sialadenitis Vaccination has decreased the incidence by 99% Salivary gland tumors are uncommon Red Flags: pain, facial paresis, fixation of the mass, associated lymphadenopathy Parotid tumors usually benign, submandibular/ submaxillary more likely to be malignant 49 Head and Neck Cancer 50 Head & Neck Cancer Pearls SCC most common type of primary cancer Biopsy lymph nodes present for greater than 6 weeks OR if constitutional symptoms are present Be suspicious of hard and nonmobile lymph nodes Traditional risk factors: abuse of tobacco, alcohol HPV associated oropharyngeal cancer Younger age, associated with oral sex, better survival, better response to treatment Presents with neck mass, sore throat, dysphagia HPV vaccines seem to be effective at incidence Contrast enhanced CT is the imaging test of choice 51 17

18 Questions? 52 References 1. Wax, MK. Primary Care Otolaryngology, 2 nd Edition. American Academy of Otolaryngology Head and Neck Surgery Foundation Wilson KF, et al. Salivary gland disorders. Am Fam Physician 2014;89(11): Albers JR, Tamang S. Common questions about Bell s palsy. Am Fam Physician 2014;89(3): Uscategui T, Doree C, Chamberlain IJ, Burton MJ. Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD Uscategui T, Doree C, Chamberlain IJ, Burton MJ. Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD References 7. Rudmik L, Soler ZM. Medical therapies for adult chronic sinusitis: a systematic review. JAMA 2015;314(9): Moore KA, Mehta V. The growing epidemic of HPV positive oropharyngeal carcinoma: a clinical review for primary care providers. J Am Board Fam Med 2015;28: Haynes J, et al. Evaluation of neck masses in adults. Am Fam Physician 2015;91(10): Harmes KM, et al. Otitis media: diagnosis and treatment. Am Fam Physician 2013;88(7):