OTOLARYNGOLOGY Update, USNAC 2013 Chuck Reese CAPT MC USN 850-452-3256 charles.reese@med.navy.mil
CAPT Reese and all others involved in the planning, development and presentation of this CME activity provide the following Disclosure information: "Nothing to disclose"
Review of several cases from the last year. Adhesive Otitis with possible Cholesteatoma Sudden Sensori-neural Hearing Loss Inverted Papilloma
True or False: If the hearing levels are with standards that is enough to meet the standard of care for evaluating an audiogram.
False. You must also assess hearing patterns and symmetry
22 yr old Marine A/C candidate s/p PE tubes as a child. Subj. slightly worse hearing in his left ear. No allergy sx Mild congestion when flying or diving. Currently feels great, ready to train. No hx of vertigo.
Subtle Low Freq Loss
What do you expect with tuning forks? A: Weber midline and AC>BC AU B: Weber to the right with AC>BC AU C: Weber to the left with BC>AC AS
C: Weber to the left and BC>AC AS There is a subtle asymmetry in the left ear with a hearing pattern that is worse in both ears in the lower frequencies. A conductive hearing loss usually affects the lower frequencies more Tuning fork will lateralize to the affected ear in a conductive loss.
Don t forget that you know how to use tuning forks!
Adhesive Otitis
Click on incudostapediopexy, preop
The drum is atelectatic and retracted Adherent to, and shrink-wrapping the incus Can even see the stapedius tendon and facial nerve canal Not to mention the fluid! An unsafe ear
The most common cause of an acquired cholesteatoma is: A: TM perforation B: PE tubes C: Eustachian Tube Dysfunction D: Q-Tip use E: Recurrent otitis externa
C: Eustchian Tube Dysfunction Chronic negative pressure leads to retraction of the TM with eventual development of a weak area, usually in region of pars flaccida or postero-sup quadrant. Retraction gets deep enough to trap dead skin keratoma or cholesteatoma
Unsafe Ear, Defined Portion of TM disappears out of sight TM adherent to incus Erosion of the incus Potential cholesteatoma Recurrent drainage/otorrhea
Click on incudostapediopexy, post-op
NL TM
White mass in middle ear and attic defect filled with debris. Click on Cholesteatoma with Valsalva
Eroded incus and postero-sup retraction
Severe Attic Retraction Pocket
Asymmetric Hearing Loss ENT evaluation if: 3 adjoining frequencies that are 10 db different from the other side 2 adjoining frequencies that are 15 db different from the other side 1 Frequency that is 25 db different from the other side Make sure to get a formal audiogram first
Hearing Questionnaire Can you tell that your hearing is diminished? Tinnitus? Describe (constant, pulsatile, etc) Vertigo? Dizziness? Family History of hearing loss? Describe noise exposure history: Construction, band/music hx, ipod use (ear bud in one or both ears?)
Hearing Questionnaire Shooting History (what type of weapons, do you wear hearing protection?) Do you shoot right or left handed? Hunting? If so, big game or small game? History of concussion? History of IV antibiotics?
Hearing Standards Aviation Applicant 500 1000 2000 3000 4000 25 25 25 45 55 (db both ears) For Enlistment/Commissioning: The average of 500, 1K and 2K is 30 db or less and no single value is greater than 35 db.
Adhesive Otitis, Lessons Learned First Question, Does Hearing Meet Standards? Second Question, Are Hearing levels Symmetric? EXTRA Careful exam when there is asymmetry affecting lower/mid frequencies (or when both ears have hearing levels close to 20-25 db in the lower frequencies, but 0-10 in mid/upper frequencies)
Sudden Idiopathic Hearing Loss SRT = 70 on the left. Word recognition was 16%
Sudden Idiopathic Hearing Loss Post treatment with aggressive prednisone taper
Nasal Polyp 27 yr old CSO presents with 6 wk history of left nasal obstruction and visible polyp. No prior history of sinusitis, epistaxis or allergy symptoms (Other than PND for ~1-2 yrs). Had completed initial flight training in T-6 with no evidence of barotrauma symptoms. Some reduction in size on flonase.
True or False: The frontal sinus drains into the superior meatus, the ethmoid sinuses drain into the middle meatus and the maxillary sinus drains into the inferior meatus.
False The frontal, maxillary and most of the ethmoid sinuses drain into the middle meatus via the ostiomeatal complex.
Sagital view of the lateral wall of the nasal cavity
Coronal and Sagital view with relative locations of sinuses
Parasagital section with turbinates removed showing sinus drainage pathways. Courtesy of F. Netter. Collection of Ciba Geigy, 1989 From Rhinosinusits, 5th Edition, 2006, AAO-HNS Foundation
Go to Video Clip of Normal Nasal Anatomy
Normal Ostiomeatal Complex OMC Middle Turbinate
Go to Video Clip of Mucociliary Clearance
Nasal Polyp Go to the video clip of the polyp
Unilateral Nasal Polyp
True or False: Unilateral disease is managed in the same manner as bilateral disease and has the same rate of recurrence.
FALSE Isolated/unilateral sinus disease requires a higher degree of suspicion for unusual pathology: Malignancies (relatively rare): Squamous Cell, Minor Salivary Gland (Adenocarcinoma, Adenoid Cystic, Mucoepidermoid), Neuroendocrine, Lymphoma, Sarcoma, Melanoma
Unilateral Nasal Polyp Benign Epithelial: Inflammatory Polyps, Antrochoanal Polyps, Sinonasal Papillomas (Inverted, Cylindrical Cell and Exophytic), Minor salivary Gland (Primarily benign mixed tumors) Benign Non-Epithelial: Fibroma, Chondroma, Osteoma, Neurofibroma, Hemangioma
Unilateral Nasal Polyp Suspicious History: Bleeding, Pain, Parasthesias or Numbness, Diplopia Suspicious findings on exam or CT: Ulcerations, Neck Mass, Exophthalmos, Cranial Nerve Abnormalities (Suspicious =suspicious for malignancy)
Inverted Papilloma A benign, but potentially aggressive lesion. Typically presents with nasal obstruction, altered olfaction, rhinorrhea, PND, other sx c/w sinusitis A surgical disease with recurrence rate ranging from <5-20% depending on location, extent of the tumor and technique. Recurrence usually occurs within 2 years, but can take longer.
Inverted Papilloma Has the potential for malignant degeneration Approx 10% chance of malignancy, usually at the time of initial resection, but may not present with malignancy until months to years later.
Inverted Papilloma Diagnosis: Exam, CT, MRI if questionable extension to skull base or orbit, biopsy. Consider biopsy of all unilateral nasal polyps prior to going to the operating room in order to assist with surgical planning. Can usually be done safely and relatively easily in the clinic using local anesthesia.
Inverted Papilloma This patient: Biopsy here in Pensacola. Due to potential involvement of frontal recess and anterior skull base surgical resection performed at UAB. Lesion was based at anterior skull base over the anterior ethmoid artery. Low Grade Dysplasia on pathology.
To obtain a waiver, aviators who are s/p sinus surgery require which of the following: A: Post-op CT scan B: 6 Month waiting period to demonstrate stability. C: Allergy Immunotherapy D: Waters View X-ray of the sinuses E: None of the above
E: None of the above. To obtain a waiver, aviators who are s/p sinus surgery require: Clearance by the surgeon Resolution of symptoms Functional chamber run or other functional check
THERE IS NO REQUIREMENT FOR A POST-OP CT SCAN!!!! Patients with chronic sinusitis can end up with many CT scans over the course of their lives and even in one year. A recent patient here had received 5 CT scans in 6 months.
Click on post-op endoscopy:
Questions?
Misc slides
Cholesteatoma/Mastoidectomy Waiver Policy A history or presence of cholesteatoma is CD A waiver can be obtained if: Surgery is done, and there are no significant sequelae such as labyrinthine or facial nerve trauma There is no continuing drainage or persistent granulation tissue post-op. Waivers should be renewed annually after ENT consultation.
Cholesteatoma/Mastoidectomy Waiver Policy - 2 When the surgeon feels that residual cholesteatoma is possible, a second look operation is often planned for. The waiver may be written so that it expires at the time of the recommended second look surgery; it can be renewed after the surgery, assuming there are no complications.
Causes of Sensorineural Hearing Loss Noise-induced HL (occupational and recreational noise) Presbycusis (aging) Sudden HL (extreme noise, viral, vascular) Fluctuating HL (Meniere s, autoimmune) Unilateral HL (Meniere s, acoustic neuroma) Etc.
Classic noiseinduced notch at 4 khz
Sudden Hearing Loss Causes: Viral (? human spumoretrovirus) Vascular (e.g. hypercoagulability) Neoplasm (acoustic neuroma) Mycoplasma infection (bullous myringitis) Perilymph fistula (weightlifting or barotrauma)
Sudden Hearing Loss - 2 Treatment: Rest, including rest from noise Steroids (appropriate in most cases) Antiviral medications (+/-)) Antibiotics (specifically against Mycoplasma and only in the presence of a middle ear effusion) Surgery if perilymph fistula suspected