Otolaryngology

Acute Hearing Loss 1、General. Hearing loss may develop over days or acutely. It may be either conductive in nature (ossicle disruption from trauma, tympanic-membrane perforation from cotton-tipped applicator or from noise, etc., cerumen in the canal, otitis media, barotrauma, etc.) or sensorineural (CVA, infectious, tumor, Ménières disease, herpes zoster oticus (may see vesicles), syphilis, collagen-vascular disease, ototoxic drug exposure, etc). An isolated vascular event causing unilateral hearing loss is not uncommon in young adults.

2、Presentation. Decrease in auditory acuity. May document using audiologic testing or by Rinne and Weber tests.
3、Approach. Treat cause if found. If no obvious cause is found and serious illness has been ruled out by a complete history and physical (especially neurologic exam), patient may be discharged with a follow-up appointment with ENT for further, specialized evaluation.

Nasal trauma.
1、Septal hematoma. Diagnosis requires a high index of suspicion, direct inspection of the septum after any nasal trauma, and recognition. The main symptom is progressive posttraumatic nasal obstruction. The nostril may be obstructed by a large, soft, red, or bluish mass. Its appearance can be confused with a polyp, a deviated septum, or enlarged turbinates. Septal hematomas can be easily missed unless the entire septum is observed visually and palpated with a blunt instrument.
1）、Evacuation of the hematoma within 48 hours is necessary to avoid avascular necrosis of the cartilage, abscess formation, or saddle deformity of the nose.
2）、Any finding of a boggy, fluctuant septum that is tender out of proportion to other findings warrants treatment.
3）、Treatment of septal hematoma.
1、Vasoconstrict and anesthetize the nasal mucosa with topical phenylephrine-tetracaine or cocaine.
2、Make a long vertical incision through the mucosa overlying the hematoma.
3、Use suction or normal-saline lavage to clean out all clots and place a sterile rubber band drain above the exposed cartilage.
4、Pack with a Merocel "rocket" or with petrolatum (Vaseline) gauze as described in the epistaxis section.
5、Place the patient on broad-spectrum antibiotic therapy. Reexamine, reaspirate, and repack daily while instructing the patient to avoid activities (nose-blowing, nasal sneezing) that increase nasal and sinus pressures.
6、If no recurrence of hematoma is seen, remove the drain and repack the nasal passage for final removal 24 hours later. Antibiotics may be stopped when the packing is discontinued.
7、Bilateral hematomas are handled in a similar manner, but ensure that the incisions are staggered over the septum so that no cartilage is underperfused on both sides.
2、Nasal fracture. Palpate dorsum of nose for deformity, instability, crepitus, and tenderness after any blunt injury causing bleeding from the nose. Diagnosis is confirmed by radiographs. However, treatment is based on presence of deformity when swelling is resolved, and so deferring radiographs until swelling is resolved is acceptable; this should be discussed with the patient. Initial bleeding should be controlled and septal hematoma ruled out. Early reduction is possible if the injury is acute and swelling insignificant. Closed reduction should occur within 3 to 7 days for children and 5 to 10 days for adults.

Otitis Media
A、General. Otalgia, fever, irritability, previous or coexisting URI, ear rubbing, and feeding problems are common presenting symptoms. However, any of the above symptoms, including ear pain and fever, may be absent. Many episodes are viral in origin. The most common bacterial pathogens are Pneumococcus, Haemophilus influenzae, and Moraxella catarrhalis.
B、Diagnosis. Diagnosis involves adequate observation of the tympanic membrane (TM), which may require cerumen removal. Hyperemia of the TM is an early sign of otitis media, but "red ear" alone does not establish the diagnosis. Other findings include bulging of the TM, indistinct landmarks, diminished light reflex, and limited mobility on pneumatic insufflation. Mastoiditis, meningitis, and abscess are possible complications. Of most concern, however, is impairment of hearing associated with middle ear effusion. Tympanometry may be used to establish the presence of fluid in the middle ear.
C、Treatment. Treatment with antibiotics is standard of care in the United States though this is not the case in many other developed countries. 81% of cases of OM will resolve spontaneously. It is necessary to treat 7 patients to effect the outcome in 1 patient. It is difficult if not impossible to demonstrate the superiority of one antibiotic over another. Start with low-cost agents and those that are well tolerated. If no response in 48 to 72 hours, consider changing antibiotic.
The most cost-effective agents.
Amoxicillin 40 mg/kg/day divided TID (125 mg/5 ml or 250 mg/5 ml suspensions) for 10 days [$14].

Trimethoprim-sulfamethoxazole oral suspension 1 ml/kg/day divided BID (8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per day) for 10 days [$25]. Avoid in children less than 2 months of age.

Erythromycin-sulfisoxazole dosed as 50 mg of erythromycin per kilogram per day divided QID (suspension is 200 mg of erythromycin per 5 ml) for 10 days [$47].



The "second-line" drugs, which are more expensive.
Cefaclor 40 mg/kg/day divided BID for 10 days (suspensions dosed 125 mg/5 ml, 250 mg/5 ml) [$68].

Amoxicillin-clavulanate dosed as 40 mg amoxicillin/kg/day divided TID for 10 days [$66].

Cefixime 8 mg/kg single daily dose or divided BID (100 mg/5 ml suspension) for 10 days [$71].

Clarithromycin 500 mg PO BID or 7.5 mg/kg PO BID for children.



Recently, ceftriaxone 50 mg/kg IM has been shown to be almost as effective as a traditional 10-day course of antibiotics. However, it is expensive and, because of emerging resistant bacteria, should be reserved for cases in which compliance is questionable.

If there is evidence of TM rupture (purulent drainage from canal), add Cortisporin otic suspension QID. The solution is acidic and tends to sting when administered.

Although traditional, a follow-up exam is not necessary in the asymptomatic patient who is older than a range of 15 months to 2 years of age. If, however, the patient is still symptomatic or the parent does not believe the otitis is resolved, follow-up exam can be done at 2 weeks.

In adults, complete resolution of symptoms such as ear fullness may take 6 weeks.

Decongestants play no role in the resolution of acute otitis media though they may be needed for associated conditions.

Pain control with topical solutions (such as Auralgan) or systemic agents such as acetaminophen, ibuprofen, or acetaminophen with codeine or hydrocodone may be required from patient comfort.


D、For Recurrent Acute Otitis MediaAntibiotic prophylaxis (such as a single dose of amoxicillin or TMP/SMX at bedtime) should be considered for recurrent disease. Avoiding exposure to cigarette smoke may be helpful. Referral for discussion of tympanostomy tube placement should be considered if there is chronic bilateral effusions of more than 3 months in duration, unilateral effusion of more than 3 months in duration, language-development delay, hearing loss of >20 dB, or failure of antibiotic prophylaxis.

Epistaxis
Causes. Nose picking, external trauma, dry nasal mucosa with vascular fragility, foreign bodies, blood dyscrasias, neoplasms, infections, vitamin deficiencies, toxic metal exposures, septal deformities, telangiectasias, angiofibromas, and aneurysm ruptures.
Determining the source of bleeding is often the most difficult part of the examination.
The posterior area of the nose is supplied by the ethmoid arteries (from the superior internal carotids) and the sphenopalatine arteries (from the external carotids); bleeding from these vessels is often difficult to control.
Kiesselbachs arterial plexus supplies the more easily controlled anterior nasal mucosa.
If the bleeding has been prolonged, check the patients Hb and HCT. A PT/INR, PTT, and platelet count may also be indicated depending on the clinical situation.
Gather a nasal speculum, a "hands-free" head mirror or lamp, suction with a Frazier suction tip, cocaine or tetracaine-epinephrine solution spray applicator, an electrocautery pencil, silver nitrate sticks, nasal packing (Merocel sponge "nasal rocket" packs, Vaseline gauze), and bayonet forceps to examine and treat a comfortable sitting or supine patient. If bleeding is easily seen and is coming from the septum, direct pressure to the site after generously spraying of the area with the vasoconstrictor-analgesic solution may be sufficient (pinch nose for 10 to 15 minutes).
If this doesnt work, try silver nitrate for small bleeders or electrocautery for the larger vessels on a well-anesthetized septum. Although there is no clear advantage to electrocautery, it may be effective in a patient who fails chemical cautery.
If this is ineffective, or if the bleeding is from under the turbinates, insert the dry Merocel pack entirely into the nostril (using a lubricant such as K-Y Jelly) and moisten it with phenylephrine or saline until it has completely formed to the convoluted nasal passage, leaving it in as necessary for bleeding control for at least 48 hours. Alternatively, pack with Vaseline gauze soaked with phenylephrine.
Patients with COPD could suffer hypoxic distress because the nasopulmonary reflex produces a drop in the PO2 by 15 mm Hg in most people who have their noses packed!


Prescribe to all patients requiring nasal packing broad-spectrum antibiotics while they are packed; TMP/SMX, amoxicillin-clavulanate, clarithromycin, or cefadroxil are good choices.
Examine the uvula. If its still dripping blood, hemostasis is inadequate and posterior packing may be required. Temporizing measures include the use of one of several commercially available posterior nasal packs or the use of a Foley catheter inserted into the posterior nasal area and inflated. Anyone requiring posterior packing should also have an anterior pack placed. Obtain an otolaryngologic consultation and hospitalize any patient with a posterior nose bleed for observation or vascular intervention.
Consult with an otolaryngologist if posterior packing is required, if nose requires repacking several times during a single ED visit, or for any patients develop signs or symptoms of an infection.

Peritonsillar Abscess (Quinsy)
General. A localized area of abscess that is typically unilateral and occurs in patients with tonsillitis.

Cause. Depending on the series, the most common organism is Streptococcus followed by anaerobes.

Clinically. Symptoms include severe throat pain with radiation to the ear, drooling from inability to swallow saliva, trismus, and fever. Almost pathognomonic of a peritonsillar abscess is a muffled, "hot potato," voice. On exam there is unilateral swelling of the palate and anterior pillar with displacement of the tonsil downward and medially and movement of the uvula away from the involved side.

Treatment. IV or IM penicillin and tonsillectomy. Several series have documented good results using oral antibiotics and needle drainage, which may need to be done many times. The major concern is the possibility of airway obstruction though this is a very rare event. ENT consultation is recommended.