EAR, NOSE, AND THROAT PROBLEMS
| OFFICE OTOLARYNGOLOGY —Paul A. Kedeshian, MD, Assistant Clinical Professor of Otolaryngology, Head and
Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles
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| Eustachian tube (ET) dysfunction: patient typically complains of aural fullness and/or clicking or popping sounds
in ears, and may have history of allergies; evaluate tympanic membrane (TM) with otoscope, then use insufflation bulb
to assess TM mobility and tenderness; use tympanography to assess degree of TM mobility and to rule out other middle
ear problems, eg, effusion; treatment—includes nasal corticosteroid sprays, saline lavage, and antihistamines,
with or without decongestants; have patient regularly insufflate ear by pinching nose and performing Valsalva maneuver
to clear pressure in middle ear
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 | Points: oral corticosteroids often helpful; significant gastroesophageal reflux disease (GERD) can adversely affect ET
function
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| Middle ear effusion: characterized by otalgia, hearing loss, and effusion line (bubbles or fluid line) on otoscopic examination;
if effusion develops in adult without other ear problems, suspect nasopharyngeal cancer or mass;
management—oral antibiotics and oral corticosteroids to dry up fluid in middle ear space and reduce inflammation; if
problem persists, insert pressure equalization (PE) tube
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| Hemotympanum: purplish TM; suspect preexisting trauma (may be subtle) or use of anticoagulants; if trauma suspected,
perform computed tomography (CT) of temporal bone and audiography (may reveal subtle temporal bone fracture); usually
resolves spontaneously over 1 to 3 mo; if condition does not resolve, consider placing PE tube
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| Tympanosclerosis: characterized by white plaque-like deposits on TM; almost always related to history of otitis media; no
treatment required, but referral indicated if mobility of TM impaired
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| TM perforations: usually due to pressure and/or fluid accumulation in middle ear space, but also caused by trauma; diagnostic
work-up—test for conductive hearing loss; ask about pain; check for otorrhea and infection; treatment—oral
antibiotics if otorrhea present, otherwise, antibiotic eardrops; patient must take precautions to prevent water from getting
in ear (ie, no swimming, no submersion, water-tight seal during showering); may resolve spontaneously in 1 to 2 mo if
perforation small or due to trauma
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| Otitis externa: exquisitely painful; canal edema and conductive hearing loss always present; can usually elicit history of
trauma to external auditory canal; bacteria (including Pseudomonas) may be present; treatment—remove debris and
reduce edema; treat underlying infection with antibiotics; carefully insert wick to press edema out of canal and to facilitate
delivery of otic drops with antipseudomonal coverage (eg, dexamethasone and tobramycin [TobraDex]; ciprofloxacin
and hydrocortisone [Cipro HC Otic]; ciprofloxacin [Ciloxan]); oral antibiotics (if given) should cover
Pseudomonas
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| Malignant otitis externa (skull-base osteomyelitis): suspect in immunocompromised and diabetic patients; may manifest
full range of cranial neuropathies (seventh most common); requires lengthy hospitalization for intravenous (IV) antibiotics
(≥2 drugs; cover Pseudomonas); may be fatal; neuropathy may persist
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| Exostosis: hypertrophy of bony external auditory canal; due to long-term exposure to cold water; may lead to conductive
hearing loss and/or recurrent infections due to fluid and debris in ear canal; no specific therapy indicated in most cases;
however, referral sometimes required for surgery
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| Nasal polyps: associated with chronic allergy; often seen by just looking at anterior aspect of nasal cavity; can cause obstruction
of sinus ostia and secondary acute sinusitis; associated with Samter’s triad (nasal polyps, asthma, and hypersensitivity
to aspirin); limited CT of sinuses only radiographic study required; treatment—if patient has acute sinusitis and nasal
polyps, give parallel courses of antibiotics and oral corticosteroids; antihistamines, with or without decongestants; nasal and
sinus lavage; key therapies—corticosteroids and surgery; points—nasal polyps have high recurrence rate, even with extensive
surgery
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| Septal hematoma: often results from nonsevere nasal trauma; may look like small purplish or reddish bulge on anterior
aspect of nasal septum; may occur in patients on anticoagulants; needle aspiration indicated if hematoma no more than 2
to 3 days old; if nothing removed on aspiration, do imaging study or reexamine patient in 3 to 5 days; unresolved hematoma
may lead to septal erosion
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| Bluish lesion on lip: accumulation of mucus in submucosal space; associated with trauma to mucus duct (lip biting);
may be popped with needle; occasionally leads to superinfection; treat by excision
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| Oral leukoplakia: sometimes premalignant lesion; usually presents on lateral aspect of tongue or on buccal mucosa; appearance
usually “very bland” (ie, whitish shallow plaque); presence of deeper invasion into substance of tongue or cheek and/or
pain or tenderness indicates more significant problem, often increased malignancy potential; comments—presence of reddish
or pinkish patches (erythroplakia) associated with high rate of transformation to malignancy (25%-30%); do biopsy if patient
insists or if plaque has nonbland-looking area; index of suspicion for malignancy highest among tobacco users and those
with risk factors for head and neck and oral cancers (eg, heavy alcohol use)
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| Geographic tongue: asymmetric hypertrophy of papillae of tongue; etiology unknown; rarely symptomatic; drugs generally
do not improve condition; may be exacerbated by low-level GERD; if patient has GERD, give 2- to 3-mo trial of
proton pump inhibitor (PPI) once daily and offer nutritional advice, then reevaluate
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| Tonsillitis: manifestations include exudates, cryptic enlargement of gland, hypertrophy, and “tonsil stones”; halitosis sometimes
present; give antibiotics for acute infection; give oral corticosteroids in presence of severe odynophagia and/or hypertrophy;
surgery indicated after acute infection if airway obstruction or halitosis remains; asymmetry of tonsils may indicate
malignancy within one tonsil (eg, lymphoma)
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| Peritonsillar abscess: almost always associated with shifting of uvula off midline; bulging of soft palate also usually
present, along with trismus; patients may have muffled voice; perform needle aspiration under anesthesia (more chance
for recurrence than with incision and drainage)
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| Parotitis: sometimes associated with erythema and fever; seen with increased frequency in patients who are diabetics, immunocompromised,
or have undergone radioiodine therapy; dehydration one of hallmarks; treatment includes antibiotics
(if infection present), adequate hydration, and use of sialagogues (add teaspoon of lemon or lime juice to 8 oz of
water bid), and direct massage over salivary gland
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| Inflammation of submandibular salivary gland: gland likely to contain stones; treatment essentially same as for parotitis;
surgical intervention sometimes required
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| Neoplasms of parotid: 80% benign; think malignancy if ipsilateral facial nerve weakness, pain, and/or adenopathy present;
ask about history of cutaneous malignancies; diagnostic work-up includes magnetic resonance imaging (MRI) of parotid,
followed by fine-needle aspiration biopsy; treatment usually surgical
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| Second branchial cleft cyst: most common lateral neck mass; not malignancy; painless fluctuant mass, sometimes contains
fluid, occasionally pus; almost always palpable; usually becomes apparent after upper respiratory tract infection (URI);
simultaneous ipsilateral tonsillectomy may be required during excision
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| EAR, NOSE, AND THROAT (ENT) EMERGENCIES AND URGENCIES —J. Gary Rose, MD, Assistant Professor of
Surgery, Division of Otolaryngology, University of Vermont College of Medicine, Burlington
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| Auricular hematoma: usually due to blunt trauma; shear injury (perichondrium slides off cartilage and bleeding occurs
in between); failure to treat results in “cauliflower ear”; usually comes back unless aspirated early; early treatment includes
fine-needle aspiration, followed by bolster dressing; if treatment delayed, surgical incision and drainage required
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| Otitis media: usual treatment analgesics and eardrops; antibiotics reserved for cases that do not resolve; neonates and immunocompromised
patients at particularly high risk for complications; infection spreading into other parts of ear can
cause mastoiditis, subperiosteal abscess, petrous apicitis, abducens palsy, labyrinthitis, vertigo, and facial paralysis; infection
spreading into brain can cause meningitis, epidural abscess, brain abscess, and sigmoid sinus thrombosis
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| Sudden hearing loss: patients typically complain of fullness or pressure in ear or unilateral hearing loss; etiology probably
viral, following URI or vascular problem (infarct) to ear; presence of dizziness denotes worse prognosis
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| Membrane rupture (perilymph fistula): usually seen in someone who has been straining, bending over, or has barotrauma;
patient typically hears “pop” in ear, then gets dizzy, followed by progressive hearing loss; requires immediate attention
to prevent permanent hearing loss
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| Work-up for sudden hearing loss: audiography; blood tests to look for hypercoagulable state, anemia, or leukemia; rule
out syphilis; point—10% of acoustic neuromas present as hearing loss; management—corticosteroids
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| Temporal bone fractures: usually due to motor vehicle accidents (MVAs); manifestations include facial nerve paralysis
(immediate onset indicates cut nerve, requiring surgery; gradual onset usually due to pressure and treated with corticosteroids);
other signs of fracture include raccoon eyes, blood behind eardrum, and laceration in ear canal; diagnostic
work-up includes temporal bone CT; treatment—treat facial nerve paralysis and cerebrospinal fluid (CSF) leak conservatively;
determine cause and type of hearing loss (eg, sensorineural, conductive) with tuning fork
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| Bell’s palsy (idiopathic facial paralysis): probably caused by herpesvirus; more common in diabetics and pregnant
women; rule out other causes of facial paralysis, eg, parotid tumor, cholesteatoma; treat with antiviral drugs and corticosteroids;
protect eyes from keratitis and corneal ulceration with moisture chamber and by applying artifical tears (day) and
ointment (night); avoid taping eye closed
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| Ramsay-Hunt syndrome (herpes zoster oticus): another cause of facial paralysis; lesions on ear resemble chickenpox;
treatment involves use of antivirals and corticosteroids; prognosis not as good as for Bell’s palsy
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| Otitis externa: causative organisms include Staphylococcus, Pseudomonas, and Proteus; management includes cleaning
ear, inserting wick, then inserting drops; if black spots or white filaments seen, suspect fungal infection and apply
clotrimazole (Lotrimin) 1% solution
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| Necrotizing otitis externa: caused by Pseudomonas; seen in immunocompromised and diabetic ketoacidotic patients;
erosion through ear canal into temporal bone; treat with antipseudomonal drugs (eg, Cipro) IV or orally
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| Epistaxis: reassure patient bleeding not life-threatening; bleeding usually anterior; diagnostic work-up—ask if patient
on warfarin (Coumadin) or has hereditary telangiectasia; rule out other medical problems; inspect nose using nasal
speculum and good light source; use suction to find source of bleeding; suck out clot, if present; when bleeding resumes,
give cocaine or other vasoconstrictor (eg, oxymetazoline [Afrin, NeoSynephrine]); once bleeding site found,
cauterize it with silver nitrate; if site cannot be found, insert posterior pack for 3 to 5 days, and give antibiotics (may infiltrate
pack with antibiotic solution)
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| Posterior epistaxis: usually managed in hospital; speaker first inserts posterior balloon pack and sponge, then anterior
pack against posterior pack; if bleeding site found, cauterize or embolize it in operating room
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| Fractures: nasal—treat early (patient may need rhinoplasty 3 mo to 1 yr later if treatment delayed); move bone back
into place under anesthesia; rule out complications, eg, septal hematoma (can lead to saddle deformity; requires early
drainage); mandible—manifestations include dental malocclusions; work-up includes dental x-rays, CT or mandible series;
if 1 mandible fracture seen, look for another; midface—often due to MVA; associated with airway problems and
CSF leaks; get CT; treatment involves surgical repair
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| Sinusitis: infection can spread into eye (causing orbital cellulitis) or intracranially; can cause osteomyelitis of frontal
bone; in diabetics and immunocompromised patients, look for signs of mucormycosis (lax turbinate, necrotic area)
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| Retropharyngeal abscess: usually seen in young children; x-rays taken on expiration; peritonsillar abscess—
usually occurs in young people with history of tonsillitis; manifestations include unilateral sore throat, trismus, low-
grade fever, pain, and swelling of neck; soft palate typically swollen and uvula usually deviated; treatment involves needle
aspiration of soft palate to remove pus
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| Angioedema: can be caused by angiotensin-converting enzyme (ACE) inhibitors; swelling in mouth; airway emergency,
sometimes requiring tracheotomy
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| Foreign body aspiration: manifestations include coughing and wheezing; x-rays may help make diagnosis; bronchoscopy
diagnostic and therapeutic; esophageal foreign bodies—do rigid esophagoscopy to remove object; call poison control
center if battery removed (caustic ingestion; do not induce vomiting)
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| Trauma to neck: blunt—“think laryngeal trauma” if patient slightly hoarse; evaluate with flexible laryngoscopy; hematoma
on vocal cords bad sign and indication for CT to detect possible broken larynx; penetrating—evaluate with angiography;
if expanding hematoma present, refer immediately for surgery
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| Upper airway problems: initial management for obstruction includes oxygen, racemic epinephrine, corticosteroids,
and intubation; for severe obstruction, consider fiberoptic laryngoscopy and intubation through nose; avoid cricothyrotomy
in children
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| Croup vs epiglottitis: croup—etiology viral; occurs in young children; presents with cough and biphasic stridor; steeple
sign seen on x-ray; epiglottitis—etiology bacterial; occurs in slightly older children; inspiratory stridor; swollen epiglottis
seen on x-ray; children look sick but typically do not move much or cry (children with croup typically cry and
cough)
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Educational Objectives
| The goal of this program is to educate the listener about ear, nose and throat problems. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. Evaluate patients with eustachian tube dysfunction, middle ear effusions, and tympanic membrane perforations.
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| 2. Diagnose and treat otitis externa.
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| 3. Evaluate patients with nasal polyps, septal hematomas, oral leukoplakia, geographic tongue, tonsillitis, peritonsillar
abscess, and parotitis.
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| 4. Deal with ear, nose, and throat emergencies and urgencies, including auricular hematoma, sudden hearing loss, temporal
bone fractures, Bell’s palsy, herpes zoster oticus, necrotizing otitis externa, nasal fractures, and epistaxis.
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| 5. Care for patients with broken jaws, midface fractures, sinusitis, angioedema, foreign body aspiration, airway obstruction,
croup, and epiglottitis.
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Discussed on This Program
Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR, Proquin XR ]
Ciprofloxacin and hydrocortisone [Cipro HC Otic]
Ciprofloxacin and neomycin sulfate [Coly-Mycin S Otic, Cortisporin-TC Otic]
Clotrimazole [Lotrimin, others]
Cocaine [Cocaine HCl, Cocaine Viscous]
Dexamethasone and tobramycin [TobraDex]
Oxymetazoline HCl [Afrin, Neo-Synephrine, others]
Racepinephrine (racemic epinephrine) [microNefrin, Nephron, S2]
Silver nitrate
Warfarin sodium [Coumadin]
Suggested Reading
Badran K, Jani P: How we do it: a new ‘one step” ear wick. Clin Otolaryngology 31:151, 2006; Burton MJ,
Doree CJ: Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev
(1):CD004461, 2004; Butler CC, MacMillan H: Does early detection of otitis media with effusion prevent delayed
language development. Arch Dis Child 82:96, 2001; Cetinkursun S et al: Safe removal of upper esophageal coins by
using Magill forceps: two centers’ experience. Clin Pediatr (Phil) 45:71, 2006; Del Mar CB et al: Antibiotics for sore
throat. Cochrane Database Syst Rev (4)CD000023. 2000; Gabor R: High humidity, low humidity, and mist therapy for
croup. JAMA 296:393, 2006; Ghanem T et al: Rethinking auricular trauma. Laryngoscope 11:1251, 2005; Hajioff D:
Otitis externa. Clin Evid 14:669, 2005; He L et al: Acupuncture for Bell’s palsy. Cochrane Database Syst Rev
(1):CD002914, 2004; Johnson D: Croup. Clin Evid 14:310, 2005; Johnson RF et al: An evidence-based review of
the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 128:332, 2003; Jones SE, Mahendran S: Interventions
for acute auricular hematoma. Cochrane Database Syst Rev (2):CD004166, 2004; Knutson D, Aring A: Viral
croup. Am Fam Physician 68:535, 2004; Kucik CJ, Clenney T: Management of epistaxis. Am Fam Physician
71:3056, 2005; Little DC et al: Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr
Surg 41:914, 2006; Ma Y et al: Topical treatment with growth factors for tympanic membrane perforations: progress toward
clinical application. Acta Otolaryngol 122:586, 2002; Moore M, Little P: Humidified air inhalation for treating
croup. Cochrane Database Syst Rev (3):CD002870, 2006; Nelson HS: Advances in upper airway diseases and allergen
immunotherapy. J Allergy Clin Immunol 117:1047, 2006; Phillips JS, Jones SE: Hyperbaric oxygen as an adjuvant
treatment for malignant otitis externa. Cochrane Database Syst Rev (2):CD004617, 2005; Pichichero ME: Acute otitis
media: improving diagnostic accuracy. Am Fam Physician 61:2051, 2000; Rachelefsky GS: National guidelines
needed to manage rhinitis and prevent complications. Ann Allergy Asthma Immunol 82:296, 1999; Rosenfeld RM et
al: Clinical practice guidelines: acute otitis externa. Otolaryngol Head Neck Surg 134(4 Suppl):S4, 2006; Rosenfeld
RM, Post JC: Meta-analysis of antibiotics for the treatment of otitis media with effusion. Otolaryngol Head Neck Surg
106:378, 1992; Smith MT, Wong RK: Esophageal foreign bodies: types and techniques of removal. Curr Treat Options
Gastroenterol 9:71, 2006; Teichgraeber JF, Russo RC: Treatment of nasal surgery complications. Ann Plast Surg
30:80, 1993; van Heerbeek N et al: Therapeutic improvement of eustachian tube function: a review. Clin Otolaryngol
Allied Sci 27:50, 2002; Vincent MT et al: Pharyngitis. Am Fam Physician 69:1465, 2004; Wei BP et al: Steroids for
idiopathic sudden sensorineural hearing loss. Cochrane Database Syst Rev (1):CD003998, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Kedeshian was recorded in Beverly Hills, CA, June 9, 2006, at the annual Family Practice Refresher Course,
sponsored by the David Geffen School of Medicine at the University of California, Los Angeles. Dr. Rose spoke June
16, 2006, in Burlington, VT, at the annual Family Medicine Review Course, sponsored by the University of Vermont
College of Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for making this program
possible.
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