ENT PROBLEMS/BACK PAIN
From the 34th annual Family Practice Refresher Course, sponsored by the David Geffen School of Medicine at the
University of California, Los Angeles
| COMMON PROBLEMS IN OTORHINOLARYNGOLOGY —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: common complaint; diagnosis depends on subjective symptoms (eg, aural fullness,
popping sounds in ears) as well as physical examination; may or may not be associated with history of allergies or
environmental insults; patients may complain of “plugged up” ears; evaluate tympanic membrane (TM) with otoscope
and pneumatic insufflation to rule out perforation, middle ear effusion, and abnormalities on surface of TM that change or
alter light reflex; tympanography—probe in ear canal applies pressure to TM, producing deformation and reformation of
TM as applied pressure changes; helpful in assessing ET dysfunction (pressure in middle ear space lower than atmospheric)
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 | Treatment: includes saline lavages of nasal cavity, nasal corticosteroid sprays, antihistamines, and decongestants; have
patient regularly insufflate ear by pinching nose and trying to make ear “pop”; oral corticosteroids usually reserved for
patients refractory to other forms of therapy or who have life situations that subject them to frequent shifts in air pressure,
eg, flight attendants; significant gastroesophageal reflux disease (GERD) can adversely affect ET function; reserve
placement of ventilation tubes for persistent ET dysfunction with intermittent middle ear effusion
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| Middle ear effusion: characterized by otalgia and subjective hearing loss; otoscopic examination should reveal presence of
effusion, with significantly reduced or absent movement of TM on insufflation; suspect mass in nasopharynx of adult who develops
new-onset effusion without other ear problems; unlike ET dysfunction, tympanogram essentially flat (ability of TM to
move so impaired that pressure shifts produce no response); treatment—includes oral antibiotics, trial of oral corticosteroids,
and placement of pressure equalization (PE) tube if condition persists; consider limited computed tomography (CT) of sinonasal
cavity (includes portions of posterior nasopharynx) to check for mass lesion or other soft tissue abnormality
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| Hemotympanum: typically associated with history of trauma; work-up should include computed tomography (CT) of
temporal bones (to look for fracture) and audiography (should demonstrate hearing loss); tympanogram should be flat as
in effusion; usually resolves spontaneously over 4 to 12 wk; reserve antibiotics for patients who are immunosuppressed,
bleeding along external auditory canal, or who have indications of superinfection; if condition fails to resolve and there
are no abnormalities on temporal bone CT, consider placing PE tube
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| Tympanosclerosis (ie, myringosclerosis): characterized by white plaque-like deposits on surface and between leaflets
of TM; usually related to history of frequent otitis media in childhood; reserve treatment for patients with abnormality
or impairment of TM function
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| TM perforations: usually associated with trauma or infection; characterized by accumulation of pressure and/or fluid in
middle ear, conductive hearing loss, and potential for otorrhea and recurrent middle ear infection; treatment—oral antibiotics;
course of ear drops (type used less important than regular use); dry-ear precautions (eg, avoid submerging head under
water; place cotton balls in ear canal before showering); if otorrhea fails to resolve, refer for aspiration of fluid; dry TM
perforation—associated with hearing loss; may heal spontaneously if small or posttraumatic; reevaluation indicated at 3 to
8 wk to make sure it remains dry; surgery occasionally required
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| Otitis externa: auditory canal exquisitely painful and tender; pain exacerbated if any pressure applied to ear itself, or if patient
yawns or chews; associated with significant canal edema, otorrhea, and conductive hearing loss (resolves when condition
cleared); usually due to history of trauma to external auditory canal, usually via device used for cleaning; culture—
shows multiple bacterial species, with Pseudomonas being most important; treatment—aggressive treatment indicated
in patients who are immunocompromised, particularly those with diabetes; give antibiotics with antipseudomonal coverage,
eg, ciprofloxacin (both orally and in eardrops); placement of ear wick by otolaryngologist to press edema out of canal
and facilitate delivery of antibiotic ear drops
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| Malignant otitis externa (skull base osteomyelitis): suspect in immunocompromised patient; characterized by ear pain,
along with some degree of facial paralysis and immunocompromised state; aggressive treatment indicated for cranial
neuropathy; patients often hospitalized and given intravenous (IV) antipseudomonal antibiotics; scan indicated to delineate
bone erosion in skull base; debridement used to remove debris; bone scan may be required to follow resolution
of osteomyelitis; associated cranial neuropathies reversible only if condition does not become advanced
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| Exostosis: hypertrophy of bone in external auditory canal; secondary to frequent cold water exposure over long term; no
treatment usually required; tell patients to remove all water from auditory canal; surgery indicated only if total occlusion
of ear canal develops
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| Nasal polyps: usually associated with chronic allergy in nasal cavity; sometimes mistaken for significant hypertrophy of
turbinates; can cause anatomic obstruction of sinus ostia and secondary acute sinusitis; associated with inflammatory process,
eg, asthma; Sampter’s triad often present (nasal polyps, asthma, aspirin hypersensitivity); limited noncontrast CT of
sinuses only radiologic study required to make diagnosis; treatment—nasal steroids and surgical removal only measures
shown to eradicate nasal polyps for short periods; other modalities for treating complications include antibiotics, oral corticosteroids,
antihistamines, decongestants, nasal and/or sinus lavage, and surgery; remark—if oral steroids given,
course of nasal steroids should follow
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| Nasal septal hematoma: usually associated with trauma, not necessarily nasal bone fracture; needle aspiration or incision
and drainage often indicated to prevent development of saddle nose deformity
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| Mucocele: characterized by accumulation of mucus in submucosa secondary to obstruction of duct that brings mucus to
surface; may be due to trauma; most common on labial and buccal surfaces; reserve antibiotics for superinfection; consider
surgical removal if it becomes very large and gets superinfected regularly
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| Oral leukoplakia: white plaque typically present on lateral aspect of tongue or on buccal mucosa along occlusal line;
usually associated with chronic inflammation or irritation; premalignant potential <5%; superficial lesions considerably
less worrisome than those with depth; reddish patches (erythroplakia) associated with higher (20%-25%) premalignant
potential and should be biopsied
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| Geographic tongue: asymmetry or hypertrophy of papillae of tongue; etiology unknown; rarely symptomatic; drug
treatment usually unnecessary; may be exacerbated by GERD (in those patients, consider 3-6 wk course of proton pump
inhibitor [PPI] or histamine-2 [H2 ] blockers)
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| Torus palatini and torus mandibularis: bony overgrowths on hard palate or inner aspect of mandible; treatment
not indicated unless irregularities present on mucosal surface or if involved area site of future denture
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| Tonsillitis: infection of palatine tissues; one typically sees exudates, sometimes cryptic enlargement, hypertrophy, or tonsil
stones; antibiotics indicated for acute infection; give steroids in presence of severe odynophagia; surgical removal indicated
if patient having chronic infections, chronic inflammation, or frequent illness severely affecting quality of life (in
adults, no threshold number of infections to indicate removal)
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| Tonsillar lymphoma: characterized by massively enlarged tonsil; lymphoma usually B-cell type, developing within
lymphoid tissue of tonsils; have high index of suspicion if asymmetry present; sometimes associated with cervical adenopathy
or constitutional symptoms
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| Peritonsillar abscess: patients typically very sick, with bulge in soft palate; these patients have abscesses that require
either needle aspiration or incision and drainage, followed by antibiotics and steroids; reaccumulation can follow
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| Parotitis: inflammation of parotid gland usually; associated with inflammatory process within ductal system; seen with
increased frequency in immunocompromised people, eg, diabetics; often associated with history of dehydration, rarely
with stone (sialolith); treatment includes antibiotics, adequate hydration, teaspoon of water with lemon or lime juice
tid, and heat and massage directly over gland; reevaluate in 1 to 3 wk
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| Inflammation of submandibular salivary gland: sialolith frequently present with pain and swelling; conservative therapy
seldom effective in dislodging stone; first treat infection, then refer for potential excision of gland and duct with stone;
recurrent infection commmon
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| Neoplasms in parotid: most benign; think malignancy if ipsilateral facial paralysis associated with enlargement in
gland, particularly in older patient; diagnostic work-up should include magnetic resonance imaging (MRI) of parotid
gland, sometimes followed by fine-needle aspiration; treatment usually surgical excision
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| Second branchial cleft cyst: typically presents in lateral aspect of neck; usually painless, and has some degree of fluctuance;
almost always occurs after upper respiratory infection; excision generally indicated
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| Thyroglossal duct cyst: most common congenital neck mass; in adults, usually presents as noninfected, nonerythematous
soft midline neck mass; almost always associated with superinfection in children; obtain CT of neck before excision
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| Bell’s palsy: usually involves paralysis of all branches of facial nerve; onset sudden; usually associated with viral prodrome
(probably involving herpes simplex); diagnosis of exclusion; rule out mastoid or ear infection, lesions within parotid
gland, and other neurologic processes; treatment includes oral corticosteroids and antiviral drugs for 7 to 10 days;
reassessment essential
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| Questions and answers: antibiotics for otitis externa—most patients managed with ≥1-wk course of oral anti-
pseudomonal antibiotics and tobramycin and dexamethasone (TobraDex) drops or ciprofloxacin and dexamethasone
(Ciprodex) drops; nasopharyngeal carcinoma—typically presents in adults with epistaxis, nasal obstruction, and some
degree of hearing loss; usually associated with ipsilateral neck mass in posterior aspect of neck
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| BACK PAIN —Jeffrey C. Wang, MD, Associate Professor of Orthopaedic and Neurosurgery, David Geffen School of
Medicine at the University of California, Los Angeles
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| Introduction: most spine conditions self limited; relatively few patients with spinal disorders require surgery; if sciatica
included, >90% of population experiences at least one episode of disabling back or leg pain during lifetime
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| Major causes of neck and lower back pain: arthritis of bones, discs, or facet joints; torn ligaments; nerve compression;
muscle strains
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| Speaker’s approach: if patient has neck or back pain, first consider structural spinal problem; if patient has primarily
arm or leg pain, think radicular problem (eg, pinched nerve); points—symptoms may provide clues about cause of problem;
physical examination can rule out urgent conditions; imaging studies confirmatory; spinal degeneration associated
with advancing age; understand angles and normal curvature of spine
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| Diagnostic work-up: look for Waddell signs (indicate nonorganic, psychologic, or secondary gain issues, eg, litigation,
workers’ compensation); have patient color in on skeletal drawing where pain located; history—inquire about inciting
event; ask about aggravating factors (eg, certain positions), neurologic symptoms (eg, numbness, weakness), presence
of groin pain (typically due to hip problem); medial ankle, lateral ankle, or testicular problem can cause S1 pain; probe
for history of malingering; ask about smoking (associated with back pain and degenerative disc disease); imaging studies
generally reserved for patients with “red flags”; try conservative therapy before resorting to surgery; injections—
have diagnostic component; if epidural injection provides pain relief at particular site, it probably denotes problem
there
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| Red flags for serious problems: bowel-bladder issues (need neuroimaging studies to examine spinal cord); weight loss;
malaise; fever and chills (check for tumor or infection); dysuria or infection in other parts of body
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| Physical examination: test for Hoffmann’s sign, hyperreflexia, and upper motor neuron signs (positive Hoffman sign denotes
problem in brain or compression in neck); check for signs of myelopathy; test for S1 problems (if patient unable
to rise on toes of affected foot or has balance problems, suspect weakness at S1); check posture (if patient bent forward
in back or neck, check for stenosis in lumbar or cervical spine); assess dermatomes and nerve roots; check for cauda
equina syndrome (saddle anesthesia, decreased rectal tone)
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| Waddell signs: seen when patients fake spinal pathology; look for same symptomatology in different position after distracting
patient; assess strength; Waddell sign patients typically overreact to manipulation
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| Disease-specific findings: arthritis of disc (more pressure on disc when sitting, less when standing or lying down);
with true radicular problem, rare to have mechanical back pain alone; herniated disc (pain usually unilateral; associated
with weakness on straight leg raise); spinal stenosis with neurogenic claudication (patients usually can walk with no fixed
distance; with vascular claudication, walking distance usually fixed); spinal stenosis (patient typically bends forward and
is subject to leg fatigue; pain sometimes absent); lumbar stenosis (characterized by shopping cart sign where patients can
walk for miles if they lean against cart; walking limited); sciatica (associated with back and leg pain with walking)
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| Imaging studies: x-rays (get anterior-posterior [AP] and lateral); MRI (shows disc herniations and signal intensity
within spinal cord); CT myelography (good for patients with significant arthritis); electromyelography (EMG; consider if
diagnosis unclear); bone scans (rarely done); MRI with gadolinium (most sensitive screening tool; abnormality seen may
not be cause of problem)
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| Conservative treatment: medications—generally reserve narcotics for acute exacerbations of pain (for 1-2 wk); switch
patients to nonsteroidal anti-inflammatory drugs (NSAIDs) as soon as possible; bed rest—no evidence that >2 days efficacious
for acute low back pain; bracing— use for first 5 to 7 days only; may help control pain for few days; chiropractic
treatment—modalities that involve exercise and mobilization of muscles have value; physical therapy—best evidence for
effective treatment of low back pain; promotes healing and strengthening of muscles; better than medication alone; passive
modalities (eg, heat, massage, ultrasound) have limited value; acupuncture—fine if it makes patient feel better; epidural
injections—provide symptom relief; also have diagnostic component
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| Surgery: reserve for refractory cases, ie, those related to structural problems
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Suggested Reading
Abdi S et al: Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 10:185,
2007; Andersson GB et al: Treatment of intractable discogenic low back pain. A systematic review of spinal fluid and
intradiscal electrothermal therapy (IDET). Pain Physician 9:237, 2006; Boswell MC et al: A systematic review of therapeutic
facet joint interventions in chronic spinal pain. Pain Physician 10:229, 2007; Brooks JK, Balciunas BA: Geographic
stomatitis: review of the literature and report of five cases. J Am Dent Assoc 115:421, 1987; Gattaz G et al:
Malignant otitis externa. Rev Bras Otorhinolaryngol 73:134, 2007; Hoffman BM et al: Meta-analysis of psychological
interventions for chronic low back pain. Health Psychol 26:1, 2007; Holmstrup P et al: Oral premalignant lesions: is a
biopsy reliable? J Oral Pathol Med 36:262, 2007; Isaacson JE, Vora NM: Differential diagnosis and treatment of
hearing loss. Am Fam Physician 68:1125, 2003; Johnson RF et al: An evidence-based review of the treatment of peritonsillar
abscess. Otolaryngol Head Neck Surg 128:332, 2003; Marchese-Ragona R et al: Treatment of complications
of parotid gland surgery. Acta Otorhinolaryngol Ital 25:174, 2005; Martell BA et al: Systematic review: opioid treatment
for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 16:1246, 2007; Michelow
P: Infective parotitis. Acta Cystol 50:601, 2006; Osguthorpe JD, Nielsen DR: Otitis externa: review and
clinical update. Am Fam Physician 74:1510, 2006; Patiar S, Reece P: Oral steroids for nasal polyps. Cochrane Database
Syst Rev (1):CD005232, 2007; Plummer C, Litewka L: The march of otitis externa. Intern Med J 37:729, 2007;
Roland PS et al: A comparison of ciprofloxacin/dexamethasone with neomycin/polymyxin/hydrocortisone for otitis externa
pain. Adv Ther 24:671, 2007; Scheid DC, Hamm RM: Acute bacterial rhinosinusitis in adults: Part I: Evaluation.
Am Fam Physician 70:1685, 2004; Shaw WS et al: Reducing sickness absence from work due to low back pain:
how well do intervention strategies match modifiable risk factors? J Occup Rehabil 16:591, 2006; van der Roer N et
al: What is the most cost-effective treatment for patients with low back pain? Best Prac Res Rheumatol 19:671, 2005; van
Geen JW et al: The long-term effect of multidisciplinary back training: a systematic review. Spine 32:249, 2007; van
Heerbeeck N et al: Therapeutic improvement of Eustachian tube dysfunction: a review. Clin Otolaryngol Allied Sci
27:50,2002.
Educational Objectives
| The goal of this program is to improve the diagnosis and medical management of patients with common ear, nose and throat
problems and back pain. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Diagnose and treat patients with eustachian tube dysfunction, middle ear effusions, hemotympanum, tympanosclerosis,
and tympanic membrane perforations.
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| 2. Manage patients with otitis externa, exostosis, nasal polyps, nasal septal hematoma, and mucoceles.
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| 3. Recognize the clinical features and provide care for patients with oral leukoplakia, geographic tongue, torus palatini,
torus mandibularis, tonsillitis, peritonsillar abscess, parotitis, neoplasms of the parotid gland, second branchial cleft
cyst, thyroglossal duct cyst, and Bell’s palsy.
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| 4. Evaluate patients complaining of low back pain and know when to order imaging studies.
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| 5. Treat patients with back pain by various conservative measures.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Wang was recorded June 1, 2007, and Dr. Kedeshian, June 2, 2007, at the 34th annual Family Practice Refresher
Course, sponsored by the David Geffen School of Medicine at the University of California, Los Angeles. The Audio-Digest
Foundation thanks the speakers and UCLA for making this program possible.
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