GEMC: Otologic and Sinus Emergencies: Resident Training

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This is a lecture by Dr. Rodney Smith from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the …

This is a lecture by Dr. Rodney Smith from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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  • 1. Project:  Ghana  Emergency  Medicine  Collabora4ve     Document  Title:  Ear  and  Sinus  Emergencies     Author(s):  Rodney  Smith  (St.  Joseph  Mercy  Hospital  Ann  Arbor),  MD  2012     License:  Unless  otherwise  noted,  this  material  is  made  available  under  the  terms  of   the  Crea9ve  Commons  A;ribu9on  Share  Alike-­‐3.0  License:     hKp://crea4vecommons.org/licenses/by-­‐sa/3.0/     We  have  reviewed  this  material  in  accordance  with  U.S.  Copyright  Law  and  have  tried  to  maximize  your  ability  to  use,   share,  and  adapt  it.  These  lectures  have  been  modified  in  the  process  of  making  a  publicly  shareable  version.  The  cita4on   key  on  the  following  slide  provides  informa4on  about  how  you  may  share  and  adapt  this  material.     Copyright  holders  of  content  included  in  this  material  should  contact  open.michigan@umich.edu  with  any  ques4ons,   correc4ons,  or  clarifica4on  regarding  the  use  of  content.     For  more  informa4on  about  how  to  cite  these  materials  visit  hKp://open.umich.edu/privacy-­‐and-­‐terms-­‐use.     Any  medical  informa9on  in  this  material  is  intended  to  inform  and  educate  and  is  not  a  tool  for  self-­‐diagnosis  or  a   replacement  for  medical  evalua4on,  advice,  diagnosis  or  treatment  by  a  healthcare  professional.  Please  speak  to  your   physician  if  you  have  ques4ons  about  your  medical  condi4on.     Viewer  discre9on  is  advised:  Some  medical  content  is  graphic  and  may  not  be  suitable  for  all  viewers.   1  
  • 2. A;ribu9on  Key     for  more  informa4on  see:  hKp://open.umich.edu/wiki/AKribu4onPolicy     Use  +  Share  +  Adapt     {  Content  the  copyright  holder,  author,  or  law  permits  you  to  use,  share  and  adapt.  }   Public  Domain  –  Government:  Works  that  are  produced  by  the  U.S.  Government.  (17  USC  §  105)   Public  Domain  –  Expired:  Works  that  are  no  longer  protected  due  to  an  expired  copyright  term.   Public  Domain  –  Self  Dedicated:  Works  that  a  copyright  holder  has  dedicated  to  the  public  domain.   Crea9ve  Commons  –  Zero  Waiver   Crea9ve  Commons  –  A;ribu9on  License     Crea9ve  Commons  –  A;ribu9on  Share  Alike  License   Crea9ve  Commons  –  A;ribu9on  Noncommercial  License   Crea9ve  Commons  –  A;ribu9on  Noncommercial  Share  Alike  License   GNU  –  Free  Documenta9on  License   Make  Your  Own  Assessment     {  Content  Open.Michigan  believes  can  be  used,  shared,  and  adapted  because  it  is  ineligible  for  copyright.  }   Public  Domain  –  Ineligible:  Works  that  are  ineligible  for  copyright  protec4on  in  the  U.S.  (17  USC  §  102(b))  *laws  in  your   jurisdic4on  may  differ   {  Content  Open.Michigan  has  used  under  a  Fair  Use  determina4on.  }   Fair  Use:  Use  of  works  that  is  determined  to  be  Fair  consistent  with  the  U.S.  Copyright  Act.  (17  USC  §  107)  *laws  in  your  jurisdic4on   may  differ   Our  determina4on  DOES  NOT  mean  that  all  uses  of  this  3rd-­‐party  content  are  Fair  Uses  and  we  DO  NOT  guarantee  that  your  use  of   the  content  is  Fair.   To  use  this  content  you  should  do  your  own  independent  analysis  to  determine  whether  or  not  your  use  will  be  Fair.     2  
  • 3. Ear  and  Sinus  Emergencies   •  Objec4ves   –  Describe  the  evalua4on  and  treatment  of  ear   disorders   –  Describe  the  evalua4on  and  treatment  of  sinus   disorders   3  
  • 4. Ear  Anatomy   Iain, Wikimedia Commons 4  
  • 5. External  Ear   Cerumen  Impac9on   •  Cerumen   Ear  Anatomy   –  Cerumen  glands   –  Sebaceous  glands   –  Desquamated  epidermis   •  Normal  clearing   –  Hair  follicles   –  Epidermal  migra4on   –  Chewing   Iain, Wikimedia Commons 5  
  • 6. External  Ear   Cerumen  Impac9on   •  Cerumen  accumula4on  that   is     Ear  Anatomy   –  Symptoma4c   –  Sufficient  to  prevent   adequate  ear  examina4on   •  Causes   –  –  –  –  Canal  obstruc4on   Foreign  body   Canal  instrumenta4on   Aging   Iain, Wikimedia Commons 6  
  • 7. External  Ear   Cerumen  Impac9on   •  Cerumenoly4c  agents   Ear  Anatomy   –  Saline/water   –  Hydrogen  peroxide   –  Mineral  oil   •  Irriga4on   –  Syringe     –  Syringe  plus  buKerfly   •  Mechanical  removal   –  CureKes   Iain, Wikimedia Commons 7  
  • 8. External  Ear   External  o99s     •  Inflamma4on  of  the   external  ear   •  Breakdown  of  normal  skin/ cerumen  barrier   Ear  Anatomy   –  Excessive  cleaning   –  Swimming   –  Foreign  body   •  Hearing  aids   Iain, Wikimedia Commons 8  
  • 9. External  Ear   O99s  Externa   •  41%    Pseudomonas   •  15%    S.  aureus   •  22%    Peptostreptococcus   •  11%    Bacteroides   Iain, Wikimedia Commons Ear  Anatomy   9  
  • 10. External  Ear   External  o99s   •  Symptoms   Ear  Anatomy   –  Pain   –  Discharge   –  Hearing  loss   •  Exam   –  –  –  –  Swelling   Redness   Drainage   Dis4nguish  from  o44s  media   with  perfora4on   Iain, Wikimedia Commons 10  
  • 11. External  Ear   External  o99s   •  Treatment   Ear  Anatomy   –  Remove  debris  in  canal   –  Topical  treatments     •  •  •  •  Acidifying  agents   An4sep4cs   An4-­‐inflammatory   An4bio4cs   –  Control  pain   –  Consider  culture  if  severe   –  Prevent  further  injury   Iain, Wikimedia Commons 11  
  • 12. External  Ear   Acidifying  agents   •  Ace4c  acid   –  VoSol   –  VoSol  HC   •  Boric  Acid   –  Domeboro  O4c   An9sep9c   •  Alcohol   •  Thimerosal   •  Thymol   •  Gen4an  Violet   •  Sulfuric  acid   •  Hydrochloric  acid   12  
  • 13. External  Ear   An9-­‐inflammatory     •  Hydrocor4sone   •  Prednisolone   •  Dexamethasone   An9bio9cs   •  Mul4ple  agents   –  Decadron  Ophthalmic   Solu4on   13  
  • 14. Product  name  (preparation) Cortisporin  Otic  Suspension   (ear) Antibiotic Polymyxin  B;   Neomycin Polymyxin  B;   Cortisporin  Otic  Solution  (ear) Neomycin Colistin;   Coly-­‐Mycin  S  Otic  (ear) Neomycin Tobradex  (eye) Tobramycin Genoptic  solution  (eye) Gentamicin Pred-­‐G  (eye) Gentamicin Vasocidin  solution  (eye) Sulfacetamide Gantrisin  Ophthalmic  (eye) Sulfisoxasole Terra-­‐Cortril  Suspension  (eye) Oxytetracycline Chloramycetin  HC  (eye) Chloramphenicol Chloramycetin  Ophthalmic   Solution  (eye) Chloramphenicol Cipro  HC  Otic  (ear) Ciprofloxacin Ciloxan  (eye) Ciprofloxacin Floxin  Otic  (ear) Ofloxacin Ocuflox  (eye) Ofloxacin Chibroxin  (eye) Norfloxacin Anti-­‐ inflammatory Acid Hydrocortisone Sulfuric Antiseptic pH Alcohol Hydrocortisone Hydrochloric 3 2 Hydrocortisone Acetic Dexamethasone Sulfuric Hydrochloric Alcohol Prednisolone Hydrochloric Alcohol Prednisolone Boric Hydrocortisone Hydrocortisone Boric Boric 5 6.0-­‐8.0 7.2-­‐7.5 5.4-­‐6.6 6.2-­‐8.2 7.2-­‐7.9 7.4 7.1-­‐7.5 Hydrochloric 7.0-­‐7.5 4.5-­‐5.0 4.5 Hydrochloric 6.0-­‐6.8 Hydrocortisone Alcohol 14  
  • 15. External  Ear   •  •  •  •  Cochrane  Database  Systema4c  Review  2010   19  RCT  with  3382  pa4ents   Trials  were  of  low  quality   Conclusions   –  Topical  an4microbials  +  steroids  vs.  Placebo   •  OR  11  (2.0  –  60.57)   –  In  general,  no  difference  in  cure  rate  related  to  topical   agent   –  Ace4c  acid  less  effec4ve  than  an4bio4cs/steroids  OR   0.29  (0.13  –  0.62)  at  2  weeks   –  An4bio4cs  +  steroids  quicker  symptoma4c  relief     15  
  • 16. External  Ear   •  External  O44s   –  Mild  disease   •  Topical  drops   •  20  minute  dwell  4me   •  7  day  course,  con4nue  addi4onal  7  days  as  needed   •  Treat  pain   –  Severe  disease   •  Consider  wick   •  Consider  systemic  an4bio4cs   •  Consider  alternate  diagnoses   16  
  • 17. External  Ear   Malignant  (Necro9zing)  OE   Ear  Anatomy   •  Invasion  of  infec4on  beyond   the  ear   –  Elderly  diabe4cs   –  Immunocompromised   •  •  •  •  •  Severe  pain   Significant  drainage   Granula4on  4ssue   CT/MRI   Admission,  an4-­‐ pseudomonas  an4bio4cs   Iain, Wikimedia Commons 17  
  • 18. Tympanic  Membrane   Barotrauma     •  Pressure  difference   between  middle  ear  and   external  ear   •  Flying   •  SCUBA  diving   •  Direct  blow  to  ear   •  Blast  injury   Iain, Wikimedia Commons Ear  Anatomy   18  
  • 19. Tympanic  membrane   Barotrauma   •  Ruptured  TM   –  –  –  –  –  Pain   Bleeding  from  canal   Hearing  loss   Tinnitus   Inspec4on  iden4fies  tear   •  Treatment   –  Avoid  water  to  the  ear   –  Decongestants   –  Outpa4ent  referral   Wellcome Photo Library, Wellcome Images 19  
  • 20. Middle  Ear   O99s  Media   Ear  Anatomy   •  Eustachian  tube  blockage   –  Fluid  build-­‐up   –  Secondary  bacterial  infec4on   •  Symptoms   –  –  –  –  –  Prodromal  symptoms   Pain   +/-­‐  Fever   +/-­‐  Hearing  loss   Rupture  of  TM   •  Exam   –  Dull/red/bulging  TM   Iain, Wikimedia Commons 20  
  • 21. Middle  Ear   •  O44s  Media   –  Treatment   •  An4bio4cs   –  Amoxicillin  500  mg  BID   –  Amoxicillin  875  mg  BID   •  If  penicillin  allergy   –  Cephalosporins  –  2nd  genera4on   –  Azithromycin   •  Treatment  failure   –  Augmen4n   –  Cephalosporins  –  2nd  genera4on   21  
  • 22. Middle  Ear   •  O44s  Media  with  TM  rupture   –  Add  topical  an4bio4c   •  Avoid     –  Alcohol   –  Aminoglycoside   –  Avoid  water  in  the  ear  un4l  healed   22  
  • 23. Product  name  (preparation) Cortisporin  Otic  Suspension   (ear) Antibiotic Polymyxin  B;   Neomycin Polymyxin  B;   Cortisporin  Otic  Solution  (ear) Neomycin Colistin;   Coly-­‐Mycin  S  Otic  (ear) Neomycin Tobradex  (eye) Tobramycin Genoptic  solution  (eye) Gentamicin Pred-­‐G  (eye) Gentamicin Vasocidin  solution  (eye) Sulfacetamide Gantrisin  Ophthalmic  (eye) Sulfisoxasole Terra-­‐Cortril  Suspension  (eye) Oxytetracycline Chloramycetin  HC  (eye) Chloramphenicol Chloramycetin  Ophthalmic   Solution  (eye) Chloramphenicol Cipro  HC  Otic  (ear) Ciprofloxacin Ciloxan  (eye) Ciprofloxacin Floxin  Otic  (ear) Ofloxacin Ocuflox  (eye) Ofloxacin Chibroxin  (eye) Norfloxacin Anti-­‐ inflammatory Acid Hydrocortisone Sulfuric Antiseptic pH Alcohol Hydrocortisone Hydrochloric 3 2 Hydrocortisone Acetic Dexamethasone Sulfuric Hydrochloric Alcohol Prednisolone Hydrochloric Alcohol Prednisolone Boric Hydrocortisone Hydrocortisone Boric Boric 5 6.0-­‐8.0 7.2-­‐7.5 5.4-­‐6.6 6.2-­‐8.2 7.2-­‐7.9 7.4 7.1-­‐7.5 Hydrochloric 7.0-­‐7.5 4.5-­‐5.0 4.5 Hydrochloric 6.0-­‐6.8 Hydrocortisone Alcohol 23  
  • 24. Middle  Ear   •  O44s  Media  with  Effusion   –  Fluid  in  middle  ear  without  infec4on   –  Oral  decongestants   –  Most  resolve   •  Mastoidi4s   –  Pre-­‐an4bio4c  complica4on  of  AOM  in  20%   –  Modern  era  incidence  of  0.5%   –  CT  scan  for  diagnosis   –  Admission  and  IV  an4bio4cs   24  
  • 25. Paranasal  Sinuses   Arcadian, Wikimedia Commons 25  
  • 26. Paranasal  Sinuses   Hellerhoff, Wikimedia Commons Hellerhoff, Wikimedia Commons 26  
  • 27. Sinusi4s   •  Acute  inflamma4on  of  the  para-­‐nasal  sinuses   •  Rhinosinusi4s   –  Acute  rhinosinusi4s   –  Acute  viral  rhinosinusi4s   •  Rhinovirus,  Influenza,  Parainfluenza   •  Acute  bacterial  rhinosinusi4s  as  complica4on  in  0.5%  to   2%  of  cases   •  85%  to  98%  of  pa4ents  prescribed  an4bio4cs  (2001)   27  
  • 28. Acute  Rhinosinusi4s   •  Symptoms  of  ARS   –  Nasal  conges4on  and  obstruc4on   –  Purulent  nasal  discharge   –  Maxillary  tooth  discomfort   –  Facial  pain  or  pressure,  worse  when  bending  forward     –  Fever   –  Fa4gue   –  Cough   –  Hyposmia  or  anosmia   –  Ear  pressure  or  fullness   –  Headache   28  
  • 29. Acute  Rhinosinusi4s   •  Hickner  JM,  et  al.  Ann  Intern  Med.  2001;134(6):498-­‐505   –  –  –  –  –  American  Academy  of  Family  Physicians   American  College  of  Physicians   American  Society  of  Internal  Medicine,     Centers  for  Disease  Control,     Infec4ous  Diseases  Society  of  America   •  Diagnosis  of  ABRS  with     –  >=  7  days  of  symptoms   –  maxillary  pain  or  tenderness  in  the  face  or  teeth  (especially  when  unilateral)     –  purulent  nasal  secre4ons   •  Observa4on  for  ARS  and  mild  ABRS   •  An4bio4c  therapy     –  moderately  severe  symptoms     –  clinical  diagnosis  of  ABRS   –  severe  rhinosinusi4s  symptoms  regardless  of  dura4on   29  
  • 30. Acute  Rhinosinusi4s   •  Rosenfeld  RM,  et  al.  Otolaryngol  Head  Neck  Surg.  2007;137(3   Suppl):S1-­‐31.   •  American  Academy  of  Otolaryngology   –  Diagnosis  of  ABRS  with  presence  of  symptoms  for  10  days   or  less  than  10  days  with  worsening  of  symptoms  arer   ini4al  improvement   –  Symptoma4c  treatment  for  AVRS   –  May  treat  ABRS  symptoma4cally  for  mild  disease:   •  Mild  pain,  temperature  <  38.3  (101)   –  No  imaging  required   –  First  line  treatment  is  amoxicillin;  macrolide  if  allergic   –  Reassess  if  worse  or  no  improvement  at  7  days   30  
  • 31. Acute  Rhinosinusi4s   •  Treatment   –  Analgesics/NSAIDs   –  Mechanical  irriga4on  of  sinuses   –  Topical  cor4costeroids   –  Decongestants   •  Topical   •  Oral   –  An4histamines   –  Mucoly4cs   –  Zinc  prepara4ons   31  
  • 32. Acute  Rhinosinusi4s   Wellcome Photo Library, Wellcome Images 32  
  • 33. Acute  Rhinosinusi4s   •  Treatment   –  Analgesics/NSAIDs   –  Mechanical  irriga4on  of  sinuses   –  *Topical  cor4costeroids   –  *Decongestants   •  *  Topical   •  (*)  Oral   –  An4histamines   –  Mucoly4cs   –  (-­‐)  Zinc  prepara4ons   33  
  • 34. Acute  Rhinosinusi4s   •  Complica4ons  of  ABRS   –  Rare   –  Local  extension   •  Meningi4s   •  Peri-­‐orbital  celluli4s   •  Orbital  celluli4s   34  
  • 35. Rhinosinusi4s   •  •  •  •  Acute  Rhinosinusi4s   Subacute  Rhinosinusi4s    4-­‐12  weeks   Chronic  Rhinosinusi4s      >12  weeks   Recurrent  ARS    4+  episodes  in  one  year   35