E.N.

T
DD of Otalgia:
Diagnosis
Acute otitis
media
Otitis media
with effusion
Bullous
myringitis
Cerumen
impaction
Hemotympanum
Otitis Externa

Clinical features
Middle ear effusion + eardrum inflammation
(Bulging eardrum &fever)
Middle ear effusion without acute
inflammation
Serous liquid-filled blisters on the tympanic
membrane
Liquid or hard wax in auditory canal
obstructing eardrum visualization
Purple or red eardrum +/- bulging
Pain with tragal traction, erythematous and
swollen external auditory canal +/- Otorhea

Acute Otitis Media:

-OrganismsStrpt. Pneumonia-H.influenza-M. catarrhalis
-ClinicallyMiddle ear effusion + Bulging tympanic membrane
-TTT 1st Amoxicillin(10 days) if persist Amox+Clavulinic
*IF >3 attacks in 6 months or 4 attacks in 12 months
MYRINGOTOMY AND TYMPOSTOMY TUBE
-ComplicationsConductive deafness-meningitis-mastoiditis

 Serous Otitis media:

-The most common middle ears pathology in AIDS patients
-Due to auditory tube dysfunction arising from HIV
lymphadenopathy or obstructing lymphomas
-CCC by presence of effusion without evidence of acute infection
-Conductive hearing loss is the most common symptom
-Ex typically reveal dull hypo-mobile tympanic membrane

Malignant Otitis Externa:

-Severe infection of the ear esp. in diabetics patients
-Pseudomonas is the MCC organism
-C/P: Ear discharge & severe pain radiate to TMJ increased with
chewing
-On Ex.: Granulation tissue in external auditory meatus
-Complications: Osteomyelitis and Cranial Nerves damage
(facial)
-TTT with IV/Oral antibiotics (ciprofloxacin)

TMJ dysfunction:
-Most Pts have history of teeth grinding during sleep
-Referred ear pain that is worsened with chewing
-Initial TTT is conservative if failed surgical

Peritonsillar abscess:
-fever, chills, sore throat, MUFFELED VOICE, UVULAR
DEVIATION (Complication of tonsillitis)
-Typically have unilateral lymphadenopathy and can be fatal
(Airway obstruction-parapharyngeal and carotid sheath involve.)
-TTT with aspiration of peritonsillar abscess and IV antibiotics

Surgery may be needed

Mucormycosis:
-Caused by Rhizopus species in POORLY controlled DM
-Fever/bloody nasal discharge/nasal congestion + Eye involvement
(Chemosis/proptosis/diplopia)
-Invasion of soft tissues can lead to blindness or cavernous sinus
thrombosis and coma if left untreated, death within days
-TTT with surgical debridement and IV amphoticin

Conductive VS SN hearing loss:

Interpretation of weber & Rinne tests
Rinne result
Weber result
Air Conducted>Bone
midline
Normal
Conducted bilaterally

Conductive

BC>AC in the affected ear + Lateralize to the

AC>BC in the unaffected
affected ear
ear

Sensorineural AC>BC in both ears

Mixed

Lateralize to
unaffected ear,
away from the
affected ear

BC>AC in the affected ear + Lateralize to

AC>BC in the unaffected
unaffected ear,
ear
away from the
affected ear

 Presbycusis:
-Bilateral SN hearing loss occur with aging
-Clue: difficulty hearing in crowded noisy environments and
trouble hearing high-pitched noises or voices

Otosclerosis: (Otospongiosis)
-Common cause of conductive hearing loss in 20-30 years with
slightly increased incidence in females
-Etiology is thought to be autoimmune process in genetically
susceptible peopleAbnormal remodeling of Otic capsule
-The stapes footplate become fixedLoss of its piston action
-TTT with hearing amplification OR surgical stapedectomy

Medication Induced Ototoxicity:

-Include (Aminoglycosides-Loop diuretics-Aspirin)
-Loop diuretics can cause reversible or permanent hearing loss
-The risk is high in high doses or pre-existing renal impairment
-Aspirin need very high doses (6-8 gm/day) to cause deafness

Cholesteatoma:
-Can be congenital or acquired due to recurrent M.E infections
-Dx should be suspected in patient with recurrent ear discharge
despite appropriate antibiotic therapy
-Chronic Middle Ear disease leads to formation of retraction
pocket in the tympanic membrane which can be filled with
granulation tissues and skin debris

-Complications include hearing loss, cranial nerve palsies, vertigo

and life-threatening brain abscess.

Nasopharyngeal carcinoma:
-Undifferentiated SCC with higher incidence in people of
Mediterranean and Far Eastern descents
-Usually asymptomatic until disease is advanced
-Patients often present with OM, epistaxis and nasal obstruction
-Strongly associated with +ve EBV serology (used to track the
progress of therapy)
-Also associated with smoking and nitrosamine consumption (diet
rich in salted fish)

Leukoplakia:
-White granular patch or plaque over the buccal mucosa in a
patient with a history of alcohol or smoking
-reactive precancerous lesion the represent hyperplasia of the
squamous epithelium (1:20% progress to SCC within 10 years)
-Development of areas of induration or ulcerationBiopsy
-Fortunately most lesion resolve in weeks of smoking cessation.

Juvenile Nasal Angiofibroma (JNA) :

-ANY adolescent with (recurrent epistaxis+ nasal obstruction+
visible nasal mass) is considered JNA unless proven otherwise
-Typically found in the back of the nose or upper throat
-Benign but can be eroding and locally invading
-Very dangerous as its extremely vascular and difficult to access
surgically (Dont touch)

-TTT with surgical removal only if enlarging, causing airway

obstruction, or chronic bleedingRecurrence is common

Torus palatinus: (remove if causing S/S)

-Benign bony growth of the hard palate (Congenital)
-Painless and tend to ulcerate easily and heal slowly.

Trauma to soft palate:

-Foreign body injury to the soft palate can lead to acute stroke
*Either due to internal carotid thrombosis and embolization
*Or due to internal artery dissectionIschemic stroke
-The onset may be delayed up to 24 hours after trauma
-Dx with MRI/MRA of clinically suspected cases
-TTT is controversial range from conservative to anticoagulation

Complications following rhinoplasty:

-Dissatisfaction Nasal obstruction Epistaxis
-Septum Complication less common but more severe (D.t poor
vascularity and regeneration capacity)septal perforation
Whistling voice heard during respiration
**DD of nasal septal perforation:
(Trauma, Syphilis, Sarcoidosis, TB, cocaine, Wegners)

Aspirin exacerbated respiratory disease (AERD):

-History of wheezing following ingestion of Aspirin/NSAID and
symptoms of rhinitis & post-nasal drainage is highly suggestive
-This condition is commonly associated with NASAL POLYPS

-Patients with NASAL POLYPS typically complain of anosmia

(bland tasting food), recurrent nasal discharge and congestion.

DD of vertigo
Menieres disease
(from distension of
the endolymphatic
compartment of the
inner ear)
BPPV

Vestibular neuritis

Migrainous vertigo

Brainstem/cerebellar
Stroke

Recurrent episodes of
vertigo/nystagmus
Preceded by ear fullness/pain
Unilateral hearing loss/tinnitus
Avoid alcohol, caffeine, nicotine and
high salt food + diuretics
Recurrent brief episodes brought on
by predictable head movements
Semicircular canal dysfunction
No neurologic/auditory symptoms
Dix-Hallpike maneuverNystagmus
Usually due to viral infection
Acute onset of single episode that
can last days
Severe vertigo but no hearing loss
Patient usually falls down toward
side of lesion
Abnormal head thrust test
Recurrent episodes of vertigo
associated with migraine headache or
other migrainous phenomenon (Aura,
photophobia, phonophobia)
No auditory symptoms
Symptoms resolve between episodes
Sudden onset, persistent vertigo
Usually other neurologic symptoms
Usually no auditory symptoms