3:20 – 4:20 PM Eustachian Tube (ET) Dysfunction Common ENT Disorders in Diagnosis of ET dysfunction Primary Care depends upon: – Subjective symptoms of aural fullness and/or ear “popping” (with or without a history of SPEAKER environmental allergies) Paul A. Kedeshian, MD – Careful otoscopic examination of the tympanic membrane with pneumatic insufflation to rule out effusion Eustachian Tube (ET) Dysfunction Eustachian Tube (ET) Dysfunction Diagnosis of ET dysfunction depends upon: Treatment – Ruling out presence of middle – Nasal steroids/saline lavage ear effusion Tympanogram usually will reveal – Antihistamines/Decongestants reduced middle ear pressure – Insufflation of ET – Oral corticosteroids – GERD treatment – Middle ear ventilation tube placement (only in rare instances) Middle Ear Effusion Nasopharyngeal Mass Diagnosis of middle ear effusion: In addition to a unilateral middle ear effusion, signs and symptoms can – Otalgia with hearing loss include: – Otoscopic examination reveals – Nasal obstruction middle ear effusion with absent – Epistaxis movement – Ipsilateral neck mass in the posterior triangle – In an adult, a mass in the Direct (endoscopic) visualization of the nasopharynx and/or diagnostic imaging nasopharynx must be considered as (CT scan of the sinonasal region) is a possible etiology indicated Middle Ear Effusion Middle Ear Effusion Audiogram will demonstrate a Treatment conductive hearing loss with a – Oral antibiotics “flat” tympanogram – Oral corticosteroids – Middle ear pressure equalization tube (PET) placement if persists Tympanic Membrane Perforation Tympanic Membrane Perforation Occurs secondary to pressure Treatment should include: and/or fluid accumulation in the – Oral antibiotics middle ear (can be post head – Ear drops trauma) – Dry ear precautions Conductive hearing loss Potential for otorrhea and If perforation is small and/or recurrent middle ear infections post-traumatic, may spontaneously heal in 3-8 weeks without surgery Hemotympanum Tympanosclerosis (aka Myringosclerosis) Bloody middle ear effusion White plaque-like deposit on usually secondary to trauma tympanic membrane (TM) Workup should include CT scan surface of temporal bones and – Usually secondary to frequent audiogram otitis media Blood will usually reabsorb spontaneously over 4-12 weeks No treatment necessary If no resolution, PET is indicated (unless impairment of TM mobility is noted) Otitis Externa Otitis Externa Infection of external auditory Treatment should include: canal (EAC) – Oral antibiotics with anti- – Exquisitely painful Psudomonal coverage – Severe canal edema (conductive hearing loss) – Otowick placement – History of EAC trauma nearly – Otic drops with anti- always elicited Pseudomonal coverage – Multiple bacterial species (including Pseudomonas) are usually present Otitis Externa Exostosis Higher incidence in Hypertrophy of the bony external immunocompromised auditory canal populations Secondary to chronic exposure to cold water (surfing, ocean swimming) If any facial nerve weakness or No treatment needed unless near-total cranial neuropathies are present, EAC occlusion and/or secondary possibility of “malignant otitis conductive hearing loss externa” (skull base Need for meticulous ear cleaning after osteomyelitis) must be considered water exposure Bilateral Inferior Turbinate Hypertrophy Nasal Polyps Frequent cause of nasal Inflammatory growths associated with obstruction chronic allergies Usually secondary to Can cause anatomic obstruction of sinus environmental allergens ostia with secondary acute sinusitis Frequently seen in patients who also Can be mistaken for nasal polyposis if asymmetric have asthma/reactive airway disease and can also include aspirin allergy First line treatment is topical (Sampter’s triad) nasal steroids Nasal Polyps Nasal Polyps Diagnosis frequently depends Treatment upon radiographic appearance – Antibiotics of sinuses (limited CT scan) – Oral corticosteroids – Antihistamines/Decongestants – Nasal/sinus lavage – Surgery High incidence of recurrence Nasal Septal Hematoma Nasal Septal Hematoma Usually secondary to trauma If hematoma is left undrained, Not always an associated nasal secondary compromise of the bone fracture vascular supply to nasal dorsal cartilage can result is so-called Needle aspiration and/or incision and drainage saddle nose deformity Nasal Septal Perforation Mucocele Can also result from an undrained nasal Accumulation of mucous in septal hematoma submucosal space Typically present with nasal crusting, Most common on labial and occasional epistaxis buccal surfaces May have a preceding history of trauma Usually secondary to dental (prior surgery, elicit drug use) or trauma collagen vascular disease, Wegner’s granulomatosis Occasional superinfection in Surgical repair usually unsuccessful which case surgical excision may be indicated Oral Leukoplakia Oral Leukoplakia “White plaque” Workup should include thorough Presents most commonly on examination of mucosa of upper lateral aspect of tongue and aerodigestive tract (especially in buccal mucosa tobacco-users) Associated with trauma or Biopsy of areas of erythroplakia chronic inflammation/irritation more important than representative sampling Low (less than 5%) premalignant potential Geographic Tongue Cobblestone Pharynx Asymmetric hypertrophy of Finding that may indicate a sinonasal etiology (with posterior drainage and papillae of tongue associated irritation) Unknown etiology Can also be secondary to gastroesophageal reflux (GERD) Rarely symptomatic particularly in the absence of nasal Treatment with antifungal or complaints antibiotic therapy not indicated Can frequently be seen in patients complaining of a “post nasal drip” May be exacerbated by GERD Torus Palatini and Torus Mandibularis Tonsillar Lymphoma Bony overgrowths present in Lymphoma (usually B-cell type) palate and inner cortex of that develops within the mandible lymphoid tissue of the palatine tonsils (part of Waldeyer’s ring) Unknown etiology Important to keep high index of Unless overlying mucosa becomes suspicion if significant inflamed, no treatment indicated asymmetry, cervical adenopathy, for these benign lesions constitutional symptoms Peritonsillar Abscess Parotitis Acute, suppurative infection with the Inflammation of the parotid ductal submucosal space around tonsils system with associated swelling, pain, Will always be uvular deviation, bulging erythema, fevers of soft palate, trismus, and muffled- Increased incidence in diabetics but can sounding voice occur secondary to episode of Treatment involves either needle dehydration aspiration and/or incision and drainage Rarely can occur secondary to parotid with oral antibiotics and corticosteroids stone (sialolith) Can re-accumulate following needle Treatment includes antibiotics, aspiration hydration, oral sialogogues, heat and massage directly over the involved gland as well as oral steroids Parotid Neoplasm Submandibular Sialoadenitis/Sialolithiasis Firm mass within the substance of parotid Acute inflammation of submandibular salivary gland salivary gland Approximately 80% are benign although it Can be secondary to dehydration (as in can also occur secondary to metastasis from parotitis) but more commonly due to a previously treated cutaneous (particularly squamous cell) carcinoma of the cheek, sialolith (stone) pinna, temporal/frontal scalp Physical exam can often palpate stone Presence of ipsilateral facial nerve weakness, along course of submandibular duct pain, or adenopathy increase likelihood of (within the floor of mouth) malignancy Treatment is same as for parotitis Diagnostic workup should include MRI of except that frequent infections with an parotid gland followed by fine needle associated sialolith may require aspiration biopsy sialoendoscopy or surgical excision of Treatment involves surgical excision of gland gland Second Branchial Cleft Cyst Thyroglossal Duct Cyst . Painless, fluctuant mass in the most common congenital lateral aspect of the neck that is neck mass (70%) situated deep to the sternomastoid muscle elevates on protrusion of . most common branchial cleft tongue or swallowing anomaly (95%) may develop draining sinus . often becomes apparent after on skin surface recent URI Thyroglossal Duct Cyst Bell’s Palsy Usually present at or just inferior Paralysis of all branches (upper to the hyoid bone and lower) of facial nerve – may be associated with ectopic Sudden onset thyroid tissue (1-2%) therefore imaging to confirm Viral prodrome (usually) the presence of normal Diagnosis of exclusion thyroid tissue is recommended Must rule out presence of co- Treatment is surgical excision existing mastoiditis, otitis (Sistrunk Procedure) externa, parotid tumor Bell’s Palsy Likely secondary to infection of facial nerve with herpes simplex virus Treatment includes oral corticosteroids with reassessment after 7-10 days.