Week 44: EENT part 2 of 3 ear, nose, and… trach

The anterior nasal septum is the common location of bleeding in epistaxis. Within the anterior septum is Kiesselbach’s plexus, a watershed area and the most common source of anterior bleeding. Most anterior nosebleeds resolve easily with treatment. The initial step in the evaluation of a nosebleed is to have the patient blow the nose and expel any clots. Inspection of the nose is facilitated using a nasal speculum and adequate light source. If ongoing bleeding is present, the vasoconstricting oxymetazoline spray (Afrin) is helpful in stopping active bleeding. Most episodes of venous anterior bleeding will resolve with the potent vasoconstrictor. If bleeding continues, packing may be used to tamponade the site of bleeding. There are many commercially available devices. Silver nitrate cautery is not useful when applied to a site of active bleeding, it is usually used after bleeding has stopped to prevent recurrence. Foley insertion is used in cases of posterior bleeds. Finally, direct pressure for 15-30 min is a first line maneuver, but it is NOT useful when applied to the BRIDGE of the nose… this is a common error amongst patients who try and prevent bleeding at home.

Acute sinusitis is defined as inflammation of the nasal cavity and paranasal sinuses lasting <4 weeks. The most common etiology of sinusitis is a viral infection with acute bacterial sinusitis responsible for only 0.5 to 2 percent of episodes. The most predictive signs of acute sinusitis are purulent rhinorrhea, nasal congestion and facial pain. Viral sinusitis and bacterial sinusitis are indistinguishable clinically and expert consensus recommends considering a bacterial cause once symptoms last more than 7 to 10 days. Treatment of sinusitis is aimed at symptomatic control. Once symptoms persist for more than 7 to 10 days, a bacterial etiology is possible and antibiotics should be considered. The use of topical glucocorticoids may confer some benefit although data are mixed in trials. Oral decongestant therapy also does not have significant evidence in support of their generalized use. In cases where eustachian tube dysfunction contributes to the development of sinusitis, oral decongestants appear to have benefits. The use of non-steroidal anti-inflammatory medication like ibuprofen does provide pain relief and should be prescribed to the patient.

One potential complication following a tracheostomy is fistula formation between the trachea and the first aortic arch branch, the innominate (or brachiocephalic) artery. A tracheoinnominate artery fistula is a feared complication following tracheostomy because it can lead to rapid exsanguination if not managed properly in a timely fashion. Fistula formation results from either direct vessel erosion from the tip of the tracheostomy cannula or from an overinflated cuff. It usually develops within the first four weeks after tracheostomy, with most patients presenting within the first two weeks. Patients may present with a transient sentinel bleed or with massive hemoptysis. The initial action of the provider should be to hyperinflate the tracheostomy balloon in an effort to tamponade the bleeding vessel. If this is unsuccessful, the provider should orotracheally intubate the patient. It is important to pass the endotracheal tube past the site of bleeding and inflate the cuff distal to this site. At the same time, the tracheostomy should be removed and a gloved finger should be inserted into the stoma, flexed down toward the innominate artery, and traction pulled against the sternum to digitally tamponade bleeding. This digital technique is called the Utley maneuver and is used to control stomal hemorrhage. These are temporizing measures, and otolaryngology or thoracic surgery should be consulted immediately as tracheobronchoscopy and operative repair are indicated.

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The most common cause of otitis externa is infection due to Pseudomonas aeruginosa and Staphylococcus aureus. The pain from otitis externa is caused by inflammation and edema of the ear canal skin, which is normally adherent to the bone and cartilage of the auditory canal. The inflammatory reaction can be caused by bacteria, fungi, or contact dermatitis. Cerumen protects the canal by forming an acidic coat that helps prevent infection. Factors that predispose to otitis externa include absence of cerumen, often from excessive cleaning by the patient, water that macerates the skin of the auditory canal and raises the pH, and trauma to the skin of the auditory canal from foreign bodies or use of cotton swabs. Treatment includes suction and gentle warm irrigation of the canal. 2% acetic acid solution or an alternative drying medication can be administered. A topical antibiotic drop with steroid is first-line therapy (neomycin/polymyxin/hydrocortisone). Use the suspension rather than the solution if the tympanic membrane is ruptured.

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The patient is complaining of symptoms consistent with iatrogenic tympanic membrane perforation that occurred during disimpaction. Tympanic membrane perforations (TMPs) can result from a complication of infection (acute otitis media, myringitis); blast injury (explosion, slap, lightening); barometric pressure changes (flying in airplane, scuba diving); and improper attempts at wax removal or ear cleaning. The pars tensa is the most common area of the TM to perforate because it is the most anterior and thinnest portion. Patients typically experience decreased or complete hearing loss, pain, and bleeding. In the setting of tympanic membrane perforation, the goal is to keep the ear dry, provide analgesics, and arrange for follow-up with an ENT. Most heal within a few months.

The patient does not require admission (A) to the hospital. ENT care can be arranged for as an outpatient. Traumatic tympanic membrane perforations do not require otic antibiotics (B) unless the ear was contaminated such as from diving in seawater or the rupture is secondary to infection. The patient should receive more than a cotton ball (D) in her ear. Her management should include analgesia and ENT follow-up because complications of tympanic membrane rupture include facial nerve palsy, vertigo, and hearing loss.

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This patient has Ménière’s disease. This disorder is associated with increased endolymph within the cochlea and labyrinth. The common triad is tinnitus, vertigo, and unilateral hearing loss (sensorineural). A key finding in Ménière’s disease is fluctuating hearing loss. Episodes are abrupt in onset and associated with nausea and vomiting. There are often long, symptom-free intervals between attacks.

Benign paroxysmal positional vertigo (A) is sudden in onset, short-lived, and positional in nature. It is not associated with tinnitus or hearing loss. Salicylate (aspirin) toxicity (C) is associated with tinnitus and reversible hearing loss. The patient has a history of osteoarthritis and may be using aspirin for her pain; however, salicylate toxicity is usually associated with bilateral hearing loss. Symptoms of vertigo are also uncommon in such patients. Vestibular neuronitis (D) manifests with severe vertigo positional in nature but not associated with hearing loss. It is usually preceded by a viral upper respiratory infection.

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This patient is exhibiting signs and symptoms of posterior epistaxis. Posterior epistaxis is less common than anterior epistaxis and is most commonly due to bleeding from the sphenopalatine artery, located at the posterior aspect of the middle nasal turbinate. Patients with posterior epistaxis typically complain of bleeding from both nostrils. Inspection of the posterior pharynx may reveal profuse bleeding. In treating epistaxis, start by having the patient gently blow his nose or suction out the blood. If the bleeding is profuse, apply cotton balls soaked in a topical anesthetic and vasoconstrictor for at least five minutes. A good option is 1% tetracaine plus 0.05% oxymetazoline solution. In posterior epistaxis, this may not achieve hemostasis or allow visualization of the location of bleeding. Management of posterior epistaxis should be with either a Foley catheter or dual balloon pack. A 10 to 14 French Foley catheter with a 30 cc inflatable balloon may be inserted past the site of the bleeding and inflated with 5 to 7 cc of air or saline. It should then be pulled back onto the site of the posterior bleed and inflated until it is snug. An anterior nasal pack should then be placed in both nares. A dual balloon pack is placed by anesthetizing the nare and advancing the pack past the site of the bleeding. The posterior balloon is inflated with 5 to 7 cc of saline or air and pulled back onto the site of bleeding. It is the further inflated until it is snug. The anterior balloon is then inflated. The opposite nare should be packed as well. Complications of posterior epistaxis packing include aspiration, hypoxia, hypercarbia, and symptomatic bradycardia. Antibiotics should be administered after all packing; however, there is significant controversy regarding whether prescribing antibiotics actually prevents toxic shock syndrome as there is no evidence to support this. All patients with posterior packing should be admitted to a telemetry bed for further monitoring while the packing is in place.

The facial artery (A) may be injured during oncologic surgery of the parotid gland or in severe facial trauma. Kiesselbach plexus (B) is the most common source of anterior bleeding. Given that this patient has profuse bleeding that appears bilateral, the source is most likely to be posterior. The labial artery (C) is most commonly injured in children who suffer electrical burns of the commissure of the lip while chewing on electrical cords.

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In this case, the patient has symptoms concerning for mastoiditis. Mastoiditis is most common in children between 1 and 3 years old. It is a complication of acute otitis media with extension of the infection into the mastoid bone. Patients typically present with ear proptosis, fever, an injected tympanic membrane on the infected side, and postauricular erythema. Organisms involved in this infection are similar to those in otitis media, including Streptococcus pyogenes, Staphylococcus aureus, and Pseudomonas aeruginosa. Diagnosis is confirmed by CT, and consultation with ENT is indicated. If the patient has not taken antibiotics before, the initial treatment is with oral antibiotics if the disease is mild and close follow-up can be ensured. If a patient develops mastoiditis after an appropriate course of oral antibiotics, then admission, ENT consultation, and intravenous antibiotic therapy are warranted. Antibiotics with good gram-positive coverage like ampicillin-sulbactam or third-generation cephalosporins are the first-line choice.

B. This patient has already completed one course of antibiotic therapy, so starting her on a different oral antibiotic is not appropriate. Admission is warranted for more aggressive management.

C. Discharging the patient with instructions for supportive care is not the right course of action, again, because initial antimicrobial treatment failed. Admission and additional antibiotics are needed to treat the acute infection process.

D. At this point in the patient’s care, intravenous antibiotic therapy is the next step. Mastoidectomy should be considered only if intravenous antibiotic therapy fails and the infection spreads beyond the mastoid.

The patient has symptoms consistent with acute otitis media. He is a candidate for a “wait-and-see” prescription for an antibiotic if his symptoms do not improve in 48 to 72 hours. He meets the criteria for “wait and see” including age ≥ to 2 years old, unilateral infection, symptoms for fewer than 48 hours, and temperature is less than 39⁰C. Assuming there are no contraindications, amoxicillin (90 mg/kg/day PO for 5-10 days) is the first-line treatment. Amoxicillin-clavulanate is appropriate if the patient has failed a course of amoxicillin. Cephalosporins like cefdinir or cefuroxime or clindamycin are appropriate in penicillin-allergic patients. Streptococcus pneumoniae is the most common bacterial organism, although most cases are viral.

A. Given the tympanic membrane visualized, antipyretics alone are not sufficient if there is no improvement within 48 to 72 hours. Complications from untreated bacterial otitis media include mastoiditis and hearing complications.

B. If the wait-and-see approach fails, the patient should complete a course of antibiotics. Referral to an ENT for possible tympanostomy should only occur after repeated episodes of otitis media.

C. Immediate use of antibiotics has been shown not to improve outcomes when using these criteria. In addition, there is an increased risk of diarrhea and antibiotic resistance for those who take antibiotics.

This patient presents with peripheral vertigo most consistent with benign paroxysmal peripheral vertigo (BPPV) and should be treated with an Epley maneuver. Vertigo is defined as the sensation of disorientation in space combined with a sensation of motion. Patients typically describe a room-spinning sensation or the feeling of sea sickness. Vertigo can be divided into two types: central and peripheral. Central vertigo are those disorders arising from the central nervous system and include ischemic stroke, vertebrobasilar insufficiency and infectious causes (meningitis, mastoiditis, syphilis). Central vertigo is characterized by longer duration of symptoms, minimal change with position, gradual onset and multidirectional nystagmus. Peripheral vertigo includes BPPV, Menieres disease, Labyrinthitis and vestibular neuritis. Peripheral vertigo may have intermittent symptoms (BPPV) or continuous symptoms but should not be associated with other neurologic deficits or changes and should have unidirectional nystagmus. The symptoms in BPPV are elicited by specific movements of the head and relieved by returning the head to a neutral position. The symptoms should be acute in onset and of a short duration. In BPPV, the symptoms are caused by the presence of an otolith in one of the semicircular canals. Although pharmacologic intervention may be necessary in the acute setting with meclizine or benzodiazepines, the best treatment for BPPV is the Epley maneuver. The Epley maneuver is a series of positions that the clinician takes the patient through that leads to expulsion of the otolith from the semicircular canal and relief of symptoms. The Dix-Hallpike test is a DIAGNOSTIC test, not a treatment

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