Common ENT disorders

Hearing loss, laryngitis, otitis externa, otitis media, and sinusitis are common ENT disorders.

Common ENT disorders: Otitis externa

Otitis externa, or inflammation of the external ear canal skin and auricle, may be acute or chronic. It usually occurs in hot, humid summer weather and is also called swimmer’s ear. With treatment, the acute form usually subsides within 7 days, although it may become chronic. Severe chronic otitis externa may reflect underlying diabetes mellitus, hypothyroidism, or nephritis.

What causes it

Causes may include:

  • bacteria, such as Pseudomonas, Proteus vulgaris, streptococci, and Staphylococcus aureus
  • fungi, such as Aspergillus niger and Candida albicans
  • dermatologic conditions, such as seborrhea or psoriasis.

Pathophysiology

Otitis externa usually results when a traumatic injury or an excessively moist ear canal predisposes the area to infection.

What to look for

Acute otitis externa is characterized by moderate to severe pain. The pain increases when manipulating the auricle or tragus, clenching the teeth, opening the mouth, or chewing. If palpating the tragus or auricle causes pain, the problem is otitis externa, not otitis media. Fungal otitis externa may be asymptomatic. However, A. niger produces a black or gray, blotting, paperlike growth in the ear canal.

Common ENT disorders: And now for more

Other signs and symptoms of acute infection include:

  • fever
  • foul-smelling aural discharge
  • regional cellulitis
  • partial hearing loss
  • scaling, itching, inflammation, or tenderness
  • a swollen external ear canal and auricle, which can be seen on otoscopy
  • periauricular lymphadenopathy (tender nodes in front of the tragus, behind the ear, or in the upper neck).

What tests tell you

  • Otoscopic examination can determine the need for microscopic examination.
  • Culture and sensitivity tests can identify the causative organism and help determine the appropriate antibiotic treatment.

How it’s treated

Treatment for acute otitis externa consists of:

  • heat application to the periauricular region (warm, damp compresses)
  • drug therapy, including topical analgesics, such as otic antipyrine and benzocaine; antibiotic eardrops (with or without hydrocortisone) that are instilled after the ear is cleaned and debris removed; and, if fever persists or regional cellulitis develops, a systemic antibiotic
  • careful ear cleaning (especially in fungal otitis externa), including application of a keratolytic or 2% salicylic acid in cream containing nystatin (for candidal organisms) or instillation of slightly acidic eardrops such as 0.5% neomycin (for most fungi and Pseudomonas organisms); performed only if the tympanic membrane is intact
  • repeated cleaning of the ear canal with baby oil (for A. niger organisms).

Common ENT disorders: The tonic for chronic

External ear infections are painful, and the patient with chronic otitis externa may require analgesia. Other treatments include:

  • cleaning the ear and removing debris with antibiotic irrigations (primary)
  • instilling antibiotic eardrops and applying antibiotic ointment or cream, such as neomycin, bacitracin, or polymyxin B, possibly combined with hydrocortisone (supplemental)
  • for mild chronic otitis externa, instilling antibiotic eardrops once or twice weekly and wearing specially fitted earplugs while showering, shampooing, and swimming.

What to do

  • Monitor vital signs, particularly temperature. Watch for and record the type and amount of aural drainage.
  • Remove debris and gently clean the ear canal with 0.5% neomycin or polymyxin B. Place a wisp of cotton soaked with solution into the patient’s ear, and apply a saturated compress directly to the auricle. Afterward, dry the ear gently but thoroughly. (If the patient has severe otitis externa, such cleaning may be delayed until after initial treatment with antibiotic eardrops.)

Common ENT disorders: Traveling in the canal

  • To instill eardrops in an adult, pull the pinna back to straighten the canal. To ensure that the drops reach the epithelium, insert a wisp of cotton moistened with eardrops, or have the patient lie  on his side with the affected ear up for 15 minutes after instilling drops.
  • If the patient has chronic otitis externa, clean the ear thoroughly. Use wet soaks intermittently on oozing or infected skin. If the patient has a chronic fungal infection, clean the ear canal well, and then apply an exfoliative ointment.
  • Evaluate the patient. Make sure the patient is afebrile and pain-free, can administer his eardrops properly, and knows which risk factors to avoid. (See Otitis externa teaching tips.)

Otitis externa teaching tips

  • Teach the patient how to administer eardrops.
  • Suggest that the patient use earplugs to keep water out of his ears when showering, shampooing, and swimming. (Tell him he can instill two or three drops of rubbing alcohol or 2% acetic acid before and after swimming to toughen the skin of the external ear canal.)
  • Instruct the patient to clean his hands after instilling drops to avoid getting them in his eyes.
  • Teach him about medications and the importance of taking the entire course of antibiotics.
  • Instruct him to avoid risk factors, such as swimming in contaminated water; cleaning the ear canal with a cotton swab; and regularly using earphones, which trap moisture in the ear canal, creating a culture medium for infection.
  • Tell the patient to see the practitioner immediately if symptoms reappear.

Common ENT disorders: Otitis media

Otitis media, or inflammation of the middle ear, may be acute, chronic, or serous. The infection appears suddenly and typically lasts only a short time. Its incidence rises during the winter months, paralleling the seasonal rise in bacterial respiratory tract infections. It results from disruption of eustachian tube patency. (See Sites of otitis media.)

 

Common ENT disorders

 

What causes it

Acute otitis media occurs as a result of pneumococci, betahemolytic streptococci, staphylococci, and gram-negative bacteria such as Haemophilus influenzae. Chronic otitis media results from inadequate treatment of acute infection as well as infection by resistant strains of bacteria.

 

Common ENT disorders: Serious about serous

Serous otitis media occurs as a result of:

  • viral upper respiratory tract infection, allergy, or residual otitis media
  • enlarged lymphoid tissue
  • barotrauma (pressure injury caused by an inability to equalize pressures between the environment and the middle ear).

The causes of chronic serous otitis media are:

  • adenoidal tissue overgrowth that obstructs the eustachian tube
  • edema resulting from allergic rhinitis or chronic sinus infection
  • inadequate treatment of acute suppurative otitis media.

Pathophysiology

With the acute form of otitis media, respiratory tract infection, allergic reaction, or positional changes (such as holding an infant in the supine position during feeding) allow reflux of nasopharyngeal flora through the eustachian tube and colonization in the middle ear.

With prompt treatment, the prognosis for acute otitis media is excellent; however, prolonged accumulation of fluid within the middle ear cavity causes chronic otitis media.

With serous otitis media, obstruction of the eustachian tube results in negative pressure in the middle ear that promotes transudation of sterile serous fluid from blood vessels in the membrane of the middle ear.

What to look for

Although the patient with acute otitis media may be asymptomatic, typical signs and symptoms include:

  • severe, deep, throbbing pain
  • upper respiratory tract infection with a mild to high fever
  • hearing loss, usually mild and conductive
  • lack of response or inattention to spoken word
  • sensation of blockage in the ear, dizziness, nausea, and vomiting
  • obscured or distorted bony landmarks of the tympanic membrane (evident on otoscopy)
  • bulging of the tympanic membrane with concomitant erythema
  • purulent drainage in the ear canal from tympanic membrane rupture.

Common ENT disorders: Serous symptoms

Many patients with serous otitis media are asymptomatic but end up developing severe conductive hearing loss ranging from 15 to 35 dB, depending on the thickness and amount of fluid in the middle ear cavity. Other signs and symptoms include:

  • a sensation of fullness in the ear or hearing an echo when speaking
  • popping, crackling, and clicking sounds with swallowing and jaw movement
  • experiencing a vague feeling of top-heaviness
  • tympanic membrane retraction, which causes the bony landmarks to appear more prominent (seen on otoscopy)
  • clear or amber fluid behind the tympanic membrane (seen on otoscopy) with possible presence of an air bubble
  • blue-black tympanic membrane (seen on otoscopy) if hemorrhage into the middle ear has occurred.

Common ENT disorders: Long-term liability

Chronic otitis media usually begins in childhood and persists into adulthood. Its effects include:

  • decreased or absent tympanic membrane mobility (tympanosclerosis)
  • cystlike mass in the middle ear (cholesteatoma)
  • erythema and perforation of the eardrum
  • painless, purulent discharge (otorrhea)
  • conductive hearing loss that varies with the size and type of tympanic membrane perforation and ossicular destruction
  • thickening and possible scarring of the tympanic membrane (seen on otoscopy).

What tests tell you

  • Otoscopic examination can determine the need for microscopic examination.
  • Computed tomography scanning can reveal effects on structures of the middle ear.
  • Culture and sensitivity testing can determine the causative organism.
  • Pneumatoscopy can show decreased tympanic membrane mobility. However, this procedure is painful because of the bulging, erythematous tympanic membrane that occurs in acute otitis media.

How it’s treated

For acute secretory otitis media, the only treatment required may be inflation of the eustachian tube several times per day using Valsalva’s maneuver. Otherwise, nasopharyngeal decongestant therapy may be helpful.

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Treatment alternatives for acute otitis media

Common ENT disorders

 

Common ENT disorders: Tube time

If decongestant therapy fails, myringotomy and aspiration of middle ear fluid, followed by insertion of a polyethylene tube into the tympanic membrane, provide immediate and prolonged equalization of pressure. The tube falls out spontaneously after 9 to 12 months. Broad-spectrum antibiotics may be used to help prevent acute otitis media in high-risk patients. In patients with recurring otitis media, antibiotics must be used sparingly and with discretion to prevent development of resistant strains of bacteria. (See Treatment alternatives for acute otitis media.)

Other treatments for acute otitis media include:

  • antibiotic therapy with ampicillin (Principen), amoxicillin (Dispermox), or cefaclor (Raniclor) or sulfamethoxazole/trimethoprim (Bactrim) for those who are allergic to penicillin derivatives
  • acetaminophen (Tylenol) or ibuprofen (Motrin) to help control pain and fever
  • myringotomy for severe, painful bulging of the tympanic membrane.

Common ENT disorders: When it goes on and on

For chronic otitis media, therapy includes:

  • antibiotics for exacerbations of acute infection
  • elimination of eustachian tube obstruction
  • myringoplasty (tympanic membrane graft)
  • tympanoplasty to reconstruct middle ear structures when thickening and scarring are present, and, possibly, mastoidectomy
  • excision of cholesteatoma, if present.

What to do

  • After myringotomy, maintain drainage flow. Don’t place cotton or plugs deep in the ear canal. Instead, place sterile cotton loosely in the external ear to absorb drainage.
  • To prevent infection after the procedure, change the cotton whenever it gets damp and wash your hands before and after providing ear care.
  • Watch for and report headache, fever, severe pain, or disorientation.

Common ENT disorders: Tympano treatment

  • After tympanoplasty, reinforce dressings, and observe for excessive bleeding from the ear canal. Administer an analgesic, if needed.
  • After completing therapy for otitis media, evaluate the patient. Make sure the patient is free from pain and fever, his hearing is completely restored, he understands the importance of completing his antibiotic therapy, and he understands how to prevent recurrence. (See Otitis media teaching tips.)

Otitis media teaching tips

  • Teach the patient the causes, signs and symptoms, and treatment of otitis media.
  • Warn the patient against blowing his nose or getting his ears wet when bathing.
  • Encourage the patient to complete the prescribed course of antibiotic treatment.
  • Instruct the patient or caregiver about medications ordered, correct administration, dosage, and adverse effects.
  • Suggest applying warm compresses to the ear to relieve pain.
  • Advise the patient with acute otitis media to watch for and immediately report pain and fever, which signal secondary infection.
  • To promote eustachian tube patency, instruct the patient to perform Valsalva’s maneuver several times daily.
  • Urge prompt treatment of otitis media to prevent perforation of the tympanic membrane.

Common ENT disorders: Sinusitis

The prognosis is good for all types of sinusitis. The types include:

  • acute, which usually results from the common cold and lingers in subacute form in only about 10% of patients
  • chronic, which follows persistent bacterial infection
  • allergic, which accompanies allergic rhinitis
  • hyperplastic, which is a combination of purulent acute sinusitis and allergic sinusitis or rhinitis
  • viral, which follows an upper respiratory tract infection in which the virus penetrates the normal mucous membrane
  • fungal, which is generally uncommon but is more common in immunosuppressed or debilitated patients.

What causes it

Sinusitis may result from:

  • an upper respiratory tract infection, allergies, or rhinitis
  • nasal polyps
  • bacterial, viral, or fungal infection (possibly due to swimming in contaminated water or dental manipulation, for example).

Pathophysiology

Ordinarily, bacteria are swept from the sinuses through mucociliary clearance. When the ostia (openings to the sinuses) become obstructed by inflammation or mucus, however, these bacteria remain in the sinus cavity and multiply. The mucous membrane inside the cavity becomes swollen and inflamed, and the cavity fills with secretions.

What to look for

Signs and symptoms associated with sinusitis include:

  • nasal congestion and pressure
  • pain over the cheeks and upper teeth (in maxillary sinusitis)
  • pain over the eyes (in ethmoid sinusitis)
  • pain over the eyebrows (in frontal sinusitis)
  • rarely, pain behind the eyes (in sphenoid sinusitis)
  • edematous nasal mucosa and edema of the face and periorbital area
  • fever (in acute sinusitis)
  • nasal discharge (possibly purulent in acute and subacute sinusitis, continuous in chronic sinusitis, and watery in allergic sinusitis)
  • nasal stuffiness and possible inflammation and pus on nasal examination.

What tests tell you

  • Sinus X-rays may reveal cloudiness in the affected sinus, air-fluid levels, or thickened mucosal lining.
  • Antral puncture promotes drainage and removal of purulent material and may provide a specimen for culture and sensitivity identification of the infecting organism (rarely performed).
  • Transillumination allows inspection of the sinus cavities by shining a light through them; however, purulent drainage prevents passage of light.

How it’s treated

The primary treatment for acute sinusitis is antibiotic therapy. Other appropriate measures include:

  • a vasoconstrictor such as phenylephrine (Afrin) to decrease nasal secretions
  • an analgesic to help relieve pain
  • steam inhalation to promote vasoconstriction and encourage drainage
  • local application of heat to relieve pain and congestion
  • an antibiotic or antifungal agent (for persistent infection)

Common ENT disorders: Antibiotics, take two

Antibiotic therapy is also the primary treatment for subacute sinusitis. A vasoconstrictor may reduce the amount of nasal secretions.

Common ENT disorders: Allergic sinusitis? Treat rhinitis.

Treatment of allergic sinusitis involves treatment of allergic rhinitis, which includes:

  • administration of an antihistamine
  • identification of allergens by skin testing and desensitization by immunotherapy
  • corticosteroids and epinephrine for severe allergic symptoms.

Common ENT disorders: If all else fails…

For chronic and hyperplastic sinusitis, an antihistamine, an antibiotic, and a steroid nasal spray may relieve pain and congestion. If irrigation fails to relieve symptoms, one or more sinuses may require surgery. Surgeries include:

  • sinus tap and irrigation for acute sinusitis
  • functional endoscopic sinus surgery
  • external ethmoidectomy or sphenoethmoidectomy
  • frontal sinusotomy for chronic sinusitis.

What to do

  • Enforce bed rest with the head of the bed elevated.
  • Encourage the patient to drink plenty of fluids to promote drainage.
  • Use a humidifier and nasal saline sprays to decrease dryness.
  • Monitor temperature to detect infection. Perform sinus irrigations as ordered.
  • To relieve pain and promote drainage, apply warm compresses continuously or four times daily for 2-hour intervals.
  • Watch for and report complications, such as vomiting, chills, fever, edema of the forehead or eyelids, blurred or double vision, and personality changes.
  • Evaluate the patient. Make sure the patient is free from pain, congestion, headaches, and fever; maintains humidification and drainage of his sinuses; understands the importance of complying with antibiotic therapy; and is able to distinguish common smells. (See Sinusitis teaching tips.)

Sinusitis teaching tips

  • Instruct the patient on how to apply compresses and take his antihistamine.
  • Teach him about all prescribed medications, including dosage, frequency, and adverse effects.
  • Tell him to finish the prescribed antibiotics, even if his symptoms disappear.
  • Encourage the patient to keep all follow-up appointments with the practitioner.
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