sinus center director, massachusetts eye and ear associate

Otolaryngology 2021

Stacey T. Gray, M.D. Sinus Center Director, Massachusetts Eye and Ear

Associate Professor, Harvard Medical School

Disclosures/ Conflicts of Interest None

Learning Objectives 1. To describe presenting signs and symptoms of

“can’t miss” diagnoses 2. To review key components of current

management of common and “can’t miss” Otolaryngology problems

3. To apply this knowledge to case vignettes

The Ear

What is your dx and treatment plan? Case 1

67 yo diabetic M with 4 weeks of left otalgia, otorrhea, muffled hearing.

Case 2 43 yo F with 2 days of sudden right hearing loss. No otalgia. Had URI last week.

Case 3 7 yo F with 2 days of right otalgia, fever, muffled hearing, mild facial paresis.

Disorders of the External Canal

Necrotizing Otitis Externa (aka Skull Base Osteomyelitis, Malignant OE, “Diabetic Ear”)

Diagnosis: Diabetic or immunocompromised Granulation tissue in ear canal Cranial neuropathies (eg.CN7)

Work up: Culture Biopsy High resolution CT temporal bone

AlEnazi AS et al. Impact of using the term “Diabetic Ear” J Family Community Med 2019.

Necrotizing Otitis Externa: Treatment • Meticulous glucose control • Aural toilet (frequent cleaning of the EAC) • Topical antipseudomonal antibiotics • Systemic antibiotics – oral or IV, may require two

anti-pseudomonal agents – Response followed with high resolution temporal

bone CT – Typically 8 weeks of therapy

Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008 Jun;41(3):537-49, viii-ix.

Herpes Zoster Oticus Otitis externa and cellulitis with vesicles Varicella Ramsay Hunt Syndrome:

Vesicular rash, Facial paralysis, Sensorineural hearing loss, Vertigo

Treatment – antivirals and steroids Worse prognosis than Bell’s palsy for facial nerve recovery

Disorders of the Middle Ear

Acute Otitis Media • Ear pain – dull, throbbing, “blocked” • No pain with movement of pinna • Hearing is decreased • TM is inflamed – not translucent • TREATMENT

– Amoxicillin – Augmentin or Cephalosporin for failure

Acute Otitis Media with TM Perforation • Diagnosis:

– Severe ear pain – Drainage from ear – Decreased hearing

• Treatment: – Oral antibiotics – Topical antibiotics – Water precautions – Most will heal

Serous Otitis Media (Otitis Media with Effusion)

• Ear pain is gone • Ear still feels blocked • This is the natural progression

after acute otitis media • TM is dull with fluid in the

middle ear space • Conductive hearing loss-

confirm this with tuning fork

Serous Otitis Media: Treatment •Observation •Autoinsufflation – marginal benefit1

•Nasal steroid spray – no definite benefit2 •No clear benefit of abx in pediatric trials3

•When to refer to ENT? –If no resolution after 2 months ? tympanostomy tube placement –If no concurrent/ preceding URI as cause ?nasopharyngoscopy

1. Perera R, et a.. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev. 2013 May 31;5: 2. Gluth MB, et al. Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 2011 May;137(5):449-55. 3. Venekamp RP1, Burton MJ, van Dongen TM, van der Heijden GJ, van Zon A, Schilder AG. Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev. 2016 Jun 12;(6):CD009163.

Chronic Otitis Media

INACTIVE COM ACTIVE COM CHOLESTEATOMA

Dry TM Perforation: Management 3 Options: 1. Observation

– Annual exam – Water precautions

2. Hearing aid – Usually only if hearing significantly impaired

or bilateral hearing loss 3. Surgical repair (tympanoplasty)

Facial Paralysis: Bell’s Palsy • Rapid onset (usually over 72 hours) • All branches affected • Often preceded by URI, otalgia, facial

numbness • Usually resolves within 3 weeks

Facial Paralysis Diffrential • Ear Infection – OM, COM • Herpes Zoster Oticus (Ramsay Hunt) • Lyme Disease • Malignancy – parotid, facial nerve, skull base • Benign facial nerve tumors • Autoimmune disease

Bell’s Palsy Treatment • Corticosteroids show significant benefit

– e.g. prednisone 60mg daily x 7 days then taper by 10mg daily

– 17% steroid tx group vs. 28% placebo group had incomplete recovery at 6 months 1

• Antivirals (Valacyclovir) – Reduction in incomplete recovery outcome with

steroids + antivirals compared to steroids alone (RR 0.64) 2

1. Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F, Sullivan F Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2016 Jul 18;7:CD001942. 2. Gagyor I, Madhok VB, Daly F, Somasundara D, Sullivan M, Gammie F, Sullivan F. Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2015 Nov 9;(11):CD001869.

Facial Paralysis: When to refer to Otolaryngology 1. Complete dense facial paralysis seen within first 14

daysConsider facial nerve decompression via craniotomy if access to a neurotologic ENT surgeon

2. Otogenic source suspected (associated hearing loss, abnomal otoscopic examination)

3. Atypical presentation of Bell’s palsy (not all branches affected,slowly progressive)

4. Incomplete recovery after Bell’s palsy

Ear Emergency: Complications of acute or chronic otitis media

• Mastoiditis • Facial paralysis -This is not Bell’s palsy • Meningitis • Intracranial abscess Treatment:

– Systemic and/or topical antibiotics – Drainage of the infection via wide myringotomy – Additional surgical management may include

mastoidectomy or intracranial abscess drainage

Ear Emergencies: Sudden Sensorineural Hearing Loss

• Acute onset hearing loss • Often associated with tinnitus • Normal otoscopic exam

Rauch SD. Idiopathic sudden sensorineural hearing loss. New Engl J Med 2008.

Ear Emergency: Sudden Sensorineural Hearing Loss

• Urgent referral for audiology and ENT • Early institution (< 4 weeks after onset) of steroids may

improve hearing recovery • PO and intratympanic steroids have equal efficacy1 , possible benefit of combined PO and IT tx • Most cases are idiopathic

– MRI for tumor typically done – Consider lyme, syphilis testing

Rauch SD, Halpin CF, Antonelli PJ, Babu S, Carey JP, Gantz BJ, Goebel JA, Hammerschlag PE, Harris JP, Isaacson B, Lee D, Linstrom CJ, Parnes LS, Shi H, Slattery WH, Telian SA, Vrabec JT, Reda DJ. Oral vs intratympanic corticosteroid therapy for idiopathic sudden sensorineural hearing loss: a randomized trial.JAMA. 2011 May 25;305(20):2071-9

What is your dx and treatment plan? Case 1

67 yo diabetic M with 4 weeks of left otalgia, otorrhea, muffled hearing.

Case 2 43 yo F with 2 days of sudden right hearing loss. No otalgia. Had URI last week.

Case 3 7 yo F with 2 days of right otalgia, fever, muffled hearing, mild facial paresis.

What is your dx and treatment plan? Case 1

Dx: Skull base osteomylitis (Malignant otitis externa) Tx: Admission for PICC line, 6 weeks IV and PO antibiotics

Case 2 Dx: Sudden sensorineural hearing loss Tx: High dose steroids, urgent audiogram and ENT referral

Case 3 Dx: AOM c/b Facial Paresis Tx: Urgent referral for myringotomy and tube, oral abx, ear drops

The Nose

Nose Case Vignettes

Case 1 56 yo M p/w 6 months of clear rhinorrhea, mainly right sided

What is your diagnosis and treatment plan?

Case 2 45 yo F with h/o bone marrow transplant for AML p/w 1 day of right eye pain and numbness in the right cheek

RHINOSINUSITIS ACUTE – lasting up to 4 weeks with total resolution of

symptoms

SUBACUTE – persisting more than 4 weeks, but less than 12 weeks, with total resolution of symptoms

RECURRENT ACUTE – 4 or more episodes per year, with resolution of symptoms between attacks

CHRONIC – Signs and symptoms lasting longer than 12 weeks

DIAGNOSIS OF ACUTE BACTERIAL RHINOSINUSITIS

• History • Anterior Rhinoscopy • Fiberoptic nasal endoscopy • CT scan – not usually necessary

– Perform if there is a concern for an intracranial or orbital complication

Rosenfeld, et al. Oto HNS 2015

ACUTE RHINOSINUSITIS

• Antibiotics are not always necessary • No antibiotics does not mean “no

treatment” – Nasal steroid sprays – Saline spray/irrigation – OTC cold medication for decongestion – Close follow up

ACUTE RHINOSINUSITIS THE ROLE OF THE OTOLARYNGOLOGIST

• Recurrent acute rhinosinusitis – Concern for frequent use of

antibiotics • Failure to respond to appropriate

medical therapy • Complications of sinusitis • Abnormal CT scan

CHRONIC RHINOSINUSITIS Inflammation of the mucosa of

the nose and paranasal sinuses of at least 12 consecutive weeks duration.

• Chronic Rhinosinusitis with polyps

• Chronic rhinosinusitis without polyps

Source: Benninger M. Ferguson BJ, Hadley JA, et al. Adult Chronic Rhinosinusitis: Definitions, Diagnosis, Epidemiology, and Pathophysiology. Otolaryngol Head Neck Surg 2003;129(suppl 3):S1-32.

Rosenfeld, et al. Oto HNS 2015

MEDICAL MANAGEMENT OF CHRONIC RHINOSINUSITIS

• Improvement in nasal hygiene – saline irrigation • Topical steroid spray • Consider antibiotics (macrolides) • Consider taper of oral steroids • Consider allergy/asthma/immunologic testing • Consider surgical intervention if medical therapy has

failed • Biologic therapy for surgical failures

CHRONIC RHINOSINUSITIS SURGICAL INTERVENTION

• Not all CRS is the same • Surgery is not intended to be

curative – Intent is to improve QOL – Polyps always recur

• It improves aeration and widens sinus ostia

• Can improve topical therapy delivery

RHINOSINUSITIS EMERGENCIES Orbital Complications: • Cellulitis • Abscess • Cavernous sinus thrombosis Signs and symptoms: • Pain with eye movement, Diplopia • Unilateral eye swelling • Conjunctival injection

RHINOSINUSITS EMERGENCIES

INTRACRANIAL COMPLICATIONS • Meningitis • Abscess • Osteomyelitis of the frontal bone

IMMUNOCOMPROMISED PATIENTS

• Immunocompromised – Transplant – Poorly controlled diabetes

• Fever is not always present • Sinus symptoms (can be mild) • New facial/orbital/palatal

swelling, eschar, pain, or numbness

INVASIVE FUNGAL SINUSITIS

INVASIVE FUNGAL SINUSITIS • Emergency Consult • Endoscopic exam and biopsy • CT/MRI (can be

underwhelming) • Requires surgical debridement • IV antifungals • High mortality even with rapid

diagnosis

UNILATERAL SINUS SYMPTOMS

• Unilateral blockage or drainage – Structural problem – Nasal polyps – Sinonasal tumor –

inverted papilloma, malignancy

UNILATERAL SINUS SYMPTOMS CSF rhinorrhea • Clear, watery, salty • Usually unilateral • More prominent with

bending forward • Associated with

intracranial hypertension

Nose Case Vignettes

Case 1 56 yo M p/w 6 months of clear rhinorrhea, mainly right sided

What is your diagnosis and treatment plan?

Case 2 45 yo F with a history of bone marrow transplant for AML p/w 1 day of right eye pain and numbness in the right cheek

Nose Case Vignettes Case 1

56 yo M p/w 6 months of clear rhinorrhea, mainly right sided Diagnosis: anterior skull base CSF leak Treatment: refer urgently to ENT, surgical repair

Case 2 45 yo F h/o bone marrow transplant for AML p/w 1 day of right eye pain and numbness in right cheek Diagnosis: invasive fungal sinusitis Treatment: emergent surgical debridement and antifungal Rx

The Throat

Throat Case Vignettes

Case 1 25 yo F p/w severe sore throat, fever, muffled voice for 2 days

What is your diagnosis and treatment plan?

Case 2 65 yo F p/w hoarseness, throat clearing and globus sensation for 6 months

PERITONSILLAR ABSCESS • Unilateral sore

throat • Deviation of uvula • TRISMUS • Ipsilateral otalgia

PERITONSILLAR ABSCESS

• TREATMENT • Immediate referral • Aspiration or I&D • Antibiotics

SUPRAGLOTTITIS • Severe sore throat. • Muffled voice. • Fever. • Normal OP exam • No trismus. • Drooling. • “Tripod” position

• Airway emergency

SUPRAGLOTTITIS • TREATMENT

• Immediate ENT referral • Establish airway

– Intubation vs. tracheotomy • Antibiotics • Steroids

SORE THROAT • OTHER CAUSES

• Unilateral sore throat • More insidious onset • Ispilateral otalgia • No fever • Lymphadenopathy

TONSILLAR CANCER • TYPES OF MALIGNANCY

– Squamous cell carcinoma – most common (70%) – Lymphoma

• Risk factors for SCCa – Tobacco – Alcohol – Association with HPV (in patients without alcohol or

tobacco history)

SORE THROAT • When to refer to an Otolaryngologist

– Severe sore throat with no abnormality on exam.

• Laryngoscopy needs to be performed. – Concern for an abscess. – Concern for malignancy. – Refractory to treatment. – Insidious onset.

HOARSENESS • Laryngitis

– Usually viral – Worse with straining voice – Vocal rest – Hydration – Resolves with time – If recurrent – can be fungal

(steroid inhaler)

HOARSENESS • When to refer to the Otolaryngologist

– Laryngoscopy – only option for visualization

– Persistent hoarseness – does not resolve after usual time period for URI

– Recurrent episodes of hoarseness – Concerning associated symptoms – Interferes with quality of life

HOARSENESS Vocal Fold Mass • Squamous cell carcinoma

– Associated with smoking – T1/T2 associated with much

higher survial rate – early detection is important

• Papilloma – Associated with HPV – Often presents in childhood

HOARSENESS • Concerning symptoms

– Pain – sore throat, ear pain – Dysphagia – Odynophagia – Aspiration

– Concern for head and neck malignancy

HOARSENESS • Vocal Fold Paralysis – breathy voice

– Injury • Intubation • Esophagoscopy, TEE

– Viral – Malignancy (affecting RLN)

• H&N malignancy, Esophageal cancer, Lung cancer, Thyroid cancer, Skull base tumor

HOARSENESS

• Heartburn infrequent • Throat clearing • Hoarseness • Globus sensation • Post nasal drip

LARYNGOPHARYNGEAL REFLUX

HOARSENESS

• Treatment –Consider medical therapy –Diet/Behavior change –Months to resolve –Botox for granuloma

LARYNGOPHARYNGEAL REFLUX

Throat Case Vignettes

Case 1 25 yo F p/w severe sore throat, fever, muffled voice for 2 days

What is your diagnosis and treatment plan?

Case 2 65 yo F p/w hoarseness, throat clearing and globus sensation for 6 months

Throat Case Vignettes Case 1

25 yo F p/w severe sore throat, fever, muffled voice for 2 days Diagnosis: peritonsillar abscess Treatment: urgent/emergent referral to ENT or ER

Case 2 65 yo F p/w hoarseness, throat clearing and globus sensation for 6 months Diagnosis: laryngopharyngeal reflux (LPR) Treatment: diet and lifestyle modifications, PPI

Key Points 1. Recognition of sudden sensorineural hearing loss 2. Differentiating Bell’s palsy from other causes of facial

paralysis 3. Otitis media complicated by facial paralysis requires urgent

care by ENT 4. CT imaging is usually not necessary for acute rhinosinusitis 5. Acute rhinosinusitis does not always require antibiotics 6. HPV related oropharyngeal squamous cell carcinoma

Next Best Steps 1. Consult ENT urgently for suspected sensorineural

hearing loss 2. Refer to Emergency Room for suspected

complications of otitis media or rhinosinusitis 3. Consult ENT for laryngoscopy in patients with

unilateral sore throat and sore throat without a visible explanation

4. Consult ENT for persistent hoarseness