Updates in

Otolaryngology

Jonathan Lara, DO

Southwestern Conference on Medicine Fall Primary Care

Update

October 27, 2012

Introduction

• Ear: Ear: Ear: Ear: • Treatment guidelines for otitis media• Guidelines for idiopathic sudden sensorineural hearing loss

• Nose: Nose: Nose: Nose: • Biofilms in chronic sinusitis• In office Balloon Sinuplasty

• Throat:Throat:Throat:Throat:• Transoral robotic surgery• Postoperative tonsillectomy pain control guidelines

Otitis Media Diagnosis

• Acute otitis mediaAcute otitis mediaAcute otitis mediaAcute otitis media

• Rapid/Recent onset symptoms or middle ear

inflammation

• Presence of middle ear effusion: bulging of TM, decreased

TM mobility, air-fluid level in ME, Otorrhea

• Otitis media with effusion: Presence of MEEOtitis media with effusion: Presence of MEEOtitis media with effusion: Presence of MEEOtitis media with effusion: Presence of MEE

Diagnosis Acute Otitis Media

•Purulent, bulging TMPurulent, bulging TMPurulent, bulging TMPurulent, bulging TM

•Serous effusion can persist for up to 3 monthsSerous effusion can persist for up to 3 monthsSerous effusion can persist for up to 3 monthsSerous effusion can persist for up to 3 months

•Pneumatic Pneumatic Pneumatic Pneumatic otoscopyotoscopyotoscopyotoscopy (88(88(88(88----99% 99% 99% 99% sensensensen, 56, 56, 56, 56----90% spec)90% spec)90% spec)90% spec)

•Tympanometry (54Tympanometry (54Tympanometry (54Tympanometry (54----96% 96% 96% 96% sensensensen, 73, 73, 73, 73----93% spec)93% spec)93% spec)93% spec)

Serous effusionAcute Otitis media

Acute Otitis Media Treatment

•Treatment of painTreatment of painTreatment of painTreatment of pain

• Acetaminophen, ibuprofen

• Topical Benzocaine (Auralgan, Americaine Otic)

•Observation of uncomplicated AOMObservation of uncomplicated AOMObservation of uncomplicated AOMObservation of uncomplicated AOM

• 48-72hrs

• Age (6m-2y, >2y), severity (temp >39◦ C), certainty of dx

Acute Otitis Media Observation

Age Certain

Diagnosis

Uncertain

Diagnosis

<6mo Antibacterial therapy Antibacterial therapy

6 mo – 2y Antibacterial therapy Antibacterial therapy

if severe, observe

non-severe

>2y Antibacterial therapy

if severe, observe if

not severe

Observation option

Acute Otitis Media observation

•By 24hr: 61% improved +/By 24hr: 61% improved +/By 24hr: 61% improved +/By 24hr: 61% improved +/---- abxabxabxabx, by 7 days 75% resolved, by 7 days 75% resolved, by 7 days 75% resolved, by 7 days 75% resolved

•12.3% reduction in clinical failure rate 212.3% reduction in clinical failure rate 212.3% reduction in clinical failure rate 212.3% reduction in clinical failure rate 2----7 days if treatment with 7 days if treatment with 7 days if treatment with 7 days if treatment with

ampicillin or amoxicillin versus placeboampicillin or amoxicillin versus placeboampicillin or amoxicillin versus placeboampicillin or amoxicillin versus placebo

•Delay of therapy 72hrs Delay of therapy 72hrs Delay of therapy 72hrs Delay of therapy 72hrs

• 76% never need antibiotics versus immediate therapy resulted

in 1 day shorter illness & ½ tsp/day less acetaminophen

•In children with more severe illness, In children with more severe illness, In children with more severe illness, In children with more severe illness, abxabxabxabx txtxtxtx has greater benefithas greater benefithas greater benefithas greater benefit

•No evidence for increased risk of complications with initial No evidence for increased risk of complications with initial No evidence for increased risk of complications with initial No evidence for increased risk of complications with initial

observationobservationobservationobservation

Otitis Media-Bacteria

•Streptococcus Streptococcus Streptococcus Streptococcus pneumoniaepneumoniaepneumoniaepneumoniae, , , , HaemophilusHaemophilusHaemophilusHaemophilus influenzaeinfluenzaeinfluenzaeinfluenzae, Moraxella , Moraxella , Moraxella , Moraxella

catarrhaliscatarrhaliscatarrhaliscatarrhalis

•Treatment:Treatment:Treatment:Treatment:

•High dose Amoxil (80-90 mg/kg/day) first line

•High dose Augmentin (90mg/kg amox, 6.4mg/kg/day clav)

• PCN allergy: cefdinir (14mg/kg/d), cefpodoxime (10mg/kg/d), cefuroxime (30mg/kg/d) , azithromycin (10mg/kg/d),

clarithromycin (15mg/kg/d), clindamycin (30mg/kg/d)

Recurrent Acute Otitis Media

•Reduce risk factorsReduce risk factorsReduce risk factorsReduce risk factors

• Avoid tobacco smoke exposure, eliminate pacifier after 6

months, day care

• Breastfeeding, immunizations protective

•TympanostomyTympanostomyTympanostomyTympanostomy tube placement tube placement tube placement tube placement

• >3 episodes in 6 months

• >4 episodes in 12 months

Otitis Media with Effusion

•Pediatrics with watchful waiting for 3 months from date of Pediatrics with watchful waiting for 3 months from date of Pediatrics with watchful waiting for 3 months from date of Pediatrics with watchful waiting for 3 months from date of

effusion/diagnosiseffusion/diagnosiseffusion/diagnosiseffusion/diagnosis

• 75-90% of OME after AOM resolves by 3 months

•Hearing testing when OME >3 months or language delay or Hearing testing when OME >3 months or language delay or Hearing testing when OME >3 months or language delay or Hearing testing when OME >3 months or language delay or

significant hearing loss suspectedsignificant hearing loss suspectedsignificant hearing loss suspectedsignificant hearing loss suspected

•Children not at risk should be monitored ever 3 to 6 months Children not at risk should be monitored ever 3 to 6 months Children not at risk should be monitored ever 3 to 6 months Children not at risk should be monitored ever 3 to 6 months

until effusion is goneuntil effusion is goneuntil effusion is goneuntil effusion is gone

•Treatment is Treatment is Treatment is Treatment is tympanostomytympanostomytympanostomytympanostomy tube insertion (Adenoidectomy tube insertion (Adenoidectomy tube insertion (Adenoidectomy tube insertion (Adenoidectomy

traditionally with second set of tubes)traditionally with second set of tubes)traditionally with second set of tubes)traditionally with second set of tubes)

Indication for ENT referral

• Complications of acute/chronic otitis media:Complications of acute/chronic otitis media:Complications of acute/chronic otitis media:Complications of acute/chronic otitis media:

• facial nerve paralysis, meningitis, and intracranial and/or neck abscess

formation

• Conductive hearing lossConductive hearing lossConductive hearing lossConductive hearing loss in a patient with otitis media with in a patient with otitis media with in a patient with otitis media with in a patient with otitis media with effusion for > effusion for > effusion for > effusion for >

3 months (need audiogram)3 months (need audiogram)3 months (need audiogram)3 months (need audiogram)

• Otitis media with effusion with associated Otitis media with effusion with associated Otitis media with effusion with associated Otitis media with effusion with associated speech delayspeech delayspeech delayspeech delay

• 3 episodes3 episodes3 episodes3 episodes of otitis media of otitis media of otitis media of otitis media in 6 monthsin 6 monthsin 6 monthsin 6 months or more than or more than or more than or more than ~4~4~4~4----5 episodes in 5 episodes in 5 episodes in 5 episodes in

12 months12 months12 months12 months

• Chronic retraction of the tympanic membrane upon examinationChronic retraction of the tympanic membrane upon examinationChronic retraction of the tympanic membrane upon examinationChronic retraction of the tympanic membrane upon examination

Review of Otitis Media

• Onset and severity of symptomsOnset and severity of symptomsOnset and severity of symptomsOnset and severity of symptoms

• Observation without antibiotics in a healthy child with reassessObservation without antibiotics in a healthy child with reassessObservation without antibiotics in a healthy child with reassessObservation without antibiotics in a healthy child with reassessment in ment in ment in ment in

48484848----72hrs72hrs72hrs72hrs

• Treat symptoms/painTreat symptoms/painTreat symptoms/painTreat symptoms/pain

• HighHighHighHigh----dose Amoxicillin is first line drug if indicateddose Amoxicillin is first line drug if indicateddose Amoxicillin is first line drug if indicateddose Amoxicillin is first line drug if indicated

• MEE persists for up to 3 months, document and monitor for hearinMEE persists for up to 3 months, document and monitor for hearinMEE persists for up to 3 months, document and monitor for hearinMEE persists for up to 3 months, document and monitor for hearing loss g loss g loss g loss

or speech delayor speech delayor speech delayor speech delay

• Refer to ENT for MEE >3Refer to ENT for MEE >3Refer to ENT for MEE >3Refer to ENT for MEE >3----6 months, hearing loss, speech delay, RAOM or 6 months, hearing loss, speech delay, RAOM or 6 months, hearing loss, speech delay, RAOM or 6 months, hearing loss, speech delay, RAOM or

complicationscomplicationscomplicationscomplications

Idiopathic Sudden Sensorineural Hearing Loss (ISSNHL)

• Theories:Theories:Theories:Theories:

• Viral

• Autoimmune (autoimmune inner ear disease – AIED)

• Vascular

• Intracochlear membrane breaks

ISSNHL: Viral

• Current belief Current belief Current belief Current belief –––– viral viral viral viral cochleitiscochleitiscochleitiscochleitis causes the majority of causes the majority of causes the majority of causes the majority of

cases of ISSNHLcases of ISSNHLcases of ISSNHLcases of ISSNHL

• 1983 1983 1983 1983 –––– Wilson and colleaguesWilson and colleaguesWilson and colleaguesWilson and colleagues

• Viral Viral Viral Viral seroconversionseroconversionseroconversionseroconversion rates greater in patients with rates greater in patients with rates greater in patients with rates greater in patients with

ISSNHL (63%) compared to control (40%)ISSNHL (63%) compared to control (40%)ISSNHL (63%) compared to control (40%)ISSNHL (63%) compared to control (40%)• Influenza B

• Mumps

• Rubeola

• VZV

ISSNHL

• New New New New ---- Sleep apnea linked to sudden hearing lossSleep apnea linked to sudden hearing lossSleep apnea linked to sudden hearing lossSleep apnea linked to sudden hearing loss

•No causality proven

• Sleep apnea causes major inflammation in the

bloodstream/brain promoting vascular complications

•Need for prospective studies, and causality studies with treatment trials (i.e., improved sleep apnea,

improved hearing).

Arch Otol Head Neck Surg. 2012; 138 [1]:55.

ISSNHL: Treatment

• 90% of cases will be Idiopathic90% of cases will be Idiopathic90% of cases will be Idiopathic90% of cases will be Idiopathic

• Treat known causes by addressing the underlying Treat known causes by addressing the underlying Treat known causes by addressing the underlying Treat known causes by addressing the underlying

conditionconditionconditioncondition

ISSHNL: Treatment

• Therapy for ISSNHL is controversialTherapy for ISSNHL is controversialTherapy for ISSNHL is controversialTherapy for ISSNHL is controversial

• Difficult to studyDifficult to studyDifficult to studyDifficult to study

•High spontaneous recovery rate

• Low incidence

•Makes validation of empiric treatment modalities

difficult

ISSNHL: Treatment

• Proposed treatment modalitiesProposed treatment modalitiesProposed treatment modalitiesProposed treatment modalities

• Anti-inflammatory – steroids, cytotoxic agents

• e.g., PrednisonePrednisonePrednisonePrednisone 1mg/kg/day (80mg) PO QD taper

over 2 weeks.

•Diuretics

• Antiviral agents

Treatment

• BAHA (Cochlear / BAHA (Cochlear / BAHA (Cochlear / BAHA (Cochlear / OticonOticonOticonOticon))))• Bone Anchored Hearing “Aid”

• Surgically implanted pin in the skull, using a vibrating digital hearing amplfication device.

• CROS/BICROSCROS/BICROSCROS/BICROSCROS/BICROS

• CCCContralateral ontralateral ontralateral ontralateral RRRRouting outing outing outing OOOOf f f f SSSSignalignalignalignal

Sinuses

1.1.1.1. Biofilms in chronic Biofilms in chronic Biofilms in chronic Biofilms in chronic rhinosinusitisrhinosinusitisrhinosinusitisrhinosinusitis

2.2.2.2. In office Balloon In office Balloon In office Balloon In office Balloon SinuplastySinuplastySinuplastySinuplasty

Biofilms in chronic rhinosinusitis

• Biofilms are complex communities of microorganisms that Biofilms are complex communities of microorganisms that Biofilms are complex communities of microorganisms that Biofilms are complex communities of microorganisms that develop a protective barrier and metabolism that makes develop a protective barrier and metabolism that makes develop a protective barrier and metabolism that makes develop a protective barrier and metabolism that makes them very difficult to eradicate by simply taking antibiotics. them very difficult to eradicate by simply taking antibiotics. them very difficult to eradicate by simply taking antibiotics. them very difficult to eradicate by simply taking antibiotics.

• Biofilms are present in the lining of chronic sinus suffers Biofilms are present in the lining of chronic sinus suffers Biofilms are present in the lining of chronic sinus suffers Biofilms are present in the lining of chronic sinus suffers and more prevalent in the sinuses of patients who have and more prevalent in the sinuses of patients who have and more prevalent in the sinuses of patients who have and more prevalent in the sinuses of patients who have had traditional FESS surgery.had traditional FESS surgery.had traditional FESS surgery.had traditional FESS surgery.

• Noted with persistent refractory chronic Noted with persistent refractory chronic Noted with persistent refractory chronic Noted with persistent refractory chronic rhinosinusitisrhinosinusitisrhinosinusitisrhinosinusitis(CRS)(CRS)(CRS)(CRS)

• The role of biofilms first recognized in otitis media. The role of biofilms first recognized in otitis media. The role of biofilms first recognized in otitis media. The role of biofilms first recognized in otitis media. • Strains of Pseudomonas aeruginosa isolated from cholesteatoma are avid biofilm formers.

Biofilm treatment options

• Antimicrobial photodynamic therapy (Antimicrobial photodynamic therapy (Antimicrobial photodynamic therapy (Antimicrobial photodynamic therapy (aPDTaPDTaPDTaPDT))))

• Treatment with a methylene blue photosensitizer and

670 nm non-thermal-activating light to break up films

• Surfactant therapy:Surfactant therapy:Surfactant therapy:Surfactant therapy:

• Use of Bactroban with baby shampoo or Sinusurf™

• SurgerySurgerySurgerySurgery

• Larger antrostomy (medial maxillectomy) for daily

debridment/irrigations.

In office Balloon Sinuplasty

Balloon Sinuplasty™

• New minimallyNew minimallyNew minimallyNew minimally----invasive way of creating a wider invasive way of creating a wider invasive way of creating a wider invasive way of creating a wider

window into certain sinuseswindow into certain sinuseswindow into certain sinuseswindow into certain sinuses

• New technique with less bleeding, quicker surgery New technique with less bleeding, quicker surgery New technique with less bleeding, quicker surgery New technique with less bleeding, quicker surgery

time, decreased healing timetime, decreased healing timetime, decreased healing timetime, decreased healing time

• Safe and effective Safe and effective Safe and effective Safe and effective –––– 0% Complication Rate, 0% Complication Rate, 0% Complication Rate, 0% Complication Rate,

morbidity/mortality.morbidity/mortality.morbidity/mortality.morbidity/mortality.

• Relieva Balloon

Sinuplasty™ devices

• Designed for customized access

• Sinus Illumination System

• Sinus Guide Catheter

• Engineered for sinus dilation

• Sinus Balloon Catheter

• Developed for controlled inflation

• Sinus Balloon Inflation Device

CLEAR One-Year Study

Efficacy Results

Maxillary Frontal Sphenoid Total

Endoscopic patency90%

(83/92)

85%

(63/74)

72%

(26/36)

85%

(172/202)

Non-patent0%

(0/92)

3%

(2/74)

0%

(0/36)

1%

(2/202)

Functional Patency

(CT L/M Score = 0)3/9 5/9 5/10 13/28

Overall functional patency

93.5%

(86/92)

91.9%

(63/74)

86.1%

(31/36)

91.6%

(185/202)

Nasal Endoscopic Evaluation by Sinus(n = 202 sinuses)

91.6% functional patency of all ballooned sinuses

Sources

CLEAR One-Year Study

L/M & SNOT-20 ResultsLund-MacKay CT Score

(n = 53)

(1) Statistically significant (p <0.001)

Symptom Assessment SNOT-20 (n = 65)

(1) Statistically significant (p <0.001)

(2) Clinically meaningful change (>0.8)

8.89

1.95

Preop 1 Year

2.14

1.01 0.91

Preop 6 months 1 year

Sources

IN office Balloon Sinuplasty Conclusions

• TransTransTransTrans----nasal BSD in the office setting can be safely nasal BSD in the office setting can be safely nasal BSD in the office setting can be safely nasal BSD in the office setting can be safely

performed in all peripheral sinuses performed in all peripheral sinuses performed in all peripheral sinuses performed in all peripheral sinuses

• InInInIn----office BSD is effective in: office BSD is effective in: office BSD is effective in: office BSD is effective in: • relieving symptoms of CRS, as evidenced by significant SNOT-20

improvement

• low revision rate

• Patients with mild/moderate Patients with mild/moderate Patients with mild/moderate Patients with mild/moderate ethmoidethmoidethmoidethmoid disease may be disease may be disease may be disease may be

suitable candidates for insuitable candidates for insuitable candidates for insuitable candidates for in----office BSD, with potential office BSD, with potential office BSD, with potential office BSD, with potential

option to avoid option to avoid option to avoid option to avoid ethmoidectomyethmoidectomyethmoidectomyethmoidectomy

Throat

1.1.1.1. TransoralTransoralTransoralTransoral robotic surgery for head and neck cancersrobotic surgery for head and neck cancersrobotic surgery for head and neck cancersrobotic surgery for head and neck cancers

2.2.2.2. New guidelines for postoperative tonsillectomy in New guidelines for postoperative tonsillectomy in New guidelines for postoperative tonsillectomy in New guidelines for postoperative tonsillectomy in

pediatricspediatricspediatricspediatrics

Transoral robotic surgery

• Use of Use of Use of Use of transoraltransoraltransoraltransoral robotics for surgery allows for precise robotics for surgery allows for precise robotics for surgery allows for precise robotics for surgery allows for precise movement, magnification, and preservation of structures.movement, magnification, and preservation of structures.movement, magnification, and preservation of structures.movement, magnification, and preservation of structures.

• Benefits:Benefits:Benefits:Benefits:

• Surgery is 30 minutes to an hour on average

• Blood loss was minimal at ~15.4 milliliters, on average, per patient.

• Patients usually can accept an oral diet within 24 hours.

• Versus traditional surgery: takes around 4 hours to Versus traditional surgery: takes around 4 hours to Versus traditional surgery: takes around 4 hours to Versus traditional surgery: takes around 4 hours to perform, requires 7 to 10 days of hospitalization on perform, requires 7 to 10 days of hospitalization on perform, requires 7 to 10 days of hospitalization on perform, requires 7 to 10 days of hospitalization on average and require a tracheostomy tube and NG tube.average and require a tracheostomy tube and NG tube.average and require a tracheostomy tube and NG tube.average and require a tracheostomy tube and NG tube.

Postop Tonsillectomy Pain control

• The USDA issued a warming (8/2012) regarding risks posed by the The USDA issued a warming (8/2012) regarding risks posed by the The USDA issued a warming (8/2012) regarding risks posed by the The USDA issued a warming (8/2012) regarding risks posed by the prescription painkiller codeine postoperatively.prescription painkiller codeine postoperatively.prescription painkiller codeine postoperatively.prescription painkiller codeine postoperatively.• Three children have died and one child experienced life-threatening breathing difficulties

• Of particular concern: Of particular concern: Of particular concern: Of particular concern: • The children received codeine of typical dose range, which meansthe drug hit their bloodstream more quickly

• More potent in so called “ultra-rapid metabolizers” of the drug. That could have raised the risk of overdose and death.

• Genetic testing for codeine to morphine metabolizer CYP2D6

• Problem arises with more elevated morphine levels than normal wiProblem arises with more elevated morphine levels than normal wiProblem arises with more elevated morphine levels than normal wiProblem arises with more elevated morphine levels than normal with th th th respiratory suppression.respiratory suppression.respiratory suppression.respiratory suppression.

• Genetic tests can identify ultraGenetic tests can identify ultraGenetic tests can identify ultraGenetic tests can identify ultra----rapid metabolizers, but most rapid metabolizers, but most rapid metabolizers, but most rapid metabolizers, but most pediatricians donpediatricians donpediatricians donpediatricians don’’’’t order them before prescribing codeine.t order them before prescribing codeine.t order them before prescribing codeine.t order them before prescribing codeine.

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