Professional Documents
Culture Documents
A conductive hearing loss in the left ear due to otitis media with effusion. Note that bone
conduction thresholds are normal in both ears, but air conduction on the left is 30 dB poorer
than that measured on the right.
HEARING LOSS -- AUDIOMETRY
This audiogram suggests noise exposure that may be encountered occasionally in younger
individuals who have been exposed to hazardous or “toxic” noise. Note the high-frequency dip, with
a maximum loss at 4000 Hz.
HEARING LOSS -- AUDIOMETRY
Audiogram of a patient with presbycusis. Note that low-tone thresholds are relatively normal,
with a drop in thresholds at higher frequencies. This is a consequence of the normal aging
process and may vary widely from patient to patient.
HEARING LOSS -- TYMPANOGRAM
• Treatment is symptomatic
• Vestibular suppressant medications (meclizine)
• Antiemetics
• Short, tapering course of oral steroids
• It may take several weeks for symptoms to completely resolve
• Residual vestibulopathy that persists for months or even years
is not uncommon, and is best managed with vestibular
rehabilitation.
MÉNIÈRE’S DISEASE
• Ménière’s disease is usually diagnosed by history.
• Patients develop intense, episodic vertigo, usually lasting from
30 minutes to four hours, and associated with fluctuating
hearing loss, roaring tinnitus, and the sensation of aural
fullness.
• Even after the episode is over, some hearing loss often remains.
• Although the cause of Ménière’s disease has not been
determined, the symptoms are thought to be due to a distention
of the endolymphatic space within the balance organs of the
inner ear.
MÉNIÈRE’S DISEASE -- TREATMENT
• The disease can be difficult to treat because its course is very
unpredictable. Patients can suffer from frequent attacks and then
abruptly stop having symptoms, only to resume attacks years later.
• Treatment focuses on decreasing the endolymphatic fluid pressure
within the inner ear.
• Salt restriction and thiazide diuretics are frequently used as first-line
agents.
• Additional intervention and referral to ENT may be neccessary.
• Vestibular ablation by instillation of ototoxic medication (i.e.,
gentamicin) into the middle ear for absorption through the round
window membrane has been used. Surgical options also exist.
ACUTE SINUSITIS
• Prolonged mucosal edema, from sinus obstruction and retention of
secretions, may lead to acute bacterial rhinosinusitis.
• Patients may exhibit several of the major symptoms:
• Facial pressure/pain
• Facial congestion/fullness
• Purulent nasal discharge
• Nasal obstruction
Although nasal circulation is complex (Figure 1), epistaxis usually is described as either anterior
or posterior bleeding. This simple distinction provides a useful basis for management.
EPISTAXIS -- ANATOMY
• Most cases of epistaxis occur in the anterior part of the nose, with the
bleeding usually arising from the rich arterial anastomoses of the nasal
septum (Kiesselbach’s plexus).
• Posterior epistaxis generally arises from the posterior nasal cavity via
branches of the sphenopalatine arteries.
• In most cases, anterior bleeding is clinically obvious.
• Posterior bleeding may be asymptomatic or may present insidiously as
nausea, hematemesis, anemia, hemoptysis, or melena.
• Infrequently, larger vessels are involved in posterior epistaxis and can result
in sudden, massive bleeding.
EPISTAXIS -- ETIOLOGY
LOCAL CAUSES SYSTEMIC CAUSES
• Chronic sinusitis • Hemophilia
• Epistaxis digitorum (nose picking)
• Hypertension
• Foreign bodies
• Leukemia
• Intranasal neoplasm or polyps
• Irritants (e.g., cigarette smoke) • Liver disease (e.g., cirrhosis)
• Medications (e.g., topical • Medications (e.g., aspirin,
corticosteroids) anticoagulants, nonsteroidal anti-
• Rhinitis inflammatory drugs)
• Septal deviation or perforation • Platelet dysfunction
• Trauma • Thrombocytopenia
• Vascular malformation or telangiectasia
EPISTAXIS -- MANAGEMENT
• Initial management includes compression of the nostrils (application of direct
pressure to the septal area) and plugging of the affected nostril with gauze or
cotton that has been soaked in a topical decongestant.
• Direct pressure should be applied continuously for at least five minutes, and
for up to 20 minutes.
• Tilting the head forward prevents blood from pooling in the posterior pharynx,
thereby avoiding nausea and airway obstruction.
• Hemodynamic stability and airway patency should be confirmed. Fluid
resuscitation should be initiated if volume depletion is suspected.
EPISTAXIS -- MANAGEMENT
Typical contents of an epistaxis tray. Top row: nasal decongestant sprays and local anesthetic, silver
nitrate cautery sticks, bayonet forceps, nasal speculum, Frazier suction tip, posterior double balloon
system and syringe for balloon inflation. Bottom row: Packing materials, including nonadherent
gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform),
Merocel, Gelfoam, and suction cautery.
EPISTAXIS -- MANAGEMENT
• Every attempt should be made to locate the source of bleeding that does not
respond to simple compression and nasal plugging
• Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic
process such as hypertension, anticoagulation, or coagulopathy. In such cases, a
hematologic evaluation should be performed
• Tests include CBC, PT/INR, PTT and, if indicated, blood typing and crossmatching
• Although most patients with epistaxis can be treated as outpatients, hospital
admission and close observation should be considered for elderly patients and
patients with posterior bleeding or coagulopathy. Admission also may be prudent for
patients with complicating comorbid conditions such as coronary artery disease,
severe hypertension, or significant anemia
EPISTAXIS -- MANAGEMENT
ANTERIOR BLEEDS
• Topical oxymetazoline (Afrin) spray alone often stops the hemorrhage.
• LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%) applied to a
cotton ball or gauze and allowed to remain in the nares for 10-15 minutes is very
useful in providing vasoconstriction and analgesia.
• For bleeding that is likely to require more aggressive treatment, a local anesthetic,
such as a 4 percent cocaine solution or tetracaine or lidocaine (Xylocaine) solution,
should be used.
• Adequate anesthesia should be obtained before treatment proceeds.
• Intravenous access should be obtained in difficult cases, especially when anxiolytic
medications are to be used.
EPISTAXIS -- MANAGEMENT
ANTERIOR BLEEDS
• Cotton pledgets soaked in vasoconstrictor and anesthetic should be placed in the
anterior nasal cavity, and direct pressure should be applied at both sides of the nose
for at least five minutes.
• If this measure is unsuccessful, chemical cautery can be attempted using a silver
nitrate stick applied directly to the bleeding site for approximately 30 seconds .
• Other treatment options include hemostatic packing with absorbable gelatin foam
(Gelfoam) or oxidized cellulose (Surgicel). Use of desmopressin spray (DDAVP) may
be considered in a patient with a known bleeding disorder.
• Larger vessels generally respond more readily to electrocautery.
• Note that use of electrocautery on both sides of the septum may increase the risk of
septal perforation.
EPISTAXIS -- MANAGEMENT
If local treatments fail to stop anterior bleeding, the anterior nasal cavity should be packed,
from posterior to anterior, with ribbon gauze impregnated with petroleum jelly or polymyxin B-
bacitracin zinc-neomycin (Neosporin) ointment. Nonadherent gauze impregnated with
petroleum jelly and 3 percent bismuth tribromophenate (Xeroform) also works well for this
purpose.5,9 Bayonet forceps and a nasal speculum are used to approximate the accordion-
folded layers of the gauze, which should extend as far back into the nose as possible.
Alternatively, a preformed nasal tampon (Merocel or Doyle sponge) may be used
EPISTAXIS -- MANAGEMENT
POSTERIOR BLEEDS
• Posterior bleeding is much less common than anterior bleeding and usually is treated
by an otolaryngologist.
• Various balloon systems are effective for managing posterior bleeding and are less
complicated than the packing procedure.
• The double-balloon device is passed into the affected nostril under topical
anesthesia until it reaches the nasopharynx. The posterior balloon then is inflated
with 7 to 10 mL of saline, and the catheter is withdrawn carefully so that the balloon
seats in the posterior nasal cavity to tamponade the bleeding source. Next, the
anterior balloon is inflated with roughly 15 to 30 mL of saline in the anterior nasal
cavity to prevent retrograde travel of the posterior balloon and subsequent airway
obstruction.
• If a specialized balloon device is not available, a Foley catheter (10 to 14 French)
with a 30-mL balloon may be used.
STREP PHARYNGITIS
• Sore throat is one of the most
common reasons for visits to family
physicians.
• Most patients with sore throat have
an infectious cause (pharyngitis), but
less than 20 percent have a clear
indication for antibiotic therapy.
• Because of recent improvements in
rapid streptococcal antigen tests,
throat culture can be reserved for
patients whose symptoms do not
improve over time or who do not
respond to antibiotics .
STREP PHARYGITIS
• Pharyngitis is diagnosed in 11 million patients in U.S. emergency departments and
ambulatory settings annually.
• Most episodes are viral.
• Group A beta-hemolytic streptococcus (GABHS), the most common bacterial
etiology, accounts for 15 to 30 percent of cases of acute pharyngitis in children and 5
to 20 percent in adults.
• One in four children with acute sore throat has serologically confirmed GABHS
pharyngitis.
• Late winter and early spring are peak GABHS seasons.
• The infection is transmitted via respiratory secretions, and the incubation period is 24
to 72 hours.
STREP PHARYNGITIS -- CENTOR CRITERIA
There are four criteria, with one point added for each positive criterion:
• History of fever
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough
The Modified Centor Criteria add the patient's age to the criteria:
• Age 2-15 add 1 point
• Age >44 subtract 1 point
STREP PHARYNGITIS -- CENTOR CRITERIA
Guidelines for management:
• -1, 0 or 1 points - No antibiotic or throat culture necessary (Risk of strep.
infection <10%)
• 2 or 3 points - Should receive a throat culture and treat with an antibiotic if
culture is positive (Risk of strep. infection 32% if 3 criteria, 15% if 2)
• 4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection
56%)
The presence of all four variables indicates a 40 - 60% positive predictive value for a
culture of the throat to test positive for Group A Streptococcus bacteria. The absence of
all four variables indicates a negative predictive value of greater than 80%.
STREP PHARYNGITIS -- DIAGNOSIS
• With correct sampling and plating techniques, a single-swab throat culture is
90 – 95% sensitive
• Rapid antigen detection testing (RADT) allows for earlier treatment, symptom
improvement, and reduced disease spread.
• RADT specificity ranges from 90 – 99%.
• Sensitivity depends on the commercial RADT kit used and was
approximately 70% with older latex agglutination assays. Newer ELISA,
optical immunoassays, and DNA probes are 90 - 99% sensitive.
• The American Academy of Pediatrics (AAP) recommends that negative
RADT results in children be confirmed using throat culture unless physicians
can guarantee that RADT sensitivity is similar to that of throat culture in their
practice
STREP PHARYNGITIS -- TREATMENT
• GABHS pharyngitis is self-limited and resolves within a few days, even without
treatment.
• Arguments for antibiotic treatment include acute symptom relief, prevention of
complications, and reduced communicability.
• Antibiotics shorten symptom duration by about 16 hours; the number needed to treat
(NNT) for symptom relief at 72 hours is four in those with positive throat swabs.
• In addition, rates of suppurative peritonsillar and retropharyngeal abscesses are
reduced (approximately one in 1,000 cases).
STREP PHARYNGITIS -- TREATMENT
• Antibiotics also reduce the
incidence of acute rheumatic
fever
• It is estimated that 3,000 to 4,000
patients must be given antibiotics
to prevent one case of acute
rheumatic fever in developed
nations.
• Children with GABHS pharyngitis
may return to school after 24
hours of antibiotic therapy.
STREP PHARYNGITIS -- TREATMENT
Based on cost, narrow spectrum of activity, safety, and effectiveness, penicillin is
recommended by the American Academy of Family Physicians (AAFP), the AAP, the American
Heart Association, the Infectious Diseases Society of America (IDSA), and the World Health
Organization for the treatment of streptococcal pharyngitis.