GEMC - Ear and Sinus Emergencies - Resident Training
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This is a lecture by Dr. Rodney Smith from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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GEMC - Ear and Sinus Emergencies - Resident Training
- 1. Project: Ghana Emergency Medicine Collabora4ve Document Title: Ear and Sinus Emergencies Author(s): Rodney Smith (St. Joseph Mercy Hospital Ann Arbor), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Crea9ve Commons A;ribu9on Share Alike-‐3.0 License: hKp://crea4vecommons.org/licenses/by-‐sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The cita4on key on the following slide provides informa4on about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any ques4ons, correc4ons, or clarifica4on regarding the use of content. For more informa4on about how to cite these materials visit hKp://open.umich.edu/privacy-‐and-‐terms-‐use. Any medical informa9on in this material is intended to inform and educate and is not a tool for self-‐diagnosis or a replacement for medical evalua4on, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have ques4ons about your medical condi4on. Viewer discre9on is advised: Some medical content is graphic and may not be suitable for all viewers. 1
- 2. A;ribu9on Key for more informa4on see: hKp://open.umich.edu/wiki/AKribu4onPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Crea9ve Commons – Zero Waiver Crea9ve Commons – A;ribu9on License Crea9ve Commons – A;ribu9on Share Alike License Crea9ve Commons – A;ribu9on Noncommercial License Crea9ve Commons – A;ribu9on Noncommercial Share Alike License GNU – Free Documenta9on License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protec4on in the U.S. (17 USC § 102(b)) *laws in your jurisdic4on may differ { Content Open.Michigan has used under a Fair Use determina4on. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdic4on may differ Our determina4on DOES NOT mean that all uses of this 3rd-‐party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2
- 3. Ear and Sinus Emergencies • Objec4ves – Describe the evalua4on and treatment of ear disorders – Describe the evalua4on and treatment of sinus disorders 3
- 4. Ear Anatomy Iain, Wikimedia Commons 4
- 5. External Ear Cerumen Impac9on • Cerumen Ear Anatomy – Cerumen glands – Sebaceous glands – Desquamated epidermis • Normal clearing – Hair follicles – Epidermal migra4on – Chewing Iain, Wikimedia Commons 5
- 6. External Ear Cerumen Impac9on • Cerumen accumula4on that is Ear Anatomy – Symptoma4c – Sufficient to prevent adequate ear examina4on • Causes – – – – Canal obstruc4on Foreign body Canal instrumenta4on Aging Iain, Wikimedia Commons 6
- 7. External Ear Cerumen Impac9on • Cerumenoly4c agents Ear Anatomy – Saline/water – Hydrogen peroxide – Mineral oil • Irriga4on – Syringe – Syringe plus buKerfly • Mechanical removal – CureKes Iain, Wikimedia Commons 7
- 8. External Ear External o99s • Inflamma4on of the external ear • Breakdown of normal skin/ cerumen barrier Ear Anatomy – Excessive cleaning – Swimming – Foreign body • Hearing aids Iain, Wikimedia Commons 8
- 9. External Ear O99s Externa • 41% Pseudomonas • 15% S. aureus • 22% Peptostreptococcus • 11% Bacteroides Iain, Wikimedia Commons Ear Anatomy 9
- 10. External Ear External o99s • Symptoms Ear Anatomy – Pain – Discharge – Hearing loss • Exam – – – – Swelling Redness Drainage Dis4nguish from o44s media with perfora4on Iain, Wikimedia Commons 10
- 11. External Ear External o99s • Treatment Ear Anatomy – Remove debris in canal – Topical treatments • • • • Acidifying agents An4sep4cs An4-‐inflammatory An4bio4cs – Control pain – Consider culture if severe – Prevent further injury Iain, Wikimedia Commons 11
- 12. External Ear Acidifying agents • Ace4c acid – VoSol – VoSol HC • Boric Acid – Domeboro O4c An9sep9c • Alcohol • Thimerosal • Thymol • Gen4an Violet • Sulfuric acid • Hydrochloric acid 12
- 13. External Ear An9-‐inflammatory • Hydrocor4sone • Prednisolone • Dexamethasone An9bio9cs • Mul4ple agents – Decadron Ophthalmic Solu4on 13
- 14. Product name (preparation) Cortisporin Otic Suspension (ear) Antibiotic Polymyxin B; Neomycin Polymyxin B; Cortisporin Otic Solution (ear) Neomycin Colistin; Coly-‐Mycin S Otic (ear) Neomycin Tobradex (eye) Tobramycin Genoptic solution (eye) Gentamicin Pred-‐G (eye) Gentamicin Vasocidin solution (eye) Sulfacetamide Gantrisin Ophthalmic (eye) Sulfisoxasole Terra-‐Cortril Suspension (eye) Oxytetracycline Chloramycetin HC (eye) Chloramphenicol Chloramycetin Ophthalmic Solution (eye) Chloramphenicol Cipro HC Otic (ear) Ciprofloxacin Ciloxan (eye) Ciprofloxacin Floxin Otic (ear) Ofloxacin Ocuflox (eye) Ofloxacin Chibroxin (eye) Norfloxacin Anti-‐ inflammatory Acid Hydrocortisone Sulfuric Antiseptic pH Alcohol Hydrocortisone Hydrochloric 3 2 Hydrocortisone Acetic Dexamethasone Sulfuric Hydrochloric Alcohol Prednisolone Hydrochloric Alcohol Prednisolone Boric Hydrocortisone Hydrocortisone Boric Boric 5 6.0-‐8.0 7.2-‐7.5 5.4-‐6.6 6.2-‐8.2 7.2-‐7.9 7.4 7.1-‐7.5 Hydrochloric 7.0-‐7.5 4.5-‐5.0 4.5 Hydrochloric 6.0-‐6.8 Hydrocortisone Alcohol 14
- 15. External Ear • • • • Cochrane Database Systema4c Review 2010 19 RCT with 3382 pa4ents Trials were of low quality Conclusions – Topical an4microbials + steroids vs. Placebo • OR 11 (2.0 – 60.57) – In general, no difference in cure rate related to topical agent – Ace4c acid less effec4ve than an4bio4cs/steroids OR 0.29 (0.13 – 0.62) at 2 weeks – An4bio4cs + steroids quicker symptoma4c relief 15
- 16. External Ear • External O44s – Mild disease • Topical drops • 20 minute dwell 4me • 7 day course, con4nue addi4onal 7 days as needed • Treat pain – Severe disease • Consider wick • Consider systemic an4bio4cs • Consider alternate diagnoses 16
- 17. External Ear Malignant (Necro9zing) OE Ear Anatomy • Invasion of infec4on beyond the ear – Elderly diabe4cs – Immunocompromised • • • • • Severe pain Significant drainage Granula4on 4ssue CT/MRI Admission, an4-‐ pseudomonas an4bio4cs Iain, Wikimedia Commons 17
- 18. Tympanic Membrane Barotrauma • Pressure difference between middle ear and external ear • Flying • SCUBA diving • Direct blow to ear • Blast injury Iain, Wikimedia Commons Ear Anatomy 18
- 19. Tympanic membrane Barotrauma • Ruptured TM – – – – – Pain Bleeding from canal Hearing loss Tinnitus Inspec4on iden4fies tear • Treatment – Avoid water to the ear – Decongestants – Outpa4ent referral Wellcome Photo Library, Wellcome Images 19
- 20. Middle Ear O99s Media Ear Anatomy • Eustachian tube blockage – Fluid build-‐up – Secondary bacterial infec4on • Symptoms – – – – – Prodromal symptoms Pain +/-‐ Fever +/-‐ Hearing loss Rupture of TM • Exam – Dull/red/bulging TM Iain, Wikimedia Commons 20
- 21. Middle Ear • O44s Media – Treatment • An4bio4cs – Amoxicillin 500 mg BID – Amoxicillin 875 mg BID • If penicillin allergy – Cephalosporins – 2nd genera4on – Azithromycin • Treatment failure – Augmen4n – Cephalosporins – 2nd genera4on 21
- 22. Middle Ear • O44s Media with TM rupture – Add topical an4bio4c • Avoid – Alcohol – Aminoglycoside – Avoid water in the ear un4l healed 22
- 23. Product name (preparation) Cortisporin Otic Suspension (ear) Antibiotic Polymyxin B; Neomycin Polymyxin B; Cortisporin Otic Solution (ear) Neomycin Colistin; Coly-‐Mycin S Otic (ear) Neomycin Tobradex (eye) Tobramycin Genoptic solution (eye) Gentamicin Pred-‐G (eye) Gentamicin Vasocidin solution (eye) Sulfacetamide Gantrisin Ophthalmic (eye) Sulfisoxasole Terra-‐Cortril Suspension (eye) Oxytetracycline Chloramycetin HC (eye) Chloramphenicol Chloramycetin Ophthalmic Solution (eye) Chloramphenicol Cipro HC Otic (ear) Ciprofloxacin Ciloxan (eye) Ciprofloxacin Floxin Otic (ear) Ofloxacin Ocuflox (eye) Ofloxacin Chibroxin (eye) Norfloxacin Anti-‐ inflammatory Acid Hydrocortisone Sulfuric Antiseptic pH Alcohol Hydrocortisone Hydrochloric 3 2 Hydrocortisone Acetic Dexamethasone Sulfuric Hydrochloric Alcohol Prednisolone Hydrochloric Alcohol Prednisolone Boric Hydrocortisone Hydrocortisone Boric Boric 5 6.0-‐8.0 7.2-‐7.5 5.4-‐6.6 6.2-‐8.2 7.2-‐7.9 7.4 7.1-‐7.5 Hydrochloric 7.0-‐7.5 4.5-‐5.0 4.5 Hydrochloric 6.0-‐6.8 Hydrocortisone Alcohol 23
- 24. Middle Ear • O44s Media with Effusion – Fluid in middle ear without infec4on – Oral decongestants – Most resolve • Mastoidi4s – Pre-‐an4bio4c complica4on of AOM in 20% – Modern era incidence of 0.5% – CT scan for diagnosis – Admission and IV an4bio4cs 24
- 25. Paranasal Sinuses Arcadian, Wikimedia Commons 25
- 26. Paranasal Sinuses Hellerhoff, Wikimedia Commons Hellerhoff, Wikimedia Commons 26
- 27. Sinusi4s • Acute inflamma4on of the para-‐nasal sinuses • Rhinosinusi4s – Acute rhinosinusi4s – Acute viral rhinosinusi4s • Rhinovirus, Influenza, Parainfluenza • Acute bacterial rhinosinusi4s as complica4on in 0.5% to 2% of cases • 85% to 98% of pa4ents prescribed an4bio4cs (2001) 27
- 28. Acute Rhinosinusi4s • Symptoms of ARS – Nasal conges4on and obstruc4on – Purulent nasal discharge – Maxillary tooth discomfort – Facial pain or pressure, worse when bending forward – Fever – Fa4gue – Cough – Hyposmia or anosmia – Ear pressure or fullness – Headache 28
- 29. Acute Rhinosinusi4s • Hickner JM, et al. Ann Intern Med. 2001;134(6):498-‐505 – – – – – American Academy of Family Physicians American College of Physicians American Society of Internal Medicine, Centers for Disease Control, Infec4ous Diseases Society of America • Diagnosis of ABRS with – >= 7 days of symptoms – maxillary pain or tenderness in the face or teeth (especially when unilateral) – purulent nasal secre4ons • Observa4on for ARS and mild ABRS • An4bio4c therapy – moderately severe symptoms – clinical diagnosis of ABRS – severe rhinosinusi4s symptoms regardless of dura4on 29
- 30. Acute Rhinosinusi4s • Rosenfeld RM, et al. Otolaryngol Head Neck Surg. 2007;137(3 Suppl):S1-‐31. • American Academy of Otolaryngology – Diagnosis of ABRS with presence of symptoms for 10 days or less than 10 days with worsening of symptoms arer ini4al improvement – Symptoma4c treatment for AVRS – May treat ABRS symptoma4cally for mild disease: • Mild pain, temperature < 38.3 (101) – No imaging required – First line treatment is amoxicillin; macrolide if allergic – Reassess if worse or no improvement at 7 days 30
- 31. Acute Rhinosinusi4s • Treatment – Analgesics/NSAIDs – Mechanical irriga4on of sinuses – Topical cor4costeroids – Decongestants • Topical • Oral – An4histamines – Mucoly4cs – Zinc prepara4ons 31
- 32. Acute Rhinosinusi4s Wellcome Photo Library, Wellcome Images 32
- 33. Acute Rhinosinusi4s • Treatment – Analgesics/NSAIDs – Mechanical irriga4on of sinuses – *Topical cor4costeroids – *Decongestants • * Topical • (*) Oral – An4histamines – Mucoly4cs – (-‐) Zinc prepara4ons 33
- 34. Acute Rhinosinusi4s • Complica4ons of ABRS – Rare – Local extension • Meningi4s • Peri-‐orbital celluli4s • Orbital celluli4s 34
- 35. Rhinosinusi4s • • • • Acute Rhinosinusi4s Subacute Rhinosinusi4s 4-‐12 weeks Chronic Rhinosinusi4s >12 weeks Recurrent ARS 4+ episodes in one year 35