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ENT Outer and Middle Ear - Coggle Diagram

- - - - Complications
      - Pathogen/Pathology
        
        Usually viral
      - Transmission/Risk
        
        Weight gain or loss
        
        Inflammatory conditions of nose,
        sinus, ears, throat
        
        More common in children (different anatomy)
      - Symptoms
        
        popping/clicking due to pressure equalization
        
        Autophonia
        
        Pain with pressure change
    - - Acute, chronic, obstructive,
        baro-chellenge-induced, patulous
      - Obstruction of the Eustachian canal resulting in improper opening/closing and hearing abnormality
    - - Allergy based (abstructive)
        
        antihistamines/leukotriene inhibitors
        
        Corticosteroids
        
        short term nasal decongestants
      - GI related
        
        Antacids or PPI
      - nasal saline, hydration
      - procedures
        
        tympanostomy tubes
        
        balloon tiboplasty
        
        adenoidectomy
      - Patulous
        
        avoid decongestents and caffeine
        
        remove/reduce irritants
        
        ENT referral if severe
    - - manage inflammatory/irritating conditions
      - Manage URI in children
      - Early treatment of AOM/OME
    - - Lab Tests
        
        Tympanometry
        
        Audiometry
      - History
        
        R/O nasopharyngeal Tumor in adults with unilateral/recurrent symptoms
      - PE
        
        hyper/hypo resonance
        (patulous or obstructive)
        
        Echoing and Autophony with
        Patulous
        
        Tinnitus, imbalance with
        obstructive
        
        Retracted tympanic membrane
      - Imaging
        
        direct visualization
  - - - Imaging
        
        direct visualization
      - Lab Tests
      - History
        
        Family history?
        
        Daycare?
        
        Tobacco smoke?
      - PE
        
        Otorrhea if membrane ruptures
        
        bulging, erythematous membrane
        (unless rupture)
    - - Complications
        
        TM perforation
        
        hearing loss
        
        mastoiditis
      - Pathogen/Pathology
        
        Strep pneumoniae,
        H. Influenze, M. Catarrhalis
      - Transmission/Risk
        
        frequently FOLLOWS viral infection
        
        MC in children
      - Symptoms
        
        Otalgia, fever
        
        fussiness, ear tugging
    - - "Acute OM" Middle ear effusion with symptoms of acute infection
        
        Abx Amoxicillin 80-90mg/kg/day x10 days
        
        Augmentin, cefdinir, azithromycin
        
        Symptomatic w/ acetaminophen, ibuprofen
        
        "Watch and wait" if >6 months old
        
        ENT referral for tube if recurrent or chronic
      - "recurrent" is 3+ episodes in 1 year
        
        Acute infection; resolves between episodes
        
        Consider underlying conditions (immunosuppression)
        
        ENT referral for tympanostomy
      - "OM w/ Effusion" is effusion
        WITHOUT infection
        
        no fever, pain, inflammation
        
        Often asymptomatic
        
        May be mild hearing loss
        
        observation
        
        Audiology referral if > 3 months
        
        Tympanostomy if chronic w/ hearing loss
      - "Chronic" is 3+ months without resolving
        
        "Suppurative" w/ discharge and
        tympanic membrane rupture
        
        conductive hearing loss
        
        TM perforation
        
        Aural toilet * topical antibiotics
        (Cipro w/ or w/o steroids)
        
        ENT referral for tympanostomy
    - - Depends on type
  - - - Imaging
        
        CT temporal bone
        
        MRI if neurologic concerns
      - Lab Tests
        
        Cultures
        
        Audiometry
      - History
        
        recurrent or chronic AOM
      - PE
        
        postauricular erythema
        
        Bulging ,erythematous membrane +/- pus
        
        Regional lymphadenopathy
    - - Complications
        
        bone erosion in/around canal
        
        Intracranial spread
        
        Facial nerve palsy
        
        Persistent conductive hearing loss
      - Pathogen/Pathology
        
        MC Strep Pneumoniae
        
        Staph, GAS, H. influenza
      - Transmission/Risk
        
        Result of AOM spread
      - Symptoms
        
        otalgia and fever
        
        Irritability, anorexia, lethargy
        
        Headache, ear pain
        
        Conductive hearing loss
    - - Suppurative infection of the mastoid air cells in temporal bone
    - - Hospital admission for ABX
        
        IV Vancomycin & Ceftriazone
        
        add anti-pseudomonal if indicated
        
        IV Steroids for inflammation
        
        Analgesia, hydration
      - Myringotomy to relieve pressure
      - Mastoidectomy if suspected abscess
        or no response to ABX
    - - vaccination
        
        pneumococcus
        
        H. influenza
        
        Influenza
  - - - Imaging
        
        CT temporal bone for extent
        
        MRI if residual/recurrent
      - Lab Tests
        
        audiometry
        
        tympanometry
      - History
        
        recurrent or chronic OM
        
        past ear surgery
      - PE
        
        White pearly growth behind TM
        
        Retraction pocket or membrane perforation
        
        Polyps or granulation tissue
    - - Complications
        
        Hearing Loss
      - Pathogen/Pathology
        
        Accumulated epithelial debris causing cyst
      - Transmission/Risk
        
        Chronic Eustachian Tube dysfunction
        
        TM perforation from chronic infection/trauma
        
        Rarely can be congenital condition
      - Symptoms
        
        chronic foul-smelling otorrhea,
        refactory to treatment
        
        Unilateral conductive hearing loss
        
        Tinnitus or vertigo
        
        Facial weakness if progressed
        to nerve involvement
    - - Non-cancerous cystic lesion of middle ear or mastoid that expands and erodes bone
    - - Surgical Treatment
        
        Tympanoplasty, mastoidectomy
        
        Ossiculoplasty
      - medical treatment supportive to surgery
        
        Abx (topical or systemic)
        
        surveillance
    - - early treatment of AOM
      - Valsalva maneuver to prevent TM retraction
- - - - Diagnosis
        
        Imaging
        
        Lab Tests
        
        biopsy if concern for
        carcinoma (poor healing)
        
        History
        
        clinical diagnosis (exposure)
        
        PE
        
        no bleeding, clean borders
      - Pathology
        
        Complications
        
        Pathogen/Pathology
        
        Idiopathic/degenerative
        
        Transmission/Risk
        
        Age
        
        Male > female
        
        Side sleeping
        
        Sun exposure
        
        Symptoms
        
        Tender erythematous nodule
        
        Crusting
        
        local pain
      - System
      - Treatment
        
        topical steroid
        
        Intralesional steroid
        
        topical nitroglycerin
        
        excision
      - Prevention
        
        sunscreen
        
        reduce pressure (sleeping)
        
        Topical ABX following treatment
    - - Diagnosis
        
        Imaging
        
        US/CT if atypical
        
        Lab Tests
        
        consider abscess or fracture
        
        History
        
        R/O battle sign or hemotympanum
        
        PE
        
        No hearing loss
        
        usually unilateral
        
        lack of systemic symptoms
      - Pathology
        
        Complications
        
        Pathogen/Pathology
        
        blunt trauma to pinna
        
        fibrous overgrowth
        
        Transmission/Risk
        
        contact sports, repeated trauma
        
        Lack of acute management
        
        Symptoms
        
        pain, swelling
        
        heat, bruising
        
        tense, "fluctuant" auricle
      - System
        
        collection of blood in cartiledge
        
        leads to deformity due to limited healing
      - Treatment
        
        I&D (promptly)
        
        follow with irrigation, compression
        
        ABX after management to prevent abscess
      - Prevention
        
        protective equipment
        
        ENT referral
    - - Diagnosis
        
        Imaging
        
        consider airway/valve care: CT chest
        
        Lab Tests
        
        elevated ESR or CRP
        
        Biospy cartilage
        
        Pulmonary function tests
        
        History
        
        Chronic, relapsing
        
        PE
        
        sensorineural hearing loss if severe
        
        tinnitus
        
        Vertigo
        
        McAdams criteria
      - Pathology
        
        Complications
        
        associated with RA,
        myelodysplastic syndrome
        
        Cardiac valvulitis
        
        destruction of other cartilaginous structures
        
        Pathogen/Pathology
        
        autoimmune mediated
        
        Transmission/Risk
        
        Uncommon
        
        40-50 years of age
        
        Symptoms
        
        Fever, Fatigue, weightloss
        
        Tender erythematous pinna
        
        Joint pain
      - System
        
        Systemic cartilaginous inflammatory disease
        
        likely auto-immune
      - Treatment
        
        mild
        
        colchicine/dapsone
        
        NSAID
        
        severe
        
        coritcosteroids
      - Prevention
        
        remove trigger for autoimmune;
        infection etc
        
        immunosuppressives
        
        methotrexate, etc
        
        Biologics (anti-TNF)
        
        Cyclophosphamide if risk to organ or airway
  - - - Diagnosis
        
        Imaging
        
        direct visualization
        
        Lab Tests
        
        check for secondary infection
        
        History
        
        use of Q-tip
        
        PE
        
        "arnold's reflex" reflexive cough
        
        visible wax plug
        
        Lack of erythema or tenderness
      - Pathology
        
        Complications
        
        Canal Abrasion
        
        membrane perforation
        
        Pathogen/Pathology
        
        accumulation due to behavior
        or anatomical change
        
        Transmission/Risk
        
        Elderly, hearing aids
        
        Children
        
        Narrow canal (normal variant)
        
        Thicker wax (normal variant)
        
        Symptoms
        
        Hearing loss (conductive)
        
        Pruritis
        
        tinnitus
      - System
        
        physical obstruction of
        canal by earwax
      - Treatment
        
        mechanical extraction
        
        immobilize or sedate
        
        Cerumenolytic
        (softening agent)
        
        various peroxides
        
        Irrigation
        
        only if membrane intact
      - Prevention
        
        patient education
        
        ENT follow up for hearing loss, recurrence, unable to remove
    - - Diagnosis
        
        Imaging
        
        direct visualization (usually)
        
        concern for surrounding tissue (corrosives or long infection)
        
        Lab Tests
        
        History
        
        "do you put things in your ears?"
        
        PE
        
        visualize object
        
        buzzing or movement
        
        erythema, drainage
      - Pathology
        
        Complications
        
        Canal laceration
        
        Hearing Loss
        
        secondary infection
        
        Pathogen/Pathology
        
        Foreign object (duh)
        
        Possible secondary infection
        
        Transmission/Risk
        
        most common in children or
        developmentally delayed
        
        Symptoms
        
        "fullness"
        
        pruritis
        
        otorrhea or bleeding
      - System
        
        Non-native object present in external auditory canal
      - Treatment
        
        forceps, curettes
        
        consider immobilization/sedation
        
        irrigation if membrane intact, solid object
        
        Mineral oil or lidocaine
        for insect immobilization
        
        ENT for battery or difficult removal
      - Prevention
        
        childprrofing/monitoring
        
        behavior modification/education
    - - Diagnosis
        
        Imaging
        
        direct visualization
        
        CT if unable to visualize
        
        Lab Tests
        
        History
        
        PE
        
        unilateral, isolated
        
        Exostosis "surfer's ear" is bilateral
        
        Hard, smooth, bony mass on stalk
        
        non-tender, non-inflamed
      - Pathology
        
        Complications
        
        increased risk of otitis externa
        
        Pathogen/Pathology
        
        idiopathic
        
        Transmission/Risk
        
        recurrent irritation
        
        Symptoms
        
        frequently asymptomatic
        
        hearing loss
        
        water trapping
      - System
        
        solitary benign bony tumor of ear canal
        
        frequently at osteocartilagenous junction
      - Treatment
        
        observation if asymptomatic
        
        monitor hearing, progression/growth
        
        Surgical excision
        
        confirm diagnosis via tissue pathology
      - Prevention
    - - Diagnosis
        
        Imaging
        
        direct visualization
        
        Lab Tests
        
        culture if severe, refractory,
        resistant, or immunocompromised
        
        History
        
        conductive hearing loss (due to debris)
        
        PE
        
        Membrane intact (usually)
        
        External ear tenderness
        
        Erytheme, edema
        
        Purulent discharge
      - Pathology
        
        Complications
        
        cellulitis
        
        perichondritis
        
        malignant otitis externa
        
        Pathogen/Pathology
        
        Pseudomonas aeruginosa
        
        Staphylococcus Aureus
        
        may be fungal in immunocompromised
        
        Transmission/Risk
        
        Loss of cerumen barrier
        
        MC in swimmers, children
        
        Trauma to canal
        
        Symptoms
        
        Pain, worsened with manipulation
        
        pruritis, fullness, otorrhea
      - System
        
        inflammation or infection of
        external auditory canal
      - Treatment
        
        Topical fluoroquinolone +/- corticosteroid
      - Prevention
        
        Keep ear dry
        
        Avoid trauma to canal
    - - Diagnosis
        
        Imaging
        
        CT or MRI for bone erosion
        
        Lab Tests
        
        elevated ESR and CRP
        
        Biopsy granulation tissue,
        R/O carcinoma (SCC)
        
        C&S
        
        History
        
        fever
        
        PE
        
        Facial nerve (CN7) palsy
        
        granulation tissue at floor of canal
      - Pathology
        
        Complications
        
        10-20% mortality rate
        
        CN palsy
        
        meningitis
        
        intracranial abscess
        
        Pathogen/Pathology
        
        pseudomonas aeruginosa
        
        Transmission/Risk
        
        elderly, diabetic, immunocompromised
        
        Symptoms
        
        severe, persistent, worsening pain (otalgia)
        
        otorrhea (severe, resistant to treatment)
      - System
        
        aggressice, invasive infection of auditory canal that may progress into osteomyelitis
      - Treatment
        
        Probably hospital admission
        
        IV tobramycin & pip/tazo
        
        surgical debridement
      - Prevention
        
        control underlying diabetes/HIV