1	Common Problems in Ear Nose and Throat Encountered by the Primary Care Physician
2	Normal Larynx Normal larynx in a 44 yr old non-smoker
3	Acute Laryngitis
4	Vocal Cord Paralysis
5	Vocal Cord Polyp
6	Laryngeal Cancer
7	Additional Laryngeal Movies
8	Laryngeal Cancer Almost all cancers of the larynx are associated with smoking. --53 of 56 larynx cancers in my practice Incidence increases with a 20 pk/yr history Quitting smoking does not decrease the patient's risk of getting a cancer but it does prevent the risk increasing Smoking causes permanent genetic damage to the epithelium.
9	Laryngeal Cancer - Smoking & Reflux Disease
10	Smoking Tobacco use remains the leading preventable cause of death in the United States, causing more than 400,000 deaths each year and resulting in an annual cost of more than $50 billion in direct medical costs. Each year, smoking kills more people than AIDS, alcohol, drug abuse, car crashes, murders, suicides, and fires---combined! Approximately 80% of adult smokers started smoking before the age of 18. Every day, nearly 3,000 young people under the age of 18 become regular smokers. Smokers pay twice as much for life insurance and will die an average of over 12 years sooner than non-smokers. Smokers have more than one chance in 10 of developing lung cancer.
11	GE Reflux Cancer of the Esophagus & Larynx Asthma Chronic Sinusitis in children Symptoms -- Dry Cough -- Food Sticking in Lower Neck -- Throat Pain – Radiating to the Ear -- May or May Not Have Heartburn
12	GE Reflux - OTC treatment Elevate head of bed by 6 to 8 inches. (Place blocks under bed posts.) Do not eat 4 hours before sleeping. Take Pepcid, Tagament or Zantac at bedtime--both are over the counter anti-reflux medications. Avoid the following Foods: Fried/Fatty, Caffeine (Coffee, Tea, Chocolate), Spices (Peppermint, spearmint, garlic, onions, cinnamon, herbs), Alcohol, Acidic Foods, Citric Foods, Tomato Juice. Avoid tight clothing. Avoid smoking. If overweight, lose weight. Check with your doctor about contraindicated medications, aspirin etc.
13	Hearing in Childhood "I am just as deaf as I am blind. The problems of deafness are deeper and more complex, if not more important, than those of blindness. Deafness is a much worse misfortune. For it means the loss of the most vital stimulus-the sound of the voice that brings language, sets thoughts astir and keeps us in the intellectual company of man." Helen Keller in Scotland A Personal Record Written By Herself. Methuen & Co. Ltd. 36 Essex Street W.C. London Page 68.
14	Hearing in Childhood - High risk registry Family history of hearing loss. Congenital infections such as toxoplasmosis, syphilis, rubella, cmv, and herpes. Head & face abnormalities. Birth weight less than 1500 grams or 3.3 lbs. Hyperbilirubinemia at a level to need exchange transfusion. Bacterial meningitis (brain infection). Ototoxic medications such as aminoglycosides (strong antibiotic). Severe depression of Apgar scores. Mechanical ventilation or intubation to aid in breathing.
15	Hearing in Childhood - Milestones 3-6 months Child should respond to your voice or speech. Does he react to your voice when he cannot see you? 7-10 months Should react when he hears, but cannot see, the dog barking, telephone ringing, footsteps, someone's voice, refrigerator opening, microwave ringing, etc. 11-15 months Can he point to or find familiar objects or people, when he is asked to? Does he respond to different sounds differently? Does he enjoy listening to music and other sounds and try to imitate them. Most children by 12 months of age are starting to say single words.
16	Types of Hearing Loss
17	Types of Hearing Loss - Loud Noise The most common preventable cause to hearing loss is noise exposure.
18	Types of Hearing Loss - Loud Noise Source--dBA SPL Heavy Traffic 80 dB Automobile (at 20 meters) 70 dB Vacuum Cleaner 65 dB Conversational Speech (at 1 meter) 60 dB Quiet Business Office 50 dB Residential Area at Night 40 dB Whisper, Rustle of Leaves 20 dB Rustle of Leaves 10 dB Threshold of Audibility 0 dB
19	Types of Hearing Loss - Loud Noise Source--Dangerous Level dBA SPL Produces Pain 140-150 dB Jet Aircraft During Takeoff (at 20 meters)130 dB Discomfort Level 120 dB Snowmobile Tractor Without Cab Rock Concert 110 dB 100-105 dB Die Forging Hammer Gas Weed Trimmer Chain Saw Pneumatic Drill Home Lawn Mowers 95 to 100 dB Semi-trailers (at 20 meters) 90 dB
20	Tinnitus Two Types – Objective and Subjective Objective: -- Carotid Bruit -- Systolic Ejection Murmur -- Venus Hum – Rule Out High Intracranial Pressure -- Glomus Tumor – MRI Best Study Subjective: -- Peripheral Hearing Loss -- If Unilateral May be Central
21	Glomus Tympanicum
22	Ear Pain 50% comes from the ear Almost always has an Abnormal Eardrum 50% does not come from the ear Temporal Mandibular Joint Disorder Maxillary Sinusitis Reflux Disease Oral Pharyngeal Inflammation or Carcinoma
23	Acute Otitis Externa This is an acute bacterial infection usually caused by pseudomonas. The outer ear canal is swollen shut, and the auricle is very painful to touch. Treatment is to open the ear canal, place a wick, and treat with ear drops. The wick is cloth or foam rubber which will allow the ear drops to penetrate the swollen canal. Unfortunately, most oral antibiotics are ineffective. The fluoroquinolones have some effect, but they are not approved in children.
24	Otomycosis
25	Chronic Otitis Externa
26	Ear Maggots
27	Eustachian Tube Dysfunction Middle Ear Negative Pressure Retraction of the Ear Drum Ear Fluid and/or Infection Retraction Pocket Formation Cholesteatoma
28	Retraction of The Eardrum
29	Serous Otitis Media Treatment-- Antibiotics 50% Culture Positive Ear Tube Placement
30	Retraction Pocket Formation
31	Cholesteatoma Formation
32	Cholesteatoma Complications
33	Cholesteatoma Formation
34	Cholesteatoma Formation
35	Valsalva Blowing a balloon with the nose held shut. Blowing the nose with the nose held shut. Mathis bulb.
36	Myringotomy Tubes
37	Myringotomy Tubes
38	Myringotomy Tubes
39	Myringotomy Tubes - Complications Perforation of eardrum Eardrum heals over tube Otitis media – 33% are pseudomonas Tube intrudes completely into the middle ear Cholesteatoma Monolayer – not clinical significant Bleeding – usually minor from a tube granuloma
40	Myringotomy Tubes – Otitis Media 33% are Culture Positive for Pseudomonas Must Use Ear Drops
41	Myringotomy Tubes – Tube Granuloma Almost all are Culture Positive for Pseudomonas Must Use Ear Drops Usually resolve in 1 to 2 weeks of treatment with an antibiotic and steroid ear drop
42	Acute Otitis Media Treatment initially with antibiotics --Amoxicillin --Amoxicillin/Clavulanate --Cefdinir. --Clindamycin Bacterial Resistance is a big problem --Antibiotics with a long half life which are present for days in subtherapeutic levels foster bacterial resistance.
43	Acute Otitis Media
44	Acute Otitis Media - Ways to help prevent ear infections
45	Acute Otitis Media Types of Bacteria Streptococcus Pneumonia, Haemophilus Influenzae (this is not the flu virus), Moraxella catarrhalis. Less commonly, Mycoplasma Pneumoniae, Streptococcus Pyogenes, Staphylococcus Aureus along with other bacteria and viruses.
46	Most Common Respiratory Tract Pathogens by Disease State
47	Strep. Pneumonia Resistance A single plasmid can carry the genes for resistance to both the penicillin and macrolide antibiotics. The mechanism of penicillin resistance in this organism is by producing a penicillin binding protein and not by producing penicillinase (an enzyme which breaks down penicillin).
48	Nonsusceptibility to Penicillin and b-Lactamase Production by H. influenzae, S. pneumoniae
49	Macrolide-Resistant S. pneumoniae:
50	Antibiotic Treatment – Acute Otitis Media No Risk Factors Amoxicillin 40 – 90 mg/kg/day If penicillin allergic TMP – SMX or Erythromycin-Sulfisoxazole or Macrolides If Treated Within Prior Month Amoxicillin, Sulfa or Macrolides are NOT RECOMMENDED
51	Streptococcus Pneumonia – Acute Otitis Media Most Likely to be Strep Pneumonia: Increase otalgia and fever Spontaneous perforation Risk Factors for Strep Pneumonia Resistance: Daycare Younger than 2 years of age Contact with an individual treated with antibiotics History of recurrent acute otitis media
52	Streptococcus Pneumonia – Acute Otitis Media Mechanism of antibiotic resistance is a penicillin binding protein and NOT by producing penicillinase. Thus, penicillinase inhibitors will NOT be effective A single plasmid can carry the genes for resistance to both the penicillin and macrolide antibiotics. Recommendations to increase the Ampicillin dosage to 90 mg/kg/day
53	Haemophilus influenzae – Acute Otitis Media Risk Factors for Haemophilus influenzae Resistance Preceding therapy with amoxicillin. Most Likely to be Haemophilus influenzae Otitis-conjunctivitis Syndrome
54	Haemophilus influenzae – Acute Otitis Media Mechanism of resistance is through the production of penicillinase. Treatment is with a penicillinase inhibitor, cefuroxime, or cefdinir.
55	Acute Sinusitis – Medical Management First Line Amoxicillin TMP-SMX Second Line Cefdinir Cefuroxime axetil Amoxicillin-clavulante
56	Azithromycin 30% to 60% of S pneumoniae and H influenzae strains resistant or not eradicated.
57	Prevnar - Heptavalent Pneumococcal Vaccine to S. Pneumonia Recommended for Children Under the Age of 2. Over the age of 2, sometimes a single dose is recommended. Decrease the incidence of ear tubes by 20% but a prevention NOT a treatment. Thus, if has recurrent otitis media on the basis of eustachian tube dysfunction, tubes will still be needed.
58	Acute Coalescent Mastoiditis
59	Acute Coalescent Mastoiditis Severe Condition Can Cause Death Usually Caused by Streptococcal Pneumonia In this Patient the Strep. Pneumonia was penicillin, trimethoprim/sulfamethoxazole, erythromycin and intermediate susceptible to Ceftriaxone Treated with IV Vancomycin.
60	Traumatic Perforation
61	Osteoma
62	Exotoses
63	Otosclerosis
64	Acoustic Neuroma Slowly Progressive Unilateral Hearing Loss. Less Than 3% Present With Vertigo. Usually Treated With Surgery. 10% of the population on autopsy have this condition
65	Balance Vision Proprioception (sensation of position) Inner Ear
66	Dizziness A loss of control or staggering like being drunk, but the room orientation is normal. The patient just cannot control his body. A lightheadedness or fainting. A sensation of motion or spinning.
67	Length of Vertiginous Spell Length of Spells Less than 10 min - Positional Vertigo 20 min to 24 hrs.- Meniere’s Disease ( tinnitus, hearing loss, vertigo & ear pressure) 24 hrs to one week - Viral Labyrinitis Over one week - Central Disease
68	Positional Vertigo Characteristics of Peripheral Vertigo -- Latency - 5 to 6 seconds -- Duration - Less than 60 Seconds -- Adapts - Less on Repeated Stimulation
69	Positional Vertigo – Treatment Particle Repositioning Maneuver
70	Allergic Rhinitis
71	Nasal Polyps
72	Nasal Steroid Complications
73	Septal Perforation
74	Nasal Septal Hematoma
75	Unilateral Nasal Polyps/Drainage/Chronic Sinusitis Always think Carcinoma Inverting papilloma Fungal Ball (Allergic Fungal Sinusitis)
76	Unilateral Nasal Polyps/Drainage/Chronic Sinusitis
77	Oral Lesion – Squamous Cell Carcinoma
78	Oral Lesions - Basal Cell Carcinoma
79	Oral Lesions - Cheilitis ( Candida )
80	Oral Lesions - Herpes Simplex ( Cold Sore )
81	Oral Lesions - Squamous Cell Carcinoma
82	Oral Lesions - Shingles
83	Oral Lesions - Apthosis Ulcers
84	CME Credits 2 hours of Category I CME Credits can be obtained by studying this course and by passing an on-line CME test. To take and submit the test, go to: http://www.cmeusa.org/medicine_test_ms.htm