the nose knows ent for the family physician · name of cme activity: acofp intensive update and...

The Nose Knows - ENT for the Family Physician

Jennifer Caudle, DO

ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary.

Name of CME Activity: ACOFP Intensive Update and Board Review in Osteopathic Family Medicine

Dates and Location of CME Activity: August 21-24, 2014, InterContinental Chicago O'Hare, Rosemont, IL

Topic(s): The Nose Knows - ENT for the Family Physician Saturday, 8/23/14 1:45-2:15pm

Name of Faculty/Moderator: Jennifer Caudle, DO

DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM

x A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing

health care goods or services.

B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care

goods or services. Please check the relationship(s) that applies.

Research Grants Stock/Bond Holdings (excluding mutual funds)

Speakers’ Bureaus* Employment

Ownership Partnership

Consultant for Fee Others, please list:

Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper:

Organization With Which Relationship Exists Clinical Area Involved

1. 1.

2. 2.

3. 3.

4. 4.

*If you checked “Speakers’ Bureaus” in item B, please continue: • Did you participate in company-provided speaker training related to your proposed topic? Yes: No: • Did you travel to participate in this training? Yes: No: • Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No: • Did the company pay the travel/lodging/other expenses? Yes: No: • Did you receive an honorarium or consulting fee for participating in this training? Yes: No: • Have you received any other type of compensation from the company? Please specify: Yes: No: • When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation

and/or lecture handout materials? Yes: No: • Will your topic involve information or data obtained from commercial speaker training? Yes: No:

DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS

__x__A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational

uses of products or devices.

____B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of

products or devices as indicated below: I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement.

Signature: Jennifer Caudle, DO Date: 6/1/14

Jennifer Caudle, DO

Please fax this form to ACOFP at 866-328-1835 or email to [email protected] as soon as possible

Deadline: Saturday, May 31, 2014

8/6/2014

1

EAR NOSE & THROAT DR. JENNIFER CAUDLE

ASST PROFESSOR, DEPT OF FAMILY MEDICINE

3RD YEAR FM CLERKSHIP DIRECTOR

ROWAN UNIVERSITY SCHOOL OF OSTEOPATHIC

MEDICINE

ACOFP Family Medicine Board Review

August 23, 2014

Otolaryngology Topics

Dizziness

Hearing Loss

Rhinosinusitis

Otitis Externa

Hoarseness & SCC of Larynx

Dizziness

Dizziness: A Diagnostic Approach ROBERT E. POST, MD, LORI M. DICKERSON, PharmD, Medical University of South Carolina,

Charleston, South Carolina. Am Fam Physician. 2010 Aug 15;82(4):361-368.

8/6/2014

2

Dizziness

Disturbance of the sensory modalities which allow perception of body's motion and position in space

vision

vestibular input

joint position

touch

hearing

CC in ~ 3% of primary care visits for patients 25 years and older

The final cause of dizziness is not identified in up to one in five patients.

Categories of Dizziness

1. Vertigo - Central Origin (Brainstem, Cerebellum, etc)

- Peripheral Origin

A. Benign paroxysmal positional vertigo (BPPV)

B. Meniere disease

C. Vestibular neuritis

D. Labyrinthitis

E. Migrainous vertigo / vestibular migraine

2. Presyncope

3. Lightheadedness

4. Disequilibrium

Symptoms

Vertigo

Perceived sense of motion, spinning sensation (45 - 54%)

Pre-syncope

Feeling of losing consciousness or blacking out (~14%)

Lightheadedness

Vague symptoms, feeling disconnected with the environment (~10%)

Disequilibrium

Feeling off-balance or wobbly (~16%)

8/6/2014

3

1. Vertigo

Perceived sense of motion, possibly spinning

sensation

1. Central Origin 2. Peripheral Origin (MCC of vertigo)

Peripheral Vestibular Disorders

Peripheral vestibular disorders are the MCC of

Vertigo:

A. Benign paroxysmal positional vertigo (BPPV)

B. Meniere disease

C. Vestibular neuritis

D. Labyrinthitis

E. Migrainous vertigo / Vestibular migraine

Peripheral Vestibular Causes of Vertigo

A. Benign Positional Paroxysmal Vertigo

MCC of peripheral vestibular vertigo

Pathophysiology

Crystalline debris forms/moves in semicircular canals which

causes labyrinthine irritation vertigo & nystagmus. Head

movement often cause symptoms.

8/6/2014

4

Benign Positional Paroxysmal Vertigo

Symptoms/Diagnosis

Brief episodes of vertigo (2-10 seconds)

Nystagmus and vertigo often caused by turning the head

Dix-Hallpike Maneuver

Reproduces vertigo, resulting in nystagmus

Diagnostic if (+) but does not rule it out if (-). Sensitivity =

50–88% for BPPV.

Has a PPV of 83% and a negative predictive value of 52%

for the diagnosis of BPPV

BPPV Diagnosis: Dix-Hallpike

Maneuver

The patient is seated, the physician (A) turns the patient's head 45 degrees to one side, then (B) rapidly lays the patient into a supine position with the head hanging about 20 degrees over the end of the table, observing the patient's eyes for approximately 30 seconds. The maneuver is repeated for the opposite side. Nystagmus is diagnostic of vestibular debris in the ear facing down, closest to the exam table. A video demonstration of this maneuver is available at http://www.youtube.com/watch?v=vRpwf2mI3SU.

Dizziness: A Diagnostic Approach ROBERT E. POST, MD, LORI M. DICKERSON, PharmD, Medical University of South Carolina, Charleston,

South Carolina. Am Fam Physician. 2010 Aug 15;82(4):361-368.

Benign Positional Paroxysmal Vertigo

Treatment Epley, modified Epley and Semont maneuvers (slide at end of lecture)

Canolith repositioning maneuvers. Goal is to reposition the

crystals into the vestibule.

80% success rate in relieving symptoms

Often resolves with time whether or not exercises are done

Vestibular Rehabilitation

Should not be routinely treated w vestibular suppressants, i.e

antihistamines or benzodiazepines

Potential side effects including drowsiness, cognitive side effects,

etc., & may interfere with CNS compensation for vestibular injury

http://www.youtube.com/watch?v=vRpwf2mI3SU

8/6/2014

5

Treatment: Epley maneuver

Dizziness: A Diagnostic Approach ROBERT E. POST, MD, LORI M.

DICKERSON, PharmD, Medical University of South Carolina, Charleston,



B. Meniere's disease

Pathophysiology (‘endolymphatic hydrops’)

Buildup of fluid in endolymphatic system, caused by excess

fluid production or decreased fluid resorption. This results in

dilation of the endolymphatic system.

Symptoms/Diagnosis

Recurrent episodes of vertigo that last hours (not mins or

days)

Sensorineural low-frequency hearing loss

Tinnitus

Aural fullness in affected ear

Meniere's disease

Treatment No cure, aim for symptom reduction

Salt restriction

Diuretic therapy, HCTZ

If acutely sensitive to ETOH, Caffeine or both, avoid these

Anti-emetics

Benzodiazepines

Surgical decompression of endolymphatic system for refractory patients

EPLEY MANEUVER & STEROIDS= NOT HELPFUL

8/6/2014

6


C. Vestibular Neuronitis

Pathophysiology Inflammation of the vestibular nerve with total sparing of the

cochlear area.

Symptoms/Diagnosis Often associated with viral infection

Severe prolonged vertigo (days) with ataxia, nausea and vomiting.

NO hearing loss, no tinnitus, no aural pain

Symptoms often initially severe and gradually decrease over 1-2 weeks.

Reduced/absent caloric response, at least initially

Vestibular Neuronitis

Treatment

Rest

Reassurance and anti-emetics

Vestibular suppressants (diazepam, meclizine)

Vestibular Rehab, Surgery (possibly for refractory cases)


D. Labyrinthitis

Pathophysiology

Inflammation of the labyrinthine organs.

Symptoms

Often associated w/ otitis media or URI (viral or

bacterial infection).

Severe vertigo, can last > days

Tinnitus

Sensorineural hearing loss

8/6/2014

7

Labyrinthitis

Diagnostic Clue

Labyrinthitis and vestibular neuronitis can occur after URI

or viral/bacterial infection, but labyrinthitis has tinnitus

and hearing loss (vestibular neuritis has neither)

Treatment

Rest, anti-emetics, antibiotics (if bacterial etiology)

Distinguishing Vertigo

VERTIGO With

Hearing

Loss

Without

Hearing

Loss

Tinnitus Without

Tinnitus

Episodic

Vertigo

Persistent

Vertigo

Associated

With URI

Meniere's

Disease

X X X

BPPV X X X

Vestibular

Neuritis

X

X

X

X

Labyrinthitis X X X X

E. Migrainous Vertigo/

Vestibular migraine

Symptoms Episodic vertigo with a current migraine or history of

migraine and one of the following during at least two

episodes of vertigo:

migraine headache

photophobia

phonophobia

aura

8/6/2014

8

2. Presyncope

Feeling of losing consciousness or blacking out

Cardiovascular causes include: Arrhythmias

Myocardial infarction

Carotid artery stenosis

Ortho-static hypotension.

Symptoms caused by postural changes suggest orthostatic hypotension.

Many cardiovascular medications increase the risk of orthostatic hypotension in older persons, including reserpine (at doses > 0.25 mg), doxazosin, and clonidine.

3. Lightheadedness

Vague symptoms, feeling disconnected with the environment

Psychiatric causes of lightheadedness are common Anxiety

Depression

Depression and alcohol intoxication have also been found to overlap with dizziness.

Hyperventilation syndrome causes lightheadedness. Patients may sigh repeatedly, have chest pain, paraesthesias, bloating, and epigastric pain.

4. Disequilibrium

Sense of feeling off-balance

Potential causes include:

Stroke

Poor vision

Parkinson disease

Peripheral neuropathy

Musculoskeletal disorders

Meds: Benzodiazepines and tricyclic antidepressants increase the risk of ataxia and falls in older persons.

8/6/2014

9

Dizziness: A Diagnostic Approach ROBERT E. POST, MD, LORI M. DICKERSON, PharmD, Medical University of South Carolina, Charleston, South Carolina. Am Fam Physician. 2010 Aug

15;82(4):361-368.

Hearing Loss

Hearing loss

Normal conversations use frequencies of 500 to

3,000 Hz at 45 - 60 dB.

After 60 years of age, hearing declines by about

1 dB annually.

Men usually experience greater hearing loss

and earlier onset compared with women.

Hearing Loss

Sensorineural Conductive

8/6/2014

10

Sensorineural vs Conductive

Hearing Loss


Problem converting mechanical vibrations to electrical potential in the cochlea and/or in auditory nerve transmission to the brain. Usually caused by permanent damage in the organ of Corti.

Conductive hearing loss

Usually caused by problems in the external or middle ear that interfere with transmitting sound and its conversion to mechanical vibrations.

Sensorineural Hearing Loss

>90% of older persons with hearing loss have age-related sensorineural hearing loss

Presbycusis= hearing loss related to aging.

Symptoms

Gradual, high-frequency, symmetric loss of hearing, worse in noisy environments.

Pathophysiology

Degenerative changes in the hair cells, auditory neurons and cochlear nuclei. (noise trauma; meds; autoimmune d/o; mechanical trauma; Meniere disease; infection)

Treatment Hearing Aid

Conductive Hearing loss

Symptoms Gradual hearing loss (otosclerosis), laterality (obstruction),

rapid onset (TM perforation).

Pathophysiology Pathologic- damage to TM or ossicular chain in middle ear

Cerumen; foreign body; perforated tympanic membrane; tympanosclerosis; Otitis media with effusion; otosclerosis; cholesteatoma.

Otosclerosis= spongy bone replaces normal bone in otic capsule causing ankylosis/fixation of stapes

Treatment Tx underlying cause

Surgical

Hearing aid (otosclerosis)

8/6/2014

11


Sudden Sensorineural Hearing Loss (SSNHL)

Otologic emergency, requiring prompt evaluation

Etiologies include vascular, thromboembolic, viral,

autoimmune and ototoxicity

Without treatment: 1/3 lose hearing, 1/3 have

partial improvement in hearing and 1/3 regain

hearing

Steroids

Diagnosing Hearing Loss

Weber Test

Tuning fork on the skull in midline (both cochlae stimulated)

Normal exam= sound heard midline or equally in both ears.

If conductive hearing loss in 1 ear, the sound will be loudest in that same ear (will lateralize)

When unilateral sensorineural hearing loss is present, tone is heard in unaffected / opposite ear

Rinne Test

Tuning fork is placed at mastoid bone, when can no longer hear sound, the tuning fork is placed in front of ear.

Compares air conduction (AC) with bone conduction (BC)

Normally AC > BC- which means that sound in front of pinna is normally perceived twice as long as sound placed on mastoid process (AC>BC)

Conductive Hearing loss= AC < BC (negative Rinne) or BC= AC

Sensorineural hearing loss= duration of both AC and BC are reduced, but 2:1 ratio remains the same (Pos Rinne)- AC > BC

Rhinosinusitis

8/6/2014

12

Rhinosinusitis

Pathophysiology

Inflammation of the mucosa of 1 or more of the paranasal

sinuses, usually occurs with rhinitis

Causes include mucosal edema, impaired local immmunity

and ciliary dysfunction which impaired sinus drainage

and mucous stasis. Bacterial infection.

Rhinosinusitis

The American Academy of Otolaryngology–Head and Neck

Surgery defines subtypes of rhinosinusitis based on symptom

duration:

Acute, sub-acute, recurrent acute, and chronic

Acute rhinosinusitis is further categorized as bacterial or viral.

Rhinosinusitis Duration of Symptoms

Acute Up to 4 weeks

Subacute At least 4 weeks, but less than

12weeks

Recurrent Acute 4 or more episodes/year with

remission btw episodes (each lasting 7

days at least)

Chronic 12 weeks or longer (variable)

Acute Rhinosinusitis in Adults. ANN M. ARING, MD, and MIRIAM M. CHAN, PharmD, Riverside Methodist Hospital, Columbus, Ohio. Am Fam

Physician. 2011 May 1;83(9):1057-1063.

Acute Rhinosinusitis

Making the Dx of Rhinosinusitis

Major vs Minor criteria Major- facial pain and pressure, nasal congestion and obstruction, nasal

discharge, discolored posterior discharge, anosmia or hyposmia, fever and purulence on intranasal exam

Minor- headache, otalgia or ear pressure, halitosis, dental pain, cough, fever (irritability in children).

Dx probable if 2 or more major factors or 1 major and 2 or more

minor factors are present

Dx suggestive if 1 major factor or 2 minor factors are present

IDSA: these diagnostic criteria do not adequately distinguish

bacterial from viral infection.

According to the 1996 Task Force on Rhinosinusitis, by Amer Acad of Otolaryngology- Head and Neck Surgery, via Rakel

8/6/2014

13


Risk Factors

Rhinitis

Anatomic abnormalities (septal deviation, choanal atresia,

foreign body, etc)

Nasal polyps

Immunodeficiency

Kartagener’s syndrome (primary ciliary dysfunction)

Smoking, nasal decongestant abuse or cocaine abuse

(ciliary dysfunction)

GERD


Etiology

Viral MCC of rhinosinusitis; prevalence 90-98%

MC viruses are rhinovirus, adenovirus, influenza virus, and parainfluenza virus.

In most patients improves in 7-10 days w/o treatment.

Mild symptoms < 7 days duration can be managed with supportive care: Analgesics, Saline nasal irrigation, Intranasal corticosteroids.

Symptom persistence increases likelihood of bacterial infection


Etiology, cont’d

Bacterial Prevalence is 2-10%

MCC causes are 1) Pneumococcus spp., 2) Haemophilus influenzae, 3) Moraxella catarrhalis (beta-lactamase production is common), Staph (esp in chronic).

Allergic, Fungal, etc

June 2013, AAP released new guidelines for Sinusitis in children

8/6/2014

14


Complications

Periorbital cellulitis

Orbital abscess

Cavernous sinus thrombosis

Meningitis

Intracranial abscess

Osteomyelitis

Mucocele

Making the Diagnosis of

Acute Bacterial Rhinosinusitis

IDSA Guidelines 2012

Symptoms lasting ≥ 10 days without evidence of clinical

improvement (strong, low moderate)

Onset with severe symptoms/signs of high fever [102F] and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness (strong, low-moderate)

‘‘Doublesickening.’’ Worsening symptoms or signs [new onset of fever, headache, or increase in nasal discharge] following a typical viral upper respiratory infection that has lasted 5–6 days and was initially improving (strong, low-moderate).

Oral Antibiotics for ABRS

(IDSA 2012 Guidelines)

Initial Empiric Tx = Amoxicillin/Clavulanate (changed from amox alone)

Amoxicillin/Clavulanate 500 mg/125 mg q8 or 875

mg/125 mg q12

Recommended length of tx = 10 days. (3-5 day tx may

be effective/have fewer adverse effects.)

8/6/2014

15

Can “High Dose Amox” be used for

Initial Empiric Therapy?

Yes! Amoxicillin/Clavunate 2 g po bid or 90 mg/kg/day po bid CAN be used as initial empiric therapy in the following situations:

Adults with ABRS from areas with high endemic rates (≥10%) of invasive penicillin-nonsusceptible S. pneumoniae,

Severe infection (eg, evidence of systemic toxicity with fever of 39C [102F] or higher, and threat of suppurative complications)

Daycare attendance

Age <2 or >65 years

Recent hospitalization

Antibiotic use within the past month

Immunocompromised

Alternatives to Amox/Clavulanate as

Empiric Therapy:

Alternatives to Amoxicillin/Clavulanate for initial empiric therapy include (PCN allergy, etc) :

Doxycycline 100 bid or 200 qdaily: Highly active against respiratory pathogens and with excellent pharmacokinetic/dynamic properties

[Fluoroquinolones (2nd line)]

The following are NO LONGER recommended as alternatives to amoxicillin/clavulanate according to IDSA: 2nd / 3rd generation cephalosporins (as monotherapy) due to variable rates of

resistance

Trimethoprim/sulfamethoxazole- high rates of resistance against S.pneumoniae and H. Influenza

Macrolides: Azithromycin, Clarithromycin- due to high rates of resistance among S. pneumoniae (strong, moderate)

Oral Antibiotics for ABRS

For moderate disease, recent antibiotic

use, or failed initial therapy, the following ARE recommended:

Amoxicillin/clavulanate XR 2,000 mg/125 mg bid for

10 days

Levofloxacin 500 mg qdaily for 10 to 14 days or 750 mg qdaily for 5 days

Moxifloxacin 400 mg per day for 10 days

IDSA.

8/6/2014

16

Chronic Sinusitis

Pearls:

Imaging is not recommended for uncomplicated

sinusitis (grade b/c).

CT is the most sensitive test for detecting

maxillary sinusitis

Otitis Externa

Otitis Externa

Inflammation/infection of the external auditory canal and/or auricle

Pathophysiology

Glands in ear canal produce cerumen that provides protection via a antimicrobial lysozyme. Cerumen has a pH level of 6.9, which discourages microbial growth.

Risk factors for otitis externa include:

Absence of cerumen (excessive cleaning)

Thickened cerumen fosters retention of H20 and debris

Water (macerates skin of canal and raises pH)

Trauma (cotton swab or foreign body)

8/6/2014

17

Symptoms

Otalgia

Itching

Fullness

With or without hearing loss or jaw pain

Tenderness of the tragus or pinna

Diffuse ear edema or erythema or both

With or without otorrhea

Regional lymphadenitis

Tympanic membrane erythema

Cellulitis of the pinna

Otitis Externa

Causes:

Pseudomonas aeruginosa (50%)

Staph aureus (23%)

Anaerobes and gram-negative organisms (12.5%)

Fungi; Aspergillus and Candida species (12.5%).

Others = furunculosis, seb derm, psoriasis, contact dermatitis

Necrotizing "malignant" otitis externa

infection that extends into deep tissues adjacent to the auditory

canal.

may cause cellulitis and osteomyelitis

RF= immunocompromised, diabetes mellitus

rarely described in children.

Otitis Externa

Topical Antibiotic Treatments

Neomycin, polymyxin B, hydrocortisone. Neomycin sensitizing in 5 to 18 percent of patients; ototoxic potential

Fluoroquinolone, with or without steroid. Minimally irritating and infrequently sensitizing; only agent approved if tympanic membrane is perforated

Aminoglycoside- Usually ophthalmic preparation (e.g., gentamicin, tobramycin) but also for bacterial acute OE; minimally irritating; ototoxic potential

8/6/2014

18

Otitis Externa

Other Topical Preparations

Steroid. For underlying dermatitis (e.g., atopic, psoriasis) if it is the cause of chronic OE; cutaneous atrophy with prolonged use

2.0% acetic acid (Vosol), with or without steroid. OE of bacterial or fungal origin in immunocompetent patients;

2.75% boric acid or 90% to 95% isopropyl alcohol. OE of bacterial or fungal origin in immunocompetent patients, but mainly applied as prophylaxis after swimming.

Tolnaftate (Tinactin) or clotrimazole (Lotrimin). OE of fungal origin solution easier than cream; minimally irritating

Hoarseness

Hoarseness

Any patient with hoarseness lasting longer than two weeks in the absence of an apparent benign cause requires a thorough evaluation of the larynx by direct or indirect laryngoscopy.

Causes of Chronic Hoarseness

Malignancy

GERD

Polyps

Nodules

Functional voice disorders

Neurological disorders

Causes of Acute Hoarseness

Vocal abuse

Laryngitis

Smoking

8/6/2014

19

Hoarseness

Important points

Cough- could indicate inflammation of vocal cords or Cancer of larynx or lung

Dysphagia/odynophagia= disorders of pharynx and esophagus

Hemoptysis with hoarseness should be considered malignancy until proven otherwise

Take note of smoking history

Visualization of the larynx by direct or indirect laryngoscopy is absolutely necessary for all patients with hoarseness that does not resolve on its own or with medical therapy.

Referral to ENT

SCC of the larynx

Hoarseness can be a very early symptom of

SCC of larynx and should never be simply

attributed to “laryngitis” without proper

evaluation

Detection of cancer requires visualization of

the larynx

Indirect or direct laryngoscopy usually shows

Well-circumscribed exophytic lesion in endolarynx

most frequently on one of the true vocal cords

SCC of the larynx

Squamous cell carcinoma of the larynx is the

most common malignancy of the larynx

Peak age= 60-65 y/o, Men > women

Malignancies of larynx are MC in smokers

and ETOH abusers

When both factors are present, the risk of cancer

becomes 50% greater than additive risk of each

Only 2-5% of laryngeal cancer patients have no

history of smoking

8/6/2014

20

Additional Slides

Vertigo:

Peripheral vs. Central

Peripheral vestibular disorder

Originates from vestibular nerve and inner ear

Vertigo often episodic

Not associated with neurology symptoms or LOC

Nystagmus is usually horizontal and rotational

Central vestibular disorder

Originates from cerebellum, brainstem, thalamus, cortex

Vertigo often constant

MAY be associated with neurological symptoms or LOC

Nystagmus is purely horizontal, vertical or rotational

BPPV treatment:

Description of the Epley Maneuver

Epley maneuver (canalith repositioning). (A) The patient sits with head rotated 45 degrees to the right.

(B) Physician lays the patient into supine position with head hanging over the end of the table.

(C) The head is then rotated 90 degrees to the left

(D) Head and body are rotated together an additional 90 degrees until the patient is 135 degrees from the initial supine position.

(E) Patient is brought to a sitting position while the head remains tilted. Finally, the head is brought forward and downward to an angle of 20 degrees. The physician should pause at each position until nystagmus resolves, and repeat the series until no nystagmus is present.

A video demonstration of this maneuver is available at: http://www.youtube.com/watch?v=ZqokxZRbJfw&NR=1

Dizziness: A Diagnostic Approach ROBERT E. POST, MD, LORI M. DICKERSON, PharmD, Medical University of South Carolina, Charleston,


8/6/2014

21

Prevention Tips for Otitis Externa

Prevention

Who needs prevention? Immunocompromised; systemic dermatologic condition, contact sensitivities to an ototopical agent, excessive perspiration excessively; when water sports activities are common

Can use acidifying or alcohol drops during the at-risk period (e.g., swim season, scuba diving trip)

Use of a hair dryer with or without a head tilt to aid fluid clearance

Avoid of cotton swabs.

Use of hypoallergenic ear canal molds with or without tight swim caps to reduce infections is controversial.

Bibliography

Treatment of Vertigo. RANDY SWARTZ, M.D., University of California, San Diego, School of Medicine, La Jolla. PAXTON LONGWELL, M.D., California; Corpus Christi, Texas. Am Fam Physician. 2005 Mar 15;71(6):1115-1122.

Dizziness: A Diagnostic Approach. ROBERT E. POST, MD, LORI M. DICKERSON, PharmD, Medical University of South Carolina, Charleston, South Carolina. Am Fam Physician. 2010 Aug 15;82(4):361-368.

Initial Evaluation of Vertigo. RONALD H. LABUGUEN, M.D., University of Southern California, Los Angeles, California. Am Fam Physician. 2006 Jan 15;73(2):244-251..

Hearing Loss in Older Adults. ANNE D. WALLING, MB, ChB, and GRETCHEN M. DICKSON, MD, MBA. University of Kansas School of Medicine—Wichita, Wichita, Kansas. Am Fam Physician. 2012 Jun 15;85(12):1150-1156.

Acute Rhinosinusitis in Adults. ANN M. ARING, MD, and MIRIAM M. CHAN, PharmD, Riverside Methodist Hospital, Columbus, Ohio. Am Fam Physician. 2011 May 1;83(9):1057-1063

Otitis Externa: Review and Clinical UpdateJ. DAVID OSGUTHORPE, M.D., Medical University of South Carolina, Charleston, South Carolina. DAVID R. NIELSEN, M.D., American Academy of Otolaryngology–Head and Neck Surgery, Alexandria, Virginia. Am Fam Physician. 2006 Nov 1;74(9):1510-1516.

Otitis Externa. Medscape. Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Sports Medicine Faculty, Department of Family and Community Medicine, University of Minnesota Medical School

Hoarseness in Adults. RAYMOND H. FEIERABEND, MD, and SHAHRAM N. MALIK, MD, Department of Family Medicine, East Tennessee State University, Bristol, Tennessee. Am Fam Physician. 2009 Aug 15;80(4):363-370.

Textbook for Family Medicine, 8th edition. Robert E. Rakel and David P. Rakel. Elselvier Saunders, 2011

Vestibular neuritis. JOSEPH B. NADOL, JR., MD, OTOLARYNGOL HEAD NECK SURG 1995; I 12:162-72.

IDSA Guidelines: IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. 2012

Dynamed

Essential Evidence Plus

the nose knows ent for the family physician · name of cme activity: acofp intensive update and...

Documents