ENT and Scuba Non-life-threatening conditions that can ruin your trip - PowerPoint Presentation

Slide1

ENT and Scuba

Non-life-threatening conditions that can ruin your tripSlide2
Slide3

BarotraumaSlide4

Middle ear barotrauma Slide5
Slide6

Sequence of events in unequilibrated middle ear

At 2.6 ft. a differential of 60 mm Hg exists and may cause discomfort from bulging of TM and round window into the tympanic cavity. Possible conductive HL and vertigo

At 3.9 ft. 90 mm Hg. ET orifice locked with no way for

valsalva

to clear. Forceful attempt could lead to round window rupture. (Studies in cats showed rupture occurring 120- 300 mm Hg at 1 ATA.)

Continued descent can lead to TM rupture from 4.3 ft. to 17.4 ft. depth. Slide7

Grades of barotrauma

0: Symptoms with no

otoscopic

signs

1: Diffuse redness with retraction

2: Grade 1 + slight hemorrhage in TM

3: Grade 1 + gross hemorrhage in TM

4: Dark and slightly bulging TM due to free blood in middle ear (A/F level +/-)

5: Free

hemorrage

into the middle ear with TM perforation. Slide8

Type 1 Barotrauma:Sxs with no otoscopic signs

No diving until:

1)

Symtoms

have cleared

2) Can

autoinflate

at surface

3) Any pre-existing nasal symptoms have cleared

Decongestants may be beneficial, systemic or topical

Antihistamines or topical steroids only in presence of allergy

Slide9

Type 2: Symtoms + signs but no perforation

Rest with no diving until complete resolution on

otoscopy

and

autoinflation

at surface possible (usually 3-14 days depending on severity)

Decongestants as above. Short course of steroids may be helpful

Antibiotics +/-. Give if purulent

rhinorhea

and/or cough with purulent sputum

Topicals

no benefit

Oral analgesics

prnSlide10

Type 3: Type 2 plus TM perf. No diving until complete

otologic

exam done after apparent complete resolution of symptoms with healing of perforation

If significant collection of blood or debris, clean ear

Caution in type of ear drops

Decongestants as above

Prophylactic antibiotics if

comtaminated

water or concurrent upper respiratory infection evidentSlide11

Otitis ExternaSlide12

CerumenMade by modified sebaceous glands

Repel water

Normalize pH

Antibacterial activity from water soluble fatty acidsSlide13
Slide14
Slide15
Slide16
Slide17

Risk Factors for OE

Absence of

cerumen

Trauma

Moisture

Presence of pathogens

Immune compromise

pH changes (more alkaline)Slide18

Pathogens

Bacterial

*

Pseudomonas sp.

*Staph.

Epi

and

Aureus

Proteus sp.

E. coli

Streptococci

Diphteroids

Enterobacter

Klebsiella

and

CitrobacterSlide19

Pathogens

Fungi

Aspergillus

Phycomycetes

Rhizopus

Actinomyces

Penicillium

YeastsSlide20
Slide21

Pathogens

Viral

Herpes Simplex

Herpes ZosterSlide22

Alternate Types

Eczematoid

Dermatitic

Traumatic

Necrotizing (malignant)

Acute Circumscribed (

furuncular

)Slide23

Treatment: Bacterial

Cleaning of EAC

Topical Drops

Ear wick

Steroids

Systemic antibiotics not necessary unless spread to adjacent areas

NSAIDs for pain

(Thank God

Auralgen

has been D/

Cd

)Slide24
Slide25

Ear Drop Prices

Neo/poly/

hydrocort

. Suspension $ 77

Ciprofloxicin

otic

$112

Floxin

otic

$136

Ciprodex

$262

Cipro

HC $286Slide26

Treatment: Fungal

Cleansing/debridement

Acidification

Topical antifungal (

Cresylate

, gentian violet, iodine,

clotrimazole

,

tolnaftate

, compounded powders)

SteroidsSlide27

Prevention1/2 white vinegar and 1/2 rubbing alcohol rinse after water contamination.

OTC preparation which is basically the same thingSlide28

Otitis MediaSlide29

Causative Factors for OMAllergy

Viral

Sinusitis

Hereditary tendencies

BarotraumaSlide30

Types of Otitis Media

Acute vs. Chronic

Suppurative

vs. Non-

suppurative

(with effusion)Slide31
Slide32
Slide33
Slide34

Treatment of Serous Otitis Media

Decongestant (not in children)

Steroids (not in children)

Antibiotics (not for serous)

Valsalva

MTTSlide35

Potential Indications for BMTT

OME in children at risk of speech, language or learning problems regardless of hearing status

Structural damage to TM or middle ear

Persistant

OME with HL ≥ 40 db

Bilateral OME of ≥ 3 mos./ unilateral OM ≥ 6 mos.

Recurrent OME with cumulative ≥ 6 mos. in 12 mos.

Symptomatic OME, e.g. pain, sleep disturbance, tinnitus, vertigo or balance problems

Complicated ET dysfunction: hearing loss, balance

problems,autophony

, retraction, pain

Recurrent severe AOM with effusion at exam timeSlide36

Rhinosinusitis

Acute vs. Chronic (4 weeks/12 weeks)

Recurrent acute- >4 episodes per year

Viral, Bacterial or Allergic?Slide37

Rhinosinusitis

An estimated fewer than 5 bouts/1000 of viral URI develop into bacterial sinusitis

Do not treat

rhinosinusitis

with antibiotics unless:

Worsening after initial improvement

Significant symptoms lasting longer than

10 days

Evidence of complicationsSlide38

Risk Factors for ARS

Air Travel

Exposure to changes in pressure (

e.g.Scuba

)

Swimming

Older Age

Smoking

Immunodeficiency

Dental disease

Asthma & AllergiesSlide39

Pathogens in AOM and ABRS

Similar bacterial species are found in

otitis

media and sinusitis of acute nature.

Streptococcus

pneumoniae

Haemophilus

influenzae

Moraxella

catarrhalis

less frequently: Group A Streptococcus,

Staph., anaerobes, otherSlide40

Treatment of ABRS and AOM

Amoxicillin/

Clavulanate

: 875 mg BID in adults and in children 45 mg/kg/d or 90 mg/kg/d if higher risk for resistant strains.

Alternatives would be

cefpodoxime

,

cefdinir

or, if no other good alternatives,

levofloxacin

High rates of resistance have been demonstrated in vitro to:

macrolides

, TMP/SMTZ and variable rates of resistance to 2

nd

and 3

rd

generation

cephalosporinsSlide41

Risk for resistanceSevere symptoms with infection

Attendance at daycare

Age of <2 or >65 years

Recent hospitalization

Antibiotic use in the past month

Immunocompromised

patientSlide42

Treatment of AOM and ABRSSaline spray- may be helpful and aids comfort

Decongestant- symptomatic help in adults, not suggested for children (can thicken mucus and decrease blood flow to mucosa)

Definitely not recommended: antihistamines, oral steroids, topical steroids

Cultures usually not performed. If done, must be done by direct visualization of sampling in middle

meatus

or sinus puncture. Swabbing of nasal passage or EAC worthless & possibly misleading!Slide43

TonsillitisChiefly due to Streptococcus

pyogenes

in acute setting

Other streptococci, anaerobes and other aerobes cause a few cases.

Consider viral causes, especially EBV (mono)

Treatment with Amoxicillin,

Augmentin

,

macrolide

or

cephalasporin

. Slide44
Slide45

Indications for Tonsillectomy/andenoidectomy≥ 7 bouts of acute tonsillitis in one year

≥ 5 bouts/yr. in 2 consecutive years

≥ 3 bouts/yr. for 3 years.

Obstruction

Chronic cryptic tonsillitisSlide46

DizzinessSlide47
Slide48

VertigoBenign Paroxysmal Positional Vertigo (40%)

Vestibular neuritis (10%)

Meniere’s

Disease (0.5%)

Migrainous

vertigo (?%, probably

underdiagnosed

)Slide49
Slide50

Causes of vertigo while diving

DCS

Hypoxia

Hypercarbia

Nitrogen narcosis

Seasickness

Alcoholic hangover

Unequal caloric stimulation or middle ear pressure

Hyperventilation

Impure gas mixtureSlide51

Vertigo treatment

Meclizine

- 25 mg TID to QID

Diazepam- 5-10 mg BID to QID

Bedrest

until able to safely ambulate

No diving until vertigo free on land

Migraine medication for

migrainous

vertigo

Sodium, caffeine and alcohol restriction for

Meniere’s

Epley

maneuver for BPPVSlide52