Common ENT disorders.

Objective: To provide a succinct and updated discussion on common ear, nose, and throat (ENT) disorders encountered by primary care physicians.

Methods: Review of recent and pertinent literature.

Results: Recent data was identified via a PubMed search as well as commonly utilized texts in otolaryngology.

Discussion: While it is impossible to discuss all of the ENT disorders encountered by primary care physicians, it is helpful to have a succinct resource to highlight the common disorders and their presenting signs, symptoms and initial treatments.

Conclusion: Recognizing specific signs and symptoms can help primary care physicians diagnose common ENT disorders. This review discusses these presentations and provides the initial management steps, as well as when to refer patients for further evaluation.

Key Words: otolaryngology, otology, nasal, oral cavity, oropharynx, larynx

Otologic Disorders

Cerumen Impaction

Cerumen is produced within the outer two thirds of the ear canal by skin appendages. It serves the purpose of moisturizing the ear canal. Despite its brown color, it is sterile and provides an important bacteriostatic effect to prevent infection. The ear canal has a natural cleaning process by which skin debris and cerumen migrate laterally. This is disrupted by a number of processes, but most commonly by self-inflicted cotton tip applicator use, which leads to cerumen impaction (CI). Common symptoms are listed in Table 1. Symptoms of otorrhea and/or severe pain suggest otitis externa (OE) instead of CI. Treatment is aimed at removal by irrigation or instrumentation. Patients with diabetes mellitus. tympanic membrane perforation, otitis externa, indwelling tympanostomy tube, or history of otologic surgery should not undergo irrigation. Irrigation should be performed with warm water, directed at the posterior ear canal. Instrumentation should never be performed blindly. The head should be immobilized and under direct vision, cerumen should be removed only as far as can be visualized. Softening agents such as Debrox (glycerin and peroxide) can be used for 3 to 5 days before removal, but will rarely alleviate the problem itself. Cerumenex is another commonly used softening agent, but should only be used for one day before removal as it can be irritating. Patients should be referred if the practitioner is uncomfortable with instrumentation and the patient cannot undergo irrigation. (1,2)

Foreign Bodies

Foreign bodies in the ear canal account for 1 in 500 ER visits. This is not limited to children, as greater than 50% of cases are in patients over the age of 12. Frequently encountered foreign bodies include insects, beads, and cotton. The history usually elucidates the foreign body; however, in the case of insects, the patient may be unaware of its presence but will complain of intense itching and a scratching sound. Hearing should be documented before attempts at removal. Mineral oil (drowns and immobilizes living insects) or lidocaine (causes the insect to flee or paralyzes the insect) can be administered before removal. Removal can then be achieved directly or with lavage. Lavage should not be used for vegetable matter as it will cause the material to expand, increasing pain and making removal more difficult. Otolaryngologists use a microscope to aid in removal. Unfortunately, complications are frequently encountered when nonspecialists attempt to remove foreign bodies, including ear canal lacerations (50% of attempts), otitis externa (15%), and tympanic membrane perforations (6%). Antibiotic drops should be administered after removal if there is any break in the skin. Alkaline batteries are a special case and necessitate expedited removal as they can cause liquefying necrosis. Referral should be made for any cases complicated by otitis externa or failed attempts at removal. (3-5)

Otitis Externa

Otitis externa is a skin infection of the ear canal. It occurs as an acute and chronic process. Risk factors include water exposure, humid climate, dermatologic conditions (eczema), trauma (attempts at cerumen removal) and absence of protective cerumen. Common symptoms are seen in Table 1. Pain occurs as inflammation and edema develop in the non-expandable bony canal. The most common organism is S aureus, but consideration should also be given to P aeruginosa, especially in diabetic patients, recalcitrant or recurrent cases. Otoscopy reveals ear canal otorrhea, erythema and edema causing canal narrowing (Fig. 1). An attempt should be made to visualize the tympanic membrane to assess for any middle ear disease. Typically, the pain is severe with auricle manipulation. Initial treatment consists of suctioning debris and otorrhea. Topical antibiotic drops with a steroid are administered. Cortisporin suspension or ciprofloxacin (with a steroid preparation) are frequently used. Tobramycin or ciprofloxacin are preferential in diabetic patients or when a pseudomonal infection is suspected. Antibiotics should be administered for 7 to 10 days and strict water precautions should be employed. If the ear canal has narrowed to a degree which does not allow penetration of topical drops, an expanding sponge wick should be placed for 2 to 3 days. If the infection involves or spreads to the auricle or preauricular region, systemic anti-Staphylococcal antibiotics are recommended, (dicloxacillin or cephalexin) in addition to topicals. If initial treatment fails, admission for IV antibiotics may be necessary. Once resolved, it is important to remove precipitating factors.

Chronic otitis externa usually presents with persistent itching. The ear canal generally is very dry with flaking skin, mild edema and erythema. This is especially common in patients with underlying dermatologic conditions. Treatment is with antibiotic and steroid preparations. Fungal otitis externa should also be considered in these cases (Table 1).

[FIGURE 1 OMITTED]

Water exposure, chronic otitis externa, humid climate, and trauma all predispose to fungal otitis externa. The most common organisms are Aspergillus niger and Candida albicans (Fig. 2). Systemic or topical antibiotics and steroids are usually not risk factors. Treatment includes aural hygiene with frequent cleaning, usually necessitating referral, and antifungal topicals with a steroid component (Mycolog) or acidic solutions (VoSoL) (6-10)

Acute Otitis Media 

Acute otitis media is an infection of the middle ear space. It is one of the most commonly diagnosed infections in childhood, but can occur in adults, especially in the setting of an upper respiratory tract infection. Symptoms are listed in Table 1. Otoscopy is essential and demonstrates an inflamed, bulging, and immobile tympanic membrane (Fig. 3). Causative bacteria differs with age (Table 2). Initial treatment is typically amoxicillin or Bactrim DS for 10 to 14 days. Treatment failure or recurrent infections require a broader spectrum of coverage with agents such as Augmentin. When tympanostomy tubes are in place, the infection should be treated with topical antibiotics. Perforations can occur, resulting in otorrhea and relief of pain for patients. These typically heal spontaneously in 4 to 6 weeks. Referral should be made at 6 weeks if the perforation persists. Serous effusion may persist after the infection has resolved, leaving the patient with a blocked sensation. This typically takes 3 to 12 weeks to resolve. (11-13)

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

Serous Otitis Media

Serous otitis media is a sterile effusion which occurs in the middle ear. It is the result of eustachian tube dysfunction. Eustachian tube dysfunction leads to negative pressure in the middle ear causing a transudate from the middle ear mucosa to accumulate in the middle ear space. Eustachian tube dysfunction is a poorly understood problem. In some cases there is a clear causative factor such as an URI, cleft palate, or physical obstruction caused by a mass in the nasopharynx. Symptoms are listed in Table 1. Physical examination reveals an intact tympanic membrane with decreased mobility. Frequently, air bubbles or an air fluid line can be visualized (Fig. 3). There is a notable lack of local infectious signs and symptoms. Antibiotics are only indicated to treat an underlying bacterial URI. Treatment includes auto-insufflation (gentle ear popping) in an attempt to aerate the middle ear. Systemic (pseudoephedrine) or topical (oxymetazoline) decongestants may also help. Serous otitis media may take weeks to months to resolve. Especially in unilateral cases without an identifiable cause, a nasopharyngeal mass must be excluded with imaging (CT). Once resolved, patients should use topical and systemic decongestants one hour before flight and abstain from alcohol during flight as it causes mucosal swelling. (12,13)

Cholesteatoma

Cholesteatoma is a collection of debris from keratinizing squamous epithelium, which normally lines the ear canal and tympanic membrane, but has grown into the middle ear space. Cholesteatoma produces osteolytic enzymes which makes cholesteatoma a slow, erosive process. If left untreated, it will eventually erode the ossicles and may potentially invade the surrounding structures such as the cochlea, vestibular system, facial nerve and middle or posterior cranial fossa.

Cholesteatoma usually develops in the setting of chronic middle ear disease and chronic eustachian tube dysfunction. Chronic middle ear disease and eustachian tube dysfunction lead to chronic retraction of the tympanic membrane, which allows squamous debris to collect in the retraction pocket. As this collects, it can turn into the erosive process described above. Patients frequently present with chronic otorrhea and hearing loss. Otoscopy demonstrates a perforation with squamous debris and otorrhea or a white keratin pearl (Fig. 4). When this is recognized, the patient should be referred to an otolaryngologist for surgical management. In the acute setting, if active otorrhea is present, the patient should be started on topical antibiotics. (14)

[FIGURE 4 OMITTED]

Hearing Loss

Hearing loss has a multitude of etiologies (Table 3). The most important aspect for the primary care physician is to recognize how urgently the patient needs to be referred for evaluation. Otoscopy and a basic tuning fork (512 Hz) examination can very helpful. When performing a tuning fork examination it is important to place the instrument in good contact with the bone, ie, firmly on the forehead for the Weber and over the mastoid for the Rinne. The tuning fork should not vibrate excessively. The Weber will routinely detect a difference of 5 to 10 dB between the ears. When the Weber lateralizes to the side of the hearing loss, a conductive hearing is suggested. In these cases the Rinne will demonstrate bone greater than air conduction on the affected side. When the Rinne lateralizes to the opposite side, a sensorineural hearing loss is suggested. Sudden sensorineural hearing loss merits special mention. Treatment with high-dose steroids within two weeks significantly increases recovery of useful hearing. Cases of hearing loss not attributed to cerumen impaction, otitis media or serous otitis media will need otolaryngology referral. (15,16)

Nasal Disorders

Epistaxis 

Epistaxis is one the most common complaints referred to otolaryngologists. The most common cause is trauma, ie, digital manipulation. There are several predisposing factors, especially cold weather, dry climates, septal deviations and perforations. Other medical conditions also predispose patients such as hypertension, Osler-Weber-Rendu, and coagulopathies including the use of anticoagulants such as aspirin, clopidogrel (Plavix) and Coumadin.

Most epistaxis arises from the anterior septum at Kiesselbach plexus, a confluence of vessels in the anterior one third of the cartilaginous septum. Epistaxis from this region frequently produces intermittent bleeding of mild to moderate flow and is often self-limited. The patient can initiate treatment by applying firm pressure by squeezing the nasal ala together against the septum (not up high on the nasal bones). Topical decongestants can also induce vasoconstriction and help cease bleeding. Pressure should be applied for 20 minutes. If bleeding persists beyond this period, the patient should seek medical care. Initial office examination includes anterior rhinoscopy and inspection of the oropharynx. When a specific bleeding site can be identified, it can be cauterized. Wide field or blind cautery is not recommended. Topical anesthesia should be applied with 4% lidocaine or lidocaine/pseudoephedrine on a cotton pledget. Care should be taken to avoid cauterizing areas opposite each other, which can lead to synechia or on opposite sides of the septum, which can lead to perforations.

Prevention is very important for these patients. Efforts should focus on creating a moist mucosal lining and avoiding trauma. Saline mist can be administered several times a day without side effects. Humidifiers, especially in the bedroom, can improve nasal dryness. Emollients such as Vaseline Petroleum Jelly or bacitracin can also be gently applied to the anterior septum once or twice daily. These can be applied on the fingertip (with the nail clipped) or via a cotton tip applicator.

In cases of more profuse epistaxis, a specific site may not be easily identified and the above measures may be ineffective in stopping the bleeding. Such bleeding may only be identified with endoscopic examination and may require additional treatment with anterior packing using strip gauze or Merocel sponges. If this does not control the bleeding, more aggressive packing is sometimes needed or more invasive management such as surgery or arterial embolization may be required. Patients should be referred at any point along the continuum where the primary care physician is no longer comfortable. (17,18)

Nasal Septal Perforation

Nasal septal perforation is a defect through the bilateral mucoperichondrial flaps and septal cartilage allowing communication from one side to the other. Nasal septal perforations are usually traumatic in origin; occurring following nasal fractures, nasal surgery, digital manipulation and chronic irritation secondary to inhaled substances such as illicit drugs. When there is not a clear etiology, other causes should be considered such as Wegener granulomatosis, collagen vascular diseases, sarcoid and atypical infections including tuberculosis and syphilis.

Patients commonly complain of nasal crusting, intermittent epistaxis, sensation of obstruction and whistling with nasal breathing (with small perforations). Initial treatment is aimed at symptom relief. Humidification and ointments may help alleviate crusting and bleeding which are usually the main problems for patients. Patients who continue to have symptomatic perforations should be referred for possible surgical management. Mucosal flap techniques can be successful up to 90% of the time in patients with perforations less then 2 cm. Often times enlarging the perforation can decrease whistling and symptomatic crusting. Silastic buttons can often alleviate whistling, but are less successful in eliminating crusting, bleeding, and obstructive symptoms. (19)

Allergic Rhinitis

Allergic rhinitis is a constellation of clear nasal discharge, sneezing, itching, and nasal obstruction. Patients often have concomitant itchy eyes, scratchy throat, cough, and postnasal drip. It affects approximately 20% of the US population and can occur in a perennial or seasonal frequency. A thorough allergy history is essential. Nasal examination reveals pale, boggy nasal mucosa and inferior turbinates with clear secretions. Allergy testing can be very useful at this point.

The first step in treatment is patient education and avoidance of allergens. First line pharmacologic treatment for mild symptoms is a nasal steroid spray. For moderate symptoms lasting more than 3 weeks at a time, a nonsedating antihistamine should be added. When significant nasal obstruction and congestion are present, a combination antihistamine decongestant can be used. Recently, the antileukotriene agents such as montelukast (Singulair) have been approved for allergic rhinitis. They are most helpful in alleviating congestion and obstructive symptoms. When symptoms become severe, immunotherapy should be considered.

Allergic rhinitis can be managed in the primary care setting. Difficulty controlling symptoms or atypical symptoms such as unilateral nasal obstruction, purulent drainage, pain, vision changes or bleeding should alert the primary care physician to refer the patient for otolaryngology consultation. (20-22)

Nasal Polyps

Nasal polyps are benign nasal masses arising from mucoperiosteal or mucoperichondrial tissue. They appear as watery, fleshy and mobile masses arising from the middle meatus. Frequently they are bilateral (Fig. 5). Polyps are filled with edematous stroma and inflammatory cells. The etiology of nasal polyps remains unknown. Despite a suspected association with systemic allergies, it has yet to be proven.

Symptoms usually consist of nasal obstruction, mouth breathing, hyponasal speech, and nasal congestion. Because of their ability to obstruct the middle meatus, patients may have significant paranasal sinus disease. However, chronic rhinosinusitis may also be a causative etiology of nasal polyps. When polyps are recognized, the first line of treatment is a topical nasal steroid for at least one month. More severe cases may benefit from systemic steroids (1-2 wk) if not contraindicated by other comorbidities. When symptoms of acute rhinosinusitis are present, systemic antibiotics should be given, such as amoxicillin/clavulanate.

Recalcitrant cases should be referred to an otolaryngologist. A dedicated sinus CT should be obtained in these cases to help assess the extent of disease and help expedite care. These patients may benefit from polypectomy or endoscopic sinus surgery. Isolated unilateral polyps or symptoms such as pain and bleeding may indicate a different disease process and should be referred for evaluation. (23,24)

[FIGURE 5 OMITTED]

Nasopharyngeal Carcinoma

Primary care physicians who treat a large population of Chinese patients need to be particularly aware of this disease. Nasopharyngeal carcinoma is one of the most common carcinomas in mainland China, specifically the Canton region. There appears to be a genetic and environmental predisposition. The incidence among those who emigrate from China and US-born Chinese is markedly decreased; however, it never reaches the level of Caucasian Americans. Suspected environmental risk factors include smoking, cooking fumes, formaldehyde and herbal medicines. Epstein-Barr virus, salted fish and nitrosamine consumption have the strongest statistical association.

The most common symptoms include epistaxis, pain, unilateral nasal obstruction, unilateral serous otitis media and cranial nerve deficits. However, the most common presentation is an enlarging posterior triangle neck mass. Anyone suspected of having nasopharyngeal carcinoma should be referred to an otolaryngologist. Treatment consists of chemotherapy and radiation with surgery reserved only for rare cases because of the difficulty and morbidity associated with resection. (25,26)

Oral Cavity, Oropharynx and Laryngeal Disorders

Oral cavity lesions

Oral cavity lesions include a large number and wide range of lesions. Lesions range from benign aphthous ulcers to malignant tumors. Distinguishing benign from malignant lesions is not always easy. When differentiation between benign and malignant lesions is difficult or a lesion is unresponsive or progressive, referral to an otolaryngologist--head and neck surgeon should be made.

Aphthous stomatitis. The most common disease of the oral cavity mucosa is the aphthous ulcer, which manifests as recurrent aphthous stomatitis. Half of Americans will have an aphthous ulcer at some point. These are classified into three types by size and number: minor--usually single and less than I cm, cluster/herpetiform--multiple lesions (3 to dozens) usually 1 to 5 mm in size but may coalesce to form large irregular lesions, major--may be up to several centimeters in size and have a deeper subepithelial involvement, which can result in scarring. The major type is rare, occurring in less than 10% of cases.

The causative agent is unknown, but several factors are implicated including infection (viral or bacterial), immune complexes, menstrual cycle, trauma and stress. The ulcers are shallow gray-white lesions with an erythematous periphery. They are typically uncomfortable and mildly painful. The lesions are self-limited and resolve in 3 to 14 days. Treatment is supportive to relieve pain. Viscous lidocaine 2% can be applied directly or in a rinse and spit fashion (5 cc of lidocaine with 5 cc of warm water) for widespread lesions. Topical steroids (fluocinonide Lidex 0.05% with plain Orabase 1:1 applied t.i.d, clobestasol propionate 0.05% with plain Orabase 1:1 applied t.i.d., dexamethasone elixir 0.5 mg/5 mL, swish and spit t.i.d.) have been shown to decrease pain and duration. Antibiotics (tetracycline 250 mg/10 mL swish and swallow q.i.d.) can be considered for cluster and major lesions. Cautery and freezing agents are discouraged.

Persistent or enlarging lesions require evaluation by a head and neck surgeon and require biopsy. Systemic diseases such as Behcet syndrome, Reiter syndrome, Crohn disease and HIV should also be considered. (27,28)

Exostosis. These are bony lesions of the hard palate and mandible. They are typically slowly progressive, nonmobile, nontender, and are covered with normal-appearing mucosa. They require no treatment.

Ranula. This is a cystic lesion found on the floor of the mouth. It is smooth and mucosally covered. It may enlarge gradually, or it may intermittently enlarge following meals. It arises from a blocked salivary gland causing a cystic dilation. Treatment involves excision.

Leukoplakia and erythroplakia. These white and red plaques are premalignant lesions. They become malignant in 8% and 20% of cases respectively. Any suspicious lesion must be biopsied. Biopsy may reveal epithelial hyperplasia, dysplasia, carcinoma in situ or invasive squamous cell carcinoma. Benign lesions require close follow-up and malignant lesions need further treatment by a head and neck surgeon. (29,30)

Oral cancer. Persistent (present for more than 3 wk), exophytic, ulcerative and firm lesions raise suspicion for malignancy. Oral cancers make up 4% of all cancers in males and 2% of females, accounting for 19,000 new cases each year. Smoking increases risk by six times compared with nonsmokers. Alcohol also is an independent risk factor, as 75 to 80% of oral cavity patients have a history of alcohol use. Their effects are also synergistic, greatly increasing the risk for malignancy. Other symptoms raising suspicion include weight loss, pain, and ill-fitting dentures. Any suspicion of an oral cancer should be referred for further evaluation by a head and neck surgeon. (29-31)

Oropharynx

Snoring and obstructive sleep apnea. Snoring simply refers to noise produced during sleep. Obstructive sleep apnea syndrome (OSAS) is a marked upper airway closure during sleep. This closure can be complete (apnea) or partial (hypopnea). Obstructive sleep apnea can be defined by the Respiratory Distress Index (Table 4). Snoring, apneas, and hypopneas eventually cause sleep disturbance and functional impairment. Most concerning is the potential long-term effects of OSAS on a patient's neurologic and cardiopulmonary systems. Signs and symptoms are seen in Table 5.

Obstructive symptoms are more common in men (4-9% of men) than women (2-4%), but they can occur across the entire population and are not limited by the stereotypical obese, hypersomnolent middle-aged male. Patients suspected of having OSAS should undergo polysomnogram testing in an approved sleep laboratory. Up to 35 to 60% of habitual snorers will have OSAS and should also be formally evaluated.

Initial treatment involves weight loss in overweight patients as well as removal of sedatives, alcohol, caffeine and tobacco. Improving sleep hygiene by creating a stable consistent sleep environment is also important. The mainstay of medical treatment is continuous positive airway pressure (CPAP). This provides a constant stenting of the airway to prevent collapse during sleep. Treatment is very effective; however, only 50% of patients will tolerate CPAP because of issues related to mask discomfort, air leak, claustrophobia, rhinitis and lifestyle impairment.

If anatomic obstructions are contributing to snoring or OSAS, or they are limiting efficacy and compliance of CPAP, surgery should be considered. Table 6 outlines potential surgical procedures based on site of obstruction. (32-35)

Peritonsillar abscess. Peritonsillar abscess (PTA) is the most common complication of pharyngitis/tonsillitis and it is the most common deep space neck infection. It is most common in adults under 40 and is rare in children. Initial symptoms include odynophagia limiting oral intake, trismus, change in voice and systemic symptoms of infection. On examination, trismus, asymmetric fullness at the tonsil pharyngeal wall interface and fluctuance should also raise suspicion.

Treatment consists of drainage and antibiotic therapy. Emergent tonsillectomy is now a rare treatment having been replaced by needle aspiration or incision and drainage with local anesthesia. The most common organism is beta hemolytic Strep followed by various aerobic and anaerobic bacteria. Cultures are not necessary. Typically, amoxicillin/clavulanic acid or clindamycin is used as first line therapy. Admission for parenteral antibiotics and IV hydration should be considered when the patient is unable to sustain adequate oral intake after drainage or if there are clinical concerns about a patient's airway or overall clinical status. Patients should be followed up 24 hours following drainage to evaluate for recollection. (36-39)

Larynx

Laryngeal pathology usually has an associated voice complaint, which can vary from hoarseness, harshness, breathiness, difficulty phonating or frequent loss of voice. When such symptoms are associated with vocal abuse or URI, conservative care with voice rest, hydration and soothing agents such as cough drops should alleviate symptoms in 2 to 3 weeks. There are several benign vocal cord lesions (Fig. 6). Many are associated with excessive vocal use, trauma or smoking. When symptoms persist for more than one month, patients should be referred to an otolaryngologist for evaluation and visualization of the larynx. (40,41)

[FIGURE 6 OMITTED]

Laryngopharyngeal reflux. Laryngopharyngeal reflux is an increasingly recognized cause of voice change and irritation. Only 20% of patients complain of typical gastroesophageal reflux symptoms. More commonly, patients complain of hoarseness, which worsens throughout the day, fluctuating throat discomfort, frequent throat clearing, chronic dry cough, dysphagia and in extreme cases, they will experience laryngospasm. Symptoms are exacerbated by spicy and caffeinated foods. Treatment focuses on behavior and lifestyle changes. If symptoms persist, twice daily proton pump inhibitors should be prescribed. (42)

Vocal cord paralysis. When patients present with a breathy voice, one should suspect a vocal cord paralysis. Patients may also have aspiration symptoms. Based on a large series, causes of vocal cord paralysis included neoplasm (36%) of which 50% were lung cancer, surgical trauma (25%) of which over 50% were secondary to thyroid surgery, inflammatory (13%) and idiopathic (14%) etiologies. Workup for suspected vocal cord paralysis begins with a chest x-ray and referral to an otolaryngologist. Visualization of the larynx can confirm the diagnosis. Further workup may include computed tomography (CT), magnetic resonance imaging (MRI) and/or electromyogram (EMG). Treatment depends on the prognosis for return of function, and may include a temporary injection into the vocal cord or more permanent procedures to medialize the vocal cord. Permanent procedures should only be performed after a period of observation (3-6 mo) to ensure there is no recovery of function. (43)

[FIGURE 7 OMITTED]

Laryngeal cancer. Voice changes frequently raise concern for malignancy, by both the patient and primary care physician (Fig. 7). This is especially true for patients with risk factors such as tobacco and alcohol use. Hoarseness persisting for greater than a month and associated symptoms of dysphagia, odynophagia, or odynophonia should increase suspicion and prompt otolaryngology referral. Any neck lymphadenopathy should also prompt expedited referral.

There are several possible treatment modalities for early laryngeal cancer including radiotherapy, endoscopic and open surgical procedures. Advanced tumors are now most commonly treated with chemotherapy and radiation, however total and partial laryngectomy procedures are still used for certain patients as a primary and salvage surgical treatment.

Summary

There are many common ENT disorders seen by primary care physicians. The above recommendations should assist the healthcare professional in providing appropriate management and referral guidelines for a variety of ear, nose and throat disorders.

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See what you have to ask yourself is what kind of person are you? Are
you the kind that sees signs, see miracles? Or do you believe that
people just get lucky?
--M. Night Shyamalan

Kevin S. Emerick, MD, and Daniel G. Deschler, MD

From Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Department of Otology and Laryngology Harvard Medical School, Boston, MA

The authors have no financial disclosures to declare.

Reprint requests to Kevin Emerick, MD, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114. Email: [e-mail]

Accepted June 12, 2006.

RELATED ARTICLE: Key Points

* There are many otolaryngology disorders which are initially seen by primary care physicians.

* A careful history and physical examination can lead to a correct diagnosis and expeditious treatment; however, some problems require further diagnostic workup which requires evaluation by an otolaryngologist.

* Certain conditions require urgent referral to an otolaryngologist, while others can be referred when initial therapies fail.

Table 1. Common otologic conditions and symptoms

CI                  OE                  Fungal OE

Mild discomfort     Moderate to severe  Varying degrees of otalgia
                      otalgia#
No otorrhea         otorrhea#           Intermittent otorrhea
Decreased hearing   Decreased hearing   Blocked sensation or mild
Blocked sensation#                        hearing loss
                                        Severe itching#

Acute OM                     Serous OM

Moderate otalgia             Mild discomfort
Otorrhea if perforation      No otorrhea
Hearing loss                 Blocked sensation or mild
Systemic signs and symptoms    hearing loss
  of infection#              Popping, crackling noises#
Aural pressure

Italic indicates key symptoms.
CI, cerumen impaction; OE, otitis externa; OM, otitis media; SOM, serous
otitis media.

Note: Key symptoms is indicated with #.

Table 2. Bacteriology of acute otitis media (modified from Bluestone,
see references)

Pathogen   Adults  Children

H Flu      26%     23%
Strep Pn.  21%     35%
M Catar.    3%     14%
No Growth  20%     16%

H. Flu, Haemophilus influenzae; Strep Pn, Streptococcus pneumoniae; M.
Catar, Moraxella catarrhalis.

Table 3. Common causes of hearing loss

Conductive                       Sensorineural

CI                               Presbycusis
OM                               Autoimmune disease
SOM                              Sudden sensorineural hearing loss
Otosclerosis                     Labyrinthitis
Cholesteatoma                    Meniere disease
Trauma--ossicular discontinuity  Acoustic schwannoma
                                 Trauma--labyrinth injury

CI, cerumen impaction; OM, otitis media; SOM, serous otitis media.

Table 4 Definition of OSAS by Respiratory Distress Index (apneas +
hypopneas / hours as observed during formal polysomnogram)

RDI   5-20  20-40     >40

OSAS  Mild  Moderate  Severe

RDI, Respiratory Distress Index; OSAS, obstructive sleep apnea syndrome.

Table 5. Signs and symptoms of obstructive sleep apnea

Signs                              Symptoms

Obesity (>120% ideal body weight)  Heroic snoring
Systemic hypertension              Stoppages of breathing with gasping
Pulmonary hypertension             Daytime somnolence
Nasopharyngeal narrowing           Impaired driving secondary to fatigue
Decreased upper airway size        Poor cognition related to fatigue
  (septal deviation, large           (poor memory, difficulty
  tonsils, macroglossia,             concentrating, etc.)
  micrognathia, etc.)              Morning headaches
                                   Restless sleep
                                   Sexual dysfunction

Table 6. Surgical Therapeutic Options by Site of Anatomical Obstruction

Site            Surgical intervention

Nose            Septoplasty, rhinoplasty, turbinate reduction
Nasopharynx     Adenoidectomy
Pharynx         Tonsillectomy, uvulopalatopharyngoplasty (UPPP)
                  uvulopalatoplasty
Base of tongue  Lingual tonsillectomy, tongue base resection or
                  reduction, tongue base suspension, genioglossal
                  advancement, maxillomandibular advancement
Airway bypass   Tracheotomy