OtoloRhinoLaryngology

Mark Montgomery MD, FACS

What is an Otolaryngologist?
Neurotology
Facial Plastics Allergy

General ENT
Laryngology Rhinology

Pediatrics

Head/Neck

4/19/2012

Mark Montgomery, MD

Otolaryngology Topics

Otology Rhinology Allergic Rhinitis Rhinosinusitis Epistaxis, Foreign bodies, etc. Oral and Oropharynx Hypopharynx Diseases of the Neck Trauma of the Head & Neck Tumors of the Head & Neck

Objectives

Discuss clinical medicine of the ears and hearing & balance mechanisms with emphasis on the common conditions Discuss diagnosis, treatment, referral indications and pitfalls in the management of these conditions Place emphasis on accurate, cost efficient treatment and management of these conditions

Topics in Otology

Auricular hematoma Foreign Body Tympanic membrane perforation Eustacian tube dysfunction Barotrauma Otitis Media

Cholesteatoma Mastoiditis Hearing loss Acoustic Neuroma Tinnitus Vertigo

Benign positional Labyrinthitis Menieres

Credits

Photos from the ENT USA web site are protected by the copyright laws of the United States and other countries. Copyright 1999-2003, Kevin T Kavanagh MD. All rights are reserved. They are used here with permission from Kevin T Kavanagh MD

External Ear or Pinna

External Ear Abnormalities

Congenital:
Microtia Protruding outstanding ears 1st branchial cleft abnormalitiesfistulas, cysts, sinuses

Microtia

1st branchial cleft abnormalities

Pathology of the Outer Ear

Metabolic Infectious Neoplasms Traumatic Vascular, iatrogenic

Auricular Hematoma

Auricular hematoma: Can lead to necrosis and permanent disfigurement. Hematoma between the perichondrium and cartilage Does not respond to aspiration REFER immediately to ENT

Cauliflower Ear

Caused by trauma (wrestling) Needs (ENT) referral. Differentiate Acute Vs Chronic Hematoma vs deformity

Auricular Hematoma Treatment

Incision & Drainage with Bolsters

Cauliflower Ear

Keloid from pierced ear ring.

Pseudomonas infection causing cellulitis

Infection: Erysipelas or Celluitis

Traumatic Idiopathic

Chondrodermatitis nodularis helicus

Dermatologic

Contact dermatitis: Atopic dermatitis: Skin lesions:

Contact Dermatitis

Relapsing Polychondritis

Inflammation of cartilage Treatment:antibiotics, may require surgical resection

Auricular Cancer

Auricular cancer

Basal cell Squamous cell Malignant melanoma Cartilage tumors

EXTERNAL CANAL ANATOMY

Cerumen production/canal maintenence

Anatomy of the Ear Region

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Ear Canal Anatomy

External Auditory Meatus

Curved tube of cartilage (lateral 1/3) & bone (medial 2/3) leading into temporal bone Lined with skin
Ceruminous glands produce cerumen = ear wax Innervation by vagus (CN X) and auriculotemporal nerve
27

Exostosis

Bony to palpation Frequently bilateral Surfers ears DDx: Cholesteatoma

EXOSTOSIS OF EAR CANAL

Cerumen

S&S
Tinnitus Conductive hearing loss Treatment: Removal under dirct visualizaion best Complication

TM perforation Abrasion EAC

Contraindication to lavage
Hx of TM perforation Hx of prior ear surgery PE tube in the ear

Cerumen

Foreign Body

Patient inserted Q tips beads Removal may be difficult Success depends on equipment, skill, and cooperation. Complications of removal: laceration of the ear canal, rupture of tympanic membrane Frequent referral to ENT Post-extraction
Topical antibiotics w/ corticosteroids

FOREIGN BODY

FOREIGN BODY

FOREIGN BODY

FOREIGN BODY

FOREIGN BODY

FOREIGN BODY

Foreign bodies
Ear Candling

Otitis Externa

Inflamationof the External ear canal Inflamatory: Eczematous or seborrheic dermatitis Infectious: Bacterial and/or fungal Symptoms:
Pain often severe Tenderness with manipulation of auricle Muffled hearing Discharge--purulent

Otitis Externa

Eczematous otitis externa

Also can be psoriasis

CHRONIC OTITIS EXTERNA

Inflamation Swelling Purulent Debris Itching

Otomycosis (fungal)

OTOMYCOSIS

CANDIDA

ASPERGILLUS

OTOTOXICITY OF OTIC GTTS

Cortisporin contains Neomycin OTOTOXIC may also aggravate itching Acetic acid is not ototoxic but is painful if TM is perforated. Ciprofloxin-type drops: Safe for the middle ear: eg. Floxin, Ciprodex

OTITIS EXTERNA TX

Usually do not need oral antibiotics unless associated with cellulitis of auricle or face/neck. NEVER treat with oral alone. Conc of otic dps higher level to infected area. Oral could lead to resistance. Most infections in FL are probably mixed bacterial (Staph and/or pseudomonas AND fungal. Bacterial: Intact TM- Neomycin or Fluoroquinolone State of TM unknown: Fluoroquinolone
Most important is to ensure drops get in. Debris needs to be cleared. Most common reason for treatment failure is improper administration. With significant swelling, consider Wick insertion

Otitis Externa Tx (con)

Treatment with antibiotic drops 7 days Dry ear care/Avoid manipulation Recheck in one weekremove debris If no improvement: culture & sensitivity Consider pseudomonas or MRSA May require change of drop and/or addition of oral antibiotic

OTITIS EXTERNA (FUNGAL)

Marked debris requiring careful cleaning of the canal. Treatment: Vosol otic drops (2% acetic acid in propolyene glycol) Vosol HC otic drops if swelling present. Lotrimin solution (clotrimazole) Cresylate Ciprodex frequently effective (acidic & steroid in addition to the antibiotic).

Untreated or under-treated fungal infections are nasty and can ulcerate and perforate the TM (Rare)

EAR CANAL PROPHALAXIS

To prevent Swimmers ear or fungus: Store preps are mainly alcohol. Mixing Two tablespoons of white vinegar in pint rubbing alcohol probably better CHEAPER. Use after swimming or when ear feels wet. Eczematous OE: Small amount of OTC 1% hydrocortisone to outer ear canal with Q-tip (depth 1 cm) when ear itches. May use 50% white vinegar and distilled H20 (Not alcohol) if ear canal feels wet.

Necrotizing (Malignant) Otitis Externa

Osteomyelitis of the skull base Pseudomonas predominantly Immunocompromised/diabetic patients Severe pain/discharge Granulation tissue in ear canal Cranial neuropathies 7,9,10,11 CT/nuclear medicine scan Long-term intravenous antibiotics Antipseudomonals Granulation in External Auditory Canal Prognosis- 60% mortality Related to response to therapy

Tympanic Membrane
Functions:
Separates the external ear from the middle ear Transmits sound from air to the ossicles Some amplification of sound wave
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NORMAL TYMPANIC MEMBRANE

(Window to the Middle Ear)

I= Incus O=oval window R=Round window A=Annulus T=Tensor tympani 1=pars flaccida 2=short process of malleus 3=handle of malleus 4=umbo 5=tubal oriface 7=hypotympanic air cells

Anatomy
1 2

I
4

T
5

1= Pars flaccida 2= Short process of maleus 3= Handle of maleus 4= Umbo 5= Supratubal recess 6= Tubal orifice 7= Hypotympanic air cells 8= Stapedeus tendon 9= Pyramidal eminence f = facial nerve co = cochleariform process j = incudostapedial joint

Anatomy

Tympanosclerosis

Tympanosclerosis with inferior perforation

TYPANOSCLEROSIS
Scaring of the TM due to chronic infections

Glomus Tumors
(Chemodectomas)

Initial symptoms: Hearing loss, pulsatile tinnitus Middle ear: promontory

Highly vascular mass

Glomus tympanicum
Glomus jugulare

BULLOUS MYRINGITIS

PRESENTATION: pain with heaing loss Etiology: Unknown, probably viral PHYSICAL FINDINGS: Blebs & erythema of the tympanic membrane Treatment: Supportive, topical anesthetic drops, monitor for secondary bacterial infection.

Bullous Myringitis

Ear Drum Perforation

Acute
Otitis Traumatic Barotrauma

Chronic

TRAUMATIC PERFORATION

TRAUMATIC PERF WITH NERVE EXPOSED

Treatment: TM Perforatioin

Rule out ossicular discontinuity (audiogram) Dry Ear Care! Pain Medication Non-ototoxic antibiotic ear drops only if the perforation occurred in wet conditions and/or ear is draining 90% perforations heal in 6 weeks if noninfected! Tympanoplasty for persistent perforation.

TM with Monolayer (Monomeric) Previous perf or PE tube site

Size

Eustachian Tube Function

Protection of middle ear Clearance of middle ear secretions Ventilation of the middle ear

Eusacian Tube ANATOMY

Critical Valve ln Nasophaynx

Tympanometer: Pressure transducer Testing function of the Eustacian Tube Measures both mobility & volume

Tympanogram Type A

NORMAL

Tympanogram Type B

Volume?

Tympanogram Type B

Volume: nl=Fluid Hi=perf

Typanogram Type C

Negative Pressure

Eustacian Tube Dysfunction Smptoms

Clicking and/or popping in the ear Hearing lossvariable Vertigo Discomfort Symptoms aggravated with change in ambient pressure: elevators, flying SCUBA diving

Eustacian Tube Dysfunction Treatment

Watchful waiting eg.URI Correcting Rhinitis: smoking, allergies, sinusitis, pregnancy, decongestant spray abuse, reflux Medication: antihistamine sprays and steroidssome benefit. (decongestants, antihistamines, steroid spraysusually ineffective) Eustacian tube exercises PE tubes: usually not recommended

Barotrauma Middle Ear

Cause: Changes in ambient pressure in the face of Eustacian Tube Dysfunction Sequelae:
Hemotympanum Ear Drum Rupture Round Window Rupture Serous Otitis

Mechanism of Barotrauma

Common Causes of Barotrauma

Plane Flights Scuba Diving

Hemotympanum due to Barotrauma

Treatment of Barotrauma

Behavior modificationno flying or SCUBA diving until resolution! Treat as Eustacian Tube Dysfunction Antibiotic drops if TM perforation is wet Myringotomy and possible PE tube if no resolution of serous otitis (6 wks approx) Perilymphatic fistulapersistent vertigo & hearing lossemergency referral

Otitis

Media Acute Recurrent OM: If a child experiences three or more episodes of AOM within 6 to 18 months With Effusion (OME)

Acute Otitis Media

AOM develops after bacteria invade the middle ear most frequently occurring childhood disease following URI leading cause of physician visits, antimicrobial therapy, and pediatric surgery in several countries. 80% of cases occur in children, with the greatest incidence occurring in those aged 6 to 9 months By 1 year of age, an estimated 75% of infants will have encountered one episode of AOM, while 17% will have suffered from at least three episodes

Pathogenesis
Infection

Immature/Impaired Immunology

Eustachian Tube Dysfunction Otitis Media Day-care Centers Lack of Breast Feeding Passive Smoking

Allergy

Diagnosis of AOM
Three specific criteria need to be met:
1. rapid onset 2. confirmed presence of middle-ear effusion (MEE) 3. signs and symptoms of middle-ear inflammation

Symptoms of AOM

Rapid onset of disease associated with one or more of the following symptoms: Otalgia Fever Otorrhea Recent onset of anorexia Irritability Vomiting or Diarrhea

Otoscopic findings of Ear Drum In AOM

Opacity Bulging Erythema Middle ear effusion (MEE) Decreased mobility with pneumatic otoscopy
50% of all complaints associated with ear pain will be associated with referred pain from another site

Acute Otitis Media

Microbiology of AOM

The most common bacterial pathogen in AOM is Streptococcus pneumoniae, followed by Haemophilus influenzae and Moraxella catarrhalis. Responsible for more than 95% of all AOM cases with a bacterial etiology Viruses most commonly associated with AOM are respiratory syncytial virus (RSV), influenza viruses, parainfluenza viruses, rhinovirus, and adenovirus

Treatment of AOM

Consider no treatment except analgesics (topical & oral) if mild. Antibiotics-oral, +/- antibiotic drops if rupture of the tympanic membrane. Amoxicillindrug of choice initially. If no resolution: High-dose oral amoxicillin/clavulanate. Oral cefuroxime. Intramuscular (IM) ceftriaxone Large-dose cefdinir (high efficacy against penicillin-susceptible S pneumoniae) Steroids (usually not recommended) Follow up exam for resolution. Is the fluid gone?

Complications of AOM

Hearing loss Chronic SOM Adhesive OM Ossicular discontinuity/fixation Labyrinthitis Mastoiditis Facial VII Paralysis Petrositis

TM perforation Cholesteatoma Tympanosclerosis Intracranial complications- Rare

Meningitis Subdural empyema Brain abscess

Complicated Otitis Media: Suggestive Features

High-risk patient Neonate Immunocompromised state Diabetes, HIV, neutropenia Intracranial Severe headache, fever Meningeal signs, seizures, DMS Otologic Pain (retro-orbital, mastoid) Severe vertigo, SNHL Cranial nerve involvement (6,7,8) Displaced pinna

Coalescent Mastoiditis

Doughy swelling Redness / Tenderness Auricular prominence Purulent otorrhea Progressive hearing loss Fever VII paralysis Intracranial signs

Acute Coalescent Mastoiditis : S & S

Acute Mastoiditis

Uncommon in US Diagnosis confirmed on CT Management

Hospitalization High dose parenteral antibiotics Surgical drainage if no resolution or VII nerve paralysis

Axial CT Temporal bone: Left sided opacity of mastoid air cell consistent with diagnosis of Mastoiditis

Chronic Suppurative OM

Chronic Mastoiditis

Tympanic membrane perforation chronic Absence of pain History of intermittent ear discharge Chronic Osteomyelitis of the Mastoid Diagnosis confirmed by CT Treatment: Mastoidectomy

Otitis Media with Efusion OME

fluid in the middle ear without signs or symptoms of infection Cause:blockage of the eustachian tube with fluid trapped in the middle ear May occur spontaneously as part of rhinosinusitis (inflammation of the nasal cavity and sinuses), or it may succeed a bout of AOM. 90% of cases occur in children between 6 months and 4 years of age

OTITIS MEDIA WITH EFFUSION

Treatment of Otitis Media with Efusion

Environmental (children)
Day Care Bottle feeding in supine position Smoking in the home Milk-free diet Consider reflux! Watchful waitiing Antibiotics, oral antihistamines, decongestants steroid spraysineffective Antihistamine sprays (Astepro, Astelin, Patanase) possibly effective Consider PE tube placement if no resolution

INDICATION FOR PE TUBE PLACEMENT

Failure of OME to resolve Hearing loss with speech & language delay Recurrent Acute Otitis Media Goal of typanostomy tubes (PE) is: Ventilation of the middle ear Temporary bypass of the Eustacian Tube PE stand for Pressure Equalizing Ventilating NOT Drainage tubes

TYMPANOSTOMY TUBES

SHORT TERM GROMMET

LONG TERM T-TUBE

TYMPANOSTOMY TUBES

PEARL
Unilateral otitis media with efusion in an adult, without a preceding URI, is a nasopharyngeal carcinoma until proven otherwise.

CHRONIC OTITIS MEDIA

RETRACTED TM

TM RETRACTION
With serous fluid

CHOLESTEATOMA

Cholesteatoma

Benign growth involving middle ear and mastoid Cause: Persistent negative pressure on the TM Hearing loss most common symptom Microbiology: pseudomonas Management: surgical middle ear with possible removal of ossicles, tympanoplasty, possible mastoidectomy Recurrence: common

CHOLESTEATOMA Pars flaccidapost sup quadrant

Pearl
Suspected perforation of the pars flaccida is a cholesteatoma until proven otherwise.

Inner Ear

Anatomy Diseases of the Inner Ear Hearing Loss Tinnitus Acoustic Neuroma Vertigo Benign Positional Vertigo Labyrinthitis Menieres Ramsey Hunt Syndrome & Bells Palsy

Anatomy of the Inner Ear

Bony Labyrinth Membranous Labyrinth

Inner Ear---Bony Labyrinth

Bony labyrinth = set of tubelike cavities in temporal bone

lined with periosteum & filled with perilymph

surrounds & protects membranous labyrinth

Semicircular canals Vestibule Cochlea

123

Inner Ear---Membranous Labyrinth

Membranous labyrinth
set of membranous tubes containing sensory receptors Hearing (cochlea) Balance (semicircular canals) 124 filled with endolymph

Classification of Hearing Loss

Conductive
Blockage of Outer Ear Cerumen Infection Dysfunction of the Middle Ear Perforation of Ear Drum Fluid Eustacian Tube Dysfunction Ossicle Malfunction Maleus, Incus, Stapes

April 19, 2012

126

Classification of Hearing Loss

(Cont)

April 19, 2012

Neurosensory Inner Ear (Nerve of Hearing) Genetic Noise Induced Medication Infection Diseases (Menieres) Growth Mixed loss Combination of neurosensory and conductive

127

Genetic (Presbyacusis)

Most common type of hearing loss Loss of nerve cells in the inner ear Begins at different ages and at a variable rate High frequency range is lost first Ability to distinguish consonants most affected (b, p, sh, t, etc)
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April 19, 2012

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Noise Induced Hearing Loss

Extremely common May occur at any age Additive effect Common sources
Guns Industrial type noise Power tools Music (ear puds etc.)

Prevention: ear protection

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April 19, 2012

Decibel Levels of Common Sounds Safe Level: 85 dB or less

85 Average traffic 20 Ticking watch 95 MRI 30 Quiet whisper 100- Blow dryer 40 Refrigerator hum 105- Power mower, 50 Rainfall chain saw 60 Sewing Machine 110- Screaming child 70 Washing 130- Jackhammer, Machine Jet engine (100 feet) 80 Alarm clock at two feet 140- Shotgun, Airbag
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Evaluation of Hearing loss

History Physical Exam

Appearance of ear canal and ear drum Tuning fork testing

Weber Test Rinne Test

Weber Test

Hold a 512 Hz tuning fork on the middle of the patient's forehead and ask them: "Where do you hear this loudest; left, right, or in the middle?

Rinne Test

Compares perception of sounds, as transmitted by air or by bone conduction through the mastoid Heinrich Adolf Rinne (1819-1868) german otologist;

Rinne test

Placing a vibrating tuning fork (512 Hz) initially on the mastoid Then next to the ear and asking which sound is loudest

Audiogram

audiogram is a graphical representation of how well a certain person can perceive different sound frequencies normalized conversion of hearing thresholds from dBSPL to dBHL, where dB is decibel, SPL is sound pressure level and HL is hearing level

Audiogram

Hearing Loss

Conductive Sensorineural Mixed Sudden SNHL

REFER

Tinnitus (Ringing in the Ears)

Causes Neurosensory hearing loss Medication (aspirin, etc.) Vascular Tempomandibular Joint Syndrome Idiopathic Ref: American tinnitus Association www.ata.org
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Tinnitus: Treatment

Medication Biofeedback Masking TMJ temporomandibular joint therapy Cognitive therapy

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Tinnitus Treatment (cont)

Alternative Therapy Hypnosis Accupuncture Ginkgo biloba Hyperbaric Oxygen Vitamin B Hearing Aids Further w/u for pulsatile tinnitus
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Acoustic Neuroma

Benign neurolemmoma or schwannoma of the Eighth Cr. Nerve Located in the internal acoustic canal Usual presentation: Progressive assymetric NSHL with poor discrimination Treatment: Observation, Cyper Knife, Surgery

Internal Acoustic Canal (IAC)

Acoustic Neuroma IAC

MRI Coronal View

38 yo c/o hearing loss left ear 3mo duration

Same pt, 8 months later

Acoustic Neuroma
MRI Coronal View

Acoustic Neuroma Axial MRI

Idiopathic Sudden Sensorineural Hearing Loss

Hearing loss Sudden - no trauma history Rapidly progressive (<3 days) Etiology - unclear Viral 30%-50% - recent viral URI Vascular - hypercoagulable state Membrane rupture Associated symptoms Aural fullness/tinnitus/vertigo Normal examination! Ear Neurologic Remember Weber & Rinne!

Left SNHL

Idiopathic Sudden Sensorineural Hearing Loss

Workup - 90% no etiology found Complete audiogram CBC/platelets/ESR/RPR MRI with gadolinium 1%-3% acoustic tumors Management Urgent ENT referral Corticosteroids - proven benefit. Oral vs. Perfusion Other therapies - controversial Carbogen, Histamine, Heparin, Dextran Prognosis - 2/3 recover hearing Related to severity Improved if responsive to steroids

Left Acoustic Neuroma

Vertigo vs. Dizziness

The hallucination of movement spinning sensation Distinct symptom complex Vertigo is not: light headedness, syncope, fainting, dysbalance Central (brain) issues and Cardiovascular issues frequently confused with Inner Ear pathology

Objectives

Differentiate the causes of vertigo Know the etiology of vertigo Describe acute labyrinthitis Describe Mnire's Disease Describe Benign Positional Vertigo Discuss the anatomy involved in inner ear pathology

Pattern of Presentation
Duration of individual attack Frequency Effect of head movements Specific position inducing symptoms

Associated aural symptoms

Concomitant ear disease

Differential Diagnosis

BPPV=benign paroxysmal positional vertigo VN=Vestibular neuronitis Menieres

Diabetes CPA tumor Migraine Otosclerosis

Hypothyroidism Neuropathy Pagets Disease of the skull (osteitis deformans Head trauma Toxic vestibulopathy Lipid abnormalities

Benign Positional Vertigo

Transient Postitional The most common type of vertigo in older patients No associated nausea or vomiting No associated hearing loss Dix-Hallpike Maneuver: Nystagmus

BPV--continued

Causes:
Head trauma Procedures Medication eg. Gentamycin

Pathophysiology: Otoconia (rocks) from utricle displaced into the posterior canal. Treatment: Responds to Physical TherapyEpley maneuver

Dix-Hallpike Maneuver for BPV

Vestibular Neuronitis, Labyrinthitis (VN)

Sudden onset severe vertigo

incapacitating Nausea and Vomiting Recent or concurrent URI Neurosensory hearing loss common Self-limited

Labyrinthitis--continued

Etiology---Viral infection inner ear

Bacteria cause occasional

Treatment:
Antiemetics Corticosteroids: oral, IV, or perfusion of the inner ear Antivirals

Menieres Syndrome
Histopathology
Clinical features

Causes

Refer!

Menieres Syndrome
Idiopathic endolymphatic hydrops Characterized by a

History of increasing ear fullness Roaring tinnitus followed by a

sensation of blocked hearing Episodic with months or years symptom free Fluctuating Neurosensory Hearing Loss

REFER!

Menieres Syndrome

Endolymphatic Hydrops: Increased pressure in the inner ear Possible causefailure of cellular pump Symptoms caused by inability membranous inner ear to swell bony labyrinth Genetic propensity

Management
Medical: Acute- Prednisone 60 mg taper

over 10 days Chronic tx: Diuretic. Low salt, Low caffeine diet Allergic desensitization Surgical (for intolerable vertigo)
Trans tympanic Steroid Perfusion

Transtympanic Gentamicin Perfusion Retrosigmoid vestibular nerve resection

Transmastoid endolymphatic sac

procedure Transmastoid labyrinthectomy

Perilymph fistula
Patterns Vertigo episodes without hearing loss Hearing loss without vertigo A Menieres syndrome pattern Dysequilibrium without vertigo Associated with barotrauma

Evaluation for Vertigo

Laboratory Radiographic studies Vestibular function tests Audiologic studies Immunologic Studies Refer

Electrocochleography (ECoG)

ECOG is performed by placing an electrode that consists of a wire, into the ear canal as close as possible to the cochlea. The ear is then stimulated with alternating clicks of different polarities, or tone bursts. These tone bursts are transformed into vibrations in the middle ear, your ear does this naturally and automatically all the time. The vibrations are turned into electrical impulses in the inner ear and are recorded and measured using computer software.

Electrocochleography (ECoG)

Conclusion
Accurate diagnosis
Suppression of nausea & vomiting Preventive medical therapy

Surgery for failed medical therapy

Rehabilitative therapy

Ramsey-Hunt Syndrome

Cause:Varicella-zoster virus (chicken pox) involving the VII facial nerve Symptoms: Pain, Rash, Facial nerve palsy, Hearing loss Treatment:
Acyclovir Steroids Complications
Permanent hearing loss Permanent weakness of facial nerve Eye damage Post Herpetic Neuralgia

Ramsey-Hunt Syndrome

Acute Facial Paralysis

Idiopathic (Bells) Palsy >50%
Etiology Facial paralysis workup Herpes simplex virus CBC, ESR, Lyme titer Neural edema in bony Glucose tolerance test sheath Audiogram Acute onset CT/MRI - if atypical/recurrent Rapid time course Diagnosis of exclusion No hearing loss or vertigo Infectious Zoster, Lyme, otitis media +/- Ear/facial pain Neoplasm Normal examination Temporal bone, parotid Head and neck examination Systemic Neurologic examination Sarcoid, diabetes, autoimmune

Bells Palsy

Idiopathic (Bells) Palsy Management

Corticosteroids/acyclovir Decreases sequealae Eye care - most important Educate patient Ocular lubricants Exposure protection Early ophthalmology consultation Prognosis - generally good 85% recover in 3 weeks 15% - delayed recovery (3-6 mos.) 10%-15% adverse sequelae Synkinesis and residual weakness