Otolaryngology in the ED

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Otologic complaints are commonly evaluated and treated in the emergency department (ED) setting. In a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), among a weighted total of 388,904,009 ED visits in the years 2009 through 2011, 8,611,282 visits were attributed to a primary otologic diagnosis, representing 2.2% of all ED visits. Stratifying further by age, nearly 7% of all pediatric ED encounters involved otologic diagnoses (Laryngoscope. 2015;125:1926-1933).

The most common diagnoses among all age groups in the study included otitis media not otherwise specified (NOS) (60.6%), infected otitis externa NOS (11.8%), and otalgia NOS (6.8%). Other notable diagnoses included impacted cerumen (3.6%) and peripheral vertigo (0.9%). The most common diagnoses for pediatric patients were suppurative or unspecified otitis media (82.1%), followed by disorders of the external ear (9.0%) and other disorders of the ear (5.5%). In contrast, the most common diagnoses for adult patients were more evenly distributed, with suppurative or unspecified otitis media (32.4%) being the most common, followed by disorders of the external ear (28.8%), vertiginous syndromes (19.1%), and other disorders of the ear (12.3%).

Of otologic diagnoses resulting in hospital admission, the most common diagnoses were related to dizziness and vertigo, including benign paroxysmal vertigo (33.3%), labyrinthitis (12.1%), and vestibular neuronitis (8.1%).

Based on these analyses, Elliott D. Kozin, MD, clinical fellow in otolaryngology at the Massachusetts Eye and Ear Infirmary/Harvard Medical School in Boston, said that despite the fact that otologic complaints are commonly treated in the ED, there is a possibility that some otologic conditions are being underdiagnosed and undertreated. For example, one emergent complaint—sudden sensorineural hearing loss—was infrequently diagnosed in their study. “Estimates of sudden hearing loss are typically much higher based on reports in the literature, suggesting that ED providers may be missing opportunities to intervene in true otologic emergencies,” he added.

True Medical Emergencies

Very few ED visits for otologic complaints are actually warranted, said Sujana S. Chandrasekhar, MD, clinical professor at Hofstra-Northwell School of Medicine in Hempstead, N.Y., and president of the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF). In another study conducted by Massachusetts Eye and Ear Infirmary that focused on the subspecialty emergency room as an alternative model for otolaryngologic care, 6% of visits were for hearing loss (Am J Otolaryngol. 2014:35:758-765). “But hearing loss is not well evaluated in the ED, because no audiologic facility exists there, and, typically, not even a tuning fork is available,” said Dr. Chandrasekhar.