E | Anesthesia Key

Earache

The analysis of earache is much like that of dysuria: It is anatomic, and inflammation accounts for the vast majority of causes. Thus, otitis externa would be like urethritis, otitis media like cystitis, and so forth.

Like cystitis, otitis media is often initiated by obstruction (e.g., swollen adenoids). Foreign bodies in the ear, like foreign bodies in the bladder, must always be looked for. Unlike dysuria, earache is often caused by referred pain. Thus, parotitis (e.g., mumps), temporomandibular joint (TMJ) syndrome, pharyngitis, and dental caries or abscesses may cause earache.

Approach to the Diagnosis

The approach to the diagnosis requires ear, nose, and throat examination; culture of any discharge; and x-ray film of the mastoids, petrous bone, TMJs, and in some cases, the sinuses and teeth. A careful neurologic examination is necessary in unexplained otalgia. Referral to an otolaryngologist or neurologist is probably best for the busy physician who is unable to find the cause on a routine examination.

Other Useful Tests

Computed tomography (CT) scan of the mastoids (mastoiditis)
Magnetic resonance imaging (MRI) of the TMJs (TMJ syndrome)
Throat culture (streptococcal pharyngitis)
X-ray of the teeth (dental abscess)
Impedance tympanogram (otitis media)
Audiogram (otitis media)
SPECT scan (TMJ syndrome)

Edema of the Extremities

Edema of the extremities is a common symptom. Most physicians, therefore, have an immediate working diagnosis when the patient walks into the office: congestive heart failure (CHF) if the edema is bilateral and deep vein phlebitis if it is unilateral. Many times this is right. However, what if the heart and chest sound normal and there is a negative Homans sign? Obviously, before the physician questions the patient the clinician needs a more complete list of diagnostic possibilities. Physiology is the key to that list.

Fluid is passing from the blood compartment into the subcutaneous tissues and back again all the time. Why does it stay in the subcutaneous tissues? There are four main physiologic reasons and three minor ones.

The pressure in the veins may be so high that it overcomes the oncotic pressure of the albumin and other proteins in the blood. This is the explanation in phlebitis, venous thrombosis, pelvic tumors, centripetal obesity, and right-sided CHF (partially).
The pressure in the arteries may be so high that more fluid is pushed out than can be reabsorbed with normal oncotic pressure. This may be the case in acute glomerulonephritis and malignant hypertension.
The level of serum albumin may be so low that the oncotic pressure drops to a point where it cannot reabsorb all the fluid being driven out by the forward pressure of the arteries or backward pressure of the veins. This is seen in conditions in which either too little albumin is produced (cirrhosis of the liver) or too much albumin is lost in the urine (nephrotic syndrome of diabetes mellitus, lupus erythematosus, amyloidosis, and several other disorders of the kidney). It is also probably a component of the edema in beriberi and CHF.
The lymphatic channels that pick up any excess fluid that the veins cannot pick up may be blocked. This occurs notably in filariasis, Milroy disease, and lymphedema following mastectomy, but other conditions may also block the lymphatics.
An abnormal protein (mucoprotein) may be deposited in the tissues and lead to edema. This results in the nonpitting edema of hypothyroidism (myxedema).
A reduction in tissue turgor pressure may be responsible for the edema in older people and beriberi (vitamin B₁ deficiency).
Retention of salt as in primary and secondary aldosteronism is a minor factor, because most cases of aldosterone-secreting adenomas do not have significant edema.

It would be a serious omission not to mention local conditions such as cellulitis, ruptured Baker cysts, burns (especially sunburn), contusions, and urticaria that may cause edema, but these are usually obvious.

Edema is classified according to the anatomic site of origin and the mechanisms that are responsible in Table 26.

Approach to the Diagnosis

Bilateral pitting edema of the lower extremities is usually due to CHF, nephrosis, or cirrhosis of the liver. Venous pressure and circulation time and serum BNP will rule out CHF, but echocardiography can be more definitive. Serum and urine osmolality can be helpful also especially in diagnosing SIADH. If there is nephrosis, there will be
significant lowering of the serum albumin level and proteinuria. Liver function studies will usually confirm cirrhosis or liver disease, but ultrasonography can reveal ascites to assist in the diagnosis. Nonpitting edema of the lower extremities will usually be due to lymphatic obstruction, but hypothyroidism can be ruled out with a free thyroxine (T₄) or thyroid-stimulating hormone (TSH) assay. Unilateral edema of the lower extremities suggests deep vein thrombosis, which can be confirmed by Doppler ultrasound studies, plethysmography, or contrast venography. A D-dimer blood test is especially useful in screening for this disorder. A CT scan of the chest will help diagnose constrictive pericarditis, which is rarely found today. Spirometry and arterial blood gas analysis will diagnose pulmonary emphysema with cor pulmonale.

Earache.

Other Useful Tests

Complete blood count (CBC) (anemia)
Chemistry panel (nephrosis, cirrhosis)
Renal function test (nephritis, nephrosis)
Antinuclear antibody (ANA) analysis (collagen disease)
CT scan of the abdomen and pelvis (ovarian cyst or tumor)
Lymphangiogram (lymphedema)
CT scan of the chest (superior vena cava syndrome)
Serum protein electrophoresis (collagen disease, multiple myeloma)
Spiral CT venography (phlebitis)

Case Presentation #21

A 66-year-old white woman was found to have 4+ pitting edema on a routine checkup. There was no history of shortness of breath or chest pain. She admitted to consuming one to two glasses of wine before dinner almost daily for many years. She also has had Type II diabetes mellitus for 5 years managed on diet alone.

Question #1. What is your list of possibilities utilizing the methods described above?

Further history reveals that she has been treated with Timolol (a beta-adrenergic antagonist) for glaucoma the past few months. Physical examination reveals that, in addition to the pitting edema, she has mild cardiomegaly, crepitant rales at both bases, and mild hepatomegaly but no ascites. Her liver function tests were unremarkable.

Question #2. What is your diagnosis?

(See Appendix B for the answers.)

Elbow Pain

A painful elbow really does not require a detailed analysis of the anatomy to discover the various causes, almost all of which are bursal or bone and joint disorders.
Of course, the skin may be involved by trauma and infection, just like the skin of the hands (see page 198). The arteries, veins, muscles, and nerves are rarely the cause of pain here. The simplest and most expedient approach is to use the mnemonic MINT and apply it to the bones, joints, and bursae.

Edema of the extremities.

M—Malformations are usually acquired, such as the Charcot joints of syphilis and syringomyelia. Bleeding into the joint in a hemophiliac is also classified here.
I—Inflammation should signal bursitis, particularly radiohumeral or lateral epicondylitis (popularly called tennis elbow) and olecranon bursitis. Medial epicondylitis
(golfer elbow) also occurs. One should also recall arthritis of the elbow joint, particularly rheumatoid arthritis, gout, and osteoarthritis. Surprisingly, rheumatic fever frequently affects the joint, and tuberculosis should be considered along with other forms of septic arthritis.
N—Neoplasms are unusual, but osteosarcomas and metastatic carcinomas nevertheless occur.
T—Trauma suggests fractures, dislocations, and elbow sprains.

Table 26 Physiologic Mechanisms of Edema

	Increased Venous Pressure	Increased Arterial Pressure	Decreased Serum Albumin	Lymphatic Obstruction	Abnormal Protein in Subcutaneous Tissue	Loss of Tissue Turgor	Aldosteronism
Congestive Heart Failure	[check mark]		[check mark]				[check mark]
Nephrosis			[check mark]				[check mark]
Cirrhosis	[check mark]		[check mark]				[check mark]
Pelvic Tumor	[check mark]
Thrombophlebitis	[check mark]
Filariasis				[check mark]
Hypothyroidism					[check mark]
Beriberi			[check mark]			[check mark]
Malignant Hypertension		[check mark]					[check mark]
Acute Glomerulonephritis		[check mark]					[check mark]
Toxemia of Pregnancy		[check mark]	[check mark]				[check mark]

Approach to the Diagnosis

In the approach to the diagnosis, the traumatic conditions and arthritic disorders will probably stand out. A diagnostic dilemma occurs when the elbow looks normal and has good movement. Nevertheless, most of these cases are caused by tennis elbow, myositis, and fasciitis. Thus, a simple injection at the trigger point will assist the diagnosis and give the patient immediate and sometimes lasting relief. If this is unsuccessful, referral to an orthopedic surgeon is wise.

Other Useful Tests

X-ray of the elbow (fracture)
CT scan or MRI of the elbow
Arthritis panel
X-ray of cervical spine (herniated disc)
Neurology consult

Enuresis (Bedwetting)

By following the innervation of the bladder from its termination to the spinal cord, brain, and “supratentorium,” one can develop an extensive list of possibilities for this mischievous condition. Thus, anatomy is the key and the mnemonic MINT is the door.

Termination: The bladder and entire urinary tract should be suspect for pathology in any case of enuresis beyond the age of 6.

M—Malformations include phimosis, small urinary meatus, and vesicoureteral reflux.
I—Inflammatory conditions form the largest group and include balanitis, urethritis, cystitis, and pyelonephritis. If a child develops chronic nephritis at an early age, his or her bladder simply may be too small to retain the polyuria during sleep.
N—Neoplasms are an unlikely cause in children, but they occur in adults.
T—Trauma from a vesical calculus or other foreign bodies inserted into the bladder must also be considered. Postprostatectomy enuresis should be considered here in the adult.

Spinal cord: The following are included in this group:

M—Malformations such as spina bifida.
I—Inflammatory conditions such as poliomyelitis and transverse myelitis.
N—Neoplasms such as spinal cord tumors.
T—Traumatic conditions such as fracture, hematomyelia, and herniated discs.

Elbow pain.

Brain: This is an important group of conditions to consider, if only briefly, because if the patient has a form of epilepsy, a cure may be easily obtained. Other neurologic conditions include mental retardation, multiple sclerosis, general paresis, brain tumors, and chronic encephalitides.