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Senior - ENT > 2 - Otolaryngology > Flashcards

2 - Otolaryngology Flashcards

1
Q

Functions of the eustacian tube?

A

Pressure equalization
- yawning/swallowing

Mucus drainage
- from middle ear to posterior pharynx

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2
Q

Why are ear infections common in kids not but adults?

A

Kids

  1. Shorter ET
  2. Horizontal ET
  3. Immature floppy elastic cartilage
  4. Larger adenoids

Tube resembles adult tubes by age 6

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3
Q

S/s of eustachian tube dysfunction (ETD)

A

Aural fullness
Fluctuating hearing
Discomfort w barometric pressure changes

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4
Q

ETD pts are at risk for?

A

Otitis media w effusion (OME)

Serous otitis media (SOM)

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5
Q

Ways to assess the TM integrity and mobility?

A

Valsalva
Otoscope w bulb
Tympanogram

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6
Q

What 2 main dysfunctions cause ear problems?

A

Dilatory dysfunction (common) - cannot dilate well

Patulous dysfunction (uncommon)

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7
Q

Dilatory dysfunction causes?

A
  1. Any type of inflammation
    - infection
    - allergies
    - irritants
    - hormones
  2. Pressure dysregulation (altitude)
  3. Anatomic congenital abnormalities
    - atresias
    - masses
    - trauma
    - hypertrophied adenoids
    - downs
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8
Q

Patulous dysfunction presentation?

A

Over patent eustation tube “i hear my body functions”

benign condition caused by

  • wt loss (6lbs)
  • scarring
  • neuromuscular d/o
  • hormonal functions (high estrogen)
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9
Q

Clinical symptoms of dilatory vs patulous dysfunctions?

A

Dilatory

  • HL,
  • TM retraction/effusion

Patulous

  • autophony (looks normal w/o HL)
  • movement w inspiration/expiration
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10
Q

Dilatory dysfunction tx?

A

URI

  • Decongestants
  • Antihistamines
  • Nasal steroids

Education
- stop smoking

Behavioral
- PPI (acid reflux)

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11
Q

Patulous dysfunction tx?

A

Mild symptoms

  • reassure/education
  • hydration
  • NS spray

Severe symptoms
surgery
- TM tubes
- cartilage grafting

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12
Q

What is SOM aka OME

A

Serous otitis media
Otitis media w effusion

  • eustachian tube remains blocked for a long time
  • negative pressure results in transudation of fluid
  • fluid in middle ear w/o illness/inflammation
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13
Q

Presentation of SOM/OME?

A

Conductive HL
Aural fullness
Reduced TM mobility - viscous bubbles

Adults - h/o

  • URI
  • Allergies
  • barotrauma
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14
Q

Adults w persistent unilateral SOM?

A

Must r/o:
nasopharyngeal carcinoma

Using nasopharyngeal endoscopy

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15
Q

Tx of SOM?

A

Mild HL

  • observe x 3 mo
  • freq valsalva
  • steroids/abx/antihistamines (controversial)
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16
Q

Why are meds controversial for SOM tx?

A

If the pt has seasonal allergic rhinitis or URI meds are useful

The controversial part is only using these empirically

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17
Q

Refractory SOM tx?

A 
PE tubes (pressure equalization)
Adenoidectomy 
- relieves nasal obstruction
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18
Q

Indications for PE tubes?

I think she said this is a test q

A
  1. Severe or recurrent AOM
  2. HL >30db w OME
  3. Impending mastoiditis or intra-cranial complications due to OME
  4. SOM >3mo
  5. Chronic retraction of tympanic membrane (ETD)
  6. Prevention or tx of barotrauma
  7. Autophony due to patulous eustacion tube (PET)
  8. Craniofacial anomalies that predispose mid ear dysfunction
  9. Mid ear dysfunction due to head/neck radiation and skull base surgery
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19
Q

With TM PE tubes you must educate pt?

A

Mid ear should be sterile so swimming and similar activities gets bacteria in there (prob bad)

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20
Q

With acute otitis media (AOM) you often see?

A

Otalgia, oft w URI

Erythema and hypomobility of TM

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21
Q

AOM is a sequela of?

A

ETD

  • infection of URT leads to mucosal inflammation -> diminishes the diameter of ET
  • leads to inadequate ventilation and backflow of secretions from throat into mid ear
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22
Q

70-90% of AOM cases?

A

Resolve spontaneously w/o abx

- but they are still often given

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23
Q

Risk factors for AOM?

A

Pacifier use
Bottle feeding
Day care attendance
Second hand smoke

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24
Q

Clinical presentation of otitis media?

A

Young kids

  • fever
  • irritability
  • crying
  • drainage of ears
  • altered sleep
  • ear pulling

Older kids/adults

  • otalgia (sudden onset)
  • mastoid tenderness
  • aural pressure
  • decrease hearing
  • fever
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25
Q

Otitis media PE?

A 
Erythema
Decreased mobility
Bulging TM 
- w/o landmarks 
Occasionally bullae

Pics on slide 27

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26
Q

Common AOM pathogens

A

S. Pneumoniae
H. Influenzae
S. Pyogenes
- GABHS

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27
Q

AOM tx?

A

Abx
Antipyretics/analgesics

Or observation if:

  • > 2y/o
  • otherwise healthy
  • fever <102.2
  • able to return if needed

Most spontaneously get better in 48-72hrs

Tympanocentesis for culture
- immunocompromised or recurrent

Myringotomy
- sever otalgia or complications of AOM (mastitis, meningitis)

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28
Q

Abx in preschoolers?

A

50% of abx in preschoolers are for ear infections

This is why observation is suggested now, trying to reduce resistant bacteria

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29
Q

Abx for AOM?

A

Amoxicillin 80-90 mg/kg/day
- 1st line

Amox-clavulante 20-40mg/kg/day

PCN allergy
- cefdinir or ceftriaxone

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30
Q

oh SNAP

A

Safety Net approach to Antibiotic Prescriptions

Based on clinical suspicion of AOM
- give prescription w instructions to only fill after 2 days or if sxs get worse

76% of kids get better w only pain management and dont need the abx

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31
Q

1 in 10 kids taking amoxicillin gets?

A

Itchy maculopapular rash >72hrs after beginning the meds

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32
Q

If the pt gets amoxicillin rash?

A

Its not contraindication for future amoxicillin use, nor should current regimen be stopped

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33
Q

Be careful though amoxicillin rash can also be?

A

Infectious mono
- 80-90% of pts w acute EBV infection given amoxicillin develop rash

I smell a new EBV test…

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34
Q

AOM prognosis?

A

At 2 weeks
- 50% will have fluid in ears

10 weeks
- 10% will have residual fluid

Many kids have cyclical infections
- recurrent acute otitis media

Can become chronic otitis media

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35
Q

Definition of recurrent AOM?

A

> /= 3 distinct episodes of AOM w/in 6 months

> /= 4 episodes w/in 12 months

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36
Q

Tx for recurrent AOM?

A

PE tubes

37
Q

What is chronic otitis media (COM)

A

Chronic infection of mid ear and mastoid, consequence of recurrent AOM or trauma

  • Chronic otorrhea w/ or w/o otalgia
  • TM perforation w conductive HL
  • often amenable to surgical correction
38
Q

When does AOM become COM?

A

Usually between 2-3 months

39
Q

COM definition?

A

Chronic otorrhea through a perforated TM

  • mucosal changes and osseous changes are present
  • bacterialolgy different from AOM (anaerobes)
40
Q

Hallmark of COM?

A

Purulent discharge that is continuous or intermittent w increased severity during URI or following water exposure

41
Q

Presentation of COM?

A 
Purulent discharge
Pain is (during exacerbations)
CHL from destruction of ossicular chain, or TM
TM perforation
42
Q

Tx for COM?

A 
Remove infected debris
Earplugs to keep water out
Topical antibiotics (drops)
- ofloxacin, ciprofloxacin w dexmethasone
Ciprofloxacin PO x 1-6 wks
Surgical TM repair
Mastoidectomy
43
Q

Complications of otitis media?

A 
Perforation of TM
Cholesteatoma
Mastoiditis
Facial paralysis
CNS infection 
- otogenic meningitis
44
Q

What causes the TM perforation in COM?

A

Purulence must go somewhere

- the TM is the path of least resitance

45
Q

Tx for TM perforation?

A

Oral and topical abx

  • ofloacin otic or cipro HC otic
  • oral abx

Prevent water in ear

46
Q

TM perforation prognosis?

A

Most heal sponataneously if <25% of TM surface

  • > 6 weeks refer to ENT
  • persistent subjective HL get audiogram and dump on ENT
47
Q

TM anatomy?

A

JK i dont care

- pretty sure she said she wont ask this but its slide 43 if you want that hundo

48
Q

What is cholesteatoma?

A

Prolonged ETD w neg mid ear pressure draws the upper flaccid protion of the TM inwards (pars flaccida)

49
Q

Progression of cholesteatoma?

A

Pars flaccida leads to

  • squamous epithelium lined sack
  • fills w desquamanated keratin
  • chronically infected
  • bony erosion penetrates the mastoid
  • ossicular chain is destroyed
  • eventually hits CN VIII and spreads intracranially

Pics on 45, 46

50
Q

Presentation of cholestematoma?

A

TM retaction pocket
Perforation w either
- Keratin debris
- granulation tissue

51
Q

Imaging for cholesteatoma?

A

CT - test of choice

MRI - cannot delineate bony anatomy but can ID non-specific opacification

52
Q

Tx for cholesteatoma?

A

Surgical excision

  • recurrence is common
  • doesnt fix the ET dysfunction

PE tubes - prevent chronic neg pressure

53
Q

Several weeks of inadequately AOM or COM can lead to?

A

Mastoiditis

54
Q

Clinical presentation of mastoiditis?

A

Children>adults

  • fever
  • posterior ear pain
  • erythema over mastoid
  • edema of pinna
  • displacement of auricle
  • protruding auricle
  • loss of postauricular crease
55
Q

If you suspect mastoiditis?

A

CT
-Immediate ENT consult if pos

** ct findings : coalescence of the mastoid air cells due to destruction of the bony septa

56
Q

Increased attenuation of the right middle ear w no osseious defects?

A

Axial CT finding for acute mastititis

Pic on slide 50

57
Q

Mastoiditis tx?

A

IV abx
- cefazoline 0.5-1.5g q 6-8 hrs

Refractory

  • myringotomy for culture and drainage
  • mastoidectomy - surgical drainage
58
Q

MC bugs for mastoiditis?

A

S. Pneumoniae
H. influenzae
S. Pyogenes

59
Q

What if the AOM infection spreads w/in the temporal bone into the petrous apex?

A

Petrous apicitis aka petrositis

60
Q

Diagnosis of petrositis?

A

Classic triad

  • Retro-orbital pain
  • AOM
  • Abducens nerve paresis (CN VI)

+

Radiographic findings of bony destruction of petrous apex

61
Q

Tx for petrositis?

A

Abx (prolonged)
- based on culture results

Surgical drainage

62
Q

How do AOM or COM cause facial paralysis?

A

AOM
- inflammation of CN VII in the middle ear

COM
- chronic pressure on CN VII by cholesteatoma (evolves slowly)

63
Q

AOM/COM facial nerve paralysis tx and prognosis?

A

AOM - Good prognosis

  • myringotomy (drain + culture)
  • IV abx

COM - poor prognosis
- surgery - fix the cholesteatoma

64
Q

Rare but serious consequence of neglected AOM?

A 
Otogenic meningitis (CNS infetion)
- MC intracranial complication of ear

Treat w myringotomy

65
Q

What is tymnpanosclerosis?

A

Firm submucosal scarring that can appear as milky white patch on TM

  • hylaine deposits
  • calcification

Injuries, PET, chronic disease

66
Q

Tympanosclerosis can lead to?

A

Chronic hearing loss

- decreased mobility of TM and immobilization of the ossicular chain

67
Q

What is otosclerosis?

A

Abnormal bony growth footplate of the stapes resulting in hearing loss

  • max 60dB
  • familial tendency
68
Q

Presentation of otosclerosis?

A

Slow progressive unilateral/bilateral CHL

Early onset 3-4th decade

69
Q

To diagnosis otosclerosis you must r/o other causes using?

A

CT/MRI
Webber
Rinne
Tympanometry

70
Q

Tx for otosclerosis?

A

Observation (mild)

Ampilficaiton
- if normal cochlear function + speech discrimination

Surgery
- stapes prosthesis (stapedectomy)

71
Q

Explain the mechanism of barotrauma

A

Middle ear is air filled

Rapdi/extreme pressure change must be equalized via eustachian tube
-If this doesnt happen the TM will retract from neg pressure

72
Q

Sxs of barotrauma?

A 
Aural fullness
Pain 
HL
Tinnitis
N/V
73
Q

PE for baotrauma?

A

TM retraction
Hemotympanum
+/- perforation

74
Q

Your pt is a skydiver on the US pro team. She has concerns that she will suffer barotrauma during an upcoming competition.
What can you give her?

A

Medication aimed at reducing obstruction around the Eustachian tube

  • pseudoephedrine 60-120mg
  • oxymetazoline (afrin)

Education
- swallow, yaw, or valsalva freq

Ventilating tubes may be need for freq fliers

75
Q

Tx for ear barotrauma

A

Usually self resolve

Meds

  • analgesics prn
  • abx (only if indicated)

Surgery (if severe)

Not useful

  • glucocorticoids
  • decongestants
  • antihistamines
76
Q

Who needs an ENT referral (barotraum)

A 
Sever otalgia
Hearing loss
Vertigo
Persistence beyond 4-5 days
Blast injury
77
Q

Impact injury, or explosive acoustic trauma can cause?

A

TM perforation
Hemotympanum
Disruption of ossicular chain

78
Q

Consider disruption of the ossicular chain if?q

A

CHL >30 dB x 3 months following trauma

79
Q

TM perforation summary?

A

HEENT exam
- webber/rinne

Treat

  • infection-> abx
  • hearing loss
  • referral

No injection/comorbids/hearing loss?

  • observe
  • avoid water
  • f/u in 2-3 months
80
Q

Though rare, you can have primary middle ear tumors.

What type of tumors are they?

A

Glomus tumors arise either in middle ear or in jugular bulb with upward erosion into he hypotympanum

81
Q

Presentation of glomus tumurs?

A

Pulsitle tinnitus
Conductive HL

PE:

  • vascular mass behind intact TM
  • CN neuropathies
82
Q

Large glomulus jugulare tumors lead to?

A
  • large glomus jugulare tumors = multiple cranial neuropathies of CN VII, IV, X, XI, and XII
83
Q

tx for glomus tumors?

A

Surgery

Radiotherapy

84
Q

Pulsatile tinnitus?

A

MRA and venography to r/o vascular mass

85
Q

MCC of earache?

A

OE

AOM

86
Q

Earache w pain out of proportion can be?

A

Herpes zoster oticus

- vesicles in ear canal/auricle

87
Q

Non-otologic causes of earache?

A

Referred otalgia from CN V, VII, IX, X and upper cervical

Glossopharyngeal neuralgia

Infection/neoplasm of oropharynx, hypopharynx and larynx

88
Q

What is glossopharyngeal neuralgia?

A

repeated episodes of severe lancinating otalgia (back of throat and ear)

  • if refractory to medical management, microvascular decompression of CN IX is required
89
Q

Being sick is just your body’s way of saying

A

That your too awesome and you need to slow down for everyone else to catch up

Senior - ENT (8 decks)

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