20 Jan Ent

Question 1

Presbycusis CF

Answer 1

Hear well in one on one conv in a quiet room
Competing sounds impair hearing loss (speech discrimination)
High frequencies affected first
Cant hear high pitched voices (women children)

Vs conductive hearing loss :

paradoxically improved speech understanding in background noise

Question 2

Presbycusis Mech

Answer 2

👣Age related cochlear hair cell loss and cochlear neuron degeneration
👣Age related brain atrophy contributes
Hence speech discrimination in older pts vs younger with SNHL

Question 3

Ttt of presbycusis

Answer 3

▶️Education of patient and family
▶️Limiting background noise
▶️Looking directly at patient when speaking to them
▶️Mayb hearing aids

Question 4

TMD RF

Answer 4

Joint trauma (injury , bruxism)
Psych illness. ( anxiety , abuse)

Question 5

TMD CF

Answer 5

➡️Facial pain. (worse with jaw motion)
➡️Ear pain , tinnitis
Otalgia in the setting of normal ear exam is likely referred otalgia
➡️Headache (UL, worse on awakening)
➡️Jaw dysfunction

Question 6

TMD dx

Answer 6

Clinical imaging not needed
Tenderness of mastication muscles
Tooth wear (evidence of bruxism)
Crepitus or clivking with jaw motion

Question 7

Management of TMD

Answer 7

🛖Education (avoid trigger , soft diet)
🛖Dental splints (if bruxism)
🛖NSAIDS (naproxen)

Question 8

Nectrotizing otitis externa RF

Answer 8

NOE is osteomyelitis of the skull base
Commonly caused by pseudomonas
RF:

Elderly
Diabetic
Aural irrigation (cerumen removal)

Question 9

NOE CF

Answer 9

Lifethreatening infection of ear canal extending to skull base

👉🏼 severe unremitting ear pain (worse at night & chewing)
👉🏼 deficits with CN 7,9,10
👉🏼 granulation tissue in external auditory canal
👉🏼 edematous external auditory canal with purulent drainage
👉🏼 ⬆️ ESR

Question 10

Ttt of NOE

Answer 10

🛞IV pseudomonal antibiotics (cipro)
Prologed course for 6-8weeks
(Despite inc risk of tendon rupture in elderly)
🛞Surgical debridement

Question 11

Pt on CPAP with nose bleed and crusting ttt

Answer 11

Warming and humidification of air throughCPAP machine
Nasal saline irrigation
Lubricating jelly to anterior septum

Question 12

Aspirin exacerbated resp disease CF

Answer 12

🚨Asthma
🚨Bronchospasm or nasal congestion
🚨Chronic rhinosinusitis with nasal polyp

Bland tasting food due to anosmia

Question 13

AERD Pathophys and ttt

Answer 13

Pseudoallergy as it is not mediated by IgE
Related to overproduction of leukotrienes

Ttt;

😡Manage asthma
😡Manage rhinosinusitis
🤬Leukotriene modifying agents
🤬Aspirin desensitization (in pts with comorbidities)

Question 14

Juvenile nasal angiofibroma

Answer 14

Teenage boy
Benign neoplasm of nasopharynx
Causes nasal obstruction and nasal drainage
Results in epistaxis

Question 15

Leukoplakia RK and Cf

Answer 15

RF:
Older pt
Tobacco
Alcohol

CF:
Painless white mucosal patch
Cannot be wiped off
(Candida is easily scraped off)

Question 16

Risks for cancer in leukoplakia

Answer 16

Non homogenous gross appearance
Large size >4cm
Dysplasia seen on biopsy

Question 17

Manangement of leukoplakia

Answer 17

😶‍🌫️ biopsy (at diagnosis and if appearance changes)
😶‍🌫️ RF modification (tobacco cessation)
😶‍🌫️ close monitoring and freq oral exams
😶‍🌫️ surgical excision

Question 18

Oral hairy leukoplakia signs

Answer 18

Young Age
Painless white mucosal lesions on lateral tongue
Multiple homogenous lesions
Corrugated (folded or wrinkled appearance -hairy)
Cannot be scraped off

H/O fatigue ,unintentional weight loss ,
Cervical adenopathy
HO immunodef esp HIV

Question 19

Oral hairy leukoplakia cause

Answer 19

Intense EBV and HIV

Do HIV testing

Question 20

Ttt for OHL

Answer 20

No ttt
Resolves with treatment of underlying immunodef (antiretroviral ttt)

Question 21

Otitis externa RF

Answer 21

🦵🏾Water exposure
🦵🏾loss of cerumen
🦵🏾Trauma (cotton swabs, ear candling)
🦵🏾Foreign material (hearing aid, headphones)
🦵🏾Derma conditions (eczema, contact dermatitis)

Question 22

Otitis externa microbiology

Answer 22

Pseudomonas
Staphylococcus

Question 23

Otitis extern CF

Answer 23

Skin and soft tissue infection if EAC
Hence pain with manipulation and erythema

🧇Otalgia , pruritis , discharge , hearing loss
🧇Pain with auricle manipulation
🧇Ear canal eythema ,edema ,debris
Indurated plaque like rash …..tympanic mem spared (clear , not inflamed, no middle ear fluid)

Question 24

Otitis externa Ttt

Answer 24

🚑Remove debris
🚑Topical antibiotic (FQ) drops
🚑Topical glucocorticoid
🚑Consider wick placement to facilitate medication delivery

Keep ear dry
Avoid further trauma

Question 25

Ototoxic medicines

Answer 25

Aminoglycosides Cisplatin High dose salicylates Furosemide (loop diuretic)

Question 26

Meniere dx CF

Answer 26

⛱Episodic vertigo (20mins to 24hrs) ass with NV ⛱SNHL : fluctuating and varying in severity worsening over time (affecting low freq first and progressing to permanent loss over all frequencies) ⛱Low freq TINNITIS in affected ear ⛱aural fullness

Question 27

Meniere dx pathophys

Answer 27

Incr volume and pressure of endolymph (endolymphatic hydrops ) Defective resorption if endolymph fluid Distension if endolyphmatic system causes damage to both vestibular and auditory components of inner ear.

Question 28

Menier dx workup

Answer 28

Clinical Dx Audiometry MRI to rule out CNS lesions

Question 29

Non allergic / vasomotor. rhinitis CF

Answer 29

Nasal congestion Rhinorrhea Sneezing Postnasal discharge Later onset (age >20) No obv allergic trigger Perennial symptoms (may worsen with season change ) Erythematous nasal mucosa

Question 30

Non allergic rhinitis ttt

Answer 30

Mild : IN glucocorticoids / antihistamine(olopatadine, azelastine)/ IN ipratropium Moderate to severe: Combination therapy

Question 31

NAR identification

Answer 31

No sneezing or allergic conjuctivitis No allergic triggers Behavior triggers ; walking into cold air , eating)

Question 32

Allergic rhinitis SS

Answer 32

➡️early age of onset ➡️watery Rhinorrhea Nasal congestion Sneezing Nasal itching ➡️Cough sec to post nasal drip ➡️ocular itching & tearing ➡️ seasonal pattern ➡️pale/blue nasal mucosa ➡️ during peak season pts exp fever and psych symptoms - fatigue irritability) ➡️ related to atopic disorders- allergic rhinitis , hay fever, asthma , eczema , eustachian tube dysfunction

Question 33

Allergic rhinitis Physical exam

Answer 33

👃🏽 allergic shiners (infraorbital edema and darkening 👃🏽 allergic salute ( transverse nasal crease) 👃🏽 pale blue enlarged turbinates 👃🏽 pharyngeal cobblestoning 👃🏽 allergic facies (high arched palate, open mouth breathing)

Question 34

Allergic rhinitis ttt

Answer 34

Allergen avoidance Intranasal corticosteroids - Fluticasine , mometasone Non sedating oral antihistamines

Question 35

Herpes zoster oticus pathophys

Answer 35

Reactivation of VZV from geniculate ganglion disrupting motor fibers of cranial nerve 7 with subsequent spread to cranial nerve 8. Painful erythematous vesicular rash on auditory canal or auricle IL facial paralysis Vertigo NV Hearing and taste disturbance Ttt : valacyclovir

Question 36

Vestibular neuritis CF

Answer 36

🛖NV 🛖Gait impairment 🛖UL hearing loss (labyrinthitis) 🛖Nystagmus suppressed by visual fixation (Peripheral) 🛖Postive head thrust test(vestibulo ocular reflex) indicating peripheral vestibular lesion.

Question 37

Vestibular neuritis ttt

Answer 37

Vestibular suppressants (meclizine) Antiemetics Corticosteroids Vestibular rehab for imbalance

Question 38

Vestibular neuritis pathophys

Answer 38

Self limiting inflammation of vestibular branch of 8th nerve following a viral infection. Vestibular neuritis plus UL hearing loss = labyrinthitis.

Question 39

Perilymphatic fistula cause

Answer 39

Head injury or barotrauma casuing fluid to leak from semicircular canal SS Vertigo Hearing loss Tinnitus Symptoms triggered by sneeze , straining , loud noise.

Question 40

Meniere dx lifestyle modifications

Answer 40

Lifestyle modifications are first line ttt 1. Dietary salt restriction: (2-3g per day) Sodium restriction reduces endolymphatic fluid helping to reduce endolymphatic hydrops 2: Limit caffeine and nicotine: Vasoconstrictors reduce blood flow to ear 3. Limit alcohol: Alcohol causes fluid shifts 4. Avoid allergy triggers : Allergies lead to inc fluid extravasation in endolymohatic sac Refractory cases : Vestibular suppressant drugs Thiazide diuretics Antiemetics (promethazine ) Benzodiazepines Vasodilator (betahistine) OCPs: for pts with premenstrual exacerbations to blunt hormonal fluctuations

Question 41

Rhinitis medicamentosa

Answer 41

Nasal congestion after prolonged use of decongestant sprays.

Question 42

Rhinitis medicamentosa Mech

Answer 42

Oxymetazoline (vasoconstrictor) leads to rapid relief of nasal congestion but in as few as 3-5 days injures endothelium causing REBOUND CONGESTION Patients keep using it consistently leading to BEEFY RED nasal mucosa. Ttt: cessation Sig counseling to discontinue Short course of nasal steroid for severe cases

Question 43

Peripheralvertigo CF and dx

Answer 43

▶️Non focal neurologic exam ▶️Unidirectional nystagmus : does not reverse direction, horizontal/torsional , not pure vertical ▶️worse with head position , prominent NV Dx. No additional testing req

Question 44

HINTS exam for central vs peripheral vertigo

Answer 44

Central vertigo signs: Head impulse : Normal - Eyes remain on target as head moves side to side Nystagmus. : Changes with lateral gaze Test of Skew. : Vertical eye shift when covered eye is uncovered.