22 Jan 24 Ent Flashcards by Zoia Akram

Pt with rhinoplasty has whistling noise during respiration

Septal perforation

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Post op Septal perforation mech

Septum is made of cartilage and has poor blood supply
Cartilage Depends completely on overlying mucosa for nurishment by diffusion
Because of poor regenerating capacity of septal cartilage trauma or surgery may result in septal perforation.

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Suppurative parotitis RF

🤪Elderly , dehydareted , post op
🤪Decreased oral intake (NPO perioperatively)
🤪Medications (anticholinergics)
🤪Obstruction (calculi , neoplasm)

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Suppurative parotitis CF

🛞Firm, erythematous pre/postauricular swelling

🛞Exquisite tenderness exacerbated by chewing and palpation

🛞Trismus , systemic findings (fever,chills)

🛞Elevated serum amylase without pancreatitis

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Suppurative parotitis ttt

USG/CT (to diff between stones , cancer, supp parotitis and an abscess)

Hydration, oral hygiene

Antibiotic

Massage (milking pus out of gland)

Sialagogues (inc salivary flow)

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Suppurative parotitis mech

Elderly post op patients with dementia have poor hydration and poor hygiene

Salivary stasis (due to NPO , poor hygiene, dehydration) leads to retrograde seeding of bacteria from oral cavity thru stensen duct to parotid.

Rapid onset painful swelling of parotid aggravated by chewing.

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Infectious epiglottitis CF

Epiglottitis is cellulitis of epiglottis , aryepiglottic folds and surrounding tissues.
Children have abrupt onset
Adults have subtle symptoms

Rapidly progressive and life threatening
Fever, sorethroat, drooling, muffled voice
Diff swallowing due to pain
Airway obs (stridor, dyspnea)
Pooled oropharyngeal secretions
Laryngotracheal tenderness
(Anterior neck tender to palpation)

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Dx of infectious epiglotitis

Direct visualization
Lateral neck XRay ( thumb sign)

Patients with hypoxia resistant to non invasive intervention need aiway establishment prior to Xray.

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Infectious epiglottitis RF

Strept pneumo , H influenzae
Diabetic
Obese
Preceding upper resp infection

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Ttt of IE

Early artificial airway if needed
IV antibiotics (ceftriaxone plus vanco)

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Centor criteria for evaluation and management of pharyngitis

👉🏼Fever by history
👉🏼Tender anterior cervical lymphadenopathy
👉🏼Tonsillar exudates
👉🏼Absence of cough

0-1 : No test or ttt

2-3.: Rapid streptococcal antigen test
Give penicillin/amoxicillin for positive results

: Empiric penicillin or RSAT and then pencillin for positive results.

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Otosclerosis CF

🚨Progressive Conductive hearing loss
🚨Normal otoscopic exam
🚨Mayb reddish hue behind TM
🚨Paradoxical improvement in speech discrimination in noisy environments
🚨May progress in pregnancy

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Ttt of otosclerosis

Hearing amplification -hearing aids
Surgical (stapes) reconstruction

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Auricular hematoma RF and CF with ttt

Contact sports injury (wrestling , martial arts)

Tender fluctuant blood collection on anterior pinna

Ttt

Immediate incision and drainage 
Pressure dressings

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Complication of auricular hematoma

Cauliflower ear (fibrocartilage overgrowth
Rapid developement of Bacterial superinfection in 2-3 days (abscess)
Reaccumulation of hematoma

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Where is auricular hematoma blood collected ?

Between perichondrium and cartilage.

As auricular cartilage has no direct blood supply and receives all its nutrition via diffusion from perichondrium
Auricular hematoma can cause AVASCULAR NECROSIS of auricle.

Subsequent fribrocartilage overgrowth can lead to permanent deformity called cauliflower ear.

Hence ttt involves prompt incision and drainage to prevent reaccumulation if hematoma

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Complications of septal hematoma

Avscular necrosis of septal cartilage
Septal perforation
External nasal deformities (saddle nose)
Internal nasal valve collapse (nasal obstruction)

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RF of septal hematoma

Trauma

All pts with nasal truma should have examination of nasal septum

Palpation to diff between deviated nasal septum (firm) vs septal hematoma(soft and fluctuant)

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Torus palatinus CF

👄Genetic
👄 benign bony growth exostosis
👄Immobile ,non tender ,hard consistency
🫦 <2cm size but enlarges over time.
Thin epithelium over bony growth ulcerates with minor trauma and heals slowly

👄Surgery for symptomatic pts.

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Branchial cleft cyst location

BCC is located between the internal and external carotid arteries anterior to sternocleidomastoid muscle and inf to mandible.

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Branchial cleft cyst CF

Presents due to secondary infection after uppr resp tract infection

CF :
erythema , tenderness and sometimes drainage of fluid from a sinus tract.

Episodes of jaw pain with tender mass worse with eating , resolve with AB.

Recurrent sialadenitis

If pt has no RF (elderly post op )
most common cause is stones
Sialolithiasis

Salivary stones Mechanism

Common in submandibular glands as they have high mucus content and duct travels against gravity ➡️ dec salivary flow.
Stones are made of Ca and seen on CT scan.

Retrograde seeding of bacteria (staph aureus) in obstructed duct leads to sialadenitis.

Ttt of sialadenitis

NSAIDS and AB.

Reccurent infection:
Stone removal.

Common cause of refered otalgia

Dental dx TMD Head n neck CA. HNSCC Tumor at the base of tongue Tumors of larynx Hypopharynx

Referred otalgia management

Otalgia in the setting if normal ear exam is reffered. If suspicion of CA do Flexible laryngoscopy

Deep neck space structure sequence

Pharyngeal mucosa Buccopharyngeal fascia RETROPHARYNGEAL SPACE (superior mediatinum) contains internal jugular vein , CN 9 10 11 12. Alar fascia Danger space : posterior mediastinum (potential space between pericardium & vertebral column) Prevertebral fascia Prevertebral space (extends to coccyx) Anterior spinal ligament.

Signs of retropharyngeal abscess

Neck pain Odynophagia Fever Neck stiffness Bulging pharyngeal wall H/o trauma

Acute nectrotizing mediastinitis

Infection from retropharyngeal space extends posteriorly thru alar fascia into danger space which can trasmit infection into posterior mediastinum.

Management of Acute nectrotizing mediastinitis

Urgent surgery. Do Chest Xray AP and lateral view for mediastinal widening in all pts with retropharyngeal abscess.

Ludwig angina Pathophys

Rapid progressive cellulitis of BL submandibular & sublingual spaces most often arising from infected mandibular molar. Displacement of tongue obstructs airflow. CF : Fever ,dysphagia , odynophagia drooling.

Nasopharyngeal CA. NPC Rf

Endemic in South China Genetics EBV reactivation

NPC CF

🍔Nasal congestion (tumor obstruction) 🍔Epistaxis 🍔Headache 🍔Cranial neuropathies (facial numbness) 🍔Serous otitis media (eustachian tube obstruction) 🍔cervical lymphadenopathy causing non tender neck mass (early presentation)

Otosclerosis epidemiology

Younger(early to mid30s) caucasian patients More common in women AD with incomplete penetrance

Otosclerosis pathophys

Imbalance of bone resorption and deposition ➡️ stiffening of stapes. And fixation of ossicukar chain. Paracusis of willis (paradoxical speech improvement in noisy env) Excessive bone resorption exposes underlying blood vessels causing reddish hue seen behind TM

Laryngeal SCC RF

Smoking Alcohol

Laryngeal SCC

Hoarseness (persistent) Dysphagia Airway obstruction Referred otalgia Hemoptysis Cervical adenopathy(mets)

Vestibular schwannoma CF

Median age 50 U/L ( bilateral is ass with NF2 ) CF: SNHL and imbalance Facial numbness /paralysis (CN 5,7 compression)

Acoustic neuroma Dx

Audiogram MRI with contrast of Internal auditory canal

Acoustic neuroma ttt

Observation (small tumors , minimal SS, Older and infirm patients ) Surgery Radiation therapy.

Why do schwannoma pts have vertigo? Esp in dark…..

Most pts do not exp vertigo bcz of tumor slow growth allows for central compensation of gradual UL loss of input. In dark pts are deprived of visual input hence the imbalance.

Barotrauma managemnet

Self resolving in a few weeks

Enlarged ulcerated tonsil with LAD and sorethroat in non smoker non alcoholic With multiple Sexual partners

HNSCC due to HPV

HNSCC CF

Pharyngitis Dysphagia Halitosis (bad breath) Persistent enlarged firm neck mass Ulcerated tonsillar lesion Neck LAD

HNSCC RF

Smoking Old age Alcohol Poor dentition Incidence of oropharyngeal HNSCC has dramaticaly increased

Why HPV HNSCC afftects oropharynx

Higher conc of lymphatic tissue facilitating viral processing

Management of HPV HNSCC

Biopsy Neck imaging (CT) for nodal mets Endoscopic evaluation of upper aerodigestive tract.

Lemiere syndrome

Deep neck space infection progressing to suppurative thrombophlebitis of internal jugular vein Causes of fusobacterium necrophorum Painful pharyngitis Odynophagia Acute High fevers >102 Rigors. Resp distress (septic pulm emboli)

Pt with hoarseness and irregular exophytic growths in clusters on surface of vocal cords

HPV 6 11. (Laryngeal papillomas)

Recurrent Resp Papillomatosis CF

Hoarseness (constant > 1 Mo) Irregular exophytic growth Warty lesions Dark red punctate areas(blood vessels) Transfer; Vertical in infants Sexual in adults Reactivation of HPV

Managemnet of RRP

Antivirals (interferon , cidofovir) Surgical debridement Ass with significant morbidity (voice outcomes, airway obs , repeated operative interventions)