58. Otolaryngology

Question 1

Otitis media: what are 3 different “subtypes”

Answer 1

with efusion - without sign/sx of acute infxn
chronic - prolonged discharge through perforation of TM
recurrent: 3 or more episodes in 6mo or 4 episodes 1 year

Question 2

Otitis media: peak incidence

Answer 2

6-15mo

Question 3

Otitis media: RF

Answer 3

cleft palate
DS
pneumococc no vaccination
male
daycare attendance
family hx of recurrent
parental smoking
pacifier and bottle use

** breast feeding is protective!

Question 4

MC bacteria in AOM

Answer 4

strep pneumoniae
H influ
Moraxella
Catarrhalis

Question 5

Bullous myringitis - what is this in AOM?

Answer 5

bullae may be seen on TM in child <5y - tx same

Question 6

List 4 intratemporal complications of AOM

Answer 6

mastoiditis
facial nerve paralysis
conductive and perceptive hearing loss

Question 7

List 2 intracranial complications of AOM

Answer 7

menignitis
intracranial abscesses

Question 8

DDX AOM

Answer 8

Otitis media with effusion Trauma
Otic foreign bodies Mastoiditis
Otitis externa
Referred pain from teeth, sinuses, throat or temporomandibular joint

Question 9

AOM observation in who?

Answer 9

between 6 months to 2 years of age, observation can be offered as an alternative to antibiotics if the infection is unilateral and the patient is absent severe signs and symptoms or otorrhea. Severe signs and symptoms are defined as moderate-to-severe otalgia of greater than 48 hours duration and temperature greater than 39°C

> /=2y: bilateral AOM without otorrhea, unilateral AOM w/o otorrhea

severe sx*:
aToxic-appearing child, persistent otalgia >48 h, temperature >39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.
bShould be a shared decision with caregivers, and a mechanism must be in place to ensure follow-up and antibiotics if the child worsens or fails to improve within 48–72 h of AOM onset.

Question 10

abx for AOM and dose

Answer 10

amoxicillin dosed at 80 to 90 mg/kg/day in two divided doses.

Question 11

nonsevere penicillin allergy abx for AOM (options and doses)

Answer 11

cefdinir (14 mg/kg/day in one or two divided doses), cefuroxime (30 mg/kg/day in two divided doses), cefpodoxime (10 mg/kg per day in 2 divided doses), and ceftriaxone (50 mg/kg once daily for 3 days, max 1000 mg/day) IM or IV for 3 days.

Question 12

Severe penicillin allergy AOM:

Answer 12

macrolides and clindamycin are possible options. However, these agents have less favorable spectra of coverage for AOM pathogens. Macrolides have limited activity against S. pneumoniae and H. influenzae, and clinda- mycin has limited coverage of H. influenzae. Despite these limitations, these agents are preferred in patients with severe penicillin allergy. Clindamycin is dosed at 30 to 40 mg/kg/day divided TID, and azithromycin is given at 10 mg/kg for an initial dose, followed by 5 mg/kg for days 2 through 5.

Question 13

How long to tx atients younger than 2 years, those with TM perforations, or those with chronic or recurrent infections

Answer 13

10d course

Question 14

Children older than 2 years with a first-time infection, non-severe signs and symp- toms and an intact TM can be treated with a ? day course

Answer 14

7

Question 15

In children with T tubes, what may be considered an infection?

Answer 15

otorrhea with incr drainage

Question 16

What bugs may additionally be seen in AOM kiddos with T tubes?

what needs to be considered?

Answer 16

pseudomonoas
s aureus
staph epidermidis

topical antibiotic administration with ofloxacin (5 drops to the affected ear bid for 10 days) or ciprofloxacin-dexamethasone (four drops to affected ear bid for 7 days) is the preferred treatmen

Question 17

Chronic OM tx with perforation

Answer 17

opical ofloxacin or ciprofloxacin are the recommended antibiotic treatments.

Question 18

First line abx AOM

Answer 18

Amoxicillin (80–90 mg/kg/day in two divided doses)

Amoxicillin-clavulanateb (90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate in 2 to 3 divided doses)

Question 19

If failure of initial abx tx AOM - first line?

Answer 19

doses
Amoxicillin-clavulanate
90 mg/kg/day of amoxicillin, with 6.4
mg/kg/day of clavulanate in 2 to 3 divided doses

Ceftriaxone 50 mg/kg IM or IV once daily for 3 days

Question 20

If failure of initial abx tx AOM - alternative line?

Answer 20

Ceftriaxone
50 mg/kg IM or IV once daily for 3 days

Clindamycin
30–40 mg/kg/day in three divided doses
with third-generation cephalosporin

Tympanocentesis Consult specialis

Question 21

Otitis externa: what is this?

Answer 21

inflamm of ext aud canal

Question 22

MC bugs in otitis externa

Answer 22

pseudomonas
S aureus

Question 23

otitis externa sx

Answer 23

itchy to pain
ear full, discharge, hearing loss, jaw pain

ear itself looks red and edematous
pulling on tragus hurts it

Question 24

What is a secondary (or can be primary) infection one must look out for in otitis externa?

Answer 24

otomycosis

itchy, mininmal pain
*aspergillosis and candida

Question 25

otitis externa ddx

Answer 25

acute OM with otorrhea fungal infection ear canal auricular cellulitis otomycosis furunculosis eczema sebhorrhea contact derm Herpes zoster oticus (Ramsey Hunt syndrome) necrotizing ext otitis

Question 26

What is Ramsey Hunt syndrome?

Answer 26

herpes zoster of auricle --> facial paralysis with pain, erythema, swelling and vesicles 3-7d later

Question 27

Tx otitis externa

Answer 27

topical abx 10d: ofloxacin otic at a dose of 5 drops in the affected ear(s) QD for 7 days in children less than 13 years and 10 drops in the affected ear(s) QD for 7 days in those older than 13 years. A reasonable alternative is ciprofloxacin plus dexametha- sone (Ciprodex), at a dose of 4 drops in the affected ear(s) BID for 7 days. give oral cipro too if infection beyond ear canal or immunocompromised

Question 28

What is necrotizing external otitis?

Answer 28

aggressive otitis externa

Question 29

RF necrotizing external otitis

Answer 29

adv age immunocomp db

Question 30

necrotizing external otitis - pathogens

Answer 30

pseudmonas s aureus s epidermidits proteus asperigillus

Question 31

necrotizing external otitis sx

Answer 31

otorrhea without response to topical meds, svere otalgia, headache, periauricular pain and swell **CN 7 Risk OM temporal bone Characteristic: granulation tissue fx ear canal at bony cartilaginous junction

Question 32

necrotizing external otitis management

Answer 32

systemic abx - Ciprofloxacin 400 mg IV every 12 hours can be given as monotherapy, or in combination with an antipseudomonal β-lactam depending on the severity of illness and local Pseudomonas resistance to fluoroquinolones. Piperacillin-tazobactam (4.5 g IV every 6 hours) or cefepime (2 g IV every 6 hours or 2 g extended infusion every 8 hours) are appropriate options for combination therapy with ciprofloxacin. Treatment may be required for 6 to 8 weeks ent consult!!

Question 33

ddx necrotizing OE:

Answer 33

otitis externa OM mastoiditis trauma referred pain

Question 34

DDX mastoiditis

Answer 34

Otitis media Otitis externa Necrotizing external otitis Skull fracture Lymphadenitis Deep space neck infections

Question 35

What is the mc suppurative complication of OM?

Answer 35

mastoiditis

Question 36

Other than OM, what 4 things can cause mastoiditis?

Answer 36

leukemia mono sarcoma of temporal bone Kawasaki disease cochlear implant placement

Question 37

How does mastoiditis occur?

Answer 37

If middle ear and mastoid ear cells become blocked, an abscess can form and eat away at bone

Question 38

Bugs implicated in mastoiditis?

Answer 38

s pneumoniae GAS Pseumonas S aureus Fusobacterium necrophorum

Question 39

Clinical signs and sx of mastoiditis

Answer 39

fever headache otalgia erythema pain PE: postauriecular erythema, tenderness, protrusion of the auricle, abnormal TM

Question 40

Mastoiditis tx

Answer 40

without recurrent/recent abx: vanco 15mg/kg IV if with: add Pseudomonas coverage: - cefepime, at a dose of 50 mg/kg IV (max 2 g) in pediatric patients, or 2 g IV in adults. Patients may be managed with or without surgical procedures which may range from myringotomy and tympanostomy tube placement to mastoidectomy

Question 41

Defn of sudden SNHL?

Answer 41

idiopathic loss of hearing of 30 dB over at least three test frequencies, occurring over a period of less than 3 days, is considered an otolaryngologic emergency.

Question 42

Causes of sudden SNHL:

Answer 42

idiopathic infection otologic disease trauma vascular disease hem disorder neoplasm

Question 43

Typical tx/management of acute SNHL

Answer 43

tapered dose of oral steroids is the most common treatment, ideally given within the first 14 days but may have benefit up to weeks after the onset.47 The usual dose and the one we recommend is prednisone 1 mg/ kg/day, up to 60 mg, tapered over 10 to 14 days. A quick referral to outpt ENT on discharge

Question 44

DDX of sudden SNHL

Answer 44

Cerumen impaction Otitis externa Otitis media Tympanic membrane perforation Medication side effects or toxicity Barotrauma Autoimmune disease

Question 45

MC epistaxis: anterior or posterior

Answer 45

90% anterior

Question 46

Anterior epistaxis usually comes from which plexus?

Answer 46

Kiesselbach's in anteroinf nasal septum, usually unilateral

Question 47

Which a is often implicated in posterior nosebleed?

Answer 47

sphenopalatine

Question 48

Name 4 a giving blood supply to nasal area

Answer 48

sphenopalatine ant and posterior ethmoidal a superior labial branch of facial a

Question 49

Approach to hx for nosebleed: include what?

Answer 49

timing freq severity trauma comorbidities meds

Question 50

Basic Approach to treating a nosebleed:

Answer 50

1. ID area 2. blow nose out 3. clamp cartilagenous portion x10-15 mins 4. cotton swab: oxymetazolone, Txa, 2% lidocaine 5. cauterize with silver nitrite 6. surgicel /rhino rocket

Question 51

List 10 causes of epistaxis

Answer 51

Nasal or facial trauma Upper respiratory tract infections Nose picking Allergies Low home humidity Nasal polyps Foreign body in the nose Environmental irritants Neoplasms Surgery (postoperative epistaxis) Anticoagulant or antiplatelet therapy Barotrauma Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) Blood dyscrasias Hepatic disease Alcoholism Vitamin K deficiency Folic acid deficiency Chemotherapy Chronic use of nasal vasoconstrictors Cocaine use

Question 52

How to manage a posterior bleed

Answer 52

double balloon cath or foley cath through nose (12Fr) nasopharynx confirm see in posterior pharynx then pulled back, into nasopharynx inflated -7ml water, then pulled anterior with additional 5-7ml water if necessary ongoing - surgical ligation vs embolization

Question 53

In which patients is embolization of nasal bleeds preferred?

Answer 53

chronic coag disorders tx with antplt or antiocoag that cannot be interrupted

Question 54

When should nasal packing be taken out?

Answer 54

24-48h given risk TSS and necrosis

Question 55

What is sialolithiasis?

Answer 55

stones in salivary gland mc submandibular

Question 56

RF sialolithiasis

Answer 56

dehydration diuretic/antichol med gout smoking ttrauma

Question 57

mc sialolithiasis bugs

Answer 57

s aureus h influ strep

Question 58

sialolithiasis ddx

Answer 58

LN disease granulomatous process soft tissue masses neoplasms

Question 59

sialolithiasis diagnostic test of choice

Answer 59

ct

Question 60

sialolithiasis management

Answer 60

if palpable stone, massage and extract if infectious amox clav or conida >5mm, stones in gland or proximal duct - consider ENT surgeon

Question 61

Name 3 major categories of neck masses

Answer 61

inflamm congenital/developmental neoplastic (benign/malign/metastasis)

Question 62

Neck mass ddx inflammatory causes

Answer 62

Adenitis Bacterial (Streptococcus, Staphylococcus) Viral (HIV, EBV, HSV) Fungal (coccidioidomycosis) Parasitic (toxoplasmosis) Cat scratch disease Tularemia Local cutaneous infections Sialoadenitis (parotid and submaxillary glands) Thyroiditis Mycobacterium avium-intracellulare Mycobacterium tuberculosis

Question 63

Neck mass ddx congenital or developmental causes

Answer 63

Brachial cleft cyst Thyroglossal duct cyst Dermoid cyst Cystic hygromas Torticollis Thymic masses Teratomas Ranula Lymphangioma Laryngocele

Question 64

Neck mass ddx benign causes

Answer 64

Mesenchymal tumors (e.g., lipoma, fibroma, neural tumor) Salivary gland masses Vascular abnormalities (e.g., hemangioma, AVM, lymphangioma, aneurysm)

Question 65

Neck masses malignant ddx

Answer 65

Primary tumors Sarcoma Salivary gland tumor Thyroid or parathyroid tumors Lymphoma

Question 66

Neck mass where can mets come from

Answer 66

From primary head and neck tumors From infraclavicular primary tumors (e.g., lung or esophageal cancer)

Question 67

When to consult ENT for neck mass

Answer 67

mass does not resolve in 2 weeks, is enlarging or fixed, is associated with matted cervical lymph nodes, or if the masses are found in the parotid or thyroid gland.