Ear, Nose, Sinus Flashcards
Describe the etiology/risk factors for otitis media
Acute: middle ear effusion leading to infection of middle ear space
Chronic: untreated 6+ weeks leading to TM retraction, perforation, cholesteatoma, mastoiditis
- common in kids <5, M>F
- mostly viral, also bacterial (strep pneumo, M. cat, H. flu)
- RF: smoke, allergies, craniofacial abnormalities
Describe the clinical presentation of otitis media
- pain, hearing loss, crackling, popping, fever, URI, drainage
- bulging, red TM with pus in middle ear, fluid, perforation and drainage
Describe the diagnostic testing for otitis media
- pneumatic otoscopy: limited mobility of TM
- criteria: bulging of TM, new onset otorrhea
Describe the treatment for otitis media
- refer to ent for PE tubes if 3+ mos hearing loss
- 1st line: amoxicillin 90mg/kg/day divided in 2 doses x10 days
Describe the etiology/risk factors for mastoiditis
- suppurative infection & inflammation of mastoid air cells that **starts in the ear
- untreated acute otitis media, s pneumo, h flu**
Describe the clinical presentation of mastoiditis
**- pain in & behind the ear
- hearing loss
- fever
- bulging, red TM
- purulent middle ear
- post-auricular warmth, erythema, edema, fluctuance
- +/- protrusion of auricle
- +/- cranial nerve palsy
Describe the diagnostic testing for mastoiditis
- CT temporal bone w/o contrast shows mastoid effusion, loss of trabecular bone
- elevated CBC, ESR, CRP
- do lactate, blood cultures, LP if toxic
Describe the treatment of mastoiditis
- IV abx +/- myringotomy
- IV abx + mastoidectomy if abscess develops/does not improve
Describe the etiology/risk factors of otitis externa
aka swimmer’s ear
- infection of external auditory canal d/t excess moisture, trauma, bacterial/fungal infection
- Bacteria: pseudomonas aeruginosa, s. epi, s. aureus
- Fungal: candida, aspergillus
Describe the clinical presentation of otitis externa
- **plugging/fullness
- hearing loss**
- drainage
- pain
- itching (fingal)
- wet, edematous canal with debris, redness, flaking
Describe the diagnostic criteria of otitis externa
- rapid onset (<48 hr) canal inflammation w/wo otorrhea, regional adenopathy, erythematous TM, cellulitis
Describe the 3 components of otitis externa treatment
- strict dry ear
- abx/antifungal drops +/- wick (fluoroquinolones with steroid, neomycin, hydrocortisone, polymixin b, clotrimazole, acetic acid)
- removal of debris
Describe the etiology/risk factors of necrotizing otitis externa
secondary to untreated otitis externa (usually pseudomonas) leading to osteomyelitis of temporal bone
- RF: elderly, diabetic, immunocompromised
Describe the clinical presentation of necrotizing OE
- +/- exposed bone
- tissue granulation
- CN7 palsy
- sepsis with altered mental status
Describe the treatment for necrotizing OE
- hospital admit with IV abx, +/- glucose control or surgery
Describe the etiology/risk factors for tympanic membrane perforation
- hole in eardrum
- M>F
- RF: recurrent AOM, flying/diving with ETD, multiple ear surgeries, barotrauma, q-tip use, water irrigation, myringotomies, non-healing PE tube sites
Describe the clinical presentation of tympanic membrane perforations
- asymptomatic if small/chronic
- sudden pop +/- drainage/blood
- hearing loss
- tinnitus
- vertigo
Describe the diagnostic testing for tympanic membrane perforation
- insufflation: no movement
- otoscopy: describe size, shape, quadrant
- tympanometry: flat with large vol
- audiogram: +/- conductive hearing loss
Describe the treatment for tympanic membrane perforation
- spontaneously healing in 2 mos
- avoid irrigation
- abx drops if concerned for infection
- refer to ENT if not healed in 2 mos, suspect ossicle injury, >40 dB hearing loss, vestibular sx
- paper patching, tympanoplasty, ossicular chain reconstruction
Describe the etiology/risk factors for vertigo
- 80% peripheral, 20% central
- MC benign paroxysmal positional vertigo (BPPV): **calcium carbonate crystals (otoliths) become loose/misplaced in semicircular canal
Describe the clinical presentation of BPPV
- room spinning
- triggered by positional movement
- +/- n/v
- residual imbalance after
- periodic recurrence for weeks/mos
- otoliths can displace posteriorly, unilateral/bilateral
Describe the diagnostic testing for BPPV
-Normal audiogram, MRI, videonystagmography
Criteria: dix-hallpike maneuver
- nystagmus/vertigo appear within seconds and last 30 sec
- Nystagmus has predictable trajectory
- Nystagmus recurs in opposite direction after sitting up
- Intensity and duration diminishes with repeat
Describe the treatment for BPPV
- Epley maneuver
- Semont maneuver
- antihistamines, antiemetics, benzos
Describe the etiology/risk factors for labyrinthitis & vestibular neuritis
Labyrinthitis: with SNHL
Vestibular neuritis: w/o SNHL
- viral/postviral (HSV) inflammatory disorder affecting a portion of CN8
Describe the clinical presentation of labyrinthitis & vestibular neuritis
- intense spinning vertigo for a few days followed by imbalance for a few months
- room spinning, n/v, gait instability toward affected side
- spontaneous nystagmus suppressed with visual fixation
Describe the diagnostic testing and PE for labyrinthitis & vestibular neuritis
- MRI shows findings 29% of the time: inflammation
- positive head thrust test
- audiogram: asymmetric SNHL in labyrinthitis
Describe the treatment for labyrinthitis & vestibular neuritis
- **high dose steroids
- TTI**
- +/- antivirals
- antihistamines
- antiemetics
- vestibular rehab
- 2% recurrence but 15% develop BPPV/panic disorder
Describe the etiology/risk factors for hematoma of the ear
auricular perichondrium separates from underlying cartilage and space fills with blood causing swelling/cauliflower ear
- RF: wrestlers, M>F, limited mobility
Describe the clinical presentation of cauliflower ear
- tense, fluctuant pinnae
- +/- pain
- +/- erythema/ecchymosis
Describe the treatment for hematoma of the ear
- drainage & reapposition of periochondrial layer asap before clotting
- I&D + bolster placement
- cephalexin x1 week, no trauma x2 weeks
Describe the etiology/risk factors for foreign bodies in the ear/nose
object lodged in small cavity of ear/nose
- mostly pediatric (nose MC)
Describe the clinical presentation of ear vs nose foreign bodies
Ear: commonly asymptomatic, +/- HL, pain, drainage/bleeding
Nose: unilateral foul nasal drainage/bleeding, congestion, +/- pain
Describe the treatment for foreign body of the nose & ear
- “mother kiss”
- forcep, suction, swab + adhesive, flushing, lidocaine/oil
- RED FLAGS for ENT: button battery, magnets, sharp objects
Describe the complications of a button battery foreign body
can erode/ulcerate in 2 hrs, perforate in 8hrs
Describe the etiology/risk factors of epistaxis
- dry weather, anticoags, clotting disorders, HTN, trauma, intranasal drug use, etoh, neoplasm
- **anterior (90%): Kesselbach’s plexus (minor)
- posterior: Woodruff’s plexus (more concerning)**
Describe the clinical presentation of epistaxis
- recurrent blood from nostrils/oropharynx
- active bleeding/stigmata of recent bleeding, obvious vessel on septum, blood in oropharynx
Describe the diagnostic testing for epistaxis
may consider CBC, INR, coag studies
Describe the treatment of epistaxis
- cotton ball soaked in Afrin + pressure for 15 mins
- pack & observe 30 mins, cephalexin, refer to ENT for rhino balloon pack or spongy foam pack
- emergent ENT page for OR intervention if persistent (cautery, silver nitrate)
Describe the etiology/risk factors of nasal septal hematoma
blood pooling in nasal septum, can lead to infection, necrosis, deformity
- RF: recent surgery, nasal trauma
Describe the clinical presentation of nasal septal hematoma
sudden onset of nasal congestion, change in nose shape, painful swelling of septum
- red fluctuant mass
Describe the treatment of nasal septal hematoma
emergent ENT referral: drainage, sterile packing, prophylactic abx
Describe the etiology/risk factors for sinusitis
acute v chronic inflammation of paranasal sinuses and nasal cavity
- RF: allergy, polyps, age, smoking, air travel, dental disease, immunodeficiency
- viral: rhino, flu, adeno, parainfluenza
- bacterial: s. pneumo, m. cat, h. flu)
Describe the stages/types of sinusitis
- acute: <4 weeks
- subacute: 4-12 weeks
- chronic: >12 weeks
- recurrent: 4+ occurrences per year with complete resolution between episodes
Describe the clinical presentation of sinusitis
- nasal congestion
- pressure/pain
- purulence
- hyposmia
- foul smell
- fever
- fatigue
- cough
- ETD
- sinuses TTP
- hyponasal voice
Describe the diagnostic criteria and treatment of acute viral sinusitis
<10d
- purulent drainage
- severe obstruction
- facial pain/pressure
saline irrigation 2-3x/day, nasal steroids (flonase)
Describe the diagnostic criteria and treatment of acute bacterial
+10d
- purulent drainage
- severe obstruction
- facial pain/pressure
- double worsening
7+ days amox+clav, cephalexin, doxy
Describe the diagnostic criteria and treatment of chronic bacterial sinusitis
12+ weeks of inflammation and 2 of:
- mucopurulent drainage
- obstruction
- facial pressure/pain
- loss of smell
21+ days abx and 10+ days oral steroid taper
What are these HINTS test results indicative of?
Nystagmus: positive
Test of Skew: positive
Head Impulse: negative
central vertigo
- single episode lasting 24+ hrs
- CNS etiology: acoustic neuroma, TIA posterior circulation, cerebellar hemorrhage
What does the HINTS exam stand for
Head Impulse, Nystagmus, Test of Skew
What is a positive head impulse on HINTS testing indicative of?
peripheral vertigo
- vestibular neuritis/labyrinthitis
What is the etiology and timeframe of Meniere’s disease symptoms
Intermittent vertigo d/t an excess of endolymph fluid in the inner ear
- +/- permanent hearing loss seen on audiometry
- triggered by stress, work, fatigue, pressure change
- vertigo lasting several minutes but less than an hour
What is the maneuver that elicits nystagmus in BPPV
Dix-Halpike maneuver
Describe what may be indicated in a positive and negative refixation/catch of saccade
Positive: peripheral, nerve problem
Negative: central, brain problem
Describe a positive test of skew
Ask pt to maintain gaze on providers nose. A positive result will be the deviation of one eye while it is being covered, followed by correction after uncovering it. (positive = ominous for central, move to head impulse test)
Describe the dix-halpike maneuver
- elicits nystagmus in BPPV
- repetitive beating of eyes with dizziness (horizontal or rotational)
- (nystagmus diagnostic for BPPV, no nystagmus may be indicative of uncommon BPPV)
- can continue into treatment if positive with the Epply
Describe what the Epply’s Maneuver does
dislodges crystals from the semicircular canals and brings them back to the utricle to relieve vertigo
