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Clin Med I > Ears and nose > Flashcards

Ears and nose Flashcards

1
Q

what type of hearing occurs in the middle ear

A
  • conductive hearing
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2
Q

what type of hearing occurs in the inner ear

A
  • sensorineural hearing
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3
Q

pathogenesis of AOM

A
  • eustachian tube dysfunction
  • allergies
  • viral infections
  • bacterial infections
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4
Q

what does AOM stand for?

A
  • acute otitis media
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5
Q

what does OME stand for?

A
  • otitis media with effusion (chronic OM)
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6
Q

what is the gold standard for dx of otitis media?

A
  • pneumatic otoscopy
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7
Q

AOM

A
  • rapid onset < 48 hours
  • si/sx of inflammation in middle ear
  • mild pain
  • bulging of TM
  • intense redness
  • +/- otorrhea
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8
Q

severe AOM

A
  • AOM
  • mod-severe pain OR fever > 102.2
  • bulging of TM
  • intense redness
  • +/- otorrhea
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9
Q

OME

A
  • inflammation of middle ear
  • liquid collection
  • no pain associated
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10
Q

middle ear effusion (MEE)

A
  • liquid in middle ear

- no reference to etiology, pathogenesis, pathology, or duration

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11
Q

otorrhea

A
  • discharge from ear

- can come from external auditory canal, middle ear, mastoid inner ear, intracranial cavity

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12
Q

otitis externa

A
  • infection of external auditory canal
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13
Q

tympanometry

A
  • measure acoustic immittance of ear

- function of ear canal pressure

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14
Q

causes of AOM

A
  • strep pneumoniae **
  • h. flu
  • m. catarrhalis
  • virus
  • ostiomeatal complex disfunction
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15
Q

causes of OME

A
  • osteomeatal complex/ eustachian tube dysfunction
  • sequelae of AOM
  • viral
  • unknown
  • bacteria
  • biofilm
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16
Q

when is watchful waiting appropriate tx for OME?

A
  • kids not at increased risk of speech, language, or learning problems
  • 3 mo from date of effusion onset/ dx
  • no suspected abnormalities in structure or TM
  • must reexamine kid at 3-6 mo intervals until effusion gone
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17
Q

tx options for OME

A
  • watch and wait
  • tubes
  • surgery
  • PO or topical prednisone (off guidelines)
  • antihistamines (off guidelines)
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18
Q

treatment guidelines for non-severe AOM

A
  • 6-23 mo. abx or watch and wait IF you have good f/u
  • 24 mo. bilat give abx
  • > 24 mo. abx or observe
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19
Q

abx options for treatment of AOM in kids

A
  • gold standard= amoxicillin 80-90 mg/kg BID to max dose of 1000 mg/dose
  • quinolone drops if perf present
  • Augmentin ES
  • bactrim if > 2 mo
  • 2nd or 3rd gen cephalosporin
  • IM ceftriaxone
  • azithromycin
  • clindamycin
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20
Q

treatment for AOM in adults

A
  • **worried about secondary causes like tumor*, sinusitis, allergies
  • f/u is mandatory
  • abx for kids plus tetracyclines and quinolones PO
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21
Q

general management of AOM (besides abx)

A
  • pain relief- APAP, NSAIDs, topical numbing drops
  • topical decongestants (avoid in peds)
  • no cold meds if kid < 2 yo
  • prob no cold meds in kid < 4 yo
  • maybe cold meds in kid > 4 yo
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22
Q

what should a normal TM look like

A
  • cone of light around 5 o’clock
  • pearly gray color
  • umbo present in middle
  • lateral process of malleus
  • TM intact
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23
Q

AOM follow up

A
  • should see improvement in 24-48 hours
  • reeval in 2 weeks
  • middle ear effusion can persist for a few months, does not mean AOM has not resolved
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24
Q

AOM prophylaxis

A
  • vaccines*
  • breast feeding
  • smoke free environment
  • no bottles in bed
  • abx prophylaxis NOT recommended
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25
Q

otitis externa (OE)

A
  • painful external ear

- **tragal movement pain

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26
Q

causes of OE

A
  • pseudomonas aeruginosa most common bacteria
  • fungal
  • furuncles
  • allergies
  • injury
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27
Q

predisposing factors for OE

A
  • inadvertent injury
  • allergies
  • psoriasis or eczema
  • seborrheic dermatitis
  • decreased canal acidity
  • irritants
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28
Q

si/sx of OE

A
  • dainage thay may be foul smelling
  • painful otoscopic exam
  • red swollen ear canal
  • purulent debris inside ear canal
  • tenderness/pain over tragus
  • hearing loss
  • crusting outside of ear
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29
Q

OE treatment

A
  • debridement
  • sx management with APAP or NSAIDs
  • topical abx
  • topical steroids
  • acetic acid
  • PO meds if they have comorbidities
  • consider using a wick for topical treatment
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30
Q

prevention of OE

A
  • 1:1 mix of rubbing alcohol and white vinegar if TM is intact after swimming
  • no q tips
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31
Q

common causes of TM perforation

A
  • infection
  • trauma
  • atmospheric overpressure
  • excessive water pressure
  • improper attempts at wax removal or ear cleaning***
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32
Q

treatment for TM perforation

A
  • most heal spontaneously
  • refer if doesnt heal in 2 months, have significant hearing loss, or ossicular trauma
  • systemic abx if also hav otorrhea
  • surgery
  • paper patch, gelfoam plug, fibrin glue in office
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33
Q

auricular hematoma

A
  • from direct trauma

- shearing forces separate anterior auricular perichondrium from cartilage

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34
Q

treatment of auricular hematoma

A
  • early ID
  • drain
  • splint
  • compression
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35
Q

mastoiditis

A
  • infection of mastoid air cells

- very concerning dx

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36
Q

treatment for mastoiditis

A
  • consult
  • medical tx same as AOM
  • surgery to remove infected bone
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37
Q

what are the most concerning FB in the nose?

A
  • button batteries
  • cause serious damage d/t alkaline tissue necrosis
  • can result in septal perforation within 4 hours
  • most other FB are removed at initial presentation and dont require ENT f/u
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38
Q

common locations for nasal FB

A
  • most on floor of nasal passage
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39
Q

paired disk magnets in nose

A
  • if have one in each nostril they are difficult to manually remove
  • prolonged attachment -> perforation of septum
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40
Q

clinical presentation of nasal FB

A
  • usually in kids or adults with intellectual disabilities
  • mucopurulent nasal discharge
  • foul oder
  • unilateral epistaxis
  • nasal obstruction and mouth breathing
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41
Q

dx of nasal FB

A
  • usually just done with otoscope or headlight
  • most FB are radiolucent so XR is not helpful
  • XR can detect button batteries or magnets and most pass easily through GIT
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42
Q

removal of intranasal FB

A
  • using positive pressure techniques
  • direct instrumentation
  • most dont require surgery
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43
Q

intranasal FB that require ENT referral

A
  • posterior FB not readily visualized
  • chronic or impacted FB with inflammation
  • penetrating or hooked FB
  • any FB that cant be removed after initial attempt
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44
Q

positive pressure techniques

A
  • have pt occlude opposite nose and blow out

- occlude unaffected nostril and have someone blow into mouth

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45
Q

intranasal FB removal via instrumentation

A
  • can be painful- use topical anesthesia
  • no nasal drops or pts with lodged button battery
  • may need procedural sedation if uncooperative
  • avoid forceps
  • can use hooks or catheters
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46
Q

prognosis of intranasal FB

A
  • depends on size, shape and contents of FB
  • duration of FB
  • result of removal attempts
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47
Q

intermittent allergic rhinitis

A
  • sx occur in response to specific exposure

- i.e. cat allergy

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48
Q

seasonal allergic rhinitis

A
  • aka hay fever
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49
Q

persistent/ perennial allergic rhinitis

A
  • sx occur year round

- i.e. mold allergy

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50
Q

what key feature distinguishes allergic rhinitis from other forms of rhinitis

A
  • nasal itching
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51
Q

physical exam findings for allergic rhinitis

A
  • nasal mucosa is edematous and pale
  • allergic shiners
  • nasal crease/ “allergic salute”
  • clear mucous
  • polyps
  • septal issues
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52
Q

management of allergic rhinitis

A
  • environmental control
  • topical intranasal steroids**
  • 2nd gen antihistamines
  • montelukast
  • mast cell stabilizers
  • immunotherapy
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53
Q

nonallergic rhinitis

A
  • chronic presence of nasal congestion, rhinorrhea, post nasal drainage
  • sx are perennial
  • no nasal or ocular itching
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54
Q

vasomotor rhinitis

A
  • nonallergic

- intermittent sx from nonspecific irritants

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55
Q

mixed rhinitis

A
  • combo of allergic and nonallergic rhinitis
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56
Q

gustatory rhinitis

A
  • nonallergic

- rhinorrhea triggered by hot or spicy foods

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57
Q

rhinitis of pregnancy

A
  • nonallergic
  • usually occurs in last six weeks
  • no known allergic cause
  • disappears 2 weeks after delivery
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58
Q

rhinitis medicamentosa

A
  • caused by nasal decongestants
  • should only use decongestants for 3 days
  • can also be caused by antiHTN meds, ED meds, antidepressants, BZDs, NSAIDs, estrogen
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59
Q

what are the most common causes of rhinosinusitis

A
  • rhinovirus
  • influenza virus
  • parainfluenza virus
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60
Q

acute rhinosinusitis duration

A
  • < 4 weeks
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61
Q

chronic rhinosinusitis duration

A
  • > 12 weeks

- usually seen in middle aged adults

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62
Q

viral rhinosinusitis

A
  • sx usually dev after first day of inoculation
  • nose blowing propels fluid from nasal cavity to sinuses
  • decreased cilliary motility
  • mucosal edema, thick secretions, obstructed sinuses
63
Q

clinical presentation of viral rhinosinusitis

A
  • usually < 10 days
  • nasal congestion/ obstruction
  • purulent d/c- yellow or green
  • fever, fatigue, cough
  • hyposmia/ anosmia
  • ear pain, HA
  • facial pain/pressure worsens when bending forward
  • mucosal edema and narrowed middle meatus
  • inferior turbinate hypertrophy
64
Q

diagnosis of rhinosinusitis (viral or bacteria)

A
  • mainly clinical
  • bacterial cultures are unreliable- should be performed by ENT
  • xray not indicated for uncomplicated
  • CT is modality of choice if complicated
65
Q

treatment for viral rhinosinusitis

A
  • fluids
  • OTC decongestants
  • intranasal steroids
  • limit nasal spray to 3-5 days use
  • analgesics
  • PO antihistamines
  • mucolytics
  • saline irrigation (neti pot)
  • tx does NOT shorten duration
66
Q

acute bacterial rhinosinusitis

A
  • sx usually last > 10 days
  • purulent d/c
  • usually unilateral sinus pain and is exacerbated by bending forward
  • usually URI that begins to improve then worsens
67
Q

predisposing factors for bacterial rhinosinusitis

A
  • usually a complication of viral infection
  • nasal mechanical obstruction
  • tooth infection
  • impaired mucocilliary clearance
  • immunodeficiency
  • smoker
68
Q

most common causes of acute bacterial rhinosinusitis

A
  • s. pneumoniae
  • h flu
  • m catarrhalis
69
Q

treatment for bacterial rhinosinusitis

A
  • same supportive tx as viral
  • augmentin for 5-7 days
  • doxycycline for PCN allergy
  • macrolides NOT recommended
  • should respond in 3-5 days, if not switch to high dose augmentin
70
Q

acute fungal rhinosinusitis

A
  • occurs in immunocompromised pts
  • usually d/t apergillus
  • treat with amphotericin
71
Q

acute fungal rhinosinusitis clinical manifestation

A
  • facial pain and nasal congestion
  • facial numbness, diplopia if facial n involvement
  • epistaxis
  • necrotic tissue
  • gingival eschars, sloughing of septum
72
Q

diagnosis of fungal rhinosinusitis

A
  • urgent ENT referral

- biopsy/ debridement

73
Q

chronic rhinosinusitis risk factors

A
  • allergic rhinitis
  • asthma
  • perennial allergies
  • smoking
  • immunodeficiency
  • anatomic abnormalities
  • defects in mucocilliary clearance
74
Q

cardinal si/sx of chronic rhinosinusitis

A
  • anterior or posterior mucopurulent drainage
  • nasal obstruction
  • facial pain/ pressure/ fullness
  • hyposmia (adults), cough (kids)
  • need at least 2 cardinal sx to dx chronic
  • may also see evidence of mucosal thickening
75
Q

subtypes of chronic rhinosinusitis

A
  • CRS with nasal polyposis
  • CRS without nasal polyposis- most common
  • allergic fungal rhinosinusitis
76
Q

CRS with nasal polyposis

A
  • bilateral nasal polyps that are gray/white color
  • polyps are not painful
  • gradual worsening nasal congestion/ obstruction
  • sinus fullness and pressure
  • hyposmia or anosmia
77
Q

what is the biggest way to tell the difference between nasal polyps and nasal turbinates

A
  • polyps= painless

- turbinates= VERY sensitive

78
Q

samter’s triad

A
  • combo of asthma, CRS with NP, and aspirin sensitivity
79
Q

CRS without polyposis

A
  • persistent sx with periodic exacerbations

- acute flares respond well to abx

80
Q

allergic fungal RS

A
  • chronic intense allergic reaction to colonizing fungi
  • usually in immunocompetent that show evidence of allergy to at least one fungi
  • presents subtly over years
  • gross facial asymmetry and/or visual changes
81
Q

CRS diagnostics

A
  • sinus CT
  • mucosal thickening bilaterally
  • obstruction of osteomeatal complex
  • sinus opacification without facial pain/ pressure/ HA
82
Q

CRS with NP treatment

A
  • PO steroids to shrink polyps
  • nasal steroids after
  • leukotriene inhibitor for maint
83
Q

CRS without NP treatment

A
  • PO steroids
  • abx for 6 weeks
  • follow with nasal steroids
  • 2nd gen antihistamines
  • leukotriene receptors
84
Q

allergic fungal CRS treatment

A
  • remove inspissated mucus

- prolonged PO steroids

85
Q

anterior nosebleeds

A
  • usually occur in kiesselbach’s plexus

- most common type of nosebleed

86
Q

posterior nosebleeds

A
  • usually d/t sphenopalatine artery
  • not usually associated with trauma
  • can result in serious hemorrhage
87
Q

cause of anterior nosebleeds

A
  • nose picking
  • mucosal trauma/ irritation
  • low moisture content
  • allergic or viral rhinitis
  • FB
  • facial trauma
  • chronic excoriation
  • OTC nasal spray
  • nasal steroids
  • alcohol
  • anticoag pts
88
Q

cause of posterior nosebleeds

A
  • carotid artery aneurysm
  • nasal neoplasm
  • anticoag pts
89
Q

treatment of anterior nosebleed

A
  • compress nares for 5-10 min
  • pt lean foward
  • short acting topical nasal decongestants
  • topical cocaine or spray
  • electrocautery
90
Q

treatment of posterior nosebleeds

A
  • topical sympathomimetics
  • double ballon packs
  • ENT consult for packing
  • rhino rocket X 3 days with keflex
91
Q

tinnitus

A
  • perception of sound when no external noise present
  • ringing, buzzhing, hissing, whistling, swooshing
  • men > women
  • more common in smokers
92
Q

subjective tinnitus

A
  • noise only perceivable to patient
  • traceable to auditory or neurological rxn to hearing loss
  • most common type of tinnitus
  • usually occurs d/t RTI
93
Q

objective tinnitus

A
  • head or ear noises that are audible to others
  • produced by internal fn in body circulation
  • rare
94
Q

causes of tinnitus

A
  • ototoxic meds
  • hearing loss- sensorineural
  • otosclerosis
  • chiari malformations
  • often d/t ear wax plug
95
Q

diagnosis of tinnitus

A
  • requires good history
  • HEENT exam, eval TM, CN exam, auscultate neck
  • MRI if unilateral esp with hearing loss- r/o retrocochlear lesion
96
Q

treatment of tinnitus

A
  • avoid excessive noise and ototoxic drugs
  • correct comorbidities
  • hearing aids
  • sound and behavioral therapy
  • TMJ tx
  • cochlear implants
97
Q

nystamgus

A
  • repetitive uncontrolled movements of eyes
  • cause reduced vision, depth perception, and affect balance/ coord
  • usually sx of another eye or medical prob
98
Q

infantile nystagmus

A
  • usually horizontal swinging

- congenital cause

99
Q

spasmus nutan nystagmus

A
  • occurs in kids
  • usually improves on its own without tx
  • kids often nod or tilt their head
  • eyes can move in any direction
100
Q

acquired nystagmus

A
  • develops later in childhood or adulthood

- cause is usually unknown

101
Q

causes of nystagmus

A
  • neuro problems
  • lack of eye development
  • astigmatism
  • congenital cataracts
  • inflammation of inner ear
  • medications (anti-seizure meds)
  • CNS diseases
102
Q

diagnosis of nystagmus

A
  • history
  • visual acuity assessment
  • det lens power needed to correct error
103
Q

treatment of nystagmus

A
  • glasses/ contacts
  • usually improves with time
  • treat underlying cause
104
Q

vertigo

A
  • illusion of motion, rotary sensation

- associated n/v, sweating, pallor

105
Q

causes of vertigo

A
  • hypofunction- vestibular neuritis
  • hyperfunction- BPPV
  • central neurological disorder- migraines
106
Q

central vertigo

A
  • gradual onset
  • cerebellum and brainstem affected
  • disproportionate gate
  • visual field defects
  • hemisensory loss
  • limb weakness
  • diplopia
  • slurred speach
  • difficulty swallowing
107
Q

peripheral vertigo

A
  • sudden onset
  • semicircular canals, otolith organs affected
  • tinnitus
  • hearing loss
  • aural fullness
108
Q

what is the most common cause of severe spontaneous vertigo

A
  • vestibular neuritis or labrythitis
109
Q

common cause of neuritis or labrythitis

A
  • usually ear infection
  • disrupts transmission of sensory info
  • typically viral cause
110
Q

neuritis

A
  • inflammation of vestibular n
  • NO hearing impact
  • dizziness and vertigo sx
111
Q

labrynthitis

A
  • inflammation of labyrinth in inner ear
  • hearing changes
  • dizziness and vertigo sx
112
Q

treatment for neuritis and labrythitis

A
  • usually pretty self limited : 2-3 weeks
  • steroids
  • antivert meds- meclizine
  • antiemetics- zofran
  • antivirals and abx rare
113
Q

benign paroxysmal positional vertigo

A
  • crystal gets displaced into semicircular canal
  • excessive response to head movement
  • commonly in females > 60
  • rapid onset dizziness or spinning
  • short duration
114
Q

clinical manifestations of BPPV

A
  • clockwise rotary nystagmus
  • rapid onset dizziness lasting sec- min
  • precipitated by sudden head movement
  • nystagmus
  • nausea
  • no impact on hearing
115
Q

diagnosis of BPPV

A
  • dix- hallpike maneuver to determine which canal is affected
  • may need MRI/CT to r/o other causes
116
Q

epley maneuver

A
  • tx for BPPV in posterior canal
117
Q

deep head hanging maneuver

A
  • tx for BPPV in superior canal
118
Q

lamperet (BBQ) maneuver

A
  • tx for BPPV in lateral canal
119
Q

tx of BPPV

A
  • epley, deep head hanging, or lampered maneuvers
  • symptomatic tx
  • antihistamines
  • antiemetics
  • bzds
  • neuro referral
  • PT
  • surgery (rare)
120
Q

Meniere’s disease

A
  • inner ear disorder -> vertigo, tinnitus, hearing loss, feeling of fullness in ear
  • frequent “drop attacks”
  • usually in one ear
  • sudden onset of sx that are separated by periods of time
  • usually seen in adult females
121
Q

what is the cause of meniere’s disease

A
  • fluid build up in inner ear -> impaired balance and hearing signals to brain
122
Q

associated diseases of meniere’s

A
  • allergies
  • stress
  • viral infections
123
Q

sx associated to diagnose meniere’s disease

A
  • usually done by ENT
  • 2+ episodes of vertigo lasting 20 min each
  • tinnitus
  • temporary hearing loss
  • fullness in ear
  • can get MRI and labs to r/o more serious causes
124
Q

treatment for meniere’s disease

A
  • meclizine
  • bzds
  • salt restriction and diuretics
  • dietary changes- no caffeine, alcohol, chocolate
  • cognitive tx
  • gentamicin injection (caution)- - steroids
  • pressure pulse tx
125
Q

drugs that can cause vertigo

A
  • aminoglycosides
  • antidepressants
  • anxiolytics
  • furosemide
  • amiodarone
  • ASA
  • alcohol
  • cocaine
126
Q

central causes of vertigo

A
  • migraines
  • tumors of CN VIII
  • chiari malformations
  • brain ischemia
  • MS
  • brain injuries
127
Q

eustachian tube dysfunction

A
  • occurs when tube is blocked or doesn’t open
  • air pressure outside TM > air pressure in middle ear
  • TM gets pushed in
  • TM becomes tense, doesn’t vibrate or move
128
Q

causes of eustachian tube dysfunction

A
  • cold or other sinus/throat infections** - sx can persist for 1 week after all other sx resolve
  • allergies
  • blockages- i.e. enlarged adenoids
  • air travel
129
Q

clinical manifestations of eustachian tube dysfunction

A
  • fullness in ear**
  • possible hearing loss
  • popping when yawning or swallowing
  • ear pain
130
Q

dilatory eustachian tube dysfunction

A
  • tube doesnt dilate
  • causes hearing loss
  • see effusions, scarring, and thickening of TM
  • treat underlying cuase
131
Q

patulous eustachian tube dysfunction

A
  • valve incompetency
  • pt hears own voice amplified
  • movement of TM on otoscopic exam
  • tx only if sx severe and last > 6 weeks
132
Q

treatment of eustachian tube

A
  • swallow, yawn, or chew to increase flow of air in and out of tube
  • valsalva maneuver
  • decongestants
  • antihistamines
  • steroid nasal spray
  • if sx are persistent refer to ENT
133
Q

what type of hearing loss is associated with outer ear problems?

A
  • conductive hearing loss
134
Q

what type of hearing loss is associated with middle ear problems?

A
  • conductive hearing loss
135
Q

what type of hearing loss is associated with inner ear problems

A
  • sensorineural hearing loss
136
Q

exostosis

A
  • multiple bony growths
137
Q

osteoma

A
  • solitary bony growth
138
Q

what is the most common cause of middle ear hearing problems?

A
  • eustachian tube dysfunction
139
Q

presbycusis

A
  • age related hearing loss
140
Q

what are endocrine issues associated with hearing loss?

A
  • DM
  • hyperthyroidism
  • anemia
141
Q

what are autoimmune diseases associated with hearing loss?

A
  • RA
  • SLE
  • polyarteritis nodosa
142
Q

what drugs are commonly associated with hearing loss?

A
  • gentamycin, tobramycin, tetracycline
  • cisplatin, 5-FU
  • high dose ASA
  • PDE-5 inhibitors
  • quinine, chloroquine
  • cocaine
  • lead, mercury, cadmium, arsenic
143
Q

vestibular schwannomas

A
  • overproduction of schwann cells on vestibular nerve
  • slow growing
  • typically unilateral
144
Q

neurofibromatosis type 2 (NF2)

A
  • mutation in merlin gene
  • causes bilateral vestibular schwannomas
  • more likely to dev other NS tumors
145
Q

clinical presentation of vestibular schwannomas

A
  • disequilibrium
  • hearing loss- asymmetric sensorineural loss
  • tinnitus
  • if tumor is large enough can compress other CN
146
Q

risk factors for vestibular schwannomas

A
  • NF2 mutation
  • childhood low dose radiation
  • hx of parathyroid adenoma
  • ? cellphones
  • exposure to loud noise
147
Q

diagnosis of vestibular schwannomas

A
  • audiometry- best initial screening
  • CT
  • MRi
148
Q

management of vestibular schwannomas

A
  • surgery- good longterm control
  • radiation
  • observation
149
Q

indications for conservative management of vestibular schwannomas

A
  • > 60 years old
  • significant comorbidities
  • small tumor size
  • lack of sx
  • risk further hearing loss
  • pt preference
150
Q

complications of vestibular schwannomas

A
  • hearing loss
  • facial weakness
  • vestibular disturbances
  • persistent HA
  • CSF leakage
  • hemorrhage
  • infections
151
Q

causes of ear barotrauma

A
  • flying- most common
  • driving/hiking up mountains
  • diving
  • blast injuries
152
Q

what cause of barotrauma is associated with inward rupture of TM

A
  • diving
153
Q

clinical manifestations of ear barotrauma

A
  • ear pressure- most common
  • pain
  • hearing loss
  • tinnitus
  • vertigo
154
Q

prevention for barotrauma

A
  • plan for pressure changes
  • avoid flying/ diving
  • decongestants and antihistamines
  • ear plugs
  • ventilation tubes
  • surgical tympanoplasty if required

Clin Med I (16 decks)

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