Ears and nose Flashcards
1
Q
what type of hearing occurs in the middle ear
A
- conductive hearing
2
Q
what type of hearing occurs in the inner ear
A
- sensorineural hearing
3
Q
pathogenesis of AOM
A
- eustachian tube dysfunction
- allergies
- viral infections
- bacterial infections
4
Q
what does AOM stand for?
A
- acute otitis media
5
Q
what does OME stand for?
A
- otitis media with effusion (chronic OM)
6
Q
what is the gold standard for dx of otitis media?
A
- pneumatic otoscopy
7
Q
AOM
A
- rapid onset < 48 hours
- si/sx of inflammation in middle ear
- mild pain
- bulging of TM
- intense redness
- +/- otorrhea
8
Q
severe AOM
A
- AOM
- mod-severe pain OR fever > 102.2
- bulging of TM
- intense redness
- +/- otorrhea
9
Q
OME
A
- inflammation of middle ear
- liquid collection
- no pain associated
10
Q
middle ear effusion (MEE)
A
- liquid in middle ear
- no reference to etiology, pathogenesis, pathology, or duration
11
Q
otorrhea
A
- discharge from ear
- can come from external auditory canal, middle ear, mastoid inner ear, intracranial cavity
12
Q
otitis externa
A
- infection of external auditory canal
13
Q
tympanometry
A
- measure acoustic immittance of ear
- function of ear canal pressure
14
Q
causes of AOM
A
- strep pneumoniae **
- h. flu
- m. catarrhalis
- virus
- ostiomeatal complex disfunction
15
Q
causes of OME
A
- osteomeatal complex/ eustachian tube dysfunction
- sequelae of AOM
- viral
- unknown
- bacteria
- biofilm
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
17
Q
tx options for OME
A
- watch and wait
- tubes
- surgery
- PO or topical prednisone (off guidelines)
- antihistamines (off guidelines)
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
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
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
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
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
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
24
Q
AOM prophylaxis
A
- vaccines*
- breast feeding
- smoke free environment
- no bottles in bed
- abx prophylaxis NOT recommended
25
otitis externa (OE)
- painful external ear
| - **tragal movement pain
26
causes of OE
- pseudomonas aeruginosa most common bacteria
- fungal
- furuncles
- allergies
- injury
27
predisposing factors for OE
- inadvertent injury
- allergies
- psoriasis or eczema
- seborrheic dermatitis
- decreased canal acidity
- irritants
28
si/sx of OE
- 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
29
OE treatment
- 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
30
prevention of OE
- 1:1 mix of rubbing alcohol and white vinegar if TM is intact after swimming
- no q tips
31
common causes of TM perforation
- infection
- trauma
- atmospheric overpressure
- excessive water pressure
- improper attempts at wax removal or ear cleaning***
32
treatment for TM perforation
- 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
33
auricular hematoma
- from direct trauma
| - shearing forces separate anterior auricular perichondrium from cartilage
34
treatment of auricular hematoma
- early ID
- drain
- splint
- compression
35
mastoiditis
- infection of mastoid air cells
| - very concerning dx
36
treatment for mastoiditis
- consult
- medical tx same as AOM
- surgery to remove infected bone
37
what are the most concerning FB in the nose?
- 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
38
common locations for nasal FB
- most on floor of nasal passage
39
paired disk magnets in nose
- if have one in each nostril they are difficult to manually remove
- prolonged attachment -> perforation of septum
40
clinical presentation of nasal FB
- usually in kids or adults with intellectual disabilities
- mucopurulent nasal discharge
- foul oder
- unilateral epistaxis
- nasal obstruction and mouth breathing
41
dx of nasal FB
- 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
42
removal of intranasal FB
- using positive pressure techniques
- direct instrumentation
- most dont require surgery
43
intranasal FB that require ENT referral
- posterior FB not readily visualized
- chronic or impacted FB with inflammation
- penetrating or hooked FB
- any FB that cant be removed after initial attempt
44
positive pressure techniques
- have pt occlude opposite nose and blow out
| - occlude unaffected nostril and have someone blow into mouth
45
intranasal FB removal via instrumentation
- 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
46
prognosis of intranasal FB
- depends on size, shape and contents of FB
- duration of FB
- result of removal attempts
47
intermittent allergic rhinitis
- sx occur in response to specific exposure
| - i.e. cat allergy
48
seasonal allergic rhinitis
- aka hay fever
49
persistent/ perennial allergic rhinitis
- sx occur year round
| - i.e. mold allergy
50
what key feature distinguishes allergic rhinitis from other forms of rhinitis
- nasal itching
51
physical exam findings for allergic rhinitis
- nasal mucosa is edematous and pale
- allergic shiners
- nasal crease/ "allergic salute"
- clear mucous
- polyps
- septal issues
52
management of allergic rhinitis
- environmental control
- topical intranasal steroids**
- 2nd gen antihistamines
- montelukast
- mast cell stabilizers
- immunotherapy
53
nonallergic rhinitis
- chronic presence of nasal congestion, rhinorrhea, post nasal drainage
- sx are perennial
- no nasal or ocular itching
54
vasomotor rhinitis
- nonallergic
| - intermittent sx from nonspecific irritants
55
mixed rhinitis
- combo of allergic and nonallergic rhinitis
56
gustatory rhinitis
- nonallergic
| - rhinorrhea triggered by hot or spicy foods
57
rhinitis of pregnancy
- nonallergic
- usually occurs in last six weeks
- no known allergic cause
- disappears 2 weeks after delivery
58
rhinitis medicamentosa
- caused by nasal decongestants
- should only use decongestants for 3 days
- can also be caused by antiHTN meds, ED meds, antidepressants, BZDs, NSAIDs, estrogen
59
what are the most common causes of rhinosinusitis
- rhinovirus
- influenza virus
- parainfluenza virus
60
acute rhinosinusitis duration
- < 4 weeks
61
chronic rhinosinusitis duration
- > 12 weeks
| - usually seen in middle aged adults
62
viral rhinosinusitis
- 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
clinical presentation of viral rhinosinusitis
- 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
diagnosis of rhinosinusitis (viral or bacteria)
- mainly clinical
- bacterial cultures are unreliable- should be performed by ENT
- xray not indicated for uncomplicated
- CT is modality of choice if complicated
65
treatment for viral rhinosinusitis
- 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
acute bacterial rhinosinusitis
- 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
predisposing factors for bacterial rhinosinusitis
- usually a complication of viral infection
- nasal mechanical obstruction
- tooth infection
- impaired mucocilliary clearance
- immunodeficiency
- smoker
68
most common causes of acute bacterial rhinosinusitis
- s. pneumoniae
- h flu
- m catarrhalis
69
treatment for bacterial rhinosinusitis
- 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
acute fungal rhinosinusitis
- occurs in immunocompromised pts
- usually d/t apergillus
- treat with amphotericin
71
acute fungal rhinosinusitis clinical manifestation
- facial pain and nasal congestion
- facial numbness, diplopia if facial n involvement
- epistaxis
- necrotic tissue
- gingival eschars, sloughing of septum
72
diagnosis of fungal rhinosinusitis
- urgent ENT referral
| - biopsy/ debridement
73
chronic rhinosinusitis risk factors
- allergic rhinitis
- asthma
- perennial allergies
- smoking
- immunodeficiency
- anatomic abnormalities
- defects in mucocilliary clearance
74
cardinal si/sx of chronic rhinosinusitis
- 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
subtypes of chronic rhinosinusitis
- CRS with nasal polyposis
- CRS without nasal polyposis- most common
- allergic fungal rhinosinusitis
76
CRS with nasal polyposis
- 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
what is the biggest way to tell the difference between nasal polyps and nasal turbinates
- polyps= painless
| - turbinates= VERY sensitive
78
samter's triad
- combo of asthma, CRS with NP, and aspirin sensitivity
79
CRS without polyposis
- persistent sx with periodic exacerbations
| - acute flares respond well to abx
80
allergic fungal RS
- 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
CRS diagnostics
- sinus CT
- mucosal thickening bilaterally
- obstruction of osteomeatal complex
- sinus opacification without facial pain/ pressure/ HA
82
CRS with NP treatment
- PO steroids to shrink polyps
- nasal steroids after
- leukotriene inhibitor for maint
83
CRS without NP treatment
- PO steroids
- abx for 6 weeks
- follow with nasal steroids
- 2nd gen antihistamines
- leukotriene receptors
84
allergic fungal CRS treatment
- remove inspissated mucus
| - prolonged PO steroids
85
anterior nosebleeds
- usually occur in kiesselbach's plexus
| - most common type of nosebleed
86
posterior nosebleeds
- usually d/t sphenopalatine artery
- not usually associated with trauma
- can result in serious hemorrhage
87
cause of anterior nosebleeds
- 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
cause of posterior nosebleeds
- carotid artery aneurysm
- nasal neoplasm
- anticoag pts
89
treatment of anterior nosebleed
- compress nares for 5-10 min
- pt lean foward
- short acting topical nasal decongestants
- topical cocaine or spray
- electrocautery
90
treatment of posterior nosebleeds
- topical sympathomimetics
- double ballon packs
- ENT consult for packing
- rhino rocket X 3 days with keflex
91
tinnitus
- perception of sound when no external noise present
- ringing, buzzhing, hissing, whistling, swooshing
- men > women
- more common in smokers
92
subjective tinnitus
- 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
objective tinnitus
- head or ear noises that are audible to others
- produced by internal fn in body circulation
- rare
94
causes of tinnitus
- ototoxic meds
- hearing loss- sensorineural
- otosclerosis
- chiari malformations
- often d/t ear wax plug
95
diagnosis of tinnitus
- requires good history
- HEENT exam, eval TM, CN exam, auscultate neck
- MRI if unilateral esp with hearing loss- r/o retrocochlear lesion
96
treatment of tinnitus
- avoid excessive noise and ototoxic drugs
- correct comorbidities
- hearing aids
- sound and behavioral therapy
- TMJ tx
- cochlear implants
97
nystamgus
- repetitive uncontrolled movements of eyes
- cause reduced vision, depth perception, and affect balance/ coord
- usually sx of another eye or medical prob
98
infantile nystagmus
- usually horizontal swinging
| - congenital cause
99
spasmus nutan nystagmus
- occurs in kids
- usually improves on its own without tx
- kids often nod or tilt their head
- eyes can move in any direction
100
acquired nystagmus
- develops later in childhood or adulthood
| - cause is usually unknown
101
causes of nystagmus
- neuro problems
- lack of eye development
- astigmatism
- congenital cataracts
- inflammation of inner ear
- medications (anti-seizure meds)
- CNS diseases
102
diagnosis of nystagmus
- history
- visual acuity assessment
- det lens power needed to correct error
103
treatment of nystagmus
- glasses/ contacts
- usually improves with time
- treat underlying cause
104
vertigo
- illusion of motion, rotary sensation
| - associated n/v, sweating, pallor
105
causes of vertigo
- hypofunction- vestibular neuritis
- hyperfunction- BPPV
- central neurological disorder- migraines
106
central vertigo
- gradual onset
- cerebellum and brainstem affected
- disproportionate gate
- visual field defects
- hemisensory loss
- limb weakness
- diplopia
- slurred speach
- difficulty swallowing
107
peripheral vertigo
- sudden onset
- semicircular canals, otolith organs affected
- tinnitus
- hearing loss
- aural fullness
108
what is the most common cause of severe spontaneous vertigo
- vestibular neuritis or labrythitis
109
common cause of neuritis or labrythitis
- usually ear infection
- disrupts transmission of sensory info
- typically viral cause
110
neuritis
- inflammation of vestibular n
- NO hearing impact
- dizziness and vertigo sx
111
labrynthitis
- inflammation of labyrinth in inner ear
- hearing changes
- dizziness and vertigo sx
112
treatment for neuritis and labrythitis
- usually pretty self limited : 2-3 weeks
- steroids
- antivert meds- meclizine
- antiemetics- zofran
- antivirals and abx rare
113
benign paroxysmal positional vertigo
- crystal gets displaced into semicircular canal
- excessive response to head movement
- commonly in females > 60
- rapid onset dizziness or spinning
- short duration
114
clinical manifestations of BPPV
- clockwise rotary nystagmus
- rapid onset dizziness lasting sec- min
- precipitated by sudden head movement
- nystagmus
- nausea
- no impact on hearing
115
diagnosis of BPPV
- dix- hallpike maneuver to determine which canal is affected
- may need MRI/CT to r/o other causes
116
epley maneuver
- tx for BPPV in posterior canal
117
deep head hanging maneuver
- tx for BPPV in superior canal
118
lamperet (BBQ) maneuver
- tx for BPPV in lateral canal
119
tx of BPPV
- epley, deep head hanging, or lampered maneuvers
- symptomatic tx
- antihistamines
- antiemetics
- bzds
- neuro referral
- PT
- surgery (rare)
120
Meniere's disease
- 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
what is the cause of meniere's disease
- fluid build up in inner ear -> impaired balance and hearing signals to brain
122
associated diseases of meniere's
- allergies
- stress
- viral infections
123
sx associated to diagnose meniere's disease
- 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
treatment for meniere's disease
- meclizine
- bzds
- salt restriction and diuretics
- dietary changes- no caffeine, alcohol, chocolate
- cognitive tx
- gentamicin injection (caution)- - steroids
- pressure pulse tx
125
drugs that can cause vertigo
- aminoglycosides
- antidepressants
- anxiolytics
- furosemide
- amiodarone
- ASA
- alcohol
- cocaine
126
central causes of vertigo
- migraines
- tumors of CN VIII
- chiari malformations
- brain ischemia
- MS
- brain injuries
127
eustachian tube dysfunction
- 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
causes of eustachian tube dysfunction
- 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
clinical manifestations of eustachian tube dysfunction
- fullness in ear**
- possible hearing loss
- popping when yawning or swallowing
- ear pain
130
dilatory eustachian tube dysfunction
- tube doesnt dilate
- causes hearing loss
- see effusions, scarring, and thickening of TM
- treat underlying cuase
131
patulous eustachian tube dysfunction
- valve incompetency
- pt hears own voice amplified
- movement of TM on otoscopic exam
- tx only if sx severe and last > 6 weeks
132
treatment of eustachian tube
- 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
what type of hearing loss is associated with outer ear problems?
- conductive hearing loss
134
what type of hearing loss is associated with middle ear problems?
- conductive hearing loss
135
what type of hearing loss is associated with inner ear problems
- sensorineural hearing loss
136
exostosis
- multiple bony growths
137
osteoma
- solitary bony growth
138
what is the most common cause of middle ear hearing problems?
- eustachian tube dysfunction
139
presbycusis
- age related hearing loss
140
what are endocrine issues associated with hearing loss?
- DM
- hyperthyroidism
- anemia
141
what are autoimmune diseases associated with hearing loss?
- RA
- SLE
- polyarteritis nodosa
142
what drugs are commonly associated with hearing loss?
- gentamycin, tobramycin, tetracycline
- cisplatin, 5-FU
- high dose ASA
- PDE-5 inhibitors
- quinine, chloroquine
- cocaine
- lead, mercury, cadmium, arsenic
143
vestibular schwannomas
- overproduction of schwann cells on vestibular nerve
- slow growing
- typically unilateral
144
neurofibromatosis type 2 (NF2)
- mutation in merlin gene
- causes bilateral vestibular schwannomas
- more likely to dev other NS tumors
145
clinical presentation of vestibular schwannomas
- disequilibrium
- hearing loss- asymmetric sensorineural loss
- tinnitus
- if tumor is large enough can compress other CN
146
risk factors for vestibular schwannomas
- NF2 mutation
- childhood low dose radiation
- hx of parathyroid adenoma
- ? cellphones
- exposure to loud noise
147
diagnosis of vestibular schwannomas
- audiometry- best initial screening
- CT
- MRi
148
management of vestibular schwannomas
- surgery- good longterm control
- radiation
- observation
149
indications for conservative management of vestibular schwannomas
- > 60 years old
- significant comorbidities
- small tumor size
- lack of sx
- risk further hearing loss
- pt preference
150
complications of vestibular schwannomas
- hearing loss
- facial weakness
- vestibular disturbances
- persistent HA
- CSF leakage
- hemorrhage
- infections
151
causes of ear barotrauma
- flying- most common
- driving/hiking up mountains
- diving
- blast injuries
152
what cause of barotrauma is associated with inward rupture of TM
- diving
153
clinical manifestations of ear barotrauma
- ear pressure- most common
- pain
- hearing loss
- tinnitus
- vertigo
154
prevention for barotrauma
- plan for pressure changes
- avoid flying/ diving
- decongestants and antihistamines
- ear plugs
- ventilation tubes
- surgical tympanoplasty if required
