EENT Flashcards
Blepharitis
Eyelid acne dt blockage of memobian gland
Sx: itching, burning, crusting eyes, no pus
Mgmt
Warm compress + baby shampoo
Optic abx to dec bacterial load but it’s not a true infection
Cataract
1 cause of blindness worldwide dt natural clouding of lens
Sx: painless gradual loss, reduced visual acuity, reduced red reflex
Mgmt
Tx indicated if vision 20/40 or worse or affects QOL
Outpt- phacoemulsification
Chalazion
Internal eyelid
Slow developing chronic blockage of oil gland
Mgmt
Aggressive warm compress
1-2wk no improvement - steroid injection or I/d
Resolve spontaneously
Corneal abrasion
Irritability in an infant Sx: Pain worse w blinking Photophobia FB sensation Conjunctival injection
Dx: evert lid, flourescein stain w Woods lamp
Tx:
Topical anesthetic (if it’s iritis, pain won’t be reduced)
Remove FB
Tetanus prophylaxis
Erythromycin or gentamicin gtt… FQ if contacts or freshwater exposure
Ophtho f/u 1-2d
Dacryoadenitis
Mc in infants
Sx: red, swollen inferior/medial canthus; mucopurulent dc w lid crusting
Tx: warm compress w massage
Refer acute lacrimal infection for dx confirmation and abx
Ectropion
Older pt w eyelid turned out
Dryness*
Tx: lubrication
Entropion
Older pt w eyelid turned in
Irritation*
Tx: lubrication
Hordeolum (Stye)
Acute inflammation of memobian gland
Painful
Mgmt
Aggressive warm compress -4x per day for 20min
I&d if persisting more than 1-2wk
Spontaneous resolution
Pterygium
Dt chronic sun exposure
White vascular growth on nasal or temporal cornea
Concern for dry eye
Tx: artificial tears
Inflammation = ophtho for steroid or excision
Acoustic neuroma (“Vestibular Schwannoma” - CN 8)
Almost all unilateral; one of the MC intracranial tumors
A/w NF 1 (bilateral = NF 2)
Sx
- auditory: unilateral SNHL (gradual or sudden)
- vestibular: tinnitus, vertigo (continuous)
Dx: enhanced MRI
Tx: radiotherapy* - prevents further growth, does not shrink
- may require surgical excision if larger
Barotrauma
Inability to equalize barometric stress on middle ear during flight/dive
Sx: tinnitus, vertigo, NV, hearing loss
Middle ear: pressure decreases with descent; if the eustachian tube does not open, fluid fills middle ear space and may rupture TM
Inner ear: difficulty equalizing inner ear pressure suddenly able to open the eustachian tube, the rush of air can cause oval or round window rupture
Tx: refer, bed rest, antivertigo meds, steroid taper, avoid Valsalva
Cholesteatoma
Et: ETD, recurrent AOM, chronic OM –> epidermal structure replaces middle ear mucosa and resorbs underlying bone
Sx: recurrent/persistent otorrhea, hearing loss, tinnitus
Tx: surgery
Conductive hearing impairment
MC cause: cerumen impaction, ETD a/w URI
Dysfunction of external or middle ear
Tx:
- AOM = abx
- cerumen removal, TM repair, ear tubes, ossicular reconstruction, hearing aids
Sensory hearing impairment
MC cause: age (presbycusis) d/t loss of hair cell function
- autoimmune: Lupus, GPA, Cogan
Sxs:
- presbycusis: high frequency loss
- sudden sensory hearing loss: unilateral, peaks in 5th decade, idiopathic (no middle ear path = refer)
- autoimmune: bilateral wax and wane; may have vestibular/balance issues
Dx: MRI if suspecting acoustic neuroma
Mgmt:
- prevent further loss, hearing aids for amplification, cochlear implants
- steroids for disease specific
- SSHL - improved odds of full recovery with quick admin of steroids
Neural hearing impairment
D/t lesions affecting CN 8
E.g. acoustic neuroma, MS, auditory neuropathy
Labyrinthitis
Inner ear inflammation d/t viral
Sxs: continuous vertigo (days-wks), hearing loss, tinnitus
- no hearing loss = vestibular neuritis
Dx:
- serous: coexisiting or recent URI/ear infection, may have hearing loss, nontoxic, may have mild fever
- bacterial: coexisting OM, severe sx, hearing loss, fever, toxic [only peripheral cause warranting admission]
Tx:
- febrile: abx
- supportive care; vertigo - meclizine
- may take several weeks to resolve, hearing may or may not return
Meniere’s disease
Idiopathic disorder of inner ear
Sx: spontaneous, recurrent attacks of episodic vertigo lasting hours; tinnitus; aural fullness; fluctuating SNHL
- w/out hearing loss = vestibular migraine
Dx: audiometric confirmation; r/o syphilis
Tx:
- acute: meclizine or short burst of steroids*
- 1st line: salt restriction, diuretics
- ablation - aminoglycosides
Tinnitus
Ddx: Meniere’s; acoustic neuroma; otosclerosis; otitis media; MS; salicylate OD; chronic; cerebrovascular disease
D/t: h/o noise exposure, episodic sounds, hearing loss; persistence indicates SNHL
Dx: audiology screening*
- labs, imaging, med history
- pulsatile: MRI & venography to r/o aneurysm or vascular tumor
Tx: refer to audiology*
TM Perf
Trauma - slap injury, foreign body
Infection - complication of otitis media
Dx: audiology eval
Tx: refer for tympanoplasty if hearing loss persists
- infection = abx
Vertigo
Sensation of disorientation in space w/sensation of motion/spinning
Central - MS, vestibular schwannoma
Peripheral - labyrinthitis/vestibular neuritis, Meniere’s, BPPV, inner ear barotrauma
Seconds: no HL - BPPV; HL - cholesteatoma
Minutes: no HL - migraines
Hours: HL - Meniere’s
Days: no HL - vestibular neuritis; HL - labyrinthitis
Weeks: no HL - Lyme, MS, central NS; HL - acoustic neuroma, psychogenic, autoimmune
Central vertigo
RF: older male vasculopath Sx: - gradual, progressive, constant; presents later in course; mild/mod intensity - vertical nystagmus** - mild nausea, HA, not affected by mvmt
Dx:
- Head CT: r/o hemorrhage
- MRI**
Peripheral vertigo
Usually not emergent
Sx:
- acute, intermittent, brief; presents early in course; severe intensity
- nystagmus always present: unidirectional, fatigable, horizontal, or rotary* (never vertical)
- intense NV; provoked by mvmt; +/- hearing loss
Peripheral vertigo DDx
- BPPV
- Labyrinthitis
- Vestibular neuronitis
- Meniere’s
- Acoustic neuroma
BPPV
Positional vertigo d/t calcium debris w/in posterior semicircular canal
MC older females
Sx:
- recurrent vertigo lasting 1 min or less provoked by specific head movements; episodes for wks-mos
- +/- NV w/out other neuro complaints
Dx: Dix-Hallpike Maneuver
Tx: Epley Maneuver
Acute sinusitis
Duration <4wk
Starts URI –> edema –> ostial blockage, mucus stasis, bacterial proliferation
MC: S. pneumo, H. flu, S. pyogenes **
Sxs:
- URI > 10d w/no improvement
- severe sxs w/high fever w/purulent nasal d/c or facial pain (3-4d)
- worsening sxs w/new onset HA, fever, INC nasal d/c following URI w/initial improvement
Tx: Amoxicillin, Augmentin, Doxycycline* or Resp FQ
- nasal saline for irrigation, nasal steroids, antihistamines
Chronic sinusitis
> 12wk d/t impaired mucociliary clearance, abnormal sinus ventilation, or immune deficiency
- nasal polyps + chronic sinusitis = CF
- different bugs: Staph, Pseudomonas, anaerobes
Dx: consider CT sinuses
Tx: ENT referral; FQ culture-directed therapy for 3-6wk
- steroids dec inflammation
Allergic rhinitis
Early phase: 10-15min histamine - sneezing, rhinorrhea, itching [antihistamines - loratadine, fexofenadine, cetirizine]
Late phase: 4-6hr cytokines/leukotrienes - inflammation, nasal congestion, postnatal drip [nasal steroid - triamcinolone, fluticasone, mometasone]
Seasonal: worse in AM and dry/windy conditions*
Perennial: pet dander, dust mite, worse PM*
Sxs: edematous, bluish/boggy turbinates
- kids: allergic shiners, mouth breathing, salute
Montelukast (Singulair): allergies + asthma
Epistaxis
90% anterior - Kesselbach’s Plexus
MC d/t URI
Posterior source - heavy, brisk, may compromise airway and be life threatening
Dx: H/H (prolonged bleed) / INR (warfarin)
Mgmt:
Anterior:
- oxymetazoline (Afrin) 3 spray + hold pressure 15 min
- continued bleed - lubricated nasal tampon
- d/c w/48hr f/u w/abx for TSS (clindamycin, augmentin)
- abx ointment to spot for 1wk
Posterior:
- double balloon device OR pass foley cath thru nose and inflate balloon
- admit w/ENT consult
Nasal polyp
Child w/allergic rhinitis
Nasal polyp + chronic sinusitis = CF
Sx: pale edematous, smooth masses arising from middle meatus
Small - nasal steroid
Large - surgical removal
Acute pharyngitis
Normal oropharynx colonization: staph, non-hemolytic strep, lactobacillus, Bacteroides
Peds - 80-90% viral infection
Sxs:
- sore throat, erythema w/out exudate a/w other URI sxs (rhinorrhea, coryza, cough)
- if oral ulcers or hoarseness, almost always viral (no need to swab)
Mgmt: self limiting
Strep throat
MC: group A beta-hemolytic strep
Sxs:
- sudden onset* sore throat; age 5-15
- fever, HA, NV, abdominal pain, pharyngeal inflammation, palatal petechiae, anterior cervical LAD
- winter/early spring
Dx:
- culture negative rapid strep in children to verify
Modified Centor Criteria*
- absence of cough
- swollen, tender anterior cervical nodes
- T > 100.4
- tonsillar exudates/swelling
- 3-14yo
- 45+ = -1pt
Mgmt:
- 4: abx [Penicillin, amoxicillin, cefdinir, azithro]
- 2-3: swab
- 0-1: unlikely to swab
No improvement after 48hr - cefuroxime or augmentin
Strep Complication: Scarlet Fever
Erythrogenic exotoxin produced by strep
- diffuse sandpaper rash, facial flushing
- petechiae in body folds (groin), strawberry tongue, desquamation
Strep Complication: Acute Rheumatic Fever
Inflammatory disease caused by ab cross-reactivity presenting 1-6wk after infection; sudden onset - fever, arthralgia, carditis
*Jones Criteria: 2 Major OR 1 Major and 2 minor + evidence of strep infection
Major: carditis, migratory polyarthritis, erythema marginatum, subcutaneous nodules, chorea
Minor: fever, arthralgia, previous RF or RHD, leukocytosis, elevated ESR/CRP, prolonged PR on ECG
Tx: treat strep, sxs treatment
- continue for 5y w/out carditis; 10y w/carditis [Benzathine PCN shot q month]
Strep Complication: Post-strep glomerulonephritis
Acute nephrotic syndrome, 10d after strep infection
Protein in urine
Swelling of eyes/face
Strep Complication: PANDAS
Pediatric autoimmune neuropsychiatric diagnosis associated with strep
New onset OCD sxs w/in a few weeks - tics, fears, anxiety, ritual
Tx: SSRI, CBT, plasmapheresis
Strep Complication: Peritonsillar Abscess
Strep infection invading beyond tonsil
Strep infection initial improvement w/meds, then abscess develops
- severe odynophagia
- trismus
- malaise
- hot potato voice
Mgmt: IV abx, I/D, quinsy tonsillectomy
Apthous ulcers
Et: stress, acid, hormone, trauma, genetic
Sxs: painful, swallow, yellow-grey ulcer w/red halo on non-keratinized mucosa (lips, gums)
- lasts 7-10d
Dx:
- magic mouthwash: benadryl + maalox
- occlusive: orabase
- anesthetics: benzocaine
- cleansing agents, antiseptics
Mgmt:
- avoid trigger
- Rx: viscous lidocaine
- other: topical steroid, cimetidine, tetracycline
- chemical cautery (silver nitrate)
Necrotizing Ulcerative Gingivitis (“Trench Mouth”)
Bacterial infection d/t overgrowth of mouth bacteria [bacteroides, fusobacterium, spirochetes]
- young adults; I/C
Sxs: gingival inflammation/necrosis
- “punched out” interdental papillae
- bleeding, pain, halitosis, fever, cervical LAD
Mgmt:
- salt water, peroxide rinse
- augmentin, penicillin
- oral hygiene, pain control, refer
Oral candidiasis
Candida albicans on oral mucosa and tongue
RF: dentures, debilitated, DM, anemia, radiation, corticosteroids or abx
Sxs:
- creamy white curd-like patches overlying erythematous mucosa, mouth pain
- CAN rub off
- angular cheilitis: another manifestation; dry cracking in corners of mouth
Tx: PO Fluconazole (Diflucan)
- clotrimazole troches
- nystatin suspension, swish and spit
Oral leukoplakia
May progress to dysplasia or early invasive SCC
Hyperkeratosis of mucosa in response to irritant (tobacco)
Sx: buccal mucosa or tongue; does NOT scrape off
Tx: referral if bx cancerous
Laryngitis
MC cause of hoarseness
- hoarseness may persist a week or two after sx of URI resolve
Mgmt:
- pt should avoid singing and shouting until voice returns to normal; persistent use may lead to polyps, nodules, cysts
Longer than 3 weeks = chronic. Requires ENT eval.
Herpetic stomatitis
Possible presentation for 1st time oral HSV outbreak (kids)
Sx: lesions on gums, tongue, oral mucosa, lips
- vesicles rupture, become ulcers
- a/w high fever, mouth pain, swollen bleeding gums, irritability, anorexia
Tx: 7-10d PO acyclovir
- pain control w/magic mouthwash, liquid/soft diet
Herpes labialis
Recurrent HSV d/t UV light, stress, fatigue, menses
Sx: itching, burning, tingling
- 1-2d later a vesicle forms on red base, ruptures, crusts and heals
Tx: PO or topical acyclovir ASAP when feel sensation or lesion coming on
Parotitis
Parotid gland - Stenson’s duct
Submandibular gland - Wharton’s duct
Mumps - bilateral swelling of parotid glands
- fever, malaise, pain, tenderness, erythema, trismus, kids 4-6yo
Sx: tender glands
Sialadenitis
MC cause: staph aureus
- predisposing factor: dehydration
- bacterial infection of salivary gland
Sx: acute unilateral swelling, erythema, pain, tenderness, trismus, purulent ductal discharge, induration, fever
Tx: IV abx, rehydration, sialogogues, oral hygiene
- no improvement in 48hr: refer to I/D to investigate potential abscess
