EENT Flashcards
Benign abnormalities of Outer Ear?
Accessory Auricle, aka Skin tag
Microtia/Anotia: abnormal development of auricle creating EAC Stenosis.
Preauricular Pit: cystic tract unclosed from embryologic development.
Concerns of a Preauricular Pit?
May develop infection, may become recurrent or abnormally enlarged.
What is an Accessory Auricle and what is the treatment?
Aka Skin Tag, a benign skin abnormality.
Tx: simple excision of extra skin.
Treatment for Microtia/Anotia?
Cosmetic Surgery
Treatment of a Pre-auricular Pit?
Incision and drainage if infected; possibly an excision.
An ENT emergency; also known as cauliflower ear, an accumulation of fluid (usually blood) within sub-perichondrial space of Pinna?
Auricular Hematoma
Treatment of an Auricular Hematoma?
Incision and Drainage ASAP w/compression bandage to prevent recurrence.
What causes an Auricular Hematoma and what can develop if there is no treatment?
Blunt force trauma but arises from decreased blood flow to perichondrial space.
If not drained within 5-7 days of onset, cauliflower ear will develop.
A hydrophobic substance produced within the ear canal creating an acidic environment to protect against infection, trauma, water damage and foreign body?
Cerumen or ear wax.
What produces ear wax?
Sebaceous and ceruminous glands of the lateral 1/3 of the EAC.
Impaction defined as symptomatic accumulation of cerumen (conductive hearing loss) and how is it treated?
Cerumen Impaction treated with an ear lovage or Debrox drops.
Symptoms of a Cerumen Impaction?
Hearing loss, otalgia, drainage, dizziness, tinnitus.
Treatment of a foreign body…”pro-tip”?
Alligator forceps or curette
More common in kids.
Pro-tip: if the FB is a bug, make sure it is dead; use lidocaine.
Infection/irritation of the skin of the EAC?
Acute Otitis Externa (AOE)
Aka “Swimmer’s Ear”
Etiology of AOE?
Acute bacterial infection
- pseudomonas 38%, staph aureus 8%, strep pneumo 6%.
- can be associated with some derm conditions like eczema or psoriasis.
Risk factors for AOE?
Swimming, trauma, DM and other immunodeficient conditions.
Clinical presentation of AOE
Tender pinna/tragus. Otorrhea Hearing loss Erythema, pt’s will say it itches. EAC edema/swelling Debris in EAC
How would you treat a mild case of swimmer’s ear?
Alcohol/vinegar ear drops.
Treat with Antifungals or Clotrimazole ear drops if a fungal infection.
AKA Herpes Zoster Oticus; presents like zoster - a painful rash, but also with acute facial palsy (CN VII).
Ramsey Hunt.
What other CN can be involved with Ramsey Hunt and what can palsy of these CNS lead to?
CN VIII, IX, X, XI
Can lead to vertigo, hearing loss, tinnitus, ataxia.
Treatment for Ramsey Hunt?
Acyclovir, Steroids, Topical Anesthetic
Steroids typically not used in herpes but because of severe inflammation, Rx it.
How can you orient yourself when looking at the pt’s TM?
TM: Tympanic Membrane or ear drum.
The cone of light will point towards the pt’s nose.
Acute illness marked by presence of fluid and inflammation of the mucosa that lines the middle ear space?
Acute Otitis Media (AOM)
MCC of AOM?
MCC caused by obstruction of the Eustachian Tube causing fluid retention and suppuration of retained secretions.
Clinical presentation and PE of child with AOM?
Tugging ears Fussy Fever Hearing loss (which resolves with resolution of effusion). Capillary injection and erythema of TM Bulging TM Possible purulent fluid Immobility on bulb insufflation.
Treatment for AOM?
MC oral Abx x10 days.
Tylenol PRN for fever.
For adults, consider adding Decongestant (to drain ET) and/or steroid.
First line Abx for AOM?
Amoxicillin is 1st line Tx for anything involving the neck up.
*includes amoxicillin/Clavulanate (Augmentin).
- Macrolides 2nd line if allergy to Amoxicillin.
- Cephalosporins are 3rd line
ASOM?
Acute Serous Otitis Media
A collection of non-infected fluid in the middle ear space (fluid is clear and serous).
Etiology of ASOM?
Usually from ET obstruction from URI of nasopharynx (Viral, Sinusitis, Allergy).
ASOM Management?
Usually self-limiting.
- Bulb suction, saline, steam.
- Nasal decongestant (Afrin) and/or steroids for adults.
- Antihistamine if due to Allergies.
- Nasal Steroid.
- If >3 months, myringotomy and tube insertion should be done to prevent long-term standing trauma and hearing loss.
Chronic inflammation (usually >3 months) of the middle ear and/or mastoid cavity, which presents with recurrent ear discharges or otorrhea through tympanic perforation?
Chronic Otitis Media
Treatment for Chronic Otitis Media in children and criteria?
Bilateral Myringotomy and tube indication (BMT): serous otitis >3 months, 6 AOM in 6 months or 7 in 1 year.
Clinical Pearl for Chronic Otitis Media in adults?
If unilateral otitis media not responding to medication, ALWAYS CONSIDER NASOPHARYNGEAL MASS and refer!
Tympanic Membrane Perforation
Excess pressure within middle ear causes the tympanic membrane to perforate - will see a hole in the TM.
Sx and presentation of TM perforation?
Sx: Otalgia, hearing loss, otorrhea, possibly 2/2 otitis externa.
Presentation: pt states intense ear pain, a pop and then resolution of pain w/drainage and decreased hearing.
Treatment of TM perforation?
Typically, self-resolving within 4 weeks. Avoid swimming, baths, submersion.
May need referral if present >6 wks, can be repaired surgically.
If caused by Otitis Media, may need Otic Drop Abx: FQs not macrolides; avoid “-mycin” - otototoxic!
Complication of severe acute/chronic otitis media with spreading of fluid and infection refractory to mastoid cavity; MC in kids? Sx?
Mastoiditis - true ENT emergency.
Sx: fever, pain atop mastoid bone, erythema, protrusion of auricle.
Work up for Mastoiditis?
CT Temporal Bone, anytime mastoiditis is expected; if +, refer to ENT.
Treatment for Mastoiditis?
IV Cephalosporins and/or Mastoidectomy.
Keratinized, desquamated epithelial collection growing rapidly in the middle ear space usually 2/2 to TM perforation?
*can occur as complication of deep retraction pocket from Chronic ETD (ET dysfunction).
Choesteatoma
Presentation and evaluation of Cholesteatoma?
MC seen in kids.
Chronic otorrhea refractory to Tx, CHL (conductive hearing loss), may see dull with debris, which is usually visible in retraction pocket.
Binocular exam, audiometry, temporal bone CT; may need ENT referral for middle ear surgery.
TMJD?
Temporomandibular Joint Disorder
MC reason for otalgia.
Classic Sx of TMJD?
Otalgia w/o evidence of otitis media or externa.
Worsened with jaw movement, eating.
Tender to palpation atop TMJ.
Treatment for TMJD?
NSAIDS, rest, heat, PT, referral to Oromaxillofacial (OMF) specialist.
Hardening (sclero-) of the ossicular chain of the middle ear, MC the stapes causing slowly progressing hearing loss, usually starting in early 20s?
Otosclerosis
Presentation and management of Otosclerosis?
Presentation: CHL but TM is mobile, dizziness, tinnitus. Often worsens with pregnancy.
Eval: audiometry, Temporal bone CT.
Mgmt: surgical detachment of stapes from oval window (stapedectomy). Hearing amplification.
Noise or ringing in the ears?
Tinnitus
Affects 1/5, it is a Sx not a disorder.
Types of Tinnitus?
Ringing - MC, typically caused by SNHL from high frequency; noise-induced, trauma, cerumen, ARS/ETD, Ménière’s disease.
Pulsation - sudden onset tinnitus; think HTN, carotid bruit, AV malformation, atherosclerosis, vascular neoplasm, ETD.
Clicking - caused by muscle spasm or ossicular changes.
Treatment for Tinnitus?
None. Can consider distraction (white noise) and amplification (hearing aids).
Look at a pt’s medications!
-common too toxic meds include loop diuretics, cancer meds (cisplatin, aminoglycosides), ASA.
What is the most important thing to do with any patient that complains of being dizzy?
Distinguish between dizziness or vertigo & establish if it is PERIPHERAL or CENTRAL
Dizziness: off-balance, lightheaded, “woozy” feeling, disequilibrium.
Vertigo: room spinning OR spinning sensation.
Function of the Cochlea?
Converts mechanical vibrations to nerve impulses interpreted by the brain as hearing.
Function of the Semicircular canals?
Sense position of head in space for input into balance formula, also allows the eyes to track objects.
CENTRAL Vertigo vs PERIPHERAL vertigo?
CENTRAL: gradual onset, no hearing loss, vertical nystagmus.
PERIPHERAL: sudden onset, changing hearing, horizontal nystagmus.
**If syncope cause is CENTRAL - it is NEVER related to inner ear problems.
MC cause of peripheral vertigo?
Benign Paroxysmal Positional Vertigo (BPPV)
*intermittent episodes of room spinning with positional changes lasting <60 seconds.
Classic: pt wakes up, stands and immediately start spinning.
Causes of BPPB and exam to evaluate?
Otolith deposits break from Celia within the semicircular canals causing disruption of brain’s interpretation of position in space.
Exam: Dix-Hallpike Maneuver, VNG (videonystagmography).
Treatment for BPPV?
Eply maneuver, vestibular therapy, meclizine, proprioception, stable gaze.
Inflammatory or post-infectious process of the inner ear causing aural fullness, vertigo, tinnitus, and N/V?
Labrynthitis or Vestibular Neuritis.
Cause of Labrynthitis, signs, Tx?
Often after URI, 1-2 weeks after; MC viral, rarely bacterial.
Signs: rotational nystagmus.
Tx: usually self-limiting, vertiginous episodes last 10-30 sec. Steroids, antiemetics.
Abnormal fluctuations of endolymph fluid within the inner ear causing a change of pressure and resultant Sx??
Meniere’s Disease (aka Endolymphatic hydrops).
What is the triad of Meniere’s Disease?
Tinnitus, hearing loss and vertigo.
Vertigo will last longer, maybe hours, with resolution on its own.
Evaluation and mgmt of Meniere’s Disease?
Evaluation: audiometry, (VNG) that measure response to inner ear stimulation.
Mgmt: vestibular therapy/balance therapy, meclizine, anxiolytics (Valium), diuretics, steroids, low salt diet.
Most severe cases may require labyrinthectomy.
Cause of Central Vertigo?
Acoustic Neuroma
What does an Acoustic Neuroma mimic?
Meniere’s Disease; S/Sx include the triad of MD - hearing loss, vertigo, tinnitus.
Classifications of Hearing Loss?
Conductive Hearing Loss (CHL)
-problem w/EAC, TM, or ossicles; problem conduction vibrations from the TM to the cochlea.
Sensorineural Hearing Loss (SNHL)
-permanent loss in cochlea’s ability to generate nerve impulses.
Mixed
-presbycusis w/cerumen impaction.
Rinne and Weber test?
Rinne test for bone conduction or conductive loss.
Weber test for sensorineural loss.
Progressive Sensorineural Hearing loss?
Presbycusis, noise-induced, congenital, trauma, iatrogenic, idiopathic.
Sudden sensorineural hearing loss?
EMERGENCY!
- start high-dose steroids within 14 days of onset.
- recheck audiogram post-Tx, consider MRI IAC if no improvement.
- Approx. 1/3 will improve/resolve, 1/3 no better, 1/3 worsen.
Hearing loss in the elderly?
Presbycusis
Majority of age-related hearing loss is sensorineural.
Hx will be gradual loss, NOT sudden.
Bilateral, assoc. with Tinnitus.
Difficulty w/speech discrimination.
