EENT TEST 2! Flashcards
1
Q
What are the 4 types of Peripheral vertigo
A
Meniere’s vestibular neuritis
labyrinthitis
BPPV
migainous, Cervicogenic
2
Q
What are some features of vestibular neuronitis?
A
- Common, usually follows URI.
- Sudden, severe vertigo with N/V
- Affects CN 8
- No tinnitus or change in hearing
- head impulse test +
- Unidirectional nystagmus
- Hypoactive vestibular apparatus
- Vertigo is frequent too constant, spontaneous, and worse with movement
3
Q
What is the prognosis for vestibular neuronitis?
A
Resolves in days to weeks down to mild positional vertigo.
4
Q
How is labyrinthitis different from vestibular neuronitis?
A
It involves both the cochlea and the labyrinth and hearing is often effected.
5
Q
Where does the nystagmus go in labyrinthitis?
A
Spontaneously to the unaffected side.
6
Q
What is the prognosis of labyrinthitis?
A
May resolve in days to weeks but unsteadiness and positional vertigo may persist for months.
7
Q
What causes labyrinthitis
A
Lots of things: ototoxic drugs, infection, autoimmune, treatment of TB.
Most commonly concomitant to acute infection like OM or sinusitis.
8
Q
What is LABYRINTHITIS?
A
inflammatory d/o of inner ear or labyrinth.
Disturbance of balance & hearing to varying degrees & mb u/l or b/l.
MB: infx acute inflmtn of labyrinth, AI d/o, ototoxic drugs, TB tx.
9
Q
What are the features of viral labyrinthitis?
A
sudden, u/l loss of vestibular fxn & hearing;
acute onset of severe vertigo, n/v, resolves usu several days-wks; but BPPV may persist for several mo;
Involves cochlea & labyrinth,
balance & hearing both affected. Mb concurrent acute URI
10
Q
What are the red flags that may indicate CNS stroke
A
hyperacute onset vertigo, occipital headache or gait ataxia.
11
Q
What is BPPV?
A
brief episode of vertigo that is ALWAYS and only positional.
12
Q
Does BPPV have hearing loss or tinnitus?
A
No it does not.
13
Q
What can cause BPPV?
A
Head trauma, dental surgery, middle ear infection, otoliths.
Otoliths roll across hairs when head moves and sends aberrant signals to brain causing vertigo.
14
Q
What test is diagnostic for BPPV?
A
Dix-Halpike
15
Q
How does one cure BPPV?
A
Epley Maneuvers
16
Q
What is the difference between central and positional vertigo?
A
The primary differentiating feature is downbeat or pure tortional nystagmus on Dix-Hallpike.
17
Q
Recurrent episodic vertigo caused by endolymphatic hydrops (edema) is what disease?
A
Meniere’s Disease
18
Q
What are some symptoms of Meniere’s disease?
A
- Episodic attacks (with dread)
- Severe to violent vertigo with N/V
- Aural fullness
- Fluctuating hearing loss
- Loud, roaring, tinnitus
- Sensitivity to loud noises
- Usually middle-aged women
- Autoimmune?
19
Q
Who does Menier’s classically affect?
A
Middle aged women
20
Q
Will Menieres present with hearing loss
A
fluctuating sensorineural hearing loss, and rarely recruitment, resulting in hypersensitivity to loud noises.
21
Q
What will the head impulse test reveal?
A
lateralized vestibular dysfunction to the symptomatic ear.
22
Q
When should one consider a brainstem stroke?
A
patients with acute audiovestibular loss who do not have typical Ménière’s symptoms.
23
Q
When should one consider an acute ischemic attack is present
A
consider when episodes get worse in a crescendo pattern.
Assess stroke risk factors (HTN, DB, hyperlipidemia)
look for focal neurologic deficits.
Mb brainstem stroke w/acute audiovestibular loss
24
Q
What is bilateral vestibular failure due to?
A
Mostly seen in hospital settings.
Bilateral vestibular failure is due to aminoglycoside toxicity.
.
25
What are the two most common causes of bilateral vestibular failure?
Gentamicin and streptomycin are the common causes
26
What do you do with any vague dizziness or vertigo with unilateral or asymmetric sensory hearing loss?
acoustic neuroma
27
What is an uncommon but dangerous condition that only causes vertigo in 50% of pts?
Assume it's an acoustic neuroma until proven otherwise.
28
What are some features of acoustic neuroma?
|
- Tinnitus
- Facial weakness
- Slowly progressive, unilateral hearing loss.
29
What is a perilymphatic fistula
Breach between the middle and inner ear. Secondary to trauma from a direct blow or sudden barotraumas, occaisionally heavy weight bearing or straining.
Disruption of the oval window allowing perilymph to leak into the middle ear space.
30
What will happen upon insufflation if a perilymphatic fistula is present?
Symptoms will be made worse by insufflation.
31
What happens in superior canal dehiscence
bone overlying the superior aspect of the superior semicircular canal becomes thin or even absent, thereby allowing pressure to be transmitted to the inner ear.
32
migranious vertigo?
Episodic moderate dizziness, N hearing, hx of migraine;
Look for environmental, food, or lifestyle triggers; stimuli - light, sound, or motion, can trigger or aggravate sx.
Dx of exclusion.
33
What are the symptoms of migranious vertigo
N Head impulse test.
If new sx - other dx = stroke or TIA should still be considered if sx do not fit a peripheral vestibular d/o;
Avoid- chocolate, aged cheese, coffee
34
What is the Neuhauser Criteria for Migrainous Vertigo for definite results?
Definite
1. Episodic vestibular symptoms of at least moderate severity
a. Vertigo; positional dizziness and head motion intolerance
2. Migraine according to the International Headache Criteria
3. One or more of the following features during at least two vertigo attacks
a. Migrainous headache
b. photophobia
c. phonophobia
d. migraine aura
4. Other diagnoses excluded by appropriate tests
Probable
35
What is the Neuhauser Criteria for Migrainous Vertigo for probable results?
Criteria for Other diagnoses excluded by appropriate tests and Episodic vestibular symptoms of at least moderate severity
plus at least ONE of the following
1. Migrainous headache
2. Migraine symptoms during vertigo
3. Migraine specific triggers of vertigo (specific foods like red wine)
Response to the anti-migraine treatments
36
What endocrine/metabolic conditions should be on your DDx when treating inner ear disorders?
-Hypothyroid
-Hyperlipidemia
-Electrolytes (specifically Na/K)
-Diabetic and dysglycemia
37
What is cervicogenic vertigo triggered by?
somatosensory input (position sense) in the cervical joints from head and neck movement
38
What red flags suggest central vertigo?
Hyper acute onset of vertigo,
risk factors for stroke
normal head impulse tests,
focal neurological deficits,
new onset headache in a patient without previous migraine,
onset associated with Valsalva.
39
What type of hearing loss is present in BPV?
None
40
What type of hearing loss is present in Vestibular
Neuronitis?
is tinnitus present?
None and no
41
What type of hearing loss is present in Labrynthitis?
is tinnitus present?
Yes w/ Tinnitus
42
What type of hearing loss is present in Ménière’s Disease
Sensorineurral 90% unilateral
43
What type of hearing loss is present in Cholesteatoma
Conductive
44
What type of hearing loss is present in Perilymphatic
| Fistula
mixed sensorineural
45
What type of hearing loss is present in Acoustic Neuroma
Sensorineural
46
How does BPV present?
Paroxysmal, brief, always positional vertigo
47
How does Vestibular Neuritis present?
Sudden onset, constant,
| < Movement, Often follows antecedent viral infection
48
How does labrynthitis present?
Mild to severe vertigo/imbalance accompanied by a concomitant Ear, sinus or nose infection
49
How does Menieres disease present
Episodic attacks of severe vertigo usually with aural fullness and hearing loss
50
How do cholesteatomas present
Recurrent vertigo with history of ASOM with perforation
51
How does a perilymphatic fistula present
History of trauma
52
How does acoutstic neuroma present
Progressive unilateral hearing loss, with vertigo
53
How do you DX BPV
History, Positive Dix- Hallpike, therapeutic response to Epley Maneuver
54
How do you DX vestibular neuritis
History, normal hearing, spontaneous horizontal nystagmus, resolves in hours to days, Abnormal VOR
55
How do you DX labrynthitis
ENT examination, Abnormal VOR
56
How do you DX menieres
History, with recurrences, ABR, Abnormal VOR
57
How do you DX cholesteatoma
Usually visible on otoscopic exam
58
How do you DX a perilymphatic fistula
Positive fistula test (insufflation) < Valsalva
59
How do you DX an acoustic neuroma
Auditory Brainstem Response, MRI
60
If Weber Lateralize to bad ear then...
= conductive hearing loss
61
If Weber Lateralize to bad ear then...Lateralizes to good ear =
sensorineural hearing loss
62
AC > BC =
Normal
63
BC > AC =
Conductive hearing loss
64
AC > BC, but both diminished =
Sensorineural hearing loss
65
Speech audiometry
measures the threshold that speech can be accurately heard.
Usually the greater cochlear hearing loss the poorer word recognition score.
66
Typanometry
is a measure of tympanic membrane mobility (impedance) and an indirect measure of middle ear pressure.
67
Electrocohleography:
is a method for recording the electrical potentials of the cochlea. It is particularly helpful in the diagnosis of Meniere’s disease/endolymphatic hydrops and screening for hearing loss in infants.
68
Auditory Brainstem Response:
This resembles a nerve conduction study. The time taken for an impulse to get from the cochlea to the brainstem is measured.
The time is prolonged with acoustic neuroma (example page 11). Can also be used as an objective hearing test in young children.
69
What is Schwartze's sign?
A pinkish blue hue to TM associated with otosclerosis
70
What might you notice in office about your pt with conductive hearing loss?
They may be very soft spoken and hear better in a noisy environment.
71
What kind of tympanogram are you likely to see in conductive hearing loss?
AS (still)
72
What is the history of a patient with otosclerosis
Progressive conductive hearing loss, usu w/ well preserved speech discrimination; mb sensorineural hearing loss w/ cochlear involvement.
Clinical Pearl: Pts often soft spoken and aware they seem to hear better in noisy environments
73
what is the most common pe in otosclerosis
Stapes & malleus fusing = m/c.
74
Review what the tympanogram for otosclerosis looks like
type a look at a chart!
75
What is Schwartze's sign:
Pinkish/blue hue on TM promontory upon otoscopic exam
associated with otosclerosis
76
What is Carhart's notch
A dip in bone conductive threshold at 2000 Hz. on audiometric testing
associated with otosclerosis
77
What are the three main causes of conductive hearing loss?
inflammatory
otosclerosis
traumatic
78
What are the four main causes of sensorineural hearing loss?
congential
trumatic
neoplastic
inflammatory
79
What is the history of a patient with traumatic sensorineural hearing loss
Head injury or Noise
| Occupations: Farmers, construction, machinists, military, musicians
80
What is the history of a patient with congenital sensorineural hearing loss
Genetic: FHx of deafness
| Non-genetic: dz & injury
81
What is the history of a patient with neoplastic sensorineural hearing loss
9 & malignant neoplasms can affect hearing granulomas, meningiomas, and acoustic neuroma;
82
What is the physical exam findings of sensorineural congenital hearing loss
Waadenburg’s Syndrome – genetic hearing loss w/ white patch of hair
Non-genetic: dt Rubella, jaundice or anoxia at birth, brain injury
83
What is the physical exam findings of traumatic sensorineural hearing loss
Initial complaint = tinnitus: is reversible until hairs in Organ of Corti are damaged beyond repair, then loss is permanent
84
What is the physical exam findings of inflammatory sensorineural hearing loss
Strep -endotoxins that pass through oval window & damage the hair cells; Other infx damage nerves (measles, syphilis)
85
What is the physical exam findings of neoplastic sensorineural hearing loss
u/l hearing loss
| Document w/ audiometry. r/o w/ MRI.
86
What does audiology show for neoplastic sensorineural hearing loss?
Acoustic Neuroma, hearing loss localized in high frequencies
| Retro-cochlear pattern = tumor, behind cochlear. “V wave” is delayed in bad (R) ear
87
What does audiology show for traumatic sensorineural hearing loss?
In noise induced hearing loss there is a characteristic drop off in ↑frequencies
88
What does audiology show for congenital sensorineural hearing loss?
loud volumes usu resonate @ 4k Hz
89
What does Audiology test?
Air and bone conduction between 250-8,000 Hz
90
What kind of tympanogram are you likely to see in conductive hearing loss?
AS (Stiff)
look at this!
91
What does speech audiometry measure?
the threshold at which speech is accurately heard
92
What does auditory brainstem response measure?
the time it takes for impulses to get from the cochlea to the brainstem
93
What minerals are helpful for presbycusis
zinc and copper (if long term)
94
What are a few ototoxic substances?
- Aspirin
- Quinine
- Aminoglycosides
- Erythromycin (high dose)
- Loop and thiazide diuretics
- Platinum based chemo
- CO2
- Nicotine
- Alcohol
- Heavy metals
- Interferon a
95
How can you improve circulation to the middle ear?
Oral: Gingko, vaccinium bilberry, vinca minor.
Local: Hypericum oil, cimicifuga
96
According to the article in american family physician, what are some causes of acute tinnitus?
```
Infection
Meds
Trauma
Loud noises
Wax
Change in BP or metabolism
```
97
According to the article in american family physician, what are some causes of chronic tinnitus?
Damage to auditory cortex from aging
98
According to the article in american family physician, what are some causes of objective tinnitus?
Vascular abnormalities
Mechanical disorders
99
According to the article in american family physician, what are some treatments for tinnitus?
-Acoustic therapy - hearing aids, sound pillows.
- Hearing protection
- Manage insomnia, anxiety, depression
- Manage metabolic disorders
100
Which supplements help stabilize cell membranes?
Antioxidants - Strength cell membranes.
- Quercetin - Stabilize mast cells
- EFAs - Stabilize cell membranes
101
Which bioflavonoid helps by inhibiting the degranulation of mast cells?
Quercetin!
102
Which bioflavonoid inhibits histidine carboxylase and is also a potent antioxidant?
Catechin
103
Which class of EFAs do atopic patients have trouble converting to PGE1?
Linoleic acid, which is an omega 6.
EPO, borage, and black currant all have GLA and avoid this step.
104
Which foods should allergic patients avoid?
Dairy, citrus, animal fat, TFAs.
All food allergens.
105
What are some ways to support the adrenals?
Standard Process: Drenotrophin, Antronex, Corrhyzadyn, Isocort, Multi B vitamins,
-DHEA if indicated by testing.
-Pantothenic acid (B5) precursor to coenzyme A
106
PE for DDx of Perilymphatic Fistula:
insufflations, pressing on tragus – makes it worse
107
PE for Dx of BPV:
dicks/hallpike, brief upbeat the fatigues and then diminishes over time if test repeated– when to suspect central vertigo? Downbeat nystagmus, doesn’t fatigue
108
How sensitive is Rinne test for Conductive hearing loss –
not very, but is specific
109
Differential diagnosis of noninflammatory rhinitis: Structural anomalies
Deviated septum
Hypertrophic turbinates (mechanism undefined)
Ostiomeatal complex (OMC) anatomic variants
Concha bullosa
Paradoxical curvature of the middle turbinate
Choanal atresia
Tumors
Adenoidal hypertrophy with recurrent infections
Complications of excessive surgical excision of mucosa
Strictures
Fracture of cribriform plate
Cerebrospinal rhinorrhea (high glucose)
Hypertrophy of fleshy components of the anterior nasal valve
Rhinophyma , Foreign body
110
Differential diagnosis of noninflammatory rhinitis: hormonal and drug related
```
Pregnancy (estrogen and progesterone)
Hypothyroidism
Acromegaly
Chlorpromazine (neuroleptic)
Adrenergic dysfunction
Antihypertensive agents
Beta Blockers
Reserpine
Rhinitis medicamentosa : Chronic topical α-adrenergic agonist abuse (afrin), Cocaine abuse
Side effects of eye drops delivered via nasolacrimal ducts Glaucoma medications
```
111
Differential diagnosis of noninflammatory Rhinitis:
| Neural dysfunction and other conditions
absent symp fxn (no vasoconstriction)
Horner's syndrome
Hyperactive cholinergic parasymp fxn (XS mucus production)
Cholinergic rhinitis (vasomotor rhinitis)
Trigeminal neuralgia
Gustatory rhinitis, 'salsa sniffles'
Nociceptive rhinitis/irritant rhinitis
weather changes, perfume, tobacco smoke, & inhalants
Nonallergic rhinitis of CFS, fibromyalgia,
Loss of parasympathetic & sympathetic innervation
112
Lab tests to Dx rhinitis lab results on CBC, nasal smear, scratch tests w/different czs of rhinitis
* CBC - may show eosinophilia
* Nasal smear/cytology (GenSa eosinophilic stain) eosinophils is suggestive, if hx matches
* Scratch tests: Pollen extracts are placed on broken skin wheal & flare = IgE rxn to Ag; 1-4+ grading
* RAST/ELISA tests-in vitro serum test: Measure IgE in relation to Ag; Expensive test, use for anaphylaxis or bad eczema/rxn
* Total serum IgE - not a particularly sensitive or specific, mb increased
* (-) findings if vasomotor/cholinergic rhinitis
113
When is the best time ti implement a nutritional program for prophylaxis of allergic rhinitis?
2 months before allergy season.
114
Is urtica dioica good for everyone with hay-fever?
it helps about 58% of the time.
115
What's a good herbal formula for hay-fever?
```
Urtica
Butterbur
Sambucus
Euphrasia
```
116
What are some ways you can help your patients abort a cold?
```
Nature cure
Rest
Water
Simple diet
Hydrotherapy
```
117
Is echinacea effective for the prevention and treatment of URIs?
Apparently yes. It decreases the incidence and duration of the common cold.
However, it's usually used in conjunction with other treatments.
118
What are a few ND sinusitis treatments?
Botanicals: achillea, euphrasia, hydrasits.
Rest, water, simple diet, garlic, etc.
Hydro: Nasal lavage, steam inhalation.
119
When should you order imaging for sinusitis?
Never for acute sinusitis.
If you have persistent sinusitis and you suspect orbital cellulitis or brain abscess.
CT is probably the most accurate.
Fiberoptic visualization of the ostia may reveal obstruction from polyps or anomalies.
120
Are ABX indicated for acute sinusitis?
Rarely, 1 in 8 cases will respond.
|
121
How do you assess and treat epistaxis?
Assess by PE, look for bleeding site.
Frontal epistaxis is usually controlled with pressure or cold.
If uncontrolled, use topical anesthetic and silver nitrate.
122
When is epistaxis potentially dangerous?
If it's a posterior bleed. Refer to an ENT!
Also dangerous if bleeding doesn't stop or if the site of bleeding can't be found.
123
What are a few of the risk factors for sinusitis?
```
VRI
Allergies
Anatomy
MEds
Irritants
Many, many more.
```
124
What is the pathophysiology of sinusitis?
Viran infection leads to blockage of the ostia. Oxygen is absorbed from the enclosed space leading to negative pressure (pain from vacuum). Then transudate and bacteria invade the space leading to inflammation, ciliary dyskinesis, and positive pressure. This causes a second stage of pain.
125
What's the prognosis for sinusitis?
May take 3-4 days for relief.
-Continue Tx for 10-14 days to avoid relapse.
-Refer: persistent HA, high fever, lethargy, orbital swelling.
126
What are some good physmed and hydro options for sinusitis?
```
Nasal specific
Craniosacral
Nasal lavage
Steam inhalation
```
127
What's the DDx for inflammatory rhinosinusitis with mostly eosinophils?
Allergic
- Non-allergic
- Asthma
- Fungal
128
What's the DDx for inflammatory rhinosinusitis with mostly neutrophils?
-Acute bacterial
-Foreign body
-Nasal polyps
-Primary ciliary dyskinesia
129
What do you think about inflammatory rhinosinusitis with complex infiltrates?
common cold
130
What's the general DDx for non-inflammatory rhinosinusitis?
-Structural
-Hormonal
-Drug induced
-Neural dysfunction
-Other (sick building, alzheimer's)
131
What would you expect on CBC, scratch, nasal smear (eos) for allergic rhinitis?
- CBC +
- Scratch +
- Nasal smear (eos) +
132
What would you expect on CBC, scratch, nasal smear (eos) for NARES?
- CBC Neg
- Scratch Neg
-Nasal smear (eos) +
133
What would you expect on CBC, scratch, nasal smear (eos) for vasomotor rhinitis?
- CBC Neg
- Scratch Neg
-Nasal smear (eos) Neg
134
What's the immune pathophysiology of allergic rhinitis?
Some Ag diffuses across the mucus membrane ->Th2 response ->IL-4, IL-13 stimulate B cells to make IgE.
Mast cells -> Histamine, PGL D2, Leukotrienes, Kinins, TNFa.
135
What does degranulation of mast cells eventually lead to in allergic rhinitis?
Contraction of smooth muscle.
Capillary dilation, increased permeability of capillary walls.
Glandular hyper-secretion.
136
Should you give urtica to every patient with hayfever?
No, it's CI for diabetic pts (increases blood glucose) and people with fluid retention secondary to cardiac or kidney disease.
137
What's Herbal Ed's formula for hayfever?
```
Hydrastis
Achillea
Euphrasia
Cochlearia
```
138
What can you give for recurrent epistaxis?
Vitamin C
Bioflavinoids
Homeopathy
139
What are three conditions (besides pharyngitis) that can cause sore throat?
Cardiovascular disease (aortic dissection)
Systemic disease
Other head and neck disorder.
140
Should you always do a quick ENT exam on all patient with a sore throat?
Yep
|
141
What are some oral lesions that can cause sore throat?
- Necrotizing gingivitis
- Herpes simplex
- Hand, foot, mouth
- Apthous ulcers
- Oral candida
- Mononucleosis
142
What are the signs and symptoms of mono?
-Posterior cervical and auricular LA
-Exhaustion and myalgia
-Tonsillar exudates
-Petechia on back of pharynx
-Hepatosplenomegaly (maybe)
143
How do you confirm mono with labs?
- Peripheral smear shows 80-100 atypical lymphocytes.
- Positive monospot.
-Elevated liver transaminases.
144
What is the CENTOR criteria for strep culture?
- Temp over 100
- No cough
- Swollen tender anterior cervical LA
- Tonsillar swelling or exudate
145
What are some cases in which you can safely decline to do a strep culture?
-Close contacts are positive.
-Scarlet fever is evident.
-In strep epidemics.
-Prior ABX
146
What is a strep carrier? Are they at risk for non-suppurative complications of strep throat?
Pts who are GABHS + but ASO titer negative.
They're not at risk, they don't mount an Ab response.
