ENT 1 Flashcards
What is the initial approach to ENT surgery?
- HPI (OLD CARTS)
- PMHx (thyroid disease, head and neck ca, recurrent tonsillitis or acute otitis media…).
- PSHx (thyroidectomy, otologic surgeries, orthopedic procedure, dental procedures).
- MEDs (antibiotics, Aspirin, chemo)
- Allegies (seasonal and medical)
- FHx (hearing loss, cancer)
- SHx (oral sex, smoking, tobacco use, alcohol)
What does the otolarngology head and neck PE involve?
- Head= battle sign, or racoon sign.
- Eyes= ecchymosis, proptosis; bulging, ptosis…
- Ears= tenderness, erythema, bulging, perforation, effusion.
- Nose= torus tubarius, adenoid pad, masses…
- Oral Cavity= dentition, floor of mouth, tongue, tonsils, lesions, swelling, trismus (painful opening of the mouth)…
- Larynx= endoscopic exam (epiglottis, piriform sinus, vallecula; space between base of tongue and epiglottis, vocal cords)
- Neck= masses, lesions, thyroid, ROM.
- cranial nerve exam= 1-12
What is CONDUCTIVE hearing loss?
- occurs due to something lateral to the oval window= EAC, TM, middle ear, r ossicles.
What could cause CONDUCTIVE hearing loss?
- infection
- effusion
- otosclerosis
- cerumen impaction (MOST COMMON in adults).
- congenital
How do we diagnose CONDUCTIVE hearing loss?
- weber-rinne test= BONE more than air.
- audiotympanogram
How do we treat CONDUCTIVE hearing loss?
- correct underlying pathology
- hearing aid (BAHA vs traditional).
What is SENSORINEURAL hearing loss?
- results from damage to the NERVE pathway (medial to the oval window).
What causes SENSORINEURAL hearing loss?
- noise induced
- presbycusis
- neoplasm
- autoimmune
- infections (meningitis)
- Meniere’s disease
- congenital
How do we diagnose SENSORINEURAL hearing loss?
- Weber-rinne test= AIR more than bone.
- audiotympanogram
How do we treat SENSORINEURAL hearing loss?
- treat underlying pathology
- hearing aid, cochlear implant.
If the WEBER test (tuning fork on top of the head) lateralizes to the left and you hear it better on the left, what type of hearing loss does this indicate?
- CONDUCTIVE because you hear bone conduction better than air in conductive hearing loss.
- if you hear it better on the right, but have a normal Rinne, test, then this is sensorineural hearing loss (on the left).
What is otitis EXTERNA?
- inflammation of the external auditory canal.
* exzematous, bacterial, fungal, malignant/necrotizing.
What is otitits MEDIA?
- inflammation of the middle ear.
* acute, serous, or chronic.
What is acute otitis externa (SWIMMER’S EAR)?
- infection of the skin of the external auditory canal (EAC) caused by retention of water or over cleaning, which leads to alkalotic EAC and an environment for bacterial overgrowth.
What pathogen is most associated with acute otitis externa?
- pseudomonas aeruginosa
* staphylococcus is 2nd
How do we treat acute otitis externa?
- cleaning and debridement of infection.
- otic acidification drops (acetic acid), or antibiotic drops for more severe infections (ciprofloxacin).
- AVOID aminoglycosides bc these are ototoxic!
How can you ensure that drops get into the EAC for acute otitis externa?
- place a wick to widen the canal
What is otomycosis?
- fungal ear infection most often caused by aspergillus.
- will see moist sheets of keratin, dotted block, white or grey membrane in EAC.
How do you treat otomycosis?
- acetic acid
- antifungal drops
- gentian violet
What is chronic and eczematous otitis externa?
- thickening and inflammation of the EAC secondary to chronic low-grade infection.
- dry flaky, itchy EAC with mild pain
How do you treat chronic and eczematous otitis externa?
- debride EAC
- corticosteroid drops
- consider derm consult
What is the most common cause of malignant or necrotizing otitis externa?
- pseudomonas aeruginosa
* immunocompromised pts are high risk
What is common on PE for malignant otitis externa?
- granulation tissue in the EAC at the bony-cartilaginous junction.
How do you diagnose malignant otitis externa?
- technetium 99 bone scan and/or CT of temporal bone
How do you treat malignant otitis externa?
- IV antibiotics
- debridement
- control blood sugar if diabetic.
What are some serious complications of malignant otitis externa?
- cranial neuropathy
- sinus thrombosis
- intracranial infections
What is acute otitis media?
- less than 3 weeks of inflammation of the middle ear due to negative middle ear pressure from Eustachian tube dysfunction, which leads to fluid collection in the middle ear and infection.
- second most common disease in children
What are the most common causes of acute otitis media?
- STREP. PNEUMONIAE= #1
- Haemophilus influenzae
- Moraxella catarrhalis
What are the risk factors for acute otitis media?
- URI
- allergic rhinitis
- second hand smoke
- GERD
- adenoid hypertrophy
What are the PE signs for acute otitis media?
- otalgia
- hearing loss
- feer
- hyperemic TM
- bulging TM
- air-fluid level
- may have perforation with purulent otorrhea
How do you treat acute otitis media?
- amoxicillin or augmentin
- myringotomy tube placed for serve cases or recurrent.
What is SEROUS otitis media?
- presence of middle ear fluid WITHOUT infection.
* most common cause of pediatric hearing loss.
What does any adult with unilateral effusion require?
- nasopharyngeal exam to rule out tumors
How do you treat serous otitis media?
- treat underlying cause
- observe 3 months
- myringotomy tube placement after failed conservative management
What must you worry about with chronic otitis media?
- cholesteatoma= epithelial tumor that can cause bony erosion.
What patients are at high risk for chronic otitis media?
- cleft palate
- down syndrome
- GERD
Will you have a maloderous otorrhea with perforated TM from chronic otitis media?
YES
What are the phases of allergic rhinitis?
- primary reaction phase= type I hypersensitivity (IgE mediated) that occurs within 5 min of exposure.
- secondary phase= 4-6 hours later due to leukotrienes and cytokine mediated. Eosinophils are hallmark.
Will mucosa be blue/boggy with clear rhinorrhea in allergic rhinitis?
- YES
How do you treat allergic rhinitis?
- avoidance of trigger
- nasal decongestants and corticosteroids.
- systemic antihistamines
What are the most common pathogens of acute rhinosinusitis?
- STREP PNEUMONIAE
- M. catarrhalis
- H. influenze
- Strep pyogenes
- Staph aureus
How do we treat acute rhinosinusitis?
- nasal irrigations
- nasal corticosteroids
- antibiotics (amoxicillin)
- surgery for severe cases
What is Pott’s Puffy tumor?
- frontal sinus abscess
What distinguishes chronic rhinosinusitis from acute?
- greater than 6 weeks
What will you see with fungal sinusitis?
- fungal ball (mycetoma) usually from aspergillus (sepatated 45 degrees).
- will be unilateral sinusitis and may lead to unilateral proptosis (bulging of the eye).
How do you treat fungal sinusitis?
surgical removal of the mainstay
What 3 things should you look for in fungal sinusitis?
- nasal polyposis
- allergic mucin (charcot-leyden crystals associated with eosinophilia) and looks like peanut butter.
- nasal mucosal inflammation
What are the common pathogens for INVASIVE fungal sinusitis?
- Mucor (90 degree broad branching hyphae)
- Rhizopus
- Aspergillus
What happens with INVASIVE fungal sinusitits?
- organism invades soft tissue, bone and blood (causing thrombosis and septic emboli).
- seen in immunocompromised pts (AIDS or diabetics).
What is classic finding for INVASIVE fungal sinusitis?
- numbness of the nasal cavity and face
- necrotic black turbinates and soft palate
How do you treat INVASIVE fungal sinusitis?
- aggressive surgical debridement
- IV amphotericin
With what areas of the nose is epistaxis associated?
- WOODRUFF’S area= POSTERIOR bleeds (sphenopalatine and ascending pharyngeal vessels).
- KIESSELBACH’S plexus (little’s area)= confluence of vessels (anterior ethmoid, greater palatine, superior labial, and sphenopalatine) located on ANTERIOR septum
What is important to remember with epistaxis?
- exam the oropharynx, because if you see blood here, you know that you haven’t controlled the nose bleed.
- do vitals, CBC, and coagulation studies
How do we treat epistaxis?
- correct underlying issue
- hold pressure
- cauterization
- packing
Is acute pharyngitis normally due to viral causes?
YES
What is the most common bacterial cause of pharyngitis?
- group A strep
What will you see with pharyngitis?
- odynophagia, drooling, fever, decreased oral intake, enlarged erythematous or exudative palatine tonsils.
How do you treat pharyngitis?
- supportive care or antibiotics
- tonsillectomy for recurrent tonsillitis
What can untreated pharyngitis cause?
- pertonsillar abscess (look for bulge of soft palate)
* treat with drainage and systemic antibiotics
Is retropharyngeal abscess more common in children or adults?
- children
* hot potato voice and difficulty turning neck
To what can retropharyngeal abscess lead?
mediastinitis of fascial plane from skull base to mediastinum
What is the most common cause of epiglottitis?
- H. influenzae type B in children 2-6.
* look for stridor, high fever and swollen epiglottis.
What will you see on X-ray with epiglottitis?
- thumbprint sign
How do you treat epiglottits?
- stabilize airway
- IV antibiotics
- inpatient monitoring
What are the 3 types of aphthous ulcers?
- minor= less than 1 cm
- major (sutton’s disease= recurrent)
- herpetiform= numerous small ulcers lasting more than a month
What is Bechet’s disease?
- aphthous ulcers of the genitalia and upper respiratory tract
What are the 2 common congenital neck masses?
- Thyroglossal duct cyst (TGDC)= failure of complete closure of the thyroglossal duct tract in utero. Treat with Sistrunk procedure.
- Branchial cleft cyst= 4 types
What will you see on PE with thyroglossal duct cyst?
- midline neck mass that moves with protrusion of the tongue. Found inferior to the hyoid and superior to the thyroid gland.
What brachial cleft cyst is the most common?
second
*differentiate from thyroglossal duct cyst by non-midline mass
What is the most common cause of lymphadenitits of the neck?
- viral (EBV, CMV, HIV, adenovirus, roseola, rubella).
What bacteria can cause infectious neck masses?
- Group A strep
- Bartonella henselae (cat scratch fever)
How do you treat infectous neck masses?
- drain and antibiotics
* don’t drain if TB or Bartonella
What is a non-malignant neoplastic neck mass?
- benign salivary gland neoplasm
What is the most common metastatic cancer of the head and neck?
- squamous cell carcinoma
What is the most common malignant salivary gland neoplasm?
- mucoepidemoid carcinoma
What should you always do on suspected neoplastic neck mass?
- Fine needle aspiration bc you need to know what you’re dealing with.
