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Senoir 21-2 > ENT > Flashcards

ENT Flashcards

1
Q

What is the most common malignant lesion of the auricle

A

Basal Cell Carcinoma

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2
Q

A pt presents with a non healing lump of the outer ear

What is the Highest DDX

A

Basal Cell Carcinoma

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3
Q

What is the Tx approach to Basal Cell Carcinoma

A

Treatment
Refer to Dermatology or ENT!!

Non-surgical

  • Topical 5-fluorouracil
  • Radiation therapy

Surgical

  • Local excision
  • Mohs surgery- 97-99% cure rate
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4
Q

A pt presents with a non healing ulcer or plaque on the ear think..

A

Squamous cell carcinoma

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5
Q

What is the Tx for Squamous Cell Carcinoma

A

Treatment
Refer to ENT or Derm

Non-surgical
-Radiation therapy

Surgical
-Local excision

  • Mohs Surgery
  • Neck dissection and parotidectomy (advanced cases)
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6
Q

What is the follow up for squamous cell

A

Requires through examination of cervical lymph nodes
Regular follow-up is required
Sooner if any recurrence of the lesion

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7
Q

A pt presents with a pigmented lesion On the ear

Think..

A

Malignant melanoma

Assoc. with high mortality

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8
Q

What does ABCDE stand for

A 
Asymmetry 
Border 
Color 
Diameter 
Evolving

Determine if its a mole or melanoma

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9
Q

What is the Tx for malignant melanoma

A

Treatment
-Early detection and excision
+/- lymph node dissection

Prognosis

  • Thin (epidermis) <10% risk of mets
  • Thick (dermis) >90% risk of mets
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10
Q

What is an auricular hematoma

A

Soft mass in the ear
(boxers ear, wrestler)

Occurs after trauma from sheering forces

  • blood vessels are torn
  • forms hematoma
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11
Q

A pt presents with a edematous, fluctuante, ecchymotic mass with loss of normal landmarks of the ear after trauma to the ear

Think

A

Auricular hematoma

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12
Q

What is the tx for auricular hematoma

A 
Treatment
-Incise and drain (I&D) Hematoma
-Pressure dressing
-Prophylactic ABX
—Cover for staph 
—Dicloxacillin or Cephalexin

If Pseudomonas concern
(water, diabetes)
—Ciprofloxacin

STAT Referral to ENT if >7 days old

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13
Q

What ABX covers pseudomonas

A

Ciprofloxacin

High concern with water exposure and DM

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14
Q

What are the complications from an auricular hematoma

A 
Ear canal blockage
Necrosis
Infection
Cauliflower ear
—If not treated in 48-72 hours
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15
Q

What defines a simple vs extensive ear lacerations

A

Simple- skin only

Extensive- Involves cartilage

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16
Q

What are three signs of a basilar skull fx

A

-Retroauricular hematoma (Battle sign)
-Ecchymosis around eyes
(Raccoon eyes)
-CSF in ears or nosE

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17
Q

What are 4 signs of middle ear trauma

A
  • Hemotympanum
  • Amber/clear middle ear effusion
  • Otorrhea
  • Hearing deficit (HL) with Weber/Rinne
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18
Q

What is the imaging choice for a EAr lac

A

CT scan non con (if severe underlying)

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19
Q

What is the Tx for an ear lac

A

Prefer primary closure
-Limits time cartilage is exposed

Secondary closure
If >24 hours old
-Inflammation/infection

Cover repairs with pressure dressing
—Prevent hematoma

Cartilage-penetrating antibiotics
—Ciprofloxacin

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20
Q

What is the best cartilage penetrating ABX

A

Ciprofloxacin

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21
Q

When should we refer an EAR lac

A

Avulsion- ENT, plastics, or maxillofacial surgeon

EAC extension- ENT

Middle ear/inner ear injury-ENT
—Vestibular symptoms
—Hearing Loss

Basilar skull fracture- neurosurgeon

If you’re not comfortable

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22
Q

What is the MC cause of ear cellulitis

A

Ear piercing and Trauma

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23
Q

What is the bug that causes cellulitis of the ear

A

Psuedomonas

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24
Q

What is the most common cause of cerumen impaction

A

MC from cleaning inside the EAC

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25
Q

What is the most common cause of foreign bodies in the ear

A

MC- Children placing something in EAC

Insects

Hearing aid batteries

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26
Q

When should you refer a foreign body ear obstruction

A

If anesthesia needed
Uncooperative child
Difficult removal

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27
Q

What are the common organisms in external otitis

A

Organisms

  • Gram negative rods- Pseudomonas, -Proteus
  • Fungus- Aspergillus
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28
Q

What are the ABX for external otitis

A

Refractory cases or cellulitis present

-Oral fluoroquinolones- ciprofloxacin 500 mg twice a day for 1 week

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29
Q

What is malignant otitis externa

A

Persistent, foul aural discharge

Deep otalgia

Temporal headaches

Late sign- CN palsies

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30
Q

A pt presents with foul aural discharage and granulations in the EAC
Late signs of CN palsy’s

Think

A

Necrotizing Otitis Externa

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31
Q

What is the Gold standard for Imaging of Nec Otitis Externa

A

CT

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32
Q

What is the Tx for Malignant Extrenal Otitis

A

Systemic ABX
Ciprofloxacin

Until Gallium scanning shows resolution

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33
Q

What is the most common cause of Pruritus

A

MC- Excoriation from overzealous cleaning

Psoriasis

Seborrheic dermatitis

Otitis externa

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34
Q

What is the tx for pruritus of the ear

A

Treatment
-Allow cerumen to regenerate

Avoid: 
Soap and water
Cotton tipped applicator (CTA)
Scratching
Excessively dry skin- Mineral oil
Inflammation- Topical steroid (0.1% triamcinolone)
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35
Q

What is an Exostoses

A

Bony overgrowths of the EAC

Symptoms:

  • Often asymptomatic
  • Occasional aural fullness or HL
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36
Q

What is surfers ear

A

Repeated exposure to cold water that leads to bone formation in the ear

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37
Q

Do we irrigate organic material out of the ear

A

NO!

Organic material can swell!

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38
Q

Describe patillas Eustachian tube defect

A

Stuck open Eustachian tube

  • Aural fullness
  • Increased autophony
  • Worse when exercising, better with a URI

2/2 Rapid wt loss, NMD, or idiopathic

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39
Q

What is the tx to patilludo eustachiain tube defect

A

Avoid decongestants
Insert ventilation tube
Surgery- Rarely

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40
Q

Describe Eustachian tube dysfunction

A

S/s

  • Aural fullness
  • Fluctuating hearing
  • Discomfort with barometric pressure change
  • Popping or cracking when yawning/swallowing

2/2 Viral URI or Allergy, Irritants, or pregnancy.

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41
Q

You see retracted TM and Decreased TM mobility

Think

A

Dilatory Dysfunction of the TM

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42
Q

What is the tx approach to dilatory dysfunction of the Eustachian tube

A

After viral illness-
Pseudoephedrine 60 mg po q 4-6 hrs and/or

Oxymetazoline 0.05% spray q 8-12 hrs (<3-5 days)

Autoinflation- if no active infection

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43
Q

What intranasal steroids are used in Eustachian tube dysfunction

A

Fluticasone 2 sprays per nostril q day

Beclamethasone dipronionate 2 sprays per nostril bid

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44
Q

What are the common causes of serous otitis media

A

More common in children

Chronic Eustachian tube dysfunction
URI, Allergies, barotrauma

Negative pressure -> fluid transudation

If persistent and unilateral- R/O nasopharyngeal carcinoma

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45
Q

If a pt has persistent and unilateral serous otitis media

What should you R/o

A

Nasopharyngeal Carcinoma

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46
Q

What are the 4 reasons that children are at an increase Risk of Serous otitis media

A 
1- Shorter ET
2- Horizontal ET
3- Immature floppy elastic cartilage
4- Larger adenoids
*Tube usually reaches adult length by age 6
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47
Q

Where does the Weber lateral to on a conductive hearing loss

A

To the effected ear

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48
Q

What is the Rhine test do in conductive hearing loss

A

Bone greater than AC

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49
Q

What is the Tx approach to serous otitis media

A

Decongestants- oral and intranasal
Intranasal corticosteroids

With autoinflation (Valsalva)- if no URI

Surgical interventions- laser or balloon dilation

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50
Q

Describe Acute Otitis media

A 
Ear Pain
URI
Decreased hearing
Aural pressure
Fussy
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51
Q

What are the most common causes of acute otitis media

A

HISSM

H. influ
Strep Pneumo
Strep Pyogenes
Moraxella (Kids)

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52
Q

What is the progression of acute otitis media

A

Viral URI- ETD- Fluid mucus build up - bacterial infection

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53
Q

What are the Tm Findings in Acute otitis media

A

White/Yellow

Dilated blood vessels

Hypomobile

Occasionally bullae

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54
Q

What is the tx for acute otitis media

A

Analgesics!

76% of children improved on symptomatic treatment alone

Children >2 y/o, mild symptoms
-SNAP protocol

Adults or children < 2 y/o, or children >2 y/o with severe symptoms
—Targeted antibiotics

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55
Q

What is SNAP treatment for acute otitis media

A

SNAP- Safety Net Approach to antibiotic Prescriptions

  • Clinical suspicion of AOM
  • Give prescription for ABX

Parent doesn’t fill Rx unless child’s condition worsens or does not improve in 48 hours

Proven to lessen # of filled Rx

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56
Q

What are the 1st line ABX in Acute otitis media

A

First line-

Kids- Amoxicillin 80-90 mg/kg/day (divided into 2 doses)

Adults- 1g q 8hrs
5-7 day course!!!

PCN allergic
—Azithromycin

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57
Q

What are the second line ABXs for acute otitis media

A

Second line- for resistant strains
—Amoxicillin/clavulanate (Augmentin)
—Cefuroxime
—Cefpodoxime

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58
Q

What is an amoxicillin rash

A

3 - 10% of children taking amoxicillin develop an itchy maculopapular rash >72 hours after beginning medication

Occasionally in adults too

Starts on the trunk and can spread from there

This rash is not a contraindication for future amoxicillin usage, nor should current regimen necessarily be stopped

But is it Infectious Mononucleosis?
80-90% of patients with acute EBV infection treated with amoxicillin develop such a rash
—Consider Monospot testing

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59
Q

Define recurrent otitis media

A

Recurrent AOM
-3-4 bouts in 6 months or 5-6 bouts/year

Daily sulfamethoxazole or amoxicillin for 1-3 months

If ABX fail->ear tubes

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60
Q

What are the 4 prevention methods to acute otitis media

A

Breastfeeding

Pneumococcal conjugate vaccine

Avoid tobacco smoke

Avoid daycare

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61
Q

What are the complications of acute otitis media

A

Facial paralysis
Sigmoid sinus thrombosis
Central nervous system infection

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62
Q

A pt presents with Aural Dc from the ear
Perferated TM and conductive hearing loss
Think?
Tx?

A

Chroninc otitis media

Tx:
Remove infected debris

Water precautions

Chronic drainage

-Oral ciprofloxacin 500 mg daily
for 1-6 weeks!!

Exacerbations
Topical floroquinolone

IF it doesnt heal on its own
Then SRGRY
With mastoidecotmy + CT

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63
Q

If you see a chronically draining ear

Think

A

Cholesteatoma

S/s chronic ear draining, intact TM, hearing loss

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64
Q

What is the most common cause of Cholestatoma

A

MC cause- Chronic ETD

Negative pressure-> Retraction pocket-> Keratin debris buildup

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65
Q

What is the Tx approach to cholestaeatoma

A

Surgery!
—Marsupialization

Complete removal of the keratin sac

ETD is still present so can recur
Need to be monitored for life

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66
Q

What are the complication of an unrepared cholesteatoma

A

Complications if not repaired

Bone erosion->destruction of mastoid-> destruction of ossicular chain (hearing loss)

If still not repaired:
—Erode into inner ear- dizziness
-Involve facial nerve (CN VII)- facial nerve palsy
—Erode intracranially (rare)- meningitis, brain abscess

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67
Q

A pt presents with Fever and post auricular eat pain
With a protruding audible

Think

A

mastoiditis

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68
Q

Which of the HISSMs do not effect mastoiditis

A

M. Catarallis

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69
Q

What is the Tx and W/u for mastoiditis

A

CRT scan!

Tx:

IV ABX (admit)
-Cefazolin 0.5-1.5g every 6-8 hours

ABX failure, more severe cases
Surgery
—Mastoidectomy

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70
Q

What is mastoiditis long term treatment requirement

A

Long term ear cleanings

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71
Q

A pt presents with deep otalgia with fouls D/c
Retro orbital pain and 6th nerve palsy

Think

A

Petrous apicitis

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72
Q

What is the treatment for petrous apicitis

A

Long term abxs

+/- surgical drainage of petrous apex

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73
Q

What is the complication of petrous apicitis

A

Meningitis

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74
Q

What is the cause of facial nerve paralysis and what is the Tx

A

Cause- Bacterial neurotoxins

Treatment

  • Myringotomy for drainage and culture
  • ABX based on culture
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75
Q

What is the chronic cause of facial nerve paralysis

A

Cause- cholesteatoma

Treatment-
Surgical correction of cholesteatoma

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76
Q

What is sigmoid sinus thrombosis

A

Cause from septic emboli in the sigmoid sinus

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77
Q

A pt present with spiking fevers, chills, ICP, HA, N/V, Lethargy, and papiledema

What thrombotic event may have occurred

A

Sigmoid sinus thrombosis

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78
Q

What is the most common cause of otogenic meningitis

A

MC intracranial ear infection complication

Acute- S. pneumo and H. flu

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79
Q

What is otosclerosis

A

Familial disease->Hearing loss

Ossicles harden progressively

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80
Q

When should we refer to ENT for hearing loss post trauma

A

If CHL >30 db lasts over 3 months, refer to ENT

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81
Q

A pt presents with pulsatile tinnitus and Hearing loss

Think what neoplasm of the ear

A

Glomus tumors

S/s:
+/- Vascular mass behind TM
CN VII, IX, X, XI, XII neuropathies

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82
Q

Any time someone presents with pulsatile tinnitus

What must you order

A

Magnetic resonance angiography (MRA)

Magnetic resonance venography (MRV)

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83
Q

When should you abort the dive if you can’t equilize your ears

A

If not equalized with in 15 feet

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84
Q

What is a perilymphatic fistula

A

From overpressurization

Oval or round window ruptures
Immediate Emesis and vertigo
Very dangerous!

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85
Q

Describe decompression sickness

A

Air bubbles develop in vasculature of ear on ascent
Hearing loss
Vertigo
Need immediate recompression

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86
Q

Which is more severe

Peripheral or central vertigo

A

Peripheral

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87
Q

How does caloric stimulation work

A

Vestibulo-ocular reflex, sensitive for vestibular disorders

Place cold water in ear, then warm water

Normal response- COWS- Cold Opposite Warm Same

Fast beat of nystagmus goes away from cold

Fast beat of nystagmus goes toward warm

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88
Q

Describe Menieres syndomre

A

S/s Vertigo: 20-min to hours
Low tone tinnitus + blowing sound
Unilateral aural pressure

2/2 syphillis of truama or idiopathic

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89
Q

What is the treatment to Menieres

A

Low-salt diet

Diuretics

Acetazolamide (not a true diuretic, but a side effect)

Symptomatic relief of acute attacks
—Diazepam
—meclizine

Surgical options: 
Ablation with gentamycin 
Sac decompression 
Nerve section 
Echtomy
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90
Q

A pt presents with hearing loss, vertigo of sudden onset
That gradually improves over weeks
+ tinnitus

Think

A

labrynthitis

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91
Q

What kind of nystagmus is present in labrynthitis

A

Spontaneous horizontal nystagmus

Improved with visual fixation

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92
Q

What is the tx for labrynthitis

A

Known bacterial infection
—Antibiotics

Vestibular suppressants

  • Meclizine
  • Diazepam

Short-term use only!!
—First 2-3 days

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93
Q

A pt presents with peripheral head movement vertigo from rolling over in bed
Lasts less than 60 seconds

Think

A

BPPV

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94
Q

What is the cause of BPPV

A

Suspected Otoconia in the semi-circular canals

Usually no inciting events

Can follow trauma or vestibular neuronitis

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95
Q

What is the most common cause of vertigo

A

BPPV

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96
Q

Describe vestibular neuronitis

A

Very similar to labrynthitis

However NO HEARING LOSS!

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97
Q

What cranial nerve inflamation leads to vestibular neuronitis

A

CN VIII from a possible viral infection

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98
Q

A pt prestns with absent caloric signs in one or both ears

Think

A

Vestibular neuronitis

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99
Q

What is the Treatmetn for vestibular neuronitis

A

Supportive care

+/- Valium or diazepam

With vestibular rehab for persistnence

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100
Q

When would hearing loss present in a traumatic vertigo

A

If there is a basilar skull fx

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101
Q

What is the chronic manifestation of traumatic vertigo

A

Cupolithiasis (positional vertigo )

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102
Q

What is the tx approach to traumatic vertigo

A

Supportive care

Vestibular suppressants
-Acute phase ONLY!

Vestibular rehabilitation

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103
Q

What is the treatment for a perilymphatic fistula

A

Refer for tissue grafting

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104
Q

What are the common causes of cervical vertigo

A

Trauma
Hyperextension
Degenerative Disc Disease

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105
Q

What is the most common complaint in vestibular schwannoma

A

Hearing loss

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106
Q

Any one with one sided hearing loss should get what ordered

A

MRI!

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107
Q

An older pt with neck extension induced vertigo

Think

A

Vascular compromised vertigo

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108
Q

What do we order for a pt with vasc compromise vertigo

A

MRA

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109
Q

What is the tx for vasc compromise vertigo

A

Asprin and vasodilation

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110
Q

How does MS present with vertigo

A

Episodic Vertigo

Chronic imbalance

Hearing loss (rare)

  • Unilateral
  • Rapid

Spontaneous recovery

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111
Q

How does MS look on MRI

A

Demylenation of white matter

Refer to neuro

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112
Q

What is sensory hearing loss

A

Deteriórate of the cochlea

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113
Q

What are the 4 main causes of conductive hearing loss

A

Obstruction- Cerumen impaction
Mass Loading- Middle ear effusion
Stiffness- Otosclerosis
Discontinuity- Ossicular disruption

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114
Q

What is the most common cause of sensorineural hearing loss

A

Presbyacusis

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115
Q

What are the rinne and Weber for conductive hearing loss

A

Weber test-
Sound louder in bad ear

Rinne test-
Bone conduction > Air conduction

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116
Q

What is the Weber and Rinne test in sensorineural hearing loss

A

Weber test- Sound lateralizes to good ear

Rinne test- AC>BC

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117
Q

What is the treatmetn for sudden (less than 72 hours) sensorineural hearing loss

A

Decompaction

Or steroids consult with ENT

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118
Q

Pulsatile tinnitus gets what

A

MRA and MRV

+ temporal bone CT

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119
Q

What is the only medication that has shown effect for tinnitus

A

Nortryptiline

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120
Q

What is the treatment for hiperacusis

A

If cochlear dysfunction then hearing ain’t with compression circuits

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121
Q

What are the levels of an Audiogram

A

0 dB= quiet tone that a young adult can hear 50%of the time
Normal: 0-20 dB
Abnormal: >25 dB
Evaluates both AC and BC

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122
Q

What speech discrimination score needs hearing aids

123
Q

What is the decible range for mild hearing loss

124
Q

What is the dB range for moderate hearing loss

125
Q

What is the dB range for severe hearing loss

126
Q

What is the dB range for profound hearing loss

A

Greater than 80

127
Q

What is a tympanograph

A

A Tympanogram is a graphic picture of the middle ear function that results as the pressure is varied against the TM

X axis = pressure against the TM;
Y axis = compliance of TM

128
Q

What is a type A Tympanograph

A

Type A: Normal Tympanogram
The peak of the pressure curve occurs near 0 daPa (decapascals)

Peak compliance falls between .2 and 1.8 ml

129
Q

What is a Type As tympanograph

A

Type AS (shallow): Abnormal

The peak of the pressure curve is near 0 daPa, which is normal, but with decreased compliance

Often associated with ossicular fixation, otosclerosis or TM scarring

130
Q

What is a type AD Tympanogram

A

Type AD (deep): Abnormal Tympanogram

The peak of the pressure curve near 0 daPa (normal)

The peak of the pressure curve is above 2.0 ml

Peak compliance very high or off chart

May result in a fairly flat, non-fluctuating hearing loss

131
Q

What is the Dx for a Type AD Tympanograph

A

Diagnoses: ossicular disarticulation or ossicular chain discontinuity

132
Q

What is a type B Tympanograph

A 
Type B (flat): poorly mobile 
Peak is absent/poorly defined and at markedly negative middle ear pressure (>-200 daPa)

Little or no mobility of TM

Indicated fluid in the middle ear or a TM perforation

133
Q

What Will Tympanograph read if there is fluid in the middle ear or a TM rupture

A

Type B flat

134
Q

What is a type C Tympanograph

A

Type C: Retracted TM or ETD
Clearly defined peak on the negative side of the chart, indicating negative middle ear pressure

Peak pressure is negative, approx. -150 daPa or less (moved to left)

135
Q

What is the Dx for a type C Tympanograph

A

Diagnosis: Eustachian tube dysfunction, may cause a very mild CHL, or hearing can be WNL

136
Q

What is the osteomeatal complex

A

channel that links the frontal sinus, anterior ethmoid air cells and maxillary sinus to the middle meatus, allowing airflow and mucociliary drainage.

137
Q

A pt presents with clear rhinorrhea, nasal congestion, hyposmia, and sore throat

Think

A

Acute Viral Rhinosinusitis

138
Q

What is the typical duration of Acute Viral Rhinosinusitis

A

Usually last less than 10 days, but can be up to 4 weeks

139
Q

What is the tx appraoch to Acute Viral Rhinosinusitis

A 
Symptomatic- NO ABX!!
Congestion
-pseudoephedrine 30-60 mg q 4-6 hrs
-Hypertonic saline nasal rinse (3-5%)
-Nasal sprays- oxymetazoline- not more than 3 days
140
Q

A pt presents with thick purulent nasal D/c with nasal congestion
Fevers, anosmia, perception of a foul odor and dental pain

Think

A

Acute bacterial Rhinosinusitis

141
Q

How long must S/s be present to Dx Acute Bacterial Rhinosinusitis

A

Symptoms must either last over 10 days or worsen after an initial improvement within 10 days to differentiate from viral sinusitis.

142
Q

What are the common pathogens in Acute Bac Rhinosinusitis

A

S. pneumoniae
H. influenza
M. catarrhalis
S. aureus

143
Q

What is the Tx approach to Acute Bacterial Rhinosinusitis

A

Symptomatic first!
-Treat pain- NSAIDs

Congestion-

  • Oral or nasal decongestants
  • Intranasal steroids
ABX: only for complicated cases or severe s/s
-amoxicillin (500) 5-7 days 
-amoxicillin (2000)  7-10 days 
(Severe or old) 
-Doxy or Clindamycin if ALRGY
144
Q

What is the presentation of Orbital Cellulitus

A 
Usually from ethmoid sinusitis
Physical exam
Proptosis
Gaze restriction
Orbital pain
145
Q

What is the approach to orbital cellulitis

A

ANY CHANGE in eye exam

Immediate CT- send to ER if you can’t get one

Treatment-
IV ABX
Refer to ENT and opthalmology

146
Q

How does an orbital abscess present

A 
Secondary to orbital cellulitis
Physical exam
-Proptosis
-Ophthalmoplegia
-Pain with medial gaze
147
Q

What is the tx for an orbital abscess

A

Immediate referral to ENT for decompression/drainage

148
Q

A pt presents with a frontal sinus inflammation with tender swelling of the forehead

Think

A

Osteomyelitis

149
Q

What is the tx for osteomyelitis

A

Treatment- Refer

Prolonged ABX

Removal of necrotic bone

Cosmetic reconstruction

150
Q

What is the number one agent of nasal vestibulitis

A

Staphylococcus aureus #1
Nasal manipulation
Nasal hair trimming

151
Q

A pt presents with erythema, tenderness, swelling, and a furuncle at the nose

Think

A

Nasal Vestibulitis

152
Q

What is the tx approach to nasal vestibulitits

A

Anti-staph antibiotics
-Dicloxacillin 250 mg po qid x 7-10 days
+/- Mupirocin

If recurrent
Dicloxacillin + Rifampin
(for last 4 days of treatment)
Attempt to eliminate carrier state

If furuncle present
I&D

153
Q

What is the most common nosocomial infection of the sinuses

A

S. Aureus

Usually causing nasal vestibulitis

154
Q

What is the Tx approach to S. Aureus colonization

A

Attempt to eliminate carrier state

-Mupirocin 2% ointment + -Chlorhexadine facial washing bid for 5 days

Still only eliminates 39% of carriers

155
Q

What pts have an increased risk of fungal sinusitis

A

DM
Long term steroids
AIDS

156
Q

What is the classic sign of fungal sinusitis

A

Black eschar on the middle turbinate

157
Q

What is the tx approach to Invasive Fungal Sinusitis

A

Medical and surgical emergency

Emergent referral to ENT

Start IV Voriconazole

158
Q

A pt presents with sneezing, tearing, clear rhinorrhea, eye irritation, and pruritus

Think

A

Allergic rhinitis

159
Q

When is allergy blood testing perferred

A

Preferred if:

  • Pregnant
  • Poorly controlled asthma
  • Hx of anaphylaxis
  • Dermatographism
  • Meds- TCA, MAOI, B-Blocker
160
Q

On exam you find pale or violaceous turbinates

Think

A

Allergic Rhinitis

161
Q

What pts should get skin prick testing

A

For patients who:
Have unknown/uncontrolled allergies

Want to avoid long term meds

Must D/C antihistamines 7 days before test

162
Q

What is the mainstay of Tx for allergic rhinitis

A

IN Steroids

163
Q

Describe vasomotor rhinitis

A

Hypersensitivity of the Vivian nerve

Triggered by air temp, odor, light, ect

164
Q

What is the tx approach to non allergic rhinitis

A

Ipatropium bromide

165
Q

Describe rhinitis mediamentosa

A

Overuse of nasal decongestant

Tx stop

166
Q

What is the most common site for epistaxis

A

Kesselbacks plexus

167
Q

What site is a bad site for epistaxis

A

Posterior- Woodruff’s plexus (worse)

168
Q

What are the tx for epistxias

A

15 minutes of direct pressure

+/- Topical Nasal Decongestant+ pressure

If that fails:
Cocaine or cauterize + lidocaine
Packing it iodofrom

169
Q

What is the tx approach to a posterior epistaxis

A

Refer to ENT for posterior packing

Emergency setting- double balloon pack

Admit

Opioids for comfort

Surgery- when packing fails

170
Q

What is the most commonly fx bone in the body

A

Nasal pyramid

171
Q

What is the ABX to use when packing the nose

A

Cephalexin or Clindamycin

172
Q

What are the two etiologies of a quantitiative platelet D/o

A

Reduced survival or reduced production

173
Q

A pt that starts bleeding a lot in the dental office from procedure

Think what D/o

174
Q

What is the difference between acute and chronic Immune Thrombocytopenia

A

Acute ITP

  • Most common in children
  • Usually follows viral illness

Chronic ITP

  • Most common in adults
  • Associated with secondary causes
175
Q

Thrombocytopenia is defined as what value

A

Less than 100,000

176
Q

What must you R/o in Immune thrombocytopenia

A

Diagnosis of exclusion

Rule out secondary causes

177
Q

What is the tx approach to Immune Thrombocytopenia

A

Bleeding and platelets ≤ 50K

  • Glucocorticoids
  • Intravenous immune globulin (IVIG)
  • Platelet transfusions

Splenectomy
(Severe cases)

178
Q

Once Hit is expected the clinician should perform…

A

Once HIT is suspected, the clinician must establish the diagnosis by performing a screening PF4-heparin antibody enzyme-linked immunosorbent assay (ELISA)

179
Q

What is a bad 4T score

A

Greater than 6

180
Q

What is the Tx for HIT

A

Initiated as soon as the diagnosis is suspected

Before results of laboratory tests are available

Discontinue all forms of heparin

Begin treatment with direct thrombin inhibitor, fondaparinux, or DOAC

NO WARFARIN! until pl found is above 100,000

Rule out DVT

181
Q

How long should anticoagulant be done after HIT

A

In patients with documented thrombosis, anticoagulation should continue for 3-6 months after the platelet count has recovered

In patients without documented thrombosis, anticoagulation should continue for 30 days after the platelet count has recovered

182
Q

What are the two main types of thrombotic microangiopathy

A

Thrombotic Thrombocytopenic Purpura (TTP)

Hemolytic Uremic Syndrome (HUS)

183
Q

What are the two primary features of Thrombotic Microangiopathy

A

Microangiopathic hemolytic anemia (MAHA)
—Shearing of RBCs in microcirculation (schistocytes)

Thrombocytopenia
—Due to incorporation of platelets into thrombi in microvasaculature

184
Q

A female pt at age 40 presents with fatigue, dyspnea, petechia with abdominal pain and tenderness

With a classic PENTAD of 
Nuero abNML 
MIcroangiopathic hemolytic anemia 
Fever 
Abnml renal function 
Thrombocytopenia

Think

A

Thombotic Thrombocytopenic Purpura

185
Q

If you see schictocytes on peripheral smear

Think

A

Thrombotic Thrombocytopenic purpura

186
Q

What is the treatment for TTP

A 
Plasma exchange
 (mainstay of care for both presumed and confirmed diagnosis)

—Untreated leads to neuro deteriorations, cardiac ischemia, irreversible renal failure, death

—Continue until platelet count recovers or alternate diagnosis made

Glucocorticoids
—In addition to plasma exchange

Rituximab

187
Q

Define hemolytic uremic syndrome

A

Defined by the simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury

One of the main causes of AKI in children

Leads to oliguric or anuric renal failure

188
Q

What is the common agent of HUS

A

Most common is SHIGA Toxin E. Coli

189
Q

A child presents with blood diarrhea

What is the possible thrombotic D.o

A

hemolytic Uremic Syndrome

2/2 STEC

190
Q

If you see schistocytes in a child think

A

Hemolytic Uremic Syndrome

191
Q

What is the tx for Hemolytic Uremic Syndrome

A

Primarily supportive care
Fluid and electrolyte management, anti-hypertensives, transfusions (platelets, pRBCs)

Often inpatient management

No ABX, NO Antimotility agents, No NSAIDS

192
Q

Why do we give TTP plasma exchange

A

To give the ADAMs13

193
Q

How do nasal polyps present

A

Chronic Nasal Obstruction
Diminished sense of smell
Usually history of allergies

Looks pale, and covered in mucus

194
Q

What is the 1st line treatment for Nasal polyps

A

Treatment
INS- first line
—Improve QoL
—Reduce need for surgery in small polyps

Short course of oral steroids

Surgery- when large or recurrent

195
Q

What medication must be avoided in a pt with nasal polyps

A

AVOID Aspirin!

May cause bronchospasm

196
Q

If a kid has nasal polyps

Think

A

Cystic Fibrosis

197
Q

What is an inverted papilloma

A

Typically benign nasal obstruction that bleeds easily

Caused by HPV

Looks cauliflower like

Often passed in utero

198
Q

What is the tx for Inverted Papilloma

A

Surgical excision

  • Medial maxillectomy
  • Occasionally endoscopically

All excised tissue must be biopsied

199
Q

What is the most common cause of malignancy in the nose

A

Squamous cell carcinoma

Common in southern Chinese

200
Q

A pt presents with unilateral nasal obstruction
With pain and recurrent hemorrhage

Think

A

Possible malignancy

201
Q

A pt presets with a unilateral serous otitis media

Think

A

Cancer UPO!!

202
Q

What is the imaging for Malignancy of the Nose

A

MRI! And Bx

203
Q

What is the treatments for malignant tumors of the nose

A

Very early stage-Local radiation

Advanced stage- radiation + chemo

Recurrent nasopharyngeal carcinoma
-Surgery + repeat chemoradiation

204
Q

A pt presents with blood stained crust and friable mucosa

Think

A

Granulomatosis with polyangitis

205
Q

A pt presents with engorged turbinates and small white granulomas

With noncaseating granulomas

Think

A

Sarcoidosis

206
Q

What is the progression of leukoplakia

A

Hyperplasia->Dysplasia->Carcinoma in situ-> malignant tumor

2-6% will become malignant

207
Q

A pt presents with a white lesion that cannot be removed by rubbing in the oral mucosa

Think??

A

Leukoplakia

208
Q

Which is more likely to be cancer

LEuko or Erythroplakia?

209
Q

What is the plan for leukoplakia and erythroplakia

A

Early referal and Bx

210
Q

Define Oral Lichen Planus

A

Autoimmune

Similar to Lacy Leukoplakia and requires Bx to Dx

Treatment: Pain MGMT, Corticosteroids and Tacrolimus

211
Q

A pt presents with a raised, firm, white lesions with ulcers at the base
In the mouth

Think…

A

Oral Cancer

212
Q

Tx approach to Oral Cancer

A

Less than 2 cm is local resection

Greater than 2 cm is neck dissection and radiation

213
Q

What does ABCDE mean for cancer

A

Assymetry, irregular Borders, variable Color, increased Diameter, Elevation

214
Q

What is the most common cause of oropharynx cancer

A

HPV»> Cigs

215
Q

A Pt presents with wt loss and unilateral odynophagia
With cervical lymphadenopathy

Think

216
Q

What is the difference between leukoplakia and Thrush

A

Thrush is easily rubbed off

217
Q

How do you test for Candida

A

Wet prep with potassium hydroxide (KOH)
—Non-septate mycelia

Biopsy
—-Intraepithelial pseudomycelia

Consider test for HIV
—-Thrush can be first sign of HIV

218
Q

How do you tx thrush

A

first line for uncomplicated cases

  • Fluconazole 100 mg daily for 7 days
  • Ketoconazole 200-400 mg daily with breakfast
  • Clotrimazole troches 10mg 5 times daily

Nystatin mouth rinse three times daily

Pain relief
-Chlorhexadine 0.12% rinse

219
Q

If a pt has HIV and thrush what is the Tx

A

Longer course of fluconazole (2-3 weeks minimum)- first line

If refractory- Itraconazole 200 mg/day

Still resistant- Voriconazole

220
Q

Define Glossitis and Glossodynia

A

Glossitis- Inflammation of the tongue with loss of texture

Glossodynia- Burning and pain of the tongue

221
Q

What should thrush pts wash their dentures in

A

Nystatin powder applied to dentures tid-qid for weeks

222
Q

If a pt presents with glossodynia that is unilateral

Think

A

REFER!!

Get MRI

223
Q

A pt presents with pain on the gums, oral bleeding and bad breath

Think

A

Nec ulcer Gingivitis

2/2 Spirochetes and fusiform Bacilli

224
Q

How do you treat NUG

A

Warm ½ strength peroxide rinse

Oral PCN three times daily for 10 days

225
Q

An ulcer that is yellow-gray center with a red halo

On a freely moving non keratinized mucosa

Think

A

Apthous Ulcer

226
Q

What is the general approach to Aphtous Ulcers

A

Usually self resolve

Can use Corticosteroids

  • trimacinnolone
  • Fluocinonide

Diclofenac
Doxy

Prednisone taper

Cimetadine- recurrent
Thalidomide- HIV

227
Q

A pt with apthous ulcers and HIV

What Rx

A

Thalidomide

228
Q

What is the most common cause of pharyngitis and tonsillitis

A

VIRAL!

Rhinovirus, adenovirus

229
Q

What are the bacterial agents most common to pharyngitis

A

Group A beta hemolytic strep (GABHS)
Gonorrhea/chlamydia
Diphtheria

230
Q

What is CENTOR criteria

A

1 point each for:

  • Lack of cough
  • Cervical Adenopathy
  • Fever over 100.4 (38C)
  • Tonsillar exudate

Modified:

  • Add 1 point if age <15
  • Subtract 1 point if age >44
231
Q

What CENTOR score need strep tests

A

greater than 2

232
Q

When should you emperically treat for strep

A

CANTOR 3 or more

233
Q

What is the tx for VIRAL Pharyngitis

A 
Analgesics
NSAIDs
Benzacaine lozenges
Salt-water gargles
Corticosteroids (prednisone)
234
Q

What is the Tx for Group A Strep Pharyngitis

A

Penicillin or Cefuroxime

If ALLERGY- Erythromycin
Avoid cephalosporin’s

235
Q

What is the cause of Mono

236
Q

A pt presents with hepatosplenomegaly and shaggy purple white exudate

Think

237
Q

How do we test for Mono

A

Lymphocyte to WBC ration

And Monospot
Positive heterophile agglutination test

238
Q

An alcoholic pt with gray pseudomembran on exam, and low grade fever

Think

A

Diphtheria

239
Q

A pt presetsn with Severe sore throat, odynophagia, and trismus

Think

240
Q

What is the progression of an abcess in the pharynx

A

Peritonsillar cellulitis->pertonisllar abscess-> retropharyngeal abscess

241
Q

A pt presents with hot potato voice, with medial deviation of the soft palate and peristonsilar fold

Uvula displaced inferior and medial

Think

242
Q

What is the tx approach for Abcess in the Tonsils

A

I&D and ABX

243
Q

How deep can you go for a tonsil abscess

A

No deeper than 1 cm to avoid carotid artery

Pass the needle medial to the molar

244
Q

What is the SRGICAL tx for Quisny (peri tons abscess)

A

Ectomy

Indications:
-If recurrent PTA or chronic infections
History of airway obstructions
Child or patient needing general anesthesia for I&D

245
Q

What are the ABX to use in Peritons abscess

A

Initial: Amoxicillin or Clinda

With at home amoxicillin, clinda, or Aug

246
Q

A pt presents with facial swelling, and pain and increased swelling at meals

Think

A

Sialadenitis

2/2 duct obstruction
Staph Aurues
Dehydration, sjorgen syndrome and periodontitis

247
Q

What are the two common glands that are effected in sialadenititis

A

Parotid or submandibular

248
Q

What is the tx approach to sialadenitis

A

IV ABX initially (nafcillin)
Switch to oral if able to tolerate
Total 10 day course

249
Q

What is the common agent in suppurative parotidis that extends to the mandible

A

Staph Aurues.

Tx with Early referal
IV Nafcilllin + Metro or Clinda

If immun comp give Vanc

250
Q

What is the most common location for sialolithiasis

A

Whartons duct< Stensons

251
Q

What is the difference in stones in whartons vs stensons duct

A

Wharton stones- large, radiopaque

Stensen stones- smaller, radiolucent

252
Q

What medications commonly cause salivary glean problems

A

Thioureas
Iodine
Cholinergics (Phenothiazine)

253
Q

What is the most common site of r salivary gland tumors

A

Parotid gland

80% are Benign

254
Q

Where are the vocal chords connected to

A

Membranous structures attached to the arytenoid and thyroid cartilages that stretch across the larynx

255
Q

Harsh larynx sounds indicate

A

Laryngitis or malignancy

256
Q

Describe stridor

A

High pitched sound

Narrowed upper airway

Above vocal folds- inspiratory
Below vocal folds- expiratory or biphasic

All cases of stridor need specialist evaluation

257
Q

A pt with 2 week duration of harshness should get….

A

Anyone with hoarseness > 2 weeks- Refer to ENT

Esp. if hx of tobacco use or lung/laryngeal cancer

-Laryngoscopy

258
Q

What is the most common cause of hoarseness in the voice

A

Laryngitis (Viral)

259
Q

What is the tx approach to laryngitis

A

Vocal rest
-Inflamed cords have greater risk of hemorrhage, polyps, cysts

Professional vocalists

  • Refer for ENT eval
  • May initiate corticosteroids after laryngoscopy
260
Q

A pt presents with hoarseness, Chronic cough, throat irritation, that occurs when upright

Often without heartburn

Think?

A

Laryngoesophageal reflux

R/o cancer and masses first with a scope

261
Q

What is the Tx approach to laryngoesophageal reflux

A

High dose PPI minimum 3 months

Can take up to 6 months to see improvement

262
Q

How does recurrent resp papillomatosis

A

Hoarseness, stridor in children with papillomas seen on laryngoscopy

2/2 HPV 6 and 11
MC in children from utero or birth

263
Q

What are the tx appraoch to recurrent resp papillomatosis

A

Laser vaporizations, and cold knife resections

DO NOT PERFROM A TRACH!

Rx: Cidofovir

264
Q

What is the prevention vaccine for recurrent resp papillomatosis

A

Prevention

—HPV vaccine for mother

265
Q

How does epiglottisis present

A

Rapidly developing
Pain OOPT exam

With stridor, leaning forward and drooling.

266
Q

What is the tx approach for epiglottis

A

Inpatient:
IV ABX
-Ceftizoxime 1-2 g q 8-12 hrs
-Cefuroxime 750-1500 mg q 8 hrs

-IV dexamethasone
4-10 mg bolus, then 4 mg q 6 hrs

Airway observation- <10% of adults need intubation

Once symptoms improve, may switch to orals for 10 day course

267
Q

What are the 5 specific steps to treating Epiglottitis in Kids

A

1) Call ENT, anesthetist and pediatrician
Don’t attempt to examine, intervene, or lay back in ED!!
Agitation can lead to complete airway obstruction
If child obstructs, use BVM initially

2) Intubate in OR
Under mask anesthesia

3) IV, blood cultures
4) IV ABX- cefuroxime
5) Extubate after confirmation of resolution

268
Q

Define screamers/singers nodules

A

Vocal fold nodules

On laryngoscopy: smooth paired lesions

269
Q

Define vocal fold polyps

A

Presents with hoarseness

Especially after trauma

With UNILATERAL mass on lamina propria

Tx with steroids and surgery

270
Q

What is the most common cause of polyploid corditis

271
Q

When would you see reinke edema

A

A pt with polypoid corditis

Encourage pt to stop smoking
And may need surgical resection

272
Q

What is the tx for ulcers and granulomas of the vocal cords

A

Acute: Fluticasone (Flovent)

Chronic: INS and PPI w voice therapy

SRGRY only for obstructions

273
Q

What are the causes of oral leukoplakia

A

SMOKING and GERD !

Stop stop stop smoking!

274
Q

All leukoplakia lesions should be…

275
Q

What is the Tx for Laryngeal Leukoplakia

A

Will require SRGRY and radiation

276
Q

When should you start thinking of Cancer in a pt with hoarseness

A

When it lasts over 2 weeks

277
Q

What is the most common malignancy of the larynx

278
Q

If Cancer presents in the larynx in a non-smoker thinks what cause

279
Q

What is the perferred imaging for a pt with laryngeal cancer

280
Q

If a pt has enlarged nodes around the trachea, thyroid, crichoid cartilage, or IJV

What image should you order

281
Q

What are the 4 goals of SCC of the Larynx Tx

A

Cure
Preserve swallowing
Preserve voice
Avoid tracheostoma

282
Q

What is the Tx for early vs late SCC of the larynx

A

Early-

  • Radiation
  • Partial laryngectomy
  • With neck node dissection in supraglottic tumors

Late

  • Chemotherapy
  • Radiation

Surgery- partial or total larynx resection

283
Q

What are the presentations of Vocal Fold Paralysis

A

Can be unilateral or bilateral

Uni: Breathy dysphonia
Effortful voicing

Bilateral: Inspiratory stridor with deep inspiration
Insidious- asymptomatic at rest w/ normal voice

284
Q

What is the most common cause of vocal fold paralysis

A

MC- Iatrogenic

Recurrent laryngeal nerve injury
Or skull base surgery

285
Q

What is the Tx approach to unilateral vocal fold paralysis

A

Often temporary- can take >1 year to resolve

-Diet modification
-Pulmonary toilet
-Temporary injections
—Gelfoam, fat, cartilage

If permanent
-Surgery and Teflon Injection

286
Q

What is the tx for bilateral vocal fold paralysis

A

Acute- specialist referral in acute care setting

Surgery

  • Vocal fold lateralization
  • Preserve airway while maintaining voice and airway protection
  • Tracheotomy
287
Q

What are the common causes of Ludwig’s angina

A

Cellulitis of submaxillary and sublingual spaces

Usually from infection of mandibular dentition
!!!STREP!!
, Staph, Bacteroides, Fusibacterium

-Diabetics-Klebsiella

288
Q

What is the w/u for Ludwig’s angina

A

CT w/ contrast
—Distinguish cellulitis from abscess

If pt has sx of Ludwig’s and severe HA
—CT with MRI- Can identify thrombophlebitis of IJV
(AKA Lemiere’s syndrome)

If pulmonary infiltrates present with neck infection

Think Lemiere’s, IV drug use, or both

289
Q

When would you think Lemieres syndrome

A

Recent dental surgery, with tongue displaced up and back with a severe HA

290
Q

What is the Tx approach to Ludwigs Angina

A 
Culture if possible
Antibiotics
-PCN + metronidazole
-Ampicillin-sulbactam
-Clindamycin
-Cephalosporins

And then drainage with dental referral

291
Q

What is the tx for a deep neck abscess

A

Medical emergency
-Can lead to rapid airway obstruction

-Secure the airway

Tracheotomy if substantial pharyngeal edema
-Intubation can cause obstruction

  • IV ABX
  • I&D
292
Q

If a pt has deep neck abcess and has blood and pus involvement

Then..

A

Bleeding means carotid or IJV involvement

Neck exploration necessary

293
Q

Learn lymph node drainage

Chart 22 of neck

294
Q

What is the mainstay of evaluation in a Reactive Cervical Lymphadenopathy

A

Fine needle Bx

295
Q

What is the threshold to do a FNA of a neck lymphnode

A

Node >1.5 cm

Persistent node

Node with necrotic center and no infectious cause

Continued enlargement of node

**Especially if Hx of smoking, alcohol use, prior cancer

296
Q

A single enlarged node/ matted node with scrofula
In the neck

Think what DDx

A

Mycobacterial Adenitis

Or TB

297
Q

What is the post placement care for tracheotomy

A

Needs humidified air

Clean several times daily

Frequent suctioning to clear saliva and secretions

Care of skin around trach

298
Q

A cleft cysts that is NOT midline and DOESNT move with swallowing

Is

A

A bronchial Cleft Cycst

299
Q

What is the most common congenital mass of the lateral neck

A

Bronchial Cleft Cyst

300
Q

What is the treatment for a Branchial Cleft Cyst

A

Complete excision with fistulous tracts to prevent:

  • Recurrent infection
  • Carcinoma (rare)

Send frozen sections for biopsy

301
Q

How does a thyroglobulin duct cyst present?

A

usually less than 20 y/o

Midline and moves when swallowing

Just below the hyoid

302
Q

What is the Tx for a thyroid loss al duct cyst

A

Complete surgical excision with middle of hyoid
Prevent infection

If no other thyroid tissue, will need levothyroxine

303
Q

A from persistent e larding neck mass is…

A

CANCER UPO

304
Q

What three scopes are required to evaluate Neck Cancer

A

Laryngoscopy
Bronchoscopy
Esophagoscopy

If nothing is found
MRI pet scan

Then consider Bx

Senoir 21-2 (77 decks)

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