ENT Flashcards
1
Q
What is the most common malignant lesion of the auricle
A
Basal Cell Carcinoma
2
Q
A pt presents with a non healing lump of the outer ear
What is the Highest DDX
A
Basal Cell Carcinoma
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
4
Q
A pt presents with a non healing ulcer or plaque on the ear think..
A
Squamous cell carcinoma
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)
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
7
Q
A pt presents with a pigmented lesion On the ear
Think..
A
Malignant melanoma
Assoc. with high mortality
8
Q
What does ABCDE stand for
A
Asymmetry Border Color Diameter Evolving
Determine if its a mole or melanoma
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
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
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
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
13
Q
What ABX covers pseudomonas
A
Ciprofloxacin
High concern with water exposure and DM
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
15
Q
What defines a simple vs extensive ear lacerations
A
Simple- skin only
Extensive- Involves cartilage
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
17
Q
What are 4 signs of middle ear trauma
A
- Hemotympanum
- Amber/clear middle ear effusion
- Otorrhea
- Hearing deficit (HL) with Weber/Rinne
18
Q
What is the imaging choice for a EAr lac
A
CT scan non con (if severe underlying)
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
20
Q
What is the best cartilage penetrating ABX
A
Ciprofloxacin
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
22
Q
What is the MC cause of ear cellulitis
A
Ear piercing and Trauma
23
Q
What is the bug that causes cellulitis of the ear
A
Psuedomonas
24
Q
What is the most common cause of cerumen impaction
A
MC from cleaning inside the EAC
25
What is the most common cause of foreign bodies in the ear
MC- Children placing something in EAC
Insects
Hearing aid batteries
26
When should you refer a foreign body ear obstruction
If anesthesia needed
Uncooperative child
Difficult removal
27
What are the common organisms in external otitis
Organisms
- Gram negative rods- Pseudomonas, -Proteus
- Fungus- Aspergillus
28
What are the ABX for external otitis
Refractory cases or cellulitis present
| -Oral fluoroquinolones- ciprofloxacin 500 mg twice a day for 1 week
29
What is malignant otitis externa
Persistent, foul aural discharge
Deep otalgia
Temporal headaches
Late sign- CN palsies
30
A pt presents with foul aural discharage and granulations in the EAC
Late signs of CN palsy’s
Think
Necrotizing Otitis Externa
31
What is the Gold standard for Imaging of Nec Otitis Externa
CT
32
What is the Tx for Malignant Extrenal Otitis
Systemic ABX
Ciprofloxacin
Until Gallium scanning shows resolution
33
What is the most common cause of Pruritus
MC- Excoriation from overzealous cleaning
Psoriasis
Seborrheic dermatitis
Otitis externa
34
What is the tx for pruritus of the ear
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)
```
35
What is an Exostoses
Bony overgrowths of the EAC
Symptoms:
- Often asymptomatic
- Occasional aural fullness or HL
36
What is surfers ear
Repeated exposure to cold water that leads to bone formation in the ear
37
Do we irrigate organic material out of the ear
NO!
| Organic material can swell!
38
Describe patillas Eustachian tube defect
Stuck open Eustachian tube
- Aural fullness
- Increased autophony
- Worse when exercising, better with a URI
2/2 Rapid wt loss, NMD, or idiopathic
39
What is the tx to patilludo eustachiain tube defect
Avoid decongestants
Insert ventilation tube
Surgery- Rarely
40
Describe Eustachian tube dysfunction
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.
41
You see retracted TM and Decreased TM mobility
Think
Dilatory Dysfunction of the TM
42
What is the tx approach to dilatory dysfunction of the Eustachian tube
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
43
What intranasal steroids are used in Eustachian tube dysfunction
Fluticasone 2 sprays per nostril q day
Beclamethasone dipronionate 2 sprays per nostril bid
44
What are the common causes of serous otitis media
More common in children
Chronic Eustachian tube dysfunction
URI, Allergies, barotrauma
Negative pressure -> fluid transudation
If persistent and unilateral- R/O nasopharyngeal carcinoma
45
If a pt has persistent and unilateral serous otitis media
What should you R/o
Nasopharyngeal Carcinoma
46
What are the 4 reasons that children are at an increase Risk of Serous otitis media
```
1- Shorter ET
2- Horizontal ET
3- Immature floppy elastic cartilage
4- Larger adenoids
*Tube usually reaches adult length by age 6
```
47
Where does the Weber lateral to on a conductive hearing loss
To the effected ear
48
What is the Rhine test do in conductive hearing loss
Bone greater than AC
49
What is the Tx approach to serous otitis media
Decongestants- oral and intranasal
Intranasal corticosteroids
With autoinflation (Valsalva)- if no URI
Surgical interventions- laser or balloon dilation
50
Describe Acute Otitis media
```
Ear Pain
URI
Decreased hearing
Aural pressure
Fussy
```
51
What are the most common causes of acute otitis media
HISSM
H. influ
Strep Pneumo
Strep Pyogenes
Moraxella (Kids)
52
What is the progression of acute otitis media
Viral URI- ETD- Fluid mucus build up - bacterial infection
53
What are the Tm Findings in Acute otitis media
White/Yellow
Dilated blood vessels
Hypomobile
Occasionally bullae
54
What is the tx for acute otitis media
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
55
What is SNAP treatment for acute otitis media
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
56
What are the 1st line ABX in Acute otitis media
First line-
Kids- Amoxicillin 80-90 mg/kg/day (divided into 2 doses)
Adults- 1g q 8hrs
5-7 day course!!!
PCN allergic
—Azithromycin
57
What are the second line ABXs for acute otitis media
Second line- for resistant strains
—Amoxicillin/clavulanate (Augmentin)
—Cefuroxime
—Cefpodoxime
58
What is an amoxicillin rash
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
59
Define recurrent otitis media
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
60
What are the 4 prevention methods to acute otitis media
Breastfeeding
Pneumococcal conjugate vaccine
Avoid tobacco smoke
Avoid daycare
61
What are the complications of acute otitis media
Facial paralysis
Sigmoid sinus thrombosis
Central nervous system infection
62
A pt presents with Aural Dc from the ear
Perferated TM and conductive hearing loss
Think?
Tx?
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
63
If you see a chronically draining ear
Think
Cholesteatoma
S/s chronic ear draining, intact TM, hearing loss
64
What is the most common cause of Cholestatoma
MC cause- Chronic ETD
Negative pressure-> Retraction pocket-> Keratin debris buildup
65
What is the Tx approach to cholestaeatoma
Surgery!
—Marsupialization
Complete removal of the keratin sac
ETD is still present so can recur
Need to be monitored for life
66
What are the complication of an unrepared cholesteatoma
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
67
A pt presents with Fever and post auricular eat pain
With a protruding audible
Think
mastoiditis
68
Which of the HISSMs do not effect mastoiditis
M. Catarallis
69
What is the Tx and W/u for mastoiditis
CRT scan!
Tx:
```
IV ABX (admit)
-Cefazolin 0.5-1.5g every 6-8 hours
```
ABX failure, more severe cases
Surgery
—Mastoidectomy
70
What is mastoiditis long term treatment requirement
Long term ear cleanings
71
A pt presents with deep otalgia with fouls D/c
Retro orbital pain and 6th nerve palsy
Think
Petrous apicitis
72
What is the treatment for petrous apicitis
Long term abxs
+/- surgical drainage of petrous apex
73
What is the complication of petrous apicitis
Meningitis
74
What is the cause of facial nerve paralysis and what is the Tx
Cause- Bacterial neurotoxins
Treatment
- Myringotomy for drainage and culture
- ABX based on culture
75
What is the chronic cause of facial nerve paralysis
Cause- cholesteatoma
Treatment-
Surgical correction of cholesteatoma
76
What is sigmoid sinus thrombosis
Cause from septic emboli in the sigmoid sinus
77
A pt present with spiking fevers, chills, ICP, HA, N/V, Lethargy, and papiledema
What thrombotic event may have occurred
Sigmoid sinus thrombosis
78
What is the most common cause of otogenic meningitis
MC intracranial ear infection complication
Acute- S. pneumo and H. flu
79
What is otosclerosis
Familial disease->Hearing loss
| Ossicles harden progressively
80
When should we refer to ENT for hearing loss post trauma
If CHL >30 db lasts over 3 months, refer to ENT
81
A pt presents with pulsatile tinnitus and Hearing loss
Think what neoplasm of the ear
Glomus tumors
S/s:
+/- Vascular mass behind TM
CN VII, IX, X, XI, XII neuropathies
82
Any time someone presents with pulsatile tinnitus
What must you order
Magnetic resonance angiography (MRA)
Magnetic resonance venography (MRV)
83
When should you abort the dive if you can’t equilize your ears
If not equalized with in 15 feet
84
What is a perilymphatic fistula
From overpressurization
Oval or round window ruptures
Immediate Emesis and vertigo
Very dangerous!
85
Describe decompression sickness
Air bubbles develop in vasculature of ear on ascent
Hearing loss
Vertigo
Need immediate recompression
86
Which is more severe
Peripheral or central vertigo
Peripheral
87
How does caloric stimulation work
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
88
Describe Menieres syndomre
S/s Vertigo: 20-min to hours
Low tone tinnitus + blowing sound
Unilateral aural pressure
2/2 syphillis of truama or idiopathic
89
What is the treatment to Menieres
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
```
90
A pt presents with hearing loss, vertigo of sudden onset
That gradually improves over weeks
+ tinnitus
Think
labrynthitis
91
What kind of nystagmus is present in labrynthitis
Spontaneous horizontal nystagmus
Improved with visual fixation
92
What is the tx for labrynthitis
Known bacterial infection
—Antibiotics
Vestibular suppressants
- Meclizine
- Diazepam
Short-term use only!!
—First 2-3 days
93
A pt presents with peripheral head movement vertigo from rolling over in bed
Lasts less than 60 seconds
Think
BPPV
94
What is the cause of BPPV
Suspected Otoconia in the semi-circular canals
Usually no inciting events
Can follow trauma or vestibular neuronitis
95
What is the most common cause of vertigo
BPPV
96
Describe vestibular neuronitis
Very similar to labrynthitis
| However NO HEARING LOSS!
97
What cranial nerve inflamation leads to vestibular neuronitis
CN VIII from a possible viral infection
98
A pt prestns with absent caloric signs in one or both ears
Think
Vestibular neuronitis
99
What is the Treatmetn for vestibular neuronitis
Supportive care
+/- Valium or diazepam
With vestibular rehab for persistnence
100
When would hearing loss present in a traumatic vertigo
If there is a basilar skull fx
101
What is the chronic manifestation of traumatic vertigo
Cupolithiasis (positional vertigo )
102
What is the tx approach to traumatic vertigo
Supportive care
Vestibular suppressants
-Acute phase ONLY!
Vestibular rehabilitation
103
What is the treatment for a perilymphatic fistula
Refer for tissue grafting
104
What are the common causes of cervical vertigo
Trauma
Hyperextension
Degenerative Disc Disease
105
What is the most common complaint in vestibular schwannoma
Hearing loss
106
Any one with one sided hearing loss should get what ordered
MRI!
107
An older pt with neck extension induced vertigo
Think
Vascular compromised vertigo
108
What do we order for a pt with vasc compromise vertigo
MRA
109
What is the tx for vasc compromise vertigo
Asprin and vasodilation
110
How does MS present with vertigo
Episodic Vertigo
Chronic imbalance
Hearing loss (rare)
- Unilateral
- Rapid
Spontaneous recovery
111
How does MS look on MRI
Demylenation of white matter
Refer to neuro
112
What is sensory hearing loss
Deteriórate of the cochlea
113
What are the 4 main causes of conductive hearing loss
Obstruction- Cerumen impaction
Mass Loading- Middle ear effusion
Stiffness- Otosclerosis
Discontinuity- Ossicular disruption
114
What is the most common cause of sensorineural hearing loss
Presbyacusis
115
What are the rinne and Weber for conductive hearing loss
Weber test-
Sound louder in bad ear
Rinne test-
Bone conduction > Air conduction
116
What is the Weber and Rinne test in sensorineural hearing loss
Weber test- Sound lateralizes to good ear
Rinne test- AC>BC
117
What is the treatmetn for sudden (less than 72 hours) sensorineural hearing loss
Decompaction
Or steroids consult with ENT
118
Pulsatile tinnitus gets what
MRA and MRV
| + temporal bone CT
119
What is the only medication that has shown effect for tinnitus
Nortryptiline
120
What is the treatment for hiperacusis
If cochlear dysfunction then hearing ain’t with compression circuits
121
What are the levels of an Audiogram
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
122
What speech discrimination score needs hearing aids
Below 90
123
What is the decible range for mild hearing loss
20-40
124
What is the dB range for moderate hearing loss
40-60
125
What is the dB range for severe hearing loss
60-80
126
What is the dB range for profound hearing loss
Greater than 80
127
What is a tympanograph
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
What is a type A Tympanograph
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
What is a Type As tympanograph
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
What is a type AD Tympanogram
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
What is the Dx for a Type AD Tympanograph
Diagnoses: ossicular disarticulation or ossicular chain discontinuity
132
What is a type B Tympanograph
```
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
What Will Tympanograph read if there is fluid in the middle ear or a TM rupture
Type B flat
134
What is a type C Tympanograph
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
What is the Dx for a type C Tympanograph
Diagnosis: Eustachian tube dysfunction, may cause a very mild CHL, or hearing can be WNL
136
What is the osteomeatal complex
channel that links the frontal sinus, anterior ethmoid air cells and maxillary sinus to the middle meatus, allowing airflow and mucociliary drainage.
137
A pt presents with clear rhinorrhea, nasal congestion, hyposmia, and sore throat
Think
Acute Viral Rhinosinusitis
138
What is the typical duration of Acute Viral Rhinosinusitis
Usually last less than 10 days, but can be up to 4 weeks
139
What is the tx appraoch to Acute Viral Rhinosinusitis
```
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
A pt presents with thick purulent nasal D/c with nasal congestion
Fevers, anosmia, perception of a foul odor and dental pain
Think
Acute bacterial Rhinosinusitis
141
How long must S/s be present to Dx Acute Bacterial Rhinosinusitis
Symptoms must either last over 10 days or worsen after an initial improvement within 10 days to differentiate from viral sinusitis.
142
What are the common pathogens in Acute Bac Rhinosinusitis
S. pneumoniae
H. influenza
M. catarrhalis
S. aureus
143
What is the Tx approach to Acute Bacterial Rhinosinusitis
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
What is the presentation of Orbital Cellulitus
```
Usually from ethmoid sinusitis
Physical exam
Proptosis
Gaze restriction
Orbital pain
```
145
What is the approach to orbital cellulitis
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
How does an orbital abscess present
```
Secondary to orbital cellulitis
Physical exam
-Proptosis
-Ophthalmoplegia
-Pain with medial gaze
```
147
What is the tx for an orbital abscess
Immediate referral to ENT for decompression/drainage
148
A pt presents with a frontal sinus inflammation with tender swelling of the forehead
Think
Osteomyelitis
149
What is the tx for osteomyelitis
Treatment- Refer
Prolonged ABX
Removal of necrotic bone
Cosmetic reconstruction
150
What is the number one agent of nasal vestibulitis
Staphylococcus aureus #1
Nasal manipulation
Nasal hair trimming
151
A pt presents with erythema, tenderness, swelling, and a furuncle at the nose
Think
Nasal Vestibulitis
152
What is the tx approach to nasal vestibulitits
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
What is the most common nosocomial infection of the sinuses
S. Aureus
Usually causing nasal vestibulitis
154
What is the Tx approach to S. Aureus colonization
Attempt to eliminate carrier state
-Mupirocin 2% ointment + -Chlorhexadine facial washing bid for 5 days
Still only eliminates 39% of carriers
155
What pts have an increased risk of fungal sinusitis
DM
Long term steroids
AIDS
156
What is the classic sign of fungal sinusitis
Black eschar on the middle turbinate
157
What is the tx approach to Invasive Fungal Sinusitis
Medical and surgical emergency
Emergent referral to ENT
Start IV Voriconazole
158
A pt presents with sneezing, tearing, clear rhinorrhea, eye irritation, and pruritus
Think
Allergic rhinitis
159
When is allergy blood testing perferred
Preferred if:
- Pregnant
- Poorly controlled asthma
- Hx of anaphylaxis
- Dermatographism
- Meds- TCA, MAOI, B-Blocker
160
On exam you find pale or violaceous turbinates
Think
Allergic Rhinitis
161
What pts should get skin prick testing
For patients who:
Have unknown/uncontrolled allergies
Want to avoid long term meds
Must D/C antihistamines 7 days before test
162
What is the mainstay of Tx for allergic rhinitis
IN Steroids
163
Describe vasomotor rhinitis
Hypersensitivity of the Vivian nerve
Triggered by air temp, odor, light, ect
164
What is the tx approach to non allergic rhinitis
Ipatropium bromide
165
Describe rhinitis mediamentosa
Overuse of nasal decongestant
Tx stop
166
What is the most common site for epistaxis
Kesselbacks plexus
167
What site is a bad site for epistaxis
Posterior- Woodruff’s plexus (worse)
168
What are the tx for epistxias
15 minutes of direct pressure
+/- Topical Nasal Decongestant+ pressure
If that fails:
Cocaine or cauterize + lidocaine
Packing it iodofrom
169
What is the tx approach to a posterior epistaxis
Refer to ENT for posterior packing
Emergency setting- double balloon pack
Admit
Opioids for comfort
Surgery- when packing fails
170
What is the most commonly fx bone in the body
Nasal pyramid
171
What is the ABX to use when packing the nose
Cephalexin or Clindamycin
172
What are the two etiologies of a quantitiative platelet D/o
Reduced survival or reduced production
173
A pt that starts bleeding a lot in the dental office from procedure
Think what D/o
VWF dz
174
What is the difference between acute and chronic Immune Thrombocytopenia
Acute ITP
- Most common in children
- Usually follows viral illness
Chronic ITP
- Most common in adults
- Associated with secondary causes
175
Thrombocytopenia is defined as what value
Less than 100,000
176
What must you R/o in Immune thrombocytopenia
Diagnosis of exclusion
| Rule out secondary causes
177
What is the tx approach to Immune Thrombocytopenia
Bleeding and platelets ≤ 50K
- Glucocorticoids
- Intravenous immune globulin (IVIG)
- Platelet transfusions
Splenectomy
(Severe cases)
178
Once Hit is expected the clinician should perform…
Once HIT is suspected, the clinician must establish the diagnosis by performing a screening PF4-heparin antibody enzyme-linked immunosorbent assay (ELISA)
179
What is a bad 4T score
Greater than 6
180
What is the Tx for HIT
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
How long should anticoagulant be done after HIT
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
What are the two main types of thrombotic microangiopathy
Thrombotic Thrombocytopenic Purpura (TTP)
Hemolytic Uremic Syndrome (HUS)
183
What are the two primary features of Thrombotic Microangiopathy
Microangiopathic hemolytic anemia (MAHA)
—Shearing of RBCs in microcirculation (schistocytes)
Thrombocytopenia
—Due to incorporation of platelets into thrombi in microvasaculature
184
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
Thombotic Thrombocytopenic Purpura
185
If you see schictocytes on peripheral smear
| Think
Thrombotic Thrombocytopenic purpura
186
What is the treatment for TTP
```
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
Define hemolytic uremic syndrome
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
What is the common agent of HUS
Most common is SHIGA Toxin E. Coli
189
A child presents with blood diarrhea
What is the possible thrombotic D.o
hemolytic Uremic Syndrome
| 2/2 STEC
190
If you see schistocytes in a child think
Hemolytic Uremic Syndrome
191
What is the tx for Hemolytic Uremic Syndrome
Primarily supportive care
Fluid and electrolyte management, anti-hypertensives, transfusions (platelets, pRBCs)
Often inpatient management
No ABX, NO Antimotility agents, No NSAIDS
192
Why do we give TTP plasma exchange
To give the ADAMs13
193
How do nasal polyps present
Chronic Nasal Obstruction
Diminished sense of smell
Usually history of allergies
Looks pale, and covered in mucus
194
What is the 1st line treatment for Nasal polyps
Treatment
INS- first line
—Improve QoL
—Reduce need for surgery in small polyps
Short course of oral steroids
Surgery- when large or recurrent
195
What medication must be avoided in a pt with nasal polyps
AVOID Aspirin!
May cause bronchospasm
196
If a kid has nasal polyps
Think
Cystic Fibrosis
197
What is an inverted papilloma
Typically benign nasal obstruction that bleeds easily
Caused by HPV
Looks cauliflower like
Often passed in utero
198
What is the tx for Inverted Papilloma
Surgical excision
- Medial maxillectomy
- Occasionally endoscopically
All excised tissue must be biopsied
199
What is the most common cause of malignancy in the nose
Squamous cell carcinoma
Common in southern Chinese
200
A pt presents with unilateral nasal obstruction
With pain and recurrent hemorrhage
Think
Possible malignancy
201
A pt presets with a unilateral serous otitis media
Think
Cancer UPO!!
202
What is the imaging for Malignancy of the Nose
MRI! And Bx
203
What is the treatments for malignant tumors of the nose
Very early stage-Local radiation
Advanced stage- radiation + chemo
Recurrent nasopharyngeal carcinoma
-Surgery + repeat chemoradiation
204
A pt presents with blood stained crust and friable mucosa
Think
Granulomatosis with polyangitis
205
A pt presents with engorged turbinates and small white granulomas
With noncaseating granulomas
Think
Sarcoidosis
206
What is the progression of leukoplakia
Hyperplasia->Dysplasia->Carcinoma in situ-> malignant tumor
2-6% will become malignant
207
A pt presents with a white lesion that cannot be removed by rubbing in the oral mucosa
Think??
Leukoplakia
208
Which is more likely to be cancer
LEuko or Erythroplakia?
Erythro!
209
What is the plan for leukoplakia and erythroplakia
Early referal and Bx
210
Define Oral Lichen Planus
Autoimmune
Similar to Lacy Leukoplakia and requires Bx to Dx
Treatment: Pain MGMT, Corticosteroids and Tacrolimus
211
A pt presents with a raised, firm, white lesions with ulcers at the base
In the mouth
Think…
Oral Cancer
212
Tx approach to Oral Cancer
Less than 2 cm is local resection
Greater than 2 cm is neck dissection and radiation
213
What does ABCDE mean for cancer
Assymetry, irregular Borders, variable Color, increased Diameter, Elevation
214
What is the most common cause of oropharynx cancer
HPV>>> Cigs
215
A Pt presents with wt loss and unilateral odynophagia
With cervical lymphadenopathy
Think
Cancer
216
What is the difference between leukoplakia and Thrush
Thrush is easily rubbed off
217
How do you test for Candida
Wet prep with potassium hydroxide (KOH)
—Non-septate mycelia
Biopsy
—-Intraepithelial pseudomycelia
Consider test for HIV
—-Thrush can be first sign of HIV
218
How do you tx thrush
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
If a pt has HIV and thrush what is the Tx
Longer course of fluconazole (2-3 weeks minimum)- first line
If refractory- Itraconazole 200 mg/day
Still resistant- Voriconazole
220
Define Glossitis and Glossodynia
Glossitis- Inflammation of the tongue with loss of texture
Glossodynia- Burning and pain of the tongue
221
What should thrush pts wash their dentures in
Nystatin powder applied to dentures tid-qid for weeks
222
If a pt presents with glossodynia that is unilateral
Think
REFER!!
| Get MRI
223
A pt presents with pain on the gums, oral bleeding and bad breath
Think
Nec ulcer Gingivitis
2/2 Spirochetes and fusiform Bacilli
224
How do you treat NUG
Warm ½ strength peroxide rinse
Oral PCN three times daily for 10 days
225
An ulcer that is yellow-gray center with a red halo
On a freely moving non keratinized mucosa
Think
Apthous Ulcer
226
What is the general approach to Aphtous Ulcers
Usually self resolve
Can use Corticosteroids
- trimacinnolone
- Fluocinonide
Diclofenac
Doxy
Prednisone taper
Cimetadine- recurrent
Thalidomide- HIV
227
A pt with apthous ulcers and HIV
What Rx
Thalidomide
228
What is the most common cause of pharyngitis and tonsillitis
VIRAL!
| Rhinovirus, adenovirus
229
What are the bacterial agents most common to pharyngitis
Group A beta hemolytic strep (GABHS)
Gonorrhea/chlamydia
Diphtheria
230
What is CENTOR criteria
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
What CENTOR score need strep tests
greater than 2
232
When should you emperically treat for strep
CANTOR 3 or more
233
What is the tx for VIRAL Pharyngitis
```
Analgesics
NSAIDs
Benzacaine lozenges
Salt-water gargles
Corticosteroids (prednisone)
```
234
What is the Tx for Group A Strep Pharyngitis
Penicillin or Cefuroxime
If ALLERGY- Erythromycin
Avoid cephalosporin’s
235
What is the cause of Mono
EBV
236
A pt presents with hepatosplenomegaly and shaggy purple white exudate
Think
Mono
237
How do we test for Mono
Lymphocyte to WBC ration
| And Monospot
Positive heterophile agglutination test
238
An alcoholic pt with gray pseudomembran on exam, and low grade fever
Think
Diphtheria
239
A pt presetsn with Severe sore throat, odynophagia, and trismus
Think
Abcess
240
What is the progression of an abcess in the pharynx
Peritonsillar cellulitis->pertonisllar abscess-> retropharyngeal abscess
241
A pt presents with hot potato voice, with medial deviation of the soft palate and peristonsilar fold
Uvula displaced inferior and medial
Think
Abcess
242
What is the tx approach for Abcess in the Tonsils
I&D and ABX
243
How deep can you go for a tonsil abscess
No deeper than 1 cm to avoid carotid artery
Pass the needle medial to the molar
244
What is the SRGICAL tx for Quisny (peri tons abscess)
Ectomy
Indications:
-If recurrent PTA or chronic infections
History of airway obstructions
Child or patient needing general anesthesia for I&D
245
What are the ABX to use in Peritons abscess
Initial: Amoxicillin or Clinda
With at home amoxicillin, clinda, or Aug
246
A pt presents with facial swelling, and pain and increased swelling at meals
Think
Sialadenitis
2/2 duct obstruction
Staph Aurues
Dehydration, sjorgen syndrome and periodontitis
247
What are the two common glands that are effected in sialadenititis
Parotid or submandibular
248
What is the tx approach to sialadenitis
IV ABX initially (nafcillin)
Switch to oral if able to tolerate
Total 10 day course
249
What is the common agent in suppurative parotidis that extends to the mandible
Staph Aurues.
Tx with Early referal
IV Nafcilllin + Metro or Clinda
If immun comp give Vanc
250
What is the most common location for sialolithiasis
Whartons duct< Stensons
251
What is the difference in stones in whartons vs stensons duct
Wharton stones- large, radiopaque
| Stensen stones- smaller, radiolucent
252
What medications commonly cause salivary glean problems
Thioureas
Iodine
Cholinergics (Phenothiazine)
253
What is the most common site of r salivary gland tumors
Parotid gland
80% are Benign
254
Where are the vocal chords connected to
Membranous structures attached to the arytenoid and thyroid cartilages that stretch across the larynx
255
Harsh larynx sounds indicate
Laryngitis or malignancy
256
Describe stridor
High pitched sound
Narrowed upper airway
Above vocal folds- inspiratory
Below vocal folds- expiratory or biphasic
All cases of stridor need specialist evaluation
257
A pt with 2 week duration of harshness should get….
Anyone with hoarseness > 2 weeks- Refer to ENT
Esp. if hx of tobacco use or lung/laryngeal cancer
-Laryngoscopy
258
What is the most common cause of hoarseness in the voice
Laryngitis (Viral)
259
What is the tx approach to laryngitis
Vocal rest
-Inflamed cords have greater risk of hemorrhage, polyps, cysts
Professional vocalists
- Refer for ENT eval
- May initiate corticosteroids after laryngoscopy
260
A pt presents with hoarseness, Chronic cough, throat irritation, that occurs when upright
Often without heartburn
Think?
Laryngoesophageal reflux
R/o cancer and masses first with a scope
261
What is the Tx approach to laryngoesophageal reflux
High dose PPI minimum 3 months
Can take up to 6 months to see improvement
262
How does recurrent resp papillomatosis
Hoarseness, stridor in children with papillomas seen on laryngoscopy
2/2 HPV 6 and 11
MC in children from utero or birth
263
What are the tx appraoch to recurrent resp papillomatosis
Laser vaporizations, and cold knife resections
DO NOT PERFROM A TRACH!
Rx: Cidofovir
264
What is the prevention vaccine for recurrent resp papillomatosis
Prevention
| —HPV vaccine for mother
265
How does epiglottisis present
Rapidly developing
Pain OOPT exam
With stridor, leaning forward and drooling.
266
What is the tx approach for epiglottis
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
What are the 5 specific steps to treating Epiglottitis in Kids
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
Define screamers/singers nodules
Vocal fold nodules
On laryngoscopy: smooth paired lesions
269
Define vocal fold polyps
Presents with hoarseness
Especially after trauma
With UNILATERAL mass on lamina propria
Tx with steroids and surgery
270
What is the most common cause of polyploid corditis
Smoking!
271
When would you see reinke edema
A pt with polypoid corditis
Encourage pt to stop smoking
And may need surgical resection
272
What is the tx for ulcers and granulomas of the vocal cords
Acute: Fluticasone (Flovent)
Chronic: INS and PPI w voice therapy
SRGRY only for obstructions
273
What are the causes of oral leukoplakia
SMOKING and GERD !
Stop stop stop smoking!
274
All leukoplakia lesions should be…
Bx
275
What is the Tx for Laryngeal Leukoplakia
Will require SRGRY and radiation
276
When should you start thinking of Cancer in a pt with hoarseness
When it lasts over 2 weeks
277
What is the most common malignancy of the larynx
SCC
278
If Cancer presents in the larynx in a non-smoker thinks what cause
HPV!
279
What is the perferred imaging for a pt with laryngeal cancer
MRI
280
If a pt has enlarged nodes around the trachea, thyroid, crichoid cartilage, or IJV
What image should you order
Chest CT
281
What are the 4 goals of SCC of the Larynx Tx
Cure
Preserve swallowing
Preserve voice
Avoid tracheostoma
282
What is the Tx for early vs late SCC of the larynx
Early-
- Radiation
- Partial laryngectomy
- With neck node dissection in supraglottic tumors
Late
- Chemotherapy
- Radiation
Surgery- partial or total larynx resection
283
What are the presentations of Vocal Fold Paralysis
Can be unilateral or bilateral
Uni: Breathy dysphonia
Effortful voicing
Bilateral: Inspiratory stridor with deep inspiration
Insidious- asymptomatic at rest w/ normal voice
284
What is the most common cause of vocal fold paralysis
MC- Iatrogenic
Recurrent laryngeal nerve injury
Or skull base surgery
285
What is the Tx approach to unilateral vocal fold paralysis
Often temporary- can take >1 year to resolve
-Diet modification
-Pulmonary toilet
-Temporary injections
—Gelfoam, fat, cartilage
If permanent
-Surgery and Teflon Injection
286
What is the tx for bilateral vocal fold paralysis
Acute- specialist referral in acute care setting
Surgery
- Vocal fold lateralization
- Preserve airway while maintaining voice and airway protection
- Tracheotomy
287
What are the common causes of Ludwig’s angina
Cellulitis of submaxillary and sublingual spaces
Usually from infection of mandibular dentition
!!!STREP!!
, Staph, Bacteroides, Fusibacterium
-Diabetics-Klebsiella
288
What is the w/u for Ludwig’s angina
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
When would you think Lemieres syndrome
Recent dental surgery, with tongue displaced up and back with a severe HA
290
What is the Tx approach to Ludwigs Angina
```
Culture if possible
Antibiotics
-PCN + metronidazole
-Ampicillin-sulbactam
-Clindamycin
-Cephalosporins
```
And then drainage with dental referral
291
What is the tx for a deep neck abscess
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
If a pt has deep neck abcess and has blood and pus involvement
Then..
Bleeding means carotid or IJV involvement
Neck exploration necessary
293
Learn lymph node drainage
Chart 22 of neck
294
What is the mainstay of evaluation in a Reactive Cervical Lymphadenopathy
Fine needle Bx
295
What is the threshold to do a FNA of a neck lymphnode
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
A single enlarged node/ matted node with scrofula
In the neck
Think what DDx
Mycobacterial Adenitis
Or TB
297
What is the post placement care for tracheotomy
Needs humidified air
Clean several times daily
Frequent suctioning to clear saliva and secretions
Care of skin around trach
298
A cleft cysts that is NOT midline and DOESNT move with swallowing
Is
A bronchial Cleft Cycst
299
What is the most common congenital mass of the lateral neck
Bronchial Cleft Cyst
300
What is the treatment for a Branchial Cleft Cyst
Complete excision with fistulous tracts to prevent:
- Recurrent infection
- Carcinoma (rare)
Send frozen sections for biopsy
301
How does a thyroglobulin duct cyst present?
usually less than 20 y/o
Midline and moves when swallowing
Just below the hyoid
302
What is the Tx for a thyroid loss al duct cyst
Complete surgical excision with middle of hyoid
Prevent infection
If no other thyroid tissue, will need levothyroxine
303
A from persistent e larding neck mass is…
CANCER UPO
304
What three scopes are required to evaluate Neck Cancer
Laryngoscopy
Bronchoscopy
Esophagoscopy
If nothing is found
MRI pet scan
Then consider Bx
