ENT Flashcards
MCC of Otitis externa (2)
Pseudomonas aeruginosa
Staphylococcus aureus
Pt presents with 2 day h/o severe ear pain, itching in the external auditory canal, Otorrhea, and conductive
On physical exam the the tragus is tender to touch
and pulling up and back on the ear causes pain. TM is clear, but canal is erythematous and edematous.
Diagnosis & Treatment?
Otitis externa
Antibiotic Ear-drops: Ciprofloxacin or Gentamicin
Topical preparations with corticosteroids
A necrotizing inflammation of the external auditory canal causing osteomyelitis
MCC Pseudomonas aeruginosa s/t immunocompromise
Diagnosis → Imaging → Treatment
Malignant otitis externa (necrotizing otitis externa)
CT scan
IV ciprofloxacin +/- surgical debridement for abscess drainage
Pt presents with a 2 day history of earache and fever.
Otoscope reveals bulging tympanic membrane (TM) with
loss of light reflex and a retracted and hypomobile TM
Otitis Media
Pt presents with tender and swollen mastoid.
On exam, ear is displaced laterally and forward.
Diagnosis and next best step in management.
Mastoiditis
CT scan of the temporal bone
Feared complication of Mastoiditis
Brain Abscess
Persistent drainage from the middle ear through a perforated tympanic membrane.
Diagnosis and treatment
Chronic otitis media Topical fluoroquinolone (ciprofloxacin)
chronic mucoid or serous effusion in the tympanic cavity in the absence of infection lasting for > 3 months
Presents with painless sensation of pressure in the affected ear
Diagnosis and Treatment:
Otitis media with effusion
Tx: Tympanostomy tubes
If 4+ yo also do adenoidectomy
Best initial test: pneumatic otoscopy
Pt presents with painless otorrhea and foul-smelling discharge. Exam reveals a pearly or brown mass on TM.
Diagnosis and Treatment
Cholesteatoma
Tx: Surgery (always)
Cx: Destruction of ear ossicles
Treatment of Otosclerosis
fixation of stapes to oval window
Stapedectomy
*Cochlear implant (if bilaterally deaf)
Pt presents with recurrent epistaxis, seizures, and hemoptysis. Diagnosis
Hereditary hemorrhagic telangiectasia
Cx: High-output cardiac failure; Paradoxical emboli
Acute bilateral cervical lymphadenopathy: most commonly caused by __
viral infections of the upper respiratory tract
Subacute bilateral cervical lymphadenopathy
Predominantly caused by __ & __
EBV
CMV
Acute unilateral cervical lymphadenopathy: most commonly caused by ___
bacterial infections
(S. aureus, Strepto pyogenes)
tx: Clindamycin
An enlarged, ulcerated tonsil with ipsilateral cervical adenopathy is likely
oropharyngeal (head and neck) squamous cell carcinoma
3 causes of oropharyngeal (head and neck) squamous cell carcinoma:
Smoking
Alcohol
HPV
Retropharyngeal abscess presents with neck pain, odynophagia, and fever following penetrating trauma to the posterior pharynx. Feared complication is
acute necrotizing mediastinitis
An avulsed permanent tooth can be briefly stored in cold milk or saliva and manually reimplanted after gentle rinsing of the tooth and socket with
normal saline
An avulsed permanent tooth can be briefly stored in cold milk or saliva and manually ___ after gentle rinsing of the tooth and socket with
reimplanted
A postoperative neck hematoma should be recognized promptly and ___ to avoid potentially lethal upper airway obstruction.
drained
cricoid only if in respiratory distress
Medullary thyroid cancer arises from the ___-secreting parafollicular C cells. Serum ___ levels correlate with the risk of metastasis and recurrence, and are measured serially following surgery.
calcitonin
calcitonin
Flexible laryngoscopy shows irregular, exophytic growths in clusters on the surfaces of the vocal cords. Pathology shows no malignant features. What is the most likely cause of this patient’s laryngeal lesions?
HPV 6/11
(Laryngeal papillomas)
tx: Surgery
Parotid masses are typically benign. [abnormality] increases concern for malignancy.
Cranial nerve dysfunction (facial droop, facial numbness)
A _____ can occur after head trauma and result in episodic vertigo triggered by sudden pressure changes (Valsalva, sneezing, flights) or loud noises.
perilymphatic fistula
Presents with sudden, brief (<1min) episodes of vertigo triggered by head movement.
It is caused by debris (otoliths) that temporarily alters endolymph flow through the semicircular canals.
Benign paroxysmal positional vertigo
Presents with a sense of ear fullness or pain and ear popping/cracking with hearing loss in response to changes in pressure.
It is caused by fluid in the middle ear space (not the inner ear vestibular system)
Eustachian tube dysfunction
A tonsil ulcer in a smoker is likely due to
squamous cell carcinoma
may present with sore throat, ulcerated/friable tonsillar lesion, and odynophagia due to tumor invasion or local irritation.
Other manifestations include referred otalgia or an isolated neck mass (representing regional nodal spread of disease).
Associated with smoking, etoh, HPV, or immunocompromise
Oropharyngeal SCC
Pt with a h/o alcohol use disorder presents with bilateral, nontender swelling of the cheeks consistent with salivary gland enlargement. Diagnosis?
Sialadenosis
*a benign, noninflammatory enlargement of the salivary glands, often caused by chronic alcohol use, bulimia, malnutrition or DM2
A _____ adenoma is a benign salivary neoplasm that presents with a unilateral, painless distinct mass over the parotid gland.
pleomorphic adenoma
Pt with h/o smoking and alcohol use presents with persistent hoarseness in his voice and hemoptysis. Physical exam reveals an irregular fungating laryngeal mass on his vocal cord that appears white in some areas and red in others with some blood crusting. Cervical lymphadenopathy is noted.
Diagnosis? Next best step in management?
Laryngeal squamous cell carcinoma (SCC)
Flexible Laryngopharyngoscopy
Other possible sxs: dysphagia, airway obstruction, referred otalgia (CN 9/10) & hemoptysis (s/t tumor friability)
Constant or Persistent hoarseness (>30 days) is often related to a vocal cord lesion & should always be evaluated by ____ to ensure no delay in diagnosis of possible laryngeal squamous cell carcinoma (SCC).
Flexible Laryngopharyngoscopy
Pt with a h/o alcohol use who works as a welder presents with ear pain. Physical exam shows poor dentition and ipsilateral cervical lymphadenopathy.
Diagnosis of ear pain?
Next best step in management?
Referred Otalgia
Flexible Laryngopharyngoscopy
- Pt has risk factors for malignancy (smoking, etoh, work exposure, and lymphadenopathy!)
- Ear pain + normal ear examination + risk factors = referred otalgia c/w head and neck SCC.
MCC of referred otalgia are ___ disease and ___ disorders.
dental disease
TMJ disorders
BUT also a commonly a presenting symptom of head and neck SCC (especially in elderly w/ risk factors)
Pt with a h/o COPD on corticosteroid inhaler presents with white patches and plaques on his tongue and throat that are easily scraped off. Diagnosis?
Oral candidiasis (thrush) & Laryngeal candidiasis
Pt presents 1w post-op with left facial pain when eating and trismus (restricted ROM/unable to open fully jaw).
Examination shows swelling, erythema, and severe tenderness in the left preauricular area.
Purulent fluid expressed from parotid gland.
Vitals show mild fever and elevated amylase.
Diagnosis and next best step in management?
Suppurative parotitis
CT scan or U/S
(to r/o salivary stones or neoplasms & to differentiate between suppurative parotitis and an abscess)
Suppurative parotitis (exquisitely painful swelling of the parotid gland)is a postoperative complication that can be prevented with adequate fluid ___ and oral ___
hydration
hygiene
In Suppurative parotitis treatment includes: - IV ABxs - Hydration - -
Sialagogues
(Chewing gum/ Pilocarpine to increase salivary flow)
Facial Massaging (to express pus from the duct)
Pt presents with 6d h/o worsening sore throat and new onset dysphagia. On exam he is febrile, excessively drooling and has moderate, trismus. The soft palate above the L tonsil is swollen, and the uvula is deviated to the R. No tonsillar exudates are present. There are enlarged, tender L cervical lymph nodes palpated.
Diagnosis and next best step in management?
Peritonsillar abscess
Start antibiotic therapy + Needle Aspiration or I&D the abscess
(cover group A hemolytic Streptococcus and respiratory anaerobes → Penicillin+Flagyl → 3º Ceph→ Amox/Ampicillin→ Pip-Tazo→ Clinda, if allergic)
Nasopharyngeal carcinoma is associated with the reactivation of ____ and commonly seen in Asians, Africans, and Middle Eastern.
Manifestations include nasal congestion with epistaxis, headaches, CN palsies, and otitis media.
Epstein-Barr virus
Asian pt presents with a month of progressive, left-sided, painless neck swelling and persistent nasal congestion with nosebleeds. He often gets headaches and a full sensation in his L ear (otitis media). This morning he had facial numbness (CN palsy). Vital signs are wnl. Exam revealsseveral enlarged and hard cervical lymph nodes.
Possible diagnosis and next best step in management?
head or neck cancer like: Nasopharyngeal Carcinoma
Get imaging like Nasopharyngoscopy and BIOPSY
*associated with EBV
Pt develops whistling noise during respiration following rhinoplasty; Diagnosis?
Nasal Septal Perforation
Likely s/t septal hematoma
5 year old girl presents with 2m of constant hoarseness. Flexible laryngoscopy reveals several finger-shaped and grape like warty lesions with red punctate on her vocal cords. Diagnosis and Tx?
Laryngeal papillomas
(likely 2/2 recurrent respiratory papillomatosis or HPV 6/11)
Treatment: surgical debridement
acquired via vertical transmission prior to delivery
____ transmission of HPV 6 or 11 can cause
recurrent respiratory papillomatosis (RPR)
which results in hoarseness due to finger-shaped growths on the vocal cords.
Vertical transmission
(mom to baby in womb)
*neither vaginal nor cesarean delivery can prevent transmission
Laryngomalacia presents in infants with ____ that worsens in the supine position and improves in the prone position.
inspiratory stridor
In Laryngomalacia,
Laryngoscopy shows collapse of the ____ structures during inspiration.
supraglottic
Laryngomalacia can also present with concurrent should be treated.
GERD
treat it
Laryngomalacia usually resolves spontaneously by age ____.
18 months
(reassurance/follow up)
*unless feeding problems, cyanosis or FTT then surgery indicated
Vascular rings occur when an aberrant branch of the aortic arch or pulmonary artery wraps around the trachea & esophagus.
This may present with _____ due to tracheal compression and feeding difficulties due to esophageal compression.
biphasic or expiratory stridor
Infant presents with recurrent episodes of vomiting feeds and expiratory stridor. Next best step in management.
barium swallow
concern for Vascular rings
diagnosis confirmed via CT or MRA
Toddler presents with fever, dysphagia, neck pain, and stridor.
Neck X-Ray shows thickening of the prevertebral space.
Likely diagnosis & confirmatory imaging?
Retropharyngeal abscesses
Neck CT scan
Pt presents with several episodes of jaw pain worsened with eating and accompanied by a tender mass under the jaw + fever. These episodes always resolve with antibiotics.
Dx and Tx?
Recurrent Sialadenitis
(2/2 salivary stasis → retrograde seeding of bacteria. Risk factors: post-op or outflow ductal obstruction by salivary stones (sialolithiasis).
NSAIDs & ABxs
____ (Salivary stones) can result in sialadenitis ( jaw pain/ swelling worsened by eating) due to ductal outflow obstruction by the stone.
However, in pt w/ recurrent secondary infections (sialadenitis) s/t ductal obstructions, referral to otolaryngology is necessary for stone removal.
Sialolithiasis
Management: hydration, milking the gland, sialagogues, and oral hygiene
Bisphosphonate induced _____ of the jaw presents with chronic swelling, mild pain, and exposed, jaw bone.
Often triggered by:
tooth extractions
invasive dental procedures
Osteonecrosis
Tx: Supportive, oral hygiene, antibacterial rinses
Mucormycosis (acute invasive fungal sinusitis) presents with rapidly progressive fever, facial pain, nasal congestion, facial bone destruction, and changes in vision or mentation
Seen commonly in ___ patients.
immunocompromised
