ENT Flashcards
Causes of tympanosclerosis
Secondary to repeat trauma, infxn, perforations, and age
How does serous effusion present?
Bubbles/fluid line
Often associated with poor drainage of auditory tubes and middle ear and can allow bacteria to grow
What is an infectious process with bacterial overgrowth in middle ear?
Otitis media with prurulent effusion (OME)
What is bullous myringitis?
Vesicular infxn ON the TM
Viral in most cases, can be mycoplasma
Generally an indication to NOT rx abx
What do serous effusions, OME, and bullous myringitis have in common?
All have sequele of TM rupture
Conductive vs sensorineural hearing loss
conductive - can’t transmit sound waves;
kids/younger adults may seem better in noisy places, own voice is soft, visible abnormality (except in otosclerosis)
Weber - lateralizes to bad ear, Rinne BC > AC, AC=BC
SN - can’t neurologically process sound waves;
middle/later years, upper tones often lost, hearing worse in loud environment, own voice may be loud (they can’t hear it), problem not visible
Weber - Lateralizes to good ear, Rinne- AC > BC
Three tonsillar tissues
Lingual
Palatine
Pharyngeal (adenoid)
Ddx sore throat
Tonsillitis - inflammation of lymphatic tissue; usually self limited, rarely can cause airway issues
Pharyngitis - inflammation of pharynx and sometimes tonsillar tissues
Abscess - dangerous infxn in deeper tissues; can be deadly
Tonsillar swelling grades
Based on 25% each of oropharyngeal opening to midline
0 - none
4- tonsils touch in center
What are the major dangers of abscesses in the throat?
Sepsis
Airway obstruction
Different types of pharyngitis ***
Tx abscesses in throat
Abx
Dexamethasone
If not better > ENT drains
Centor criteria
Group A BH strep; should you test for strep
Exudates, tender ant cervical LA, fever, absence of cough, <15 (extra), 15-25
What is a thyroglossal duct cyst? How is it treated?
Midline swelling; goes all the way back to pre-vertebral area needs surgery
What is the most common congenital cyst formation in the neck?
Branchial cleft cysts (benign)
How do brachial cleft cysts present?
Large swellings on side of neck, pops out between scalenes when turns head
Benign, need to be removed
Etiologies of facial paralysis
Idiopathic (Bell’s palsy) - acute onset, viral prodrome
Trauma - sudden/acute
Herpes zoster - Ramsay hunt
Tumor - slow progression
Infxn/inflammation - mastoiditis, OM, Lyme, CN
Birth
Brain/CNS lesion
How is Bell’s palsy dx?
Only CN 7 involvement, hemiplegic paralysis
Otherwise, get imaging
Etiologies of epistaxis
HTN
Anticoags
Tumors (bleeding wont stop)
Trauma/surgery, barometric changes, structural deformities, inflammatory, tumor, HTN, hepatic/renal failure, coagulation disorders, drugs, valvular disorders
Epiglottitis presentation, dx, tx
H flu, BH strep
Sudden onset fever, drooling, toxic appearing
DONT OPEN THEIR MOUTH
Lateral cervical radiograph (thumbprint sign)
IMMEDIATE ER REFERRAL
Retropharyngeal abscess presentation, dx, and tx
Child/adult (trauma); fever, sore throat, stiff neck, no trismus (jaw spasm)
Lateral cervical radiograph or CT
Stabilize airway, surgical drainage, abx
Ludwig angina presentation, dx, and tx
Submaxillary, sublingual, or submental mass with elevation of tongue, jaw, swelling, fever, chills, trismus
Lateral cervical radiograph or CT
Stabilize airway, drain abscess, abx (penicillin, metronidazole)
Peritonsillar abscess presentation, dx, and tx
Swelling in peritonsillar region with uvula pushed aside, fever, sore throat, dysphagia, trismus
Cervical radiograph or CT
Aspiration of region with pus
Abscess drainage, abx
Presentation + etiology of laryngeal cancer
Tobacco smoke
30-50% has Mets at sx
Presentation + etiology of upper respiratory polyps
Reactive nodes that rarely become cancerous
Vocal cords of heavy smokers or singers, men
Presentation + etiology of Leukoplakia of larynx
Any hyperkeratotic lesion
Benign or malignant, depends how much atypia present
Strongly correlated with tobacco and alcohol
What is ear retraction?
TM retraction = pressure in external versus internal ear is imbalanced > dizziness, esp if uneven R to L
Abx generally used for ear complaints
Penicillins, macrolides
Sometimes fluouroquinolones
Macrolides and tetracyclines for mycoplasma
What are important things to consider in a pt with tinnitus?
Ototoxic drugs - salicylates (aspirin), cinchona alkaloids (quinine, quinidine), lots others
Thyroid, adrenal issues
Trauma
work up for dizziness/vertigo
BP/vitals, neuro exam, HEENT, chest and abdomen screening
MRI in all recurrent cases, and all acute cases with no peripheral explanation
CT sinuses
CMP, CBC, RBC element profile
In terms of “red eye” - what findings should you key in on?
- pattern of injection (conjunctival, ciliary, or hemorrhagic)
- level of (or presence of) pain (constant, with blinking, with movement)
- visual disturbance
- presence or level of photophobia
In terms of “red eye” - What are your common ddx?
Conjunctivitis (v, bac, all, toxic)
Conjunctival hemorrhage
Keratitis (corneal irritation)
Corneal injury
Iritis/uveitis
Scleritis
Acute glaucoma attack
Ciliary vs peripheral/conjunctival flush/injection
Ciliary - deeper
Peripheral/conjunctival - peripheral vasculature
Tells you if its “bad” or “good” red eye
Which types of red eye have ciliary vs conjunctival hemorrhage?
Conjunctival - conjunctivitis, sub conjunctival hemorrhage
Ciliary - corneal injury or infxn, acute iritis, acute glaucoma
Name the pathology:
Red eye with ciliary flush, cloudy cornea, plasmoid aqueous
Acute ant uveitis/iris in a pt with UC/IBD
EMERGENCY > can cause blindness
Etiologies of acute uveitis
Trauma, inflammation in adjacent tissue, acute episode of a chronic condition (chrohns)
Etiologies of chronic uveitis
Systemic disease such as Bechets, IBD, juvenile RA, reiters, sarcoidosis, syphilis, TB, Lyme
Name the pathology: Red eye with diffuse ciliary injection and corneal clouding
Acute angle closure glaucoma
Painful
EMERGENCY to save eye and sight
Presentation of acute angle closure glaucoma
Fluid drain becomes blocked; ant chamber is shallow, filtration angle narrowed, iris may obstruct entrance of schlemm or pupil may become blocked
Unilateral severe pain and rapid loss of vision
Possible N/V
Prodrome sx (transitory episodes of diminished visual acuity, colored halos around lights, pain in eye and head)
Hazy cornea (hypopion), fixed mid dilated pupil, eye firm to palpation
Hallmark signs/sx of orbital cellulitis
Systemic signs/sx of infection and lid/EOM dysfunction
EMERGENCY > CLOSE TO BRAIN
keratitis tx
Cornea involvement (MUST REFER TO EYE DR/ER) > can scar and blind
What is Hutchison sign?
Zoster coming down to nose > affecting CN to eye > can lead to blindness
Conjunctivitis presentation
No pain
Clear cornea
Presentation, tx of retrobulbar (optic) neuritis
Pain on eye rotation
Inflammatory disorder
Typically self limited (NSAIDS)
May indicate systemic dz (orbital cellulitis, recurrent neuritis > MS)
Presentation, tx of Ocular/atypical migraine
Pain with eye movement
Photophobia
Ddx by doing EOM in dark room
Normal fundus
Normal cup/disc, lateral to disc is macula
Eroded/large cup/disc ratio is indicative of what
Chronic Glaucoma
All forms of age related macular degeneration have initial common destructive changes in the _______-
Macular retinal pigment epithelium
Dry vs wet macular degeneration
Dry: RPE degeneration, vascular failure, loss of photoreceptors
Wet: all of above plus neurovascular component (leakage of plasma, lipid, glucose into choroid and retina > fibrous disciform scar formation)
Vision loss patterns macular degeneration vs glaucoma
MD: central vision loss (dec in eye chart acuity and central on perimetry)
Glaucoma: peripheral vision loss/“tunnel vision” (dec in peripheral vision on perimetry)
Nutrients/supp for macular degeneration
Taurine
Zinc
Selenium
Antioxidants
Carotenoids
Vit C, E
Vaccinum myrtilus, ginkgo biloba and crataegus
Arteriosclerosis vs atherosclerosis
ARTERIO - trouble with artery wall, “hardening of arteries” (small artery, big vein)
ATHERO - atheroma or lesion inside vascular lumen
Changes seen in HTN retinopathy?
Where else might you see these changes?
Hard leaking exudates, flame hemorrhage (blow out end of arterioles), cotton wool spots (scarred flame hemorrhages), papilledema, copper wire, silver wire
HIV retinopathy, renal disease retinopathy
What is the pathophysiology behind diabetic retinopathy?
Excess sorbitol destroys pericyte cells that support vascular epithelium > inc leakage of blood, protein, lipids > vascular insufficiency > retinal hypoxia
Release of angiogenic factors > neovascularization (poor quality, leak) > cont cycle
Retinal detachment presentation, dx, tx
Signs/sx: sudden onset single/multiple floating spots, flashes of light. Recent hx trauma to head/eye. Vitreous hemorrhage > multiple floaters. Vision loss
Binocular indirect ophthalmoscopy
EMERGENCY - lie supine and wait for transport to ER
Presentation, dx, tx posterior vitreous detachment
Due to aging and dec hyaluronic acid > lack of collagen integrity > vitreous collapses forward
50+, acute onset floaters with one large floating spot. If dec in vision > vitreous hemorrhage
Direct referral for evaluation
Lipemia retinalis vs atherosclerosis
Atherosclerosis - only Arteries change color/lighten
Lipemia - fat in all of the tree from high blood lipids
Presentation, dx, tx
Hereditary degenerative process of rod cells
Slow progressive BL loss of night vision > dec central vision. Ring scotoma on perimetry, “bone spicule” pigment changes
No tx, some use Vit A - AVOID Vit E
Common bugs blepharitis
Staph or strep
What is a hordeolum?
Stye; painful tender red infection around hair follicle on eyelid margin of eyelashes
External: glands of zeis or moll
Internal: meibomian glands
What is parotitis?
Infection of parotid gland; viral/mumps most common
What is herpangina?
Acute febrile illness associated with small vesicles on post oropharyngeal structures (soft palate, uvula)
Occur during summer, typically mild and self limiting
Etiologies of glossitis
Iron def
Pellagra
B12/folate def
Scurvy
Scarlet fever
EBV associated hairy leukoplakia
What is stomatitis?
Canker sore
Work up and tx for oral thrush
KOH wet punt with hyphae, pseudo hyphae, budding yeast cells
Tx: nystatin, fluconazole if severe
What are the forms of oral cancer?
Gingival, tongue, tonsillar
Presentation, tx of Meniere dz
Progressive condition affecting labyrinth > vertigo, tinnitus, hearing loss episodes
No sure, sx management only
What is a Cholesteatoma?
Desctructive and expanding growth of keratinizing squamous epithelium in the middle ear and/or mastoid process
Causes and sx of retinal hemorrhage
Diabetic retinopathy
Retinal vein occlusions
Ocular ischemic syndrome
Sickle cell retinopathy
Sx: floaters
What is CMV retinitis? What is the presentation and workup?
Retinitis most common manifestation in pts who are HIV+
Blurred vision, floaters, progressive blinding, necrotizing retinitis with retinal hemorrhage, esophagitis, ulcers, colitis, fever
Culture, PCR, exam shows “cottage cheese and ketchup”
retinoblastoma
white pupillary reflex (leukocoria)
vision problems
