ENT 2 Flashcards
1) What is Ramsay Hunt syndrome a major otologic complication of?
2) What is the typical triad?
3) What are some other findings? Ipsilateral or bilateral?
1) VZV reactivation; “shingles” that affects CN VII
2) Ipsilateral facial paralysis, otalgia (pain out of proportion to PE findings), & vesicles in EAC or on auricle
3) Possibly ipsilateral altered taste perception & tongue lesions, hearing abnormalities, lacrimation, & vertigo
How do you treat Ramsay Hunt syndrome?
(Within 3 days):
1) Antiviral (valacyclovir) x 7-10 days
2) Steroid (prednisone) x 5 days (no taper)
& IV therapy for severe cases (vertigo, tinnitus, or hearing loss)
1) What is the most common suppurative complication of AOM?
2) Define this term
3) What are its 3 forms?
1) Mastoiditis
2) Suppurative infection of mastoid air cells
3) Acute, subacute, & chronic forms
Mastoiditis:
1) Highest incidence in children ___________
2) What are the symptoms?
3) What is seen upon exam?
4) What about upon otoscopy?
1) < 2 y/o
2) May have otalgia, fever, lethargy, malaise, irritability, poor feeding, diarrhea
3) Prominent auricle, retro-auricular swelling, tenderness over the mastoid process
4) Edematous EAC, bulging or perforated TM, middle ear effusion
Mastoiditis:
1) What would labs are abnormal in most cases?
2) When should you order a CT w contrast?
1) Non-specific elevations of WBC, ESR, and/or CRP
2) For intra/extracranial complications, toxic appearing, AOM with no response to antibiotics
Mastoiditis:
1) What specimens should you obtain?
2) What are two potential treatments?
1) Middle ear, abscess fluid, CSF, or blood culture
2) IV antibiotics, surgery Refer to otolaryngologist early
Mastoiditis:
1) How do you treat uncomplicated cases?
2) What about complicated cases?
1) IV antibiotics & middle ear drainage with myringotomy (+ T-tube placement)
2) Aggressive surgery with mastoidectomy
1) Define Meniere’s disease
2) What is its etiology?
3) Is it typically unilateral or bilateral?
4) When can it occur?
1) Condition characterized by episodic vertigo, tinnitus, & sensorineural hearing loss
2) Cause is unknown, but likely caused by endolymphatic hydrops (distention of the endolymphatic compartment) of the inner ear
3) Most commonly occurs in one ear (unilateral), but may occur in both ears (bilateral)
4) Occurs at any age; typical age 20-40
List the 4 diagnostic criteria of Meniere’s disease
1) 2 or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours
2) Audiometrically documented low- to mid-frequency SNHL in affected ear
3) Fluctuating aural symptoms (reduced or distorted hearing, tinnitus, or fullness) in affected ear
4) Symptoms not better accounted for by another vestibular diagnosis
How is Meniere’s disease treated?
(Improve quality of life/symptomatic)
1) Diet & lifestyle adjustment:
-Low-salt diet
-Avoid/limit triggers (caffeine, alcohol, nicotine, stress, MSG)
2) Medications (daily vasodilators or diuretics with as-needed vestibular suppressants & antiemetics)
3) Vestibular rehabilitation (for residual disequilibrium between attacks)
1) Define tinnitus
2) What does it present as?
3) What are different types of tinnitus?
1) Perception of noise in the absence of an acoustic stimulus outside the body (It is a symptom-not a disease).
2) Buzzing, ringing, hissing
3) Continuous or intermittent
-Pulsatile or non-pulsatile (tonal)
List potential causes of tinnitus
1) Auditory system dysfunction
-Sensorineural HL (most common), ototoxic medications, presbycusis, otosclerosis, vestibular Schwannoma, Chiari malformations, Meniere’s disease, head & neck injury, infectious, metabolic
2) Vascular disorders
3) Neurologic disorders (i.e., MS)
4) Eustachian tube dysfunction (ETD)
5) Somatic disorders (i.e., TMJ)
List some medications associated with tinnitus
1) Aspirin
2) NSAIDs
3) Sulfasalazine
4) Quinine & chloroquine
5) Aminoglycosides
6) Macrolides
7) Tetracyclines
8) Vancomycin (rare by itself)
9) Loop diuretics (highest risk with rapid infusions)
What 3 things should you obtain when taking history of a pt with tinnitus? Describe each
1) Associated events: Hearing loss, noise exposure, acoustic trauma, otitis media, head or neck trauma, dental treatments
-Medication use
2) Associated symptoms
-Headaches, TMJ, neck pain, hyperacusis (40%)
-Hearing loss – most common risk factor for tinnitus
3) Location: 2/3 of patients have bilateral
-Unilateral more likely vestibular schwannoma or Meniere disease
What should you look at/ for during a head and neck exam of a pt with tinnitus?
1) Ear (cerumen impaction, effusion)
2) Eye (papilledema or visual field changes)
3) MSK (teeth grinding, neck tenderness, TMJ pain)
4) Neuro (abnormal CN testing, vestibular schwannoma, abnormal equilibrium)
5) Vascular (bruits or murmurs)
1) List diagnostic tests you should perform for tinnitus
2) What about for non-pulsatile? Why?
3) What about for unilateral (esp with HL)?
4) What about for pulsatile?
1) Assessment of air & bone conduction
2) Speech discrimination testing
3) Tympanometry
4) Audiometry: for non-pulsatile (to exclude HL)
MRI: unilateral, especially with HL (exclude retro-cochlear lesion such as vestibular Schwannoma)
MRA/MRV & temporal bone CT: pulsatile (exclude vascular lesion or sigmoid sinus abnormality)
1) What is the goal of treating tinnitus?
2) Describe how this is done
1) Goal: decrease awareness & impact on quality of life
2) -Address associated conditions than can exacerbate symptoms (i.e., depression, insomnia, vascular abnormalities, presbycusis)
-Avoidance of exposure to excessive noise, ototoxic agents & other factors possibly damaging cochlea
-Masking with music or amplification of normal sounds (hearing aids)
-Oral antidepressants most effective (nortriptyline 50 mg PO qhs)
1) What percent of pts over the ages of 50 and 80 have HL?
2) List the 3 types
1) Affects 25% of patients > age 50 & 50% of patients > age 80
2) Conductive
Sensorineural
Mixed (combination of conductive & SN)
Conductive hearing loss (CHL):
1) What causes it?
2) What is it most commonly due to?
3) How is it treated?
1) Result from external or middle ear dysfunction
2) Most commonly due to cerumen impaction & transient ETD
Treatment: Usually correctable with medical or surgical therapy
List 5 mechanisms of CHL
1) Obstruction (cerumen impaction, otitis externa)
2) Mass loading (middle ear effusion, cholesteatoma)
3) Stiffness (otosclerosis)
4) Discontinuity (ossicular disruption)
5) Other (congenital atresia, stenosis, foreign body, neoplasm)
1) What causes Sensorineural HL?
2) What is its most common form?
3) Other causes?
4) Is it correctable?
1) Deterioration of cochlea
2) Presbycusis
3) Excessive noise exposure, head trauma, & systemic diseases
4) Usually not
HL evaluation:
1) What test should you do for all pts?
2) What about for pts with CHL?
3) For pts without obvious cause?
1) Directed H&P (office test of hearing, Weber & Rinne) for all patients
2) Exam of auricle & EAC for patients with CHL
3) Formal audiologic testing for patients without obvious cause
HL evaluation:
1) When should you do an MRI or CT?
2) What about for pts with unexplained SNHL?
3) When should you refer to an otolaryngologist
1) MRI or CT for patients with progressive or sudden asymmetric SNHL
2) Glucose, CBC w/diff, TSH, & serologic test for syphilis for patients with unexplained SNHL
3) Patients with unclear cause
Presbycusis:
1) What is it also called?
2) Describe its characteristics
3) What its causes?
4) What does auditory loss lead to?
5) How is it traditionally managed?
1) Age-related hearing loss (ARHL)
2) Gradually progressive, predominately high-frequency, & symmetrical
3) Multifactorial causes: genetics, CV health, Hx of noise exposure, ototoxic drugs, smoking, DM, hypercholesterolemia
4) Auditory loss leads to social isolation, which increases cognitive decline
5) Traditional management: hearing aids
Hearing aids/ hearing amplification:
1) What pts is this appropriate for?
2) Where are contemporary hearing aids placed?
3) When are bone-conducting hearing aids appropriate?
4) When do cochlear implants typically provide auditory rehabilitation for adults?
1) Indicated for patients with HL not correctable by medical therapy
2) Contemporary hearing aids contained in EAC or behind ear
3) Bone-conducting hearing aids for CHL or unilateral profound SNHL
4) With severe to profound sensory HL
List and describe the two main types of external ear neoplasms. Which is most common in the EAC?
1) Malignant: Squamous cell carcinoma (SCC): most common neoplasm of EAC
-Suspect if apparent otitis externa fails medical therapy
-Get biopsy
2) Benign: Adenomatous tumors from ceruminous glands
Middle ear neoplasms:
1) True or false: Primary middle ear tumors are rare (possible glomus tumor)
2) What are some symptoms?
3) What may be visualized behind an intact TM
4) What tests may it warrant? Why?
1) True
2) Pulsatile tinnitus & hearing loss
-Cranial neuropathies (CN 7, 9, 10, 11, 12)
3) Vascular mass may be visualized behind intact TM
4) MRA & MRV to rule out vascular mass
1) What is another name for inner ear neoplasms?
2) How is it Dxd?
3) What are its treatments?
1) Acoustic neuroma (Vestibular Schwannoma)
2) Diagnosed with MRI
3) Observation, surgical excision, and/or radiation therapy
Epistaxis?
1) How common are single episodes?
2) What percent seek medical attention?
3) Who are bimodal cases most common in?
4) When are seasonal cases most common?
5) Why may it occur in children?
6) What is increased >40 y/o?
1) Single episode in 60% adults; common reason for hospitalization
2) <10% seek medical attention
3)<10 y/o or 45-65 y/o
4) > in winter, URIs, allergic rhinitis, mucosal changes with humidity changes
5) Predominantly anterior & due to digital trauma
6) Posterior source
Anterior nosebleeds often result from mucosal trauma or irritation; how may this occur?
1) Trauma (nose picking, forceful nose blowing)
2) Rhinitis
3) Nasal mucosal drying (low humidity, nasal oxygen)
4) Foreign body (purulent discharge)
5) Chronic intranasal drug use (ie, cocaine)
6) Facial trauma
7) Septal deviation
8) Atherosclerotic disease
9) Alcohol abuse
10) Neoplasm
