ENT Flashcards
Patient presents to ER and states she has had some ear discomfort for the past day or so, and a sense fullness in her ear. She c/o only a slight hearing loss. On exam a finding of TM rupture, and visual blood in the canal is seen. How would you tx this?
This is a Barotrauma. Instruct the patient on how to reduce the pressure in her ears in the future by sucking on candy, or yawning during her next flight. She should also take decongestants at least 2 hours prior to flying. You could prescribe her NSAIDs or opiates for the pain as well. She may be referred to ENT for the TM rupture management
Patient presents to your office. She states that she was cleaning her ear the other day and noticed a sudden whistling sound accompanied by pain. What test might be done to check for TM perforation and how would you treat it?
Check for TM with otoscopy, complete a bubble test-have patient valsalva while looking in ear-If bubbles are present pt has ruptured the TM. Tx by reducing the risk of infection, drops if indicated by ENT, SX ABX if purulent drainage, surgical rx if hearing loss persists
A 25 year old boxer presents to the ER. He was hit in the ear about 2 weeks ago and developed what he says is some swelling. He states he didn’t want to come to the ER because he “knows a lot of guys who look like this and they’re fine” but now the ear is causing him quite a lot of pain and he wants to do something about it now. What will you do for him.
Refer pt emergently to ENT. If he had presented within 7 days you could have performed an I&D of the hematoma and dressed with a pressure dressing. You would have drained it and then seen him daily until you could get him in to see an ENT. Since has waited so long now it is not advisable to do a simple I&D and he will need more urgent workup by ENT to repair the ear.
Conductive Hearing Loss Definition
Loss between External Auditory Canal up to the middle ear ossicles (stick your finger in your ear-you just created a conductive hearing loss.)
Causes of Conductive Hearing loss
Cerumen impaction, foreign body in EAC, Otitis Externa (swelling), TM perf, Middle ear fluid collection, Otosclerosis, Eustachian tube dysfunction, Cholestatoma
A 25 year old female presents to the office. She states that for the last year she has been traveling a lot for work and hasn’t been able to get in to see someone. She states she has a chronically draining ear, and although it isn’t too painful she does notice that her hearing is starting to be effected. She thought at first it had to do with all of the flying that she has been doing, but nothing seems to make it better, even staying home for a few weeks. Her uncle who is a doctor gave her a prescription for an antibiotic without examining her since she was on the go so much but the abx doesn’t really seem to be helping either. What do you suspect this patient might have, what might you see on otoscope exam, and how would you treat it?
Cholesteatoma, white cheesy material will be seen on otoscope exam, refer to ENT for surgical removal
Sensorineural Hearing Loss Definition
Loss from Inner ear to the brain (problems with cochlea and CN VIII into the brain along auditory pathway)
Sensorineural Hearing Loss Causes
Presbyacusis (most common), Chronic noise exposure, Meniere’s DZ, Ototoxicity, Neoplasms, Vascular DZ, Demyelinating DZ (such as MS), Infection, Trauma
75 year old male patient named Ralph presents to the office with his wife Betty. She states that for the last year or so she has noticed that Ralph has been slowly losing his hearing; he “turns the television up so loud the neighbors can hear it” She is increasingly frustrated but Ralph doesn’t seem to even notice that his hearing is going. He is very adamant that he can hear just fine. What does he have and why doesn’t he seem to notice?
Presbyacusis is generally very gradual and almost always symmetric. Ralph’s hearing has gone so slowly and symmetrically that he doesn’t notice……Poor Betty! He might want to get a hearing aid, this will help with the volume but maybe not the clarity, of what he is missing out on.
A 43 year old female presents to the ER with her 4 kids. She looks extremely tired and states that 2 of her kids had stomach bugs last week and she hasn’t gotten any sleep in days!! Her husband is traveling for business and she apologizes for having to take the kids with her but she just can’t seem to get over these strange dizzy spells she has been having. She c/o severe vertigo lasting about 3 hours at a time, sometimes it is difficult to hear, and she has a “full feeling” in her R ear.” She thinks she might have to stomach bug as well and is hoping to get some treatment and get herself and her kids back home soon. What might be her real problem, and how would you address it?
This patient may have Meniere’s disease. You can treat this with a low sodium diet, short course of steroids, and a thiazide diuretic…..and maybe a really good family member or babysitter for a night.
A 65 year old patient who was admitted to the hospital service last week for a separate issue is consulted regarding some hearing loss. He has been in the hospital for just a few days and his meds include Gentamicin, Metoprolol, Lisinopril, a multivitamin, plaque nil, and pravastatin. What might be the first thing you would think of regarding his hearing loss-given this med list.
Ototoxicity can be caused by Gentamicin. If it is possible to d/c this medication advise immediately. Unfortunately the damage may not be reversible because of the permanent effect that gentamicin has on the nerve.
A patient presents to the ER for eval complaining of asymmetric hearing loss, and poor word discrimination. Her husband states that she was fine yesterday but when she woke up this morning she said she couldn’t hear well out of her right ear. Upon exam the patient notes a loss of sensation on her Right side around the forehead and lower face. She also notes a loss of balance, although not really a “room spinning” kind of dizziness. What might be most concerning about this? Why is is happening in this way? and What referral should you make?
An accoustic neuroma is the concerning factor here. Its close proximity to CNVII may be causing the loss of sensation. The dizziness without true vertigo is also a sign of this. Referral to a neurosurgeon should be the treatment plan-no worry about metastasis with these though since these tumors are benign.
What might an isolated labyrinthe infarct cause?
Sudden hearing loss and vertigo due to vascular disease
Mixed Hearing Loss (cause)
Trauma or Neoplasm
Tinnitus Presentation and treatment and DDX
C/o buzzing, roaring or ringing will be tinnitus, DDX with a vascular tumor which is more of a rhythmic whooshing. If Tinnitus is caused by trauma steroids can help if picked up quickly-otherwise not much can be done about it.
Weber Test: Usefulness, procedure, and interpretation
If patient lateralizes to one ear or not: 512 tuning fork placed in center of patients head. Ask pt if they hear sound equally or more on one side. If more in 1 ear pt “lateralizes” to that ear. This could mean pt has conductive hearing loss in the lateralized ear OR sensorineural hearing loss in the other.
Rinne Test: Usefulness, Procedure, and Interpretation
Used to determine if air conduction is better than bone conduction: Tuning fork placed over mastoid bone of ear you are testing Name this number 1-without restriking place the fork next to the outer ear on the other side and Name this number 2. Ask the pt which was louder number 1 or number 2. Number 2 should be louder since air conduction is better than bone. If patient hears bone better than air-they have Conductive hearing loss in that ear.
Formal Hearing Test Parameters
Determines hearing threshold levels between 250 and 8000Hz measured in decibels. Higher the threshold the poorer the patients hearing. Measures for both air and bone conduction as well as speech discrimination.
A 50 year old Asian male presents to your ENT office. CC: Sore throat. He c/o throat pain, headaches, and rhinorrhea x 3 months. He states that he has had recurrent ear infections for the past year or so and can’t seem to get them under control. He states “I feel like I always have a frog in my throat.” Upon physical exam you note slightly swollen cervical lymph nodes as well as some dried blood in his nasal passage. He also has what appears to be an enlarged Left tonsil with swelling that tracks from up in his nasal passage down the posterior aspect of his oropharynx. He lives at home with his wife and a 20 year old daughter who just had her first baby. He is concerned that he will get the baby sick and requests that you give him an Abx. What do you do in this case? And what should you be looking for specifically.
You must consider that this patient may have a Nasopharyngeal cancer. Indicators would include: Age and race, epistaxis, unresolving OM, and headaches. He did not mention a hx of Epstein Barr but that would be a major indicator here as well. Patient should have a endoscopic bx to determine and aggressive treatment and follow up since late recurrences are common. (Lifelong follow up is required).
DDx would include: Sinus infection, Strep throat, Recurrent OM,
Where does an Acoustic Neuroma arise from? A. Acoustic Portion of Nerve VIII B. Acoustic Portion of Nerve VI C. Vestibular Portion of Nerve VIII D. Meatal Portion of Nerve VI
C. Vestibular Portion of Nerve VIII
*Acoustic Neuroma is actually a misnomer-Tumor actually arises from the vestibular portion which is responsible for vestibular function. The more accurate name is Vestibular Schwannoma
25 yo male patient presents to the office. He states that he has had a runny nose for weeks now! He does state that he has allergies but this is worse than they have been in the past few years. He has missed a few days of work already because his symptoms were so bad. On physical exam you note thin watery discharge from the nose, slightly indurated oropharynx. He is otherwise asymptomatic of the eyes, or ears. LN are normal on palpation. He states a med list of just a daily multivitamin and Afrin. What question should you ask him?
You should ask how often he has been using the Afrin. Consider Rhinitis Medicamentosa which can be caused by overuse of Topical Alpha-adrenergic agents such as Afrin.
What is the most common cause of TM perf
Infection/mass
What is best to prescribe for TM perf (if indicated)
Quinolones are best but not to be used in children under 16yo
MC pathology of Nasal cavity Ca
Squamous cell
MC associated diag for Nasopharyngeal Ca
Assoc with EBV
Pathology of Nasopharyngeal ca
Non keratiinized squam cell or Lymphoepitheliomas. Sporadic cases (outside of SE asia and Non-EBV) Squam cell
Oropharynx MC pathology
Squamous cell
Oral Ca epidemiology
MC cause is tobacco use and MC effects males 50-70yo
Indications for enlarge occipital LN
Can be considered NEVER MALIGNANT: unless there is an obvious scalp ca.
