ENT Flashcards
what is involved in the ENT exam?
ear - external, otoscopy, tuning forks
nose- anterior rhinoscopy
throat- oral cavity/pharygeal exam
neck - palpation, thyroid exam
CN exam
respiratory
this is common in wrestlers, where blood collects between mucoperipchonidrium and cartilage.
auricular hematoma
tx: drainage and bolster dressing to avoid cauliflower ear
this is a benign condition, more common in AA. Difficult to treat because comes back, and is treated by surgical removal or steroids
keloid
this comes from an alkalotic environment/trauma by the pathogen pseudomonas or staph aureau
otitis externa (swimmers ear)
how is otitis externa treated?
oto-topical drops, oral abx (quinolones to tx pseudomonas)
what are complications of otitis externa and who are they more common in?
malignant otitis externa (skull base osteomyelitis)
more common in diabetics- usually admitted for IV abx
this is a fairly commonly seen benign body overgrowth of the ear canal. typically doesn’t cause any problems or pain
osteomas
why does an ear drum become retracted?
eustachian tube dysfunction
common problem secondary to q-tips
ruptured tympanic membrane - wait 3 months for healing, keep dry, most heal on their own
what is the difference between otitis media and effusion?
otitis media is an inflammatory condition of the middle ear space - think eustachian tube dysfunction
effusion just means there is fluid in the middle ear space. middle ear liquid resulting from infection of inflammation (can be serous, mucoid, purulent)
different classifications of otitis media
acute ( 12 weeks)
what is acute otitis media?
fluid with infection
2nd most common disease in children (URI is #1)
what is the cause of acute otitis media?
eustachian tube dysfunction
sxs: fever, otalgia, bulging red TM
pathogens for otitis media
s pneumo, h flu, m cat
what is the first line treatment for otitis media?
amoxicillin (usually 45 mg/kg 2x a day)
beta-lactamase inhibitor is 2nd line
Tympanocentesis if not improving with abx
what is otitis media with effusion and how do you treat?
fluid without infection
cause: eustachian tube dysfunction
sxs: hearing loss, speech delay
treatment depends on chronicity, dont need antibiotics
these are used to help ventilate middle ear space and normalize pressures
ear tubes (surgery)
what are the indications for ear tubes?
recurrent acute otitis media - 3 infections in 6 months or 4 in 1 year with current effusion on exam
Chronic Otitis Media with Effusion – greater than 3 months of effusion with evidence of hearing loss
Think about the adenoids!!! – sits in posterior nasopharynx. If enlarged, can cause obstruction of orifices and can be cause
what will the tympanic membrane look like with otitis media with effusion and acute otitis media?
otitis media with effusion will have yellow or amber colored fluid behind tympanic membrane (indicated serous fluid)
acute otitis media with be Erythematous
what are some complications of otitis media/chronic ear disease?
they’re uncommon now because of antibiotics but infection can spread to brain, sigmoid sinus, mastoid air cells (mastoiditis)
all need to be treated aggressively with IV antibiotics, ear tube drainage, possible mastoidectomy
1 chronic complication of otitis media
cholesteatoma - skin debris gets trapped in middle ear space and continues to dequemate
inflammation of tympanic membrane as opposed to middle ear space in AOM. very painful, due to pathogen mycoplasma pneumonia
bullous myringitis
if associated with blisters in canal need to think about zoster infection
first test for hearing. you place the fork on the top of the head in midline. conduction losses latralize to side of lesion, sensorineural losses lateralize to opposite ear
WEBER
hearing test for bone vs air conduction
AC>BC in SNHL, BC>AC in CHL
t or f: almost all cases of conductive hearing loss are correctable with surgery
true - osteosclerosis
how should you treat a sudden sensorineural HL?
should be evaluated by an ENT within 24 hours and treated with steroids
asymmetric SNHL is what until proven otherwise?
acoustic neuroma- benign tumor on vestibulocochlear nerve. patient needs MRI
perception of motion in the absence of movement. usually described as the room spinning
vertigo - this is a symptom, not a diagnosis
what body parts are involved in balance system?
visual cues
propioception
brain input
vestibular system
this is caused by otoliths in the semicircular canal, lasts seconds to minutes, associated with head movement. patients usually say that they ““Lay in bed, turn to my right side and the room spins really badly for 2 min then goes away”
benign paroxysmal position vertigo (BPPV)
Dx: Dix-Hallpike test
Rotary nystagmus beating toward affected ear
Tx: Canolith repositioning – done in office. Lay back and hit mastoid bone repeatedly
Epley Maneuver
when someone has acute onset vertigo, what should be your first thought?
stroke
what is acute onset vertigo?
sudden onset that lasts hours to days, even weeks
diagnosis:
central: Central (neurologic cause) – NEEDS IMAGING!
Vestibular, unclear cause
Labrynthitis (associated with hearing loss) vs Vestibular Neuritis (just vertigo)
Hearing loss/tinnitus?
Tx
Supportive
Meclizine, valium, anti-emetics
Steroids
this is caused by an increase in endolymphatic pressure, and symptoms include episodic vertigo usually lasting several hours with fluctuating SNHL, aural fullness, and tinnitus.
meniere’s disease
Tx
Initial main treatment goal is to reduce pressure in inner ear
Low salt diet
Diuretics
most common causes of epistaxis
mucosal drying and trauma (picking your nose)
Auto Dominant disorder with defect in contractile elements of blood vessels and formation of AV malformations
Osler-Weber-Rendu Syndrome (Hereditary Hemorrhagic Telangiectasia)
what is the difference between the classifications of sinusitis?
acute: 3 months
something going on thats causing poor drainage of the mucus at sinus ostia
most common pathogen of acute sinusitis
rhinovirus
then S. pneumo, H flu, M Cat
Fungus – Aspergillus/Mucor
Chronic
Staph Aureus, anaerobes
how do you treat sinusitis?
acute: abx 10-14 days
irrigations, decongestants
chronic: 3-6 weeks antibiotics, needs CT if not responding
benign, jelly filled sacks formed off the mucosa. can cause some secondary sinusitis because blocking drainage
polyps
septal perforations
think of intranasal drug use or trauma
benign oral presentations
mucoseal geographical tongue bony overgrowth of the palate dark veins under tongue Torus mandibularis
lymphoid tissue that sits in continuous circle in the oro and nasopharynx to accept Ag’s for the upper AD tract.
waldeyer’s ring
if adenoids are enlarged (adenoid hypertrophy), what can they affect?
the eustachian tube (usually in kids)
what is the most frequent cause of otolaryngologic infection in children?
common cold
rhinovirus, influenza, parainfluenza, adenovirus, RSV
Viral pharyngitis usually more mild in presentation.
symptoms of common cold
sore throat, dysphagia, fever with tonsillar erythema
Small vesicles with erythematous base that become ulcers and spread
herpangia- Coxsackievirus
supportive care
high fever, malaise, large swollen dirty gray exudative tonsils. Hepatosplenomegaly
Large bilateral tender posterior LAD
EBV
Petechiae at junction of hard and soft palate not pathognomonic.
most specific test for EBV
monospot - latex agglutination assay
very specific but low sensitivity so high false negative rate- (False negative rates 25% in first week down to 5% by 3rd week.)
If clinical suspicion is high despite negative Monospot, can do EBV antibody testing.
treatment for EBV
usually supportive
what should be avoided in patients with EBV?
ampicillin because a rash can develop
when should you hospitalize a patient with EBV?
cases of severe hypertrophy with dehydration, upper airway obstruction – treat with steroids or emergent tonsillectomy if needed in rare cases.
most common pathogen for pharyngitis
group A streptococcus - Public health importance due to its frequency and serious sequelae.
treatment for Streptococcal Tonsillitis-Pharyngitis
PCN
symptoms of Streptococcal Tonsillitis-Pharyngitis
odyophagia (pain when swallowing food) , otalgia (ear pain), fever, headache, malaise, cervical adenopathy, enlarged red exudative tonsils
in which patients is thrush most common?
patients you use inhaled corticosteroids, diabetics
tx with nystatin, clotrimazole, diflucan
Classic complication of tonsillitis that brings patients to the ER for evaluation and treatment. patient presents with tonsillitis that is not responding appropriately to ABX and is now worsening after days of treatment. UNILATERAL symptoms, OTALGIA, drooling with severe odynophagia (poor PO intake), trismus (irritation of pterygoid musculature)
peritonsillar abscess (quinsy)
on exam, uvula pushed off midline
Can occur as a sequelae from an infection of the nose, sinuses, or pharynx since the lymph nodes of this space drain these areas. They usually occur in children less than 2 years old and present with some of the same symptoms in addition to having a stiff neck and sometimes some muffled speech.
retropharyngeal space abscess
indications for tonsillectomy
OSA chronic tonsillitis (7 infections in one year, 5 for past two years, or 3/year for the past 3 years)--> just guidelines, everyone is diff
if one tonsil is bigger than other (unilateral), then most concerning so would probs do tonsillectomy
Note size of tonsils in children with loud snoring and breathing difficulties at night noted by parents.
Questions/Critical exam features to look for in hoarse patient
progression over time associated breathing problems dysphagia signs of infection fever stridor drooling poor secretion management pain associated with voice changes
presents with drooling, hot potato voice, rapid progression, posturing forward, systemic toxicity/fever, inspiratory stridor
epiglottitis - now more common in adults (Group A strep, Staph aureus)
Thumbprint sign – inflamed/swollen epiglotis
treat with IV abx, rapidly secure airway if necessary
infection of the subglottic larynx causing biphasic stridor. commonly caused by parainfluenza virus but any upper repiratory infection in young child can cause it. steeple sign on xray
croup
how do you treat croup?
cool mist humidity, steroids in severe cases with hospital admit
usually presents slowly over few months and almost always in a chronic smoker/EtOH abuse but not always.
larynx cancer
common/benign disease of larynx
vocal cord nodules
vocal cord polyps
layngo-pharyngeal reflux
what are the symptoms of laryngopharyngeal (LPR) reflux?
hoareseness, globus, throat clearing, AM symptoms
diff from GERD which has heartburn, chest pain, regurgitation, and PM symptoms
how do you treat LPR (Laryngopharyngeal Reflux)?
more aggressive PPI (bid)
which salivary glands are most commonly affected in parotitis/sialoadenitis?
parotid and sublingual
common symptoms of Parotitis/Sialoadenitis?
painful swelling, often worse after eating. erythema over the area, purulent drainage from the duct
image looks like a swollen neck
common causes of parotitis/sialoadenitis?
sialolithiasis (a condition where a calcified mass or sialolith forms within a salivary gland, usually in the duct of the submandibular gland )
bacterial
viral
autoimmune
treatment of parotitis/sialoadenitits
conservative measures: massage, warm compresses, sialogogues
abx: augmentin, clindamycin
recurrent episodes may require excision of the gland
Most common non-cutaneous head and neck site for masses/cancer
oral cavity - vast majority is squamous cell carcinoma
risk factors: smoking/EtOH use
presentation of head and neck masses/cancer
unexplained throat pain, dysphagia, hoarseness especially in patient with above risk factors needs further workup
when evaluating a patient with a neck mass, what should be the first consideration?
age of the patient
Pediatric (0-15 years old)
Inflammatory>Congenital>Neoplasm
Young Adult (16-40 years old) Inflammatory>Neoplasm>Congenital
Adult (40+ years old)
Neoplasm>Inflammatory>Congenital
second consideration of a patient with a neck mass?
location of the mass
If it is in the anterior compartment, think either thyroid neoplasm or lymphoma
when inflammation is suspected with a neck mass, what is the longest amount of time you can have an antibiotic trial?
2 weeks
what is the most cost effective and most productive single diagnostic evaluation available for a patient with a neck mass?
FNA (fine needle aspiration)
an undiagnosed neck mass in an adult is what until proven otherwise?
metastatic carcinoma
t or f: Excisional biopsy of a mass in an adult prior to a complete head and neck evaluation is recommended
FALSE. contraindicated and could lead to a worse treatment outcome
prefix for eyelids
blephar-
sebaceous glands of eye
Meibomian: inner eyelid
glands of zeis: outer eyelid
large sweat glands at the outer eyelid margin
glands of moll
eyelids are given shape and form by the tarsal plates within them
differences between chalazion and stye
chalazion is internal in the meibomian gland so treated from inside the eye
stye is outside so tx from outside
where are the lacrimal glands located?
upper outer eyelids. Tears are secreted from the glands secretory ducts –> collected at the nasal edge of the palpebral fissure and pass through the puncta into the sup &inf canaliculi –> lacrimal sac
From the lacrimal sac, they pass into the nasolacrimal duct and then into the nose in the inferior meatus (below the inferior turbinate)
blockage of tear duct/not fully matured in babies
dacrocystitis - tx with warm compress
function of tears
form smooth refractive surface on epithelium- inhibits bacterial growth
maintains moist environment for epithelium
carries oxygen to the eye
what is the term for inflammed conjuctivae?
chemosis
three coats of eye
inner layer - retina
- inner nerve layer (axons and ganglia)
- outer pigmented (photoreceptive layer with rods and cones)
middle vascular layer - uveal tract (iris, ciliary body, choroid)
outer fibrous layer (sclera)
white of the eye which surrounds the entire eye except for the cornea
sclera (superficial is episcler- and deep is scler-)
this composes the anterior 1/6 of the eye and is avascular
cornea - receives nourishment from aqueous humor
where does the greatest change in refractive index occur
at the air-corneal tear film interface
where does the bulbar conjuctiva meet the cornea?
limbus (limbic margin)
round sphincter muscle that controls pupil size
iris
Outer aspect of the iris forms an angle with the cornea (the “anterior chamber angle”) that is important in glaucoma
kayser-fleischer rings are associated with what?
wilsons disease - copper storage disease
term for pupillary dilation
midriasis - when the iris dilator muscle contracts (under SNS control), the pupil dilates
Pupils dilate under dark conditions and when focused on a distant object
term for pupillary constriction
miosis - When the iris constrictor muscle contracts (under PSNS control), the pupil constricts
Pupils constrict under light conditions and when focused on a near object
Both pupils should be equal
Pupils diameter should not vary by more than 1 mm between the eyes
Be sure to check in dim light if you see a difference in a bright room
term when there is a pupil size difference of > 1 mm
anisocoria
is the lens vascular or avascular?
avascular (65% water)
biconvex, colorless, transparent
when does the lens become thicker and thinner?
It is an elastic structure that becomes more spherical (thicker) when relaxed for near vision, and more flat (thinner) when stretched for far vision
what divides the eye into the aqueous cavity in front and a vitreous cavity behind?
the lens
what determines the shape of the lens?
ciliary muscle tension - lens is suspended from the suspensory ligaments that are attached to the ciliary muscle
Contraction of the ciliary muscles pulls on the choroid, thereby relaxing tension on the suspensory ligaments. This then allows the lens to assume a more spherical shape for near vision
Relaxation of the ciliary muscles results in more tension on choroid, thereby increasing tension on the suspensory ligaments. This then causes the lens to assume a more flattened shape for distance vision
the space between the cornea and iris, filled with aqueous humor
anterior chamber
what maintains IOP and nourishes the avascular lens and cornea?
aqueous humor
blood in the anterior chamber is called what?
hyphema
pus in the anterior chamber is called what?
hypopyon
the space between the iris and the lens, filled with aqueous humor
posterior chamber
large eye cavity located behind the lens
vitreous cavity
Filled with a jelly-like vitreous humor
*Acts as a “shock-absorber”
what are little dots, circles, lines, to clouds or cobwebs in the vitreous cavity?
floaters - if you have an increase, may be retinal detachment
The dark brown/black vascular coat of the eye, located between the sclera and retina
choroid
this is comprised of the iris, ciliary body and choroid
uveal tract
The anterior uveal tract consists of the iris & ciliary body
The posterior uveal tract consists of the choroid
yellow spot in the posterior central area of the retina, just lateral to the optic disk
macula lutea
this is an area in the macula lutea with densely packed cones, that is the area of most acute vision
fovea centralis - has deeper blood supply than the rest of the retina
The “fundus” refers to that part of the retina that is able to be visualized with an ophthalmoscope
Tasacks disease (sp?) – lipid disorder **cherry red spots - preserved in fovea
which area is responsible for the blind spot?
optic disk - point of transition from the retinal to the optic nerve
This area contains the optic nerve (containing over 1 million nerve axons), central retinal artery & vein
how many bones make up the walls of the orbit?
7
Many Friendly Zebras Enjoy Lazy Summer Picnics
Maxillary Frontal Zygomatic Ethmoid Lacrimal Sphenoid Palatine
a lesion here will result in bi-temporal vision loss?
optic chiasm
Galactoria and bitemporal visual field loss – PITUITARY ADENOMA
a lesion here will result in homonymous (same side) defects
optic tracts and radiations
a lesion here will result in loss of vision of only this one eye
optic nerve
90% of eye’s blood supply is through what?
choroid layer blood supply - Supplied by 10-20 short posterior ciliary arteries that enter near the optic nerve
normal cup: disk ratio
hemorrhages with central clearing
roth spots - endocarditis
Blot hemorrhages occur deep in the retina
Flame hemorrhages are superficial hemorrhages that follow the nerve layer pattern
these represent focal retinal ischemia
soft (cotton wool) exudates
Must be distinguished from myelination of the optic nerve
Represent leakage of proteins and lipids from blood vessels
hard exudates
represent small white hyaline (a substance from cell degeneration) deposits that develop beneath the retinal pigment epithelium. Occur most frequently in persons older than 60 y/o (a consequence of aging)
May be a precursor of age-related macular degeneration
Must be distinguished from hard exudates
drusen
difference in vision loss between glaucoma and macula
macula is central vision loss
glaucoma is peripheral vision loss
Psudopapilledema
drusen is deposited right over where you would see optic nerve
patients describe this as a curtain being drawn over vision
retinal detachment
Sometimes gravity will help so just have them lay supine
cherry red spots are pathomneumonic for what?
Tay-Sachs
no refractive error
emmetropia
farsightedness
hyperopia (shorter than normal eye)
Require a bi-convex lens to converge the light rays more
nearsightedness
myopia (longer than normal eye)
Light rays focus in front of the eye
Require a bi-concave lens to diverge the light rays more
A distortion of vision caused by a difference in refractive power along different meridians of any of the main refractive surfaces (cornea, anterior lens, or posterior lens surfaces)
astigmatism
a pinhole corrector will overcome most refraction errors and is helpful in determining in refraction is the cause of visual loss or not
outward displacement of the eyeball with a widening of the palpebral fissure
Exophthalmos
May be bilateral or unilateral
More serious (pathological) causes:
Thyroid orbitopathy (e.g., Graves Disease)
Intraorbital inflammation and edema (cellulitis)
Intraorbital tumor
Intraorbital trauma (to bones or EOMs resulting in hemorrhage)
Endocrine disorders
lack of parallelism (misalignment) of the visual axes of the eyes such that the optic axes cannot be directed to the same object (eyes don’t focus and move together properly)
strabismus
May be convergent strabismus (“Esotropia”) resulting in crossed-eyes,
or divergent strabismus (“Exotropia”)
May be unilateral, bilateral, alternating
May be permanent or intermittent
at what age should you be concerned about strabisumus?
after age 6, when binocular vision should be well established
Leads to vision loss if not corrected early-on (by age 5 or 6 at the latest)
Eye patching in kids may cause an iatrogenic strabismus!
this refers to poor or complete loss of vision in one eye that cannot be corrected with a lens. It usually is the end result of when the images of the two eyes cannot be properly fused into one, leading the occipital cortex of the brain to ignore one of the images. Complication or sequela of strabismus
Amblyopia
can be caused by :
Strabismus (misalignment of the eyes)
Anisometropia (a large diffference in refraction between the eyes)
Opacity anywhere along the visual axis (corneal opacity, congential cataract, etc.)
how do you treat amblyopia
Correct the underlying cause as soon as possible
Congenital cataracts should be corrected in the first few months of life
If underlying cause of the amblyopia is not corrected by age 5 or 6, the brain will permanently ignore the bad eye’s image
Patch the good eye to force the brain to use the image from the bad eye
double vision
diplopia. usually from an imbalance in EOMs.
May result from many different causes, such as orbital blowout fracture, myasthenia gravis, head injury, intracranial tumors, et al.
You must distinguish between binocular diplopia and monocular diplopia. You must distinguish between horizontal diplopia and vertical diplopia
painful aversion to light
photophobia
Potential causes: Corneal inflammation (abrasions, ulcerations, etc.) Inflammation of the iris Inflammation of the sclera During acute glaucoma
what are potential causes of eye pain?
Inflammation of the EOMs
Inflammation of the uveal tract (iris, ciliary body, choroid)
Corneal abrasion or ulceration
Acute closed angle glaucoma (markedly elevated IOP)
Referred pain from extra-orbital problems (e.g., sinusitis)
spots that are occasionally seen floating across the visual field
and are usually due to vitreous opacities and are of no consequence
floaters
