ENT Flashcards
Viral Tonsillitis and Pharyngitis Causes
Most common cause: viral
Adenovirus Rhinovirus H. Influenza Coronavirus RSV Rarely: EBV, HSV, CMV
Bacterial Tonsillitis and Pharyngitis causes
2nd most common cause of tonsillitis and pharyngitis
Group A Beta-hemolytic Streptococcus
Less common: S. Aureus (incl. MRSA) S. Pneumonia Mycoplasma pneumonia Bordetella pertussis Fusobacterium C. Diphtheriae T. Pallidum N. Gonorrhoeae
Otitis Media (intact TM)
Cause: bacteria (most common)
- Strep pneumoniae
- H influenza
- Moraxella catarrhalis
- Group B strep
- Staph aureus
Treat:
- Penicillin
- <5y old: amoxicillin
- Moraxella: Co-amoxiclav (amoxicillin + clavulanic acid)
Otitis media with perforation
Cause: bacteria (most common)
- Strep pneumoniae
- H influenza
- Moraxella catarrhalis
- Group B strep
- S aureus
Treat:
-Topical Ciprofloxacin (fluoroquinolones effective against staph and pseudomonas) + dexamethasone (corticosteroid)
Otitis Externa causes
Mainly due to bacteria
- Pseudomonas aeruginosa
- S aureus
Then fungal (called otomycosis)
- Candida albicans
- Aspergillus
Otitis Externa Treatment
Otic drops: acetic acid, fluoroquinolones + steroids (eg. cilodex) Alternatively aminoglycosides (avoid in grommets or perforation)
Bells palsy
- most common cause of unilateral facial paralysis
- due to oedema of VII in the fallopian (facial) canal (bony canal)
- secondary to HSV type 1
Rx:
Oral corticosteroids (Prednisone for 10d)
Antivirals: acyclovir/valacyclovir within 72h
Eye drops: artificial tears / ocular ointment
Acute otitis media
H influenza, S pneumoniae, M catarrhalis
Mild: Amoxicillin
Moderate/severe: Augmentin
Macrolides in penicillin allergy
Chronic suppurative otitis media
Mixed, S aureus, P aerurginosa, anaerobes
Topical AB (fluoroquinolones, aminoglycoside with steroid drops (neomycin/ polymycinB) \+ Aural Toilet
Acute otitis externa
P aeruginosa, S aureus, <2% fungal, viral or eczema
Topical acetic acid / alcohol + topical antimicrobials + removal of debris
Acute bacterial rhinosinusitis
H influenza, S pneumonia, M catarrhalis, S pyogenes, S aureus, P aeruginosa, anaerobes (odontogenic)
Spontaneous resolution OR
Amoxicillin (10-4d) / Augmentin
Penicillin allergy: doxycycline / bactrim
Chronic rhinosinusitis
Mixed: S aureus, P aeruginosa and anaerobes
Combined quinolones & steroids
Acute bacterial tonsillitis or pharyngitis
S pneumoniae, Group A beta-hemolytic strep
Penicillin
Local anaesthesia mechanism
Interferes with Na channel functioning
Decreased Na intracellularly
Prevents propagation of action potential
Cocaine
Amino-ester
Blocks re-uptake of Na & dobutamine at adrenergic nerve endings
Onset: slow, duration 30-60min
Side effects:
-vasoconstriction, tachycardia, HT, mydriasis, addiction
Admin route:
-topical
Lidocaine
Amno-amide
Interrupts vagal afferent pathways
Onset: rapid, duration 1-3h
Admin route: topical, IVI, submucosal, endotracheal
Aphthous ulcer
Theory: T-cell mediated immune response to nutritional deficiencies, stress, trauma, hormonal and allergies
Treat: topical anaesthetic & anti-inflammatory agents
- Viscous lidocaine 2%
- Apthasol 5%
- Temovate 0.05% (glucocorticoid: clobetasol)
AND antimicrobial mouthwash (reduces ulcer size, duration and pain) - chlorhexidine gluconate
Allergy medication
Anti-histamines
Decongestants
Corticosteroids
Leukotriene receptor antagonist
Antihistamines
H1 receptor antagonists
Target cells: eyes, nose, skin, lungs
-best for immediate, early phase allergic response
1st Generation antihistamines
- highly lipophilic (cross BBB - sedation & CNS suppression)
- highly anticholinergic (dries mucosa, increased mucous tenacity, blurred vision, constipation & urinary retention)
Diphenhydramine
Chlorpheniramine
Triprolidine
Azatadine
2nd Generation antihistamines
Lipophobic
- doesn’t cross BBB, no likely sedation
- little/no anticholinergic activity (safe in asthma, little/no tachyphylaxis)
Loratadine Fexofenadine Cetirizine Desloratidine Levocetirizine
Decongestants mechanism
Alpha-agonists
-binds alpha-2 receptors - vasoconstriction (decreases engorgement)
Systemic decongestants
Pseudoephedrine, phenylephrine
Significant alpha-adrenergic side effects
-increased BP, appetite, cardiac symptoms (tachycardia, arrhythmia)
Topical decongestants
Oxymetazolin, Phenylephrine, Naphazoline, Tetrahydrozoline
Rapid rebound congestion can develop within 3 days of use
Rapid tachyphylaxis with increased use
Mucosal hypoxia & neurotransmitter depletion
Leads to RHINITIS MEDICANTOSA
Corticosteroids
Block generation & release of mediators and influx of inflammatory cells
Wide range of effects:
- cellular: mast cells, eosinophils, macrophages, lymphocytes & neutrophils
- humoral mediators: histamines, eicosanoids, leukotrienes & cytokines
Prolonged systemic usage -> suppression of hypothalamic pituitary axis (innate corticosteroid production) -> tapering doses NB
Systemic Corticosteroids
-short course in serious allergic inflammation (effects 12-24h)
Commonly used preps:
-prednisone, methylprednisone, dexamethasone
Side effects:
- reduced bone density
- increased intraocular pressure
- cataracts
- increased glucose and potential difficulty controlling diabetes
- increased peptic ulcer disease
- capillary fragility
- reduction in bone growth in children
Topical
-allergic rhinitis and nasal polyps
Beclomethasone diproprionate Fluticasone proprionate Mometasone furoate Fluticasone furoate Budesonide
Side effects: epistaxis, rarely septal perforation
Leukotriene receptor antagonsists
Blocks binding of leukotrienes to target cells
Montelukast - also for asthma & exercise induced bronchospasm
-use from >6mo old
Ototoxic medications
Cochlear & vestibular toxicities
-reversible or permanent hearing loss
- Aminoglycosides
- loop diuretics
- cytotoxic drugs (platinum based chemotherapy)
- ARV’s
- Anti-malaria: quinine
-salicylates (reversible)
Aminoglycosides
- bilateral permanent and high frequency sensorineural hearing loss
- excreted by kidneys - renal dysfunction needs dose adjustment to decrease ototoxic effects
Binds to outer hair cells in cochlea, chelates iron leading to free radical formation and cell destruction
Tobramycin, Gentamycin and Streptomycin -> vestibulotoxic
Neomycin, Kanamycin -> cochleotoxic
Topical: only when TM is INTACT!!!
Loop diuretics
Transient cochlear toxicity (affects striavascularis)
Furosemide (commonly used) - administer parenterally over several minutes
Chemotherapy (platinum based)
Cochleotoxic - stria vascularis and outer hair cells
Tinnitus: presenting symptom
Commonly used: Cisplatin & Carboplatin
Vertigo
Peripheral
- benign paroxysmal positional vertigo
- Meniere’s disease
- vestibular neuritis
- vestibular migraine
Central
-stroke
Other:
-toxin exposure (carbon monoxide, aspirin, alcohol)
Vertigo Management
Meniere’s disease
- low salt diet, caffeine & alcohol avoidance
- diuretics (HCTZ)
- diazepam (vestibular suppressant)
- intratympanic injections of gentamycin
- antihistamines: betahistine, dimenhydrinate, meclizine may have antiemetic properties
Laryngopharyngeal reflux and Gastroesophageal reflux presentation
Chronic cough
Throat clearing
Hoarseness
Globus sensation
Laryngopharyngeal/gastroesophageal reflux treatment
1st line: lifestyle modification
-elevate head of bed, decrease fat intake, avoid certain foods (caffeine, alcohol, peppermint), smoking cessation
Antacids: hydroxide aluminum and magnesium, sodium bicarbonate, calcium bicarbonate
Alginic acid
Combination preps (gaviscon)
Acid suppression for persistent reflux: H2 receptor antagonists, proton pump inhibitors
H2 receptor antagonists
-prevent histaminergic stimulation of acid secreting parietal cells
Ranitidine
Famotidine
Cimetidine (CYP450 inhibitor - monitor for interactions)
-take 30 min before meals
Side effects
- headache
- constipation
- confusion
- elevated liver enzymes
- confusion
Proton pump inhibitors
Act on luminal surface of parietal cell - inhibit H+/K+ ATPase (site of acid entry into gastric lumen)
Omeprazole
Lansoprazole
Esomeprazole
Pantoprazole
Take 30-60 min before meals
Side effects: long term - B12 deficiency and fracture risk
