ENT Flashcards
what questions should be asked on an ear infection history
OPQRST(DFP) AAA
otalgia hearing loss tinnitus otorrhea aural fullness/pressure association with fever or vertigo or URTI sx previous ear infections/episodes
eating
trauma (q tip use), recent swimming
symptoms of acute otitis media
moderate to severe TM bulge
effusion
mild bulge plus less than 48 hours of acute pain or intense erythema
acute onset
inflammation
*no read gold standard for assessment of the tympanic membrane in AOM
most common bacterial causes of AOM
strep pneumo
moraxella cattarhalis
h. influenza
investigations for AOM
none needed
treatment for AOM
key factors are age, severity, levels of illness, estimated degree of access to follow up
abx first line –amoxicillin (erythromycin if pen allergy)
children over 6 with uncomplicated cases can be managed by watchful waiting
tubes/ventilation for recurrent AOM (3 in 6 mo or 4 in 12 mo)
first line abx for AOM
amoxicillin–erythromycin if allergic to penicillin
5 days if older than 2 years, 10 days if under 2 years
how do AOM and OM with effusion differ
AOM has infection of the effusion
symptoms of otitis externa
pain, especially with manipulation of the pinna
externa effusion
etiology of otitis externa
usually bacterial but can be fungal
management of otitis externa
discharge suctioned and removed
topical abx drops (target pseudomonas, s aureus)–often cipro-dex
keep ear dry
avoid Q tips
ear wick for severely swollen canal
abx used for otitis externa
cipro-dexamethasone
what is the role of the ossicles
amplify sound from a larger tympanic membrane to a finer point
types of hearing loss
conductive
sensorineural
hearing loss questions to ask
speed of onset
ototoxic medications
family history of hearing loss
noise exposure
previous surgery
recurrent infections
physical exam for hearing loss
weber and rinne
pure tone audiogram**
what does a pure tone audiogram investigate
used to test hearing loss
investigate each ear separately and check air vs. bone curves for each ear
if air bone curves are at the same level–> SNHL
if air bone gap present–> CHL
if on pure tone audiogram, there is an air bone gap, what type of hearing loss
conductive
if on pure tone audiogram there is no air bone gap but hearing loss is present, what type of hearing loss
SNHL
describe the weber test and what it indicates
tuning for placed in middle of forehead
lateralizes findings to detect unilateral CHL or SNHL
if defective ear hears the tuning fork louder than normal ear–> CHL
if defective ear hears the tuning fork worse than normal ear–> SNHL
describe the rinne test and what it indicates
expectation is louder at the front, but if its louder at the back then its CHL
positive Rinne is NORMAL–> sound heard outside the ear (air conduction) is louder than the initial sound heard when the tuning fork is placed against the mastoid process
in CHL, bone conduction is better than air conduction (negative Rinne)
what is otoscleritis
thickening of the ossicles with normal TM (leads to conductive hearing loss)
treatment for otoscleritis
ongoing observation
trial of amplification
surgery–> stapedotomy if air bone gap above 30 dB
what can cause CHL in external canal
cerumen impaction–> must be completely impacted
severe otitis externa
stenosis
masses
what can cause CHL in the middle ear
otitis media (acute or chronic)
tympanic perforation
cholesteatoma
otosclerosis
ossicular fixation
ossicular deformity
what causes sensorineural hearing loss
either neuropathic or noise induced
noise induced typically has a history of significant exposure over 85 dB for 8hr/day, 5 day/wk and progressively affects lower and higher frequencies
how do you investigate SNHL
audiogram
how do you treat SNHL
hearing protection to prevent further damage
ongoing observation
trial of amplification–> could include hearing aid, cochlear implant etc
list the types of SNHL
- presbicusys
- noise induced
- genetic
- ototoxicity
- temporal bone trauma
- SSNHL
- vestibular schwannoma
what do you do if someone has sudden onset SNHL
it is likely SSNHL and you must refer emergently and start steroids as there are better results with early treatment
what is presbycusis
gradual loss of hearing associated with old age
treat with amplification
what questions to ask for a kid presenting with worries about hearing ability and speech
recurrent infections
meningitis or perinatal disease
birth and prenatal history
developmental milestones
ototoxic meds
how do you investigate bilateral otitis media with effusion
pure tone audiogram
tympanometry (test mobility of TM and ossicles)
how do you treat bilateral otitis media with effusion
observation
hearing aids
ventilation tubes–> for prolonged/over 3 months of OME in kids with documented hearing loss or for prolonged OME in kids with developmental difficulties
what is a cholesteatoma
destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear
different types and mechanisms exist
not classified as tumours but do have invasive and erosive properties that can spread to the bones and brain
usually initially erodes the ossicles
usually starts with CHL but can progress to SNHL if inner structures are invaded
what kind of hearing loss is associated with cholesteatoma
first CHL but can progress to SNHL
list etiologies other than OME for pediatric hearing loss
genetic–> most are syndromic
developmental–> inner ear abnormalities
infections in utero–> toxoplasmosis, rubella, CMV
perinatal factors–> hypoxia, severe jaundice
what are the most common causes of SNHL
presbicusys and noise induced
how might childhood hearing loss present
with speech delay
definition of vertigo
sense of motion, especially motion of the surroundings
what do you ask on history for vertigo
quality of the dizziness/spinning/motion
ENSURE THEY DONT HAVE A STROKE OR HEAD TRAUMA OR INCREASED ICP
duration –seconds/days/weeks
otologic symptoms
hx of head trauma
N/V, URTI sx, cranial and neuro sx
what does vertigo for seconds usually suggest?
BPPV
nystagmus is the objective finding, vertigo the subjective finding
physical exam for vertigo
ENT exam
neuro-otologic exam
neurologic exam
what is a neuro-otologic exam
- spontaneous or gaze-evoked nystagmus
- cranial nerve tests
- cerebellar tests
- romberg test and gait
- dix-hallpike to detect BPPV
- -> rotatory nystagmus
investigations for BPPV
none initially
recommended tx for BPPV
usually self limited and improves over weeks to months
particle-repositioning maneuver–> epley maneuver
medications NOT helpful
what is the cause of BPPV
otolith crystals that have broken off and gone into the semicircular canals
what is acute vestibulopathy
AKA vestibular neuritis/recurrent labyrinthitis
can involve inflammation of CN VIII (vestibular nerve)
make sure you dont miss a stroke
diagnosis of acute vestibulopathy
based on history
exclude CNS cause or other vestibular pathology
exam performed if disease process doesnt follow usual course –> spontaneous vertigo usually resolves after 1-2 days, motion induced vertigo after 1-2 weeks
progressively improved motion tolerance thereafter
treatment for acute vestibulopathy
anti emetics initially (dont use for long)
early return to physical activity (central compensation)
what is the classic Meniere’s disease presentation
vertigo lasting minutes to hours with aural fullness/hearing loss/tinnitus associated
hearing loss during episodes but recovery between episodes early on
as disease progresses, hearing loss becomes permanent and progressive, affecting low frequencies first
investigations for meniere’s
audiogram
has a unique audiogram profile, with low frequency SNHL
what is the type of hearing loss pattern you see on audiogram with menieres
low frequency SNHL
treatment for menieres
lifestyle mods (low salt, avoid caffeine and alcohol)
medications–> diuretic, vestibular sedative, Serc to improve healing
surgery or intra-tympanic meds (IT steroids, IT gentamycin injections, ventilation tube, endolymphatic sac surgery, vestibular neurectomy)–> only as LAST RESORT
what are the 4 pairs of paranasal sinuses
frontal
ethmoid
maxillary
sphenoid
which paranasal sinuses are present at birth
ethmoid
maxillary
frontal and sphenoid take up to age 21 to fully solidify
why do we have the paranasal sinuses
- temperature regulation and warming of air (humidifies and moisturizes)
- filters and cleans air and provides immuno-protection (IgA, NO)
- equalizes pressure between outside and ear
- produces snot from the goblet cells of the sinuses (can make up to 1L of snot per day)
- lightens the skull
what structures lie between the sinuses in the skull
eyes
optic nerves
carotid arteries
cavernous sinuses
what is the osteomeatal complex
where all of your sinuses drain except for the sphenoid (because close to brain)–most important area for adequate sinus ventilation
what do you do with pus
culture it
how do you investigation increasing nasal sinus mucopurulence
xray
CT
cultures
what is rhinosinusitis
sinus inflammation that often follows viral URTI or allergic reactions–> occur in 90% of those with common cold
colds that dont resolve over 7 days with worsening symptoms go on to become acute bacterial rhinosinusitis (ABRS)
thus–> duration and persistence in symptoms after 5-7 days but less than 12 weeks
define duration for recurrent ABRS
4 or more infections per year with complete resolution between
what do you call ABRS that doesnt resolve after 12 weeks
chronic rhinosinusitis (CRS)–> need to do everything we can to prevent chronic rhinosinusitis
what is the pathophysiology of acute bacterial rhinosinusitis
congestions of the SINUS OSTIA (i.e due to cold, allergies) creates obstruction of the osteum and predisposes to ABRS
there is nitric oxide in the sinuses–bacteriocidal and makes the cilia work really well
the cycle leading to sinusitis includes triggering illness causing mucosal congestion, stagnant secretions and pH changes, damage to cilia and epithelium, creation of a closed cavity culture medium, infection and mucosal thickening
break the cycle leading to sinusitis at the level of the ostium by treating with a nasal corticosteroid spray
what are the pathogens most associated with ABRS
strep pneumo-1st
h influenza -2nd
m catarrhalis-3rd
also staph aureus and strep pyogenes
how do you diagnose ABRS
based on clinical symptomatology, with ddx usually viral URTI or allergic rhinitis
viral sx usually resolve within 5 days and are treated with symptomatic relief
abx are thus needed after 5-7 days if symptoms are more severe
how do you approach a sinusitis (i.e ABRS)
assess severity–> if severe and strongly symptomatic, we then give abx
for mild to moderate therapy, start with intranasal cortisosteroids which will generally accelerate normal healing
if patients dont feel better, and actually feel worse in 5-7 days, give abx
treatment for rhinosinusitis
- topical nasal steroids–> first reduce inflammation in the OMC–> MOMETASONE is indicated for ABRS
- topical and systemic decongestants can help the patient feel better but usually cause rebound of symptoms and should be avoided or limited to 3 days use
- abx as warranted
when should you order anx for rhinosinusitis
“PODS”
Pain (facial pain, pressure, fullness)
Obstruction of the nose
Discharge (nasal purulence/discolored discharge)
Smell loss
how long should you prescribe abx therapy for rhinosinusitis
10 days to 2 weeks for acute episodes
3-6 weeks for chronic sinusitis
what is the abx of choice for the top 3 pathogens of rhinosinusitis
anaerobes and gram -
AMOXIL or AMOX-CLAV
2nd line is for those with no response after 72 hours, abx allergy, protracted sx etc—include fluoroquinolones, macrolides (CLARITHRO not azithro), oral beta lactams, clindamycin
treatment goals for sinusitis
maintain patency of the sinus ostea
prevent chronic sinusitis by eradicating infection –> need nasal steroid spray, oral steroids, abx for aout 6-12 weeks
complications from rhinosinusitis
- orbital abscess (periorbital erythema, edema, compromise of vision)
- cavernous sinus thrombosis
- intracranial abscess
- death
what is a frontal lobe abscess
bad complication from sinus infection
associated with frontal headaches
investigate with CT
why do you use maximal medical management for ABRS
to prevent chronic rhinosinusitis because success of medical management drops significantly past 12 weeks
common presentations of chronic rhinosinusitis
post nasal drainage
dull pressure type headaches
fatigue
cough
adult onset asthma
(less common–facial pain and pressure, more common in ABRS)
classic symptoms of chronic rhinosinusitis
anterior nasal discharge post nasal drip* fever dental pain halitosis facial pain and pressure headache reduced sense of smell
investigations for chronic rhinosinusitis
none required initially but sinus CT (coronal views are best) for underlying chronic pathology looking for air-bone interfaces are used if the dx if questionable or poor response to tx and surgery is a consideration
look for mucosal thickening, opacification, anatomic abnormalities on CT
rigid nasal endoscopy for visualization of the OMC and collection of sterile culture to direct abx tx (culture mucus and pus)
treatment for chronic rhinosinusitis
cover gram - and anaerobes
cultures key for choosing appropriate abx
1st line–amoxicillin in high doses
can also use amox clav/clinda/etc
sometimes use systemic steroids for allergic fungal sinusitis or massive nasal polyps pre op
treat for 3-6 weeks prior to imaging
mucolytics (guaifenesin) thin secretions and improve daily drainage but are not easily available or dosed
how do you management rhinosinusitus not medically
- saline nasal irrigation or saline spray–> can also use gentamycin irrigations, shampoo sinus rinse in water to clear biofilms and MANUKA HONEY SINUS RINSE to help with staph, pseudomonas, fungal infections
- nasal steaming
- increased water intake/hydration due to mucus loss
- reduction of dehydrating agents
when should you do surgery for chronic rhinosinusitis
only after failure of exhaustic and maximal medical management, usually for chronic rhinosinusitis
computer assisted sinus surgery (CASS) allows for sub-millimetric accuracy during surgery, reduces risk of injury to vital structures, and allows for advanced skull base surgery through the nose
where do 90% of all bleeds in the nose originate
anterior part –> most from Little’s area, from front of septum
(10% in back of nose)
nose is very vascular for humidification, hydration etc
what to ask on history for epistaxis
duration and volume of bleeding
precipitating factors
frequency
use of nasal sprays
nasal trauma or cocaine use
nasal obstruction
history of bleeding disorders
meds–blood thinners
“when you are sitting up, where did the blood go?”
do you need to investigate anterior epixstaxis?
no–do nasal endoscopy only if concerning picture
management of epistaxis
nasal lubricant and hyrdate
put head forward, pinch nose, use ice pack
cautery–> be careful! use silver nitrate or electrocautery
packing for diffuse active bleeding or bleeding not controlled by cautery –> cause or nasal tampons
definitive management is a correct deviation
what investigations should you do in a patient with posterior epistaxis
CBC with PTT/INR
nasal endoscopy if possible
management of posterior epistaxis
ABCs
IV fluid
sphenopalatine artery ligation
abx with nasal pack–> posterior pack is rarely done now because dangerous and painful
REFER to nearest expert
why should you avoid bilateral septal cauterization as a a management for epistaxis
can lead to perforation
who is at greater risk for posterior epistaxis
elderly patients with co-morbidities
what should you ask on a sore throat history
dysphagia odynophagia otalgia fever associated URTI sx oral intake past history of recurrent sore throats
physical exam for sore throat
vitals and general appearance
ENT exam with special attention to oropharynx and tonsils with a tongue depressor and otoscope
look at pharynx–> redness, swelling, asymmetry of palate, trismus
look at neck–> LAD, stiffness, swelling
respiratory exam
what size are normal lymph nodes in lower neck? at junction with submandibular gland?
lower neck –less than 1 cm
junction– less than 1.5 cm
what should you think in a patient with a sore throat and big, bulky lymph nodes
mono
may also have ALT/AST rise, splenomegaly
ddx for sore throat
viral tonsillitis
bacterial tonsillitis
infectious mononucleosis
investigations for sore throat
CBC and diff–> left shift of increased neutrophil bands, atypical lymohocytes suggest bacterial cause
monospot–> heterophile antibody test antibody test (these develop after one week of infection; 85% have positive test but not specific)
throat C and S
CT scan for complicated deep abscesses
management of bacterial tonsillitis
supportive therapy with hydration, analgesia, saline gargle
oral abx–> AMOXICILLIN is first line
are most sore throats viral of bacterial
viral
what is the characteristic finding of tonsillitis
bilateral large symmetric lymph nodes
what should you do to manage mono
supportive treatment including steroids for airway obstruction
what can be a complication of tonsillitis
peritonsillar abscess
how does peri tonsillar abscess present
unilateral palate swelling and trismus
management of peritonsillar abscess
needle aspiration or incision and drainage with abx
what to ask on history for pediatric snoring
onset and duration
mouth breathing
observed apneas? hypopnea? how often and when?
enuresis?
FTT or development problems?
daytime somnolence
Downs? other syndrome/
how do you manage adenotonsillar hypertrophy causing OSA in a kid
topical nasal steroids
tonsillectomy and adenoidectomy if not responsive to steroids
what % of kids have primary snoring
10%
how do you usually treat OSA in kids
tonsillectomy and adenoidectomy
how do you treat OSA in adults
CPAP
what is stridor a sign of
airway obstruction
what causes stridor in kids
- congenital–> laryngomalacia (dysfunctional cartilage), vocal cord paralysis, subglottic hemangioma
- acquired–> foreign body, infection (croup), subglottic stenosis, laryngeal papillomatosis (HPV)
what causes stridor in adults
- anaphylaxis
- infection (neck abscess)
- trauma (blunt or penetrating laryngeal trauma or inhalation injury)
- neoplasms
what should you ask on history of airway obstruction
trauma or recent intubation infections choking or aspiration hoarseness/dysphonia dysphagia/odynophagia cough/URTI hemoptysis smoking and alcohol (higher risk for cancer) weight loss and B symptoms
id on ENT exam for airway obstruction there is a loss of laryngeal crepitus, what should you think?
T4 invasive laryngeal cancer
how should you manage airway obstruction
- airway management–> intubation awake with flexible endoscopy/awake tracheostomy // surgical tracheostomy or cricothyroidotomy (last resort)
- after airway secured, direct laryngoscopy and biopsy
what is the most common type of cancer in the throat
SCC
*if dx this, do head and neck and chest CT to rule out mets
how do you treat laryngeal SCC
radiation
surgery (laryngectomy)
possible chemo
what does biphasic stridor indicate
obstruction at the level of the GLOTTIS–> uniphasic stridor suggests obstruction below the glottis
if a patient comes in with dysphonia and she is a smoker, what should you think first?
cancer until proven otherwise
(dysphonia in a smoker is cancer until proven otherwise)
also make sure to ask about GERD risk factors
GERD risk factors
alcohol
fatty foods
caffeine
late night meals
stress
ddx for dysphonia
- inflammatory–>
- -laryngopharyngeal reflux
- -polyp (happens with lots of talking) or nodules (more severe callus from overuse)
- -granuloma - infectious
- -HPV laryngeal papillomatosis
- -candida (risks include steroid use) - neoplasms
what is the most common cause of hoarseness on the differential
laryngopharyngeal reflux
if PPI treatment for hoarseness fails, what should you do
consider barium swallow and pH study for reflux
management of laryngopharyngeal reflux
lifestyle modifications–> tilt head of bed up, change diet to exclude precipitating foods (alcohol, caffeine, fatty foods, late night eating etc..)
PPI
how should you manage prolonged hoarseness
ENT referral
what imaging should you get or a kid with history of foreign body ingestion and choking episode
x ray soft tissues of neck–do AP and lateral to tell you trachea versus esophagus
how do you manage foreign body ingestion
rigid esophagoscopy and foreign body removal with bronchoscopy
what should be considered in a child with a chronic cough
bronchial foreign bodies
what are two things that strongly predispose someone to tonsil cancer
smoking and drinking
what characteristics would you use to characterize a mass on the neck?
- location–> what the disease might be, and where the tumour may be originating from
- size
- fluctuance
- mobility (hard is more malignant)
- pain (pain is more inflammatory)
what is the usual cause of a posterior neck mass
nasopharyngeal cancer
what is the usual cause of an anterior neck pass
thyroglossal duct cyst
what is the usual cause of a neck mass deep to the SCM
oral duct cancer
what is the usual cause of bilateral neck masses
infection
unilateral is more likely cancer
what investigations should you do for a neck mass
biopsy of tonsil and FNA of neck mass
CT neck
CXR
how do you manage tonsillar carcinoma
radiation of primary and metastatic sites
trans-oral robotic surgery (TORS)–under investigation
neck mass in an adult over 30–what is it
assumed malignant but usually a met from a head or neck site
neck mass in a patient under 30–what is it
likely a cyst (i.e thyroglossal)
what patients are more likely to get a nasopharyngeal cancer with neck mass as first symptom
chinese patients (often posterior mass)
what is the investigation of choice for a neck mass in an adult
FNA
what are two risk factor for head and neck cancer
smoking and excessive drinking
what virus can cause oropharynx or tonsil cancer
HPV
how do you usually treat surgery of the head and neck
radiation or surgery or both
what are the usual causes of neck masses in kids
infectious, inflammatory or congenital usually
ddx infectious pediatric neck mass
cat scratch disease
cervical adenitis
mycobacterium
ddx congenital pediatric neck mass
branchial cleft cyst
lymphatic malformation
what neoplasm may present as a neck mass in a kid
lymphoma
what should the investigations be in a kid with a neck mass
observe and give trial of abx
U/S and CT
biopsy if concerned about malignancy
management of branchial cleft cyst
surgical excision
if there is fluctuation in size in a mass under the jaw, what is it
fluctuation in size is pathognomonic for a stone in the duct of one of the salivary glands
also, increased pain with eating is classic for a stone
where is wharton’s duct located
under the frenulum
where is stensons duct located
on the inner cheek
what investigations are needed for a salivary gland stone
none initially
after treatment trial, consider imaging for stones (U/S, xray, or CT)
sialogram of duct
management of acute sialadenitis (infection of salivary gland)
MASH
massage
antibiotics (staph aureus most common)
sialogogues (citrus, sour foods)
hydration/warm compresses
management of chronic sialadenitis or sialolithiasis
remove of stone and/or gland
what bacteria usually causes infection of the parotid or submandibular gland
staph aureus
what is a risk factor for sialadenitis
dehydration
