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Surgery > ENT > Flashcards

ENT Flashcards

1
Q

what questions should be asked on an ear infection history

A

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

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2
Q

symptoms of acute otitis media

A

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

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3
Q

most common bacterial causes of AOM

A

strep pneumo

moraxella cattarhalis

h. influenza

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4
Q

investigations for AOM

A

none needed

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5
Q

treatment for AOM

A

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)

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6
Q

first line abx for AOM

A

amoxicillin–erythromycin if allergic to penicillin

5 days if older than 2 years, 10 days if under 2 years

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7
Q

how do AOM and OM with effusion differ

A

AOM has infection of the effusion

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8
Q

symptoms of otitis externa

A

pain, especially with manipulation of the pinna

externa effusion

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9
Q

etiology of otitis externa

A

usually bacterial but can be fungal

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10
Q

management of otitis externa

A

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

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11
Q

abx used for otitis externa

A

cipro-dexamethasone

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12
Q

what is the role of the ossicles

A

amplify sound from a larger tympanic membrane to a finer point

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13
Q

types of hearing loss

A

conductive

sensorineural

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14
Q

hearing loss questions to ask

A

speed of onset

ototoxic medications

family history of hearing loss

noise exposure

previous surgery

recurrent infections

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15
Q

physical exam for hearing loss

A

weber and rinne

pure tone audiogram**

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16
Q

what does a pure tone audiogram investigate

A

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

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17
Q

if on pure tone audiogram, there is an air bone gap, what type of hearing loss

A

conductive

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18
Q

if on pure tone audiogram there is no air bone gap but hearing loss is present, what type of hearing loss

A

SNHL

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19
Q

describe the weber test and what it indicates

A

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

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20
Q

describe the rinne test and what it indicates

A

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)

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21
Q

what is otoscleritis

A

thickening of the ossicles with normal TM (leads to conductive hearing loss)

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22
Q

treatment for otoscleritis

A

ongoing observation

trial of amplification

surgery–> stapedotomy if air bone gap above 30 dB

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23
Q

what can cause CHL in external canal

A

cerumen impaction–> must be completely impacted

severe otitis externa

stenosis

masses

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24
Q

what can cause CHL in the middle ear

A

otitis media (acute or chronic)

tympanic perforation

cholesteatoma

otosclerosis

ossicular fixation

ossicular deformity

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25
Q

what causes sensorineural hearing loss

A

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

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26
Q

how do you investigate SNHL

A

audiogram

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27
Q

how do you treat SNHL

A

hearing protection to prevent further damage

ongoing observation

trial of amplification–> could include hearing aid, cochlear implant etc

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28
Q

list the types of SNHL

A
  1. presbicusys
  2. noise induced
  3. genetic
  4. ototoxicity
  5. temporal bone trauma
  6. SSNHL
  7. vestibular schwannoma
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29
Q

what do you do if someone has sudden onset SNHL

A

it is likely SSNHL and you must refer emergently and start steroids as there are better results with early treatment

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30
Q

what is presbycusis

A

gradual loss of hearing associated with old age

treat with amplification

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31
Q

what questions to ask for a kid presenting with worries about hearing ability and speech

A

recurrent infections

meningitis or perinatal disease

birth and prenatal history

developmental milestones

ototoxic meds

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32
Q

how do you investigate bilateral otitis media with effusion

A

pure tone audiogram

tympanometry (test mobility of TM and ossicles)

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33
Q

how do you treat bilateral otitis media with effusion

A

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

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34
Q

what is a cholesteatoma

A

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

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35
Q

what kind of hearing loss is associated with cholesteatoma

A

first CHL but can progress to SNHL

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36
Q

list etiologies other than OME for pediatric hearing loss

A

genetic–> most are syndromic

developmental–> inner ear abnormalities

infections in utero–> toxoplasmosis, rubella, CMV

perinatal factors–> hypoxia, severe jaundice

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37
Q

what are the most common causes of SNHL

A

presbicusys and noise induced

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38
Q

how might childhood hearing loss present

A

with speech delay

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39
Q

definition of vertigo

A

sense of motion, especially motion of the surroundings

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40
Q

what do you ask on history for vertigo

A

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

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41
Q

what does vertigo for seconds usually suggest?

A

BPPV

nystagmus is the objective finding, vertigo the subjective finding

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42
Q

physical exam for vertigo

A

ENT exam

neuro-otologic exam

neurologic exam

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43
Q

what is a neuro-otologic exam

A
  1. spontaneous or gaze-evoked nystagmus
  2. cranial nerve tests
  3. cerebellar tests
  4. romberg test and gait
  5. dix-hallpike to detect BPPV
    - -> rotatory nystagmus
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44
Q

investigations for BPPV

A

none initially

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45
Q

recommended tx for BPPV

A

usually self limited and improves over weeks to months

particle-repositioning maneuver–> epley maneuver

medications NOT helpful

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46
Q

what is the cause of BPPV

A

otolith crystals that have broken off and gone into the semicircular canals

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47
Q

what is acute vestibulopathy

A

AKA vestibular neuritis/recurrent labyrinthitis

can involve inflammation of CN VIII (vestibular nerve)

make sure you dont miss a stroke

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48
Q

diagnosis of acute vestibulopathy

A

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

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49
Q

treatment for acute vestibulopathy

A

anti emetics initially (dont use for long)

early return to physical activity (central compensation)

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50
Q

what is the classic Meniere’s disease presentation

A

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

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51
Q

investigations for meniere’s

A

audiogram

has a unique audiogram profile, with low frequency SNHL

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52
Q

what is the type of hearing loss pattern you see on audiogram with menieres

A

low frequency SNHL

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53
Q

treatment for menieres

A

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

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54
Q

what are the 4 pairs of paranasal sinuses

A

frontal
ethmoid
maxillary
sphenoid

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55
Q

which paranasal sinuses are present at birth

A

ethmoid
maxillary

frontal and sphenoid take up to age 21 to fully solidify

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56
Q

why do we have the paranasal sinuses

A
  1. temperature regulation and warming of air (humidifies and moisturizes)
  2. filters and cleans air and provides immuno-protection (IgA, NO)
  3. equalizes pressure between outside and ear
  4. produces snot from the goblet cells of the sinuses (can make up to 1L of snot per day)
  5. lightens the skull
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57
Q

what structures lie between the sinuses in the skull

A

eyes

optic nerves

carotid arteries

cavernous sinuses

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58
Q

what is the osteomeatal complex

A

where all of your sinuses drain except for the sphenoid (because close to brain)–most important area for adequate sinus ventilation

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59
Q

what do you do with pus

A

culture it

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60
Q

how do you investigation increasing nasal sinus mucopurulence

A

xray

CT

cultures

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61
Q

what is rhinosinusitis

A

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

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62
Q

define duration for recurrent ABRS

A

4 or more infections per year with complete resolution between

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63
Q

what do you call ABRS that doesnt resolve after 12 weeks

A

chronic rhinosinusitis (CRS)–> need to do everything we can to prevent chronic rhinosinusitis

64
Q

what is the pathophysiology of acute bacterial rhinosinusitis

A

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

65
Q

what are the pathogens most associated with ABRS

A

strep pneumo-1st
h influenza -2nd
m catarrhalis-3rd

also staph aureus and strep pyogenes

66
Q

how do you diagnose ABRS

A

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

67
Q

how do you approach a sinusitis (i.e ABRS)

A

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

68
Q

treatment for rhinosinusitis

A
  1. topical nasal steroids–> first reduce inflammation in the OMC–> MOMETASONE is indicated for ABRS
  2. 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
  3. abx as warranted
69
Q

when should you order anx for rhinosinusitis

A

“PODS”

Pain (facial pain, pressure, fullness)

Obstruction of the nose

Discharge (nasal purulence/discolored discharge)

Smell loss

70
Q

how long should you prescribe abx therapy for rhinosinusitis

A

10 days to 2 weeks for acute episodes

3-6 weeks for chronic sinusitis

71
Q

what is the abx of choice for the top 3 pathogens of rhinosinusitis

A

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

72
Q

treatment goals for sinusitis

A

maintain patency of the sinus ostea

prevent chronic sinusitis by eradicating infection –> need nasal steroid spray, oral steroids, abx for aout 6-12 weeks

73
Q

complications from rhinosinusitis

A
  1. orbital abscess (periorbital erythema, edema, compromise of vision)
  2. cavernous sinus thrombosis
  3. intracranial abscess
  4. death
74
Q

what is a frontal lobe abscess

A

bad complication from sinus infection

associated with frontal headaches

investigate with CT

75
Q

why do you use maximal medical management for ABRS

A

to prevent chronic rhinosinusitis because success of medical management drops significantly past 12 weeks

76
Q

common presentations of chronic rhinosinusitis

A

post nasal drainage

dull pressure type headaches

fatigue

cough

adult onset asthma

(less common–facial pain and pressure, more common in ABRS)

77
Q

classic symptoms of chronic rhinosinusitis

A 
anterior nasal discharge
post nasal drip*
fever
dental pain
halitosis
facial pain and pressure headache 
reduced sense of smell
78
Q

investigations for chronic rhinosinusitis

A

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)

79
Q

treatment for chronic rhinosinusitis

A

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

80
Q

how do you management rhinosinusitus not medically

A
  1. 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
  2. nasal steaming
  3. increased water intake/hydration due to mucus loss
  4. reduction of dehydrating agents
81
Q

when should you do surgery for chronic rhinosinusitis

A

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

82
Q

where do 90% of all bleeds in the nose originate

A

anterior part –> most from Little’s area, from front of septum

(10% in back of nose)

nose is very vascular for humidification, hydration etc

83
Q

what to ask on history for epistaxis

A

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?”

84
Q

do you need to investigate anterior epixstaxis?

A

no–do nasal endoscopy only if concerning picture

85
Q

management of epistaxis

A

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

86
Q

what investigations should you do in a patient with posterior epistaxis

A

CBC with PTT/INR

nasal endoscopy if possible

87
Q

management of posterior epistaxis

A

ABCs

IV fluid

sphenopalatine artery ligation

abx with nasal pack–> posterior pack is rarely done now because dangerous and painful

REFER to nearest expert

88
Q

why should you avoid bilateral septal cauterization as a a management for epistaxis

A

can lead to perforation

89
Q

who is at greater risk for posterior epistaxis

A

elderly patients with co-morbidities

90
Q

what should you ask on a sore throat history

A 
dysphagia 
odynophagia
otalgia
fever
associated URTI sx
oral intake
past history of recurrent sore throats
91
Q

physical exam for sore throat

A

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

92
Q

what size are normal lymph nodes in lower neck? at junction with submandibular gland?

A

lower neck –less than 1 cm

junction– less than 1.5 cm

93
Q

what should you think in a patient with a sore throat and big, bulky lymph nodes

A

mono

may also have ALT/AST rise, splenomegaly

94
Q

ddx for sore throat

A

viral tonsillitis

bacterial tonsillitis

infectious mononucleosis

95
Q

investigations for sore throat

A

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

96
Q

management of bacterial tonsillitis

A

supportive therapy with hydration, analgesia, saline gargle

oral abx–> AMOXICILLIN is first line

97
Q

are most sore throats viral of bacterial

A

viral

98
Q

what is the characteristic finding of tonsillitis

A

bilateral large symmetric lymph nodes

99
Q

what should you do to manage mono

A

supportive treatment including steroids for airway obstruction

100
Q

what can be a complication of tonsillitis

A

peritonsillar abscess

101
Q

how does peri tonsillar abscess present

A

unilateral palate swelling and trismus

102
Q

management of peritonsillar abscess

A

needle aspiration or incision and drainage with abx

103
Q

what to ask on history for pediatric snoring

A

onset and duration

mouth breathing

observed apneas? hypopnea? how often and when?

enuresis?

FTT or development problems?

daytime somnolence

Downs? other syndrome/

104
Q

how do you manage adenotonsillar hypertrophy causing OSA in a kid

A

topical nasal steroids

tonsillectomy and adenoidectomy if not responsive to steroids

105
Q

what % of kids have primary snoring

A

10%

106
Q

how do you usually treat OSA in kids

A

tonsillectomy and adenoidectomy

107
Q

how do you treat OSA in adults

A

CPAP

108
Q

what is stridor a sign of

A

airway obstruction

109
Q

what causes stridor in kids

A
  1. congenital–> laryngomalacia (dysfunctional cartilage), vocal cord paralysis, subglottic hemangioma
  2. acquired–> foreign body, infection (croup), subglottic stenosis, laryngeal papillomatosis (HPV)
110
Q

what causes stridor in adults

A
  1. anaphylaxis
  2. infection (neck abscess)
  3. trauma (blunt or penetrating laryngeal trauma or inhalation injury)
  4. neoplasms
111
Q

what should you ask on history of airway obstruction

A 
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
112
Q

id on ENT exam for airway obstruction there is a loss of laryngeal crepitus, what should you think?

A

T4 invasive laryngeal cancer

113
Q

how should you manage airway obstruction

A
  1. airway management–> intubation awake with flexible endoscopy/awake tracheostomy // surgical tracheostomy or cricothyroidotomy (last resort)
  2. after airway secured, direct laryngoscopy and biopsy
114
Q

what is the most common type of cancer in the throat

A

SCC

*if dx this, do head and neck and chest CT to rule out mets

115
Q

how do you treat laryngeal SCC

A

radiation

surgery (laryngectomy)

possible chemo

116
Q

what does biphasic stridor indicate

A

obstruction at the level of the GLOTTIS–> uniphasic stridor suggests obstruction below the glottis

117
Q

if a patient comes in with dysphonia and she is a smoker, what should you think first?

A

cancer until proven otherwise

(dysphonia in a smoker is cancer until proven otherwise)

also make sure to ask about GERD risk factors

118
Q

GERD risk factors

A

alcohol

fatty foods

caffeine

late night meals

stress

119
Q

ddx for dysphonia

A
  1. inflammatory–>
    - -laryngopharyngeal reflux
    - -polyp (happens with lots of talking) or nodules (more severe callus from overuse)
    - -granuloma
  2. infectious
    - -HPV laryngeal papillomatosis
    - -candida (risks include steroid use)
  3. neoplasms
120
Q

what is the most common cause of hoarseness on the differential

A

laryngopharyngeal reflux

121
Q

if PPI treatment for hoarseness fails, what should you do

A

consider barium swallow and pH study for reflux

122
Q

management of laryngopharyngeal reflux

A

lifestyle modifications–> tilt head of bed up, change diet to exclude precipitating foods (alcohol, caffeine, fatty foods, late night eating etc..)

PPI

123
Q

how should you manage prolonged hoarseness

A

ENT referral

124
Q

what imaging should you get or a kid with history of foreign body ingestion and choking episode

A

x ray soft tissues of neck–do AP and lateral to tell you trachea versus esophagus

125
Q

how do you manage foreign body ingestion

A

rigid esophagoscopy and foreign body removal with bronchoscopy

126
Q

what should be considered in a child with a chronic cough

A

bronchial foreign bodies

127
Q

what are two things that strongly predispose someone to tonsil cancer

A

smoking and drinking

128
Q

what characteristics would you use to characterize a mass on the neck?

A
  1. location–> what the disease might be, and where the tumour may be originating from
  2. size
  3. fluctuance
  4. mobility (hard is more malignant)
  5. pain (pain is more inflammatory)
129
Q

what is the usual cause of a posterior neck mass

A

nasopharyngeal cancer

130
Q

what is the usual cause of an anterior neck pass

A

thyroglossal duct cyst

131
Q

what is the usual cause of a neck mass deep to the SCM

A

oral duct cancer

132
Q

what is the usual cause of bilateral neck masses

A

infection

unilateral is more likely cancer

133
Q

what investigations should you do for a neck mass

A

biopsy of tonsil and FNA of neck mass

CT neck

CXR

134
Q

how do you manage tonsillar carcinoma

A

radiation of primary and metastatic sites

trans-oral robotic surgery (TORS)–under investigation

135
Q

neck mass in an adult over 30–what is it

A

assumed malignant but usually a met from a head or neck site

136
Q

neck mass in a patient under 30–what is it

A

likely a cyst (i.e thyroglossal)

137
Q

what patients are more likely to get a nasopharyngeal cancer with neck mass as first symptom

A

chinese patients (often posterior mass)

138
Q

what is the investigation of choice for a neck mass in an adult

A

FNA

139
Q

what are two risk factor for head and neck cancer

A

smoking and excessive drinking

140
Q

what virus can cause oropharynx or tonsil cancer

A

HPV

141
Q

how do you usually treat surgery of the head and neck

A

radiation or surgery or both

142
Q

what are the usual causes of neck masses in kids

A

infectious, inflammatory or congenital usually

143
Q

ddx infectious pediatric neck mass

A

cat scratch disease

cervical adenitis

mycobacterium

144
Q

ddx congenital pediatric neck mass

A

branchial cleft cyst

lymphatic malformation

145
Q

what neoplasm may present as a neck mass in a kid

A

lymphoma

146
Q

what should the investigations be in a kid with a neck mass

A

observe and give trial of abx

U/S and CT

biopsy if concerned about malignancy

147
Q

management of branchial cleft cyst

A

surgical excision

148
Q

if there is fluctuation in size in a mass under the jaw, what is it

A

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

149
Q

where is wharton’s duct located

A

under the frenulum

150
Q

where is stensons duct located

A

on the inner cheek

151
Q

what investigations are needed for a salivary gland stone

A

none initially

after treatment trial, consider imaging for stones (U/S, xray, or CT)

sialogram of duct

152
Q

management of acute sialadenitis (infection of salivary gland)

A

MASH

massage
antibiotics (staph aureus most common)
sialogogues (citrus, sour foods)
hydration/warm compresses

153
Q

management of chronic sialadenitis or sialolithiasis

A

remove of stone and/or gland

154
Q

what bacteria usually causes infection of the parotid or submandibular gland

A

staph aureus

155
Q

what is a risk factor for sialadenitis

A

dehydration

Surgery (20 decks)

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