ENT Flashcards
A 34-year-old woman presents with facial pain, discolored nasal discharge, bad taste in her mouth, and fever. On physical examination she has facial tenderness.
Which of the following is the most accurate diagnostic test?
a. Sinus biopsy or aspirate
b. CT Scan
c. X-Ray
d. Culture of the discharge
e. Transillumination
A. Remember that in infectious diseases, the radiologic test is never “the most accurate test.” Only a biopsy or aspirate can give you a precise microbiological diagnosis. There is a difference between a question that says, “What is the most accurate test?” and one that asks, “What will you do?” CT Scan is the most common wrong answer to this question. You cannot stain or culture a CT scan.
A 34-year-old woman presents with facial pain, discolored nasal discharge, bad taste in her mouth, and fever. On physical examination she has facial tenderness.
What is the most appropriate next step OR action OR management?
a. Linezolid
b. CT Scan
c. X-Ray
d. Amoxicillin/clavulanic acid and a decongestant
e. Erythromycin and a decongestant
D. When the diagnosis is as clear as in this case, radiologic testing is unnecessary. Amoxicillin/clavulanic acid, doxycycline, and trimethoprim/sulfamethoxazole remain first-line therapy for both otitis and sinusitis. The efficacy of these agents is the same as newer or more “broad spectrum” agents such as quinolones. Imaging is done if the diagnosis is equivocal. A decongestant is used in all cases to promote sinus drainage.
Erythromycin is inadequate because of poorer coverage for Streptococcus pneumoniae. Linezolid, although excellent for resistant gram-positive organisms, would not cover Haemophilus. Antibiotics are rarely needed, because most cases are viral in etiology. Antibiotics are used with fever and discolored nasal discharge.
This is a venous drainage system that receives venous drainage from the face, nose, orbits, and tonsils.
Cavernous sinus
Patient presents with a history of sinusitis and diplopia with the inability to move the eyes normally on examination. What is the most likely diagnosis?
Cavernous Sinus Thrombosis
What is the best initial test for Cavernous Sinus Thrombosis?
CT or MRI with contrast showing the thrombosis
What is your best treatment option for Cavernous Sinus Thrombosis?
Ampicillin/Sulbactam with Vancomycin
This is a granulomatous inflammation of the cavernous sinus with ophthalmoplegia. Patient presents with eye pain and paralysis of the same cranial nerves (III,IV, and VI).
Tolosa-Hunt Syndrome
These are the cranial nerves affected in cavernous sinus thrombosis.
CN III, IV, VI
How would you diagnose Tolosa-Hunt Syndrome?
MRI
How would you treat Tolosa-Hunt Syndrome?
Steroids
90-95% of epistaxis are anterior, venous bleeds of the ________.
Kiesselbach venous plexus.
This presents with redness, immobility, bulging, and a decreases light reflex of the tympanitic membrane. Pain is common. Decreased hearinf and fever also occur.
Otitis Media
Which of the following is the most sensitive physical finding for otitis media?
a. Redness
b. Immobility
c. Bulging
d. Decreased light reflex
e. Decreased hearing
B. Immobility is so sensitive a physical finding that a fully mobile tympanitic membrane essentially excludes otitis media
This is the most accurate diagnostic test for otitis media.
Tympanocentesis for a sample of fluid for culture
This is the best initial therapy for otitis media.
Amoxicillin
This is a cellulitis of the skin of the external auditory canal, also known as “swimmer’s ear.” Exposure to water raises the pH of the canal, facilitating bacterial growth. Maceration of the canal with cotton swabs also promotes bacterial growth. There is pain in moving the tragus.
Otitis Externa
How would you treat Otitis Externa?
- Topical neomycin-polymyxin, topical quinolones, or gentamicin
- Hydrocortisone ear drops to decrease inflammation and relieve pain
- Removing desquamated skin and cerumen will make it easier to disinfect the ear canal
This infection is actually cranial osteomyelitis in the portion of the skull near the auditory canal, caused by pseudomonas. It occurs in poorly controlled diabetics. Severe ear pain is common.
Malignant (Necrotizing) External Otitis
This is the best initial test for Malignant (Necrotizing) External Otitis
CT or MRI of the skull base
This is the most accurate test for Malignant (Necrotizing) External Otitis
Biopsy
How would you treat Malignant (Necrotizing) External Otitis?
IV antibiotics such as ceftazidime (or cepefime), quinolones, aztreonam, or piperacillin/tazobactam
If question ask you to choose a single agent, answer CIPROFLOXACIN
This is an infection of the mastoid air cells that occurs when nearby otitis media spreads. The skin over the mastoid process can become red and the area tender. Inadequate or delayed treatment can result in deafness and meningitis.
The organisms are the same with pneumococcus, Haemophilus, and Moraxella.
Mastoiditis
What is the best initial test for Mastoiditis?
CT or MRI
What is the most accurate test for Mastoiditis?
Biopsy
How would you treat Mastoiditis?
Ceftriaxone and Levofloxacin
Give causes of vertigo/nystagmus that does not cause hearing problems
Stroke of the posterior circulation of the brain (the vertebral/basilar system), Multiple Sclerosis, Phenytoin Toxicity
These 2 diseases cause vertigo and nystagmus in association with hearing loss and tinnitus.
Labyrinthitis and Meniere disease
What should be given for acute hearing loss in the presence of labyrinthitis?
Glucocorticoids
How would you treat Meniere disease?
Diuretics and carbonic anhydrase inhibitors
Patients with this disease can have hearing loss/tinnitus and ataxia.
Acoustic neuroma / 8th cranial nerve tumor
There is a history of barotrauma or exposure to explosion; presents with a leaking hole in the oval window of the inner ear
Perilymph fistula
There is no hearing loss or tinnitus or ataxia. This is a transient problem in the vestibular/semicircular canal system of the inner ear.
Benign positional vertigo
How would you treat BPV?
Repositioning of the head
Meclizine
This presents with pain on swallowing, enlarged lymph node in the neck, exudate in the pharynx, and fever. There is no cough or hoarseness.
Pharyngitis
What is the best initial test for Pharyngitis?
Rapid strep test
What is the best initial therapy for Pharyngitis?
Penicillin or Amoxicillin
What would you give for Pharyngitis if patient is penicillin allergic?
Cephalexin - rash reaction only
Clindamycin or Macrolide - anaphylaxis
This occurs when an infection of Fusobacterium necrophorum (from pharyngitis, peritonsilar abscess, mastoiditis, or parotitis) expands beyond the mouth to infect the neuromuscular bundle around the jugular vein; this allows easy spread of bacteria both locally and into the bloodstream.
Lemiere Syndrome (Septic Jugular Thrombophlebitis)
How would you diagnose Lemiere Syndrome?
CT of the neck
This is cellulitis of the floor of the mouth. It is caused by the spread of oral flora from dental infection of the mandibular molars into the submandibular and sublingual spaces. It can cause tongue to swell and can compromise the airway, necessitating intubation or tracheostomy.
Ludwig Angina
How would you treat Lemiere Syndrome / Ludwig Angina?
Ampicillin/Sulbactam or
Piperacillin/Sulbactam combined with a beta-lactam/ beta-lactamase inhibitor
What is the best initial test for Ludwig Angina?
CT of the neck
These are stones (calculi) in the ducts draining the salivary glands that cause postprandial pain and local swelling. Recurrent stones lead to strictures and sialadenitis..
Sialolithiasis
This is an acute bacterial infection of the parotid or submandibular gland, most often caused by Staphylococcus aureus. Eating meals causes swelling and increased pain in the erythematous duct. Often pus can be expressed from the duct.
Sialadenitis
