ENT Flashcards
1
Q
Neck triangle containing spinal accessory nerves
A
Pisterior
2
Q
Triangle containing hypoglossal nerve
A
Carotid
3
Q
Ciliary ganglion
A
Pupillary constriction
4
Q
Pterygopalatine ganglion
A
Parasympathetic:
Lacrimal gland
Nasal mucosa
5
Q
Submandibular ganglion
A
Parasympathetic:
Submandibular
Sublingual
6
Q
Otic ganglion
A
Parasympathetic:
Parotid gland
7
Q
Functions if facial nerve
A
Stapedius muscle
Lacrimation (lacrimal gland)
Salivation (parotid gland)
Facial muscles
Sensation of anterior 2/3 of tongue (via chorda tympani)
8
Q
Peripheral vs Central vertigo in terms of persistence of symptoms
A
Vertigo/nystagmus will never last longer than a few weeks in peripheral lesions.
But persist if central lesion
9
Q
Auditory acuity tests
A
Whispered-voice test
Tuning fork test (512 Hz)
10
Q
Interpretation of Rinne test
A
If AC> BC: positive Rinne test: Nl
11
Q
Interpretation of Weber test
A
If heard centrally: negative Weber test: Nl
Others: Weber right, Weber left
Will only lateralize if difference between ears > 6 dB
More sensitive in detecting conductive hearing loss than the Rinne test
12
Q
Order of neural pathway for hearing
A
ECOLI:
Eighth nerve Cochlear nucleus Olivary nucleus Lateral lemniscus Inferior colliculus
13
Q
Minimum hearing loss for Rinne to reverse with 512 Hz
A
30 dB
14
Q
Range of frequencies audible to human ear
A
20-20,000 Hz
Most sensitive: 1000-4000
Human speech: 500-2000
15
Q
Conductive hearing loss in Pure tone audiometry
A
BC: normal range
AC: outside of normal range
Gap > 10 dB
16
Q
SNHL in PTA
A
BC: below normal
Gap < 10 dB (no air-bone gap)
17
Q
Mixed hearing loss on PTA
A
Both AC and BC below normal threshold
Gap > 10 dB
18
Q
Occupational hearing loss frequency
A
SNHL
At 4000 Hz
19
Q
Otosclerosis hearing loss frequency
A
Conductive
2000 Hz (Carhart notch)
20
Q
Speech reception threshod
A
Lowest hearing level at which pt is able to repeat 50% of two syllable words with equal emphasis on each syllable
Used to assess reliability of PTA
21
Q
If > 5 dB difference between SRT and PTA in 500-2000 Hz range:
A
Retrocochlear lesion
Or
Functional hearing loss
22
Q
Speech discrimination test
A
Percentage of words pt correctly repeats from a list of 50 monosyllabic words
Tested at 40 dB above SRT
If normal hearing: Score > 90%
If conductive hearing loss: score > 90%
If difference between ears > 20%: retrocochlear lesion
If rollover effect ( decrease in discrimination as sound intensity increases) retrocochlear lesion
Best predictor of hearing aid response: poor response = significant neural degeneration = hearing aid not the best option
23
Q
Normal range of tympanogram peak
A
-100 to +50 mmH2O
Normal middle ear pressure
24
Q
Tympanogram in otosclerosis
A
Normal, but lower amplitude
Type A curve
25
Tympanogram in ossicular chain discontinuity
Normal peak pressure but higher amplitude
| Type A curve
26
Tympanogram in perforated TM
No peak
Type B
27
Tympanogram in middle ear effusion
No peak
Type B
28
Tympanogram in eustachian tube dysfunction
Negative pressure peak
Type C
29
Tympanogram in early otitis media without effusion
Negative peak pressure
Type C
30
Normal static compliance (ear canal volume)
0.3-1.6 cc
| Static compliance
31
What does static compliance show?
Overall stiffness of middle ear system
32
Type B curve + static compliance > 2cc in children and 2.5 cc in adults indicates:
TM perforation
| Patent ventilation tube
33
Acoustic reflex threshold
70-100 dB greater than hearing threshold
Bilateral and symmetrical in either ear stimulation
Needs: intact conduction an nerve VII function
If hearing threshold > 85 dB, reflex likely absent
34
Acoustic reflex decay test
Ability of stapedius muscle to sustain contraction for 10 sec
Normal: little decay at 500 and 1000 Hz
35
Acoustic reflex threshold in cochlear hearing loss
25-60 dB
36
ART in retrocochlear pathology
Absent or marked decay
37
Auditory brainstem response
Can be used to determine the site of lesion
If delay in brain response: cochlear/retrocochlear abnormalities
Of value in children or malingering (co-operation not needed)
38
Otoacoustic emissions
Measures echo generated by cochlea
Absence of emission: hearimg loss or fluid in the middle ear
39
Newborn hearing screening test
Otoacoustic emissions
40
Tests used in malingering
Auditory brainstem response
Otoacoustic emission
41
Negative prognostic factors in aural rehabilitation
Poor speech discrimination
Narrow dynamic range (recruitment)
Unrealistic expectations
42
Indication for cochlear implants
Profound, bilateral SNHL, not rehabilitated with conventional hearing aids
Post-lingually deafened adults
Pre- and post- lingually deaf children
43
The best candidates for aural rehabilitation
Pre-lingually deaf infants
44
Bone anchored hearing aid indications
Conductive hearing loss
Unilateral hearing loss
Mixed hearing loss
(Who cannot wear conventional hearing aids)
45
Vertigo with duration of seconds
BPPV
46
Vertigo with minutes to hours duration
Ménière’s disease
47
Vertigo with duration of hours to days
Labyrinthitis/ vestibular neuronitis
48
Vertigo with chronic duration
Acoustic neuroma
49
Vertigo with bilateral hearing loss
Ménière disease (also unilateral possible)
50
Vertigo with unilateral hearing loss
Accoustic neuroma
Labyrinthitis
Ménière
51
Vertigo with tinnitus
Accoustic neuroma
Labyrinthitis
Ménière
52
Vertigo with whistling tinnitus
Labyrinthitis
53
Vertigo with aural fullness
Meniere
54
Vertigo with associated ataxia, CN VII palsy
Acoustic neuroma
55
Vertigo with recent AOM
Labyrintitis/ vestibulitis
56
Imbalance in peripheral vs central vertigo
Peripheral: mod-sev
Central: mild-mod
57
Nausea and vomiting in peripheral vs central vertigo
P: severe
C: variable
58
Auditory symptoms in peripheral vs central vertigo
P >>> C
59
Neurologist symptoms in peripheral vs central vertigo
C >>>P
60
Compensation in peripheral vs central vertigo
P: rapid
C: slow
61
Nystagmus in peripheral vs central vertigo
P: unidirectional, horizontal or rotatory
C: bidirectional, horizontal or vertical
62
Nystagmus in BPPV
Tortional, geotropic (. Fast phase towards the floor)
63
The most common cause of episodic vertigo
BPPV
64
The most common semicircular Canal affected in BPPV
Posterior
65
BPPV in Dix-Hallpike maneuver
Latency: 20 sec
Lasting: 20 sec
Crescendo-decrescendo vertigo
Nystagmus ( must be present)
Sitting up: Reversal of nystagmus
Fatigability
66
Tx of BPPV
Reassurance
Resolves spontaneously
Epley maneuver
Brandt-Daroff exercises
Refractory: surgery
If N/V: antiemetic
67
Drugs that are not to be used in BPPV
Drugs to suppress the vestibular system delay eventual recovery and are therefore not used
68
Diagnostic criteria for Meniere
All 3 of:
2 spontaneous episodes of rotational vertigo 20 minutes or longer
Audiometric confirmation of SNHL
Tinnitus and/or aural fullness
69
Type of hearing loss in meniere
SNHL, low frequencies
70
Meniere time course
Attacks come in clusters
In each attack, vertigo disappears within minutes to hours bur SNHL persists
Early: fluctuating SNHL
Late: progressive SNHL, persistent tinnitus
71
Triggers of Meniere
High salt intake
Caffeine
Stress
Nicotine
Alcohol
72
Acute Mx of meniere
Bed rest
Antiemetics
Antivertiginous drugs:
Betahistine,
Meclizine,
Dimenhydrinate
Anticholinergics:
Scopolamine
73
Long-term Mx of Meniere
Low salt diet
Diuretics
Serc (betahistine)
Intratympanic gentamycin (results in complete SNHL), first an MRI to check for CPA tumor
Intratympanic CS (may improve symptoms)
Surgical vestibular neurectomy, endolymphatic sac decompression
Monitor opposite ear (35% bilateral)
74
Drop attack
Without LOC
Meniere
75
Nystagmus in labyrinthitis
Acute phase: Fast phase towards affected ear
Convalescence: away from affected side
76
Ataxia in vestibular neuritis/labyrinthitis
Pt veers towards affected side
77
Tx of acute vestibular neuritis
Bed rest
Antivertiginous drugs
Methylprednisolone
+/- antivirals
If bacterial:
IV AB
drainage
Mastoidectomy
78
Tx of convalescent phase of vestibular neuritis
Progressive ambulation
Vestibular exercise
79
Symptoms of acoustic neuroma
SNHL
Tinnitus
Dizziness, unsteadiness, but true vertigo is rare
80
Unilateral tinnitus/SNHL in elderly
Acoustic neuroma until proven otherwise
81
RFs of acoustic neuroma
Exposure to loud noise
Childhood low-dose radiation
Parathyroid adenoma
82
Gold standard for Dx of acoustic neuroma
MRI with gadolinum contrast
83
Vestibular test in acoustic neuroma
Caloric test: Nl or asymmetric
84
Objective tinnitus DDx
```
Vascular lesions
Hypo/Hyperthyroidism
Patulous eustachian tube
Palatal myoclonus
Stapedial muscle spasm
```
85
Drugs causing tinnitus
```
ASA
NSAIDs
Aminoglycosides
Antihypertensives
Heavy metals
```
86
Metabolic causes of tinnitus
Hyper/hypothyroidism
Hyperlipidemia
Vitamin A, B, Zn deficiency
87
General recommendations for tinnitus
Avoid loud noise
Avoid ototoxic meds
Avoid caffeine
Avoid nicotine
Tinnitus clinics
Identify situations where tinnitus is most bothersome
Mask tinnitus with soft music or white noise
Hearing aid for coexistent hearing loss
Trial of tocainamide
88
Contraindications for syringing of the ear canal
Active infection
Previous ear surgery
Only hearing ear
TM perforation
89
Tx of cerumen impaction
Water or ceruminolytics:
```
Bicarbonate solution
Olive oil
Glycerine
Cerumenol
Cerumenex
```
90
Disease possibly associated with swimming in cold water
Ear canal exostosis
91
RFs of acute otitis externa
```
Swimming
Skin conditions
Q-tips
Aggressive scratching
Devices occluding ear canal
```
92
Indications for ear syringing for cerumen impaction
Decreased hearing
Totally occlusive cerumen with pain
Tinnitus
93
External otitis etiology
90% bacterial:
Pseudomonas, S. Aureus
94
Tx of acute otitis externa
Clean ear: irrigation, suction, dry swabbing
C&S
If bacterial:
Ciprofloxacin otic drop (anti-pseudomonal)
+/- otic steroids
Pop wick if edematous external canal
+/- 3% acetic acid solution to acidify ear canal
If cervical LAP : systemic AB
If cellulitis: systemic AB
If fungal:
Repeated debridement
Topical antifungals (gentian violet, mycostatin powder, boric acid...)
+/- analgesics
95
Tx of chronic otitis externa
CS drops (diprosalic acid)
96
RFs for malignant otitis externa
Elderly diabetics
| ImComp
97
Etiology of malignant otitis externa
99% pseudomonas
98
Complications of malignant otitis externa
CN palsy
VII > X > XI
Systemic infection
Death
99
Mx of malignant otitis externa
Imaging:
High resolution temporal bone CT
MRI with gadolinium
Technetium scan
Hospital admission
Debridement
IV AB
Hyperbaric O2
100
Gallium vs technetium scans
Gallium: shows sites of active infection. Presence of PMNs. It will not show the extent of osteomyelitis. Helps with F/U
Technetium: shows sites of osteomyelitis. Osteoblast activity. Help with diagnosis.
101
Chronic otitis media definition
TM perforation in the setting of chronic/recurrent ear infection
102
Chronic otitis types
Benign: dry, no active infection
Serous: continuous serous drainage
Suppurative: persistent purulent drainage
103
Presentation of congenital cholesteatoma
Small white pearl, behind intact TM
Conductive hearing loss
Not associated with otitis media/Eustachian tube dysfunction
104
Types of acquired cholesteatoma
Primary:
Retraction pocket in pars flaccida.
Secondary:
Pearly mass behind TM, associated with marginal perforation
Progressive destruction of surrounding bony structures due to associated chronic inflammation
105
Type of hearing loss in cholesteatoma
Conductive
SNHL in later stages
106
Positive Hx in cholesteatoma:
Otitis media
Ventilation tubes
Ear surgery
107
Granulation tissue in the ear
Malignant otitis media
| Cholesteatoma
108
Inv an Tx for cholesteatoma
Inv: audiogram, CT
Tx: surgery, tympanoplasty, ossicular reconstruction
109
Etiology of mastoiditis
2 weeks after untreated or inadequately treated AOM
S. Pneumoniae, H. Influenza, M. Catarrhalis, S. Pyogen, S. Aureus, P. Aeruginosa
110
Dx of mastoiditis
CT: opacification of mastoid cells, interruption of normal trabeculation of cells
111
Triad of mastoiditis
Otorrhea
Tenderness over the mastoid
Retroauricular swelling with protruding ear
112
Tx of mastoiditis
IV AB + ventilation tube
+/-Cortical mastectomy
Indications for surgery:
failure of medical Tx after 48 h
Symptoms if intracranial complications
Aural discharge prsisting for 4 wk, resistent to AB
113
Otosclerosis definition
Fusion of stapes to oval window
F>M
AD
Progressive course
114
Otosclerosis during pregnancy
Progression
115
Age of onset in otosclerosis
Teens, 20s
116
Type of hearing loss in otosclerosis
Conductive
SNHL in later stages
117
TM in otosclerosis
Normal +/- pink bluish (Schwartz sign) due to neovascularization of otosclerotic bone
118
Audiogram of otosclerotic
Dip at 2000 Hz (Carhart notch)
119
Tx of otosclerosis
Monitor with serial audiogram
Hearing aid
Definitive Tx: stapedectomy/stapedotomy with laser/drill with prosthesis
120
The most common cause of conductive hearing loss in 15-50 yr old
1st: cerumen impaction
2nd: otosclerosis
121
Most common cause of non-syndromic congenital hearing loss
Connexin 26 defect
AR
122
RFs for hearing loss in newborn
```
Low birth weight
Prematurity
Kernicterus (Bil>25)
Craniofacial abn
FHx of deafness in childhood
1st trimester illness (TORCH)
Neonatal sepsis
Ototoxic drugs
Perinatal infection (meningitis, mumps, measles)
Consanguinity
```
123
Type of hearing loss in presbycusis
SNHL
Initially high frequencies, then middle frequencies
Low speech discrimination (especially with background noise)
Recruitment phenomenon (inability to tolerate loud noises)
Tinnitus
124
Tx of presbycusis
Hearing aid indications:
If: difficulty functioning
Hearing loss > 30-35 dB
Good speech discrimination
Lip reading
Auditory training
Auditory aids (doorbell, phone lights)
125
The most common cause of SNHL
Presbycusis
126
Inv in sudden SNHL
CBC, ESR, RF, ANA to R/O AI diseases
If other focal neurological signs:
MRI: R/O tumor
CT: R/O stroke
127
Tx of sudden SNHL
CS within 3 d:
Intratympanic
Or
Oral x 10-14 d
128
Prognosis of sudden SNHL
70% resolve within 10-14 d
20% partial resolution
10% permanent
129
Clinic of sudden SNHL
Usually unilateral
+/- tinnitus, aural fullness
Usually idiopathic
130
Clinic of AI inner ear disease
20-50 yr
Rapidly progressive or fluctuating
Bilateral
SNHL
+/- tinnitus, aural fullness, vestibular symptoms
SLE, RA, GPA, PAN, allergy
131
Tx of AI inner ear disease
High dose CS: early, at least 30 d
If no response: cytotoxic meds
132
Aminoglycosides ototoxicity
Toxic by any route
Days to weeks after treatment
Toxic to hair cells
Otoacoustic emission lost first
High frequency lost first
133
Mx of aminoglycosides
Monitor with peak and trough levels
(Esp if neutropenia, ear/renal problem)
q 24 h dosing
CrCl determines dosage
Immediately stop if ototoxicity develops
134
The most important predictor of ototoxicity in treatment with AG
Duration of treatment
135
Salicylate ototoxicity
Hearing loss
Tinnitus
Reversible if DC
136
Ototoxicity with antimalarials
Hearing loss
Tinnitus
Reversible with DC or permanent
137
Noise-induced SNHL pathogenesis
85-90 dB over months or years
Or
Single > 135 dB
Cochlear damage
138
Hearing loss type in Noise-induced hearing loss
SNHL
Most prominent at 4000 Hz (boilermaker’s notch)
Extends to lower and higher frequencies over time
Speech reception not altered first, until > 30 dB loss at speech frequency
139
Phases of Noise-induced SNHL
Temporary threshold shift (returns to normal with removal of noise)
Permanent threshold shift (does not return)
140
Tx of Noise-induced SNHL
Hearing aid
141
Prevention of Noise-induced SNHL
Ear protection
Limit exposure (frequent rest periods)
Regular audiologic F/U
142
Transverse temporal bone fx
Mechanism: frontal/ occipital trauma
Prevalence: less common than longitudinal
CN: CN VII palsy 50% (transection)
Extension: bony labyrinth, internal auditory canal
Hearing loss: SNHL
Vestibular symptoms: present
CSF leak: via eustachian tube into pharynx, rhinorrhea
External ear, TM: intact, hemotympaneum
143
Longitudinal temporal bone fx
Extention: into middle ear
Incidence: more common than transverse
Mechanism: lateral skull trauma
CN: CN VII palsy: 10-20% (stretch, impingement)
Hearing loss: conductive
Vestibular symptoms: rare
TM: torn, hemotympaneum, otorrhagia
CSF leak: otorrhea
Battle sign, raccoon eyes
144
Dx of temporal bone fx
Otoscopy
CT head
Audiology, facial nerve test, schimmer test, stapedial reflex
If suspect CSF leak:
Halo sign, B-2 transferrin/ B trace protein in fluid
145
Mx of temporal bone fx
ABC
Expectant: prevent otogenic meningitis (Do not syringe or manipulateexternal auditory meatus)
```
Surgical if:
CN VII palsy
Gunshot wounds
Depressed fx of external auditory meatus
Early meningitis
Intracranial bleeding from sinus
CSF otorrhea
```
146
Bell’s palsy etiology
Idiopathic/HSV infection of VII nerve
147
RFs for Bell’s palsy
DM
Pregnancy
Viral prodrome
148
Clinic of Bell’s palsy
Acute onset
Numbness of ear
Schimer test
Hyperacusis
One side facial paralysis/paresis
149
Inv for Bell’s palsy
Stapedial reflex: absent
Audiology: normal
EMG: best measure for prognosis
MRI with gadolinum: enhancement of CN VII
High resolution CT
Topognostic testing
150
Tx of Bell’s palsy
Prevent exposure keratitis
Systemic steroids
Antivirals
151
F/U of Bell’s palsy
Spontaneous remission begins within 3 wk
If delayed recovery (3-6mo): some function loss
152
Px of Bell’s palsy
ENoG between 3-14 d of onset:
<90% degeneration: high likelihood of recovery
>90% + no voluntary EMG potentials = surgical decompression
```
Poorer if:
Hyperacusis
>60y
DM
HTN
Severe pain
```
153
Ramsay Hunt syndrome etiology
VZV infection of CN VII, CN VIII
154
RFs for Ramsay Hunt
```
>60 yr
Impaired immunity
Cancer
RT
Chemo
```
155
Ramsay Hunt clinic
Hyperacusis
Facial nerve paresis/paralysis
SNHL
Severe pain of pinna, mouth, face
Vesicles on pinna, external ear canal, mouth, 3-7 d after onset of pain
+/- vestibular, cochlear symptoms
Associated herpes zoster ophthalmicus (uveitis, keratoconjuctivitis, optic neuritis, glaucoma)
156
Inv for Ramsay Hunt
Stapedial reflex: absent
Audiology:
SNHL
Viral ELISA studies: confirm Dx
MRI with gadolinium: CN VII, CN VIII enhancement
157
Rx of Ramsay Hunt
Avoid touching lesions
Systemic steroids: relieve pain, vertigo, prevent PHN
Acyclovir: lessen pain, aid healing of vesicles
158
Px of Ramsay Hunt
Poorer than Bell’s
22% recover completely
66% incomplete paralysis
10% complete paralysis
159
If iatrogenic skull fx and facial nerve palsy:
Wait for lidocaine effect to wear off
If any movement present: Do nothing
If no movement: exploration
160
Types of atrophic rhinitis
Primary: Klebsiella ozena esp in elderly
Acquired: post-surgery (too much mucosa or turbinate resection)
161
Causes of non-inflammatory rhinitis
Pregnancy
Medicamentosa
Estrogen
Hypothyroidism
162
Allergic rhinitis types
Acute: seasonal: pollen from trees
Chronic: perennial:
Inhaled: house dust, wool, feather, foods, tobacco, hair, mould
Ingested: wheat, egg, milk, nuts
Concentration of allergens correlates with symptoms
IgE mediated
Onset <20 y
163
Mucosa and rhinorrhea in allergic rhinitis
Mucosa: swollen, pale, boggy
Rhinorrhea: clear, increased eosinophils
164
Complications of rhinitis
Chronic sinusitis
Polyps
Serous otitis media
165
Congestion in allergic rhinitis
Reduces nasal airflow and allows the nose to repair itself
Tx should focus on the initial insult rather than target this defense mechanism
166
Mx of allergic rhinitis
Identification and avoidance of allergens
Nasal irrigation with Saline
Antihistamines
Oral decongestants
Topical decongestants (up to 5-7 days) Dristan, Otrivin
Topical steroids
If severe:
Oral steroids
Desensitization by immunotherapy
167
Vasomotor rhinitis etiology
Disorder of nasal parasympathetic system (vidian nerve, going to sphenopalatine ganglion)
Non-specific reflex hypersensitivity of nasal mucosa
168
Triggers in vasomotor rhinitis
```
Temperature change
Smoke
Dust
Alcohol
Stress
Anxiety
Neurosis
Hypothyroidism
Pregnancy
Menopause
Parasympathomimetics
```
169
Tx of vasomotor rhynitis
Elimination of irritants
Parasympathetic blockers: Atrovent nasal spray
Steroids
Surgery: electrocautery/cryo/laser treatment. Removal of inferior/middle turbinates. Vidian neurectomy
Exercise: symptomatic relief
170
Clinical Dx of bacterial rhinosinositis
Dx if any of:
Symptoms > 7 d
Worsening after 5-7 d
High fever with purulent discharge 3-4 d
Plus 2 of:
Pain/ Pressure/ Fullness
Obstruction
Discharge (purulent, discolored)
Smell (hyposmia, anosmia)
Atleast 1 of O or D
171
Etiology of bacterial rhinosinositis
```
S. Pneumoniae
H. Influenza
M. Catarrhalis
S. Aureus
Dental aerobes
```
If immunocompromised: mucormycosis
172
The most common sinus affected in bacterial sinusitis
Maxillary
173
Factors predisposing to acute bacterial RS
URTI
allergy
Dental disease
Anatomical defects
174
Mx of acute bacterial RS
Depends on severity
Mild-mod: INCS
If no response after 72 h, add AB
Severe: INCS + AB
AB:
1st line: amoxicillin 10 d
If allergy to penicillin, TMP-SMX or macrolides
If no response within 72 h:
2nd line: switch to Q or amoxicillin-clavulanate
Adjunct therapies:
Saline/ HOCL irrigation
Analgesics
Oral/topical decongestants
175
Indications of CT in ABRS
If complications develop:
```
Preseptal, postseptal cellulitis
Subperiosteal abscess
Orbital abscess
Cavernous sinus thrombosis
Meningitis
Intracranial abscess
Sub-periostal frontal bone abscess
Osteomyelitis
Superior orbital fissure syndrome
Orbital apex syndrome
```
176
Pott’s puffy tumor
Subperiosteal abscess of frontal bone
177
Superior orbital fissure sundrome
Immobile globe:CN III/IV/VI palsy
Dilated pupils
Ptosis
V1 hypoesthesia
178
Orbital apex syndrome
```
Immobile globe
Dilated pupil
Ptosis
V1 hyposthesia
+
Optic neuritis, papilledema, decreased visual aquity
```
179
RS Timing
Acute: < 4wk
Subacute: 4-8 wk
Chronic > 8-12 wk
180
Dx of chronic rhinosinositis
```
2 of:
Congestion and fullness
P
O
D
S
```
181
Mx of chronic RS
Identify and address contributing factors
CT or endoscopy
If polyps: INCS, oral CS, AB (if signs of infection), referral
If no polyps: INCS, AB, oral CS (if severe), saline irrigation
AB: 3-6 wk
amoxi-clav, Q, clarithro, clinda, metro
Surgery: if medical fails, or if fungal
182
Factors contributing to chronic RS
Inadequately treated ABRS
Allergy
Anatomical defects
Ciliary disorders: CF, kartagener
Chronic inflammatory disorders: GPA
Untreated dental disease
Fungal
Bacterial biofilm/colonization
183
Allergic fungal rhinosinositis
Young
Chronic
Atopic
Tx: functional endoscopic sinus surgery + INCS + antifungal + immunotherapy
184
Internal vs external carotid epistaxis
Internal: above middle turbinate
External carotid: below middle turbinate
185
Recurrent unilateral epistaxis in adolescent male
Juvenile nasopharyngeal angiofibroma
186
Epistaxis inv
CBC
PT/PTT
Xray, CT as needed
187
Tx of epistaxis
```
ABC:
Lean forward
Constant firm pressure for 20 min
V/S
+/- IV NS, cross match blood
```
Determine site
Control bleeding:
1st line: topical vasoconstrictor: Otrivin
If failed: cauterize with silver nitrate
If failed:
Anterior: anterior pack 2-3 d
Posterior: admission. Posterior pack, then bilateral layer anterior pack for 3-5 d.
If packing failed: embolization +/- septoplasty
188
Complications of posterior packing
```
Hypoxemia
TSS
Aspiratin
Pharyngeal fibrosis/stenosis
Alar/septal necrosis
```
189
AB in packing
For:
All posterior packings
Anterior packing > 48h
190
Prevention of epistaxis
Prevent drying:
Humidifiers
Saline spray
Topical ointment
Avoidance of irritants
Mx of HTN and coagulopathies
191
Indication of laryngoscopy in smoker with hoarseness
> 2 wk persistence
192
laryngitis timing
Acute < 2 wk
Chronic > 2 wk
193
Tx of acute laryngitis
Self-limited
Voice rest
Humidification
Hydration
Avoid irritants
If co-existent bacterial pharyngitis: AB
194
If ulceration/granuloma formation on vocal cord
Chronic laryngitis
195
Tx of chronic laryngitis
Remove irritants:
Dust
Smoke
Chemical fumes
```
Treat underlying disorders:
PND
GERD
EtOH
Zenker
Hiatus hernia
Hypothyroidism
Allergy
Addison
```
Speech therapy with voice rest
+/- AB, CS
Laryngoscopy to R/O malignancy
196
Most common benign tumor of vocal cords
Polyps
M>F
30-50 yr
197
Etiology of polyps
Manifestation of vocal cord irritation
Voice strain
Irritants: GERD, allergy, tobacco
198
Most common site of polyp
Anterior 1/3 of vocal cords
Asymetrical
199
Tx of polyp
Avoid irritants, PPI
If persistent or high risk of malignancy:
Microsurgical removal
200
Vocal cord nodules etiology
Submucosal hemorrhage, hyalinization
Chronic voice strain
Frequent URTI, smoke, EtOH
201
Epidemiology of vocal cord nodule
F>M
Singers
School teachers
Children
Bartenders
202
Nodule clinic
Bilateral
Hoarseness Worse at the end of the day
Junction of anterior 1/3 and posterior 2/3
203
Tx of vocal cord nodule
Voice rest
Hydration
Speech therapy
Avoid irritants
Surgery for refractory nodules
204
Unilateral vocal cord paralysis symptoms
Early: paramedian position: weak, breathy voice
With time: medialization: improved phonation and aspiration
205
Tx of unilateral vocal cord paralysis
Voice therapy
Injection laryngoplasty
Medialization
206
Symptoms of bilateral cord paralysis
Cords in midline
Voice: good
Respiration: compromised, stridor
207
Tx of bilateral cord paralysis
If no respiratory issue: monitor
If respiratory issues: intubate, cord lateralization
208
Onset of polyp vs nodule
Polyp: acute
Nodule: gradual
209
Tx of laryngeal papillomatosis
Microdebridement
CO2 laser
HPV vaccine may prevent or decrease the incidence
210
The most common cause of sialadenitis
Viral (mumps)
211
The most common bacterial causes of sialadenitis
S. Aureus
S. Pneumoniae
H. Influenza
212
Predisposing factors to sialadenitis
HIV
anorexia/bulimia
Sjögren
Cushing, hypothyroidism, DM
Hepatic/renal failure
Meds that increase stasis: diuretics, TCA, BB, anticholinergics, AB
Sialolithiasis
213
Inv for sialadenitis
U/S: to differentiate obstructive vs. non obstructive
214
Tx of sialadenitis
Viral: nothing
Bacterial:
cloxacillin
+/- abscess drainage
Sialogogues
215
The most common location if sialolithiasis
Submandibular gland > parotid
216
RFs for sialolithiasis
Duct stenosis
```
Change in salivary secretion:
Dehydration
Diabetes
EtOH
Hypercalcemia
Psychiatric medicine
```
217
Inv for sialolithiasis
U/S +/- sialogram
218
Tx of sialolithiasis
May resolve spontaneously
Encourage salivation
Massage
Analgesia
AB
Sialogogues (lemon wedges, sour lemon candies)
Warm compress
Calculi removal (endoscopy, surgery)
219
The most common salivary gland developing neollasm
Parotid > submandibular
220
The most common benign salivary gland tumor
Mixed (pleomorphic adenoma): 5% risk of malignant transfusion
221
Proportion of parotid gland tumors that are benign
80 %
222
Most common malignant tumor of parotid gland
Mucoepidermoid
223
Inv in parotid gland tumor
FNA Bx (incisional Bx: contra)
CT
U/S
MRI
224
Tx of salivary gland neoplasm
Choice: surgery (malignant or benign)
225
When to investigate a neck mass?
If persisting > 2wk
226
Most common causes of neck mass in different age groups
<20 yr: congenital
20-40: inflammatory
>40: neoplastic
227
Inv for neck mass
Depends on findings
```
CBC
PPD
TFT, Thyroid scan
U/S
CT
Angio
FNA
needle Bx
Open Bx
Panendoscopy (lryngo, esophago, bronchoscopy with washing and Bx)
```
228
Findings in favor of inflammatory neck mass (vs. neoplastic)
```
Painful
Presence of H&N infection
Fever
Tender
Rubbery
Mobile
Younger
```
No: wt loss, no CA risk factor
229
The most common branchial malformation
2nd branchial cleft
230
Sites of branchial cleft malformations
2nd: anterior to SCM
1st: preauricular area, angle of mandible
3rd: recurrent thyroiditis or thyroid abscesses. Usually have a tract leading to the left pyriform sinus.
Air on CT in or near the thyroid gland is pathognomonic
231
Tx of branchial malformations
If infected: AB
Tx: surgical resection
232
Thyroglossal duct cyst presentation
Childhood
20-40 yr
Enlarges with URTI
Small potential for malignancy
233
Tx of thyroglossal cyst
Pre-operative AB to reduce inflammation
Complete excision of cyst and tissue around tract up to foramen cecum and central portion of hyoid bone
234
Lymphatic malformation in fetus
Common
Regresses before birth
235
Presentation of lymphatic malformation
By age 2
Macrocystic: below level of myohyoid
Microcystic: above level of myohyoid muscle
Sudden increase in size by infection or trauma
236
Tx of lymphatic malformations
Do Not Plan surgical intervention until several month after infection (might regress)
Macrocystic: sclerotherapy, surgical excision
Microcystic: debulk if it dies not cause loss of function of normal structures or injected with sclerotherapy
237
Risk of malignant transformation in leukoplakia
5-20%
238
Erythroplakia is associated with in situ/invasive carcinoma in what percent of lesions?
40%
239
Histologic features of dysplastic epithelium
Mitoses, prominent nucleoli
240
Progression of dysplasia to invasive cancer
15-30%
241
Inv in pre-malignant oral lesions
Bx
CXR (for mets w/u)
Liver/brain/bone scans if clinically indicated
CT ( to find pathologic nodal disease, bone invasion)
MRI (to discriminate tumor from mucus and to detect bone marrow invasion)
+/- PET scan
242
General Tx for ENT malignancies
Oral cavity:
Surgery
RT reserved for salvage or poor prognosis
Nasopharynx, oropharynx, hypopharynx, larynx:
Primary: RT
Surgery reserved for salvage
If mets/incurable:
Palliative chemo
Chemo prior to RT, Surgery
Advanced local/regional disease:
Anti-EGFR + RT
243
Synchronous, late developed 2nd primary tumor rate
Synchronus: 9-15%
Late development of 2nd primary: the most common cause of post treatment failure after 36 mo
244
Radiographic definition of pathologic LN
Jugulodigasteric > 1.5 cm
Retropharyngeal > 1 cm
Any size with central necrosis
245
Most common site of distant mets for H&N tumors
Lung > liver > bone
246
Most common site of H&N cancer
Oral cavity
95% SCC
M> F
247
RF for oral SCC
Smoking/ EtOH
Poor oral hygiene
Leukoplakia/ erythroplakia
LP
Chronic inflammation
Sun exposure
HPV
248
RFs for nose, paranasal sinus SCC
Wood/ Shoe/Textile industry
Hardwood dust
Nickle, chromium
Air pollution
Chronic rhinosinusitis
249
Carcinoma of nasopharynx
EBV
Salted fish
Nickle
Poor oral hygiene
Genetic
250
RFs for carcinoma of oropharynx
Smoking
Alcohol
HPV 16
251
RFs for carcinoma of hypopharnx
Smoking
| EtOH
252
RFs for carcinoma of Larynx
Smoking
EtOH
HPV16
253
Percentage of malignant tumors in salivary glands
Minors: >80%
Submandibular 40%
Parotid 20%
254
Thyroid gland carcinoma RFs
```
Radiation
FHx: papillary carcinoma, MEN II
Older age
Male
Gardner: papillary
Cowden: papillary
FAP: papillary
```
255
Survival of HPV + vs HPV - H&N tumors
Better survival in HPV +
256
Chemo agent with highest effect for H&N SCC
Cisplatin +/- 5-FU
Concomitant chemo better than neo-adjuvant
257
Poor Px factors in oral cavity carcinoma
Depth of invasion
Close surgical margins
Location: tongue is worse
Cervical nodes
Extra-capsular spread
258
F/U of thyroid and parathyroid cancers
Thyroid: clinical exam, Tg
Parathyroid: Ca
259
Histology of papillary thyroid carcinoma
Orphan annie
Psammoma bodies
Lymphatic spread
260
Tx of papillary thyroid carcinoma
Total/near-total thyroidectomy
+/- neck dissection
+/- post-operative I131 treatment
No RT
261
Follicular thyroid carcinoma Tx
Thyroidectomy/lobectomy/isthmectomy
Radioiodine therapy
Chemo
RT
Hematogenous spread
262
MTC pathology
Amyloid
Secrets: calcitonin, PG, ACTH, serotonin, kallikrein, bradykinin
Lymphatic/hematogenous spread
263
Tx of MTC
Total thyroidectomy
Node dissection
Post-operative thyroxine, RT, tracheostomy
Screen relatives
264
Anaplastic thyroid carcinoma pathology
Giant cells
Spindle cells
Elderly women
Hx of differentiated thyroid carcinoma/ nodular goitre mass
Rapidly enlarging
265
Tx of anaplastic thyroid carcinoma
Subtotal/total thyroidectomy
RT
Chemo
Palliative care
266
Thyroid lymphoma
```
NHL
Rapidly enlarging
Hx of hashimoto
Female
B symptoms
```
Tx: RT, chemo
267
If thyroid nodule, next step?
TSH
| U/S
268
Indication of FNA for thyroid nodule
If intermediate-high suspicion: >1cm
If low suspicion: >1.5 cm
If < 1cm + clinical symptoms/LAP: further evaluation
269
If non-diagnostic FNA?
Repeat FNA with U/S guide
270
Mx of thyroid nodule with hyperthyroidism
Radioiodine
271
Thyroid mass, benign on FNA, but increasing in size or >3-4 cm, next step
Surgical excision
272
Thyroid nodule with suspicious FNA
Surgical resection
273
Definition of AOM
All of:
Middle ear effusion
Middle ear inflammation
Acute onset
Peak: winter
Peak: 6-15 mo
274
Most common bacteria in AOM
```
S. Pneumoniae
Non-typable H. Influenza
M. Catarrhalis
GAS
S.aureus
```
275
Primary defect causing AOM
Eustachian tube dysfunction/obstruction
276
The most common viruses causing AOM
RSV
Influenza
Parainfluenza
Adenovirus
277
Mechanism of AOM by adenoid hypertrophy
Maintaining a source of infection
278
RFs for AOM and OME
```
Young age
FHx
Prematurity
Orofacial abnormalities
ImDef
Down
Race
Ethnicity
```
```
Lack of breastfeeding
Day care
Household crowding
Cigarette smoke exposure
Air polution
Pacifier
```
279
Triad of AOM
Fever
Otalgia
Conductive hearing loss
280
The most useful symptom in AOM
Ear pain
281
Useful otoscopic signs in AOM
Erythemato
Bulging
Cloudy
Immobile TM
282
General Mx of AOM
Hydration
Analgesics
Antipyretic
+/- AB
283
Indications for AB therapy in AOM
<6 mo
```
Moderate-severe illness:
Irritable
Difficulty sleeping
Poor antipyretic response
Severe otalgia
Fever 39 and higher
Duration > 48 h
Perforated TM with purulent drainage
```
284
If mildly ill child + MEE + bulging TM
Analgesic
| F/U for 24-48 h
285
Referral of AOM if
Recurrent AOM
286
AB therapy for AOM
1st line: amoxicillin
2nd line: cefprozil, cefuroxime, ceftriaxone, azithro, clarithro
If failure after 2-3 d:
Amoxi-clav
If failure:
Ceftriaxone
287
Duration of AB therapy for AOM
If 6-24 mo: 10 d
If > 24 mo: 5 d
If TM perforation: 10 d
If recurrent: 10 d
288
Advantages of AB therapy in AOM
Pain control in day 2-7
Reduce risk of TM perforation
Reduce risk of contralateral AOM
289
Most common cause of pediatric hearing loss
Otitis media with effusion
290
Mx of otitis media with effusion
Observe for 3 mo
Audiogram and tympanogram
Myringotomy +/- ventilation tube
+/- adenoidectomy if:
> 4 yr
(<4 yr only if nasal obstruction, chronic adenitis)
291
Most reliable finding in OME
Immobile TM with pneumatic otoscopy
292
Complications of OME
```
Hearing loss
Speech delay
Learning problems
Chronic mastoiditis
Ossicular erosion
Cholesteatoma
Retraction of TM
Atelectasis
Ossicular fixation
```
293
Indications for myringotomy, tympanostomy tube
Chronic Bilateral OME and documented hearing difficulties > 3mo
```
Unilateral / Bilateral OME > 3 mo and:
Balance problems
Poor school performance
Ear discomfort
Other symptoms attributable to OME
```
```
Unilateral/ Bilateral OME > 3 mo and:
Permanent hearing loss
Speech/language delay
Autism spectrum
Syndromes/ craniofacial disorders
Blindness
Cleft palate
Developmental delay
```
Recurrent AOM ( >3 in 6 mo or > 4 in 12 mo) with Unilateral/ Bilateral OME
294
Age of adenoid size peak and resolution in children
5 yr -12 yr
295
Dx of enlarged adenoid
Flexible nasopharyngoscope: enlarged
Lateral soft tissue x-ray
296
Complications of adenoid hypertrophy
Eustachian tube obstruction (leading to serous otitis media)
Problem with nasal breathing
Malocclusion
Sleep apnea/respiratory disturbance
Orofacial developmental abnormality
297
Indications for adenoidectomy
Sleep disturbance/apnea +/- cor pulmonale
Chronic nasopharyngitis, resistant to medical therapy
Chronic serous otitis media, chronic suppurative otitis media (with 2nd set of tubes)
Recurrent AOM resistant to AB
Suspicion of nasopharyngeal malignancy
Persistent rhinorrhea secondary to nasal obstruction
298
Contraindications to adenoidectomy
Uncontrollable coagulopathy
Recent pharyngeal infection
Conditions predisposing to velopharyngeal insufficiency (cleft palate, impaired palatal function, enlarged pharynx)
299
Complications of adenoidectomy
Bleeding
Infection
Velopharyngeal insufficiency (hypernasal voice, nasal regurgitation)
Scarring of eustachian tube orifice
300
Inv for sleep-disordered breathing
Flexible nasopharyngoscopy
Polysomnography
301
Tx of OSA in children
```
Wt loss
Sleep hygiene
CPAP
BiPAP
Topical nasal CS/ LT-rec antagonist
Surgery
```
302
Bacteria in Quinsy abscess
(Peritonsillar abscess)
```
GAS
S. Pyogenes
S. Aureus
H. Influenza
Anaerobes
```
303
Tiad of Quinsy
Trismus
Uvular deviation
Dysphonia (hot potato voice)
15-30 yr
304
The most reliable indicator of Quinsy
Trismus
305
Tx of quinsy
Secure aurway
Surgical drainage (incision, needle aspiration), with C&S
Warm saline irrigation
IV penicillin G (if positive for GAS)
+ PO/IV metro or clinda x 10 d (if positive bacteroids)
Tonsillectomy: after second episode
306
Tonsillectomy absolute indications
Sleep disordered breathing (most common)
Recurrent throat infection (2nd most common)
Hypertrophy causing upper airway obstruction, obstructive sleep apnea, severe dysphagia, cardiopulmonary complications
Suspicion of malignancy
Orofacial/dental deformity
Hemorrhagic tonsillitis
307
Tonsillectomy relative indications
```
Recurrent throat infection
+
At least one of:
T > 38.3
Cervical adenopathy
Tonsillar exudate
Positive test for GAS
```
Chronic tonsilitis with halitosis/ soar throat/tonsilloliths
Complications of tonsillitis: quinsy, parapharyngeal abscess, retropharyngeal abscess
FTT
308
Relative contraindications of tonsillectomy
Velopharyngeal insufficiency
Coagulopathy
Anemia
Active local infection (unless urgent obstructive symptoms)
309
Etiology of sleep disordered breathing
Adenotonsillar hypertrophy
Craniofacial abnormality
Neuromuscular hypotonia
Obesity
310
Complications of tonsillectomy
```
Hemorrhage
Infection
Odynophagia
Otalgia
Atlantoaxial subluxation
```
311
Most common cause of stridor in children
Laryngomalacia
312
Nasal polyps in children
Suspect CF
313
Stridor if lying prone
Double aortic arch
314
Stridor if lying supine
Laryngomalacia
| Glossoptosis
315
Inspiratory stridor, site?
Vocal cords or above
316
Expiratory stridor
Distal tracheobronchial tree
317
Biphasic stridor
Subglottis and extrathoracic trachea
318
Inflamed tissues in croup
Subglottic space and tracheobronchial tree
319
If recurrent/prolonged croup, suspect:
Subglottic stenosis
Perform:
High kV croup series Xray (AP, Lat) when well
Consider bronchoscopy for definite Dx
320
Tx of croup
```
Systemic steroid
Hydration
If respiratory distress, racemic epinephrine via MDI q 1-2 h
Close observation 3-4 h
If severe, intubation
```
Hospitalize if: poor response to steroids after 4 h and persistent stridor at rest
Consider alternate Dx if poor response
321
Tx of epiglottitis
```
Intubation
IV and hydratio
IV cefuroxim, cefotaxime, ceftriaxone
Moist air
Extubate when: leak around tube and afebrile
Watch for meningitis
```
322
Subglottic stenosis definition
<4 mm in neonate
323
The most common acquired cause of subglottic stenosis
Intubation
324
Dx and Tx of subglottic stenosis
Dx: rigid laryngoscope, bronchoscopy
Tx:
If soft: divide with knife or laser, balloon +/- steroid
If firm: laryngotracheoplasty
325
Laryngomalacia symptoms
High-pitched inspiratory stridor at 1-2 wk
Constant or intermittent
More pronounced in supine position or after URTI
Usually mild
Sometimes cyanosis, FTT, feeding difficulty
Spontaneously subsides by 12-18 mo
326
Yx of laryngomalacia
Observation + PPI
If severe: division of aryepiglotic fold
327
Foreign body is usually stuck at
Cricopharyngeal muscle
If aspirated: Rt main bronchus
328
Tx of foreign body ingestion/aspiration
NPO
older pts: Inspiratory/expiratory CXR (if stable)
Younger pts: Rt and Lt decubitus CHR. If lack of lung deflation while resting on dependent side: foreign body blocking bronchus
Bronchoscopy, esophagoscopy for removal
329
The most common cause of accidental death in children
Foreign body inhalation
330
Battery on Xray
Halo sign around the rim
| Step sign on lateral Xray
331
Deep neck space bacteria
Often mixed
332
Dx of deep neck abscess
Lateral cervical Xray
CT
MRI
Surgeon should consider accompanying pt for imaging
333
Tx of deep neck abscess
Secure airway
Sugical drainage
Maximum dose of IV systemic AB
334
Ludwig angina
Infection of submandibular, sublingual spaces
