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ENT Flashcards

1
Q

Neck triangle containing spinal accessory nerves

A

Pisterior

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2
Q

Triangle containing hypoglossal nerve

A

Carotid

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3
Q

Ciliary ganglion

A

Pupillary constriction

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4
Q

Pterygopalatine ganglion

A

Parasympathetic:
Lacrimal gland
Nasal mucosa

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5
Q

Submandibular ganglion

A

Parasympathetic:

Submandibular
Sublingual

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6
Q

Otic ganglion

A

Parasympathetic:

Parotid gland

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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)

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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

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9
Q

Auditory acuity tests

A

Whispered-voice test

Tuning fork test (512 Hz)

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10
Q

Interpretation of Rinne test

A

If AC> BC: positive Rinne test: Nl

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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

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12
Q

Order of neural pathway for hearing

A

ECOLI:

Eighth nerve
Cochlear nucleus
Olivary nucleus
Lateral lemniscus
Inferior colliculus
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13
Q

Minimum hearing loss for Rinne to reverse with 512 Hz

A

30 dB

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14
Q

Range of frequencies audible to human ear

A

20-20,000 Hz

Most sensitive: 1000-4000

Human speech: 500-2000

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15
Q

Conductive hearing loss in Pure tone audiometry

A

BC: normal range

AC: outside of normal range

Gap > 10 dB

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16
Q

SNHL in PTA

A

BC: below normal

Gap < 10 dB (no air-bone gap)

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17
Q

Mixed hearing loss on PTA

A

Both AC and BC below normal threshold

Gap > 10 dB

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18
Q

Occupational hearing loss frequency

A

SNHL

At 4000 Hz

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19
Q

Otosclerosis hearing loss frequency

A

Conductive

2000 Hz (Carhart notch)

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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

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21
Q

If > 5 dB difference between SRT and PTA in 500-2000 Hz range:

A

Retrocochlear lesion

Or

Functional hearing loss

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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

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23
Q

Normal range of tympanogram peak

A

-100 to +50 mmH2O

Normal middle ear pressure

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24
Q

Tympanogram in otosclerosis

A

Normal, but lower amplitude

Type A curve

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25
Q

Tympanogram in ossicular chain discontinuity

A

Normal peak pressure but higher amplitude

Type A curve

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26
Q

Tympanogram in perforated TM

A

No peak

Type B

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27
Q

Tympanogram in middle ear effusion

A

No peak

Type B

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28
Q

Tympanogram in eustachian tube dysfunction

A

Negative pressure peak

Type C

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29
Q

Tympanogram in early otitis media without effusion

A

Negative peak pressure

Type C

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30
Q

Normal static compliance (ear canal volume)

A

0.3-1.6 cc

Static compliance

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31
Q

What does static compliance show?

A

Overall stiffness of middle ear system

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32
Q

Type B curve + static compliance > 2cc in children and 2.5 cc in adults indicates:

A

TM perforation

Patent ventilation tube

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33
Q

Acoustic reflex threshold

A

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

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34
Q

Acoustic reflex decay test

A

Ability of stapedius muscle to sustain contraction for 10 sec

Normal: little decay at 500 and 1000 Hz

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35
Q

Acoustic reflex threshold in cochlear hearing loss

A

25-60 dB

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36
Q

ART in retrocochlear pathology

A

Absent or marked decay

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37
Q

Auditory brainstem response

A

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)

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38
Q

Otoacoustic emissions

A

Measures echo generated by cochlea

Absence of emission: hearimg loss or fluid in the middle ear

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39
Q

Newborn hearing screening test

A

Otoacoustic emissions

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40
Q

Tests used in malingering

A

Auditory brainstem response

Otoacoustic emission

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41
Q

Negative prognostic factors in aural rehabilitation

A

Poor speech discrimination

Narrow dynamic range (recruitment)

Unrealistic expectations

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42
Q

Indication for cochlear implants

A

Profound, bilateral SNHL, not rehabilitated with conventional hearing aids

Post-lingually deafened adults

Pre- and post- lingually deaf children

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43
Q

The best candidates for aural rehabilitation

A

Pre-lingually deaf infants

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44
Q

Bone anchored hearing aid indications

A

Conductive hearing loss

Unilateral hearing loss

Mixed hearing loss

(Who cannot wear conventional hearing aids)

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45
Q

Vertigo with duration of seconds

A

BPPV

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46
Q

Vertigo with minutes to hours duration

A

Ménière’s disease

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47
Q

Vertigo with duration of hours to days

A

Labyrinthitis/ vestibular neuronitis

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48
Q

Vertigo with chronic duration

A

Acoustic neuroma

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49
Q

Vertigo with bilateral hearing loss

A

Ménière disease (also unilateral possible)

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50
Q

Vertigo with unilateral hearing loss

A

Accoustic neuroma

Labyrinthitis

Ménière

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51
Q

Vertigo with tinnitus

A

Accoustic neuroma

Labyrinthitis

Ménière

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52
Q

Vertigo with whistling tinnitus

A

Labyrinthitis

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53
Q

Vertigo with aural fullness

A

Meniere

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54
Q

Vertigo with associated ataxia, CN VII palsy

A

Acoustic neuroma

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55
Q

Vertigo with recent AOM

A

Labyrintitis/ vestibulitis

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56
Q

Imbalance in peripheral vs central vertigo

A

Peripheral: mod-sev

Central: mild-mod

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57
Q

Nausea and vomiting in peripheral vs central vertigo

A

P: severe

C: variable

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58
Q

Auditory symptoms in peripheral vs central vertigo

A

P&raquo_space;> C

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59
Q

Neurologist symptoms in peripheral vs central vertigo

A

C&raquo_space;>P

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60
Q

Compensation in peripheral vs central vertigo

A

P: rapid

C: slow

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61
Q

Nystagmus in peripheral vs central vertigo

A

P: unidirectional, horizontal or rotatory

C: bidirectional, horizontal or vertical

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62
Q

Nystagmus in BPPV

A

Tortional, geotropic (. Fast phase towards the floor)

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63
Q

The most common cause of episodic vertigo

A

BPPV

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64
Q

The most common semicircular Canal affected in BPPV

A

Posterior

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65
Q

BPPV in Dix-Hallpike maneuver

A

Latency: 20 sec

Lasting: 20 sec

Crescendo-decrescendo vertigo

Nystagmus ( must be present)

Sitting up: Reversal of nystagmus

Fatigability

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66
Q

Tx of BPPV

A

Reassurance

Resolves spontaneously

Epley maneuver

Brandt-Daroff exercises

Refractory: surgery

If N/V: antiemetic

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67
Q

Drugs that are not to be used in BPPV

A

Drugs to suppress the vestibular system delay eventual recovery and are therefore not used

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68
Q

Diagnostic criteria for Meniere

A

All 3 of:

2 spontaneous episodes of rotational vertigo 20 minutes or longer

Audiometric confirmation of SNHL

Tinnitus and/or aural fullness

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69
Q

Type of hearing loss in meniere

A

SNHL, low frequencies

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70
Q

Meniere time course

A

Attacks come in clusters

In each attack, vertigo disappears within minutes to hours bur SNHL persists

Early: fluctuating SNHL

Late: progressive SNHL, persistent tinnitus

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71
Q

Triggers of Meniere

A

High salt intake

Caffeine

Stress

Nicotine

Alcohol

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72
Q

Acute Mx of meniere

A

Bed rest

Antiemetics

Antivertiginous drugs:
Betahistine,
Meclizine,
Dimenhydrinate

Anticholinergics:
Scopolamine

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73
Q

Long-term Mx of Meniere

A

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)

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74
Q

Drop attack

A

Without LOC

Meniere

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75
Q

Nystagmus in labyrinthitis

A

Acute phase: Fast phase towards affected ear

Convalescence: away from affected side

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76
Q

Ataxia in vestibular neuritis/labyrinthitis

A

Pt veers towards affected side

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77
Q

Tx of acute vestibular neuritis

A

Bed rest

Antivertiginous drugs

Methylprednisolone

+/- antivirals

If bacterial:
IV AB
drainage
Mastoidectomy

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78
Q

Tx of convalescent phase of vestibular neuritis

A

Progressive ambulation

Vestibular exercise

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79
Q

Symptoms of acoustic neuroma

A

SNHL

Tinnitus

Dizziness, unsteadiness, but true vertigo is rare

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80
Q

Unilateral tinnitus/SNHL in elderly

A

Acoustic neuroma until proven otherwise

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81
Q

RFs of acoustic neuroma

A

Exposure to loud noise

Childhood low-dose radiation

Parathyroid adenoma

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82
Q

Gold standard for Dx of acoustic neuroma

A

MRI with gadolinum contrast

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83
Q

Vestibular test in acoustic neuroma

A

Caloric test: Nl or asymmetric

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84
Q

Objective tinnitus DDx

A 
Vascular lesions
Hypo/Hyperthyroidism
Patulous eustachian tube
Palatal myoclonus
Stapedial muscle spasm
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85
Q

Drugs causing tinnitus

A 
ASA
NSAIDs
Aminoglycosides
Antihypertensives
Heavy metals
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86
Q

Metabolic causes of tinnitus

A

Hyper/hypothyroidism

Hyperlipidemia

Vitamin A, B, Zn deficiency

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87
Q

General recommendations for tinnitus

A

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

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88
Q

Contraindications for syringing of the ear canal

A

Active infection
Previous ear surgery
Only hearing ear
TM perforation

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89
Q

Tx of cerumen impaction

A

Water or ceruminolytics:

Bicarbonate solution
Olive oil
Glycerine
Cerumenol
Cerumenex
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90
Q

Disease possibly associated with swimming in cold water

A

Ear canal exostosis

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91
Q

RFs of acute otitis externa

A 
Swimming
Skin conditions
Q-tips
Aggressive scratching
Devices occluding ear canal
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92
Q

Indications for ear syringing for cerumen impaction

A

Decreased hearing

Totally occlusive cerumen with pain

Tinnitus

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93
Q

External otitis etiology

A

90% bacterial:

Pseudomonas, S. Aureus

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94
Q

Tx of acute otitis externa

A

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

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95
Q

Tx of chronic otitis externa

A

CS drops (diprosalic acid)

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96
Q

RFs for malignant otitis externa

A

Elderly diabetics

ImComp

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97
Q

Etiology of malignant otitis externa

A

99% pseudomonas

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98
Q

Complications of malignant otitis externa

A

CN palsy
VII > X > XI

Systemic infection

Death

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99
Q

Mx of malignant otitis externa

A

Imaging:
High resolution temporal bone CT
MRI with gadolinium
Technetium scan

Hospital admission

Debridement

IV AB

Hyperbaric O2

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100
Q

Gallium vs technetium scans

A

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.

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101
Q

Chronic otitis media definition

A

TM perforation in the setting of chronic/recurrent ear infection

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102
Q

Chronic otitis types

A

Benign: dry, no active infection

Serous: continuous serous drainage

Suppurative: persistent purulent drainage

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103
Q

Presentation of congenital cholesteatoma

A

Small white pearl, behind intact TM

Conductive hearing loss

Not associated with otitis media/Eustachian tube dysfunction

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104
Q

Types of acquired cholesteatoma

A

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

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105
Q

Type of hearing loss in cholesteatoma

A

Conductive

SNHL in later stages

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106
Q

Positive Hx in cholesteatoma:

A

Otitis media
Ventilation tubes
Ear surgery

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107
Q

Granulation tissue in the ear

A

Malignant otitis media

Cholesteatoma

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108
Q

Inv an Tx for cholesteatoma

A

Inv: audiogram, CT

Tx: surgery, tympanoplasty, ossicular reconstruction

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109
Q

Etiology of mastoiditis

A

2 weeks after untreated or inadequately treated AOM

S. Pneumoniae, H. Influenza, M. Catarrhalis, S. Pyogen, S. Aureus, P. Aeruginosa

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110
Q

Dx of mastoiditis

A

CT: opacification of mastoid cells, interruption of normal trabeculation of cells

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111
Q

Triad of mastoiditis

A

Otorrhea

Tenderness over the mastoid

Retroauricular swelling with protruding ear

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112
Q

Tx of mastoiditis

A

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

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113
Q

Otosclerosis definition

A

Fusion of stapes to oval window

F>M

AD

Progressive course

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114
Q

Otosclerosis during pregnancy

A

Progression

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115
Q

Age of onset in otosclerosis

A

Teens, 20s

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116
Q

Type of hearing loss in otosclerosis

A

Conductive

SNHL in later stages

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117
Q

TM in otosclerosis

A

Normal +/- pink bluish (Schwartz sign) due to neovascularization of otosclerotic bone

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118
Q

Audiogram of otosclerotic

A

Dip at 2000 Hz (Carhart notch)

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119
Q

Tx of otosclerosis

A

Monitor with serial audiogram

Hearing aid

Definitive Tx: stapedectomy/stapedotomy with laser/drill with prosthesis

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120
Q

The most common cause of conductive hearing loss in 15-50 yr old

A

1st: cerumen impaction
2nd: otosclerosis

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121
Q

Most common cause of non-syndromic congenital hearing loss

A

Connexin 26 defect

AR

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122
Q

RFs for hearing loss in newborn

A 
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
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123
Q

Type of hearing loss in presbycusis

A

SNHL

Initially high frequencies, then middle frequencies

Low speech discrimination (especially with background noise)

Recruitment phenomenon (inability to tolerate loud noises)

Tinnitus

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124
Q

Tx of presbycusis

A

Hearing aid indications:

If: difficulty functioning
Hearing loss > 30-35 dB
Good speech discrimination

Lip reading

Auditory training

Auditory aids (doorbell, phone lights)

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125
Q

The most common cause of SNHL

A

Presbycusis

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126
Q

Inv in sudden SNHL

A

CBC, ESR, RF, ANA to R/O AI diseases

If other focal neurological signs:
MRI: R/O tumor
CT: R/O stroke

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127
Q

Tx of sudden SNHL

A

CS within 3 d:

Intratympanic
Or
Oral x 10-14 d

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128
Q

Prognosis of sudden SNHL

A

70% resolve within 10-14 d
20% partial resolution
10% permanent

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129
Q

Clinic of sudden SNHL

A

Usually unilateral
+/- tinnitus, aural fullness
Usually idiopathic

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130
Q

Clinic of AI inner ear disease

A

20-50 yr

Rapidly progressive or fluctuating

Bilateral

SNHL

+/- tinnitus, aural fullness, vestibular symptoms

SLE, RA, GPA, PAN, allergy

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131
Q

Tx of AI inner ear disease

A

High dose CS: early, at least 30 d

If no response: cytotoxic meds

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132
Q

Aminoglycosides ototoxicity

A

Toxic by any route

Days to weeks after treatment

Toxic to hair cells

Otoacoustic emission lost first

High frequency lost first

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133
Q

Mx of aminoglycosides

A

Monitor with peak and trough levels
(Esp if neutropenia, ear/renal problem)

q 24 h dosing

CrCl determines dosage

Immediately stop if ototoxicity develops

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134
Q

The most important predictor of ototoxicity in treatment with AG

A

Duration of treatment

135
Q

Salicylate ototoxicity

A

Hearing loss

Tinnitus

Reversible if DC

136
Q

Ototoxicity with antimalarials

A

Hearing loss

Tinnitus

Reversible with DC or permanent

137
Q

Noise-induced SNHL pathogenesis

A

85-90 dB over months or years

Or

Single > 135 dB

Cochlear damage

138
Q

Hearing loss type in Noise-induced hearing loss

A

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
Q

Phases of Noise-induced SNHL

A

Temporary threshold shift (returns to normal with removal of noise)

Permanent threshold shift (does not return)

140
Q

Tx of Noise-induced SNHL

A

Hearing aid

141
Q

Prevention of Noise-induced SNHL

A

Ear protection

Limit exposure (frequent rest periods)

Regular audiologic F/U

142
Q

Transverse temporal bone fx

A

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
Q

Longitudinal temporal bone fx

A

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
Q

Dx of temporal bone fx

A

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
Q

Mx of temporal bone fx

A

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
Q

Bell’s palsy etiology

A

Idiopathic/HSV infection of VII nerve

147
Q

RFs for Bell’s palsy

A

DM
Pregnancy
Viral prodrome

148
Q

Clinic of Bell’s palsy

A

Acute onset

Numbness of ear

Schimer test

Hyperacusis

One side facial paralysis/paresis

149
Q

Inv for Bell’s palsy

A

Stapedial reflex: absent

Audiology: normal

EMG: best measure for prognosis

MRI with gadolinum: enhancement of CN VII

High resolution CT

Topognostic testing

150
Q

Tx of Bell’s palsy

A

Prevent exposure keratitis

Systemic steroids

Antivirals

151
Q

F/U of Bell’s palsy

A

Spontaneous remission begins within 3 wk

If delayed recovery (3-6mo): some function loss

152
Q

Px of Bell’s palsy

A

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
Q

Ramsay Hunt syndrome etiology

A

VZV infection of CN VII, CN VIII

154
Q

RFs for Ramsay Hunt

A 
>60 yr
Impaired immunity
Cancer
RT
Chemo
155
Q

Ramsay Hunt clinic

A

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
Q

Inv for Ramsay Hunt

A

Stapedial reflex: absent

Audiology:
SNHL

Viral ELISA studies: confirm Dx

MRI with gadolinium: CN VII, CN VIII enhancement

157
Q

Rx of Ramsay Hunt

A

Avoid touching lesions

Systemic steroids: relieve pain, vertigo, prevent PHN

Acyclovir: lessen pain, aid healing of vesicles

158
Q

Px of Ramsay Hunt

A

Poorer than Bell’s

22% recover completely
66% incomplete paralysis
10% complete paralysis

159
Q

If iatrogenic skull fx and facial nerve palsy:

A

Wait for lidocaine effect to wear off

If any movement present: Do nothing

If no movement: exploration

160
Q

Types of atrophic rhinitis

A

Primary: Klebsiella ozena esp in elderly

Acquired: post-surgery (too much mucosa or turbinate resection)

161
Q

Causes of non-inflammatory rhinitis

A

Pregnancy
Medicamentosa
Estrogen
Hypothyroidism

162
Q

Allergic rhinitis types

A

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
Q

Mucosa and rhinorrhea in allergic rhinitis

A

Mucosa: swollen, pale, boggy

Rhinorrhea: clear, increased eosinophils

164
Q

Complications of rhinitis

A

Chronic sinusitis
Polyps
Serous otitis media

165
Q

Congestion in allergic rhinitis

A

Reduces nasal airflow and allows the nose to repair itself

Tx should focus on the initial insult rather than target this defense mechanism

166
Q

Mx of allergic rhinitis

A

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
Q

Vasomotor rhinitis etiology

A

Disorder of nasal parasympathetic system (vidian nerve, going to sphenopalatine ganglion)

Non-specific reflex hypersensitivity of nasal mucosa

168
Q

Triggers in vasomotor rhinitis

A 
Temperature change
Smoke
Dust
Alcohol
Stress
Anxiety
Neurosis
Hypothyroidism
Pregnancy
Menopause
Parasympathomimetics
169
Q

Tx of vasomotor rhynitis

A

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
Q

Clinical Dx of bacterial rhinosinositis

A

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
Q

Etiology of bacterial rhinosinositis

A 
S. Pneumoniae
H. Influenza
M. Catarrhalis
S. Aureus
Dental aerobes

If immunocompromised: mucormycosis

172
Q

The most common sinus affected in bacterial sinusitis

173
Q

Factors predisposing to acute bacterial RS

A

URTI
allergy
Dental disease
Anatomical defects

174
Q

Mx of acute bacterial RS

A

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
Q

Indications of CT in ABRS

A

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
Q

Pott’s puffy tumor

A

Subperiosteal abscess of frontal bone

177
Q

Superior orbital fissure sundrome

A

Immobile globe:CN III/IV/VI palsy
Dilated pupils
Ptosis
V1 hypoesthesia

178
Q

Orbital apex syndrome

A 
Immobile globe
Dilated pupil
Ptosis
V1 hyposthesia
\+
Optic neuritis, papilledema, decreased visual aquity
179
Q

RS Timing

A

Acute: < 4wk

Subacute: 4-8 wk

Chronic > 8-12 wk

180
Q

Dx of chronic rhinosinositis

A 
2 of:
Congestion and fullness
P
O
D
S
181
Q

Mx of chronic RS

A

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
Q

Factors contributing to chronic RS

A

Inadequately treated ABRS

Allergy

Anatomical defects

Ciliary disorders: CF, kartagener

Chronic inflammatory disorders: GPA

Untreated dental disease

Fungal

Bacterial biofilm/colonization

183
Q

Allergic fungal rhinosinositis

A

Young

Chronic

Atopic

Tx: functional endoscopic sinus surgery + INCS + antifungal + immunotherapy

184
Q

Internal vs external carotid epistaxis

A

Internal: above middle turbinate

External carotid: below middle turbinate

185
Q

Recurrent unilateral epistaxis in adolescent male

A

Juvenile nasopharyngeal angiofibroma

186
Q

Epistaxis inv

A

CBC
PT/PTT
Xray, CT as needed

187
Q

Tx of epistaxis

A 
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
Q

Complications of posterior packing

A 
Hypoxemia
TSS
Aspiratin
Pharyngeal fibrosis/stenosis
Alar/septal necrosis
189
Q

AB in packing

A

For:
All posterior packings
Anterior packing > 48h

190
Q

Prevention of epistaxis

A

Prevent drying:
Humidifiers
Saline spray
Topical ointment

Avoidance of irritants

Mx of HTN and coagulopathies

191
Q

Indication of laryngoscopy in smoker with hoarseness

A

> 2 wk persistence

192
Q

laryngitis timing

A

Acute < 2 wk

Chronic > 2 wk

193
Q

Tx of acute laryngitis

A

Self-limited

Voice rest

Humidification

Hydration

Avoid irritants

If co-existent bacterial pharyngitis: AB

194
Q

If ulceration/granuloma formation on vocal cord

A

Chronic laryngitis

195
Q

Tx of chronic laryngitis

A

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
Q

Most common benign tumor of vocal cords

A

Polyps

M>F

30-50 yr

197
Q

Etiology of polyps

A

Manifestation of vocal cord irritation

Voice strain

Irritants: GERD, allergy, tobacco

198
Q

Most common site of polyp

A

Anterior 1/3 of vocal cords

Asymetrical

199
Q

Tx of polyp

A

Avoid irritants, PPI

If persistent or high risk of malignancy:
Microsurgical removal

200
Q

Vocal cord nodules etiology

A

Submucosal hemorrhage, hyalinization

Chronic voice strain

Frequent URTI, smoke, EtOH

201
Q

Epidemiology of vocal cord nodule

A

F>M

Singers
School teachers
Children
Bartenders

202
Q

Nodule clinic

A

Bilateral

Hoarseness Worse at the end of the day

Junction of anterior 1/3 and posterior 2/3

203
Q

Tx of vocal cord nodule

A

Voice rest

Hydration

Speech therapy

Avoid irritants

Surgery for refractory nodules

204
Q

Unilateral vocal cord paralysis symptoms

A

Early: paramedian position: weak, breathy voice

With time: medialization: improved phonation and aspiration

205
Q

Tx of unilateral vocal cord paralysis

A

Voice therapy

Injection laryngoplasty

Medialization

206
Q

Symptoms of bilateral cord paralysis

A

Cords in midline

Voice: good

Respiration: compromised, stridor

207
Q

Tx of bilateral cord paralysis

A

If no respiratory issue: monitor

If respiratory issues: intubate, cord lateralization

208
Q

Onset of polyp vs nodule

A

Polyp: acute
Nodule: gradual

209
Q

Tx of laryngeal papillomatosis

A

Microdebridement

CO2 laser

HPV vaccine may prevent or decrease the incidence

210
Q

The most common cause of sialadenitis

A

Viral (mumps)

211
Q

The most common bacterial causes of sialadenitis

A

S. Aureus
S. Pneumoniae
H. Influenza

212
Q

Predisposing factors to sialadenitis

A

HIV

anorexia/bulimia

Sjögren

Cushing, hypothyroidism, DM

Hepatic/renal failure

Meds that increase stasis: diuretics, TCA, BB, anticholinergics, AB

Sialolithiasis

213
Q

Inv for sialadenitis

A

U/S: to differentiate obstructive vs. non obstructive

214
Q

Tx of sialadenitis

A

Viral: nothing

Bacterial:
cloxacillin
+/- abscess drainage
Sialogogues

215
Q

The most common location if sialolithiasis

A

Submandibular gland > parotid

216
Q

RFs for sialolithiasis

A

Duct stenosis

Change in salivary secretion:
Dehydration
Diabetes
EtOH
Hypercalcemia
Psychiatric medicine
217
Q

Inv for sialolithiasis

A

U/S +/- sialogram

218
Q

Tx of sialolithiasis

A

May resolve spontaneously

Encourage salivation

Massage

Analgesia

AB

Sialogogues (lemon wedges, sour lemon candies)

Warm compress

Calculi removal (endoscopy, surgery)

219
Q

The most common salivary gland developing neollasm

A

Parotid > submandibular

220
Q

The most common benign salivary gland tumor

A

Mixed (pleomorphic adenoma): 5% risk of malignant transfusion

221
Q

Proportion of parotid gland tumors that are benign

222
Q

Most common malignant tumor of parotid gland

A

Mucoepidermoid

223
Q

Inv in parotid gland tumor

A

FNA Bx (incisional Bx: contra)

CT

U/S

MRI

224
Q

Tx of salivary gland neoplasm

A

Choice: surgery (malignant or benign)

225
Q

When to investigate a neck mass?

A

If persisting > 2wk

226
Q

Most common causes of neck mass in different age groups

A

<20 yr: congenital
20-40: inflammatory
>40: neoplastic

227
Q

Inv for neck mass

A

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
Q

Findings in favor of inflammatory neck mass (vs. neoplastic)

A 
Painful
Presence of H&amp;N infection
Fever
Tender
Rubbery
Mobile
Younger

No: wt loss, no CA risk factor

229
Q

The most common branchial malformation

A

2nd branchial cleft

230
Q

Sites of branchial cleft malformations

A

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
Q

Tx of branchial malformations

A

If infected: AB

Tx: surgical resection

232
Q

Thyroglossal duct cyst presentation

A

Childhood
20-40 yr

Enlarges with URTI

Small potential for malignancy

233
Q

Tx of thyroglossal cyst

A

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
Q

Lymphatic malformation in fetus

A

Common

Regresses before birth

235
Q

Presentation of lymphatic malformation

A

By age 2

Macrocystic: below level of myohyoid

Microcystic: above level of myohyoid muscle

Sudden increase in size by infection or trauma

236
Q

Tx of lymphatic malformations

A

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
Q

Risk of malignant transformation in leukoplakia

238
Q

Erythroplakia is associated with in situ/invasive carcinoma in what percent of lesions?

239
Q

Histologic features of dysplastic epithelium

A

Mitoses, prominent nucleoli

240
Q

Progression of dysplasia to invasive cancer

241
Q

Inv in pre-malignant oral lesions

A

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
Q

General Tx for ENT malignancies

A

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
Q

Synchronous, late developed 2nd primary tumor rate

A

Synchronus: 9-15%

Late development of 2nd primary: the most common cause of post treatment failure after 36 mo

244
Q

Radiographic definition of pathologic LN

A

Jugulodigasteric > 1.5 cm

Retropharyngeal > 1 cm

Any size with central necrosis

245
Q

Most common site of distant mets for H&N tumors

A

Lung > liver > bone

246
Q

Most common site of H&N cancer

A

Oral cavity

95% SCC

M> F

247
Q

RF for oral SCC

A

Smoking/ EtOH

Poor oral hygiene

Leukoplakia/ erythroplakia

LP

Chronic inflammation

Sun exposure

HPV

248
Q

RFs for nose, paranasal sinus SCC

A

Wood/ Shoe/Textile industry

Hardwood dust

Nickle, chromium

Air pollution

Chronic rhinosinusitis

249
Q

Carcinoma of nasopharynx

A

EBV

Salted fish

Nickle

Poor oral hygiene

Genetic

250
Q

RFs for carcinoma of oropharynx

A

Smoking

Alcohol

HPV 16

251
Q

RFs for carcinoma of hypopharnx

A

Smoking

EtOH

252
Q

RFs for carcinoma of Larynx

A

Smoking
EtOH
HPV16

253
Q

Percentage of malignant tumors in salivary glands

A

Minors: >80%

Submandibular 40%

Parotid 20%

254
Q

Thyroid gland carcinoma RFs

A 
Radiation
FHx: papillary carcinoma, MEN II
Older age
Male
Gardner: papillary
Cowden: papillary
FAP: papillary
255
Q

Survival of HPV + vs HPV - H&N tumors

A

Better survival in HPV +

256
Q

Chemo agent with highest effect for H&N SCC

A

Cisplatin +/- 5-FU

Concomitant chemo better than neo-adjuvant

257
Q

Poor Px factors in oral cavity carcinoma

A

Depth of invasion

Close surgical margins

Location: tongue is worse

Cervical nodes

Extra-capsular spread

258
Q

F/U of thyroid and parathyroid cancers

A

Thyroid: clinical exam, Tg

Parathyroid: Ca

259
Q

Histology of papillary thyroid carcinoma

A

Orphan annie
Psammoma bodies

Lymphatic spread

260
Q

Tx of papillary thyroid carcinoma

A

Total/near-total thyroidectomy
+/- neck dissection
+/- post-operative I131 treatment

No RT

261
Q

Follicular thyroid carcinoma Tx

A

Thyroidectomy/lobectomy/isthmectomy
Radioiodine therapy

Chemo

RT

Hematogenous spread

262
Q

MTC pathology

A

Amyloid

Secrets: calcitonin, PG, ACTH, serotonin, kallikrein, bradykinin

Lymphatic/hematogenous spread

263
Q

Tx of MTC

A

Total thyroidectomy

Node dissection

Post-operative thyroxine, RT, tracheostomy

Screen relatives

264
Q

Anaplastic thyroid carcinoma pathology

A

Giant cells
Spindle cells

Elderly women

Hx of differentiated thyroid carcinoma/ nodular goitre mass

Rapidly enlarging

265
Q

Tx of anaplastic thyroid carcinoma

A

Subtotal/total thyroidectomy
RT
Chemo
Palliative care

266
Q

Thyroid lymphoma

A 
NHL
Rapidly enlarging
Hx of hashimoto
Female
B symptoms

Tx: RT, chemo

267
Q

If thyroid nodule, next step?

268
Q

Indication of FNA for thyroid nodule

A

If intermediate-high suspicion: >1cm

If low suspicion: >1.5 cm

If < 1cm + clinical symptoms/LAP: further evaluation

269
Q

If non-diagnostic FNA?

A

Repeat FNA with U/S guide

270
Q

Mx of thyroid nodule with hyperthyroidism

A

Radioiodine

271
Q

Thyroid mass, benign on FNA, but increasing in size or >3-4 cm, next step

A

Surgical excision

272
Q

Thyroid nodule with suspicious FNA

A

Surgical resection

273
Q

Definition of AOM

A

All of:

Middle ear effusion
Middle ear inflammation
Acute onset

Peak: winter
Peak: 6-15 mo

274
Q

Most common bacteria in AOM

A 
S. Pneumoniae
Non-typable H. Influenza
M. Catarrhalis 
GAS
S.aureus
275
Q

Primary defect causing AOM

A

Eustachian tube dysfunction/obstruction

276
Q

The most common viruses causing AOM

A

RSV
Influenza
Parainfluenza
Adenovirus

277
Q

Mechanism of AOM by adenoid hypertrophy

A

Maintaining a source of infection

278
Q

RFs for AOM and OME

A 
Young age
FHx
Prematurity
Orofacial abnormalities
ImDef
Down
Race
Ethnicity

Lack of breastfeeding
Day care
Household crowding
Cigarette smoke exposure
Air polution
Pacifier
279
Q

Triad of AOM

A

Fever
Otalgia
Conductive hearing loss

280
Q

The most useful symptom in AOM

281
Q

Useful otoscopic signs in AOM

A

Erythemato
Bulging
Cloudy
Immobile TM

282
Q

General Mx of AOM

A

Hydration
Analgesics
Antipyretic
+/- AB

283
Q

Indications for AB therapy in AOM

A

<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
Q

If mildly ill child + MEE + bulging TM

A

Analgesic

F/U for 24-48 h

285
Q

Referral of AOM if

A

Recurrent AOM

286
Q

AB therapy for AOM

A

1st line: amoxicillin

2nd line: cefprozil, cefuroxime, ceftriaxone, azithro, clarithro

If failure after 2-3 d:
Amoxi-clav

If failure:
Ceftriaxone

287
Q

Duration of AB therapy for AOM

A

If 6-24 mo: 10 d

If > 24 mo: 5 d

If TM perforation: 10 d

If recurrent: 10 d

288
Q

Advantages of AB therapy in AOM

A

Pain control in day 2-7
Reduce risk of TM perforation
Reduce risk of contralateral AOM

289
Q

Most common cause of pediatric hearing loss

A

Otitis media with effusion

290
Q

Mx of otitis media with effusion

A

Observe for 3 mo

Audiogram and tympanogram

Myringotomy +/- ventilation tube

+/- adenoidectomy if:
> 4 yr
(<4 yr only if nasal obstruction, chronic adenitis)

291
Q

Most reliable finding in OME

A

Immobile TM with pneumatic otoscopy

292
Q

Complications of OME

A 
Hearing loss
Speech delay
Learning problems
Chronic mastoiditis
Ossicular erosion
Cholesteatoma
Retraction of TM
Atelectasis
Ossicular fixation
293
Q

Indications for myringotomy, tympanostomy tube

A

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
Q

Age of adenoid size peak and resolution in children

A

5 yr -12 yr

295
Q

Dx of enlarged adenoid

A

Flexible nasopharyngoscope: enlarged

Lateral soft tissue x-ray

296
Q

Complications of adenoid hypertrophy

A

Eustachian tube obstruction (leading to serous otitis media)

Problem with nasal breathing

Malocclusion

Sleep apnea/respiratory disturbance

Orofacial developmental abnormality

297
Q

Indications for adenoidectomy

A

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
Q

Contraindications to adenoidectomy

A

Uncontrollable coagulopathy

Recent pharyngeal infection

Conditions predisposing to velopharyngeal insufficiency (cleft palate, impaired palatal function, enlarged pharynx)

299
Q

Complications of adenoidectomy

A

Bleeding

Infection

Velopharyngeal insufficiency (hypernasal voice, nasal regurgitation)

Scarring of eustachian tube orifice

300
Q

Inv for sleep-disordered breathing

A

Flexible nasopharyngoscopy

Polysomnography

301
Q

Tx of OSA in children

A 
Wt loss
Sleep hygiene
CPAP
BiPAP
Topical nasal CS/ LT-rec antagonist
Surgery
302
Q

Bacteria in Quinsy abscess

A

(Peritonsillar abscess)

GAS
S. Pyogenes
S. Aureus
H. Influenza
Anaerobes
303
Q

Tiad of Quinsy

A

Trismus
Uvular deviation
Dysphonia (hot potato voice)

15-30 yr

304
Q

The most reliable indicator of Quinsy

305
Q

Tx of quinsy

A

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
Q

Tonsillectomy absolute indications

A

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
Q

Tonsillectomy relative indications

A 
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
Q

Relative contraindications of tonsillectomy

A

Velopharyngeal insufficiency

Coagulopathy

Anemia

Active local infection (unless urgent obstructive symptoms)

309
Q

Etiology of sleep disordered breathing

A

Adenotonsillar hypertrophy

Craniofacial abnormality

Neuromuscular hypotonia

Obesity

310
Q

Complications of tonsillectomy

A 
Hemorrhage
Infection
Odynophagia
Otalgia
Atlantoaxial subluxation
311
Q

Most common cause of stridor in children

A

Laryngomalacia

312
Q

Nasal polyps in children

A

Suspect CF

313
Q

Stridor if lying prone

A

Double aortic arch

314
Q

Stridor if lying supine

A

Laryngomalacia

Glossoptosis

315
Q

Inspiratory stridor, site?

A

Vocal cords or above

316
Q

Expiratory stridor

A

Distal tracheobronchial tree

317
Q

Biphasic stridor

A

Subglottis and extrathoracic trachea

318
Q

Inflamed tissues in croup

A

Subglottic space and tracheobronchial tree

319
Q

If recurrent/prolonged croup, suspect:

A

Subglottic stenosis

Perform:
High kV croup series Xray (AP, Lat) when well
Consider bronchoscopy for definite Dx

320
Q

Tx of croup

A 
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
Q

Tx of epiglottitis

A 
Intubation
IV and hydratio
IV cefuroxim, cefotaxime, ceftriaxone
Moist air
Extubate when: leak around tube and afebrile
Watch for meningitis
322
Q

Subglottic stenosis definition

A

<4 mm in neonate

323
Q

The most common acquired cause of subglottic stenosis

A

Intubation

324
Q

Dx and Tx of subglottic stenosis

A

Dx: rigid laryngoscope, bronchoscopy

Tx:
If soft: divide with knife or laser, balloon +/- steroid

If firm: laryngotracheoplasty

325
Q

Laryngomalacia symptoms

A

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
Q

Yx of laryngomalacia

A

Observation + PPI

If severe: division of aryepiglotic fold

327
Q

Foreign body is usually stuck at

A

Cricopharyngeal muscle

If aspirated: Rt main bronchus

328
Q

Tx of foreign body ingestion/aspiration

A

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
Q

The most common cause of accidental death in children

A

Foreign body inhalation

330
Q

Battery on Xray

A

Halo sign around the rim

Step sign on lateral Xray

331
Q

Deep neck space bacteria

A

Often mixed

332
Q

Dx of deep neck abscess

A

Lateral cervical Xray
CT
MRI

Surgeon should consider accompanying pt for imaging

333
Q

Tx of deep neck abscess

A

Secure airway

Sugical drainage

Maximum dose of IV systemic AB

334
Q

Ludwig angina

A

Infection of submandibular, sublingual spaces

Med (25 decks)

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