ENT Flashcards
Discuss the differential for otalgia
Primary: CN8 has no pain fibres so should not be painful
- auricle: hematoma, laceration, perichondritis (infection of pinna), herpes zoster (Ramsay-Hunt syndrome)
- External auditory canal: acute otitis external, malignant otitis externa, foreign body, cerumen impaction
- Middle ear: acute/chronic otitis media, myringitis (infection of tympanic membrane), mastoiditis, choleastoma
Secondary otalgia: referred pain from CN5, 7, 9, 10 and C2 and C3
- infection: tonsilitis
- trauma
- TMJ syndrome
- dental pain
- glossopharyngeal neoplasm
Discuss the presentation and management of TMJ
Presentation: - referred otalgia - pain in TMJ area - clicking, popping of joint - restricted jaw opening - headache, neck pain Management: - soft food - avoid grinding teeth - no gum - NSAIDs - occlusal dental splint
Name of of the triangles in the neck and important structures within
Submental: Bilateral anterior digastrics and hyoid bone
- submental lymph nodes
- myohyoid muscle
Submandibular: anterior and posterior digastric and mandible
- submandibular gland
- facial artery and vein
- mandibular branch of facial nerve
- hypoglossal nerve
Muscular: Median line, omohyoid, sternocleidomastoid
- thyroid gland
- larynx
- strap muscles
Carotid: omohyoid, sternocleidomastoid, posterior digastric
- Carotid artery and its division into the internal and external carotid
- internal jugular vein
- Vagus nerve
- Ansa cervicalis
Posterior cervical: sternocleidomastoid, trapezius, clavicle
- External jugular vein
- Phrenic nerve
- Accessory nerve
- Roots of brachial plexus
- ansa cervicalis
Name the divisions of the External Carotid Artery
Some Anatomists Like Freaking Out Poor Medical Students Superior thyroid Ascending pharyngeal Lingual Facial Occipital Posterior auricular Maxillary Superficial temporal
Name the Levels of the neck
Submental - I (Ia and Ib) Submandibular - II (IIa and IIb) Middle sternocleidomastoid - III Inferior sternocleidomastoid - IV Posterior cervical - V Muscular - VI Supraclavicular
List the differential for a midline neck mass
Congenital: - Thyroglossal duct cyst - Dermoid - Teratoma - Thymic cyst - Vascular tumours and malformations Inflammatory/Infectious: - lymphadenitis - thyroiditis Neoplastic - thyroid
List the differential for a lateral neck mass
Congenital: - Brachial cleft cyst - pre-auricular pit/sinus/cyst - vascular malformation - pseudotumour of infancy - thymic cyst Infectious: - lymphadenitis: viral, bacterial, infectious mononucleosis, atypical mycobacterium, cat-scratch disease - infection of congenital mass - deep neck space infection - parotitis Inflammatory: - Kawasaki - Sarcoidosis Neoplastic: Benign: vascular tumour, teratoma, dermoid, lipoma, nerve tumour Malignant: lymphoma, rhabdomyosarcoma, thyroid
List the most common brachial cleft cyst?
Second brachial cleft
Discuss the presentation and treatment of a first brachial cleft cyst
Presentation:
- Cyst or draining sinus that is anterior to the ear
- can extend over parotid or angle of mandible
- tract can extend into external auditory canal
Treatment:
- surgical excision with careful dissection of facial nerve
iscuss the presentation and management of a second brachial cleft cyst
Location: - Cyst located along anterior border of middle to lower third of SCM - tract extends along carotid sheath -> between divisions of carotid -> terminating in tonsillar fossa Presentation: - cyst with clear or mucoid drainage Investigations: - ultrasound and then CT Treatment: - surgical excision
Discuss the presentation and management of pseudotumour of infancy
- Intra-uterine trauma to the neck resulting in hematoma and subsequent fibrosis Presentation: - firm, round mass along SCM that presents in 2-3 weeks of life - possible torticollis Investigations: - ultrasound - FNA Treatment: - physiotherapy
Discuss the presentation and management of a lymphatic malformation of the neck
Presentation: soft, mobile, painless, cystic mass in posterior triangle. Grow with infant growth
Investigations: MRI
Treatment: bleomycin
Discuss the presentation and management of infantile hemangioma
Presentation: soft, mobile, bluish/red masses. Must discuss risk of airway hemangioma. Most improve within 5-7 years
Treatment: Propanolol
What are the most likely organisms for acute suppurative lymphadenitis?
Staph aureus
Group A beta-hemolytic strep
What inflammatory neck lesion presents in an asymptomatic child in the submandibular region of the neck?
Atypical mycobacterium
Concern with surgery is mandibular branch of facial nerve
Discuss the presentation and management of a thyroglossal duct cyst
Demographics:
- Children 2-10 years old
Presentation:
- soft, smooth, painless cyst at the level of the hyoid
- Elevates with swallowing
Investigations:
- ultrasound (must ensure normal thyroid is present)
Treatment:
- Sistrunk procedure (remove cyst and hyoid bone)
Discuss the presentation and management of malignant otitis externa
Develops from otitis externa where pseudomonas extends through haversion canals into the skull causing osteomyelitis
Presentation:
- otitis externa with granulation tissue
- CNVII palsy
Treatment:
- topical ciprodex
- long term IV 3rd generation cephalosporin
List the indications for tympanostomy tubes with acute otitis media
Recurrent (>=4 in 6 months or >=6 in 12 months)
Language delay
Febrile seizures
List some of the complications of acute otitis media
Perforated tympanic membrane -> squamous epithelium invaginate and shed kerratin -> form epithelial cyst cholesteatoma -> activates osteoclasts -> erodes ossicles and nerves
List the indications for tympanostomy tubes for chronic otitis media with effusion (>3 mont
Bilateral COME with hearing loss >30dB for >3 months
Any language or speech delay
Unilateral COME with hearing loss >30dB for >6 months
What are the different forms of hearing loss and how are they detected?
Conductive hearing loss: air-bone gap where bone is better than air
Sensorineural hearing loss: decrease in both air and bone conduction, especially in higher frequencies
Mixed: both
List the differential and pertinent signs for sensorineural hearing loss
Presbycusis: bilateral high frequency hearing loss, age-related
Noise-related: bilateral, acute with temporal shift, chronic have 4kHz decrease in hearing
Meniere’s disease: unilateral low frequency hearing loss, tinnitus, episodic vertigo, sensation of fullness
Vestibular Schwannoma: unilateral hearing loss, tinnitus, vertigo
Ototoxicity: Aminoglycosides, Erythromycin, Furosemide, Cisplatin, Quinone
Sudden Sensorineural Hearing Loss: Occur over 3 days, >30dB loss in 3 consecutive frequencies
List the common typanometry findings
Type A: Normal
Type Ad: flaccid tympanic membrane (dislocation of ossicle) - increased
Type As: stiff tympanic membrane or ossicle - decreased
Type B: fluid or mass in middle ear - flat with no peak
Type C: Eustachian tube dysfunction - negative peak pressure
List the differential for conductive hearing loss
Intact tympanic membrane: - Otosclerosis - Ossicular dysfunction - Trauma - acute otitis media - Middle ear effusion Perforated tympanic membrane: - trauma
Discuss the presentation and management of BPPV
Symptoms:
- episodic vertigo lasting seconds to minutes
- aggravated with head motion
Signs:
- positive Dix-Hallpike
- rotatory nystagmus with reversibility and latency
Treatment:
- Epley maneuver to remove cupololithiasis from posterior semicircular canal
Discuss the presentation and management of Meniere’s disease
Symptoms: - severe episodic vertigo lasting hours to days - sensation of fullness - tinnitus - ataxia - nystagmus Signs: - unilateral low frequency hearing loss - decreased vestibular activity Treatment: - lifestyle: smoking cessation, decreased salt intake - Medications: hydrochlorothiazide, antihistamine - Surgery
Discuss the presentation and management of vestibular neuritis
Symptoms: - antecedent URTI - vertigo lasting days to weeks - nausea/vomiting Signs: - ataxia - nystagmus - decreased vestibular activity Treatment: - self-limiting in 3-6 weeks - methylprednisone 100mg PO daily tapered to 10mg PO daily over 3 weeks - gravol, ondansetron
List the two main arteries and their divisions within the nose
Internal carotid: - anterior ethmoidal - posterior ethmoidal External carotid - sphenopalantine - greater palantine - superior labial
List the differential for causes of epistaxis
Local: - trauma - inflammatory: allergy, infection - neoplasm - foreign body - medication: steroid, cocaine - idiopathic Systemic - medication: anticoagulant - vascular: congenital - cardiovascular: hypertension
Discuss the presentation and management of anterior epistaxis
Pathophysiology: bleeding from Kiesselbech’s plexus Presentation: blood out of nose first then oropharynx, can visualize bleeding with anterior rhinoscopy Treatment: - Trotter method - silver nitrate coagulation - Surgicel - Anterior nasal packing - Surgery
Discuss the presentation and management of posterior epistaxis
Location: sphenopalantine artery
Presentation: bleeding into the oropharynx and then anterior nose, not visualized on anterior rhinoscopy
Treatment: posterior nasal pack, embolization, surger
Differentiate between anterior nasal packing and posterior nasal packing
Anterior:
- apply nasal tampon with Otrixin in nose horizontal to palate OR
- use Vaseline gauze inserting from inferior to superior compressing down after each pass
- tape string on outside cheek to avoid aspiration
- Packing remains for 2-3 days as outpatient and have MD remove
- post-removal use nasal saline spray (hydrasense) and vaseline q12h for 2 weeks
Posterior:
- insert Foley into nostril and inflate balloon in oropharynx and pull back
- proceed with nasal packing technique
- treat as inpatient with continuous cardiac monitorin
List some complications of anterior and posterior packing for epistaxis
- Toxic shock syndrome (prevented with Amoxicillin or Cephalexin)
- sinusitis (prevented with Amoxicillin or Cephalexin)
- nasal trauma or synechiae
- alar necrosis
- aspiration of packing material
What is Samter’s Triad?
Asthma
Nasal polyps
Sensitivity to NSAIDs
Discuss the presentation and management of chronic sinusitis
Definition: chronic sinusitis with or without nasal polyp
Symptoms:
- CPODS (C for congestion)
Treatment:
- With nasal polyp: topical intransal corticosteroid and antibiotic, surgery
- Without nasal polyp: topical intranasal corticosteroid spray with irrigation, 2nd-line long term antibiotics (clarithromycin)
Discuss the treatment of a tympanic membrane perforation
Most will heal spontaneously
Must avoid ototoxic antibiotic ear drops and water in ear
antibiotics only if signs of infection (otalgia, otorrhea) - amoxicillin, Septra
Surgery if persists >2 months or have conductive hearing loss
What are some of the reversible risk factors for COME?
Sleeping with a bottle Smoking or wood burning stove in household Cat Daycare with >=6 kids Pacifier
