ENT Flashcards
1
Q
How does BCC on auricle present
How is it Tx
A
Nodular lesion that ulcers, bleeds but rarely metastasizes
Topical 5-Fluorouracil
Excision
Radiation
Mohs surgery
2
Q
What are the words used to describe BCC of the auricle
SCC of auricle are present in ? PT populations w/ ? RFs
A
Bleeds Ulcerated Rolled edges Nodular Translucent
Pedunculated
UV radiation Chemical exposure Old males ImmSupp Non-healing ulcer
3
Q
What step is required upon Dx of SCC of the auricle
How does SCC look on presentation
How is SCC of the auricle Tx
A
Eval neck nodes
Plaque Ulcer Nodule that bleeds
Parotidectomy
Excision
Neck dissection
Mohs
4
Q
What type of finding of malignant melanoma of the ear is indicative to chance of metastases?
How are they Tx?
A
<10% w/ thin
>90% w/ thick
Detect/excision
Possible lymph node dissection
5
Q
What words may be used to describe auricular hematoma?
How are these Tx?
A
Fluctulant Edematous Ecchymotic Lost landmarks
Evacuate hematoma Splint x 7days w/ f/u at 24hrs PO ABX- Diclox/Cephalexin Cipro- Staph/Pseudomonas Refer if >7d old
6
Q
Where is the anesthetic injection for local blocks placed prior to Tx?
? type of anesthetic block is best for Tx of auricular hematomas w/ least risk for tissue distortion?
A
3-4mL posterior sulcus, needle insertion inferior pole
Regional block- best for extensive lacs, needle inserted SQ 1cm above superior pole of auricle
7
Q
How doe Peri/Chondritis present to clinic?
Usually indistinguishable, but what is the exception
A
Swollen, warm erythematous auricle tender to touch w/ pain on deflection
Chondritis doesn’t involve lobule
8
Q
What is usually the infecting microbe of Peri/Chondritis
How are these Tx based on severity
A
P aeruginosa
Mild: PO FQN, f/u 24hrs
Mod-Sev: FQN + Aglycoside
9
Q
What does the lateral/medial EAC contain?
A
Lateral third: cartilage section w/ hair and glandular skin
Medial: bony section w/ skin attached to periosteum of temporal bone
10
Q
What landmark of the ear is the narrowing point of the canal?
What are the 4 main reasons cerumen impaction occur?
A
Isthmus
Failed migration
Overproduction
Narrowing
Obstruction- Crohns SLE Sjogren
11
Q
Cerumenolytics can be used in ? PT populations
When is the use c/i?
If given to PT for at home use, do not give more than ? use
A
No Infection Hx Perforation or Otologic surgery
Suspected TM damage- otorrhea otalgia
Hx frequent ear infections
3-5 days
12
Q
What post-cerumen irrigation step is important?
When do these impactions need to be referred to ENT for cleaning?
A
Visual exam
Acetic/Boric acid or alcohol- must do if ImmComp
TM perforation
Recurrent impaction
Routine Tx failure
Hx of OM/TM perf
13
Q
What is the criteria of recurring symptomatic cerumen impaction?
When is irrigation not done for removing foreign bodies out of the ear canal?
How are live insects removed
A
> 1/year despite removal in other wise normal ear
Organics- beans, insects
2% viscous lidocaine
14
Q
How does Otitis Externa present to clinic and on exam?
What happens to this if left untreated?
A
Erythema, edema in canal w/ exudate, painful w/ auricle manipulation
Osteomyleitis of skull base
15
Q
Otitis Externa is AKA ? w/ ? two processes present due to ? microbes
What RFs place PTs at risk
A
Swimmer Ear- inflammatory, infection of EAC
Pseudo aeruginosa
Staph A
Scratching Lacking cerumen
Water Q-tips
16
Q
How is a mild case of AOE Tx
How is a moderate case Tx
A
Isopropyl alcohol
White vinegar
2% Acetic Acid 5gtts TID/QID
Corticosporin: Polymyxin B, HCZ and Neomycin- sensitizer
Gentamicin Sulfate (A-glycoside): ototoxic, c/i if TM perf
Cipro/Ofloxacin: Quinolone if suspected perf is present
17
Q
When do systemic ABX need to be used for AOE Tx in combo w/ ototopicals?
A
Cipro 500mg PO BID x 7d if any are present: CIDERS
Cellulitis ImmDef DM
Edema preventing topicals
Radiation Hx Severe OE
18
Q
Why is Acetic acid use for mild AOE
When does this medication need to be avoided?
A
Pseudomonas and Staph A grow between 6.5-7.3pH
Painful exam/to touch
19
Q
What is the worst case and most feared complication outcome of AOE that is due to ? microbe
What PTs are more likely to develop this worst case?
A
Necrotizing/Malignant Otitis Externa
Pseudomonas
Bacterial infection of EAC and skull base
DM ImmComp Elderly
20
Q
How does Necrotizing/Malignant OE present?
What presentation is a poor prognosis?
How is Necrotizing/Malignant Otitis Externa Dx
A
Foul otorrhea
Otalgia, deep
Granulation
CN palsies: 6 7 9 10 11 12
CT w/ bone windows
21
Q
How is Necrotizing/Malignant Otitis Externa Tx
How is it Tx if case is refractory to medical Tx
A
Daily anti-Pseudo drop/ABX
IV/PO Cipro
ENT refer
Surgical debrisment
22
Q
Define Exostoses, it’s association w/ ? and it’s AKA
Define Osteoma
A
Reactive lamellar bone formation causing EAC lesions
Chronic cold exposure
Surfer Ear
Pedunculated EAC lesion of benign osseous neoplasms attached to tympano squamous/mastoid suture line
23
Q
What are the essentials for Dx of Eustacian Tube Dysfunction
What are these PTs at risk for?
A
Fluctuating hearing
Aural fullness
Discomfort w/ barometric change
Serous/Effusion Otitis media
24
Q
? is an easy way to assess TM integrity and eustachian tube patency
What are two other alternative methods
A
Valsalva
Otoscope bulb insufflation
Tympanogram
25
What are the 3 causes of dilatory dysfunction resulting in decreased ability to dilate
Inflammation:
MC- viral URI/allergies
Acid reflux
Pregnancy hormone 3rd-T
Pressure dysregulation from altitude changes
```
Anatomic abnormalities:
Masses
Atresia/stenosis
Trauma- surgery, intubation
Congenital: Downs Turners
Hypertrophic adenoid
```
26
Define Patulous Dysfunction
Overly patent Eustacian tube
PT 'hears body functions'
Weight loss- 6lbs
Atrophy neuromuscular
Scarring
Hormones- pregnant, OCP, prostate Ca Tx
27
How are eustacian tube dysfunctions clinically dx?
What are the risk factors for developing ETD conditions
Dilatory: HL, TM retraction/effusions
Patulous: autophony, TM moves w/ respiration
```
Smoker
Infection Hx
Neuromuscular d/o
Child w/ cough
Reflux
```
28
How are eustachian tube dysfunctions Tx
```
Dilatory:
Behavior mod/PPIs
Antihistamines
Nasal steroids
Decongestants
Frequent valsalva
```
Patulous:
Hydrate Educate Reassure
Nasal spray Surgery
29
What are the essentials of Dx for Serous Otitis Media
This condition is AKA ?
What PT population does it typically present in?
Prolonged ET blockage
Neg pressure= transudation
Otitis Media w/ Effusion
Peds w/ narrow/horizontal ET
30
How does Serous Otitis Media present
What is the best way to Dx
```
Barotrauma
Adult w/ Hx of URI, Allergy,
Dec TM mobility w/ bubbles
Aural fullness
Conductive HL
```
Tympanometry
31
Adult PTs w/ persistent unilateral Serous Otitis Media >3mon need to have ? DDx r/o?
How is this Tx
Nasopharyngeal carcinoma w/ endoscopy
Mild HL: observe x 3mon
```
PE tubes
Endoscopic widening
Adenoidectomy:
Relieves obstruction
Improves tube function
Simultaneous PT placement
```
32
What are the 9 indications to place PE tubes in PTs
HL >30dB w/ OME
SOM >3mon
```
Craniofacial abnormalities
Autophony from PET
Mastoiditis/intracranial issue
Prevent/Tx barotrauma
ETD w/ chronic retraction
Radiation/skull surgery causing middle ear dysfunction
Severe/recurrent AOM
```
33
What are the essentials of Dx for AOM
What are the cardinal signs of inflammation that may be seen?
Hypomobility
Otalgia w/ URI
Erythema
Heat Redness Pain Loss of function Swelling
34
AOM is a sequelae of ?
What are the two MC illnesses affecting kids?
ETD w/ inflammation narrowing the tube causing throat reflux into tube
URI, OM
35
How does OM present to clinic?
How is it Dx
Dec hearing/pressure
Mastoid tenderness
Sudden otalgia/fever
PE findings
Pneumatic otoscopy
36
What are the MC microbes causing AOM?
How is this Tx
H influenzae
Strep pneumo
*Strep pyogenes- GABHS
Observe: >2y/o, <102.2 fever, healthy w/ mild case
ABX Antipyretic Ibuprofen/Acetaminophen
Spontaneous resolution <72hrs
37
When are ABX used for AOM
Which ones are used?
Adults
Kids <2y/o or no improvement >72hrs of observation
Severe Sxs
Amoxicillin- first line
Augmentin- resistant cases
PCN allergy:
Mild/Mod: Cefdinir/Ceftriax
Severe: Erythro + Sulfonamide
38
# Define SNAP Approach to OM
What is the MC Sx of OM
Safety Net approach ABX Prescription:
Paper Rx, only if child does not improve/worsens
Ear pain, Tx w/ Ibuprofen/Acetaminophen
39
How does an Amoxicillin rash present
What PT education piece goes w/ this presentation?
What f/u test needs to be ordered?
Itchy maculopapular rash >72hrs after taking meds, spreads from trunk
Rash is not indication of future c/i ABX use
90% of PTs w/ EBV infection Tx w/ Amox develop rash, order Monospot
40
Pts w/ AOM that are ImmComp or persistently have recurrent infections needs ?
Why do so many Peds PTs have cycles of repeat AOM?
Tympanocentesis for culture
Myringotomy if severe otalgia, mastoiditis, meningitis occur
Fluid remains in ears x 10wks in 10% of population, progression to chronic OM
41
Criteria for recurrent AOM
How are these cases Tx
3 or + Dx of AOM <6mon or,
4 or more w/in 12mon
PE tubes
42
# Define COM
What microbes can cause this?
Chronic otorrhea through perforated TM w/ mucus and bone changes
Pseudomonas Anaerobes Proteus Staph A
43
What is the hallmark presentation for COM?
What is an uncommon presenting complaint?
What type of hearing loss can present
Purulent d/c w/ inc severity during URI/after water exposure w/ TM perf
Pain unless during exacerbation
CHL, destruction of ossicles and/or TM
44
How is COM Tx
Refer for debris removal
Oflo/Cipro w/ Dexameth drops
PO Cipro BID x 6wks
Mastoidectomy
Ear plug use
Surgical TM repair
45
What complications can arise from COM
Facial paralysis
Otogenic meningitis
Perforated TM
Cholesteatoma
Mastoiditis
46
How are TM perforations Tx
What drugs must be avoided?
Combo PO and Topical ABX:
Ofloxacin/Cipro HC
PO ABX if infected
Polymyxin/neomycin ETOH
Aminoglycosides Water
47
What are the 3 layers of the TM
? type of disruption leads to a chronic perf that then needs to be Tx by ?
Squamous epithelium (outter)
Collagen fibrous
Cuboidal in middle ear
Squamous and cuboidal junction meet, causes fibrous layer to stop growing
Tympanoplasty
48
# Define Cholesteatoma
What type of destruction can this lead to?
Prolonged ETD w/ negative pressure causes TM retraction (pars flaccida)
Osteoid destruction
Intracranial spread
CN8 involvement
49
How does Cholesteatoma present
What is the imaging modality of choice for this condition?
How are Cholesteatomas Tx
TM retraction
Perf w/ keratin/granulation
Chronic draining ear
CT/MRI if post-op
Surgical excision, ETD remains
PE tube
50
How does mastoiditis present
What is the next step if this is suspected
Inadequeatley Tx AOM/COM in Peds w/: Fever
Posterior ear pain
Auricle displacement
Pinna edema
CT
Positive= coalescence of mastoid air cells from bone destruction
Immediate ENT referral
51
What microbes are most likely to cause mastoiditis?
How is it Tx
How are PTs Tx that are ABX failure?
Strep pneumo
H influenza
Strep pyogenes
IV Cefazolin
Myringotomy for culture
Mastoidectomy- definitive
52
# Define Petrous Apicitis AKA Petrositis
What is the classic Triad
AOM infection spreads through temporal bone into petrous apex
Gradenigo Syndrome:
CN 6 paralysis
AOM
Retro-orbital pain
53
How is Gradenigo Syndrome Dx
Facial palsy can also be associated w/ ?
Clinical exam
X-ray shows bone destruction in petrous apex
AOM inflammation of CN7
COM pressure of CN7 from cholesteatoma
54
How is facial paralysis from AOM Tx
How is it Tx if from COM?
Myringotomy and IV ABx
Surgicaly correct cholesteatoma, poorer prognosis
55
? is the MC intracranial complication of ear infections
How is it Tx
What is a severe but uncommon complication due to untreated AOM
Otogenic meningitis from severe/neglected AOM
Myringotomy
Brain abscess
56
# Define Tympanosclerosis
What can cause this to happen?
How is tympanosclerosis Dx
Hyaline/Ca deposits in TM leading to CHL
PET Injury Chronic dz
Pneumatic otoscopy shows decreased mobility
57
# Define Otosclerosis
How is Otosclerosis Tx
Familial tendency, abnormal bone growth on stapes foot plate causing 60dB HL
Observe Amplify Stapdectomy
58
How can ear barotrauma be prevented?
When do they need to be referred to ENT?
Pseudophedrine hrs before descent
Oxymetazoline 60m before descent
Tubes if PT must travel often
>4 days HL Vertigo Blast injury
Severe otalgia
59
When does disruption to the ossicular chain need to be suspected in PTs after middle ear trauma?
How is it Tx
CHL >30dB x 3mon
Surgical exploration and reconstruction
60
Primary middle ear tumors are rare, but what kind can develop?
How does this present in clinic?
How are they Tx
Glomus tumors in middle ear or in jugular bulb w/ erosion into hypotympanum
Pulsatile tinnitus w/ CHL
Vascular mass behind TM
CN 7 9-12 defects
Surgery/radiotherapy
61
If PT has suspected middle ear neoplasia w/ pulsatile tinnitus, what imaging study is warranted?
What are the MC causes of ear aches that need to be r/o?
MRA and venography to r/o vascular masses
OE, AOM
62
What could cause PT to present w/ ear aches w/ Pain OOP
Why/how does referred otalgia occur?
Herpes zoster oticus
Sensory innervation from CN 5 7 9 10
TMJ dysfunction
63
# Define Bruxism and what does it mean for ear pain
How are these PTs Tx
TMJ pain exacerbated by chewing from dental malocclusion
Heat/NSAID
Dental refer
Soft food
64
What are types of non-otologic causes of ear aches?
What presentation indicates this Dx and how is it Tx
Glossopharyngeal neuralgia- repeated severe lancinating otaliga- pain in throat/in ear
Refractory to medical management
Microvascular decompression of CN9
65
# Define Perilymph
Define Endolymph
Fluid similar to perilymph that surrounds labyrinth
Fluid inside labyrinth w/ high K+ content w/ role in auditory signal generation
66
? part of the ear play roles in situational awareness and location in space?
? is the important component to balance control?
Semi-circular canal
Vestibular system
67
Difference between Vertigo and Dizziness
What can cause dizziness?
All vertigo is dizzy
Not all dizzy is vertigo
Vertigo
Pre/Syncope
Disequalibrium
Non-specific light headed
68
# Define Vertigo
Wat is an important part of making this Dx
Sensation of motion where there is none of exaggerated sense of motion in response to movement
Duration
+/- HL
69
Vertigo can be caused from asymmetry of the vestibular system due to damage/dysfunction of ?
Otolaryngologists focus on Dz processes that cause vertigo due to ? causes while Neurologists focus on ? causes
Labyrinth
Vestibular nerve
Vestibular structure in brain stem
O: Peripheral
N: Central
70
# Define Peripheral Vertigo
Define Central Vertigo
P: dysfunction of labyrinth or vestibular nerve
Sxs: Severe, sudden
C: dysfunction of balance center in brainstem or cerebellum
Sxs: mild/neuro deficit
Brain pathology causes disequalibirum
71
What are etiologies of Peripheral Vertigo
```
Meniere dz
Vestiubular/babyrinth-itis
Inner ear barotrauma
Benign position vertigo
ETOH
Semicircular canal dehiscence
```
72
What are etiologies of Central Vertigo
```
Stem/Cerebellar tumor
Seizure
Wernicke
A/V malformation
MS
```
73
? type of diet can cause vertigo
+ Romberg is indicative of ? underlying issue
High Na
Central cause of vertigo
74
What meds can cause vertigo?
```
Aminoglycoside
Tranquilizer
Tobacco
Anti-HTN
Caffeine
Hypnotic
ETOH
Diuretic
```
Anticonvulsant
Analgesic
Phenothiazine
Antidepressant
Diuretic
Vasodilator
Dopaminergic
75
When assessing vertigo, evidence of brainstem involvement r/o ? but ?
If vertigo is persistent or suspected CNS Dz is present, evaluate PT w/ ?
R/o peripheral lesion
Absence of brain stem involvement doesn't r/o central lesion
Brain MRI
Audiogram
E/VNG
76
? test is used to discriminate between central and peripheral vertigo etiologies
What is the caloric stimulation used for?
ENG: electrodes record eye movement
VNG: video record eye movement
Vestibulo-ocular reflex for vestibular d/o
Norm= COWS, cold-opposite, warm same
77
? type of nystagmus may be seen in peripheral etiologies of vertigo
What can PT do to suppress this type of nystagmus
Horizontal w/ rotary
Fatigable
Latency
Visual fixation
78
Meniere Syndrome is AKA ?
What is believed to cause this syndrome
Endolymphatic Hydrops
Secondary to distension of endolymphatic space in inner ear
79
What is the classical Dx for Meniere Syndrome
Although etiology is unknown, what are two known causes of this syndrome?
Sensory neural HL
Episodic vertigo
Tinnitus, low tone/blowing
Sensation unilateral aural fullness
Syphilis Trauma
80
What two tests are conducted when evaluating Meniere Syndrome
What meds can be used for Sx relief
What can be done for cases that are refractory to Tx
Audiometry
Caloric Testing
Acute: PO Meclizine/Valium
Primary: low Na diet, Acetazolamide
Intratympanic CCS injection
Vestibular ablation
Endolymph decompression
81
What is the difference between vestibular neuritis and labyrinthitis?
What is the believed etiology?
V: no hearing loss
L: unilateral SHL
Inflammation of vestibular nerve/labyrinth from viral URI
82
How does labyrinthitis usually present?
How is it Dx
What will be seen on PE?
PT wakes w/ room spinning vertigo that decreases over days
Clinical
Spontaneous horizontal nystagmus
Post head thrust test
83
How are Sxs from labyrinthitis Tx
Define BPPV and what causes it
Benzo- Meclizine/Diazepam
Antihistamine
Rehab after acute Sxs stop
Benign Paroxysmal Position Vertigo from otoconia (Ca Carbonate crystals) free floating in semicircular canals
84
How does BPPV present
What type of precipitating event frequently causes this presentation
Quick movement causes sediment in endolymph to stimulate vestibular nerve
Rolling over in bed
85
What type of PE test is used for assessing BPPV
This test will provoke a response if ? type of dysfunction is present
Dick Hallspike maneuver
Posterior canal
86
How is BPPV Tx
? med can be used for vertigo during pregnancy
? drug class is DOC for vertigo overall?
Epley particle reposition maneuver- debris moved to common crus of ant/post canal, exits auricular cavity
Meclizine
Antihistamine
87
? is the MC cause of vertigo after a head injury
How does a basilar skull Fx present differently
Labyrinthe Concussion
Severe vertigo w/ deafness in involved ear
88
Chronic post-traumatic vertigo can be a result of ?
How are cases of traumatic vertigo Tx
Cupulolithiasis- BPPV
Diazepam/Meclizine
Vestibular therapy
89
# Define Perilymphatic Fistula
How do these present
Inner ear barotrauma causing leakage of perilymph fluid into middle ear
Vertigo worse w/ straining
Sensory HL
90
Perilymphatic fistula can be a s/e of ? surgery
How is this Tx
What is done if case is refractory?
Stapedectomy
Bed rest w/ elevation
Avoid straining
Tissue graft window seal
91
? is a mixed peripheral and central etiology of vertigo
How does this form present to clinic?
Migrainous
HA
Visual/motion sensitivity
Phono/photo phobia
Worse w/ sleep deprivation/stress
92
What type of Hx is usually seen in PTs w/ migrainous vertigo
What are possible dietary triggers?
Motion intolerance as Ped
Caffeine
Alcohol
Chocolate
93
How is migrainous vertigo Tx
How does this differ from Meniere Dz
Lifestyle mod
Anti-migrain prophylactic
No HL or Tinnitus
94
# Define Semicircular Canal Dehiscence
How does it present
Deficiency in bone covering superior semi-circular canal
Vertigo from loud noise or straining w/ CHL
95
What is different about central vertigo nystagmus compared to peripheral induced?
If central vertigo is suspected where are they referred to?
Central: non-fatigueable and vertical w/out latency and non-suppressable
Neurology
96
Dzs of central auditory and vestibular systems include lesions on CN? and can cause ?
What studies are ordered for evaluation?
What 3 d/os does this include?
CN8 lesion
Neural HL w/ vertigo
Deteriorated speech
BAER- differs cochlear from neural loss
MRI
Vestibular Schwannoma- acoustic neuroma
Vascular compromise
MS
97
# Define Acoustic Neuroma/Vestibular Schwannoma and where most are located
These growths usually start ? and grow into ?
Sheath tumor on CN 8
Unilateral
Start: internal auditory canal
End: cerebellopontine angle
98
How do Acoustic Neuromas present
How are they Dx
How are they Tx
Unilateral SNHL
Disequalibrium
MRI w/ contrast
ASx: observe
Sx: excise, radiation
Annual MRI
99
How does MS present similar to Meniere's
```
Unilateral SHL
Facial numbness
Episodic vertigo
Chronic imbalance
Hyper/hypoacusis
Diplopia
```
100
How do cases of vertebrobasilar insufficiency present?
How are they empirically treated?
Vertigo w/ changes in posture or neck extension
ASA
Vasodilators
101
What type of vertigo prevents PTs from getting better even w/ therapy?
What are the two types of hearing loss
Bilateral Vestibular
Conductive: external/middle ear dysfunction
Sensorineural: cochlea deterioration, CN8 lesion
102
What are the 5 classifications of HL and dB equivalent
Normal: soft whisper, 0-20
Mild: soft spoken, 20-40
Mod: normal spoken, 40-60
Sev: loud spoken, 60-80
Profound: shout, >80
103
# Define how Weber test appear on PE w/ different HL types
How does Rinne appear on PE for different HL types
R ear CHL, Weber better R
R ear SNHL, Weber better L
R ear CHL, BC>AC
R ear SNHL, AC>BC, same pattern for normal hearing
104
# Define CHL
What are the 4 causes of this type of hearing loss
Dysfunction of external/middle ear w/ impaired sound passage to inner ear
Mass
Obstruction- impaction MC
Discontinuity
Stiffness
105
Transient CHL is usually due to ?
Presistent CHL is usually due to ?
How are they Tx
Cerumen impaction- MC
ETD from URI
Chronic ear infections
Otosclerosis
Trauma
Tx infection/impaction
Tympanoplasty
Prosthesis
106
What causes sensory HL
What causes neural HL
Usually bilateral, what does unilateral SNHL mean?
Deterioration of cochlea, irreversible
Lesions of CN8 or higher
Lesion proximal to cochlea (acoustic neuroma)
107
What are the 7 etiologies of SNHL
Sounds above ? dB injure cochlea?
```
Presbycusis- inc age, MC
Hereditary
Noise
Sudden
Ototoxicity
Autoimmune
Physical
```
>85dB
108
Characteristics of Age Related HL
What is the MC complaint on presentation
MC cause
High frequency, symmetric
Hard hearing bird/phone
Loss of speech discrimination in noisy environments
109
? is the 2nd MC cause of SNHL
What is the first issue noted in these PTs
Noise/physical trauma
Loss of high frequencies >4KHz
110
Ototoxic substances affect ? and ?
? is the MC ototoxic med
Auditory and Vestibular
Aminoglycosides
Loop diuretics
Antineoplastics
111
How can the risk of ototoxicity be reduced?
What usually is the cause of sudden unilateral hearing loss in PTs >20y/o
How is it Tx
Serial audiometry
Peak/trough levels
Non-ototoxic drugs
Viral infections
Vascular occlusions of internal auditory artery
PO CCS/Intratympanic injection ASAP, worse if >6wks after onset
112
What are 3 autoimmune d/os that can cause SHL
How does it present in PTs
SLE
Granulomatosis w/ polyangitis
Cogan Syndrome: hearing loos, keratitis, aortitis
Wax/waning loss leading to permanent hearing loss
113
What labs are ordered for PTs w/ suspected autoimmune induced SNHL
What first and second line meds may be used?
ANA RF ESR
PO CCS
Methotrexate
114
? Sx usually indicates presence of SNHL
What are two types of this Sx that may present
Tinnitus
Pulsatile- abnormal, possible CHL; get MRA/V
Staccato: clicking, middle ear muscle spasm
115
# Define Palatal myoclonus
Other than noise avoidance, white noise and behavior mod, what medication can be used for these PTs
Rhythmic involuntary movement of soft palate associated w/ staccato tinnitus
Notriptyline
116
# Define Hyperacusis
What can cause this
How is this Tx
Excessive sensitivity to sound in PTs w/ normal hearing
Migraine Hx Ear dz
Psych
Ear plugs
Habituation
117
What are the evaluation goals for HL
```
Configuration
Degree
Anatomy of impairment
Type
Etiology
```
118
Sudden hearing loss is usually due to ? and PTs complain of ?
Gradual hearing loss is usually due to ? w/ ? complaints
Viral infection
Vascular occlusion
Poor sound localization, difficulty hearing w/ background noise
Otosclerosis
Vestibular schwannoma
Menieres dz
119
How do vestibular schwannomas present?
? HEENT PE finding is indicative of immediate referral to ENT
Large= CN 5/7neuropathy
Asymmetric hearing loss
Tinnitus
Imbalance
Unilateral serous effusion in adult PT
120
Audiology assessment includes ? 4 parts
All PTs w/ hearing loss get ? unless ?
Pure tone air/bone conduction (audiogram)
Acoustic reflex
Speech reception
Tympanometry
Refer to audiology exam
Impaction/OM etiology
121
Audiology assessment measures thresholds between ? range
Thresholds above ? are abnormal
250-8000Hz
>20dB
122
Pure tone test is AKA ?
OSHA definition of STS
Audiogram
10dB or more at 2-4000Hz
Sum of shift 2-4000 >30dB
123
# Define Tympanometry
What is this particularly good for detecting?
Evaluates TM and middle ear status
Assesses TM mobility in response to pressure changes
Middle ear fluid
124
What do the X and Y axis of a tympanometry indicate
Type A Tymapnogram
X: pressure against TM
Y: movement of TM
Peak curve near 0 daPa
Peak compliance .2-1.8
Absence of middle ear pathology
If HL present, SNHL
125
Type As Tympanogram
Type Ad Tympanogram
Shallow, peak near 0 but dec compliance below 0.2
Associated w/ ossicular fixation, otosclerosis or TM scars
Flat, non-fluctuating HL
Normal ET function
```
Peak near 0, normal
Peak pressure above 2.0
Indicates ossicular disarticulatio/discontinuity
Peak compliance very high
Flat, non-fluctuating HL
Normal ET function
```
126
Type B Tymapnogram
Type C Tympanogram
```
Flat, poorly mobile
Peak absent/poorly defined w/ neg middle ear pressure
Little/no TM movement
Compliance below normal
Indicates middle ear fluid/TM perf
```
Retracted TM/ETD
Peak falls on negative side d/t middle ear neg pressure
Normal peak compliance
ET dysfunction, mild CHL or normal hearing
127
What two sinuses are not well developed in small kids?
Define the Ostiomeatal Complex
Frontal Sphenoid
Channel linking frontal sinus, anterior ethmoid and maxillary sinus to middle meatus
Allows air and mucus drainage
128
How is acute viral rhinosinusitis Tx
Why are these drugs only used for 3 days max?
Buffered Hypertonic Saline
PO Decongestants:
Pseudophedrine
Oxymetazoline and phenylephrine
Rhinitis medicamentosa- rebound congestion
129
What is the difference in presentation between viral and bacterial rhinosinusitis
What does bacterial infections occur?
V: clear
B: yellow/green, facial pain
Largest complex in middle meatus clogs, secondary bacteria infection starts
130
What microbes cause community acquired ABRS
What microbes cause Hospital acquired ABRS
Strep Pneumo
H influena
Staph A
M catarrhalis
P aeruginosa
Gram negs
Staph A
131
What is an important distinction to tell PTs about AVRS or ABRS
How does the IDSA recommend IDing ABRS
Viral improves 7-10 days
Sxs x 10d w/out improving
Severe Sx/fever >102 w/ nasal d/c x 4d
Worsening Sxs after initial improvement (double sick)
132
What are the 4 classifications of ABRS?
Acute <4wks
Subacute 4-12wks
Chronic >12wks
Recurrent 4 or + episodes per year w/ Sx resolution
133
Paranasal sinusitis MC presents as ?
How does is commonly appear on PE
Acute maxillary sinusitis, larger, easily obstructed
Pressure
Unilateral facial fullness
Tenderness over cheek
CN5 pain= dental infection
134
? type of sinusitis usually accompanies maxillary sinusitis w/ pain/pressure over high lateral wall of nose between eyes and radiates to orbit
How does Sphenoid Sinusitis present
How does Frontal Sinusitis present
Acute ethmoid sinusitis
Pan-sinusitis- HA in middle of head
Pain on forehead
135
Hospital associated sinusitis is associated w/ presence of ?
? image modality is used in acute rhinosinusitis cases and when
Prolonged NG tube placement
CT if Tx failure or pre-op work up
136
How is ABRS Tx
If ABX is used, which one is and is NOT used
PO Pseudophedrine
Intranasal CCS- Mometasone fuorate
NSAID/Acetaminophen
Topical decongestants
```
Use:
Augmentin- first line
PCN allergy- Doxy
Clinda + Cefixime
No: Macrolide, TMP/SMX
```
137
Initial ABRS Tx includes observation for mild Sxs and temp <101, when does this change to use ABX?
What complications may arise
Persistent Sxs >10days
Severe Sxs
Sxs worse after improving
Orbital cellulitis/abscess
Osteomyelitis- MC in frontal sinus
138
What condition creates Pott Puffy Tumor?
What is a rare complication that can arise from ABRS?
What are the S/Sxs of this complication
Osteomyelitis from frontal sinusitis complications
Intracranial extension from hematogenous spread (Cavernous Sinusthrombosis
Meningitis), confirm w/ MRI for Danger Triangle
Severe HA AMS Fever
139
When are ARBS PTs referred?
```
PO ABX failure
Sxs >12wks
Dz extends out sinus cavity
Facial swelling/erythema
Proptosis
ImmComp
```
140
# Define Nasal Vestibulitis and it's cause
How is it Tx
Inflammation from infect nasal vestibule d/t folliculitis from Staph A
Dicloxacillin w/ Mupirocin
InD
Chlorhexidine washes
141
# Define Rhinocerebral Mucomycosis
Although presentation is similar to other sinusitis, how is this different?
Invasive Fungal Sinusitis- fungal infection in ImmComp PT w/ Asperigllus/Mucor
Severe facial pain
142
How does Rhinocerebral Mucomycosis classically present on PE
Early Dx requires biopsy which will show ?
Black eschar on middle turbinate
Silver stains- branching nonseptate hyphae
143
? is the DOC for Tx of Rhinocerebral Mucomycosis
? antifungals may be used
What surgical procedure is done?
Amphotericin B
Varizonazole
Caspofungin
Medial maxillectomy
144
? three PT populations have the highest morality rates due to Rhinocerebral Mucomycosis
? is the source of allergies from dust mites?
AIDS/malignancy w/ neutropenia- 100%
CKDz >50%
DM 20%
Protein in feces/decaying bodies
145
? is the mainstay of Allergic Rhinitis Tx
What PT education piece has to be given
```
Intranasal CCS:
Beclomethasone
Flunisolide
Mometasone
Budesonide
Fluticasone propionate
```
Target middle turbinate, not septum
146
? other meds can be used in the Tx of Allergic Rhinitis other than CCS
How are these others broken up by sedation ability
? is used if PT is intolerant to s/e of PO meds
PO antihistamine H1 blockers
Sedation:
Non: Lorat/Deslorat/Fexofenadine
Min: Cetirizine
Most: Bromophen/Chorpheniramine
Azelastine spray
147
What adjunctive meds can be added to the Tx of Allergic Rhinitis
? is the most effective way to alleviate Sxs of this condition
Montelukast
Mast cell stabilizer Corolyn Sodium (most useful optho)
Sodium Nedocromil
Reducing/avoiding exposures
148
What are the 4 types of non-allergic rhinitis
What meds can be used to help Afrin PTs during d/c and prevent rebound congestion
Gustatory- hot/spicy foods
R. Medicamentosa- rebound
Vasomotor- hyper activity
Occupational- fumes
Flunisolide
Ipratropium
Prednisone
NSAID
149
Nose bleeds MC occur from ?
Nose bleeds from ? source are more severe due to violation of ? structure from ? RFs
Most can be Tx w/ ?
Uliateral anterior cavity from Kiesselbach plexus
Posterior, Woodruff plexus
Atherosclerosis
HTN
Pressure x 15min
150
What are the Tx steps for anterior nose bleeds
Don PPE
Direct pressure x 15min while sitting and leaning fwd
Still bleeding after 15min, Phenylephrine/Oxymetazoline then 15m more pressure
Still bleeding, reapply Oxymetazoline and -caine
Cautery w/ silver nitrate/electrocautery
Still bleeding, pack
151
If packing nose to help stop epistaxis, what is the packing covered in first and why
How are posterior nose bleeds Tx
ABX ointment, reduces toxic shock syndrome
Pneumatic tamponade
Packing
Double balloon
Admit and monitor for potential need to surgically ligate
152
After packing nose for epistaxis Tx, what ABX is needed?
? pain meds are given for posterior packings?
Anti-Staph
Opioids
153
If septal hematoma is ID'd after nasal trauma, how long is packing left in place for after InD
What are the 3 levels of LaFort Fxs
2-5 days w/ Cephalex/Clinda
I: horizontal maxiallary Fx
II: pyramidal maxiallary Fx
III: craniofacial dysjunction
154
PTs w/ nasal polyps usually have a Hx of ?
? event can precipitate these PTs having bronchospasms
Asthma
ASA
155
# Define Samter Triad
If this is discovered in a child what Dz needs to be r/o
How are nasal polyps Tx
Asthma triad
Cystic fibrosis
Topical CCS
Prednisone
Surgery
156
Benign nasal tumors are AKA ?
What causes these growths
They need to be removed to prevent development into ?
Inverted/Schneiderian papillomas
HPV
SCC
157
? is the best imaging prior to surgery for nasal Ca removal
Granulomatosis w/ Polyangiitis is AKA ? and defined as ?
What will be seen on PE and Dx biopsy results?
MRI
Wegeners- blood vessel dz of nose and paranasal sinuses
Crust/friable mucosa
Necrotizing granul/vasculitis
158
What will be seen on PE and biopsy results if PT has Sarcoidosis
Define Lethal Midline Granuloma
What will be seen on PE and biopsy results
Turbinates w/ engorged white granulomas
Non-caseating granulomas
Polymorphic reticulosis, type of lymphoma
Nasal bone destruction
Nasal T cell/NKC lymphoma
159
? is the best known precancerous lesion in the mouth
How does this MC present on PE
Leukoplakia
White patches that can't be removed, represents hyperplasia of squamous epithelium
160
What is the sequence of cellular changes in leukoplakia
This can also be seen in ? non-Ca conditions
Hyperplasia Dysplasia Insitu Invasive tumor
Hyperkeratosis from irritation- denture, tobacco
161
# Define Erythroplakia
How is this different from leukoplakia
Leukoplakia but more erythematous
More likely to exhibit dysplasia or microscopic carcinoma
162
If erythro/luekoplakia is found, what is the next step?
When is consult for biopsy warranted
Palpate neck nodes, adenopathy= FNA
Presence >2wks
163
? is the MC PO cancer
How does it present
What is the biggest RF
SCC
Non healing ulcer/mass
Alcohol/Tobacco, especially if combined
164
# Define Melanosis
Define Melanotic macules
Symmetric pattern of dark skin in DPP
Symmetric w/ sharp border discoloration in adults
165
# Define Amalgam Tattoo
Where is MC seen
What is the key component to Dx
Black/blue mark near silver amalgam material
Mandibular arch
Visualization of amalgam
166
# Define Fordyce Spots
Where/how do they present on PE?
Benign neoplasms of sebaceous gland etiology
Vermillion/buccal mucosal border as scattered papules 1-2mm
167
# Define Mucocele
Where are the MC seen
Fluid filled cavity w/ mucus glands lining epithelium
Lower lip from biting
168
# Define PO Lichen Planus
What are the two types and how are they differentiated
How is this Dx and Tx
Waxing/waning of inflammatory conditions from immune mediated responses
Reticular- painless wickham striae
Erosive- tender erythema w/ radiating striae
Dx: biopsy
Tx: Topical and Systemic steroids, Cyclosporines and Retinoids
169
? is the first manifestation of HIV infections
What are the two types
PO Candidiasis, Thrush
Pseudomembranous: MC, white plaques
Atrophic- AKA denture stomatitis, erythema w/out plaques
170
How are infants w/ thrush Tx
How are refractory cases Tx
Topical antifungal
Nystatin suspensions
Gentian violet
PO fluconazole
171
How is Thrush Tx in older kids
How are adults Tx
Mild, <50%: Topical nystatin
Clotrimazole
Sev, >50%: Systemic fluconzaole
Fluconazole
Ketoconazole
Nystatin rinse
Chlorhexidine for Sx Tx
172
? is the MC oral ulcer
What is believed to be the etiology
Recurrent aphthout stomatitis
on non-keratinized mucosa
HHV-6
Celiac/IBD
B/Fe/Folic/Z deficiency
173
How are recurrent aphthous uclers Tx
How can lip herpes Dx be confirmed
Traimcinolone/Fluocinonide
Amlexanox
Diclofinac
Severe pain- Predinsone
Multinucleated giant cells on Tzanck smear
174
How does Varicella-Zoster of the PO cavity present
Define and what causes atrophic glossitis
How does it present?
Vesicles and erosion in PT w/ chicken pox Hx
Inflammatory d/o of tongue leading to papillae atrophy
Fe/B12/Folic deficiency
Sjogren/Candidiasis
Malnutrition/Celiac dz
Burning when eating acid/salty foods
175
What d/os are associated w/ geographic tongues
What are the 4 grades of tonsil sizes
Candidiasis
Psoriasis
Reiter syndrome
Lichen planus
```
0- removed
1- hidden behind pillars
2- extend to pillars
3- beyond pillars
4- extend to midline
```
176
What is the Centor Criteria
What do score cut off mean for the next step
```
3/4= 90% chance of GAS
Fever >100.4
Anterior adenopathy
No cough
Exudative tonsils
Modified: <15, >44
```
2: rapid Ag test
3 or more: rapid Ag test/empiric Tx
177
What does Mono look like on PE
MC cause of pharyngitis is ? and presents as ?
Petechiae
Adeonpathy
White/purple tonsil exudate
Viral- cough rhionrrhea w/out exudate
178
How does Diphtheria present on PE
When is GABHS Tx w/ ABX
What is the DOC
Pharyngitis
Malaise
Gray pseudomembrane exudate
Sx and confirmed culture
Pen VK
Amoxicillin- better taste for kids
179
How is GABHS Tx
Ault:
PVK- DOC
IM Benzathine Peng G- noncompliant
PCN sensitivity:
Azith/Clinda
Kids:
PVK
Bicillin
PCN sensitivity:
Azith
180
How is Mono Tx
What limitation is PT placed on
Analgesis
NSAID
Lozenge
CCS if significant edema
Splenomegaly profile
181
# Define Quinsy Tonsil
How is it Dx
How are they Tx
Peritonsilar cellulitis/abscess
Hot potato voice
US/CT
Cellulitis: Amox/Clinda
Abscess- Aspirate/InD
Admit for tonsilectomy
182
What are the guidelines for tonsilectomy?
What are the two salivary ducts and their location
1-18y/o w/ watching best if:
<7 episodes in past year
<5 per year x 2yrs
<3 per year x 3 yrs
Parotid- stenson
Submandibular- wharton
183
# Define Sialadenitis
How is it Tx
MC Staph A infection causes swelling/pain w/ meals
Sialagogues
Severe: Nafcillan
184
# Define Suppurative Parotitis
How does it present
Staph A infection of parotid gland due to dehydration/poor hygiene
Stenson duct purulence
Fever/chills
Pain down angle of mandible
185
How is Suppurative parotitis Tx
Define Sialoithiasis
Immediate refer
IV Nafcillin/Clinda
Vanc if ImmComp
MC Wharton duct w/ post-prandial pain and swelling
186
When CT imaging sialothiasis cases, what will be seen in relation to location and size
How are these Tx?
Wharton: large, paque
Stenson: small, lucent
<2cm from opening- massage and extract
>2cm, sialoendoscopy, especially if chronic
187
Most salivary gland tumors are in ? duct
Tumors that are small are more likely to be ?
When is the concern for parotid gland malignancy increased?
Parotid gland w/ medial deviation of soft palate
Adenoid cystic carcinoma
CN7 affected
188
How are salivary gland tumors Dx and Tx
Framework of the larynx is composed of ? 6 cartilages?
These are innervated by ?
CT/MRI
Excise/FNA by ENT
Cricoid Thyroid Arytenoid
Epiglotic Corn Cune
Superior/Recurrent laryngeals
189
When producing voice, what structures move together?
How is pitch controlled?
Arytenoid cartilage
Tension, tighter- higher
190
? produces vowel sounds
Why do males have lower voices
? produces enunciation
Pharynx muscles
Larger/thicker folds from androgens
Face/Tongue/Lips
191
Primary Sxs of laryngeal dz
Which one of these lasting longer than ?wks needs referral
Hoarse, Stridor
Hoarseness
192
MC cause of hoarseness
What microbes usually cause this MC
Acute laryngitis <3wks
M catarrhalis
H Influenza
193
Criteria for chronic laryngitis
What usually causes this
>3wks
Cord lesions
194
When is Epiglotittis/Supreglottitis suspected?
? presentation indicates impending airway comprimise
Rapid onset sore throat/odynophagia OOP to exam
Drooling
195
How is Epiglotittis/Supreglottitis Tx
Essentials of Dx for LarygoPharyng Reflux
Dx is made based on PTs response to ?
IV Ceftriax and Dexameth
PO steroid taper
Throat irritation
Hoarse
Chronic cough
Response to PPI- Omeprazole
196
What causes Recurrent Respiratory Papillomatosis
This the ? MC in ?
If PT smokes, this can transform into ? Sxs
Lesions on larynx where ciliated/squamous epithelia meet due to HPV 6/11
Benign larygneal tumor in kids
Warty lesions on cords
197
? is the mainstay of Tx for laryngeal papillomatosis
How can this condition be prevented
What is the goal of Tx
Laser vaporization
Cold knife resections
Gardasil
Voice development
Avoid tracheotomy
Preserve structures
198
Vocal cord nodules and papules are both manifestations of /
Vocal fold nodules are AKA ? in adults or kids
These are common causes of hoarseness due to ?
Chronic vocal fold irritation
Singer nodule
Screamer nodule
Vocal cord abuse
199
# Define Vocal Cord Polyps
Their prevalence is related to ?
Unilateral mass forming on superficial lamina propria on vocal fold
Yelling, Smoking
200
# Define Vocal Fold Cyst
How are they Tx
Mucus secreting gland cyst on inferior aspect of vocal fold
Laryngoscopy
201
? laryngeal issue is a common cause of hoarseness in smokers
How is this Dx
How is it Tx
Laryngeal Leukoplakia
Biopsy
Cessation w/ PPI as mainstay
202
How does SCC of larynx present
This development is related to ? infection
It's prevalence is strongest in ? PT population
Ear/throat pain w/ swallowing
Mass/hemoptysis
HPV 16/18
Non-smokers
203
What is the relation of metastases and SCC in larynx
Vocal cord paralysis can be caused by lesions on ? or ?
Uncommon- true vocal cord Ca if cords mobile
Common- supraglottic Ca
Vagus
Unilateral recurrent laryngeal
204
How does vocal cord paralysis d/t neuro dysfunction present
What it the MC and 2nd MC cause of vocal cord paralysis
But first, Ca must be r/o w/ ? images
Breathy dysphonia
Effortful voicing
Iatrogenic injury
Idiopathic
Normal CN- CT w/ contrast
Abnormal CN- MRI
205
Unilateral recurrent laryngeal nerve injury causes vocal cords to be stuck in ? position
Bilateral vocal fold paralysis is a rare adverse effect from ?
Paramedian- partially lateralized
Total thyroidectomy after reoperations
Normal voice, respiratory compromise
Dyspnea/stridor upon extubation
206
How does vocal cord dysfunction present
How is it Dx
Dyspnea/wheezing refractory to bronchodilator Txs
Direct visualization of adduction w/ inspir/exspiration
207
What is the first step in Tx of vocal cord dysfunction
Normal nodes in the neck are smaller than ? size
Speech therapy
<1cm
208
What is the Rule of 7s for neck masses
Masses in PTs >40 are usually
7 days- inflammatory
7wk-7mon- neoplastic
7 years- congenital
Ca
209
What are the most important parts of H/P for neck masses?
? is the MC neck space infection
Why is this a medical emergency
Size Age Duration
Ludwig angina, bilateral infection of submandibular space
Tongue pushed up and back into airway
210
? is the MC cause of deep neck abscesses
Define Lemierre Syndrome
Who does this typically present in
Odontogenic infections
Thrombophlebitis of internal jugular vein secondary to oropharyngeal inflammation
ICU PT w/ jugular catheter
211
? microbes are the MC cause of Ludwig Angina
What image is used for Dx
Strep
Staph
Bacterioides
Fusobacterium
CT w/ contrast
212
How is Ludwig Tx
How is Lemierre Tx
PCN + Metronidazole or,
Clindamycon
Metronidazole
213
? is the MC cause of neck masses across all age groups
What causes this MC
How is it Tx
Reactive Cervical adenopathy
Infection of pharynx, salivary gland or scalp
Self resolves over weeks
Clinda/Augmentin
214
? microbe can cause Reactive Cervical Adenopathy
Two primary indications for a tracheotomy
Cat scratch fever- Bartonella Henslae
Airway obstruction at/above larynx
Respiratory failure needing prolonged mechanical vent-MCC
215
? is the MC congenital mass of the lateral neck
Where do they present
What are two facts that would r/o this Dx?
Brachial cleft cyst, remnant of embryologic development
Anywhere on SCM as painless lump 2-3rd decade
Not midline
Don't move w/ swallowing
216
How are branchial cleft cysts Dx
How are they Tx
CT
Excision
217
? MC congenital mass of the central neck
How does this MC present
Thyroglossal duct cyst from embryologic descent of thyroid
<20y/o w/ midline lump below hyoid bone and moves w/ swallowing/tongue protrusion
218
How are Thyroglossal Duct Cysts Dx
How are they Tx
TSH, abnormal= scan
CT
Surgical removal via Sistrunk procedure
219
Most of neck tumor metastases is ?
Almost all of these tend to be from ? parts of the body
SCC from upper aerodigestive tract
Neck nodes to lung, liver, bone and brain
220
Name of laryngoscope used to depress tongue during neck Ca eval
? specialty uses rigid endoscopes more than any other and why
Jako
ENT, biopsy
221
Suspected head/neck Ca needs ? exam prior to refer for ?
R ear AD stand for ?
L ear AS stands for ?
Both ears AU stands for ?
Auricle is Latin for ?
HEENT
Triple endoscopy
Auris dextra
Auris sinistra
Auris utraque
Ear
222
How is a lymphoma Dx of the head/neck made
FNA can make it
| Open biopsy confirms Dx
223
What are the different thyroid Cas
Papillary- slow, Dx w/ FNA
Follicuar- aggressive, needle biopsy for Dx
Medullary- poor uptake by thyroid, associated w/ MEN2A
Dx w/ FNA
Anaplastic- least common, most aggressive
Dx w/ FNA
All Tx w/ surgery and post-op iodine ablation
224
Flow chart
Slide 72
| Neck slide deck
225
PTs w/ TM ruptures lasting longer than 4mon and HL are at risk for ? damage
What are the 3 parts of balance control that work w/ vestibular inputs?
Incus damage
Cervical musculature
Eye movement/vision
Arm/leg extensor muscles
226
A lack of ? on BPPV exam makes Dx uncertain
If this is present, when/how does it change?
Nystagmus
DHM causes nystagmus to a direction
Upon sitting up, paroxysmal nystagmus in opposite direction should occur
227
What antihistamines are used for acute vertigo?
What Benzos can be used
What anti-emetics can be used
What meds are reserved for Tx room/ED only
Dimenhydrinate
Diphenhydramine
Meclizine
Clonazepam
Lorazepam
Alprazolam
Diazepam
Metoclopramide
Ondansetron
Prochlorperazine
```
Metoclopramide
Ondansetron
Prochloperazine
Promethazine
Diphenhydramine
```
