ENT Flashcards
How does BCC on auricle present
How is it Tx
Nodular lesion that ulcers, bleeds but rarely metastasizes
Topical 5-Fluorouracil
Excision
Radiation
Mohs surgery
What are the words used to describe BCC of the auricle
SCC of auricle are present in ? PT populations w/ ? RFs
Bleeds Ulcerated Rolled edges Nodular Translucent
Pedunculated
UV radiation Chemical exposure Old males ImmSupp Non-healing ulcer
What step is required upon Dx of SCC of the auricle
How does SCC look on presentation
How is SCC of the auricle Tx
Eval neck nodes
Plaque Ulcer Nodule that bleeds
Parotidectomy
Excision
Neck dissection
Mohs
What type of finding of malignant melanoma of the ear is indicative to chance of metastases?
How are they Tx?
<10% w/ thin
>90% w/ thick
Detect/excision
Possible lymph node dissection
What words may be used to describe auricular hematoma?
How are these Tx?
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
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?
3-4mL posterior sulcus, needle insertion inferior pole
Regional block- best for extensive lacs, needle inserted SQ 1cm above superior pole of auricle
How doe Peri/Chondritis present to clinic?
Usually indistinguishable, but what is the exception
Swollen, warm erythematous auricle tender to touch w/ pain on deflection
Chondritis doesn’t involve lobule
What is usually the infecting microbe of Peri/Chondritis
How are these Tx based on severity
P aeruginosa
Mild: PO FQN, f/u 24hrs
Mod-Sev: FQN + Aglycoside
What does the lateral/medial EAC contain?
Lateral third: cartilage section w/ hair and glandular skin
Medial: bony section w/ skin attached to periosteum of temporal bone
What landmark of the ear is the narrowing point of the canal?
What are the 4 main reasons cerumen impaction occur?
Isthmus
Failed migration
Overproduction
Narrowing
Obstruction- Crohns SLE Sjogren
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
No Infection Hx Perforation or Otologic surgery
Suspected TM damage- otorrhea otalgia
Hx frequent ear infections
3-5 days
What post-cerumen irrigation step is important?
When do these impactions need to be referred to ENT for cleaning?
Visual exam
Acetic/Boric acid or alcohol- must do if ImmComp
TM perforation
Recurrent impaction
Routine Tx failure
Hx of OM/TM perf
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
> 1/year despite removal in other wise normal ear
Organics- beans, insects
2% viscous lidocaine
How does Otitis Externa present to clinic and on exam?
What happens to this if left untreated?
Erythema, edema in canal w/ exudate, painful w/ auricle manipulation
Osteomyleitis of skull base
Otitis Externa is AKA ? w/ ? two processes present due to ? microbes
What RFs place PTs at risk
Swimmer Ear- inflammatory, infection of EAC
Pseudo aeruginosa
Staph A
Scratching Lacking cerumen
Water Q-tips
How is a mild case of AOE Tx
How is a moderate case Tx
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
When do systemic ABX need to be used for AOE Tx in combo w/ ototopicals?
Cipro 500mg PO BID x 7d if any are present: CIDERS
Cellulitis ImmDef DM
Edema preventing topicals
Radiation Hx Severe OE
Why is Acetic acid use for mild AOE
When does this medication need to be avoided?
Pseudomonas and Staph A grow between 6.5-7.3pH
Painful exam/to touch
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?
Necrotizing/Malignant Otitis Externa
Pseudomonas
Bacterial infection of EAC and skull base
DM ImmComp Elderly
How does Necrotizing/Malignant OE present?
What presentation is a poor prognosis?
How is Necrotizing/Malignant Otitis Externa Dx
Foul otorrhea
Otalgia, deep
Granulation
CN palsies: 6 7 9 10 11 12
CT w/ bone windows
How is Necrotizing/Malignant Otitis Externa Tx
How is it Tx if case is refractory to medical Tx
Daily anti-Pseudo drop/ABX
IV/PO Cipro
ENT refer
Surgical debrisment
Define Exostoses, it’s association w/ ? and it’s AKA
Define Osteoma
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
What are the essentials for Dx of Eustacian Tube Dysfunction
What are these PTs at risk for?
Fluctuating hearing
Aural fullness
Discomfort w/ barometric change
Serous/Effusion Otitis media
? is an easy way to assess TM integrity and eustachian tube patency
What are two other alternative methods
Valsalva
Otoscope bulb insufflation
Tympanogram
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
Define Patulous Dysfunction
Overly patent Eustacian tube
PT ‘hears body functions’
Weight loss- 6lbs
Atrophy neuromuscular
Scarring
Hormones- pregnant, OCP, prostate Ca Tx
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
How are eustachian tube dysfunctions Tx
Dilatory: Behavior mod/PPIs Antihistamines Nasal steroids Decongestants Frequent valsalva
Patulous:
Hydrate Educate Reassure
Nasal spray Surgery
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
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
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
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
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
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
How does OM present to clinic?
How is it Dx
Dec hearing/pressure
Mastoid tenderness
Sudden otalgia/fever
PE findings
Pneumatic otoscopy
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
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
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
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
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
Criteria for recurrent AOM
How are these cases Tx
3 or + Dx of AOM <6mon or,
4 or more w/in 12mon
PE tubes
Define COM
What microbes can cause this?
Chronic otorrhea through perforated TM w/ mucus and bone changes
Pseudomonas Anaerobes Proteus Staph A
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
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
What complications can arise from COM
Facial paralysis
Otogenic meningitis
Perforated TM
Cholesteatoma
Mastoiditis
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
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
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
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
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
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
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
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
How is facial paralysis from AOM Tx
How is it Tx if from COM?
Myringotomy and IV ABx
Surgicaly correct cholesteatoma, poorer prognosis
? 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
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
Define Otosclerosis
How is Otosclerosis Tx
Familial tendency, abnormal bone growth on stapes foot plate causing 60dB HL
Observe Amplify Stapdectomy
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
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
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
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
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
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
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
Define Perilymph
Define Endolymph
Fluid similar to perilymph that surrounds labyrinth
Fluid inside labyrinth w/ high K+ content w/ role in auditory signal generation
? 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
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
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
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
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
What are etiologies of Peripheral Vertigo
Meniere dz Vestiubular/babyrinth-itis Inner ear barotrauma Benign position vertigo ETOH Semicircular canal dehiscence
What are etiologies of Central Vertigo
Stem/Cerebellar tumor Seizure Wernicke A/V malformation MS
? type of diet can cause vertigo
+ Romberg is indicative of ? underlying issue
High Na
Central cause of vertigo
What meds can cause vertigo?
Aminoglycoside Tranquilizer Tobacco Anti-HTN Caffeine Hypnotic ETOH Diuretic
Anticonvulsant
Analgesic
Phenothiazine
Antidepressant
Diuretic
Vasodilator
Dopaminergic
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
? 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
? 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
Meniere Syndrome is AKA ?
What is believed to cause this syndrome
Endolymphatic Hydrops
Secondary to distension of endolymphatic space in inner ear
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
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
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
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
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
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
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
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
? 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
Chronic post-traumatic vertigo can be a result of ?
How are cases of traumatic vertigo Tx
Cupulolithiasis- BPPV
Diazepam/Meclizine
Vestibular therapy
Define Perilymphatic Fistula
How do these present
Inner ear barotrauma causing leakage of perilymph fluid into middle ear
Vertigo worse w/ straining
Sensory HL
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
? 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
What type of Hx is usually seen in PTs w/ migrainous vertigo
What are possible dietary triggers?
Motion intolerance as Ped
Caffeine
Alcohol
Chocolate
How is migrainous vertigo Tx
How does this differ from Meniere Dz
Lifestyle mod
Anti-migrain prophylactic
No HL or Tinnitus
Define Semicircular Canal Dehiscence
How does it present
Deficiency in bone covering superior semi-circular canal
Vertigo from loud noise or straining w/ CHL
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
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
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
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
How does MS present similar to Meniere’s
Unilateral SHL Facial numbness Episodic vertigo Chronic imbalance Hyper/hypoacusis Diplopia
How do cases of vertebrobasilar insufficiency present?
How are they empirically treated?
Vertigo w/ changes in posture or neck extension
ASA
Vasodilators
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
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
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
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
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
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)
What are the 7 etiologies of SNHL
Sounds above ? dB injure cochlea?
Presbycusis- inc age, MC Hereditary Noise Sudden Ototoxicity Autoimmune Physical
> 85dB
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
? is the 2nd MC cause of SNHL
What is the first issue noted in these PTs
Noise/physical trauma
Loss of high frequencies >4KHz
Ototoxic substances affect ? and ?
? is the MC ototoxic med
Auditory and Vestibular
Aminoglycosides
Loop diuretics
Antineoplastics
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
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
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
? 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
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
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
What are the evaluation goals for HL
Configuration Degree Anatomy of impairment Type Etiology
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
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
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
Audiology assessment measures thresholds between ? range
Thresholds above ? are abnormal
250-8000Hz
> 20dB
Pure tone test is AKA ?
OSHA definition of STS
Audiogram
10dB or more at 2-4000Hz
Sum of shift 2-4000 >30dB
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
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
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
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
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
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
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
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
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)
What are the 4 classifications of ABRS?
Acute <4wks
Subacute 4-12wks
Chronic >12wks
Recurrent 4 or + episodes per year w/ Sx resolution
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
? 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
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
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
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
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
When are ARBS PTs referred?
PO ABX failure Sxs >12wks Dz extends out sinus cavity Facial swelling/erythema Proptosis ImmComp
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
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
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
? is the DOC for Tx of Rhinocerebral Mucomycosis
? antifungals may be used
What surgical procedure is done?
Amphotericin B
Varizonazole
Caspofungin
Medial maxillectomy
? 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
? 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
? 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
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
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
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
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
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
After packing nose for epistaxis Tx, what ABX is needed?
? pain meds are given for posterior packings?
Anti-Staph
Opioids
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
PTs w/ nasal polyps usually have a Hx of ?
? event can precipitate these PTs having bronchospasms
Asthma
ASA
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
Benign nasal tumors are AKA ?
What causes these growths
They need to be removed to prevent development into ?
Inverted/Schneiderian papillomas
HPV
SCC
? 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
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
? 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
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
Define Erythroplakia
How is this different from leukoplakia
Leukoplakia but more erythematous
More likely to exhibit dysplasia or microscopic carcinoma
If erythro/luekoplakia is found, what is the next step?
When is consult for biopsy warranted
Palpate neck nodes, adenopathy= FNA
Presence >2wks
? is the MC PO cancer
How does it present
What is the biggest RF
SCC
Non healing ulcer/mass
Alcohol/Tobacco, especially if combined
Define Melanosis
Define Melanotic macules
Symmetric pattern of dark skin in DPP
Symmetric w/ sharp border discoloration in adults
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
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
Define Mucocele
Where are the MC seen
Fluid filled cavity w/ mucus glands lining epithelium
Lower lip from biting
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
? 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
How are infants w/ thrush Tx
How are refractory cases Tx
Topical antifungal
Nystatin suspensions
Gentian violet
PO fluconazole
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
? 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
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
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
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
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
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
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
How is GABHS Tx
Ault:
PVK- DOC
IM Benzathine Peng G- noncompliant
PCN sensitivity:
Azith/Clinda
Kids:
PVK
Bicillin
PCN sensitivity:
Azith
How is Mono Tx
What limitation is PT placed on
Analgesis
NSAID
Lozenge
CCS if significant edema
Splenomegaly profile
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
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
Define Sialadenitis
How is it Tx
MC Staph A infection causes swelling/pain w/ meals
Sialagogues
Severe: Nafcillan
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
How is Suppurative parotitis Tx
Define Sialoithiasis
Immediate refer
IV Nafcillin/Clinda
Vanc if ImmComp
MC Wharton duct w/ post-prandial pain and swelling
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
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
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
When producing voice, what structures move together?
How is pitch controlled?
Arytenoid cartilage
Tension, tighter- higher
? produces vowel sounds
Why do males have lower voices
? produces enunciation
Pharynx muscles
Larger/thicker folds from androgens
Face/Tongue/Lips
Primary Sxs of laryngeal dz
Which one of these lasting longer than ?wks needs referral
Hoarse, Stridor
Hoarseness
MC cause of hoarseness
What microbes usually cause this MC
Acute laryngitis <3wks
M catarrhalis
H Influenza
Criteria for chronic laryngitis
What usually causes this
> 3wks
Cord lesions
When is Epiglotittis/Supreglottitis suspected?
? presentation indicates impending airway comprimise
Rapid onset sore throat/odynophagia OOP to exam
Drooling
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
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
? 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
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
Define Vocal Cord Polyps
Their prevalence is related to ?
Unilateral mass forming on superficial lamina propria on vocal fold
Yelling, Smoking
Define Vocal Fold Cyst
How are they Tx
Mucus secreting gland cyst on inferior aspect of vocal fold
Laryngoscopy
? 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
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
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
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
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
How does vocal cord dysfunction present
How is it Dx
Dyspnea/wheezing refractory to bronchodilator Txs
Direct visualization of adduction w/ inspir/exspiration
What is the first step in Tx of vocal cord dysfunction
Normal nodes in the neck are smaller than ? size
Speech therapy
<1cm
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
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
? 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
? microbes are the MC cause of Ludwig Angina
What image is used for Dx
Strep
Staph
Bacterioides
Fusobacterium
CT w/ contrast
How is Ludwig Tx
How is Lemierre Tx
PCN + Metronidazole or,
Clindamycon
Metronidazole
? 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
? 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
? 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
How are branchial cleft cysts Dx
How are they Tx
CT
Excision
? 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
How are Thyroglossal Duct Cysts Dx
How are they Tx
TSH, abnormal= scan
CT
Surgical removal via Sistrunk procedure
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
Name of laryngoscope used to depress tongue during neck Ca eval
? specialty uses rigid endoscopes more than any other and why
Jako
ENT, biopsy
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
How is a lymphoma Dx of the head/neck made
FNA can make it
Open biopsy confirms Dx
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
Flow chart
Slide 72
Neck slide deck
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
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
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
