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ENT Phase 2 Flashcards

1
Q

BCC is the MC ? and most likely to occur ?

What causes incidence to increase?

How does it present on PE?

A

MC auricle malignancy, most often on face

Age/Exposure

Pedunculated Ulcerated Nodular Translucent
Rolled Bleeding

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2
Q

How is BCC Tx

What are the 3 types

A

Freeze Topical 5-FU
Mohs Excision Radiation Currette

Superficial spreading
Ulcerated
Nodular (morpheaform)

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3
Q

SCC is more common in ? PTs

What findings are indicative of advanced cases/poor prognosis

A

Elderly males

CN7/node involvement

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4
Q

What are the RFs for developing SCC

How does these appear on PE

A

Age Non-healing ulcer ImmSupp Chemical exposure
UV radiation

Ulcerated plaque/nodule prone to bleeds

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5
Q

How are SCCs Tx

Why is Tx harder

What type are more likely to metastasize

A

Dissection w/ parotidectomy (adv cases)
Excision
Radiation
Mohs

Aggressive SCC>BCC
Larger excision areas

Recurrent/deep ulcerations

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6
Q

? is the MC neoplasm of the ear canal?

When is a Dx of malignancy considered?

A

SCC

Otitis externa doesn’t resolve on therapy

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7
Q

Why is malignant melanoma so dangerous?

How does malignant melanoma look on PE?

A

Affects all age groups w/ high mortality rate

Pigemented lesion w/ changes to ABCDE
Moves Epidermis to Dermis

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8
Q

How are malignant melanomas Tx

What do the ABCDEs used for monitoring stand for?

A

Excision w/ lymph node dissection

Asymmetry
Border
Color
Diameter
Evolving
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9
Q

What is the suspected RF for malignant melanoma?

What is the classification system used to measure lesion invasion depth?

A

Sun exposure during childhood

Breslow:
Thin- 1mm or less
Intermediate- 1-<4mm
Thick- >4mm

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10
Q

PTs w/ malignant melanoma need to have skin exams to detect ? types of lesions early?

How are these cases Tx?

A

Darkly pigmented/bleed
Changes in ABCDE

Excision
Lymph node dissection

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11
Q

How does an Epidermal Inclusion Cyst appear on exam?

How are they Tx

A

Central punctum w/ well defined borders w/out tenderness or mobility;
+ drainage possible

Only at PT request:
Triamcinolone injection 3mg/mL

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12
Q

Auricular hematoma occur when blood accumulates between ? structures?

What word would be used to describe a hematoma?

A

Cartilage and Perichondrium- hematoma to necrosis

Fluctuant Edematous Ecchymotic Lost landmarks

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13
Q

What are the steps to Tx of auricular hematomas?

Any hematoma older than ? required referral

A

Evac hematoma
Pressure dressing/spint
ABX- Staph (Diclox/Cephalexin) or Pseudomonas (Cipro)

> 7days to ENT
Cauliflower can develop in 48-72hrs

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14
Q

When can/do local or regional blocks need to be used during auricular hematoma evacuation?

What are the landmarks for injection?

A

Local- simple lacerations
Regional: extensive, best to avoid tissue distortion

Local-
Posterior: posterior sulcus
Anterior: superior/anterior to tragus

Regional-
Superior to superior pole above tragus

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15
Q

When performing regional blocks for auricular hematoma evacuations, do not exceed using ? much lidocaine?

Lacerations anterior to the ear can damage ? structures but can be evaluated w/ ? imaging?

A

4mg/kg of 1%

CN7, Parotid
CT w/out contrast

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16
Q

All PTs that have ear lacerations repaired need ? final steps taken for Tx

Ear lacerations need to be referred to plastics, OMFS, ENT or neurosurgery if ? structures are involved?

A

Pressure dressing
ABX- quinolones

Basilar skull Fx
HL
EAC 
Avulsion
Vestibular Sx
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17
Q

95% of Peri/chondritis cases are due to ? microbe?

How are these cases Tx?

A

P. aeruginosa

Mild: PO FQN w/ f/u <24hrs
Mod/Sev: IV FQN + Aminoglycoside; possible debridement

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18
Q

Cellulitis of the auricle must be promptly Tx to prevent ? development

Define Relapsing Polychondritis and what is done to slow progression/prevent damage

A

Perichondritis

Recurrent bilateral episodes of auricular erythema/edema; progresses to involve tracheobronchial tree
CCS slow progression/damage

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19
Q

What are the two protective factors cerumen offers?

What are the two parts of the EAC and contents of each part?

A

Acidic enviroment
Lipid rich/hydrophobic

Lateral 1/3- cartilage w/ hair and glandular skin
Medial 2/3- bony w/ attachment to temporal periosteum

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20
Q

What is the narrowest point of the EAC?

What are the 4 causes of cerumen impaction?

A

Isthmus

Obstruction- SLE, Crohn’s
Narrowing
Failed migration
Over production

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21
Q

What is the expected result for Tx of symptomatic cerumen impaction?

If Tx is needed, what are the 3 methods

A

Inc hearing by 10dB

Cerumenolytics
Irrigation
Manual removal

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22
Q

When are cerumenolytic agents safe/contradicted for use

What are 3 examples of lytic agents used?

A

Safe- no Hx of infection, perf, otologic surgery
No- TM damage suspected

Mineral oil
H2O2 3%
Carbamide peroxide 6.5%, max 4 days

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23
Q

When attempting irrigation removal of cerumen impactions, don’t insert syringe past ?

What direction is the stream aimed in?

A

Beyond lateral 1/3- 8mm

Posterior and upward

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24
Q

Cerumen impaction removed w/ irrigation have the best results when ? step out is done post-wash

When is this post-irrigation step a must?

A

Acidification w/ 2% acetic/boric acid or alcohol

PT is ImmComp

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25
Q

When should cerumen impactions be referred to ENT for removal under microscope?

PTs are classified as recurrent impactions if they have more than ? and can do ? prophylactic care to reduce impactions

A

TM perf
Recurrent impactions
Routine measures fail
Hx of COM/TM perf

> 1/yr in normal ear:
Cotton ball w/ mineral oil x 10-20min 1/wk
Remove inserts prior to sleep
Scheduled cleaning q6-12mon

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26
Q

Cerumen impaction are most often due to ?

Drying of the EAC after cleaning/removal is important to prevent development of ?

A

Self induced cleaning attempts

Otitis externa

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27
Q

Foreign bodies in the ear present w/ ? Sxs

What may happen if persistent object retention occurs?

A

Pain Pruritus CHL Bleeding

Infection
Tissue granulation

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28
Q

MC ear foreign bodies get lodged in ? area

How are insects best killed?

A

Lateral EAC

Olive oil
3% lidocaine

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29
Q

How do Peds PTs w/ foreign objects lodged in the nose present?

What Tx attempt can be done prior to considering surgical removal?

A

Unilateral purulent rhinorrhea

Topical anesthetic
Vasoconstrictive nose drops

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30
Q

How does Otitis Externa present

When is this Dx a concern for a dangerous future sequelae?

A

Painful erythem/edema of the canal skin w/ exudate
Auricle/tragus manipulation= pain

Malignant external otitis- osteomyelitis of skull base in ImmComp/DM PTs

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31
Q

External otitis is caused by ? microbes

A

Gram-pos cocci:
Staph A

Gram-neg rods:
Pseudomonas
Proteus

Fungi:
Aspergillus

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32
Q

Malignant external otitis is caused by ? microbe

What is the sequential path of spread?

A

Pseudomonas

Floor of ear canal
Middle fossa floor
Clivus
Contralateral skull base

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33
Q

What are the RFs for AOE?

What is the difference of TM mobility on PE between External Otitis and AOM?

A

Frequent/aggressive Q-tips
Water
Scratching
Lack of cerumen

EO- normal movement w/ pneumatic otoscopy

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34
Q

What will be seen on PE if PT has malignant external otitis?

Advanced cases can present w/ ? and CN palsy in ? nerves

How is this Dx confirmed w/ imaging

A

Ottorhea
Canal granulations
Deep otalgia

Periauricular/anterior adenopathy
6 7 9 10 11 12

CT showing osseous erosions

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35
Q

How are mild and mod/sev cases of AOE Tx?

A

Mild: 2% acetic acid or 50/50 isopropyl/white vinegar (swimmer’s ear w/out infxn) prevent Pseudo/Staph A growth 6.5-7.3pH

Mod:
Aminoglycoside (genta sulfate)- ototoxic, desensitizer
FQN- Cipro/Ofloxacin

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36
Q

When are systemic ABX needed for the Tx of AOE?

What ABX is used?

A 
Cellulitis
ImmDef
DM
Edema preventing topicals
Radiation Hx (ear)
Severe OE

Cipro

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37
Q

PTs being Tx for AOE need to avoid water for how long?

Any persistent otitis externa in ? two PTs need referrals

A

10days

ImmComp
DM

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38
Q

What ABX is used for Tx of malignant external otitis?

How long its Tx continued for?

A

Cipro

Gallium scanning proves inflammation reduction

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39
Q

What is the most feared complication of AOE?

What microbe causes it and how does it spread?

A

Malignant OE

Pseudomonas- enters DM/AIDS PT temporal bone to base of skull
Sequelae- bone infection

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40
Q

How are PTs w/ malignant OE Tx who fail medical therapy?

Define Exostoses and it’s AKA

A

Hyperbaric chamber

EAC lesion of reactive lamellar bone growth w/ broad base; Surfer’s ear from cold water exposure

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41
Q

Define Osteoma and their location of growth

? is the MC neoplasm of the ear canal?

A

EAC lesion w/ pedunculated base; a benign osseous neoplasm on tympano-squamous/mastoid line

SCC

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42
Q

When is a Dx of SCC brought into consideration?

Why is there such a high mortality rate?

How are they Tx

A

OE fails to resolve w/ therapy; obtain biopsy

Invasion of lymphatics in cranial base

Wide resection w/ radiation

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43
Q

What is the less lethal type of ear canal neoplasm if SCC is excluded?

What are the etiologies of dilatory ET dysfunction?

A

Adenomatous- grow from cerumen glands

PICA
Pressure
Inflammation (3rd-T pregnant)
Congenital
Anatomic
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44
Q

What are the MCC of ET dysfunction?

What are the 4 etiologies of patulous ET dysfunction?

A

Viral URI
Allergies

Weight loss
Atrophy
Scars
Hormone- high E, OCPs, prostate Ca Tx

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45
Q

What do PTs w/ dilatory ET dysfunction present w/?

What do PTs w/ patulous dysfunction present w/?

A

HL
TM retraction/effusion

Autophony
TM moves w/ in/expiration

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46
Q

How is dilatory ET dysfunction Tx

How is patulous ET dysfunction Tx?

A

PPIs
Antihistamines
Decongestants
Steroids

Mild- hydrate, saline spray, avoid decongestants
Sev- surgery: PE tubes and cartilage grafts

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47
Q

Why should PTs w/ active intranasal infection avoid from valsalva maneuvers?

What are 2 unique complaints/findings that may signal PT has patulous ET dysfunction?

A

Precipitates middle ear infections

Autophony worse w/ exertion, better w/ URIs

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48
Q

What causes serous otitis media to develop?

What is this Dx AKA?

A

Prolonged negative ET pressure cause trandudative formation

Otitis media w/ effusion

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49
Q

Serous Otitis Media is common in ? PT population?

What are the presenting S/Sxs?

How are these best Dx

A

Peds w/ narrow/horizontal ET

CHL w/ fullness
Dec TM mobility

Tympanometry

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50
Q

How are cases of Serous Otitis Media Tx

A

Mild HL- observe x 3mon
Meds only if seasonal allergy/URI present

If above fail, then:
PE tubes
Endoscopic widening of nasopharngeal orifice
Adenoidectomy

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51
Q

What are the 3 etiologies of Serous Otitis Media in adults?

At what point does the concern shift to a Ca Dx concern?

A

URi
Barotrauma
Chronic allergic rhinitis

> 3mon and unilateral

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52
Q

What are the 9 indications for PE tube placement

A

Autophony from PET

Severe/recurrent AOM
HL > 30dB
Impending OME complication
Prevent/Tx barotrauma
SOM x 3mon

Chronically retracted TM
Mid ear dysfunction- radiation/surgery
Craniofacial abnormalities

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53
Q

How does AOM present

AOM is a sequelae of ? Dx

A

Hypomobility of TM
Otalgia w/ URI
Erythema

ETD- inflammation/swelling

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54
Q

What are the modifiable RFs for AOM

What are the non-modifiable

A

Pacifiers
Bottles
Day care
2nd hand smoke

Craniofacial abnormalities
Allergies

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55
Q

What 3 bacteria are most likely to cause AOM infections?

How is it Dx

A

Strep Pneumo/Pyogens (GABHS)
H influenza

Pneumatic otoscopy

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56
Q

How is mastoid tenderness assess during AOM

How is AOM Tx

A

Tender= pus filled mastoid= nonsurgical
Mastoid swelling, cranial neuropathy= surgery

(SEA)
Sulfonamide+Erythromycin/Amox
CA
Resistance- Cefaclor/Augmentin
CC SE
PCN allergy: Cefdinir/Ceftriaxone (mild) or Erythromycin + sulfonamide (severe)
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57
Q

Why/how are tymapnocentesis done for AOM

When would this procedure be indicated?

Why would surgical drainage of the middle ear via myringotomy need to be done?

A

Bacteria/fungi culture- 20g through inferior TM

ImmComp
Persistent/recurrent after multiple ABXs

Severe otalgia
Complications occur- mastoiditis, meningitis

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58
Q

What medication is used for recurrent AOM prophylaxis?

What is the final option of PTs fail prophylaxis therapy?

Criteria for Recurrent AOM Dx

A

Sulfamethoxazole
Amoxicillin

Indication for PE tubes

3 or more in 6mon
4 or more in 12mon

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59
Q

When is observation of AOM appropriate?

What is the SNAP approach?

A

> 2y/o
Mild otalgia
Fever <102.2

Safety Net approach to ABX Prescriptions

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60
Q

Why do PTs w/ AOM and Tx w/ Amoxicillin present w/ rashes?

When does AOM get re-defined as COM?

A

EBV infections, conduct Monospot test

2wks-3mon

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61
Q

Define COM

Since this Dx is due to different microbes than AOM, what can cause it to develop?

A

Otorrhea through TM perf

Pseudomonas
Proteus
Staph A

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62
Q

How does COM present to clinic

How are these cases managed/Tx

A

Purulent d/c, increases w/ URI/water exposure
Pain only w/ exacerbation
CHL w/ TM perf

PO Cipro- Pseudomonas coverage, chronic d/c
Oflox/CiproDex- exacerbation
Debridement and water protection
Surgery/mastoidectomy- definitive

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63
Q

When Tx COM w/ surgery, how is the TM repaired

What are the 6 possible complications to arise from OM?

A

Temporalis muscle fascia

TM perf
Mastoiditis
Facial paralysis
Cholesteatoma- MCC ETD
Otogenic meningitis
Petrous apicitis
Sigmoid sinus thrombosis
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64
Q

How are cholesteatomas Tx

What microbes are most likely to cause mastoiditis?

What ABX is used for Tx

A

Marsupialization and PE tubes
Mastoid bowl- canal and mastoid joined
ABX failure= myringotomy and mastoidectomy

Strep pneumo/Pyogenes
H influenzae

IV Cefazolin

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65
Q

Define Petrous Apicitis and how it’s Tx

This causes Gradenigo Syndrome which presents as ?

What complication can develop?

A

Petrous bone infected from blocked pneumatic cell tract blockage; Tx w/ petrous apicectomy

Foul d/c
Retro-orbital pain
CN6 (L abducent) palsy- no L eye abduction

Meningitis

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66
Q

How are TM Perfs Tx

What needs to be avoided?

A

Contaminated EACs- Ofloc/Cipro
Infections- PO ABX

Neomycin
Aminoglycosides
Polymyxin
Alcohol

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67
Q

What are the 3 layers of the TM

Chronic perfs develop is ? two layers meet first but can be corrected w/ ? procedure?

A

Squamous
Collagen
Cuboidal

Squamous + Cuboidal
Tympanoplasty- cigarette patch

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68
Q

Long standing cholesteatomas can invade and involve ? CN?

What imaging is preferred for evaluating cholesteatomas

A

CN8

CT
MRI if post-op eval

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69
Q

How does AOM/COM cause facial paraylsis

How is it Tx

Paralysis from ? etiology has a poorer prognosis

A

Bacteria neurotoxins

Myringotomy for drain/culture
IV ABX

COM leading to cholesteatoma

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70
Q

Define Sigmoid Sinus Thrombosis

What are the S/Sxs

A

Infection in mastoid air cells next to sigmoid sinus causing septic thrombophlebitis

Systemic sepsis
Inc ICP

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71
Q

How is Sigmoid Sinus Thrombosis Dx

How is it Tx

A

MRV

IV ABX
Internal jugular vein ligation

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72
Q

? is the MC intracranial complication from ear infections?

What microbes cause this and how do they pass through the body?

A

Otogenic meningitis

Acute SOM via hematogenous spread of:
H influenza
Strep pneumo

COM-
passes through petrosquamous suture line
Direct extension through dural plates of petrous pyramid

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73
Q

How do epidural abscesses from ear infections develop?

How do they present?

A

Direct extension from chronic infections to temporal/cerebellar lobes

ASx
Deep pain
HA
Low fever

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74
Q

Brain abscesses that arise in the temporal/cerebellar lobes are results of ? underlying issue

What are the most likely microbes?

A

Septic thrombophlebitis next to an epidural abscess

Staph A
Strep pyogenes/pneumo

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75
Q

Brain abscesses from ear infections are ? complications due to untreated ?

Define Tympanosclerosis

A

Uncommon
AOM

Dz limited to middle ear w/ hyaline/calcification deposts on TM

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76
Q

Define Otosclerosis

How is this Dx

A

Familial lesions on stapes leading to max of 60dB CHL

R/o other causes w/ CT/MRI, Weber/Rinne, Tymapnometry

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77
Q

How is ototsclerosis Tx

What causes barotrauma and when is it most likely to occur?

A

Speech discrimination, normal cochlea- amplification
Stapedectomy

Ascent- dec atmosphere pressure
Descent- inc atmosphere pressure; most likely time for trauma

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78
Q

What meds can be used to help prevent barotrauma?

How are PTs Tx suffering from barotrauma pain and HL when on the ground?

A

PO Pseudophedrine- hrs prior
Topical Phenylephrine- 1hr prior
Oxymetazoline
PE tubes

Myringotomy

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79
Q

PTs that chose to dive w/ URI or nasal allergies can fail to equalize and experience pain at ? depth

Divers must descend slowly to allow for equalization and prevent the development of ?

A

15ft

Hemotympanium
Perilymphatic fistula- burst oval window; SHL w/ vertigo

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80
Q

During a diving ascent, what can be the first or only Sxs of developing decompression sickness?

Why do PTs w/ TM perf Hx need to avoid diving?

A

SHL
Vertigo

Unequal thermal stimulus to semicircular canal= vertigo, disorientation, emesis

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81
Q

When do barotraumas need to be referred to ENT

What procedure can be preventive or Tx

When is ossicular damage suspected after middle ear trauma?

A

Blast injury
Otalgia HL Vertigo 4-5 days later

Myringotomy

CHL >30dB x 3mon

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82
Q

What are the two types of middle ear glomus tumors and where do they arise from?

How do these growths present to clinic and what images are needed?

A

Glomus tympanicum- middle ear
Glomus jugulare- jugular bulb

Pulsatile tinnitus w/ HL- MRA/MRV

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83
Q

Glomus tumors can grow large enough to cause cranial neuropathies in ? CNs?

How are they Tx

A

7 9 10 11

Surgery
Radiotherapy

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84
Q

How does Ramsay Hunt Syndrome present

How are they Tx

A

Pain oo Proportion to exam
Lesions in EAC prior to paralysis onset

Antivirals and PO steroids

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85
Q

TMJ issues can cause referred otalgia due to sensory invervation from ? nerves

Glossopharyngeal neuralgia is non-otologic cause of pain that presents as ? and is Tx w/ ?

A

5 7 9 10
Upper cervical nerves

Lancinating pain in throat/ear
Tx w/ microvascular decompression of CN9

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86
Q

Perilymph is similar to ? fluid

Endolymph has high amounts of ? E+ and for ? purpose

A

CSF

K+, auditory signal generation

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87
Q

The ‘otolith organ’ is made up of ? and ?

What is the similarity/difference between vertigo and dizziness

A

Urticle
Saccule

All vertigo= dizziness
Not all dizziness= vertigo

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88
Q

Vertigo is Latin for ?

What is the key to Dx of vertigo

A

To turn

Duration of vertigo episode
Presence/lack of HL

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89
Q

What are the etiologies of peripheral vertigo

A 
BPPV 
Menieres 
Vestibular neuritis/labyrinthitis
Barotrauma
ETOH
Dehiscence of semi-circular canals
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90
Q

What are the etiologies of central vertigo

? is the cardinal Sx of vestibular Dz

A 
M SWAT
MS
Seizures
Wernicke encephalopathy
AV malformation
Tumor- brainstem/cerebellum

Vertigo

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91
Q

Vestibular d/os causing vertigo lasting for seconds

A

+ / - (PF/CMV)

+ auditory Sxs:
perilymphatic fistula

  • auditory Sxs:
    Cupulolithiasis
    Vertebrobasilar insufficiency
    Migraine associated vertigo
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92
Q

Vestibular d/os causing vertigo lasting hours

A

+ auditory Sxs:
Menieres
Syphilis
Head trauma

  • auditory Ss:
    migraine associated vertigo
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93
Q

Vestibular d/os causing vertigo lasting days

A

+ auditory Sxs:
Labyrinthitis
Labyrinthine concussion
Auotoimmune inner ear dz

  • auditory Sxs:
    Vestibular neuronitis
    Migraine associated vertigo
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94
Q

Vestibular d/os causing vertigo lasting months?

A

+ auditory Sxs:
Acoustic neuromas
Ototoxicity

  • auditory Sxs:
    MS
    Cerebellar degeneration
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95
Q

Acute peripheral lesions will cause ? type and direction of nystagmus

Visual fixation will usually suppress these nystagmus’ except for ?

A

Horizontal and rotary w/ fast phase away from diseased side

Very acute peripheral lesion
CNS diseases

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96
Q

Since visual fixation tends to suppress nystagmus of peripheral vestibular dzs, what type of goggles are used to suppress visual fixation

Define the Fukuda Test

A

Frenzel

Demonstrates vestibular asymmetry w/ PT steps in place and eyes closed, consistent rotation

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97
Q

What is included in a persistent vertigo or suspected CNS dz work up?

What tests are used to discriminate between central or peripheral vertigo etiolgies?

A 
MRI
Audiogram
Caloric stimulation
ENG* (objective)/VNG
Vestibular evoked myogenic potentials (VEMPs)

ENG/VNG

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98
Q

Characteristics of a peripheral vertigo induced nystagmus

Characteristics of central vertigo induced nystagmus

A

Fatigable horizontal nystagmus w/ rotary component that can be suppressed w/ visual fixation

Non-fatigable vertical nystagmus w/out latency and unsuppressed w/ visual fixation

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99
Q

What type of Sxs/vertigo do PTs complain of who have external ophthalmoplegia

If PT has cerebellar lesion in cerebral cortex, what can be the initial Sx they’re about to have a seizure?

A

Episodic vertigo in PTs w/ diplopia, maximized when looking toward greatest image separation

Vertigo

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100
Q

What is the theorized pathogenesis of Endolymphatic Hydrops?

What are the two known causes?

A

Distension of endolymphatic compartments

Syphillis
Trauma to head

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101
Q

What are the classic Sxs of Menieries?

If PTs present w/ the above Sxs but deny fluctuations in hearing, ? Dx is suggested

A

Episodic vertigo
Low frequency SNHL
Low/blowing tinnitus
Unilateral aural fullness

Migraine associated dizziness

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102
Q

What would caloric testing show in PTs w/ Meniere’s?

How are these PTs managed?

What is done for cases refractory to medical therapy?

A

Loss of thermal induced nystagmus to affected side

Acetazolamide
PO Meclizine/Diazepam
Vestibular rehab

Intratympanic CCS injection
Endolymph decompression
Vestibular ablation

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103
Q

What is the difference between vestibular neuritis and labyrinthitis?

What causes vestibular neurontitis

How do PTs w/ labyrinthtis present?

A

Labyrinthitis= + unilateral SHL

Post-URI/flu inflammation of CN8 w/out HL

Vertigo x days-week w/ HL and tinnitus

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104
Q

How is labyrinthitis Tx?

What meds can be used during the acute phase to reduce severity of vertigo?

A

Vestibular therapy ASAP
ABX (febrile/bacterial infection)

PO Meclizine
PO Diazepam

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105
Q

What causes BPPV

What do PTs present complaining of

How are these PTs Tx

A

Otoconia- Ca carbonate crystals in posterior semicircular canal/capula from trauma/vestibular neuronitis

Vertigo x1min after changes in head position

Epleys/Semont maneuver
Brandt-Daroff exercises
Avoidance of vestibular suppresants

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106
Q

? tests are performed to confirm Dx of BPPV in relation to ? canal is affected

Maneuvers used to Tx BPPV encourage migration of sediment to ?

? medication is used for Tx acute vertigo that is safe for pregnancy

A

Dix-Hall: posterior
Supine roll: lateral

Common crus of Ant/Post canals into auricular cavity

Meclizine (Antihistamine class- DOC)

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107
Q

When/why are benzos used for vertigo lasting hrs-days?

What anti-emetics can be used?

A

C/i to anticholinergic (prostatism, glaucoma)

Metoclopramide
Odansetron
Prochlorperazine

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108
Q

What are 3 etiologies of trauma induced vertigo?

A

Labyrinthine concussion- MCC of vertigo after trauma

Basilar skull Fx- vertigo and deafness on involved side

Chronic Post-Trauma vertigo from cupulolithiasis, sediment rests in ampulla of posterior semi-circular canal

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109
Q

How are cases of traumatic vertigo Tx

Define perilymphatic fistulas and how they can occur

A

Vestibular suppressant- Meclizine/Diazepam
Vestibular therapy

Perilymph leaks into middle ear via oval window;
Physical injury
Barotrauma
Valsalva
Post-stapedectomy
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110
Q

How do PTs w/ perilymphatic fistulas present?

How are perilymphatic fistulas Tx

A

Vertigo and SHL worse w/ straining

Bed rest w/ head elevation
Surgery w/ window sealing graft

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111
Q

How does Migrainous Vertigo present?

What type of FamHx do most of these PTs have?

A

Mixed etiology of-
Episodic vertigo w/ HA, Vision/motion sensitivity
Phono/Photo phobia

Hx of motion intolerance

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112
Q

How is Migrainous Vertigo Tx

This etiology of vertigo is similar to Meniere’s except ?

A

Diet/life changes
Migraine prophylaxis

No HL/tinnitus

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113
Q

What causes cervical vertigo to happen?

How do PTs present complaining of vertigo?

A

Post- neck injury (hyperextension)
Cervical disc degeneration

Vertigo triggered after assuming head position

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114
Q

What causes semicircular canal dehiscence

What do PTs present complaining of

A

Deficient bony covering over superior semi-circular canal

CHL and vertigo w/ straining/after loud noises

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115
Q

How does central vertigo present

A

Gradually more severe/debilitating
Auditory spared

Nonfatigable/latent vertical nystagmus worse w/ visual fixation

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116
Q

How do lesions on CN8/central audiovestibular pathways present?

How are these PTs best evaluated?

A

NHL w/ vertigo
Dec speech discrimination

BAER- brainstem auditory evoked responses to distinguish cochlear from neural loss

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117
Q

Diseases of the Central Auditory and Vestibular systems encompasses ? 3 Dxs?

Evaluation of central audiovestibular d/os usually requires ? imaging in order to see ? areas

A

Acoustic neuroma
Vascular compromise
MS

Enhanced MRI- IAC, cerebellopontine angle and brain

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118
Q

Characteristics of Acoustic Neuromas

Since almost all are unilateral, what does the discovery of bilateral tumors suggest?

A

Common intracranial tumors on sheath of CN8

Neurofibromatosis Type 2- meningiomas and intracranial/spinal tumors

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119
Q

What happens if Acoustic Neuromas are allowed to continue growth w/out interruptions?

How are they Dx

How are these cases Tx

A

IAC to cerebellarpontine angle and compress pons= hydrocephalus

MRI w/ contrast

ASx- observe w/ annual MRI
Sxs- excision, radiation and annual MRI
NFT-2: Bevacizumab- growth factor blocker

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120
Q

Define Vascular Compromise induced vertigo

What image is used for Dx

How are they TRx

A

Common vertigo etiology in elderly after change in position or neck extension

MRA

Dilators and ASA w/ rehab

121
Q

What PT population is more likely to present w/ MS induced auditory/vestibular Sxs

What type of hearing issues do these PTs have

They commonly have ? Sxs due to adjacent cranial nerve involvement

A

20-40y/o F w/ FamHx

Rapid onset unilateral SHL

Hyper/po-acoustics
Facial numbness
Diplopia

122
Q

How is acute peripheral vertigo Tx

How is chronic peripheral vertigo Tx

A

Object focusing w/ blank background and moving head up/down or R/L for 2-3m/day several times

Eye/head movement while standing, walking and on uneven surfaces

123
Q

How is bilateral vestibular injuries Tx

How is Chronic Vertigo Tx

A

Complete bilateral loss- no improvement
Fall prevention

Gait/balance exercise w/ head/eye movements
Longer rehab than peripheral vertigo

124
Q

HL is MC due to ? 3 etiologies

HL classifications

A

Cerumen impaction
Age related HL
Transient ETD from URI

Norm: whisper, 0-20
Mild: soft voice, 20-40
Mod: normal voice, 40-60
Sev: loud voice, 60-80
Profound: shout, >80
125
Q

4 causes of CHL

What causes S/NHL

A

Mass loading- effusion
Obstruction- impaction
Discontinuity
Stiffness- sclerosis

Sensory: dec hair cells in Corti/deteriorated cochlea
Neural: lesion on CN8

126
Q

What is the MCC of SNHL

Usually irreparable or reversible except for ? which is controlled with ?

A

Presbyacusis- high freq and symmetrical (hard hearing bird chirps/phone rings)

Sudden onset SHL; CCS

127
Q

NHL lesions can be located where?

What can cause this form of HL

A

CN8
Auditory nuclei/cortex
Ascending tracts

Acoustic neuromas
MS
Auditory neuropathy

128
Q

Since SHL is usually bilateral, unilateral or asymmetric SNHL suggests ?

? is the MC complaint of PTs w/ presbycusis

A

Lesion proximal to cochlea (acoustic neuroma)

Lost speech discrimination in noisy environments

129
Q

What is the 2nd MCC of SNHL

How does this type of HL manifest?

A

1st- presbycusis
2nd- noise trauma, >85dB= cochlea damage

Lost high frequencies 4K Hz

130
Q

? are the MC ototoxic meds?

How can these toxic risks be reduced?

A

Aminoglycosides
Loop diuretics
Anti-neoplastics- Cisplatin

Serial audiometry
Peak/trough monitoring
Medication substitutions

131
Q

? types of autoimmune d/os can lead to SHL

SHL is possible after ? and frequently seen after ?

A

SLE
Granulomatosis w polyangitis
Cogan Syndrome (HL, keratitis, aortitis)

Concussion
Frequently after skull fx

132
Q

? is the MCC of genetic deafness

PTs w/ autoimmune HL may also suffer from ? issues

A

Connexin-26 mutation

Dysequilibrium
Posture instability

133
Q

? lab tests can be used to screen for autoimmune dzs leading to HL?

What is the first and second line therapy/Tx for autoimmune HL?

Persistent tinnitus usually indicates ? is present while ? type is considered normal

A

Ana-Ab
RF
ESR

1st: PO CCS
2nd: Methotrexate

Persistent- SHL
Intermittent high/mild

134
Q

What image is needed to evaluate for vascular lesions or sigmoid sinus abnormalities causing pulsatile tinnitus?

Hyperacusis can indicate a probable issue w/ ?

When vestibular schwannomas grow large in size, ? CNs can be affected

A

CT of temporal bone
MRA and MRV

Cochlea

5 or 7 in cerebropontine angle

135
Q

Audiology assessment for HL consists of ? four parts

Pure tone testing thresholds above ? are considered abnormal

Define STS

A

Pure tone air/bone conduction (250-8K Hz)
Acoustic reflexes
Speech reception threshold
Tympanomety

> 20dB

10dB or more at 2-4K Hz
Combined 30dB or more between 2-4K Hz

136
Q

Audiogram symbols

A 
Air conduction:
Blue X- L ear
Red O- R ear 
Blue square: L ear masked
Red triangle: R ear masked

Bone conduction:
Blue > L ear
Red < R ear
Blue ] L ear masked
Red [ R ear masked
137
Q

What are the X and Y axis of a tympanometry

Define Decapascal

A

X- pressure against TM
Y- compliance of TM

Unit of pressure, equal to one newton per sq/meter

138
Q

Type A Tympanogram

A

Normal

Peak near 0

Compliance .2-1.8ml

No middle ear pathology
Normal TM/ET
+HL= SNHL

139
Q

Type As Tympanogram

A

Peak near 0daPa
Compliance below 0.2ml

Ossicular fixation, sclerosis, TM scars

Non-fluctuating HL

Normal ET

140
Q

Type Ad Tympanogram

A

Peak near 0 daPa and above 2.0ml

Ossicular disarticulation or discontinuity

Non-fluctuating HL

Normal ET

141
Q

Type B Tympanogram

A

Absent/poor peak w/ middle ear pressure > -200 daPa

Little/no TM mobility

Middle ear fluid
TM perf

142
Q

Type C Tympanogram

A

Peak on negative side of chart= neg middle ear pressure -150 daPa

ETD
Mild CHL/normal hearing

143
Q

What are the 4 sinus cavities?

Which ones are not fully developed in young children?

Define the Ostiomeatal Complex

A

Maxillary
Ethmoid
Frontal
Sphenoid

Frontal, Sphenoid

Drainage linkage of frontal, ethmoid air cells and maxillary sinuses w/ middle meatus

144
Q

How is Viral Rhinosinusitis Tx

? is the considered the most effective management strategy to prevent viral rhinosinusitis

A 
Hypertonic Saline
PO decongestant (pseudoephedrine, oxymetazoline, phenylephrine)

Annual influenza

145
Q

? dietary supplement may help reduce duration of cold Sxs?

? meds are used for the withdrawal phase when Tx Rhinitis Medicamentosa

A

Zinc

Intranasal CCS- Flunisolide
Intranaal anticholinergic- Ipratropium
PO Prednisone

146
Q

What are three mild and rare complications that can occur due to viral rhinitis?

One of these complications involves the largest ostiomeatal complex which is located ?

A

Bacterial rhinosinusitis
ETD
Transient middle ear effusion

Bacterial rhinosinusitis- deep to middle turbinate in middle meatus (drains maxillary, ethmoid and frontal sinuses)

147
Q

What predisposing conditions can make PTs prone to developing Bacterial Rhinosinusitis?

Since bacterial rhinosinusitis usually infects the largest complex, where does the sphenoid space drain to?

A

URI
Allergies
Mechanical obstructions

Between septum and superior turbinate

148
Q

? pathogens usually cause bacterial rhinosinusitis in community and hospital populations?

A 
Community:
Strep pneumo
H infuenza
Staph A
Moraxella catarrhalis

Hospital:
Pseudomonas
Staph A

149
Q

How is bacterial rhinosinusitis differentiated from viral etiologies?

Criteria for acute, subacute, chronic and recurrent rhinosinusitis

A

Sxs >10 days
Worsening Sxs <10days of improvement
Severe Sxs/>102*F and nasal d/c or face pain x 3-4 days

Acute: <4wks
Subacute: 4-12wks
Chronic: >12wks
Recurrent: 4 or more episodes/year

150
Q

? is the MC form of acute bacterial rhinosinusitis?

How does this MC present in clinic?

What non-ENT etiology can cause this type of sinusitis

A

Acute maxillary sinusitis due to largest sinus w/ single drainage path

Unilateral facial fullness
Pain over teeth from CN5

Dental infections

151
Q

How does localized ethmoid sinusitis present?

What is unique about sphenoid sinusitis presentations?

A

Pain over lateral high wall of nose between eyes

HA in middle of head

152
Q

? type of sinusitis causes pain in the forehead?

Hospital associated sinusitis is usually seen in ? admitted PT populations?

A

Frontal sinusitis

NG tubes
Nasotracheal tubes

153
Q

When is imaging for sinusitis warranted?

What types of images can be taken?

A 
Difficult clinical criteria
Failure to respond/multiple ABX Txs
Intracranial involvement
CSF rhinorrhea 
Dental infection
Sxs of serious infection observed

Waters view x-ray
Non-contrast CT- image of choice
MRi if malignancy, intracranial extension or opportunistic infections are suspected

154
Q

How is acute bacterial rhinosinusitis Tx

When are ABX considered and which ones are used?

A

NSAIDs/Tylenol
PO Pseudoephedrine
Oxymetazoline
Mometasone fuoate- facial pain/congestion

Sxs >10days
Fever, face pain, swelling Sxs
ImmDef

<65y/o w/ mild-mod:
Augmentin
PCN Allergy/liver impaired: Doxy or Clinda w/ Cefixime

155
Q

What types of ABX are avoided during the Tx of Acute Bacterial Rhinosinusitis

Why are these types of ABX avoided?

A

Macrolides
TMP/SMX
2nd/3rd Gen cephalosporin

High resistance
Poor sinus penetration

156
Q

How is hospital associated bacterial sinusitis Tx

A

Nasal saline spray
Humidified O2
Nasal decongestants

Broad spectrum ABX against Pseudomonas/Staph A

157
Q

What are 4 possible complications that can arise from acute bacterial rhinosinusitis?

How do these complications develop?

A

Orbital cellulitis/abscess
Osteomyelitis
Cavernous sinus thrombosis
Intracranial extensions

Orbital complication from ethmoid sinusitis via lamin papyracea

158
Q

How do orbital cellulitis and abscesses present?

A

Cellulitis-
Proptosis
Gaze restriction
Orbital pain

Abscess-
Proptosis
Ophthalmoplegia
Pain w/ medial gaze

159
Q

What happens if orbital abscesses are not promptly Id’d and Tx

How are orbital complications best seen w/ images

A

Permanent visual impairement
Frozen globe

Orbital CT

160
Q

Osteomyelitis complications from sinusitis MC occurs in ?

What PE finding is indicative

A

Frontal sinus

Pott puffy tumor- tender swelling of forehead

161
Q

How do intracranial compications from sinusitis develop?

A

Hematogenous spread-
Cavernous sinus thrombosis
Meningitis

Direct extension-
Epidural/intraparenchymal abscesses (AMS, persistent fever, severe HA)

162
Q

What are the heralding S/Sxs of a cavernous sinus thrombosis complication from sinusitis?

How is this Dx

Both hematogenous spread and direct extension complications need ABX but direct extension needs ?

A

Ophthalmoplegia
Chemosis
Visual loss

MRI

Surgery

163
Q

When is nasal endoscopy and CT imaging for rhinosinusitis warranted?

How is nasal vestibulitis w/ Staph A colonization Tx

A

Unresolved in 4-12wks

Diclox against Staph A
Topical mupirocin
Recurrent- add Rifampin to Diclox Tx

164
Q

Why is Tx of nasal vestibulitis important?

How can MRSA carrier state be eliminated?

A

Prevent spread to cavernous sinuses or intracranial spaces

Mupirocin
Chlorhexidine washes

165
Q

? fungus can cause Rhinocerebral Mucormycosis

This Dx is almost always in PTs w/ ? commodities

A

Aspergillus

DM
Hematologic malignancy
AIDS
Long term CCS use
ESRDz
166
Q

How do PTs w/ Rhinocerebral Mucormycosis present

How is this Dx

A

Clear/straw d/c
Black eschar- middle turbinate
No nasal findings= visual Sxs

Biopsy w/ Silver Stains showing broad non-septate hyphae

167
Q

What is the drug of choice for Tx of Rhinocerebral Mucormycosis

How is this Tx w/ wurgery

What are the mortality rates by underlying comorbidity?

A

Amphotericin B
Voriconazole
Caspofungin

Debridement w/ medial maxillectomy

DM: 20%
Kidney dz: >50%
AIDS/malignancy w/ neutropenia: 100%

168
Q

Seasonal allergic rhinitis is MCC by ?

What is the MC cause of allergies if they occur in spring, summer or fall?

A

Pollen/spores

Spring- shrub/tree pollen
Summer- plants/grass
Fall- ragweed/mold

169
Q

Allergic rhinitis needs to be distinguished from ?

What will be seen on PE tha can differentiate the etiology?

A

Vasomotor rhinitis- inc sensitivity of vidian nerve from hot/cold, odors or light;
common cause of clear rhinorrhea in elderly PTs

Mucosa/turbinates are pale/violaceous from venous engorgement

170
Q

? is the mainstay of Tx fo allergic rhinitis

A

Intranasal CCS-
Beclomethason
Flunisolide
Fluticasone propionate

Budesonide
Mometasone furoate

171
Q

Since CCS can take up to 2wks to provide relief for allergic rhinitis, what can be given for immediate relief?

A

PO Antihistamines/H1 blockers:
Non-sedate-
Des/Loratadine

Min Sedate-
Cetirizine

Sedate-
Chlor/Brompheniramine

172
Q

What is the medical option for PTs that can’t tolerate the side effets (xerostomia, sedation) of PO meds for allergic rhinits

What meds are used as adjuncts?

A

Azelastine

Antileukotriene: Montelukast
Mast cell stabilizer: Cromolyn sodium and sodium nedocromil

173
Q

What mediation is most useful for opto Sxs of allergic rhinits?

What is the most effective way to alleviating Sxs?

A

Cromolyn sodium

Red/avoid exposure to allergens

174
Q

What is the next step for an allergic rhinitis work up for PTs w/ extremely bothersome Sxs?

What are the 4 types of non-allergic rhinitis

A

Serum Radioallergosorbent Test by allergist

Gustatory
Medicamentosa
Vasomotor
Occupational

175
Q

Steps for managing epistaxis

A

Pressure x 15min

Phenylephrine/oxymetazoline w/ pressure x 15min

Oxymetazoline, Tetra/Lido/Cocaine
Cautery- sliver nitrate
Surgicel/Gelfoam

Packing indicated

176
Q

? hereditary d/o puts PTs at risk for epistaxis?

Bleeds from posterior cavity are more associated w/ ?

A

Osler-Weber-Rendu Syndrome: hemorrhagic telangiectasia

Atherosclerotic dz
HTN

177
Q

If anterior packing fails to Tx epistaxis, ENT may be needed for packing ? structure

PTs w/ posterior packs will also need ?

What is the last resort if posterior packing fails?

A

Choana

Opioids for pain and HTN along w/ admission

Ligation of arterial supply- internal maxillary, facial or ethmoid artery
Rarely- ligation of external carotid artery

178
Q

? ABX are used for PTs w/ nasal packings and post nasal hematomas?

PTs w/ nasal Fxs need to have ? two issues r/o

A

Cephalexin
Clindamycin

Infraorbital rim numbness/step off suggesting zygomatic fx

179
Q

How do nasal hematomas appear?

Nasal structures receive nutrition/supply from ? structure

Why is this structure important?

A

Wide anterior septum posterior to columella

Mucoperichondrium

Hematomas InD on inferior sides

180
Q

Closed reduction of nasal Fxs can be attempted when ?

What system is used to define facial Fxs

A

<7d of injury

LeFort:

1: maxillary
2: pyramidal maxillary
3: craniofacial dysfunction

181
Q

How are recurrent polyps removed via surgery?

Define Schneiderian Papilloma

Why is complete excision a must and how is this done?

A

Ethmoidectomy

HPV induced benign nasal tumors on lateral walls

Prevent SCC progression via maxillectomy w/ radiological f/u

182
Q

Since early Sxs of malignant nasopharyngeal/paranasal tumors are simply rhinitis/sinusitis, what are late findings?

How are they best Dx

A

Proptosis
Ill-fitting dentures
Expanded cheek

Biopsy and MRI

183
Q

Nasophargyngeal carcinoma is more common in ? PT populations

What are 4 less common neoplasms that could be seen?

A

Chinese descent w/ capsid to EBV and weaker association w/ tobacco use than other head/neck SCCs

Mucosal melanoma
Adenocarcinoma
Non-Hodgkins
Sarcoma

184
Q

? is a common maxillary sinus tumor Sx

How do Pts w/ Wegeners present to ENT

What would be seen on biopsy results

A

Malar hypesthesia from infraorbital nerve involvement

Nose and paranasal sinus involvement w/ blood stained crusts/friable mucosa

Necrotizing granulomas and vasculitis

185
Q

Granulomatosis w/ Poly is common in nose/paranasal sinuses but can also be seen ?

What would be seen on PE w/ Sarcoidosis

This Dx may be foreshadowed by ? complaints

A

Subglottis
Middle ear

Engorged turbinates w/ white granulomas

Rhinorrhea
Hypo/anosmia

186
Q

What would be seen on biopsy results in sarcoidosis PTs

Pts w/ sarcoidosis in paranasal sinuses usually have ? Tx prognosis

A

Non-caseating granulomas

More difficult managing sarcoidosis in other organ systems

187
Q

Polymorphic reticulosis is AKA ? and usually signal ? prognosis

What wold be seen on biopsy results

What is an essential part of histologic evaluation?

A

Lethal midline granuloma; type of lymphoma
Death <12mon

Nasal T-cell/NK-cell lymphoma

CD56 expression

188
Q

? is the best known pre-cancerous lesion of the mouth

What does this finding indicate is occurring at a cellular level?

A

Leukoplakia- white patches that can’t be removed

Hyperplasia of squamous epithelium

189
Q

If leukoplakia is the first step in cellular transformation towards cancer, what are the remaining steps?

If not associated with Ca, what does this findings indicate?

A

Hyperplasia
Dysplasia
Carcinoma in situ
Invasive malignancy

Hyperkeratosis from chronic keratosis

190
Q

Define Erythroplakia

What is the next step if adenopathy is found along w/ leuk/erythroplakia?

What are the indications to biopsy either of these findings?

A

More erythematous than leukoplakia; more likely to show dysplasia/SCC

FNA

Present for >2wks

191
Q

What are the RFs for the MC Ca of the mouth

What type of erythr/luekoplakia lesions are more worrisome?

Define Melanosis

A

SCC- alcohol and tobacco use

Ulcerated

Symmetric pattern on gums in dark pigmented PTs

192
Q

Define melanotic macules

? is the MC site to see amagam tattoos and what is key up their discovery?

A

Symmetric dark lesions that are stable in adults

Mandibular arch; seeing the amalgam due to ability to mimic melanomas

193
Q

Define Fordyce spots

How do they appear on exam

A

Benign neoplasms in sebaceous glands

1-2mm white/yellow papules at the vermillion/buccal mucosal border

194
Q

Define Lichen Planus

What are the two different types?

A

Waxing/waning inflammatory condition immune mediated condition in PTs >40y/o

Reticular: painless white, lacy Whickham striae on muccal mucosa
Erosive: painful ulcers w/ radiating white striae

195
Q

How is Lichen Planus definitvely Dx

How are these cases medically managed?

A

Biopsy
Exfoliative cytology

Topical and systemic CCS, cyclosporines and retinoids

196
Q

4 fungal etiologies of thrush?

What are the two presentations that could be seen

A

Candidiasis
Glabrata
Kruseia
Tropicalis

Pseudomembranous: MC overall; white plaques on soft mucosal tissue
Atrophic/denture stomatitis- MC adult form; erythema w/out plaques

197
Q

What are the seven RFs that can lead to development of thrush

What other Dx may co-exist w/ thrush

A 
Dentures
Debilitated/poor hygiene
DM
Anemia
Chemo/radiation
CCS use
Broad ABX

Cheilitis

198
Q

How is thrush Dx

How is it Tx

A

KOH prep- non-septate mycelia
Biopsy showing pseudomycelia

Fluconazole- longer in +HIV 
Ketoconazole
Clotrimazole
Nystatin rinse/powder (denture)
Flucon resistance- Itraconazole
Voriconazole

Older kids, mild: <50% mucosa involved and no deep/erosive lesions:
Nystatin or Clotrimazole

Severe: 50% or more of mucosa and/or deep, erosive lesions or refractory:
Fluconazole

199
Q

How is thrush Tx in infants

How do aphthous ulcers appear on PE

A

Nystatin suspension x 3days after lesion resolution
Refractory: gentian violet or PO Fluconazole

Ulcerations w/ yellow/gray base surrounded by red halo

200
Q

? is the MCC of oral ulcers

What part of the mouth is involved

A

Recurrent Aphthous Stomatitis

Non-keratinized mucosa- labial/buccal, ventral tongue

201
Q

What is the suspected etiology of aphthous ulcers?

What are the RFs for their development?

What are two independent predictors of frequency/severity?

A

HHV-6

Stress
Celiac/IBDz
Deficient B1,2,6,12, Fe, Folic acid, Zn

Frequency of viral rhinitis
Bedtime after 11pm

202
Q

How is Recurrent Aphthous stomatitis managed?

What is the etiology of Herpetic Gingivostomatitis

A 
Fluocinonide
Amlexanox
Triamcinolone
Diclofinac in hyaluronan
Severe pain- PO Prednisone

HSV-1

203
Q

What medication is used for PTs w/ recurrent aphthous ulcers?

What medication is used for HIV PTs w/ recurrent aphthous ulcers?

A

Cimetidine

Thalidomide

204
Q

How does Herpetic Gingivostomatitis present

How is it Dx

How is it Tx

A

Small clustered vesicles on vermillion border

Multi-nucleated gian cells on Tzanck smears

Vala/Acyclovir
Both initiated <48hrs of Sx onset
Ineffective after vesicles rupture

205
Q

How does Varicella Zoster present in the oral cavity

How does atrophic glossitis present

A

Grouped vesicle/erosion unilaterally along dermatome

Painless inflammation w/ papilla atrophy

206
Q

What are the etiologies of Atrophic Glossitis

What causes geographic tongue?

A

Protein/Fe/B12/Folic acid deficiency
Sjogren/chronic dryness
Candidiasis
Celiac dz

Loss of filiform pappilae leading to ulcer-like lesions and erythematous patches

207
Q

Geographic tongue is associated with many d/s including ?

How are tonsil sizes graded?

A

Thrush
Psoriasis
Reiter syndrome
Lichen planus

0- removed
1- hidden behind pillars
2- extend to pillars
3- beyond pillars
4- to midline
208
Q

Define Centor Criteria

What do scores correlate to?

A 
Fever >100.4
Anterior adenopathy
Cough, none
Exudate, tonsil
Modified: <15, >44

0-1: no test/Tx
2: rapid Ag
3: rapid Ag/empirical Tx
4 or more: rapid Ag/empirical Tx

209
Q

How does Mononucleosis present?

What lab work needs to be done?

A

Cervical adenopathy
Palatal petechiae
White/purple tonislar exudate

CBC
Mono-spot (heterophile auto-Abs)
EBV Ab test

210
Q

What lab test has high sensitivity for EBV Dx?

What three things are corroborative for an EBV Dx

? is the MC etiology of pharngyitis

A

Lymphocyte:WBC ratio >35%

Hepatosplenomegaly
Pos heterophile agglution test
High anti-EBV titier

Viral

211
Q

? ABX need to be avoided if Mono Dx is suspected?

Diphtheria is more likely to present in ? PT population and appears as ?

A

Ampicillin

Alcoholics
Low fever/gray tonsil pseudomembrane

212
Q

Throat infections from C diphtheria/haemolyticum or anaerobic strep respond better to ? ABX instead of PCN

? drug is used for GABHS Tx if PT has Hx of rheumatic heart Dz or lives in confines areas?

A

Erythromycin

IM Benzathine Pen G or Erythromycin x 5yrs

213
Q

How is GABHS Tx?

A

Adults:
Pen VK (DOC)
Benzathine PCN IM x 1

PCN sensitivity:
Clinda/Azithromycin

ASA/NSAIDs
Acetaminophen
CCS
Salt water gargle

Peds <27kg:
Pen VK (DOC)
Bicillin IM x 1

PCN sensitivity:
Azithromycin

214
Q

How is Mono Tx

Define Quinsy Tonsil

What complications can occur from extensions?

A

Analgesic/NSAID/lozenge
CCS for edema
Profile for splenomegaly mil/mod x3wks or strenuous x 4-6wks

Peritonsillar Cellulitis and Abscess- infection penetrates tonsil capsule and surrounding tissue

Posterior mediastinal
Retropharyngeal
Deep neck

215
Q

Define Cellulitis

Define Abscess

A

Inflammation and infection of tissue w/ no pus

Pus collection between tonsil capsule and muscle wall

216
Q

How is cellulitis of the PO/pharynx Tx

A

Non-PO:
Amoxicillin
Clinda

PO tolerant:
Amoxicillin
Augmentin
Clinda

217
Q

How are Peritonsillar Abscesses Tx

Suspected PTA w/out airway compromise, septicemia or trsimus is Tx by ?

A

Aspiration/InD/Tonsillectomy
Same IV ABX used for cellulitis

Observation and IV ABX x 24hrs

218
Q

When aspirating peritonsillar abscesses, ? structure must be avoided and how is this done?

PTs w/ Sleep Disordered Breathing may present w/ ? other issues that may be relieved by tonsillectomy

A

Carotid artery
Insert needle <8mm

Delayed growth
Poor academic/behavior
Bed wetting

219
Q

When is observation better than tonsillectomy

When is post-tonsillectomy bleeding a concern?

A

<7 in past year
<5 in past 2yrs
<3 a year x 3yrs

5-8 days post-op

220
Q

Define Sialadenitis

How does this present to clinic?

What underlying issues may contribute to it’s development

A

MC Staph A infection of parotid/submandibular galnd

Pain/welling w/ meals
Tender/Erythema

Sjogrens
Peridontitis

221
Q

How is Sialadenitis Tx

What is the life threatening form of this infection?

A

IV Nafcillin
Sialagogues

Suppurative sialadnitis- no pus drains from stensen papilla- CT/US then InD

222
Q

What causes Suppurative Parotitis to develop

How will this present in clinic?

A

Staph A in PTs that are debilitated, dehydrated or have poor PO hygience

Firm swelling along mandible angle
Pain w/ F/C

223
Q

How is Suppurative Partotitis Tx

Define Sialolithiasis

A

Nafcillin and Metronidzaole/Clinda
ImmComp PT- Vanc

Calculus formatoin in Wharton duct

224
Q

How does Sialolithiasis present

What is the difference in stones appearance on imaging and location

A

Post-prandial pain
Swelling
Hx of acute sialadenitis

Wharton- opaque, large
Stenson- lucent, smaller

225
Q

Sialolithiasis discovered w/ in ? to the ductal opening can NOT be removed w/ dilate and incision?

Why is this?

A

> 1.5-2cm

Damage to lingual nerve

226
Q

What is the preferred management method for chronic sialolithiasis

Tumors found in ? salivary glands are more likely to be malignant of ? type

A

Sialoendoscopy

Minor glands- adenoid cystic carcinoma

227
Q

Most parotid gland tumors are ASx and present for months/years but become concerning for Ca when ?

? PE finding would suggest the tumor is located in the parapharyngeal space

A

CN7 affected

Medial deviation of soft palate

228
Q

? granulomatous dz can affect the salivary gland

? drugs have been associated w/ parotid enlargement

80% of salivary gland tumors occur in ?

A

Sarcoidosis

Thioureas
Iodine
Cholinergic drugs- Phenothiazine

Parotid gland

229
Q

What 6 cartilage structures make up the larynx

What is it innervated by?

A 
Cricoid
Corniculate
Cuneiform
Arytenoid
Thyroid
Epiglottic

Superior/Recurrent laryngeal nerves

230
Q

What structures support the vocal folds?

Which structure brings folds closer together to produce sound?

A

Arytenoid and Thyroid

Arytenoid

231
Q

What controls the pitch in voice production

What helps produce vowels?

A

Vocal fold tension:
Taut= higher
Thicker/loose= lower

Pharynx muscles

232
Q

? are the primary Sxs of laryngeal Dz

Define Stridor

A

Hoarseness ad Stridor

High pitch sound on inspiration from narrowing at/above vocal folds

233
Q

What type of sounds are produced if there is a narrowing below the vocal folds?

Hoarseness lasting longer than ? need ENT referral

A

Expiratory/biphasic stridor

> 2wks

234
Q

What are ‘worrisome’ co-existant Sxs if PT presents w/ horaseness?

? is the MCC of hoarseness

A 
Severe cough
Hemoptysis
Unilateral ear/throat pain
Odyno/Dysphagia
Unexpected weight loss

Acute viral laryngitis (<3wks) from Catarrhalis, H influenza or laryngopharyngeal reflux

235
Q

What causes chronic hoarseness

When Tx acute laryngitis, only use CCS if ? w/ ? PT education

What ABX are used and when

A

Vocal fold lesion

PT has to use voice; warning for cord hemorrhage/trauma (cyst/polyp)

Erythromycin- hoarseness >7d or cough >14days

236
Q

What types of changes can tobacco use cause that leads to chronic laryngitis?

How are these cases managed?

A

Keratosis
Polypoid corditis

Remove offending agent

237
Q

How is laryngopharyngeal reflux Dx

? is the best way to monitor and document laryngopharyngeal reflux

A

PTs response to PPIs (Omeprazole x 3mon but larynx changes take 6mon)

Double pH probe

238
Q

Supraglottitis is more common in ? PT populations

What is the difference in work ups between adults and kids?

A

DM

Kids- no indirect laryngoscopy
Adults- safe

239
Q

What ABX are used during the Tx of supraglottitis

? are indications PTs need to be intubated

A

Admission w/:
Ceftizoxime/Cefuroxime/Ceftriax w/ Dexamethasone

Dyspnea
Rapid pace of sore throat
Endolaryngeal abscess on CT

240
Q

? is a sign of impending airway compromise in PTs w/ supraglottitis

Where do respiratory papillomas commonly develop

A

Drooling

Ciliated and squamous epithelia meet

241
Q

Recurrent Respiratory Papillomatosis is almost always due to ? virus

These are also the MC ?

? PT population do these benign growth transform?

A

HPV 6 and 11

Benign laryngeal tumor in kids due to inoculation during vaginal delivery

Smokers

242
Q

What are the Sxs of Recurrent Respiratory Papillomatosis

How are they Tx

How are they prevented

A

Hoarsenss to stridor changes
Warty lesions on folds

Laser vaporizations
Cold knife resections

Gardasil 9

243
Q

What is the only indication to use interferon for the Tx of Recurrent Respiratory Papillomatosis

? medication has proven intralesional success

A

Severe cases w/ pulmonary involvement

Cidofovir; potential for adenocarcinoma development

244
Q

What are the 4 types of traumatic/benign lesions of the vocal cord?

Which two are manifestations of chronic vocal fold irritation?

A

Nodule
Polyp
Cyst
Polypoid corditis

Nodule/Polyp

245
Q

Vocal fold nodules are AKA ? depending on age of PT

How do the appear?

How are they Tx

A

Singers- adult
Screamer- kids

Smooth, paired lesion at junction of ant/post vocal folds from vocal abuse

Behavior modification
Surgical excision

246
Q

How do vocal fold polyps present

These are associated w/ ? and can be the resolution from ?

How are they Tx

A

Unilateral mass on lamina propria of folds from yelling

Smoking
Vocal fold hemorrhage

Small: CCS, voice rest
Large- surgical excision

247
Q

Where do vocal fold cysts emerge from?

These are considered to be ?

Why is Tx difficult/frustrating

A

Mucus glands on inferior aspect of folds

Traumatic lesions

Scarring/sulcus leading to chronic dysphonia

248
Q

Smokers w/ hoarseness typically have ? Dx

How are these cases Tx

A

Laryngeal leukoplakia

PPIs- mainstay
Smoking cessation

249
Q

SCC of the larynx develops almost exclusively in ? PT population

This can be due to ? viruses
and have ? predominant factor

A

Smokers

HPV 16/18- strongest association w/ non-smokers and oropharyngeal Ca

250
Q

What is usually the presenting complaint of PTs w/ SCC in larynx

Because of this presenting Sx, glottic Cas are among the ? of human Cas

A

Changes in voice quality

Smallest detectable Ca

251
Q

When is SCC of the larynx more likely to metastasize

When is a chest CT indicated

A

Rare in true cord Ca if cords are mobile
Common in supraglottic carcinoma- false folds/epiglottis

Level 6 nodes- around trachea/thyroid
Level 4- inferior to cricoid cartilage
Concerning CXR

252
Q

How are early glottic and supraglottic cancers Tx

TMN staging

A

Radiation therapy

Page 97

253
Q

Vocal cord paralysis can occur due to lesion/damage to ? nerves

What type of MedHx/SurgHx can narrow the etiology

A

Vague
Recurrent laryngeal

Mediastinal/Apical lung ca
Skull base tumor presses vagus

254
Q

What are the 1st and 2nd MCC of unilateral cord paralysis

What images are used

A

1st: iatrogenic injury
2nd: idiopathic

Normal CNs: enhanced CT for masses
Abnormal CNs: MRI for nerve lesions

255
Q

Unilateral recurrent laryngeal nerve injury causes the vocal cord to rest in ? position

When is early surgical Tx indicated

A

Paramedian- partially lateralized

Severe Sxs (aspiration pneumonia)
Breathy hypophonia
Ineffective cough
Disabling dyspnea

256
Q

What can cause bilateral vocal fold paralysis

What type of respiratory issues will be seen in these PTs

A

Reoperations of total thyroidectomies

Dyspnea/stridor w/ extubation

257
Q

How is unilateral vocal cord paralysis Tx

Once the paralysis has been Dx as permanent, what procedure is done?

A

Teflon/Collagen/Fat inplants

Medialization thyroplasty- inplant between thyroarytenoid muscle and thyroid cartilage

258
Q

Define Vocal Cord Dysfunction/Paradoxical Vocal Fold Movement

What Dx co-exists w/ vocal cord dysfunction nearly half of the time

A

Acute/Chronic upper airway obstruction w/ paradoxical vocal cord adduction

Asthma

259
Q

What PE finding can suggest PT has VCD w/ asthma

How is this Dx

What will other work up tests results look like?

A

Sxs unresponsive to bronchodilators

Visualization of cords adducting w/ in and expiration
(Norm= abduct, in/out)

Spirometry: upper airway obstruction, normal after attacks
Bronchial provocation test- normal

260
Q

How is Vocal cord dysfunction Tx

What are the landmarks of the ant/post/sub-clavian triangles?

A

Speech therapy
Stop steroids/Txs
CPAP/therapy
Long term: botox

Ant- Digastric/SCM
Post- Trap/SCM/Belly of omohyoid
Sub: SCM/Clavicle/omohyoid

261
Q

A normal lymph node size is considered ?

What is the Rule of 7s for masses

A

<1cm

7d: inflammatory
7w-7m: neoplastic
7yrs: congenital

262
Q

Neck masses in PTs <16y/o are ? origin

Masses in PTs that are 16-40y/o are ? origin

? is the MCC of neck masses in PTs >40y/o

A

Inflammatory
Congenital

Inflammatory/Congenital
Risk for malignancy starts

Malignancy

263
Q

PTs w/ neck masses that are <30 or >70 need to have ? Dxs r/o

Rapid growth/tenderness suggests ? etiology

Slow growth, painless suggest ?

A

Lymphoma

Inflammatory

Neoplasm

264
Q

What 3 pieces of info are most significant for predicting neoplastic neck masses?

Ludwigs Angina is an abscess infection located where?

A

PT age
Size
Duration

Submandibular spaces

265
Q

? is the MC neck space infection

? is the MC cause of deep neck abscesses?

A

Ludwig’s- cellulitis of sublingual/maxillary spaces from mandibular dentition

Odontogenic infections

266
Q

What are the microbes that causes Ludwigs?

What is the predominant microbe in PTs w/ DM and how is their presentation different?

A

Staph
Strep
Bacteroides
Fusobacteriium

Klebsiella; more aggressive

267
Q

? is a rare cause of Ludwig’s Angina/neck abscesses?

What PT population does this typically occur in?

What are the Sxs

A

Lemierre syndrome: thrombophlebitis of internal jugular vein secondary to oropharyngeal inflammation

ICU PTs w/ internal jugular central venous catheters

Severe HA
Pulmonary infiltrates

268
Q

How is Ludwig’s Angina Tx

How is Lemierre Syndrome Tx

A

PCN+Metronidazol/Clinda/Amp-Sulbactam
Submental incision for drainage

Metronidazole aimed a Fusobacterium Necrophorum

269
Q

What are common causes of cervical adenopathy

What are two rare causes?

A

SCC tumors
Infections

Kikuchi Dz- histiolytic necrotizing lymphadenitis
Autoimmune adenopathy

270
Q

Define Reactive Cervical Lymphadenopathy

This is the MCC of ? findings

A

Painful enlargement from response to infection/inflammation

MCC of neck masses over all age groups

271
Q

How is Reactive Cervical Adenopathy Tx

When would FNA be considered for this Dx

A

Augmentin
Clinda

Node >1.5 w/out infection
Hx tobacco/ETOH/Ca
Persistent/growing

272
Q

? is the criteria used for grading snoring

? are the two MC sites of obstruction leading to snoring

A

Epworth Sleepiness Scale- 0-24 w/ >10 considered abnormal

Oropharynx
Base of tongue

273
Q

Two indications for a tracheotomy

What are the benefits of a crichothyrotomy

A

MCC- respiratory failure requiring prolonged ventilation
Airway obstruction at/above larynx

Fewer complications of PTx or Hemorrhage

274
Q

? is the risk from extended periods of extended endotracheal intubation?

What are 3 more rare but possible indications for a tracheostomy

A

Subglottic stenosis

Aspiration pneumonia
OSA
Insufficient pulm toilet

275
Q

What daily function is reduced/inhibited after placement of a tracheotomy

How are foreign body aspirations Dx/Tx

A

Swallowing

Dx: CXR aided w/ in/expiration films
Tx: rigid bronchoscopy

276
Q

What PT population is at the greatest risk for foreign bodies in trachea?

How do foreign bodies in the esophagus present, get Dx and Tx

A

Older adults
Denture wearers

Drooling/pointing to level of obstruction
Dx: x-ray
Tx: observation/endoscopic removal

277
Q

How does the appearance of coins on x-ray hint at their location?

If foreign body is suspected ? Dx test can help

A 
Coronal= esophagus
Sagital= trachea

Barium swallow

278
Q

What Tx method should be avoided if PT presents w/ esophageal meat obstruction?

? are the MC congenital masses of the lateral neck

A

Papain- damages esophageal mucosa causing stenosis/perfs

Branchial cleft cysts- remnant of embryological development

279
Q

Where do branchial cleft cysts tend to appear?

What PE findings can solidify a Dx

How are they Dx w/ images

A

Along SCM
On face near auricle

Not midline
No movement w/ swallowing

CT showing cystic mass medial to SCM

280
Q

Define First Branchial Cleft Cyst

Define Second Branchial Cleft Cyst

Define Third Branchial Cleft Cyst

A

High neck/below ear, fistula connection w/ EAC

More common, connect w/ tonsilar fossa

Rare, connect w/ piriform sinus

281
Q

? is the MC congenital mass of the central neck

What is this structure a remnant from?

A

Thyroglossal duct cyst appearing <20y/o

Descent of thyroid as embryo

282
Q

How do thyroglossal cysts appear on PE

How are these Dx

A

Midline neck mass below hyoid and moves w/ swallowing/tongue protrusion

Abnormal TSH= thyroid scan
CT

283
Q

How are thyroglossal duct cysts Tx w/ surgery

What needs to be done prior to surgery

A

Sistrunk procedure w/ segment of hyoid bone removed

Thyroid US

284
Q

How is Head/Neck Ca completely examined?

If this fails to establish Dx, what is the next step?

A

Under anesthesia w/ triple endoscopy:
Direct laryngoscopy
Bronchoscopy
Esophagoscopy

MRI or PET scan

285
Q

What is the path of SCC metastases from Head/Neck Ca

Why do ENTs use rigid endoscopes more than other specialties?

A

Early to nodes then lung, liver, brain or bones

Biopsy capabilities

286
Q

Cancer from ? parts of the body have the capability to metastases to the neck?

A 
Thyroid
Lung
Liver
Gastroesophageal
Breast
Bone 
Brain
Renal
Testes
287
Q

How does Non/Hodgkins lymphoma present?

How are these definitively Dx

A

Occurring at 20 or >50 as multiple rubbery nodes

Open biopsy

288
Q

What are the 4 types of thyroid Ca

A

Papillary:
Dx: FNA
Tx: surgery then I-131 ablation

Follicular:
Dx: biopsy
Tx: surgery then I-131 ablation

Medullary:
Dx: FNA
Tx: surgery and poor I-131 uptake

Anaplastic/undifferentiated: most aggressive, poor prognosis
Dx: FNA
Tx: surgery and radiation, poor I-131 uptake

289
Q

What type of thyroid cancer is associated w/ MEN-2A

How are adenopathy <7wks old managed

A

Medullary

Broad ABX
No improvement= CXR/PPD
Negative/suspicious findings: Contrast CT and FNA

290
Q

How is adenopathy 7wks-7mon old managed?

How is adenopathy present for >7yrs managed?

A

Contrast CT and FNA
Endoscopy consult

CT
Excisional biopsy

291
Q

How is the location of Ludwigs Angina indicated?

What airway Tx step is avoided and what is used in it’s place?

A

2/3rd molar pus- submandibular

1st molar fwd (above myohyloid line)- sublingual

No intubation
Perform tracheotomy

292
Q

PTs w/ recurrent deep neck infections need ? Dx r/o

What is the STOP-BANG questionnaire

A

Brachial cleft cyst

OSA Screening tool:
Snoring
Tired
Observed cessations
P Tx for HTN
BMI >35
Age >50
Neck >16"
Male gender
0-2: low
3-4: mod
>5; high
293
Q

Modified Malampati scale is AKA ?

What are the scores

A

Friedman tongue position

1- all visible

2: only top of tonsil/bottom of uvula visible
3: only soft palate visible
4: only hard palate seen

294
Q

Onset of sleep during PSG is made by ?

What are the 30sec snapshots called?

A

EEG and EMG

Epochs

295
Q

How is the AHI score calculated for a sleep study

What does these scores correlated to

A

Apnea + Hypopnea/hrs of sleep

Mild: 5-15/hr
Mod: 15-30/hr
Sev: >30hr

296
Q

Foreign objects in the pharynx or laryngeal inlet can be extracted w/ ? types of forceps

What finding indicates a child has a ball-valve obstruction?

A

Magill

Hyper inflation of obstructed lobe w/ lateral decubitus

297
Q

What type of inhaled object can be more difficult to remove w/ bronchoscopy

Most parotid neoplasms are ? type

A

Peanuts- salt/oil cause inflammation and swelling

Mixed pleomorphic adenomas

298
Q

Define T1-T4 cancers

A

1: <2cm
2: 2-4cm
3: >4cm
4: large, invasive and surround structures

299
Q

Thyroid Ca Dx w/ biopsy

Thyroid Ca w/ poor uptakes of I-131

A

Follicular

Medullary
Anaplastic

IPAP (212 decks)

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