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
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)
3
Q
SCC is more common in ? PTs
What findings are indicative of advanced cases/poor prognosis
A
Elderly males
CN7/node involvement
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
25
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
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
26
Cerumen impaction are most often due to ?
Drying of the EAC after cleaning/removal is important to prevent development of ?
Self induced cleaning attempts
Otitis externa
27
Foreign bodies in the ear present w/ ? Sxs
What may happen if persistent object retention occurs?
Pain Pruritus CHL Bleeding
Infection
Tissue granulation
28
MC ear foreign bodies get lodged in ? area
How are insects best killed?
Lateral EAC
Olive oil
3% lidocaine
29
How do Peds PTs w/ foreign objects lodged in the nose present?
What Tx attempt can be done prior to considering surgical removal?
Unilateral purulent rhinorrhea
Topical anesthetic
Vasoconstrictive nose drops
30
How does Otitis Externa present
When is this Dx a concern for a dangerous future sequelae?
Painful erythem/edema of the canal skin w/ exudate
Auricle/tragus manipulation= pain
Malignant external otitis- osteomyelitis of skull base in ImmComp/DM PTs
31
External otitis is caused by ? microbes
Gram-pos cocci:
Staph A
Gram-neg rods:
Pseudomonas
Proteus
Fungi:
Aspergillus
32
Malignant external otitis is caused by ? microbe
What is the sequential path of spread?
Pseudomonas
Floor of ear canal
Middle fossa floor
Clivus
Contralateral skull base
33
What are the RFs for AOE?
What is the difference of TM mobility on PE between External Otitis and AOM?
Frequent/aggressive Q-tips
Water
Scratching
Lack of cerumen
EO- normal movement w/ pneumatic otoscopy
34
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
Ottorhea
Canal granulations
Deep otalgia
Periauricular/anterior adenopathy
6 7 9 10 11 12
CT showing osseous erosions
35
How are mild and mod/sev cases of AOE Tx?
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
36
When are systemic ABX needed for the Tx of AOE?
What ABX is used?
```
Cellulitis
ImmDef
DM
Edema preventing topicals
Radiation Hx (ear)
Severe OE
```
Cipro
37
PTs being Tx for AOE need to avoid water for how long?
Any persistent otitis externa in ? two PTs need referrals
10days
ImmComp
DM
38
What ABX is used for Tx of malignant external otitis?
How long its Tx continued for?
Cipro
Gallium scanning proves inflammation reduction
39
What is the most feared complication of AOE?
What microbe causes it and how does it spread?
Malignant OE
Pseudomonas- enters DM/AIDS PT temporal bone to base of skull
Sequelae- bone infection
40
How are PTs w/ malignant OE Tx who fail medical therapy?
Define Exostoses and it's AKA
Hyperbaric chamber
EAC lesion of reactive lamellar bone growth w/ broad base; Surfer's ear from cold water exposure
41
# Define Osteoma and their location of growth
? is the MC neoplasm of the ear canal?
EAC lesion w/ pedunculated base; a benign osseous neoplasm on tympano-squamous/mastoid line
SCC
42
When is a Dx of SCC brought into consideration?
Why is there such a high mortality rate?
How are they Tx
OE fails to resolve w/ therapy; obtain biopsy
Invasion of lymphatics in cranial base
Wide resection w/ radiation
43
What is the less lethal type of ear canal neoplasm if SCC is excluded?
What are the etiologies of dilatory ET dysfunction?
Adenomatous- grow from cerumen glands
```
PICA
Pressure
Inflammation (3rd-T pregnant)
Congenital
Anatomic
```
44
What are the MCC of ET dysfunction?
What are the 4 etiologies of patulous ET dysfunction?
Viral URI
Allergies
Weight loss
Atrophy
Scars
Hormone- high E, OCPs, prostate Ca Tx
45
What do PTs w/ dilatory ET dysfunction present w/?
What do PTs w/ patulous dysfunction present w/?
HL
TM retraction/effusion
Autophony
TM moves w/ in/expiration
46
How is dilatory ET dysfunction Tx
How is patulous ET dysfunction Tx?
PPIs
Antihistamines
Decongestants
Steroids
Mild- hydrate, saline spray, avoid decongestants
Sev- surgery: PE tubes and cartilage grafts
47
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?
Precipitates middle ear infections
Autophony worse w/ exertion, better w/ URIs
48
What causes serous otitis media to develop?
What is this Dx AKA?
Prolonged negative ET pressure cause trandudative formation
Otitis media w/ effusion
49
Serous Otitis Media is common in ? PT population?
What are the presenting S/Sxs?
How are these best Dx
Peds w/ narrow/horizontal ET
CHL w/ fullness
Dec TM mobility
Tympanometry
50
How are cases of Serous Otitis Media Tx
Mild HL- observe x 3mon
Meds only if seasonal allergy/URI present
If above fail, then:
PE tubes
Endoscopic widening of nasopharngeal orifice
Adenoidectomy
51
What are the 3 etiologies of Serous Otitis Media in adults?
At what point does the concern shift to a Ca Dx concern?
URi
Barotrauma
Chronic allergic rhinitis
>3mon and unilateral
52
What are the 9 indications for PE tube placement
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
53
How does AOM present
AOM is a sequelae of ? Dx
Hypomobility of TM
Otalgia w/ URI
Erythema
ETD- inflammation/swelling
54
What are the modifiable RFs for AOM
What are the non-modifiable
Pacifiers
Bottles
Day care
2nd hand smoke
Craniofacial abnormalities
Allergies
55
What 3 bacteria are most likely to cause AOM infections?
How is it Dx
Strep Pneumo/Pyogens (GABHS)
H influenza
Pneumatic otoscopy
56
How is mastoid tenderness assess during AOM
How is AOM Tx
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)
```
57
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?
Bacteria/fungi culture- 20g through inferior TM
ImmComp
Persistent/recurrent after multiple ABXs
Severe otalgia
Complications occur- mastoiditis, meningitis
58
What medication is used for recurrent AOM prophylaxis?
What is the final option of PTs fail prophylaxis therapy?
Criteria for Recurrent AOM Dx
Sulfamethoxazole
Amoxicillin
Indication for PE tubes
3 or more in 6mon
4 or more in 12mon
59
When is observation of AOM appropriate?
What is the SNAP approach?
>2y/o
Mild otalgia
Fever <102.2
Safety Net approach to ABX Prescriptions
60
Why do PTs w/ AOM and Tx w/ Amoxicillin present w/ rashes?
When does AOM get re-defined as COM?
EBV infections, conduct Monospot test
2wks-3mon
61
# Define COM
Since this Dx is due to different microbes than AOM, what can cause it to develop?
Otorrhea through TM perf
Pseudomonas
Proteus
Staph A
62
How does COM present to clinic
How are these cases managed/Tx
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
63
When Tx COM w/ surgery, how is the TM repaired
What are the 6 possible complications to arise from OM?
Temporalis muscle fascia
```
TM perf
Mastoiditis
Facial paralysis
Cholesteatoma- MCC ETD
Otogenic meningitis
Petrous apicitis
Sigmoid sinus thrombosis
```
64
How are cholesteatomas Tx
What microbes are most likely to cause mastoiditis?
What ABX is used for Tx
Marsupialization and PE tubes
Mastoid bowl- canal and mastoid joined
ABX failure= myringotomy and mastoidectomy
Strep pneumo/Pyogenes
H influenzae
IV Cefazolin
65
# Define Petrous Apicitis and how it's Tx
This causes Gradenigo Syndrome which presents as ?
What complication can develop?
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
66
How are TM Perfs Tx
What needs to be avoided?
Contaminated EACs- Ofloc/Cipro
Infections- PO ABX
Neomycin
Aminoglycosides
Polymyxin
Alcohol
67
What are the 3 layers of the TM
Chronic perfs develop is ? two layers meet first but can be corrected w/ ? procedure?
Squamous
Collagen
Cuboidal
Squamous + Cuboidal
Tympanoplasty- cigarette patch
68
Long standing cholesteatomas can invade and involve ? CN?
What imaging is preferred for evaluating cholesteatomas
CN8
CT
MRI if post-op eval
69
How does AOM/COM cause facial paraylsis
How is it Tx
Paralysis from ? etiology has a poorer prognosis
Bacteria neurotoxins
Myringotomy for drain/culture
IV ABX
COM leading to cholesteatoma
70
# Define Sigmoid Sinus Thrombosis
What are the S/Sxs
Infection in mastoid air cells next to sigmoid sinus causing septic thrombophlebitis
Systemic sepsis
Inc ICP
71
How is Sigmoid Sinus Thrombosis Dx
How is it Tx
MRV
IV ABX
Internal jugular vein ligation
72
? is the MC intracranial complication from ear infections?
What microbes cause this and how do they pass through the body?
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
73
How do epidural abscesses from ear infections develop?
How do they present?
Direct extension from chronic infections to temporal/cerebellar lobes
ASx
Deep pain
HA
Low fever
74
Brain abscesses that arise in the temporal/cerebellar lobes are results of ? underlying issue
What are the most likely microbes?
Septic thrombophlebitis next to an epidural abscess
Staph A
Strep pyogenes/pneumo
75
Brain abscesses from ear infections are ? complications due to untreated ?
Define Tympanosclerosis
Uncommon
AOM
Dz limited to middle ear w/ hyaline/calcification deposts on TM
76
# Define Otosclerosis
How is this Dx
Familial lesions on stapes leading to max of 60dB CHL
R/o other causes w/ CT/MRI, Weber/Rinne, Tymapnometry
77
How is ototsclerosis Tx
What causes barotrauma and when is it most likely to occur?
Speech discrimination, normal cochlea- amplification
Stapedectomy
Ascent- dec atmosphere pressure
Descent- inc atmosphere pressure; most likely time for trauma
78
What meds can be used to help prevent barotrauma?
How are PTs Tx suffering from barotrauma pain and HL when on the ground?
PO Pseudophedrine- hrs prior
Topical Phenylephrine- 1hr prior
Oxymetazoline
PE tubes
Myringotomy
79
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 ?
15ft
Hemotympanium
Perilymphatic fistula- burst oval window; SHL w/ vertigo
80
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?
SHL
Vertigo
Unequal thermal stimulus to semicircular canal= vertigo, disorientation, emesis
81
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?
Blast injury
Otalgia HL Vertigo 4-5 days later
Myringotomy
CHL >30dB x 3mon
82
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?
Glomus tympanicum- middle ear
Glomus jugulare- jugular bulb
Pulsatile tinnitus w/ HL- MRA/MRV
83
Glomus tumors can grow large enough to cause cranial neuropathies in ? CNs?
How are they Tx
7 9 10 11
Surgery
Radiotherapy
84
How does Ramsay Hunt Syndrome present
How are they Tx
Pain oo Proportion to exam
Lesions in EAC prior to paralysis onset
Antivirals and PO steroids
85
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/ ?
5 7 9 10
Upper cervical nerves
Lancinating pain in throat/ear
Tx w/ microvascular decompression of CN9
86
Perilymph is similar to ? fluid
Endolymph has high amounts of ? E+ and for ? purpose
CSF
K+, auditory signal generation
87
The 'otolith organ' is made up of ? and ?
What is the similarity/difference between vertigo and dizziness
Urticle
Saccule
All vertigo= dizziness
Not all dizziness= vertigo
88
Vertigo is Latin for ?
What is the key to Dx of vertigo
To turn
Duration of vertigo episode
Presence/lack of HL
89
What are the etiologies of peripheral vertigo
```
BPPV
Menieres
Vestibular neuritis/labyrinthitis
Barotrauma
ETOH
Dehiscence of semi-circular canals
```
90
What are the etiologies of central vertigo
? is the cardinal Sx of vestibular Dz
```
M SWAT
MS
Seizures
Wernicke encephalopathy
AV malformation
Tumor- brainstem/cerebellum
```
Vertigo
91
Vestibular d/os causing vertigo lasting for seconds
+ / - (PF/CMV)
+ auditory Sxs:
perilymphatic fistula
- auditory Sxs:
Cupulolithiasis
Vertebrobasilar insufficiency
Migraine associated vertigo
92
Vestibular d/os causing vertigo lasting hours
+ auditory Sxs:
Menieres
Syphilis
Head trauma
- auditory Ss:
migraine associated vertigo
93
Vestibular d/os causing vertigo lasting days
+ auditory Sxs:
Labyrinthitis
Labyrinthine concussion
Auotoimmune inner ear dz
- auditory Sxs:
Vestibular neuronitis
Migraine associated vertigo
94
Vestibular d/os causing vertigo lasting months?
+ auditory Sxs:
Acoustic neuromas
Ototoxicity
- auditory Sxs:
MS
Cerebellar degeneration
95
Acute peripheral lesions will cause ? type and direction of nystagmus
Visual fixation will usually suppress these nystagmus' except for ?
Horizontal and rotary w/ fast phase away from diseased side
Very acute peripheral lesion
CNS diseases
96
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
Frenzel
Demonstrates vestibular asymmetry w/ PT steps in place and eyes closed, consistent rotation
97
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?
```
MRI
Audiogram
Caloric stimulation
ENG* (objective)/VNG
Vestibular evoked myogenic potentials (VEMPs)
```
ENG/VNG
98
Characteristics of a peripheral vertigo induced nystagmus
Characteristics of central vertigo induced nystagmus
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
99
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?
Episodic vertigo in PTs w/ diplopia, maximized when looking toward greatest image separation
Vertigo
100
What is the theorized pathogenesis of Endolymphatic Hydrops?
What are the two known causes?
Distension of endolymphatic compartments
Syphillis
Trauma to head
101
What are the classic Sxs of Menieries?
If PTs present w/ the above Sxs but deny fluctuations in hearing, ? Dx is suggested
Episodic vertigo
Low frequency SNHL
Low/blowing tinnitus
Unilateral aural fullness
Migraine associated dizziness
102
What would caloric testing show in PTs w/ Meniere's?
How are these PTs managed?
What is done for cases refractory to medical therapy?
Loss of thermal induced nystagmus to affected side
Acetazolamide
PO Meclizine/Diazepam
Vestibular rehab
Intratympanic CCS injection
Endolymph decompression
Vestibular ablation
103
What is the difference between vestibular neuritis and labyrinthitis?
What causes vestibular neurontitis
How do PTs w/ labyrinthtis present?
Labyrinthitis= + unilateral SHL
Post-URI/flu inflammation of CN8 w/out HL
Vertigo x days-week w/ HL and tinnitus
104
How is labyrinthitis Tx?
What meds can be used during the acute phase to reduce severity of vertigo?
Vestibular therapy ASAP
ABX (febrile/bacterial infection)
PO Meclizine
PO Diazepam
105
What causes BPPV
What do PTs present complaining of
How are these PTs Tx
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
106
? 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
Dix-Hall: posterior
Supine roll: lateral
Common crus of Ant/Post canals into auricular cavity
Meclizine (Antihistamine class- DOC)
107
When/why are benzos used for vertigo lasting hrs-days?
What anti-emetics can be used?
C/i to anticholinergic (prostatism, glaucoma)
Metoclopramide
Odansetron
Prochlorperazine
108
What are 3 etiologies of trauma induced vertigo?
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
109
How are cases of traumatic vertigo Tx
Define perilymphatic fistulas and how they can occur
Vestibular suppressant- Meclizine/Diazepam
Vestibular therapy
```
Perilymph leaks into middle ear via oval window;
Physical injury
Barotrauma
Valsalva
Post-stapedectomy
```
110
How do PTs w/ perilymphatic fistulas present?
How are perilymphatic fistulas Tx
Vertigo and SHL worse w/ straining
Bed rest w/ head elevation
Surgery w/ window sealing graft
111
How does Migrainous Vertigo present?
What type of FamHx do most of these PTs have?
Mixed etiology of-
Episodic vertigo w/ HA, Vision/motion sensitivity
Phono/Photo phobia
Hx of motion intolerance
112
How is Migrainous Vertigo Tx
This etiology of vertigo is similar to Meniere's except ?
Diet/life changes
Migraine prophylaxis
No HL/tinnitus
113
What causes cervical vertigo to happen?
How do PTs present complaining of vertigo?
Post- neck injury (hyperextension)
Cervical disc degeneration
Vertigo triggered after assuming head position
114
What causes semicircular canal dehiscence
What do PTs present complaining of
Deficient bony covering over superior semi-circular canal
CHL and vertigo w/ straining/after loud noises
115
How does central vertigo present
Gradually more severe/debilitating
Auditory spared
Nonfatigable/latent vertical nystagmus worse w/ visual fixation
116
How do lesions on CN8/central audiovestibular pathways present?
How are these PTs best evaluated?
NHL w/ vertigo
Dec speech discrimination
BAER- brainstem auditory evoked responses to distinguish cochlear from neural loss
117
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
Acoustic neuroma
Vascular compromise
MS
Enhanced MRI- IAC, cerebellopontine angle and brain
118
Characteristics of Acoustic Neuromas
Since almost all are unilateral, what does the discovery of bilateral tumors suggest?
Common intracranial tumors on sheath of CN8
Neurofibromatosis Type 2- meningiomas and intracranial/spinal tumors
119
What happens if Acoustic Neuromas are allowed to continue growth w/out interruptions?
How are they Dx
How are these cases Tx
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
120
# Define Vascular Compromise induced vertigo
What image is used for Dx
How are they TRx
Common vertigo etiology in elderly after change in position or neck extension
MRA
Dilators and ASA w/ rehab
121
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
20-40y/o F w/ FamHx
Rapid onset unilateral SHL
Hyper/po-acoustics
Facial numbness
Diplopia
122
How is acute peripheral vertigo Tx
How is chronic peripheral vertigo Tx
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
How is bilateral vestibular injuries Tx
How is Chronic Vertigo Tx
Complete bilateral loss- no improvement
Fall prevention
Gait/balance exercise w/ head/eye movements
Longer rehab than peripheral vertigo
124
HL is MC due to ? 3 etiologies
HL classifications
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
4 causes of CHL
What causes S/NHL
Mass loading- effusion
Obstruction- impaction
Discontinuity
Stiffness- sclerosis
Sensory: dec hair cells in Corti/deteriorated cochlea
Neural: lesion on CN8
126
What is the MCC of SNHL
Usually irreparable or reversible except for ? which is controlled with ?
Presbyacusis- high freq and symmetrical (hard hearing bird chirps/phone rings)
Sudden onset SHL; CCS
127
NHL lesions can be located where?
What can cause this form of HL
CN8
Auditory nuclei/cortex
Ascending tracts
Acoustic neuromas
MS
Auditory neuropathy
128
Since SHL is usually bilateral, unilateral or asymmetric SNHL suggests ?
? is the MC complaint of PTs w/ presbycusis
Lesion proximal to cochlea (acoustic neuroma)
Lost speech discrimination in noisy environments
129
What is the 2nd MCC of SNHL
How does this type of HL manifest?
1st- presbycusis
2nd- noise trauma, >85dB= cochlea damage
Lost high frequencies 4K Hz
130
? are the MC ototoxic meds?
How can these toxic risks be reduced?
Aminoglycosides
Loop diuretics
Anti-neoplastics- Cisplatin
Serial audiometry
Peak/trough monitoring
Medication substitutions
131
? types of autoimmune d/os can lead to SHL
SHL is possible after ? and frequently seen after ?
SLE
Granulomatosis w polyangitis
Cogan Syndrome (HL, keratitis, aortitis)
Concussion
Frequently after skull fx
132
? is the MCC of genetic deafness
PTs w/ autoimmune HL may also suffer from ? issues
Connexin-26 mutation
Dysequilibrium
Posture instability
133
? 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
Ana-Ab
RF
ESR
1st: PO CCS
2nd: Methotrexate
Persistent- SHL
Intermittent high/mild
134
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
CT of temporal bone
MRA and MRV
Cochlea
5 or 7 in cerebropontine angle
135
Audiology assessment for HL consists of ? four parts
Pure tone testing thresholds above ? are considered abnormal
Define STS
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
Audiogram symbols
```
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
What are the X and Y axis of a tympanometry
Define Decapascal
X- pressure against TM
Y- compliance of TM
Unit of pressure, equal to one newton per sq/meter
138
Type A Tympanogram
Normal
Peak near 0
Compliance .2-1.8ml
No middle ear pathology
Normal TM/ET
+HL= SNHL
139
Type As Tympanogram
Peak near 0daPa
Compliance below 0.2ml
Ossicular fixation, sclerosis, TM scars
Non-fluctuating HL
Normal ET
140
Type Ad Tympanogram
Peak near 0 daPa and above 2.0ml
Ossicular disarticulation or discontinuity
Non-fluctuating HL
Normal ET
141
Type B Tympanogram
Absent/poor peak w/ middle ear pressure > -200 daPa
Little/no TM mobility
Middle ear fluid
TM perf
142
Type C Tympanogram
Peak on negative side of chart= neg middle ear pressure -150 daPa
ETD
Mild CHL/normal hearing
143
What are the 4 sinus cavities?
Which ones are not fully developed in young children?
Define the Ostiomeatal Complex
Maxillary
Ethmoid
Frontal
Sphenoid
Frontal, Sphenoid
Drainage linkage of frontal, ethmoid air cells and maxillary sinuses w/ middle meatus
144
How is Viral Rhinosinusitis Tx
? is the considered the most effective management strategy to prevent viral rhinosinusitis
```
Hypertonic Saline
PO decongestant (pseudoephedrine, oxymetazoline, phenylephrine)
```
Annual influenza
145
? dietary supplement may help reduce duration of cold Sxs?
? meds are used for the withdrawal phase when Tx Rhinitis Medicamentosa
Zinc
Intranasal CCS- Flunisolide
Intranaal anticholinergic- Ipratropium
PO Prednisone
146
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 ?
Bacterial rhinosinusitis
ETD
Transient middle ear effusion
Bacterial rhinosinusitis- deep to middle turbinate in middle meatus (drains maxillary, ethmoid and frontal sinuses)
147
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?
URI
Allergies
Mechanical obstructions
Between septum and superior turbinate
148
? pathogens usually cause bacterial rhinosinusitis in community and hospital populations?
```
Community:
Strep pneumo
H infuenza
Staph A
Moraxella catarrhalis
```
Hospital:
Pseudomonas
Staph A
149
How is bacterial rhinosinusitis differentiated from viral etiologies?
Criteria for acute, subacute, chronic and recurrent rhinosinusitis
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
? 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
Acute maxillary sinusitis due to largest sinus w/ single drainage path
Unilateral facial fullness
Pain over teeth from CN5
Dental infections
151
How does localized ethmoid sinusitis present?
What is unique about sphenoid sinusitis presentations?
Pain over lateral high wall of nose between eyes
HA in middle of head
152
? type of sinusitis causes pain in the forehead?
Hospital associated sinusitis is usually seen in ? admitted PT populations?
Frontal sinusitis
NG tubes
Nasotracheal tubes
153
When is imaging for sinusitis warranted?
What types of images can be taken?
```
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
How is acute bacterial rhinosinusitis Tx
When are ABX considered and which ones are used?
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
What types of ABX are avoided during the Tx of Acute Bacterial Rhinosinusitis
Why are these types of ABX avoided?
Macrolides
TMP/SMX
2nd/3rd Gen cephalosporin
High resistance
Poor sinus penetration
156
How is hospital associated bacterial sinusitis Tx
Nasal saline spray
Humidified O2
Nasal decongestants
Broad spectrum ABX against Pseudomonas/Staph A
157
What are 4 possible complications that can arise from acute bacterial rhinosinusitis?
How do these complications develop?
Orbital cellulitis/abscess
Osteomyelitis
Cavernous sinus thrombosis
Intracranial extensions
Orbital complication from ethmoid sinusitis via lamin papyracea
158
How do orbital cellulitis and abscesses present?
Cellulitis-
Proptosis
Gaze restriction
Orbital pain
Abscess-
Proptosis
Ophthalmoplegia
Pain w/ medial gaze
159
What happens if orbital abscesses are not promptly Id'd and Tx
How are orbital complications best seen w/ images
Permanent visual impairement
Frozen globe
Orbital CT
160
Osteomyelitis complications from sinusitis MC occurs in ?
What PE finding is indicative
Frontal sinus
Pott puffy tumor- tender swelling of forehead
161
How do intracranial compications from sinusitis develop?
Hematogenous spread-
Cavernous sinus thrombosis
Meningitis
Direct extension-
Epidural/intraparenchymal abscesses (AMS, persistent fever, severe HA)
162
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 ?
Ophthalmoplegia
Chemosis
Visual loss
MRI
Surgery
163
When is nasal endoscopy and CT imaging for rhinosinusitis warranted?
How is nasal vestibulitis w/ Staph A colonization Tx
Unresolved in 4-12wks
Diclox against Staph A
Topical mupirocin
Recurrent- add Rifampin to Diclox Tx
164
Why is Tx of nasal vestibulitis important?
How can MRSA carrier state be eliminated?
Prevent spread to cavernous sinuses or intracranial spaces
Mupirocin
Chlorhexidine washes
165
? fungus can cause Rhinocerebral Mucormycosis
This Dx is almost always in PTs w/ ? commodities
Aspergillus
```
DM
Hematologic malignancy
AIDS
Long term CCS use
ESRDz
```
166
How do PTs w/ Rhinocerebral Mucormycosis present
How is this Dx
Clear/straw d/c
Black eschar- middle turbinate
No nasal findings= visual Sxs
Biopsy w/ Silver Stains showing broad non-septate hyphae
167
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?
Amphotericin B
Voriconazole
Caspofungin
Debridement w/ medial maxillectomy
DM: 20%
Kidney dz: >50%
AIDS/malignancy w/ neutropenia: 100%
168
Seasonal allergic rhinitis is MCC by ?
What is the MC cause of allergies if they occur in spring, summer or fall?
Pollen/spores
Spring- shrub/tree pollen
Summer- plants/grass
Fall- ragweed/mold
169
Allergic rhinitis needs to be distinguished from ?
What will be seen on PE tha can differentiate the etiology?
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
? is the mainstay of Tx fo allergic rhinitis
Intranasal CCS-
Beclomethason
Flunisolide
Fluticasone propionate
Budesonide
Mometasone furoate
171
Since CCS can take up to 2wks to provide relief for allergic rhinitis, what can be given for immediate relief?
PO Antihistamines/H1 blockers:
Non-sedate-
Des/Loratadine
Min Sedate-
Cetirizine
Sedate-
Chlor/Brompheniramine
172
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?
Azelastine
Antileukotriene: Montelukast
Mast cell stabilizer: Cromolyn sodium and sodium nedocromil
173
What mediation is most useful for opto Sxs of allergic rhinits?
What is the most effective way to alleviating Sxs?
Cromolyn sodium
Red/avoid exposure to allergens
174
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
Serum Radioallergosorbent Test by allergist
Gustatory
Medicamentosa
Vasomotor
Occupational
175
Steps for managing epistaxis
Pressure x 15min
Phenylephrine/oxymetazoline w/ pressure x 15min
Oxymetazoline, Tetra/Lido/Cocaine
Cautery- sliver nitrate
Surgicel/Gelfoam
Packing indicated
176
? hereditary d/o puts PTs at risk for epistaxis?
Bleeds from posterior cavity are more associated w/ ?
Osler-Weber-Rendu Syndrome: hemorrhagic telangiectasia
Atherosclerotic dz
HTN
177
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?
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
? ABX are used for PTs w/ nasal packings and post nasal hematomas?
PTs w/ nasal Fxs need to have ? two issues r/o
Cephalexin
Clindamycin
Infraorbital rim numbness/step off suggesting zygomatic fx
179
How do nasal hematomas appear?
Nasal structures receive nutrition/supply from ? structure
Why is this structure important?
Wide anterior septum posterior to columella
Mucoperichondrium
Hematomas InD on inferior sides
180
Closed reduction of nasal Fxs can be attempted when ?
What system is used to define facial Fxs
<7d of injury
LeFort:
1: maxillary
2: pyramidal maxillary
3: craniofacial dysfunction
181
How are recurrent polyps removed via surgery?
Define Schneiderian Papilloma
Why is complete excision a must and how is this done?
Ethmoidectomy
HPV induced benign nasal tumors on lateral walls
Prevent SCC progression via maxillectomy w/ radiological f/u
182
Since early Sxs of malignant nasopharyngeal/paranasal tumors are simply rhinitis/sinusitis, what are late findings?
How are they best Dx
Proptosis
Ill-fitting dentures
Expanded cheek
Biopsy and MRI
183
Nasophargyngeal carcinoma is more common in ? PT populations
What are 4 less common neoplasms that could be seen?
Chinese descent w/ capsid to EBV and weaker association w/ tobacco use than other head/neck SCCs
Mucosal melanoma
Adenocarcinoma
Non-Hodgkins
Sarcoma
184
? is a common maxillary sinus tumor Sx
How do Pts w/ Wegeners present to ENT
What would be seen on biopsy results
Malar hypesthesia from infraorbital nerve involvement
Nose and paranasal sinus involvement w/ blood stained crusts/friable mucosa
Necrotizing granulomas and vasculitis
185
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
Subglottis
Middle ear
Engorged turbinates w/ white granulomas
Rhinorrhea
Hypo/anosmia
186
What would be seen on biopsy results in sarcoidosis PTs
Pts w/ sarcoidosis in paranasal sinuses usually have ? Tx prognosis
Non-caseating granulomas
More difficult managing sarcoidosis in other organ systems
187
Polymorphic reticulosis is AKA ? and usually signal ? prognosis
What wold be seen on biopsy results
What is an essential part of histologic evaluation?
Lethal midline granuloma; type of lymphoma
Death <12mon
Nasal T-cell/NK-cell lymphoma
CD56 expression
188
? is the best known pre-cancerous lesion of the mouth
What does this finding indicate is occurring at a cellular level?
Leukoplakia- white patches that can't be removed
Hyperplasia of squamous epithelium
189
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?
Hyperplasia
Dysplasia
Carcinoma in situ
Invasive malignancy
Hyperkeratosis from chronic keratosis
190
# 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?
More erythematous than leukoplakia; more likely to show dysplasia/SCC
FNA
Present for >2wks
191
What are the RFs for the MC Ca of the mouth
What type of erythr/luekoplakia lesions are more worrisome?
Define Melanosis
SCC- alcohol and tobacco use
Ulcerated
Symmetric pattern on gums in dark pigmented PTs
192
# Define melanotic macules
? is the MC site to see amagam tattoos and what is key up their discovery?
Symmetric dark lesions that are stable in adults
Mandibular arch; seeing the amalgam due to ability to mimic melanomas
193
# Define Fordyce spots
How do they appear on exam
Benign neoplasms in sebaceous glands
1-2mm white/yellow papules at the vermillion/buccal mucosal border
194
# Define Lichen Planus
What are the two different types?
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
How is Lichen Planus definitvely Dx
How are these cases medically managed?
Biopsy
Exfoliative cytology
Topical and systemic CCS, cyclosporines and retinoids
196
4 fungal etiologies of thrush?
What are the two presentations that could be seen
Candidiasis
Glabrata
Kruseia
Tropicalis
Pseudomembranous: MC overall; white plaques on soft mucosal tissue
Atrophic/denture stomatitis- MC adult form; erythema w/out plaques
197
What are the seven RFs that can lead to development of thrush
What other Dx may co-exist w/ thrush
```
Dentures
Debilitated/poor hygiene
DM
Anemia
Chemo/radiation
CCS use
Broad ABX
```
Cheilitis
198
How is thrush Dx
How is it Tx
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
How is thrush Tx in infants
How do aphthous ulcers appear on PE
Nystatin suspension x 3days after lesion resolution
Refractory: gentian violet or PO Fluconazole
Ulcerations w/ yellow/gray base surrounded by red halo
200
? is the MCC of oral ulcers
What part of the mouth is involved
Recurrent Aphthous Stomatitis
Non-keratinized mucosa- labial/buccal, ventral tongue
201
What is the suspected etiology of aphthous ulcers?
What are the RFs for their development?
What are two independent predictors of frequency/severity?
HHV-6
Stress
Celiac/IBDz
Deficient B1,2,6,12, Fe, Folic acid, Zn
Frequency of viral rhinitis
Bedtime after 11pm
202
How is Recurrent Aphthous stomatitis managed?
What is the etiology of Herpetic Gingivostomatitis
```
Fluocinonide
Amlexanox
Triamcinolone
Diclofinac in hyaluronan
Severe pain- PO Prednisone
```
HSV-1
203
What medication is used for PTs w/ recurrent aphthous ulcers?
What medication is used for HIV PTs w/ recurrent aphthous ulcers?
Cimetidine
Thalidomide
204
How does Herpetic Gingivostomatitis present
How is it Dx
How is it Tx
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
How does Varicella Zoster present in the oral cavity
How does atrophic glossitis present
Grouped vesicle/erosion unilaterally along dermatome
Painless inflammation w/ papilla atrophy
206
What are the etiologies of Atrophic Glossitis
What causes geographic tongue?
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
Geographic tongue is associated with many d/s including ?
How are tonsil sizes graded?
Thrush
Psoriasis
Reiter syndrome
Lichen planus
```
0- removed
1- hidden behind pillars
2- extend to pillars
3- beyond pillars
4- to midline
```
208
# Define Centor Criteria
What do scores correlate to?
```
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
How does Mononucleosis present?
What lab work needs to be done?
Cervical adenopathy
Palatal petechiae
White/purple tonislar exudate
CBC
Mono-spot (heterophile auto-Abs)
EBV Ab test
210
What lab test has high sensitivity for EBV Dx?
What three things are corroborative for an EBV Dx
? is the MC etiology of pharngyitis
Lymphocyte:WBC ratio >35%
Hepatosplenomegaly
Pos heterophile agglution test
High anti-EBV titier
Viral
211
? ABX need to be avoided if Mono Dx is suspected?
Diphtheria is more likely to present in ? PT population and appears as ?
Ampicillin
Alcoholics
Low fever/gray tonsil pseudomembrane
212
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?
Erythromycin
IM Benzathine Pen G or Erythromycin x 5yrs
213
How is GABHS Tx?
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
How is Mono Tx
Define Quinsy Tonsil
What complications can occur from extensions?
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
# Define Cellulitis
Define Abscess
Inflammation and infection of tissue w/ no pus
Pus collection between tonsil capsule and muscle wall
216
How is cellulitis of the PO/pharynx Tx
Non-PO:
Amoxicillin
Clinda
PO tolerant:
Amoxicillin
Augmentin
Clinda
217
How are Peritonsillar Abscesses Tx
Suspected PTA w/out airway compromise, septicemia or trsimus is Tx by ?
Aspiration/InD/Tonsillectomy
Same IV ABX used for cellulitis
Observation and IV ABX x 24hrs
218
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
Carotid artery
Insert needle <8mm
Delayed growth
Poor academic/behavior
Bed wetting
219
When is observation better than tonsillectomy
When is post-tonsillectomy bleeding a concern?
<7 in past year
<5 in past 2yrs
<3 a year x 3yrs
5-8 days post-op
220
# Define Sialadenitis
How does this present to clinic?
What underlying issues may contribute to it's development
MC Staph A infection of parotid/submandibular galnd
Pain/welling w/ meals
Tender/Erythema
Sjogrens
Peridontitis
221
How is Sialadenitis Tx
What is the life threatening form of this infection?
IV Nafcillin
Sialagogues
Suppurative sialadnitis- no pus drains from stensen papilla- CT/US then InD
222
What causes Suppurative Parotitis to develop
How will this present in clinic?
Staph A in PTs that are debilitated, dehydrated or have poor PO hygience
Firm swelling along mandible angle
Pain w/ F/C
223
How is Suppurative Partotitis Tx
Define Sialolithiasis
Nafcillin and Metronidzaole/Clinda
ImmComp PT- Vanc
Calculus formatoin in Wharton duct
224
How does Sialolithiasis present
What is the difference in stones appearance on imaging and location
Post-prandial pain
Swelling
Hx of acute sialadenitis
Wharton- opaque, large
Stenson- lucent, smaller
225
Sialolithiasis discovered w/ in ? to the ductal opening can NOT be removed w/ dilate and incision?
Why is this?
>1.5-2cm
Damage to lingual nerve
226
What is the preferred management method for chronic sialolithiasis
Tumors found in ? salivary glands are more likely to be malignant of ? type
Sialoendoscopy
Minor glands- adenoid cystic carcinoma
227
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
CN7 affected
Medial deviation of soft palate
228
? granulomatous dz can affect the salivary gland
? drugs have been associated w/ parotid enlargement
80% of salivary gland tumors occur in ?
Sarcoidosis
Thioureas
Iodine
Cholinergic drugs- Phenothiazine
Parotid gland
229
What 6 cartilage structures make up the larynx
What is it innervated by?
```
Cricoid
Corniculate
Cuneiform
Arytenoid
Thyroid
Epiglottic
```
Superior/Recurrent laryngeal nerves
230
What structures support the vocal folds?
Which structure brings folds closer together to produce sound?
Arytenoid and Thyroid
Arytenoid
231
What controls the pitch in voice production
What helps produce vowels?
Vocal fold tension:
Taut= higher
Thicker/loose= lower
Pharynx muscles
232
? are the primary Sxs of laryngeal Dz
Define Stridor
Hoarseness ad Stridor
High pitch sound on inspiration from narrowing at/above vocal folds
233
What type of sounds are produced if there is a narrowing below the vocal folds?
Hoarseness lasting longer than ? need ENT referral
Expiratory/biphasic stridor
>2wks
234
What are 'worrisome' co-existant Sxs if PT presents w/ horaseness?
? is the MCC of hoarseness
```
Severe cough
Hemoptysis
Unilateral ear/throat pain
Odyno/Dysphagia
Unexpected weight loss
```
Acute viral laryngitis (<3wks) from Catarrhalis, H influenza or laryngopharyngeal reflux
235
What causes chronic hoarseness
When Tx acute laryngitis, only use CCS if ? w/ ? PT education
What ABX are used and when
Vocal fold lesion
PT has to use voice; warning for cord hemorrhage/trauma (cyst/polyp)
Erythromycin- hoarseness >7d or cough >14days
236
What types of changes can tobacco use cause that leads to chronic laryngitis?
How are these cases managed?
Keratosis
Polypoid corditis
Remove offending agent
237
How is laryngopharyngeal reflux Dx
? is the best way to monitor and document laryngopharyngeal reflux
PTs response to PPIs (Omeprazole x 3mon but larynx changes take 6mon)
Double pH probe
238
Supraglottitis is more common in ? PT populations
What is the difference in work ups between adults and kids?
DM
Kids- no indirect laryngoscopy
Adults- safe
239
What ABX are used during the Tx of supraglottitis
? are indications PTs need to be intubated
Admission w/:
Ceftizoxime/Cefuroxime/Ceftriax w/ Dexamethasone
Dyspnea
Rapid pace of sore throat
Endolaryngeal abscess on CT
240
? is a sign of impending airway compromise in PTs w/ supraglottitis
Where do respiratory papillomas commonly develop
Drooling
Ciliated and squamous epithelia meet
241
Recurrent Respiratory Papillomatosis is almost always due to ? virus
These are also the MC ?
? PT population do these benign growth transform?
HPV 6 and 11
Benign laryngeal tumor in kids due to inoculation during vaginal delivery
Smokers
242
What are the Sxs of Recurrent Respiratory Papillomatosis
How are they Tx
How are they prevented
Hoarsenss to stridor changes
Warty lesions on folds
Laser vaporizations
Cold knife resections
Gardasil 9
243
What is the only indication to use interferon for the Tx of Recurrent Respiratory Papillomatosis
? medication has proven intralesional success
Severe cases w/ pulmonary involvement
Cidofovir; potential for adenocarcinoma development
244
What are the 4 types of traumatic/benign lesions of the vocal cord?
Which two are manifestations of chronic vocal fold irritation?
Nodule
Polyp
Cyst
Polypoid corditis
Nodule/Polyp
245
Vocal fold nodules are AKA ? depending on age of PT
How do the appear?
How are they Tx
Singers- adult
Screamer- kids
Smooth, paired lesion at junction of ant/post vocal folds from vocal abuse
Behavior modification
Surgical excision
246
How do vocal fold polyps present
These are associated w/ ? and can be the resolution from ?
How are they Tx
Unilateral mass on lamina propria of folds from yelling
Smoking
Vocal fold hemorrhage
Small: CCS, voice rest
Large- surgical excision
247
Where do vocal fold cysts emerge from?
These are considered to be ?
Why is Tx difficult/frustrating
Mucus glands on inferior aspect of folds
Traumatic lesions
Scarring/sulcus leading to chronic dysphonia
248
Smokers w/ hoarseness typically have ? Dx
How are these cases Tx
Laryngeal leukoplakia
PPIs- mainstay
Smoking cessation
249
SCC of the larynx develops almost exclusively in ? PT population
This can be due to ? viruses
and have ? predominant factor
Smokers
HPV 16/18- strongest association w/ non-smokers and oropharyngeal Ca
250
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
Changes in voice quality
Smallest detectable Ca
251
When is SCC of the larynx more likely to metastasize
When is a chest CT indicated
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
How are early glottic and supraglottic cancers Tx
TMN staging
Radiation therapy
Page 97
253
Vocal cord paralysis can occur due to lesion/damage to ? nerves
What type of MedHx/SurgHx can narrow the etiology
Vague
Recurrent laryngeal
Mediastinal/Apical lung ca
Skull base tumor presses vagus
254
What are the 1st and 2nd MCC of unilateral cord paralysis
What images are used
1st: iatrogenic injury
2nd: idiopathic
Normal CNs: enhanced CT for masses
Abnormal CNs: MRI for nerve lesions
255
Unilateral recurrent laryngeal nerve injury causes the vocal cord to rest in ? position
When is early surgical Tx indicated
Paramedian- partially lateralized
Severe Sxs (aspiration pneumonia)
Breathy hypophonia
Ineffective cough
Disabling dyspnea
256
What can cause bilateral vocal fold paralysis
What type of respiratory issues will be seen in these PTs
Reoperations of total thyroidectomies
Dyspnea/stridor w/ extubation
257
How is unilateral vocal cord paralysis Tx
Once the paralysis has been Dx as permanent, what procedure is done?
Teflon/Collagen/Fat inplants
Medialization thyroplasty- inplant between thyroarytenoid muscle and thyroid cartilage
258
# Define Vocal Cord Dysfunction/Paradoxical Vocal Fold Movement
What Dx co-exists w/ vocal cord dysfunction nearly half of the time
Acute/Chronic upper airway obstruction w/ paradoxical vocal cord adduction
Asthma
259
What PE finding can suggest PT has VCD w/ asthma
How is this Dx
What will other work up tests results look like?
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
How is Vocal cord dysfunction Tx
What are the landmarks of the ant/post/sub-clavian triangles?
Speech therapy
Stop steroids/Txs
CPAP/therapy
Long term: botox
Ant- Digastric/SCM
Post- Trap/SCM/Belly of omohyoid
Sub: SCM/Clavicle/omohyoid
261
A normal lymph node size is considered ?
What is the Rule of 7s for masses
<1cm
7d: inflammatory
7w-7m: neoplastic
7yrs: congenital
262
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
Inflammatory
Congenital
Inflammatory/Congenital
Risk for malignancy starts
Malignancy
263
PTs w/ neck masses that are <30 or >70 need to have ? Dxs r/o
Rapid growth/tenderness suggests ? etiology
Slow growth, painless suggest ?
Lymphoma
Inflammatory
Neoplasm
264
What 3 pieces of info are most significant for predicting neoplastic neck masses?
Ludwigs Angina is an abscess infection located where?
PT age
Size
Duration
Submandibular spaces
265
? is the MC neck space infection
? is the MC cause of deep neck abscesses?
Ludwig's- cellulitis of sublingual/maxillary spaces from mandibular dentition
Odontogenic infections
266
What are the microbes that causes Ludwigs?
What is the predominant microbe in PTs w/ DM and how is their presentation different?
Staph
Strep
Bacteroides
Fusobacteriium
Klebsiella; more aggressive
267
? is a rare cause of Ludwig's Angina/neck abscesses?
What PT population does this typically occur in?
What are the Sxs
Lemierre syndrome: thrombophlebitis of internal jugular vein secondary to oropharyngeal inflammation
ICU PTs w/ internal jugular central venous catheters
Severe HA
Pulmonary infiltrates
268
How is Ludwig's Angina Tx
How is Lemierre Syndrome Tx
PCN+Metronidazol/Clinda/Amp-Sulbactam
Submental incision for drainage
Metronidazole aimed a Fusobacterium Necrophorum
269
What are common causes of cervical adenopathy
What are two rare causes?
SCC tumors
Infections
Kikuchi Dz- histiolytic necrotizing lymphadenitis
Autoimmune adenopathy
270
# Define Reactive Cervical Lymphadenopathy
This is the MCC of ? findings
Painful enlargement from response to infection/inflammation
MCC of neck masses over all age groups
271
How is Reactive Cervical Adenopathy Tx
When would FNA be considered for this Dx
Augmentin
Clinda
Node >1.5 w/out infection
Hx tobacco/ETOH/Ca
Persistent/growing
272
? is the criteria used for grading snoring
? are the two MC sites of obstruction leading to snoring
Epworth Sleepiness Scale- 0-24 w/ >10 considered abnormal
Oropharynx
Base of tongue
273
Two indications for a tracheotomy
What are the benefits of a crichothyrotomy
MCC- respiratory failure requiring prolonged ventilation
Airway obstruction at/above larynx
Fewer complications of PTx or Hemorrhage
274
? is the risk from extended periods of extended endotracheal intubation?
What are 3 more rare but possible indications for a tracheostomy
Subglottic stenosis
Aspiration pneumonia
OSA
Insufficient pulm toilet
275
What daily function is reduced/inhibited after placement of a tracheotomy
How are foreign body aspirations Dx/Tx
Swallowing
Dx: CXR aided w/ in/expiration films
Tx: rigid bronchoscopy
276
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
Older adults
Denture wearers
Drooling/pointing to level of obstruction
Dx: x-ray
Tx: observation/endoscopic removal
277
How does the appearance of coins on x-ray hint at their location?
If foreign body is suspected ? Dx test can help
```
Coronal= esophagus
Sagital= trachea
```
Barium swallow
278
What Tx method should be avoided if PT presents w/ esophageal meat obstruction?
? are the MC congenital masses of the lateral neck
Papain- damages esophageal mucosa causing stenosis/perfs
Branchial cleft cysts- remnant of embryological development
279
Where do branchial cleft cysts tend to appear?
What PE findings can solidify a Dx
How are they Dx w/ images
Along SCM
On face near auricle
Not midline
No movement w/ swallowing
CT showing cystic mass medial to SCM
280
# Define First Branchial Cleft Cyst
Define Second Branchial Cleft Cyst
Define Third Branchial Cleft Cyst
High neck/below ear, fistula connection w/ EAC
More common, connect w/ tonsilar fossa
Rare, connect w/ piriform sinus
281
? is the MC congenital mass of the central neck
What is this structure a remnant from?
Thyroglossal duct cyst appearing <20y/o
Descent of thyroid as embryo
282
How do thyroglossal cysts appear on PE
How are these Dx
Midline neck mass below hyoid and moves w/ swallowing/tongue protrusion
Abnormal TSH= thyroid scan
CT
283
How are thyroglossal duct cysts Tx w/ surgery
What needs to be done prior to surgery
Sistrunk procedure w/ segment of hyoid bone removed
Thyroid US
284
How is Head/Neck Ca completely examined?
If this fails to establish Dx, what is the next step?
Under anesthesia w/ triple endoscopy:
Direct laryngoscopy
Bronchoscopy
Esophagoscopy
MRI or PET scan
285
What is the path of SCC metastases from Head/Neck Ca
Why do ENTs use rigid endoscopes more than other specialties?
Early to nodes then lung, liver, brain or bones
Biopsy capabilities
286
Cancer from ? parts of the body have the capability to metastases to the neck?
```
Thyroid
Lung
Liver
Gastroesophageal
Breast
Bone
Brain
Renal
Testes
```
287
How does Non/Hodgkins lymphoma present?
How are these definitively Dx
Occurring at 20 or >50 as multiple rubbery nodes
Open biopsy
288
What are the 4 types of thyroid Ca
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
What type of thyroid cancer is associated w/ MEN-2A
How are adenopathy <7wks old managed
Medullary
Broad ABX
No improvement= CXR/PPD
Negative/suspicious findings: Contrast CT and FNA
290
How is adenopathy 7wks-7mon old managed?
How is adenopathy present for >7yrs managed?
Contrast CT and FNA
Endoscopy consult
CT
Excisional biopsy
291
How is the location of Ludwigs Angina indicated?
What airway Tx step is avoided and what is used in it's place?
2/3rd molar pus- submandibular
1st molar fwd (above myohyloid line)- sublingual
No intubation
Perform tracheotomy
292
PTs w/ recurrent deep neck infections need ? Dx r/o
What is the STOP-BANG questionnaire
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
Modified Malampati scale is AKA ?
What are the scores
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
Onset of sleep during PSG is made by ?
What are the 30sec snapshots called?
EEG and EMG
Epochs
295
How is the AHI score calculated for a sleep study
What does these scores correlated to
Apnea + Hypopnea/hrs of sleep
Mild: 5-15/hr
Mod: 15-30/hr
Sev: >30hr
296
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?
Magill
Hyper inflation of obstructed lobe w/ lateral decubitus
297
What type of inhaled object can be more difficult to remove w/ bronchoscopy
Most parotid neoplasms are ? type
Peanuts- salt/oil cause inflammation and swelling
Mixed pleomorphic adenomas
298
Define T1-T4 cancers
1: <2cm
2: 2-4cm
3: >4cm
4: large, invasive and surround structures
299
Thyroid Ca Dx w/ biopsy
Thyroid Ca w/ poor uptakes of I-131
Follicular
Medullary
Anaplastic
