ENT Pt 2 Flashcards
Define AD
Define AS
Define AU
R ear; Auris Dextra
L ear; Auris Sinistra
Both ears; Auris Utraque
Basal Cell Carcinoma is the MC ?
How does this form of Ca present on PE?
MC malignant neoplasm of auricle; from sun exposure
Pedunculated Ulcerated Nodule Translucent Rolled Bleeding
What are the 3 types and one benefit of Dx w/ BCC of the auricle?
How is it Tx both Non/Surgically?
Superficial spreading
Ulcerating
Nodular- morpeaform
Rarely metastasizes
Non: Topical 5-FU, Radiation
Surg: Excision, Mohs surgery
What is the precursor to Squamous Cell Carcinoma?
What PT population is this form more likely to be seen in?
Actinic Keratosis
Older male PTs
What are the RFs for PTs to develop Squamous Cell Carcinomas on the auricle?
Age
Non-healing ulcer
ImmSupp
Chemical
UV radiation
How do Squamous Cell Carcinomas of the auricle present on PE?
Why is this Dx less favorable than BCC?
Ulcerated plaque/nodule prone to bleeding
More aggressive, requires larger excision area for Tx
How are auricle SCC cases Tx w/ Non/Surg methods?
How do these Tx options change for cases that are more advanced?
Non: radiation
Surg: excision, Mohs
Neck dissection w/ parotidectomy
What is a poor prognosis finding for PTs w/ auricle SCC?
Characteristics of Malignant Melanoma
CN7 and lymph node involvement
Unpredictable tumor that affects all ages w/ high mortality rates
How does a Malignant Melanoma of the Auricle present on PE?
What is used to determine the severity and PT survivability?
Pigmented lesion that moves from epidermis to dermis w/ ABCDE changes
Depth of invasion
How are Malignant Melanomas of the Auricle Tx
What are the ABCDEs of determining if a lesion is a mole or melanoma?
Excision w/ possible lymph node dissection
Asymmetry Border Color Diameter Evolving
How doe Epidermal Inclusion Cysts present in clinic?
When/how are these growths Tx?
Well defined borders around soft, mobile and non-tender punctum that can spontaneously drain smely contents
At PTs request w/ Triamcinalone injection 3mg/mL
Where does blood accumulate during the formation of an Auricular Hematoma?
How are they Tx
Between cartilage and perichondrium
<24hrs: needle aspiration
>24 hrs but <7d: incision
Pack x 7days w/ 24hr f/u
What ABX are used for Auricular Hematomas
When do these PTs need to be referred?
Staph coverage: Dicloxicillin, Cephalexin
Pseudomonas coverage: Ciprofloxacin
Hematoma >7days old
When/where are Local Blocks used for Tx of Auricle Hematomas?
Simple lacerations
10mL 1% Lidocaine via 25-27g needle
Posterior: sulcus behind inferior pole of auricle
Anterior: superior and anterior to tragus
When/where are Regional Blocks used for Tx of Auricle Hematomas?
Up to 5mL of anesthetic can be used on each pass but do not exceed how much total?
Extensive lacerations, best for avoiding tissue distortion
Inject 5mL 1cm above superior pole of auricle directed anterior to tragus
4mg/kg of 1% Lidocaine
Lacerations to the ear that travel anterior to ear may disrupt or damage what two structures?
If imaging is needed for evaluating these injuries, what type is ordered?
CN7
Parotid gland
CT w/out contrast
What Tx method is preferred for ear lacerations?
When does this preference change?
Primary closure
Delayed closure if >24hrs or signs of inflammation
When do ear lacerations need to be referred to Plastics, OMFS, ENT or NeuroSurgery?
Basilar Skull Tx
Auricular avulsion
Laceration w/ EAC extension
Laceration w/ Middle/Inner injury (HL, Vestibular Sxs)
Define Cellulitis
Define Perichondritis
Define Chondritis
Infection of the skin
Infection of the tissue surrounding cartilage
Infection of the cartilage; spares lobule
Peri/Chondritis cases difficult to Tx due to ? and are MC caused by ? microbe
How are they Tx?
Lack of blood supply to cartilage
P. aeruginosa
Mild: PO Fluoroquinolone w/ f/u <24hrs
Mod-Sev: IV Fluoroquinolone w/ Aminoglycoside, possible surgical debridement
Characteristics of cerumen
How many impactions need to occur per year for a PT to be Dx w/ recurrent impactions?
Hydrophobic substance that creates acidic environment against bacteria/fungus and prevents skin penetration/maceration
> 1/yr
What are the two parts of the EAC
What is the name of the point where the EAC narrows
Lateral 1/3: cartilage w/ hair and glands
Medial 2/3: bone w/ skin attached to temporal bone
Isthmus, superior to mastoid process
What are the 4 etiologies of cerumen impactions?
Usually ASx, what Sxs can this condition present w/?
EAC Dz induced obstruction
Narrowed EAC
Failed migration
Over production
HL Otalgia Fullness Itching
What is the recommended hygiene frequency for PT w/ cerumen impaction?
What is the indication to remove impaction and what benefit can be expected?
External cleaning w/ washcloth max of 1/wk
Only remove if Sxs
PT hearing improves x 10dB
What are the 3 recommended methods in order of preference for removing cerumen impactions?
Do not use the first method for longer than ? days
Cerumenolytics
Irrigation
Manual removal
3-5days max use
Cerumenolytics are safe to use in PTs after r/o ? c/is?
When should these meds be avoided?
No Hx of Infection Perf or Oto surgery
Suspected TM damage: Otorrhea Otalgia Frequent infxn Hx
What are three types of cerumenolytics that can be sued for impaction Tx?
If irrigation is done, what mixture is used and where is it aimed at in the canal?
Mineral oil
3% Hydrogen Peroxide
Carbamide Peroxide 6.5%- 5-10 drops/ear x 15min BID x 4days or less
1:10 water/hydrogen peroxide dilution aimed posterior and up in canal w/out inserting catheter past lateral 1/3 of canal (<8mm)
After irrigating ear canal to remove impactions, what two steps should be done?
When are these f/u steps required?
Inspect
Acidification w/ water and 2% Acetic/Boric Acid
ImmComp PTs
Refer cerumen impactions to ENT for manual removal if ?
If PTs have predisposing conditions that put them at risk for recurrent impactions, what at home steps can be done to prevent formation?
TM perf
Recurrent impactions
Conservative Tx failure
COM/TM perf Hx
Mineral oil cotton ball x 1-15min 1/wk
Remove hearing aids at night
Provider cleaning q6-12mon
When using water during irrigation cleanings, why must water be at body temp?
Why does drying of the canal w/ air or alcohol after irrigation need to be done?
Avoid vestibular caloric response
Prevent development of external otitis
How do FOBs in the ear canal present?
What can happen if chronic/persistent retention occurs?
Pain Pruritis CHL Bleeding
Infection
Tissue granulation
What Tx step is not done for organic objects such as food or bugs found in ear canals?
What is done for insects discovered in the canal?
Irrigation
2% lidocaine
How does Otitis Externa present in clinic?
What adverse outcome can develop from this condition?
Painful erythema, edema and exudate from ear canal skin w/ pain from auricle manipulation
ImmComp can develop Osteomyleitis of skull base (malignant external otitis)
If PTs develop osteomyelitis from external otitis, what microbe is usually the cause?
Where does the infection start and how does it progress inward?
Pseudomonas aeruginosa
Floor of ear canal
Middle fossa floor
Clivus
Contralateral skull base
External Otitis is AKA ? and usually due to ? microbe/fungi?
These microbes or fungi are usually the cause of this AKA due to their preference to grow between ? pH?
Swimmer’s Ear
Gram Neg rods: Pseudomonas, Staph A
Aspergillus
6.5-7.3
What PE findings during assessing External Otitis indicates PT has an advanced/more severe case?
How are these cases w/out underlying infections Tx?
Adenopathy at periauricular/anterior nodes
50/50 isopropyl alcohol/white vinegar
2% Acetic acid
What ABX can be used for the Tx of moderate AOE?
Polymyxin B/Hydrocortixone- caution, contains neomycin, potential sensitizer of skin
Aminoglycosides- ototoxic, do not use if TM perf present
Quinolones- Cipro/Ofloxacin
When/why would systemic ABX need to be used for AOE Tx?
What medication is added and used in conjunction w/ systemic ABX?
Cellulitis DM ImmDef Severe Otitis Externa Edema present preventing application of topical meds
Cipro 500mg BID x 7d
Why does the TM become erythematous during otitis externa infections?
Why is this differentiation important
Lateral part of TM is ear canal skin
AOM allows TM to move w/ pneumatic otoscopy
Malignant external otitis can infect and impair ? CNs and signifies ?
How is this diagnosis confirmed?
6 7 9 10 11 12
Poor prognosis
Osseous erosion on CT scans
How is Necrotizing Otitis Externa Tx
Daily debridment w/ Antipseudomonal drops and systemic ABX
Cipro 200-400mg IV q12h,
Cipro 500mg PO BID until gallium scan proves dec/no inflammation
Refractory= surgical debridement
Define Exostoses
Define Osteoma
EAC lesions of broad based bony lesions made from lamellar bone
(AKA Surfer ear from cold water)
Pedunculated EAC lesion of benign neoplasms on tympanosquamous/mastoid line
? is the MC Ca neoplasm of the ear canal?
When is this Dx considered?
SCC
Otitis externa doesn’t resolve w/ therapy
Why do SCC in the ear canal have such a high fatality rate?
How are these Tx
Tumors tend to invade lymphatics in cranial base
Wide surgical resection and radiation therapy
Define Adenomatous tumors in EAC
What are the MC causes of ET dysfunctions
Tumor originating from ceruminous glands, indolent course usually
Viral URI
Allergies
PTs w/ ET dysfunction are at risk for ?
If dysfunction is due to viral illness, what meds may offer relief?
What third med is offered if PTs cause is allergies?
Serous otitis media
Pseudoephedrine
Oxymetazoline
Intranasal CCS- Beclomethasone dipropionate
What can cause the development of a Patulous Eustacian Tube
How is this condition’s presentation unique and used for Dx
Rapid weight loss
Worse w/ exertion
Better w/ URI
How are patulous ETs Tx
How is dilatory ET dysfunction Tx
Avoid decongestants
Ventilation tube insertion to reduce outward stretch
ET surgery
Pseudoephedrine Oxymetazoline Beclomethasone dipropionate (allergies)
Why are Peds PTs at higher risk for ET dysfunction
These RFs tend to self resolve by ? age of development
Shorter ET
Horizontal ET
Immature cartilage
Large adenoids
6y/o
What can cause Dilatory ET dysfunction to develop
What can cause Patulous ET dysfunction?
Inflammation (VURI, Allergy, 3rd Trimester)
Altitude changes
Anatomic/Congenital abnormalities
Weight loss
Scars
Neuro d/o induced atrophy
Hormones- high E during pregnancy, OCP, prostate Ca Tx
How does TM w/ dilatory dysfunction appear on PE
How does TM w/ patulous dysfunction appear on PE?
HL w/ retraction/effusion
Autophony
Normal TM w/out HL
TM moves w/ ins/expiration
Serous Otitis Media is AKA ?
What causes these conditions
OM w/ Effusion
Prolonged blockage in ET tube causing negative pressure forming transudate fluids
SOM is usually caused by ? three things
When does this Dx become concerning?
URI
Barotrauma
Chronic allergic rhinitis
Unilateral and persistent >3mon- nasopharyngeal Ca
How does SOM present on PE
What is the best way to confirm Dx
CHL w/ fullness
Dec TM mobility w/ visible bubbles
Tympanometry
How is SOM Tx
PO CCS- prednisone
Amoxicillin
No relief after months, ventilation tubes
Define AOM
How does this present in clinic
Bacterial infection in temporal bone
Otalgia w/ URI
Erythemic, hypomobile TM
What are the 3 MC microbes causing AOM
What mastoid findings may be seen on PE and what do they mean?
Strep Pneumo
H influenza
Strep pyogens
Tenderness, due to pus- non-emergent
Swelling over mastoid bone or CN neuropathies- urgent
What are 4 modifiable RFs for the development of AOM
What are the two non-modifiable RFs
Pacifier
Bottles
Day care
Second hand smoke
Allergies
Craniofacial abnormalities
How is AOM Tx w/ ABX
This step is only used if ? criteria are met?
Amoxicillin Resistant: Cefaclor, Augmentin* PCN Allergy- Mild-Mod: Cefdinir, Ceftriaxone Sev: Erythromycin + Sulfonamide
ABX:
Adult or <2y/o
No improvement x72hrs
Severe Sxs
Observe:
>2y/o
Healthy w/ mild illness (<102.2*)
Able to f/u, start ABX
When/why would a tympanocentesis be conducted for AOM work up?
When is surgical drainage indicated?
ImmComp and infection is recurrent w/ proper attempts at medical Tx
Myringotomy- severe otalgia or complications (mastoiditis, meningitis) occur
What is the criteria for recurrent AOM?
Recurrent cases of AOM can be managed w/ ? prophylactic drug?
What is the next step if this Tx method fails?
3 or more in 6mon
4 or more in 12mon
PO Sulfamethoxazole
PO Amoxicillin
Insert ventilation tubes
Define SNAP Approach to AOM Tx
Safety Net approach to ABX Prescriptions
Give Rx but only fill if failure to improve >72hrs or Sxs worsen
What is the #1 Sx of AOM that frequently goes untreated
What is an expected Amoxicillin reaction seen in kids?
Why is this expectation important to note?
Pain
Maculopapular rash on trunk, spreads >72hrs after ABX start
EBV infection= rash
Monospot test
What types of osseous changes may be seen in COM cases?
What are the common microbes seen in these cases?
Osteitis- inflammation of bone
Sclerosis- abnormal hardening
Pseudomonas
Proteus
Staph A
Mixed anaerobes
What is the hallmark of COM?
What ABX are used for Tx along w/ water avoidance?
Purulent aural discharge, worse during URIs or post-water exposure
Drops:
Ofloxacin 0.3%
Ciprofloxacin w/ Dexameth
PO Cipro- Pseudomonas infxn, helps keep draining ears dry
What is the definitive Tx method for COM?
What step is done if mastoid air cells are infected w/ irreversible infections?
Surgical TM repair w/ temporalis muscle fascia
Extended via mastoidectomy
Define Cholesteatoma
How is it Tx
COM variant;
MC from ET dysfunction w/ TM moving inward. Sac formed, filled w/ keratin= mastoid penetration, CN8 involvement
Surgical marsupialization- mastoid bowl
PE tubes
What meds are used for TM Perfs w/ purulence?
What types of meds must be avoided?
Ofloxacin/Cipro HC
Aminoglycosides
Alcohol
Polymyxin/Neomycins
When do TM perfs need to be referred to ENT for surgical repair?
What are the 3 layers of TM
Why are the layers important?
> 25% TM surface
Last >6wks
Persistent HL
Squamous Collagen Cuboidal
Squamous + Cuboidal= chronic perf, Tx w/ tympanoplasty
What is the image of choice for suspected cholesteatomas?
When is the imaging modality also preferred in suspected emergent cases?
CT
Mastoiditis
+ finding= emergency ENT
How is mastoiditis Tx w/ ABX
These ABX are directed at ? 3 MC microbes
IV Cefazolin
Myringotomy for culture
Tx failure/definitive= mastoidectomy
Strep Pneumo
H Influenza
Strep Pyogenes
How does Petrous Apicitis develop
What syndrome develops
Medial petrous bone between inner ear and clivus is obstructed
Gradenigos-
Retro-orbital pain
AOM/foul d/c
Abducens nerve/CN6 palsy
How are cases of Petrous Apicitis Tx
What complication can develop
Surgical drainage- petrous apicectomy w/ ABX
Meningitis
What is the difference in presentation and Tx between AOM and COM induced facial paralysis?
AOM- CN7 inflammation in middle ear (neurotoxin from bacteria)
Tx: myringotomy w/ IV ABX
COM: pressure of CN7 from cholesteatoma
Tx: surgery; less favorable prognosis
? is MC intracranial complication of ear infections
What is an uncommon complication from ear infections?
Otogenic meningitis
Brain abscess
What causes AOM to develop into Otogenic Meningitis
What causes COM to develop into Otogenic Meningitis
Hematogenous spread of H influena or Strep Pneumo
Spread through petrosquamous suture or through petrous pyramid dural plates
Brain abscesses from chronic infections are usually located in ? parts of the brain
These abscesses are usually d/t ? microbes?
Temporal lobe
Cerebellum
Staph A
Strep Pyogenes/Pneumo
Define Otosclerosis
What is the difference in types of HL in this condition
Familial tenency for bony growth on stapes, induces 60dB HL
Lesions on stapes= CHL
Lesion on cochlea= SHL
What medications can be used prior to air descent to help prevent barotrauma?
What is done for Tx of acute middle ear pressure persisting on ground level w/ pain and HL
Pseudoephedrine- hrs prior
Oxymetazoline- one hr prior
Myringotomy
Define Perilymphatic Fistula
What may be the only S/Sxs of decompression sickness during the ascent phase of a saturation dive?
Diving induced pressure causing round window rupture= SHL and Vertigo
SHL, Vertigo
Why are TM perfs a c/i for diving?
What Sxs can be experienced?
Unbalanced thermal stimulus to semicircular canals
Vertigo Disorientation Emesis
Since primary middle ear tumors are rare, what two types may be seen
How to they present to clinic?
Glomus tympanicum (middle ear) Glomus jugulare (jugular bulb w/ upward erosion into hypotympanum)
Pulsatile tinnitus and CHL
PTs w/ pulsatile tinnitus need ? imaging modality
Large glomus jugulare tumors can impact ? CNs?
Magnetic Resonance Angiography/Venography
CN 7 9 10 11 12
? two MC causes of earaches
Sensory innvervation of the ear is derived from ? nerves
OE and AOM
Trigeminal Facial Glossopharyngeal Vagal Upper cervical
What medication can be used to help reduce pain from glossopharyngeal neuralgia
If refractory to this medical management, what Tx step is next?
Carbamazepine
Microvascular decompression of CN9
? fluid surrounds the membranous labyrinth?
? fluid is within the membranous labyrinth and why is this type important?
Perilymph- similar to CSF
Endolymph- K+ ions for auditory signal generation
What is the difference between vertigo and dizziness?
What are the 4 broad categorical causes of dizziness?
All V is D, not all D is V
Vertigo
Pre/Syncope
Disequilibrium
Non-specific light headed (dec blood flow)
Vertigo is Latin for ?
Asymmetry of the vestibular system is due to damage/dysfunction in ? parts of the ear?
To turn
Labyrinth
Vestibular nerve/structures
What is the difference between peripheral and central vertigo?
Peripheral- studied by otolaryngologists
Central- studied by neurologists
Define Peripheral Vertigo
Define Central Vertigo
From dysfunction in labyrinth or vestibular nerve; more severe w/ sudden onset
Dysfunction in brain stem/cerebellum; milder/insidious onset
How can PTs w/ central vertigo present
How can PTs w/ peripheral vertigo present?
Slurred speech
Diplopia
Pathologic nystagmus
No auditory Sxs
Tinnitus
HL
Horizontal nystagmus
What is the key to Dx of vertigo
Vertigo work ups include ? evaluations
Duration
Associated HL
Audiogram
ENG/VNG
Head MRI
Peripheral causes of vertigo
Vestibular neur/labyrinthitis Meniere dz BPPV ETOH Barotrauma Semicircular hehiscence
Central causes of vertigo
Seizure
MS
Wernicke encephalopathy
Cerebellar ataxia syndrome
*evidence of brainstem involvement r/o peripheral but lack of brainstem involvement does NOT r/o central lesions
? is the cardinal Sx of vestibular dz
This cardinal Sx needs to be differentiated from ? three DDx
Vertigo
Imbalance
Light headed
Syncope
Acute peripheral lesions usually cause ? type of nystagmus to be seen?
What PE test can be conducted
Horizontal w/ rotary components and fast phase beating away from side w/ dz
Dix-Hallspike- elicits delayed fatigable nystagmus (peripheral)
Non-fatigable- CNS dz
What device is used during peripheral vestibular dz work ups to prevent visual fixations?
What is the name of the test used to demonstrate vestibular asymmetry?
Frenzel goggles
Fukuda test
Define ENG
Define VNG
Electronystagmography- electrodes record eye movements from visual/vestibular stimuli
Videonystagmography- camera records eye movement in response to stimuli
? test is sensitive and used to evaluate vestibular d/o?
Meniere’s Syndrome is AKA ? and only has ? two known etiologies
Caloric stimulation
Endolymphatic hydrops- trauma, syphilis
Classical Dx of Meniere is made w/ ? criteria
What would be seen on caloric testing in these PTs?
Episodic vertigo
SNHL
Tinnitus
Aural fullness
Loss/Impairment on affected side
How is Menieres managed?
What is added for Tx to refractory cases?
PO Meclizine/Diazepam
Acetazolamide
Intratympanic steroids
Endolymphatic decompression
Vestibular ablation
PT has vertigo, SNHL and tinnitus but NO hearing fluctuations means ?
Vestibular Neuronitis is AKA ? 3 terms
Migraine associated dizziness
Vestibular neuritis- preserved hearing
Labyrinthitis- unilateral SHL
Peripheral vestibulopathy
How do PTs w/ Labyrinthitis present
What will be seen on PE
Acute, continuous and severe vertigo <7days
HL w/ tinnitus
Spontaneous horizontal nystagmus, suppressed w/ fixation
+ head thrust test
What meds are used for Tx of labyrinthitis
What causes the Sxs of BPPV
ABX (fever/bacterial infxn)
Diazepam/Meclizine
Otoconia/sediment entering semicircular canals, shifts endolymph= stims CN8
? CNS d/o can mimic BPPV?
What imaging is needed for this suspected Dx
Vertebrobasilar insufficiency
MRI
How are central lesion PE findings different than those seen on BPPV exam?
How is BPPV Tx?
CNS- no latent period, fatigability of habituation of S/Sxs
PT: Epley maneuver, Brandt-Daroff exercises
How does the Epley maneuver help Tx BPPV
Only medication that is pregnancy safe for acute vertigo Tx
Encourages debris migration to ant/post canal and exit
Meclizine
What do PTs w/ Vestibular Neuronitis present w/?
What would be seen on PE
Vertigo w/out impaired auditory function x days-weeks
+ nystagmus
No caloric response bilateral
How are PTs w/ Vestibular Neuronitis Tx?
? is the MC cause of vertigo after a head injury?
Meclizine/Diazepam
Labyrinthine concussion
If PT has a basilar skull Fx after traumatic vertigo, what do they present w/?
What causes chronic post-traumatic vertigo to develop?
Severe vertigo x days-week
Same sided deafness
Cupulolithiasis- otoconia become detached during trauma
How is traumatic vertigo Tx
What do PTs w/ perilymphatic fistula present complaining of?
Diazepam/Meclizine
Vestibular therapy
SHL and vertigo worse w/ straining
What are 4 scenarios that can cause the development of perilymphatic fistulas?
How are these cases Tx
Ear slap
Barotrauma (fly/scuba)
Weight lifting valsalva
Stapedectomy complication
Head elevation w/ bed rest
Tx failure: middle ear exploration w/ grafting to close window
How does Migrainous Vertigo present
What may be seen in FamHx of these PTs
Episodic vertigo w/ HA
Phono/Photo-phobia
Sxs worse w/ sleep deprivation/stress, caffeine, chocolate and ETOH
Motion intolerance
How does migrainous vertigo differ from Menieres?
How are these PTs managed?
No HL/tinnitus
Antimigraine prophylaxis
Lifestyle changes
How do PTs w/ Superior Semicircular canal dehiscence present?
What form of imaging is needed?
How are they Tx?
Vertigo after loud noises or straining w/ CHL
Autophony
CT and VEMPs
Surgical resurface/plugs
How do nystagmus’ from central vertigo etiologies appear on PE?
What form of testing is useful for these cases?
Non-fatigable
Vertical and w/out latency
Not suppressed w/ fixation
ENG
Lesions on CN8 and central audiovestibular pathways cause ? issues
Characteristics of this type of lesion
Neural HL and vertigo
Dec speech discrimination
Auditory adaptation
What type of test is done to distinguish between cochlear from neural HL?
What type of imaging is needed and of ? structures?
Brainstem Auditory Evoked Response
MRI of internal AC, cerebellopontine angle and brain
What are the 3 d/os of the central auditory and vestibular system?
What is one of the MC types of intracranial tumors?
Vestibular schwannoma (acoustic neuroma)
Vascular compromise
MS
CN8 schwannomas (vestibular/acoustic neuroma)
Since most vestibular/acoustic schwannomas are unilateral, what condition causes bilateral growths?
What other types of growths may be seen intracranial/spinal?
Neurofibromatosis Type 2
Meningiomas
Where do vestibular/acoustic neuromas grow and cause issues?
What is the typical auditory Sx that PTs complain of?
Start in internal AC, grow into cerebellopontine angle, compressing pons= hydrocephalus
Unilateral HL w/ deteriorating speech discrimination
Any PTs presenting w/ sudden unilateral and asymmetric hearing loss need to have ? r/o
Prior to radiotherapy and surgery, what medication can be attempted for Tx of Neurofibromatosis Type 2 growths?
Intracranial mass via MRI w/ gadolinium
Bevacizumab- vascular endothelial growth blocker
How are PTs w/ acoustic neuromas Tx/managed?
? etiology of central vertigo can present nearly identical to Meniere’s w/ F>M and a genetic component?
ASx: observe w/ annual MRI
Sxs: excision, radiation and annual MRI
MS
How does MS induced vestibular issues present?
These PTs often present w/ ? associated Sxs from adjacent CNs?
Episodic vertigo
Chronic imbalance
Unilateral/rapid onset SHL
Hyper/poacusis
Facial numbness
Diplopia
? is a common cause of vertigo in elderly PTs after posture/neck extension movements?
What image is ordered prior to ? Tx
Vertebrobasilar insufficiency
MRA prior to empiric Tx w/ vasodilators, ASA
Hemifacial spasms and tic douloureux are examples of manifestations caused by ?
Vascular loops impinging on brainstem
How is Acute Peripheral Vertigo Tx
Object focus w/ blank back ground w/ slow head movements; inc speed w/out exacerbating N/V
How is Chronic Peripheral Vertigo Tx
Head/eye movements while standing and walking fwd/back including uneven surfaces
How are Bilateral Vestibular injuries Tx
No possibility for adaption, no improvement will occur
Fall prevention education*
Dark/uneven surface particularly challenging
How is central vertigo Tx?
Gait/balance exercise w/ head/eye movements
Take longer for improvement
Path of sound through ear
Sound waves of varying pressure heights enter
TM vibrates
Ossicles amplify vibration
Vibration passes through oval window to move fluid in vestibuli
Cochlear membrane movement bends hairs in basilar membrane
What are the two types of HL and parts of ear involved
How are these seen on Weber/Rinne tests
Conductive- external/middle ear
Sensorinureal- degeneration of Cochlea, CN8 lesion
CHL, Weber louder in affected side/BC>AC
SHL, Weber louder in normal ear/AC>BC
What are the 4 causes of conductive hearing loss?
Obstruction (MCC of CHL) Mass loading (middle ear effusion) Stiffness effect (otosclerosis) Discontinuity (disrupted ossicles)
Transient CHL is usually d/t ?
Persistent CHL is usually d/t ?
Impaction
ETD from URI
Chronic ear infection
Trauma
Otosclerosis
SHL is d/t ? while NHL is d/t ?
PTs w/ unilateral or asymmetric sensorineural HL suggests ? issues?
S: deteriorated cochlea (loss of hairs in organ of Corti)
N: lesion on CN8 or higher
Lesion proximal to cochlea (acoustic neuroma)
What is the first and second MC form of SNHL?
SHL is not medically or surgically correctable except for ? and ? can be used
Presbyacusis- loss of high frequency (bird chirp, phone)
2nd: noise trauma
Sudden SHL, CCS used
NHL can be due to lesions located where?
What other non-lesion causes can lead to this type of HL?
CN8
Auditory nuclei/cortex
Ascending tract
Acoustic neuroma
MS
Auditory neuropathy
What is the MC complaint of PTs w/ presbycusis?
Sounds above ? dB level can cause damage to cochlea
Lost speech discrimination in noisy environments
85dB
Noise trauma induced HL usually begins to be seen at ? frequency level?
Head trauma has an affect on the inner ear similar to ? type of trauma?
4000Hz
Severe acoustic
Certain degrees of SHL may be noted after simple concussions but is frequent after ?
What are the 3 most ototoxic medications?
Skull Fx
Aminoglycosides
Loop diuretics
Antineoplastics (Cisplatin)
How do PTs w/ sudden SHL present
How are these PTs managed
Sudden, unilateral HL in PTs >20y/o from infection/internal auditory artery occlusion
Prompt PO Prednisone w/ 10 day taper
Equal/better outcome w/ intratympanic CCS
Medical Tx for sudden SHL needs to be started w/in ? of start
What other test needs to be ordered w/ medication
<6wks
Audiogram
SHL is associated w/ ? autoimmune d/os?
What two issues can usually be seen accompanying the HL?
SLE
Granulomatosis w/ polyangitis (Wegener granulomatosis)
Cogan Syndrome- HL, keratitis, aortitis
Dysequilibrium
Posture instability
What lab tests are elevated in PTs w/ autoimmune induced HL?
What is the first and second line Tx?
ANA RF ESR
1st: PO Prednisone every morning x 2-3wks
2nd: Cytotoxic meds (Methotrexate)
What can cause PTs to experience pulsatile tinnitus?
What form of imaging do these PTs need?
Glomus tumor Venous sinus stenosis Carotid vaso-occlusive dz AV malformation Aneurysm
MRA and venography
What causes PTs to experience staccato tinnitus?
What medication can be used for tinnitus management?
Palatal myoclonus- soft palate movement
Nortriptyline 50mg qHS (every bed time)
What images are ordered for PTs w/ unilateral tinnitus w/out obvious precipitating factor?
Define Recruitment
MRA/MRV
Temporal bone CT
PTs w/ cochlear dysfunction experiencing hyperacusis to loud sounds and reduced sensitivity to softer ones
Sudden onset unilateral HL, regardless if tinnitus is present, can present ? issues
What do these PTs present complaining of?
Viral infection
Vascular accident
Poor sound localization
Difficulty hearing w/ background noise
Gradual loss of hearing can be due to ? issues
What CNs can be involved w/ one of these etiologies?
Otosclerosis
Noise induced loss
Vestibular schwannoma
Meniere dz
Vestibular schwannoma causing neuropathy w/ CN 5 or 7
Adult PT w/ HL and unilateral serous effusion should have ? next step taken
Audiology assessments consist of what 4 tests?
Fiberoptic exam of nasopharynx for neoplasms
Pure tone air/bone conduction
Speech reception threshold
Tympanometry
Acoustic reflexes
Audiogram thresholds are tested between ? ranges
These thresholds are measured in ? and relate to ? conclusion
250-8000 Hz
dB, higher threshold= poorer hearing
Define OSHA criteria for a STS
Audiogram symbols
> 10dB at 2-4000 Hz or,
Sum from 2-4000Hz is >30dB
Blue X- L ear, air conduction
Red O- R ear, air conduction
Blue >- L ear, bone conduction
Red
What are the two axis of the tympanometry?
Define Decapascal
X- pressure against TM
Y- compliance of TM
Unit of pressure equal to 1 Newton/sq meter
Type A Tympanogram
Normal
Peak near 0 decapascal
Compliance .2-1.8ml
Result: no middle ear pathology, intact TM, normal ET function
+HL= SNHL
Type As Tympanogram
Peak near 0 daPA, but dec compliance near 0.2ml
Results: ossicular fixation, otosclerosis or TM scars
Normal ET function
Type Ad Tympanogram
Peak pressure near normal, peak pressure above 2.0, extremely high compliance
Result: ossicular disarticulation/chain discontinuity
Normal ET function
Type B Tympanogram
Flat, no/poor peak w/ negative middle ear pressure > -200daPa
Little to No TM mobility present
Compliance below normal
Result: Fluid in middle ear or TM perf
Type C Tympanogram
Retracted TM or ET dysfunction
Define peak on negative side, indicated negative mid ear pressure
Normal peak compliance
Result: ET dysfunction w/ mild CHL and normal hearing
What are the names of the 4 sinus cavities?
What two are less developed in kids?
Frontal Ethmoid Sphenoid Maxillary
Frontal and sphenoid
Define the Ostiomeatal Complex
What is the function of this structure?
Connection between frontal, anterior ethmoid air cells and maxillary sinus and the middle meatus
Airflow and mucociliary drainage
PTs w/ ? presentation suggests a bacterial infection instead of acute viral rhinosinusitis
What “may be” the most effective management strategy against viral rhinitis?
Purulent nasal d/c
Annual influenza shot
What is the first medication for the Tx and prevention of influenza for high risk PTs
These high risk PTs include ?
Oseltamivir via neuroamidase inhibition
Young kids
Pregnant women
>65y/o
Although not proven to prevent the common cold, daily intake of ? >75mg has proven to shorten the course
What is used for Sx relief instead of NSAIDs for PTs w/ common cold?
Zinc acetate
3-5% hypertonic solution
PO pseudoephedrine
What are two nasal sprays that can provide rapid relief of common cold Sxs but only used for <3days?
If these meds are used chronic, what condition can PTs develop?
Oxymetazoline
Phenylephrine
Rhinitis medicamentosa
What are 3 medical options for Pts during the withdrawal phase of rhinitis medicamentosa?
What is a ‘well-accepted’ complication of acute viral rhinitis and what PE finding suggests this Dx
Flunisolide (CCS)
Anticholinergic- Ipratropium
PO Prednisone
Acute bacterial rhinosinusitis;
Sxs >10days
Green/yellow nasal secretion
Unilateral tooth pain
Where is the largest ostiomeatal complex located?
This largest complex is the drainage point for ? sinuses
What is the only sinus cavity not drained by the ostiomeatal complex and where does it drain to?
Deep to middle turbinate of middle meatus
Maxillary, Ethmoid, Frontal
Sphenoid- between septum/superior turbinate
What microbes can cause Community Acquired ABRS
What microbes cause Hospital acquired ABRS?
Strep pneumo
H influenza
Staph A
M catarrhalis
Pseudomonas/Gram negs
Staph A
How is bacterial rhinosinusitis distinguished from viral etiologies?
What are the time frames for Dx acute, subacute and chronic rhinosinusitis?
Sxs >10 days
Worsening Sxs w/in 10 days after improvement
Severe Sxs/>102.2* fever and facial pain/discharge x 4days
Acute: <4wks
Sub: 4-12wks
Chronic: >12wks
? is the MC form of acute bacterial rhinosinusitis
What is this MC form’s etiology
Maxillary sinusitis
Largest sinus w/ single drainage path
S/Sxs of Acute Maxillary Sinusitis
? other form of sinusitis usually accompanies Maxillary Sinusitis?
Unilateral facial fullness
Pain over upper incisor/canine d/t CN5 on floor of sinus
Ethmoid
Pt w/ HA in middle of head may have ? type of sinusitis
This form of sinusitis is usually seen in the setting of __-sinusitis
Sphenoid
Pan sinusitis
PT w/ painful/tender forehead may have ? type of sinusitis and has pain elicited by ?
? type of sinusitis presents w/out usual Sxs, fever, and may be in PTs w/ NG tubes
Frontal sinusitis, tapping on orbital roof below medial eyebrow
Hospital Associated sinusitis
What are expected PE findings of acute rhinosinusitis
Although heavily discouraged, if x-ray is ordered to view maxillary sinus, what view is ordered?
Pain w/ palpation/bending*
Narrowed middle meatus
Hypertrophic inferior turbinate
Septal deviation/polyps
Upright water’s view
How are PTs w/ bacterial rhinosinusitis Tx
Since ABX are controversial, when are they used and recognized as the most cost-effective Tx strategy?
NSAIDs PO Pseudoephedrine (systemic decongestant) Nasal oxymetazoline (topical decongestant) Mometasone furoate (intranasal CCS) for facial pain
Sxs >10days
Fever and facial pain/swelling
ImmDeficient
What ABX are recommended for use if Tx ABRS?
Due to increased resistance and poor sinus penetration, what are three ABX that are not used for Tx?
Augmentin
PCN allergy/dec liver function- Doxy or Clinda w/ Cephalosporin (Cefixime)
Macrolides (Azithromycin)
TMP/SMX
2nd/3rd Gen cephalosporins
How does acute bacterial rhinosinusitis lead to orbital complications?
If this complication develops, PTs will present complaining of ?
Via ethmoid sinus through lamina papyracea (thin bone in medial orbital wall)
Proptosis
Restricted gaze
Orbital pain
What part of the face is MC involved in Osteomyelitis complications from ABRS?
This condition creates tender swelling of forehead that is AKA ?
Frontal sinus
Pott Puffy Tumor
PT presents w/ proptosis, ophthalmoplegia and pain w/ medial gaze indicates ? issue
What happens if these cases are delayed and do not receive prompt decompression?
Subperiosteal abscess (orbital abscess)
Permanent visual impairment and “frozen globe”
How is ABRS extension into intracranial space visualized?
This form of imaging is needed to evaluate ? area
MRI
Danger Triangle
How do intracranial spread of ABRS occur and what do the different types of spread cause?
Hematogenous- cavernous sinus thrombosis; meningitis
Direct extension- epirdural/intraparenchymal abscesses
What are the S/Sxs of a cavernous sinus thrombosis
What image is used to confirm Dx and how is it Tx
Ophthalmoplegia
Chemosis
Visual loss
MRI; IV ABX
Although typically silent, how do frontal epidural/intracranial abscesses present?
What microbe is usually the cause of nasal colonization/vestibulitis?
AMS Fever Severe HA
Staph A
How is nasal vestibulitis/nasal colonization Tx
What is added if cases are recurrent and used to eliminate carrier states?
Why do these cases need to be Tx quickly and effectively?
Dicloxacillin w/ Mupirocin
Chlorhexidine facial washes
Rifampin
Prevent spread into cavernous sinuses and intracranial structures
Define Rhinocerebral Mucormycosis
What microbe is usually the cause?
What are the feared end results of these cases?
Fungal infection in ImmComp PTs
Aspergillus or Mucor/Absidia/Rhizopus
Spread to optic nerve/thrombosis/seizure/stroke
How do PTs w/ rhinocerebral mucormycosis present?
What is the classic PE finding of this Dx?
Sxs like ABRS but more severe facial pain w/ clear/straw nasal d/c
Black eschar on middle turbinate
What procedure is done to confirm Dx of rhinocerebral mucormycosis?
How is it Tx w/ meds?
How is it Tx w/ surgery?
Nasal biopsy for silver stains showing branching non-septate hyphae w/ necrosis
Amphotericin B- DOC
Voriconazole
Caspofungin
Wide debridement w/ medial maxillectomy
Since rhinocerebral mucormycosis is almost exclusively seen in ImmComp PTs, what are the mortality rates of the different compromised?
What is the source of dust mite allergies?
Diabetics- 20%
Kidney dz- >50%
AIDS/heme malignancy w/ neutropenia- 100%
Protein in mite feces/decaying bodies
Allergic rhinitis is associated w/ ? Dx
Seasonal allergic rhinitis is MC caused by ?
What are the etiologies of year round allergies?
Asthma
Pollen/Spores
Dust Mites Pollution Dander
? Dx has strong FamHx of Atopy?
? is the mainstay of Tx of this condition
Allergic rhinitis
Atopy- genetic tendency to develop allergic dzs
Intranasal CCS
What are examples of intranasal CCS used for Tx allergic rhinitis
Since these usually don’t provide relief until after 2wks of used, what can be given for immediate relief?
What medication is reserved for last and only for PTs that can’t tolerate s/e of PO meds?
Beclomethasone Flunisolide Mometasone furoate Budesonide Fluticasone propionate
PO antihistamines:
Non-sedate: Des/Lorata/Fexofenadine
Min-sedate: Cetirizine
Sedate: Brom/Chlorpheniramine
Azelastine nasal spray
What adjunct meds are used for the Tx of allergic rhinitis?
Anti-leukotrienes:
Montelukast
Mast cell stabilizers:
Cromolyn sodium
Soidum nedocromil
When Tx allergic rhinitis, what med is best for optho Sxs?
What is the most effective method for relief of Sxs?
Mast Cell stabilizer:
Cromolyn sodium
Allergen avoidence
If PTs have extreme Sxs of allergic rhinitis, consider referral to allergist for ? test
What are the 4 types of non-allergic rhinitis?
RAST: Serum Radioallergosorbent Test
Gustatory- spicy food
Medicamentosa- Afrin
Vasomotor- hyper reactivity
Occupational- smell/fumes
Allergic rhinitis needs to be carefully r/o from ? rhinitis?
This DDx is due to ? and often seen as ? in elderly PTs
Vasomotor
Sensitivity of vidian nerve
Clear rhinorrhea
What is the MC s/e of using intranasal CCS for the Tx of allergic rhinitis?
What medication is better for Tx of vasomotor rhinitis?
Epistaxis
Intranasal anticholinergic- Ipratropium Bromide
Epistaxis MC occurs from ? location
If pressure x 15min fails to stop bleeding, what is the next step?
Unilateral anterior cavity from Kiesselbach plexus
Topical sympathomimetics
Nasal tamponade
Define Osler-Weber-Rendu Syndrome
What two types of medication classes are associated but not a cause of epistaxis?
Hemorrhagic telangiectasia causing epistaxis
Anti-coag/platelet
Posterior nosebleeds come from ? plexus and are usually due to ?
Steps for anterior epistaxis Tx
Woodruff plexus
Artherosclerosis and HTN
1- PPE
2- Pressure x 15min in sitting/leaning position
3- Phenylephrine/Oxymetazoline w/ 15min pressure
4- Oxymetazoline or Tera/Lidocaine
5- Cauterize w/ silver nitrate;
Patch w/ GelFoam
6- Pack
How are anterior epistaxis cases packed?
ABX- prevents TSS
Insert along floor
Push w/ speculum
Use 2x floor length, grasp midpoint and insert posteriorly
How are posterior epistaxis cases managed?
What is the final disposition for these PTs?
Tamponade Packing Double balloon Ligate- internal maxillary, facial, ethmoid arteries Rarely- external carotid
Admit- vasovagal HOTN possible
After posterior epistaxis packing, ? needs to be avoided?
What meds are given to these epistaxis PTs?
Spicy food
Tobacco
Opioids- relief and BP
Epistaxis lasting longer than ? need to go to ER
PTs w/ nasal Fx need to have ? Dx r/o during PE?
15min
Zygomatic complex Fx causing step offs/numbness
Septal hematomas form between ? structures?
What is the concern w/ these injuries?
Perichondrium and Cartilage
Necrosis to perforation
Septal hematomas are at risk for becoming ? or infected w/ ? and prevented w/ ? med
How are they managed?
Saddle Nose
Staph A
Cephalexin/Clinda
InD bilaterally
How long after nasal Fxs are closed reduction attempted?
How are complex Fxs of the midface classified?
<7days of injury under general anesthesia
Le Fort System:
1- horizontal
2- pyramidal
3- craniofacial
Anterior epistaxis that are not controlled by tamponades need to have packing placed to occlude ? structure
? is the MC Fx bone in body
Choana- opening between nasal cavity and nasopharynx
Nasal pyramid
What must be r/o on all nasal Fxs?
Where does septum receive nutrients from?
Septal hematoma- looks like widening of anterior septum posterior to columella
Mucoperichondrium
Asthma + nasal polyps= no ? meds
This can cause ? triad
ASA
Samter- Polyp Asthma Spasms
? is the best known precancerous lesion of the mouth
This finding represents ? pathological/histological occurrence?
Leukoplakia
Hyperplasia of the squamous epithelium
What is the sequence of changes at the cellular layer in leukoplakia?
Although associated w/ Ca, what non-malignancy condition can it be seen in?
Hyperplasia
Dysplasia
Carcinoma in situ
Malignant tumor invasion
Hyperkeratosis from chronic irritation
What oral finding is similar to leukoplakia but more erythematous and more likely to show dysplasia/carcinoma changes?
If adenopathy is found during an exam, what is the next step for these Pts?
Erythroplakia
FNA
? is the MC PO Ca and how does it appear on PE
? RFs indicate PT may have this Dx
SCC- raised firm and white at base w/ pain and >4mm
Tobacco and ETOH
How is SCC of the mouth Tx by size
<4mm deep- unlikely to metastasize
<2cm- local resection
Pos margins/metastatic- radiation
Oral lesions lasting longer than ? should be considered for referral
? is believed to the etiology of nearly 70% of oropharyngeal SCC development?
> 2wks to OMFS/ENT
HPV-16
What are the ABCDEs of melanomas?
Define melanosis
Assymetry Border irregularity Color variation Diameter increase Elevation
Symmetric dark patches in oral mucosa in PTs w/ darker skin
Define Melanotic Macule
? is the MC site to find amalgam tattoos?
Symmetric shape w/ sharp borders in adults that don’t change
Mandibular arch
Define Fordyce Spots
Define Lichen Planus and the two types
Benign neoplasm of sebaceous glands at border of vermillion/buccal mucosa
Wax/waning inflammatory condition in PTs >40y/o
Reticular: painless white striae or buccal papules
Erosive: painful erythema/ulcers w/ white striae surroundings
How is Lichen Planus Dx
How are these PTs managed?
Exfoliative cytology or biopsy
Topical CCS
Cyclosporin
Retinoids
Tacrolimus- most evidence
? other Dx may be present in PTs w/ thrush
What are the 4 types of Candidiasis that can cause thrush?
Angular cheilitis
Albicans*
Glabrata
Krusei
Tropicalis
What are the two different presentations of oral thrush?
Pseudomembranous- MC overall; white plaques on mucosa
Atrophic- denture stomatitis, MC in adults; erythema w/out plaques
How is thrush Dx
What are the known RFs that can lead to it’s development?
KOH- budding yeast, pesudohyphae, non-septate mycelia, spores
Dentures Debilitated w/ poor hygiene DM Anemia Chemo/radiation CCS Broad ABX
How is thrush Tx in infants and kids?
Infant:
Topical antifungal
Nystatin
Refractory cases- gentian violet, PO Fluconazole
Older kid w/ <50% mucosa involved and no erosion:
Topical nystatin
Clotrimazole
Older kid w/ >50% mucosa involved, erosive or refractory:
Systemic therapy
Fluconazole
How are PTs w/ HIV and thrush Tx
PTs that wear dentures and develop thrush are Tx w/ ?
Fluconazole
PO Itraconazole (refractory)
Voriconazole (resistant to first line -azole)
Nystatin powder
How are adults w/ Thrush Tx
Fluconazole
Ketoconazole
Nystatin rinse
Chlorhexidine
Half H2O2 rinses
Nystatin powder
Aphthous ulcers have a known incidence finding due to ?
Where are they found and how do they appear
HPV-6
Fee moving, non-keratinized mucosa (+buccal/labia/ventral tongue, - gingiva, palate)
Yellow/gray center w/ red halo
Size criteria for minor and major aphthous ulcers
What is the major/most common predisposing factors to an aphthous eruption?
Minor: <1cm
Major: >1cm
Stress
Viral rhinitis
Bedtime after 11pm
How are aphthous ulcers Tx/managed?
What medication is used for maintenance therapy and recurrent ulcers?
What is used for recurrent ulcers in HIV PTs?
Triamcinolone acetonide Fluocinonide 7d Prednisone taper Diclofinac in hyaluronan Amlexanox
Cimetidine
Thalidomide
? is MC cause of oral ulcers
What are two GI Dxs that can cause ulcers to appear
What vitamin deficiencies can lead to eruptions?
Recurrent Aphthous stomatitis
Celiac/IBD
B 1,2,6, 12
Fe/Zn
Folic acid
Herpetic ginigvostomatitis is from ? virus
Where do they appear and what do they look like?
HSV-1
Clustered vesicles on vermilion border
Rupture, ulcer and crust <48hrs, heal 7-10d
? are the precipitating factors that can lead to a herpetic gingivostomatitis eruption?
HOw is a Dx confirmed from clinical suspicion?
UV light Trauma Fatigue Stress Menstruation
Multi-nucleated giant cells on Tzanck smear
How are PTs w/ Herpetic Ginigvostomatitis Tx
How does Varicella Zoster appear on exam?
Acyclovir
Valacyclovir
Only effective if initiated <48hrs of prodrome Sxs
Vesicles and erosions grouped unilaterally on dermatome in PT w/ Hx of chicken pox
Define Atrophic Glossitis
What are the causes of this condition?
Inflammatory d/o of tongue leading to atrophy of papillae leading to smooth/red tongue
Fe/B12/Folic acid Sjogren syndrome Candidiasis Protein/calorie malnutrition Celiac dz
Loss of ? part of the tongue leads to geographic tongue?
This finding is associated w/ ? other d/os?
Filiform papillae
Candidiasis
Reiter syndrom
Psoriasis
Lichen planus
How are tonsils graded?
0- no tonsils 1- hidden behind pillars 2- extend to pillar 3- extend beyond pillar 4- extend to midline
Define Centar Criteria
How do scores correlate to Tx
3/4 suggest GAS Dx: Fever >100.4 Anterior cervical adenopathy No cough Exudate from tonsils Modified: <15y/o or >44y/o
0-1: no Tx, rapid Ag, culture
2-3: culture/Ag test
4 or +: empiric Tx w/out Ag/culture results
Identifying and Tx GAS infection of the throat is important for prevention of ? two sequelae?
Why is there hesitancy to giving ABX to all sore throats?
Rheumatic fever
Glomerulonephritis
Developing ABX resistant Strep Pneumo
Lymphadenopathy and shaggy, white/purple tonsil exudate moves Dx from GAS to ?
What lab results suggests EBV etiology?
Mono
Lymphocyte to WBC ratio >35%
PTs w/ Mono and underlying tonsilitis need to avoid ? ABX
Alcoholics w/ low fever and gray tonsilar pseudomembrane don’t have Mono or Strep but ? Dx
Ampicillin- can cause rash that is mis-Dx as PCN allergy
Diphtheria
What are the MC pathogens other than GABHS in a sore throat DDx?
What PE finding suggests a viral etiology?
N gonorrhoeae
Mycoplasma
Chlamydia trachomatis
Rhinorrhea
Lack of exudate
? 3 microbes can cause PTs to appear to have pharyngitis from GABHS?
What ABX is used instead
Corynebacterium diphtheria
Anaerobic streptococci
Corynebacterium haemolyticum
Erythromycin
What ABX is the TxOC for GAS
Pen VK 1.2M units
Cefuroxime
IM Benzathine Pen G- compliance/crowded living concerns
PCN sensitivity:
Clinda/Azithromycin
Peds <27kg:
Pen VK
Bicillin C-R
PCN Sensitivity: Azith
How are PTs w/ Mono Tx
How long do these PTs need to avoid sports/contact activities?
NSAID/lozenges
CCS
Mod sports x 3wks Sx onset
Strenuous/contact x 4-6wks
Peritonsillar Cellulitis and Abscesses are AKA ? and develop when ?
What do PTs present w/?
Quinsy tonsil; infection penetrates tonil capsule and surrounding tissue
Odynophagia
Trismus
Medial deviation of soft palate
Hot potato voice
After Tx, if peritonsillar cellulitis doesn’t resolve it can turn into ?
This Dx is confirmed by doing ? procedure
Peritonsillar abscess
Aspirating pus from peritonsillar fold superior and medial to upper tonsil pole w/ 19-21g
When aspirating pus from peritonsillar abscess, needle depth should not exceed ? because ?
Since most PTs are seen in ER, what meds are they given?
1cm
Internal carotid lies medially
Amoxicillin
Clindamycin
All peritonsillar abscesses must be Tx via ? 3 methods?
When can these PTs be monitored w/ IV ABX prior to Tx
Needle aspiration
InD
Tonsillectomy
No airway compromise, septicemia or trismus
Criteria for adults to be considered for Tonsillectomy only after observation?
How many minor salivary glands are there?
<7 infections in past year
<5 infections in past 2yrs
<3 in past 3 years
750-1000 submucosally in lips-trachea
What glands does Sialadenitis involve?
What causes this condition to develop?
Parotid
Sub-mandibular
Dehydration
Sjogren
Staph A- MC microbe
How is Sialadenitis Tx
If the above medical Tx fail, what Dx need to be considered?
Sialagogues- lemon drops
IV Nafcillan
Abscess
Stricture
Stone/tumor
How is Suppurative Saladenitis different?
Since an immediate referral is needed, what ABX are PTs placed on?
No pus is expressed from stenson papilla
No response to hydration/ABX
Nafcillin and either Metronidazole or Clindamycin
ImmComp PT: Vancomycin
Sialolithiasis MC affects ? structure?
What imaging is used and what will be seen depending on the structure involved?
Wharton duct
CT-
Wharton- large, radiopaque
Stenson- small, radiolucent
How is Sialolithiasis Tx based on size of stone
<2cm from duct: sialagogues, massage, InD
> 2cm from opening: sialoendoscopy; management of choice if chronic case
What are 3 examples of drugs that have caused parotid gland enlargement?
Salivary gland tumor and ? PE finding correlates to probable malignancy?
Thioureas
Iodine
Phenothiazine/cholinergics
CN7 involvement
Vocal cords are attached to ? structures
How is pitch controlled?
Arytenoid/Thyroid cartilage
Vocal fold tension-
Tight= higher
Larger/thicker folds in men= deeper pitch
What structures help produce vowel sounds of words?
What structures help w/ enunciation?
Pharynx muscles
Face Tongue Lip muscles
What are the primary Sxs of laryngeal Dz
What causes these Sxs
Hoarseness
Stridor
Hoarse- abnormal vibration of vocal folds
What causes ‘breathy’ voices?
What causes ‘harsh’ voice?
What causes a ‘rough’ voice?
Breathy- paraylsis or mass
Harsh- stiff w/ irregular vibrations, laryngitis, malignancy
Rough- edematous folds
Define Stridor
What is the opposite of stridor?
High pitch sound of inspiration d/t narrowed glottis at/above vocal folds
Expiratory/biphasic stridor- narrowing below vocal folds
PTs w/ hoarseness lasting longer than ? need to be referred?
If co-existing Sxs such as ? are present, worry level increases
2wks
Severe cough Hemoptysis Unilateral throat/ear pain Dys/Odynophagia Unexplained weight loss
? is the MC cause of hoarseness
This MC cause is usually due to ?
Acute laryngitis <3wks
Vocal abuse
Post-URI x 7 days
What two microbes are most likely to cause acute laryngitis?
? medication may be used to shorten the course of hoarseness due to acute laryngitis and what does it provide?
M catarrhalis
H Influenza
Erythromycin
Horaseness at 7d
Cough at 14d
What PT population may benefit from a IM CCS injection to help Tx acute laryngitis?
Why are most people with this Dx recommended to avoid straining their voice?
Pro singers
Vocal cord hemorrhage
Poly/Cyst formation
What are the etiologies of chronic laryngitis?
Time frame for a Dx of chronic laryngits
Toxins GERD Post-nasal drip ETOH abuse Chronic vocal strains
> 3wks
Tobacco use + chronic laryngitis can cause ? development to occur
How do PTs w/ Epi/Supraglottits present and ? presentation is a red flag?
Keratosis
Polypoid corditis
Odynophagia OOP to exam
Drooling
Epiglottitis is more likely to occur in ? PT population
Upon Dx, PTs are admitted and Tx w/ ? ABX?
DM
Ceftriaxone or,
Cefuroxime and,
Dexamethasone
What are the indications that a PT w/ epiglottitis needs to be intubated?
How do PTs w/ Laryngopharyngeal Reflux present?
Dyspnea
Rapid sore throat progression
Endolaryngeal abscess seen on CT images
Hoarseness
Persistent cough
Esophageal spasm
Globus sensation in throat
What is the best method for documenting reflux to the pharynx in PTs w/ Laryngopharyngeal Reflux?
The test is considered the best option for evaluation?
How are PTs Dx?
24hr pH monitor but, difficult and not widely used
Double pH probe
Omeprazole x 3mon
H2 antagonist- less efficacy
? are the MC lesions of the larynx
Where do these MC lesions tend to develop?
Papillomas
Ciliated/Squamous epithelium junctions
Recurrent papillomas are almost always due to ?
What medication has proven effective to Tx recurrent respiratory papillomatosis
What is the risk of using this medication?
These are the MC lesion of the larynx and also the MC ?
HPV 6,11
Cidofovir- cytosine nucleotide analog used to Tx CMV rhinitis
Adenocarcinoma development
Benign laryngeal tumor in kids
What PT population is likely to have cell transformation of recurrent respiratory papillomatosis?
How do PTs present and what would be seen?
Smokers
Hoarse to stridor progression
Multiple warty lesions on cords
How are papillomatosis cases Tx?
How can this condition be prevented?
Laser/Cold knife
Gardasil 9
What are the goals of papillomatosis Tx?
What are the 4 traumatic but benign lesions of vocal cords?
Voice development
Structure preservation
Avoid tracheotomy
Nodule Polyp Cyst
Polypoid corditis
Vocal fold nodules are AKA in adults and AKA in kids
What type of appearance do they develop into?
Adult- singer nodule
Kid- screamer nodule
Smooth paired lesions at junction of ant/post folds
How to vocal fold polyps appear
These can be a common sequelae in PTs after ?
Unilateral mass within superficial lamina propria of folds
Vocal fold hemorrhage
Where do vocal fold cysts tend to develop?
Why is Tx of these difficult?
Mucus secreting glands in inferior vocal folds
Leave behind sulcus/scar resulting in permanent/chronic dysphonia
Laryngeal leukoplakia of the vocal cords have common associations w/ ? PT populations?
Almost all PTs will get ? procedure and ? can be the initial discovery
How are these cases Tx
Smokers
Direct laryngoscopy w/ biopsy; SCC
Smoking cessation
PPI (mainstay)
Radiation
How does SCC of the larynx present
SCC of the larynx is the MC ?
Smoker w/ hoarsenss >2wks
Throat/ear pain w/ swallowing
Mass/hemoptysis
Malignancy of larynx
SCC of the larynx can be due to ? infection
This Dx has the strongest prevalence in ? PT population?
HPV 16, 18
Non-smoker
What is the MC initial complaint of PTs w/ SCC in the larynx
What is the difference between glottic cancer and supraglottic cancer?
Change in voice quality
True vocal fold- mobile cords, rarely metastasize
False/aryepiglottic/epiglottis- metastasize early in dz
When do PTs w/ laryngeal SCC need a CXR?
What are the 4 goals of Tx
Level 6 nodes around trachea/thyroid
Level 4 nodes inferior to cricoid cartilage along internal jugular
Cure
Preserve swallowing
Preservation of voice
Avoiding tracheostoma
Table 8-1
Slide Deck 6
How are supra/glottic Ca Tx
If PT has vocal cord paraylsis from damaged vagus/recurrent nerves, how doe they present?
Early- radiation, standard of care
Late/large/metastasis- multi-modal Tx
Breathy dysphonia
Effortful voice
? is the MC cause of unilateral vocal cord paralysis?
? is the second MC cause?
If no SurgHx, what is the next step
Iatrogenic
Idiopathic
Normal CN exam- CT w/ contrast
Abnormal CN exam- MRI
Unilateral recurrent nerve injury causes the affected vocal cord to assume ? position?
What causes vocal cord dysfunction/paradoxical vocal fold movement?
Paramedian- partially lateralized
Upper airway obstruction from paradoxical cord adduction
PTs w/ Vocal Cord Dysfunction have a 40% chance of having ? Dx too
How is this condition Dx
Asthma non-responsive to bronchodilators
Direct visualization showing adduction w/ both ex/inspiration
How is Vocal Cord Dysfunction Tx
An enlarged lymph node is any node larger than ?
Speech therapy- 1st line Tx
Stop any steroids
Acute Tx: CPAP and breathing exercises
> 1cm
What is the Neck Mass Rule of 7s?
How does this rule apply w/ age considered?
Days- inflammatory. rapid growth/pain
Weeks-Months- neoplasm, slow growth/painless
Years- congenital
<16: inflammatory, congenital
16-40: inflammatory/congenital but malignancy risk begins to increase
>40: Ca MC cause
<30, >70: lymphoma needs to be r/o
What are the 3 most significant predictors of a neck mass?
What types of Hx are concerning for possible malignancy
PT age
Size
Duration
Smoking
Heavy ETOH
Radiation Tx to neck
Define Ludwig Angina
This Dx is the MC ?
Why does this become a medical emergency?
Bilateral infection of submandibular space (submylohyoid + sublingual spaces)
Neck space infection
Tongue pushed up/back
? is the MC cause of deep neck abscesses?
Define Lemierre Syndrome
Odotogenic infection
Thrombophlebitis of internal jugular vein secondary to oropharyngeal inflammation
Lemierre Syndrome is typically seen in ? PT populations?
What are the S/Sxs of this Dx
ICU w/ prolonged internal jugular catheters
Severe HA
Pulmonary infiltrates
PTs w/ recurrent deep neck infections need to have ? Dx r/o
Deep neck infections w/ suppurative lymphadenopathy in middle age PTs w/ ? Hx are suspected ? Ca
Congenital lesions- brachial cleft cyst
Tobacco/ETOH
SCC
? are the 4 MC microbes causing Ludwigs/Deep neck abscesses?
What type of images are needed?
Strep
Staph
Bacteroides
Fusobacterium
CT w/ contrast
What ABX are given via IV for the Tx of Ludwigs Angina
If the airway is compromised, ? procedure is needed?
PCN + Metronidazole/Clina
External drainage via bilateral submental incisions
Lemierre Syndrome is usually due to ? microbe
? ABX is used for Tx
Fusobacterium Necrophorum
Metronidazole
Define Reactive Cervical Lymphadenopathy
This Dx has ? MC title
What causes this condition
Painful enlargement of nodes from infection/inflammation
Neck masses in all age groups
Pharynx/salivary/scalp infection
How is Reactive Cervical Lymphadenopathy Tx
What are the 3 indications for FNA
Augmentin
Clinda
> 1.5cm w/out infection
Tobacco/ETOH/Ca Hx
Persistent enlargement
What are the two etiologies of Reactive Cervical Lymphadenopathy?
Tumors- SCC Lymphoma, Metastases
Infection-
Virus
Mycobacteria
Cat Scratch (Bartonella Henselae)
What tool is used to measure the severity of sleep apnea?
How is this complaint Dx
Epworth Sleepiness Scale: 0-24
>10= abnormal, supports excessive daytime sleepiness complaints
Polysomnography
What are the non-surgical methods for Tx of OSA
What are the surgical methods for Tx of OSA
CPAP
BiPAP
Radiofrquency thermal fibrosis
UPPP
Craniofacial procedure
Hypoglossal nerve stimulation w/ simulator
What are the two primary indications for tracheotomy?
How are foreign bodies in the upper aerodigestive tract Dx and Tx
MCC- respiratory failure requiring prolonged mechanical ventilation
Obstruction at/above larynx
Dx: CXR
Tx: bronchoscopy
S/Sxs of foreign body in esophagus
How are they Dx
How can this be Tx
Drooling w/ pointing to level of obstruction
Radiograph
Observation/endoscopic removal
? is the MC congenital mass of the lateral neck
Where does this MC tend to appear in PTs
How are these findings confirmed w/ PE?
Branchial Cleft Cyst- remnant of embryological development in the neck during 2-3rd decade
Along SCM
On face near auricle
Not midline, don’t move w/ swallowing
What image is used to Dx Brachial Cleft Cysts
What is done for Tx
CT
Excision w/ fistula to prevent future infection/Ca
Frozen sections to r/o malignancy
? is the MC congenital mass of the central neck
How can this Dx be confirmed w/ PE
Thyroglossal Duct Cyst- remnant of embryologic descent of thryoid
<20y/o w/ midline cyst below hyoid; moves w/ swallowing and tongue protrusion
How are Thyroglossal Duct Cysts Dx
How are these Tx
What must be done prior to Tx
TSH levels; abnromal= thyroid scan w/ CT
Surgical removal of cyst and fistula
Thyroid US to confirm thyroid positioning
What is the name of the procedure to remove a thyroglossal duct cyst
How are head and neck Ca exams fully completed
Sistrunk procedure- removes duct at base of tongue, cyst and medial segments of hyoid bone
Triple endoscopy:
Direct laryngoscopy
Bronchoscopy
Esophagoscopy
What is the next step for head/neck Ca if triple endoscopy fails to show a confirmed Dx
SCC of the head/neck tends to metastasize first to ? part of the body prior to moving to ?
MRI/PET and biopsy
First- neck lymph nodes
Then- lung, liver, bone, brain
Why do ENTs use rigid endoscopes more often than other specialties
What ages do Non/Hodgkins Lymphoma peak
Easier to biopsy
20 and >50
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 and
Tx: surgery and poor I-131 uptake
Anaplastic/undifferentiated: most aggressive, poor prognosis
Dx: FNA
Tx: surgery and radiation, poor I-131 uptake
What type of thyroid Ca has an association with MEN-2A
Medullary
