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ENT Pt 2 Flashcards

1
Q

Define AD

Define AS

Define AU

A

R ear; Auris Dextra

L ear; Auris Sinistra

Both ears; Auris Utraque

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2
Q

Basal Cell Carcinoma is the MC ?

How does this form of Ca present on PE?

A

MC malignant neoplasm of auricle; from sun exposure

Pedunculated Ulcerated Nodule Translucent Rolled Bleeding

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3
Q

What are the 3 types and one benefit of Dx w/ BCC of the auricle?

How is it Tx both Non/Surgically?

A

Superficial spreading
Ulcerating
Nodular- morpeaform
Rarely metastasizes

Non: Topical 5-FU, Radiation
Surg: Excision, Mohs surgery

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4
Q

What is the precursor to Squamous Cell Carcinoma?

What PT population is this form more likely to be seen in?

A

Actinic Keratosis

Older male PTs

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5
Q

What are the RFs for PTs to develop Squamous Cell Carcinomas on the auricle?

A

Age
Non-healing ulcer

ImmSupp
Chemical
UV radiation

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6
Q

How do Squamous Cell Carcinomas of the auricle present on PE?

Why is this Dx less favorable than BCC?

A

Ulcerated plaque/nodule prone to bleeding

More aggressive, requires larger excision area for Tx

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7
Q

How are auricle SCC cases Tx w/ Non/Surg methods?

How do these Tx options change for cases that are more advanced?

A

Non: radiation
Surg: excision, Mohs

Neck dissection w/ parotidectomy

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8
Q

What is a poor prognosis finding for PTs w/ auricle SCC?

Characteristics of Malignant Melanoma

A

CN7 and lymph node involvement

Unpredictable tumor that affects all ages w/ high mortality rates

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9
Q

How does a Malignant Melanoma of the Auricle present on PE?

What is used to determine the severity and PT survivability?

A

Pigmented lesion that moves from epidermis to dermis w/ ABCDE changes

Depth of invasion

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10
Q

How are Malignant Melanomas of the Auricle Tx

What are the ABCDEs of determining if a lesion is a mole or melanoma?

A

Excision w/ possible lymph node dissection

Asymmetry Border Color Diameter Evolving

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11
Q

How doe Epidermal Inclusion Cysts present in clinic?

When/how are these growths Tx?

A

Well defined borders around soft, mobile and non-tender punctum that can spontaneously drain smely contents

At PTs request w/ Triamcinalone injection 3mg/mL

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12
Q

Where does blood accumulate during the formation of an Auricular Hematoma?

How are they Tx

A

Between cartilage and perichondrium

<24hrs: needle aspiration
>24 hrs but <7d: incision
Pack x 7days w/ 24hr f/u

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13
Q

What ABX are used for Auricular Hematomas

When do these PTs need to be referred?

A

Staph coverage: Dicloxicillin, Cephalexin
Pseudomonas coverage: Ciprofloxacin

Hematoma >7days old

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14
Q

When/where are Local Blocks used for Tx of Auricle Hematomas?

A

Simple lacerations
10mL 1% Lidocaine via 25-27g needle
Posterior: sulcus behind inferior pole of auricle
Anterior: superior and anterior to tragus

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15
Q

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?

A

Extensive lacerations, best for avoiding tissue distortion
Inject 5mL 1cm above superior pole of auricle directed anterior to tragus

4mg/kg of 1% Lidocaine

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16
Q

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?

A

CN7
Parotid gland

CT w/out contrast

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17
Q

What Tx method is preferred for ear lacerations?

When does this preference change?

A

Primary closure

Delayed closure if >24hrs or signs of inflammation

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18
Q

When do ear lacerations need to be referred to Plastics, OMFS, ENT or NeuroSurgery?

A

Basilar Skull Tx
Auricular avulsion
Laceration w/ EAC extension
Laceration w/ Middle/Inner injury (HL, Vestibular Sxs)

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19
Q

Define Cellulitis

Define Perichondritis

Define Chondritis

A

Infection of the skin

Infection of the tissue surrounding cartilage

Infection of the cartilage; spares lobule

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20
Q

Peri/Chondritis cases difficult to Tx due to ? and are MC caused by ? microbe

How are they Tx?

A

Lack of blood supply to cartilage
P. aeruginosa

Mild: PO Fluoroquinolone w/ f/u <24hrs
Mod-Sev: IV Fluoroquinolone w/ Aminoglycoside, possible surgical debridement

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21
Q

Characteristics of cerumen

How many impactions need to occur per year for a PT to be Dx w/ recurrent impactions?

A

Hydrophobic substance that creates acidic environment against bacteria/fungus and prevents skin penetration/maceration

> 1/yr

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22
Q

What are the two parts of the EAC

What is the name of the point where the EAC narrows

A

Lateral 1/3: cartilage w/ hair and glands
Medial 2/3: bone w/ skin attached to temporal bone

Isthmus, superior to mastoid process

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23
Q

What are the 4 etiologies of cerumen impactions?

Usually ASx, what Sxs can this condition present w/?

A

EAC Dz induced obstruction
Narrowed EAC
Failed migration
Over production

HL Otalgia Fullness Itching

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24
Q

What is the recommended hygiene frequency for PT w/ cerumen impaction?

What is the indication to remove impaction and what benefit can be expected?

A

External cleaning w/ washcloth max of 1/wk

Only remove if Sxs
PT hearing improves x 10dB

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25
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
26
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
27
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)
28
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
29
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
30
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
31
How do FOBs in the ear canal present? What can happen if chronic/persistent retention occurs?
Pain Pruritis CHL Bleeding Infection Tissue granulation
32
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
33
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)
34
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
35
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
36
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
37
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
38
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
39
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
40
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
41
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
42
# 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
43
? is the MC Ca neoplasm of the ear canal? When is this Dx considered?
SCC Otitis externa doesn't resolve w/ therapy
44
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
45
# Define Adenomatous tumors in EAC What are the MC causes of ET dysfunctions
Tumor originating from ceruminous glands, indolent course usually Viral URI Allergies
46
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
47
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
48
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) ```
49
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
50
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
51
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
52
Serous Otitis Media is AKA ? What causes these conditions
OM w/ Effusion Prolonged blockage in ET tube causing negative pressure forming transudate fluids
53
SOM is usually caused by ? three things When does this Dx become concerning?
URI Barotrauma Chronic allergic rhinitis Unilateral and persistent >3mon- nasopharyngeal Ca
54
How does SOM present on PE What is the best way to confirm Dx
CHL w/ fullness Dec TM mobility w/ visible bubbles Tympanometry
55
How is SOM Tx
PO CCS- prednisone Amoxicillin No relief after months, ventilation tubes
56
# Define AOM How does this present in clinic
Bacterial infection in temporal bone Otalgia w/ URI Erythemic, hypomobile TM
57
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
58
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
59
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
60
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
61
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
62
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
63
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
64
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
65
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
66
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
67
# 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
68
What meds are used for TM Perfs w/ purulence? What types of meds must be avoided?
Ofloxacin/Cipro HC Aminoglycosides Alcohol Polymyxin/Neomycins
69
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
70
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
71
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
72
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
73
How are cases of Petrous Apicitis Tx What complication can develop
Surgical drainage- petrous apicectomy w/ ABX Meningitis
74
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
75
? is MC intracranial complication of ear infections What is an uncommon complication from ear infections?
Otogenic meningitis Brain abscess
76
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
77
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
78
# 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
79
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
80
# 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
81
Why are TM perfs a c/i for diving? What Sxs can be experienced?
Unbalanced thermal stimulus to semicircular canals Vertigo Disorientation Emesis
82
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
83
PTs w/ pulsatile tinnitus need ? imaging modality Large glomus jugulare tumors can impact ? CNs?
Magnetic Resonance Angiography/Venography CN 7 9 10 11 12
84
? two MC causes of earaches Sensory innvervation of the ear is derived from ? nerves
OE and AOM ``` Trigeminal Facial Glossopharyngeal Vagal Upper cervical ```
85
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
86
? 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
87
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)
88
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
89
What is the difference between peripheral and central vertigo?
Peripheral- studied by otolaryngologists Central- studied by neurologists
90
# 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
91
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
92
What is the key to Dx of vertigo Vertigo work ups include ? evaluations
Duration Associated HL Audiogram ENG/VNG Head MRI
93
Peripheral causes of vertigo
``` Vestibular neur/labyrinthitis Meniere dz BPPV ETOH Barotrauma Semicircular hehiscence ```
94
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
95
? is the cardinal Sx of vestibular dz This cardinal Sx needs to be differentiated from ? three DDx
Vertigo Imbalance Light headed Syncope
96
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
97
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
98
# Define ENG Define VNG
Electronystagmography- electrodes record eye movements from visual/vestibular stimuli Videonystagmography- camera records eye movement in response to stimuli
99
? 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
100
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
101
How is Menieres managed? What is added for Tx to refractory cases?
PO Meclizine/Diazepam Acetazolamide Intratympanic steroids Endolymphatic decompression Vestibular ablation
102
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
103
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
104
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
105
? CNS d/o can mimic BPPV? What imaging is needed for this suspected Dx
Vertebrobasilar insufficiency MRI
106
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
107
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
108
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
109
How are PTs w/ Vestibular Neuronitis Tx? ? is the MC cause of vertigo after a head injury?
Meclizine/Diazepam Labyrinthine concussion
110
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
111
How is traumatic vertigo Tx What do PTs w/ perilymphatic fistula present complaining of?
Diazepam/Meclizine Vestibular therapy SHL and vertigo worse w/ straining
112
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
113
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
114
How does migrainous vertigo differ from Menieres? How are these PTs managed?
No HL/tinnitus Antimigraine prophylaxis Lifestyle changes
115
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
116
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
117
Lesions on CN8 and central audiovestibular pathways cause ? issues Characteristics of this type of lesion
Neural HL and vertigo Dec speech discrimination Auditory adaptation
118
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
119
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)
120
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
121
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
122
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
123
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
124
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
125
? 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
126
Hemifacial spasms and tic douloureux are examples of manifestations caused by ?
Vascular loops impinging on brainstem
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How is Acute Peripheral Vertigo Tx
Object focus w/ blank back ground w/ slow head movements; inc speed w/out exacerbating N/V
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How is Chronic Peripheral Vertigo Tx
Head/eye movements while standing and walking fwd/back including uneven surfaces
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How are Bilateral Vestibular injuries Tx
No possibility for adaption, no improvement will occur Fall prevention education* Dark/uneven surface particularly challenging
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How is central vertigo Tx?
Gait/balance exercise w/ head/eye movements Take longer for improvement
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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
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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
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What are the 4 causes of conductive hearing loss?
``` Obstruction (MCC of CHL) Mass loading (middle ear effusion) Stiffness effect (otosclerosis) Discontinuity (disrupted ossicles) ```
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Transient CHL is usually d/t ? Persistent CHL is usually d/t ?
Impaction ETD from URI Chronic ear infection Trauma Otosclerosis
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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)
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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
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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
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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
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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
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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)
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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
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Medical Tx for sudden SHL needs to be started w/in ? of start What other test needs to be ordered w/ medication
<6wks Audiogram
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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
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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)
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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
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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)
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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
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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
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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
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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
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Audiogram thresholds are tested between ? ranges These thresholds are measured in ? and relate to ? conclusion
250-8000 Hz dB, higher threshold= poorer hearing
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# 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
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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
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Type A Tympanogram
Normal Peak near 0 decapascal Compliance .2-1.8ml Result: no middle ear pathology, intact TM, normal ET function +HL= SNHL
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Type As Tympanogram
Peak near 0 daPA, but dec compliance near 0.2ml Results: ossicular fixation, otosclerosis or TM scars Normal ET function
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Type Ad Tympanogram
Peak pressure near normal, peak pressure above 2.0, extremely high compliance Result: ossicular disarticulation/chain discontinuity Normal ET function
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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
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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
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What are the names of the 4 sinus cavities? What two are less developed in kids?
Frontal Ethmoid Sphenoid Maxillary Frontal and sphenoid
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# 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
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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
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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
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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
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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
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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
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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
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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
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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
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? is the MC form of acute bacterial rhinosinusitis What is this MC form's etiology
Maxillary sinusitis Largest sinus w/ single drainage path
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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
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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
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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
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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
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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
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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
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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
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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
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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"
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How is ABRS extension into intracranial space visualized? This form of imaging is needed to evaluate ? area
MRI Danger Triangle
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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
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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
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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
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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
184
# 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
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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
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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
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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
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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
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? 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
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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
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What adjunct meds are used for the Tx of allergic rhinitis?
Anti-leukotrienes: Montelukast Mast cell stabilizers: Cromolyn sodium Soidum nedocromil
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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
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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
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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
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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
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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
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# 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
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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
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How are anterior epistaxis cases packed?
ABX- prevents TSS Insert along floor Push w/ speculum Use 2x floor length, grasp midpoint and insert posteriorly
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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
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After posterior epistaxis packing, ? needs to be avoided? What meds are given to these epistaxis PTs?
Spicy food Tobacco Opioids- relief and BP
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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
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Septal hematomas form between ? structures? What is the concern w/ these injuries?
Perichondrium and Cartilage Necrosis to perforation
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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
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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
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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
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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
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Asthma + nasal polyps= no ? meds This can cause ? triad
ASA Samter- Polyp Asthma Spasms
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? is the best known precancerous lesion of the mouth This finding represents ? pathological/histological occurrence?
Leukoplakia Hyperplasia of the squamous epithelium
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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
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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
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? 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
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How is SCC of the mouth Tx by size
<4mm deep- unlikely to metastasize <2cm- local resection Pos margins/metastatic- radiation
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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
215
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
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# Define Melanotic Macule ? is the MC site to find amalgam tattoos?
Symmetric shape w/ sharp borders in adults that don't change Mandibular arch
217
# 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
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How is Lichen Planus Dx How are these PTs managed?
Exfoliative cytology or biopsy Topical CCS Cyclosporin Retinoids Tacrolimus- most evidence
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? 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
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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
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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 ```
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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
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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
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How are adults w/ Thrush Tx
Fluconazole Ketoconazole Nystatin rinse Chlorhexidine Half H2O2 rinses Nystatin powder
225
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
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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
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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
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? 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
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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
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? 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
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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
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# 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 ```
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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
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How are tonsils graded?
``` 0- no tonsils 1- hidden behind pillars 2- extend to pillar 3- extend beyond pillar 4- extend to midline ```
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# 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
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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
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Lymphadenopathy and shaggy, white/purple tonsil exudate moves Dx from GAS to ? What lab results suggests EBV etiology?
Mono Lymphocyte to WBC ratio >35%
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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
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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
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? 3 microbes can cause PTs to appear to have pharyngitis from GABHS? What ABX is used instead
Corynebacterium diphtheria Anaerobic streptococci Corynebacterium haemolyticum Erythromycin
241
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
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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
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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
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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
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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
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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
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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
248
What glands does Sialadenitis involve? What causes this condition to develop?
Parotid Sub-mandibular Dehydration Sjogren Staph A- MC microbe
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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
250
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
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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
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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
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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
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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
255
What structures help produce vowel sounds of words? What structures help w/ enunciation?
Pharynx muscles Face Tongue Lip muscles
256
What are the primary Sxs of laryngeal Dz What causes these Sxs
Hoarseness Stridor Hoarse- abnormal vibration of vocal folds
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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
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# 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
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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 ```
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? is the MC cause of hoarseness This MC cause is usually due to ?
Acute laryngitis <3wks Vocal abuse Post-URI x 7 days
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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
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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
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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
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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
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Epiglottitis is more likely to occur in ? PT population Upon Dx, PTs are admitted and Tx w/ ? ABX?
DM Ceftriaxone or, Cefuroxime and, Dexamethasone
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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
267
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
268
? are the MC lesions of the larynx Where do these MC lesions tend to develop?
Papillomas Ciliated/Squamous epithelium junctions
269
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
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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
271
How are papillomatosis cases Tx? How can this condition be prevented?
Laser/Cold knife Gardasil 9
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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
273
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
274
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
275
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
276
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
277
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
278
SCC of the larynx can be due to ? infection This Dx has the strongest prevalence in ? PT population?
HPV 16, 18 Non-smoker
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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
280
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
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Table 8-1
Slide Deck 6
282
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
283
? 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
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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
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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
286
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
287
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
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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
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# 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
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? is the MC cause of deep neck abscesses? Define Lemierre Syndrome
Odotogenic infection Thrombophlebitis of internal jugular vein secondary to oropharyngeal inflammation
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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
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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
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? are the 4 MC microbes causing Ludwigs/Deep neck abscesses? What type of images are needed?
Strep Staph Bacteroides Fusobacterium CT w/ contrast
294
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
295
Lemierre Syndrome is usually due to ? microbe ? ABX is used for Tx
Fusobacterium Necrophorum Metronidazole
296
# 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
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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
298
What are the two etiologies of Reactive Cervical Lymphadenopathy?
Tumors- SCC Lymphoma, Metastases Infection- Virus Mycobacteria Cat Scratch (Bartonella Henselae)
299
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
300
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
301
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
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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
303
? 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
304
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
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? 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
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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
307
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
308
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
309
Why do ENTs use rigid endoscopes more often than other specialties What ages do Non/Hodgkins Lymphoma peak
Easier to biopsy 20 and >50
310
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
311
What type of thyroid Ca has an association with MEN-2A
Medullary

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