ENT Treatment Flashcards
1
Q
Microtia
A
- Auditory brainstem response testing immediately to ensure sensorineural function intact
- Auditory screening of unaffected ear
- CT prior to reconstruction around age 6-7
- If bilateral or poor hearing in unaffected ear - hearing aids
- Regular otoscopic exams of unaffected ear and prompt treatment of infections
- Surgery delayed until 5-6 years –> pinna reaches about 85-90% of size by this age and ribs are large enough by now to harvest graph
2
Q
Atopic Dermatitis of the ear
white scale
A
Topical steroids
3
Q
Seborrheic Dermatitis of the ear
greasy scale
A
- Ketoconazole shampoo/cream
- Steroids (acute only - i.e. doesn’t treat the yeast, only treats the symptoms)
- Topical calcineurin inhibitors (Elidel)
4
Q
Impetigo of the ear
honey colored crust
A
-Mupirocin cream or ointment (Bactroban TID x5d) OR Retapamulin (Altabax) BID for 5d
5
Q
Furuncle of the ear
A
- Generally resolve within 2 weeks
- Warm compress to facilitate drainage
6
Q
Cellulitis
lobule involved
A
Oral antibiotics and follow-up
7
Q
Perichondritis
lobule NOT involved
A
- IV antibiotics (staph and pseudomonas)
- Drain abscess if present
- Debride if devitalized
8
Q
Auricular Hematoma
A
- Drain and pack
- ABX
- Consider other injuries and hearing evaluations
9
Q
Bites/Lacerations of the ear
A
- Primary repair
- Close follow-up (24 hr)
- Update tetanus
- In trauma, evaluate TM
- Bites –> antibiotics, rabies if warranted
- Complication –> auricular hematoma, auricular notching, perichondritis
10
Q
Cerumen Impaction
A
- Mechanical removal, irrigation, suction
- Softening agents: Debrox, Cerumenex
- Microscopic removal by ENT in recurrent cases, or if unsuccessful
- Irrigation contradictions –> TM perforation, myringotomy tubes, trauma
11
Q
Foreign Body Removal
A
- Animate –> H2O2 or lidocaine
- Inanimate –> consider removal in the OR if near TM, if near EAC attempt removal under the microscope with appropriate equipment
12
Q
Otitis Externa
A
- Avoidance of moisture
- Antibiotic drops +/- steroid (Cortisporin, Ciprodex)
- Pain control
- Cases involving periauricular cellulite: oral ciprofloxacin X1 week
- Prevention: after swimming, put a few drops of equal parts white vinegar and rubbing alcohol and instruct patients not to use q-tips
13
Q
Malignant Otitis Externa
A
-Long term IV ABX (ciprofloxacin)
14
Q
Fungal/Otomycosis
A
- Flush or remove fungal debris (irrigate)
- Topical antifungal (main treatment): ketoconazole, clotrimazole
- Acetic acid (to change the pH)
- Oral antifungal: Diflucan (flucanozole) or Sporonox (itraconazole)
15
Q
Eustachian Tube Dysfunction
A
- Inhaled nasal steroids/decongestants
- Oral decongestants, antihistamines
- Autoinflation (not during infection)
- In more severe/chronic cases –> tympanostomy tube placement or adenoidectomy
16
Q
Barotrauma of the middle ear
A
- Decongestants
- Nasal steroid
- Wait for TM to heal if perforated
- this generally heals on its own
17
Q
Barotrauma of the inner ear
A
- Refer to ENT
- Bed rest with head of bed elevated, anti-vertigo meds, steroid taper, avoid Valsalva
- Most recover spontaneously, but surgical exploration required if vertigo persists or worsens over 4-5 days
18
Q
TM perforation - trauma
A
- Does not generally require drops
- Refer is hearing loss persists (surgical exploration/repair) –> tympanoplasty
19
Q
TM perforation - infection
A
- Requires ABX (oral/drops)
- Re-check once infection resolves
- may need oral antibiotic if blocked with pus –> drops won’t be able to reach the middle ear
20
Q
Serous Otitis Media
A
- Generally none (abx, decongestants, nasal steroids controversial at best)
- Watchful waiting –> 3 months from date of onset/diagnosis
- Most OME is self-limited
- Need to consider hearing levels, recurrent infections, development (language)
21
Q
Chronic Serous Otitis Media (OME > 3 months)
A
- Concerned about speech delay
- Tympanostomy tubes - allow for drainage of middle ear space and resolution of hearing
- Adenoidectomy - relieves nasal obstruction, improves eustachian tube function, eliminates reservoir of bacteria
22
Q
Acute Otitis Media
A
-Initial antibiotic therapy OR initial observation limited to symptomatic relief with commencement of antibiotic therapy only if the child’s condition worsens at any time or does not show clinical improvement within 48-72 hours
-Start with amoxicillin –> 2nd line Augmentin
-If at risk for resistance start with Augmentin –> 2nd line Cefdinir (Omnicef)
-PCN allergy (not type 1 hypersensitivity) –> start with cefdinir (Omnicef) –> 2nd line clindamycin
-PCN allergy (type 1 hypersensitivity) –> start with fluoroquinolones, azithromycin, clarithromycin –> 2nd line clindamycin
-3rd line therapy –> tympanocentesis (aka aspirating fluid from the middle ear)
*significant past history of AOM - consider tube placement
(ugh)
23
Q
Chronic Suppurative Otitis Media
A
-Medical (abx, ENT referral) and surgical (TM repair)
24
Q
Acquired Cholesteatoma
A
Surgical treatment
25
Ototopical Therapy
For ear tubes or if you can visualize the TM
- Fluoroquinolones (cover pseudomonas) - may be with or without addition of steroid (dexamethasone)
- Ex. ciprofloxacin/dexamethoasone (Ciprodex) vs ofloxacin (Floxin)
26
Mastoiditis
IV antibiotics (broad spectrum) +/- surgery
27
Otosclerosis
- Observation (best in unilateral disease of mild CHL)
- Amplification - most patients have intact cochlear function and do well with hearing aids
- Surgical - stapedectomy and prosthesis placement, do worst ear first and wait at least 6 months before proceeding with second ear, cochlear implant for patients with severe hearing loss
28
Benign Paroxysmal Positional Vertigo (BBPV)
- Generally resolves within a few months
| - Epley maneuver - successful in up to 80% of patients after one attempt
29
Meniere Disease
Medical
-Acute episodes: vestibular suppressants and anti-emetic (Meclizine)
-Salt restriction and diuretics (1st line) - so they don't retain fluid in the ear
-Aminoglycoside therapy (vestibular ablation)
-Short burst of steroids for acute exacerbation
Surgery
-Labyrinthectomy
30
Acute Labyrinthitis
- If febrile - antibiotics
- Supportive care
- Vestibular suppressants (Meclizine)
31
Submucous Cleft Palate
- Team approach
- Feeding concerns - cleft nurser
- Timing of initial surgery - lip --> Rule of 10s (10 weeks, 10 pounds, hgb 10)
- Palate: main concern is speech (not feeding), better speech development associated with earlier repair
32
Necrotizing Ulcerative Gingivitis
- Salt water and/or peroxide rinses
- Antibiotics (Augmentin/penicillin)
- Oral hygiene
- Pain control
- Refer to dentist/periodontist
33
Aphthous Ulcer (canker sore)
Home treatments
-Avoid triggers
-"Magic Mouthwash" - swish and spit equal parts Maalox and Benadryl (+/- lidocaine)
-OTC options: occlusive (orabase), anesthetics (benzocaine), cleaning agents/antiseptics
Prescription Treatments
-Viscous lidocaine (2% gel) - applied up to 4x a day (toxicity if too much)
-Topical steroid - triamcinolone (Kenalog)
-Cimetidine (Tagamet) may be used in prevention
-1 week tapering course of prednisone
-Chemical cautery: silver nitrate, Debacterol
34
Herpetic Stomatitis
- Oral Acyclovir (7-10 days)
- Pain control (magic mouthwash)
- Liquid/soft diet
35
Herpes Labialis
Topical or oral acyclovir ASAP
36
Herpangina
| **hand foot and mouth disease
Resolves spontaneously
37
```
Oral candidiasis (Trush)
**angular cheilitis = manifestation
```
- Oral fluconazole (Diflucan)
- Clotrimazole throches 10mg dissolves orally 5 times a time
- Nystatin suspension, swish and swallow (or spit)
38
Denture Stomatitis
- Denture hygiene and soaking at night
- Clotrimazole or nystatin lozenges
- If still no improvement, consider systemic disease (T2DM)
39
Glossodynia
Based on the cause
- Oral lubricant
- Change meds
- Smoking cessation
- Hydration
- Nutritional therapy
- Clonazepam for burning mouth syndrome
40
Hairy Tongue
Oral hygeine
41
Ankyloglossia
-Generally asymptomatic --> speech delays most likely to indicate need for surgical correction
Management
-Speech therapy
-Surgical correction
-Frenectomy - bedside snip with local anesthesia, preferred in infants
-Flenuloplasty - >1-2 y/o, release with plastic repair, brief general anesthesia
42
Oral leukoplakia
Only 2-6% represent dysplasia or early invasive SCC --> if it is stable and there is no change, you don't necessarily need to biopsy
43
Erythroplakia
90% represent dysplasia or carcinoma --> biopsy
44
Oral Lichen Planus
Generally no treatment --> biopsy if concerned
45
Viral Tonsillitis
Self limited, no treatment necessary
46
Strep Throat
-Penicillin/Amoxicillin --> 2nd line treatment Cefuroxime (Ceftin) or Augmentin
If allergic
-1st generation cephalosporin, azithromycin, clindamycin
Treatment of Recurrence
- nonadherence: penicillin IM
- Initially first gen cephalosporin (cephalexin) or Augmentin
- If first generation was already used: second or third generation cephalosporin (cefuroxime (Ceftin), cefdinir (Omnicef))
47
Acute Rheumatic Fever
- Treat group A streptococcal infection regardless of organism detection
- Symptom specific treatment
- Prophylaxis against GABHS - 5 years for patients without carditis and 10 years-life for those who have rheumatic carditis
48
PANDAS
- Anti-streptococcal antibiotic (azithromycin or cephalosprin --> not augmentin)
- Tonsillectomy is not recommended
- Treat tics and OCD the same as you would in any child - cognitive behavioral therapy, anti-obsessional medications (SSRI)
- Plasma exchange (plasmapheresis) and immunoglobulin (IVIG) - has shown improvement, but associated with negative side effects, only consider in severe disease
49
Peritonsillar Abscess
```
First:
-IV antibiotics
Surgical management options:
-Incise and drain
-Needle aspiration
-Tonsillectomy
-Quinsy tonsillectomy
```
50
Uvilitis
Antibiotics, steroids, ice chips, salt water gargles
51
Retropharyngeal Abscess
- Secure/monitor the airway
- Broad spectrum IV antibiotics
- ENT consult
- Incision and drainage
52
Lemierre's Syndrom
- IV antibiotics
- Surgery in those not responding to antibiotics
- Anticoagulation only is thrombus is extending
53
Ludwig Angina
Appropriate antibiotic therapy and monitoring/protection of the airway
54
Infectious Mononucleosis
- Treatment with ampicillin/amoxicillin during mono induces a rash!
- Generally resolves in 2-3 weeks
- Stay out of contact sports until hepatosplenomegaly resolves to reduce risk of rupture
- Quarantine not necessary
- NSAIDS for pain control
- Fluids to prevent dehydration
- Oral corticosteroids in cases of possible upper airway obstruction
55
Chronic Tonsillitis
- Clindamycin or Augmentin
| - If symptoms persist: consider tonsillectomy
56
Chronic Tonsillar Hypertrophy
Diagnose with sleep study
57
Indications for tonsillectomy
- Recurrent acute tonsillitis
- Recurrent acute tonsillitis with febrile seizure
- Chronic tonsillitis, unresponsive to medical tx
- Peritonsillar abscess with h/o recurrent infections
- OSAS (obstructive sleep apnea syndrome)
- Mono with obstructive tonsillar hypertrophy, not responsive to steroids
- Asymmetric growth or lesion suspicious for malignancy
58
Indications for adenoidectomy
- Adenoidal hypertrophy with Eustachian tube dysfunction and persistent MEE
- Adenoidal hypertrophy with chronic sinusitis not responsive to therapy
- Adenoidal hypertrophy with craniofacial or occlusive abnormalities
- Adenoidal hypertrophy with moderate to severe nasal obstructive symptoms (mouth breathing, hyponasal speech and impaired olfaction)
59
Indications for adenotonsillectomy
- Adenotonsillar hypertrophy with dysphagia or speech problems
- Severe snoring with chronic mouth breathing
60
Epiglottitis
- Secure airway in patients under 6 years old or in respiratory distress
- Admission and IV antibiotic with close observation
* Hib vaccine has been important in preventing cases
61
Pharyngeal Foreign Bodies
Refer for consultation and removal --> flexible or rigid endoscopy
62
Croup
- Cool or moist air
- NSAIDS/acetaminophen for fever or discomfort
- For mild, moderate, severe croup --> dexamethasone (Decadron) IM or PO
- For moderate to severe croup --> nebulized racemic epinephrine (rebound effect)
63
Acute Laryngitis
- Patients should avoid singing and shouting until voice returns to normal
- Laryngitis > 3 weeks (chronic laryngitis) --> requires ENT evaluatuon
64
Laryngopharyngeal Reflux
- PPI (proton pump inhibitor = omeprazole/Prilosec)
| - Should note improvement in 3-6 months
65
Recurrent Respiratory Papillomatosis
Multiple surgical procedures - laser ablation (scarring)
66
Vocal Cord Nodules
Conservative treatment: speech therapy
| -generally causes regression of lesions
67
Vocal Cord Polyps
- Small ones may respond to conservative therapy (speech therapy)
- Most require surgical excision and biopsy to r/o malignancy
68
Vocal Process Granuloma
- Voice therapy and anti-reflux therapy
| - Surgical removal if unresponsive
69
Reinke Edemea
- Generally responds to smoking cessation and voice therapy
| - Surgery in severe cases
70
SCC of larynx
- Must be rules out with new and persistent hoarseness in a smoker
- Refer suspicious patients to ENT
- Direct laryngoscopy with biopsy, followed by CT/MRI to determine the extent of the lesion
- Very treatable, but early detection is key
71
Vocal Cord Paralysis
- May resolve spontaneously within a year
| - Surgical medialization of paralyzed cord to give stable platform for vocal fold vibration
72
Nonallergic Rhinitis
1. Saline irrigation
2. Topical Steroids
- reduce inflammation, reduce mast-cell related reactions, decrease intracellular edema
- little systemic absorption, spray away from nasal septum
3. Adrenergic Agents (oral/topical, OTC)
- Phenylamines --> dose related side effects such as tremors, irritability, tachycardia, hypertension, urinary retention - contraindicated in patients with HTN, severe CAD, MAO inhibitors
note: these shrink the blood vessels which leads to decongestion
- Imidazolines (oxymetazoline) --> topical nasal spray (Afrin), vasoconstriction results in decreased edema of nasal mucosa, severe rebound effect if used for more than 5 days
4. Anticholinergic agents
- Ipatropium Bromide - blocks parasympathetic input - decreases rhinorrhea
- contraindicated in narrow angle glaucoma, prostatic hypertrophy
5. Mast cell stabilizer
- OTC nasal spray
- Chromolyn Sodium (Nasalcrom)
- Safe, but short half-life
- Must be used 4x daily
73
Viral Rhinitis (Common Cold)
- Oral decongestants (pseudoephedrine)
- Nasal sprays (oxymetazoline and phenylephrine)
- Rest and fluids
74
Vasomotor Rhinitis
- Avoid triggers
| - Nasal steroid
75
NARES
Nasal steroids
76
Rhinitis Medicamentosa
- Discontinue vasoconstrictive nasal spray (i.e. Afrin)
- Initiate nasal steroid
- May benefit from short course of oral steroid during acute phase
77
Septal Deviation
- Nasal steroid to relieve minor obstruction
| - Septoplasty (surgery)
78
Nasal Foreign Body
- Positive pressure - blow nose, parent blows into child's mouth
- Direct instrumentation
- Balloon catheter
- Suction
- Refer to ENT if concern for complication of removal (posterior displacement, mucosal damage)
79
Nasal Vestibulitis
- Topical mupirocin ointment bid for 5d
- Dicloxacillin 7-10 days if widespread
- Topical mupirocin ointment bid for prevention of recurrences
80
Allergic Rhinitis
- Must be individualized based on: main symptoms, severity, quality of life, cost of therapy, allergens involved
1. Avoidance and environmental controls (reduce outdoor activity during bad times, wash bed linens, air purifier, etc.)
2. Pharmacotherapy
- Same treatments as non-allergic rhinitis: intranasal corticosteroids, decongestants, anticholinergics, cromolyn sodium
- Nasal steroids: may be the most effective at controlling symptoms, max effect may take 1-2 weeks, act of late phase inflammation and therefore relieve congestion as well as some itching, rhinorrhea and sneezing
- Antihistamines: work on early phase symptoms (not congestion), 1st generation causes drowsiness, 2nd generation safer
- Leukotriene inhibitors
3. Immunotherapy
- Indications: long-term pharmacotherapy, inadequacy or intolerability of drug therapy, significant allergen sensitivity
- Gradually increase dosage of causative antigen until mild symptoms occur
- Therapy may continue for 2-3 years
81
Acute Sinusitis
Antibiotics
-First line therapy = Augmentin
-If penicillin-allergic: doxycycline, respiratory fluoroquinolone
-Risk for resistance: high dose Amox/Clav
Adjuvant
-Nasal saline/irrigation
-Nasal steroids
-Nasal/oral decongestants and antihistamines
82
Chronic Sinusitis
- High dose Amox/Clav, clindamycin, fluoroquinolones (moxifloxacin) --> 3-10 weeks of therapy, should probably go to ENT
- Nasal steroid sprays - reduce intranasal inflammation
- Saline irrigation - reduces crusts and promotes mucociliary clearance
- Systemic steroids - a steroid taper may be helpful initially in reducing inflammation
- Decongestants and mucolytics
- Allergy management
- Sinus surgery if mucosal disease or ostiomeatal unit obstruction persists despite maximal treatment ---> functional endoscopic surgery to remove polyps, enlarge natural ostia and unroof ethmoids sinuses
83
Nasal Polyps
- Small - nasal steroids
- Large - surgical removal
- Aspirin needs to be avoided in patients with asthma and nasal polyps
84
Epistaxis
- Continuous pressure of nares for 15 minutes
- Short acting topical nasal decongestant may help
- If bleeding persists, identify source of bleeding and apply 4% topical cocaine or mix of oxymetazoline and lidocaine
- Cautery with silver nitrate or electrocautery
- Packing with nasal tamponade product if unable to identify the source (may need prophylactic antistaphylococcal)
- If bleeding persists --> ENT should be consulted for posterior packing - antistaphylococcal antibiotics and possibly opioid analgesics for patient comfort
85
Olfactory dysfunction
- Counseling regarding food spices (pepper vs salt)
- Food expiration dates
- Smoke alarms
- Electric vs gas appliances
86
Gingivitis
-Reversible --> professional cleaning (q 6months) and regular brushing/flossing
87
Periodontitis
- Scaling/root planning (dental hygienist) - removes calculus and smooths surface of tooth
- Surgery - flap surgery, soft tissue graft, bone graft, guided tissue regeneration
88
Bell's Palsy
- Corticosteroids (x1 week) are most helpful if started in the first 3 days of symptoms
- Lubricating drops/ointment for the eye - possibly eye patch
- Conflicting research regarding addition of acyclovir
89
Herpes Zoster Oticus
- Corticosteroids + antiviral therapy
- Oral acyclovir
- IV acyclovir in severe cases or in immunocompromised patients
- Lubricating drops/ointment for the eye - possibly eye patch
- Also may consider vestibular suppressants for vertigo and opioids for pain management as needed
90
Trigeminal Neuralgia
- Carbamazepine (Tegratol)
- Oxcarbazepine (Trileptal), Baclofen, pimozide, lamotrizine - possibly effective
- Surgical options - microvascular decompression
91
TMJ
- Soft foods, good posture, no gum chewing, etc.
- Medications --> NSAIDs, muscle relaxants (cyclobenzaprine - Flexeril), tricyclic antidepressant (amitriptyline), short course of steroids, opioid analgesics (severe pain)
- Physical therapy --> relaxation, strengthening, posture
- Oral splint --> most commonly prescribed treatment, acrylic plastic worn at night, decrease joint load with grinding
- Surgery --> less than 5% of cases, when there is an identifiable structural defect
92
Mumps
Self-limiting with good prognosis (2 weeks)
93
Acute Suppurative Sialadenitis
- IV antibiotics, rehydration, sialogogues (make you salivate), oral hygiene, analgesics (pain killers)
- If no improvement in 48 hours, abscess may be present (ENT referral - I & D)
94
Sialolithiasis
- Hydration and sialogogues
- Serial dilatation
- Surgical excision
95
Mucoceles
Surgical intraoral excision is curative
96
Salivary Gland Tumor
FNA (fine needle aspiration) biopsy followed by excision
97
Brachial Cleft Cyst
-Antibiotics and surgical removal of cyst and tract
98
Thyroglossal Duct Cyst
-Surgical excision of cyst and fistulous tract (which usually includes the middle portion of the hyoid bone)
99
Reactive Viral Lymphadenopathy
-Lymph nodes greater than 1-1.5 cm present for more than 4-6 weeks, or getting larger, warrant further work-up
Diagnostics to consider:
-Gram stain and cx of aspirated tissue
-Monospot or EBV serologies
-B. henselae serology - cat scratch disease
-Skin testing or PPD - TB
-CBC count - elevated WBC could indicate infectious etiology
-ESR, CPR - indicators of inflammation
-Liver function test
100
Bacterial lymphadenitis (acute)
Empirical antibiotic tx, followed by referral and I&D if no improvement
101
Cat-scratch disease (Bartonella henselae)
Azithromycin x5days
102
Atypical Mycobacteria
Surgical excision and cx for diagnosis and treatment
