ENT, Upper, and Lower Respiratory Problems Flashcards
1
Q
Conductive Hearing Loss
A
- Inability of ossicles to conduct sound properly
- involves external auditory canal or middle ear
2
Q
Sensorineural Hearing Loss
A
- Inability of eardrum to vibrate in response to sound
- Involves the inner ear or 8th cranial nerve
3
Q
Normal Weber Test
A
the patient hears sound equally in both ears
4
Q
Normal Rhine Test
A
the patient hears the sound beside the ear twice as long as when it is placed on the mastoid bone
- air conduction should be twice as long as bone conduction
5
Q
Causes of Conductive Hearing Loss
A
- Cerumen impaction
- damage to ossicles
- tympanic membrane perforation
- serous otitis media
- tympanosclerosis
- myringosclerosis
- cholesteatoma
- otosclerosis
- foreign object in ear canal
- tumors
- scarring on eardrum
- repeated otitis
6
Q
Causes of Sensorineural Hearing Loss
A
- Acoustic neuroma
- Meniere’s disease
- Ototoxic drugs (ASA, gentamycin)
- Injury due to noise
- Childhood infections (mumps, meningitis, scarlet fever)
7
Q
Causes of bacterial otitis externa
A
- pseudomonas (most common)
- staphylococcus
- streptococcus
** 98% of otitis externa cases are bacterial
8
Q
Causes of Fungal Otitis Externa
A
- aspergillus (most common)
- candida albicans
9
Q
Risk Factors for Otitis Externa
A
- swimming
- hearing aid use
- DM
- hot/humid climates
- trauma to external canal
- not drying ears
- absence of cerumen
- alteration of pH of ear canal
10
Q
Clinical Manifestations of Otitis Externa
A
- otalgia/conductive hearing loss
- edema and redness in the external auditory canal
- itching in the external auditory canal
- otorrhea
- tragal/pinna pain
- normal TM
- fever (occasional)
- tinnitus
- bilateral involvement is RARE
11
Q
Otorrhea Appearance in Otitis Externa (Acute Bacterial)
A
scant, white mucus, may be thick
12
Q
Otorrhea Appearance in Otitis Externa (Chronic Bacterial)
A
bloody if granulation tissue present
13
Q
Otorrhea Appearance in Otitis Externa (Fungal)
A
fluffy and white to off-white, may be black, grey, bluish-green, or yellow
14
Q
Diagnostics of Otitis Externa
A
- culture of discharge
- otoscopy: the TM will move
15
Q
Prevention of Otitis Externa
A
- Avoid prolonged ear exposure to warm, humid conditions
- Use a mixture of rubbing alcohol and white vinegar (50/50) or 2% acetic acid (if TM not perforated or tubes not present) to use as drops after swimming to help dry ear and restore pH
- Dry ears after showering, profuse perspiration, and swimming
- Do not place object in the ear which may cause trauma to the external auditory canal
- Treat ear infections aggressively
- Can also use hair dryer on low heat to dry ear
16
Q
Treatment of Mild Otitis External (TM intact)
A
Topical acetic acid/hydrocortisone combination for 7 days
17
Q
Treatment of Moderate Otitis Externa (TM intact)
A
- Ciprofloxacin-hydrocortisone
- Neomycin-polymyxin B-hydrocortisone
18
Q
Treatment of Otitis Externa (TM not intact)
A
Topical Fluoroquinolones for 7 days
- ciprofloxacin-dexamethasone
- ciprofloxacin
- ofloxacin
19
Q
Treatment of Otitis Externa (If TM not intact and Fluoroquinolones ineffective)
A
- Refer to ENT, then begin empiric oral antibiotics
- Levofloxacin 500mg PO QD
- Ciprofloxacin 500mg PO BID
- Cefuroxime 500mg PO BID
- Augmentin 875mg PO BID
** Should be tailored based on culture results
20
Q
Treatment of Otitis Externa (If TM not intact and pt cannot tolerate fluoroquinolones)
A
- Refer to ENT
- Obtain culture
- Start empiric oral antibiotics
- cefuroxime 500mg PO BID
- Augmentin 875mg PO BID
21
Q
When to Refer Otitis Externa
A
- Consider referral if evidence of systemic involvement (fever)
- Lack of response to therapy
- Recurrent or persistent otitis exerna
22
Q
Expected Course of Otitis Externa
A
- Improvement in 48-72 hours with treatment
- Resolution in a few days
- Abstain from water sports and wetting the head for 7-10 days during treatment
- Instruct patient not to insert cotton in ears to absorb drainage; can prolong or cause fungal superinfections
23
Q
Otitis Media
A
- middle ear infections
- most common in kids 6-18 months
24
Q
Otitis Media Causes
A
- Usually caused by an upper respiratory illness
- Strep pneumoniae
- H. influenzae
25
Risk Factors for Otitis Media
1. Daycare attendance
2. Poverty
3. Secondhand smoke exposure
4. Cleft palate, Down's syndrome
5. Fall and winter seasons
6. Male
7. Preceding respiratory infection
26
Clinical Manifestations of Otitis Media
1. Otalgia
2. Distorted TM landmarks, displaced light reflex of TM, decreased TM mobility
3. Cloudy, dull, opaque, or erythematous TM
4. Irritability, crying, sleep disturbance (nonverbal)
5. Fever
27
Otitis Media Prevention
- Breastfeeding for first 3 months
- Avoiding cigarette smoke
- Do not lie down with bottle or pacifier
- Immunization with PCV 13 and flu vaccine
- Elimination of pacifier in 2nd 6 months of life
- Frequent handwashing and toy cleaning
28
Treatment of Otitis Media
- Amoxicillin 875mg
- Augmentin 875/125 PO BID
- Augmentin 2000/125 ER PO BID
- Secondary Options: cefdinir, cefpodoxime, cefuroxime, or IM ceftriaxone
** Ibuprofen or acetaminophen for pain
29
When to Refer Otitis Media
- ENT referral for recurrent OM (3 presentations in 6 months OR 4 in 1 year)
- Emergency treatment needed for signs of mastoiditis and/or meningitis
- Refer if language delay detected (audiology/ENT as well as speech therapy)
- Refer/consult for neonates
30
Expected Course for Otitis Media
- Improvement in 48-72 hours
- At 4 weeks, approximately 50% have MEE (middle ear effusion)
- At 3 months approximately 10% have MEE
31
Possible Complications of Otitis Media
- TM perforation
- Conductive and/or sensorineural hearing loss
- Acute mastoiditis
- Meningitis
- Epidural abscess
- Language delay form hearing loss
32
Acute Rhinosinusitis
- usually due to viral etiology
- usually self-limiting: treat symptoms
- duration of symptoms > 10 days - may be bacterial
- imaging is not required
- antibiotics are only recommended in immunocompromised patients or those with severe disease
33
Risk Factors for Acute Rhinosinusitis
1. Viral URI
2. Allergic rhinitis
3. Cigarette smoking
4. Swimming in contaminated water
34
Clinical Manifestations of Acute Rhinosinusitis
- if symptoms last < 10 day, then its viral
- if symptoms last > 10 days but less than 4 weeks, then its bacterial
- symptoms that worsen after an initial improvement (bacterial)
- Cough (worse at night)
- Nasal discharge (starts watery then get prurulent)
- Facial pain/pressure (more common in adults)
- Anosmia
- Halitosis
35
Acute Rhinosinusitis Treatment (viral)
- symptom treatment (rest, hydration, warm facial packs, vitamin C, zinc)
- tylenol or ibuprofen
- decongestant (oxymetazoline nasal spray for 3-5 days)
- Intranasal corticosteroid (mometasone nasal spray for 1 month)
- Ipratropium-ipratropium bromide nasal spray (anticholinergic)
- Saline nasal spray or irrigation
36
Acute Rhinosinusitis Treatment for Immunocompromised/severe illness patient (Bacterial)
1. Augmentin 500/125 PO TID
2. Augmentin 875/125 PO BID for 5-10 days
3. Clindamycin 300mg PO Q8h x 10 days
4. Cefpodoxime 200mg Q12h x 10 days
5. Doxycycline 100mg PO QD
37
Acute Rhinosinusitis Treatment for Immunocompromised/non-severe illness patient (Bacterial)
- watchful waiting for up to 10 days
- if not better after days, then consider the illness severe and treat accordingly
38
When to Refer Acute Rhinosinusitis
- Refer to ENT for recurrent infections or treatment-resistant infections; may require endoscopic surgical intervention
- Symptoms of physical exam findings of unilateral facial pressure/pain, nasal drainage and/or polypoid nasal masses warrant referral to ENT: concern for etiologies other than chronic rhinosinusitis
- Consider immediate referral for periorbital cellulitis
- Emergency care if meningitis is suspected
39
Chronic Sinusitis
- lasting more than 12 weeks
- diagnosis is clinical initially
- CT may be needed if initial medical treatment fails
40
Chronic Sinusitis Treatment
- nasal saline irrigation
- topical intranasal corticosteroids
- oral antibiotics
- oral corticosteroids
- antihistamines
- leukotriene receptor antagonists
- Functional endoscopic sinus surgery is effective for patients unresponsive to medical treatment
41
Pharyngitis
- infection and inflammation of the pharynx and surrounding lymph tissue
- Bacterial pharyngitis is more common in winter
- More common in school age children during the winter months
- Goal of treatment is to prevent acute rheumatic fever
42
Viral Causes of Pharyngitis
- Epstein Barr virus
- adenovirus
- enterovirus
- flu A and B
- parainfluenza
- COVID
43
Bacterial Causes of Pharyngitis
group A streptococcus
44
Fungal Causes of Pharyngitis
Candida
45
Clinical Manifestations of Pharyngitis
- sore throat
- rhinorrhea
- congestion, cough (viral)
- cervical lymphadenopathy
- fever, HA, N/V, malaise
- beefy red tonsils
- palatal petichiae, scarlatiniform rash, strawberry tongue
**If patient presents with drooling, stridor, respiratory distress, muffled voice, then stabilize them and send them to ER (epiglottitis)
46
Symptoms seen with Viral Pharyngitis
- concurrent conjunctivitis
- nasal congestion
- hoarseness
- cough
- diarrhea
- viral rash
47
Symptoms Seen with Bacterial Pharyngitis
- cervical adenopathy
- fever (> 102)
- absence of other resp findings (cough, nasal congestion)
- petechiae on soft palate
- beefy red tonsils
- sandpaper rash
- abd pain, HA
- strep tonsilitis has distinct odor
48
Diagnostic Tests for Pharyngitis
- Rapid antigen test for group A strep
- if rapid antigen test negative, follow up with throat culture
- Monospot for Epstein barr virus
- Centor criteria
49
Centor Criteria
- Used for Pharyngitis
- Include four features: fever over 38C, tender anterior cervical adenopathy, lack of cough, and pharyngotonsillar exudate
- These four features, when present, strongly suggest group A strep
- When 2 or 3 of the four are present, there is an intermediate likelihood of group A strep
- When only one criterion is present, group A strep is unlikely
50
Pharyngitis Treatment (without confirmed group A strep)
Supportive care- gargling with salt water, anesthetic sprays, tylenol/ibuprofen, throat culture
51
Pharyngitis Treatment (with confirmed group A strep)
Supportive care PLUS antibiotics
- Oral PCN V potassium 500mg BID x 10 days
- Amoxicillin 500mg BID x 10 days
- Amoxicillin 1000mg QD x 10 days
- PCN G benzathine IM x 1 dose
- If allergic to PCN, use a cephalosporin, macrolide (azithromycin), or clindamycin
52
Pharyngitis Treatment (for recurrent infection)
- Supportive care
- Tonsillectomy
53
When to Refer Pharyngitis
- evidence of acute renal failure and reddish, tea-colored urine (2-3 weeks post-infection) may indicate acute post-strep glomerulonephritis
- tonsillar edema and upper airway obstruction
- peritonsillar abcess
- unilateral tonsillar hypertrophy
- recurrent infections: at least 7 episodes in the last year, at least 5 episodes per year for 2 years, or at least 3 episode per year for 3 years
54
Risk Factors for Asthma
- family or personal history of atopy or allergen exposure
- exposure to tobacco smoke and air pollution
- viral infections (RSV, rhinovirus, flu)
- bacterial infections (mycoplasma pneumoniae or chlamydia pneumoniae)
- allergen exposure (dust mites, mold, furry animals, cockroaches, pollen)
- occupational exposure
- black race
- female sex
- obesity
- residing in an urban area
55
Clinical Manifestations of Asthma
- Dyspnea
- Cough
- Expiratory wheezes
- Chest tightness
- May be worse at night
- tachypnea
- tachycardia
- reduced exercise tolerance
56
Diagnostic Tests for Asthma
- Spirometry (prior to bronchodilator and post bronchodilator)
- Peak expiratory flow rate (PEFR), monitors treatment effectiveness
- CXR
- CBC with diff
- Allergy testing
57
Step 1 of Asthma Management Plan
SABA as needed
58
Step 2 of Asthma Management Plan
- Low dose ICS daily, SABA as needed
- Concomitant ICS and SABA as needed
59
Step 3 of Asthma Management Plan
- Combination low-dose ICS plus formoterol daily and as needed
60
Step 4 of Asthma Management Plan
Combination medium-dose ICS-formoterol (LABA) daily and as needed
61
Step 5 of Asthma Management Plan
Medium-high dose ICS-LABA plus LAMA and SABA as needed
62
Step 6 of Asthma Management Plan
High-dose ICS-LABA plus oral systemic corticosteroids plus SABA as needed
63
SABAs
- Albuterol (Ventolin/Proair)
- Levalbuterol (xenopenex)
** Asthma
64
ICS
- Budesonide (pulmicort)
- Ciclesonide (alvesco)
- fluticasone (flovent)
** Asthma
65
ICS-LABA combinations
1. Fluticasone-salmeterol (advair)
2. Fluticasone-propionate-salmeterol (airduo)
3. Mometasone-formoterol (dulaera)
4. Fluticasone-vilanterol (Breo)
5. Budesonide-formoterol (Symbicort)
** Asthma
66
Leukotriene Blockers
1. Montelukast (singulair)
2. Zafirlukast (accolate)
3. Zileuton (Zyflo)
** For asthma
67
LABAs
1. Salmeterol (serevent)
** For asthma
68
Anticholinergics
1. Tiotropium (spiriva)
** For asthma
69
COPD
- 2 diseases: emphysema and chronic bronchitis
- primarily caused by smoking
- more common in those over 65
- equal incidence in men and women
70
Chronic Bronchitis
The production of sputum for at least 3 months annually for 2 consecutive years accompanied by cough. Chronic mucus production results from hyperplasia of the mucus membranes lining the bronchial walls. This is usually irreversible and progressive.
71
Emphysema
Lung disease characterized by enlargement of the alveolar ducts and air spaces distal to the terminal bronchioles. The mechanism by which alveolar walls are destroyed is incompletely understood, but this results in air trapping and loss of elastic recoil or the lungs. This is also usually irreversible and progressive.
72
Risk Factors for COPD
- Cigarette smoking and 2nd hand smoke
- Advanced age
- Genetic factors
- Lung growth and development
73
Clinical Manifestations of COPD
- Cough
- Dyspnea on exertion
- Sputum production
- Barrel chest (severe)
- Wheezes and coarse crackles
- End stage: tripod position
74
COPD Diagnostic Testing
1. Spirometry
2. Pulse Oximetry
3. CXR
4. CBC, BMP, TSH, BNP
5. Alpha-1 antitrypsin level
6. Post bronchodilator spirometry
75
Maintenance Medications for COPD
- Purpose of therapy is to reduce symptoms, decreased exacerbations, improved health and improved exercise tolerance
- Start patient on single or combination bronchodilator therapy. If persistent symptoms on single agent, increase to 2 bronchodilators
- Antitussives are NOT recommended
- ICS-LABA combination
76
SAMAs
1. Ipratropium (atrovent)
** COPD
76
Acute Exacerbation Management of COPD
- SABAs, with or without SAMAs
- Systemic steroids
- Antibiotics if there is a bacterial cause only
77
LAMAs
1. Aclidinium bromide (Tudorza)
2. Glycopyrrolate
3. Tiotropium (spiriva)
4. Umeclidinium
5. Yupelri
** COPD
78
Acute Bronchitis
An inflammation of the bronchi, bronchioles, and trachea; usually follows an upper respiratory infection or exposure to a chemical irritant
- usually self-limiting
- an acute illness of < 21 days
- More common in fall/winter
- most commonly viral
- cough may last longer than a month
79
Clinical Manifestations for Acute Bronchitis
- productive cough for < 30 days
- fatigue
- fever
- burning sensation in chest
- crackles, wheezes
- chest wall pain
80
Acute Bronchitis Treatment (cough less than 4 weeks)
1. Observation
2. Antipyretics
3. SABAs
4. Antitussives
5. Consider immediate or delayed antibiotics
81
Acute Bronchitis Treatment (cough more than 4 weeks)
1. Evaluate for other causes
2. SABAs
3. Consider immediate or delayed antibiotics
82
Acute Bronchitis Prevention
- smoking cessation
- avoid known respiratory irritants
- treat underlying conditions (GERD, asthma)
- Flu immunization
83
Nonpharmacologic Treatment for Acute Bronchitis
- increase fluid intake
- throat lozenges
- hot tea, honey
- humidifier
- rest
- patient education regarding disease, treatment, and emergency actions
84
Pneumonia Causing Organisms
1. Mycoplasma pneumoniae
2. Streptococcus pneumoniae (most common in the world)
3. H. influenza
85
Risk Factors for Pneumonia
- Age greater than 65
- living in homeless shelter or prison
- living in low income housing
- COPD
- exposure to cigarette smoke
- alcohol abuse
- malnutrition
- chronic lung or heart problems
- inability to protect the airway
- contact with children
- HIV infection or other immunocompromising condition
86
Clinical Manifestations of Pneumonia
- cough with or without sputum production
- fever or chills
- dyspnea
- pleuritic chest pain
- rales/rhonchi
- tachypnea/increased work of breathing
- dullness to percussion
- fatigue, malaise
87
Diagnostic Tests for Pneumonia
- CXR
- PSI/CURB-65
- CBC with diff
- BMP
- Covid/flu swabs
88
Pneumonia Prevention
- Flu and pneumonia vaccines
- Smoking cessation
- High risk individuals should avoid crowds
89
Nonpharmacologic Treatment for Pneumonia
- hydration
- reduced activity during acute phase
- patient education regarding disease, treatment, emergency actions
90
Pneumonia Treatment (for Patient without comorbidities)
- Amoxicillin 1 g PO TID
- Doxycyline 100 mg PO BID
- Azithromycin 500 mg BID
- Supportive care
- Consider antiviral therapy in outpatients who test positive for flu
91
Pneumonia Treatment (for Patient with comorbidities)
- Azithromycin or doxycyline PLUS augmentin
- Moxifloxicin 400mg PO QD
- Gemifloxacin 320mg PO QD
- levofloxacin 750mg PO x 7 days
- Supportive care
- Consider antiviral therapy in patients who test positive for flu
92
Tuberculosis
- caused my mycobacterium tuberculosis
- airborne transmission
- 10% of individuals with latent TB infection will progress to active TB in their lifetimes (usually when they become immunocompromised)
93
Risk Factors for Tuberculosis
- exposure to infection
- birth in or travel to an endemic country
- HIV infection
- Immunosuppressive medications
- medically underserved, low-income populations, persons who abuse drugs or alcohol
- healthcare workers
94
Clinical Manifestations of TB
- chronic cough
- fever
- anorexia
- weight loss
- malaise
- hemoptysis
95
Diagnostic Tests for TB
- CXR
- Acid fast bacilli sputum smear
- Sputum culture
- CBC
- Nucleic acid amplification tests (NAAT)
- TB skin test or interferon gold
** Induration of 10mm or more is considered positive
96
Treatment for Active TB in non-pregnant, HIV negative patient
- Isoniazid, Rifampin, Pyrazinamide, and ethambutol for 2 months
- If no suspicion of drug resistance, discontinue to he ethambutol and pyrazinamide
- During the remaining 4 months, just use isoniazid and rifampin daily
97
Treatment for Latent TB in non-pregnant, HIV negative patient
Four different Options
1. Isoniazid 300mg PO QD x 9 months
2. Isoniazid 300mg and rifampin 600mg PO QD for 3 months
3. Isoniazid 15mg/kg and rifapentine 15-30 mg/kg once weekly for 3 months
4. Rifampin 600mg PO QD for 4 months if unable to tolerate isoniazid
98
TB Treatment Monitoring
1. Lab tests: CBC, bilirubin, LFTs, BUN and creatinine before starting TB meds
2. Visual acuity and red-green color vision tests before starting ethambutol
3. Serum uric acid before starting pyrazinamide
4. Monthly follow-ups with questioning for symptoms of med toxicity with sputum smear and culture until there are 3 consecutive negative sputum spears/cultures
5. Monthly labs are not needed unless there is an indication for med toxicity noted or liver disease is present
99
Pertussis
- AKA "whopping cough"
- An upper respiratory infection characterized by a severe cough
- Bordetella pertussis is the typical etiological agent
- Transmission through direct contact with droplet discharges
- Highly contagious
100
Risk Factors for Pertussis
- Age less than 6 months
- Baby born to mother who became infected at less than 34 week gestation
- No or incomplete immunization
- Close or household contact with an infected person
101
Clinical Manifestations of Pertussis
- cough
- inspiratory whooping
- rhinorrhea
- post-tussive vomiting
- mild fever
- excessive lacrimation
- conjunctival injection
102
Diagnostic Tests for Pertussis
- cough of less than 2 weeks up to 4 weeks, culture and PCR form the posterior nasopharynx
- cough for more than 4 weeks: serology
103
Pertussis Prevention
- Follow CDC vaccination schedule
- Vaccinate pregnant women with Tdap between 27-36 weeks with each pregnancy
104
Pertussis Treatment
Adult Dosages:
1. Erythromycin 500mg PO QID x 7 days
2. Clarithromycin 500mg PO BID x 7 days
3. TMP-SMX 160-800mg PO BID x 7 days
** Only use azithromycin in pregnant individuals
