Exam 2 Flashcards
test/tools, intro, ear disorders, hearing impairment, rhinosinusitis
1
Q
Audiometry
A
- tests for low/high pitch, loudness, and distinguishing voice and white noise
- performed in office or by audiologist
- Risk: none
- Gold standard: pure tone audiology
- technique: place headphones on ear, series of noises are played into headphones and pt signals when they hear nose
2
Q
Tympanometry
A
- detects problems with fluid/wax buildup, perforated eardrum, ossicle bone damage, tumor in middle ear
- can dx otitis medis, hearing disorders
- can be done in primary care or audiologist
- procedure: insert tympanometer into ear, present a probe tone, want ear canal and middle ear air pressures to be equal
- Looking for compliance: TM moves with small changes in pressure
- Noncompliance: TM is stiff/does not move easily - reduced mobility
3
Q
Newborn hearing test
A
- 2 common tests
- passing test does not indicate clear hearing in adult life
- Otoacoustic emissions (OAE): test outer hair cells response to sound, not adequate for neural hearing loss or any middle ear pathology
- Automated auditory brainstem response (AABR): auditory nerve and brainstem respond to sound, wears small earphones and electrodes, pass/fail results
4
Q
Nasopharyngoscopy
A
- allows visualization of structures from the nasal cavity to vocal cords
- indicated for suspected tumors, polyps, obstructions, hypertrophied tonsils, vocal cord nodules
- Fiberoptic gold standard
- pt is sitting and tube is inserted through nare and down pharynx
5
Q
Tympanocentesis
A
-small puncture through tympanic membrane to draw fluid or administer medication directly to middle ear
6
Q
Pneumatic Otoscopy
A
- examination that determines mobility of pt tympanic membrane in response to pressure changes
- indicates presence of effusion
- gold standard for TM
- want to see movement
- dx: otitis media with effusion, perforation, tympanosclerosis
7
Q
Tympanostomy tubes
A
- small plastic or metal tubes surgically placed in TM to allow drainage of fluid
- indications: fluid in both ears for 3 months and hearing loss or problems with pain, balance, repeated infections
- benefits: decrease ear infections, improved hearing
- Risks: infection
- tubes fall out in 1-2 years
8
Q
Allergy Testing
A
- skin test
- ELISA and RAST
9
Q
Strep testing
A
- test for antibodies of group A step from throat swab
- do culture if negative - gold standard
10
Q
Bordetella
A
- “whooping cough” requires pertussis test
- collect nasopharyngeal secretions or blood
- culture is gold standard
11
Q
Rhinoplasty
A
- nose job
- changes nose shape or improve function
- injury, breathing problems, devited septum, birth defect, cosmetic
12
Q
Uvuloplasty
A
- surgical remedy to snoring and some sleep apneas
- removing part or entire uvula with laser
- not covered by insurace
13
Q
Perichondritis
A
- infection of ear cartilage
- serious
- usually secondary to trauma or psedumonas
- hard to cure due to poor vascularity
14
Q
Cellulitis v. Perichondritis
A
- cellulitis: soft tissue inflamed. Lobe is inflamed and it may spread upward
- perichondritis: cartilage inflamed. lobe is not involved
15
Q
Relapsing polychondritis
A
- same, but bilateral
- probably auto-immune related
16
Q
Otitis Externa
A
- inflammatory disorders of the ear canal not middle ear
- Culprits: psedumonas, fungas, staph aureus
- Swimmer’s ear: excess water in ear canal
- Malignant external otitis is often associated with DM
- Sx: otalgia, pruritis, discharge
- Exam: erythema, edema, pain, can’t really see TM
- tx: otic drops (can use wick), abx if bacterial, isopropyl alcohol for drying, half-strength vinegar for fungal or psedumonal
17
Q
Ceruminosis
A
- accumulate cerumen
- interferes with hearing
- gently irrigate ear
- Cerumenex soften wax and then irrigate
- loops and scoops for stubborn wax
- typically not painful, but if contacting TM very painful
18
Q
Acute otitis media
A
-bacterial infection of middle ear
-S. pneumo, M. cat, H. flu, viruses very important as well
-precipitated by a URI
-more common in children
-
19
Q
Acute Otitis Media Diagnosis
A
- mobility of the TM is the gold standard for determining infection
- single best predictor of AOM is TM immobility
- combo of TM immobility and “cloudiness” is best
- dx: moderate to severe TM bulge, mild TM bulge and ear pain/intense TM erythema
- no effusion then not AOM
- bulging TM, decreased/distorted/absent light reflex, redness
20
Q
Acute otitis media risk factors
A
- Age: 6mo-18mo
- Gender: male>females
- Day care centers
- Pacifier use: slight increase
- Breast feeding: decrease
- Smoking
21
Q
Acute otitis media history
A
- PMHx: known/suspected medical problem, prior surgeries, current medications, allergies, hospitalizations, immunizations status
- CC
- HPI: symptoms, description of each, onset, course, sacred 7
- ROS: fever, appeitite, URI sx, n/v/d, abd pain, lethargic, cough, runny nose, decreased hearing
22
Q
Normal TM
A
- translucent/transparent
- gray or pink color
- neutral position
- fully mobile with pneumatic otoscope
- no effusion
23
Q
Acute Otitis Media TM characteristics
A
- opaque
- red, yellow, white color
- Bulging or full position
- reduced mobility but may respond to positive pressure on pneumatic otoscopy
- effusion present
- white/cloudy stuff is pus
24
Q
Acute Otitis Media tx
A
- decrease fever and pain
- prevent developmental delays
- 80% heal spontaneously
- 94% w/ abx
- tx pain: tylenol/ibuprofen, warm compresses
- observation and waiting is a good tx plan if pt is not really sick
- Amoxicillin: first line
- Augmentin: second line, H. flu
- S.pneumonia needs larger dose of amoxicillin not augment
- should see improvement in 72 hours using abx
- effusion can presist for 12 weeks
25
Q
Acute Otitis Media Prevention
A
- vaccines: pneumococcal vaccine and influenza
- ear tubes
26
Q
Otitis Media w/ Effusion (OME)
A
- not really otitis as there is no infection
- serious middle ear effusion
- can last months
- Worry about hearing: can affect language development
- decreased mobility of TM
- TM often retracted, but not always
- occurs spontaneously b/c of poor estachian tube function or as inflammatory response following AOM
- Referral to ENT
- Place tubes
27
Q
Otitis Media w/ Effusion (OME) TM characteristics
A
- translucent or opaque
- gray or pink color
- neutral or retracted position
- reduced mobility, responds to negative pressure on pneumatic otoscopy
- effusion present
28
Q
OME concerns
A
- hearing loss
- effects on speech, language, and learning
- quality of life
- need accurate diagnosis to distinguish AOM from OME
- distinguishing OME in health child from child at risk for developmental delays
29
Q
OME guidelines
A
- use pneumatic otoscopy as primary diagnostic method to distinguish OME from AOM
- tympanometry is an option
- distinguish child with OME who is at risk for speech, language, or learning problems and promptly evaluate and tx
- children not at risk watch for 3 months
30
Q
Hearing loss with OME
A
- HLs < 20 dB (normal hearing): repeat hearing test should be performed in 3-6 months if OME persists
- HLs 21-39 dB (mild hearing loss): audiologic evaluation, repeat hearing test in 3-6 months if OME persists
- HLs > 40 dB (moderate hearing loss): audiologic evaluation, surgery recommended, can impact speech, language, academic performance
31
Q
Benign Paroxysmal Positional Vertigo (BPPV)
A
- benign, but scary
- ever time someone moves they get very dizzy and throw up
- get a club of cells that don’t role to one side. This sends different signal to the brain from side to side and that gives you vertigo
32
Q
Vertigo
A
- produced by: Meniere disease, BBPV, labyrinthitis, acoustic tumors
- n/v are frequently associated with vertigo and dizziness
33
Q
Maneuvers
A
- Dix-Hallpike: localize labyrinthine dysfunction - positive test with affected ear down, nystagmus toward affected ear
- Epley: reposition otoliths - referral to audiology, ENT, or PT
34
Q
Meniere disease
A
- inner ear disorder
- AKA: idiopathic endolymphatic hydrops
- Onset: 40-60 yr
- Prevalence: 50-200 per 100,000
- too much fluid that causes a triad (tinnitus, hearing loss, vertigo)
- caused by buildup of endolymph pressure
- typically unilateral (nystagmus, possible ear fullness)
- intermittent attacks (last minutes to hours, n/v, sweating, pallor, falling down)
- Not positional: can’t reproduce with changing head position like BBVP
- Risk: white, genetic, stress, allergy
- Differential: teriary syphilis, MS, vestibular schwannoma, BPPV
- Lab: RPR (syphilis), CT
35
Q
Meniere disease tx
A
- meclizine
- scopolamine patch behind ear
- diuretics to reduce fluid, low Na+ diet
- endolymphatic shunt (surgical)
36
Q
Vestibular neuronitis
A
- sudden onset of vertigo related to neural afferents w/o inflammation
- vertigo due to imbalance in vestibular inputs
- possible involvement of latent herpes simplex virus type 1
37
Q
Labyrinthitis
A
- inflammatory disorder of inner ear or labyrinth
- hearing loss, vertigo, w/wo tinnitus, systemic signs
- hearing loss always present
- tends NOT to recur
38
Q
Vestibular neuronitis vs. labyrinthitis
A
- vestibular: no inflammation, does not having hearing loss
- labyrinthitis: inflammatory, hearing loss
39
Q
ABRS
A
- bacterial infection of maxillary, frontal, or ethmoid sinuses
- not viral, not inflamed, not allergic
- acute onset
- must distinguish between ABRS and viral illness
40
Q
Parthenogenesis of ABRS
A
- Rhinitis to sinusitis
- cold/URI to inflammation to bacterial infection
- Mucociliary clearance is important in keeping sinuses clear of fluid
41
Q
Microbial etiology for sinus infection
A
- Viruses: most common by far (rhinovirus, parainfluenza, etc.)
- Bacterial: community acquired or nosocominal
- Fungal: uncommon
42
Q
Bacterial sinusitis
A
- community acquired: S.pneumoniae, H. influenza, M.catarrhalis and group A strep, Staph aureus
- Nosocomial: nasogastric tubes or NG tube (staph, pseduomonas, and G-)
43
Q
ABRS Guidelines Diagnosis
A
- persistent symptoms or sign for more than 10 days
- onset with severe symptoms (high fever, purulent nasal discharge, facial pain)
- “double-sickening”: sick for a few days, got better and then got sick again (just as bad or worse)
44
Q
ABRS Guidelines Therapy
A
- empiric antimicrobial therapy be initiated as soon as clinical diagnosis of ABRS is established
- Amoxicillin-clavulanate not amoxicillin alone
- alternative management if symptoms worsen (in 2-3 days) or fail to improve (3-5 days)
45
Q
Further studies for ABRS if therapy is not working
A
- cultures be obtained by direct sinus aspiration (gold standard)
- cultures of the middle meatus may be considered as alternative in adults
- Nasopharyngeal cultures are unreliable
- CT for pt with suspected suppurative complications (don’t do MRI or sinus film typically)
- seriously ill and immunocompromised, continue to deteriorate clinically despite extended courses of antimicrobial therapy, or have recurrent bouts of acute rhinosinusitis refer to ENT
46
Q
ABRS signs and symptoms
A
- nasal secretions of any color
- congestion and facial pressure / HA are common to both viral and bacterial
- recent onset (<7-10 days) with no fevers likely to be viral not ABRS
- failure to resolve in 7-10 days
- higher fever / “severe” symptoms even if <7 days
- “re-sickening”
- foul odor for mouth
- dental pain (maxillary - upper teeth)
- Anosmia (can’t smell)
47
Q
ABRS red flags
A
- abnormal vision
- change in mental status
- periorbital edema
- high fevers
48
Q
ABRS physical exam
A
- vital signs: may be febrile or afebrile
- eye: possible clear discharge, otherwise normal
- nose: turbinates swollen, possible purulent discharge visible
- throat: likely inflamed, absence of tonsillar exudates, possible posterior drainage, possible posterior pharyngeal cobblestoning
- face: tenderness to palpation/percussion of maxillary and/or frontal sinuses (especially unilateral)
- neck: possible anterior cervical lymphadenopathy
- chest: should be normal, but cough possible
49
Q
Cobblestoning
A
- clumps of hypertropied lymphoid tissue at the posterior pharynx due to CHRONIC postnasal drainage and irritation of the tissue
- not specific for ABRS
50
Q
ABRS tests
A
- transillumination
- sinus puncture and aspiration (gold standard)
- radiology: CT (very sensitive) only order for pt with recurret ABRS or suspect structural problem
51
Q
ABRS treatment
A
- Antibiotics
- pain/fever: antiinflammatories
- congestion: decongestant -tx 5 days only “Afrin rule”
- expectorants: guaifenisen (Mucinex/Robitussin)
- Avoid 1st generation antihistamines (thickens secretions)
- guidelines support saline irrigation and intranasal corticosteroids
52
Q
Complications for ABRS
A
- periorbital tissues
- osteomyelitis
- CNS: meningitis, brain abscess
- chronic sinusitis
- paranasal sinus cancer should always be a differential of sinusitis
53
Q
AVRS
A
- AKA: URI
- do not ABRS specific signs
- almost never a fever (possibly a low grade at beginning)
- shorter duration: resolves on own in 5-7 days
- similar c/o w/ ABRS (congestion, nasal d/c, ha, pressure, possible tenderness, fluid in sinuses, possible associated hx of allergies)
54
Q
AVRS treatment
A
- treat symptoms
- avoid antibiotics
- be alert for ABRS
- must decided if viral or bacterial
- viral: block inflammation events (antihistamines, NSAID’s, cough suppressant, decongestants, mucolytics)
55
Q
Hadley’s take on sinus infection tx
A
- if bacterial tx with augmentin with doxy second
- Afrin 2 spays each nostril BID x4 day THEN STOP
- anti-inflammatory meds (ibuprofen/naproxen) for comfort
- Guaifenesin (mucinex/robitussin) also drink a lot of fluids
- maybe saline sinus rinse if copious discharge
- if allergic trigger nasal steroid spray (not Flonase). Start concurrently with Afrin and continue long term, consider chronic antihistamine
- pt education (why they are not getting antibiotic)
56
Q
Chronic sinusitis sx
A
- chronic (>12 weeks)
- anterior or posterior mucopurulent drainage
- nasal obstruction
- facial pain/fullness/tenderness
- purulent mucus or edema in middle meatus or ethmoid region OR polyps in nasal cavity or middle meatus OR imaging showing inflammation
57
Q
Chronic sinusitis etiology
A
- persistent infection
- allergy and other immunologic disorder
- intrinsic factors of upper airway
- superantigens
- colonizing fungi that induce/sustain eosinophilic inflammation
- aspirin sensitivity
- all affecting mucociliary clearance
58
Q
Chronic sinusitis history
A
- major symptoms: purulent anterior / posterior nasal drainage, nasal obstruction or blockage, facial congestion/fullness, facial pain/pressure, hyposmia, anosmia
- minor symptoms: HA, ear pain/fullness, halitosis, dental pain, cough, fever, fatigue
- duration
- hx of previous sinus surgery
- hx of asthma, allergies, immunocompromising disease
- active or passive tobacco use
59
Q
Chronic sinusitis physical exam
A
- nasal exam: purulent drianage, polyps , septal deviation, turbinate hypertrophy/edema, consider endoscopic exam
- sinus palpation/percussion for tenderness - consider sinus CT
- Ears: TM fluid
- Neck: LAD
- throat: postnasal drip
- Eye: oculomotor involvement
- lung: lower infection / asthma
60
Q
Allergic rhinosinusitis
A
- non-infectious
- look for allergic history
- chronicity: possible recurrent ABRS or AVRS
- clear rhinorrhea with associated allergic sx (sneezing, itching eyes/ears, itchy throat)
- benign PE, possible swollen/boggy turbinates, cobblestoning, clear eye discharge, clear fluids behind TMs
61
Q
Allergic triggers
A
- seasonal allergic rhnitis (pollens)
- Perennial allergic rhinitis: symptoms all year round (dust mites, mold, pet dander)
- allergy and asthma are closely tied; suspect one when you see the other
62
Q
Allergic treatment
A
- avoidance therapy
- drug therapy: inhibit release and action of mediators, reversal of inflammatory response
- Immunotherapy: repeated long term injection (for one specific allergy - not multiples)
63
Q
Drug Allergic treatment
A
- antihistamines
- anticholergic agents: stop mucus secretion
- corticosteroid nasal spray: anti-inflammatory
- mast cell stabilizer: cromolyn sodium and sodium nedocromil
- Leukotriene antagonists: give symptomatic relief by inhibiting vascular permeability and eosinophilic inflammation
- nasal saline lavage: wash away mucus
64
Q
Vasomotor rhinitis
A
- one form of nonallergic rhinitis
- triggers are cold air, strong odors, stress, or inhaled irritants
- sx are rhinorrhea, sneezing, and congestion
- due to parasympathetic overactivity of nasopharynx
65
Q
Vasomotor rhinitis treatment
A
- avoidance of triggers
- Ipatropium nasal spray is anticholinergic
- Intranasal steroid of unclear benefit
- oral antihistamines (1st gen) may help due to anticholinergic effects
- intranasal antihistamines: Astelazine -anti-inflammatory
- Intranasal and oral sympathomimetics: oxymetazolien, pseduoephedrime (decongestants) - can help promote vasoconstriction
66
Q
Vasomotor rhinitis relatives
A
- other nonallergic rhinitis
- occupational rhinitis
- hormonal rhinitis: estrogen increase (puberty most common cause)
- drug induced rhinitis: over use of topical decongestants
- gustatory rhinitis: response to spicy foods
- NARES (nonallergic rhinitis with eosinophilia syndrome) abnormal prostaglandin metabolism, can precede NSAID sensitivity
67
Q
Nasal polyps
A
- associated with asthma, chronic sinus infections, cystric fibrosis, allergic rhinitis, hypoosmia
- outgrowth of nasal mucosa
- can be removed, but most return
68
Q
Nasal polyps triad
A
- ASA sensitivity is found in 1/3 of pt with polyps, rhinosinusitis, and asthma
- chronic rhinitis followed by astham and asa sensitivity with subsequent development of nasal polyposis
- type 1 hypersensitivity
- sx: watery eyes, rhinorrhea, flushing of head, neck, and chest, bronchoconstriction, wheezing, cyanosis, n/v/d, cramps
- very responsive to bronchodilators
69
Q
Symptoms associated with hearing loss
A
- tinnitus
- hyperacusis
- vertigo/dizziness
- aural fullness/pain
- otorrhea
- delayed speech / language development in children
70
Q
Type A tympanogram
A
- normal
- TM intact
- like looks like pointy mountain
- pressure peak is at 0 (equal pressure)
- Type As: “s” is shallow or stiff, suggest middle ear system (ossicular fixation, thickened/scarred TM)
- type Ad: “d” is deep, can suggest ossicular discontinuity, also seen with monomeric, healed TMs, post PE tube or perforation
71
Q
Type B tympanogram
A
- opposite of type A
- “flat”
- consistent with middle ear fluid
- flat tymp PLUS high volume indicates TM perforation or pt has PE tube
72
Q
Type C tympanogram
A
- negative middle ear pressure / TM retraction
- consistent with eustachian tube dysfunction
- 0 +/- 100daPa range is normal
- peak off center
73
Q
Sound treated booth
A
- only proper way to perform a hearing evaluation
- hearing test not done in booth is a hearing screening
74
Q
Audiometric symbols
A
- right is red
- blue is left
- O—O right ear, air conduction
- X—X left ear, air conduction
- (blue) unmasked bone conduction
75
Q
Types of hearing loss
A
- sensorineural (SNHL)
- conductive
- mixed
- central
- seduohypacusis
76
Q
Causes of sensorineural hearing loss
A
- congenital/genetic
- presbycusis
- bacterial/viral infection
- medications / ototoxicity
- acoustic nerve tumors
- meniere’s disease
- sudden: autoimmune ear disease, vascular, perilymphatic, fistula, unknown
- acoustic trauma / noise exposure
77
Q
Noise induced hearing loss
A
- type of SNHL
- most common occupational illness or injury
78
Q
SNHL treatment
A
- prevention / education/ hearing conservation measures
- amplification (hearing aids)
- medications (sudden loss, Meniere’s, autoimmune ear disease)
- surgery (cochlear/brainstem implant)
79
Q
Conductive hearing loss
A
- inner ear is fine, but sound is not conducted to the inner ear
- air conduction issue
80
Q
Causes of conductive loss
A
- cerumen impaction
- foreign body
- external ear infection
- middle ear fluid / infection
- TM perforation
- otosclerosis
- tumors /growths in external or middle ear
- congenital anomalies
81
Q
Conductive hearing loss treatment
A
- cerumen management
- surgery (for the 10% that can be corrected)
- medication
- amplification
82
Q
Conductive hearing loss treatment
A
- cerumen management
- surgery (for the 10% that can be corrected)
- medication
- amplification (hearing aids)
83
Q
Mixed hearing loss
A
-combination of SNHL and conductive hearing loss
84
Q
Central hearing loss
A
- stroke or head injury is effecting hearing
- anatomy of ear and nerve is working fine
85
Q
Pseudohypacusis hearing loss
A
- faked hearing loss
- can be purposeful or psych related
86
Q
Hearing loss prevention
A
- hearing protection
- education
- screening and early intervention
- healthy lifestyle and exercise
87
Q
Chronic sinusitis treatment
A
- bugs: staph aureus, coagulase negative staph, anaerobes, G-, fungus
- Abx tx for 3-4 weeks
- intranasal steroids, saline, oral steroids, decongestants, mucolytics
- smoking cessation
- surgery if anatomical cause found
