Head/Neuro/ENT Flashcards
A 58-year-old female presents with a 6-month history of persistent intermittent unilateral rhinorrhea. The drainage is clear, and seems to be worse in the early morning when she first gets up. Her past medical history includes hypertension and controlled migraines. Her surgical history includes a total hysterectomy 5 years ago and septal deviation surgery 7 months ago. She has tried oral antihistamines and intranasal corticosteroids without relief.
The patient should undergo further evaluation for: (check one)
vasomotor rhinitis
allergic rhinitis
cerebrospinal fluid rhinorrhea
an intranasal tumor
cerebrospinal fluid rhinorrhea
Cerebrospinal fluid (CSF) rhinorrhea is not that rare, and has both surgical and nonsurgical causes. It results from a direct communication between the subarachnoid space and the paranasal sinuses. Accidental trauma causes 70%–80% of CSF rhinorrhea cases, with 2%–4% of acute head injuries resulting in CSF rhinorrhea. Nontraumatic CSF rhinorrhea includes high-pressure and normopressure leaks from causes including tumors, processes including boney erosion, empty sella syndrome, and congenital defects including meningoceles. The rhinorrhea is clear and often has a sweet or salty taste. The drainage can be continuous or intermittent, and is often associated with a gush when changing from a recumbent to an upright position. CSF rhinorrhea can lead to meningitis or other infections by serving as a pathway for bacteria.
You are treating an 18-year-old college freshman for allergic rhinitis. It is September, and he tells you that he has severe symptoms every autumn that impair his academic performance. He has a strongly positive family history of atopic dermatitis.
Which one of the following intranasal medications is considered optimal treatment for this condition? (check one)
Glucocorticoids
Cromolyn sodium
Decongestants
Antihistamines
Glucocorticoids
Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety. Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms. Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.
Azelastine, an intranasal antihistamine, is effective for controlling symptoms but can cause somnolence and a bitter taste. Oral antihistamines are not as useful for congestion as for sneezing, pruritus, and rhinorrhea. Overall, they are not as effective as topical glucocorticoids.
A 30-year-old female presents to your office with a clear nasal discharge, sneezing, nasal congestion, and nasal itching. She notes that these symptoms generally occur in the spring and fall.
The most effective drug for treatment and prevention is?
(check one)
Cetirizine (Zyrtec)
Cromolyn nasal spray (NasalCrom)
Ipratropium nasal spray (Atrovent
Montelukast (Singulair)
Fluticasone nasal spray (Flonase)
Fluticasone nasal spray (Flonase)
The initial treatment of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone, with the use of second-line therapies for moderate to severe disease (SOR A). The adverse effects and higher cost of intranasal antihistamines, as well as their decreased effectiveness compared with intranasal corticosteroids, limit their use as first-or second-line therapy for allergic rhinitis. Moderate to severe disease not responsive to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation.
A 64-year-old male with a previous history of hypertension and atrial fibrillation presents with an acute onset of ataxia, headache, mild confusion, and restlessness. His only current medications are lisinopril (Prinivil, Zestril) and warfarin (Coumadin). On examination his blood pressure is 160/100 mm Hg, pulse rate 86 beats/min, respirations 12/min, and temperature 36.7°C (98.1°F). A CBC, serum electrolyte levels, and cardiac enzyme levels are normal. His INR is 1.1. Noncontrast CT shows a cerebellar hemorrhage with a hematoma volume of 50 mL.
Which one of the following should be performed urgently?
(check one)
Neurosurgical consultation for posterior cerebellar hematoma decompression
A reduction in blood pressure to 140/90 mm Hg
Administration of vitamin K, 10 mg intravenously
Administration of mannitol (Osmitrol), 0.5–1.0 mg/kg intravenously
Induction of hypothermia to achieve a body temperature of 34.4°C (94.0°F)
Neurosurgical consultation for posterior cerebellar hematoma decompression
Aggressive neurosurgical intervention is not indicated to evacuate clots in patients with intracerebral hemorrhage except in those with a cerebellar hemorrhage, which is always an indication for neurosurgical consultation. Guidelines have been developed by the American Heart Association for lowering blood pressure in patients with a systolic blood pressure >180 mm Hg, or a mean arterial pressure >130 mm Hg. The use of various forms of osmotherapy, including mannitol, to prevent the development of cerebral edema has not been shown to improve outcomes. The data regarding hypothermia induction is unclear. Patients with an INR >1.5 should receive therapy to replace vitamin K–dependent factors and have their warfarin withheld.
A 40-year-old male presents with a sudden onset of unilateral peripheral facial nerve weakness 1 hour ago. Which one of the following is most likely to shorten his symptoms?
(check one)
Corticosteroid therapy
Antiviral therapy
Thrombolytic therapy
Hyperbaric oxygen therapy
Facial nerve decompression
Corticosteroid therapy
This patient has Bell’s palsy. Only corticosteroids have been shown to improve the outcome. Antiviral agents have little value in the treatment of Bell’s palsy. Thrombolytic therapy may be useful for a patient with central facial nerve weakness if it is due to a vascular event (level of evidence 3; SOR A).
A 51-year-old male presents to your office with right arm weakness. He has a history of multiple sclerosis (MS) with infrequent flares only. His MS is managed with interferon as the long-term disease-modifying therapy. After a thorough history and examination, you diagnose a flare of MS.
In addition to notifying his neurologist, which one of the following would be the most appropriate next step? (check one)
Doubling his dosage of interferon for 5 days
Initiating high-dose aspirin
Initiating corticosteroids
Ordering plasmapheresis
Referral to physical therapy
Initiating corticosteroids
Although multiple sclerosis (MS) is often managed by a neurologist and a multidisciplinary team, family physicians sometimes see these patients for symptoms that could be related to their disease process. If an MS flare is thought to be the etiology, corticosteroids are the treatment of choice, most often oral methylprednisolone with recommendations of 500 mg daily for 5 days or 1000 mg daily for 3 days. Intravenous administration has not been found to be more efficacious than oral administration. Corticosteroids speed the recovery process but do not generally alter the long-term outcomes. Patients without an adequate response to the corticosteroid burst may potentially benefit from plasmapheresis. High-dose interferon, high-dose aspirin, and physical therapy are not used to treat acute exacerbations.
A 45-year-old male presents with a 3-month history of hoarseness. He denies any other complaints and has not been ill recently. He is not on any medication, has no history of chronic medical problems, and does not smoke cigarettes or drink alcohol.
Which one of the following would be the most appropriate management of this patient?
(check one)
Voice rest for 1 month
Laryngoscopy
A trial of a proton pump inhibitor
A trial of inhaled corticosteroids
Oral corticosteroids
Laryngoscopy
Laryngoscopy should be performed to visualize the larynx and evaluate for vocal cord pathology in a patient whose hoarseness does not resolve within 3 months (SOR C). If a serious condition is suspected for some other reason, laryngoscopy should be performed regardless of the duration of symptoms. If there is a recent history of upper respiratory infection or vocal abuse, then it would be appropriate to recommend voice rest for 2 weeks. Laryngoscopy would then be indicated if the hoarseness did not improve or recurred after voice rest. For patients with symptoms of gastroesophageal reflux, a trial of a proton pump inhibitor is recommended (SOR B). Inhaled corticosteroids, especially fluticasone, may cause hoarseness. Oral corticosteroids do not have a role in the management of hoarseness.
A 16-year-old afebrile, otherwise healthy female presents with a 4-day history of right ear pain. She says she has spent a fair amount of time swimming recently. Traction on the pinna causes pain. The erythema and inflammation is limited to the ear canal but there is too much edema to easily visualize the tympanic membrane.
Which one of the following would be the most appropriate treatment?
(check one)
Amoxicillin
Amoxicillin/clavulanate (Augmentin)
Amoxicillin/clavulanate plus acetic acid 2% topically
Ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex) topically
Ciprofloxacin 0.3%/dexamethasone 0.1% (Ciprodex) topically
Acute otitis externa is treated with topical antibiotics. Although no preparation has been shown to be most effective, a fluoroquinolone does not create a risk of ototoxicity if the tympanic membrane is not intact. Topical corticosteroids may hasten symptom reduction. Oral antibiotics are not appropriate unless the infection has spread beyond the ear canal, or if the patient has diabetes mellitus or is immunocompromised.
An 84-year-old African-American female is brought to your office by her daughter, who is concerned that the mother has memory problems and is neglecting to pay her monthly bills. The mother also is forgetting appointments and asks the same questions repeatedly. This problem has been steadily worsening over the last 1–2 years. The patient has very little insight into her problems, scores 24 out of a possible 30 points on the Mini-Mental State Examination, and has difficulty with short-term recall and visuospatial tasks. Her physical examination and a thorough laboratory workup are normal. A CT scan of the brain reveals diffuse atrophy. Which one of the following is the most likely etiology for this patient’s memory problem? (check one)
Alzheimer’s disease
Dementia resulting from depression
Lewy body dementia
Multi-infarct dementia
Normal aging
Alzheimer’s disease
The patient shows classic symptoms of early Alzheimer’s disease, with difficulties in at least two cognitive domains that are severe enough to influence daily living. Normal aging changes can decrease one’s ability to retrieve information but do not influence daily living and are usually noticed more by the patient than by family members. Depression was previously thought to cause “pseudodementia” with significant regularity. However, several recent studies have shown that treating depressive symptoms does not result in significantly improved cognitive performance. It is now believed that progressive memory loss frequently results in depressive symptoms, rather than the converse. Lewy body dementia is associated with physical findings of parkinsonism and often the presence of visual hallucinations, both of which are absent in this patient. There are no signs of multiple infarcts on brain imaging, effectively ruling out this diagnosis.
A 58-year-old male who works with heavy machinery at a local factory presents to your office for evaluation of hearing loss of several years’ progression. He notes that the loss is mainly in the left ear and he also has mild tinnitus. He has had no trauma to his head, and he has no history of ear infections. Examination of the ears reveals normal tympanic membranes and a neurologic examination is negative. When a tuning fork is placed in the center of his forehead, he says the sound is much louder on the right side (Weber test). Comparing sound in front of the ear to the sound when the tuning fork is placed on the mastoid (the Rinne test) reveals that air conduction is better than bone conduction in the left ear. Which one of the following is true regarding further evaluation and management? (check one)
No treatment or further diagnostic studies are indicated
A hearing aid plus better hearing protection is all that is needed
Carotid ultrasonography should be ordered
A tympanogram is indicated
Audiometry is the best initial screening test
Audiometry is the best initial screening test
Acoustic neuroma symptoms are due to cranial nerve involvement and progression of tumor size. Hearing loss is present 95% of the time and tinnitus is very common. The loss is usually chronic (over 3 years) and as many as one-third of patients are unaware it has occurred. Vestibular nerve involvement most often causes mild unsteadiness and rarely has accompanying true vertigo. Trigeminal involvement can cause pain, paresthesias, or numbness of the face. Facial paresis occurs 6% of the time. The diagnosis of acoustic neuroma is based on asymmetric sensorineural hearing loss or another cranial nerve deficit, with confirmation based on MRI with gadolinium contrast or a CT scan. The best initial screening laboratory test is audiometry, as only 5% of patients with acoustic neuroma will have a normal test. Sensorineural loss is usually in the higher frequencies. Brainstem-evoked response audiometry may be used as a further screening measure when there are unexplained symmetrics and standard audiometric testing.
Which one of the following causes rhinitis medicamentosa with prolonged use in the treatment of rhinitis? (check one)
Intranasal antihistamines
Intranasal decongestants
Intranasal anticholinergics
Intranasal mast cell stabilizers
Leukotriene antagonists
Intranasal decongestants
Intranasal decongestants such as phenylephrine should not be used for more than 3 days, as they cause rebound congestion on drug withdrawal. When used for several months or more, these agents can cause a form of rhinitis, rhinitis medicamentosa, that can be extremely difficult to treat.
Pallidotomy is a surgical therapy for: (check one)
Alzheimer’s disease
Parkinson’s disease
Huntington’s chorea
Vascular dementia
Temporal lobe epilepsy
Parkinson’s disease
Thalamotomy and pallidotomy, contralateral to the side of the body that is most affected, are most effective for the treatment of disabling unilateral tremor and dyskinesia from Parkinson’s disease.
A 52-year-old male sees you for follow-up after a recent right-sided ischemic stroke. The evaluation in the hospital demonstrated an unremarkable cardiac workup, an LDL-cholesterol level of 110 mg/dL, and a right internal carotid artery stenosis of 45%. His blood pressure today is 120/75 mm Hg and an examination is notable for some residual right-sided facial weakness. His current medications are aspirin, clopidogrel (Plavix), and hydrochlorothiazide.
Which one of the following would be most likely to reduce his risk for a secondary stroke? (check one)
Atorvastatin (Lipitor)
Losartan (Cozaar)
Warfarin
Carotid endarterectomy
Atorvastatin (Lipitor)
Two randomized, controlled trials (RCTs) have demonstrated significant reduction in risk for secondary stroke with high-dose statin therapy. The studies further demonstrated that an LDL-cholesterol goal <70 mg/dL was superior to targets of 90–100 mg/dL in preventing secondary stroke events.
Data from RCTs and large meta-analyses show compelling evidence that blood pressure targets in patients with previous stroke should be similar to targets for other cardiovascular conditions, namely <130/80 mm Hg. There has been no benefit shown with lower blood pressure targets. Although angiotensin receptor blockers such as losartan are recommended for the treatment of hypertension, there is limited evidence of efficacy for secondary stroke prevention, so losartan would not be appropriate for this patient whose blood pressure is at goal. Use of warfarin in addition to aspirin does not provide any benefit and increases the risk for hemorrhage. Several randomized clinical trials have demonstrated that the greatest benefit for carotid endarterectomy (CEA) was in asymptomatic patients with >70% stenosis, with other analyses demonstrating no benefit in patients with <50% stenosis. In symptomatic patients (e.g., ipsilateral TIA or nondisabling stroke), CEA is recommended in those with moderate (50%–69%) or severe (70%–99%) carotid artery stenosis.
A 40-year-old male presents to the urgent care clinic with a 2-day history of a progressive inability to walk. His husband is concerned that he has Guillain-Barré syndrome.
Which one of the following, if present in this patient, would be concerning for Guillain-Barré syndrome? (check one)
Afferent pupillary defect
Asymmetric flaccid weakness
Muscle spasticity
Nystagmus
Symmetric hyporeflexia
Symmetric hyporeflexia
Guillain-Barré syndrome (GBS) is a common cause of acute weakness. While the clinical presentation can vary, patients commonly present with progressive symmetric ascending flaccid weakness and symmetrical hyporeflexia or areflexia. Asymmetric flaccid weakness and muscle spasticity are not seen in GBS. While patients may have cranial nerve findings, those are not common. Nystagmus is not typically associated with GBS.
Which one of the following is true regarding temporomandibular joint disorder? (check one)
Dental splints are the treatment of choice
Mandibular clicking is an essential diagnostic element
Ultrasonic phonophoresis with cortisone is the treatment of choice
The majority of cases resolve without treatment
MRI is preferred over CT to confirm the diagnosis
The majority of cases resolve without treatment
Temporomandibular joint (TMJ) disorders occur in a large number of adults. The etiology is varied, but includes dental malocclusion, bruxism (teeth grinding), anxiety, stress disorders, and, rarely, rheumatoid arthritis. Dental occlusion problems, once thought to be the primary etiology, are not more common in persons with TMJ disorder. While dental splints have been commonly recommended, the evidence for and against their use is insufficient to make a recommendation either way. Physical therapy modalities such as iontophoresis or phonophoresis may benefit some patients, but there is no clearly preferred treatment. Radiologic imaging is unnecessary in the vast majority of patients, and should therefore be reserved for chronic or severe cases. In fact, the majority of patients with TMJ disorders have spontaneous resolution of symptoms, so noninvasive symptomatic treatments and tincture of time are the best approach for most.
