Head Nose Sinus Flashcards
• What are the 5 general approaches to seeing a patient?
o History, physical exam, laboratory (as indicated), imaging/procedure (as indicated), referral (as indicated)
• What are some hx question?
o Head pain? (get full history with presentation of head pain)
o Accompanying symptoms (eg. eye, ears, cranial nerves, neurologic, GI, temperature, etc)
o History of head injury? Any loss of consciousness?
o Lesions, tumors, scalp hair loss?
• What are some things involved in the PE?
o Observation: normocephalic (microcephalic, macrocephalic)
o Vitals
o Palpation of head and scalp: lesions, masses, tenderness; On infants, examine fontanelles
o Full exam of Ears, Eyes, Nose, Sinus, Throat, Neck
o Appropriate neurological exams (CN, peripheral, orientation, cognitive)
• What are some common labs?
o ESR, CRP, CBC, CMP
• What are some common imaging/procedures?
o MRI, CT, angiography, lumbar puncture and CSF analysis
• What are some common referrals?
o Emergency, Neurology, Dermatology
• What is the mortality of a head trauma?
o ~ 50% with severe injury (more deaths & disability than other neuro cause in >50 yo)
o Damage to nerve tissue, blood vessels and meninges can result in neural disruption, ischemia, hemorrhage and edema
• What are the 2 types of head traumas?
o Open and closed head injuries
• What may be the effects of an open head injury?
o Emergency
o Piercing of the skull, direct trauma e.g. GSW (gunshot wound)
o direct effects from the tissue damage and shock waves
• How may closed head injuries occur? Emergency?
o Emergency or urgency
o Eg. acceleration-deceleration injury (whiplash)- local injury and opposite side of skull
o “contra-coup injury”
• How is the severity of closed head injuries based?
o loss of consciousness or not
o presence or absence of neurologic signs
• What are the 2 classes of closed head injuries?
o Primary and secondary injuries
• What are the 3 types of primary head injuries?
o Mild traumatic brain injury (TBI)-simple concussion
o Moderate diffuse TBI
o Severe diffuse TBI
• What are the grades of severity of mild TBI?
o American Academy of Neurology guidelines
o Grade 1- Confusion, sx last < 15 min, no LOC
o Grade 2- Symptoms last >15 min, no LOC
o Grade 3- LOC for seconds to minutes
• What are the signs and symptoms of mild TBI?
o No to brief loss of consciousness, dilated pupils, breathing stops, muscles flaccid heart slows.
o Recovery in seconds to minutes- may have days to weeks of giddiness, anxiety, poor concentration, headaches, sleep disturbance
• What PE should be done for mild TBI?
o perform neuro exam; CT scan may be needed if persistent symptoms
• What is characteristic of a moderate diffuse TBI?
o Unconsciousness for up to an hour with slower recovery of orientation and behavior.
• What are the signs and symptoms for moderate diffuse TBI?
o Lethargic for 1-7 days. Many have agitation or anxiety
o Imaging: CT may be normal or may show scattered petechiae or contusion in brain. May show hematoma at contra-coup position
• What is the treatment for moderate diffuse TBI?
o hospitalization to watch for complications; rest (physical & cognitive), NO alcohol or drugs
• What are red flag symptoms in moderate diffuse TBI?
o unconsciousness, altered mental status, convulsions, persistent HA, extremity weakness, bleeding from ear(s), loss of hearing
• What is the prognosis for moderate diffuse TBI?
o Complete recovery in days to weeks in those under 40yrs. Those > 40 may have permanent intellectual and psychological effects. Worse prognosis in alcohol/drug abusers.
• How is severe diffuse TBI categorized?
o by patient response rather than the injury
• What are the signs and symptoms of severe diffuse TBI?
o Severe brain edema, ischemic infarction, hemorrhages-immediate or delayed several hours (20%)
o usu. deep unconsciousness from the start
o Respiratory obstruction due to aspiration of vomit or saliva
o Brain stem damage shown by bilateral pupillary fixation, slow responses to light, or anisocoria
• What is the treatment for severe diffuse TBI?
o emergency hospitalization required
• What is post-concussion syndrome?
o In some individuals, symptoms of mild TBI persist for weeks to years.
o Sx can include: HA, fatigue, anxiety, dizziness, memory problems, attention problems, sleep disturbance, irritability
• What is a secondary head injury?
o Requires careful monitoring in pts with TBI
o after primary injury: further brain swelling and can lead to secondary brainstem damage and death—from hypotension, hypoxia, infection, hematoma
• Generally, what may cause headaches? How common are they? Where does the pain come from?
o head or neck pain may be a disorder in its own right or caused by underlying medical condition
o Common! 5 -10% US population seek medical help for headache, 20% kids have significant HA
o Brain tissue itself does not have sensory nerves, so headache pain comes from outside the brain (meninges, scalp, blood vessels and muscles)
• What are the classifications of HA?
o International Headache Society (HIS)
o Primary or secondary
o Vascular or nonvascular
• What is a primary HA? How common? Examples?
o not caused by underlying medical diagnosis
o 90% of all Has
Main examples: migraine (with or without aura), tension-type (episodic or chronic), cluster
What is a secondary HA?
o caused by underlying medical condition
• What are 10 examples of a secondary HA?
o Head and neck trauma – eg. post-concussion syndrome
o Cranial or cervical vascular disorders – eg. temporal arteritis, hematoma, hemorrhage
o Nonvascular intracranial disorders - either high CSF pressure (e.g., secondary to tumors) or low CSF pressure; benign intracranial hypertension
o Infection – eg meningitis or systemic infection
o Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, etc
o Disorders of homeostasis - diving, high altitude, hypoxia, hypertension, hypothyroidism, fasting, heat stroke, “sphenopalantine ganglioneuralgia”
o Substance use or its withdrawal: Acute substance use (e.g., nitric oxide, alcohol, food additives, cocaine, cannabis, histamine); Medication overuse headache (e.g., from triptans, analgesics, opioids, combinations); Substance withdrawal headaches (e.g., from caffeine, opioids)
o Psychiatric conditions – eg depression, anxiety disorders, somatization disorders
o Cranial neuralgia - both trigeminal and glossopharyngeal neuralgias
o Iatrogenic: lumbar puncture, manipulation, physiotherapy
• What are 3 types of features or concomitant symptoms suggestive of secondary HAs?
o Change in typical HA
o Following head trauma
o Associated with systemic condition
• What may be considered changes in the typical HA?
o Sudden onset of new HA, “Worst HA ever”(Consider subarachnoid hemorrhage)
o Drowsiness, confusion, memory loss (infection, mass, subdural hematoma)
o Progressive vision loss (tumor, inc ICP, MS, Lyme, glaucoma, arteritis)
o High blood pressure
• What features may present with a HA may follow a head trauma?
o Progressively worsening HA
o Metabolic imbalance eg Hypoglycemia, thyroid problem
o Fever (common sign of infection)
o Focal neurological signs
• What features associated with systemic conditions may present with a HA?
o Onset with exertion, coughing, straining, sexual activity, Valsalva (mass, subarachnoid hemorrhage)
o Chronic malaise, myalgia, arthralgia (temporal arteritis, collagen vasc dz, Lyme dz)
o Weakness, clumsiness, postural instability (focal brain dz)
o CSF rhinorrhea
• What is a vascular HA? Examples?
o quality of pain: throbbing or pounding, sharp
o Various triggers lead to rapid changes in artery size; from spasm/ constriction.
o Other arteries in the brain and scalp then dilate, and throbbing pain is perceived in the head
o Examples: migraine with or without aura, cluster, fever, hypertension, exertion, hangover
• What is a non-vascular HA? Examples?
o quality of pain: steady, constant, dull
o Examples: tension-type, TMJ, brain tumor, sinus or dental infection, inner or middle ear
• Why is a hx important? Letters?
o 99% of information needed to make diagnosis!
o L, M, N, O, P, Q, R, S, T, concomitants
• What are common questions in a hx of HA?
o When and how (sudden, gradual) did HA begin?
o First or Worst HA?
o Worsening HA? (often organic)
o Effect of activity on pain
o Location of HA, does it move? Is it always on the same side? (changeable less likely organic)
o Age of first HA? (90% migraines in <40 yo)
o Is THIS HA similar to prior ones?
o Frequency, pattern of HA (episodic, daily)
o Duration of HA
o Family history of HA (migraine, cluster)
o Medications (change in method of birth control)
o Any prodromal symptoms?
o Any recent change in vision?
o Known triggers and aggravations (light, sound)
o Stressors: home, work, relationships
o Association to recent trauma
o Any association to environmental factors
o Relationship to food/alcohol
o Any recent change in sleep, exercise, weight
o Response to previous treatment
o PMHx: any concurrent medical problem
o General health status
• What are the red flags of a HA hx?
o Onset after age 50: temporal arteritis, intracranial mass
o Incr. frequency and severity: subdural hematoma, mass, medication overuse
o Sudden onset of headache: subarachnoid hemorrhage, vascular malformation, mass
o Pain moves to lower neck and thoracic spine: meningeal irritation
o First or worst headache: intracranial hemorrhage, CNS infection
o History of head trauma: intracranial hemorrhage, subdural hematoma, epidural hematoma
o History of HIV or cancer: meningitis, brain abscess, metastasis, opportunistic infection
o Any change in mental status, personality, level of consciousness
• What is done for a PE for a HA?
o vital signs (BP, temp)
o head and neck – carotid and temporal artery pulsations, cervical ROM, tenderness of muscles of head and neck, palpate cranium, jaw, neck, sinus; perform oral and ear exam
o neurological exam (cranial nerves, motor/sensory, reflexes, coordination)
o HEENT (fundoscopic exam extremely important, to check for papilledema)
• What are the red flags for PE of a HA?
o Fever: intracranial, systemic or local infection
o Neck stiffness/rigidity: meningitis
o Papilledema: meningitis, mass, pseudotumor cerebri, increased intracranial pressure
o Focal neurological signs
Signs of systemic illness or infection: meningitis, encephalitis, Lyme dz, systemic infx, collagen vascular disease
What are the 16 types/causes of HA (more and less common)?
o Most common: Migraine; Tension-type headache (TTH); Cluster; Trigeminal neuralgia
o Less common: Hemicrania continua; SUNCT syndrome; Medication overuse; Dietary related; Inflammation/infection in skull/brain; Related to BP; Intracranial masses; Giant cell (temporal) arteritis; Subarachnoid hemorrhage; TMJ syndrome; Depressive; Eye pain
• What are some general characteristics of a migraine HA?
o Often familial.
o Recurrent attacks, variable in intensity, frequency, duration
o Usually unilateral and associated with anorexia, nausea and vomiting
o Photophobia Aura may or may not occur
• What are the frequency, sex, age features of migraine?
o ~10-20% of the US population suffers from migraines; second most common type of headache (tension-type the most common)
o F:M 3:1
o First attack often is in childhood, incidence increases in adolescence; > 80% of patients have a first attack by age 30; less common > age 50. (less frequent and less severe)
o Note: Age of onset > 55 years is a strong predictor for intracranial pathology
• What is the impact of migraine on the patient and their family?
o Patient: decreased energy and vitality; decreased social functioning; 50% of pts miss at least 2 workdays/mo; avg at least 6 days of impaired ability/mo; 43% reduction in performance effectiveness
o Family: negative impact on family and partner, eg missed activities
• What are some theories on the pathophysiology of migraine?
o Neurovascular, vasoactive neuropeptides (substance P), cortical spreading depression, role of serotonin? Genetics? Combination
• What does poly-factoral mean?
o Multiple vectors of treatment approaches!
• What are 12 co-existing/commonly associated medical conditions?
o Epilepsy; asthma; sleep disorders; hemorrhagic telangiectasia; Tourette syndrome; Raynaud’s; familial dyslipoproteinemias; chronic fatigue syndrome; depression and anxiety; ischemic stroke (migraine c aura risk); hypertension; atrial septal defect
• How is info gathered for migraine diagnosis?
o Medical History: get clear picture and chronology of symptoms
o Headache diary: date(s) of attack; medications/dose taken; what time the attack began; what time the attack ended; any warning signs? symptoms including aura, if present; previous few days (activity, triggers)
• What are some common precipitating factors/trigger for migraine?
o emotional and physical STRESS (strongest trigger in most sufferers)
o hormones in women: PMS, use of BCP or HRT
o skipped meals, hypoglycemia
o loss of sleep, changes in normal sleeping patterns, sleeping in late
o changing weather conditions
o odors, lights, smoke
o exercise
o food intolerances/ allergies: studies range from 30-93%
o Tyramine-containing foods:
• What are some changing weather conditions that can trigger migraine?
o storm fronts, changes in barometric pressure, strong winds, changes in altitude or temperature (heat)
• What are some food intolerances/allergies that can trigger migraine?
o common: cow’s milk, eggs, chocolate, wheat, oranges, walnuts, tomato, alcohol, MSG
• What are some tyramine-containing foods that can cause migraine?
o Cheeses (blue cheeses, brie, cheddar, feta, gorgonzola, mozzarella, Muenster, parmesan, swiss, stilton); aged, canned, cured or processed meats, certain beans (fava, broad, garbanzo, lima, pinto), onions, olives, pickles, avocados, raisins, canned soups, and nuts.
• What is the screening test for a migraine?
o Self-administered 3 question test has >90% accuracy at detecting migraine.
o 1. Has a headache limited your activities for a day or more in the last 3 months?
o 2. Are you nauseated or sick to your stomach when you have a headache?
o 3. Does light bother you when you have a headache?
• What is some other possible work-up for migraine, only to exclude secondary causes?
o EEG; CT and/or MRI; EMG; TMJ radiography; Cervical spine films; CMP; Psychometric testing
• What are the 2 classifications for migraine?
o Migraine without aura (previously termed “common migraine”)
o Migraine with aura (previously termed “classic migraine”)
• What is the diagnostic criteria for a migraine without aura?
o at least 5 attacks with the following:
o HA lasting 4-72 hr. (untreated or unsuccessfully treated)
o At least 2 of the following characteristics: unilateral location; pulsating quality; moderate to severe pain; worse with routine activity
o During headache at least one of the following occurs: nausea and/or vomiting; photophobia and phonophobia
o History, physical exam, and neuro exam show no evidence of organic dz.
• What are the 4 phases/sequence of symptoms of a migraine w/o aura?
o Prodrome, headache, resolution, recovery
• What symptoms are seen in the prodrome phase of a migraine?
o Food craving, fatigue, heightened perception, fluid retention
• What symptoms are seen in the HA phase of a migraine?
o Gradual onset; dull then pulsatile; 1/3 have sharp pain; unilateral may change sides;
o Duration <1 day – 72 hrs
o Decreased motion; vomiting; coughing; pallor, fluid gain; photophobia
o Nausea leading to vomiting in 50%
o Withdrawn, irritable
• What symptoms are seen in the resolution phase of migraine?
o Sleep: long, deep
o Catharsis through vomiting, lacrimation, urination, diarrhea, menses
• What symptoms are seen in the recovery phase of migraine?
o Hours to days
o Limited food tolerance, Fatigue, feeling drained
o Depression, some report elation
• What are the diagnostic criteria for a migraine with aura?
o at least two attacks of:
o aura includes at least one visual, sensory, or dysphasic quality
o Aura develops over 5-20 min, usu lasting < 60 min
o HA follows during or after aura, lasts 4-72 hr, similar to non-aura migraine
o History, physical exam, and neuro exam show no evidence of organic dz
What are the visual, sensory, and dysphasic symptoms of an aura (reversible)
o Visual: scintillating scotoma (area of loss of vision, irregular luminous patch); photopsia (flashing lights)
o Sensory: paresthesia on face; numbness; unilateral weakness; olfactory hallucinations
o Dysphasic: speech disturbance (aphasia)
• What are the prodromal symptoms that may be seen with an aura migraine?
occurring hours/day before migraine: hyperactivity, lethargy, depression, cravings, frequent yawning
• When/how does the headache occur in an aura migraine?
o Similar to non-aura migraine, starting during the aura or w/in 60 min
• What are the 6 subtypes/variants of migraine with aura (previously “complicated migraine”)?
o Hemiplegic migraine: temporary paralysis (hemiplegia) or nerve or sensory changes on one side of the body (such as muscle weakness--reversible). o Retinal (ocular) migraine: temporary, monocular scotoma or blindness in one eye, along with a dull ache behind the eye lasting about an hour, followed by headache. o Basilar-type migraine: dizziness, confusion or loss of balance can precede the headache; pain may affect the back of the head; symptoms usually occur suddenly and can be associated with the inability to speak properly, tinnitus, vertigo, diplopia, dysarthria, ataxia, decreased level of consciousness and vomiting. o Migraine aura without headache: confused as TIAs in elderly o Status migrainosus (rare): HA pain and nausea are very intense o Ophthalmoplegic migraine (rare) emergency!- Affecting CN III, IV, VI; pain around the eye, including paralysis in muscles surrounding the eye; other symptoms: ptosis, diplopia, or other vision changes.
• What is the most common form of HA?
o Tension-type HA (TTH)
• What are the 3 classifications of TTH?
o Infrequent episodic TTH: headache episodes less than one day a month (30-80% of pop)
o Frequent episodic TTH: headache episodes 1-14 days a month
o Chronic TTH: headaches 15 or more days a month (3% of pop)
