LA ENT Flashcards
ears
MC cause of conductive and SN hearing loss
conductive: ceruman impaction
SN: prebycusis
damaged ossicle, mastoiditis, OM, FB, ETD, secondary to URI, Perf TM, fluid, otosclerosis, cholesteatoma, tumors
causes of conductive HL
CNS lesion, neuro d/o, aminoglycosides, loops, meniere, neuroma, labyrinthitis, infection
causes of SN HL
vertigo
SE of reglan, promethazine
extrapyramidal, tardive dyskinesis, dystonia, parkinsonism
dangers of dopamine blockers
reglan, promethazine
neuroleptic malignant syndrome
Neuro leptic malignancy syndrome
stop dopamine blocker
anticholinergics: meclizine, scopolamine,
only 2 meds
avoid anticholinergics in what pts
acute angle glaucoma, BPH with urinary retention
can follow a URI. episodic vertigo. 1 minute duration.
No hearing loss, ataxia, or tinnitus.
BPPV
do hallpike manuver
dec salt, meclizine
Has hearing loss. Episodic vertigo, No relation to movement, last hours
menieres
treatment?
vestibular on left
laby on right. (unilateral HL)
1st line glucortcoids
peripheral on left
central on right
After ETD or URI. PAINLESS otorrhea (brown and odor),
Conductive HL
Cholesteatoma
After URI. Fullness, popping, underwater feeling, fluctuating conductive HL, tinnitus
ETD
Percussion TENDER posteriorly, FEVER, deep ear pain(worse at night)
next step?
Mastoiditis
CT with contrast!! IV antibx (IV vanco plus (piper/taz, ceftazadine, cefepime)
Otalgia, sudden pain relief with bloody otorrhea.
Can lead to cholesteatoma.
avoid what
TM perf
aminoglycosides
Autosomal dominant. Slowly progressive hearing loss especially at low frequencies.
next step?
Otosclerosis
Tone audiometry and hearing aids.
Abnormal bony overgrowth of foot plate of stapes, conductive, hearing loss, family history, Autosomal dominant
Otosclerosis
Cholesteatoma
conductive
acoustic vestibular neuroma
MRI and audiometry
trigeminal CN 5
abducens CN 6
facial CN 7
how is the eustachian tube different in kids
shorter, narrower, and more horizontal
MC organism in acute OM
strep pneumo
serous otitis media on left
acute otitis medial on right
most sensitive test for acute otitis media
tx
pneumatic otoscope, TM will not mobilize
amox 1st choice
MC organism in chronic OM
pseudomonas
MC organism in otitis externa
pseudomonas
pain with tragus pulling, purulent discharge
tx?
otitis externa
topical antibx
painless, purulent otorrhea, ear fullness, conductive hearing loss
chronic OM
ear disorder that peaks at 6-18 months
acute OM
malignant necrotizing otitis externa
CT/MRI next. Bx to confirm.T
ADMIT and IV antipsedomonal antibx
Cipro 1st line.
granulomatous tissue at cartilaginous part of ear canal
malignant necrotizing otitis externa
otoscope: effusion with TM retracted/flat. hypomobility with air. No signs of inflammation
serous OM with effusion.
resolves on its own
what antibiotic is ototoxic?
aminoglycosides
avoid in TM perf
hordeolum on right
chalazion on the left
entropian on left
ectropian on right
Blockage of nasolacrimal duct
dacrocystitis
dacrocystitis
blepharitis
blow out fx
dry on left
wet on left
Macular degeneration?
cotton wool spots, DM retinopathy
DM retinopathy
DM retinopathy
DM retinopathy
circinate ring in dm retinopathy
blot and dot hem in dm retinopathy
papilladema in htn retinopathy
retinal detachment
next step
get opthalm, emergency!
lay supine towards side of retinal detachment
ice rink; corneal abrasion
limbal flush: keratitis
hazy cornea
, keratitis
hypopyon, bacterial keratitis. And 1 more
dendritic corneal ulceration: herpes keratitis
amblyopia.
think strabismus
clouding of the Lens (versus clouding of cornea)
clouding of the Lens: cataract
(clouding of cornea = glaucoma)
globe rupture
globe rupture
leukocoria, retinoblastoma
retinal blastoma
hyphema
central artery retinal occlusion
boxcar
central artery retinal occlusion
blood and thunder
central vein retinal occlusion
marcus gunn pupil .
optic neuritis and retinal detachment
moa of acetazolamide
decreases production of aqueous humor and CSF production
dangerous glaucoma
acute angle closure
glaucoma common in blacks and asians
open angle with blacks.
closed angle with asians.
slow, progressive painless bil. peripheral vision loss, halos(worse at night) sometimes
cupping of optic disc
tx
chronic open angle glaucoma
1st line is prostaglandin analogs(latanoprost to decrease IOP)
precipitants: mydriasis, anticholinergics, adrenergic meds
sudden severe unilateral ocular pain, halos, tunnel vision, blurred vision
appears unwell
acute angle closure glaucoma
exam: conjunctiva red, cloudy cornea, pupil fixed and dilated
optic disc cupping/blurring
next step
acute angle closure
lie on back, pilocarpine drops
need iridotomy
pathogen of hordeolum
mc st aureus
upper eyelid common finding
chalazion
hordeolum gland
meibomian found under eyelid
entropion vs ectropion
entropion is inverted.
FB sensation, tearing ,red eye
condition due to spasm of orbiculis oculi muscle
entropion
tearing, dry eye symptoms, red conjunctiva
condition due to relaxation of orbiculis oculi muscle
ectropion
hyphema, teardrop shaped pupil, obscured red reflex
enophthalmos more than exopthalmos
exam for what
afferent pupillary defect
put on rigid eye shield
unilateral, severe pain, swelling, redness, tearing, drainage to medial side of lower lid area
treatment
anterior dacrocystitis
warm compresses and antibiotic (clindamycin, vanco + ceftriaxone)
mucopurulent drainage from punta. No signs of infection.
posterior dacrocystitis
dacrocystorhinostomy
meimobian gland dysfunction is most common cause of what
posterior blepharitis
crusting, scaling, red rimming, flaking
blepharitis
sunken eye
what bones are involved
orbital blowout
zygomatic, palantine, maxillary bone
most common kind of orbital blowout
inferior
diplopia(upward gaze), dec acuity, epistaxis, orbital emphysema, parathesias to gums/lips
next step/ avoid what
orbital blowout
order CT
avoid sneezing
CT: teardrop line
orbital blowout
most common cause of permanent blindness and vision loss in older adults
macular degeneration
most common type of macular degeneration
dry/atrophic
bilateral gradual central vision field loss(detailed/colored), microopsia, metamorphopsia(straight lines bent)
macular degeneration
ocular pain with eye movement, opthaloplegia with diplopia(EOM weakness), proptosis, visual changes, eyelid edema and erythema
septal orbital cellulitis
order what for a septal orbital cellulitis
next step
high resolution CT
admit and IV vanco plus (ceftriaxone or cefotaxime)
unilateral ocular pain, eyelid erythema/edema.
next step
preseptal orbital cellulitis
MRSA coverage for preseptal orbital cellulitis
clindamycin
drusen bodies (white-yellow spots on outer retina.
dry macular degeneration
most common kind of diabetic retinopathy
nonproliferative
AV nicking, abnormal light reflexes on dilated tortuous arteriole
hypertensive retinopathy
hypertensive retinopathy
AV nicking
hypertensive retinopathy
flame & dot hemorrhages, cotton wool spots, soft/hard exudates, microaneurysms
hypertensive retinopathy
most common primary intraocular malignancy in childhood
retinoblastoma
ocular ultrasound shows an intraocular calcified mass
retinoblastoma
leukocoria(presence of abnormal white reflex instead of the nml red reflex; may develop strabimus or nystagmus
next step
retinoblastoma
order a ocular u/s after dilated opthalmic exam
small moving flashing lights, floaters, progressive unilateral vision loss, decreased peripheral and central
+ shafers sign clumping of brown color pigment vitreous cells in anterior vitreous humor resembling tobacco dust
retinal detachment
avoid what in retinal detachment and what to do when diagnosed
miotic drops
lay supine with head turned towards affected side
ocular pain, tearing, red eye, photophobia
ice rink/linear abrasion
ocular FB and/or corneal abrasion
size of corneal abrasion to treat and tx
antibx
over 5 mm, patch for no longer than 24 hours
e mycin ointment
contact lens wearers-pseudomonas- topical cipro or oxofloxacin
1st symptom with ocular fb/corneal abrasion
decreased visual acuity
MC pathogen with bacterial and viral conjunctivitis
bacterial: staph aureus
viral: adenovirus
why get a fluorscein stain with bacterial conjunctivitis?
to rule out keratitis or abrasions
red, itchy, nml vision, ipsilateral preauricular lymphadenopathy, copius watery tearing. poss mucoid discharge. may be bilateral symptoms in 2-3 days
viral conjunctivitis
marked pruritis to eyes, usually bilateral
allergic conjunctivitis
opthalmia neonatorium conjunctivitis
pathogens day 2-5 and 5-7
gonococcal
chylamydia trachomatis
pathogens for bacterial keratitis
s aureus, strep, pseudomonas-cls wearers
opthalmia neonatorium conjunctivitis
conjunctivitis occurs due to what chemical given
prophylaxis?
silver nitrate
e mycin ointment given immediately after birth
ocular pain, photophobia, eye redness, vision changes, discharge, tearing, FB sensation,
hazy cornea, limbic injection, hypopyon if severe
“difficulty keeping eye open”
bacterial keratitis
what disease may rapidly progress and be sight threatening
bacterial keratitis
findings with fluorescein uptake with bacterial keratitis
increased uptake, more than an abrasion
do not patch eye in what disorder
bacterial keratitis
herpes keratitis is a reactivation of virus in what ganglion
trigeminal
acute onset unilateral ocular pain, photophobia, eye redness, blurred vision, watery discharge
hazy cornea, limbic injection, conjunctiva erythema, preauricular lymphadenopathy
major cause of blindness in US
*what will you find on fluorescein stain?
dendritc corneal abrasion
phenytoin, alcholism, sedating medications that can affect labyrinthitis, inner ear disorder, menieres
all can cause what symptom
nystagmus
occurs between sclera and conjunctiva, bleeding
could be due to blepharitis, corneal abrasion/ulcers, FB, increased BP, trauma
subconjunctival hemorrhage
drifting eye
name 2 types
strabismus
esotropia, deviated inward (nasally)
exotropia, deviated outward (temporally)
diplopia, scotomas or amblyopia
asymmetric corneal reflex
strabismus
hirschberg test for what
strabismus
cover/uncover test for what
looks for latent strabismus
1st line treatment for strabismus
eye patch to nml eye
what if strabismus persists over 4-6 months of age
referral for intermittent manifest strap to decrease incidence of amblyopia
transient monocular vision loss over visual field, temporary curtain/shade comes down then resolves within an hour
amaurosis fugax
etio: migraine aura, lupus, arteritis, retinal embolie
amaurosis fugax
most common cause of blindness in the world
cataracts
TORCH syndrome
toxoplasmosis, rubella, CMV, HBV
neonatal cataracts
painless, slow progressive blurred vision loss over mnths to years. absent red reflex
poss diplopia, halos around lights,
avoid driving at night and reading
cataracts
emergency
central retinal artery or vein occlusion
artery
acute sudden painless monocular vision loss, may be preceded by amaurosis fugax
central retinal artery occlusion
fundoscope: pale retina with cherry red macula. Boxcar appearance of vessels.
central retinal artery occlusion
sudden onset, monocular vision loss, may be painless or not
etio: HTN, DM, glaucoma, smoking, hypercoagulable state, multiple myeloma
central retinal vein occlusion
blood and thunder hemorrhages, optic disc swelling, retinal vein dilation
central retinal vein occlusion
marcus gunn pupil
possible relative afferent pupillary defect
central retinal vein occlusion
which is worse, alkali or acidic burns to eye
alkali, causes liquidification necrosis
what happens with acidic eye burns
coagulative necrosis
ocular pain!, decreased vision, blepharospam(cant open eyelid), photophobia
next step
Chemical burn
immediate irrigation until pH is 7-7.4 with lactated ringers
unilateral severe ocular pain and photophobia, eye redness, tearing, blurred or dec vision
constricted pupil, “cell and flare”
anterior uveitis
blurred or decreased vision, floaters, may not be painful.
constricted pupil, “cell and flare”
posterior uveitis
cell and flare
uveitis
treatments for anterior and posterior uveitis
anterior: topical glucocorticoids
post: systemic glucocorticoids
can occur with ethambutol, chloramphenicol. MS or autoimmune.
most common in woman and young pts 20-40yo
acute mono-ocular vision loss and decrease in color vision
optic neuritis
marcus gunn pupil
fundoscopy: 2/3 of nml disc cup retrobulbar or 1/3 of disc swelling and blurring(papillitic)
optic neuritis
headache, n/v, vision may be disturbed for a few seconds; usually bilateral
fundoscopy: swollen optic disc and blurred margins.
due to increased intraocular pressure
papilledema
what tests to order with papilledema
MRI/CT to rule out mass effect
lumbar puncture if increase in CSF pressure
treatment for papilledema
acetazilomide
strept pharyngitis.
rapid antigen test, if neg, throat culture
peritonsillar abscess
retropharyngeal abscess
leukoplakia left
candiaiasis right
erythroplakia
most common type
lichen planus
reticular
local glucocorticoids
HA, sore throat, fever
HOARSENESS
acute pharyngitis
FEVER, no viral sx, anterior cervical lymphadenopathy
pharyngeal edema/exudate
tx
strep!
PCN!
muffled hot potato voice, drooling, trismus, severe unilateral pharyngitis, high fever
peritonsillar abscess
uvula deviation to contralateral side, buldging of soft palate, ant cervical lymphadema, poss referred ear pain
peritonsillar abscess
test for peritonsillar abscess
CT
torticollis, fever, drooling, anterior cervical lymphadenopathy, lateral neck mass
retropharyngeal abscess
cotton like feels
candidiasis
yellow gray center
apthous ulcer
white patchy lesion cannot be scaped off
oral leukoplakia
painless, erythematous, soft, velvety patch, on mouty, floor, soft palate, ventral tongue
erythroplakia
hoarseness, aphonia, dry scratchy throat
laryngitis
rapidly spreading cellulitis of floor of mouth
fever, chills, malaise, stiff neck, dysphagia, drooling, muffled void, stridor if severe.
no lymphadenopathy
ludwig’s angina
ludwig angina test of choice
CT
sudden onset of very firm and tender gland swelling with purulent discharge.
acute bacterial sialadenitis, suppurative
order CT
sudden onset fever, ulcerative lesions of gingiva friablilty with vesicles on mucous membrae of mouth.
dew drops on a rose petal
acute herpetic gingiovo stomatitis
vesicles that rupture
acute herpetic pharyngotonsillitis
painless, white smooth, corrugated hairy plaque along lateral border to mucosa cannot be scraped off
oral hairy leukoplakia
painful swelling in her right cheek, exacerbated during meals. She reports a recent episode of flu-like symptoms, including fever and malaise, erythema and tenderness over the area of the right parotid gland. Palpation of the gland expresses purulent material from the Stensen’s duct, leukocytosis
. A diagnosis of acute bacterial sialadenitis is made. She is started on IV antibiotics targeting Staphylococcus aureus, advised on adequate hydration, and sialogogues to stimulate saliva flow. Warm compresses to the affected area are also recommended. She is scheduled for a follow-up in one week to assess response to treatment.
malaise and swelling of his face. He has no significant past medical history, but it is documented in his chart that his mother declined the recommended standard immunizations for children because of personal beliefs. Vital signs are stable, with the exception of a mild fever. In addition to the facial swelling, physical exam is also notable for swelling around the testes. There are no rashes.
This classic presentation points toward mumps parotitis – fever, bilateral parotid gland swelling, and occurring within a timeframe post-MMR vaccination (while vaccine effectiveness is high, it isn’t 100%).
______disorder that is not premalignant. It is an Epstein-Barr virus-induced lesion that occurs almost entirely in HIV-infected patients
Generally affects the lateral portions of the tongue, although the floor of the mouth, the palate, or the buccal mucosa may also be involved
TX: Unlikely to progress to squamous cell carcinoma
Oral hairy leukoplakia is a separate
Treatment with zidovudine, acyclovir, ganciclovir, foscarnet, and topical podophyllin or isotretinoin
Therapy is usually not indicated
_____is an oral potentially malignant disorder that presents as white patches of the oral mucosa that cannot be wiped off with gauze. (compare this to oral candidiasis)
Tobacco use (smoked and especially smokeless), alcohol abuse, HPV infections
Leukoplakia is in itself a benign and asymptomatic condition. However, some patients will eventually develop squamous cell carcinoma (SCC)
Oral leukoplakia
DX: The diagnosis of leukoplakia is suspected in patients presenting with a white lesion of the oral mucosa that cannot be wiped off with gauze and that persists after eliminating potential etiologic factors, such as mechanical friction, for a six-week period
Biopsy is indicated for any undiagnosed leukoplakia
TX: For 2–3 circumscribed lesions, surgical excision
Destructive therapies (e.g., laser ablation, cryosurgery), medical therapies (e.g., retinoids, vitamin A, carotenoids, NSAIDs), and watchful waiting with close clinical and histologic follow-up
The child has had a high fever, sore throat, and stridor. She has a muffled voice and is sitting up on the stretcher drooling while leaning forward with her neck extended. The patient’s parents are adamantly against vaccinations, claiming that they are a “government conspiracy.” You order a lateral neck x-ray, which shows
a swollen epiglottis. The patient recovered following treatment with prednisone and ceftriaxone.
a 17-year-old female complaining of a painful rash on her cheek. She says that it has come and gone a few times before and that she usually can feel itching and a tingling discomfort before a break out of the lesions. On physical exam, you observe clusters of small, tense vesicles on an erythematous base.
Orolabial herpes (gingivostomatitis) is the most prevalent form of mucocutaneous herpes infection. Overall, the highest rate of infection occurs during the preschool years. Female gender, history of sexually transmitted diseases, and multiple sexual partners have also been identified as risk factors for HSV-1 infection. Primary herpetic gingivostomatitis usually affects children below the age of 5 years. It typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Edema, halitosis, and drooling may be present, and tender submandibular or cervical lymphadenopathy is not uncommon. Hospitalization may be necessary when pain prevents eating or fluid intake. Systemic symptoms are often present, including fever (38.4 ° to 40 ° C [101 ° to 104 ° F]), malaise, and myalgia. The pharyngitis and flulike symptoms are difficult to distinguish from mononucleosis in older patients. The duration of the illness is 2 to 3 weeks, and oral shedding of the virus may continue for as long as 23 days. Recurrences typically occur two or three times per year. The duration is shorter and the discomfort less severe than in primary infections; the lesions are often single and more localized, and the vesicles heal completely by 8 to 10 days. Pain diminishes quickly in 4 to 5 days. UV radiation predictably triggers recurrence of orolabial HSV-1, an effect that, for unknown reasons, is not fully suppressed by acyclovir. Pharmacologic intervention is therefore more difficult in patients with orolabial infection.
a 33-year-old male presents to the emergency department with a 3-day history of severe throat pain, fever, and difficulty swallowing. He mentions that the pain has progressively worsened, now radiating to his ear, and describes a feeling of tightness and swelling in his neck. He also reports a muffled voice and difficulty breathing, particularly when lying down. His medical history is notable for untreated dental caries and a recent upper respiratory tract infection. On examination, he is febrile with a temperature of 39.2°C (102.6°F). Inspection of the oropharynx is limited due to trismus. There is noticeable swelling and tenderness to palpation on the left side of his neck, with overlying erythema and warmth. His voice is hoarse, and he appears to be in respiratory distress with stridor noted on auscultation. Laboratory tests reveal leukocytosis. A CT scan of the neck with contrast shows a large abscess in the left parapharyngeal space with surrounding cellulitis, consistent with a
deep neck infection. The patient is admitted to the intensive care unit for airway monitoring given his respiratory distress. Immediate intravenous broad-spectrum antibiotics are initiated, and an urgent otolaryngology consultation is obtained for possible surgical drainage. He is also evaluated by a dentist for management of his dental caries, which is suspected to be the source of the infection
a 14-year-old who is brought to your Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleeding. In the ED, a topical vasoconstrictor is tried but also fails to stop the bleeding.
Persistent bleeding despite anterior packing, especially with visualization in the posterior oropharynx, indicates a posterior source. A posterior balloon pack is designed to tamponade a posterior bleed and is the most appropriate next step. These patients must be admitted to the hospital and prompt consultation with an otolaryngologist is indicated.
a 6-year old female who is being seen for a routine well-child exam is noted to have multiple teardrop-shaped growths partially obstructing the nasal passages. The child has a history of chronic sinusitis and recurring ear infections. As an astute PA, you order a sweat chloride test.
Nasal polyps, while relatively common in adults, are much less frequent in young children. Their presence in a child should prompt consideration of cystic fibrosis (CF), an inherited condition affecting the function of exocrine glands. Early diagnosis and treatment of CF are crucial.
a 13-year-old boy with clear fluid discharge from his nose for 2 days duration. This has also been associated with sneezing. On nasal exam, the mucosa and turbinates appear edematous and slightly bluish. He has swollen dark circles under his eyes and a transverse nasal crease.
Along with a minimally sedating oral antihistamine intranasal corticosteroids are considered first-line treatment for moderate to severe allergic rhinitis. They reduce inflammation and symptoms such as sneezing, itching, and nasal congestion. The can be administered regularly or as needed. For predictable exposures it’s best to initiate therapy two days before, continuing through, and for two days after the end of exposure.
a 34-year-old previously healthy male with complaints of facial pressure and rhinorrhea for the past 3 weeks. The patient reports that several weeks prior, he had a “common cold,” which resolved. However, he has since developed worsening facial pressure, especially over his cheeks and forehead. He reports over 1 week of green-tinged rhinorrhea. His temperature is 100.1 F (37.8 C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min. The nasal exam reveals edematous turbinates and purulent discharge. The patient has facial tenderness with palpation over the involved sinus.
ABRS should be diagnosed when signs and symptoms of acute rhinosinusitis (ARS) (purulent nasal drainage plus nasal obstruction, facial pain-pressure or both) persist without improvement for at least 10 days or if signs and symptoms worsen within 10 days after initial improvement.
MC pathogen chronic sinusitis
staph aureus bacterial
aspergillus fungal
