Lecture 10 (HEENT)-Exam 4 Flashcards

Question 1

Q

Fill in the blanks? Is this a left or right TM?

Question 2

Q

What are the outer, middle and inner ear structures?

Question 3

Q

Left or right?

Question 4

Q

What type of questions do you need to ask for history?

Question 5

Q

Approach to the Ear- Exam
* What do you need to palpate?
* What do you need to look at?
* What are the tests for hearing loss?
* What other exams can you do?

Question 6

Q

What are the external ear disorders?

Answer

A

o Cerumen impaction
o Otitis externa
o Trauma
o Foreign Bodies
o Neoplasms

Question 7

Q

Cerumen Impaction
* What does the cerumen do?
* often what?
* What are symtomes?
* How do you dx?

Question 8

Q

What are the different types of txts for cerumen impaction?

Answer

A

Treatment (if symptomatic)
* cerumenolytic agents (1st line)
* irrigation (avoid if perforation)
* manual removal

Question 9

Q

What is first, second, third and 4th line for Cerumen Impaction txt

Question 10

Q

Otitis Externa (swimmer’s ear)
* What is it?
* Common or not?
* What are the organisms?
* Can be what?
* What are the Risk factors?
* What are the types?

Question 11

Q

What is the clinical presentation of OE?

Answer

A

Clinical Presentation (acute)
* Rapid onset
* Ear ear pain/fullness
* Itching
* Drainage
* Tenderness

Question 12

Q

How do you clinical dx OE?

Answer

A

Clinical Diagnosis
* Visualize erythema and swelling of the ear canal
* Tenderness with palpation of tragus/auricle (tug test)
* otorrhea with otoscopy

Question 13

Q

Otitis Externa-
* What is the Treatment?
* What do you need to consider?

Question 14

Q

Otitis Externa-Treatment
* What are the different types of antibiotic drops/steriods? For how long?

Answer

A

Topical antibiotic drops +/-steroids x 7-10 days
* ciprofloxacin/dexamethasone otic (Ciprodex- can be $$$, less side effects, high potency)
* ciprofloxacin/hydrocortisone otic—(low-potency steroid)
* ofloxacinotic (no steroid)
* neomycin/polymyxin B/hydrocortisoneotic (Cortisporin- inexpensive, avoid if TM perforated)

Question 15

Q

Otitis Externa-Treatment
* if mild cases under a week, what can we try?
* What do you for a severe/ immunocompromised patients?
* What do you control?
* What can you do for supportive?
* What should you do if no improvement?

Answer

A

Mild cases <1 week- can try acetic acid (acidifying)
Severe/ immunocompromised-Topical + Oral Abx, consider wick placement
Pain control
Warm Compresses
Culture if no improvement

Question 16

Q

Otitis Externa-
* When does it resolve with meds and without meds?

Answer

A

Prognosis- Resolves in approximately 6 days with combo antibiotic/steroid drop.
* Typically resolves in 6 weeks without treatment

Question 17

Q

What should you tell people to prevent recurrence of OE?

Answer

A

Counsel on proper ear hygiene (no Q tips!)
Ear plugs/blow drying ears/shake head after water exposure
Alcohol/acetic acid drops (no clear evidence to support)
Remove hearing aids nightly and clean regularly

Question 18

Q

Malignant Otitis Externa
* Where does the infection spread to?
* Potentially what?
* What are the risk factors?
* What is it ususally caused by?

Answer

A

Infection spreads to bones of the skull
Potentially life-threatening
Risk factors= DM, immunocompromised, elderly
Usually caused byPseudomonas aeruginosa

Question 19

Q

Malignant Otitis Externa
* What are the sx?
* how do you dx?
* What is the txt?

Answer

A

Sx:
* Foul discharge, granulations, severe ear pain (can progress to cranial nerves palsies)

Diagnostics
* CT/MRI showing bone erosion

Treatment
* Long antipseudomonal IV abx course (ciprofloxacin) 4-6 wks
* ENT Consult
* Surgery if no improvement

Question 20

Q

Progression of malignant otitis externa can affect what cranial nerves?

Answer

A

cranial nerve VII, IX, XI, or XII

Question 21

Q

Fungal OE:
* When should you consider this?
* How do you dx?
* What is the txt?

Answer

A

ex of med: clotrimazole

Question 22

Q

External Ear Trauma:Auricular Hematoma
* What is it?
* What is separated?
* What is the clinical presentation?

Answer

A

Direct trauma to the auricle
Separation of perichondrium from underlying cartilage, blood vessels torn, blood collects, hematoma forms
Clinical presentation- Bleeding/swelling from ear with history of trauma, swelling of the pinna +/- fluctuance

Question 23

Q

External Ear Trauma:Auricular Hematoma
* What is the txt?

Answer

A

Treatment: I&D to avoid deformity and necrosis (Cauliflower ear/wrestlers ear)
* Compression dressing (prevent reaccumulating)
* Empiric antibiotics

Question 24

Q

External Auditory Canal Abrasion
* MC occurs with what?
* What is the presentation?
* What is the txt?
* What is the complications?

Question 25

Q

Foreign Bodies of the Ear Canal
* Common in who?
* What is the MC ages? and groups of people?
* Often what?
* How do you diagnosis?

Answer

A

Fairly common in a Pediatrics (toys, beads, insects, etc)
Most common ages 1-6
Adults in sports and outdoor activities
Often asymptomatic
Diagnosis: Visualization with otoscope (check the nose too!)

Question 26

Q

Foreign Body Management->Insects
* What do you do before removal?
* Apply what to kill the bug? What can be the result?
* What is an alternative?
* May need what?

Question 27

Q

Foreign Body Management (excluding insects)
* What are the different options? What do you not do?
* There may be more than one foreign body so what do you do?
* ENT consult for what?

Question 28

Q

When do you refer and follow up with a foreign body?

Question 29

Q

If there is an abnormal lesion that doesn’t improve, what do you need to do and why?

Answer

A

If there is an abnormal lesion that doesn’t improve, refer!
* Basal cell carcinoma
* Squamous cell carcinoma
* Melanoma

Question 30

Q

Neoplasm: basal cell carcinoma
* MC what?
* Slow or fast?
* What do you need to do?
* What is the txt?

Question 31

Q

Neoplasm: squamous cell carcinoma
* Can be what?
* What do you need to do?
* What is the txt?

Question 32

Q

Neoplasm: melanoma
* What is it?
* Can be what?
* What do you need to do?

Question 33

Q

What are the middle ear disorders?

Answer

A

Otitis Media
Tympanic Membrane Perforation
Cholesteatoma
Mastoiditis

Question 34

Q

What is Acute Otitis Media (AOM)?

Answer

A

Acute, suppurative infectious process marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the middle ear space

Question 35

Q

Otitis Media- Epidemiology
* MC what?
* What age groups gets it more?
* What are the different types?

Question 36

Q

Otitis Media- Pathogenesis
* What are the different causes?

Answer

A

Eustachian tube dysfunction with subsequent tube obstruction
Increased negative pressure
Accumulation of fluid
Microbial grown
Suppuration

Question 37

Q

What are the most common pathogens for AOM?

Answer

A

Most common pathogens – Streptococcus Pneumoniae, Haemophilus Influenzae, Moraxella catarrhalis, Staph aureus
Can also be viral (~ 16%)

Question 38

Q

What are the risk factors for AOM?

Question 39

Q

Otitis Media- Clinical Presentation
* What are the most common sxs?

Question 40

Q

how do you dx AOM? What do you see?

Question 41

Q

What is this?

Answer

A

Pneumatic otoscope
* TM does not move: OM
* TM moves: normal

Question 42

Q

What is this showing?

Question 43

Q

What is this?

Question 44

Q

What is this?

Question 45

Q

What is this?

Question 46

Q

Acute Otitis Media-Treatment
* What is the first choice for txt?
* What do you need to consider?
* Who gets abx therapy?
* What do adults get?
* Obs in who?

Answer

A

Antibiotic therapy –> #1 Amoxicillin
* Consider severity, age, risk factors, caregiver
* <6 months, severe sx, toxic appearing- Abx therapy
* Uncomplicated children Abx therapy
* Adults: amoxicillin or amoxicillin/clavulanate (Augmentin)
* Observation before abx if parental preference and low risk (explain risks/benefits/f/u)

Question 47

Q

AOM

What is the dose of amox and for how long?
What do you use for Pain control of AOM?

Answer

A

Amoxicillin 90 mg/kg per day ( high dose) -divided in two doses, max 3g/day

Duration
* 10 days (<2 years, perf TM, or hx of recurrence)
* 5-7 days (> 2 years with intact TM and no recurrent hx)

Pain control- ibuprofen/acetaminophen

Question 48

Q

Otitis Media- Antibiotics Alternatives
* What is first line?
* What do you give if recurrence?
* What do you give for PCN allergy (mild)
* What do you give for severe PCN allergy?

Question 49

Q

Otitis Media-
When do you need to refer

Question 50

Q

Otitis Media-Tympanostomy Tubes
* Who gets this?
* May cause what?
* Tubes permit what?
* Who do you refer to?

Answer

A

Recurrent AOM (4 or more episodes per year)
May cause TM sclerosis
Tubes permit drainage of the middle ear fluid, aeration, and return of mucosa to normal
Refer to ENT for placement

Question 51

Q

What is this?

Question 52

Q

Otitis Media-Follow- up
* When do you need to see patients who are txt with observation?
* What do you do if not beter?
* Monitor for what?
* Who are reliable reporters?
* What do you educate parents on?

Question 53

Q

Otitis Media-Prevention & Prognosis
* What are the vaccines?
* What about breast feeding vs bottle?
* Without antibiotics, AOM often resolves within what?

Answer

A

Vaccine – Pneumococcal Vaccine (PCV) offers modest prevention (~7% risk reduction)
Influenza vaccine under age 6 offers modest prevention (~4%)
Exclusive breastfeeding until 6 months reduces risk (~43%)
Without antibiotics, AOM often resolves within 24 hours in ~ 60%

Pneumococcal 15-valent conjugate vaccine, also PCV 20 now available

Question 54

Q

Otitis Media Effusion (Serous Otitis Media)
* What is it?
* What is the presentation?
* What are the otoscopic findings?
* When does it resolve?
* Differentiate from what?

Question 55

Q

Question 56

Q

What is this?

Answer

A

Otitis Media with Effusion
* Otoscopic findings of OME include visible fluid (often yellowish, but sometimes clear) behind an intact tympanic membrane.

Question 57

Q

Otitis Media Effusion- Treatment
* What is the txt?
* When do you refer? What do they do?
* What has not been shown to be useful?

Answer

A

Watchful waiting (often spontaneous resolution <6 weeks)
Consider early surgical referral in children at risk for speech/learning problems
Tympanostomy tube placement if >3 months
Antibiotics, antihistamines, and steroids have not been shown to be useful in the treatment of OME

Question 58

Q

What are the complications of AOM?

Answer

A

Cholesteatoma
Tympanic Membrane Perforation
Mastoiditis
Facial Nerve Palsy

Question 59

Q

Tympanic Membrane Perforation
* occurs when?
* Due to what?
* What are the sx of rupture?
* How will it heal?
* Often resolves what?
* What do you need to ensure?
* When do you refer out?

Question 60

Q

Cholesteatoma
* What is it? What happens?
* Rare complication of what?

Answer

A

Abnormal accumulations of epithelium in middle ear and mastoid
Skin cells become trapped in middle ear, proliferate, and erode bone and surrounding structures
Rare complication of AOM or OME, ET dysfunction (9/100,000)

Question 61

Q

Cholesteatoma
* When do you suspect this?
* What are the sx?
* What does the exam show?
* How do you dx?

Answer

A

Suspect in any patient with a chronically draining ear
Sx: Ear drainage and hearing loss
Exam: Focal retractions and white mass behind intact TM
Dx: Temporal Bone CT

Question 62

Q

Cholesteatoma
* What is the txt?
* What is the prognosis?
What are the complications?

Answer

A

Txt: ENT referral for surgery
Prognosis: Frequent recurrence
Complications: labyrinthitis, facial palsies and paralysis, meningitis and hearing loss

Question 63

Q

What is this?$

Question 64

Q

What is this?

Answer

A

Cholesteatoma

Answer 33

A

Usually after weeks of inadequately treated AOM
Presentation: Postauricular pain/erythema, fevers
Exam: Tenderness and erythema posterior over mastoid bone

Answer 34

A

Dx: CT -reveals coalescence of the mastoid air cells due to bony septa destruction.
TX – IV antibiotics (first line)
No improvement->surgical drainage or mastoidectomy

Answer 35

A

Acoustic neuroma
Barotrauma
Dysfunction of eustachian tube
Labyrinthitis
Vertigo (BPPV)
Meniere’s disease

Answer 36

A

Presentation:
* Unilateral hearing loss (95%-sensorineural), +/- disequilibrium (continuous), tinnitus

Diagnosis: Enhanced MRI or CT
* Can confirm hearing loss with audiogram

Answer 37

A

Treatment – Refer to ENT Surgery
* May do observation with repeat imaging

Answer 38

A

with unilateral, asymptomatic hearing loss
* Any individual with a unilateral or asymmetric sensorineural hearing loss should be evaluated for an intracranial mass lesion

Answer 39

A

acoustic neuroma

Answer 40

A

Increased barometric stress exerted on the middle ear can cause trauma
Common causes: air travel (#1), scuba diving, blast injuries

The problem is generally most acute during airplane descent, since the negative middle ear pressure tends to collapse and block the eustachian tube, causing pain.

Answer 41

A

Presentation: ear pressure, hearing loss (conductive), pain, +/- tinnitus
Diagnosis: Clinical (suspect based on symptoms and history)
* May visualize trauma (hemotympanum) on otoscope exam

Answer 42

A

Treatment: Conservative-Usually resolves spontaneously
* Recommend bedrest, head elevation, avoid anything that increases pressure
* NSAIDS

No improvement in a few days->requires urgent referral to ENT
* SNL hearing loss& vertigo->concern for perilymph fistula

Answer 43

A

Patient Education:
* Avoid diving with TM perforation or URI

Prevention: Oral decongestants, antihistamines, and nasal decongestant sprays used prior to flying or diving
* Counsel to swallow, yawn, and autoinsufflatation

autoinsufflate(pinching nostrils closed while gently exhaling through the nose)

Answer 44

A

Tympanic membrane barotrauma (bleeding)

Answer 45

A

ET connects middle ear to the nasopharynx
Provides ventilation and drainage for the middle ear
May dysfunction with URI, sinusitis, diving
Increased in kids, improves by age 6
Can hypo or hyper function

Answer 46

A

Presentation:
* Fullness in ear, decreased hearing, popping of ears

Clinical diagnosis
* TM may be retracted or normal
* Can confirm with nasal endoscopy or tympanogram

Answer 47

A

Txt: Treat the underlying cause (rhinosinusitis, allergic, mass?)
* Rhinosinusitis -pseudoephedrine, antihistamines, nasal steroids, pain control
* autoinsufflation (if no active nasal infection)- Modified Valsalva

Education: Avoid travel, diving, rapid altitude change

Answer 48

A

Inflammation of the inner ear (labyrinth) or the nerves that connect the inner ear to the brain
Not dangerous, but incapacitating

Answer 49

A

Broad differential (consider vascular events in >60, HA, neuro deficits, risk factors)
Diagnosis is clinical (consider MRI to r/o other diagnoses)

Answer 50

A

Txt:
* Viral (secondary to URI)- supportive treatment (antihistamines, antiemetics, vestibular suppressants <24hrs)
* Consider oral steroids (Grade 2C) if no contraindications (short-term relief, long term outcome uncertain)
* Vestibular rehab in ongoing
* Bacterial- (with otitis media or meningitis)- Abx treatment

Differentiate from vestibular neuritis (auditory function preserved, no cochlear involvement)

Answer 51

A

Sensation of self motion when no motion occurs
Occurs in conditions affecting the vestibular sensory organs of inner ear, cerebellum and brainstem and the connections between them.
Difficult to diagnose and determine etiology

Answer 52

A

Must differentiate peripheral from central causes
* Peripheral: Sudden onset, +/- tinnitus and hearing loss; horizontal nystagmus
* Central: Onset is gradual, no associated auditory symptoms, neuro symptoms

Most common:Benign paroxysmal positional vertigo (BPPV)

Answer 53

A

Walk test before discharging from an ED!
Peripheral- hearing loss/tinnitus
Central- usually no ear complaints
Good neuro exam required either way document your neuro exam

Answer 54

A

Most common form of peripheral vertigo (about 1⁄2 of vertigo cases)
Pathogenesis: Occurs when calcium debris are displaced spontaneously into the semicircular canals

Answer 55

A

Presentation: Recurrent, short episodes of vertigo (seconds to 1 min)
* Usually provoked by head movements
* +/- N/V (intermittent)
* +/-imbalance
* Dizziness lasting minutes to hours is not BPPV

Answer 56

A

Dx: Dix-Hallpike maneuver (move to supine position at head 45 angle) and normal neuro exam
* DHM: delayed nystagmus (2-40secs) which lasts less than a minute + moderate vertigo
Treatment: Epley maneuver (can refer to physical therapy)

Answer 57

A

Idiopathic condition (exact cause unknown)
Believed to be associated with excess endolymph fluid in the inner ear (endolymphatic hydrops)

Answer 58

A

Presentation (classic triad): Episodic vertigo, tinnitus, hearing loss (sensorineural, low frequency)
Though hearing loss comes and goes, there is an expected progressive loss of hearing in the low frequencies

Answer 59

A

Refractory Symptoms: Refer to ENT
* Steroids orally or intratympanic
* Middle ear injection of Gentamycin
* Surgical options: decompression

Persistent disequilibrium: Vestibular rehabilitation

For patients with MD and persistent disequilibrium symptoms between attacks, we suggest referral for vestibular rehabilitation therapy (Grade 2C). Helps compensate
Hearing loss may accompany Meniere disease or posterior circulation ischemia (due to infarction of the labyrinth) and is not pathognomonic of Meniere disease)

Answer 60

A

Nearly 20% of the global population live with hearing loss
~15% of American adults aged 18 and over report some trouble hearing
2 to 3 out of every 1000 neonates are born with a detectable hearing loss
30 million people in US are exposed to dangerous noise levels on a regular basis
Increased prevalence of hearing loss with age (43% ages 65-84)

Answer 61

A

Should be a part of every yearly H & P (physical diagnosis/Bates)
Screening for hearing is done during well child visits for peds
Any detected hearing loss in primary care should be referred for audiologist testing
Screen the elderly regularly
Audiologist-professional licensed medical professional who works in various settings treating patients with hearing loss and balance disorders

Answer 62

A

Common complaints:
* inability to hear or understand speech in a noisy environment
* difficulty understanding consonants
* inability to hear high-pitched voices or noises
* tinnitus

Diagnostics: Screening questions, Weber/Rinne, otoscope exam, refer to audiology

Answer 63

A

Treatments:
* Adaptative techniques and environmental modifications
* Hearing aids beneficial but underutilized
* Cochlear implantation an option those who have not benefited from hearing aids

Answer 64

A

Impairment of the passage of sound vibrations to the inner ear:
* Obstruction (eg, cerumen)
* Mass loading (eg, middle ear effusion)
* Stiffness (eg, otosclerosis)
* Discontinuity (eg, ossicular disruption)

Answer 65

A

Etiologies:
* Cerumen impaction
* Transient eustachian tube dysfunction due to upper respiratory tract infection
* Chronic ear infection (OM, cholesteatoma)
* Trauma (perforation)
* Otosclerosis
* Perforations of the tympanic membrane

Often correctable with medical or surgical therapy, or both

Answer 66

A

Weber –Normal test- sound heard equally in both ears
* Tuning fork placed on midline of head –tone is heard loudest in ear with hearing loss
* Unilateral conductive hearing loss- tone is heard loudest in ear with hearing loss
* Unilateral sensorineural hearing loss – the tone is heard louder in the normal ear

Answer 67

A

Tuning fork held against mastoid bone, then, comparing its sound when held lateral to the patient’s ear (air conduction)
Normal is when tone can still be heard (AC>BC)
Conductive hearing loss- Bone conduction sounds louder than air conduction (BC>AC)

Answer 68

A

B Left-sided conductive hearing loss

Answer 69

A

C Right-sided sensorineural hearing loss