Midterm Assignment

Question 1

What is the term for hearing loss associated with the normal aging process?

Answer 1

Presbycusis


◦ Begins after age 20, affects higher frequencies first

Question 2

Explain the basic physiology of allergic responses.

Answer 2

The first time we are exposed to a substance, we do not have an allergic response. But if the antigen is presented to T cells and B cells, it can cause the B cells to start to produce IgE in recognition of that allergen. Then, the next time the substance is present, the IgE can bind to it, which in turn can stimulate mast cells and eosinophils to release histamine and other inflammatory cytokines (and slow-reacting substances - a mixture of leukotrienes which result in prolonged inflammation) that cause swelling, edema, itching and vascular changes. This response can even be so severe it can lead to anaphylactic shock.

Question 3

Understand the possible sequelae of allergies and how they can contribute to disease processes of the HEENT.

Answer 3

Allergies can lead to chronic inflammation, which can be the cause of many other problems. Allergies can cause a chronic cough, eczema of the external ear (which can contribute to otitis externa), post nasal drip, conjunctivitis, otitis media and sinusitis.

Question 4

Examine the function of key enzymes in the eicosanoid cascade, including:

Answer 4

A. Phospholipase A2- liberates eicosanoids from the phospholipid membrane. First step in making eicosanoid signaling pathways.

B. Delta-5 desaturase-

• Omega – 6 pathway
• **Converts dihomogammalinolenic acid (DLGA) -> arachidonic acid
• Omega – 3 pathway
• **Converts 20:4 fatty acid -> Eicospentonoic acid (EPA - 20:3)

C. Delta-6 desaturase-

• Omega – 6 pathways
• **Converts linoleic acid -> Gammalinolenic acid (GLA)
• Omega – 3 pathway
• **Converts alpha linolenic acid (ALA – 18:3) -> 18:4

D. Lipoxygenase- takes arachidonic acid and makes it into leukotrienes.

E. Cyclooxygenase- takes arachidonic acid and make it into prostaglandins.

Question 5

Be able to explain the major nutrients and pharmaceuticals used in the treatment of allergies and how physiologically they work.

Answer 5

A. Vitamins A, C, E, Selenium. Vitamin C- promotes nonenzymatic histamine degradation. The others are antioxidants that act to reduce the prostaglandin 2 pathways. Antioxidants also strengthen cell walls, lessening histamine release. They can also help correct leaky gut issues.

B. Quercitin and other bioflavonoids- mast cell stabilizer (less degranulation of histamine), helps mediate GI allergic response. Inhibits LOX.

C. Vitamins B-6, B12, Mg
B12 and B6 are required for the methylation of histamine (histamine metabolism)

D. Glycyrrhiza glabra - Blocks series 4 leukotrienes.

E. Urtica diocia- source of bioflavinoids (so similar effect to quercitin).

F. Scutellaria baicalensis - Quercitin like, blocks phospholipase.

G. Antihistamines- blocks the H1 receptor, preventing histamine from acting on endothelium, mast cells and smooth muscles, which downregulates inflammatory processes. Histamine normally makes the vessels more permeable to fluid leakage, which can cause congestion. This can block that response and dry things out.

H. Pseudoephedrine- vasoconstrictor of respiratory mucosa (that is what it says on the slide, I think it’s actually the blood vessels). That vasoconstriction prevents some of the fluid leakage seen in allergies. Can cause systemic symptoms, like tachycardia, insomnia and agitation.

I. Nasal steroid inhalers and systemic steroids- blocks phospholipase enzymes, leads to less tissue permeability because there is less inflammation. Can block mast cells and basophils.

Question 6

I am a patient with a 6th grade education. Describe for me the difference between a decongestant and an antihistamine:

Answer 6

Histamine is a product released from certain cells called mast cells. Histamine is released when you are exposed to something you are allergic to. Antihistamines causes blood vessels to become more narrow, which keeps them from leaking fluid into the tissue, leading to less congestion. Decongestants act in a similar way. They stimulate the blood vessels to get more narrow too, which also prevents the leakage of fluid, which also decreases congestion.

Question 7

A patient seems to need Omega – 3 EFA’s (and even was tested and is low) and has taken large doses of Flax Oil for 6 months. They seem to be having very little response. What possible biochemical trouble may be happening as discussed in class, and what alternative oil supplementation might be worth a try?

Answer 7

Flax oil is mostly ALA (alpha-linolenic acid), which is a precursor to omega 3 fatty acids in the body. However, this conversion takes many steps and it is not very efficient.. They would be better to take fish oil instead, which is a more direct way to get anti-inflammatory eicosanoids into cellular membranes.

Question 8

List two keynotes for each of the following homeopathic remedies associated with acute allergic sx.

a. Nose- burning d/c. Better open air.
b. Eyes- inflamed, burning, itchy. D/C causes eyes to stick together.
c. eyes “full of sand”, rims of eyelids red and crusted. Lachrymation that burns.
d. Hay fever in intellectual, repressed patient. Coryza like “egg-white”
e. worse with sun, better cold app.

Answer 8

a. Allium cepa:
b. Euphrasia:
c. Sulphur:
d. Nat Mur:
e. Pulsatilla:

Question 9

What is the ddx for nasal congestion including key elements of hx, PE, and labs/imaging.

Answer 9

((Most types of rhinitis have similar symptoms: nasal congestion, rhinorrhoea and sneezing.))

Question 10

Nasal congestion with mucopurulent drainage, facial pain/pressure, worse lying down
Viral etiology: improvement w/ in 7 days
Bacterial superinfection: sx 10+ days

Answer 10

Sinusitis:

Question 11

> 12 wks, may present with PND (“racing stripes” in posterior oropharynx) and thus a chronic cough.

Answer 11

Chronic Rhinosinusitis:

Question 12

Accompanied by anosmia and rhinorrhoea. Usually b/l, occupying middle meatus, grey/ white in color, slightly translucent, soft, and mobile.

Swollen nasal turbinates can be mistaken for nasal polyps but turbinates are pink and sensitive to touch.

Unilateral nasal polyps must be biopsied

Answer 12

Nasal polyp:

Question 13

Simple acute infective rhinitis

Answer 13

(common cold) Pale, edematous nasal mucosa

Question 14

Seasonal “Hay Fever” also complains of watery, itchy eyes

Year round: Damp, pale nasal lining with swollen oedematous turbinates.

Answer 14

Allergic Rhinitis:

Question 15

similar sx to allergic rhinitis but tests for allergens are negative (same tx as allergic rhinitis)

Answer 15

Vasomotor Rhinitis:

Question 16

acquired sensitivity in a rebound response once decongestants are discontinued

Answer 16

Rhinitis medicamentosa:

Question 17

Other types of rhinitis:

1. associated with abnormal patency of nostril
2. response to hormone changes, resolves after parturition
3. “dewdrop nose” particularly found in older men
4. nasal symptoms that occur with sexual excitation
5. occurs with exposure to extremely hot dry conditions

Answer 17

1. Atrophic Rhinitis:
2. Rhinitis of pregnancy:
3. Senile Rhinitis:
4. Honeymoon Rhinitis:
5. Rhinitis sicca:

Question 18

Sx: unilateral nasal obstruction, blood- stained rhinorrhoea and lump in the nose

Answer 18

Tumors and destructive lesions of the nose:

Question 19

How would you distinguish viral from bacterial rhinosinusitis?

Answer 19

Viral etiology: improvement w/ in 7 days

Bacterial superinfection: sx 10+ days

Question 20

Know which sinuses are affected most commonly in rhinosinusitis and how the sinuses can present in this condition.

1. dental pain, nasal congestion, anterior or posterior mucopurulent drainage, facial pain/pressure/fullness, decreased sense of smell.
2. facial pain/pressure/fullness, headaches (migraine, tension, and cluster)
3. pain and pressure between the eyes
4. Headache in the middle of the head

Answer 20

1. Maxillary sinuses:
2. Frontal sinuses:
3. Ethmoid sinus (anterior):
4. Sphenoid sinus:

Question 21

If you want sensitive testing for sinus disease, what imaging modality is standard of care and why?

Answer 21

Sinus x rays are confirmatory but generally CT scans of sinuses give far more info (EENT textbook)

Question 22

Understand the basic management of sinusitis.

Answer 22

1. Avoid dairy and wheat until mucous clears
   - ->Avoid food triggers in general for acute and chronic
2. Steam inhalation 5 mins BID
3. Nasosympatico
4. Herbs
   - ->Horseradish – counter irritant
   - ->Thyme – Antimicrobial and very drying
   - ->Euphrasia

5. Obstructed ostia
Anti-inflammatory
-->Euphrasia, urtica, bromelain
Astringents
-->Hydrastis, salvia officinalis
Decongestants
Ephedra vulgaris or sinica hypertonic saline
Amoracia, euphrasia, sambucus, urtica 

6. Decrease viscosity of mucous
Hydration
Mucolytics
Steam inhalation
Nasal lavage
-->Hypertonic saline, berberine
Contrast hydro

7.Impaired immunity/pathogens
Antimicrobials and immune support
–>Botanicals
–>Xylitol

8. Send to hospital if:
Facial cellulitis
Proptosis (exopthlamos)
Vision changes or gaze abnormality indicative of orbital cellulitis
Abscess or cavernous sinus involvement
Mental status changes
Immunocompromised status

Question 23

Look at the populations that might present with invasive fungal sinusitis.

Answer 23

Immunosuppressed patients
Diabetics
Elderly
ESRD
Long-term steroid use
Cancer
HIV/AIDS

Question 24

Examine the different presentations of conditions causing facial pain.

Over involved sinuses (exception of sphenoid- the pain tends to be central and more diffuse), esp. with palpation

Answer 24

Sinusitis

Question 25

Examine the different presentations of conditions causing facial pain. Alarm symptom of sinusitis Tender, puffy swelling of the forehead

Answer 25

Osteomyelitis

Question 26

Examine the different presentations of conditions causing facial pain. Shooting pain with brushing of teeth or touching cheek If associated with sensory alteration must consider cancer Typically 2nd or 3 rd division of trigeminal nerve Usually unilateral Typically presents in 40-60s If < 40 years old MS should be in your ddx

Answer 26

Trigeminal (tic douloureux) Neuralgia

Question 27

Examine the different presentations of conditions causing facial pain. Similar to trigeminal neuralgia Affects ophthalmic branch of trigeminal most often

Answer 27

Post-herpetic neuralgia

Question 28

Examine the different presentations of conditions causing facial pain. Elderly women with unilateral facial pain

Answer 28

Temporal arteritis

Question 29

Examine the different presentations of conditions causing facial pain. This should be included in ddx in patients with facial pain

Answer 29

TMJ

Question 30

Be able to differentiate tension HA versus migraine HA and understand some basic management options.

Answer 30

1. Tension HA: Tension HA: bilateral, non-throbbing, frontal/temporal regions, worsen as the day goes by, worse with stress, responds to NSAIDS 2. Migraine HA Prodrome of visual disturbance Tx: Avoid high tyramine food: cheese, wine, sauerkraut

Question 31

Be able to differentiate the different causes of ear pain for different populations.

Answer 31

Children: AOM, OME, otitis externa Elderly: malignant otitis externa Immunocompromised: malignant otitis externa, fungal otitis externa

Question 32

Know the basics of foreign body removal and excess cerumen removal from the external ear.

Answer 32

Foreign body: refer if TM perforated, complete occlusion of canal, bean or object that can swell, hearing loss or difficulty removing, Hx of trauma + foregin body, uncooperative child, battery in the ear. Removal Irrigation of ear canal with body temperature water is the safest way Can use ring curette, alligator forceps or a small magnet Cerumen impaction: debrox 4-7 days before removal to soften wax. Ear lavage with warm water and H2O2 solution. Use curette or wax hook to gently remove wax.

Question 33

What is a finding on PE that would suggest malignant otitis externa?

Answer 33

* Progressively worse, constant, severe pain. * Typically preceded by otitis externa * Observation of granulation tissue on PE

Question 34

How do extoses present and what are they thought to be due to?

Answer 34

- They look like skin covered mounds of bone in the external auditory canal; like teeth in the ear canal. - They are thought to be caused by chronic exposure to cold, wind or cold water.

Question 35

What are some possible concerning sequelae of otitis externa?

Answer 35

``` Malignant otitis externa possibly leading to death Abscess Narrowing of the ear canal Myringitis possibly leading TM rupture Cellulitis ```

Question 36

What is the utility of pneumatic otoscopy in assessing conditions of the external or middle ear?

Answer 36

- Middle ear: AOM is confirmed by pneumatic otoscopy (TM Will be IMMOBILE in AOM) - External ear: pneumatic otoscopy is used to rule out AOM

Question 37

Increase in pain substantially, until TM “pops” which releases the pressure and alleviates the pain. May have some associated discharge, shouldn’t be as excessive as seen in external ear infection.

Answer 37

-TM rupture: -If otalgia persists after TM perforation, must consider either otitis externa or extension of the infection to a contiguous space, such as the mastoid -management: 10 days antibiotic tx May also consider additional topical therapy with quinolone otic drops (ofloxacin or ciprofloxacin), as they are considered safe in the context of tympanostomy tubes (patent TM)

Question 38

White plaques on TM. usually secondary to mult infections or TM perforations

Answer 38

-Tympanosclerosis: Management: may require surgery or hearing aids. Consider antifibrotics such as centella, silybum or colchicum (low-dose)

Question 39

What finding on PE suggests serous otitis media?

Answer 39

``` Bubbles Immobile tm Fluid line Asymptomatic Possibly retracted TM ```

Question 40

What factors predispose to otitis media?

Answer 40

``` Anatomy: eustachian tube is more horizontal in children making drainage harder than in adults who have a more vertical tube. Viral URI Allergies, exposure to smoke PACIFIER use Daycare attendance Immune deficiencies Native american or alaskan native heritage Bottle fed infants (especially feeding lying down) Reflux Exposure to tobacco smoke Obstruction: adenoids Craniofacial anomalies Ex: cleft palate and Down syndrome ```

Question 41

What would be the presentation of an allergic caused serous otitis media?

Answer 41

Bilateral serous fluid present behind TM

Question 42

What is the presentation of acute mastoiditis?

Answer 42

Usually occurs after 2 weeks of untreated AOM | Tenderness over mastoid process with redness and swelling which can displace the pinna (lateral and inferior)

Question 43

When is OM considered chronic?

Answer 43

OM that lasts longer than 3 months OR suppurative middle ear process that does not respond to antibiotic treatment (need to go through the treatment failure process)

Question 44

What PE finding would suggest a cholesteatoma?

Answer 44

- White debris in ext. canal with TM perforation - Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Although cholesteatomas are not classified as either tumors or cancers, they can still cause significant problems because of their erosive and expansile properties resulting in the destruction of the bones of the middle ear (ossicles), as well as their possible spread through the base of the skull into the brain. They are also often infected and can result in chronically draining ears.

Question 45

Understand the tx options for otitis media.

Answer 45

1. Nothing “About 70% of children who present with ear infections get better on their own within two or three days, and about 80% are better within a week to 10 days” 2. Antibiotics Amoxicillin or augmentin are first line antibiotics Azithromycin, clarithromycin or Clindamycin are first line for those with penicillin allergies ``` 3. Tx should treat pain Acetaminophen or ibuprofen Onion ear muffs Garlic mullein drops Homeopathics Benzocaine, procaine, lidocaine ``` 4. ND Tx *Botanical medicine Immune modulators Antimicrobials *Wet sock Tx *Mucolytics NAC or guaifenesin *Phys Med CST Chiro Massage 5. Tympanostomy tubes For drainage

Question 46

1. right side, sudden onset, thirstless, red TM/face, glassy eyes 2. sudden onset following exposure to wind/chill, fearful, worse night, thirst for cold drinks 3. thick offensive discharge, stitching pains 4. thin purulent (yellow-green) discharge, pt perspiring, teeth marks on tongue 5. thick bland discharge, red swollen pinna, pt is weepy, clingy, thirstless 6. One cheek warm and hot, the other pale and cold; very irritable; exquisite pain, can’t bear to be touched; better being held and motion

Answer 46

1. Belladonna: 2. Aconite: 3. Hepar sulph: 4. Mercury: 5. Pulsatilla: 6. Chamomille:

Question 47

Which mucolytics and decongestants are typically used in conventional medicine tx of OM?

Answer 47

``` Mucolytics -NAC -Guiafensasin Decongestants -Pseudoepinephrin -Oxymetazonline ```

Question 48

When are tympanostomy tubes considered in conventional medicine, and what are some possible consequences of their use?

Answer 48

1. Conventional medicine considers if no results from abx tx. This theoretically allows drainage of fluid from middle ear, however, the benefits are short-lived. 2. Tympanosclerosis often develops in ears with tympanostomy tubes, resulting in conductive hearing loss. Calcification of middle ear and TM. 2o OM or the presence of a tympanostomy tube (greater risk the longer left in place). Requires surgical correction. Calcification renders TM less sensitive to vibration. Leads to conductive hearing loss. 3. OME in children who are at risk of speech and language, or learning problems regardless of hearing loss 4. Structural damage to the TM, tympansclerosis or cholesteatoma 5. Persistent OME-associated hearing loss > 40 dB 6. B/l OME for > 3 months; unilateral OME for > 6 months; or recurrent episodes of OME with cumulative duration of OME for > 6 of the previous 12 months 7. Symptomatic OME (ex: ear pain, sleep disturbances, tinnitus, vertigo or balance problems) 8. Signs of Eustachian tube dysfunction (ex: fluctuating hearing loss, disequilibrium or vertigo, tinnitus autophony, severe retraction pocket of TM, intermittent pain) 9. Recurrent and severe AOM

Question 49

Speaking louder to pt. inc. hearing, pt. speaks with soft voice (since BC is normal); on PE may see visible defect/blockage

Answer 49

Conductive Hearing Loss: | Unilateral conductive hearing loss:

Question 50

hearing does not improve with louder noise.

Answer 50

Conductive Hearing Loss: | Bilateral conductive hearing loss:

Question 51

Hearing worse with noise, patient’s voice is loud, nothing remarkable on PE

Answer 51

Nerve-Deficit (Sensorineural) Hearing Loss: | Unilateral:

Question 52

Dec. hearing b/l

Answer 52

Nerve-Deficit (Sensorineural) Hearing Loss: | Bilateral

Question 53

What are the major causes of Conductive hearing loss?

Answer 53

Most common cause in adults: cerumen impaction or eustachian tube dysfunction (2o to URI) Other causes: otitis media/otitis externa, perforated TM, otosclerosis

Question 54

What are the major causes of Sensorineural hearing loss?

Answer 54

Loss of hair cells from organ of Corti most common cause. Presbycusis: gradually progressive loss of hearing (high-frequency tones especially) with age. Noise exposure

Question 55

What are Sudden onset of conductive hearing loss?

Answer 55

TM perforation | Serous otitis media

Question 56

What are Sudden onset of sensorineural hearing loss

Answer 56

Vascular accident in CNS Viral etiology – mumps or measles, influenza, varicella, mono, adenovirus Course of Disease

Question 57

ddx conductive hearing loss

Answer 57

1. Otoscopic exam shows: cerumen, foreign body, extoses, otitis externa, TM perforation 2. Serous otitis media –Fluid in middle ear inhibits transmission of sound through the TM. 3. Tympanosclerosis – white plaques on TM. 4. Otosclerosis – Progressive conductive hearing loss in a pt. under 50y, both ears involved, often a family hx, otoscopic exam nl. 5. Cholesteatoma – white debris in ext. canal with TM perforation. 6. Tumors of middle ear 7. Nasopharyngeal carcinoma

Question 58

Ddx of Sensorineural Hearing Loss

Answer 58

``` Noise damage Presbycusis Hereditary/congenital Viral infection Ototoxic medications Metabolic causes Autoimmune dz ```

Question 59

How does the patient present as far as their speech and hearing abilities? Conductive hearing loss-

Answer 59

Speaking louder to pt. inc. hearing, pt. speaks with soft voice (since BC is normal)

Question 60

How does the patient present as far as their speech and hearing abilities? Sensorineural hearing loss-

Answer 60

Unilateral: Hearing worse with noise, patient’s voice is loud, nothing remarkable on PE Bilateral: Dec. hearing b/l

Question 61

What are the top two diagnoses for conductive hearing loss?

Answer 61

Cerumen impaction or eustachian tube dysfunction (2o to URI)

Question 62

What are the top two diagnoses for sensorineural hearing loss?

Answer 62

Noise damage – most common cause of sensorineural hearing loss Presbycusis – high frequency hearing loss (eventually progressing to lower frequencies) that occurs with age

Question 63

What is the most common cause of sudden deafness? What else would be in your ddx? Sudden onset of conductive hearing loss?

Answer 63

TM perforation | Serous otitis media

Question 64

What is the most common cause of sudden deafness? What else would be in your ddx? Sudden onset of sensorineural hearing loss

Answer 64

1. Vascular accident in CNS 2. Viral etiology – mumps or measles, influenza, varicella, mono, adenovirus 3. Course of Disease

Question 65

What would you see on otoscopic exam that would suggest serous otitis media?

Answer 65

Cloudy tympanic membrane | Concave or retracted tymp. Membrane with Pneumatic otoscopy

Question 66

White plaques on the TM suggest what condition?

Answer 66

Tympanosclerosis

Question 67

How about white debris or bony erosion seen in the external auditory canal?

Answer 67

Extoses or cholesteatoma

Question 68

What would one of your top ddx be for bilateral conductive hearing loss in a patient younger than 50? What questions could you ask to confirm your suspicions?

Answer 68

Otosclerosis | FHx of early hearing loss?

Question 69

What is the most common cause of sensorineural hearing loss?

Answer 69

Noise damage – most common cause of sensorineural hearing loss Rule of thumb: If you have to shout to hear yourself, it’s too loud. You know damage has occurred if tinnitus, hearing loss, or a feeling of ear fullness occurs after noise exposure.

Question 70

What is the term for hearing loss associated with the normal aging process?

Answer 70

Presbycusis | Begins after age 20, affects higher frequencies first

Question 71

What are three metabolic conditions associated with sensorineural hearing loss?

Answer 71

1. hypothyroidism (run thyroid panel – TSH, T4, fT3), 2. hyperlipidemia (run lipid screen), 3. DM (run fasting glucose)

Question 72

What is the presentation of herpes zoster oticus? Why is prompt treatment essential and what does it consist of? What are two substances that have been shown to reduce post-herpetic pain syndrome?

Answer 72

1. Reactivation of herpes zoster virus, leading to viral infection of the inner, middle, and external ear. 2. Contributed to by: •Decreased immune function •Physical and emotional stress 3. Especially concerning is infection of the 8th cranial nn and facial nn, leading to •Severe ear pain •Hearing loss •Vertigo •Paralysis of facial nn (transient or permanent) •Taste loss in anterior 2/3 of tongue with ipsilateral facial palsy 4. PE •Otoscopy: vesicles on pinna and in external auditory canal •Neuro exam •Full EENT exam •CSF: positive lymphocytes, elevated protein, antibody titer, PCR 5. •Pharmaceutical Remedies •Acyclovir: 800mg 5x/day for 1 week

Question 73

Distinguish conductive versus sensorineural hearing loss. Weber Test: (tuning fork held on top of head, midline)

Answer 73

Normal: sound is localized centrally with equivalent hearing in both ears. Sensorineural loss: sound localizes to better hearing side Conductive loss: sound localizes more to the involved ear

Question 74

Distinguish conductive versus sensorineural hearing loss. Rinne Test:

Answer 74

should hear tuning fork in air when cannot on the mastoid Conductive hearing loss: bone>air Sensorineural hearing loss: air>bone (normal pattern)

Question 75

When should you refer a patient with hearing loss for an audiologic evaluation?

Answer 75

When the cause is not easily identifiable Trauma Suspect sensorineural

Question 76

With a case of sensorineural hearing loss, what are some lab test on the CBC that can indicate an easily corrected nutrient deficiency?

Answer 76

Iron- 426 pt. with idiopathic hearing loss exhibiting low Hgb, low serum Fe, low serum ferritin – responded well to Fe supplementation. B12 and folic acid Low levels of serum B12 and RBC folate associated with noise-induced hearing loss, hearing loss in elders, and tinnitus. On CBC this would show as micro or macrocytic (probably hypochromic) anemia

Question 77

What are some key elements in the PE and laboratory evaluation of tinnitus?

Answer 77

May be a sx of nearly all ear disorders: external auditory canal obstruction; infection; eustachian tube obstruction; otosclerosis; middle ear neoplasms; Meniere’s disease; arachnoiditis; cerebellopontine angle tumors; ototoxicity; hereditary sensorineural or noise-induced hearing loss; acoustic trauma; head injury; TMJ d/o Cardiovascular dz Anemia Hypothyroidism Assessment: HEENT exam Audiologic assessment Labs: thyroid panel, CBC, Chem screen, lipid profile 10% tinnitus cases associated with medication: antiinflammatories (asprin, NSAIDs), tricyclic antidepressants, loop diuretics, aminoglycoside antibiotics, caffeine, alcohol, cocaine, marijuana, OCPs, propranolol

Question 78

What is masking and how is it useful in the treatment of tinnitus?

Answer 78

1. Use of masking – place device on non-affected ear that produces noise. Match pitch and loudness of tinnitus and the brain preferentially focuses on the noise being produced. a. Masking – often combined with a hearing aid, overrides the tinnitus signal to the brain and gives temporary relief. b. Helps 55% of tinnitus cases.

Question 79

In the treatment of tinnitus what is a key emotional factor that needs to be addressed?

Answer 79

Anxiety associated with tinnitus helpful to address

Question 80

Shooting pain with brushing of teeth or touching cheek. Unilateral

Answer 80

Trigeminal neuralgia

Question 81

Affects 1st ophthalmic branch of trigeminal nerve

Answer 81

Post herpetic neuralgia

Question 82

Contact between septum and lateral nasal wall causing local pain and radiating pain to maxilla/zygoma/preauricular area

Answer 82

Contact headache

Question 83

Worsens as the day goes by and with stress

Answer 83

Tension headache

Question 84

rare unless bp is greater than 150/95

Answer 84

HTN headache

Question 85

Prodrome with vision disturbance

Answer 85

Migraine

Question 86

Young men, woken at night with unilateral stabbing pain behind the eye/temple

Answer 86

Cluster headache

Question 87

Elderly women with constant unilateral facial pain

Answer 87

Temporal arteritis

Question 88

What is the initial tx strategy for epistaxis?

Answer 88

Firm pressure above nasal alar cartilage for minimum of 15 minutes. Position seated and leaning forward. Lubricate the nasal passage With q-tip applicator with olive oil or coconut oil Use humidifier in bedroom at night Simple saline spray in nose 3-4 times a day Refer with Recurrent or large volume epistaxis Bleeding persists after 15 min of direct pressure

Question 89

What are the major causes of anosmia?

Answer 89

1. Anatomic blockage - most common cause of hyposmia or anosmia. Polyps, septal defects, nasal tumors 2. Head trauma 3. Common cold, allergies lead to transient olfactory dysfunction. 4. Parkinson’s dz and Alzheimer’s dz assoc with anosmia 5. Medication SE can cause 6. Degenerative with increasing age 7. CNS neoplasms considered if no other explanation (20% idiopathic).