Otolaryngology Flashcards
External ear causes of ear pain?
Cerumen Impaction Otitis Externa Cellulitis of the Auricle Herpes Zoster Oticus Malignant OE
Signs/symptoms of otitis externa?
Infection of the external ear canal – recent swimming, pain in the tragus, feeling of fullness in the ear, pruritis in the ear canal, hearing loss, swelling, erythema/macerated ear canal, discharge, may see erythematous TM
Signs/symptoms of herpes zoster oticus?
Burning pain, hyperesthesia, pruritis preceding vesicle eruption, headache/fever/malaise/fatigue
What causes 99% of malignant OE?
Pseudomonas
When should you suspect malignant OE?
Immunodeficient + insulin dependent DM + otalgia + facial nerve involved
Signs/symptoms of malignant OE?
Otalgia and purulent otorrhea that is refractory to medical therapy
Tx of malignant OE?
Requires hospital admission, debridement, IV antibiotics, hyperbaric O2
Middle ear causes of ear pain?
AOM, Cholesteatoma, Barotrauma, Mastoiditis, Auricular Hematoma
What is malignant OE?
Osteomyelitis of the temporal bone
What is cholesteatoma?
A cyst composed of keratinized desquamated epithelial cells occurring in the middle ear, may present with sense of ear fullness and presence of a red or yellow mass typically involving the posterior aspect of the TM
Signs and symptoms of cholesteatoma?
Symptoms:
- Progressive hearing loss (predominantly conductive, although may get SNHL in late stage)
- Otalgia, aural fullness, fever
Signs
- Retraction pocket in TM, may contain keratin debris
- TM perforation
- Granulation tissue, polyp visible on otoscopy
- Malodourous, unilateral otorrhea
What is barotrauma?
History of rapid change in air pressure (eg, air travel, scuba diving). Often hemorrhage on or behind TM
What is mastoiditis and when is the onset?
Infection (usually subperiosteal) of mastoid air cells, most commonly seen approximately two wk after onset of untreated or inadequately treated AOM (suppurative)
Symptoms of mastoiditis?
Otorrhea, tenderness to pressure over the mastoid , retroauricular swelling with protruding ear, fever, hearingloss, ± TM perforation (late)
Nonotologic causes of ear pain?
Tumors of the External Auditory Canal
TMJ Dysfunction
Oropharyngeal Infections
Who should be evaluated for the possibility of a tumor in the ear canal?
Patients that appear to have a relapsing or unremitting case of otitis externa or perforated otitis media should be evaluated for the possibility of a tumor in the ear canal
Symptoms of TMJ dysfunction?
Pain, crepitus at TMI exacerbated by jaw movement, palpation of the TMJ region may reveal tenderness, or a palpable clicking sensation with joint motion
What should be done on physical exam for ear pain?
o Ear: Pinna + mastoid, ear canal and TM
o Throat
o TMJ
o Neck - LN
What is AOM?
Infection of middle ear caused by fluid stasis due to lack of middle ear drainage
▪ Often preceded by URTI
Risk factors of AOM?
Non-modifiable: young age, family history of OM, prematurity, orofacial abnormalities, immunodeficiencies, Down syndrome, race, and ethnicity
Modifiable: lack of breastfeeding, daycare attendance, household crowding, exposure to cigarette smoke or air pollution, pacifier use
Common organisms of AOM?
S. Pneumo > H. Influenza > Moraxella Catarhallis > GAS
Which organism is most likely pathogen associated with perforate TMs?
GAS
Triad for AOM?
Triad of otalgia + fever (especially in younger children) + conductive hearing loss;
What might be seen on otoscope for AOM?
Hyperemia, bulging, pus may be seen behind TM, loss of landmarks (e.g. handle and long process of malleus not visible)
Criteria for diagnosis of AOM?
1) Acute Onset Otalgia - Systemic symptoms: Difficulty sleeping, irritability, fever. Otalgia, otorrhea
2) Middle Ear Effusion w/ Inflammation (seen via decreased tympanic membrane mobility or bulging tympanic membrane on otoscopy)
Approach for generally healthy child >6mo of age with unilateral, non-severe, suspected AOM, without MEE or with MEE but non-bulging or mildly erythematous TM?
Consider viral etiology - reassess in 24-48h for worsening or change
Supportive care and symptom management: maintain hydration, analgesic, and antipyretic (acetaminophen, ibuprofen)
MEE Present + Bulging TM:
- Mildly Ill: alert, responsive, no rigors, responding to antipyretics, mild otalgia, able to sleep - <39C in absence of antipyretics, <48h of illness
Reassess 24-48h with analgesia, if no improvement then treat
MEE Present + Bulging TM:
- Mod-Severely Ill: irritable, difficulty sleeping, poor response to antipyretics, severe otalgia, OR =>39C in absence of antipyretics or >48h of symptoms
Treat with antimicrobials: 10 d course if 6-24 mo, 5 d if >2 yr old
Perforated TM +/- Purulent Discharge
Treat with antimicrobials for 10d
What antibiotic is 1st line for AOM
Amoxicillin 80 mg/kg/day BID - If someone fails amoxicillin, the next line is amoxi-clav 90 mg.
Extracranial complications of AOM?
Hearing loss and speech delay (secondary to persistent middle ear effusion), TM perforation, extension of suppurative process to adjacent structures (mastoiditis, petrositis, labyrinthitis), cholesteatoma, facial nerve palsy, middle ear atelectasis, ossicular necrosis, vestibular dysfunction)
What is otitis media with effusion?
Residual fluid in middle ear without signs of acute infection, can persists for weeks but self-limited and generally don’t need treatment
Otoscopy of TM from OM w/ effusion
Discolouration (amber or dull grey), meniscus fluid level behind TM, air bubbles, retraction pockets/TM atelectasis, flat tympanogram, immobility of TM
Tx of OM w/ effusion
90% resolve on their own, document hearing loss with audiogram
- If >3-6 Months/Affected Speech Development/Learning difficulties: consider myringotomy tubes (tubes fall out after 6-12 months)
What are the indications for myringotomy tubes?
Indications: persistent MEE (3 m bilateral or 6m unilateral) recurrent AOM (3 episodes/6 mo; 4 episodes/12 mo)
What is otitis externa?
Diffuse inflammation of external auditory canal +/- infection
Risk factors for otitis externa?
Prolonged water exposure (impairs natural defense mechanism in external ear - washes away cerumen, desquamation of keratin layer, altered pH), micro fissures from dermatologic conditions, hearing aids
Two most common organisms for otitis externa
90% pseudomonas aeruginosa and staphylococcus aureus
Presentation of otitis externa?
Rapid onset (w/n 48h) inflammation - Otalgia, itching, jaw pain, tenderness of tragus and/or pinna, edematous and erythematous ear canal
Management of otitis externa?
- Antipyretics
- Clean ear under magnification with irrigation, suction, dry swabbing, and C&S
- Antipseudomonal otic drops (e.g. ciprofloxacin) or a combination of antibiotic and steroid (e.g. Cipro HC)
- ± 3% acetic acid solution to acidify ear canal (low pH is bacteriostatic)
Tx of chronic otitis externa (pruritus without obvious infection)?
Corticosteroid alone (e.g. diprosalic acid)
Prevention of otitis externa?
Remove water from ears after swimming
Ddx of dizziness can be divided into which 2 categories?
o Vertigo (vestibular) o Nonvertiginous (nonvestibular)
What is the definition of vertigo?
Objective (external world seems to revolve around individual) or subjective (individual revolves in space)
Vertigo is a problem with the _____
Inner ear a.k.a. labyrinthine system
Vertigo can be divided into 2 categories
▪ Central (15%): brainstem / cerebellar (tumour, cerebrovascular disorders – TIA, Migrainous vertigo, Multiple sclerosis, drugs - anticonvulsants, hypnotics, alcohol))
▪ Peripheral (85%): inner ear / vestibular nerve (Meniere’s, BPPV, acoustic neuroma, trauma, drugs, labyrinthitis)
What are the symptoms of nonvestibular dizziness?
Feeling light-headed, giddy, dazed, disoriented
Causes of nonvestibular dizziness?
▪ Cardiac- Arrhythmias, Aortic stenosis ▪ Vasovagal ▪ Orthostatic hypotension - should do orthostatic BP lying down, sitting up, standing to see if any change in BP and HR ▪ Anemia ▪ Hypoglycemia ▪ Peripheral neuropathy ▪ Visual impairment ▪ Psychogenic: diagnosis of exclusion – panic disorder, anxiety, depression
What is the most common cause of vertigo?
Benign Paroxysmal Positional Vertigo
Signs and symptoms of BPPV?
Brief, recurrent episodes (30 seconds to 2 minutes) usually worse in morning (triggered by head movements), +/- nausea and vomiting, sensation of aural fullness, usually unilateral, tinnitus
What is vestibular neuronitis?
Inflammation of the vestibular portion of CN VIII
Signs and symptoms of vestibular neuronitis?
Sudden, incapacitating, severe vertigo with no hearing loss, leaving a residual imbalance that lasts days to weeks. Lasts up to 1 week, with gradual lessening of symptoms. Accompanied by N/V, unilateral horizontal nystagmus (towards offending ear in acute phase)
Treatment of vestibular neuronitis?
Bed rest, antivertiginous drugs, corticosteroids (methylprednisolone) ± antivirals
Signs and symptoms of Ménière’s disease?
Recurrent episodic episodes (minutes to hours), fluctuating hearing loss, tinnitus, vertigo, and aural fullness.
What causes Ménière’s disease?
Caused by inner ear filling up with fluid
Diagnostic Criteria for Meniere’s Disease
● Two spontaneous episodes of rotational vertigo > min
● Audiometric confirmation of SNHL (often low frequency)
● Tinnitus and/or aural fullness
MUST HAVE ALL 3
Treatment of ménière’s disease?
Tx: Managed with low sodium diet, dietary changes, diuretics, intratympanic gentamicin to destroy vestibular end-organ, results in complete SNHL
What is acoustic neuroma?
Schwannoma of the vestibular portion of CN VIII
Clinical features of acoustic neuroma?
● Usually presents with unilateral progressive SNHL (chronic) or tinnitus.
● Dizziness and unsteadiness may be present, but true vertigo is rare as tumour growth occurs slowly, and thus compensation occurs
● Facial nerve palsy and trigeminal (V1) sensory deficit (corneal reflex) are late complications
Treatment of acoustic neuroma?
● Expectant management if tumour is very small, or in elderly
● Definitive management is surgical excision
Which drugs are cause vestibular toxicity?
Aminoglycosides, loop diuretics, ASA, NSAIDs, amiodarone, quinine, cisplatin
Vertiginous Work-Up?
ENT/neurologic exams + Dix Hallpike Maneuver + Audiometry + MRI if indicated (meniere disease)
How do you perform the Dix Hallpike Maneuver?
Seat patient with legs extended, head at 45o rotation, rapidly shift patient to supine position with head fully supported in slight extension (for 45s) – observe for rotatory nystagmus + ask re: vertigo sensation
Syncopal Work-Up
o Orthostatic hypotension - Investigate underlying etiology. New meds or alcohol? Consider CBC and electrolytes.
o Vasovagal - If recurrent episodes or pt is at risk of injury, consider referral for tilt test (+/- carotid sinus massage if >40 yo)
What is an antihistamine anti-vertigo medication one could use to treat vertigo?
Betahistine, sold under the brand name Serc
What is the physiotherapy treatment called for BPPV?
Epley’s
When should you refer your patient to an ENT specialist for vertigo?
When significant central disease is suspected, when peripheral vertigo persistent (lasting >2-4wks), or if atypical presentation
What percentage of pharyngitis is viral and what is the most common bacteria?
90% viral, most common bacterial is Group A Strep
What is pharyngitis?
Inflammation of the oropharynx
Viral etiology of pharyngitis?
Viral Etiology: rhinovirus, adenovirus, influenza, coronavirus, respiratory syncytial virus are the most common viral causes, but occasionally Epstein-Barr virus (the cause of mononucleosis), herpes simplex , cytomegalovirus , or primary HIV infection is involved.
Presentation of viral pharyngitis?
Presentation: rhinorrhea, cough, congestion, hoarseness, Nonspecific flu-like symptoms such as fever, malaise, and myalgia Likely sick contacts
When should infectious mononucleosis be considered for pharyngitis?
Infectious mononucleosis should be considered when there is posterior cervical or generalized adenopathy, hepatosplenomegaly, and fatigue and malaise for > 1 week.
Bacterial etiology of pharyngitis?
Bacterial Etiology: Group A β-Hemolytic Streptococcus (GABHS), Group C + Group β-Hemolytic Streptococcus, Neisseria gonorrhoeae, Chlamydia pneumoniae, Mycoplasma pneumoniae, Corynebacterium diphtheriae
Potential complications of bacterial pharyngitis?
Complications: rheumatic fever, glomerulonephritis, suppurative complications (abscess, sinusitis, otitis media, cervical adenitis, pneumonia), meningitis, impetigo
S/S of bacterial pharyngitis?
▪ Symptoms: pharyngitis, fever, malaise, headache, abdominal pain, absence of cough
▪ Signs: fever, tonsillar/pharyngeal erythema/exudate, swollen/tender anterior cervical nodes, halitosis
Red flags for pharyngitis?
RED FLAGS: persistence of symptoms longer than a week without improvement, respiratory difficulty (particularly stridor, croup, etc.), difficulty in handling secretion (peritonsillar abscess), difficulty in swallowing (Ludwig’s angina), severe pain in the absence of erythema (supraglottis/epiglottitis), palpable mass (neoplasm), blood in the pharynx or ear (trauma)
Workup for pharyngitis?
Throat culture (gold standard), rapid test for streptococcal antigen
What is the centor criteria for bacterial tonsillitis?
Centor Criteria (criteria of likelihood of bacterial tonsillitis): Absence of cough, fever, tonsillar exudates and anterior cervical lymphadenopathy. ● 0-1 points – no antibiotic or throat culture ● 2-3 points – throat culture ● 4 points – treat with antibiotics empirically, consider culture
Management of viral pharyngitis?
▪ Antibiotics not indicated
▪ Supportive + honey + acetaminophen, ibuprofen, saline nasal spray, adequate hydration, and rest
▪ A single low dose of a corticosteroid such as oral dexamethasone—0.6 mg per kg for children at least five years of age and up to 10 mg for adults—is effective in decreasing pain in the first 24 hours.
Workup for suspected EBV?
▪ Suspected EBV (Infectious Mononucleosis): peripheral blood smear, heterophile antibody test (i.e. the latex agglutination assay or “monospot”)
Management for EBV Mono Pharyngitis
Acetaminophen/NSAIDs for fever/myalgias/pharyngitis/malaise, avoid heavy physical activity and contact sports for 1 month or until splenomegaly resolves (risk rupture)
▪ If Acute Airway Obstruction: corticosteroids + consult ENT
For GABHS pharyngitis is the incidence of glomerulonephritis or rheumatic fever decreased with the use of antibiotics?
Incidence of glomerulonephritis is not decreased with antibiotic treatment but rheumatic fever is
Pediatrics 1st line treatment for GABHS pharyngitis?
Pediatrics 1st Line: penicillin V 40 mg/kg/d PO BID-TID (max 750 mg/d) x 10 d (use adult dose if >27 kg) or amoxicillin 40 mg/kg/d PO BID-TID x 10 d
Adults 1st line treatment for GABHS pharyngitis?
Adults 1st Line: penicillin V 300 mg PO TID or 600 mg BID x 10 d
When should tonsillectomy occur if recurrent strep tonsillitis?
Tonsillectomy if recurrent strep tonsillitis - 7 episodes in the past year, 5 episodes per year in the past 2 years or 3 episodes per year in the past 3 years, and all infections should be culture confirmed group A strep.
What is the progression of retropharyngeal abscess/cellulitis?
You will see progression from cellulitis > phlegmon > abscess (often polymicrobial)
What is the retropharyngeal space?
Retropharyngeal space is from base of skull to posterior mediastinum
Presentation of retropharyngeal abscess/cellulitis?
Presentation: young children, looks sick, torticollis/refusal to move neck, resp distress (stridor), chest pain, cervical lymphadenitis, drooling, midline or unilateral swelling of posterior pharyngeal wall
Investigations for retropharyngeal abscess/cellulitis?
Investigations: Lateral neck xray (in full extension)
Treatment for retropharyngeal abscess/cellulitis?
Management: secure the airway + emergency surgical drainage (consult ENT) vs. abx for 1-2d (ampicillin, clindamycin)
What is a peritonsillar abscess
A peritonsillar abscess is a bacterial infection that usually begins as a complication of untreated strep throat or tonsillitis. It generally involves a pus-filled pocket that forms near one of your tonsils
What is the quinsy triad for peritonsillar abscess?
Trismus (lock jaw) + Uvular Deviation (contralateral side) + Dysphonia (hot potato voice
Management of peritonsillar abscess?
Secure the airway + surgical drainage (incision/needle aspiration) + saline irrigation + IV penicillin G x 10d (if GAS) +/- metronidazole/clindamycin
After how many episodes of peritonsillar abscess should you consider tonsillectomy?
After 2 episodes consider tonsillectomy
What is epiglottitis?
Epiglottitis: supraglottic laryngitis
What is the pathophysiology of epiglottitis?
Pathophysiology – cellulitis of the epiglottis and supraglottic structures leading to airway obstruction
Most common ethology of epiglottitis?
H. influenza type b
Presentation of epiglottitis?
Presentation: Abrupt onset of severe throat pain and dysphagia, usually with no preceding URI symptoms. Children often have drooling and signs of toxicity. Sometimes (more often in children), there are respiratory manifestations, with tachypnea, dyspnea, stridor, and sitting in the tripod position.
What are the four D’s of epiglottitis?
4 D’s: drooling + dysphagia + dysphonia + distress
Investigations of epiglottitis?
Clinical diagnosis; avoid examining throat to prevent further respiratory exacerbation
Sign of epiglottitis on lateral neck X-ray?
Thumb-sign
Treatment + prevention of epiglottitis?
Treatment: intubation + antibiotics (ceftriaxone) + prevented with H. Influenzae vaccine
Presentation of oral thrush?
Presentation: sore painful mouth, burning feeling on mucous membranes + dysphagia + white/cheesy material that can’t be scraped off or in a lacy pattern +/- erythema. Afebrile
Management of oral thrush?
Management: nystatin suspension for mild disease + fluconazole or amphotericin B for severe
Definition of allergic rhinitis?
Definition: rhinitis characterized by an IgE-mediated hypersensitivity to foreign allergens
Clinical features of allergic rhinitis?
▪ Nasal: congestion with pruritus, sneezing
▪ Clear rhinorrhea (containing increased eosinophils)
▪ Patients with seasonal and perennial allergic rhinitis also may have allergic conjunctivitis, asthma, and eczema
▪ Frontal headache and pressure
▪ Mucosa: swollen, pale, “boggy”
Two subgroups of allergic rhinitis?
▪ Seasonal (summer, spring, early autumn) - Pollens from trees, Lasts several wk, disappears, and recurs the following year at same time
▪ Perennial - inhaled: house dust, wool, feathers, foods, tobacco, hair, mould
Treatment of allergic rhinitis?
▪ Education: identification and avoidance of allergen
▪ Nasal irrigation with saline
▪ Antihistamines (e.g. diphenhydramine, fexofenadine)
▪ Oral decongestants (e.g. pseudoephedrine, phenylpropanolamine)
▪ Topical decongestant (may lead to rhinitis medicamentosa)
Definition of vasomotor sinusitis?
Definition: Neurovascular disorder of nasal parasympathetic system (vidian nerve) affecting mucosal blood vessels. Nonspecific reflex hypersensitivity of nasal mucosa
Etiology of vasomotor sinusitis?
▪ Temperature change ▪ Alcohol, dust, smoke ▪ Stress, anxiety, neurosis ▪ Endocrine: hypothyroidism, pregnancy, menopause ▪ Parasympathomimetic drugs
Clinical features of vasomotor sinusitis?
▪ Chronic intermittent nasal obstruction, varies from side to side
▪ Rhinorrhea: thin, watery
▪ Mucosa and turbinates: swollen
Diagnosis of vasomotor sinusitis?
Vasomotor rhinitis is diagnosed through exclusion; patients should have normal serum IgE levels, negative skin testing or RAST, and no inflammation on nasal cytology
Treatment of vasomotor sinusitis?
▪ Elimination of irritant factors
▪ Parasympathetic blocker (Atrovent – nasal spray)
▪ Steroids (e.g. beclomethasone, fluticasone)
▪ Surgery (often of limited lasting benefit): electrocautery, cryosurgery, laser treatment, or removal of inferior or middle turbinates
What is rhinitis medicamentosa (rebound rhinitis)?
Repetitive use of topical alpha-adrenergic decongestant sprays (for five to seven consecutive days) may induce rebound nasal congestion after withdrawal
Investigation for nasal cavity foreign body?
Ant. rhinoscopy, nasal endoscopy
Presentation for nasal cavity foreign body?
Unilateral purulent rhinorrhea (for wks!)
Definition of acute bacterial rhinosinusitis?
Definition: clinical diagnosis requiring ≥2 major symptoms, and at least one of the symptoms is either nasal obstruction or purulent/discoloured nasal discharge
Major symptoms of acute bacterial rhinosinusitis?
Major Symptoms (at least 2 of PODS, 1 must be O or D): ▪ P Facial Pain/Pressure/fullness ▪ O Nasal Obstruction ▪ D Purulent/discoloured nasal Discharge ▪ S Hyposmia/anosmia (Smell)
Which sinus is most commonly affected in acute bacterial rhinosinusitis?
Maxillary sinus most commonly affected
What population is more prone to a bacterial etiology for acute bacterial rhinosinusitis?
Children are more prone to a bacterial etiology, but viral is still more common
What must you r/o in immunocompromised hosts, especially if painless black or pale mucosa on examination
Must rule out fungal causes (mucormycosis)
Clinical features of acute bacterial rhinosinusitis?
Sudden onset of:
- nasal blockage/congestion and/or purulent nasal discharge/posterior nasal drip
- ± facial pain or pressure, hyposmia, sore throat
- Persistent/worsening symptoms >5-7d or presence of purulence for 3-4d with high fever
Differentiate acute bacterial rhinosinusitis? from acute viral rhinosinusitis?
Differentiate from acute viral rhinosinusitis (course: <10d, peaks by day 3)
What are predisposing factors for acute bacterial rhinosinusitis?
Predisposing factors: viral URTI, allergy, dental disease, anatomical defects
What would be seen on speculum exam for acute bacterial rhinosinusitis?
Speculum exam: erythematous mucosa, mucopurulent discharge, pus originating from the middle meatus
Treatment for acute bacterial rhinosinusitis?
Treatment:
▪ Mild-moderate: INCS; If no response within 72 h, add antibiotics
▪ Severe: INCS + antibiotics
▪ 1st line: amoxicillin x 10 d (TMP-SMX or macrolide if penicillin allergy) - If no response to 1st line antibiotics within 72h, switch to 2nd line
▪ 2nd line: fluoroquinolones or amoxicillin-clavulanic acid
▪ Adjuvant therapy (saline or hypochlorous acid (pediatric sinusitis) irrigation, analgesics, oral/topical decongestant) may provide symptomatic relief
Definition of chronic rhinosinusitis?
Inflammation of the mucosa of paranasal sinuses and nasal passages >8-12wk
Clinical features of chronic rhinosinusitis?
Clinical Features (similar to acute, but less severe) - at least 2 of CPODS for >8-12 wk
▪ Facial Congestion/fullness
▪ Facial Pain/Pressure
▪ Chronic nasal Obstruction
▪ Purulent anterior/posterior nasal Discharge
▪ Hyposmia/anosmia (Smell)
Diagnosis of chronic rhinosinusitis?
Diagnosis requires ≥ 2 major symptoms for >8-12wk and ≥1 objective finding of inflammation of the paranasal sinuses (CT/endoscopy)
Investigations for chronic rhinosinusitis?
Obtain CT or perform endoscopy
Management if polyps present for chronic rhinosinusitis?
If polyps present: INCS, oral steroids ± antibiotics (if signs of infection), refer to otolaryngologist/H&N surgeon
Antibiotics for 3-6wk - Amoxillin-clavulanic acid, fluoroquinolone (moxifloxacin), macrolide (clarithromycin), clindamycin (metronidazole)
Management if polyps not present for chronic rhinosinusitis?
If polyps absent: INCS, antibiotics, saline irrigation, oral steroids (severe cases)
Antibiotics for 3-6wk - Amoxillin-clavulanic acid, fluoroquinolone (moxifloxacin), macrolide (clarithromycin), clindamycin (metronidazole)
When should surgery be considered for chronic rhinosinusitis and what procedures are done?
Surgery if medical therapy fails or fungal sinusitis: FESS, balloon sinoplasty
What is the Ddx for neck mass?
Acute
- Acute sialadenitis
- Hematoma
- Pseudoaneurysm or arteriovenous fistula
- Reactive lymphadenopathy (CMV, EBV, HIV, mycobacterium tuberculosis (extrapulmonary), viral URI
Subacute (weeks to months)
- Cancer (Hodgkin lymphoma, HPV-related SCC, Metastatic cancer, Non-Hodgkin lymphoma, Parotid tumors)
Chronic
- Carotid body tumors
- Congenital disorders (Branchial cleft cyst, Dermoid or sebaceous cyst, Thyroglossal duct cyst)
- Goiters (Graves disease, Hashimoto thyroiditis, Iodine deficiency, Lithium use, Toxic multinodular
- Laryngocele
- Lipomas
- Liposarcoma
- Parathyroid cysts or cancer
What is the typical history of acute sialadenitis?
History: Older, debilitated persons with dehydration or recent dental procedures
What are the physical exam findings for acute sialadenitis?
Physical: Rapid or gradual onset of pain and swelling; local edema, erythema, tenderness, or fluctuance consistent with an abscess
What is used for the diagnosis of acute sialadenitis?
Diagnosis: Contrast-enhanced CT
What is the management of acute sialadenitis?
Management: Sialagogues, gentle massage; abscess, express by compressing the gland
What is the typical history of parathyroid cysts or cancer?
History: Hypercalcemia symptoms, family history of multiple endocrine neoplasia
What are the physical exam findings for parathyroid cysts or cancer?
Physical: Anterior cervical triangle
What is used for the diagnosis of parathyroid cysts or cancer?
Diagnosis: Serum calcium, parathyroid hormone immunoassay
What is the management of parathyroid cysts or cancer?
Management: Refer to endocrinology, ENT
What is the typical history of laryngocele?
History: Repetitive nose blowing, coughing, or blowing into a musical instrument
What are the physical exam findings of laryngocele?
Physical: Midline, superior to thyroid cartilage; resonant, intermittent, globus sensation
What is used for the diagnosis of laryngocele?
Diagnosis: CT or laryngoscopy
What is the management of laryngocele?
Management: Refer to ENT
What is the typical history of gaiters?
History: Hyperthyroid or hypothyroid symptoms, reduced dietary iodine (Iodine deficiency), bipolar disease (lithium use)
What are the physical exam findings of goiters?
Physical: Diffusely nodular/enlarged thyroid
Associated exophthalmos, pretibial myxedema (Graves)
What is used for the diagnosis of goiters?
Diagnosis:
- TSH-receptor antibody; diffuse uptake on scintigraphy (Graves)
- Thyroid peroxidase antibody (Hashimoto thyroiditis)
- Multiple foci on scintigraphy (Toxic multinodular)
What is the management of goiters?
Management:
- Radioactive iodine ablation, thyroidectomy, methimazole or propylthiouracil (Graves or toxic multinodular)
- Levothyroxine (Hashimoto thyroiditis)
- Increase iodine/decrease thiocyanate containing compounds (Iodine deficiency)
- Monitor thyroid function at 6 to 12 months, treat dysfunction, discontinuation not required (Lithium)
What is the typical history of thyroglossal duct cyst?
History: Often diagnosed in childhood; slow growing or may arise quickly after URI; may present as acute or subacute
What are the physical exam findings of thyroglossal duct cyst?
Physical: Midline, adjacent to the hyoid bone; rises with deglutition, non tender
What is used for the diagnosis of thyroglossal duct cyst?
Diagnosis: CT (assures no thyroid cancer calcifications)
What is the management of thyroglossal duct cyst?
Management: Antibiotics; refer to ENT for excision after repeated infections
What is the typical history of carotid body tumors?
History: Flushing, palpitations, hypertension if hormonally active, dysphagia, dyspnea, eustachian tube dysfunction
What are the physical exam findings of carotid body tumors?
Physical: Painless oropharyngeal or upper anterior triangle of the neck; pulsatile, compressible with a bruit or thrill, mobile from medial to lateral direction
What is used for the diagnosis of carotid body tumors?
Diagnosis: CT, CT angiography (lyre sign); plasma and urine metanephrines, catecholamines
What is the management of carotid body tumors?
Management: Refer to ENT
What is the typical history of dermoid or sebaceous cyst?
History: Children and young adults
What are the physical exam findings of dermoid or sebaceous cyst?
Physical: Submental triangle; soft, doughy, painless
What is used for the diagnosis of dermoid or sebaceous cyst?
Diagnosis: CT
What is the management of dermoid or sebaceous cyst?
Management: Surgical excision
What is the typical history of lipomas?
History: Age > 35 years, possible history of trauma
What are the physical exam findings of lipomas?
Physical: Soft, mobile, discrete subcutaneous tumors
What is used for the diagnosis of lipomas?
Diagnosis: CT
What is the management of lipomas?
Management: Monitor or excise
What is the typical history of hematoma?
History: Trauma
What are the physical exam findings of hematoma?
Physical: Soft, possible overlying ecchymosis
What is used for the diagnosis of hematoma?
Diagnosis: Ultrasonography or contrast-enhanced CT
What is the management of hematoma?
Management: Monitor if small; surgical drainage if large or expanding
What is the typical history of HPV-related SCC?
History: 35- to 55-year-old white men with a history of smoking, heavy alcohol use, and multiple sex partners (especially involving orogenital contact)
What are the physical exam findings of HPV-related SCC?
Physical: Rapidly enlarging, lateral, cystic lymph nodes; persistent cervical nodal hypertrophy; palatine or lingual tonsillar asymmetry; dysphagia; voice changes; pharyngeal bleeding
What is used for the diagnosis of HPV-related SCC?
Diagnosis: Nasal endoscopy, laryngoscopy, bronchoscopy with biopsies
What is the management of HPV-related SCC?
Management: 2-week trial of antibiotics; refer for biopsy if no resolution
What is the typical history of pseudoaneurysm or arteriovenous fistula?
History: Trauma with shearing forces
What are the physical exam findings of pseudoaneurysm or arteriovenous fistula?
Physical: Lateral; soft, pulsatile mass with a thrill or bruit
What is used for the diagnosis of pseudoaneurysm or arteriovenous fistula?
Diagnosis: CT with or without CT angiography
What is the management of pseudoaneurysm or arteriovenous fistula?
Management: Surgical evaluation for ligation
What is the typical history of reactive lymphadenopathy?
History: URI symptoms (CMV, EBV, viral URI), blood/sexual contact (HIV), travel to or immigration from an endemic area, homelessness, immunocompromise (tuberculosis)
What are the physical exam findings of reactive lymphadenopathy?
Physical: Rubbery, mobile, cervical, and generalized; > 2 cm. Subsides in 3-6 weeks (viral)
What is used for the diagnosis of reactive lymphadenopathy?
Diagnosis: Cytomegalovirus titer, Monospot, Epstein-Barr virus titer, HIV enzyme-linked immunoassay,
What is the management of reactive lymphadenopathy?
Biopsy if no resolution after 8 weeks
What is the typical history of hodgkin and non-hodgkin lymphoma?
HL: 15 to 34 years of age and > 55 years, constitutional symptoms, later splenomegaly
NHL: Older persons
What are the physical exam findings of hodgkin and non-hodgkin lymphoma?
Painless, rapidly growing lymph node; rubbery, soft, mobile
May involve the tonsillar ring in the pharynx (NHL)
What is used for the diagnosis of hodgkin and non-hodgkin lymphoma?
Contrast-enhanced CT of the neck, chest, abdomen, pelvis; biopsy
What is the management of hodgkin and non-hodgkin lymphoma?
Refer to oncology
What is the typical history of parotid tumors?
History: Asymptomatic
What are the physical exam findings of parotid tumors?
Physical: Slow-growing, unilateral, mobile, asymptomatic; cranial nerve (often VII [facial]) involved if malignant
What is used for the diagnosis of parotid tumors?
Diagnosis: Contrast-enhanced CT and/or FNAB
What is the management of parotid tumors?
Management: Refer to ENT for excisional biopsy
What is the typical history of branchial cleft cyst?
History: Often diagnosed as a child; slow or rapidly growing after URI; acute or subacute
What are the physical exam findings of branchial cleft cyst?
Physical: Mandibular angle, anterior to sternocleidomastoid, often with a sinus or fistula
What is used for the diagnosis of branchial cleft cyst?
Diagnosis: Ultrasonography
What is the management of branchial cleft cyst?
Management: Antibiotics; refer to ENT for excision after repeated infections
What questions should be asked on history for neck mass?
o History of present illness should note how long the mass has been present and whether it is painful. Important associated acute symptoms include sore throat, URI symptoms, and toothache.
o Review of systems should ask about difficulty swallowing or speaking and symptoms of chronic disease (eg, fever, weight loss, malaise). Regional and distant cancers causing metastases to the neck occasionally cause symptoms in their system of origin (eg, cough in lung cancer, swallowing difficulty in esophageal cancer).
o Past medical history should inquire about known HIV or tuberculosis and risk factors for them.
o Risk factors for cancer are assessed, including consumption of alcohol or use of tobacco (particularly snuff or chewing tobacco), ill-fitting dental appliances, and chronic oral candidiasis. Poor oral hygiene also may be a risk.
A non-midline mass in older patients, particularly those with risk factors, should be considered _____ until proven otherwise; a midline mass is likely of _______ (benign or malignant).
cancer
thyroid origin
What are the red flags of neck masses?
o Hard, fixed mass
o Older patient
o Presence of oropharyngeal lesions (other than simple pharyngitis or dental infection)
o A history of persistent hoarseness or dysphagia
What should be included on physical exam for neck mass?
o The neck mass is palpated to determine consistency (ie, whether soft and fluctuant, rubbery, or hard) and presence and degree of tenderness. Whether the mass is freely mobile or appears fixed to the skin or underlying tissue also needs to be determined.
o The scalp, ears, nasal cavities, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx are closely inspected for signs of infection and any other visible lesions. Teeth are percussed to detect the exquisite tenderness of root infection. The base of the tongue, floor of the mouth, and the thyroid and salivary glands are palpated for masses.
o The breasts and prostate gland are palpated for masses, and the spleen is palpated for enlargement. Stool is checked for occult blood, suggestive of a GI cancer.
Initial diagnostic test of choice in an adult with a persistent neck mass i
Contrast-enhanced CT
CT angiography is recommended for evaluating a ____ neck mass
pulsatile
What is subjective tinnitus?
Perception of sound in the absence of an acoustic stimulus and is heard only by the patient. Most tinnitus is subjective.
Etiology of subjective tinnitus?
- Otologic: Hearing loss, acoustic neuroma, Meniere’s disease.
- Sensorineural hearing loss: Presbycusis, Noise-induced hearing loss
- Conductive hearing loss: Cerumen, Otitis media with effusion, Otosclerosis
- Metabolic conditions: thyroid, hyperlipidemia, Vitamin A, B, Zinc deficiency
- Neurologic: MS, brainstem lesion
- Medications: ASA, NSAIDs, Aminoglycosides, Antihypertensives, Heavy metals
- Psychologic: Anxiety, Depression
Etiology of objective tinnitus?
- Vascular - Benign intracranial hypertension, Arteriovenous malformation, Glomus tympanicum, Glomus jugulare, Arterial bruits, Venous hum
- Mechanical: Patulous eustachian tube, Palatal myoclonus, Stapedius muscle spasm
Questions to be asked on history for tinnitus?
- Onset, location, unilateral vs bilateral, duration
- Pattern, character (pulsatile, intermittent, constant) pitch, ‘whoosh’ pitch, aggravating/alleviating factors
- Association: hearing loss, vertigo, aural fullness, otalgia, otorrhea
- PMHx: unilateral/bilateral hearing loss, trauma/whiplash, infections/meningitis, vascular ischemia, Meniere’s disease, TMJ dysfunction, CHF, CRF
- PSHx: Chiari malformation surgery, ear surgery
- PO&GHx: Currently pregnant, previous pregnancies
- Meds: Aminoglycosides, ASA, NSAIDs, loop diuretics, cisplatin, anticonvulsants, hypnotics
- Allergies: Allergic rhinitis
- FHx: hearing loss, tinnitus, neurofibromatosis type 2
- Social: Noise exposure, smoking, caffeine, EtOH, IVDU, heavy metals
Red flags of tinnitus?
- Bruit, particularly over the ear or skull
- Accompanying neurologic symptoms or signs (other than hearing loss)
- Unilateral tinnitus
Physical exam for tinnitus?
- Inspect: pinna, canal, anterior rhinoscopy, oropharynx for pulsatile mass, patent Eustachian tubes
- Otoscopy: wax, foreign bodies, perforation, retracted/bulging TO/OM/OE, pulsatile mass behind TM, blue mass behind mass behind TM
- Pneumatic otoscopy: movement of TM,does red/blue mass blanch
- Palpation: check neck for masses, TMJ for crepitus, check if pressure on IJ/carotid changes
- Auscultation: ear canal, auscultate around the external ear and over neck and carotid artery and jugular vein for masses
- Neuro exam
- Weber and Rinne testing
What is objective tinnitus?
Results from noise generated by structures near the ear
Investigations for tinnitus?
- CBCd, lytes, Cr, urea, TSH, lipid profile, glucose, VDRL
- MRA head, carotid Doppler for pulsatile tinnitus
- Gadolinum-enhanced MRI of posterior cranial fossa - vestibular schwannoma
Special tests for tinnitus?
- Audiogram – first test of choice
- VNG for vestibular dysfunction
- Pre-op angiogram with embolization, urine catecholamines for carotid body tumor
Treatment for tinnitus?
- Correcting hearing loss – hearing aids/tinnitus masker
- Treat anxiety/depression, allergic rhinitis
- Stop ototoxic drugs
- Lifestyle: noise exposure, decrease salt intake (Meniere’s), BP, glucose, thyroid control
- Wax removal
- Cognitive behavioural therapy/ tinnitus retraining therapy
Signs and symptoms of Glomus Tympanicum/Jugulare Tumour?
- Pulsatile tinnitus
- Hearing loss
- Blue mass behind TM
- Brown’s sign (blanching of the TM with pneumatic otoscopy)
