Otolaryngology Flashcards
What are the two types of hearing loss?
Conductive and sensorineural
What are the most common causes of hearing loss?
- Cerumen impaction
- Eustachian tube dysfunction (2/2 to URI)
- Increasing age (presbycusis)
Weber lateralizes to the affected ear. Rinne test might show greater bone conduction than air conduction on affected side. What type of hearing loss?
Conductive pattern via weber and rinne
Weber lateralizes to the better hearing/unaffected side. Ring test will show that air conduction is greater than bone conduction. What type of hearing loss?
Sensorineural pattern via weber and rinne
What is the definition of conductive hearing loss?
Impaired sound transmission to inner ear
What is definition of sensorineural hearing loss and how does it present?
Damage/impairment of the inner ear (cochlea) or neural pathways
Possible causes of conductive hearing loss
- blockage/obstructoin due to cerumen impaction or exudate from otitis externa
- otitis media with effusion
- otosclerosis (abnormal bony growth of the middle ear)
- ear trauma/injury
Possible causes of sensorineural hearing loss?
- Presbycusis is most common (age)
- Meniere disease
- Acoustic trauma (second most common)
How does presbycusis present?
Genetic predisposition is strong; risk increased with noise exposure and exposure to various medications
What is the cause and what are the symptoms of Meniere disease?
Cause: unknown etiology
- Recurrent vertigo
- Lower range hearing loss
- Tinnitus
- One-sided aural pressure
Caloric testing shows nystagmus is lost on impaired test (normally with cold water, eyes turn toward the ipsilateral ear, with horizontal nystagmus to the contralateral ear
What is the first-line tx for Meniere disease?
Low-sodium diet and diuretics (.e., acetazolamide); if unresponsive may try more invasive procedures like intratympanic corticosteroid therapy, surgery
Acoustic trauma occurs at what dB?
> 85 dB can cause cochlear damage. Increased risk with chronic exposure
What nerve do acoustic neuromas (vestibular schawnnomas) affect?
Intracranial benign tumor affecting the 8th CN
Typical presentation of acoustic neuroma?
Uni vs. bilateral
Acute vs. progressive
Other sxs
Patient presents with unilateral, progressive (but may be more acute) one-sided hearing loss with impaired speech discrimination. Other sxs include vertigo, which is usually continuous
How to dx and treat acoustic neuroma?
Dx: MRI
Tx: Maybe surgery or focused radiation depending on age, health status, and tumor size
What drugs may induce hearing loss?
Permanent damage can occur despite correct dosing
- Aminoglycosides
- Loop diuretics
- Vancomycin
- Anticancer drugs (cisplatin)
What are causes of hearing loss in infants and children?
- Congenital (asphyxia, erythroblastosis, maternal rubella)
2. Acquired: measles, mumps, pertussis, meningitis, influenza, labrynthitis
Explain the process of AOM
- Begins usually as viral URI that leads to eustachian tube dysfunction or blockage
- A bacterial infection occurs with the subsequent buildup of fluid and mucus
What are most common agents of AOM?
- Strep pneumo
- H. flu
- Moraxella catarrhalis
- Strep pyogenes
A child presents with fever, otalgia, and hearing impairment. On exam, the TM may appear erythematous. It has limited mobility with pneumotoscopy. what’s the dx?
AOM
If someone with ear pain has otorrhea and an abrupt decrease in pain, what might be the cause?
AOM -> Bulging and eventual rupture of TM
When can tx for AOM be “watchful waiting”?
- If >2 years old w/o otorrhea
2. If
What is the treatment of AOM?
- Amoxicillin
- Cephalosporin, TMP/SMX, and Azithromycin also might be acceptable.
- Amox/Clav or Cofactor in resistant cases
What is a complication of inadequately treated otitis media?
Mastoiditis
A child presents with spiking fever, post auricular pain, erythema, and a fluctuant painful mass behind the ear. What is the cause?
Mastoiditis from inadequately treated AOM. Treat initially with IV antibiotics and myringotomy followed by full course of oral antibiotic. If ineffective, surgery (mastoidectomy) is indicated.
What are causes of chronic otitis media?
Repeated episodes of acute otitis media, trauma, or cholesteatoma
What are the causative organisms of chronic otitis media?
- Pseudomonas aeruginosa
- Staph aureus
- Proteus
- Anaerobes
What will the exam show for chronic otitis media?
Perforated tympanic membrane and chronic ear discharge +/- pain. TM and/or ossicular damage may result in conductive hearing loss.
A patient presents with ear pain, especially when moving tragus/auricle. There is redness and swelling of ear canal. Purulent exudate may be present. What’s the dx and tx?
Otitis externa, or “swimmer’s ear.”
Tx: antibiotic otic drops (aminoglycoside or FQ +/- corticosteroids) and avoiding further moisture or ear injury
What are causes of otitis externa?
Water exposure, trauma (ear scratching/cleaning), or exfoliative skin conditions (psoriasis, eczema)
Complications of otitis external in diabetic or immunocompromised patient?
Malignant otitis externa may develop, which is necrotizing infection extending to blood vessels, bone, and cartilage
tx: hospitalization and parenteral abx
What are peripheral causes of vertigo?
- Labrynthitis
- BPPV
- Meniere (endolymphatic hydrops)
- Vestibular neuritis
- Head injury
What are central causes of vertigo?
- Brainstem vascular disease
- Arteriovenous malformations
- Tumors
- Multiple sclerosis
- Vertebrobasilar migraine
What is the difference in presentation for peripheral vs. central vertigo?
Peripheral: sudden onset, nausea/vomiting, tinnitus, hearing loss, nystagmus (horizontal)
Central: more gradual, vertical nystagmus. No auditory symptoms. Usually associated with motor, sensory, or cerebellar deficits
How to dx BPPV?
Dix-Hallpike maneuver produces delayed fatigable nystagmus
if non-fatigable, then more likely a central cause
Tx of vertigo
Depends on underlying cause
vestibular suppressants (diazepam, meclizine) may help with acute symptoms
BPPV may respond to PT
Acute severe vertigo, hearing loss and vertigo several days to a week -cause and dx?
Labyrinthitis - vertigo improves over a few weeks, hearing loss may or may not resolve
may be caused by bacteria or viruses in conjunction with local or systemic infections, also may be caused by autoimmune
Tx of labyrinthitis?
Antibiotics if fever or signs of bacterial infection
Vestibular suppressants during initial acute sxs
What is barotrauma?
Inability to equalize barometric pressure on the middle ear, associated with eustachian tube dysfunction (from congenital narrowing or acquired mucosal edema)
can occur while flying, diving, rapid altitude changes
can cause TM rupture
Causes of TM rupture?
AOM/infection, trauma (barotrauma, direct impact, explosion)
Tx of TM rupture?
most resolve on their own; however surgical repair of the tympanic membrane as well as ossicular chain may be necessary.
water/moisture to ear should be avoided to prevent secondary infection that can impeded closure
Causative organisms of acute sinusitis?
Usually follows URI and can be viral or bacterial in nature. Bacterial origin same as AOM (s. pneuma, h flu, m cat, less often staph)
Risk factors of sinusitis?
cigarette smoke, history of trauma, presence of foreign body
Patient presents with purulent nasal discharge, facial pain and pressure, nasal obstruction or congestion, and fever. Tenderness of affected sinus. D?
Acute sinusitis
Tx for sinusitis?
Most get better within 2 weeks even without antimicrobial therapy
- NSAIDs for pain
- Nasal saline wash
- Steam
- Oral/nasal decongestants, intranasal corticosteroids
- Abx if extended duration of sxs (10-14d) or more significant symptoms (fever, facial pain, swelling). Amoxicillin 1st line; Macrolides, TMP/SMX, or doxycycline can be used if allergic.
Pt presents with rhinorrhea, “shiners” below eyes, itchy/watery eyes, sneezing, nasal congestion, dry cough and pale/boggy/bluish mucosa. Discharge is clear. What’s the tx?
Dx: Allergic rhinitis
Tx: Avoid known allergens, anti-histamine (2nd gen like loratadine less likely to make drowsy) for mild; nasal corticosteroid first line for mod-severe. Nasal saline drops or washes, immunotherapy possibly since IgE mediated reactivity to airborne antigens.
Allergic rhinitis is more likely in people who also have what conditions?
Asthma, eczema, atopic dermatitis, other atopic diseases
Three types of rhinitis?
- allergic
- vasomotor (increased secretion of mucus precipitated by changes in temp or humidity, odors, alcohol or other)
- rhinitis medicamentosa (medication overuse, d/c med)
What is the most common etiology of sore throat?
Viral
What clinical features with sore throat suggest GABHS? What are the criteria called?
Centor Criteria
- Fever
- Tender anterior cervical adenopathy
- Lack of cough
- Pharyngotonsillar exudate
What clinical features are NOT suggestive of streptococcal pharyngitis?
Cough, coryza, hoarseness
What is the treatment for streptococcal pharyngitis?
- Penicillin (IM or oral)
- Other options: amox, cefuroxime
- If allergy: erythromycin or other macrolide
What are complications of untreated strep throat?
Rheumatic fever, scarlet fever, glomerulonephritis, abscess formation
Pt presents with significant sore throat, pain with swallowing, truisms, deviation of soft palate/uvula, and muffled “hot potato” voice. What’s the dx and tx?
Dx: Peritonsillar abscess/cellulitis
Tx: aspirate, incise and drain, and/or antibiotics. tonsillectomy considered if recurrent.
Abx therapy: amoxicillin, augmentin, clindamycin
Laryngitis usual cause and tx?
- viral illness following URI
- can be bacterial - m. cat or h. flu
Tx: supportive therapy, vocal rest
might consider corticosteroid tx in vocal performers but need to evaluate vocal fold first
mouth lesson - painful, round ulcer with yellow-gray center and red halo. What is the likely dx? Tx?
aphthous ulcer (happens on non-keratinzed skin like buccal or labial mucosa, usually recurrent)
tx: topical therapies like corticosteroids can provide symptomatic relief. 1-week oral prednisone taper may help
cimetidine can be used in maintenance therapy in recurrent cases
A pt presents with throat/mouth pain and creamy white patches that can be scraped off. What’s the etiology, dx, tx?
Oral thrush - candida albicans
dx clinically or by wet prep or biopsy
Tx: antifungal
Who is more at risk for oral thrush?
Children, diabetics and other immunocompromised, people who wear denture, undergoing chemotherapy or radiation, or undergoing treatment with corticosteroids or broad spectrum antibiotics
A patient presents with white oral non-painful lesion that cannot be scraped off. What is the dx? Who is most at risk?
Leukoplakia
5% are dysplastic or squamous cell carcinoma (more likely if associated with erythematous appearance)
At risk: people who use tobacco, alcohol, or dentures
What is the major risk of epiglottitis?
Airway compromise
An adult abruptly develops a sore throat and pain on swallowing. Later on may include fever, drooling, and, in children, a tripod or sniffing posture. Dx and tx?
Acute epiglottitis
Dx with laryngoscopy - swollen erythematous epiglottis, or lateral x-ray may show thumbprint sign
Tx: IV antibiotics (ceftizoxime or cefuroxime) and IV corticosteroids (dexamethasone).
As pt improves can switch to oral and complete 10 day course (and taper corticosteroids)
If dyspnea or rapid course, intubation may be indicated, monitor closely regardless
epistaxis most commonly occurs where?
anterior, Kiesselbach plexus
What are ways to stop epistaxis?
Pressure for 15 min (lean forward to don’t swallow blood), topical cocaine (vasoconstrictor and anesthetic) or other topical decongestant and topical anesthetic
If bleeding can be visualized, can use cautery
If bleeding can’t be stopped, anterior pack or posterior pack depending on source (posterior should be done by specialist)
Patients with nasal polyps often have what other two conditions?
Atopy triad:
- Atopic dermatitis
- Allergic rhinitis
- Nasal polyps
A patient with nasal polyps and asthma may also have what condition?
aspirin allergy
Tx for nasal polyps?
3-month course of topical nasal corticosteroid effectivee for small polyps; oral steroid (six day taper) could also help
