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MCC Part 1 > Otolaryngology > Flashcards

Otolaryngology Flashcards

1
Q

Otalgia

A

nonspecific ear pain

  • primary = pain originates within inner ear
  • referred = pain originates from organ that shares sensory innervation with ear
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2
Q

Common causes of otalgia?

A

primary - otitis media and externa

secondary - dental pathology and pharyngeal infections

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3
Q

Nerves supplying sensory innervation to external ear?

A
  • great auricular nerve (from cervical plexus)
  • lesser occipital nerve (from cervical plexus)
  • auricular branch of vegas nerve
  • auriculotemperal nerve (mandibular branch of trigeminal nerve)
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4
Q

What supplies inner ear?

A
  • branches of CN V, IX, X
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5
Q

Rapid onset of which sx in AOM?

A
  • otalgia
  • decreased hearing
  • fever
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6
Q

Mastoiditis

A
  • complication of AOM

- erythema and swelling over mastoid region -> clinical dx

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7
Q

AOM underlying etiology and pathogens

A
  • Estachain tube obstruction secondary to deem from URTI, allergies or inadequate opening
  • negative middle ear pressure = influx of pathogens from nasopharynx

S. pneumonia, H. influenza, M. catarrhalis
Viral

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8
Q

OE underlying pathogens

A
  • pseudomonal

- r/o malignant otitis external (rapidly destructive osteomyelitis of temporal bone in immunocompromised host)

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9
Q

Treatment AOM

A
  • observation and symptomatic management
  • amoxicillin
  • second line = amoxicillin-clavulin, second generation cephalosporin
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10
Q

Treatment OE

A
  • antipseudomonal ear drops (Ciprodex)
  • oral antipseudomonal abx if severe
  • manual debridement or ear wick if oedematous or obstructed canal
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11
Q

What is vertigo

A

Illusion of movement, often spinning or turning of oneself or one’s environment
peripheral (vestibular system) vs. central (CNS)

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12
Q

What is the vestibular system?

A
  • utricle
  • saccule
  • 3 semicircular canals (lateral, posterior, superior)
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13
Q

What detects linear acceleration?

A

utricle - horizontal acceleration

saccule - vertical acceleration

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14
Q

What detects angular acceleration?

A

semicircular canals

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15
Q

What are the otolith organs?

What occurs with displacement of otoliths?

A

utricle and saccule - contain calcium carbonate crystals (otoliths)
- displacement of otoliths = movement of sensory hair cells that transduce information into neural signal of movement

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16
Q

CNS components of motion sensing and control of balance?

A

cerebellum
cerebral cortex
brainstem

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17
Q

Ddx true vertigo -peripheral

A
  • BPPV
  • vestibular neuronitis
  • labrynthitis
  • Meniere disease
  • ototoxicity
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18
Q

Ddx true vertigo - central

A
  • CPA tumor
  • CVA
  • MS
  • drugs (anticonvulsants, EtOH)
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19
Q

Ddx non vertiginous dizziness

A
  • disequilibrium: peripheral neuropathy, visual impairment
  • presyncope
  • psychiatric
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20
Q

Will peripheral vertigo continue for weeks?

A

No, it is episodic and won’t continue for weeks due to central compensation

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21
Q

Associated sx with central cause of vertigo?

A

Neurologic sx: diplopia, vision loss, unilateral weakness, dysarthria, ataxia

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22
Q

What is likely dx with vertigo lasting minutes to hours, associated with fluctuating hearing loss, tinnitus and aural pressure?

A

Meniere’s disease

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23
Q

What is likely dx with vertigo lasting <1min, initiated by change in head position, no other otological findings?

A

BPPV

- Epley maneuver can be therapeutic

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24
Q

Tumarkin crisis

A
  • sudden falls occurring without warning and without LOC

- associated with Meniere’s disease

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25
Q

Peripheral vs. central vertigo

A

nystagmus

  • peripheral = horizontal, never vertical; never reverses direction
  • central = vertical or horizontal; can reverse direction with change of gaze direction

neurologic sx

  • peripheral = absent
  • central = common

otologic sx

  • peripheral = common
  • central = absent

time course

  • peripheral = abrupt onset/offset, never continuous due to central compensation
  • central = tends to be continuous
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26
Q

Dix-Hallpike maneuver

A
  • pt head rotated 45 degrees to one side, quickly lay pt down with head over edge of bed
  • hold position at least 30sec and note presence of vertigo and nystagmus
  • bring pt upright and repeat maneuver opposite side
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27
Q

Special tests for vertigo - ENG

A

ENG
- caloric testing (ear irrigated with cold and hot water)
-> nystagmus caused by cold water is toward opposite ear; hot water causes nystagmus towards same ear
(COWS - cold opposite, warm same)

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28
Q

Vestibular neuronitis

A
  • vertigo hr to days, viral prodrome, no hearing loss
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29
Q

Labrynthitis

A
  • vertigo lasting days to weeks
  • viral or bacterial prodrome
  • unilateral hearing loss

CT head if intracranial infection suspected, blood work if indicated

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30
Q

Medications to suppress vertigo in acute attack?

A
  • betahistine (BPPV, Menieres)
  • antihistamines (meclizine, dimenhydrinate)
  • anticholinergics (scopolamine)
  • benzodiazepines (anxiety sx too)
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31
Q

Tx Menieres disease

A
  • salt restriction
  • thiazide diuretic
  • intratympanic steroids
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32
Q

Epistaxis

A

bleeding from nasal cavity

  • primary = due to local factors affecting nasal mucosa/ vascular tissue
  • secondary = coaglopathic or ‘medical epistaxis’
  • posterior epistaxis = bleeding that fails routine anterior packing or direct therapy to anterior septum
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33
Q

What is blood supply to anterior septum?

A

Kiesselbach’s plexus = little’s area

- septal branch of superior labial artery, greater palatine artery and anterior ethmoid artery

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34
Q

Blood supply to posterior septum?

A

Woodruff’s plexus

  • sphenopalatine artery and posterior ethmoidal artery
  • more severe, more difficult to control
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35
Q

Treatment minor bleeding

A
  • local cautery
  • bactriban ointment
  • tranexamic gel
  • nasopore
  • > bactriban or nasogel or rhinaris x6 wk
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36
Q

Treatment significant bleeding

A
  • merocels in each name
  • vaseline gauze in each nare
  • posterior packing and vaseline gauze
    + keflex or ancef
    + otrivin 0.1%
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37
Q

Post-expistaxis treatment

A
  • saline irrigation, humidified air, vaseline/polysporin to anterior nares for 60d
  • bed rest/ light activity for 24-48h
  • remove rigid nasal packing (merocel) in 48-72h
  • reverse anticoagulant if indicated
38
Q

Tinnitus

A
  • perception of sound in absence of external auditory stimulus
    subjective - only pt can hear noise
    objective - sound can also be heard by examiner (rare); cause by para-auditory structure
39
Q

Pathophys of tinnitus

A

CNS is the generator

  • perception of tinnitus because loss of input (damage or injury to cochlea) to neutrons in central auditory pathways
  • abnormal firing of neutrons = perception of sound
40
Q

Is underlying pathology more likely in unilateral or bilateral tinnitus?

A

Unilateral

- CPA tumor, head and neck cancer

41
Q

Medications associated with tinnitus?

A

NSAIDs
ASA
ahminoglycosides
diuretics

42
Q

Most common cause of transient tinnitus?

A

Excess noise exposure

43
Q

Investigations re: tinnitus

A

Audiogram

+/- imaging (CT temporal bones or MRI) if indicated

44
Q

Common causes of hearing loss

A
  • otitis media (OME or AOM)

- cerumen impaction, presbycusis (SNHL)

45
Q

Sound wave transmission

A

external auditory canal -> TM -> vibration ossicles -> oval window -> cochlea -> hair cells displaced -> neuronal activity -> CN VIII -> primary auditory cortex (temporal lobe)

46
Q

What is the end organ of hearing?

A

Cochlea

47
Q

Compartments of cochlea (fluid-filled)?

A

organ of Corti

  • auditory hair cells
  • middle compartment of cochlea
48
Q

Where is primary auditory cortex?

A

Temporal lobe

49
Q

CHL?

A

interference of sound wave transmission from external auditory canal to cochlea
- defect in external or middle ear

50
Q

SNHL

A
  • defect of cochlea or auditory neural pathways
51
Q

Ototoxic medications

A

aminoglycosides
chemotherapy agents
loop diuretics

52
Q

Likely dx in elderly pt with progressive HL and specific difficulty with speech discrimination in setting of loud background noises?

A

Presbycusis

53
Q

Sudden SSNL

A
  • sudden onset unilateral HL with normal exam
  • immediate tx with steroids and antivirals
  • refer ENT
54
Q

Rinne test

A

512 Hz tuning fork

  • press against mastoid process to test BC
  • place beside external auditory canal to test AC

AC louder than BC = normal hearing to SNHL
BC > AC = CHL

55
Q

Weber test

A

512 Hz tuning fork

  • hold on vertex of head
  • pt asked if sound heard centrally or materializes

laterializes toward ear with CHL
lateralizes away from SNHL

56
Q

HL investigations

A

audiogram

+/- CT temporal bones/ imaging if suspect pathology

57
Q

Audiogram air-bone gap

A

Difference between AC and BC

- >15 dB = CHL

58
Q

Most common pathogens responsible for sore throat?

A

adenovirus
EBV
GAS

59
Q

Complications GAS?

A

glomerulonephritis

rheumatic fever

60
Q

Centor criteria re: GAS pharyngitis

A 
cough absent - 1
fever >38 - 1
tonsillar exudates - 1
swollen, tender anterior nodes - 1
age 3-14 - 1
age 15-44 - 0
age >45 - -1

score
0-1 = no culture or abx
2-3= culture, abx only if culture +
>4 = culture, treat with abx, d/c abx if culture -

61
Q

Idiopathic or vasomotor rhinitis

A
  • watery nasal discharge and intermittent congestion induced by nonspecific irritants (temperature changes, spicy food)
62
Q

What can lead to nasal obstruction, facial pain, and purulent nasal discharge?

A

Sinusitis

63
Q

Initial screen for GAS

A

RADT - rapid antigen detection test
- specificity >95%
- sensitivity 65-90%
(10-35% false negative -> if negative culture)

64
Q

Post-strep glomerulonephritis

A
  • elevated antistreptolysin O quantitative titer

- RBC casts on urinalysis

65
Q

Acute rheumatic fever

A
  • clinical dx based on antecedent pharyngeal GAS infection and Jones criteria (2major or 1major and 2 minor)

Jones criteria

  • major criteria: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules
  • minor criteria: arthralgia, fever, elevated ESRm elevated CRP, prolonged PR interval on ECG
66
Q

What is Jones criteria used to dx?

A

Rheumatic fever

Jones criteria

  • major criteria: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules
  • minor criteria: arthralgia, fever, elevated ESRm elevated CRP, prolonged PR interval on ECG
67
Q

GAS pharyngitis tx

A
  • Penicillin V in adults
  • Amoxicillin in kids
    x10d
    -> prevent rheumatic fever but don’t reduce incidence of glomerulonephritis
68
Q

Is total loss of taste common?

A

No because of neural cross-innervation

69
Q

Disorders of taste/smell

A

conductive vs. sensorineural

conductive - odor can’t reach olfactory epithelium because of nasal obstruction
sensorineural - central neural structures cannot interpret neural transmission

70
Q

What are taste buds?

A
  • globular clusters of cells on the tongue papillae containing microvilli within a taste pore
71
Q

Innervation tongue

A 
CN IX (glossopharyngeal) - taste and general sensation to posterior third of tongue
CNVII (chorda tympani nerve br) supplies taste to anterior two-thirds of tongue
72
Q

Olfactory innervation

A

CN I - olfactory nerve

- olfactory receptors located on cruciform plate are carried to brain via CN I

73
Q

Neoplastic red flag sx with smell and taste dysfunction

A
  • dysphagia
  • odynophagia
  • otalgia
  • voice change
  • fever/chills/wt loss
74
Q

Investigation of neurologic sx with small and taste dysfunction?

A

MRI - r/o intracranial pathology (tumor, stroke)

75
Q

Investigation chronic nasal obstruction and purulent d/c?

A

CT paranasal sinuses - evaluate sinusitis, polyps or intranasal mass

76
Q

Samter triad?

A

for aspirin-sensitive asthma

  • nasal polyps
  • asthma
  • ASA sensitivity
77
Q

Nasal congestion or polyposis tx?

A

intranasal corticosteroid spray

78
Q

Acute sinusitis tx?

A

abx

saline irrigation

79
Q

2 main types of dental infections?

A
  • dental caries: caused by bacteria within plaques which produce acid -> demineralizes enamel -> bacteria invade pulp
  • periodontal disease: bacterial plaques within gingival margin -> infection of gums, ligaments and bones that support teeth
80
Q

Inv dental infection/ pathology?

A

panorex X-ray

CT soft tissue neck with contrast if lesions suspicious for malignancy or deep neck space infection

81
Q

Main bacterial pathogens?

A

S. mutant and serotypes

- lactobacilli are progressive (acid-producing)

82
Q

Tx dental infection?

A

Abx - penicillin, ampicillin-sulbactam, clindamycin

83
Q

Presentation of odontogenic abscess/ deep neck space infection?

A

neck swelling
trismus
hoarseness
stridor

84
Q

Anatomical triangles of the neck?

A

Anterior cervical triangle - midline of neck to posterior border of SCM to inferior border of mandible
- submandibular, submental, carotid, muscular triangles

Posterior cervical triangle - clavicle to posterior border SCM to anterior border trapezius

  • occipital and supraclavicular triangles
  • important structures: pleural apices, phrenic n, brachial plexus trunks, subclavian artery and vein, spinal accessory n
85
Q

LN levels

A

Level I = submittal and submandibular nodes
Level II = cervical nodes from skull base to level of hyoid
Level III = cervical nodes from level of hyoid bone to inferior border of cricoid
Level IV = cervical nodes from inferior border of cricoid to root of neck
Level V = posterior triangle
Level VI = central compartment LN bounded by carotids, hyoid and suprasternal notch

86
Q

Ddx neck masses

A

Congenital

  • branchial cleft cyst
  • thyroglossal duct cyst
  • lymphatic malformation
  • teratoma/ dermoid cyst
  • external laryngocele
Infectious/inflammatory/systemic
- bacterial/viral lymphadenitis
- TB
- sebaceous cyst
- abscess
- Kawasaki disease
- catch scratch
etc.

Endocrine

  • thyroid hyperplasia
  • thymic cyst
  • parathyroid cyst

Neoplastic

  • metastatic or regional malignancy
  • thyroid neoplasm
  • lymphoma
  • salivary gland tumor
  • lipoma
  • vascular/neurogenic tumor
  • hemangioma
87
Q

What is likely if neck mass rises with swallowing?

A

thyroid

88
Q

What is likely if neck mass rises with tongue protrusion?

A

thyroglossal duct cyst

89
Q

FNA vs open biopsy neck mass

A

FNA - thyroid

Open biopsy - lymphoma suspected

90
Q

Investigations for neck mass

A

depends on likely ddx

MCC Part 1 (22 decks)

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