Otolaryngology Flashcards
Otalgia
nonspecific ear pain
- primary = pain originates within inner ear
- referred = pain originates from organ that shares sensory innervation with ear
Common causes of otalgia?
primary - otitis media and externa
secondary - dental pathology and pharyngeal infections
Nerves supplying sensory innervation to external ear?
- great auricular nerve (from cervical plexus)
- lesser occipital nerve (from cervical plexus)
- auricular branch of vegas nerve
- auriculotemperal nerve (mandibular branch of trigeminal nerve)
What supplies inner ear?
- branches of CN V, IX, X
Rapid onset of which sx in AOM?
- otalgia
- decreased hearing
- fever
Mastoiditis
- complication of AOM
- erythema and swelling over mastoid region -> clinical dx
AOM underlying etiology and pathogens
- 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
OE underlying pathogens
- pseudomonal
- r/o malignant otitis external (rapidly destructive osteomyelitis of temporal bone in immunocompromised host)
Treatment AOM
- observation and symptomatic management
- amoxicillin
- second line = amoxicillin-clavulin, second generation cephalosporin
Treatment OE
- antipseudomonal ear drops (Ciprodex)
- oral antipseudomonal abx if severe
- manual debridement or ear wick if oedematous or obstructed canal
What is vertigo
Illusion of movement, often spinning or turning of oneself or one’s environment
peripheral (vestibular system) vs. central (CNS)
What is the vestibular system?
- utricle
- saccule
- 3 semicircular canals (lateral, posterior, superior)
What detects linear acceleration?
utricle - horizontal acceleration
saccule - vertical acceleration
What detects angular acceleration?
semicircular canals
What are the otolith organs?
What occurs with displacement of otoliths?
utricle and saccule - contain calcium carbonate crystals (otoliths)
- displacement of otoliths = movement of sensory hair cells that transduce information into neural signal of movement
CNS components of motion sensing and control of balance?
cerebellum
cerebral cortex
brainstem
Ddx true vertigo -peripheral
- BPPV
- vestibular neuronitis
- labrynthitis
- Meniere disease
- ototoxicity
Ddx true vertigo - central
- CPA tumor
- CVA
- MS
- drugs (anticonvulsants, EtOH)
Ddx non vertiginous dizziness
- disequilibrium: peripheral neuropathy, visual impairment
- presyncope
- psychiatric
Will peripheral vertigo continue for weeks?
No, it is episodic and won’t continue for weeks due to central compensation
Associated sx with central cause of vertigo?
Neurologic sx: diplopia, vision loss, unilateral weakness, dysarthria, ataxia
What is likely dx with vertigo lasting minutes to hours, associated with fluctuating hearing loss, tinnitus and aural pressure?
Meniere’s disease
What is likely dx with vertigo lasting <1min, initiated by change in head position, no other otological findings?
BPPV
- Epley maneuver can be therapeutic
Tumarkin crisis
- sudden falls occurring without warning and without LOC
- associated with Meniere’s disease
Peripheral vs. central vertigo
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
Dix-Hallpike maneuver
- 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
Special tests for vertigo - ENG
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)
Vestibular neuronitis
- vertigo hr to days, viral prodrome, no hearing loss
Labrynthitis
- vertigo lasting days to weeks
- viral or bacterial prodrome
- unilateral hearing loss
CT head if intracranial infection suspected, blood work if indicated
Medications to suppress vertigo in acute attack?
- betahistine (BPPV, Menieres)
- antihistamines (meclizine, dimenhydrinate)
- anticholinergics (scopolamine)
- benzodiazepines (anxiety sx too)
Tx Menieres disease
- salt restriction
- thiazide diuretic
- intratympanic steroids
Epistaxis
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
What is blood supply to anterior septum?
Kiesselbach’s plexus = little’s area
- septal branch of superior labial artery, greater palatine artery and anterior ethmoid artery
Blood supply to posterior septum?
Woodruff’s plexus
- sphenopalatine artery and posterior ethmoidal artery
- more severe, more difficult to control
Treatment minor bleeding
- local cautery
- bactriban ointment
- tranexamic gel
- nasopore
- > bactriban or nasogel or rhinaris x6 wk
Treatment significant bleeding
- merocels in each name
- vaseline gauze in each nare
- posterior packing and vaseline gauze
+ keflex or ancef
+ otrivin 0.1%
Post-expistaxis treatment
- 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
Tinnitus
- 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
Pathophys of tinnitus
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
Is underlying pathology more likely in unilateral or bilateral tinnitus?
Unilateral
- CPA tumor, head and neck cancer
Medications associated with tinnitus?
NSAIDs
ASA
ahminoglycosides
diuretics
Most common cause of transient tinnitus?
Excess noise exposure
Investigations re: tinnitus
Audiogram
+/- imaging (CT temporal bones or MRI) if indicated
Common causes of hearing loss
- otitis media (OME or AOM)
- cerumen impaction, presbycusis (SNHL)
Sound wave transmission
external auditory canal -> TM -> vibration ossicles -> oval window -> cochlea -> hair cells displaced -> neuronal activity -> CN VIII -> primary auditory cortex (temporal lobe)
What is the end organ of hearing?
Cochlea
Compartments of cochlea (fluid-filled)?
organ of Corti
- auditory hair cells
- middle compartment of cochlea
Where is primary auditory cortex?
Temporal lobe
CHL?
interference of sound wave transmission from external auditory canal to cochlea
- defect in external or middle ear
SNHL
- defect of cochlea or auditory neural pathways
Ototoxic medications
aminoglycosides
chemotherapy agents
loop diuretics
Likely dx in elderly pt with progressive HL and specific difficulty with speech discrimination in setting of loud background noises?
Presbycusis
Sudden SSNL
- sudden onset unilateral HL with normal exam
- immediate tx with steroids and antivirals
- refer ENT
Rinne test
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
Weber test
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
HL investigations
audiogram
+/- CT temporal bones/ imaging if suspect pathology
Audiogram air-bone gap
Difference between AC and BC
- >15 dB = CHL
Most common pathogens responsible for sore throat?
adenovirus
EBV
GAS
Complications GAS?
glomerulonephritis
rheumatic fever
Centor criteria re: GAS pharyngitis
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 -
Idiopathic or vasomotor rhinitis
- watery nasal discharge and intermittent congestion induced by nonspecific irritants (temperature changes, spicy food)
What can lead to nasal obstruction, facial pain, and purulent nasal discharge?
Sinusitis
Initial screen for GAS
RADT - rapid antigen detection test
- specificity >95%
- sensitivity 65-90%
(10-35% false negative -> if negative culture)
Post-strep glomerulonephritis
- elevated antistreptolysin O quantitative titer
- RBC casts on urinalysis
Acute rheumatic fever
- 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
What is Jones criteria used to dx?
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
GAS pharyngitis tx
- Penicillin V in adults
- Amoxicillin in kids
x10d
-> prevent rheumatic fever but don’t reduce incidence of glomerulonephritis
Is total loss of taste common?
No because of neural cross-innervation
Disorders of taste/smell
conductive vs. sensorineural
conductive - odor can’t reach olfactory epithelium because of nasal obstruction
sensorineural - central neural structures cannot interpret neural transmission
What are taste buds?
- globular clusters of cells on the tongue papillae containing microvilli within a taste pore
Innervation tongue
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
Olfactory innervation
CN I - olfactory nerve
- olfactory receptors located on cruciform plate are carried to brain via CN I
Neoplastic red flag sx with smell and taste dysfunction
- dysphagia
- odynophagia
- otalgia
- voice change
- fever/chills/wt loss
Investigation of neurologic sx with small and taste dysfunction?
MRI - r/o intracranial pathology (tumor, stroke)
Investigation chronic nasal obstruction and purulent d/c?
CT paranasal sinuses - evaluate sinusitis, polyps or intranasal mass
Samter triad?
for aspirin-sensitive asthma
- nasal polyps
- asthma
- ASA sensitivity
Nasal congestion or polyposis tx?
intranasal corticosteroid spray
Acute sinusitis tx?
abx
saline irrigation
2 main types of dental infections?
- 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
Inv dental infection/ pathology?
panorex X-ray
CT soft tissue neck with contrast if lesions suspicious for malignancy or deep neck space infection
Main bacterial pathogens?
S. mutant and serotypes
- lactobacilli are progressive (acid-producing)
Tx dental infection?
Abx - penicillin, ampicillin-sulbactam, clindamycin
Presentation of odontogenic abscess/ deep neck space infection?
neck swelling
trismus
hoarseness
stridor
Anatomical triangles of the neck?
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
LN levels
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
Ddx neck masses
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
What is likely if neck mass rises with swallowing?
thyroid
What is likely if neck mass rises with tongue protrusion?
thyroglossal duct cyst
FNA vs open biopsy neck mass
FNA - thyroid
Open biopsy - lymphoma suspected
Investigations for neck mass
depends on likely ddx
