Otolaryngology Flashcards
AOM: presentation, Hx, PEx, mgmt
Presentation: fever, irritability, ear tugging, recent URTI.
Hx: Duration of illness, ear d/c, previous ear infections, oral intake.
PEx: bulging TM, yellow opacity.
No investigations.
Mgmt: Analgesics and antipyretics. majority are self-limited. If >2 yrs and uncomplicated AOM, can watch and wait for 48-72 hrs and if no resolution, give amox.
If >2yrs: 40 mg/kg amox x5 days, <2 yrs, x20d.
Tx of + consequences of current AOM/prolonged OME
Recurrent: 3 episodes of AOM in 6 months or 4 in 12.
Can give abx prophylaxis.
Do tympanogram/pure audiogram to r/o hearing loss/language development problem.
May require hearing aids.
Indications for ventilation tubes:
1) Prolonged (>3 mo) OME w/ documented hearing loss.
2) Prolonged OME in kids with developmental difficulties.
Otitis externa: presentation, Hx, PEx, Mgmt
Presentation: ear pain, plugging.
Hx: other ear symptoms (hearing loss, tinnitus, vertigo, aural fullness, otorrhea), fever, recent URTI, Hx DM (assoc increased risk of infxn to ear canal–> malignant otitis externa!), trauma, recent swimming, barotrauma. Previous episodes.
PEx: extreme pain with manipulation of pinna and external auditory canal. Inflamed early canal (swollen with white debris).
No investigations but do C+S if no response to initial tx.
Mgmt: Aural toilet (suction/remove d/c, don't use water b/c makes infection worse). Topical drops: Ciprodex (tx's pseudomonas, staph aureus), keep ear dry, avoid Q tips, use ear wick for severely swollen canal.
Differentiate between conductive hearing loss and sensorineural hearing loss
conductive: problem in the middle or outer ear.
Sensorineural: damage to hair cells, cochlear nerve or CNS.
Mixed: both conductive and sensorineural possible
How does the Rinne test work?
Place tuning fork on mastoid, once the pt no longer hears the sound, move the tuning fork to air in from of auditory canal until pt no longer hears sound.
Normal hearing: air conduction > bone conduction. I.e. hear sound at pinna after they can no longer hear at mastoid.
Conductive loss: bone conduction > air conduction. Unable to hear post-mastoid.
Sensorineural: bone and air conduction both equally decreased.
How does the Weber test work?
Place tuning fork in the middle of the forehead/top of the head (in contact with bone) -> ask which ear the sound is heard louder in.
Normal/symmetric hearing loss: equal both ears.
Defective ear hears louder: conductive hearing loss.
Normal ear hears louder: sensorineural loss in quiet ear.
Important questions on history for pt complaining of hearing loss.
Ear symptoms: progressive vs fluctuating hearing loss, unilateral vs bilateral loss, tinnitus, vertigo, aural fullness, otalgia, otorrhea.
Trauma, previous surgery, recent infections.
Ototoxic meds (gentamicin, cisplatin).
Noise exposure.
FamHx of hearing loss.
PEx for hearing loss (2)
Clinical voice test.
Weber and Rinne.
Describe how to interpret an audiogram
X axis = frequency, Y axis is dB lost.
Plot air conduction response (O=R, X=L) and bone conduction response ( [ = R, ] = L) for each ear.
If air and bone conduction curves decrease together for same ear: sensorineural hearing loss.
If air conduction drops > bone conduction: conductive loss for that ear.
When conducting test, need to mask one ear to ensure sound is heard only by other ear (often play white noise).
DDx for conductive hearing loss
External canal:
1) Cerumen impaction,
2) Severe otitis externa,
3) Stenosis of canal,
4) Masses.
Middle ear:
1) Otitis media (acute or chronic),
2) Tympanic perforation,
3) Cholesteatoma,
4) Otosclerosis: F>M, worse with pregnancy, does not cause scarring. Relatively uncommon (fluoridated H2O protective),
5) Ossicular fixation: ask about hx infxns in childhood.
6) ossicular discontinuity.
DDx for sensorineural hearing loss
1) Noise induced: hx noise exposure, progressively affecting lower and higher frequencies.
2) Presbycusis: loss of high frequency sounds.
3) Genetic causes.
4) Ototoxicity: e.g. cytotoxic meds/anti-metabolites, aminoglycosides.
5) Acoustic neuroma: suspect if sudden hearing loss, start steroids urgently.
6) Vestibular schwannoma.
Mgmt of conductive hearing loss
Ongoing observation.
Trial of amplification (hearing aid).
Surgical: stapedotomy if air-bone gap >30dB (however, risk of losing all hearing and balance fxn).
Mgmt of sensorineural hearing loss
Ongoing observation, hearing protection, trial of amplification (aid)
What is an acoustic neuroma, how is it managed?
Schwannoma of the vestibular portion of CN 8.
Presents with acute sensorineural hearing loss or tinnitus (if a pt presents like this, consider neuroma until proven otherwise).
If elderly, unilateral tinnitus or SNHL = neuroma until proven otherwise.
Start steroids ASAP for acute SNHL, do MRI to look for neuroma.
Surgically excise tumor
Define tinnitus
auditory perception in the absence of acoustic stimuli. Loss of input to neurons in central auditory pathways –> abnormal firing.
What are the RF for tinnitus?
Loud noise exposure, older age, male, smoking history, CVD.
Most commonly associated with SNHL.
If elderly person presenting with new tinnitus/SNHL, r/o acoustic neuroma.
Definition of vertigo
Illusion of rotational, liner or tilting movement of self or environment.
Difference between peripheral and central vertigo.
Peripheral = inner ear problem. Presents with otolgic symptoms (hearing loss, tinnitus, aural pressure, pain discharge), nystagmus and vertigo last for a couple of weeks only.
Central = CNS problem. neurological symptoms common. Pt will have persistent nystagmus and vertigo.
Etiology of non-vertiginous dizziness
Organic: cardiac, vasovagal, hypoTN, anemia, visual impairment.
Functional: depression, anxiety, panic, personality disorder
Important Q’s on Hx for vertigo
Duration, otologic symptoms (hearing loss, tinnitus, aural pressure, pain, discharge), aggravating and alleviating factors (e.g. head position), head trauma, n/v.
Important parts of PEx for vertigo
ENT exam.
Neuro-otologic exam: spontaneous or gaze-evoked nystagmus, CN exam, cerebellar testing + Romberg, gait, Fukuda step test, head thrust or shake.
Neurologic exam.
Describe benign paroxysmal positional vertigo
Acute attacks of transient rotatory vertigo that lasts for seconds to minutes.
Initiated by certain head positions.
Caused by ‘canalithiasis,’ i.e. migration of free floating otoliths in the endolymph.
PEx:
1) Dix-Hallpike maneuver: have pt sit upright, rotate head 45* to one side then lie the pt down quickly with head hanging off the table. Observe the eyes for 45s, looking for nystagmus.
If you see rotational nystagmus, this is +ve for BPPV. Geotropic = fast phase toward floor. Reversal = sit back up and nystagmus reverses for brief time.
(If there is up or downbeating nystagmus, indicates CNS dysfunction).
Mgmt:
Self-limited, improves over weeks to months.
Can try the ‘Epley maneuver,’ particle repositioning to try to move otoliths in the canals to alleviate vertigo.
Medications not helpful.
Describe acute vestibulopathy
Caused by viral infection.
Acute onset of spontaneous vertigo w/ n/v that usually resolves after 1-2 days. May have residual motion induced vertigo that lasts 1-2 weeks. Progressively improved motion tolerance after this.
No hearing loss.
PEx: look for spontaneous unidirectional nystagmus (fast to affected ear).
No investigations needed, need to exclude CNS or other vestibular pathology.
Mgmt with anti-emetics, early return to physical activity.
Describe Meniere’s disease
Caused by accumulation of endolymph with inadequate reabsorption.
Presents with acute attacks of vertigo, otologic symptoms (tinnitus, aural fullness, hearing loss). Attacks last for minutes to hours.
Audiogram will show hearing loss during episodes with recovery in between. Hearing loss becomes permanent and progressive between episodes. Lower frequencies affected first.
Mgmt:
1) lifestyle modification: low salt, no caffeine/alcohol.
2) Meds: systemic (diuretics, vestibular sedative- betahistine), intra-tympanic (steroids, gentamicin ablation).
3) Surgical: ventilation tube, endolymphatic sac surgery, vestibular neurectomy.
What are the 4 paranasal sinuses, what is their function?
Frontal, ethmoid, maxillary and sphenoid sinuses. Only ethmoid and maxillary sinuses present at birth (the rest develop by age 20 yrs).
Functions:
1) Clean, humidify, moisturize and warm air entering nose.
2) Small, mucous production, immunoprotection, voice resonation.
What is the ostiomeatal complex?
Common drainage pathway for anterior ethmoid, maxillary and frontal sinuses. Area for adequate sinus ventilation.
What is sinusitis, describe the pathophys
What: sinus inflammation that often follows a viral URTI or allergic reactions.
Congestion of sinus ostia may predispose to acute sinusitis.
Closed ostium causes mucosal congestion that blocks airflow and drainage. Results in stagnant secretions -> tissue inflammation -> bacterial infection -> further mucus.
Most common pathogens: strep pneumo, haemophilus influenza, M catarrhalis.
How to diagnose acute sinusitis
URTI that doesn’t resolve in 7 days with worsening symptoms.
Only 2% of viral URTIs will cause acute sinusitis, once >7d, greater likelihood the infection is bacterial.
Symptoms are non-specific and similar to viral URTI’s however viral usually resolves within 5 days.
Diagnosis: 7d w/o symptom improvement or worsening PLUS PODS symptoms:
1) Pain/Pressure/fullness.
2) nasal Obstruction.
3) Discharge: nasal purulence, discolored postnasal d/c.
4) Smell disrupted (anosmia, hyposmia).
Must have obstruction or purulence AND at least 1 other symptom.
On PEx: erythematous, edematous nasal mucosa, purulent d/c, tender sinus. Can percuss face to look for tenderness, fullness.
Investigations for acute sinusitis
imaging is NOT needed (only done if dx is unclear). If XR is done, can look for air-fluid level (only seen if ACUTE sinusitis, not present in chronic).
Anterior rhinoscopy: use nasal speculum _ headlight. Can look for septal deviation and obstruction. Look for polyps or purulence at middle meatus.
Complications of acute sinusitis requiring urgent referral.
1) Orbital abscess: periorbital erythema, edema, vision compromise.
2) Cavernous sinus thrombosis: visual loss, pain, sick.
3) Intracranial abscess.
4) Death
Treatment of acute sinusitis
Antibiotics + nasal steroids + ancillary measures.
Abx: target strep pneumo, H influenza, M catarrhalis +/- anaerobes, grame negs. Give for 10-14 days.
1st line: amoxicillin (1g TID) if moderate-severe sinusitis.
Topical intra-nasal steroids to alleivate inflammation.
Non-medical mgmt: aim to reduce inflammation, congestion. Provide saline irrigation, nasal steaming, increase water intake, redue dehydrating agents (coffee, EtOH), manuka honey sinus rinse.
Important to treat acute sinusitis early before it develops into chronic sinusitis which is harder to tx.
AVOID: oral steroids, decongestants (no reduction in severity/duration and cause cardiac stress), antihistamines (thicken mucus and do not reduce inflammation).
Time frame at which acute sinusitis –> chronic
URTI >12 weeks without resolution.
SS of chronic sinusitis
Postnasal d/c, full pressure type HA, fatigue, cough, asthma symptoms, ‘cold not going away.’
PEx: edematous nasal mucosa, no nasal discharge, percussion of sinus normal.
Imaging for chronic sinusitis
Typically NOT indicated. Sinus CT (coronal) can be done if questionable diagnosis or poor response to tx. Purpose is to look at underlying chronic pathology and anatomical detail. May see mucosal thickening, opacification, anatomic abnormalities. Indicated if medical therapy fails (4-6 wks after completion tx).
Not due for acute sinusitis!!
Anterior rhinoscopy can be done but if the dx is chronic sinusitis, there will be nothing to see.
Tx for chronic sinusitis
Antibiotics: amoxi-clav, clinda or fluoroquinolones. Tx x3-6 wks prior to imaging.
Medical therapy often fails.
Unlike acute, topical nasal steroids not very helpful.
Mucolytics: guaifenesin to thin mucus secretions and improve drainage.
Surgery: only after failure of exhaustive and maximal medical therapy. Can use computer assisted sinus surgery to enlarge natural sinus openings and create better drainage pathways.
Symptoms of nasal obstruction
Breathing difficulty, mouth breathing, decreased sense of smell/taste, no seasonal variation, no sneezing/itching or discharge.
Investigations and what to look for with symptoms of nasal obstruction
ENT physical.
Anterior rhinoscopy to look for nasal masses, nasal septum deviation, turbinate swelling, enlarged adenoids.
Describe nasal polyposis
Associated with allergies 50% of the time.
If present in children, suspect CF (otherwise are uncommon in this age bracket).
Investigations not initially required- sinus CT if planning surgery.
Mgmt: often recur.
Tx allergies if that is the underlying cause.
Steroids: oral steroids to shrink polyps before surgery. Can also give topical nasal steroids.
Surgery: polypectomy or endoscopic sinus surgery.
Allergic rhinits: what, SS, investigations, mgmt
IgE mediated hypersensitivity to foreign allergens.
SS: rhinorrhea/post-nasal drip, frequent sneezing (thin, clear, nasal d/c), severe nasal obstruction (worse supine), itchy/watery eyes, variation with season.
On PEx:
ENT exam shows bluish/pale, edematous nasal mucosa with clear d/c.
Allergic shiners (under eyes from lower eyelid venous stasis due to congestion).
Allergic salute (crease in nose from stroking nasal tip).
Conjunctival injection.
Investigations: allergy testing.
Mgmt: antigen avoidance, antihistamines, nasal saline lavage, nasal steroid spray. AVOID decongestants (cause rebound congestion if used longer than 5d which can cause nasal obstruction).
Important Q’s on hx for epistaxis
Duration/volume of bleeding, precipitating factors, frequency, nasal trauma/obstruction, cocaine use, hx of bleeding disorder, medications (anticoagulants, nasal sprays), nasal dryness (aggravates anterior nose bleeds).
Ask about SS posterior epistaxis: blood going down throat, heavy bleeding, hard to see up nose, elderly.
Important parts of PEx for epistaxis
look at nasal mucosa, septum. Look at Little’s area (anterior nasal septum where Kisselbach’s plexus is).
Look for intranasal masses and view the oropharynx.
If indicated, do INR/PTT, CBC
Mgmt of anterior epistaxis
Nasal lubricant (most important! Need to keep tissues moist).
Cautery with silver nitrate, electrocautery (but avoid bilateral septal cauterization b/c can cause septal perforation cia tissue necrosis).
Packing for diffuse active bleeding or uncontrolled by cautery. ANterior pack with vaseline from nasal floor toward nasal roof for 2-3 days. Gauze or nasal tampon.
Mgmt of posterior epistaxis
Posterior packing can be done with foley catheter, gauze, balloon. Admit to hospital with packs for 3-5 days.
Sphenopalatine artery ligation (endoscopic procedure).
Antibiotics: prevent TSS if pack in >48 hrs.
Surgery and embolization if packing fails.
What are the 3 main areas of the URT and their subcomponents
Oral cavity (ends at circumvallae papillae and oral arches).
Pharynx: nasopharynx, oropharynx, hypopharynx.
Larynx: supraglottis, glottis, subglottis.
Important parts of PEx if sore throat
Vitals, gen appearance. Pharynx (redness, swelling, asymmetry of palate, trismus, tonsils).
At neck, look for lymphadenopathy, swelling, stiffness.
Do a respiratory exam.
What is trismus?
Difficulty opening the mouth -> medial pterygoid is inflamed and creates tight/painful sensation when trying to open mouth.
Investigations/labs for sore throat
CBC + diff, monospot (heterophile antibody test), throat C+S, CT if indicated (looking for complicated or deep abscesses).
What are the limitations of the monospot (aka hetereophile Ab) test?
Only can detect Ab one week after infection has already set in (thus false negatives in 1st week). Peaks at 2-5 weeks.
85% have positive test but its not specific.
Strep pharyngitis: presentation, mgmt
Tonsil enlargement, white exudate, cervical adenopathy.
Note that most sore throats are viral thus throat swabs often helpful.
Mgmt:
1) Supportive: hydration, analgesia, saline gargles.
2) Oral abx (penicillin)
How to tx mono
Requires supportive tx plus steroids! for airway obstruction (if very enlarged tonsils).
Peritonsillar abscess: presentation + tx
Presents with unilateral symptoms and trismus. Hot potato voice, watchi for tripoding. Look for bulge in soft palate with deviation of uvula. Located behind tonsil, not swelling of tonsil itself (tonsilitis)
Tx with needle aspiration or I+D. Give abx.
R/o Ca, especially if middle aged male smoker.
Define OSA and describe the etiologies
Obstruction of the airway during sleep with normal voluntary effort made to breath.
Etiologies:
1) adenotonsillar hypertrophy: may be physiologic in kids.
2) Long uvula.
3) Excessive pharyngeal folds.
4) Upper airway collapsibility/resistance.
5) obesity
6) genetics (congenital syndromes with narrow nasopharynx/mandible or large tongue).
What are the 3 types of stridor?
Inspiratory: upper airway narrowing with laryngeal obstruction.
Expiratory:
Biphasic: suggests something is happening at the vocal cords.
Functions of the larynx
Phonation, airway protection and maintenance.
Etiologies of stridor in children
1) Congenital: laryngomalacia, vocal cord paralysis, subglottic hemangioma.
2) Acquired: infection (croup, epiglottitis), subglottic stenosis, laryngeal papillomatosis, post-intubation trauma.
etiology of stridor in adults
Anaphylaxis, infection (deep neck space abscess), trauma (blunt/penetrating laryngeal trauma/inhalation injury), neoplasms.
Questions on history for stridorous pt
Hx of hoarseness, dysphagia, odynophagia, cough, hemoptysis, smoking and EtOH, wt loss.
What is laryngeal crepitus?
Normal. Move larynx from side-side and felt between cartilage and vertebrae.
If not present, consider swelling or mass that may be stopping the movement.
Investigation for prolonged hoarse voice.
Flexible laryngoscopy should be done on pt who has persistent hoarseness for >2 weeks if >40 yrs, suggestive of malignancy.
Mgmt of a laryngeal mass (and unstable)
Airway intubation: awake with flexible endoscopy or surgically with tracheotomy or cricothyroidotomy.
After airway secured, do laryngoscopy and biopsy.
What is a cricothyroidotomy?
Puncture through the cricothyroid ligament anteriorly between the thyroid cartilage and cricoid cartilage.
Assessment of a pt with neck mass suspicious for head and neck cancer.
Hx: Pain, enlargement, oral ulceration, throat pain, swallowing difficulty. Hemoptysis, cough, hoarseness. Wt loss? RF: smoking, excess drinking.
PEx: characteristic of mass (location, size, pain, fluctuance, mobility).
More likely malignant if fixed, hard, large, cystic.
Investigations: flexible endoscopy of pharynx/larynx, biopsy of tonsil, FNA of neck mass (gold standard), US/CT neck, CXR.
DDx for a neck mass
Infectious: cervical adenitis, cat scratch fever, mycobacterium.
Congenital: branchial cleft cyst, lymphatic malformation.
Neoplasm: lymphoma, head/neck cancer. Nasopharyngeal cancer (more common in Chinese, often presents with neck mass).
Neck mass in adult: assume is malignant (usually metastatic from head/neck site).
Approach to neck mass in children
Investigations: can observe/watchful waiting to start, trial of abx, US (solid vs cystic), CT if indicated.
What are branchial cleft anomalies?
Anomalies occur when…
1) branchial pouch persists as a branchial sinus.
2) Fistula develops between this pouch and groove.
3) Cyst develops if part of a groove or pouch becomes separated from the surface and does not resorb (promotes infection).
Branchial cleft cyst: Associated with URTI, get enlarged, unchanging mass with erythema. Mobile, soft, non-tender and cystic, well-circumbscribed. Requires surgical excision.
Sialadenitis: glands/nerves that can be affected.
Infection of a salivary gland.
Parotid gland: drained by Stensen’s duct lateral to the second upper molar. PSNS CN IX.
Submandibular gland: Drained by Wartan’s duct lateral to the frenulum on floor of mouth. PSNS CNVII (chorda tympani).
Sublingual gland: ducts of Rivinius drain normall.
RF: dehydration
Symptoms of sialadenitis
Erythema, pain, swelling and purulent ductal discharge from gland.
Acute sialadenitis: what, bugs, mgmt
Inflammation of gland due to infection, usually staph aureus.
No investigations initially.
Mgmt: rehydration, sialagogues to stimulate secretion (e.g. lemons), warm compress, antibiotics.
After treatment completed, consider imaging for stone (XR, US or CT). Can do sialogram where contrast is injected into gland (not used acutely)
Chronic sialadenitis: what, presentation, mgmt.
Recurrent, painful enlargement of gland caused by salivary stasis.
Usually due to duct stricture or stones.
E.g. hydroxyapatite stones in salivary duct/gland (typically submandibular), causing pain/swelling that worsens before eating.
Conservative mgmt: massage, sialogogues, hydration.
Surgery: remove gland.
Describe retropharyngeal abscesses: what, presentation, imaging, mgmt.
Supurating lymph node in the retropharyngeal space.
Presents as: ill pt, febrile, dehydrated. Dysphagia and pain +/- stridor.
Imaging:
Lateral neck XR shows marked swelling of prevertebral tissues.
CT shows location.
Mgmt: drain, maintain airway with intubation if needed.
Laryngitis
Infection of the larynx, usually due to extension of viral URTI.
Presents with: hoarse voice, laryngeal pain, irritative cough.
Laryngoscopy (if performed) shows red, swollen larynx, thickened cords, lots of mucus secretion.
Mgmt: usually self-resolving so voice rest, humidification, increased fluid intake.
Describe laryngeal SCC
RF: smoking, EtOH.
Presentation: progressive hoarse voice due to interface with vocal cords. Dyspnea, dysphagia, ear pain. May have metastatic lymphadenopathy to neck.
Laryngoscopy: raise and warty larynx.
Mgmt: RT for early tumors, laryncectomy + postop RT if complicated early tumor.
Epiglottitis: what, RF, presentation, mgmt.
Acute laryngitis with inflammation spreading to affect the epiglottis.
Typically affects kids aged 2-7, caused by H influenzae.
Presents with rapidly progressing dyspnea, inspiratory stridor. Medical emergency. Associated dysphagia, refusal to eat, drooling, dehydration, fever, tachycardia.
Mgmt: bring to OR immediately. Do not try to visualize airway as may cause resp distress. Do orotracheal intubation or tracheostomy. Visualize epiglottis, culture and give abx.
Give steroids for edema and swelling.
Extubate once edema and swelling subside.
If imaging done, look for thumbprinting of epiglottis.
Describe Bell’s palsy
Facial nerve paralysis affecting muscles of facial expression, sensation and taste to anterior 2/3 of tongue, autonomic function to salivary glands.
UMN would affect lower half of face only, LMN (Bell’s palsy) affects upper and lower half of face.
Idiopathic facial nerve paralysis: unilateral facial weakness with sudden onset that resolves. No CNS symptoms or ear disease. Can give steroids or surgically decompress the nerve.
