Otorrino 2 Flashcards
In the audio logic testing, what structures does physiologic measures evaluate?
Middle ear, cochlear and retro cochlear status
What test does physiologic measures has?
- otoacoustic emissions testing for peripheral auditory status (OAE)
- Tympanometry
- acoustic reflex
What does electrophysiologic testing evaluates
Peripheral auditory function and auditory nervous system function
Involuntary Reflex caused by a strong contraction of the stapedius muscle, which is detonated by loud noises in order to protect the ear
Acoustic or stapedius reflex
Three tests that audiologic testing comprises, and which ones are behavioral and objective
Behavioral tests: hearing sensitivity, and speech recognition like audiometry
Objective tests: physiologic measures en electrophysiologic, for example, tympanometry, acoustic reflex, auditory brainstem, response, etc.
Introduction of noise to the non-test ear during a pure tone Audiogram with white noise to prevent crossover, usually done to identify asymmetric hearing loss 
Masking
Test in which you put the patient in a Cavan to measure volume and frequency starting on the healthiest year
Puretone audiogram
Symbols of the audiogram
Right - red
< - bone conduction
O - air conduction
Left - blue
> - bone conduction
X - air conduction
Bone conduction can be below the air conduction on the audiometry
Force bone conduction must be above air conduction
How to classify the audiometry based on the hearing loss patterns
Conductive
AC >25
BC <25
ABG >10
Sensory neural
AC >25
BC >25
ABG <10
Mixed
AC >25
BC >25
ABG >10
How do you classification the magnitude of hearing loss and how many types are there?
Base of the Puretone average adding the threshold where is the AC symbol, falls in 500 1000 and 2000 Hz and dividing by 3
Mild 25 to 40
moderate 40 to 55
Moderate severe 55 to 70
Severe 70 to 90
Profound more than 90 
What type of pathologies can cause a conductive hearing loss
otitis media, earwax, Tim panic membrane rupture, foreign body 
What type of pathologies can calls sensory neural hearing loss
Presbiacusy, ototoxicity, tumors, trauma
This test represents the lowest intensity, at which the patient can correctly repeat half of the spondaic words or other speech, stimuli
Speech audiometry
Types of test done in pediatric patients for audiology testing
<6 months: behavioral observation audiometry
6 months - 2.5 years: visual reinforcement audiometry
2.5 to 4 years: play audiometry
Test that measures of movement of the membrane by sealing the ear canal, pumping air and causing movement 
Tympanometry 
Normal tympanometry threshold’s
DaPa > -50
MmHg 0.5-1.3
Types of tympanometry patterns
Type A = sensorineural HL
Normal parameters
Type As = otoesclerosis
DaPa normal
mmHg <0.5
Type Ad = osicular chain luxation
DaPa normal
mmHg >1.3
Type B = otitis media/conductive HL y perforación
DaPa x
mmHg x
Type C = eustaquian tube disfunction (adenoid, rhinitis)
DaPa < -50
mmHg normal
Nerve In Charge Of Moving stapedius muscle and, tympanic muscle
Stapedius- facial nerve
Tympanic - trigeminus
Where is the place where the vestibular nerve crosses in the brain stem
Medial superior olive nucleus 
Causes of an absent acoustics reflex threshold
Conductive hearing loss
Sensory neural hearing loss above 50 dB
Nerve lesion
Stapedius lesion
Acoustic admittance testing is useful for the detection of middle ear, effusion in pediatric population. True or false
True
Screening test used to track the movement of the outer cells. Useful in detection of hearing disorders, ototoxicity and retro cochlear pathology.
Oto acoustic emissions
Anatomical site, which contains the tectorial membrane that causes the movement of the Celia, particularly external cilia
Corti organ
Tool for recording the very early latency vote potential’s from the cochlea and distal auditory nerve
Electrocochleograpgy
Test in which you put an electrode before head over there in the mastoid to measure evoked potential. Useful in babies, patients with palsy, autism, that can’t cooperate with audiometry. 
Auditory brainstem response
Parts of the pinna
Helix
Antihelix
Anti-tragus
Tragus
Lobule
Narrowest point of the external ear canal
Bony cartilaginous Junction
First third is cartilage and the second and third is bony structure
Ear epithelium
Stratified squamous
Which one of the following nerves doesn’t give innervation to the ear
Trigeminal facial Vegas, spinal or great auricular nerve
Spinal
Artery that gives irrigation to the medial ear canal and timpani membrane
Maxillary artery
Unilateral malformation’s present at birth classified with the Marx system
Microtia 
What grade of microtia that’s no recognizable landmarks of the pinna and has a peanut shape
3
Grade of microtia, when there’s a mild deformity, with a dysmorphic helix, and anti-helix
1
The absence of the external ear is called
Anotia or grade 4 microtia
Which type of hearing loss do patients with microtia present
Conductive hearing loss detected with auditory brainstem response
Is caused by the lack of antihelix fold in prominence of concha bowl
Protruding ears
Neck masses among the branchial, cleft anomalies associated with infection, and present with pain and swelling
First branchial Cleft anomalies
Accumulation of blood in the subpericondral space secondary to blunt trauma
Auricular hematoma
Pathology the presents with otalgia, otorrhea, hearing loss and tragus sign
Often caused by pseudomonas and S Aureus
Otitis externa
Inflammatory process of the EAC due to infection with fungi
Otomicosis
Pathology that presents usually with facial palsy, Otorrhea
In the otoscopy, you can see a granulation tissue
Skull base osteomielitis
Hypersensitivity that causes contact dermatitis
Type 4
Most common malignant neoplasm in the ear
Basal cell carcinoma 
Growth of the lamellar bone common in surfers
Exostosis
The middle ear cleft comprises 3 contiguous components:
eustachian tube,
the tympanic cavity (middle ear)
the mastoid air cells (antrum is the biggest cell)
Mucosa inflammation in absence of effusion caused by an infection which causes bulging
* Upper respiratory infection prior
* Otoscopy: Hyperemia, Purulent secretion posterior to the membrane
* Fever
ACUTE OTITIS MEDIA
common pathogens for otitis media
H. Influenzae, S. Pneumoniae, Moraxella catharalis
Intracranial OM complications
4
- Meningitis
- Otitic hydrocephalus
- Abscess
- Sigmoid sinus thrombophlebitis
Increased intracranial pressure secondary to AO or OME.
* Headaches, lethargy, and papilledema
* no meningeal signs or evidence of intracranial abscess
Otitic hydrocephalus
OM complication in which Patients present classically with diurnal or “picket fence” fever curves, septicemia, and torticollis.
Sigmoid sinus thrombophlebitis
OM complications (no intracraneal)
5
- Tympanic perforation
- Mastoiditis - Bezold abscess (sternocleoidmastoid)
- Petrous apicitis- Gradenigo syndrome
- Facial nerve palsy - indicator of tx with tympanostomy tubes
- Labyrinthitis - mixed hearing loss and Vertigus
Ephitelium of middle ears forms sterile liquid (mucous or secretion); common in children (manifested with speech delay or need to much volume to hear)
* Asymptomatic
* NOT painful
* Aural fullness
* Hearing loss
Otoscopy: liquid with air bubbles
OM with effusion
OE complications
4
- Conductive hearing loss
- Speech delay
- Atelectasis
- Choleastoma
Complication in medium ear that can expand locally destroying nearby structures, leading to serious long-term complications including facial paralysis, labyrinthitis, meningitis, and hearing loss.
OE complication
Choleastoma
Recurrent AOM
- ≥ 3 episodes in a 6-month period
- ≥ 4 episodes in a 12-month period
with complete resolution of symptoms between episodes.
Tympanostomy tube placement is the surgical treatment of choice for chronic OME in children < 4 years old.
True or false
True
Tympanostomy tube placement AND adenoidectomy is the surgical treatment of choice for chronic OME in children > 4 years old.
True or false
True
Chronic OME
the presence of effusion for ≥ 3 months
fever, headache, photophobia, fluctuating mental status, and neck rigidity during an episode of AOM
Meningitis post OM
Outgrowth of the bone in the cartilaginoid-bone junction; usually unilateral
- Pedunculated and hard
- Causes conductive hearing loss
Osteoma
Complication where the classic triad of symptoms includes retro-orbital pain, AOM, and ipsilateral abducens nerve paresis
Para
Gradenigo syndrome from Petrous apicitis
Petrous apicitis
main tumor of cerebellopontine angle tumor that can cause sensorineural HL
Schwanoma
Test indicated to trace movement of the outer hair cells
Otoacoustic emissions
Weber test interpretation
If sound lateralizes to one side
Sensorineural = lateralizes to UNAFFECTED SIDE
Conductive = lateralizes to AFFECTED side
Rinne test interpretation
(+) = normal/sensorineural = AC > BC
(-) = conductive = BC > AC
unilateral or asymmetric sensorineural hearing losses should undergo an MRI
True
Congenital cause of sensorineural Hearing Loss caracterized by RETINITIS
Usher syndrome
The predominant etiology of hearing impairment in children
Viral
Congenital cause of sensorineural Hearing Loss caracterized by pigmentary abnormality
Waardenburg
Age-associated hearing loss most common cause of hearing loss in adults; high-frequency hearing loss that eventually progresses to involve all frequencies
presbycusis
Sensorineural hearing loss is more commonly associated with what kind of fracture
transverse fractures
Fluctuating episodes of hearing loss, vertigo, tinnitus, and aural fullness.
The underlying pathophysiology is believed to be an increase in fluid pressure within the endolymphatic compartment that results in periodic tears in the delicate cochlear membranes.
Meniere disease
One of the most common types of peripheral vertigo
* vertigo lasting seconds to couple of minutes in certain positions
* No spontaneous nystagmus
* arising as a result of debris in the posterior semicircular canal.
NO associated HEARING LOSS
BENIGN PAROXYSMAL POSITIONAL VERTIGO
Characteristic fatigable nystagmus ONLY when performing manneuver Dix Hallpike test
BENIGN PAROXYSMAL POSITIONAL VERTIGO
Tx BENIGN PAROXYSMAL POSITIONAL VERTIGO
- Epley manneuver
*
Presents
- unilateral, fluctuating sensorineural hearing loss (often involving low frequencies)
- vertigo that lasts minutes to hours
- tinnitus typically increasing in intensity before or during the vertiginous attack
- aural fullness
MENIERE DISEASE
Meniere treatment
- Sodium restricted diet (≤ 2000 mg/d)
- diuretics (eg, diazide).
Refractory = gentamicin therapy
Acute exacerbation = oral steroids
The endolymphatic sac is also located along an imaginary line called
Donaldson line
sudden onset of vertigo with nausea and vomiting lasting days after an upper respiratory infection
* Spontaneous nystagmus
* suppressed by visual fixation
* NO headache
Primary cause for acute vertigo lasting days is a brainstem stroke
The most likely cause is the reactivation of a latent herpes simplex virus type 1 (HSV-1) infection.
VESTIBULAR NEURONITIS
Nerve commonly affected in neuronitis
superior vestibular nerve
Tx vestibular neuronitis
- vestibular suppressants
- antiemetics
- antiviral HSV
Vertigo when exposed to loud noises
Tullio phenomenon
Vertigo with pressure changes in the ear
Hennebert sign
- Vertigo induced by loud noises, pressure on the external auditory canal
- Autophony
- Nystagmus
- Conductive Hearing loss
SUPERIOR SEMICIRCULAR CANAL DEHISCENCE
The central compensation for vestibular injury occurs via
Cerebellum
primary pathophysiological site in Bell palsy
the meatal foramen BUT he said fallopian canal in ear
“physiological bottleneck”
Patología donde
- Acute onset (<48 hour)
- unilateral paresis consistent with peripheral nerve dysfunction
- Dysfunction of cranial nerves V, VIII, IX, and X
- Others: Pain or numbness affecting the ear, midface, and tongue taste disturbances hearing loss and dizziness
- instead of closing the eye, the eyeball goes upward
Bell palsy
Syndrome of acute peripheral facial palsy associated with otalgia and varicellalike cutaneous lesions that may involve the external ear
Ramsay Hunt syndrome
House Brackman scale
6
1 - normal
2 - complete eye closure w/little effort, moderate forehead movement, slight mouth assymetry w/movement - normal at rest
3 - not disfiguring facial assymetry, synkinesis, hemifacial spasm, slight forehead movement, eye close w/effort - normal at rest
4 -disfiguring facial weakness, no forehead movement, incomplete eye closure, assymetrical mouth movement - normal at rest
5 - assymetry at rest,slight noticeable movement, no forehead movement, incomplete eye closure, slight mouth movement
6 - NO FACIAL FUNCTION
Tx bell palsy
- Steroid therapy
- Antiviral therapy
- Physical therapy
- Progression of a facial palsy >3 weeks
- Facial hyperkinesia, particularly hemifacial spasm, antecedent to the palsy
- Associated dysfunction of regional cranial nerves
- Prolonged otalgia or facial pain
- Mass in the middle ear, external ear canal, digastric region, or parotid gland
- Recurrent ipsilateral palsy
Most frequently a facial neuroma
FACIAL NERVE NEOPLASMS
Tx surgery
Multisystem infection induced by the tickborne strain of the Borrelia burgdorferi spirochete
- Erythema migrans (targetshaped rash)
- Interval between the onset of the rash and facial palsy is less than 2 months
- Facial palsy associated with other neurological deficits
LYME DISEASE
Evidence of prior or existing suppurative otitis media, or if there is a history of prior otologic surgery, an otogenic etiology should be suspected
* Palsy is often progressive over a 2day to 3day interval
* Hearing loss, otorrhea, and vestibular symptoms
ACUTE OTITIS MEDIA AND MASTOIDITIS!
- Infection by Pseudomonas aeruginosa is the primary offending agent
- patients with diabetes mellitus or in others who are immunocompromised
- GRANULATION TISSUE at the bonycartilaginous junction
Dx: Gammagraphy w/gallium
NECROTIZING (MALIGNANT) OTITIS EXTERNA
Tx NECROTIZING (MALIGNANT) OTITIS EXTERNA
- Antibiotic IV (quinolone) 8-12 week
- debridement
- Radioisotope scanning
Möbius syndrome encompasses a wide spectrum of anomalies due to dysgenesis at the level of the brainstem with resultant neuromuscular deficits peripherally.
Facial and Abducens
Congenital Perinatal Facial Palsy
Define the salivary glands
6
- 2 parotid glands
- 2 submandibular glands
- 2 principal sublingual glands
The secretions of the parotid and submandibular glands are primarily stimulated by
autonomic nervous system
- largest of the paired major salivary glands
- Location: lateral to the masseter muscle anteriorly and extends posteriorly over the sternocleidomastoid muscle behind the angle of the mandible.
- Divided by the branches of the seventh cranial nerve (VII).
- The Stensen duct
Parotid gland
- Second largest salivary glands in the body
- Divided by the posterior edge of the mylohyoid muscle
- The Wharton duct, is inelastic and therefore, when obstructed causes pain
Submandibular gland
- Locatin: in the submucosa, superficial to the mylohyoid muscle.
- Multiple small or “minor” sublingual ducts called ducts of Rivinus, which open directly into the oral cavity.
- The lingual nerve descends laterally to the anterior end gland
Sublingual Glands
Saliva is produced by the** clustered acinar cells** (500 to 1500 mL) and contains electrolytes, enzymes (eg, ptyalin and maltase), carbohydrates, proteins, inorganic salts, and even some antimicrobial factors and its acid
True or False
False, its alkaline
hyperproduction of saliva
Ptyalism
INFECTIOUS DISEASE
- most common viral disorder causing parotitis and is contagious.
- Acute, bilateral swelling of the parotid glands
- Pain, erythema, tenderness, malaise, fever, and occasionally trismus.
- Peak incidence in young children aged 4 to 6 years.
Mumps (Paramyxovirus)
INFECTIOUS DISEASE
stasis of salivary flow in patients, obstruction, of the ducts then follows.
- Acute painful
- fever and purulent salivary secretions.
- Risk factors include dehydration, trauma, immunosuppression, and debilitation
- Untreated may lead to an abscess
Tx: rehydratation, IV antibiotic, warm compresses
acute suppurative sialadenitis
1º gland affected in Sialolithiasis
submandibular gland , more susceptible to calculi formation than the parotid gland because of the longer course of its duct, higher salivary mucin and alkaline content, and higher concentrations of calcium and phosphate.
NONINFECTIOUS INFLAMMATORY DISEASE
- Acute, painful swelling
- Aggravation of symptoms with eating; swelling may subside after approximately 1 hour.
- A stone in the floor of the mouth may be palpated
Sialolithiasis
Chronic sialadenitis - NONINFECTIOUS INFLAMMATORY DISEASE
- Autoimmune disorder
- PAINLESS
- parotid enlargement, xerostomia, and keratoconjunctivitis sicca.
- It also may be associated with a connective tissue disease
High risk for development of malignant lymphoma in primary Sjögren syndrome.
More commonly seen in postmenopausal women
Chronic sialadenitis
Sjögren syndrome
INFECTIOUS DISEASE
- Painless,
- bilateral enlarged parotid glands
- Xerostomia
- Associated cervical lymphadenopathy
Hiv infection of the parotid glands
Treatment Sialolithiasis
Depends on the location of the calculus
* Anterior portion of the submandibular duct = Intraoral Extraction
- Symptomatic stone embedded in the body of the parotid gland or larger stones = Surgical Excision
NONINFLAMMATORY DISEASE
Rare, noninflammatory condition that causes bilateral, diffuse, and painless enlargement of the salivary glands (parotid gland is the most affected)
This condition may also cause degenerative changes to the autonomic innervation of the glands.
Alcohol risk factor
Sialadenosis
Differencia in type 1 cysts and type 2
type 1
anteroinferior to the ear lobule.
type 2
sternocleidomastoid muscle or the external auditory canal
NONINFLAMMATORY DISEASE
Dilatations of the minor salivary gland ducts frequently in the lip (60%–70%), buccal mucosa, floor of the mouth (ranula), and palate.
Mucoceles
Neoplasic Lesion
Benign mixed tumors, are the most common neoplasms of the salivary glands.
Pleomorphic adenomas
Neoplasic Lesion
- known as papillary cystadenoma lymphomatosum and is found almost exclusively in the parotid gland.
- Bilateral
- associated risk with smokers
Dx: biopsy with oncocytes
Tx Complete excision of the affected portion of the gland with uninvolved margins
Warthin tumor
A hybrid between an endotracheal tube and a face mask. It can easily be inserted blindly
Contraindications to using this airway therefore include patients with full stomachs or hiatal hernias, pregnancy, obesity, and abdominal surgeries – Aspiration
Laryngeal Mask Airway
The definitive nonsurgical control of the airway is via DIRECT LARINGEAL intubation or in situations in which intubation is contraindicated
True or false
true
Principal causes of difficult airway in adults vs children
Children
Congenital airway anomalies (eg, laryngomalacia, choanal atresia, hemangioma, tracheomalacia) and acute inflammatory causes
Adult
trauma
Can effectively ventilate the upper airway regardless of whether it is placed into the trachea or into the esophagus
Contraindicated in pediatric and very small adult patients.
Combitube/King Airway
Device that makes easier to manage past obstructing lessions and edema
Jackson slide laryngoscope
- Can be performed either via a nasal or an oral route.
- Performing the technique on a patient while awake and breathing spontaneously
- the method of choice when transoral access to the larynx is difficult
FIBER OPTIC (guided) INTUBATION
In emergency situations, is generally considered the procedure of choice
cricothyroidotomy
“cannot intubate, cannot ventilate.”
indications for establishing an urgent surgical airway:
6
- severe maxillofacial trauma in which injuries make the airway inaccessible for translaryngeal intubation
- significant laryngeal trauma in which intubation may potentially cause more damage
- excessive hemorrhage or emesis obscuring landmarks required for successful intubation
- cervical spine injury with vocal cords that are difficult to visualize
- failed translaryngeal intubation
- cases where nonsurgical means (bag-mask ventilation; LMA) are not possible or have failed
A tracheotomy is a procedure that exteriorizes the trachea to the cervical skin
True or false
False, a tracheotomy is generally described as a procedure that involves opening the trachea
A tracheostomy is a procedure that exteriorizes the trachea to the cervical skin
indications for performing a tracheotomy include:
6
- bypassing an upper airway obstruction
- providing a means for assisting mechanical ventilation (ie, chronic ventilator dependence),
- enabling pulmonary hygiene
- temporarily securing an airway in patients undergoing major **head and neck surgery **
- relieving obstructive sleep apnea
- eliminating pulmonary “dead space.”
Incision used for emergency tracheotomy
Vertical between 2-3 ring
hepful in obese patients
** most emergent surgical airway** done through a transverse incision and can complicate in stenosis
CRICOTHYROIDOTOMY
Postoperative Considerations
1) humidifying inspired air is necessary to prevent crusting and tracheitis
2) suctioning the tube and trachea on a frequent basis
3) Bjork flaps removed 3-5 days
Before decannulation:
- disease process resolved
- Good airway patency
- adequate airway after 24-hour tube occlusion
Early tracheotomy complications
- Infection
- Hemorrhage
- Subcutaneous emphysema (air is trapped in the subcutaneous tissues from suturing)
- Pneumomediastinum (air is sucked through the wound or from coughing into the deep tissue planes of the neck and into the mediastinum)
- Pneumothorax
- Tracheoesophageal fistula (tracheal incision is made too deep)
- Recurrent laryngeal nerve injury
- Tube displacement (minimized using stay sutures or the Björk flap)
Late tracheotomy complications
- Tracheal-innominate artery fistula. One of the most dire complications when the major vessel is eroded by pressure necrosis from the tracheotomy cuff or directly from the tip of the tube itself. Revealed by minor sentinel bleeding
- Tracheal stenosis
- Delayed tracheoesophageal fistula
- Tracheocutaneous fistula (after decannulation of a long-standing tracheotomy)
