Otorrino ordinario Flashcards
Nasal epithelium
ciliated, pseudostratified columnar
a donde drena el nasolacrimal duct
al inferior meatus
a donde drenan los frontal, maxillary and anterior sinues
al ostheomeatal complex
a donde drena el posterior ethmoid sinus
al superior meatus
a donde drena el anterior ethmoid sinus
middle meatus
a donde drena el sphenoid sinus ostia
to the superior turbinate
the vasculatiry its given by..
Internal carotid –> ophthalmic–> anterior and posterior ethmoid arteries
External carotid –> sphenopalatine artery
the venois drainage its by…
pterygoid and ophtalmic plexuses
Principales symptoms of rhinits
nasal obstruction, hypeirrtibility and hypersecretion
persistent rhinits
more then 4 days a week AND more the 4 weeks
intermitent rhinits
symptoms for less then 4 days a week or less then 4 weeks
mild vx moderate/severe rhinits
normal or abnormal sleep (moderate and severe)
symptons of NON allergic rhinitis
nasal obstruction, clear rhinorrhea,
not tha common: sneezing, itchy and watery eyes
viral non allergic rhinits
associated with other manifestations of viral illness: headache, malaise, body aches, cough.
occupational non allergic rhinits
pollutants like dust, ozone, garden sprays, etc. (irritant agents). Nasal dryness.
vasomotos non allergyc rhinits
symptons associated with changes of temperature, eating, alcohol use, etc.
non allergyc rhitis with eosinophilia
they have more severe exacerbations (eosinophilia >25%)
medicamentosa non allergic rhinits
because of the over-the-corner topical vasoconstrictive nasal sprays (Afrin most common drug that gives this)
pregnancy non allergic rhinits
rise of estrogen –> rise of hyaluronic acid –> rise of nasal edema and congestion
basic tx of non allergic rhinits
-Irritant avoidance
-Saline irrigation (for a clean nose, improves ciliary function)
-Topical Intranasal steroids (reduce eosinophil and neutrophil chemotaxis and inflammation) (don’t give IV, IM)
-a-adrenergic drugs (2 main familys: phenylamines [contraindicated in px with hypertension, coronary artery disease, etc] and imidazolines)
-Anticholinergics (ipratropium, azelastine, cromolyn, etc)
for mild intermittent/persistent non allergic rhinits TX
- INAH
- INCS
for moderate/severe intermittent non allergic rhinitis tx
- INAH
- INCS
- IN (AH & CS) o INAH + INCS
for moderate/severe persisiten non alergic rhintis tx
- IN (AH & CS) o INAH+ INCS
- INAH
- INCS
surgical measures for non allergic rhinits
septoplasty and turbinate surgery (inferior turbinate)
*for anatomical problems
pathogenesis de allergic rhintis
IgE- mediated inflammatory nasal condition resulting from allergen introduction (sensitazion fase) and early inflammation by mast cell that liberates histamine and then late inflammation caused by chemotaxis (2 phase) (type 1 hypersensitivity)
typical symptoms of allergic rhinits
sneezing, itching, rhinorrea and nasal congestion
classification: season allergic rhinits
symptoms usually worst in the morning, aggravated by dry, windy conditions
classification: perennail allergic rhinits
only happens in specific moment or places, indoor inhalants like dust mites, animal dander, mold spores, etc. Most common sign its nasal congestion
FR de allergic rhinits
family history (atopias)
Male sex
Birth during the pollen season
1 born
Early use of antibiotics
Maternal smoking exposure
Exposure to allergens
Associated chronic conditions: asthma, otitis media with effusion
for intermittent mild allergic rhintis tx
- OAH o INAH
- OAH + PSE
- INCS
for intermittent moderate/severe allergic rhinits tx
- OAH o IANH
- INCS
- IN (AH & CS) o INAH + INCS
- OAH
for persisiten mild allergic rhintis tx
- INCS
- OAH o INAH
- OAH + PSE
- Intranasal cromolyn sodium
for persistent moderate/severe allergic rhinits tx
- IN ( AH & CS) or INAH+ INCS
- INCS
- INAH
dx for allergic rhinits
-Complete HC
-Physical examination
-Rhinoscopy: bluish, pale, boggy turbinates, wet and swollen mucosa, nasal congestion (predominant sign in perennial allergies), anatomic abnormalities
-Conjunctivitis, eczema, asthmatic wheezing, nasal salute, OME
-Allergy testing
-Skin testing (skin-prick test SPT most common, (gold standard)
-ID testing
-In vitro testing
Etiología rhinosinusitis
90% viral (sintomas < 10 dias y no empeoran)
sintomas que te orientan a bacteriano: purulent rhinorrhea, facial pain/pressure, and nasal obstruction., fever >38°, unilateral
bacterias mas comunes en ARS
Streptococcus pneumoniae, Haemophilus influenzae, M. catarrhalis
bacterias más comunes en CRS
S. auerus. P. auriginos, H. influenzae, Anaerobios
acute rhinosinusits ARS generalidades
incia como un resfriado, normalmente es vrial ( adenovirus, rhinovirus, respiratory virus)
acute rhinosinusitis ARS dx
2 o mas sintomas, 1 a fuerzas nasal congestion o nasal discharge y el otro facial pain, reduction or loss of smell de > 4 semanas
subacute rhinosinusitis
4-12 weeks
recurretn acute rhinosinusists
4 or more episodes in 1 year, with complete resolution between episodes
CRS
2 or more symptoms, one of which should be either nasal blockage/congestion or nasal discharge, and facial pan/pressure, reduction or loss of smell for > 12 weeks
classification of CRS
-primary CSR: unilateral o bilateral
-secundary CSR: localize o diffuse
dx rhinosinusists
2 o mas major factors + 1 minos
mayor factors RS
facial pain/pressure
nasal obstruction/blocakege
nasal dishcarge/ postnasal drainage
hyposmia
purulance
fever
minor factors RS
headache
fever
halitosis
fatgiue
dental pain
cough
ear pain
caldweel RX
for ethomoidal and frontal
water rx
maxillary
lateral rx
Sphenoid, Frontal, ethmoidsandmaxillary
lund mackey system
del 0 al 2(obstruccion total) y en ostiomeatal complex es 0 o 2 , se califica cada lado, de 0-6 es leve, 6-10 moderado y >10 severo
que sinues califica lund mackey system
-frontal
-anterior ethmoidal
-posterior ethmaidal
-maxillary
-esphenoid
-osteomeatal complex
pathogenesis the RS
Mucosal swelling (allergy, infection, enviorment, etc)–> obstruction of sinus ostia –> mucus stasis –> infecion
TX ARS
Saline irrigation
Nasal steroids
Antibiotics (for bacterial): amoxicillin with clavunate
Antihistamine
Systemic steroids
Decongestant (like Afrin: oxymetazoline)
tx CRS
Antibiotics
Nasal steroids
Saline irrigation
Leukotriene antagonist
Oral steroids
Antihistamine
Monoclonal bodies (omalizumab [ige] or mepolizumab [IL5]
Antifungal
fuctional endsocpic sinus surgery
tx for CRS with polips
dupilamab
tx fungal infectio RS (common in no control DM)
Anfortemince B
alarma symptoms in RS (inmediate referral)
-periorbital edema/erythema
-displaced globe
-dobule vision
-ophtalmoplejia
-reduced visual acuity
-severe headche
-frontal swelling
-signs of sepsis
-signs of meningitis
-neurologicla signs
chandler complicatiosn of SR
1 inflammatory edema: no visual lost ni ophtalmoplejia
2 Orbital cellulitis: pain, proptosis, chemosis, little ophthalmoplejia, edema of extra vascular muscles and mild disminución of agudeza visual tx: intravenous antibiotic
3 Subperiosteal abscess: operative drainage
4 Orbital abscess: proptosis, chemosis, ophtalmoplejia, visual lost operative drainage
5 Cavernous sinus thrombosis: tromboflebitis, 3,4,5 NC affected, life threatening, IV antibiotic + OR drainage
most common emergency 60% in otorrino
epistaxis
causes epistaxis
1° idiopathic
2° traumatic
3 iatrogenic
leucemia (common in children)
irrigation of nasal cavity
EXTERNAL CAROTID
-facil artery (anterior nasal septum)
-internal maxillary artery
-sphenopalatine artery
(septal y conchal brand)
-descendign palatine
artery
irrigation of nasal cavitiy
INTERNAL CAROTIDE
-ophtalmic artery
-anterior ethomoid artery
-posterior ethomoid artery
el 90% de anterior epistaxis viene de
Kieselbach plexus or littles area
la anterior y posterior (dificl de controlar la bleeding) epistaxisi se divide por el
ostium of the maxillary sinus
cuantos ml es lo habitual de epistaxisis
700-900 ml
manegement epistaxis
-initial assesment (HC, EF, BH, future crossmatching)
-headlamp examination (local anestesia)
-nasal endoscopy (mostly in posterior)
- identify site de sangrado
- buscar patolgoia desecadenante
- digital pressure on alar cartilages fot 20 min
most common source of bleedign in children
from a vessel in the mucocutaneous junction
5-10% of epistaxisis in children its cause
of an undiagnosed von willbrand disease
tx epistaxis
-topical silver nitrate
-petroleum jelly (Best method)
-cautery in OR (NEVER bilateral)
-nasal packign with antibiotic (gauze, bilateral,) (never in children)
*if after packing sigue sangrado, suele ser posterior, y se manda al otrorrino para poner foley catheter
every posterior epistaxis belongs in the hospital
true
tx posterior epistaxis
-nasal packing
-gold standar: cauterization (endoscopic sphenopalatin artery ligation)
-maxillary a., external carotid a. ligation
-embolization
donde es mas comun una neoplasia paranasal de sinus
en el maxilary sinus
sintomas que sugieren proceso neoplasico
unilateral swelling, pain, and epistaxis.
que es lo primero que pido ante un tumor
CT scan WITH constras and RM (T1 liquod negro, T2 liquido blanco)
inverted papilloma “scheinderian tumor”
Most common benignal tumor, HPV has 75% grade of malignization, usually men, usually on maxilary sinus, pale, multiboluted, dx CT with contrast and MR
-TX: surgical resection +adyuvant RT
osteoma
slow growth, benignal, 2-5° decade of life, males, msot common place: anterior ethomidal, the frontal then maxillary then sphenoidal
-tx: watchfull waiting, open approach
juvenile angiofibroma
vascular tumor, adolscent boys, usually in the pterigomaxilar fosse. has holamn miller sign (tumor psuhes the posterior bone of maxillary sinus)
juvenile angiofibroma manifestations, and tx
-common manifestation: recurrent epistaxis, nasal voice, eustachian tube dysfunction
-tx: surgical resection after embolization preop
AVOID BIOPSY
Lobular capillary hemangioma
caused by Nasal trauma
Microscopic AVM
Veryyy small and can grow sooo much
beingn
fibrous dysplasia
-tumor on the bone medula
-loose teeth, numbness, facr assymetry
-tx: observation, embolization 1°, cx (quitan todo el hueso, queda el hueco) 2°,
squamosu cell carcioma
-most common mallignat tumor
-cx + rt
-bado rpognosis
olfatory neuroblastoma
-olfacory epithelium
-malignat
-extension to the orbit and anterior fossa
-kadish classification
ESTHESIONEUROBLASTOMA
from the olfatory epitheluim
-anosmia, iposmia
larynx roles
-protection (epiglotis, vocal cords, cough
-respiration
-phonation
we divide the larynge in:
-supraglottic (suprahyoid and infrahyod epiglotis, ariepiglotic folds, aritenoids, vocal fols)
-glottis (vocal cords)
-subglottic
cartilages of the larynx
-Epiglottis
-Thyroid (biggest, protection of vocal cord)
-Cricoid (like an incomplete ring, attachment with the traquea)
-Cuneiform
-Arytenoid
muscles in the larynx are inerveted by the
-recurretn laryngeal nerve (branch of vagus)
-other ones: superior laryngeal nerve (external [moves cricothyroid msucle] and internal [gives the sensibility])
vocal cords
-anterior view es donde se forma el pico de la V
-es un squamous stratified epitheluim
-most common cancer in cords: suqamosu cell carcinoma
-has tyroarithenoid muslce
que divide larynge de hipofarigne?
the aryepiglothic
4 types of cords paralisis
-vagal bialteral
-vagal unialteral
vocal cords in intermediate position (cadaveric)
-recurrent laryngeal bilateral
-recurrent laryngeal unilateral
parameida position
*recurrent larygneal are more common
*leer its more common
vagal bilaterla cord paralysis
idiopathic or neurological causes, CANT generate voice, hisotry of choking
vagal unilateral cord paralysis
iatrogenic, neoplasia, brainstem infarction
-weak, breathy hoarseness
-history of aspiration
recurrent laryngeal cord paralysisi bilateral
-usually after a cx
-Stridor, problems breathing
-no dysphonia
-its an emergency
tx of recurrent laryngeal cord paralysis
-lateralization of vocal cord (but wont be able to speak)
-or cordectomy
recurrent laryngeal cord paralysisi unilateral
-causes: neoplasia, iatrogenic, trauma, anerurysm (left)
-hay disphonia
-bovine cough
-tx: vocal and speech therapy, hyalurnic acid or fat to the cord, or thyroplasty (impkan tpushes the cord to middle line)
bening laryngeal lesions
vocal cord nodules, polyps, intubation granuloma, reinke edema, laryngeal cyst, laryngocele, papillomatosis
vocal cord nodules
-comunes en gente que usa mucho la voz
-nodulos no permiten que se toquen las cuerdas: dysphonia
-bilateral
-in the junction of the 1/3 anterior and 2/3 posterior
-tx: speehc therapy 3 meses, no se extirpan porque crecen back
vocal cord polyps
-unilateral
-red and pednculated
-por reflujo o UN esfuerzo vocal grande
-tx: speech therapy 3 months, omprazol and cx (take out polyp)
intubation granuloma
-usually unilateral
-neer to the arythenoid process
-in posterior 1/3
-px with intubation hisotory
-tx: NO smoking or drinking, dietic control, speech therapy or cx (quitas tejido para adelgazar la cord)
reinke edema
-Bilateral in the lamina propia
- Diffuse polyposis of the vocal cord (like they have water inside)
- Risk factor: smoking
- Clinic: raspy voice (like alejandra guzman)
- Treatment
o Avoid smoking, food irritants and voice overuse
o Speech therapy
o If that doesn’t work: surgery
laryngeal cyst
-usually unilateral
-INSIDE the mucosa (full of mucosa and epithelial cells)
-big
-dysphonia
-tx: surgery 1°
papillomatosis
-infection by VPH 6 and 11
-children
-lesiones verrugosas en larynx
-dysphonia
-tx: surgery (but they grow again)
malignant laryngela lesions donde es mas comun de las vocal cros
1 glotis 59%
2 supraglotis 40%
3 suglotis 1% (bad prognosis)
in stage 3 we never have vocal cord fixation
false, we ALWAYS haver cord fixation in a malingant laryngeal vocal cord tumor
tx of malingant laryngeal vocal cord tumor
Early stage T1 or T2: take a biopsy, send it to the surgeon oncologist to see if they can resect the tumor, so they need RT or cordectomy (lo hace el otorrino)
Advance stage T3 y T4: dual modal therapy: surgery and adjuvant RT
dx: CT scan
tonsils
-1 adenoid (biggest)
-2 tubal
-2 palatines (in the orofarin, we see them)
-1 lingual
2 pillars delimitate the tonsillar fossa
-palatoglossal muscle (anterior pilar)
-palatopharyngeal muscle (posterior pilar)
irrigation of tonsils
branches of the external carotid artery
Most common complication if a tonsillectomy:
bleeding
adenotonsil disease
-usually viral (adenovirus, rhinovirus, covid, influenza [aqui si se da ocetamivir], parainfluenza, syncytial)
-it looks red, hyperemia, edema (se da tx sintomatico, antihistamines, AINES, don’t give antiviral)
coxsaquie
-presence of herpangia in the tonsils
-hay aftas
-very high fever for days
-tx sintoamtico NO antibiotics
herpes
-VHZ por varicela
-vesicles in soft palete, tosnisl,
-history of varicela or vesicles in lips
-very painful, neuropatic pain
-tx: aciclovir, valaciclovir
mononucleosis
-VEB
-linfaadenopaty
-white-grey exudate localized
-too much adenopaty, fever
-complication: hepatoesplenomegaly
b-hemolytic
complete hemolysis
a-hemolytic
partial hemolysis
y-hemolysisi
no hemolysisi
bacterian adenotonsil desease
-purulent exudate, inflammation, pus generalized
-give antibiotic
-most common bacteria: acute streptococco
Acute Streptococcal Pharyngotonsillitis
-group A b-hemolityc (GABHS)
-most common cause of acute bacterial
dx: gold standar blood agar plate (BAP)
tx: 10-day course of penicillin V or amoxicilina
no suppurative complications of adenotonsil desease
-scarlet fever: “strawberry tongue”, fever , rash
-rheumatic fever: can cause heart damage. (1-4 semanas desp)
-poststreptoccocal glomerulonephritis (1-2 semanas desp)
-Pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal (PANDAS): in children with TOC
tx para reumatic fever
peniciclian benzatina 1,200, 000 unit every 21 days for 3 months
suppurative complications of adenotonsil desease
-peritonsillar abscess (abscess surrounding the capsule of the tonsil, que emuja la tonsil so se ve mas inflamado de one side, its bilateral, se da ceftriaxone, it’s a big infectiosn, sometimes they go to the hospital, hot potato voice/ muffled voice
-parapharyngeal space abscess (decreased neck range of motion)
-retropharyngeal bases (spread t lymph nodes, usually in childre)
paradise criterio for tonsilectomy
-7 o mas epidosido en el año o 5 o mas epidosidos en cada año en 2 años, o 3 o mas episodios en cada año en 3 años
-fiebre >38.3 o lymphandeopati cervical (nodes > 2 cm) o exudado en las tonsil, cultivo positivo para a-hemolitico strepto
-tosnil cronicas sin respuesta a tx
-roncar y respirar por boca
-sleep-disordered breathing
-tonsialr diseas with dysphagia
-tosnila disases with craniofacil growth
-monucleosis with obstructive tonsilar hypertrofphy
grades oftonsil obstruction
satge 1: <25%
stage 2: 25-50%
stage 3: 50-75%
stage 4: >75% (they are touching)
centor criteria para ver si es bacteriana
fever 1
tosnilla exude 1
absent cough 1
anterior cervical Linphadenopaty 1
3- 14 años 1
15-44 años 0
>44 años -1
centor score valores risk of infection
0: 1-2.5% risk
1: 5-10% risk
2: 11-17% risk
3: 28-35% risk
4 > 51-53% risk
*apartir de 3 puntos das antibiotico
diphteria
membrane on the tonsil that blocks the airway
chronicotonsillitis: cassium
se acumula food en la tonsil
muscle that opens the vocal cord
posterior cricoarythenoid
Behavioral audiologic measures
-pure tone air conduction
-pure tone bone conduction
-speech-recognitios threshold (STR)
-suprathreshold speech recognition socres
Objetive physiological measures
-otoacousitc emissions
-acoustic admittance test battery
-tympanometry
-acoustic-reflex threshold (adaptation)
objective auditory electrophysiologic measures
- auditory evoked potentials testing/ electrocochleography (ECochG)
- auditory brainstem response (ABR)
-auditory middle latency response (AMLR)
-auditory steady state response (ASSR)
cortical auditory evoked potentials (CAEPs)
puretone audiogram: air-conduction thresholds (AC)
-frequencies 250, 500, 1000, 2000, 4000, 8000 hertz
-we can block the none tested ear with masking noise
puretone audogram: bone conduction thresholds (BC)
-frequencies: 250, 500, 1000, 2000, and 4000 Hz
-with a bone vibrator placed in the mastoid process of temporal bone.
-it shoul be in an isolated room
Normal hearing audiogram
-10 to 25 db
-x its frequency (Hz)
-y its dB
audiogram symbols
-red: right
-blue: left
-AC: circule (right) and X (left)
-BC: < (right) and > (left)
-AC masked: triangle (right) and square (left)
-BC masked: [ (right) and ] (left)
BC always arriba de AC
que indica HL en AC and BC
-AC: heraign problem in the conductive and/or sensorineural
-BC: just sensorineural
air bone GAP
difference of dB between AC and BC
-in normal hearign its < 10dB
normal hearing
-AC: < 25
-BC: <25
-ABG: <10
normal hearing with significant ABG
-AC: <25
-BC: <25
-ABG: >10
conductive HL
-AC: >25
-BC: <25
-ABG: >10
-ej: otitis media or external, ear wax, tumor on middle or external ear, eustachian tube dysfunction, genetic HL like treacher collins sx
sensorineural HL
-AC: >25
-BC: >25
-ABG: <10
-Ej: noise-induced HL, presbycusis, ototoxicity, meniere diseas, genetic HL like Connexian 26, Usher sx, acosutic neuroma, esclerosis multiple, sx caratgena, schwannoma
PTA pure tone average
-para ver la magnitud de la HL
-vemos los db de 500, 1000 y 2000 hz, los sumas y dividimos entre 3
-solo los valores de AC
mixed HL
-AC: >25
-BC: >25
-ABG: >10
-ej: otosesclerosis and presbycusis, uno y uno
Normal PTA
<25
mild PTA
25-40
moderate PTA
40-55
modeately severe PTA
55-70
severe PTA
70-90
profound PTA
> 90
high frequencie audiometry
-test at 9000, 10000, 11,200, 12,500, 14.000, 16.000, 18.000 y 20.000 Hz
-nos dice sobre early ototoxic effects (gentamicen, amicasin), early presbycusis or early noise-induced HL
interaural attenuation
The reduction in intensity of a signal, such as a pure-tone signal, as it travels by BC from the TE to the NTE (where the masking goes)
speech audiometry
–spondaic or speechrecognition threshold (SRT): based on spondaic words bisyllabic
-es a la intensidad mas baja a la que el px repite las palabras
Retrochoclear lession
with more dB, they hear more distortion instead of hearing ir louder
TPP tympanometric peak pressure
-unit: daPa
-its when the air pressure intriduced in to the external ear, equals de pressur ein the middle ear
TPP typanometric peak pressure
low: < -50 daPa its not normal, suggestive of eustachian tube dysfunction
normal: >.35 daPa
tympanometry
measures the movement of the tympanic membrane
-speaker at 225 hz
peak-compensated static-acoustic admittance
in adultos: 0.35-1.30
-abajo de eso: rigidez
-arriba: ossicular discontinuity or tympanic perforation
type A tympanometry
normal TPP
normal peak height
normal middle ear function
type Ad
-TPP normal
-admitance higher peak height >1.30
-ej: ossicular discontinuity
type As
-reduced height at the peak (admitance < .35)
-normal TPP
-stiffening middle ear, like otoesclerosis
type B
flat tympanogram
-stiffening middle-ear pathology or tympanic membrane perforation (or a patent tympanostomy tube), ear wax, foreign body, air fluid levels
type C
-negative TPP (<-50)
-eustachian tube-dysfunction
little bones:
-malleus (pegado al timpano)
-incus (de enmedio)
-stapes (parece una Y)
Acoustic reflex
-se oye un ruido fuerte en un oido, y se contraen los 2 musuclos
-primary muscle involved: stapedius, su origen es in the pyramidal eminene of the tympanic cavity, y se inerva por 1 branch of facial nerve
-at high intesities: the tensor tympani (inervado por trigeminal nerve
pathway acoustic reflex
-ipsylateral: Coclea –> NC8 –> nucleo coclear–> facial nerve (7) –>stapiduis
-contralateral: coclea –> NC8 –> nucleo coclear–> contralteral meadlle supirior oliva nucleos –> facila nerve motor –> stapiduis (el contralateral)
otoacustic emissions
-records the sound of the movement of the outer hair cells
-dx of hering disordes in infants
Auditory brainstem responses (ABRs)/ brainstem auditory evoked potentials (BAEPs)
it evaluates all the auditory pathway
anatomy of the external ear (pinna)
-24 mm length with 1-2 ml volume
-lateral 1/3 its fibrocartilage
-medial 2/3 it sbone
-junction de esos es narrowest poinr
pinnas skin
-Stratified squamous epithelium
-subcutaneous layer: hair follicles, sabaceos glands and ceruminous glands, 1mm
-osseous canal: 0.2 mm
Cerumen
-secreciones glandulares + epitelio desprendido
-hydrophobic
-acid pH
-antibacterial effects
pinna innervation
-laterally, inferiorly, and posteriorly by the great auricular nerve (cervical plexus).
-Arnold’s nerve (a branch of the vagus nerve) innervates the inferior bony canal (concha and floor ear canal)
-posterosuperior bony EAC by branches of the facial nerve
-anterior (tragus and roof): auriculotemproal branch of V3 of the trigeminal nerve
microtia
-malformaciones evidentes
Marx system:
-G1: deformidad leve el helix y antihelix
-G2: (atypical microtia): tissue deficiency and defromity
-G3: peanut ear
-G4: absence
tx microtia
-observation
-protesis
-single stage reconstrutction with implant
-staged autologous costochondral reconstruction. (4 stages)
atresia and stenosis
-la microtia esta asociada
-tienen conductive HL moderate severe
-risk of chloesteatoma
-CT scan para ver si es candidato a cx
protruding ears (prominauris)
- increase in the distance from the helical rim to the mastoid (due to a lack of the antihelical fold and prominence of the conchal bowl)
-usually bilateral
-normal Auriculocephalic angle 20-25° with Auriculomastoid distance 15-20 mm
tx: otoplasty (esthetic)
First branchial cleft anomalies
-10% de las BCA
-Fusion 1st and 2nd branchial arch por incomplete obliration of 1 BC
-hay infeccion, dolor, hinchazon, escurrimiento
-clasificacion Work: tipo 1 (duplicates the membranous EAC ) and tipo 2 (mas comun, duplicates both the membranous and cartilaginous EAC.)
tx: complete excision, no si esta infectada
external ear trauma: hematoma auricular
-accumulation of blood in the subperichondrial space
-el cartilago depende de la vascularizacion del pericondrio via diffusion
-necrosis del cartilago, predispone a infecciones
-cauliflower ear
tx: quinolones, drainage and ferula
auricular laceration
-trauma –> laceracion o avulsion
-reparacionn expedita y prevencion de infecciones
-tx: quinolones, vendaje, secondary reconstruction
auricular burns
1st degree: superficial layer of epidermis, red, hurt. Most common junto con la 2)
2nd degree: epidermis and extension to dermis
3rd degree: full thickness of dermis
4th degree: affection of another tissue that’s not the skin (fat, muscle, etc)
Tx: moisturizing creams, silver sulfadiazine (antiseptic cream), debridement, antibiotic ointment
otitis externa
-Usually by p. aeruginosa and s. aureus
-Chronic >3 m, acute <3 m
-Tx: topic, NO oral antibiotics, debridement of the EAC, analgesia (AINES), culture, otic drops (acetic and boric acid, gentian violet, thimerosal, alcohol, ofloxacine), avoid water exposure
otomycosis
-Fungical 10%
-80% aspergillus
-FR:immunocompromised
tx: debridement of EAC, acifiyng EAC (alcohol), antifungical agents (gentian violetm thimerosal, clotrimazole, nystatin, ketoconazole), avoid water exposure
Skull base osteomyelitis/ malignant otitis external
-inmunocomprometidos
-otitis ext que afecta hueso temporal, puede dar meningitis fata, sepsis ,muerte
-progreso: cellulitis, chondritis, osteitis, and osteomyelitis
-travels through: Haversian canals, fissures of Santorini, foramina, and vascularized spaces
-90% pseudomona aeruginosa
-Usually they have facial paralysis
-dx: VSG, PCR, elevadas, cultivo, CT, MRI
tx skull base osteomielitis
-long term parenteral antibiotics (6 wks), antipseudomonal (pip-tz, cefepime, ceftazidime, ciprofloxacin, ofloxacin)
-Hyperglycemia control
-Surgical debridement
-Hyperbaric oxygen
atopic dermatitis
-cronic, recurrent
-AHF de atopia
-niveles altos de linfocitos T TH2
-lesiones eritematosas y prurito
-> 1 mes
-tx: decloxizine, emollients, soaking baths, topical corticoesteroids, calccineurin inhibitars (tacrolimus, sirolimus)
soriasis
-cronica, inflamatoria
-18% lo manifoestan en el oido externo
-triggers: AINE, BB, carbonato de lithium, antimalarial agents, infection, trauma, stress
-papulas eritematosas (sangran si se rasca: signo de Auspitz) roud salmon-pink plaques
-tx: topical nonfluorinated corticoesteroids (mometasone, hydrocortisone), warm water soaks, 1-5% coal tar, oral proralens
contact dermatitis
-por concancto con allergents and irritants
-hipersensibilidad type 4
-eritematoso, mal delimitado
tx: pruebas cutaneas, evitar irritante, glucocorticoestoried topicos
foreign bodies
-no es emergencia (si es bateria si)
-tx: removal atraumatic manner, oil or glycerin
keratosis obturans
-acumulacion de restos descamados
-asociado a broquitis cronica y sinusitis
-diferential dx: cholesteatoma
basal cell carcinoma
-maligna mas comunde la pinna 45%
-FR: expo cronica al sol
-mutacion en gen p53 y via de señalizacion Hedgehog
-lesion nodular, ulcerada, sangrante
-dx: biopsy
-tx: photodinamic therapy with aminolevulinic acid, Topical 5-fluorouracil, Imiquimod is a topical immunomodulator, RT, Electrodessications, cryosurgery, mohs micrographic surgery
squamous cell carcinoma
-hombres mayores
-mayor riesgo de metastasis
-FR: rayos UV, de lesiones precursoras
-acumulacion de mutaciones p53, Wnt, Ras, p 16
-son placas
-tx: 5-fluoruoracilo, ablacion con laser, chemical peeles, RT, inhibidores de la tirosina quinasa, ocal excision and Mohs micrographic surgery (MMS).
melanoma of the external ear
-la mayoria en el helix
-dx: biopsia, rx torax, niveles de lactato deshidrogensasa, TAC, RM
-tx: escicion qx,
osteomas
-benigna
-pediculado, unilateral
-nucelo fibrovascular rodeado de hueso laminar
otitis media
-principal FR: disfuncion en tormpa de eustaquio
-h. influenzae y s. penumoniae y m. catarrhalsi
inflamacion en la middle ear cleft. hay dos:
-AOM
-OME
exostoses
-firme, osea, base ancha (borad-based), de hueso laminar
-lesiones multiples
-FR: agua fria
otitis media with effusion OME
-inflamacion con presencia de effusion
-tiene air bubbles
-no sintomas agudos de infección
-cronica: derrame por > 3 meses
-usually after AOM no resuelta
-my be cancer, so hacer nasalendoscpy
-tx: antibiotic, tympanostomy tubes (en pox con >3 meses y HL) + adenoidectomy (en px mayores a 3 de edad)
acute otitis media AOM
-rapida aparición de sintomas
-inflamacion secundaria a infeccion so hay fever, hyperemia, edema
-timpano red
-recurrent AOM: >3 en 6 meses o >4 en 12 meses con resolucion entre episodios
-tx: espontaneo, antibiotico (amoxi)
complicaciones de OME
-conductive HL and speech delay
-atelectasis (timpano muy retraida)
-cholesteatoma (primario por atelectasia y secudnario por perforacion timpanica)
complicaciones de AOM
-perforacion timpanica
-mastoiditis coalescente aguda
-petrous apicitis (retro-orbital pain, AOM, and ipsilateral abducens nerve paresis [Gradenigo syndrome])
-facial nerve paressi
-laberintitis (sudden sensorineural HL, vertigo and nistagmo, se forma un conducto entre perilymph and the cerebrospinal fluid)
-intracraneal complications
Acute coalescent mastoiditis
-complicacion mas comun de AOM
-hay fevers, postauricular erythema tenderness, ear proptosis
-si la infeccion avanza al esternocelidomastoidea, se puede formar absceso profundo –> Bezold abscess
-citelli abscess: se expande al digastric muscle
intracraneal complications of AOM
-Meningitis (fever, photofobia, fluctuating mental staus, rigidez de nuca, tx: myringotomy)
-Encephalitis
-Otitic hydrocephalus (letargo, papiledema)
-intracraneal abscess (s. aureus, s.pneumonaiea, h. influenzae)
-sigmoid sinus thrombosis ((picket fence fever, torticollis)
*mondid dysplasia (cochlea only 1.5 coils) : meningitis+ congenital senosrineural HL+vestibular symtoms
sensorineural HL
-por perdida de funcion de celulas ciliadas y afectacion del nervio coclear
causas:
-mas comun en adultos es presbycusis
-unilateral: tumor (schawannoma in cerebellum [ataxia, vertigo, HL], meningiomas, etc=
-infections
-TORCH
que musuclo abre la estachian tube
tensor of the elevator palati
-en sanos esta cerrada
-causas de su obstruccion: adenoid hypertrophy, failure of the contraction of tensor veli palating (like in a palsy), cleft palete
hair cells
-otoacustic emission: test that measure how the outer HC move
-we have 12, 000 outer HC, and 3,500 inner HC
sensorineural HL dx with tuninf fork
-with diapason of 256 hz o 512 hz
-rinne y weber
-normal: AC better then BN
rinne
-sensible para conductivas HL
-en el mastoid process
-sensorineural HL: escucha mas AC que BC
-conductive HL: escucha mas por BN que por AC
negativa indica que AC esta afectada
positiva indica que AC esta conservado
weber
-se pone en la cabeza
-se pregunta si escucha en ambos o mejor uno que el otro, se evalua BN
-Conductive HL: se oye mas en el afectado
-sensorineural HL: oye mas el lado sano
*lateralization a cierto lado indica que escucha mas de ese lado
presbycuisis
-causa mas comun de HL en adultos
-por perida de celulas ciliadas basales
-alelo GRM7
etiology of sensorineural HL
-presbycuisis
-infections
teratogenic exposure
-hereditarias: 2/3 so sindormaticas, 1/3 sindromaticas
(genes: GJB2–> conexina 26, o 32delH y 167delT)
TORCH
toxoplasmosis, otras [sífilis, varicela-zóster], rubéola, citomegalovirus, herpes
prevencion HL sensorineural
-vacunacion contra H. influnzae B, meningitis, measles, mumps, and rubeolla
-evitar ruidos fuertes (earplugs)
tx sensorineurla HL
-hearing aids (Lyric, for unilateral: CROS or BAHA)
-implantes cocleares (para sordera profunda)
-brainstem Auditory Implant (px con ambos NC8 por trauam o schawnomas)
-para el tinnitus (abnomral sounds as ringins): masking
vertigo
-illusion of movement
-se quejan de dizziness
-presence of nystagmus
*podemos tener nystagmus sin vertigo, pero no vertifo sin nistagmus
-dx: GS videomistagmography (VOR and VER)
2 types of vertigo
Peripheral (on the ear), its sudden, the nystagmus its unidirectional
-Benign positionla vertig, meniere diseasem vestibular neuronitits, etc
-Ask for drug use, family history, psychological factors,
Central (on the brain)
- its gradual, the nystagmus its pure vertical multidirectional
benign paroxysmal positional vertigo
–1° causa de vertigo
-es repentino, dura seg, cuando giras la cabeza al lado afectado
-sin HL
-nistgmo latent, geotropic (descendete y rotatorio) and fatigable
-its cause a semicircular canal has debris either attached to the cupula or free floating in the endolymph
-semicircular mas afectado: posterior, then horizontal y leugo superior
-hay cupulolithiasis y canalolithiasis
dx and tx of benign paroxysmal positional vertigo
-MRI a px que no responden a tx
dx: Dix-hallpike test (cabeza a 45° y luego lo bajas)
tx: epley and semontmaneuver
miniere disease/ endolymphatic hydrops
-2° causa de vertigo
-vertigo episdoico de horas
-HL fluctuante y unilateral (de low frequencies)
-tinnitus
-plenitud otica
*traes el ataque, se sienten agotados por dias, y pueden tener vomito y nausea
-increased endolymphatic fluid owing to impaired reabsorption in the endolymphatic duct and sac.
dx meniere
-audiometria (sensorineural HL de baja frequencia)
-FTA-ABS para descartar sifilis
-RM para descartar patologia retrococlear
-electronistagmografia
-VEMP
-electrocochleography (GS)
tx miniere
-dieta restringida en sodio
-diureticos
-ataques: vestibular suppressants (meclizine and diazepam) and antiemetic (prochlorperazine)
-cx: mastoidectomy (open the endolymphatic sac), vestibular nerve section, labyrinthectomy
VESTIBULAR NEURONITIS
-3° causa de vertigo
-vertigo agudo
-nistagmo lento: hacia oido lesionado
-nistagmo rapido: hacia oido opuesto
-inestabilidad psotural hacia el oido afectado
-etiology: infeccion viral (VHS1), oclusion vascular (superior vestibular nerve), inmune, brainstem or cerebellar stroke (princial de vertigo que drua varios dias)
vestibular neuronitis tx
-vestibular suppressants and antiemetics
superior semiciruclar canal dehiscence
-fenomeno de tullio (vertigo cuando ruidos fuertes)
-signo de hennebert (vertigo al valsalva)
-They have a piece of bone missing in the semicurlcar canal
-tienen autofonia (se escuchan a si mismos), inner-ear Conductive HL, no tinnitus
-dx: TAC con proyeccion Poschl
facial nerve
-Gives the movement of the face
-eye protection, speech articulation, chewing, swallowing, emotional expression
-divide a las parotid glands
-pasa por el fallopian canal
bells palsy
-inica con paralisis unilateral, aguda < 48 hrs
-asociado con disfucnion de V, VIII, IX, y X
-bell sign: cuando parpadea, un ojo no cierra y se va hacia arriba
ramsay hunt sx, VHZ
-asocaida a otalgia y varicela
-se extiende a V, IX, y X y ramas cervicales 2, 3, 4
-mayor incidenai de disfucnión cocleosacular
-meatal foramen like “physiological bottleneck”
House Brackman facial paralisis grading system
- normal
- complete eye closure easy
- complete eye closured with effort
- incomplet eye closure
- asymmetry at rest
- no movement
tx paralisisi facial
-steroids: prednisone 1mg/kg/day
-antiviral: acyclovir (in ramsey give it the first hour)
-electrical estimulation, exercises in the mirrori, eye care
-surgery (decompresse the edema)
dx facial paralisis
1° electromiography
2° electroneurography
>95% necesita descompresion
other facila nerve disorders: facial nerve neoplasm
-facial nerve hemangioma: recurrent and progressive more severe unilateral facila palsy
other facial nerve dissorders: lyme disease
-por borrelia burgdorferi
-rash adjacent to the site of the tick bite
-eritema migrants
-dx: ELISA para ver IgG y IgM
tx: tetracyclcine (No en niños, dar peniciline)
other facial nerve disoirders: AOM and mastoiditis
-acute otitis media and mastoiditis
-chronic otitis media
-necrotizing otitis externa (pathognomonic signs: otoscopic evidence of ear canal inflammation or a breach of the external canal skin [granulation tissue]) (por p. aureiginosa)
childohood facila palsy: congenital perinatal facial palsy
-malforaciones que afectan al 1 y 2 arco branquial
-sx de Möbius (dysgenesis at the brainstem) (bilateral, no movement, type 6 brackman) (gen HOX)
-
salivary glands
Mayor Salivary Glands (6): 2 parotid glands, 2 submandibular glands, 2 principal sublingual glands
*each one has an acinus (produce saliva)
parotid glands
-largest, 25 gr
-lateral an anterior to masseter muscle
-divide by the 7 NC
-Stensen duct pasa
submanidbular glands
-2nd largest, 10-15 grs
-divided by the posterior edge of the mylohyoid
-wharton duct
sublingual glands
-en la submucosa
-duct of rvinus are mutiple minor ducts
-ducts of bartholin: submandibular ducts + wharton duct
Mumps
-most common viral causing parotitis
-bilateral swelling, pain, tenderness, malaise, trismus
-tx: autolimita, NSAIDS
acute suppurative sialadenitis
-usually in parotid
-purulent discharge in the duct
-puede haber a la palpación induration and a doughlike consistency of the gland
–submandibular abscess can cause Ludwig
-tx: antibiotics (SARM coverage), sialogogues
VIH of the parotid glands
-in the parotid due to presence of intraglandular lymph nodes
-bilateral parotid swelling, painless, no fever
dx: CT or USG reveal bilateral multiple cystic masess, serologic test for HIV
tx: drainage, sclerotherapy, gland excision
chronic granulomatosis sialadenitis
-acute or chronic uni or bilateral salivary swelling
-minimal pain
-FR: tuberculosis
sialolithiasis/ hydroxyapatite salivary calculi
-80-90% in submandibular gland
-swelling and pain exacerbated with eating
-hisotry of xerostomia, and sandlike sensation
-stone in the floor of the mouth
-tx: intraoral extration (if its on the anterior portion) or surgical excision (stone its too big)
Chronic sialadenitis
-decreased production of saliva –> salivary stasis
-inflamacion dolorsa al comer, bilateral
-RF: smoking
-Tx: parotedectomy
sjorgren syndrome
-parotid enlargment + xerostomia + keratoconjuntivitis sicca
-SS-A or SS-B autoantiboides
-dx: biopsy >1 focus/4mm^2
-lymphocitic inflitrate in acinars + epimoyoepithelial islands surrounde by lymphoid stroma
-dry eyes. mouth, vagina
sialosis
-noninflamatory, enlargement of the parotid and submandibular (bilateral, diffuse)
-FR: alcohol
-dx: acinar enlargemnet
parotyd cyst
-fluctuant swellign of the salivary glands
-congenital: (brachial cleft anomalies) type 1 (ectodermal) y type2 (mesodermal and ectodermal)
-adquired
mucoceles/mocous retentions cyst
-trauma of minor salivary gland ducts
-acumulated mocus secretations
-plane, smooth, bluish
-simple ranula: true cyst
-plunign ranula: pseudocyst
xerostomia
dry mouth, alterated taste
ptyalism
-saliva hyperproduction
-tx: drying agents or cx of the chroda tympani nerve
benign neoplasic disorders
-80% in th parotyd gland
-most common: epithelial tumors
-slow growing, painless, solitary
dx: fine needle aspiration
tx: surgical excision
pleomorphic adenoma
-most common neoplasm of the salivory gland
-epithelia + myoepithelia +stroma elements
-isolated swelling
warthin tumor
-FR: smoking
-only on th parotid gland
-males
-bilaterl and multicentricity
-well defined mass in the posterioinferior segmento del lobulo superior de la parotids
-oncocytes papilary structures
stridors
inspiratory: obstruction at the larynx or above
expiratory: distal
biphasic: subglottic
voice, donde esta la obstruccion
-muffle voice: supraglotic or epiglotis
-hoarse voice: laryngeal
-breathy/cry voice: vocal cord
ororfaringeal and nasopharyngeal airways
px < 8 de glasgow
tracheotomy
-trasnverse incision 2 anillos abajo de sternal notch. (vertical only in emergency)
complicatiosn of tracheotomies
-early: infection, hemorragia, emfisema, penumomediastino, neumotorax, fistual traqueesofagal, RL nerve injury, tube dislacement
-delayed: traqueal innominate artery fistula
-tracheal estenosis
-delayed tracheoesophageal fistual, tracheocutaneo fistula
Que musculos del ojo inerva el 3 par craneal
recto superior, inferior, interno, elevador del párpado, oblicuo inferior,
que musculos del ojo inverva el 6 p y 4 ar craneal
6: recto externo
4: oblicuo sup
