OTORRINO P2 Flashcards
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
mixed HL
-AC: >25
-BC: >25
-ABG: >10
-ej: otosesclerosis and presbycusis, uno y uno
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
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
tympanometry
measures the movement of the tympanic membrane
-speaker at 225 hz
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
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
exostoses
-firme, osea, base ancha (borad-based), de hueso laminar
-lesiones multiples
-FR: agua fria
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
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
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)
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)
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
complicaciones de OME
-conductive HL and speech delay
-atelectasis (timpano muy retraida)
-cholesteatoma (primario por atelectasia y secudnario por perforacion timpanica)
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
TORCH
toxoplasmosis, otras [sífilis, varicela-zóster], rubéola, citomegalovirus, herpes
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
etiology of sensorineural HL
-presbycuisis
-infections
teratogenic exposure
-hereditarias: 2/3 so sindormaticas, 1/3 sindromaticas
(genes: GJB2–> conexina 26, o 32delH y 167delT)
presbycuisis
-causa mas comun de HL en adultos
-por perida de celulas ciliadas basales
-alelo GRM7
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
dx facial paralisis
1° electromiography
2° electroneurography
>95% necesita descompresion
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)
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
