PD ENT Flashcards
Inspection and otoscopy of ear
External ear
External auditory canal
Tympanic membrane
Palpation of ear
External structures
Hearing tests
Whisper test
Weber test
Rinne test
What questions do we ask about difficulty of hearing?
Onset of hearing loss
Unilateral or bilateral
What factors could contribute to hearing loss?
Medications (aminoglycosides)
Trauma
Vertigo
Family Hx of hearing loss
Inspection of external ear
Mastoid process Auricle Tragus Scaphoid fossa Helix Antihelix Lobule Auditory canal Meatus
Assessment of ears
Position
Shape
Color
Lesions
Position of ears
Down syndrome
Outstanding ears
Shape of ears
Microtia Creased lobule Elongation Replcaition of lobes Gouty tophus Cauliflower ear Darwin's tubercle
Color of ears
Inflammation
Infection
Hemangiomas
Lesions of ears
Scars Hematomas Dermatitis Trauma Infectious processes
Area surrounding the ears
Always look behind patient's pinna Battle sign Preauricular pits Erythema Edema
Hair distribution in ears
Hairy tragus
Hairy pinna
Microtia
Gross hypoplasia of the pinna Blind or absent auditory canal Bilateral Could have completely formed and functioning cochlea Helped with hearing aides and surgery
Preauricular pits
Autosomal dominant, unilateral 75%
Can become infected
Surgical excision if repeated infections
Outstanding ears
Angle between auricle and side of head is greater than normal
Not pathologic
Easily surgically corrected
Darwin’s tubercle
Small cartilaginous protuberance, most commonly along concave edge of posterosuperior helix
Normal variation
Gouty tophi
Deposits of uric acid crystals
Hairy tragus/pinna
Most common in men, occurs with aging
Common in people of Indian descent
Creased lobe
May be associated with increased risk for CAD
Hematomas
Cause
Sequela
Accumulation of blood between skin and cartilage
Blunt trauma most common cause
Inspect for trauma and check hearing
Cauliflower ear is late sequela
Cauliflower ear
Cause
Caused by repeated trauma to auricle
Subperichondrial separation with focal generation of fibrous tissue and scar formation
Potential hearing loss, can be surgically corrected
Keloid
Abnormal wound healing
Excessive bulk produced at site of cutaneous injury (highly compacted bundles of hyalinized collagen)
Common in AA, and older than 20
Battle sign
Hematoma behind the ear
Indication of base of skull fracture
Palpation
Nodules Swelling Tenderness Warmth Assessment of lesions
Otoscopy
Visualize auditory canal and TM
Otoscopy in adults versus children
Adults: pinna upward and outward
Children: pinna down and back
What does straightening of the canal allow for?
Better visualization of the tympanic membrane
Where does the auditory canal start and end?
External auditory meatus and medially TM
What joint makes up part of the posterior external auditory canal wall?
TMJ
Skin adheres to periosteum along the … and to cartilage and soft tissue along the …
Inner 2/3, outer 1/3
Skin of the outer 1/3 contains what structures?
Hairs and glands that secrete cerumen
Where is cerumen not produced?
Middle or inner canal
What is the average length of the auditory canal?
3.7 cm
Innervation of auditory canal
CN V, VII, X
What does the stimulation of a small branch of the vagus nerve (Arnold’s nerve) do to the patient?
Cough during exam
What is the blood supply to the auditory canal?
Branches of auricle temporal branch of the inferior maxillary artery
The canal … from the pinna to the TM
Conducts sound waves
Cerumen impaction
Painful depending on extent of cerumen
Conductive hearing loss
Common in elderly and children
Tx for cerumen impaction
Debrox drops, irrigation, curette/otoloop
Otitis externa
Swimmer's ear, common in summer Painful infection of skin Swelling erythema or canal Pinna edematous and red Narrowed lumen with purulent drainage
Bacterial causes of otitis externa
Pseudomonas, Staph aureus
Tx of otitis externa
Otic drops, oral abx
Common foreign body in the ear
Q tip, beans, peas, jewelry
Common in kids and psych
Result from foreign body
Complete conductive hearing loss
Caution with foreign body
Don’t irrigate if organic material suspected or insects
Carefl not to cause TM perforation
Exostosis
Small boney growths of canal
Benign
Multiple and bilateral
Aris more commonly near TM
Exostosis Tx
Usually no tx necessary unless recurrent cerumen impactions
Cholesteatoma
Overgrowth of epidermal tissue, usually in pts with hx of chronic otitis media
Canal or middle ear
Painful, erode into bone
Conductive or sensorineural hearing loss
Middle ear
Small air filled cavity within temporal bone
Lined with squamous epithelium
Boundaries of middle ear
TM oval window and round window
What is the opening in the posterior wall in the middle ear?
Opening to mastoid sinus
Where does infection of epithelial lining of the middle ear come from?
Nasopharynx via the eustacian tube
What structure transmits sound waves through the middle ear?
TM vibrates, transmitting sound waves from the canal into mechanical motion, setting the ossicles into motion
Ossicles
Malleus, incus, stapes
Augment vibrations and distribute mechanical energy to cochlea
Eustachain tube
Connects middle ear to posterior portion of nasopharynx
Neutralizes internal and external air pressures
Why do children have more otitis media infections?
Eustachian tube is much smaller and more horizontal, so pathogens are more easily introduced to the middle ear
Otitis media
Hx of recent URI
Bacterial or viral
More common in infants and children
Unilateral
Complications of otitis media
Mastoiditis Meningitits Osteomyelitis Sigmoid sinus thrombosis Facial nerve involvement
Common pathogens causing otitis media
Strep pneumoniae
Haemophilus influenzae
M. cattarhalis
S&S of otitis media
Pain Fever Erythematous, building TM Decreased TM mobility TM may rupture and cause purulent drainage in external auditory canal Decreased hearing Effusion behind TM
Serous otitis media
Pts
Can procede AOM
May be due to poor Eustachian tube function
May be concurrent with URI
Common in people with allergies
Look for fluid, bubbles behind TM, TM not inflamed
Bullous myringitits
Otalgia
Erythematous TM
Blisters
Accompanies URI symptoms
Pathogens of bullous myringitits
Mycoplasma pneumoniae
Virus
Cause of TM perforations
Trauma
Infection
Barotrauma (divers, airplane)
Results of TM perforation
Conductive hearing loss
Increased risk of infection
Cuase of TM scarring
Previous infections
Trauma
Perforations
Results of TM scarring
Decreased hearing over time due to decreased mobility of TM
Otosclerosis
Progressive hearing loss
Due to deposition of bone in cochlea/stapes foot
S&S of otosclerosis
No pain
Tinnitus
Normal TM
Patent Eustachian tube
Common in females, 30-40, familial tendency
Tx otosclerosis
Stapedectomy
Hemotympanum
blood in middle ear behind TM
Result of head trauma or severe barotrauma
Could be painful
Tx hemotympanum
Spontaneous resolution over several weeks is normal
Result of hemotympanum
Could result in conductive hearing loss
Pneumatic otoscopy
Done if loss of mobility of TM is suspected
Puff of air from otoscope gulf creates a positive pressure, and the TM should move inward, then return to normal position quickly
No movement or decreased movement during pneumatic otoscopy
Increased pressure within middle ear is suspected
Cause of no movement
Porr functioning Eustachian tube
Fluid within middle ear
Is pneumatic otoscopy part of the normal physical exam?
No
What are the three hearing tests?
Whisper
Rinne
Weber
Whisper test
Occlude opposite ear, stand behind patient and whisper words for patient to repeat, or ask a simple question and ask for an answer
Patient should be able to hear your whisper from 1-2 feet away from their ear
What does the whisper test test?
Grossly defines hearing
What does the Weber test test?
If hearing loss is noted in history or detected on exam
Weber test
Bottom of vibrating tuning fork is placed on midline of patient’s head
Ask patient if sound is heard equally in both ears, or better in one ear (lateralization of sound)
Should be heard equally
2 abnormal results of Weber test
Conductive hearing loss in the lateralizing ear
Sensorineural loss in the ear opposite of the lateralizing ear
What test is used as a follow up after the Weber test?
Rinne test
Rinne test
Placing the base of vibrating tuning fork against patients mastoid process
Ask when patient no longer hears the sound
Quickly position vibrating fork 1-2 cm from auditory canal and ask when sound is no longer heard
Count the time sound is heard
What is a normal Rinne test?
Air conduction is twice as long as bone conduction
Conductive loss in Rinne test?
Bone conduction is longer than air conduction in affected ear
Sensorineural loss in Rinne test
Air conduction is longer or equal to bone conduction in affected ear
Functions of the nose
Airway Warms air Filtration of dust particles, pathogens Humidification of air Receives secretions from sinuses and eyes Peripheral organ of smell
CN for smell
CN I Olfactory
History complaints relating to the nose
Nasal obstruction Discharge Epistaxis Change in sense of smell Trauma Itching nose Olfactory hallucinations
Inspection of nose
Shape Size Color Patent nares Columnella, septum midline Ala flaring Discharge Lesions
External/middle/inner ear - conductive/sensorineural
External middle ear - conductive hearing loss
Inner ear - sensorineural hearing loss
Rhinophyma
Bulbous enlargement of the distal 2/3 of nose from multiple sebaceous adenomas
Follows long standing rosacea
Saddle nose
Causes
Sunken bridge
Loss of cartilage from septal hematoma or abscess
Congenital or acquired syphilis
Internal inspection
Stabilize head, tilt head back
Gently introduce speculum
Avoid touching septum
Observation of internal inspection
Anterior nares Mucosa Septum Turbinates Posterior nares
Inspection of mucosa
Edematous Pale Erythematous Moist/dry Discharge
Inspection of septum
Deviation
Perforation
Posterior nares
Open to the nasopharynx
Watery clear discharge
Allergies
Vial rhinitis/URI
Rhinitis medicamentosa
CSF leak
Purulent discharge
Viral URI
Bacterial sinusitis
Foreign body
Serosanginous discharge
Trauma
Neoplasm
Bloody (sanginous) discharge
Trauma Coagulopathies Carcinoma Vasculitis HTN Ulceration Drug use
Nasal polyps
Examples
soft protrusions of mucosa
Pale, edematous, non tender
Chronic allergic rhinitis
Positive relationship with asthma
What do you need to determine with epistaxis?
Anterior or posterior bleed
Which is more common, anterior or posterior bleeds? Which is more serious?
Anterior is most common 90%
Posterior has greatest risk to hemorrhage
Anterior bleed
Causes
Risk factors
Digital trauma to Kiesselbach’s plexus
Trauma, dry/cold weather, dehydration, blood thinners
Anterior bleed tx
Small - cauterize with silver nitrate sticks
Extensive - nasal packing
Posterior bleed
Risk factors
Acute blood loss anemia
HTN, coagulopathies, blood thinners, carcinoma
Posterior bleed tx
Posterior packing
Transfusion
Hospitalization*
What is the most common malformation of the nasal airway?
Choanal atresia
Choanal atresia
Who present with it?
Congenitally closed orifice
Usually infants have difficulties breathing with first URI
If bilateral, respiratory distress at birth
Hyperosmia causes
Addison’s disease
Allergies
Hunger
Nausea
Cacosmia
Causes
Perception of four odor when one doesn’t exist
Sinusitis
Psych DO
Tumor
Tetracyclines
Anosmia causes
Infection Allergies Septal deviation Pregnancy Tumor Trauma to head or nose Sjogren's syndrome Diabetes Polyps Zinc deficiency Vitamin A deficiency Schizophrenia
Paranasal sinus tenderness
Palpate over frontal and maxillary sinuses looking for swelling or tenderness
Percuss sinuses
Causes of sinus tenderness
Swelling, tenderness, and pain may indicate infection or obstruction
Functions of oropharynx
Emission of air for vocalization and respiration
Passageway for food, liquid, saliva, vomitus
Initiation of digestion - mastication and salivary enzymes
Identification of taste
History of complaints for oropharynx
Pain Lesions Difficulty swallowing/chewing Dry mouth Excess salivation Decreased taste, bad taste Halitosis
Inspection of lips and mouth
Symmetry Color Swelling/edema Moisture Lesions
Pallor in lips causes
Anemia
Vitamin deficiencies
Scarlet fever
Cyanosis in lips causes
Hypoxia
Cardiac and respiratory DO
Erythema in lips causes
CO poisoning
Infection
Allergy
Swelling edema in lips causes
Allergies
Trauma
Infections
Dry lips and mouth causes
Dehydration
Mouth breathing
Sjogren’s syndrome
Lesions in lips in mouth causes
Neoplasm
Infection
Irritations
Cheilosis
Fissures/cracks at angles of lips
Causes of cheilosis
Dehydration Ill fitting dentures Nervous habit Riboflavin deficiency Medications (chemo) Malignancy
Angioedema
Causes
Swelling of one or both lips
Develops rapidly
Usually not pruritic
Allergic reaction, anaphylaxis, infection
SCC
Non painful Lesions grow slowly, often bleed Non healing Most common oral tumor Hx of sun exposure
Herpes Simplex Virus
HS1, could be HS2
Groups of vesicles with clear fluid on erythematous base
May be painful, burn
Develop in times of illness or stress
Petz Jehger’s syndrome
Associated with…
Blue or black patches of pigmentation in skin or mucosa (buccal, fingers, hands, face)
Associated with FAP, internal bleeding, anemia
Chancre
Primary lesion of syphilis
Painless, raised border
Button like
Can become crusted or ulcerated
Inspection of teeth
Number Missing or loose Dental hygiene Color, staining Shape Caries Malocclusion Abscesses Dental appliances
Malocclusion
Crowding of teeth
Upper molars should rest directly on lower molars and upper incisors should override lower incisors slights
Causes of malocclusion
Congenital
Trauma
Jaw pain
Thumb sucking
Hutchinson teeth
Cause
Notching of the permanent upper central incisors
Small than normal, tips resemble a cone
Congenital syphilis
Tetracycline staining
Mother took tetracycline while in utero, or tetracycline was given as a child
Before 1980
Inspection of gingiva
Color Bleeding Swelling Hyperplasia Masses/lesions
Gingivitis
Inflammation of the gums
Erythematous, swollen, bleeds easily
Causes of gingivitis
Poor hygiene Systemic infection Leukemia Vitamin deficiencies Pregnancy OCP DM
Gingival hypertrophy
Insidious onset
Non painful
Non pathologic
Causes of gingival hypertrophy
Dilatin Cyclosporin Leukemia Pregnancy OCP Genetic disorders Crohn's Sarcoidosis
Peridontitis (pyorrhea)
Receding and bleeding gums Often painful Halitosis Pus pockets form between gums and teeth Anaerobes
Cause and result of peridontitis
Caused by untreated gingivitis
Common cause of tooth loss
Periapical abscess
Tender swelling in adjacent gum
Sinus tract may form draining pus
Common cause of toothache
Pain accentuated by tapping tooth
Scurvy
Vitamin C deficiency
Deep red/purple, swollen gums
Tender, bleed easily
Vincent stomatitis
Trench mouth, acute necrotizing ulcerative gingivitis
Abrupt onset, painful, increased salivation
Punched out ulcers covered in gray yellow membrane
Halitotis is horrible
Systemically ill
Cause of vincent stomatitis
Anaerobes (Fusobacterium)
Kaposi sarcoma
Malignancy of vascular origin
Red/blue plaques and nodules
Commonly found on skin
Seen in advanced AIDS
Inspection of buccal mucosa
Color Moisture Exudates Masses, lesions Ulcers Stensen's duct
Apthous ulcers
Canker sores
Painful ulcers with white floor and yellow margins on erythematous base
Anteriorly in mouth on tip or sides of tongue and labial/buccal mucosa
Cause of apthous ulcers
Virus
Malnutrition
Stress
Oral candidiasis
White, raised exudates on buccal mucosa, palate, pharynx, or tongue
Can interfere with taste and eating
Scrapable
Not painful
Risk factors for oral candidiasis
Antibiotics Steroids Immunosuppression HIV/AIDS Cancer, chemo DM
Leukoplakia
Appears anywhere in oral cavity
Painless white plaque adherent to mucous membrane
Not scrapable
Premalignant lesions
Risk factors for leukoplakia
Smoker
HIV/AIDS
Autoimmune DO
Alcohol abuse
Fordyce spots
Mucosal sebaceous cysts
Small white or yellow spots on mucosa of lips, cheeks, tongue
Painless, non pathologic
Inspection of palate
Continuity of palate (clefts)
Lesions
Masses
Color
Cleft palate
Midline opening in hard palate due to congenital failure of fusion of the maxillary process
Usually associated with cleft lip
Severity varies
Complications of cleft palate
Breathing and speech difficulty Hearing deficits Chronic otitis media Degluttination deficits Improper teeth development/feeding problems
Torus palatinus
Bony outgrowth of the palate Non painful Benign Arises in puberty 25% women, 15% men
What is the bony outgrowth of the mandible?
Torus mandibularis
Inspection of the uvula
Color Size Lesions Masses Deviation
Bifid uvula
May indicate underlying cleft palate
Need to palpate palate to assure bony closure
Uvular deviation causes
Peritonsillar abscess
Lesion/defect of CN X
Which way will the uvula deviate with a lesion?
Have patient say ahh
Uvula will deviate away from side that has lesion/defect
Soft palate on affected side will not rise
Inspection of the tongue
Size Papillae Deviation Moisture Masses/lesions Dorsal and ventral surfaces
Tongue deviation
Due to lesion/abnormality of CN XII or muscle weakness of tongue muscles
Which way will the tongue deviate?
Towards side of the lesion or weakness
Fissured tongue
Median sulcus is deepened
Dorsal surface interrupted with transverse furrow
Harmless, inherited
What would longitudinal furrowing indicate?
Syphilitic glossitis
Geographic tongue
Migratory glossitis
Irregular patches of bright red denuded epithelium - no papillae
Patches heal in a few days, only to develop new ones in other areas
Harmless, idiopathic
Varicose veins
Normal, more common in elderly
Hairy tongue
Overgrowth of filiform papillae
Yellow, brown, green, black
Bacterial or fungal overgrowth may play a role
Non pathologic
Risk factors for hairy tongue
Poor oral hygiene
Antibiotics
Smokers
Coffee drinker
Glossitis
Sore, painful, tnder, erythematous tongue
Causes of glossitis
Nutritional deficiencies Autoimmune Medications Smoking, alcohol Infection Trauma Dehydration
Atrophic glossitis
Atrophy of papillae Dryness Intermittent burning Paresthesia of taste Tongue becomes smaller Slick and glistening surface Small, punctate red dots
Cause of atrophic glossitis
Poor nutrition
Alcoholic with vitamin deficiencies - folic acid, B vitamins
Inspection of pharynx
Presence of tonsils Size of tonsils Swelling Exudate Post nasal drip Masses, lesions
Grading tonsillar size
1 - visible
2 - halfway between tonsillar pillars and uvula
3 - touching uvula
4 - touching each other (kissing tonsils)
Pharyngitis accounts for 20% of … and 50% of …
Outpatient sick visits
Outpatient antibiotics
Bacterial causes of pharyngitis
Group A Strep
Neisseria gonorrhea
Corneybacterium diptheriae
Viral causes of pharyngitis
Rhinovirus HSV CMV Adenovirus Echovirus EBV Parainfluenza Coxsackie virus
Other causes of pharyngitis
Allergies Sinusitis GERD Peritonsilar abscess Carcinoma Fungal infections
Incubation of Group A strep
2-5 days
Symptoms of Group A strep
Sore throat Fever/chills Malaise Headache Nausea Vomiting Abdominal pain
PE with Group A strep
Erythema of pharynx and uvula
Enlarged tonsils, patchy white exudates
Enlarged, tender anterior cervical LN
Diagnosis for Group A strep
Rapid strep test
If negative, culture for 24 hours
Tx for Group A strep
Pen VK
Amoxicillin
Erythromycin
Viral pharyngitis tx
NO ABX
Motrin, tylenol
Warm salt water gargles
Lots of fluids and rest
Diphtheria S&S
Sore throat Hoarseness Malaise Fever Nasal discharge Tenacious gray membrane on pharynx, tonsil, palate, or uvula
Diphtheria cause
Corneybacterium diphtheriae
Complications of diphtheria
Myocarditis
Neuropathies
Infectious mononucleosis
Fatigue Malaise Fever Lymphadenopathy Pharyngitis Headache Hepatosplenomegaly
Cause of mono
EBV
CMV
Tx for mono
Rest Fluids Proper nutrition Time Avoid contact sports and heavy lifting NO ABX
Peritonsillar abscess S&S
PAIN Deviation of uvula Fever Odynophagia Hot potato voice LAD
Tx for peritonsillar abscess
I&D often required
Abx, usually IV to start
Oral HIV/AIDS manifestations
Hairy leukoplakia Oral candidiasis Herpes simplex Kaposi's sarcoma Apthous ulcers Peridontal disease
