Week 4 EENT Resp Flashcards
Risk factors for hearing loss?
- older age
- male
- lighter complexion
High frequency loss
- low education
- toxic noise exposure
Presbycusis
-what type of hearing loss? (sensorineural or conductive?)
SNHL
symmetric and insidious
high frequency tones first
“I can hear you but I can’t understand you”
When to screen for hearing loss in older adults?
-insufficient evidence to support asymptomatic screening in older adults
- whisper test has good sensitivity and specificity in older adults
- “do you feel you have any difficulty hearing?”
- “has anyone told you you have difficulty hearing?”
screen especially if cognitive concerns OR depressive symptoms
Indications for ENT referral?
*sudden acute or rapidly progressive hearing loss (<72 hours) is URGENT referral
- unilateral or pulsatile tinnitus
- hearing loss with hx of noise exposure, fam hx, TB, syphilis, HIV, Meniere, autoimmune, ototoxic med, otosclerosis
- acute recurrent chronic dizziness
conductive or sensorineural hearing loss?
- cerumen
- presbycusis
- Meniere’s
- otitis externa/media
- diabetes
- otosclerosis
- cerumen: C
- presbycusis: S
- Meniere’s: S
- otitis externa/media: C
- diabetes: S
- otosclerosis C
Common ototoxic medications
“don’t loop and snag my plate Christine Quinn”
“Don’t Loop and SNAG My Plate Cristine Quinn”
• Loop diuretics: furosemide • Salicylates: high dose ASA • NSAIDs: Ibuprofen, Indomethacin • Antibiotics: tetracyclines, macrolides • aminoglycosides • vancomycin • PDE5 inhibitors: tadalafil • chemotherapeutic agent: such as cisplatin Quinine
red flags for red eye
-decreased VA (unless vision clears with blinking)
-pain
-photophobia
-coloured halos
-ciliary flush
-corneal opacification
corneal disruption (fluorescein uptake)
-abnormal pupils
-increased IOP
-proptosis
***same day access to ophthalmology
Blepharitis
- signs and symptoms
- management
red eye, no red flags
flaky deposits on eyelashes
worse in AM
Treatment:
- warm compresses 3-5 min BID
- eyelid scrub (2 drops baby shampoo in 2 oz water) BID if oily
- lubricating eyedrops BID/TID
Dry Eye Disease aka keratoconjunctivitis sicca
what is the most important treatment?
- identify exacerbating factors
- minimize contributing meds
Dry eye disease (sicca)
risk factors?
Non modifiable risk factors
- Female sex
- Sjogrens
- age
Modifiable -dry enviro -meds -blepharitis -smoking -alcohol use contact lens use -LASIK pollution, activities with decreased blinking -topical ocular meds
- poorly fitting sleep apnea masks
- Parkinson
- peripheral neuropathy
- lid abnormality
- thyroid disease
Treatment for dry eye disease?
- hot compresses
- artificial tears
- nighttime lubrication ointments
**artificial tears with preservatives used >QID will worsen symptoms **
What are some medications that can cause dry eyes?
Medications that may impair aqueous production include the following: • Antihistamines • Beta blockers • Phenothiazines • Atropine • Oral contraceptives • Anxiolytics • Antiparkinsonian agents • Diuretics • Anticholinergics • Antiarrhythmics • Topical preservatives in eye drops (eg, benzalkonium chloride [BAK], thimerosal) • Topical anesthetics • Isotretinoin
DDx for acute bilateral painless vision loss?
acute unilateral painless vision loss?
stroke
**needs urgent imaging
central retinal artery occlusion
stroke
what is the pattern of vision loss in age-related macular degeneration?
begins CENTRALLY, extends PERIPHERALLY
Risk factors for age-related macular degeneration?
- age
- european descent
- genetics
- female
- SMOKING
what is the pathognomonic sign of macular degeneration?
DRUSEN (yellow deposits of macula from death of retinal cells)
symptoms of progression from early/intermediate AMD to late AMD?
- loss of far and near vision
- sudden visual distortion
- central vision loss
- change in colour vision
Cataracts
signs and symptoms
- decreased VA/blurred/dim vision
- decreased color perception
- starbursts around lights
- sensitivity to light and glare
- difficulty with night driving
- difficulty with vision at night
**cataracts are only clinical relevant if they impact ADLs
what is the pattern of vision loss with primary open angle glaucoma?
begins peripherally extends centrally
risk factors for glaucoma?
high IOP (most important risk factor) **IOP is relative
- age
- sub-Saharan African ethnicity
- family hx
- high myopia
- male
- low SES (late detection)
Symptoms of open angle glaucoma?
rare to have symptoms bilateral no ocular pain loss of central vision is late sign often unaware of peripheral vision loss
Symptoms of closed angle glaucoma?
elevated IOP >50 mm Hg mild to severe unilateral severe ocular pain blurred/cloudy vision halos headache, nausea, vomiting
Signs: ciliary flush fixed dilated pupils corneal edema worse in evening
***needs same day assessment
what change in aging causes chronic rhinosinus drainage and postnasal drip?
what groups are at highest risk of rhinitis?
nasal passages narrowed, decreased collagen
Geriatric rhinitis: lengthening of the nose and drooping of the tip –> restriction of nasal airflow and narrowing of the nasal passages –> rhinitis.
high risk groups:
- women
- younger age
- snoring
- GERD
what are the 3 components of standard PFTs?
- spirometry
- lung volume assessment
- diffusion capacity
Chronic rhinosinusitis in older adults
what is a major risk factor?
most common organism?
SMOKING is major risk factor
S. Aureus most common
4 main symptoms of sinusitis? PODS
- pain and pressure (facial)
- obstruction
- discharge (mucopurulent)
- smell loss (anosmia)
Chronic rhinosinusitis in older adults
frequent co-morbidities?
- nasal polyps
- asthma (especially severe eosinophilia asthma)
- elevated IgE levels
- otitis media
Chronic rhinosinusitis in older adults
pt counselling re: decongestants?
Decongestants: to correct underlying mucosal edema
*must limit use to 3 days to prevent rebound congestion and rhinitis medicamentosa
*overuse of oxymetazoline can lead to body being dependent on its vasoconstricting properties
*caution with HTN or cardiac disorder
• Oxymetazoline (Afrin) 0.05% 1-2 sprays each nare 1-2x/day
• Phenylephrine 1% spray/drops 1-2 each nare q4h
*Use with caution in older adults! Especially with HTN or enlarged prostate
Chronic rhinosinusitis in older adults
pt counselling re: nasal corticosteroid sprays?
Nasal corticosteroid sprays: to reduce nasal inflammation
*lean forward, angle spray towards cheek, minimal sniffing
*never use with head back (in sniffing position) or pointing to septum
• Fluticasone propionate (Flonase) 50 mcg/spray
• Mometasone (Nasonex) 50 mcg/spray
• Beclomethasone (Beconase) 42 mcg/spray or Qnasl) 80 mcg/spray
• Budesonide (Rhinocort) 32 mcg/spray
Safe for older adults, but can cause epistaxis
What is the spirometry finding that confirms diagnosis of asthma?
FEV1 > 12% after bronchodilator
this is demonstration of reversibility
- need to use age-adjusted spirometry value
- greater variability = greater confidence in asthma
Asthma
What are some
common triggers?
which medications?
viral infections (common in older adults) allergens smoke exercise stress
Medications:
beta-blockers, ACE-I, ASA, NSAIDs, COX-2
4 questions to ask to determine level of asthma control
in the last 4 weeks
- daytime symptoms > 2 x/week
- any night wakening due to symptoms
- SABA use > 2 x/week
- any exercise limitation due to symptoms
partly controlled = 1 to 2
poor control = 3 to 4
signs and symptoms of interstitial lung disease?
Dyspnea
Cough
Dry inspiratory bibasilar crackles
Clubbing (40-70%)
risk factors for interstitial lung disease?
Risk factors:
- environmental/occupational exposure: silica, asbestos, mold
- autoimmune
- drug-induced
- family hx
Findings on CXR and high res CT for interstitial lung disease?
CXR: reticular opacities in mid and lower lobes
CT: reticulation and honeycombing
Risk factors for PE
- cancer (strongest risk factor)
- surgery
- traumatic fractures
- prolonged bed rest/sedentary factors
- hx of DVT or PE
- meds: tamoxifen, HRT, oral contraceptives
**many are unprovoked
What is D-dimer?
age-related changes associated with D-dimer?
fibrin degradation product –> small protein fragment after a blood clots is degraded by fibrinolysis
D-dimer can exclude VTE if low clinical probability of PE
D-dimer INCREASES with age so older patients have higher change of false-positives
Components of Wells score for PE
- clinical suspicion for DVT
- tachycardia (HR >100 bpm)
- immobilization (3+ days) or surgery in last 4 weeks
- hx of DVT/PE
- hemoptysis
- cancer treatment or palliative
- alternative diagnosis less likely
Findings on physical exam for PE:
- vitals
- resp
- CV
- DVT
- Vitals: tachycardia (often absent), tachypnea (57-90%), hypotension, hypoxemia, low grade fever (40%)
- Resp: decreased air entry, rales, (50-58%) wheezing
- CVS: parasternal heave, increased JVP, loud P2 (from R ventricular overload), pleural chest rub, cyanosis
- DVT symptoms: asymmetrical swelling, tenderness, pain
Signs and symptoms of PE
PE's are frequently asymptomatic ******Dyspnea at rest or with exertion (73% of symptomatic pts) • Palpitations *******Pleuritic chest pain (66%) • Hemoptysis (only in 13%) • Anxiety/apprehension • Syncope (not common) Signs of DVT (asymmetric lower extremity swelling, pain, erythema)
Imaging workup for suspected PE?
- US for DVT
- CT pulmonary angiogram or V/Q scan
risk factors for aspiration pneumonia?
poor oral care
-esp gram negative organisms
What are the 5 A’s of smoking cessation?
- ask
- advise to quit
- assess willingness to quit
- assist in quit attempt
- arrange follow up
CT chest should be done for lung cancer screening in high risk patients
what are the risk factors?
- age 55-74, and
- at least 30 pack year history of tobacco, and
- smoking within the last 15 years.
OSA is a risk factor for what 2 conditions?
strokes
cardiovascular diseases
OSA
symptoms?
Daytime: sleepiness, fatigue (mental and physical), falling asleep while watching TV/reading, morning headaches, dry mouth
Nighttime: restless sleep, loud snoring/gasping/snorting
OSA
STOP-BANG
- snoring
- tired during the day
- observed apnea
- pressure (HTN)
- BMI > 35
- Age > 50
- Neck circumference > 16 inches (40 cm)
- Gender: male
What is the difference between obstructive and restrictive lung disease?
obstructive: PROXIMAL
- difficulty exhaling air all the way out (hyperinflation)
restrictive: DISTAL lung parenchyma
- difficulty filling lungs
3 types of respiratory infections in the elderly?
- community-acquired pneumonia
- acute exacerbation of chronic obstructive pulmonary disease
- non pneumonic respiratory tract infection.
CURB-65 for CAP
-what does CURB stand for?
- confusion
- uremia (BUN)
- resp rate >30
- BP: SBP <90, DBP <60
Age: 65 and older
(can omit U for CRB-65)
**score of 0 = <2% mortality, ok to treat as outpatient, any score above 0 consider hospital assessment
Pulmonary TB
common lymph nodes involved:
anterior or posterior cervical and supraclavicular nodes
Less commonly involved: submandibular, axillary, and inguinal lymph nodes.
What is the gold standard diagnostic test for pulmonary TB?
Sputum culture with acid-fast smear (AFB) x 3 samples: gold standard for detection of active pulmonary TB
*ideally in the morning, can be collected same day at least 1 hour apart
What is the diagnostic finding on spirometry for ASTHMA?
Spirometry showing reversible airflow
12% or greater improvement in FEV1 and >200 mL from baseline after bronchodilator
Signs and symptoms of pulmonary fibrosis?
Typically age 60+ with hx of smoking
Symptoms: gradual onset of SOBOE and several months of non-productive cough
Exam: bibasilar crackles
-finger clubbing is advanced sign
How often should hearing screening be done?
for all adults 60+: every 2 years
annually if hearing loss detected
*not covered by MSP
Infective endocarditis prophylaxis
antibiotics are recommended in prior to dental cleaning and extractions in these following conditions
- prosthetic cardiac valve
- hx of IE
- congenital heart disease
- cardiac transplant recipients who develop cardiac valvulopathy
Infective endocarditis prophylaxis
first line med? dose (for adults)?
amoxicillin 2 g po single dose 30-60 min before procedure
Acronym RULE for oral cancer lesions?
red or red/white lesion
ulcer
lump
especially if in combination OR indurated
**these need to be biopsied
Risk factors to consider for oral cancer?
- smoking
- smokeless (chewing) tobacco
- alcohol consumption
- sores in mouth
- hx of childhood cancer
- feeding via G/J-tube
- inhaled corticosteroids
Management of dry mouth (xerostomia)?
- stimulate saliva flow with sugar-free candies and lozenges or chewing gum
- artificial saliva if insufficient benefit
Common auto-immune cause of xerostomia?
Sjogren’s syndrome
Xerostomia increases risk of ______
candidiasis
-• Saliva is part of the natural defense system with anti-viral, anti-fungal, antibacterial properties.
As salivary flow decreases (due to many causes), Candida count increases thus patients have a higher prevalence of Candida infections
symptoms:
burning, mouth pain, or sensitivity and may exhibit apparent resistance to treatment for symptoms of oral dryness.
definition of sinusitis timeline
acute:
subacute:
chronic:
- acute: up to 4 weeks
- subacute: 4-12 weeks
-chronic: 12+ weeks
acute viral usually is <10 days, then usually clears or transforms into bacterial sinusitis
Presentation of pneumonia in older adults:
- low grade temp (oral >37.8)
- fever can be absent in 30-50%!*
- increased O2 requirements
- CONFUSION!
- falling
- anorexia
True or false: the colour of nasal discharge indicates bacterial vs viral sinusitis
first line tx for bacterial sinusitis?
FALSE
-colour of discharge indicates inflammation but not of bacteria
first line:
amoxil 500 mg TID x 5 days
high dose amox (1 g TID) OR amox-clav 875 mg if antibiotic use in the last month, age >65, close contact with child in daycare, immunocompromised, comorbidities (DM, heart), smoker
risk factors for cataracts
diabetes
long term use of topical, systemic
intravitreal, inhaled, or oral corticosteroids
prior intraocular surgery
cataracts
finding on eye exam
darkening of the red reflex
opacities within the red reflex
or
obscuration of ocular fundus detail
when red reflex is lost –> this is a mature cataract
nuclear cataracts
affect distance or near vision?
distance is affected far more
most common in old age
progresses very slowly
which two types of cataract are more common with diabetes?
cortical
posterior subscapular (very quick progression, usually changes in night vision first)
signs and symptoms of cataracts
Decreased visual acuity, blurred or dim vision, decrease color perception
Increasing difficulty with vision at night
Sensitivity to light and glare
signs and symptoms of closed angle glaucoma
ocular pain redness blurry vision headache nausea visual halos
**ciliary flush
what medications increase risk for closed angle glaucoma?
Sympathomimetics&anticholinergic drops TCA MAOIs antihistamine antipsychotic antiparkinson antispasmodics sulpha
infective endocarditis prophylaxis
med?
indication?
amoxil 2 g po 30-60 min prior to procedure
- prosthetic valves
- hx infective endocarditis
- cardiac transplants that end up with valve issues
- congenital cardiac conditions ONLY CERTAIN
symptoms venous insufficiency
pain/aching worst at end of day
edema to ankle and calf, relieved by elevation
stasis dermatitis
hemosiderin deposit and fibrosis
shallow ulcers above medial malloelus, wet, weeping, painless, irregular
BP targets for adults 60+
BP AOBP <145/85
corneal abrasion: treatment if contact wearer?
must cover for pseudomonas: cipro, genta or tobramycin
what is difference between presyncope, vertigo and disequilibrium?
presyncope: lightheaded, feeling of falling from decreased blood flow, “almost fainting”
vertigo: room spinning (labyrinthe/vestibular)
disequilibrium: unsteadiness only when standing/walking
* disappears with sitting/lying* (MSK/cerebellar/neuropathy)
what makes vertigo worse?
what makes disequilibrium worse?
vertigo: head movement
disequilibrium: walking, standing
what is the most common cause of hearing loss in older adults?
presbycusis
- symmetrical
- SNHL
- high frequency first
