Comp: ENT disease flashcards

Focus on the bold!!

Acute Viral Rhinosinusitis

• Etio: rhinovirus, influenza, parainfluenza

• S/Sx: pressure over sinuses, watery secretions, HA

• Dx: water’s view Xray, CT scan (most dx, GOLD)

• Tx: supportive care, decongestants, NSAIDS; should improve in 7-10 days

  • decongestants NOT for pts w/ cardiac problems use mucolytics (guaifensin) instead

Acute Bacterial Rhinosinusitis

• Etio: secondarily infected inflamed sinus cavity

• S/Sx: TRIAD- pain/pressure over sinuses, HA, fever; purulent secretions

• Dx: double sickening pattern; fever, 3-4 days of consecutive of purulent discharge and facial pain; CT scan (most dx, GOLD)

• Tx: Augmentin; PCN allergy → Doxy; Alt: Azith

  • adult: 5-7 days; kids: 7-10 days

Chronic Sinusitis

• Etio: sx lasting 3+ mo or 3x in 6 months; G-, Staph. A, Anaerobes

• EMERGENCY -meningitis, sepitcemia, orbital cellulitis, brain abscess, sinus thrombosis

• Dx: CT (most dx, GOLD)

Samter’s Triad

• ASA -exacerbated respiratory disease

• asthma, nasal polyps, aspirin sensitivity

  • pts w/ nasal polyps and asthma are advised to AVOID the use of ASA or NSAIDs

  • limit alcohol

Allergic Rhinitis (“Hay fever”)

• Etio: association with/ asthma & eczema; seen w/ a seasonal pattern

• S/Sx: coryza, sneezing; inflamed lower turbinate (pale and boggy), allergic salute (line on bridge of nose)

• Tx: Anti-histamines, intranasal corticosteroids (helps decrease inflammation and shrink polyps)

Viral Rhinitis (“common cold”)

• benign and self-limited

• PE: edematous, erythematous nasal mucosa and oropharynx, watery discharge, purulent nasal discharge w/ double sickness

• Tx: No curative tx, only sx relief -Afrin, tylenol, pseudoephedrine

Anterior Epistaxis

• Etio: digital manipulation, trauma, rhinitis, low humidity, HTN, cocaine, EtOH

• MC site- Kiesselbach plexus

• Tx: pressure for 15 minutes and lean forward

  • phenylephrine which is a vasoconstrictor and a topical anesthetic

  • cautery or nasal packing

Posterior Epistaxis

• associated w/ HTN, pts w/ blood thinners

• occur more in the elderly; more serious than anterior, bleeding down the throat

• MC site- sphenopalatine artery

• Tx: nasal packing necessary!! hospitalize for cardiac monitoring; if give abx must cover for staph

Vestibulitis

• Etio: S. Aureus from folliculitis

• Tx: mupirocin (Bactroban); alt. systemic - Doxy or Bactrim; I&D if abscess is present → tx of choice

Nasal Fracture

• Nasal fx: upper 1/3 of nasal pyramid

• trauma, epistaxis, edema, periorbital ecchymosis

• must visualize nasal septum to r/o septal hematoma

• Nasal xray, CT to r/o Le Fort fx

• Tx: manage hemorrhage first, r/o septal hematoma

  • topical vasoconstrictors

  • reduction

  • ENT referral

Nasal Septal Hematoma

• URGENT drainage; blood accumulation, hematoma lifts pericardium causing disruption of blood supply

• Complications: saddle nose deformity, septal necrosis, abscesses

• Tx: Abx, drainage, topical anti-staph

Le Fort Fractures T1

• Horizontal: alveolar ridge

• Swelling of upper lip

• Buccal surface bruising

• malocclusion

• loosening of teeth

Le Fort Fracture T2

• Pyramidal: nasofrontal suture

• deformity and swelling of midface

• epistaxis, malocclusion

• periorbital edema and ecchymosis

• cerebrospinal fluid rhinorrhea

Le Fort Fracture T3

• Horizontal: craniofacial dislocation

• lengthening and flattening of face

• orbital hooding, exophthalmos

• mastoid region bruising

• ear drainage

Malignant Nasopharyngeal and Paranasal Sinus Tumor

• RARE, but asx until late in clinical course

  • proptosis, pain/expansion of cheek, poorly fitting maxillary dentures

• SCC is MC in maxillary and ethmoid

  • blocks eustachian tube → associated with/ EBV or mono

• Biopsy and MRI

• Tx: radiation, chemo, surgical resection

Inverted Papilloma (transitional cell or schneiderian)

• benign tumors usually on lateral nasal wall; HPV

• unilateral nasal obstruction and hemorrhage

• ant. rhinoscopy; appear as cauliflower like growth

• Tx: complete excision, high recurrence rate, f/u mandatory

Granulomatosis w/ Polyangiitis (Wegners)

• 90% involve nose and sinus first; grouped vasculitis

• TRIAD: necrotizing granulomas of upper/lower airways, glomerulonephritis, disseminated vasculitis

• pus like drainage, SOB, ulcers, bloody phlegm, fever, joint pain, blood in urine

• Tx: nasal biopsy

Oral Leukoplakia

• Chronic irritation: hyperkeratosis, M > F

• RF: HPV, immunocompromised, syphilis, alc and tobacco inc chance of SCC

• White lesions, CANNOT be scraped off

• benign: elective excision, moderate/premalignant: excision, cryotherapy, or laser

Erythroplakia

• 90% of cases are dysplasia or carcinoma

• RF: alc and tobacco in age > 45 and older

  • poor oral health, long term trauma, HPV

• red lesions CANNOT be scraped off

Oral Lichen Planus

• T-cell mediated AI disease in which auto cytotoxic CD8+ T cells trigger apoptosis of oral epithelial cells

• F > M

• presents as lacey leukoplakia, Wickham striae, affects bilaterally, painful

• biopsy → definitive dx; corticosteroids

Oral Cancer (SCC)

• early lesions are similar to leukoplakia or erythroplakia

• lateral border of the tongue

• 90% are SCC w/ association w/ HPV t-16 (60%) or 18

• resection w/ biopsy; large → combination resection, neck dissection and radiation

Oral Candidiasis (“thrush” or yeast)

• Candida albicans

• RF: DM, AIDs, inhaled steroids, Abx, immunocompromised

• Painful, creamy white curd like plaques, can be easily scraped off and can cause bleeding

• Dx: KOH wet prep is the best- spores hyphae

• Tx: Nystatin oral suspension, clotrimazole lozenges

  • 2nd line: oral fluconazole

Angular Cheilitis

• candidiasis or nutritional deficiencies in malnutrition and alcoholism (B vitamins)

• immunocompromised pts HIV babies from over exposure to saliva

Glossitis

• Loss of paillae → red smoothie surface

• Tx: tx underlying cause

• Nutritional deficiencies (B), drug rxns, dry mouth, dehydration, AI rxn, food, liquids

Torus Palatinus

• common abnormality, benign bony exostosis

• Palatinus: midline hard palate

• Mandibularis: floor of mouth

• R/o tumors cysts w/ a CT

• surgical removal only if problematic

Dental Abscess

• Acute lesions characterized by localization of pus in the structures around the teeth; strep or oral anaerobes

• S/Sx: Pain, swelling, dental caries

• Tx: PCN; allergic → Clindamycin

  • Augmentin or Erythromycin

  • Dental or surgical intervention

Necrotizing Ulcerative Gingivitis (“trench mouth”)

• caused by spirochetes and Prevotella intermedia

• associated w/ stress in YA

• painful gingival inflammation, halitosis, fever, LAD

• Tx: PCN, chlorohexidine (mouthwash), viscous lidocaine, Abx if fever of immunosuppressed

Aphthous Ulcers (“canker sore” or ulcerative stomatitis)

• very common, can be early manifestation of a systematic disease

  • Bechet, Celiac, Crohn, Ulcerative

• Painful stage 7-10 days; Healing stage 1-3 wks

• Dx: clinical, nonspecific tx, avoid spicy food

Herpetic Stomatitis (cold sores)

• HSV-1 (oral); 85% acquired in childhood

• HSV-2 (genital); 25% acquired via sexual contact

• S/sx: burning, stinging small grouped vesicles on vermillion border

• Tx: self limiting; Acyclovir or Valacyclovir

  • avoid magic mouthwash and lidocaine (absorption can lead to toxicity)

• Education: contagious until scabbed over

Acute Pharyngitis and Tonsillitis (viral)

• MC is viral

• S/sx: Red swollen tonsils, throat redness, cough

• Rapid strep antigen test

• Tx: symptomatically - NSAIDs, salt water gargles, viscous lidocaine

Acute Pharyngitis and Tonsillitis bacterial (GABHS)

• caused by group A beta hemolytic strep

• swollen uvula, whitish spots on tonsils (exudates)

• CENTOR criteria to dx

• rapid strep antigen

• Tx: PCN IM -painful; PCN, amoxicillin, Ceph, Azith if allergic

Mononucleosis

• YA, most commonly caused by EBV

• S&S: cough, malaise, fever, white or purple exudates, splenomegaly

• monospot

• Tx: avoid PCN, supportive, avoid physical activity bc of spleen rupture

Peritonsillar Abscess

• MC deep space infection of the head and neck

• RF: chronic tonsillitis, multiple Abx trials, previous episode

• Etio: mixed aerobic/ anaerobic flora

• usually seen on one side of the oral cavity, “hot potato” voice, deviation of soft palate or uvula

• Dx: CT, needle aspiration for culture

• Tx: needle aspiration → I&D, recurrence: tonsillectomy

Retropharyngeal Abscess

• suppurative URI; secondary infection

• Etio: iatrogenic, DM, immunosuppressed states

• EMERGENCY -neck stiffness, stridor, drooling, hyoid tenderness

  • send to ER!!! airway management, IV Abx, I&D

Sialadenitis

• Viral, Bacterial (S. Aureus), AI (Sjogren’s)

• tumors more common in Wharton duct

• Pain and edema w/wo meals

• unresponsive Abx → life-threatening

• culture, US or CT

• Tx: IV abx, followed by PO 10 days

  • inc salivary flow

Sialoithiasis

• MC in Wharton

• postprandial pain and local swelling, can recur

• Whartons: large, radiopaque, white

• Stensens: small, radiolucent, sneaky

• Tx: duct dilation, lithotripsy, sialendoscopy

Vocal Cord Nodules/ Polyps

• common cause of hoarseness secondary to vocal cord abuse

  • chemical irritants, shouting, smoking

• Tx: inhaled corticosteroids, change voice habits, occasionally surgery

Epiglottitis (supraglottitis)

• Viral or bacterial

• more common in DM

• Etio: MC in children -H influenza type B bacteria

  • HiB vaccine → less common in kids more seen in adults

• EMERGENCY -rapid onset, sore throat, odynophagia, tripod, LAD, drooling, stridor, no cough

• Dx: lat Xray; “thumb print”

• Tx: hospital → IV Abx 3rd gen cephs, corticosteroids (dexa) monitor airway

Ludwig Angina

• MC encountered neck space infection

• Etio: infxn of mandible - Strep or Staph

• S&S: tongue protrusion or elevation, “hot potato”, choking sensation, ant neck swelling, drooling, nuchal rigidity

• CT scan w/ IV contrast

• EMERGENCY → airway management, IV vanc and zosyn, clindamycin

Laryngeal Cancer

• SCC of larynx, MC laryngeal malignancy

• almost exclusive to tobacco and alcohol, 50-75 y/o; HPV type 16 or 18

• change in voice (MC complaint), persistent throat or ear pain, wt loss, hemoptysis, stridor

• CT or MRI; check for METS; biopsy

• Tx: cure, preservation of safe swallowing, preservation of useful voice, avoidance or permanent tracheostomy

  • early CA gets radiation as standard of care

Parotid Tumor

• 80% of salivary gland tumors; 80% are benign adults

• Asx, superficial mass, MRI or CT, parotidectomy w/ FNA biopsy

Auricular Hematoma

• shearing force that disrupts perichondrium and a hematoma forms disrupting blood supply

• common in boxers, wrestler, rugby, MMA

• painful swelling follow blunt force trauma, bluish swelling

• I&D to prevent cauliflower deformity and aseptic/septic necrosis

Perichondritis

• inflammation of auricular cartilage; secondary to cellulitis, frostbite, trauma, and poorly controlled OE

• Etio: Staph, Pseduo, Strep pyogenes

• tender, tense auricle, red; can have discharge and crusting

• Tx: Abx - FQs (cipro, leva) for pseudo coverage

Relapsing Polychondritis

• rare AI collagen vascular disease

• ears, nose, joints; saddle nose w/o trauma

• biopsy

• Tx: systemic corticosteroids

Otitis Externa

• diffuse inflammation of the skin of the external ear canal

• trapped water in canal or washes off oily protectant

  • MC - pseudomans aeruginosa

• S&S: pain, pruritus, purulent discharge, pain w/ traction, conductive hearing loss

• Tx: Abx drops (cipro & dex, ofloxacin, Neomycin/ polymyxin/hydrocortisone, acetic acid)

  • if TM perforated no neomycin (cortisportin) or acetic acid

Malignant External Otitis

• common in DM and immunocompromised

• MC -P. aeruginosa

• foul discharge, granulations in canal, deep otalgia, CN palsies

• CT scan, bone scan → osseous erosion

• Tx: IV abx w/ pseudo coverage (FQ), outpt - cipro; surgical debridement

Eustachian Tube Dysfunction

• tubal lining edema; viral uri or allergies

• last days to weeks, follows viral illness

• S&S: fullness of ear, hearing impairment, pop or crackles, TM retraction and dec mobility

• Tx: systemic and intranasal decongestants, antihistamines, topical nasal steroid sprays

Otic Barotrauma

• injury to internal ear due to change in pressure; diving

• S&S: ear pain/pressure, hearing loss, tinnitus

• Tx: decongestants and antihistamines before flight, valsalva/chewing gum, ventilation tubes

Acute Otitis Media

• suppurative infection of medial ear; bacterial 70-90% of cases: kids - S pneumonia, H influenza, M catarrhalis; adults- S aureus

• fever, earache, Tm bulging, red, opaque, landmarks hidden, pressure

• Tx: peds- Amox; Augmentin if amox give in last 30 days or failure to improve

  • adults- Amox; allergy → macrolide

Serous Otitis Media

• chronic inflammation leads to increased mucin production w/o infxn. blockage leads to fluid accumulation

• RF: second hand smoke and GERD

• dull, hypermobile TM, air bubbles, conductive hearing

• Dx: tympanometry

• Tx: tubes if - bilateral > 3 mo; unilateral > 6 mo; recurrent w/ duration for >6/12 months

Tympanosclerosis

• scarring of the eardrum, damage by injury, recurrent infection, or surgery

• chalky white on TM, conductive hearing loss, ear pain

• Tx: tympanoplasty or hearing aids

Chronic suppurative Otitis Media

• 2-6 wks infxn of middle ear w/o intact TM; occurs after TM perforation w/ failure to heal

• Etio: P aeruginosa, S aureus, proteus

• CT to r/o cholesteatoma

• Tx: ototopical FQ (cipro, ofloxacin)

Cholesteatoma

• typically erodes bone and penetrates mastoid → ossicular destruction, can erode inner ear

• Epitrympanic retraction pocket, TM perforation exuding keratin debris

• Tx: surgical removal of the sac and create a mastoid bowl; ear canal and mastoid rejoined

Bullous Myringitis

• variant of AOM → bullae on the outer TM

• extreme pain, blister, pain subsides after bullae burst

• Peds- Amox; Augmentin if given in last 30 days or no improvement

• Adults- Amox; PCN allergy→ macrolide

Mastoiditis

• most frequent serious acute complication of middle ear infection; usually after inadequately treated AOM

• postauricular pain, erythema, fever

• CT head/neck w/ contrast

• Tx: IV ceftriaxone, myringotomy, mastoidectomy, drainage

TM perforation

• Etio: trauma, pressure change, iatrogenic, chronic OM

• pain, vertigo, tinnitus, hearing change

• marginal less common need ENT; central -MC

• Tx: no abx unless caused by OM, NO topical steroids, cotton ball, 80% heal on own

Hemotympanum

• blood behind Tm, caused by trauma, infxn, tumor or posterior epistaxis

• ALWAYS refer to ENT

• EMERGENCY

Battle’s Sign

• crescent shape bruise that appears behind one or both ears that is purple/red

• sign of significant head trauma

• possible basilar skull fx “raccoon eyes”

• Glasgow coma scale, CT scan

Herpes Zoster Oticus “Ramsey Hunt”

• shingles infection affects the facial nerve near the ears

• rash, hearing loss, may cause facial paralysis

• Tx: antiviral drugs- acyclovir, famcyclovir, valacyclovir

  • corticosteroids will boost

Tinnitus

• perception of abn noises; intermittent periods of ringing or buzzing

• pulsatile: sounds like heartbeat → conductive hearing loss, vascular abnormality

• Clicking: staccato → middle ear spasm, rapid series of popping noises followed by fluttering

• exposure avoidance- excessive noise, ototoxic agent, oral antidepressants

Vertigo

• sensation of motion; sx of vestibular disease

• “tumbling, falling, ground rolling”

• Peripheral - usually sudden onset w/ N/V. tinnitus & hearing loss

  • BPPV, Meniere’s, Labyrinthitis, horizontal nystagmus

• Central - brainstem or cerebellum, gradual

  • vertical nystagmus, TIA, CVA

• Dx: romber, gait, nystagmus, Dix-Hallpike (GOLD)

• Tx: meclizine, antihistamines, zofran

Benign Paroxysmal Positional Vertigo (BPPV)

• MC peripheral vertigo seen in 50+ y/o; no associated hearing loss

• debris in posterior semicircular canal

• may be unable to walk or stand, nystagmus w/ Dix-Hallpike

• Tx: Epley maneuver

Meniere’s Disease

• inc volume of endolymph (fluid)

• Tetrad: vertigo, hearing loss, tinnitus, aural pressure

• Acute - horizontal nystagmus, hearing loss, audiometry (loss of low frequency tone)

• Tx: lower pressure → dec salt, diuretics, no smoking, meclizine for acute; vertigo resolves as hearing loss worsens

Labyrinthitis

• inflammation of inner ear

• vertigo: acute, several days, hearing loss, tinnitus

  • follows URI

• Self limiting; short term meclizine

Vestibular Neuropathy

• more permanent form of positional vertigo

• constant vertigo and nausea w/ tinnitus due to compression of CN8 caused by artery near cerebellopontine angle

• “disabling positional vertigo”

Acoustic Neuroma “Schwannoma”

• noncancerous, MC intracranial tumor

• initial sx: asymmetric or unilateral hearing loss, tinnitus, vague vertigo

Conductive Hearing Loss

• problem w/ sound traveling to inner ear

• Etio: OM, otosclerosis, cerumen impaction, ossicular disruption, URI

• correctable w/ medical or surgical intervention

• BC>AC in affected ear; lateralizes to affected ear

Sensory Hearing Loss

• Gradual, progressive, bilateral, high frequency lost w/ age (presbycusis)

• not correctable but can be prevented or stabilized (unless sudden or due to corticosteroids)

• AC>BC bilaterally; lateralizes to unaffected ear

Inflammatory Lesions (deep)

• suppurative lymphadenitis and retropharyngeal abscess

• Danger space: post to retropharyngeal space and anterior to prevertebral space

  • infxn of carotid sheath can erode → hemorrhage

• fever, rigors, pain, trismus, nuchal rigidity, DP

• EMERGENCY: IV Abx prior to drainage

Brachial Cleft Cysts

• 1+ branchial clefts or pharyngeal pouches do not close after development from sinuses

• Not midline, non-tender, ant border of SCM, massaging mass → foul taste in mouth, does not move w/ swallowing

• prone to become infected → cellulitis or abscess

• First -2nd MC, ear related; Second -MC, Ant to SCM; 3rd/4th -uncommon, pit in the pyriform sinus

Thyroglossal Duct Cyst

• Remnant occurring along thyroid; dx < 20 yo, 7p% of congenital neck cysts, present as infection in 5+ yo

• 90% midline, nontender, move w/ swallowing and tongue protrusion

• Painful operation: usually involves removing part of hyoid and connection to tongue base, can damage hypoglossal nerve

Carotid Body Tumor

• arise from neural crest cells

• painless, slowly enlarge, Fonatine’s sign - moves freely rather than vertically (attached to carotid artery

• neck mass, hoarseness, sore throat, dysphagia, CN palsy