ENT, Nose, and Throat: Practice Flashcards
Ear
Diagnostic framework for hearing loss
Distinguish conductive vs sensorineural loss
Conductive: external auditory canal (EAC) or middle ear problems block vibration to the tympanic membrane (TM) and ossicles
Sensorineural: cochlear or neural components impaired
Mixed picture can occur in real life
How to differentiate (Weber and Rinne)
Weber test: place tuning fork on frontal bone
Normal: sound heard in both ears equally
Conductive loss: lateralizes to the bad ear (the ear with obstruction/cerumen)
Sensorineural loss: lateralizes to the good ear
Rinne test: place tuning fork on mastoid, then move to air conduction
Normal: air conduction > bone conduction
Conductive loss: bone conduction > air conduction
Sensorineural loss: air conduction > bone conduction (same as normal, not particularly helpful for distinguishing sensorineural from normal)
Major causes by location
Outer ear: cerumen impaction, external otitis, exostosis, osteoma, foreign bodies
Middle ear: otitis media, cholesteatoma, otosclerosis, TM perforation, eustachian tube dysfunction, barotrauma
Sensorineural: presbycusis (age-related), ototoxic drugs, Menière disease, acoustic neuroma, MS, autoimmune inner ear disease
Ear exam and treatment principles
Remove wax if intact TM: flush or curette; avoid if TM perforation suspected
Treatable issues (e.g., infection) aim to resolve hearing loss when possible
Sensorineural or unclear cases may require hearing amplification, cochlear implant, or referral to audiology/ENT
Auricular hematoma
Blunt trauma to the auricle causes hematoma, cartilage ischemia, and potential cauliflower ear if not drained
Management: incise and drain ASAP; prophylactic antibiotics; ENT referral
If untreated: fibrocartilaginous overgrowth causing deformity and infection risk
Cerumen impaction
Often asymptomatic or cause hearing loss; remove by irrigation if TM intact or by curettage if not
Foreign bodies in the ear
Tick example: brown material and feces seen; insect can be painful; remove promptly
General foreign bodies: beads, beans, small objects; history helps
External otitis (swimmer’s ear)
Usually painful with tragus/pinna palpation; red, swollen canal; purulent discharge possible
Common pathogen: Pseudomonas; others: Staph epidermidis, Strep/Staph aureus
Management: thorough ear canal lavage before starting topical therapy; topical fluoroquinolone ± steroid (e.g., Ciprodex: ciprofloxacin + dexamethasone); consider wick if TM not visible to ensure medication reaches TM
Systemic antibiotics rarely needed
Ramsay Hunt syndrome (herpetic otitis externa)
Viral etiology (varicella, measles, herpes; most commonly herpes zoster)
Symptoms: ear pain out of proportion; vesicles may be seen in canal; facial weakness may occur
Treatment: antivirals (e.g., valacyclovir/acyclovir); corticosteroids may be added if facial paralysis, to hasten recovery
Otitis media (AOM)
Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis; viruses also implicated (RSV, rhinovirus, influenza)
Exam: TM may be bulging with loss of landmarks; purulence behind TM; immobile TM with decreased light reflex
Management decisions depend on age and severity; early antibiotics in many cases
Amoxicillin: 80\ ext{mg/kg/day} for 7\ \text{days} (typical pediatric dosing window described); consider Augmentin if conjunctivitis present
If penicillin allergy: alternatives include doxycycline or cefdinir/ceftriaxone
Eustachian tube dysfunction (ETD)
Post-viral edema with poor ET drainage; ear popping or crackling sounds, aural fullness
Management: intranasal corticosteroids (e.g., fluticasone) to improve tube mobility; Valsalva maneuvers; allow time for resolution
Barotrauma
Occurs with flying or diving; eardrum injury due to pressure changes; prevention includes decongestants before/during flights (e.g., oxymetazoline) for up to about 3\ \text{days}; babies should nurse/swallow during ascent/descent
Most barotrauma injuries heal spontaneously; perforations typically heal in 2-4\ \text{weeks}; if not healing, ENT referral
Tympanic membrane perforation
Presents as a TM perforation on otoscopy; size of perforation correlates with hearing loss potential (more than 25\% perforation often results in some hearing loss)
Most perforations heal spontaneously in 2{-}4\ \text{weeks}; if not healing, ENT referral
Mastoiditis (complication of AOM)
Ill patient with AOM and post-auricular tenderness or proptosis; mastoid air cells become infected and inflamed
Requires IV antibiotics and hospitalization
Inner ear disorders and vertigo overview
Central vs peripheral vertigo differentiation is critical for imaging/neurologic workup
Peripheral vertigo (benign)
Nystagmus: horizontal component; fixation suppresses nystagmus
Spinning sensation with positional changes; postural instability often mild; tinnitus or episodic hearing loss may accompany
Central vertigo
Any direction of nystagmus (often vertical or torsional); fixation does not suppress nystagmus; marked postural instability; may have diplopia, dysarthria, or focal weakness
Tinnitus and related concepts
Very common; about 50 million in the US have had tinnitus
Pulsatile tinnitus warrants imaging (e.g., MRA) to rule out vascular anomalies
Management: desensitization (white noise at night, meditation); caution with benzodiazepines for chronic tinnitus; antidepressants may help in some cases
Common causes: sensorineural hearing loss, noise exposure, presbycusis, and other conditions; typically accompanied by other symptoms
Benign paroxysmal positional vertigo (BPPV)
Dislodged otolith in semicircular canal (posterior canal most commonly) triggers vertigo with head movements
Episodes are brief (often seconds to a couple minutes) and recur
Treatment: Epley maneuver (can be performed in clinic); home YouTube-guided self-Epley; vestibular rehabilitation for lingering symptoms
Vestibular neuritis and labyrinthitis
Viral inner ear infections; vertigo with nausea/vomiting
If hearing loss is present: labyrinthitis; if hearing preserved: vestibular neuritis
Treatments: vestibular suppressants (e.g., antiemetics like Zofran, antihistamines, or benzodiazepines for short-term relief); corticosteroids may speed recovery in some cases
Menière disease
Fluids and ion homeostasis disturbance in the inner ear; vertigo, tinnitus, fluctuating SNHL, and aural fullness
Management: lifestyle modifications (low-salt diet, avoid caffeine, alcohol, and stress); diuretics; hearing aids and vestibular rehab; severe cases may consider other interventions
Presbycusis
Age-related high-frequency sensorineural hearing loss; symmetric in both ears; may have tinnitus
Management: hearing aids or cochlear implants for severe cases
Vestibular schwannoma (acoustic neuroma)
Schwann cell tumor on cranial nerve VIII; unilateral SNHL with tinnitus
Diagnosis: Weber/Rinne indicating SNHL; audiology testing
Imaging: brain MRI; management based on age, tumor size, and patient preference (surgery, radiation, or observation)
Practice scenario (central vs peripheral, MRI IAC note)
Example: 62-year-old with 24 hours of vertigo and inability to walk with vertical nystagmus not suppressed by fixation
Diagnosis: central vertigo; note to order MRI of the brain with internal auditory canal (IAC) imaging for suspected vestibular schwannoma when appropriate
Nose
Seasonal and infectious rhinitis basics
Seasonal viruses (rhinovirus) most common; ten to fourteen days of symptoms: runny nose, sore throat, morning cough, malaise; fever and conjunctivitis less common
Primary approach: symptomatic therapy and education
Symptomatic options: saline nasal irrigation, intranasal corticosteroids (e.g., fluticasone), oral/lozenges for sore throat, humidification, supportive cough remedies
Acute bacterial rhinosinusitis (ABRS)
Criteria: symptoms beyond 10\ \text{days} with purulent nasal drainage and facial pain/pressure and fever; double sickening (temporary improvement followed by worsening) or high fever within first 3{-}4\ \text{days}
First-line antibiotic: Augmentin (amoxicillin-clavulanate)
Guideline note: IDSA recommends a shorter course for less severe cases: 5{-}7\ ext{days}
Penicillin allergy alternatives: doxycycline or respiratory fluoroquinolones
Adjuncts: nasal saline irrigation, intranasal corticosteroids, decongestants (short-term)
Chronic rhinosinusitis (CRS)
Symptoms persisting > 12\ \text{weeks}: nasal obstruction, mucopurulent drainage, facial pain, decreased sense of smell
Management: imaging as indicated, ENT involvement, intranasal corticosteroids, systemic steroids in some cases, consider surgical opening of sinuses
Allergic rhinitis
IgE-mediated disease with allergen exposure (tree pollen, ragweed, dust mites, animal dander)
Classic symptoms: sneezing, rhinorrhea, itch, obstruction; postnasal drip and cough may occur
Treatments: intranasal corticosteroids (Flonase), oral antihistamines (loratadine/cetirizine; prefer non-sedating), intranasal antihistamines if needed, intranasal cromolyn and montelukast as adjuncts
Rhinitis medicamentosa (rebound congestion)
Due to prolonged use of topical decongestants (e.g., oxymetazoline).
Mechanism: extreme vasoconstriction followed by rebound congestion when the drug wears off; management involves stopping the decongestant and using non-steroidal options like saline and intranasal steroids; education is key
Nasal polyps
Pale edematous masses seen on nasal exam; associated with CRS; may indicate cystic fibrosis in children; treated with intranasal corticosteroids
Epistaxis (nosebleed)
Common in winter or due to dry mucosa; Kiesselbach’s plexus is a common anterior source; posterior bleeds may be more severe
Initial management (ABC approach): assess airway, breathing, circulation; place patient upright with head forward; apply direct compression to the anterior nasal septum (lower third) for about 10\ ext{minutes}
Adjuncts: two sprays of oxymetolazine to promote vasoconstriction; if source visualized anteriorly, chemical cautery or electrical cautery can be used
If bleeding persists or source is posterior: nasal packing or balloon catheter; posterior bleeds may require admission to telemetry; remove packing after 24{-}48\ ext{hours} to prevent tissue necrosis
Nasal foreign bodies
Common in children; unilateral foul-smelling discharge can indicate a foreign body
First-line: positive-pressure technique (blow with the other nostril occluded) under parental supervision; if visible, retrieval with appropriate instrument; if unsuccessful, call ENT/EMT
A note on penicillin allergy and ABRS in adults
A patient with a penicillin allergy who presents with sinus pain, pressure, and dental pain but has a history suggestive of non-severe sinusitis: doxycycline is a common alternative; Augmentin is not a penicillin-based choice for this patient if true allergy is present
Mouth, Throat, and Oral Health
Tongue and mucosal lesions
Leukoplakia: white plaque that cannot be rubbed off; hyperkeratotic lesion; needs biopsy to evaluate premalignant/malignant potential
Erythroplakia: red lesion with biopsy warranted for premalignant/malignant potential
Oral hairy leukoplakia: lateral tongue lesions; EBV association; screen for HIV
Thrush (oral candidiasis): white plaques that can be wiped off to reveal red underlying mucosa
Aphthous ulcers (canker sores): self-limited; saltwater gargles and topical steroids (e.g., triamcinolone) can help accelerate healing
Dental health
Gingivitis: inflammatory gum disease; reversible with oral hygiene; can progress to periodontitis if not treated; reinforce dental care and hygiene
Periodontitis: loss of supporting structures and alveolar bone; may require dental or surgical intervention
Dental caries: cavities needing dental dental treatment; prevention is key
Ludwig’s angina: bilateral infection of submandibular spaces; can cause airway compromise; requires urgent care
HSV-1 oral infections
Prodrome with painful vesicles and ulcers; treat with antiviral therapy (e.g., valacyclovir/acyclovir) to reduce lesion duration and viral replication; first episode typically more severe; consider suppressive therapy in recurrent cases
Oral candidiasis (thrush)
Common in infants (due to maternal antibiotics), denture use, diabetes, steroids; diagnosis is clinical; wet prep can aid in diagnosis
Treatment: topical nystatin suspension; oral fluconazole if widespread or esophagitis suspected; HIV testing if no risk factors or recurrent infection
Acute sialadenitis
Inflammation of a salivary gland; bacterial (often Staph aureus) usually unilateral; viral (e.g., mumps) can be bilateral
Exam: tender, swollen gland; purulent drainage from the duct occasionally observed intraorally
Management: warm compresses, sialogogues to promote saliva flow, hydration; antibiotics (ampicillin-sulbactam or similar) if bacterial; IV antibiotics for severe illness
Sialolithiasis (salivary duct stones)
Stone formation within a salivary duct; swelling and pain with salivation, especially around mealtimes
Management: hydration, warm compresses, sialogogues; relief with lemon candies or sour flavors to stimulate saliva; aim to relieve obstruction
Acute laryngitis
Hoarseness, possible loss of voice; usually viral; management includes voice rest and humidified air; prognosis is self-limited
If symptoms persist > ~2 weeks or red flags (stridor, neck mass, dysphagia) arise, pursue ENT evaluation
Head and neck cancer considerations
HPV16-associated cancers become more common; maintain a high index of suspicion for persistent throat symptoms or masses
Evaluate risk factors (tobacco, alcohol, HPV) and consider imaging or referral as indicated
Angioedema
Swelling of lips, tongue, and mouth; can be part of anaphylaxis requiring epinephrine, H1 and H2 blockers, steroids; non-life-threatening angioedema treated with steroids and antihistamines
Temporomandibular joint (TMJ) disorders
Pain with jaw movement, jaw clicking, earache; often related to bruxism or stress; management includes physical therapy and night guards; self-care strategies
Epiglottitis (emergency scenario)
Rapidly progressive illness in a child or adult with fever, sore throat, drooling, tripod position, mild respiratory distress
Prior to entering the oropharynx, ensure airway readiness: intubation tray and airway team
Classic radiographic sign: lateral neck X-ray with visible thumb sign
Etiology less common since Hib vaccination; can be caused by other bacteria/viruses
Management: third-generation cephalosporin antibiotic; secure airway if needed with intubation
Quick reference and key numbers (LaTeX notation)
Amoxicillin dosing for acute otitis media: 80\ \text{mg/kg/day} \text{ for } 7\ \text{days}
ABRS antibiotic duration (new guidelines): 5{-}7\ \text{days}
Tympanic membrane perforation healing: 2{-}4\ \text{weeks}
Epistaxis initial anterior management: apply pressure for 10\ \text{minutes}; consider oxymetazoline sprays (2 sprays) as adjuncts
Barotrauma prevention around flights: use decongestants for up to 3\ \text{days} around travel
Barotrauma posterior source management: often requires balloon catheter and ENT admission
TM perforation size significance: perforations > 25\% associated with more noticeable hearing loss
Cold duration: typical viral URI lasts 10{-}14\ \text{days}
CRS duration criterion: >12\ \text{weeks} or 3\ months of symptoms
Vertigo duration in BPPV: episodes often last seconds to a few minutes; Epley maneuver used for treatment
MRI recommendation for vestibular schwannoma: brain MRI with internal auditory canal (IAC) imaging
Key cross-links and practical takeaways
Always perform a full ear exam in vertigo to differentiate central vs peripheral etiologies; central vertigo may indicate more serious neurologic pathology requiring prompt imaging
In epistaxis, start with conservative measures and escalate to cautery/packing as needed; posterior bleeds require specialist management and possible hospitalization
For suspected ABRS, use clinical criteria to decide antibiotics; shorter courses may be appropriate for less severe cases; adjust for penicillin allergy as needed
Be mindful of red flags in throat and mouth exams: odynophagia with submucosal swelling, unilateral persistent lesions, or aHS symptom pattern could indicate premalignant or malignant processes; biopsy when indicated
Prioritize airway safety with epiglottitis and large peritonsillar abscess; involve ENT and prepare for potential intubation or surgical drainage
For tinnitus and vertigo, distinguish between peripheral etiologies (often manageable with targeted maneuvers and desensitization) and central etiologies (often requiring neuroimaging and multidisciplinary care)
Counseling and patient education are essential across ENT conditions (e.g., rhinitis medicamentosa—break the decongestant cycle; post-tonsillectomy expectations; Eustachian tube dysfunction recovery)
Practice questions (based on transcript content)
Quick case: A 48-year-old with a Rinne test showing bone conduction greater than air conduction. What type of hearing loss is most likely?
Answer: Conductive hearing loss (outer/middle ear pathology). This mirrors the dramatic example given in the transcript.
A 3-year-old with rapid onset fever, sore throat, drooling, and tripod positioning. Top differential diagnosis and initial management?
Answer: Epiglottitis is a top concern; prepare airway management (airway team and intubation tray) before any oral-pharyngeal examination; definitive treatment includes antibiotics and securing the airway if needed
A patient with unilateral sensorineural hearing loss and tinnitus should raise concern for what potential diagnosis?
Answer: Vestibular schwannoma (vestibular schwannoma/acoustic neuroma); order brain MRI with IAC imaging and refer to audiology/ENT
A patient presents with persistent nasal congestion despite decongestant use for more than a week. What is the likely condition, and what is the key management concern?
Answer: Rhinitis medicamentosa; management involves discontinuing the decongestant and using nasal steroids and saline; educate about rebound congestion risk
When evaluating a patient with vertigo, what clinical feature would favor peripheral vertigo over central vertigo?
Answer: Horizontal nystagmus that is suppressed by visual fixation; absence of other neuro deficits supports peripheral etiology
Notes on etiology and practical implications
ENT conditions are often multifactorial; treatment frequently targets the underlying cause (e.g., wax removal for conductive hearing loss, topical antibiotics for otitis externa, decongestants for ETD) while addressing symptom relief (pain control, inflammation reduction, vestibular rehabilitation)
Vaccination and immunizations can influence the incidence of certain ENT emergencies (e.g., Hib vaccine reducing epiglottitis)
Early ENT involvement is crucial in acute, potentially life-threatening conditions (epiglottitis, peritonsillar abscess with airway compromise, mastoiditis)
Consider psychosocial and functional impacts (e.g., tinnitus management, vertigo-related impairment, learning and school performance in CRS-related nasal symptoms)
Notes on numeric and procedural specifics
Amoxicillin dosing and duration for AOM: 80\ \text{mg/kg/day} \text{ for } 7\ \text{days}
ABRS antibiotic duration per newer guidelines: 5{-}7\ \text{days}
TM perforation healing window: 2{-}4\ \text{weeks}
Epistaxis first-line actions include applying nasal pressure for 10\ \text{minutes} and, if needed, two sprays of oxymetolazine; posterior bleeds may require balloon catheter and ENT admission
Acute rhinosinusitis duration criterion: symptoms lasting > 10\ \text{days} with purulent drainage and facial pain/fever, or double sickening or severe fever within the first 3{-}4\ \text{days}
CRS duration threshold: > 12\ \text{weeks} (~3 months)
Epiglottitis management emphasizes airway readiness and prompt antibiotic therapy with attention to potential intubation
If you want, I can tailor these notes further to fit a specific exam format (e.g., rapid-fire flashcards, a condensed outline, or a full-page study guide).