Diagnostics

Question 1

Purpose of the sinus Xrays?

3

Answer 1

1. Detect sinusitis (inflammation of the sinuses)- conform fluid in the sinuses
2. Detect fluid in the sinuses
3. Detect polyps

Question 2

Indications for XRAY of the sinuses? 2

Answer 2

1. Pain and pressure in the face, especially when lowering head 2. When clinical symptoms need supportive evidence to make the diagnosis

Question 3

What is a Waters View, Waters Projection radiograph?

Answer 3

A posterioranterior radiographic view of the skull made with the orbitomeatal line at an angle of 37° from the plane of the film, to show the orbits and maxillary sinuses.

Question 4

1. What is a maxillary sinus radiograph?
2. Why do we use it?

Answer 4

1. a radiographic frontal view of the maxillary sinuses, orbits, nasal structures and zygomas;
2. permits direct comparison of the sides.

Question 5

What is the steeple sign for?

Answer 5

Croup

Question 6

1. What is the best test for a retropharyngeal abscess?
2. What can it also be seen on?

Answer 6

Retropharyngeal abscess can be seen on xray but the imaging test of choice is a CT scan of the neck

Question 7

Advantages of CT scan?

3

When is it preferable to MRI?3

Answer 7

1.

• Good for bone involvement, better than X-ray
• Sensitive to bone destruction (Trauma, infection)
• Sensitive to inflammatory changes (Retropharyngeal abscess, Ludwig’s angina)
  2. Preferable to MRI for scanning the
• larynx for neck nodes,
• tumor volume,
• cartilage sclerosis and destruction

Question 8

What does this CT show?

Answer 8

• Coronal CT scan of the sinuses showing bilateral maxillary sinusitis.
• The opacification is more prominent on the left side.

Question 9

What does this CT show?

3

Answer 9

• Coronal CT scan showing right maxillary sinus opacification.
• There is septal deviation to the right
• Notice the hypertrophy of the left inferior turbinate.

Question 10

CT of the sinuses is useful for what?

5

Answer 10

1. Give further info about certain tumors of the nasal cavity and sinuses
2. Can provide important information about sinus and nasal obstruction
3. Able to detect sinuses that are filled with fluid
4. Can detect if sinus membranes are thickened
5. Assist with dx of sinusitis

•

Question 11

What are the arrows pointing to?

Answer 11

Arrows are pointing to abscess (lighter spots)

Question 12

Advantages of MRI

4

Answer 12

1. Extremely valuable in demonstrating soft tissue involvement
2. Sensitive enough to evaluate mucous membranes
3. Can distinguish tumor from inflammation and inspissated mucus
4. Useful if malignancy suspected (acoustic neuroma)

Question 13

Throat & Nasal Swab and Culture

1. INdications for throat? 3
2. Indications for nose? 2

Answer 13

1. Indications: (throat)

–Sore throat

–Fever of unknown origin

–Chronic carriers with a recurrent infection

2. Indications: (nose)

–Nasal or sinus infections (usually not for sinusitis because you get too much normal flora to differentiate)

–Carriers of pathogenic bacteria

Question 14

What do we need to remember about cultures?

Answer 14

•All cultures should be performed before antibiotic therapy is initiated

Question 15

•Throat Cultures

–Used to identify a few particular pathogens that indicate the need for treatment. What are some examples? 4

Answer 15

1. Bordatella pertussis
2. Streptococci, esp. beta-hemolytic strep
3. Meningococci,
4. Corynebacterium diptheriae

Question 16

•Nasal and nasopharnygeal cultures or PCR

1. Purpose?
2. Which bugs would we use a nasal swab for? 2
3. Nasopharyngeal swab? 4

Answer 16

–Identify infections and carrier states

1. Nasal swab

• Staph aureus
• MRSA

2. Nasopharyngeal swab

• H-flu
• RSV
• Influenza
• Pertussis

Question 17

•Nasal swab and culture: Steps to the procedure?

5

Answer 17

1. Gently raise tip of nose
2. Insert flexible swab into nare
3. Rotate swab against side of nare
4. Remove swab and place in appropriate culture tube
5. Always wear gloves and handle the specimen carefully

Question 18

•Nasopharyngeal swab and culture: Steps to the procedure 5

Answer 18

1. Gently raise the tip of the nose
2. Insert FLEXIBLE swab along bottom of nare medially
3. Gently move the swab until it reaches the posterior pharynx
4. Rotate swab to obtain secretions
5. Place swab in an appropriate culture tube

Question 19

1. What kind of swab is a rapid strep test?
2. What does it have an antiserum to?
3. Advantage?
4. What should we do if its negative?
5. Culture for Strep takes how long?
6. What if the culture is negative?

Answer 19

1. Posterior pharyngeal swab
2. Has an antiserum against group A strep
3. Very accurate without cultures
4. If negative, and symptoms are consistent with GAS, culture should be done
5. Culture will take at least two days
6. If culture is negative, no strep infection exists

Question 20

If the cerumen can be removed using a ___________, this is the safest method and usually only mildly uncomfortable to the patient.

•The ear canal is much _____sensitive along the top, compared to the bottom.

Answer 20

curette or otoloop

less

Question 21

Treatment of Epistaxis

3

Answer 21

1. Topical vasoconstrictors/analgesics
2. Direct pressure
3. Silver nitrate cautery

Question 22

1. If ongoing nose bleeding is seen what should we use?
2. What are the specific medications? 2

Answer 22

1. If ongoing bleeding is seen use topical vasoconstrictor and analgesic

2.

–Inhaled Afrin

–Cotton balls soaked in Epinephrine and Lidocaine

Question 23

Who can we not use ear irrigation for?

Answer 23

Someone with a ruptured or previously ruptured tympanic membrane

Question 24

1. After how many minutes of direct pressure can we cauterize?
2. What must you be able to see for nasal cautery?

Answer 24

1. After 20 min of direct pressure

–Remove cotton balls

–Gently evacuate the clot by suction or gentle nose blowing

2. •If ongoing bleeding is seen apply a silver nitrate stick to the site for 10 sec then roll it over the surrounding area (MUST SEE SITE OF THE BLEED)

Question 25

Three things to remember about nasal cautery?

Answer 25

1. Do not cauterize both sides of the nasal septum –Risk for septal perforation 2. Must be able to directly visualize the bleeding area 3. Apply antibiotic ointment over the cauterized area

Question 26

What are the two kinds of nasal packing? Whats the most common?

Answer 26

•Anterior nasal packing –90% of cases of epistaxis occur from the anterior portion •Posterior nasal packing –Should be done by an experienced physician or ENT doc

Question 27

What are the three ways we can anterior nasal pack?

Answer 27

1. Gauze –Petrolatum soaked •Commercial nasal tampon 2. Rhino rocket 3. Mercel

Question 28

Nasal packing: 1. Follow up when? 2. Leave in place for how long? 3. If packing is too tight what could this cause? 4. Complications? 3

Answer 28

1. Follow up is required within 24 hours 2. Leave in place usually for 48 hours 3. May cause necrosis if the packing is too tight 4. May develop - sinusitis, - otitis media, - toxic shock syndrome

Question 29

Where is movement of the TM best visualized?

Answer 29

•The degree of mobility of the tympanic membrane using pneumatic otoscopy or tympanometry is more helpful. • •Movement is best visualized in the posterosuperior quadrant of the ear drum.

Question 30

What could increased mobility of the TM mean? 2

Question 31

Pure Tone Audiometry: Hearing is measured at frequencies varying from low pitches \_\_\_\_\_\_to high pitches \_\_\_\_\_?

Answer 31

(250 Hz) (8000 Hz).

Question 32

1. The hearing level (HL) is quantified relative to "normal" hearing in decibels (dB), with higher numbers of dB indicating what? 2. The dB score is not really percent loss, but nevertheless 100 dB hearing loss is nearly equivalent to \_\_\_\_\_\_\_\_\_\_\_\_\_for that particular frequency.

Answer 32

worse hearing complete deafness

Question 33

Audiometry: 1. Whats a normal score? 2. What about scores less than 0? 3. Pure-tone average (PTA) is the average of pure tone hearing thresholds at what levels?

Answer 33

1. A score of 0 is normal. 2. It is possible to have scores less than 0, which indicate better than average hearing. 3. 500, 1000, and 2000 Hz

Question 34

What is the purpose of the weber/rinne tests?

Answer 34

–To determine whether the hearing loss is caused by a sensory problem (sensorineural hearing loss) or a mechanical problem (conductive hearing loss). – –The tests should be done together –Perform the Rinne first

Question 35

Whats a normal rinne test?

Answer 35

**•Normal result AC \> BC**

Question 36

1. Rinne test is for what? 2. If BC is greater than AC what does this mean? 3. Will this be positive in sensorineuronal hearing?

Answer 36

1. Test is mainly for conductive hearing loss 2. If BC \> AC there is something that is blocking the air conduction = conductive hearing loss 3. In sensorineural hearing loss the AC and BC will be equally diminished and the AC will still be \> BC * A normal Rinne is called “positive” * An abnormal Rinne is called “negative”

Question 37

1. In the weber test what are we noting? 2. How do we combine this with the rinne to get our diagnosis?

Answer 37

1. Note which side the sound is heard the loudest 2. Cannot determine if the ear that heard the sound best is normal or abnormal without the Rinne test. * If Rinne was completely normal then there is a SNHL in the ear opposite of where Weber was heard best. * If the Rinne is abnormal in the same ear that the Weber lateralizes to then there is a CHL in that ear

Question 38

Describe the results of the weber and rinne combined tests? 2

Answer 38

Question 39

1. What does tympanometry measure? 2. •It uses an airtight seal and a microphone to do what? 3. The amount of sound that is absorbed or reflected from the middle ear is measured at the microphone as what?

Answer 39

1. •Measures the impedance of the middle ear to sound. 2. deliver sound into the ear canal. 3. normal, positive, and negative air pressures.

Question 40

Tympanometry is useful in what? 9

Answer 40

1. Is useful in identifying middle-ear effusions in children 2. detect facial nerve paralysis and 3. may differentiate sensory from neural hearing losses. 4. Detects fluid in middle ear, 5. negative middle ear pressure, 6. disruption of the ossicles, and 7. otosclerosis. 8. detect abnormally stiff ear drums (often due to fluid behind them, scarring or otosclerosis) 9. abnormally floppy ear drums (called "hypercompliant"), usually due to excessive clearing of the ears.

Question 41

•Tympanometry can be used to detect abnormal contractions of the stapedius and tensor tympani muscles. This requires what?

Answer 41

a machine that can run the tympanogram over 30 seconds, at a single frequency, looking for blips in the trace.

Question 42

1. The result of the test is recorded in a visual output, called a tympanogram. •If there is fluid in the middle ear, the tympanic membrane will not vibrate properly and the line on the tympanogram will be\_\_\_\_? 2. If there is air in the middle ear (the normal condition) but the air is at a higher or lower pressure than the surrounding atmosphere, the line on the tympanogram will be what?

Answer 42

1. flat 2. shifted in position

Question 43

1. Vestibular Caloric Testing used for what? 2. •Part of an ENG (electronystanography) specifically diagnosing what? 5

Answer 43

1. Used to test disorders of the ear or brainstem •Part of an ENG (electronystanography) 2. Used in the diagnosis of - benign positional vertigo, - perilymph fistula, - vestibular neuritis, - gentamycin ototoxicity - May be useful in the work up of the dizzy patient

Question 44

1. When cold water enters the ear and the inner ear changes temperature, it should cause what? 2. •Next, warm water is placed into the ear. What should happen?

Answer 44

1. fast nystagmus. –The eyes should move away from the cold water and slowly back 2. –The eyes should move toward the warm water and then slowly away

Question 45

What is ice water caloric?

Answer 45

* Can be used to help confirm absence of brainstem function in the comatose patient * If eyes do not move with instillation of ice water into the ear canal, there is lack of brainstem function