Purpose of the sinus Xrays?
1. Detect sinusitis (inflammation of the sinuses)- conform fluid in the sinuses
2. Detect fluid in the sinuses
3. Detect polyps
Indications for XRAY of the sinuses? 2
1. Pain and pressure in the face, especially when lowering head 2. When clinical symptoms need supportive evidence to make the diagnosis
What is a Waters View, Waters Projection radiograph?
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.
1. What is a maxillary sinus radiograph?
2. Why do we use it?
1. a radiographic frontal view of the maxillary sinuses, orbits, nasal structures and zygomas;
2. permits direct comparison of the sides.
What is the steeple sign for?
1. What is the best test for a retropharyngeal abscess?
2. What can it also be seen on?
Retropharyngeal abscess can be seen on xray but the imaging test of choice is a CT scan of the neck
Advantages of CT scan?
When is it preferable to MRI?3
-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,
-cartilage sclerosis and destruction
What does this CT show?
•Coronal CT scan of the sinuses showing bilateral maxillary sinusitis.
•The opacification is more prominent on the left side.
What does this CT show?
•Coronal CT scan showing right maxillary sinus opacification.
•There is septal deviation to the right
•Notice the hypertrophy of the left inferior turbinate.
CT of the sinuses is useful for what?
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
What are the arrows pointing to?
Arrows are pointing to abscess (lighter spots)
Advantages of MRI
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)
Throat & Nasal Swab and Culture
1. INdications for throat? 3
2. Indications for nose? 2
1. Indications: (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
What do we need to remember about cultures?
•All cultures should be performed before antibiotic therapy is initiated
–Used to identify a few particular pathogens that indicate the need for treatment. What are some examples? 4
1. Bordatella pertussis
2. Streptococci, esp. beta-hemolytic strep
4. Corynebacterium diptheriae
•Nasal and nasopharnygeal cultures or PCR
2. Which bugs would we use a nasal swab for? 2
3. Nasopharyngeal swab? 4
–Identify infections and carrier states
1. Nasal swab
2. Nasopharyngeal swab
•Nasal swab and culture: Steps to the procedure?
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
•Nasopharyngeal swab and culture: Steps to the procedure 5
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
1. What kind of swab is a rapid strep test?
2. What does it have an antiserum to?
4. What should we do if its negative?
5. Culture for Strep takes how long?
6. What if the culture is negative?
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
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.
curette or otoloop
Treatment of Epistaxis
3.Silver nitrate cautery
1. If ongoing nose bleeding is seen what should we use?
2. What are the specific medications? 2
1. If ongoing bleeding is seen use topical vasoconstrictor and analgesic
–Cotton balls soaked in Epinephrine and Lidocaine
Who can we not use ear irrigation for?
Someone with a ruptured or previously ruptured tympanic membrane
1. After how many minutes of direct pressure can we cauterize?
2. What must you be able to see for nasal cautery?
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)
Three things to remember about nasal cautery?
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
What are the two kinds of nasal packing?
Whats the most common?
•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
What are the three ways we can anterior nasal pack?
•Commercial nasal tampon
2. Rhino rocket
1. Follow up when?
2. Leave in place for how long?
3. If packing is too tight what could this cause?
4. Complications? 3
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
-toxic shock syndrome
Where is movement of the TM best visualized?
•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.
What could increased mobility of the TM mean? 2
Pure Tone Audiometry: Hearing is measured at frequencies varying from low pitches ______to high pitches _____?
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.
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?
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
What is the purpose of the weber/rinne tests?
–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
Whats a normal rinne test?
•Normal result AC > BC
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?
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”
1. In the weber test what are we noting?
2. How do we combine this with the rinne to get our diagnosis?
1. Note which side the sound is heard the loudest
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
Describe the results of the weber and rinne combined tests?
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?
1. •Measures the impedance of the middle ear to sound.
2. deliver sound into the ear canal.
3. normal, positive, and negative air pressures.
Tympanometry is useful in what?
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
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.
•Tympanometry can be used to detect abnormal contractions of the stapedius and tensor tympani muscles. This requires what?
a machine that can run the tympanogram over 30 seconds, at a single frequency, looking for blips in the trace.
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?
2. shifted in position
1. Vestibular Caloric Testing used for what?
2. •Part of an ENG (electronystanography) specifically diagnosing what? 5
1. Used to test disorders of the ear or brainstem
•Part of an ENG (electronystanography)
2. Used in the diagnosis of
-benign positional vertigo,
-May be useful in the work up of the dizzy patient
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?
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
What is ice water caloric?
•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