ENT Flashcards
Nasal congestion with discharge, sneezing, cough and sore throat is called _________ and is commonly caused by ______ , ______ , or _______
Nasopharyngitis (common cold)
Caused by:
- Rhinovirus
- Influenza virus
- Coronovirus
Croup (laryngotracheitis) presents with ______ and is caused by _____
Croup (laryngotracheitis) is an upper respiratory tract infection that presents with hoarseness, barking cough, stridor, and possibly respiratory distress.
Most commonly caused by Parainfluenza virus.
A patient with a sore throat, dysphagia, drooling and respiratory distress likely has _______ , which is most commonly caused by _____ .
This is likely epiglottitis and this is commonly caused by Haemophilus influenzae.
A patient with and upper respiratory tract infection that is followed by wheezing, cough, and respiratory distress is likely ______ , which is caused by ________ .
This is likely bronchiolitis
commonly caused by
Respiratory syncytial virus (RSV).
What is the name for the medication that prevents RSV in neonates?
Palivizumab
A patient has ear pain, canal edema and discharge, and pain with auricle manipulation.
What is the diagnosis?
What is the treatment?
Diagnosis: otitis externa
Treatment: otic antibiotic drops
Topical antibiotic/glucocorticoid preparations decrease canal inflammation and may speed symptom resolution.
A patient has a smooth, glossy tongue that lacks normal filiform papillae. Name 3 nutritional deficiencies that may be the cause.
Iron, vitamin B12, or folate deficiency
Causes include atropic gastritis, celiac disease and protein calorie malnutrition.
Choanal Atresia is often associated with ____ and ______
Associated with CHARGE and Treacher-Collins
CHARGE:
Coloboma
Heart defects
Retarded growth and development
Genital hypoplasia
Ear abnormalities
Unilateral choanal atresia is most common and may initially present with mucopurulent discharge, but will mainly will reveal later in life during childhood with unilateral nasal discharge and obstruction.
Bilateral: Presents in infancy mainly as a neonate, with cyclic cyanosis, worse with activities not allowing for mouth breathing (feeding) and improves with crying. There is a failure in ability to pass a catheter through nares.
Dx: CT scan (confirms narrowing of pterygoid plate in posterior nasal cavity)
Initial tx is establishing an oral airway and feeding tube. Establishing an airway is an acute otolaryngologic emergency. While this should be done in the operating room, a Montgomery nipple can be used as an interim measure prior to surgery. Correction can be done endoscopically or surgically.
What condition causes an infection in the floor of the mouth that causes the tongue to be pushed up and back, eventually obstructing the patient’s airway?
Ludwig’s angina
Clinical findings include fever, dysphagia, odynophagia, and drooling.
The most common cause of this abscess is infection in the teeth. This is a rapidly progressive cellulitis of the bilateral submandibular and sublingual spaces, most often arising from an infected mandibular molar.
What is the treatment for cellulitis of the sublingual and submandibular space … ?
The treatment for Ludwig’s angina requires incision and drainage of the abscess along with Abx.
Ludwig’s angina requires use of what type of Abx?
Antibiotic coverage should include oral cavity anaerobes.
Commonly used Abx are Amp-Sulbactam or Clindamycin and Vancomycin if MRSA is suspected or know to be present.
What if the principle cause for a patient’s Ludwig’s angina is from infected 2nd or 3rd molars?
Since the mylohyoid line on the inner aspect of the body of the mandible descends on a slant, and the tips of the roots of the second and third molars are behind and below this line, if these teeth are abscessed, the pus will go into the submandibular space and may spread to the parapharyngeal space. Usually, the infected tooth is not painful.
Patients with these infections present with unilateral neck swelling, redness, pain, and fever.
Treatment is incision and drainage over the submandibular swelling.
What if the principle cause for Ludwig’s angina is from infected 1st molar or forward?
Tooth roots that are above the mylohyoid line, as they are from the first molar forward, the infection will enter the sublingual space, above and in front of the mylohyoid. The infection will cause the tongue to be pushed up and back and these patients usually will require an awake-tracheotomy, as the infection can progress quite rapidly and produce airway obstruction. The firm tongue swelling prevents standard laryngeal exposure with a laryngoscope blade, so intubation should not be attempted. Even if there is no airway obstruction on presentation, it may develop after you operate and drain the pus. This results from post- operative swelling, which can be worse than the swelling on initial presentation.
How is acute angioneurotic edema managed?
Acute angioneurotic edema is dramatic swelling of the tongue, pharyngeal tissues, and the supraglottic airway and urgently requires a surgical airway.
Angioneurotic edema, can either familial or due to a functional or quantitative deficiency of C1-esterase inhibitor, can also result in swelling can progress rapidly, and oral intubation may quickly become impossible, which is why this condition urgently requires a surgical airway.
Common medical treatments are IV steroids, and H1 and H2 histamine blockers.
A child appears anxious with a constellation of noisy breathing, stridor, hoarseness, high fever, and drooling, while sitting upright with the jaw thrusted forward, what is the most important consideration in management of this patient?
Secure the airway!
This condition is likely a result of infections, and epiglottitis, should first come to mind. Once common in children, epiglottitis is now rare because of the widespread utilization of vaccination against Haemophilus influenzae. Even though this condition is still rare, epiglottitis can be caused by other pathogens, such as other strains of H influenzae, Streptococcus species (S pneumoniae, S pyogenes), and Staphylococcus aureus.
Epiglottitis is cellulitis of the epiglottis, aryepiglottic folds, and other adjacent tissue. Swelling of these structures often leads to rapid airway deterioration. Epiglottic or supraglottic edema prevents swallowing. Early recognition of the constellation of noisy breathing, hoarseness, high fever, drooling, and the characteristic posture—sitting upright with the jaw thrust forward—may be lifesaving. Relaxation and an upright position keep the airway open. These patients must not be examined until after the airway is secured, therefore, airway management is the main priority. In patients unable to maintain adequate oxygen saturations, bag-valve-mask ventilation (BVM) with 100% oxygen (to keep oxygen saturation ≥88%) should be initiated. If BVM does not result in adequate oxygenation (ie, oxygen saturation remains low), endotracheal intubation using a video laryngoscope (to facilitate direct visualization of the epiglottis) should be attempted. Given the risk of rapid respiratory deterioration, failure of a single attempt at endotracheal intubation with a video laryngoscope should immediately prompt the establishment of a surgical cricothyrotomy by the most experienced provider available (preferably an otolaryngologist or general surgeon). Cricothyrotomy establishes an airway below the epiglottal swelling and potential obstruction.
Does epiglottitis have any obvious pharyngeal signs?
Lateral neck radiographs are often obtained for suspected epiglottitis. Although epiglottitis can present with fever, dysphagia, severe sore throat, and muffled voice, pharyngeal findings are typically normal.
what condition is marked by fullness of the anterior tonsillar pillar, uvular deviation away from the side of the abscess, a “hot potato” voice, and, in some patients, trismus (difficulty opening the jaws)
….
what is the most likely condition?
This is most likely a peritonsillar abscess, which is caused by purulence in the space between the tonsil and the pharyngeal constrictor.
This typically occurs when the patient has a history of untreated sore throat for several days, which has now gotten worse on one side.
Treatment includes drainage or aspiration, adequate pain control, and antibiotics. Tonsillectomy may be indicated, depending on the patient’s history.
Foreign bodies in the pharynx or laryngeal inlet can often be extracted by
Magill forceps
These are used after laryngeal exposure with a standard laryngoscope. The patient will usually vomit, so suction is mandatory.
hyperinflation of the obstructed lobe or segment following an aspiration is due to to a … ?
ball-valve obstruction
If a ball-valve obstruction results, hyperinflation of the obstructed lobe or segment can occur and this is easier to visualize on __________ .
inspiration-expiration films
Bronchial foreign bodies will require ______ for removal.
Operative bronchoscopy
Occasionally, a tracheotomy will be required, such as for a patient who has aspirated a partial denture with imbedded hooks.
These patients can present as airway emergencies, although they more typically present with unexplained cough or pneumonia.
A fungal infection of the sinonasal cavity that occurs in immunocompromised hosts is called … ?
Mucormycosis
Typically it appears in patients receiving bone marrow transplantation or chemotherapy. It is a devastating disease, with a significant associated mortality. Mucor is a ubiquitous fungus that can become invasive in susceptible patients, classically those with diabetes with poor glucose regulation who became acidotic. If there is any other system failure (e.g., renal failure), mortality goes up significantly. The fungus grows in the blood vessels, causing thrombosis and distal ischemia and, ultimately, tissue necrosis. This also leads to an acidic environment in which the fungus thrives.
The primary symptom is facial pain, and physical exam will show black turbinates due to necrosis of the mucosa. Diagnosis is made by biopsy. Acutely branching nonseptate hyphae are seen microscopically. Usually the infection starts in the sinuses, but rapidly spreads to the nose, eye, and palate, and up the optic nerve to the brain. Treatment is immediate correction of the acidosis and metabolic stabilization, to the point where general anesthesia will be safely tolerated (usually for patients in diabetic ketoacidosis who need several hours for rehydration, etc.). Then, wide debridement is necessary, usually consisting of a medial maxillectomy but often extending to a radical maxillectomy and orbital exenteration (removal of the eye and part of the hard palate) or even beyond. Amphotericin B is the drug of choice. Many patients with mucormycosis also have renal failure, which precludes adequate dosing. Newer lysosomal forms of amphotericin B have been shown to salvage these patients by permitting higher doses of drugs. If the underlying immunologic problem cannot be arrested, survival is unlikely. In patients who are neutropenic, unless the white blood cell count improves, there is no chance for survival.
What part of the nose is most commonly known to bleed?
The most common bleed is from the anterior part of the septum, which accounts for 90% of the nose bleeds.
The anterior region of the Kiesselbach plexus is formed from the internal carotid artery, which produces an ophthalmic artery, which then terminate to the ethmoid and septal arteries. Specifically, the Kiesselbach plexus is the anastomosis of the septal branch of the anterior ethmoidal artery and the lateral nasal branch of the sphenopalatine artery. Another vessel from the facial artery joins the network from the superior septal branch.
Posterior epistaxis occurs from which branches?
This is less common (10% of the nose bleeds) and may result in significant hemorrhage. The posterior bleeding occurs from the posterolateral branches of the sphenopalatine artery, which is the terminal branch of the maxillary artery (which comes from the external carotid). Rarely the external carotid artery can cause this hemorrhage.
What are the causes for epistaxis?
Local causes of epistaxis include mucosal irritation (eg, nose picking, dry air, rhinitis, foreign body), facial trauma, intranasal drugs (cocaine, intranasal corticosteroids), or tumors (nasopharyngeal carcinomas). Systemic conditions or drugs may also cause epistaxis (eg, anticoagulation, antiplatelet medications, alcohol, bleeding disorders [eg, von Willebrand disease], vascular malformations [nasal hemangioma], or hypertension).
The most common initiating event for these kinds of nosebleeds is digital trauma from a fingernail. Children’s fingernails should be trimmed, and adults should be informed about avoiding digital trauma. Another consideration may be an occult bleeding disorder; therefore, adequate coagulation parameters should be studied if the patient continues to have problems.
What is a common cause for epistaxis in an adult?
Cocaine abuse is a possible etiology in any patient and must be considered. A perforated nasal septum can be a warning sign.
Other causes are trauma, Afrin, or prior surgery.
Recurrent bleeding from the back of the nose in an adolescent male is considered to be _______ until proven otherwise.
Juvenile nasopharyngeal angiofibroma
These patients frequently also have nasal obstruction.
Diagnosis is made by physical examination with nasal endoscopy.
What are the initial steps in management for epistaxis (either anterior or posterior)?
ABC’s: Assess and treat for airway, breathing, and circulation
(fluid resuscitation, redundant large-bore IV lines as indicated).
Position the head forward.
Provide oxymetazoline or phenylephrine nasal spray (and possibly lidocaine) and digital pressure for 5–10 minutes.
Cold compress.
What labs are indicated for nosebleeds?
A targeted history can help to rule out other conditions that predispose to bleeding, but in general the labs that are indicated are, Coags (for anticoagulated patients), CBC, type-screen or cross-match.
Patients with hypertension and arthritis (for which they are taking aspirin), who have frequent nosebleeds, are treated with … ?
Topical vasoconstriction (oxymetazoline, phenylephrine), which almost always stops the bleeding. These patients should also be treated with medication to lower their blood pressure. The diastolic pressure has to be reduced below 90 mm Hg.
What is the approach to nose bleeding if the nosebleed is anterior and the source can be seen?
If anterior and a bleeding source is seen, it can be cauterized with either electric cautery or chemical cauterization with silver nitrate and packing (nasal tampons, ribbon gauze, nasal balloon catheter).
Nasal endoscopes permit identification of the bleeding site, even if it is not immediately seen on the anterior septum.
Brisk bleeding even after adequate nasal packing may indicate
a posterior source of bleeding
What is the measure performed for epistaxis when the bleeding will not stop and can not be seen?
When posterior nosebleeds can not be stopped, treatments include:
- Packing (nasal tampons, ribbon gauze, nasal balloon catheter)
- Balloon catheter is preferred or a Foley catheter can be used
These patients may require hospitalization and ENT consultation.
Once a patient presents with a nosebleed and is properly managed, when can a patient be discharged home?
When would they needed to be admitted for observation?
Patients who undergo anterior packing on one side may go home.
Many patients can then go home, using oxymetazoline for a few days. Furthermore, methylcellulose coated with antibiotic ointment can be placed into the nose to prevent further trauma and allow the mucosal surfaces to heal. This is usually left in place for 3 to 5 days.
Bilateral nasal packing is used or if a posterior pack is placed, patients will need to be admitted to the hospital and carefully watched, because they can suffer from hyperventilation and oxygen desaturation.
In general, the packing is left in place for three to five days and removed. During this time, prophylactic oral or parenteral antibiotics should be administered to decrease risk of infectious complications.
If the patient re-bleeds, the packing should be replaced, and arterial ligation, endoscopic cautery, or embolization can be considered. As always, these patients should be worked up for bleeding disorders.
A patient with a severe nosebleed can develop
Hypovolemia, or significant anemia, if fluid is being replaced.
These conditions necessitate increased cardiac output, which can lead to ischemia or infarction of the heart itself.
What are the major complications of epistaxis?
Prolonged retention of nasal packing (>72 hours) increases the risk of complications, including necrosis, toxic shock syndrome, sinus or nasolacrimal infections, and dislodgement.
A patient subsequently presents with fever, hypotension, desquamation, and mucosal hyperemia after receiving nasal packing, what is the likely issue?
toxic shock syndrome
What is the name for the infection spreads due to a severe infection of the external auditory canal to the temporal bone leading to osteomyelitis of the temporal bone?
Necrotizing otitis externa.
This is a severe infection of the external auditory canal, usually caused by Pseudomonas organisms. The infection spreads to the temporal bone and, as such, is really an osteomyelitis of the temporal bone. This can extend readily to the base of the skull and lead to fatal complications if it is not adequately treated. This disease occurs most commonly in older patients with diabetes, and can occur in AIDS patients. Any patient with otitis externa should be asked about the possibility of diabetes. It can be caused by traumatic instrumentation or irrigating wax from the ears of patients with diabetes.
Patients with necrotizing otitis externa present with deep ear pain, temporal headaches, purulent drainage and granulation tissue at the area of the bony cartilaginous junction in the external auditory canal and facial nerve followed by other cranial neuropathies.
What is required to diagnose necrotizing otitis externa?
To diagnose an actual infection in the bone, a computed tomography (CT) scan of the bone, with bone windows, must be obtained.
A technetium bone scan will also demonstrate a “hot spot,” but is too sensitive to discriminate between severe otitis externa and true osteomyelitis.
What is the treatment regimen for necrotizing otitis externa?
The standard therapy is meticulous glucose control, aural hygiene, including frequent ear cleaning, systemic and topical anti-pseudomonal antibiotics (quinolones are the drugs of choice as they are active against Pseudomonas organisms).
Hyperbaric oxygen is used in severe cases that do not respond to standard care.
Is sudden sensorineural hearing loss (SSHL) considered an emergency?
Yes, SSHL is a medical emergency that warrants urgent consultation and follow-up with an otolaryngologist. The prognosis is variable and depends on the patient’s age, initial severity of the hearing loss, and promptness of medical treatment. SSHL is usually idiopathic, unilateral, with sensorineural hearing loss over a period of less than 72 hours. The most common theories for the etiology are a viral infection or a disorder of inner ear circulation due to vascular disease. The most common treatment for SSHL is a tapered course of oral corticosteroids and/or intratympanic corticosteroid injections, yet there is no clear-cut evidence that shows a significant treatment effect. There are a wide variety of treatments have been used to treat SSHL, including oral and intratympanic steroids, hemodilutional agents, anticoagulants, antivirals, hyperbaric oxygen, and vitamins.
Inflammation of the middle ear space is called … ?
Otitis media
This is the second most common disease diagnosed in children.
The eardrum on pneumatic otoscopy with a patient with acute otitis media will be …
bulging with decreased movement
A child presents with sudden onset of fever, ear pain, and fussiness. On physical exam, the child has an eardrum that is bulging and
yellow and white in color with dilated vessels, and there is decreased movement of with insufflation of air into the ear canal, what is the most likely diagnosis?
Acute otitis media
Complications of Acute Otitis Media
Meningitis, sigmoid sinus thrombosis, subperiosteal abscess of the mastoid, brain abscess, and facial nerve paralysis
Common bacteria that cause acute otitis media in children are
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
When is observation the treatment option for acute otitis media?
Observation for 48-hours is considered in healthy children older than two years of age who present with less severe symptoms
If treatment is necessary, what is the treatment option for acute otitis media?
Amoxicillin dosed at 80 to 90 milligrams per kilogram per day is the first-line antibiotic therapy.
Azithromycin is used to treat patients who have a penicillin allergy.
A common second-line therapy for acute otitis media is high-dose amoxicillin-clavulanate. This is to address those who do not respond to first-line antibiotic therapy, which is likely due to a beta-lactamase-producing organism or a resistant Streptococcus organism.
What can decrease the incidence in acute otitis media in children?
Breastfeeding and vaccination with a pneumococcal conjugate preparation may decrease the incidence of acute otitis media in children.
What factors increase the incidence of acute otitis media in children?
Daycare attendance, young siblings at home, and exposure to tobacco smoke, may predispose children to develop otitis media.
Pressure equalization (PE) tubes, or ear tubes, are indicated in children with:
Chronic OME for 3 months and evidence of hearing loss
or
3 to 4 bouts of acute otitis media in 6 months
or
5 to 6 bouts in a single year
An advantage of PE tubes is the ability to treat episodes of ear drainage with topical antibiotic therapy, such as fluoroquinolone ototopical drops applied to the ear canal. Fluoroquinolone drops are favored over neomycin/polymyxin B/hydrocortisone, due to the risk of ototoxicity.
What helps to prognosticate the use of PE tubes in children?
Children usually grow out of the need for the tubes as they get older, as the eustachian tube assumes a longer and more downward-slanted course with time.
However, there are certain subsets of patients, such as children with a history of cleft palate or trisomy 21, who can have long-term problems with otitis media and eustachian tube dysfunction.
Injury to the hair cells in the cochlea or neural elements innervating the hair cells due to persistent noise exposure, age-related changes of the eighth cranial nerve (presbycusis), genetic factors, and infectious or post inflammatory processes, and tumor growth (acoustic neuroma), lead to ______ hearing loss.
Sensorineural
(bone conduction)
What is a major complication of Frontal Sinusitis
Meningitis and Brain Abscesses
This is due to the penetration of organisms or the propagation of an infected clot into the posterior sinus that leads directly into the dura from the frontal sinus lining.
When must this condition be corrected?
When the obstruction involves the nasal pyramid, it, too, must be corrected by rhinoplasty.
Rhinoplasty involves controlled chisel cuts of the bones (osteotomies) on either side of the nose and placement of the bones into the correct position. A splint is used to hold this position for a week after surgery. Rhinoplasty can be combined with trimming of the nasal cartilage to subtly change the contour of the tip of the nose. When the obstruction involves the softer, cartilaginous middle third of the nose and/or the nostril openings, then nasal valve repair may be indicated. This surgery may entail placing cartilage grafts to widen or strengthen the lateral wall of the nasal cavity to relieve the nasal obstruction. This surgery can be performed concomitantly with a septoplasty or rhinoplasty.
What is the condition when a patient presents with extremely edematous nasal or sinus mucosa?
Nasal polyps
These growths are localized, extremely edematous nasal or sinus mucosa, and are a frequent cause of nasal blockage. Microscopically, they are essentially full of water. They can enlarge while in the nose, and obstruct either the nose or the ostia through which the sinuses drain.
What is a concha bullosa?
An air cell within the middle turbinate
