Inner Ear, Nose and Sinus, Throat Flashcards
(87 cards)
1
Q
Recurrent episodic vertigo caused by endolymphatic hydrops (edema)?
A
Meniere’s disease - potentially over diagnosed?
2
Q
What are some symptoms of Meniere’s disease?
A
- Episodic attacks (with dread)
- Severe to violent vertigo with N/V
- Aural fullness
- Fluctuating hearing loss
- Loud, roaring, tinnitus
- Sensitivity to loud noises
- Usually middle-aged women
- Autoimmune?
3
Q
Who does Meniere’s classically affect?
A
Middle aged women
4
Q
What is an uncommon but dangerous condition that causes vertigo in 50% of pts?
A
Acoustic neuroma
5
Q
What are some features of acoustic neuroma?
A
- Slowly progressive, unilateral hearing loss.
- Tinnitus
- Facial weakness
6
Q
What do you do with any vague dizziness or vertigo with unilateral or asymmetric sensory hearing loss?
A
Assume it’s an acoustic neuroma until proven otherwise.
7
Q
What are some features of vestibular neuronitis?
A
- Common, usually follows URI.
- Sudden, severe vertigo with N/V
- Affects CN 8
- No tinnitus or change in hearing
- Unidirectional nystagmus
- Hypoactive vestibular apparatus
8
Q
What is the prognosis for vestibular neuronitis?
A
Resolves in days to weeks down to mild positional vertigo.
9
Q
How is labyrinthitis different from vestibular neuronitis?
A
It involves both the cochlea and the labyrinth.
10
Q
Where does the nystagmus go in labyrinthitis?
A
Spontaneously to the unaffected side.
11
Q
What is the prognosis of labyrinthitis?
A
May resolve in days to weeks but unsteadiness and positional vertigo may persist for months.
12
Q
What causes labyrinthitis?
A
Lots of things: ototoxic drugs, infection, autoimmune, treatment of TB.
Most commonly concomitant to acute infection like OM or sinusitis
13
Q
What is BPPV?
A
It’s a brief episode of vertigo that is ALWAYS and only positional.
14
Q
Does BPPV have hearing loss or tinnitus?
A
No it does not.
15
Q
What can cause BPPV?
A
Head trauma, dental surgery, middle ear infection, otoliths.
16
Q
What endocrine/metabolic conditions should be on your DDx when treating inner ear disorders?
A
- Hypothyroid
- Hyperlipidemia
- Electrolytes (specifically Na/K)
- Diabetic and dysglycemia
17
Q
What is the most common cause of traumatic hearing loss?
A
Rupture of the TM? It may actually be noise or head injury.
18
Q
What type of tympanogram does ruptured TM cause?
A
A(d) – Type A disrupted
19
Q
What PE can you use to assess conductive hearing loss?
A
Rinne, it’s specific but not sensitive.
20
Q
What is the big DDx list for types of hearing loss?
A
- Conductive
- Sensorineural (congenital, genetic)
- Traumatic (noise, head injury)
- Inflammatory (ASOM, SOM)
- Neoplastic
- Metabolic/vascular
- Ototoxicity
21
Q
What syndrome has a lock of grey hair in the front of the head?
A
Waadenberg’s - it’s a genetic cause of sensorineural hearing loss.
22
Q
What is Schwartze’s sign?
A
A pinkish blue hue to TM associated with otosclerosis.
23
Q
What does the Weber test differentiate?
A
Conductive from sensorineural hearing loss.
24
Q
What does the Rinne test differentiate?
A
Air conduction vs bone conduction.
25
What might you notice in office about your pt with conductive hearing loss?
They may be very soft spoken and hear better in a noisy environment.
26
What kind of tympanogram are you likely to see in conductive hearing loss?
A(s) -- (stiff)
27
What does audiology test?
Air and bone conduction between 250-8,000Hz.
28
What is Carhart's notch?
Dip in bone conductive threshold at 2000 Hz where sound is loudest for human ears.
29
What does speech audiometry measure?
The threshold at which speech is accurately heard.
30
What does auditory brainstem response measure?
The time it takes for impulses to get form the cochlea to the brainstem.
31
Which mineral is helpful for presbycusis?
Zinc (add copper if using long term).
32
Which minerals are helpful for aminoglycoside and antibiotic ototoxicity?
Magnesium
| Glutathione if gentamicin toxicity
33
What are a few ototoxic substances?
- Aspirin
- Quinine
- Aminoglycosides
- Erythromycin (high dose)
- Loop and thiazide diuretics
- Platinum based chemo
- CO2
- Nicotine
- Alcohol
- Heavy metals
- Interferon a
34
How can you improve circulation to the middle ear?
Oral: Gingko, vaccinium bilberry, vinca minor.
Local: Hypericum oil, cimicifuga.
35
Which vitamin deficiencies are associated with sensorineural hearing loss?
Vitamins A and D.
36
According to the article in American Family Physician, what are some causes of acute tinnitus?
```
Infection
Meds
Trauma
Loud noises
Wax
Change in BP or metabolism
```
37
According to the article in American Family Physician, what are some causes of chronic tinnitus?
Damage to auditory cortex from aging.
38
According to the article in American Family Physician, what are some causes of objective tinnitus?
Vascular abnormalities
| Mechanical disorders
39
According to the article in American Family Physician, what are some treatments for tinnitus?
- Acoustic therapy - hearing aids, sound pillows
- Hearing protection
- Manage insomnia, anxiety, depression
- Manage metabolic disorders
40
Which supplements help improve cell membrane integrity?
Antioxidants - Strengthen cell membranes
Quercetin - Stabilize mast cells
EFAs - Stabilize cell membranes
41
Which bioflavonoid helps by inhibiting the degranulation of mast cells?
Quercetin!
42
Which bioflavonoid inhibits histidine carboxylase and is also a potent antioxidant?
Catechin
43
Which class of EFAs do atopic patients have trouble converting to PGE1?
Linoleic acid, which is an omega 6.
| EPO, borage, and black currant all have GLA and avoid this step.
44
Which foods should allergic patients avoid?
Dairy, citrus, animal fat, TFAs.
| All food allergens.
45
What are some ways to support the adrenals?
- Standard Process: Drenotrophin, Antronex, Corrhyzadyn, Isocort, Multi B vitamins.
- DHEA if indicated by testing.
- Pantothenic acid (B5) precursor to coenzyme A.
46
When is the best time to implement a nutritional program for prophylaxis of allergic rhinitis?
2 months before allergy season.
47
Is urtica dioica good for everyone with hay-fever?
It helps about 58% of the time.
48
What's a good herbal formula for hay-fever?
Butterbur
Urtica
Sambucus
Euphrasia
49
What are some ways you can help your patients abort a cold?
```
Nature cure
Rest
Water
Simple diet
Hydrotherapy
```
50
Is echinacea effective for the prevention and treatment of URIs?
Apparently yes. It decreases the incidence and duration of the common cold.
However, it's usually used in conjunction with other treatments.
51
What are a few ND sinusitis treatments?
Botanicals: achillea, euphrasia, hydrasits.
Hydro: Nasal lavage, steam inhalation.
Rest, water, simple diet, garlic.
52
When should you order imaging for sinusitis?
Never for acute sinusitis.
If you have persistent sinusitis and you suspect orbital cellulitis or brain abscess.
CT is probably the most accurate.
Fiberoptic visualization of the ostia may reveal obstruction from polyps or anomalies.
53
Are abx indicated for acute sinusitis?
Rarely, 1 in 8 cases will respond.
54
How do you assess and treat epistaxis?
Assess by PE, look for bleeding site.
Frontal epistaxis is usually controlled with pressure or cold.
If uncontrolled, use topical anesthetic and silver nitrate.
55
When is epistaxis potentially dangerous?
If it's a posterior bleed. Refer to an ENT!
Also dangerous if bleeding doesn't stop or if the site of bleeding can't be found.
56
What are a few of the risk factors for sinusitis?
```
VRI
Allergies
Anatomy
Meds
Irritants
Many, many more
```
57
What is the pathophysiology of (infectious) rhinosinusitis?
Viral rhinitis => blocked ostia => O2 absorbed => negative pressure (pain at this stage = vacuum sinusitis) => transudate. (Then maybe) => bacteria invade => inflammation => Ciliary dykinesis=> positive pressure => pain.
58
What's the prognosis for sinusitis?
- May take 3-4 days for relief.
- Continue Tx for 10-14 days to avoid relapse.
- Refer: persistent HA, high fever, lethargy, orbital swelling.
59
What are 4 signs and symptoms are the most helpful in predicting acute bacterial rhinosinusitis?
1. Purulent nasal discharge
2. Maxillary tooth or facial pain
3. Unilateral maxillary sinus tenderness
4. Worsening symptoms after initial improvement
60
What are some good physmed and hydro options for sinusitis?
Nasal specific
Craniosacral
Nasal lavage
Steam inhalation
61
What's the DDx for inflammatory rhinosinusitis with mostly eosinophils?
- Allergic
- Non-allergic
- Asthma
- Fungal
62
What's the DDx for inflammatory rhinosinusitis with mostly neutrophils?
- Acute bacterial
- Foreign body
- Nasal polyps
- Primary ciliary dyskinesia
63
Probably diagnosis for inflammatory rhinosinusitis with complex infiltrates?
Sounds like a common cold.
64
What's the general DDx for non-inflammatory rhinosinusitis?
- Structural
- Hormonal
- Drug induced
- Neural dysfunction
- Other (sick building, alzheimer's)
65
What would you expect on CBC, scratch, nasal smear (eos) for allergic rhinitis?
- CBC may show eosinophilia
- Scratch: +
- Nasal smear: eosinophils +
66
What would you expect on CBC, scratch, nasal smear (eos) for perennial nonallergic rhinitis, aka nonallergic rhinitis with eosinophilia syndrome (NARES)?
- CBC: -
- Scratch: -
- Nasal smear: eosinophils +
67
What would you expect on CBC, scratch, nasal smear (eos) for cholinergic rhinitis?
- CBC: -
- Scratch: -
- Nasal smear: eosinophils -
68
What is the pathogenesis of cholinergic rhinitis?
Thought to be secondary to imbalance between the sympathetic and parasympathetic nervous systems.
Parasympathetic dominance => increase in cholinergics (ACH) => vasodilation, nasal congestion and increased mucous secretion.
69
Hx for cholinergic rhinitis?
Triggers are key to dx:
(1) Emotions/crying
(2) Odors, smoke
(3) Weather changes, especially cold air
(4) Recumbency
(5) Trauma
(6) Trigeminal neuralgia
(7) Spicy food, alcoholic beverages
Chronic, not seasonally or geographically associated.
Bilateral, unilateral, or alternating.
70
What is the immune pathophysiology of allergic rhinitis?
Ag diffuses across the mucus membrane =>Th2 response => IL-4, IL-13 stimulate B cells to make IgE.
Mast cells => Histamine, PGL D2, Leukotrienes, Kinins, TNFa.
71
What does degranulation of mast cells eventually lead to in allergic rhinitis?
Contraction of smooth muscle.
Capillary dilation, increased permeability of capillary walls.
Glandular hyper-secretion.
72
Should you give urtica to every patient with hayfever?
No, it's contraindicated for diabetic pts (increases blood glucose) and people with fluid retention secondary to cardiac or kidney disease.
73
What is Herbal Ed's formula for hayfever?
Hydrastis
Achillea
Euphrasia
Cochlearia
74
What can you give for recurrent epistaxis?
Vitamin C
Bioflavinoids
Homeopathy
75
What are three conditions (besides lesions) that can cause sore throat?
```
Cardiovascular disease (sudden severe throat pain in older patients should suggest aortic dissection or pneumothorax)
Systemic disease (RA, HIV, leukemia)
Other head and neck disorder (thyroiditis, mumps, postnasal drip)
```
76
Should you always do a quick ENT exam on all patient with a sore throat?
Yes, doy
77
What are some oral lesions that can cause sore throat?
- Necrotizing gingivitis
- Herpes simplex
- Hand, foot, mouth
- Apthous ulcers
- Oral candida
- Mononucleosis
78
What are the signs and symptoms of mono?
- Posterior cervical and auricular LA
- Exhaustion and myalgia
- Tonsillar exudates
- Petechia on back of pharynx
- Hepatosplenomegaly (maybe)
79
How do you confirm mono with labs?
- Peripheral smear shows 80-100 atypical lymphocytes.
- Positive monospot
- Elevated liver transaminases
80
What is the Centor criteria for strep culture?
- Temp over 100
- No cough
- Swollen tender anterior cervical LA
- Tonsillar swelling or exudate
81
What are some cases in which you can safely decline to do a strep culture?
- Close contacts are positive.
- Scarlet fever is evident.
- In strep epidemics.
- Prior ABX.
82
What is a strep carrier? Are they at risk for non-suppurative complications of strep throat?
Pts who are GABHS + but ASO titer negative.
| They're not at risk, they don't mount an Ab response.
83
Are antibiotics helpful in treating strep throat?
Perhaps: likely do not alter the length of dz, but may decrease the incidence of "ping-ponging" between relatives and, and do prevent suppurative complications.
84
What is the AANP position on abx for strep throat?
If patient is unresponsive to other treatments within 1 week, recommend antibiotics.
85
Botanical tx of strep pharyngitis?
HEMP tincture: Hydrastis or Berberis (berberine - good coverage of Streptococcus) , Echinacea, Myrrh, Phytolacca.
Even more effective with a synergist!
86
Synergists for HEMP tincture:
Gelsemium: trembling with nervous excitement, high temp, may have miosis (small pupils).
Belladonna: dull expressionless face which is red, dilated pupils, throbbing pain.
Bryonia: sharp cutting pain, < pressure, < Movement, hard pulse.
Aconite: small and fast pulse, very red and dry throat, fast onset with fever.
87
Botanicals for non-strep pharyngitis?
```
Many:
Echinacea (good for analgesia)
Andrographis paniculata
Glycyrrhiza
Ligusticum - for viral
Usnea - for anti-viral and anti-bacterial (w/ Stevia & Glyc)
Ginger
Propilus
Achillea
Garlic, thyme oil, myrrh
```
