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Passmed ENT Mushkies Flashcards

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1
Q

What is an autosomal dominant cause of deafness affecting young adults?

A

Otosclerosis

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2
Q

What kind of hearing loss does otosclerosis cause?

A

Conductive

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3
Q

What kind of hearing loss do acoustic neuromas cause?

A

Sensorineural

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4
Q

How does Menieres disease usually present?

A
  1. Episodic vertigo
  2. Hearing loss
  3. Tinnitus
  4. Fullness/pressure in one or both ears
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5
Q

What is otosclerosis?

A

Replacement of normal bone in the ear by vascular spongy bone, causing progressive conductive deafness due to fixation of the stapes at the oval window

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6
Q

What are some features of otosclerosis?

A
  1. 20-40 y/o
  2. Conductive deafness
  3. Tinnitus
  4. Normal tympanic membranes
  5. Positive FHx
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7
Q

What is the management of otosclerosis?

A
  1. Hearing aid

2. Stapedectomy

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8
Q

How can you classify the causes of otitis externa?

A
  1. Infection
  2. Seborrhoeic dermatitis
  3. Contact dermatitis (allergic and irritant)
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9
Q

What are the infective causes of otitis externa?

A
  1. Bacterial = S. aureus, P. aeruginosa
  2. Viral
  3. Fungal
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10
Q

What are some features of otitis externa?

A
  1. Ear pain
  2. Itch
  3. Discharge
  4. Otoscopy = red, swollen, or eczematous canal
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11
Q

What is the first line management of otitis externa?

A
  1. Topical Abx/combined topical Abx with steroid e.g. topical gentamicin + hydrocortisone drops
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12
Q

What can be inserted to manage an extensively swollen ear canal due to otitis externa?

A

Ear wick

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13
Q

What are second line treatments for otitis externa?

A
  1. Spreading infection = oral flucloxacillin

2. Empirical antifungal

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14
Q

What should you do with otitis externa that fails to respond to topical Abx?

A

Referral to ENT

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15
Q

What is malignant otitis externa, and what pt group do you typically see it in?

A
  1. Extension of infection into bony ear canal and soft tissues deep to the bony canal
  2. Found in immunocompromised individuals (90% diabetics)
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16
Q

What causes an elderly pt that becomes dizzy upon extending his neck?

A

Vertebrobasilar ischaemia

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17
Q

What is vertigo?

A

The false sensation that the body or environment is moving

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18
Q

What are features of viral labyrinthitis?

A
  1. Recent viral infection
  2. Sudden onset
  3. N&V
  4. Hearing may be affected
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19
Q

What are features of vestibular neuronitis?

A
  1. Recent viral infection
  2. Recurrent vertigo attacks lasting hours or days
  3. No hearing loss
  4. Horizontal nystagmus usually present
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20
Q

What are features of BPPV?

A
  1. Gradual onset
  2. Triggered by change in head position
  3. Each episode lasts 10-20s
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21
Q

How does an acoustic neuroma present?

A
  1. Hearing loss
  2. Vertigo
  3. Tinnitus
  4. Absent corneal reflex is an important sign
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22
Q

What condition are acoustic neuromas associated with?

A

NF2

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23
Q

Is air conduction (AC) usually better than bone conduction (BC)?

A

Yes

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24
Q

What does BC > AC on Rinne’s test imply?

A

Conductive deafness

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25
In Weber's test, to which side is unilateral sensorineural deafness localised to?
To the unaffected side
26
In Weber's test, to which is is unilateral conducive deafness localised to?
To the affected side
27
Is hearing normal or abnormal in vestibular neuronitis?
Normal
28
What exam can be used to distinguish vestibular neuronitis from a posterior circulation stroke?
The HiNTs exam
29
What is the management of vestibular neuronitis?
1. Vestibular rehab exercises if chronic 2. Buccal/IM prochlorperazine for rapid relief in severe cases 3. Short oral course of prochlorperazine to alleviate less severe cases
30
Why should pts with hoarseness being referred down the cancer pathway have a CXR?
To exclude an apical lung lesion
31
What are some causes of hoarseness?
1. Voice overuse 2. Smoking 3. Infection = viral 4. Inflammation = GORD 5. Malignancy = laryngeal, lung 6. Hypothyroidism
32
What is otitis externa with worsening unrelenting pain suggestive of?
Malignant (necrotising) otitis externa
33
What is the most common cause of malignant otitis externa?
P. aeruginosa
34
What can malignant otitis externa progress to?
Temporal bone osteomyelitis
35
How is malignant otitis externa usually diagnosed?
CT
36
How is malignant otitis externa usually managed?
IV Abx that cover pseudomonas
37
What percentage of otitis media is viral?
50%
38
What percentage of otitis media improve without Abx?
60%
39
When should you usually treat otitis media with Abx?
1. Sx > 4d or not improving 2. Systematically unwell but not requiring admission 3. Immunocompromise or high risk of complications secondary to other disease 4. Younger than 2 y/o with bilateral otitis media 5. Otitis media w/ perforation and/or discharge in the canal
40
What is the first line Abx for treatment of tonsillitis?
Penicillin V/Phenoxymethylpenicillin for 10 days
41
What is the first line Abx for treatment of otitis media?
Amoxicillin 500mg TDs for 7 days
42
What is the most common cause of neck swellings?
Reactive lymphadenopathy
43
What is a characteristic of a thyroid swelling?
Moves upward on swallowing
44
In what age group are thyroglossal cysts more common?
<20 y/o
45
What are some features of a thyroglossal cyst?
1. Usually midline, between isthmus of thyroid and the hyoid bone 2. Moves upward on protrusion of the tonge 3. May be painful if infected
46
In what pt group are pharyngeal pouches more common?
Older men
47
What is a pharyngeal pouch?
A posteromedial herniation between the thyropharyngeus and cricopharyngeus muscle
48
What are some features of a pharyngeal pouch?
1. Usually not seen, but if large then a midline neck lump that gurgles on palpation 2. Dysphagia 3. Regurgitation 4. Aspiration 5. Chronic cough
49
What is a cystic hygroma?
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
50
In what pt group are cystic hygromas more common?
Most evident at birth, 90% present before 2 y/o
51
What is a branchial cyst?
An oval, mobile mass that develops between the SCM and the pharynx
52
How does a branchial cyst form?
Develops due to failure of obliteration of the second branchial cleft in embryonic development i.e. failure of fusion of the second and third branchial arches
53
In what pt group do branchial cysts usually appear?
Early adulthood
54
What is a complication of a cervical rib?
10% develop thoracic outlet syndrome
55
In what pt population are cervical ribs more common?
Adult females
56
What does a carotid aneurysm look like clinically?
Pulsatile lateral neck mass which doesnt move on swallowing
57
What are some ototoxic medications?
1. Gentamicin 2. Quinine 3. Furosemide 4. Aspirin 5. Chemo
58
What are 2 uses for quinine?
1. Antimalarials | 2. Nocturnal leg cramps
59
What is presbyacusis?
Age-related sensorineural hearing loss
60
What does one see on audiometry of presbyacusis?
Bilateral high frequency hearing loss
61
What is the hearing loss seen with noise damage from e.g. heavy industry?
Bilateral and worse at frequencies of 3000-6000 Hz
62
How can you classify how acoustic neuromas present?
1. CN V = absent corneal reflex 2. CN VII = facial palsy 3. CN VIII = hearing loss, vertigo, tinnitus
63
What is the most common cause of a perforated tympanic membrane?
Infection
64
What are 2 other causes of a perforated tympanic membrane?
1. Direct trauma | 2. Barotrauma
65
What is the management of a perforated tympanic membrane?
1. Usually no tx as will heal in 6-8wks, avoid getting water in ear in this time 2. Abx for perforations that occur following a case of acute otitis media
66
What surgery can be performed if a tympanic membrane does not heal by itself?
Myringoplasty
67
What is Meniere's disease?
A disorder of the inner ear of unknown cause, characterised by excessive pressure and progressive dilatation of the endolymphatic system
68
How long do attacks in Meniere's disease typically last?
Mins to hours
69
What is the natural history of Menieres disease?
1. Symptoms resolve in the majority of pts after 5-10 yrs 2. Most will be left with a degree of hearing loss 3. Psychological distress is common
70
What is the management of Menieres disease?
1. Acute = buccal/IM prochlorperazine | 2. Prevention = Betahistine and vestibular rehab exercises
71
What special ting needs to be done with Menieres in terms of management?
DVLA should be informed, cease driving until satisfactory control of sx is achieved
72
What would cause facial pain that is worse on leaning forwards?
Sinusitis
73
What is acute sinusitis?
Inflammation of the mucous membranes of the paranasal sinuses
74
What are the most common infectious agents seen in acute sinusitis?
1. S. pneumoniae 2. H. influenzae 3. Rhinoviruses
75
What are some predisposing factors for acute sinusitis?
1. Nasal obstruction e.g. septal deviation/nasal polyps 2. Recent local infection e.g. rhinitis/dental extraction 3. Swimming/diving 4. Smoking
76
What are some features of acute sinusitis?
1. Facial pain (frontal, worse on bending down) 2. Nasal discharge (thick and purulent) 3. Nasal obstruction
77
What is the management of acute sinusitis?
1. Analgesia 2. Intranasal decongestants 3. Intranasal corticosteroids 4. Oral phenoxymethylpenicillin if severe
78
What can be given for tx of acute sinusitis if symptoms have not resolved after 10 days?
Intranasal corticosteroids
79
What is the most common cause of acute tonsillitis?
S. pyogenes
80
What is unilateral swelling and fever most likely to represent with acute tonsillitis?
Quinsy
81
What is quinsy?
Local abscess formation around the tonsil
82
What are 4 investigations for presbyacusis?
1. Otoscopy = normal 2. Tympanometry = normal 3. Audiometry = bilateral sensorineural 4. Bloods = normal
83
How many neural pathways lead to referred otalgia?
5
84
What are the 5 neural pathways that can lead to referred otalgia?
1. CNs 5, 7, 9, 10 | 2. C2 & C3
85
What is otalgia in the absence of any ear signs a red flag for?
Head and neck malignancy
86
What virus is nasopharyngeal carcinoma associated with?
EBV
87
How can you classify how nasopharyngeal carcinomas present?
Local and Systemic
88
How are some local ways nasopharyngeal carcinomas can present?
1. Otalgia 2, Unilateral serious otitis media 3. Nasal obstruction/discharge/epistaxis 4. CN palsies III-VI
89
In what part of the world is nasopharyngeal carcinoma most common?
Southern China
90
What is the 1st line treatment for nasopharyngeal carcinoma?
Radiotherapy
91
What can extended use of topical decongestants cause?
Rhinitis medicamentosa
92
What is rhinitis medicamentosa?
A condition of rebound nasal congestion brought about by extended use of topical decongestants
93
What is allergic rhinitis?
An inflammatory disorder of the nose where the nose becomes sensitised to allergens such as house dust mites and grass, tree and weed pollens
94
How can one classify allergic rhinitis?
1. Seasonal 2. Perennial 3. Occupational
95
What are some features of allergic rhinitis?
1. Sneezing 2. Bilateral nasal obstruction 3. Clear nasal discharge 4. Post-nasal drip 5. Nasal pruritis
96
What is the management of allergic rhinitis?
1. Allergen avoidance 2. Oral/intranasal antihistamines 3. Intranasal corticosteroids 4. Oral steroids to cover important life events 5. Short course of topical nasal decongestants
97
What is an example of a topical nasal decongestant?
Oxymetazoline
98
What do you call the phenomenon where increasing doses of a drug are required to achieve the same effect?
Tachyphylaxis
99
What must be done if there is primary haemorrhage after tonsillectomy and why?
Immediate return to theatre, due to risk of further more extensive bleeding
100
What are the 2 main post-operative complications of tonsillectomy?
Pain and Haemorrhage
101
What manoeuvre is diagnostic for BPPV?
Dix-Hallpike
102
What manoeuvre is curative for BPPV?
Epley
103
What are some features of BPPV?
1. Vertigo triggered by change in head position 2. Nausea 3. 10-20s 4. Positive Dix-Hallpike
104
In what % of pts with BPPV is the Epley manoeuvre successful?
80%
105
What is the eponym for the vestibular rehabilitation exercises that can be done at home for BPPV?
Brandt-Daroff Exercises
106
What medication can be prescribed for BPPV, but is of limited value?
Betahistine
107
What is the prognosis of BPPV?
1. Good, usually resolves spontaneously after a few weeks to months 2. 50% will have recurrence of symptoms 3-5 years after diagnosis
108
What is Ramsay Hunt Syndrome?
Facial nerve palsy caused by VZV reactivatoin in the geniculate ganglion of CN VII
109
What are some features of Ramsay Hunt Syndrome?
1. Auricular pain often first 2. Facial nerve palsy 3. Vesicular rash (around ear commonly) 4. Vertigo 5. Tinnitus
110
What is the management of Ramsay Hunt syndrome?
Oral aciclovir and corticosteroids
111
What is halitosis, mouth pain, poor dental hygiene with bleeding gums and widespread gingival ulceration suggestive of?
Acute necrotizing ulcerative ginigivitis
112
What is the management of acute necrotizing ulcerative gingivitis?
1. Refer to dentist, meanwhile: 2. Oral metronidazole for 3 days 3. Chlorhexidine 4. Analgesia
113
What abx should be given to treat malignant otitis externa in diabetics and why?
Ciprofloxacin to cover pseudomonas
114
How can thyroid surgery lead to hypocalcaemia?
Damage to parathyroid glands
115
What is an ECG feature of hypocalcaemia?
Prolonged QT interval
116
What are some complications of thyroid surgery?
1. Anatomical = recurrent laryngeal nerve damage 2. Bleeding = respiratory compromise 3. PTH glands = hypocalcaemia
117
What is the classical pathological finding in a branchial cyst?
Acellular fluid with cholesterol crystals
118
Why are branchial cysts prone to infection?
They may have a fistula
119
What is the DDx for a neck lump in a child?
1. Congenital 2. Inflammatory 3. Neoplastic
120
What are the congenital causes of a neck lump in a child?
1. Branchial cyst 2. Thyroglossal cyst 3. Dermoid cyst 4. Vascular malformation
121
What are the inflammatory causes of a neck lump in children?
1. Reactive lymphadenopathy | 2. Lymphadenitis
122
What are the neoplastic causes of a neck lump in children?
1. Lymphoma 2. Thyroid tumour 3. Salivary gland tumour
123
What are some causes of vertigo?
1. Viral labyrinthitis 2. Vestibular neuronitis 3. BPPV 4. Menieres disease 5. Vertebrobasilar ischaemia 6. Acoustic neuroma
124
On an audiogram, values above which line is normal?
20dB lin
125
On an audiogram, which forms of conduction are impaired in sensorineural hearing loss?
Both air and bone conduction
126
On an audiogram, which forms of conduction in conductive hearing loss?
Only air conduction is impaired
127
On an audiogram, which forms are conduction in in mixed hearing loss?
Both air and bone conduction, with air being worse than bone
128
What are the Centor criteria?
Abx for 3+/4 of: 1. Tonsillar exudate 2. Tender cervical lymphadenopathy/lymphadenitis 3. Fever 4. Absence of cough
129
What phenomenon is seen after using nasal decongestants for a long period of time?
Tachyphylaxis
130
What is a cholesteatoma?
A benign growth of squamous epithelium that is forms a cyst within the middle ear or mastoid, causing local destruction
131
What increases the risk of a cholesteatoma?
Being born with a cleft palate
132
What are the main features of a cholesteatoma?
1. Foul-smelling, non-resolving discharge | 2. Hearing loss
133
What do you see on otoscopy of a cholesteatoma?
'Attic crust' seen in the uppermost part of the eardrum
134
What is the management of a cholesteatoma?
ENT referral for surgical removal
135
What is the main cause of sudden sensorineural hearing loss?
Idiopathic
136
What is the management for sudden sensorineural hearing loss?
High dose steroids (60mg/day) for 7 days and refer urgently to ENT
137
What are some complications of tonsillitis?
1. Otitis media 2. Quinsy (peritonsillar abscess) 3. Rheumatic fever 4. Glomerulonephritis
138
What are the criteria for tonsillectomy?
All of: 1. Sore throats are due to tonsillitis 2. 5 or more episodes per year 3. Symptoms for at least a year 4. Disabling and preventing normal functioning
139
Why is mastoiditis a clinical emergency?
Due to the risk of meningitis
140
What are some complications of mastoiditis?
1. Meningitis 2. CN palsies 3. Hearing loss 4. Osteomyelitis 5. Carotid artery spasm
141
What are some features of mastoiditis?
1. Otalgia 2. Fever 3. Systemic upset 4. Swelling, tenderness and erythema over mastoid process 5. External ear protrudes forwards 6. Hx of recurrent otitis media
142
What is the management of haemorrhage 5-10 days after a tonsillectomy and why?
Admission and Abx, as it is associated with wound infection
143
What is a key differentiating feature between viral labyrinthitis and vestibular neuronitis?
Hearing can be affected in viral labyrinthitis, is spared in vestibular neuronitis
144
What medication is useful for helping to prevent attacks of Menieres disease?
Betahistine
145
What is labyrinthitis?
Inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs
146
How can you classify the causes of labyrinthitis?
1. Viral 2. Bacterial 3. Systemic disease
147
What is the most common cause of labyrinthitis?
Viral
148
In tonsillitis, what may uvular deviation be suggestive of?
A peritonsillar abscess (quinsy)
149
What are some features of peritonsillar abscess (quinsy)?
1. Severe throat pain, lateralises to one side 2. Uvular deviation to unaffected side 3. Trismus 4. Reduced neck mobility
150
What is trismus?
Difficulty opening the mouth, a.k.a. lockjaw
151
How is quinsy normally managed?
1. IV Abx 2. Needle aspiration under LA 3. Tonsillectomy considered in 6 weeks
152
Are polyps usually uni or bilateral in rhinosinusitis?
Bilateral
153
What must one be suspicious of when seeing a unilateral nasal polyp?
Malignancy
154
What are some associations of nasal polyps?
1. Asthma 2. Aspirin sensitivity 3. Infective sinusitis 4. CF 5. Kartagener's 5. Churg-Strauss
155
How are nasal polyps usually managed?
Topical corticosteroids
156
What is Samter's triad?
1. Asthma 2. Nasal polyps 3. Aspirin sensitivity
157
What would cause a young adult to present with mumps and pancreatitis/orchitis/reduced hearing/meningoencephalitis?
Mumps
158
How can you classify parotid tumours?
Benign and malignant
159
What are some benign parotid tumours?
1. Benign pleomorphic adenoma 2. Warthin tumour (adenolymphoma) 3. Monomorphic adenoma 4. Haemangioma
160
What are some malignant parotid tumours?
1. Mucoepidermoid carcinoma 2. Adenoid cystic carcinoma 3. Mixed tumours 4. Acinic cell carcinoma 5. Adenocarcinoma 6. Lymphoma
161
What is the most common parotid neoplasm (80%)?
Benign pleomorphic adenoma
162
What is the second most common parotid neoplasm (5%)?
Warthin tumour
163
What is a Warthin tumour?
Adenolymphoma
164
What is Sjogren's syndrome?
Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca
165
How does Sjogren's present in the parotid?
Bilateral, non-tender enlargement
166
How can Sarcoidosis present in the parotid?
Bilateral, non-tender enlargement
167
What are 3 disorders of the submandibular glands?
1. Sialolithiasis 2. Sialadenitis 3. Submandibular tumours
168
How much saliva to the submandibular glands produce per day?
800-1000ml
169
Where are salivary stones most likely to be impacted?
Whartons duct
170
What is colicky pain and postprandial swelling of the submandibular gland indicative of?
Sialolithiasis
171
What is the most common cause of sialadenitis?
S. aureus infection
172
What duct drains the parotid gland?
Stensens duct
173
What causes an epidermoid cyst?
Proliferation of epidermal cells within a circumscribed space of the dermis
174
What are some causes of tinnitus?
1. Menieres disease 2. Otosclerosis 3. Acoustic neuroma 4. Hearing loss 5. Drugs 6. Impacted ear wax 7. Chronic suupurative otitis media
175
What are 4 drugs that can cause tinnitus?
1. Aspirin 2. Aminoglycosides 3. Loop diuretics 4. Quinine
176
What are some complications of a large cholesteatoma?
1. Vertigo 2. Facial nerve palsy 3. Sensorineural hearing loss 4. Cerebellopontine angle syndrome
177
What condition causing hearing loss can be precipitated by pregnancy in those who are genetically predisposed?
Otosclerosis
178
What is sialadenitis?
Inflammation of the salivary gland, likely secondary to obstruction by a stone impacted in the duct
179
What are the 3 main salivary glands?
1. Parotid glands 2. Submandibular glands 3. Sublingual glands
180
How can one remember the rule of salivary gland tumours?
80% parotid, 80% of these are pleomorphic adenomas, 80% superficial lobe
181
What is the most common site for epistaxis to originate from?
Little's area (anterior bleed)
182
What is Little's area?
Site of Kiesselbach's plexus, supplied by 4 arteries
183
How can you classify the cause of epistaxis?
Anterior or Posterior
184
Which location produces profuse epistaxis?
Posterior haemorrhage
185
What position should be assumed for management of a nosebleed?
Sit with torso forward and mouth open, pinch soft area of nose firmly for 15mins and ask pt to breathe through mouth
186
What can be used to reduce crusting and risk of vestibulitis if first aid measures are successful for epistaxis?
Naseptin
187
What is Naseptin?
Chlorhexidine and neomycin
188
What are some cautions to use of Naseptin?
Peanut/soy/neomycin allergies --> Mupirocin is a viable alternative
189
What should be done to nosebleeds if bleeding doesnt stop after 10-15 mins of continuous pressure?
1. Cautery if source of bleed is visible and is tolerated | 2. Packing if bleeding point cannot be visualised
190
What are 3 drugs that cause gingival hyperplasia?
1. Phenytoin 2. Ciclosporin 3. CCBs
191
What condition can cause gingival hyperplasia?
AML
192
What is an important complication of nasal trauma which should always be looked for?
Nasal septal haematoma
193
What is a nasal septum haematoma?
Development of a haematoma between the septal cartilage and the overlying perichondrium
194
How does a nasal septal haematoma typically present?
Bilateral, red swelling arising from the nasal septum, that feels boggy
195
What is the management of a nasal septal haematoma?
1. Surgical drainage | 2. IV Abx
196
What is a complication of nasal septal haematoma if left untreated?
Irreversible septal necrosis within 3-4 days --> saddle-nose deformity
197
When should mouth ulcers be sent to oral surgery as a 2 week referral?
Persisting for >3 weeks
198
When should intranasal corticosteroids be considered for sinusitis?
If symptoms have persisted for 10 days or more
199
What does the umbrella term head and neck cancer cover?
1. Oral cavity cancer 2. Pharynx cancer 3. Larynx cancer
200
What are 4 presentations of head and neck cancers?
1. Neck lump 2. Hoarseness 3. Persistent sore throat 4. Persistent mouth ulcer
201
What head and neck cancer may present as a painless lymphadenopathy because of its tendency for early spread?
Nasophargyngeal carcinoma
202
What might be the cause of otitis externa after returning from holiday?
Swimming pools
203
What is pain on palpation of the tragus suggestive of?
Otitis externa
204
What is the management of a perforated tympanic membrane caused by barotrauma?
Reassure and follow up (it is self limiting)
205
What may be performed if a perforated tympanic membrane does not heal by itself?
Myringoplasty
206
What virus is tonsillar SCC associated with?
HPV
207
What 3 things does a 'sore throat' encompass?
1. Pharyngitis 2. Tonsillitis 3. Laryngitis
208
What is the commonest tumour of the parotid gland?
Pleomophic adenomas
209
What is an example of a concern for nasal cancer?
Recurrent unilateral epistaxis
210
In pts with chronic or recurrent ear discharge, what must you examine and why?
Attic of tympanic membrane to exclude a cholesteatoma
211
What is Ludwig's angina?
Cellulitis at the floor of the mouth
212
What is a risk factor for developing Ludwig's angina?
Immunocompromised pts with poor dentition
213
Why is Ludwig's angina deadly?
It can spread to the fascial spaces of the head and neck
214
What is a pre-auricular sinus?
Congenital condition in which an epithelial defect forms around the external ear
215
What is the management of a pre-auricular sinus?
1. Small sinuses require no treatment | 2. Deeper sinuses may need to be excised
216
What is black hairy tongue?
A relatively common condition which results from defective desquamation of the filiform papillae
217
What are predisposing factors for black hairy tongue?
1. Poor oral hygiene 2. Abx 3. Head and neck radiation 4. HIV 5. IVDU
218
What is the management of black hairy tongue?
1. Tongue scraping | 2. Topical antifungals if Candida
Medicine and Surgery Mushkies
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