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Flashcards in PD ENT Deck (203):
1

Inspection and otoscopy of ear

External ear
External auditory canal
Tympanic membrane

2

Palpation of ear

External structures

3

Hearing tests

Whisper test
Weber test
Rinne test

4

What questions do we ask about difficulty of hearing?

Onset of hearing loss
Unilateral or bilateral

5

What factors could contribute to hearing loss?

Medications (aminoglycosides)
Trauma
Vertigo
Family Hx of hearing loss

6

Inspection of external ear

Mastoid process
Auricle
Tragus
Scaphoid fossa
Helix
Antihelix
Lobule
Auditory canal
Meatus

7

Assessment of ears

Position
Shape
Color
Lesions

8

Position of ears

Down syndrome
Outstanding ears

9

Shape of ears

Microtia
Creased lobule
Elongation
Replcaition of lobes
Gouty tophus
Cauliflower ear
Darwin's tubercle

10

Color of ears

Inflammation
Infection
Hemangiomas

11

Lesions of ears

Scars
Hematomas
Dermatitis
Trauma
Infectious processes

12

Area surrounding the ears

Always look behind patient's pinna
Battle sign
Preauricular pits
Erythema
Edema

13

Hair distribution in ears

Hairy tragus
Hairy pinna

14

Microtia

Gross hypoplasia of the pinna
Blind or absent auditory canal
Bilateral
Could have completely formed and functioning cochlea
Helped with hearing aides and surgery

15

Preauricular pits

Autosomal dominant, unilateral 75%
Can become infected
Surgical excision if repeated infections

16

Outstanding ears

Angle between auricle and side of head is greater than normal
Not pathologic
Easily surgically corrected

17

Darwin's tubercle

Small cartilaginous protuberance, most commonly along concave edge of posterosuperior helix
Normal variation

18

Gouty tophi

Deposits of uric acid crystals

19

Hairy tragus/pinna

Most common in men, occurs with aging
Common in people of Indian descent

20

Creased lobe

May be associated with increased risk for CAD

21

Hematomas
Cause
Sequela

Accumulation of blood between skin and cartilage
Blunt trauma most common cause
Inspect for trauma and check hearing
Cauliflower ear is late sequela

22

Cauliflower ear
Cause

Caused by repeated trauma to auricle
Subperichondrial separation with focal generation of fibrous tissue and scar formation
Potential hearing loss, can be surgically corrected

23

Keloid

Abnormal wound healing
Excessive bulk produced at site of cutaneous injury (highly compacted bundles of hyalinized collagen)
Common in AA, and older than 20

24

Battle sign

Hematoma behind the ear
Indication of base of skull fracture

25

Palpation

Nodules
Swelling
Tenderness
Warmth
Assessment of lesions

26

Otoscopy

Visualize auditory canal and TM

27

Otoscopy in adults versus children

Adults: pinna upward and outward
Children: pinna down and back

28

What does straightening of the canal allow for?

Better visualization of the tympanic membrane

29

Where does the auditory canal start and end?

External auditory meatus and medially TM

30

What joint makes up part of the posterior external auditory canal wall?

TMJ

31

Skin adheres to periosteum along the ... and to cartilage and soft tissue along the ...

Inner 2/3, outer 1/3

32

Skin of the outer 1/3 contains what structures?

Hairs and glands that secrete cerumen

33

Where is cerumen not produced?

Middle or inner canal

34

What is the average length of the auditory canal?

3.7 cm

35

Innervation of auditory canal

CN V, VII, X

36

What does the stimulation of a small branch of the vagus nerve (Arnold's nerve) do to the patient?

Cough during exam

37

What is the blood supply to the auditory canal?

Branches of auricle temporal branch of the inferior maxillary artery

38

The canal ... from the pinna to the TM

Conducts sound waves

39

Cerumen impaction

Painful depending on extent of cerumen
Conductive hearing loss
Common in elderly and children

40

Tx for cerumen impaction

Debrox drops, irrigation, curette/otoloop

41

Otitis externa

Swimmer's ear, common in summer
Painful infection of skin
Swelling erythema or canal
Pinna edematous and red
Narrowed lumen with purulent drainage

42

Bacterial causes of otitis externa

Pseudomonas, Staph aureus

43

Tx of otitis externa

Otic drops, oral abx

44

Common foreign body in the ear

Q tip, beans, peas, jewelry
Common in kids and psych

45

Result from foreign body

Complete conductive hearing loss

46

Caution with foreign body

Don't irrigate if organic material suspected or insects
Carefl not to cause TM perforation

47

Exostosis

Small boney growths of canal
Benign
Multiple and bilateral
Aris more commonly near TM

48

Exostosis Tx

Usually no tx necessary unless recurrent cerumen impactions

49

Cholesteatoma

Overgrowth of epidermal tissue, usually in pts with hx of chronic otitis media
Canal or middle ear
Painful, erode into bone
Conductive or sensorineural hearing loss

50

Middle ear

Small air filled cavity within temporal bone
Lined with squamous epithelium

51

Boundaries of middle ear

TM oval window and round window

52

What is the opening in the posterior wall in the middle ear?

Opening to mastoid sinus

53

Where does infection of epithelial lining of the middle ear come from?

Nasopharynx via the eustacian tube

54

What structure transmits sound waves through the middle ear?

TM vibrates, transmitting sound waves from the canal into mechanical motion, setting the ossicles into motion

55

Ossicles

Malleus, incus, stapes
Augment vibrations and distribute mechanical energy to cochlea

56

Eustachain tube

Connects middle ear to posterior portion of nasopharynx
Neutralizes internal and external air pressures

57

Why do children have more otitis media infections?

Eustachian tube is much smaller and more horizontal, so pathogens are more easily introduced to the middle ear

58

Otitis media

Hx of recent URI
Bacterial or viral
More common in infants and children
Unilateral

59

Complications of otitis media

Mastoiditis
Meningitits
Osteomyelitis
Sigmoid sinus thrombosis
Facial nerve involvement

60

Common pathogens causing otitis media

Strep pneumoniae
Haemophilus influenzae
M. cattarhalis

61

S&S of otitis media

Pain
Fever
Erythematous, building TM
Decreased TM mobility
TM may rupture and cause purulent drainage in external auditory canal
Decreased hearing
Effusion behind TM

62

Serous otitis media
Pts

Can procede AOM
May be due to poor Eustachian tube function
May be concurrent with URI
Common in people with allergies
Look for fluid, bubbles behind TM, TM not inflamed

63

Bullous myringitits

Otalgia
Erythematous TM
Blisters
Accompanies URI symptoms

64

Pathogens of bullous myringitits

Mycoplasma pneumoniae
Virus

65

Cause of TM perforations

Trauma
Infection
Barotrauma (divers, airplane)

66

Results of TM perforation

Conductive hearing loss
Increased risk of infection

67

Cuase of TM scarring

Previous infections
Trauma
Perforations

68

Results of TM scarring

Decreased hearing over time due to decreased mobility of TM

69

Otosclerosis

Progressive hearing loss
Due to deposition of bone in cochlea/stapes foot

70

S&S of otosclerosis

No pain
Tinnitus
Normal TM
Patent Eustachian tube

Common in females, 30-40, familial tendency

71

Tx otosclerosis

Stapedectomy

72

Hemotympanum

blood in middle ear behind TM
Result of head trauma or severe barotrauma
Could be painful

73

Tx hemotympanum

Spontaneous resolution over several weeks is normal

74

Result of hemotympanum

Could result in conductive hearing loss

75

Pneumatic otoscopy

Done if loss of mobility of TM is suspected
Puff of air from otoscope gulf creates a positive pressure, and the TM should move inward, then return to normal position quickly

76

No movement or decreased movement during pneumatic otoscopy

Increased pressure within middle ear is suspected

77

Cause of no movement

Porr functioning Eustachian tube
Fluid within middle ear

78

Is pneumatic otoscopy part of the normal physical exam?

No

79

What are the three hearing tests?

Whisper
Rinne
Weber

80

Whisper test

Occlude opposite ear, stand behind patient and whisper words for patient to repeat, or ask a simple question and ask for an answer

Patient should be able to hear your whisper from 1-2 feet away from their ear

81

What does the whisper test test?

Grossly defines hearing

82

What does the Weber test test?

If hearing loss is noted in history or detected on exam

83

Weber test

Bottom of vibrating tuning fork is placed on midline of patient's head
Ask patient if sound is heard equally in both ears, or better in one ear (lateralization of sound)

Should be heard equally

84

2 abnormal results of Weber test

Conductive hearing loss in the lateralizing ear
Sensorineural loss in the ear opposite of the lateralizing ear

85

What test is used as a follow up after the Weber test?

Rinne test

86

Rinne test

Placing the base of vibrating tuning fork against patients mastoid process
Ask when patient no longer hears the sound
Quickly position vibrating fork 1-2 cm from auditory canal and ask when sound is no longer heard
Count the time sound is heard

87

What is a normal Rinne test?

Air conduction is twice as long as bone conduction

88

Conductive loss in Rinne test?

Bone conduction is longer than air conduction in affected ear

89

Sensorineural loss in Rinne test

Air conduction is longer or equal to bone conduction in affected ear

90

Functions of the nose

Airway
Warms air
Filtration of dust particles, pathogens
Humidification of air
Receives secretions from sinuses and eyes
Peripheral organ of smell

91

CN for smell

CN I Olfactory

92

History complaints relating to the nose

Nasal obstruction
Discharge
Epistaxis
Change in sense of smell
Trauma
Itching nose
Olfactory hallucinations

93

Inspection of nose

Shape
Size
Color
Patent nares
Columnella, septum midline
Ala flaring
Discharge
Lesions

94

External/middle/inner ear - conductive/sensorineural

External middle ear - conductive hearing loss
Inner ear - sensorineural hearing loss

95

Rhinophyma

Bulbous enlargement of the distal 2/3 of nose from multiple sebaceous adenomas
Follows long standing rosacea

96

Saddle nose
Causes

Sunken bridge
Loss of cartilage from septal hematoma or abscess
Congenital or acquired syphilis

97

Internal inspection

Stabilize head, tilt head back
Gently introduce speculum
Avoid touching septum

98

Observation of internal inspection

Anterior nares
Mucosa
Septum
Turbinates
Posterior nares

99

Inspection of mucosa

Edematous
Pale
Erythematous
Moist/dry
Discharge

100

Inspection of septum

Deviation
Perforation

101

Posterior nares

Open to the nasopharynx

102

Watery clear discharge

Allergies
Vial rhinitis/URI
Rhinitis medicamentosa
CSF leak

103

Purulent discharge

Viral URI
Bacterial sinusitis
Foreign body

104

Serosanginous discharge

Trauma
Neoplasm

105

Bloody (sanginous) discharge

Trauma
Coagulopathies
Carcinoma
Vasculitis
HTN
Ulceration
Drug use

106

Nasal polyps
Examples

soft protrusions of mucosa
Pale, edematous, non tender
Chronic allergic rhinitis
Positive relationship with asthma

107

What do you need to determine with epistaxis?

Anterior or posterior bleed

108

Which is more common, anterior or posterior bleeds? Which is more serious?

Anterior is most common 90%
Posterior has greatest risk to hemorrhage

109

Anterior bleed
Causes
Risk factors

Digital trauma to Kiesselbach's plexus
Trauma, dry/cold weather, dehydration, blood thinners

110

Anterior bleed tx

Small - cauterize with silver nitrate sticks
Extensive - nasal packing

111

Posterior bleed
Risk factors

Acute blood loss anemia
HTN, coagulopathies, blood thinners, carcinoma

112

Posterior bleed tx

Posterior packing
Transfusion
Hospitalization*

113

What is the most common malformation of the nasal airway?

Choanal atresia

114

Choanal atresia
Who present with it?

Congenitally closed orifice
Usually infants have difficulties breathing with first URI
If bilateral, respiratory distress at birth

115

Hyperosmia causes

Addison's disease
Allergies
Hunger
Nausea

116

Cacosmia
Causes

Perception of four odor when one doesn't exist

Sinusitis
Psych DO
Tumor
Tetracyclines

117

Anosmia causes

Infection
Allergies
Septal deviation
Pregnancy
Tumor
Trauma to head or nose
Sjogren's syndrome
Diabetes
Polyps
Zinc deficiency
Vitamin A deficiency
Schizophrenia

118

Paranasal sinus tenderness

Palpate over frontal and maxillary sinuses looking for swelling or tenderness
Percuss sinuses

119

Causes of sinus tenderness

Swelling, tenderness, and pain may indicate infection or obstruction

120

Functions of oropharynx

Emission of air for vocalization and respiration
Passageway for food, liquid, saliva, vomitus
Initiation of digestion - mastication and salivary enzymes
Identification of taste

121

History of complaints for oropharynx

Pain
Lesions
Difficulty swallowing/chewing
Dry mouth
Excess salivation
Decreased taste, bad taste
Halitosis

122

Inspection of lips and mouth

Symmetry
Color
Swelling/edema
Moisture
Lesions

123

Pallor in lips causes

Anemia
Vitamin deficiencies
Scarlet fever

124

Cyanosis in lips causes

Hypoxia
Cardiac and respiratory DO

125

Erythema in lips causes

CO poisoning
Infection
Allergy

126

Swelling edema in lips causes

Allergies
Trauma
Infections

127

Dry lips and mouth causes

Dehydration
Mouth breathing
Sjogren's syndrome

128

Lesions in lips in mouth causes

Neoplasm
Infection
Irritations

129

Cheilosis

Fissures/cracks at angles of lips

130

Causes of cheilosis

Dehydration
Ill fitting dentures
Nervous habit
Riboflavin deficiency
Medications (chemo)
Malignancy

131

Angioedema
Causes

Swelling of one or both lips
Develops rapidly
Usually not pruritic

Allergic reaction, anaphylaxis, infection

132

SCC

Non painful
Lesions grow slowly, often bleed
Non healing
Most common oral tumor
Hx of sun exposure

133

Herpes Simplex Virus

HS1, could be HS2
Groups of vesicles with clear fluid on erythematous base
May be painful, burn

Develop in times of illness or stress

134

Petz Jehger's syndrome
Associated with...

Blue or black patches of pigmentation in skin or mucosa (buccal, fingers, hands, face)

Associated with FAP, internal bleeding, anemia

135

Chancre

Primary lesion of syphilis
Painless, raised border
Button like
Can become crusted or ulcerated

136

Inspection of teeth

Number
Missing or loose
Dental hygiene
Color, staining
Shape
Caries
Malocclusion
Abscesses
Dental appliances

137

Malocclusion

Crowding of teeth
Upper molars should rest directly on lower molars and upper incisors should override lower incisors slights

138

Causes of malocclusion

Congenital
Trauma
Jaw pain
Thumb sucking

139

Hutchinson teeth
Cause

Notching of the permanent upper central incisors
Small than normal, tips resemble a cone

Congenital syphilis

140

Tetracycline staining

Mother took tetracycline while in utero, or tetracycline was given as a child

Before 1980

141

Inspection of gingiva

Color
Bleeding
Swelling
Hyperplasia
Masses/lesions

142

Gingivitis

Inflammation of the gums
Erythematous, swollen, bleeds easily

143

Causes of gingivitis

Poor hygiene
Systemic infection
Leukemia
Vitamin deficiencies
Pregnancy
OCP
DM

144

Gingival hypertrophy

Insidious onset
Non painful
Non pathologic

145

Causes of gingival hypertrophy

Dilatin
Cyclosporin
Leukemia
Pregnancy
OCP
Genetic disorders
Crohn's
Sarcoidosis

146

Peridontitis (pyorrhea)

Receding and bleeding gums
Often painful
Halitosis
Pus pockets form between gums and teeth
Anaerobes

147

Cause and result of peridontitis

Caused by untreated gingivitis
Common cause of tooth loss

148

Periapical abscess

Tender swelling in adjacent gum
Sinus tract may form draining pus
Common cause of toothache
Pain accentuated by tapping tooth

149

Scurvy

Vitamin C deficiency
Deep red/purple, swollen gums
Tender, bleed easily

150

Vincent stomatitis

Trench mouth, acute necrotizing ulcerative gingivitis
Abrupt onset, painful, increased salivation
Punched out ulcers covered in gray yellow membrane
Halitotis is horrible
Systemically ill

151

Cause of vincent stomatitis

Anaerobes (Fusobacterium)

152

Kaposi sarcoma

Malignancy of vascular origin
Red/blue plaques and nodules
Commonly found on skin
Seen in advanced AIDS

153

Inspection of buccal mucosa

Color
Moisture
Exudates
Masses, lesions
Ulcers
Stensen's duct

154

Apthous ulcers

Canker sores
Painful ulcers with white floor and yellow margins on erythematous base
Anteriorly in mouth on tip or sides of tongue and labial/buccal mucosa

155

Cause of apthous ulcers

Virus
Malnutrition
Stress

156

Oral candidiasis

White, raised exudates on buccal mucosa, palate, pharynx, or tongue
Can interfere with taste and eating
Scrapable
Not painful

157

Risk factors for oral candidiasis

Antibiotics
Steroids
Immunosuppression
HIV/AIDS
Cancer, chemo
DM

158

Leukoplakia

Appears anywhere in oral cavity
Painless white plaque adherent to mucous membrane
Not scrapable
Premalignant lesions

159

Risk factors for leukoplakia

Smoker
HIV/AIDS
Autoimmune DO
Alcohol abuse

160

Fordyce spots

Mucosal sebaceous cysts
Small white or yellow spots on mucosa of lips, cheeks, tongue
Painless, non pathologic

161

Inspection of palate

Continuity of palate (clefts)
Lesions
Masses
Color

162

Cleft palate

Midline opening in hard palate due to congenital failure of fusion of the maxillary process
Usually associated with cleft lip
Severity varies

163

Complications of cleft palate

Breathing and speech difficulty
Hearing deficits
Chronic otitis media
Degluttination deficits
Improper teeth development/feeding problems

164

Torus palatinus

Bony outgrowth of the palate
Non painful
Benign
Arises in puberty
25% women, 15% men

165

What is the bony outgrowth of the mandible?

Torus mandibularis

166

Inspection of the uvula

Color
Size
Lesions
Masses
Deviation

167

Bifid uvula

May indicate underlying cleft palate
Need to palpate palate to assure bony closure

168

Uvular deviation causes

Peritonsillar abscess
Lesion/defect of CN X

169

Which way will the uvula deviate with a lesion?

Have patient say ahh
Uvula will deviate away from side that has lesion/defect
Soft palate on affected side will not rise

170

Inspection of the tongue

Size
Papillae
Deviation
Moisture
Masses/lesions
Dorsal and ventral surfaces

171

Tongue deviation

Due to lesion/abnormality of CN XII or muscle weakness of tongue muscles

172

Which way will the tongue deviate?

Towards side of the lesion or weakness

173

Fissured tongue

Median sulcus is deepened
Dorsal surface interrupted with transverse furrow
Harmless, inherited

174

What would longitudinal furrowing indicate?

Syphilitic glossitis

175

Geographic tongue

Migratory glossitis
Irregular patches of bright red denuded epithelium - no papillae
Patches heal in a few days, only to develop new ones in other areas
Harmless, idiopathic

176

Varicose veins

Normal, more common in elderly

177

Hairy tongue

Overgrowth of filiform papillae
Yellow, brown, green, black
Bacterial or fungal overgrowth may play a role
Non pathologic

178

Risk factors for hairy tongue

Poor oral hygiene
Antibiotics
Smokers
Coffee drinker

179

Glossitis

Sore, painful, tnder, erythematous tongue

180

Causes of glossitis

Nutritional deficiencies
Autoimmune
Medications
Smoking, alcohol
Infection
Trauma
Dehydration

181

Atrophic glossitis

Atrophy of papillae
Dryness
Intermittent burning
Paresthesia of taste
Tongue becomes smaller
Slick and glistening surface
Small, punctate red dots

182

Cause of atrophic glossitis

Poor nutrition
Alcoholic with vitamin deficiencies - folic acid, B vitamins

183

Inspection of pharynx

Presence of tonsils
Size of tonsils
Swelling
Exudate
Post nasal drip
Masses, lesions

184

Grading tonsillar size

1 - visible
2 - halfway between tonsillar pillars and uvula
3 - touching uvula
4 - touching each other (kissing tonsils)

185

Pharyngitis accounts for 20% of ... and 50% of ...

Outpatient sick visits
Outpatient antibiotics

186

Bacterial causes of pharyngitis

Group A Strep
Neisseria gonorrhea
Corneybacterium diptheriae

187

Viral causes of pharyngitis

Rhinovirus
HSV
CMV
Adenovirus
Echovirus
EBV
Parainfluenza
Coxsackie virus

188

Other causes of pharyngitis

Allergies
Sinusitis
GERD
Peritonsilar abscess
Carcinoma
Fungal infections

189

Incubation of Group A strep

2-5 days

190

Symptoms of Group A strep

Sore throat
Fever/chills
Malaise
Headache
Nausea
Vomiting
Abdominal pain

191

PE with Group A strep

Erythema of pharynx and uvula
Enlarged tonsils, patchy white exudates
Enlarged, tender anterior cervical LN

192

Diagnosis for Group A strep

Rapid strep test
If negative, culture for 24 hours

193

Tx for Group A strep

Pen VK
Amoxicillin
Erythromycin

194

Viral pharyngitis tx

NO ABX
Motrin, tylenol
Warm salt water gargles
Lots of fluids and rest

195

Diphtheria S&S

Sore throat
Hoarseness
Malaise
Fever
Nasal discharge
Tenacious gray membrane on pharynx, tonsil, palate, or uvula

196

Diphtheria cause

Corneybacterium diphtheriae

197

Complications of diphtheria

Myocarditis
Neuropathies

198

Infectious mononucleosis

Fatigue
Malaise
Fever
Lymphadenopathy
Pharyngitis
Headache
Hepatosplenomegaly

199

Cause of mono

EBV
CMV

200

Tx for mono

Rest
Fluids
Proper nutrition
Time
Avoid contact sports and heavy lifting
NO ABX

201

Peritonsillar abscess S&S

PAIN
Deviation of uvula
Fever
Odynophagia
Hot potato voice
LAD

202

Tx for peritonsillar abscess

I&D often required
Abx, usually IV to start

203

Oral HIV/AIDS manifestations

Hairy leukoplakia
Oral candidiasis
Herpes simplex
Kaposi's sarcoma
Apthous ulcers
Peridontal disease