EENT

Question 1

Acute Rhinosinusitis

Answer 1

Inflammation of the nasal mucosal and paranasal sinuses lasting up to 4 weeks casued by allergens, environmental irritants, and or infection (virus [majority], bacteria, and fungi).

Question 2

Acute Bacterial Rhinosinusitis

Answer 2

Secondary bacerial infection of paranasal sinuses
* usually following viral URI
* relatively uncommon Less than 2%
* Majority will resolve without Abx

Question 3

Most common bacterial causes of ABRS

Answer 3

1. S. pneumoniae (gram+)
2. H. influenzae (gram -)
3. M. catarrhalis (gram -)

Question 4

Diseases cuased by S. pnemoniae

Answer 4

• COMPS
• Conjunctivitis
• Otitis media
• menengitis
• pneumonia
• sinusitis (#1 cause)
• gram+ diplococci
• > 25% drug-resistant

Question 5

Diseases caused by H. Influenzae

Answer 5

• COMPS
  1. Conjunctivitis
  2. otiits media
  3. menengitis (B)
  4. Pneumonia
  5. Sinusitis (#2 cause)
• Gram - baccillus
• > 30% penicillin resistant via production of beta lactamase - breaks up the beta-lactam ring in most penicillians including amoxicillin, ampicillin
• most ceplasporins are stable in the presents of beta-lactamase

Question 6

Diseases Casued by M. catarrhalis

Answer 6

• less common pathogen in ABRS (#3 cause), AOM, uncommon cause of CAP
• gram- coccus
• > 90% penicillin resistant via beta lactamase production.

Question 7

Most common fetures of Acute Bacterial Rhiniosinusitis

Answer 7

• fever and symptom durration more than 10 days
• maxillary toothache
• Initial symptom improvement and then worsening of symptoms
• Cacosmia - sense of bad odor in the nose
• Unilateral facial pain

Question 8

Treatment of ABRS

Answer 8

• any prior systemic abx use in last month
• risk for resistance? (use 2nd line ABX)
• Initiate first line abx
• If improvement in 3-5 days continue therapy for 5-7 days
• Worsening or no improvement in 3-5 days, broaden coverage or switch to different abx class

Question 9

Initial ABX regimens for ABRS

Answer 9

• Macrolide abx (azithromycin, clarithromycin, erythromycin, and TMP-SMX{bactrim}) are not reccomended in ARBS due to resistance rates and resulting tx failure
• fluroqinolones (cipro, levo, moxifloxacin) risks outweigh the benifits and should not be used for ARBS, Bronchitis, and uncomplicated UTI, were other treatments are available
• Amoxicillin 500mg TID or 875mg BID
• Amoxicillin-clavulante 875/125 PO BID (augmentin)
• addition of clavulante is a beta-lactamase inhibitor increasing drug effectiveness against h. influinzae and m. catarrhalis

Question 10

ABRS in penicillin allergy

Answer 10

• usually casue by an allergry to beta-lactam found in penicillins
• without anaphyaxis hx (cephalosporins)
  1. cefdinir
  2. cefpodoxime
  3. cefuroxime
• With anaphylaxis Hx (respiratory fluroquinolones)
  1. Levofloxacin (preg risk c)
  2. Moxifloxacin (pre risk C)
  3. Doxycycline (pregnancy risk D)

Question 11

ARBS treatment failure in 3-5 days

Answer 11

1. Amoxicillin-clavulante
2. 2/3rd gen cephaloporin (cefpodoxime. cefprozil. cefdinir)
3. Levo or moxifloxacin

Question 12

Medication Substrate

Answer 12

a medication that is metabolized/biotransformed by the isoenzyme (CYP450 34A) usually found in the liver, inorder for the drug to reach site of action and be eliminated
Ex: sildenafil, atorvostatin, simvastatin, alprazolam

Question 13

Inhibitor

Answer 13

a drug or substance that blocks the activity of the isoenyme (CYP450 34A), limiting substrate excretion, allowing increase in substrate levels, with possible risk of substrate-induced toxicity
* ex: erythromycin, clarithromycin = CYP450 inhibitor
* concomitant use of one of these abx plus drugs that are CYP450 34A substrates will result in increase in substrate levels by decresing iotransformation and elimination.
* ex: Clrithromycin + simvastatin = statin induced rhabdomyolisis risk
* ex: clarithromycin + alprazolam = increased sedation and fall risk

Question 14

Inducer

Answer 14

Accelerates the activity of the isoenzyme (CYP450 34A) so that the substrate is pushed out the exit pathway, leading to a reduction in substrate level causing dimished therapudic effect, possible treatment failure
* Ex: St john’s wort + COC = off loading estrogen/progestin= spotting and potential contraceptive failure

Question 15

Conductive hearing loss

Answer 15

• Location: outter or middle ear
• Cause: sound is being blocked ( earwax, forien body, damaged eardrum, serous otits media, bone abnormality)
• Weber result: sound lateralizes to affected ear - buzzing sound louder in affected ear due to increased tissue denisty
• Rinne result: abnormal - bone conduction better than air conduction
• Tx: often self resolves after cerumen removal, post URI or AOM

Question 16

Sensorineural hearing loss

Answer 16

• Location: inner ear vestibulocochlear nerv CNV111V
• Cause: inner ear or nerve becomes damaged-advanced age, ototoxic meds, immune disorders, trauma
• Weber result - sound lateralizes to the unaffected ear
• Rinne result: normal air conduction > bone conduction
• Tx: hearing aids, cochlear implant possible

Question 17

Common cold Vs. Flu/COVID

Answer 17

• Cold: primary symptoms are sneez, achs and pain. runny/stuffy nose, and sore throat
• Flu Same as above without sneeze, and the addition of fever, diarhhea, and headache
• Covid: similar to flu with the addition of loss of taste/smell and SOB

Question 18

Allergic rhinitis treatment

Answer 18

inflammatory, IgE-mediated, characterized by nasal congestion, rhinorrhea, sneezing, intraocular and/or nasal itching.
1. Allergen avoidance
2. Controller therapy - prevent symptoms by preventing formation of or inactivating inflammatory mediators
* Intranasal corticosteroids 1st line (fluticasone, triamcinolone) - up to a week for relief
* Intranasal antihistamine - azelastine - rapid symptom relief
3. Reliver therapy - to relieve acute symptoms by blocking histamine
* 2nd gen oral antihistamine - loratadine, certirazine, levocetirazine
* ocular antihistamine

Therapies not reccomended: Leukotrine modifier (montelukast) or systemic corticosteroids

Question 19

Oral Cancer

Answer 19

Sqamous Cell Carcinoma 95% cases, HPV16 contributing factor

Risks Factors: Longstanding HPV infection, Tabacco use, alcohol misuse
Presentation: painless, ulcerating oral lesion, usually present many months prior to presenting clincally. Adjacent lymphadenopathy = imobile, nontender node usually >1cm
Dx: referral for bx

Question 20

angle -closure glaucoma

Answer 20

• sudden increase in intraoccular pressure
• Usually unilateral, acutely red, painful eye with vision change including halos. eyeball firm when compared to other

Question 21

Macular degeneration

Answer 21

• painless gradual central vision loss
• risks: advanced age, hx of smoking, light eye color, sun exposure, family hx
• test: amsler grid test
• fundoscopic: drusden - soft yellow deposits in macular region

Question 22

open angle glaucoma

Answer 22

• gradual peripheral vision loss
• avoidable with treatment
• Risks: older adult, African american, long standing DM
• test: abnormal tonometry

Question 23

Bacterial Vs. Viral Pharyngitis

Answer 23

Bacterial
* significant anterior cervicle lymphadenopathy
* frontal headaches without body aches
* patchy exudates in posterior pharynx - bad breath
* sudden onset

Viral
* Clear nasal drainage
* horseness
* scattered small vessicles on soft palate and tonsils
* generalized body aches
* sore throat preceeded by nasal drainage

Question 24

Exudative pharygitis treatment

Answer 24

• only with documented group a beta-hemolytic strep infction using positive strep screen or throat culture
• Abx therapy:
  1. Penicillin V PO x10 days or amoxicillin 500 PO BID
  2. alterantive 1st or 2nd gen cephalosporin x4-6 days
  3. beta lactam allergry (penicillan allergry) - azithromycin, clarithromycin, clindamycin (macrolides)

Question 25

Suppurative conjunctivitis treatment

Answer 25

Common pathogen - S. Aureus, s. pneumoniae, h. influenzae (outbreaks coused by s. pneumoniae) 1. cipro ocular solution, or polymixin B with trimethoprim opthalmic solution 2. alternative axithromycin opthalmic solution

Question 26

Otitis Externa

Answer 26

Common pathogen: Psudomonas spp., S. aureus, rarely fungi 1. mild: acedic acid with propylene glycol and hydrocortosone drops 2. Mod-severe: otic cipro, with hydrocortisone or dexamethasone * decrease risk of infection by using 1:2 white vinegar and rubbing alcohol * do not use neomycin - containing product if TM rupture suspected.

Question 27

Malignant Otitis externa (necrotizing)

Answer 27

* persons with DM,HIV/AIDS or on chemo * Pseudomonas * Treatment oral Cipro * risk for osteomylitis of skull or TMJ

Question 28

Otitis media with effusion

Answer 28

* Hx: sensation of fullness or pressure, itch and/or otalgia, conductive hearing loss, no fever or otorrhea * Exam: air fluid level visable, often with bubbles, opaque yellow or blue, cone of light or bony landmarks diminished. TM mobility limited * Tx undrlying cause usually allergic rhininitis. usually resolves 1-3 weeks without special intervention.

Question 29

Acute otitis media

Answer 29

* Hx: sensation of ear fullness, pressure and otalgia, conductive hearing loss, fever common * Exam: TM redness, bulging, cone of ligt and bone landmarks absent, TM mobility absent, otoorrhea possible with TM rupture. * Tx: analgesia, abx typically given

Question 30

AOM ABx

Answer 30

if no abx in prior month * amoxicillin high dose or * amoxicillin-clavulante ER or * cefdinir If Abx in last month * amoxicillin-clavulante or * ceftriaxone If allergy to beta-lactam (options are less effective) * TMP-SMX * or macrolide