ENT surgery

Question 1

What is the most common cause of lower motor neuron facial nerve paralysis?

What are the classic symptoms?

Treatments?

Prognosis?

Answer 1

Bells Palsy - usually sudden unilateral onset, usually after an URI. thought to be a reactivation of latent HSV1 infection

Hyperacusis - everything sounds loud because the stapedius muscle in the ear is paralyzed.

Most cases resolve spontaneously in about 1 month, although some have permanent sequelae.

PO prednisone and antivirals (valacyclovir, acyclovir) may improve outcomes and lessen duration of symptoms.

Question 2

What are other causes of LMN facial nerve paralysis? 7

Answer 2

• Herpes infection (Ramsay Hunt syndrome), which commonly involves CN 8. Look for vesicles on the pinna and inside the ear; encephalitis or meningitis may be present.
• Lyme disease
• Stroke
• Middle ear or mastoid infection
• Meningitis
• Temporal bone fracture (Battle sign and/or bleeding from ear)
• Tumor, classically an acoustic schwannoma (i.e., neuroma) of the cerebellopontine angle

Question 3

What are the common causes of hearing loss? (lots)

Answer 3

• Aging (presbyacusis) - most common
• Prolonged/intense exposure to loud noises
• Congenital ToRCH (toxoplasmosis, others, rubella, cytomegalovirus, herpes virus).
• Ménière disease (+severe vertigo, tinnitus, N/V)
  
  • treat acute episodes w/ benzodiazepines, anticholinergics [scopolamine], and antihistamines [meclizine or dimenhydrinate]
  • diuretics are often used for ongoing treatment
  • surgery may be necessary for refractory cases
• Drugs (aminoglycosides, aspirin, quinine, loop diuretics, cisplatin).
• Tumor (classically acoustic neuroma)
• Labyrinthitis (may be viral or extend from meningitis or otitis media).
• Diabetes
• Hypothyroidism
• Multiple sclerosis
• Sarcoidosis
• Pseudotumor cerebri (increased intracranial pressure)

Question 4

What is the usual cause of sudden deafness?

How are these patients treated?

Prognosis?

Answer 4

Sudden sensorineural hearing loss (SSNHL)

• idiopathic in most cases
• usually unilateral
• tinnitus is present in 90% of cases
• occurs over hours ( < 72 hours)

Treatment: steroids

Prognosis: ²/₃ recover over 2 weeks, although the resolution is often not complete

Question 5

What is the most common cause of acquired hearing loss in children?

Answer 5

Bacterial meningitis.

All children should receive formal hearing testing after a bout of meningitis.

Question 6

What are the common causes of vertigo?

Answer 6

can arise from a CN8 lesion that cause hearing loss

• Meniere disease (due to ∆volume/composition of inner ear fluid)
• tumor
• infection
• MS

BPPV (induced via certain head positions, nystagmus, ø hearing loss)

Question 7

How is a deviated nasal septum treated in patients with recurrent sinusitis?

Answer 7

surgical correction

Question 8

What are the three common causes of rhinitis?

Answer 8

Viral

allergic

bacterial

Question 9

How do you recognize and treat viral rhinitis (common cold)?

What can cause viral rhinitis?

Answer 9

treatment is symptomatic

Vasoconstrictors (phenylephrine) can be used for short-term symptomatic relief, but they may cause rebound congestion when discontinued

causes: rhinovirus (most common), influenza, parainfluenza, coxsackie virus, adenovirus, RSV, coronavirus, or echovirus.

Question 10

How do you recognize and treat allergic rhinitis?

Answer 10

symptoms: seasonal flare-ups, boggy/bluish turbinates, onset before 20yo, nasal polyps, sneezing, pruritus, conjunctivitis, wheezing or asthma, eczema, (+) family hx, eosinophils in nasal mucous, and elevated IgE

diagnose: skin test

treatment: avoid known antigens, antihistamine, nasal steroids, and/or cromolyn in more severe cases; desensitization

Question 11

What causes bacterial rhinitis? How does it present?

How is it diagnosed and treated?

Answer 11

culprits: Group A streptococci, pneumococci, or staphylococci

symptoms: coexisting sore throat, fever, and tonsillar exudate

diagnosis: strep throat cultures

treatment: antibiotics

Question 12

What causes nosebleeds?

Answer 12

• trauma (nose-picking)
• nasopharyngeal angiofibroma (tumor in adolescent boys w/o history of trauma or blood dyscrasia)
• leukemia (typically in children with associated fever and anemia)

Question 13

True or false: A neck mass is more likely to be benign in a child than in an adult.

Answer 13

TRUE

Question 14

What are the common causes of a neck mass?

Answer 14

CHILDREN

• thyroglossal duct cysts - midline, elevates with tongue protrusion
• branchial cleft cysts - lateral; often become infected
• cystic hygroma - aka lymphangioma; benign, associated with Turners and treated with surgical resection
• cervical lymphadenitis - due to streptococcal pharyngitis, EBV, cat-scratch disease, or mycobacterial infection (scrofula)
• malignancy - leukemia or lymphoma may present with cervical lymphadenopathy

ADULTS

• malignancy - either lymphadenopathy from a 1˚ (lymphoma, thyroid), metastatic (usually squamous cell carcinoma) neoplasm

Question 15

Describe the workup for an unknown cancer in the neck.

Answer 15

Triple endoscopy with triple biopsy:

biopsy of nasopharynx, palatine tonsils, and base of the tongue as well as laryngoscopy, bronchoscopy, and esophagoscopy

Question 16

What is the scientific name for “swimmer’s ear?” What causes it?

What are the symptoms of this?

How do you treat it?

Answer 16

Otitis externa - commonly caused by Pseudomonas aeruginosa

Signs:

• pain with manipulation of the auricle
• erythematous, swollen skin in the auditory canal
• foul-smelling discharge
• conductive hearing loss also may be present

Treatment:

• topical antibiotics (e.g., ofloxacin, neomycin, polymyxin B)
• steroids (to reduce swelling)

Question 17

What causes otitis media?

How do you recognize and treat it?

Answer 17

extremely common pediatric infection, most often due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis

symptoms: ø pain with manipulation of the auricle; earache, fever, erythematous and bulging tympanic membranes (the light reflex and landmarks are difficult to see with otoscopy), and nausea and vomiting.

Question 18

What are the complications of otitis media? How are they avoided?

Answer 18

• tympanic membrane perforation (bloody or purulent discharge)
• mastoiditis (fluctuance and inflammation over the mastoid process roughly two weeks after the onset of OM)
• labyrinthitis
• cranial nerves VII and VIII palsies
• meningitis
• cerebral abscess
• dural sinus thrombosis
• chronic OM (because of permanent perforation of the tympanic membrane); may develop cholesteatomas (expanding/destructive growth of keratinizing squamous epithelium in the middle ear and/or mastoid process) with marginal perforations that require surgical excision.

treated with antibiotics to avoid these complications (e.g., amoxicillin, second generation cephalosporin such as cefuroxime, macrolide).

Question 19

What is the problem with recurrent otitis media? How is it treated?

Answer 19

can cause hearing loss with resultant developmental problems (speech, cognitive functions)

treat with prophylactic antibiotics or tympanostomy tubes

Question 20

What is infectious myringitis and what causes it??

How do you recognize and treat it?

Answer 20

Infectious myringitis (aka bullous myringitis) - inflammation of the tympanic membranes; can be diagnosed when otoscopy reveals vesicles on the tympanic membrane.

causes: Mycoplasma species, Streptococcus pneumoniae, or viruses
treatment: erythromycin or clarithromycin to cover Mycoplasma species and S. pneumoniae.

Question 21

What are the common bacterial causes of sinusitis?

How is this condition recognized clinically?

Answer 21

causes: S. pneumoniae, H. influenzae, or other streptococcal or staphylococcal species

symptoms: tenderness over the affected sinuses, headache, and purulent nasal discharge (yellow or green), headache and/or toothache (maxillary sinusitis)

diagnosis: Xray or CT shows opacification of the sinus, classically with an air-fluid level in acute sinusitis; CT preferred to evaluate chronic sinusitis or suspected extension of infection outside the sinus (watch for high fever and chills)

treatment: amoxicillin, amoxicillin-clavulanate, TMP-SMX, a second or third generation cephalosporin, a macrolide for 10 to 14 days or for up to 6 weeks in chronic cases)

• surgical intervention (drainage procedure, sinus obliteration) may be required for resistant cases.

Question 22

By what age are the frontal sinuses well developed in children?

Answer 22

10 yo

Question 23

Define otosclerosis. How is it treated?

Answer 23

otic bones become fixed together and impede hearing

treatment: hearing aid or surgery

Question 24

most common cause of conductive + sensorineural hearing loss in adults

Answer 24

conductive: otosclerosis
sensorineural: presbyacusis

Question 25

What causes parotid gland swelling?

Answer 25

causes: mumps (most common), neoplasms (pleomorphic adenoma), sjogren syndrome, sialolithiasis (stone is parotid duct), sarcoidosis, bulimia, alcoholism

Question 26

How do you recognize a nasal fracture? What complication may result?

Answer 26

XRays or CT scan watch for **septal hematoma**, which must be removed surgically to prevent pressure-induced septal necrosis

Question 27

What is the Weber test used to evaluate? How is it performed and interpreted?

Answer 27

compares bone conduction in the two ears ## Footnote The normal response is to hear the vibration in the middle (or equally in both ears). In patients with conductive hearing loss, the sound is heard best in the **affected** ear In patients with sensorineural hearing loss, the sound is heard best in the **unaffected** ear (since affected ear is not conducting any stimuli)

Question 28

What is the Rinne test used to evaluate? How is it performed and interpreted?

Answer 28

compares air conduction with bone conduction ## Footnote Because air conduction is normally greater than bone conduction, patients can hear the tuning fork when it is placed next to the auditory meatus (air conduction) even after they can no longer hear it vibrating on the mastoid (bone conduction). In patients with **conductive** hearing loss, bone conduction is greater than air conduction; thus they cannot hear the tuning fork when it is placed next to the external auditory meatus. In patients with **sensorineural** hearing loss, *both air and bone conduction are impaired, but the normal ratio (air conduction \> bone conduction) is maintained*. Thus, they still hear the tuning fork next to the ear after they can no longer hear it on the mastoid.